Download Psychiatric conditions

Clinical guidelines
for the Queensland workers’
compensation scheme
Psychiatric conditions
Contents
Before you start
Relevance to the workers’ compensation sector............................................................................................................................. 2
Agree appraisal .......................................................................................................................................................................................... 3
Register of clinical practice guidelines for psychiatric conditions ............................................................................................... 4
Click to the relevant guideline
Anxiety disorders...................................................................................................................................................................................... 5
Stress related conditions and other mental disorders ................................................................................................................. 15
Practice guideline for the treatment of acute stress disorder sand post traumatic stress disorder .............................. 25
Post-traumatic stress disorder. The management of PTSD in adults and children in primary and secondary care ... 35
Anxiety: Management of anxiety (panic disorder, with or without out agoraphobia, and generalised anxiety
disorder) in adults in primary, secondary and community care ................................................................................................ 47
Guideline for the evaluation and treatment of injured workers with psychiatric conditions ............................................ 66
VA/DoD clinical practice guideline for the management of post-traumatic stress ............................................................ 72
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Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Foreword
Clinical guidelines for the Queensland workers’ compensation scheme is a selection of clinical guidelines or
‘treatment protocols’ used by other jurisdictions and medical bodies.
Q-COMP compiled this selection to create a resource for clinicians treating injured workers in Queensland.
Over the course of our research it became clear what type of guidelines are successfully applied to practice and
what we should include.
They include guidelines where:
•
•
•
•
•
•
•
medical providers were consulted
nurse and allied health providers identified relevant areas to include
medical specialty groups endorsed the guidelines
an effective promotion program was used
patient education brochures or fact sheets for General Practitioners to provide to their patients were developed
an education strategy included the Continuing Professional Development (CPD) program
frameworks for evaluating the guidelines effectiveness were developed ahead or simultaneously with the
guidelines themselves.
I am looking forward to receiving your feedback on Clinical guidelines for the Queensland workers’ compensation
scheme and your support in achieving the best outcomes for injured workers in Queensland.
Elizabeth Woods
Chief Executive Officer
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
1
2
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
16
5
4
1
1
1
8
3
1
3
1
7
2
1
1
3
5
Anxiety Management of
anxiety (panic
disorder, with
or without
agoraphobia, and
generalised anxiety
disorder) in
adults in primary,
secondary and
community care
5
1
2
1
1
Guideline for the
evaluation and
treatment of
injured workers
with psychiatric
conditions.
6
10
2
1
3
4
VA/DoD
clinical practice
guideline for the
management of
post-traumatic
stress
7
Rating criteria
CPG 1 and CPG 3 have the highest rating score. This is due to their higher scores in all four of the categories. Both CPG 5 and CPG 6 rate less than CPG1 and CPG 3 on the
Psychological factors, but are high in at least two of the other categories.
5
1
To what degree does the
guideline consider Risk Factors
for Recovery?
Total Score
4
4
1
1
1
Anxiety disorders
3
Stress related
conditions and
other mental
disorders
2
Post-traumatic
stress disorder.
The management
of PTSD in adults
and children
in primary and
secondary care
Practice guideline
for the treatment
of acute stress
disorders and post
traumatic stress
disorder.
To what degree does the
guideline consider the Return
to Work Process (vocational
rehabilitation)?
Risk Factors for Recovery
To what degree does
the guideline consider
psychosocial factors that may
influence recovery?
Return to Work Process
(vocational rehabilitation)
Does the guideline consider
graded increases in activity
and function?
Psychosocial Factors
Functional Restoration
4
3
2
1
Each item is rated on a 5-point scale ranging from 5 “Strongly Agree” to 1 “Strongly Disagree”. The scale measures the extent to which a criterion (item) has been fulfilled.
Relevance to the workers compensation sector
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
3
Scope and
Purpose
Stakeholder
Involvement
Rigour of
Development
Clarity and
Presentation
Applicability
Editorial
Independence
56%
29%
47%
63%
11%
17%
46%
36%
46%
0%
17%
Stress related
conditions and
other mental
disorders
2
72%
Anxiety disorders
1
4
67%
0%
50%
57%
42%
67%
8%
67%
2%
0%
79%
2%
Post-traumatic
Practice guideline
stress disorder.
for the treatment
The management
of acute stress
of PTSD in adults
disorders and post
and children
traumatic stress
in primary and
disorder.
secondary care
3
42%
44%
83%
48%
79%
72%
5
Anxiety Management of
anxiety (panic
disorder, with
or without
agoraphobia,
and generalised
anxiety disorder)
in adults
in primary,
secondary and
community care
25%
0%
36%
24%
36%
61%
Guideline for the
evaluation and
treatment of
injured workers
with psychiatric
conditions.
6
17%
11%
92%
60%
46%
67%
VA/DoD
clinical practice
guideline for the
management of
post-traumatic
stress
7
Each item is rated on a 5-point scale ranging from 5 “Strongly Agree” to 1 “Strongly Disagree”. The scale measures the extent to which a criterion (item) has been fulfilled.
The aggregate scores are then converted into a percentage scale ranging from 100%” Strongly Agree” to 1% “Strongly Disagree”.
Agree appraisal
Register of clinical practice guidelines for
psychiatric conditions
CPG
1
Name
Anxiety disorders
Source
National Guideline
Clearinghouse
www.guideline.gov
2
3
4
5
6
7
4
Stress related
conditions and other
mental disorders
National Guideline
Clearinghouse
Practice guideline for
the treatment of acute
stress disorders and
post traumatic stress
disorder.
Post-traumatic
stress disorder. The
management of PTSD
in adults and children in
primary and secondary
care
Anxiety - Management
of anxiety (panic
disorder, with or
without agoraphobia,
and generalised anxiety
disorder) in adults in
primary, secondary and
community care
Guideline for the
evaluation and
treatment of injured
workers with
psychiatric conditions.
National Guideline
Clearinghouse
VA/DoD clinical
practice guideline for
the management of
post-traumatic stress
www.guideline.gov
Developed by
Singapore Ministry of Health, National Medical Research
Council. Anxiety disorders. Singapore: Singapore Ministry
of Health;2003 Nov.69 p. [74 references]
Work Loss Data Institute. Stress related conditions and
other mental disorders. Corpus Christi (TX): Work Loss
Data Institute; 2006.91 p. [128 references]
American Psychiatric Association. Practice guideline for
the treatment of patients with acute stress disorder and
post traumatic stress disorder. Arlington (VA); American
www.guideline.gov Psychiatric Association :2004 Nov.57 p. [463 references]
National Guideline
Clearinghouse
National Collaborating Centre for Mental Health. Posttraumatic stress disorder: the management of PTSD
in adults and children in primary and secondary care.
www.guideline.gov London (UK): National Institute for Clinical Excellence
(NICE);2005.167 p. [69 references]
National Guideline
Clearinghouse
National Collaborating Centre for Primary Care - National
Institute for Clinical Excellence London 2004
www.guideline.gov
National Guideline
Clearinghouse
Washington State Department of Labor and Industries.
Guideline for the evaluation and treatment of injured
workers with psychiatric conditions. Olympia (WA) :
www.guideline.gov Washington State Department of Labor and Industries;
National Guideline 2004 .6 p.
Clearinghouse
www.guideline.gov
National Guideline Veterans Health Administration, Department of Defence.
Clearinghouse
VA/DoD clinical practice guideline for the management
of post-traumatic stress. Version 1.0. Washington
www.guideline.gov (DC): Veterans Health Administration , Department of
Defense;2004 Jan. Various p. [479 references]
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Anxiety disorders
Contents
1.
2.
3.
4.
5.
6.
7.
Developed by ...................................................................................................................................................................................... 6
Guideline status .................................................................................................................................................................................. 6
Where located/how accessed ........................................................................................................................................................ 6
Description/scope ............................................................................................................................................................................. 6
Outcomes considered ....................................................................................................................................................................... 8
Agree appraisal.................................................................................................................................................................................... 8
Relevance/appropriateness of use in workers’ compensation sector .................................................................................. 8
a) Functional progression ............................................................................................................................................................... 8
b) Physical/psychiatric rehabilitation ........................................................................................................................................ 12
c) Risk factor/recovery ................................................................................................................................................................ 13
d) Return to work........................................................................................................................................................................... 14
8. Priority for Q-COMP ...................................................................................................................................................................... 14
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
5
1. Developed by
Singapore Ministry of Health, National Medical Research Council. Anxiety disorders. Singapore: Singapore Ministry
of Health; 2003 Nov.69 p. [74 references]
2. Guideline status
This is the current release of the guideline.
3. Where located/how accessed
National Guideline Clearinghouse www.guideline.gov
Electronic copies; Available in Portable Document Format (PDF) from the Singapore Ministry of Health Web Site
Print copies; Available from the Singapore Ministry of Health, College of Medicine Building, Mezzanine Floor
16 College Rd, Singapore 169854
4. Description/scope
Disease/condition(s)
• Anxiety disorders
• Panic disorder
• Agoraphobia
• Specific phobias
• Social anxiety disorder (SAD, social phobias)
• Generalized anxiety disorder
• Obsessive-compulsive disorder
• Post-traumatic stress disorder
Guideline category
• Counselling
• Diagnosis
• Evaluation
• Management
• Treatment
Clinical speciality
• Family Practice
• Psychiatry
• Psychology
Intended users
• Allied Health Personnel
• Physicians
• Psychologists/ Non-physician Behavioural Health Clinicians
• Social Workers
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Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Guideline objectives
1. To provide optimal care and good outcomes to patients with anxiety disorders
2. To assist primary health care physicians in clinical decision-making when assessing and treating patients
with anxiety
3. To help medical practitioners recognise the presence of anxiety disorders in patients and to assess and manage
them appropriately
4. To provide evidence-based recommendations on appropriate psychological and pharmacological therapy
for anxiety.
Target population
Adults and children with anxiety disorders in Singapore
Interventions and practices considered
Diagnosis and assessment
1. Evaluation of symptoms: psychotic symptoms , severity/ complexity of symptoms, and severity of
functional impairment
2. Evaluation and mobilization of family and social resources
3. Assessment for suicide risk
4. Assessment for coexisting mental health disorders such as depression and drug/alcohol problems
5. Patient response to treatment: monitoring for remission and relapse.
Treatment: Non-pharmacotherapy
1. Supportive counselling and monitoring: reassuring patient; educating patient, including providing information on
treatment options
2. Lifestyle changes: stress reduction strategies; reducing alcohol and caffeine ; avoiding nicotine and drug use;
regular exercise
3. Group therapy
4. Referral to psychiatrist or other behavioural treatment specialist
5. Psychotherapy
• Cognitive behaviour therapy (CBT), including psychoeducation; exposure to symptoms or situations;
cognitive restructuring; breathing retraining; continuous panic monitoring.
• Other psychotherapies
Treatment: Pharmacotherapy
1. Antidepressants
• Selective serotonin reuptake inhibitors (SSRIs )as first-line drug treatment, including citalopram, fluoxetine,
fluvoxamine, sertraline, and paroxetine
• Tricyclic antidepressants including imipramine and clomipramine
• Monoamine oxidase inhibitor (MAOIs) such as phenelazine and tranylcypromine
• Selective reversible inhibitor of MAO type A (RIMA) (moclobemide)
2. Benzodiazepines: alprazolam, bromazepam, clonazepam, diazepam, lorazepam
3. Beta-blockers, such as propanolol and atenolol
4. Venlafaxine, a serotonin norepinephrine reuptake inhibitor (SNRI)
5. Serotonin antagonist and reuptake inhibitor (nefazadone) and noradrenergic and serotonin antagonist
(mirtazapine)
6. Antihistamine (hydroxyzine)
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
7
5. Outcomes considered
•
•
•
•
•
Symptoms of anxiety disorders
Morbidity and overall functioning
Effectiveness of counselling and behavioural therapies
Effectiveness of safety of medications
Side effects, adverse reactions, and potential interactions of medications
6. Agree appraisal
•
•
•
•
•
•
Scope and Purpose
Stakeholder Involvement
Rigour of Development
Clarity and Presentation
Applicability
Editorial Independence
72%
46%
36%
46%
0%
17%
7. Relevance/appropriateness of use in workers’ compensation sector
a) Functional progression
No specific functional progression stated
Two clinical algorithms are provided in the original guideline document for:
• Diagnosing Anxiety Disorders
• Treatment of Anxiety Disorders
Major recommendations
The recommendations that follow are those from the guideline´s executive summary; detailed recommendations
can be found in the original guideline document.
Treatment settings for anxiety disorders
Helpful immediate steps that can be instituted at the primary care level include (“Practice guideline for the
treatment of patients with panic disorder,” 1998):
• Evaluating particular symptoms and performing a diagnostic evaluation, in order to arrive at a provisional
diagnosis of an anxiety disorder
• Evaluating the type and severity of functional impairment
• Establishing and maintaining a therapeutic alliance with the patient based upon empathy and understanding
• Educating the patient about the nature and origin of their anxiety symptoms and appropriate reassurance
(e.g., that they are not having a “heart attack” or are “going crazy”)
• Evaluation and mobilization of family and social resources to aid the patient
• Suggestion of lifestyle changes as appropriate
• Stress reduction strategies
• Reducing alcohol and caffeine
• Avoiding nicotine and drug use
• Regular exercise
• Supportive counseling
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Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
• Symptomatic relief with medication prescribed on a short-term basis
• Monitoring over time and addressing early signs of relapse.
