Guidance
Rationale and impact
- Supporting transitions between services
- Access to care
- Principles of care
- Planning treatment and supporting engagement
- Active monitoring
- Psychologically-focused debriefing
- Psychological interventions for the prevention of PTSD in children and young people
- Psychological interventions for the treatment of PTSD in children and young people
- Drug treatments for children and young people
- Psychological interventions for the prevention of PTSD in adults
- Psychological interventions for the treatment of PTSD in adults
- Drug treatments in adults
- Care for people with post-traumatic stress disorder and complex needs
Rationale and impact
These sections briefly explain why the committee made the recommendations and how they might affect practice. They link to details of the evidence and a full description of the committee's discussion.
Supporting transitions between services
Recommendations 1.2.4 to 1.2.6
Why the committee made the recommendations
There was not enough good evidence about access to care, developing care pathways and coordinating care, so the committee drew on sources from other mental health disorders describing pathways and systems that support access and engagement with care. Based on this information they used a formal consensus method to make recommendations on good practice.
The committee discussed strategies to improve care coordination and provide smooth transitions of care for people with post-traumatic stress disorder (PTSD). They agreed it was important to plan transitions in advance, involve families and carers, make sure everyone involved in the person's care is aware of their role and responsibility, and ensure that different services are communicating with each other, as well as with the person with PTSD. They noted that overall coordination and continuity of care could be achieved by having a key professional to oversee the whole period of care – they agreed that this was already covered by the recommendations on GPs taking responsibility and management shared between primary and secondary care in the section on assessment and coordination of care. The committee also identified certain groups that might need extra support during care transitions.
Access to care
Recommendations 1.3.1 and 1.3.2
Why the committee made the recommendations
In the absence of good evidence the committee used formal consensus to recommend some key strategies for promoting access to care. Based on their clinical experience the committee agreed that a common barrier to accessing care can be the person's belief that PTSD is untreatable. The committee agreed it was important to present a more hopeful and optimistic picture of the treatment of PTSD.
They also discussed evidence on delivering care more flexibly. Qualitative evidence showed that some people with PTSD prefer to have their treatment away from a clinical environment. There was also clinical evidence that some types of remote care (for example, computerised trauma-focused cognitive behavioural therapy [CBT] and video consultation) can be as successful as face-to-face interventions. Based on this, the committee agreed that delivering care in more flexible ways, including by making it available in non-clinical locations like schools or offices, would improve access.
How the recommendations might affect practice
These recommendations will help to improve consistency in the way services are provided. Any resource impact should be offset by time savings and efficiency benefits from improved uptake and engagement. Currently video consultation is not available everywhere so this recommendation could have a moderate impact on resources. However, it is expected to save resources in the future, in particular in remote areas where therapists need to travel further to deliver trauma-focused CBT in person.
Principles of care
Recommendations 1.4.1 to 1.4.9
Why the committee made the recommendations
Supporting people with PTSD
Recommendations 1.4.1 and 1.4.2 and recommendation 1.4.4
Based on the evidence and their own clinical experience, the committee discussed how people with PTSD are often apprehensive about making contact with services and may not know what treatments and help are available. They agreed that this underlined the need for good information and support, tailored to people's needs, about interventions and services. This should cover what care and treatment people can expect and how it will be provided (for example where and by whom).
The committee discussed the importance of maintaining safe environments for people with PTSD. Based on their clinical experience, they agreed that a number of environmental triggers could worsen people's symptoms or stop them from engaging in treatment. Practitioners assessing and treating people with PTSD – including those providing treatment for other mental or physical health conditions – should be aware of the need to minimise this risk.
Peer support
The evidence for peer support groups was limited but included some compelling reports from people with PTSD that sharing experiences with other people who had also experienced a traumatic event was beneficial, and this was reported for different types of traumatic experience. Findings suggested that peer support could also help people overcome their doubts and fears about having treatment by telling them about available help and support and encouraging them to engage with services.
