Experts Call for Global PTSD
Treatment Guidelines

 

Practice guidelines to help clinicians assess and treat posttraumatic stress disorder (PTSD) have many similarities, but they also contain areas of apparent differences.These differences can cause confusion among the target audience of health care providers, consumers, and purchasers of mental health services for people affected by trauma, according to new research published online September 13 in the Journal of Traumatic Stress.

During the past 10 years a series of clinical practice guidelines for PTSD have been published in Australia, the United Kingdom, and the United States, writes David Forbes, MD, from the University of Melbourne, Victoria, Australia, and colleagues.

However, the range of guidelines for PTSD "published at different times, in different countries, for different constituencies, with different methodologies, and potentially deriving different clinical recommendations can make it extremely difficult for the clinician to determine which of these guidelines' recommendations best apply to them in their clinical work," Dr. Forbes and his team write.

In their article, they examine 7 practice guidelines for PTSD and outline some of their relevant features to help clinicians make decisions about their use.

The guidelines they examine are:

The authors stress that the guidelines have many similarities. All strongly support the use of trauma-focused psychological treatment for adults and children, all recognize some benefit of pharmacotherapy for the treatment of PTSD, and all caution against the routine use of psychological debriefing as an early preventive intervention for populations exposed to trauma.

"These are important areas of agreement that can do much to drive the wider adoption of evidence-based practice," the authors write.

The 3 most important differences have to do with recommending the use of pharmacotherapy, especially selective serotonin reuptake inhibitors; the parameters of psychological treatment and whether eye movement desensitization and reprocessing is an equivalent for first-line treatment to trauma-focused cognitive behavioral therapy; and the degree to which guidelines seek evidence for and provide recommendations in the area of screening and assessment in addition to intervention, the authors note.

Many of the recommendations lack sufficient empirical data, but it is unrealistic to assume that every aspect of care will be guided by level 1 empirical data, given the current state of knowledge about PTSD. What is important is that the guidelines must be read carefully.

"Readers should be able to easily differentiate which recommendations are evidence-based and which are based on clinical consensus," the researchers comment, adding that as the body of empirical knowledge expands, "we will presumably rely less and less on clinical opinion to drive recommendations for practice."

Translation of Research Into Practice Too Slow

Commenting on this study for Medscape Medical News, Nancy Talbot, PhD, from the University of Rochester School of Medicine and Dentistry in New York, said that conflicting recommendations may be confusing to clinicians, but the bigger issue is that the translation of research into clinical practice is so slow.

"The National Institute of Mental Health talks about this in its mission statement. The translation of research into clinical practice has been exceedingly slow. We go about doing our treatment research and getting findings, and showing that this treatment is or is not effective, but there is not a lot of take-up by your regular clinicians out in the field doing their work. They are not changing their practice very much as a result of the research that is going on. That's a real concern of the NIMH [National Institute of Mental Health]."

Although some clinicians are very attentive to research, others prefer to continue doing what works or seems to work. "Even though there has been a lot of research on PTSD, and it is a rapidly growing field, there are only a handful of psychotherapies that have been examined and researched, and most have been cognitive behavioral therapies," she commented.

Dr. Talbot says that the authors' tips for evaluating the various guidelines are useful.

"I do PTSD and depression research with traumatized women, many of whom have PTSD, and I pay attention to the guidelines," she said. "I notice the differences among them, but I don't think I ever really thought it through about where these differences are stemming from. I think the authors did a really nice job of discussing this continuum, with some clinical practice guidelines being heavily research based, and others being based on expert opinion, and still others being a mix of the two."

Dr. Forbes and colleagues conclude that the absence of evidence does not equate to evidence of the absence of a treatment effect.

"The fact that no research has been conducted on a given intervention should not necessarily be interpreted to mean that the intervention is ineffective; it simply means that we do not have evidence to support it at this stage," they write. "Until such data are available, it is wise to first consider interventions for which good evidence does exist."

Dr. Forbes and Dr. Talbot have disclosed no relevant financial relationships.

J Trauma Stress. Published online September 13, 2010.

-From “Experts Call for Global PTSD Treatment Guidelines”,by Fran Lowry, Medscape Medical News, http://www.medscape.com/viewarticle/729711, retrieved 10/15/10.

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