Psychiatric evaluation and treatment is appropriate when
•
•
•
•
•
There is serious risk of suicide
There are psychotic symptoms
Cooccurring drug/alcohol problems exist
Symptoms are severe/complex
If symptoms fail to improve on initial treatment and follow-up
Psychosocial interventions for anxiety disorders
Psychological therapy should be routinely considered as a treatment option when assessing mental health problems,
including anxiety disorder. Patients should be informed about all available forms of treatment, including psychological
therapies, and their preference for the type of treatment should be taken into account when considering the overall
treatment plan (“Practice guideline for the treatment of patients with panic disorder,” 1998).
Medications for anxiety disorders
Pharmacological treatment is indicated when:
• Symptoms are severe
• There is significant impairment of social, occupational and role functioning
• There is concurrent moderate or severe depressive disorder (“Practice guideline for the treatment of patients
with panic disorder,” 1998).
Antidepressants
Antidepressants are recommended as effective agents for the treatment of panic disorders, social phobia,
obsessive compulsive disorders, generalized anxiety disorder, and post-traumatic stress disorder.
Selective serotonin reuptake inhibitors (SSRIs) are recommended as first-line drug treatment for anxiety disorder.
Benzodiazepines
The lowest effective dose to achieve symptom relief should be used over a limited period. The dose should
be gradually tapered off. Long-term use should be closely supervised for adverse effects, abuse, tolerance,
dependency, and withdrawal symptoms (“Guidelines for prescribing benzodiazepines,” 2002; “College Guidelines
for use of benzodiazepines,” 1999; “Benzodiazepines: risks, benefits or dependence,” 1997).
Treatments for different types of anxiety disorders
Panic Disorder
For panic disorder, high potency agents like alprazolam and clonazepam are effective in providing rapid relief. With
discontinuation of these agents, however, patients should be closely monitored for recurrence of symptoms, as the
rates of relapse are very high, especially for shorter-acting agents (Noyes et al., 1991).
Almost all the SSRIs (fluoxetine, sertraline, fluvoxamine, citalopram, paroxetine) have documented efficacy in the
treatment of panic disorder (Otto et al, 2001).
Imipramine is effective in the treatment of panic disorder. An optimal effective dose for treatment is 100 to 225 mg
and should be continued for 8 to 12 weeks (“Drug treatment of panic disorder,” 1992; Mavissakalian & Perel, 1989).
Clomipramine is effective for panic disorder at a dose of 50 to 100 mg for a duration of 6 to 12 weeks (Cassano et
al., 1988).
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
9
Cognitive behaviour therapy (CBT) is the psychotherapy of choice for panic disorder. Possible treatment
components for panic disorder, with or without agoraphobia, are (“Practice guideline for the treatment of patients
with panic disorder,” 1998; Clum, Clum, & Surls, 1993; Clark et al, 1994; Trull, Nietze, & Main, 1988):
•
•
•
•
•
Psychoeducation
Exposure to symptoms or situations
Cognitive restructuring
Breathing retraining
Continuous panic monitoring
Specific Phobias
Phobic symptoms respond best to exposure therapy to the feared situation or object (Dupont, 1982;
Park et al., 2001).
Beta-blockers are effective for specific and circumscribed performance anxiety, especially for patients with
prominent sympathetic hyperarousal such as palpitations and tremor. Propranolol 10 to 40 mg taken 45 to 60
minutes before the performance is sufficient for most patients (Tyrer, 1988).
Social Anxiety Disorder (Social Phobia)
Cognitive behaviour therapy (CBT) is recommended as effective treatment for social anxiety disorder. Exposure
to feared situations is a crucial component. Group approaches are useful and often include elements of social skills
training. SSRI antidepressants are effective for the treatment of social phobia, and their favourable side-effect
profile make them recommended first-line treatment for social phobia. Paroxetine has been the most extensively
studied SSRI for social phobia (Leibowitz et al., “A randomized, double-blind, fixed dose comparison of paroxetine,”
2002).
There is limited support for the use of moclobemide for social anxiety disorder (SAD) (Stein et al., 2002).
Generalised Anxiety Disorder
Cognitive behaviour therapy in generalised anxiety disorder delivered by experienced therapists shows good
evidence of efficacy. Two-thirds of patients show clinically significant improvement at 6 months follow-up
(Durham et al, 2003; Borkovec & Costello, 1993).
Imipramine for 3 to 6 months is recommended for treating generalized anxiety disorder (GAD) (Rickels et al, 2000).
Paroxetine has shown efficacy compared to placebo for GAD treatment (Stocchi et al., 2003).
Venlafaxine, a serotonin norepinephrine reuptake inhibitor (SNRI) has been shown to be effective in GAD
(Gelenberg et al., 2000).
Serotonin antagonist and reuptake inhibitors such as nefazodone and the noradrenergic and serotonin selective
antagonist mirtazapine may have useful anxiolytic effects in GAD (Goodnick et al., 1999; Hedges et al., 1996).
Antidepressants can be considered as first-line agents over benzodiazepines in the treatment of GAD over the long
term (Kapczinski et al., 2003).
Hydroxyzine 50 mg/day has shown efficacy for treatment of GAD.
Obsessive Compulsive Disorder
The recommended first line of pharmacotherapy for obsessive compulsive disorder (OCD) is a 10 to 12 week trial
with an SSRI at adequate doses. Fluvoxamine, fluoxetine, citalopram, sertraline, and paroxetine, have all been shown
to be effective in adults with OCD (Greist et al., 1995).
The efficacy of fluvoxamine, fluoxetine, and sertraline in OCD has also been confirmed in children (Cook et al.,
2001; Liebowitz et al., “Fluoxetine in children and adolescents,” 2002).
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Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Clomipramine is effective treatment for OCD in the dose range of between 100 to 300 mg/day for a period of 5
to 12 weeks (McDonough & Kennedy, 2002; Mundo, Maina, & Uslenghi, 2000).
It has been suggested that an adequate treatment trial in OCD would be for at least 10 to 12 weeks, with a
minimum mean daily dosage of one of the following agents:
•
•
•
•
•
Clomipramine 150 mg
Fluvoxamine 150 mg
Fluoxetine 40 mg
Sertraline 150 mg
Paroxetine 40 mg
Behaviour therapy using Exposure-Response Prevention (ERP) is the treatment of choice for limiting the
dysfunction resulting from obsessions and/or compulsions (Van Balkom et al., 1994; O´Sullivan et al., 1991).
Post-Traumatic Stress Disorder (PTSD)
SSRIs are generally the most appropriate medication of choice for PTSD, and effective therapy should be continued
for 12 months or longer. Paroxetine, sertraline, and fluoxetine all have well documented evidence of efficacy
(Ballenger et al., 2000).
It is not recommended, however, that treatment of PTSD, including medication treatment, be instituted and
continued only at the primary care setting, over a long term (Khouzam & Donnelly, 2001). Studies of cognitive
behaviour therapy (CBT) have shown the most effective results in the treatment of PTSD. The most appropriate
psychotherapy is exposure therapy, and it should be continued for 6 months, with follow-up therapy as needed.
Support groups may be beneficial (Ballenger et al., 2000; Davidson & Parker, 2001).
Choosing and combining medication and psychosocial interventions
Choosing between medications or psychosocial interventions with or without medications should take into account
comparable efficacies, differences in risks/benefits, differences in costs, the availability/accessibility of trained
therapists and patient preferences (“Practice guideline for the treatment of patients with panic disorder,” 1998).
There is evidence that, in the short-term, combined cognitive behaviour therapy with medication does confer
additional benefits of faster onset of symptom relief and lasting remission for panic disorder (Lader & Bond, 1998).
For panic disorder, recent evidence supports the use of combined cognitive behaviour therapy with medication as
superior to either therapy alone in the longer term maintenance phase (Barlow et al., 2000).
Anxiety and coexisting conditions
Depression, when coexisting with anxiety, should be treated aggressively (Rapaport, 2001; Essau, Conradt, &
Petermann, 2002).
Antidepressants have good antianxiety properties and should be the medication of choice in comorbid depression
and anxiety. Some SSRIs and venlafaxine have demonstrated efficacy for treatment of comorbid depression and
anxiety (Ballenger, 1999; Silverstone & Salinas, 2001).
Alcohol/substance abuse should be concurrently treated with the anxiety disorder (Tomasson & Vaglum, 1996;
LaBounty et al., 1992; Tollefson, Montague- Clouse, & Tollefson, 1992).
Benzodiazepines prescribed for anxiety may be abused by some patients with comorbid alcohol/substance abuse/
dependence and are best avoided where possible (Posternak & Mueller, 2001).
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
11
Long-term treatment
Long-term maintenance treatment of anxiety disorder is recommended following the amelioration of acute
symptoms, as it strongly predicts continued remission following discontinuation of medications (Rickels &
Schweizer, 1998).
Relapse is common after discontinuation of medication for most anxiety disorders. Maintenance therapy may be
indicated for individuals who frequently relapse (Mavissakalian & Perel, 2001).
Medication should be continued in OCD treatment for most patients for at least 1 year. The relapse rate with
abrupt discontinuation of medication is high, as much as 90% in some studies. A gradual taper of medication over a
longer period (e.g. 6 months) is recommended (Ravizza et al., 1996).
After improvement with medication, antidepressant treatment for panic disorders and social phobias should be
continued for at least 6 months (Michelson et al., 1999; Walker et al., 2000).
Similarly for psychological treatments, there is evidence that continuation of therapy sessions during long term
follow-up can further lead to improvement and reduce relapse (Ost, 1989).
Abrupt discontinuation of benzodiazepines should be avoided. Medication should be tapered off gradually over a
number of weeks, titrating against symptoms to avoid withdrawal syndrome and symptom rebound (Pecknold et
al., 1988).
Longer-acting benzodiazepines are less likely to cause withdrawal and may be used during the tapering period to
ameliorate symptoms (Noyes et al, 1991).
Gradual tapering of dosage of medication is recommended in discontinuing benzodiazepines after long-term
treatment of anxiety disorder (Voshaar et al., 2003).
Cognitive behaviour therapy may facilitate the tapering of benzodiazepines (Otto et al., 1993).
Discontinuation of antidepressants poses less of a problem in terms of withdrawal symptoms, although changes in
mood, affect, appetite, and sleep may occur with SSRI discontinuation, more so with a shorter acting SSRI, such as
paroxetine (Lejoyeux & Ades, 1997).
Clinical algorithm(s)
Two clinical algorithms are provided in the original guideline document for:
1. Diagnosing Anxiety Disorders
2. Treatment of Anxiety Disorders
b) Physical/psychiatric rehabilitation
As above.
12
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
c) Risk factor/recovery
Potential harms
Potential side effects and adverse reactions of psychotherapeutic.
Medications
Benzodiazepines
• Dependence, tolerance, and withdrawal symptoms can occur, especially in patients with history of drug dependence.
• Central nervous system effects (e.g., sedation, drowsiness, muscle weakness, ataxia. Less commonly, slurred
speech, vertigo, headache, confusion). In elderly, risk of confusion and falls. Symptoms decrease after
continued use.
• Paradoxical excitement can occur.
Selective serotonin reuptake inhibitors (SSRIs)
• Sexual side effect; cost may be higher compared with other medication classes.
Special Instructions: Initial feeling of increased anxiety may occur with SSRIs. Therefore initial dose should be
lower than normally prescribed for depression and increased slowly. If discontinued after long-term use, taper
dose over several weeks. Use with caution in patients with hepatic or renal dysfunction and in patients with
seizure disorders.
• Citalopram: Dry mouth, nausea, insomnia, sexual dysfunction, sweating, tremor, diarrhea, somnolence,
and dyspepsia.
• Fluoxetine: Dose related reactions: nervousness and anxiety, insomnia. Other reactions are headache, nausea,
diarrhea, anorexia, blurred vision, sexual dysfunction, drowsiness, sleep disturbance, abnormal dreams, and mania.
• Fluvoxamine: Headache, somnolence, insomnia, dizziness, nervousness, nausea, diarrhea, muscle weakness,
palpitations, yawning, sexual dysfunction, and tremors.
• Paroxetine: Dose related reactions: Somnolence, asthenia, dizziness, tremor, and nausea. Other reactions are
headache, insomnia, nervousness, anxiety, dry mouth, constipation, diarrhea, sexual dysfunction, oropharyngeal
disorders, and myopathy.
• Sertraline: Headache, somnolence, drowsiness, fatigue, dizziness, insomnia, tremor, anxiety, paresthesia,
agitation, sexual dysfunction, nausea, dry mouth, diarrhea, constipation, and abnormal vision.
Serotonin and Norepinephrine Reuptake Inhibitor (SNRI)
• Venlafaxine: Dose related reactions: vasodilation and hypertension. Other reactions are headache, somnolence,
dizziness, insomnia, nervousness, nausea, anorexia, constipation, diarrhea, sexual dysfunction, anxiety, abnormal
dream, yawning, tremor, and blurred vision.
• Special Instructions: If discontinued after long-term use, taper dose over several weeks. Use with caution in
renal and hepatic impairment.