Involving family members in treatment
Recommendations 1.4.6 and 1.4.9
There was evidence that involving families and carers in treatment provided extra support for the person while also giving the family or carer a greater understanding of PTSD. However, family or carer involvement was not universally reported as positive, with some people not liking the feeling of being talked about in their absence, so the committee agreed this should be discussed with the person first.
Limited evidence showed that involving families and carers in treatment had benefits for improving carer mental health and reducing parenting difficulties. However, the evidence was too uncertain to support any recommendations for specific interventions to support family members and carers. The committee recommended good practice points based on their own expert opinion.
Supporting families and carers
Recommendations 1.4.5, 1.4.7 and 1.4.8
Qualitative evidence suggested that a common reason for not seeking help for PTSD is a lack of awareness about interventions and services. The committee agreed that information and support provided to family and carers could act as a facilitator for accessing services for both the carer and the person with PTSD.
The committee discussed the potential for more than one family member to have PTSD. They considered it important to raise awareness about this risk so that people are offered support promptly.
How the recommendations might affect practice
These recommendations are good practice points that will help to improve consistency of care. Any minor resource impact should be offset by time savings and efficiency benefits from improved uptake and engagement.
Peer support groups are not routinely offered everywhere but they are in fairly widespread use. The committee noted that facilitating access to these groups should not involve major resource implications. Any costs would be offset by potential savings associated with promoting earlier access to support that will help to prevent people from developing more severe problems.
Planning treatment and supporting engagement
Recommendations 1.6.1 to 1.6.3
Why the committee made the recommendations
The committee agreed it was important to use a holistic approach when planning treatment, for example by thinking about every aspect of a person's life that could be contributing to their continuing PTSD symptoms, whether they might have any other physical or mental health conditions, and whether they might be at significant risk of harm to themselves or others. It was also important to ask the person if any treatments had worked for them in the past and to take into account their preferences. In the committee's opinion these were important points of good practice, along with providing information and support to help the person to make an informed choice about treatments.
The committee agreed that any strategies for promoting engagement need to be based on an understanding that people with PTSD are often highly anxious about having treatment and frequently avoid it. This was supported by evidence that common reasons for not seeking help include worry about engaging with a therapist, fear of exacerbating symptoms and stigmatisation. People may also have difficult emotions, such as shame, linked to the trauma, which can stop them from engaging with treatment. The committee agreed that healthcare professionals need to understand these reasons so that they don't misinterpret why someone is not engaging and they know the best ways to help them – including by contacting them if they don't come for an arranged appointment.
Active monitoring
Why the committee made the recommendation
There was no consistent evidence for effective interventions to prevent PTSD in people with subthreshold PTSD symptoms within 1 month of a traumatic event. The committee drew on their clinical experience and discussed how some people do not develop PTSD symptoms after a trauma even with no, or limited, interventions. Conversely, some people develop chronic symptoms if intervention is not provided early. Based on consensus, the committee agreed that active monitoring within the first month after the trauma could help professionals to judge whether people with less severe symptoms would need further intervention.
Psychologically-focused debriefing
Why the committee made the recommendation
Evidence on psychologically-focused debriefing, either individually or in groups, showed no benefit for children or adults, and some suggestion of worse outcomes than having no treatment. The committee agreed that psychologically-focused debriefing should not be offered. Providing an ineffective intervention can be regarded as harmful because it means that people are being denied access to another intervention with greater evidence of benefits.
Psychological interventions for the prevention of PTSD in children and young people
Recommendations 1.6.6 to 1.6.8
Why the committee made the recommendations
There was no evidence for individual trauma-focused CBT for children and young people within the first month of trauma. Despite the lack of direct evidence, the committee decided to make a recommendation for this intervention in light of the strong evidence for its efficacy for children who have experienced trauma more than 1 month ago, and the evidence for benefits in adults within 1 month of trauma. There can be a lot of natural recovery in the early weeks and it can be difficult to gauge a child or young person's readiness for intervention within 1 month of trauma. Based on consensus, the committee agreed that individual trauma-focused CBT and active monitoring could both be considered as options within 1 month of trauma for children and young people with clinically important PTSD symptoms or acute stress disorder, and that this decision was best left to clinical judgement.
