March 29, 2005
by Angela Hussain

People diagnosed with post-traumatic stress disorder should be offered psychological treatment rather than drug treatment, a guideline for the NHS in England and Wales has recommended.

The National Institute for Clinical Excellence guideline says that up to 30% of people who experience an exceptionally threatening or catastrophic event may develop the disorder.

The guideline says that trauma focused psychological therapy should be used as a routine first line treatment for adults in preference to drug treatments.

The facilitator of the guideline's development, Stephen Pilling, a clinical psychologist and coordinator of London's National Collaborating Centre for Mental Health, said: "We were not able to find very convincing evidence for efficacy of drug treatment in PTSD.

"So, in contrast to US guidelines, which recommend use of SSRI [selective serotonin reuptake inhibitor] antidepressants as first line treatment, we advised against this."

After reviewing evidence, including unpublished data from drug trials, the group that developed the guideline also advised that people who experience a traumatic event should not be given brief, single-session interventions, often termed debriefing.

Dr Pilling said: "We found little evidence of benefit from a single psychological intervention in people with PTSD [post-traumatic stress disorder], and some evidence of harm."

He said that debriefing may not allow enough time for people to work adequately through the traumatic event and associated emotional and psychological feelings.

"PTSD is associated with incomplete processing of a traumatic event, so effective therapy needs to allow a person to fully process what happened," he said.

The guideline, issued last week, recommends that all people diagnosed with post-traumatic stress disorder be offered several sessions of psychological treatment-either cognitive behaviour therapy or eye movement desensitisation and reprocessing (a technique in which the therapist guides the patient to move his or her eyes in a random way while the patient talks about the trauma).

Dr Pilling told bmj.com: "The key factor that makes these treatments effective is that they are structured psychological treatments that focus specifically on the traumatic event, in contrast to other more general therapies, such as counselling."

The guideline also emphasises the need to improve the detection and management of the disorder in children, because the effects could be very long lasting. It said that detection of the disorder could be improved by asking children directly about their experiences.

Children and young people with the disorder, including those who have been sexually abused, should be offered a course of trauma focused cognitive behaviour therapy, adapted as needed to suit their age, circumstances, and level of development.

Read for yourself:
National Institute for Clinical Excellence guidance on post-traumatic stress disorder (pdf)

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Medication does have benefits

Comment by: Ceylon Marable, third year mental health student nurse, Oxford Brookes University, Oxford
Date: April 11, 2005

I have worked on a placement that works especially with people with PTSD.

The clients did have CBT-based therapy work, but they also found SSRI medication helpful to treat sypmtoms of PTSD, for example panic attacks.

Although I agree with the NICE guidelines that more psychological treatments should be used to help this client group, I also feel that low doses of medication should help treat the symptoms as well. And as the person grows to understand the traumatic event, the SSRIs can be decreased.

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