Tricyclic Antidepressants (TCAs)
• Clomipramine and imipramine: Side effects are mostly due to antimuscarinic actions and may be decreased if
started at low dose and increased gradually. Dry mouth, constipation (may lead to paralytic ileus), blurred vision,
increased intraocular pressure, urinary retention, hyperthermia, drowsiness can occur, nervousness, insomnia,
headache, peripheral neuropathy, ataxia, tremor, confusion/delirium can occur especially in older patients,
nausea/vomiting, gastric irritation, hypotension, tachycardia, sweating, and weight gain. Risk of cardiovascular
and anticholinergic side effects are greater for the elderly or patients with general medical problems. TCAs are
suboptimal for suicidal patients because an overdose may be fatal.
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
13
• Special Instructions: do not stop medication abruptly; taper dose over several weeks. Use with caution in
patients with urinary retention, prostatic hyperplasia, chronicconstipation, untreated angle-closure glaucoma,
cardiovascular disease, history of epilepsy, diabetes mellitus, and impaired hepatic function. Elderly patients may
be sensitive to side effects; lower dose should be used.
Antihistamine
• Hydroxyzine: Drowsiness, sedation, dizziness, and lassitude which may diminish over time. Headache,
psychomotor impairment, muscarinic side effects, (e.g., dry mouth, blurred vision, urinary retention,
constipation, gastroesophageal reflux disease), nausea/vomiting, sweating, and myalgia.
Beta Blockers
• Atenolol and propranolol: Adverse reactions are not usually significant when only taken on an “as needed” basis.
Cardiovascular effects (e.g., bradycardia, hypotension. In patient´s with preexisting cardiovascular disorders:
heart block, heart failure), bronchospasm, fatigue, depression, dizziness, and sleep disturbances. May interfere
with carbohydrate and lipid metabolism and cause a rash.
• Special Instructions: use with caution in patients with asthma, chronic obstructive pulmonary disease, and
diabetes mellitus.
d) Return to work
Not discussed
8. Priority for Q-COMP
Rating criteria
14
Functional restoration
Does the guideline consider graded increases in activity and function?
2
Psychosocial factors
To what degree does the guideline consider psychosocial factors that may influence
recovery?
1
Return to work process (vocational rehabilitation)
To what degree does the guideline consider the Return to Work Process (vocational
rehabilitation)?
1
Risk factors for recovery
To what degree does the guideline consider Risk Factors for Recovery?
1
Total rating
5
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Stress related conditions and other mental
disorder
Contents
1.
2.
3.
4.
5.
6.
7.
Developed by ................................................................................................................................................................................... 16
Guideline status ............................................................................................................................................................................... 16
Where located/how accessed ..................................................................................................................................................... 16
Description/scope .......................................................................................................................................................................... 16
Outcomes considered .................................................................................................................................................................... 18
Agree appraisal................................................................................................................................................................................. 18
Relevance/appropriateness of use in workers’ compensation sector ............................................................................... 19
a) Functional progression ............................................................................................................................................................ 19
b) Physical/psychiatric rehabilitation ........................................................................................................................................ 20
c) Risk factor/recovery ................................................................................................................................................................ 20
d) Return to work........................................................................................................................................................................... 20
8. Priority for Q-COMP ...................................................................................................................................................................... 24
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
15
1. Developed by
Work Loss Data Institute. Stress related conditions and other mental disorders. Corpus Christi (TX): Work Loss Data
Institute; 2006.91 p. [128 references]
2. Guideline status
This is the current release of the guideline.
This guideline updates a previous version: Work Loss Data Institute. Stress related conditions and other mental
disorders. Corpus Christi (TX): Work Loss Data Institute; 2005.104 p.
3. Where located/how accessed
National Guideline Clearinghouse www.guideline.gov
Electronic copies; Available to subscribers from the Work Loss Data Institute web site
Print copies; Available from the Work Loss Data Institute ,169 Saxony Road, Suite 210 Encinitas, CA 92024;
Phone 800-488-5548, 760-753-9993, Fax: 760-753-9995; www.worklosdata.com.
The following companion documents are available:
• Background information on the development of the Official Disability Guidelines of the Work Loss Data Institute
is available from the Work Loss Data Institute Web site.
• Appendix A. ODG Treatment in Workers’ Comp. Methodology description using the AGREE instrument. Available
to subscribers from the Work Loss Data Institute Web site
The following patient resources are available:
• Appendix B. ODG Treatment in Workers’ Comp. Patient information resources. 2006.
Electronic copies: Available to subscribers from the Work Loss Data Institute Web site.
Print copies: Available from the Work Loss Data Institute, 169 Saxony Road, Suite 210, Encinitas, CA 92024;
Phone: 800-488-5548, 760-753-9992, Fax: 760-753-9995; www.worklossdata.com
4. Description/scope
Disease/condition(s)
• Work-related stress and other mental disorders
Guideline category
• Counseling
• Diagnosis
• Evaluation
• Management
• Treatment
16
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Clinical speciality
• Family Practice
• Internal Medicine
• Psychiatry
• Psychology
Intended users
• Advanced Practice Nurses
• Health Care Providers
• Health Plans
• Nurses
• Physician Assistants
• Physicians
• Psychologists/ Non-physician Behavioural Health Clinicians
Guideline objectives
To offer evidence-based step-by-step decision protocols for the assessment and treatment of workers’
compensation conditions.
Target population
Workers with occupational stress and other mental disorders.
Interventions and practices considered
The following interventions were considered and recommended as indicated in the original guideline document:
3.
4.
5.
6.
Acceptance and commitment therapy (ACT)
Activity restrictions/Work modifications
Acupressure
Antidepressants (the choice of first-line therapy between selective serotonin reuptake inhibitors [SSRIs] and
tricyclic antidepressants [TCA] is currently under study)
7. Aromatherapy
8. Cognitive therapy
9. Cognitive behavioural stress management
10. Depression screening
11. Disease management programs
12. Distractive methods
13. Duloxetine (Cymbalta ®)
14. Electroconvulsive therapy
15. Exercise
16. Kava extract
17. Light therapy
18. Massage therapy
19. Mind/body interventions
20. Music
21. Patient education
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
17
22. Peer support
23. Psychological evaluation
24. Psychosocial empowerment programs
25. Return to work
26. St john’s wort
27. Stress inoculation training
28. Stress management , behavioural/cognitive interventions
29. Stress management, physical interventions (aerobic exercise)
30. Therapist optimism
31. Vitamin use (multi-vitamin and mineral supplements)
32. Yoga
The following interventions/procedures are under study and are not specifically recommended:
1. Acupuncture
2. Brain wave synchronizers for stress reduction
3. Computer-assisted cognitive therapy
4. Expatriate employee adjustment
5. fatigue (as precursor to stress)
6. Folate
7. Hypnosis
8. Innovative promotion program
9. Opioid antagonist (naltrexone)
10. Pharmaceuticals versus behavioural therapy for tension headaches
11. Psychosocial and pharmacological treatment (for deliberate self harm)
12. SAMe (S-adenosylmethionine)
13. Technological stress
The following interventions/procedures were considerd, but are not recommended:
1. Psychological debriefing (for preventing post-traumatic stress disorder)
2. Vitamin B6
5. Outcomes considered
Effectiveness of treatments in reducing stress and anxiety.
6. Agree appraisal
•
•
•
•
•
•
18
Scope and Purpose
Stakeholder Involvement
Rigour of Development
Clarity and Presentation
Applicability
Editorial Independence
56%
29%
47%
63%
11%
17%
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
7. Relevance/appropriateness of use in workers’ compensation sector
a) Functional progression
Major recommendations
Initial diagnosis
Stress is the most common mental condition treated by occupational or primary care physicians and will be the
focus of this guideline. References to additional mental disorders are found in the procedure summary in the
original guideline document, although the more severe of those usually require referral to a specialist. Stress is not
its own diagnosis but rather a combination of non-specific emotional or physical symptoms varying in intensity
and duration, which may or may not be related to a specific incident. The stress might also be associated with a
particular disease or syndrome, but that is not always the case.
A stressor is defined as anything that exerts a physical, emotional, or mental demand on an individual. Stress often
occurs when the individual has anxiety because of a mismatch between perceived demands and resources, whether
work-related or personal. The source of stress can be acute (such as an employee relocation) or chronic (such as
consistently poor relations with a supervisor).
For some people, stress causes or contributes to a deterioration of physical health, resulting in more headaches
or more common colds. While the scientific literature is not clear on this topic, stress may also contribute to the
worsening of more serious conditions such as heart disease, irritable bowel disease, or ulcers, depending on the
individual’s coping methods. On the other hand, the presence of certain physical conditions could be the cause
of stress.
Initial evaluation
Focus on identifying possible red flags or warning signs for potentially serious psychopathology that would require
immediate specialty referral. Red flags may include impairment of mental functions, overwhelming symptoms,
signs of substance abuse, or debilitating depression. In the absence of red flags, the occupational or primary care
physician can handle most common stress-related conditions safely.
In talking to the patient, it is important for the physician to get him or her to try and explain or pinpoint incidents
or reasons for the stress, rather than to just generalize (i.e., “I hate my job,” “Everything makes me stressed out”).
The physician may have to ask more specific questions about work or home life if the patient is initially unwilling or
unable to address specific issues.
Occupational stress usually stems from one of three common models:
1. Person-environment fit model: Poor job fit, such as a mismatch between the skills of the individual and the
demands of the job, or a disparity between the individual’s career-related desires versus actual opportunities
presented, is a leading cause of workplace stress.
2. Demand control model: Jobs that place high demands on the worker but give him or her little control or
opportunities for decision-making lead to high job strain, a source of stress that is consistently linked as
a contributor to physical conditions such as cardiovascular mortality, heart disease, and hypertension.
Consideration should be given to the influence of the individual’s occupational and personal history, which may
have an effect on how this model applies to his or her situation.
3. Effort-reward model: Shows that stress is often the result of high effort without social reward. Like the demand
control model, this model points out that a low ratio of effort to reward leads to sustained autonomic arousal
and can cause physical effects such as high blood pressure or myocardial infraction.
Exploration of how and if the patient’s stress follows the path of one of the above models will be helpful in
determining treatment.
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
19
More specific sources of stress include bereavement, illness, familial changes or disorder, or other common and/or
traumatic life changes. Time off work may be helpful, although the ultimate goal should be to preserve the patient’s
ability to function both occupationally and socially. Time off should not be so excessive that the employee loses his
or her sense of function and appreciation at work and at home.
Initial therapy
1. Pursuing the patient’s thoughts on how his or her stress relates to the above models may help determine
the source of stress and cultivate ideas on how to eliminate or cope with the stress. Patient education and
understanding about stress is necessary for effective stress management to take place. Other common
treatment pathways include the use of one or more of the following:
a. Relaxation techniques (such as meditation)
b. Exercise (aerobic exercise has been shown to positively influence mood)
c. Behavioral training (such as time management, anger management, assertiveness, or conflict
resolution training)
d. Stress inoculation therapy
e. Cognitive therapy
f. Modified work
g. Organizational interventions
2. Pharmaceutical therapy (limited, short-term use of anti-anxiety agents to improve function – anything else
should be used in conjunction with a specialty referral)
Follow-up visits are an important part of treatment and should be conducted by a mid-level practitioner in
person or via phone every three or four days, depending on the severity of the case, while a path to recognizable
treatment is established and followed. Failure to improve or make significant progress after several months may
indicate the need for psychiatric assessment or counseling.
b) Physical/psychiatric rehabilitation
As above.
c) Risk factor/recovery
Potential harms
• Despite the relative low prevalence of side effects associated with selective serotonin reuptake inhibitors
(SSRIs) a significant minority of older people find these drugs intolerable and experience nausea, vomiting,
dizziness and drowsiness.