There was evidence that trauma-focused CBT group interventions were effective for improving PTSD symptoms and other important outcomes for children and young people who had been exposed to ongoing trauma, for example from living in a war zone. The committee agreed that these findings could also apply to other types of large-scale shared traumas. There were some gaps and uncertainties in the evidence, for example in how long the benefits might last and whether they were specific to that intervention or could be explained by other general factors such as receiving attention from a therapist. Based on this evidence and the additional considerations, the committee recommended the intervention should be considered as a possible option. The cognitive and language demands of trauma-focused group CBT mean that it would not be suitable for children under 7 so the committee used an age range that reflected the age of children in the included studies.
Although specific group trauma-focused CBT interventions use the same broad approach, the committee was concerned that psychological interventions are not always delivered in a consistent way, so they agreed to specify the structure and content.
How the recommendations might affect practice
There is currently variation in care for children and young people with acute stress disorder or clinically important symptoms of PTSD within 1 month of a traumatic event. Recommending active monitoring or individual trauma-focused CBT as options to consider should improve consistency in practice and help to reduce the use of more resource-intensive interventions for which the effectiveness is unknown.
There is currently no guidance on interventions for children exposed to large-scale shared trauma, and current practice has involved providing a range of different interventions. Without a clear steer on what works best there has been variability in access to interventions, the type of interventions offered and the extent to which they have been evidence-based. The recommendation for group trauma-focused CBT will lead to more consistency in practice and improve clinical outcomes for children who might otherwise need more costly management for PTSD later in the care pathway.
Psychological interventions for the treatment of PTSD in children and young people
Recommendations 1.6.9 to 1.6.13
Why the committee made the recommendations
The evidence showed that trauma-focused CBT is effective in improving PTSD symptoms and other important outcomes, and that improvements last for at least a year. Benefits were seen for different specific trauma-focused interventions and different types of trauma. Trauma-focused CBT is more effective, as well as more cost effective, when it is provided individually than in a group so the committee agreed it should be delivered individually.
Most of the evidence for trauma-focused CBT came from children aged over 7 years. There was some evidence from 5 and 6 year olds so the committee agreed it could be an option for them, but could not be recommended with the same certainty.
There was no evidence for treatment with trauma-focused CBT between 1 and 3 months after a traumatic event compared with a non-active control, so the committee could not recommend it with the same certainty as for more than 3 months after trauma. However, by extrapolating from the broad evidence base for benefits more than 3 months after trauma and drawing on members' own clinical experience, the committee agreed that trauma-focused CBT could be an option during this period.
Although specific trauma-focused CBT interventions use the same broad approach, the committee was concerned that psychological interventions are not always delivered in a consistent way, so they agreed to specify the structure and content. This recommendation was informed by the evidence and modified by the committee's expert advice. For example, a typical number of sessions was recommended based on the evidence, but the committee agreed that more might be needed, including for those who have experienced multiple traumas.
There was limited evidence for eye movement desensitisation and reprocessing (EMDR) suggesting possible benefits on PTSD symptoms in children older than 7 years. However, EMDR was found to be less clinically effective and cost effective than all individual trauma-focused CBT interventions. On this basis, the committee decided it should be considered only if children do not respond to or engage with trauma-focused CBT.
How the recommendations might affect practice
Offering trauma-focused CBT more than 3 months after a traumatic event is in line with previously recommended practice and the committee was not aware of wide variation in practice. Considering trauma-focused CBT between 1 and 3 months after a traumatic event and recommending EMDR as an option are both new. They are only recommended as options to consider, which should limit their impact on practice, as should the fact that EMDR should only be considered for children who do not respond to or engage with trauma-focused CBT.
NICE's previous guideline made recommendations for children with PTSD, whereas current recommendations are also relevant to children and young people with clinically important symptoms of PTSD. The structure, content and time of the assessment, as well as the benefits from treatment, are broadly the same for both populations and it was the committee's view that there should not be a significant impact on practice.
Drug treatments for children and young people
Why the committee made the recommendation
There was very little evidence on the use of drug treatments to prevent or treat PTSD in children and young people. This limited evidence showed no significant benefits so the committee agreed drug treatment should not be offered.
Psychological interventions for the prevention of PTSD in adults
Why the committee made the recommendation
Evidence showed that individual trauma-focused CBT interventions were effective for improving PTSD symptoms in adults who had experienced a traumatic event within the last month. They also reduced the number of adults who met the criteria to be diagnosed with PTSD after 1 month. There was also limited evidence from outside the UK that trauma-focused CBT is cost effective in adults at risk of PTSD.
There was evidence for a number of specific interventions within the trauma-focused CBT class, and the committee agreed it would be helpful to give some examples of named therapies that fall under this term.
The evidence of benefits was restricted to adults with clinically important symptoms or acute stress disorder, so the committee only recommended the intervention for these groups and not for people with less significant symptoms.
Psychological interventions for the treatment of PTSD in adults
Recommendations 1.6.16 to 1.6.23
Why the committee made the recommendations
Trauma-focused CBT
Recommendations 1.6.16 and 1.6.17
There was extensive evidence that trauma-focused CBT interventions improve PTSD symptoms as well as other important outcomes, and that these improvements can be maintained up to a year later. Benefits were seen across a wide range of types of trauma, including both single and multiple incident traumas. There was evidence for a number of specific interventions within the trauma-focused CBT class, and the committee agreed it would be helpful to give some examples of named therapies that fall under this term.
Most of the evidence for trauma-focused CBT interventions came from adults who had been exposed to 1 or more traumatic events more than 3 months ago, although there was limited evidence showing benefits between 1 and 3 months after trauma. The committee discussed this limited evidence alongside the broader evidence base that showed benefits within the first month and more than 3 months after trauma. They thought it was unlikely that effects would be different in this 2‑month time period, so recommended trauma-focused CBT for adults with a diagnosis of PTSD or clinically important symptoms of PTSD more than 1 month after a traumatic event.
There was good evidence that offering up to 12 sessions of individual trauma-focused CBT was clinically and cost effective. Group trauma-focused CBT was not seen to be clinically or cost effective based on the guideline network meta-analysis and economic analysis, although the evidence was limited. Based on the standard number of sessions outlined in most validated treatment manuals and the most common number of sessions in the evidence base, the committee recommended providing 8 to 12 sessions. However, based on their clinical experience, they recommended offering more sessions if needed, including for people who have experienced multiple traumas.
Using both the evidence and their clinical experience, the committee outlined the structure and content of individual trauma-focused CBT interventions to make sure they are delivered in a consistent way because they were concerned that this may not happen in practice.
Psychoeducation was found to be highly clinically and cost effective in comparisons with psychological interventions according to the guideline network meta-analysis and economic analysis, but its evidence base was very limited and uncertain. The committee agreed that the evidence could not support a recommendation for psychoeducation on its own but it should be delivered as part of individual trauma-focused CBT.
Eye movement desensitisation and reprocessing
Recommendations 1.6.18 to 1.6.20
Less evidence was found on EMDR than on trauma-focused CBT, but the committee agreed that what was available justified recommending EMDR. Although studies that compared EMDR directly with trauma-focused CBT did not show significant differences, there was a trend towards EMDR. This trend in favour of EMDR was also present in the cost effectiveness results. The evidence suggested EMDR was not effective in people with military combat-related trauma, and this was in marked contrast to all other included trauma types for which benefits were observed. On this basis, the committee restricted their recommendation to non-combat-related trauma.
Most of the evidence for EMDR came from adults who had been exposed to 1 or more traumatic events more than 3 months ago, although there was limited evidence showing benefits between 1 and 3 months after trauma. Based on this limited evidence and by extrapolating from the stronger evidence for EMDR more than 3 months after trauma, the committee recommended considering EMDR between 1 and 3 months after a non-combat-related trauma. This recommendation was made with less certainty than treatment after 3 months because of the very limited direct evidence (a single study) and because limited evidence suggested non-statistically significant benefits of EMDR within 1 month of trauma.
Although EMDR interventions use the same broad approach, the committee was concerned that psychological interventions are not always delivered in a consistent way, so they agreed a specific structure and content based on the interventions in the evidence and modified by their expert opinion.