• Hypomania as a potential adverse effect of light therapy needs to be considered.
d) Return to work
Official Disability Guidelines (ODG) Return-To-Work Pathways
Senile and presenile organic psychotic conditions (see original guideline document for International
Classification of Diseases, Ninth Revision [ICD-9] codes for this and other diagnoses) Not severe, medical
treatment: 0 days Severe, specially designed, limited modified work: 7 days Severe, regular work: indefinite
Senile dementia with delusional or depressive features
Severe, specially designed, limited modified work: 7 days
Severe, affecting fellow worker productivity & safety: indefinite
Severe, regular work: indefinite
20
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Alcohol withdrawal delirium
Without hospitalization: 1-7 days
Including rehab, substance abuse professional (SAP) evaluation: 28 days
Including rehab, SAP evaluation, job safety issues: 42 days
Drug withdrawal syndrome
Without hospitalization: 0-5 days
With hospitalization, without suicidal ideation: 7 days
With hospitalization, with suicidal ideation: 21 days
Paranoid and/or hallucinatory states induced by drugs
Without hospitalization: 1-3 days
With hospitalization, without threat of harm: 7 days
With hospitalization, with threat of harm: 21 days
Transient organic psychotic conditions
14 days
Paranoid type
Without hospitalization, no job safety issues: 0-7 days
With hospitalization: 42 days or by report
Unspecified schizophrenia
Without hospitalization, no job safety issues: 0-7 days
With hospitalization: 16-42 days
Major depressive disorder, single episode
Rule out impaired mood/personality disorder: 0 days
Outpatient therapy, without symptoms affecting work: 0-7 days
Outpatient therapy, with symptoms interfering with work: 21-42 days
With hospitalization, non-cognitive/modified work: 21 days
With hospitalization, cognitive work: 42 days
Major depressive disorder, recurrent episode
Outpatient therapy, without symptoms affecting work: 0-7 days
Outpatient therapy, with symptoms interfering with work: 14-28 days
With hospitalization, non-cognitive/modified work: 21 days
With hospitalization, cognitive work: 42 days
Bipolar affective disorder, depressed
Rule out impaired mood/personality disorder: 0 days
Without hospitalization: 0-21 days
With hospitalization: 21-42 days
Bipolar affective disorder, mixed
Without hospitalization: 0-14 days
With hospitalization: 21-42 days
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
21
Paranoia
Without hospitalization: 0-14 days
With hospitalization: 14-21 days
Depressive type psychosis
Without hospitalization: 0-56 days
With hospitalization: 21-64 days
Anxiety states
Rule out impaired mood/personality disorder: 0 days
Without hospitalization: 0-7 days
With hospitalization: 14-21 days
Panic disorder
1-14 days
Generalized Anxiety Disorder
14-21 days
Hysteria
Without hospitalization: 0 days
With hospitalization: 7-14 days
Obsessive-compulsive disorders
Without hospitalization: 0 days
With hospitalization: 10 days
Personality disorders
0 days
Alcohol dependence syndrome
Without hospitalization: 1 day
Without hospitalization, considering fellow worker danger & morale: 7-14 days
With hospitalization, including rehab: 14-28 days
Safety sensitive position: as determined by the substance abuse professional (SAP)
Acute alcoholic intoxication
1-2 days
Also treated as rule violation absence
Opioid type dependence
Without hospitalization: 0 days
Without hospitalization, considering fellow worker danger & morale: 7-14 days
With hospitalization, including rehab: 14-38 days (10 days post-discharge)
Safety sensitive position: as determined by the SAP
Barbiturate and similarly acting sedative or hypnotic dependence
Without hospitalization: 0 days
Without hospitalization, considering fellow worker danger & morale: 7-14 days
With hospitalization: 21 days
With hospitalization, plus rehab: 28 days
Safety sensitive position: as determined by the SAP
22
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Cocaine dependence
Without hospitalization: 0 days
Without hospitalization, considering fellow worker danger & morale: 7-14 days
With hospitalization: 28 days
Safety sensitive position: as determined by the SAP
Cannabis dependence
0-2 days
Amphetamine and other psychostimulant dependence
Without hospitalization: 0 days
Without hospitalization, considering fellow worker danger & morale: 7-14 days
With hospitalization: 14 days
With hospitalization, plus rehab: 28 days
Safety sensitive position: as determined by the SAP
Hallucinogen dependence
Without hospitalization: 0 days
Without hospitalization, considering fellow worker danger & morale: 7-14 days
With hospitalization: 10 days
With hospitalization, plus rehab: 28 days
Safety sensitive position: as determined by the SAP
Alcohol abuse
1 day
Cocaine abuse
Without hospitalization: 0-1 days
With hospitalization: 10 days
With hospitalization, plus rehab: 28 days
Amphetamine or related acting sympathomimetic abuse
Without hospitalization: 1 day
With hospitalization: 14 days
With hospitalization, plus rehab: 28 days
Acute reaction to stress
Without hospitalization (on-going counseling/drug therapy): 1 day
With hospitalization: 10 days
Unspecified acute reaction to stress, post-traumatic stress disorder
Without hospitalization (on-going counseling): 1 day
With hospitalization: 10 days
Chemical dependence comorbidity: 28 days
Adjustment Reaction
Without hospitalization: 1-6 days
Outpatient care: 1-6 days
With inpatient hospitalization: 14-28 days
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
23
Postconcussion syndrome
Mild: 1 day
Severe: by report
Depressive disorder, not elsewhere classified
Rule out impaired mood/personality disorder: 0 days
Outpatient therapy, without symptoms affecting work or other job issues: 0-7 days
Outpatient therapy, with symptoms interfering with work: 21 days
Outpatient therapy, with serious job satisfaction issues: 28-42 days
With hospitalization, non-cognitive/modified work: 28 days
With hospitalization, cognitive work: 42-56 days
Attention deficit disorder
1 day
(See ODG Capabilities & Activity Modifications for Restricted Work under “Work” in the Procedure Summary of the
original guideline document)
8. Priority for Q-COMP
Rating criteria
Functional restoration
Does the guideline consider graded increases in activity and function?
Psychosocial factors
To what degree does the guideline consider psychosocial factors that may influence recovery?
Return to work process (vocational rehabilitation)
To what degree does the guideline consider the Return to Work Process (vocational rehabilitation)?
Risk factors for recovery
To what degree does the guideline consider Risk Factors for Recovery?
Total rating
24
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
3
4
4
5
16
Practice guideline for the treatment of
acute stress disorders and post traumatic
stress disorder
Contents
1.
2.
3.
4.
5.
6.
7.
Developed by ................................................................................................................................................................................... 26
Guideline status ............................................................................................................................................................................... 26
Where located/how accessed ..................................................................................................................................................... 26
Description/scope .......................................................................................................................................................................... 26
Outcomes considered .................................................................................................................................................................... 29
Agree appraisal................................................................................................................................................................................. 29
Relevance/appropriateness of use in workers’ compensation sector ............................................................................... 30
a) Functional progression ............................................................................................................................................................ 30
b) Physical/psychiatric rehabilitation ........................................................................................................................................ 33
c) Risk factor/recovery ................................................................................................................................................................ 33
d) Return to work........................................................................................................................................................................... 33
8. Priority for Q-COMP ...................................................................................................................................................................... 34
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
25
1. Developed by
American Psychiatric Association. Practice guideline for the treatment of patients with acute stress disorder and
post traumatic stress disorder. Arlington (VA); American Psychiatric Association: 2004 Nov. 57 p. [463 references]
2. Guideline status
This is the current release of the guideline.
3. Where located/how accessed
National Guideline Clearinghouse www.guideline.gov
Electronic copies; Available in Portable Document Format (PDF) from the American Psychiatric Association’s Web
site. Print copies; Available from the American Psychiatric Press, inc (APPI), 1400 K Street NW, Washington, DC
2005; (202) 682-6262; (800) 368-5777; fax (202) 789-2648.
The following companion documents are available:
• Treating patients with acute stress disorder and post traumatic stress disorder. A Quick Reference Guide.
Washington, DC: APA, 2004. Electronic copies: Available in Portable Document Format (PDF) from the American
Psychiatric Association (APA) Web site.
• American Psychiatric Association practice guideline development process. Washington, DC: APA, 2004.
Electronic copies: Available in Portable Document Format (PDF) from the APA Web site.
Print copies: Available from the American Psychiatric Press, Inc (APPI), 1400 K Street NW, Washington, DC 20005;
(202) 682-6262; (800) 368-5777; fax (202) 789-2648.
4. Description/scope
Disease/condition(s)
• Acute stress disorder and post traumatic stress disorder
Guideline category
• Diagnosis
• Evaluation
• Management
• Treatment
Clinical speciality
• Psychiatry
Intended users
• Physicians
Guideline objectives
To assist psychiatrists in the assessment and care of adult patients with cute stress disorder (ASD) and post
traumatic stress disorder (PTSD).
26
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Target population
Adults (18 years of age and older) with suspected acute stress disorder or post traumatic stress disorder, according
to the criteria defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).
Interventions and practices considered
Assessment/ Diagnosis
1. Differential diagnosis of acute stress disorder (ASD) and post traumatic stress disorder (PTSD) according to
Diagnostic and Statistical Manual of Depression, 4th Edition (DSM-IV) criteria
2. History of traumatic experience
3. Complete psychiatric evaluation
4. Functional assessment
5. Determination and treatment of comorbid physical or psychiatric disorders (including major depressive
disorders, anxiety disorders , and substance use disorders)
6. Determination of comorbid somatisation disorder or other somatoform disorders
7. Assessment of patients at risk for suicide
8. Assessment of patients potential to harm others
Psychiatric management
1. Establishment of a therapeutic alliance with the patient
2. Patient education regarding acute stress disorder (and post traumatic stress disorder)
3. Enhancement of treatment adherence
4. Coordination of care by collaborating with other clinicians
5. Psychotherapeutic and psychoeducational interventions
6. Monitoring of patient’s treatment response
7. Monitoring for comorbid medical conditions or substance abuse disorders
8. Clinical assistance for family members who may require intervention
9. Assistance with life issues (e.g., family and social relationships, living conditions, vocational issues , and
financial support)
Pharmacotherapy
1. Selective serotonin reuptake inhibitors (SSRI’s)
• Fluoxetine
• Sertraline
• Paroxetine
• Fluvoxamine
• Citalopram
2. Tricyclic antidepressants
• Amitriptyline
• Imipramine
• Desipramine
• Phenelzine
3. Monoamine oxidase inhibitors (MAOIs)
• Phenelzine
• Brofaromine
• Moclobemide
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
27
4. Other antidepressants
• Nefazodone
• Trazodone
• Bupropion
• Venlafaxine
• Mirtazapine
5. Second-generation antipsychotic medications
• Olazapine
• Quetiapine
• Risperidone
6. Anticonvulscents
• Divalproex
• Carbamazepine
• Topiramate
• Lamotrigine
• Tiagabine*
*Note form the National Guideline Clearinghouse: On February 18, 2005, the US Food and Drug
Administration (FDA) announced that a bolded Warning will be added to the labelling for Gabitril (tiagibine)
to warn prescribers of the risk of seizures in patients without epilepsy being treated with this drug. Although
Gabitril has been shown to reduce the frequency of seizures in patients with epilepsy, paradoxically, Gabitril’s
use has been associated with the occurrence of seizures in patients without epilepsy. Gabitril is approved for
use only as adjunctive therapy in adults and children 12 years and older in the treatment of partial seizures.
Because Gabitril has not been systematically evaluated in adequate and well-controlled trials for any other
indication, its safety and effectiveness have not been established for any other use. Cephalon will undertake
an educational campaign to discourage off-label use of Gabitril. See the FDA web site for more information.
7. Other therapeutic agents
• Benzodiazepines, including alprazolam
• Valproic acid
• Cyproheptadine
• Inositil
• Alpha-adrenergic blockers, including prazosin and clonidine
• Bet-adrenergic blockers, including propanolol
• Chloral hydrate
• Lithium carbonate
Psychotherapeutic Interventions
1. Cognitive behavioural therapy
2. Patient utilization of existing support network
3. Psychological debriefing
4. Single-session therapy
5. Eye movement desensitization and reprocessing (EMDR)
6. Reactive eye dilation desensitization and reprocessing (REDDR)
7. Hypnotherapy
8. Desensitization
9. Stress inoculation
28
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
10. Imagery rehearsal
11. Prolonged exposure techniques
12. Case management
13. Group therapies including present-centred and trauma-focused group therapies
14. Optimism training
15. Goal setting and achievement
16. Biofeedback
17. Multiple channel exposure therapy
18. Assertiveness training
19. Relaxation exercises
20. Internet based therapies
21. Outward Bound group recreational therapies
5. Outcomes considered
• Reduction in severity of symptoms of acute stress disorder (ASD) and post traumatic disorder (PTSD)
symptoms
• Prevention/ reduction of trauma-related comorbid conditions
• Patient adherence to treatment plan
• Response to treatment
• Speed of recovery
• Social, occupational, adaptive, and interpersonal functioning
• Length of hospitalisation
• Quality of life
• Rate of relapse
6. Agree appraisal
•
•
•
•
•
•
Scope and Purpose
Stakeholder Involvement
Rigour of Development
Clarity and Presentation
Applicability
Editorial Independence
67%
42%
57%
50%
0%
67%
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
29
7. Relevance/appropriateness of use in workers’ compensation sector
a) Functional progression
Major recommendations
Each recommendation is identified as falling into one of three categories of endorsement, indicated by a bracketed
Roman numeral following the statement. Definitions of the categories of endorsement are provided at the end of
the “Major Recommendations” field.
1. Initial assessment
The initial step in identifying individuals with acute stress disorder (ASD) or post traumatic stress disorder (PTSD)
involves screening for recent or remote trauma exposure, although the clinical approach may vary depending on the
recency of the traumatic event [I]. If eliciting vivid and detailed recollections of the traumatic event immediately
after exposure enhances the patient’s distress, the interview may be limited to gathering information that is
essential to provide needed medical care [I]. The first interventions in the aftermath of an acute trauma consist
of stabilizing and supportive medical care and supportive psychiatric care and assessment [I]. After large-scale
catastrophes, initial psychiatric assessment includes differential diagnosis of physical and psychological effects of
the traumatic event (e.g., anxiety resulting from hemodynamic compromise, hyperventilation, somatic expressions
of psychological distress, fatigue) and identification of persons or groups who are at greatest risk for subsequent
psychiatric disorders, including ASD or PTSD [I]. This identification may be accomplished through individual
evaluation, group interviews, consultation, and use of surveillance instruments [I].
Diagnostic evaluation may be continued after the initial period has passed and a physically and psychologically safe
environment has been established, the individual’s medical condition has been stabilized, psychological reassurance
has been provided, and, in disaster settings, necessary triage has been accomplished. It is important for this
diagnostic assessment to include a complete psychiatric evaluation that specifically assesses for the symptoms of
ASD and PTSD, including dissociative, reexperiencing, avoidance/numbing, and hyperarousal symptom clusters and
their temporal sequence relative to the trauma (i.e., before versus after 1 month from the traumatic event) [I].