Supported trauma-focused computerised CBT
Recommendations 1.6.21 and 1.6.22
There was evidence that both supported and unsupported self-help, and computerised trauma-focused CBT in particular, were beneficial in terms of self-rated PTSD symptoms and other important outcomes. These benefits were maintained up to a year later. Both interventions were cost effective compared with other psychological interventions. The evidence was limited for some of the outcomes that were looked at, and it was unclear whether self-help was effective across different types of trauma. Although both supported and unsupported self-help were found to be effective, the former was more clinically and cost effective because the greater effect sizes were sufficient to offset the higher costs.
Taking the evidence for efficacy together with the gaps in the evidence, the committee agreed that supported computerised trauma-focused CBT should be considered as an option for adults with PTSD who prefer this to face-to-face trauma-focused CBT or EMDR. The committee was concerned that a lower intensity intervention might not be clinically appropriate for all adults with PTSD, so this recommendation was limited to those who do not have severe PTSD symptoms (in particular dissociative symptoms) and are not at risk of harm to themselves or others.
A number of computerised trauma-focused CBT interventions are available, and the committee felt it was important to specify their structure and content to make sure a minimum standard was set.
CBT interventions for specific symptoms
There was some evidence that non-trauma-focused CBT is beneficial when targeted at specific symptoms such as sleep disturbance or anger, and also leads to improvements in PTSD symptoms, but it was not clear how long these benefits would be maintained. Non-trauma-focused CBT was less cost effective than individual trauma-focused CBT, EMDR and self-help, but more cost effective than other interventions such as present-centred therapy, group trauma-focused CBT, combined individual trauma-focused CBT and SSRIs, counselling and no treatment. The committee agreed the potential benefits of non-trauma-focused CBT were important, but that symptom-specific interventions should not be seen as an alternative to a trauma-focused first-line treatment. Instead, they could be an option when people are not ready to directly confront memories of the trauma and could promote uptake and engagement with a trauma-focused intervention. They could also be used to target residual symptoms after a trauma-focused intervention.
How the recommendations might affect practice
NICE's previous guideline made recommendations for adults with PTSD, whereas current recommendations are also relevant to adults with clinically important symptoms of PTSD. The structure, content and time of the assessment, as well as the benefits from treatment, are broadly the same for both populations and it was the committee's view that there should not be a significant impact on practice.
Both trauma-focused CBT and EMDR were already recommended and the committee did not think there was wide variation in practice. The new recommendation for non-trauma-focused CBT interventions targeted at specific symptoms represents a bigger change because previous recommendations stated that non-trauma-focused interventions should not be routinely offered to people with chronic PTSD. The impact on resources is difficult to predict because it is recommended only as an option to consider, but it might bring potential savings by improving uptake and engagement with trauma-focused therapies that should reduce missed appointments and early drop-out.
The recommendation for supported computerised trauma-focused CBT is also thought to represent a bigger change. Self-help-based interventions were not previously part of recommended practice and the committee was not aware of such interventions being in widespread use. The cost of supported computerised trauma-focused CBT includes, in addition to a therapist's time, the cost of the digital mental health programmes and computers needed for delivery. If such an intervention is delivered in a public place (like a library), or the person's home, there is no equipment cost. If the computer is used in a clinical practice setting, it can be shared by many people having computerised therapy, minimising the equipment cost. It could therefore lead to cost savings if part of routine practice is shifted from the more resource-intensive individual trauma-focused CBT and EMDR to the less resource-intensive supported computerised trauma-focused CBT.
The committee acknowledged that there would be a cost associated with providing extra trauma-focused therapy sessions if they are needed (for example, for people who have experienced multiple traumas). Previous recommended practice was to consider more than 12 sessions for people after multiple incident trauma, or who have chronic disability or significant coexisting conditions or social problems. However, in clinical practice the provision of additional sessions is variable.