Other important components of the assessment process include functional assessment, determining the availability
of basic care resources (e.g., safe housing, social support network, companion care, food, clothing), and identifying
previous traumatic experiences and comorbid physical or psychiatric disorders, including depression and substance
use disorders [I].
2. Psychiatric management
Psychiatric management for all patients with ASD or PTSD includes instituting interventions and activities to ensure
physical and psychological safety, required medical care, and availability of needed resources for self-care and
recovery [I]. The patient’s level of functioning and safety, including his or her risk for suicide and potential to harm
others, is always important to evaluate during initial assessment and may determine the treatment setting [I]. The
goals of psychiatric management for patients with ASD and PTSD also include establishing a therapeutic alliance
with the patient; providing ongoing assessment of safety and psychiatric status, including possible comorbid
disorders and response to treatment; and increasing the patients understanding of and active adaptive coping with
psychosocial effects of exposure to the traumatic event, such as injury, job loss, or loss of loved ones [I]. Additional
goals of psychiatric management include providing education regarding ASD and PTSD, enhancing treatment
adherence, evaluating and managing physical health and functional impairments, and coordinating care to include
collaborating with other clinicians [I].
3. General principles of treatment selection
The goals of treatment for individuals with a diagnosis of ASD or PTSD include reducing the severity of ASD or
PTSD symptoms, preventing or treating trauma-related comorbid conditions that may be present or emerge,
improving adaptive functioning and restoring a psychological sense of safety and trust, limiting the generalization
of the danger experienced as a result of the traumatic situation(s), and protecting against relapse [I].
30
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Patients assessed within hours or days after an acute trauma may present with overwhelming physiological and
emotional symptoms (e.g., insomnia, agitation, emotional pain, dissociation). Limited clinical trial evidence is
available in this area, as randomized designs are difficult to implement; however, clinical experience suggests that
these acutely traumatized individuals may benefit from supportive psychotherapeutic and psychoeducational
interventions [II]. Pharmacotherapy may be the first-line intervention for acutely traumatized patients whose
degree of distress precludes new verbal learning or nonpharmacological treatment strategies [II]. Research has not
consistently identified patient- or trauma-specific factors that predict the development of ASD or interventions
that will alter the evolution of ASD into PTSD. However, early after a trauma, once the patient’s safety and medical
stabilization have been addressed, supportive psychotherapy, psychoeducation, and assistance in obtaining
resources such as food and shelter and locating family and friends are useful [II].
Effective treatments for the symptoms of ASD or PTSD encompass psychopharmacology, psychotherapy, and
psychoeducation and other supportive measures [I]. Although studies using a combination of these approaches
for ASD and PTSD are not presently available, combination treatment is widely used and may offer advantages
for some patients [II]. The psychotropic medications used in clinical practice and research for the treatment of
ASD and PTSD were not specifically developed for these disorders but have been used in doses similar to those
recommended or approved for other psychiatric illnesses.
For patients with ASD or PTSD, choice of treatment includes consideration of age and gender, presence of
comorbid medical and psychiatric illnesses, and propensity for aggression or self-injurious behavior [I]. Other
factors that may influence treatment choice include the recency of the precipitating traumatic event; the severity
and pattern of symptoms; the presence of particularly distressing target symptoms or symptom clusters; the
development of interpersonal or family issues or occupational or work-related problems; preexisting developmental
or psychological vulnerabilities, including prior trauma exposure; and the patient’s preferences [I].
When the patient’s symptoms do not respond to a plan of treatment, selection of subsequent interventions will
depend on clinical judgment, as there are limited data to guide the clinician. It is important to systematically review
factors that may contribute to treatment nonresponse, including the specifics of the initial treatment plan and
its goals and rationale, the patient’s perceptions of the effects of treatment, the patient’s understanding of and
adherence to the treatment plan, and the patient’s reasons for nonadherence if nonadherence is a factor [I]. Other
factors that may need to be addressed in patients who are not responding to treatment include problems in the
therapeutic alliance; the presence of psychosocial or environmental difficulties; the effect of earlier life experiences
such as childhood abuse or previous trauma exposures; and comorbid psychiatric disorders, including substancerelated disorders and personality disorders [I].
4. Specific treatment strategies
• Psychopharmacology
Although it has been hypothesized that pharmacological treatment soon after trauma exposure may
prevent the development of ASD and PTSD, existing evidence is limited and preliminary. Thus, no specific
pharmacological interventions can be recommended as efficacious in preventing the development of ASD or
PTSD in at-risk individuals.
For patients with ASD, there are few studies of pharmacological interventions. However, selective serotonin
reuptake inhibitors (SSRIs) [II] and other antidepressants [III] represent reasonable clinical interventions that
are supported by limited findings in ASD as well as by findings of therapeutic benefits in patients with PTSD.
SSRIs are recommended as first-line medication treatment for PTSD [I]. In both male and female patients,
treatment with SSRIs has been associated with relief of core PTSD symptoms in all three symptom clusters
(reexperiencing, avoidance/numbing, hyperarousal). Other antidepressants, including tricyclic antidepressants
and monoamine oxidase inhibitors (MAOIs), may also be beneficial in the treatment of PTSD [II].
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
31
Benzodiazepines may be useful in reducing anxiety and improving sleep [III]. Although their efficacy in treating
the core symptoms of PTSD has not been established, benzodiazepines are often used in trauma-exposed
individuals and patients with PTSD. However, clinical observations include the possibility of dependence,
increased incidence of PTSD after early treatment with these medications, or worsening of PTSD symptoms after
withdrawal of these medications. Thus, benzodiazepines cannot be recommended as monotherapy in PTSD.
In addition to being indicated in patients with comorbid psychotic disorders, second generation antipsychotic
medications (e.g., olanzapine, quetiapine, risperidone) may be helpful in individual patients with PTSD [III].
Anticonvulsant medications (e.g., divalproex, carbamazepine, topiramate, lamotrigine), alpha-2- adrenergic
agonists, and beta-adrenergic blockers may also be helpful in treating specific symptom clusters in individual
patients [III].
• Psychotherapeutic interventions
Some evidence is available about the effectiveness of psychotherapeutic intervention immediately after trauma
in preventing development of ASD or PTSD. Studies of cognitive behavior therapy in motor vehicle and industrial
accident survivors as well as in victims of rape and interpersonal violence suggest that cognitive behaviour
therapies may speed recovery and prevent PTSD when therapy is given over a few sessions beginning 2-3
weeks after trauma exposure [II].
Early supportive interventions, psychoeducation, and case management appear to be helpful in acutely
traumatized individuals, because these approaches promote engagement in ongoing care and may facilitate
entry into evidence-based psychotherapeutic and psychopharmacological treatments [II]. Encouraging
acutely traumatized persons to first rely on their inherent strengths, their existing support networks, and their
own judgment may also reduce the need for further intervention [II]. In populations of patients who have
experienced multiple recurrent traumas, there is little evidence to suggest that early supportive care delivered
as a stand-alone treatment will result in lasting reductions in PTSD symptoms. However, no evidence suggests
that early supportive care is harmful. In contrast, psychological debriefings or single-session techniques are
not recommended, as they may increase symptoms in some settingsand appear to be ineffective in treating
individuals with ASD and inpreventing PTSD.
No controlled studies of psychodynamic psychotherapy, eye movement desensitization and reprocessing
(EMDR), or hypnosis have been conducted that would establish data-based evidence of their efficacy as an
early or preventive intervention for ASD or PTSD.
For patients with a diagnosis of ASD or PTSD, available evidence and clinical experience suggest that a number
of psychotherapeutic interventions may be useful. Patients with ASD may be helped by cognitive behavior
therapy and other exposure-based therapies [II]. In addition, cognitive behavior therapy is an effective
treatment for core symptoms of acute and chronic PTSD [I]. EMDR also appears to be effective [II]; however,
therapeutic benefit for the rapid eye movement component of this therapy has not been consistently
demonstrated. Stress inoculation, imagery rehearsal, and prolonged exposure techniques may also be indicated
for treatment of PTSD and PTSD-associated symptoms such as anxiety and avoidance [II]. The shared element
of controlled exposure of some kind may be the critical intervention.
Psychodynamic psychotherapy may be useful in addressing developmental, interpersonal, or intrapersonal issues
that relate to the nature, severity, symptoms, or treatment of ASD and PTSD and that may be of particular
importance to social, occupational, and interpersonal functioning [II].
Case management, psychoeducation, and other supportive interventions may be useful in facilitating entry
into ongoing treatment, appear not to exacerbate PTSD symptoms, and in some pilot investigations have been
associated with PTSD symptom reduction [II]. Present-centered and trauma-focused group therapies may also
reduce PTSD symptom severity [III].
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Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Definitions
Each recommendation is identified as falling into one of three categories of endorsement, indicated by a bracketed
Roman numeral following the statement. The three categories represent varying levels of clinical confidence
regarding the efficacy of the treatment for the disorder and conditions described. [I] Recommended with
substantial clinical confidence [II] Recommended with moderate clinical confidence [III] May be recommended on
the basis of individual circumstances.
b) Physical/psychiatric rehabilitation
As above.
c) Risk factor/recovery
Potential harms
• Successful treatment may require patients to tolerate intense affect and/ordisruptive or unpleasant medication
side effects.
• Use of benzodiazepines may produce an increased incidence of post traumatic stress disorder (PTSD) after early
treatment or worsening of PTSD symptoms after benzodiazepine withdrawal. There are also concerns about
addictive potential in individuals with comorbid substance use disorders, which may prompt additional caution
regarding use of benzodiazepines.
• In-depth exploration of the traumatic event and the patient’s experiences may increase patient distress and
result in increased symptom severity.
• Insensitive or premature exploration of recent life threatening events or losses may cause the patient to avoid
medical care.
• Discussion of distressing memories and events in heterogeneously exposed groups may adversely affect those
with little or no exposure when they hear of the frightening and terrifying experiences of others.
• Psychological debriefing may increase symptoms in some patients.
• Nefazodone has been associated with irreversible and life-threatening hepatic failure.
Contraindications
• While psychosocial treatments that attempt to identify and process traumatic experiences may be effective
for individuals from Western cultures, they may be contraindicated for some Southeast Asian populations and
persons from other non-Western cultures.
• Clinicians reluctance to prescribe monoamine oxidase inhibitors (MAOIs) generally relates to concerns about
the capacity of patients to adhere to tyramine-free diets or to abstain from alcohol, certain drugs of abuse, and
contraindicated prescription medications (e.g., selective serotonin reuptake inhibitors [SSRIs], central nervous
system [CNS] stimulants, decongestants, and meperidine).
d) Return to work
Not discussed.
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
33
8. Priority for Q-COMP
Rating criteria
Functional restoration
Does the guideline consider graded increases in activity and function?
Psychosocial factors
To what degree does the guideline consider psychosocial factors that may influence recovery?
Return to work process (vocational rehabilitation)
To what degree does the guideline consider the Return to Work Process (vocational rehabilitation)?
Risk factors for recovery
To what degree does the guideline consider Risk Factors for Recovery?
Total rating
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Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
1
1
1
1
4
Post-traumatic stress disorder
The management of PTSD in adults and
children in primary and secondary care
Contents
1.
2.
3.
4.
5.
6.
7.
Developed by ................................................................................................................................................................................... 36
Guideline status ............................................................................................................................................................................... 36
Where located/how accessed ..................................................................................................................................................... 36
Description/scope .......................................................................................................................................................................... 36
Outcomes considered .................................................................................................................................................................... 38
Agree appraisal................................................................................................................................................................................. 38
Relevance/appropriateness of use in workers’ compensation sector ............................................................................... 39
a) Functional progression ............................................................................................................................................................ 39
b) Physical/psychiatric rehabilitation ........................................................................................................................................ 40
c) Risk factor/recovery ................................................................................................................................................................ 46
d) Return to work........................................................................................................................................................................... 46
8. Priority for Q-COMP ...................................................................................................................................................................... 46
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
35
1. Developed by
National Collaborating Centre for Mental Health. Post-traumatic stress disorder: the management of PTSD in adults
and children in primary and secondary care. London (UK): National Institute for Clinical Excellence (NICE);2005.167
p. [69 references]
2. Guideline status
This is the current release of the guideline.
3. Where located/how accessed
National Guideline Clearinghouse www.guideline.gov
Electronic copies; Available in Portable Document Format [PDF] from the National Institute for Health and Clinical
Excellence (NICE) Web site
The following companion documents are available:
• National Collaborating Centre for Mental Health. Post-traumatic stress disorder (PTSD). The management of
PTSD in adults and children in primary and secondary care. NICE guideline (Clinical guideline 26). London (UK):
National Institute for Health and Clinical Excellence (NICE); 2005 Mar. 41 p. Electronic copies: Available in
Portable Document Format (PDF) from the National Institute for Health and Clinical Excellence (NICE) Web site.
• National Collaborating Centre for Mental Health. Post-traumatic stress disorder (PTSD). The management
of PTSD in adults and children in primary and secondary care. Quick reference guide. London (UK): National
Institute for Health and Clinical Excellence (NICE); 2005 Mar. 17 p. Electronic copies: Available in Portable
Document Format (PDF) from the NICE Web site.
• Post-traumatic stress disorder--presenter slides. Available from the NICE Web site.
The following patient resource is available:
• Post-traumatic stress disorder (PTSD): the treatment of PTSD in adults and children. Understanding NICE
guidance – information for people with PTSD, their advocates and carers, and the public. National Institute for
Health and Clinical Excellence (NICE), 2005 Mar. 36 p. Available in Portable Document Format (PDF) from the
National Institute for Clinical Excellence (NICE) Web site.
Print copies: Available from the National Health Service (NHS) Response Line 0870 1555 455, ref N0849.
4. Description/scope
Disease/condition(s)
• Post-traumatic stress disorder (PTSD)
Guideline category
• Diagnosis
• Evaluation
• Management
• Treatment
36
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Clinical speciality
• Family Practice
• Internal Medicine
• Paediatrics
• Psychiatry
• Psychology
Intended users
• Intended users
• Advanced Practice Nurses
• Allied Health Personnel
• Emergency Medical Technicians/Paramedics
• Hospitals
• Nurses
• Occupational Therapists
• Patients
• Physicians
• Psychologists/Non-physician Behavioural Health Clinicians
• Social Workers
Guideline objectives
To make recommendations and suggest good practice points for the treatment and management of post-traumatic
stress disorder (PTSD). Specifically, the guideline aims to:
1.
2.
3.
4.
5.
Evaluate the role of specific psychological interventions in the treatment and management of PTSD
Evaluate the role of specific pharmacological interventions in the treatment and management of PTSD
Evaluate the role of early psychological and pharmacological interventions shortly after the traumatic event
Address the issues of diagnosis, detection, and the use of screening techniques in high-risk situations
Provide key review criteria for audit, which will enable objective measurements to be made of the extent and
nature of local implementation of this guidance, particularly its impact upon practice and outcomes for people
with PTSD.
Target population
Adults and children of all ages , who meet the diagnostic criteria for , or are at risk for, post-traumatic stress
disorder (PTSD).
Interventions and practices considered
Screening and diagnosis of Post-Traumatic Stress Disorder (PTSD)
1. Symptom assessment and coordination of care (including determinations of need for emergency or
psychiatric assessment)
2. Screening of individuals involved in major disasters, refugees, and asylum seekers
3. Assessment of comorbid conditions
4. Familiarisation with ethnic and cultural background of patient
5. Special considerations for assessing PTSD symptoms in children
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
37
Psychological interventions
1. Trauma focused cognitive behavioural therapy
2. Eye movement desensitisation and reprocessing (EMDR)
Pharmacological therapy
1. Antidepressants
• Mirtazapine
2. Selective serotonin reuptake inhibitors
• Paroxetine
3. Tricyclic antidepressants
• Amitriptyline
4. Monoamine oxidase inhibitors
• Phenelzine
5. Hypnotic medication
6. Antipsychotic agents
• Olanzapine
7. Management of side effects of therapy and discontinuation/withdrawal symptoms
Other practices
1. Watchful waiting
Supportive measures
1. Family and carer support
2. Disaster planning (organization of social and psychological support)
Interventions considered but not recommended
Serataline, fluoxetine, imipramine, venlaxafine, risperidone relaxation therapy, hypnotherapy, supportive therapy,
non-directive therapy, systematic psychotherapy and psychodynamic therapy, debriefing, repetitive transcranial
magnetic stimulation (rTMS).
5. Outcomes considered
•
•
•
•
•
Incidence and prevalence of post-traumatic stress disorder (PTSD)
Symptom improvement (as measured by independent assessors or self-report)
Side effects of pharmacologic therapy
Relapse rate
Impact on patient carers.
6. Agree appraisal
•
•
•
•
•
•
38
Scope and Purpose
Stakeholder Involvement
Rigour of Development
Clarity and Presentation
Applicability
Editorial Independence
2%
79%
0%
2%
67%
8%
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
7. Relevance/appropriateness of use in workers’ compensation sector
Recognition of Post-traumatic Stress Disorder (PTSD)
Effective treatment of PTSD can only take place if the disorder is recognised. In some cases, for example following
a major disaster, specific arrangements to screen people at risk may be considered. For the vast majority of people
with TSD, opportunities for recognition and identification come as part of routine healthcare interventions, for
example, following an assault or an accident for which physical treatment is required, or when a person discloses
domestic violence or a history of childhood sexual abuse. Identification of PTSD in children presents particular
problems but is improved if children are asked directly about their experiences.
Recognition in primary care
PTSD can present with a range of symptoms, which in most adults are most commonly in the form of very vivid,
distressing memories of the event or flashbacks (otherwise known as intrusive or re-experiencing symptoms).
However, at times the most prominent symptoms may be avoidance of traumarelated situations or general social
contacts. It is important when recognising and identifying PTSD to ask specific questions in a sensitive manner
about both the symptoms and traumatic experiences. A number of problems such as depression are often comorbid
with PTSD. Often these problems will improve with the treatment of the PTSD, but where this does not happen or
the comorbid disorder impedes the effective treatment of the PTSD, it may be appropriate to consider providing
specific treatment for that disorder.
PTSD may present with a range of symptoms (including re-experiencing, avoidance, hyperarousal, depression,
emotional numbing, drug or alcohol misuse and anger) and therefore, when assessing for PTSD, members of the
primary care team should ask in a sensitive manner whether or not patients with such symptoms have suffered
a traumatic experience (which may have occurred many months or years before) and give specific examples of
traumatic events (for example, assaults, rape, road traffic accidents, childhood sexual abuse and traumatic childbirth).
General practitioners and other members of the primary care team should e aware of traumas associated with the
development of PTSD. These include single events such as assaults or road traffic accidents, and domestic violence
and childhood sexual abuse.
For patients with unexplained physical symptoms who are repeated attendees to primary care, members of the
primary care team should consider asking whether or not they have experienced a traumatic event, and provide
pecific examples of traumatic events (for example, assaults, rape, road traffic accidents, childhood sexual abuse
and traumatic childbirth).
When seeking to identify PTSD, members of the primary care team should consider asking adults specific questions
about re-experiencing (including flashbacks and nightmares) or hyperarousal (including an exaggerated startle
response or sleep disturbance). For children, particularly younger children, consideration should be given to asking
the child and/or the parents about sleep disturbance or significant changes in sleeping patterns.
Recognition in general hospital settings
Many people attending for medical services in a general hospital setting may have experienced traumatic events.
This may be particularly so in emergency departments and in orthopaedic and plastic surgery clinics. For some
people with PTSD, this may be the main point of contact with the healthcare system and the opportunity that this
presents for the recognition and identification of PTSD should be taken.
PTSD may present with a range of symptoms (including re-experiencing, avoidance, hyperarousal, depression,
emotional numbing and anger) and therefore when assessing for PTSD, members of secondary care medical teams
should ask in a sensitive manner whether or not patients with such symptoms have suffered a traumatic experience
and give specific examples of traumatic events (for example, assaults, rape, road traffic accidents, childhood sexual
abuse and traumatic childbirth).
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
39
Screening of individuals involved in a major disaster, programme refugees and asylum seekers
Many individuals involved in a major disaster will suffer both short- and long-term consequences of their
involvement. Although the development of single-session debriefing is not recommended, screening of all
individuals should be considered by the authorities responsible for developing the local disaster plan. Similarly,
the vast majority of programme refugees (people who are brought to the UK from a conflict zone through
a programme organised by an agency such as the United Nations High Commission for Refugees) will have
experienced major trauma and may benefit from a screening programme.
For individuals at high risk of developing PTSD following a major disaster, consideration should be given (by those
responsible for coordination of the disaster plan) to the routine use of a brief screening instrument for PTSD at 1
month after the disaster.
For programme refugees and asylum seekers at high risk of developing PTSD, consideration should be given (by
those responsible for management of the refugee programme) to the routine use of a brief screening instrument
for PTSD as part of the initial refugee healthcare assessment. This should be a part of any comprehensive physical
and mental health screen.
Specific recognition issues for children
Children, particularly those aged under 8 years, may not complain directly of PTSD symptoms such as reexperiencing or avoidance. Instead, children may complain of sleeping problems. It is therefore vital that all
opportunities for identifying PTSD in children should be taken. Questioning the children as well as parents or
guardians will also improve the recognition of PTSD. PTSD is common (up to 30%) in children following attendance
at emergency departments for a traumatic injury. Emergency department staff should inform parents or guardians
of the risk of their child developing PTSD following emergency attendance for a traumatic Injury and advise them
on what action to take if symptoms develop.
When assessing a child or young person for PTSD, healthcare professionals should ensure that they separately and
directly question the child or young person about the presence of PTSD symptoms. They should not rely solely on
information from the parent or guardian in any assessment.
When a child who has been involved in a traumatic event is treated in an emergency department, emergency staff
should inform the parents or guardians of the possibility of the development of PTSD, briefly describe the possible
symptoms (for example, sleep disturbance, nightmares, difficulty concentrating and irritability) and suggest that
they contact their general practitioner if the symptoms persist beyond 1 month.
b) Physical/psychiatric rehabilitation
Assessment and coordination of care
For PTSD sufferers presenting in primary care, General Practitioners (GPs) should take responsibility for the initial
assessment and the initial coordination of care. This includes the determination of the need for emergency medical
or psychiatric assessment.
Assessment of PTSD sufferers should be conducted by competent individuals and be comprehensive, including
physical, psychological and social needs and a risk assessment.
Patient preference should be an important determinant of the choice among effective treatments. PTSD sufferers
should be given sufficient information about the nature of these treatments to make an informed choice.
Where management is shared between primary and secondary care, there should be clear agreement among
individual healthcare professionals about the responsibility for monitoring patients with PTSD. This agreement
should be in writing (where appropriate, using the Care Programme Approach) and should be shared with the
patient and, where appropriate, their family and carers.
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Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Support for families and carers
Families and carers have a central role in supporting people with PTSD. However, depending on the nature of the
trauma and its consequences, many families may also need support for themselves. Healthcare professionals should
be aware of the impact of PTSD on the whole family.
In all cases of PTSD, healthcare professionals should consider the impact of the traumatic event on all family
members and, when appropriate, assess this impact and consider providing appropriate support.
Healthcare professionals should ensure, where appropriate and with the consent of the PTSD sufferer where
necessary, that the families of PTSD sufferers are fully informed about common reactions to traumatic events,
including the symptoms of PTSD and its course and treatment.
In addition to the provision of information, families and carers should be informed of self-help groups and support
groups and encouraged to participate in such groups where they exist.
When a family is affected by a traumatic event, more than one family member may suffer from PTSD. If this is the
case, healthcare professionals should ensure that the treatment of all family members is effectively coordinated.
Practical support and social factors
Practical and social support can play an important part in facilitating a person’s recovery from PTSD, particularly
immediately after the trauma. Healthcare professionals should be aware of this and advocate for such support
when people present with PTSD.
Healthcare professionals should identify the need for appropriate information about the range of emotional
responses that may develop and provide practical advice on how to access appropriate services for these problems.
They should also identify the need for social support and advocate the meeting of this need.
Healthcare professionals should consider offering help or advice to PTSD sufferers or relevant others on how
continuing threats related to the traumatic event may be alleviated or removed.
Language and culture
People with PTSD treated in the National Health Service (NHS) come from diverse cultural and ethnic backgrounds
and some have no or limited English, but all should be offered the opportunity to benefit from psychological
interventions. This can be achieved by the use of interpreters and bicultural therapists. In all cases, healthcare
professionals must familiarise themselves with the cultural background of the sufferer.
Where a PTSD sufferer has a different cultural or ethnic background from that of the healthcare professionals who
are providing care, the healthcare professionals should familiarise themselves with the cultural background of the
PTSD sufferer.
Where differences of language or culture exist between healthcare professionals and PTSD sufferers, this should
not be an obstacle to the provision of effective trauma-focused psychological interventions.
Where language or culture differences present challenges to the use of trauma-focused psychological interventions
in PTSD, healthcare professionals should consider the use of interpreters and bicultural therapists.
Healthcare professionals should pay particular attention to the identification of individuals with PTSD where the
culture of the working or living environment is resistant to recognition of the psychological consequences of
trauma.
Care for all people with PTSD
PTSD responds to a variety of effective treatments. All treatment should be supported by appropriate information
to sufferers about the likely course of such treatment. A number of factors, which are described below, may
modify the nature, timing and course of treatment.
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
41
Care across all conditions
When developing and agreeing a treatment plan with a PTSD sufferer, healthcare professionals should ensure that
sufferers receive information about common reactions to traumatic events, including the symptoms of PTSD and
its course and treatment.
Healthcare professionals should not delay or withhold treatment for PTSD because of court proceedings or
applications for compensation.
Healthcare professionals should be aware that many PTSD sufferers are anxious about and can avoid engaging
in treatment. Healthcare professionals should also recognize the challenges that this presents and respond
appropriately, for example by following up PTSD sufferers who miss scheduled appointments.
Healthcare professionals should treat PTSD sufferers with respect, trust and understanding, and keep technical
language to a minimum.
Healthcare professionals should normally only consider providing traumafocused psychological treatment when the
sufferer considers it safe to proceed.
Treatment should be delivered by competent individuals who have received appropriate training. These individuals
should receive appropriate supervision.
Comorbidities
When a patient presents with PTSD and depression, healthcare professionals should consider treating the PTSD
first, as the depression will often improve with successful treatment of the PTSD.
For PTSD sufferers whose assessment identifies a high risk of suicide or harm to others, healthcare professionals
should first concentrate on management of this risk.
For PTSD sufferers who are so severely depressed that this makes initial psychological treatment of PTSD very
difficult (for example, as evidenced by extreme lack of energy and concentration, inactivity, or high suicide risk),
healthcare professionals should treat the depression first.