Drug treatments in adults
Recommendations 1.6.24 to 1.6.26
Why the committee made the recommendations
Prevention
There was no consistent evidence that any drug treatments are effective in preventing PTSD. Given the limited evidence of benefits and the potential harms, including side effects, the committee agreed that drug treatments should not be offered to prevent PTSD in adults. The committee specifically referred to benzodiazepines because of the lack of benefit in the evidence, concerns about harm and their clinical experience of these drugs being prescribed in practice.
Treatment
Recommendations 1.6.25 and 1.6.26
There was evidence that SSRIs and venlafaxine are effective in treating PTSD. There was a large number of studies for SSRIs but the sizes of the effects were smaller than for venlafaxine. The committee decided that either an SSRI or venlafaxine could be considered if a person prefers to have drug treatment, but they should not be offered as first-line treatment for PTSD. This is based partly on the lack of follow-up data for SSRIs and venlafaxine, and because evidence showed that SSRIs are less effective than any of the psychological interventions recommended. Economic modelling also showed SSRIs are less cost effective than EMDR, brief individual trauma-focused CBT or self-help with support.
There was no evidence for significant differential efficacy of specific SSRIs (sertraline, fluoxetine and paroxetine), so the committee agreed to allow prescribers to decide which SSRI to use. However, they included sertraline as an example because it is 1 of 2 drugs licensed in the UK for this indication and the other drug, paroxetine, is more likely to be associated with discontinuation symptoms.
The committee agreed that it was important to review antidepressant treatment regularly to manage any side effects and to review clinical progress and outcomes.
There was some evidence that antipsychotics, either alone or in addition to routine medications, are effective in treating PTSD symptoms. However, it was more limited than the evidence supporting SSRIs and the psychological interventions (for example, the evidence for other important outcomes was limited and there were no follow-up data). The committee agreed that antipsychotics should not be seen as an alternative to a trauma-focused psychological intervention as first-line treatment for PTSD and should only be considered as an adjunct to psychological therapy. However, they might be beneficial for symptom management for adults with a diagnosis of PTSD if their symptoms have not responded to other drug or psychological treatments and they have disabling symptoms and behaviours that makes it difficult for them to engage with psychological treatment. Given the different side effect profiles, the committee agreed to leave the choice of antipsychotic to clinical judgement. Risperidone was included as an example because the evidence for risperidone included more participants.
The committee discussed concerns about the tolerability of antipsychotic drugs and agreed they should only be prescribed in a specialist setting, or after consultation with a specialist.
How the recommendations might affect practice
The committee was concerned that drug treatment within the first month of trauma may be reasonably common in clinical practice. The do not offer drug treatments recommendation in the section on drug treatments for adults will therefore help to reduce the use of non-evidence-based interventions and improve consistency of practice. These recommendations represent a small change in practice because the previous guideline recommended drug treatment as an option only for adults who could not start a psychological therapy, did not want to start trauma-focused psychological therapy or who had gained little or no benefit from it.
In the UK, only paroxetine and sertraline are licensed for the treatment of PTSD so the recommendations involve off-licence use. Offering antipsychotics only in a specialist setting or after consultation with a specialist is expected to reduce variation in the way antipsychotics are used in current practice. Regular review of drug treatment is essential but might not be happening currently, so this should also improve consistency.
Care for people with post-traumatic stress disorder and complex needs
Recommendations 1.7.1 to 1.7.3
Why the committee made the recommendations
There was a lack of evidence on care for people with PTSD and complex needs, including people with coexisting conditions such as depression or substance misuse, so the committee used a formal consensus method to agree some overarching principles.
The evidence was limited on interventions for people who have complex PTSD, but it suggested that trauma-focused therapies could also benefit this group. Based on their clinical experience, the committee recommended modifications that may be needed to trauma-focused therapies to facilitate engagement for those with complex PTSD or other additional needs.
How the recommendations might affect practice
The committee acknowledged that there would be a cost associated with increasing the duration or the number of therapy sessions, if this is necessary for people with PTSD and additional needs. Previous recommended practice was to consider more than 12 sessions for people after multiple incident trauma, or who have chronic disability or significant coexisting conditions or social problems. However, in clinical practice the provision of additional sessions is variable.