For PTSD sufferers with drug or alcohol dependence or in whom alcohol or drug use may significantly interfere with
effective treatment, healthcare professionals should treat the drug or alcohol problem first.
When offering trauma-focused psychological interventions to PTSD sufferers with comorbid personality disorder,
healthcare professionals should consider extending the duration of treatment.
People who have lost a close friend or relative due to an unnatural or sudden death should be assessed for PTSD
and traumatic grief. In most cases, healthcare professionals should treat the PTSD first without avoiding discussion
of the grief.
Treatment of PTSD
Early interventions
A number of sufferers with PTSD may recover with no or limited interventions. However, without effective
treatment, many people may develop chronic problems over many years. The severity of the initial traumatic
response is a reasonable indicator of the need for early intervention, and treatment should not be withheld in such
circumstances.
Watchful Waiting
Where symptoms are mild and have been present for less than 4 weeks after the trauma, watchful waiting, as a
way of managing the difficulties presented by individual sufferers, should be considered by healthcare professionals.
A follow-up contact should be arranged within 1 month.
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Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Immediate Psychological Interventions for All
As described in this guideline, practical support delivered in an empathetic manner is important in promoting
recovery for PTSD, but it is unlikely that a single session of a psychological intervention will be helpful.
All health and social care workers should be aware of the psychological impact of traumatic incidents in their
immediate post-incident care of survivors and offer practical, social and emotional support to those involved.
For individuals who have experienced a traumatic event, the systematic provision to that individual alone of brief,
single-session interventions (often referred to as debriefing) that focus on the traumatic incident should not be
routine practice when delivering services.
PTSD where symptoms are present within 3 months of a trauma
Brief psychological interventions (five sessions) may be effective if treatment starts within the first month after
the traumatic event. Beyond the first month, the duration of treatment is similar to that for chronic PTSD.
Trauma-focused cognitive-behavioural therapy should be offered to those with severe post-traumatic symptoms
or with severe PTSD in the first month after the traumatic event. These treatments should normally be provided on
an individual out-patient basis. Trauma-focused CBT should be offered to people who present with PTSD within 3
months of a traumatic event.
The duration of the trauma-focused CBT should normally be 8-12 sessions, but if the treatment starts in the first
month after the event, fewer sessions (about 5) may be sufficient. When the trauma is discussed in the treatment
session, longer sessions (for example, 90 min) are usually necessary. Treatment should be regular and continuous
(usually at least once a week) and should be delivered by the same person.
Drug treatment may be considered in the acute phase of PTSD for the management of sleep disturbance. In this
case, hypnotic medication may be appropriate for short-term use but, if longer-term drug treatment is required,
consideration should also be given to the use of suitable antidepressants at an early stage in order to reduce the
later risk of dependence.
Non-trauma-focused interventions such as relaxation or non-directive therapy, which do not address traumatic
memories, should not routinely be offered to people who present with PTSD symptoms within 3 months of a
traumatic event.
PTSD where symptoms have been present for more than 3 months after a trauma
Most patients presenting with PTSD have had the problem for many months, if not years. The interventions
outlined below are effective in treating such individuals and duration of the disorder does not itself seem an
impediment to benefiting from effective treatment provided by competent healthcare professionals.
Psychological Interventions
All PTSD sufferers should be offered a course of trauma-focused psychological treatment (trauma-focused CBT or
eye movement desensitisation and reprocessing). These treatments should normally be provided on an individual
out-patient basis.
Trauma-focused psychological treatment should be offered to PTSD sufferers regardless of the time that has
elapsed since the trauma.
The duration of trauma-focused psychological treatment should normally be 8- 12 sessions when the PTSD results
from a single event. When the trauma is discussed in the treatment session, longer sessions than usual are generally
necessary (for example, 90 min). Treatment should be regular and continuous (usually at least once a week) and
should be delivered by the same person.
Healthcare professionals should consider extending the duration of treatment beyond 12 sessions if several
problems need to be addressed in the treatment of PTSD sufferers, particularly after multiple traumatic events,
traumatic bereavement or where chronic disability resulting from the trauma, significant comorbid disorders or
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
43
social problems are present. Trauma-focused treatment needs to be integrated into an overall plan of care. For
some PTSD sufferers it may initially be very difficult and overwhelming to disclose details of their traumatic
events. In these cases, healthcare professionals should consider devoting several sessions to establishing a trusting
therapeutic relationship and emotional stabilisation before addressing the traumatic event.
Non-trauma-focused interventions such as relaxation or non-directive therapy, which do not address traumatic
memories, should not routinely be offered to people who present with chronic PTSD.
For PTSD sufferers who have no or only limited improvement with a specific trauma-focused psychological
treatment, healthcare professionals should consider the following options:
• an alternative form of trauma-focused psychological treatment
• the augmentation of trauma-focused psychological treatment with a course of pharmacological treatment.
When PTSD sufferers request other forms of psychological treatment (for example, supportive therapy/nondirective therapy, hypnotherapy, psychodynamic therapy or systemic psychotherapy), they should be informed
that there is as yet no convincing evidence for a clinically important effect of these treatments on PTSD.
Drug treatment
The evidence base for drug treatments in PTSD is limited. There is evidence of clinically significant benefits for
mirtazapine, amitriptyline and phenelzine. (Dietary guidance is required with phenelzine.) For paroxetine there were
statistically but not clinically significant benefits on the main outcome variables. Nevertheless, this drug has also
been included in the list of recommended drugs. This is the only drug in the list of recommendations with a current
UK product licence for PTSD.
Drug treatments for PTSD should not be used as a routine first-line treatment for adults (in general use or by
specialist mental health professionals) in preference to a trauma-focused psychological therapy.
Drug treatments (paroxetine or mirtazapine for general use, and amitriptyline or phenelzine for initiation only by
mental health specialists) should be considered for the treatment of PTSD in adults where a sufferer expresses a
preference not to engage in a trauma-focused psychological treatment.
Drug treatments (paroxetine or mirtazapine for general use, and amitriptyline or phenelzine for initiation only by
mental health specialists) should be offered to adult PTSD sufferers who cannot start a psychological therapy
because of serious ongoing threat of further trauma (for example, where there is ongoing domestic violence).
Drug treatments (paroxetine or mirtazapine for general use and amitriptyline or phenelzine for initiation only by
mental health specialists) should be considered for adult PTSD sufferers who have gained little or no benefit from
a course of trauma-focused psychological treatment. Where sleep is a major problem for an adult PTSD sufferer,
hypnotic medication may be appropriate for short-term use but, if longer-term drug treatment is required,
consideration should also be given to the use of suitable antidepressants at an early stage in order to reduce the
later risk of dependence.
Drug treatments (paroxetine or mirtazapine for general use and amitriptyline or phenelzine for initiation only by
mental health specialists) for PTSD should be considered as an adjunct to psychological treatment in adults where
there is significant comorbid depression or severe hyperarousal that significantly impacts on a sufferer’s ability to
benefit from psychological treatment.
When an adult sufferer with PTSD has not responded to a drug treatment, consideration should be given to
increasing the dosage within approved limits. If further drug treatment is considered, this should generally be with a
different class of antidepressant or involve the use of adjunctive olanzapine.
When an adult sufferer with PTSD has responded to drug treatment, it should be continued for at least 12 months
before gradual withdrawal.
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Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
General Recommendations Regarding Drug Treatment
All PTSD sufferers who are prescribed antidepressants should be informed, at the time that treatment is initiated,
of potential side-effects and discontinuation/withdrawal symptoms (particularly with paroxetine).
Adult PTSD sufferers started on antidepressants who are considered to have an increased suicide risk and all
patients aged between 18 and 29 years (because of the potential increased risk of suicidal thoughts associated
with the use of antidepressants in this age group) should normally be seen after 1 week and frequently thereafter
until the risk is no longer considered significant.
Particularly in the initial stages of SSRI treatment, practitioners should actively seek out signs of akathisia, suicidal
ideation and increased anxiety and agitation. They should also advise PTSD sufferers of the risk of these symptoms
in the early stages of treatment and advise them to seek help promptly if these are at all distressing.
If a PTSD sufferer develops marked and/or prolonged akathisia while taking an antidepressant, the use of the drug
should be reviewed.
Adult PTSD sufferers started on antidepressants who are not considered to be at increased risk of suicide should
normally be seen after 2 weeks and thereafter on an appropriate and regular basis, for example, at intervals of 2-4
weeks in the first 3 months, and at greater intervals thereafter, if response is good.
Recommendations Regarding Discontinuation/Withdrawal Symptoms
Discontinuation/withdrawal symptoms are usually mild and self-limiting but occasionally can be severe. Prescribers
should normally gradually reduce the dosage of antidepressants over a 4-week period, although some people may
require longer periods.
If discontinuation/withdrawal symptoms are mild, practitioners should reassure the PTSD sufferer and arrange for
monitoring. If symptoms are severe, the practitioner should consider reintroducing the original antidepressant (or
another with a longer half-life from the same class) and reduce gradually while monitoring symptoms.
Chronic disease management
Chronic disease management models should be considered for the management of people with chronic PTSD who
have not benefited from a number of courses of evidence-based treatment.
Children
It is particularly difficult to identify PTSD in children (see section above titled “Specific Recognition Issues for
Children”). The treatments for children with PTSD are less developed but emerging evidence provides an indication
for effective interventions.
Early Intervention
Trauma-focused CBT should be offered to older children with severe post traumatic symptoms or with severe
PTSD in the first month after the traumatic event.
PTSD Where Symptoms Have Been Present for More Than 3 Months After a Trauma
Children and young people with PTSD, including those who have been sexually abused, should be offered a course
of trauma-focused CBT adapted appropriately to suit their age, circumstances and level of development.
The duration of trauma-focused psychological treatment for children and young people with chronic PTSD should
normally be 8–12 sessions when the PTSD results from a single event. When the trauma is discussed in the
treatment session, longer sessions than usual are usually necessary (for example, 90 min). Treatment should be
regular and continuous (usually at least once a week) and should be delivered by the same person.
Drug treatments should not be routinely prescribed for children and young people with PTSD.
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
45
Where appropriate, families should be involved in the treatment of PTSD in children and young people. However,
treatment programmes for PTSD in children and young people that consist of parental involvement alone are
unlikely to be of any benefit for PTSD symptoms.
When considering treatments for PTSD, parents and, where appropriate, children and young people should be
informed that, apart from trauma-focused psychological interventions, there is at present no good evidence for the
efficacy of widely used forms of treatment of PTSD such as play therapy, art therapy or family therapy.
Disaster planning
Both health and social services have a role in organising the appropriate social and psychological support for those
affected by disasters.
Disaster plans should include provision for a fully coordinated psychosocial response to the disaster. Those responsible
for developing the psychosocial aspect of a disaster plan should ensure it contains the following: provision for
immediate practical help, means to support the affected communities in caring for those involved in the disaster and
the provision of specialist mental health, evidence based assessment and treatment services. All healthcare workers
involved in a disaster plan should have clear roles and responsibilities, which should be agreed in advance.
c) Risk factor/recovery
Potential harms
• Side effects of paroxetine may include anxiety, agitation, suicidal thoughts and akathisia.
• Dietary restrictions and careful monitoring are required for patients taking monoamine oxidase inhibitors.
• Medication discontinuation/withdrawal symptoms may occur.
• Administration of some drugs to nursing mothers may lead to effects in breastfeeding infants.
d) Return to work
Not discussed.
8. Priority for Q-COMP
Rating criteria
Functional restoration
Does the guideline consider graded increases in activity and function?
Psychosocial factors
To what degree does the guideline consider psychosocial factors that may influence recovery?
Return to work process (vocational rehabilitation)
To what degree does the guideline consider the Return to Work Process (vocational rehabilitation)?
Risk factors for recovery
To what degree does the guideline consider Risk Factors for Recovery?
Total rating
46
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
1
3
0
3
7
Anxiety: Management of anxiety (panic
disorder, with or without agoraphobia, and
generalised anxiety disorder) in adults in
primary secondary and community care
Contents
1.
2.
3.
4.
5.
6.
7.
Developed by ................................................................................................................................................................................... 48
Guideline status ............................................................................................................................................................................... 48
Where located/how accessed ..................................................................................................................................................... 48
Description/scope .......................................................................................................................................................................... 48
Outcomes considered .................................................................................................................................................................... 49
Agree appraisal................................................................................................................................................................................. 49
Relevance/appropriateness of use in workers’ compensation sector ............................................................................... 49
a) Functional progression ............................................................................................................................................................ 49
b) Physical/psychiatric rehabilitation ........................................................................................................................................ 50
c) Risk factor/recovery ................................................................................................................................................................ 64
d) Return to work........................................................................................................................................................................... 64
8. Priority for Q-COMP ...................................................................................................................................................................... 65
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
47
1. Developed by
National Collaborating Centre for Primary Care.
2. Guideline status
Current published December 2004.
3. Where located/how accessed
NICE website (www.nice.org.uk/CGO22NICEguideline)
An abridged version of this guidance is also available from the same site.
Printed copies of the quick reference guide can be obtained from the NHS Response Line: telephone 0870 1555
455 and quote reference number N0763.
Information for the Public is available from the NICE website or from the NHS Response Line (quote reference
number N0764 for a version in English and N0765 for a version in English and Welsh).
4. Description/scope
Disease/condition(s)
Anxiety disorders including:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Panic disorder without agoraphobia
Panic disorder with agoraphobia
Specific phobia
Social anxiety disorder (SAD)/Social phobia
Generalised anxiety disorder (GAD)
Obsessive compulsive disorder (OCD)
Post traumatic stress disorder (PTSD)
Acute stress disorder
Adjustment disorder with anxiety
Guideline category
• None stated
Clinical speciality
• None stated
Intended users
• Primary health care physicians
Guideline objectives
The guidelines are developed in an attempt to provide optimal care and good outcomes to patients with anxiety
disorders. In particular it aims to assist primary health care physicians in clinical decision making when assessing and
treating patients with anxiety.
48
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Target population
None stated.
Interventions and Practices Considered
Interventions and Practices Considered
1.
2.
3.
4.
5.
6.
7.
8.
9.
Clinical evaluation of anxiety disorders
Treatment settings for anxiety disorders
Psychosocial interventions for anxiety disorders
Treatments for different types of anxiety disorders
Psychosocial interventions
Medications for anxiety disorders
Choosing and combining medical and psychological interventions
Anxiety and co-exiting conditions
Long-term treatment
5. Outcomes considered
The overall aim of the treatment is to control and remove symptoms, reduce morbidity and improve
overall functioning.
6. Agree appraisal
•
•
•
•
•
•
Scope and Purpose
Stakeholder Involvement
Rigour of Development
Clarity and Presentation
Applicability
Editorial Independence
72%
79%
48%
83%
44%
42%
7. Relevance/appropriateness of use in workers’ compensation sector
a) Functional progression
Functional progression is not specifically stated.
Clinical Algorithms are provided in the full version of the original guideline document for:
• Management of panic disorder in primary care: Steps 2-4
• Management of generalised anxiety disorder in primary care: Steps 2-4
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
49
b) Physical/psychiatric rehabilitation
Rehabilitation is not specifically stated. The guideline covers general management, stepped approach to care,
psychological interventions, pharmacological interventions, self-help interventions, monitoring and follow up.
Major recommendations
Diagnosis and decision making
Recognition and diagnosis of panic disorder and generalised anxiety disorder
Consultation Skills
All healthcare professionals involved in diagnosis and management should have a demonstrably high standard of
consultation skills so that a structured approach can be taken to the diagnosis and subsequent management plan
for panic disorder and generalised anxiety disorder. The standards detailed in the video workbook Summative
Assessment For General Practice Training: Assessment Of Consulting Skills - the Member of the Royal College of
General Practitioners (MRCGP)/Summative Assessment Single Route (see www.rcgp.org.uk/exam) and required of
the Membership of the Royal College of General Practitioners are a good example of standards for consulting skills.
Diagnosis
The accurate diagnosis of panic disorder or generalised anxiety disorder is central to the effective management of
these conditions. It is acknowledged that frequently there are other conditions present, such as depression, that
can make the presentation and diagnosis confusing. An algorithm has been developed to aid the clinician in the
diagnostic process, and to identify which guideline is most appropriate to support the clinician in the management
of the individual patient.
The diagnostic process should elicit necessary relevant information such as personal history, any self medication,
and cultural or other individual characteristics that may be important considerations in subsequent care.
There is insufficient evidence on which to recommend a well-validated, self-reporting screening instrument to use
in the diagnostic process, and so consultation skills should be relied upon to elicit all necessary information.
Comorbidities
The clinician should be alert to the common clinical situation of comorbidity, in particular, anxiety with depression
and anxiety with substance abuse.
The main problem(s) to be treated should be identified through a process of discussion with the patient. In
determining the priorities of the comorbidities, the sequencing of the problems should be clarified. This can be
helped by drawing up a timeline to identify when the various problems developed. By understanding when the
symptoms developed, a better understanding of the relative priorities of the comorbidities can be achieved, and
there is a better opportunity of developing an effective intervention that fits the needs of the individual.
When the patient has depression or anxiety with depression, the National Institute for Health and Clinical Excellence
(NICE) guideline on management of depression should be followed.
Presentation in Accident and Emergency (A&E) with Panic Attacks
It is important to remember that a panic attack does not necessarily constitute a panic disorder, and appropriate
treatment of a panic attack may limit the development of panic disorder. For people who present with chest
pain at A&E services, there appears to be a greater likelihood of the cause being panic disorder if coronary artery
disease is not present or the patient is female or relatively young. Two other variables, atypical chest pain and
self-reported anxiety, may also be associated with panic disorder presentations, but there is insufficient evidence
to establish a relationship.
50
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
If a patient presents in A&E, or other settings, with a panic attack, they should:
•
•
•
•
•
•
Be asked if they are already receiving treatment for panic disorder
Undergo the minimum investigations necessary to exclude acute physical problems
Not usually be admitted to a medical or psychiatric bed
Be referred to primary care for subsequent care, even if assessment has been undertaken in A&E
Be given appropriate written information about panic attacks and why they are being referred to primary care
Be offered appropriate written information about sources of support, including local and national voluntary and
self-help groups.
Shared Decision-Making and Information Provision
People who have panic disorder or generalised anxiety disorder and their carers need comprehensive information,
presented in clear and understandable language, about the nature of their condition and the treatment options
available. Such information is essential for shared decision-making between patients and healthcare professionals,
particularly when making choices between broadly equivalent treatments. In addition, given the emotional, social,
and economic costs that generalised anxiety disorder or panic disorder usually entail, patients and their families
may need help in contacting support and self-help groups. Support groups can also promote understanding and
collaboration between patients, their carers, and healthcare professionals at all levels of primary and secondary care.
Shared decision-making should take place as it improves concordance and clinical outcomes.
Shared decision-making between the individual and healthcare professionals should take place during the process of
diagnosis and in all phases of care.
Patients and, when appropriate, families and carers should be provided with information on the nature, course, and
treatment of panic disorder or generalised anxiety disorder, including information on the use and likely side-effect
profile of medication.
To facilitate shared decision-making, evidence-based information about treatments should be available and
discussion of the possible options should take place.
Patient preference and the experience and outcome of previous treatment(s) should be considered in determining
the choice of treatment.
Common concerns about taking medication, such as fears of addiction, should be addressed.
In addition to being provided with high-quality information, patients, families, and carers should be informed of
self-help groups and support groups and be encouraged to participate in such programmes where appropriate.
Language
When talking to patients and carers, healthcare professionals should use everyday, jargon free language. If technical
terms are used, they should be explained to the patient.
Where appropriate, all services should provide written material in the language of the patient, and appropriate
interpreters should be sought for people whose preferred language is not English.
Where available, consideration should be given to providing psychotherapies in the patient’s own language if this is
not English.
Screening tools
There is insufficient evidence on which to recommend a well-validated, self-reporting screening instrument to use
in the diagnostic process, and so consultation skills should be relied upon to elicit all necessary information.
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
51
Care of people with panic disorder
Step 1: Recognition and diagnosis of panic disorder (see above)
Step 2: Offer treatment in primary care
The recommended treatment options have an evidence base: psychological therapy, medication, and self-help
have all been shown to be effective. The choice of treatment will be a consequence of the assessment process and
shared decision-making.
There may be instances when the most effective intervention is not available (for example, cognitive behavioural
therapy [CBT]) or is not the treatment option chosen by the patient. In these cases, the healthcare professional will
need to consider, after discussion with the patient, whether it is acceptable to offer one of the other recommended
treatments. If the preferred treatment option is currently unavailable, the healthcare professional will also have to
consider whether it is likely to become available within a useful timeframe.
Benzodiazepines are associated with a less good outcome in the long term and should not be prescribed for the
treatment of individuals with panic disorder.
Sedating antihistamines or antipsychotics should not be prescribed for the treatment of panic disorder.
In the care of individuals with panic disorder, any of the following types of intervention should be offered and
the preference of the person should be taken into account. The interventions that have evidence for the longest
duration of effect, in descending order are:
• Psychological therapy
• Pharmacological therapy (antidepressant medication)
• Self-help
The treatment option of choice should be available promptly.
There are positive advantages of services based in primary care (for example, lower rates of people who do not
attend) and these services are often preferred by patients.
Psychological Interventions
Cognitive behavioural therapy (CBT) should be used.
CBT should be delivered only by suitably trained and supervised people who can demonstrate that they adhere
closely to empirically grounded treatment protocols.
CBT in the optimal range of duration (7-14 hours in total) should be offered.
For most people, CBT should take the form of weekly sessions of 1-2 hours and should be completed within a
maximum of 4 months of commencement.
Briefer CBT should be supplemented with appropriate focussed information and tasks.
Where briefer CBT is used, it should be around 7 hours and designed to integrate with structured self-help materials.
For a few people, more intensive CBT over a very short period of time might be appropriate.
52
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Pharmacological Interventions
The following must be taken into account when deciding which medication to offer:
• The age of the patient
• Previous treatment response
• Risks
• The likelihood of accidental overdose by the person being treated and by other family members if appropriate
• The likelihood of deliberate self-harm, by overdose or otherwise
• Tolerability
• The preference of the person being treated
• Cost, where equal effectiveness is demonstrated
All patients who are prescribed antidepressants should be informed, at the time that treatment is initiated,
of potential side effects (including transient increase in anxiety at the start of treatment) and of the risk of
discontinuation/withdrawal symptoms if the treatment is stopped abruptly or in some instances if a dose is missed
or, occasionally, on reducing the dose of the drug.
Patients started on antidepressants should be informed about the delay in onset of effect, the time course of
treatment, the need to take medication as prescribed, and possible discontinuation/withdrawal symptoms. Written
information appropriate to the patient’s needs should be made available.
Unless otherwise indicated, a selective serotonin reuptake inhibitor (SSRI) licensed for panic disorder should
be offered.
If an SSRI is not suitable or there is no improvement after a 12-week course and if a further medication is
appropriate, imipramine or clomipramine (which are not licensed for panic disorder but have been shown to be
effective in its management) may be considered.
When prescribing an antidepressant, the healthcare professional should consider the following:
Side effects on the initiation of antidepressants may be minimised by starting at a low dose and increasing the dose
slowly until a satisfactory therapeutic response is achieved.
In some instances, doses at the upper end of the indicated dose range may be necessary and should be offered
if needed.
Long-term treatment may be necessary for some people and should be offered if needed.
If the patient is showing improvement on treatment with an antidepressant, the medication should be continued
for at least 6 months after the optimal dose is reached, after which the dose can be tapered.
If there is no improvement after a 12-week course, an antidepressant from the alternative class (if another
medication is appropriate) or another form of therapy should be offered.
Patients should be advised to take their medication as prescribed. This may be particularly important with short
half-life medication in order to avoid discontinuation/withdrawal symptoms.
Stopping antidepressants abruptly can cause discontinuation/withdrawal symptoms. To minimise the risk of
discontinuation/withdrawal symptoms when stopping antidepressants, the dose should be reduced gradually over
an extended period of time.
All patients prescribed antidepressants should be informed that, although the drugs are not associated with
tolerance and craving, discontinuation/withdrawal symptoms may occur on stopping or missing doses or,
occasionally, on reducing the dose of the drug. These symptoms are usually mild and self-limiting but occasionally
can be severe, particularly if the drug is stopped abruptly.
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
53
Healthcare professionals should inform patients that the most commonly experienced discontinuation/withdrawal
symptoms are dizziness, numbness and tingling, gastrointestinal disturbances (particularly nausea and vomiting),
headache, sweating, anxiety, and sleep disturbances.
Healthcare professionals should inform patients that they should seek advice from their medical practitioner if they
experience significant discontinuation/withdrawal symptoms.
If discontinuation/withdrawal symptoms are mild, the practitioner should reassure the patient and monitor
symptoms. If severe symptoms are experienced after discontinuing an antidepressant, the practitioner should
consider reintroducing it (or prescribing another from the same class that has a longer half-life) and gradually
reducing the dose while monitoring symptoms.
Self-help
Bibliotherapy based on CBT principles should be offered.
Information about support groups, where they are available, should be offered. (Support groups may provide
face-to-face meetings, telephone conference support groups [which can be based on CBT principles], or additional
information on all aspects of anxiety disorders plus other sources of help.)
The benefits of exercise as part of good general health should be discussed with all patients as appropriate.
NICE 2002 – Current research suggests that the delivery of cognitive behavioural therapy via a computer
interface (CCBT) may be of value in the management of anxiety and depressive disorders. This evidence is,
however, an insufficient basis on which to recommend the general introduction of this technology into the National
Health Service (NHS).
Step 3: Review and offer alternative treatment if appropriate
If, after a course of treatment, the clinician and patient agree that there has been no improvement with one
type of intervention, the patient should be reassessed and consideration given to trying one of the other types
of intervention.
Step 4: Review and offer referral from primary care if appropriate
In most instances, if there have been two interventions provided (any combination of psychological intervention,
medication, or bibliotherapy) and the person still has significant symptoms, then referral to specialist mental health
services should be offered.
Step 5: Care in specialist mental health services
Specialist mental health services should conduct a thorough, holistic re-assessment of the individual, their
environment, and social circumstances. This reassessment should include evaluation of:
•
•
•
•
•
•
•
Previous treatments, including effectiveness and concordance
Any substance use, including nicotine, alcohol, caffeine, and recreational drugs
Comorbidities
Day-to-day functioning
Social networks
Continuing chronic stressors
The role of agoraphobic and other avoidant symptoms
A comprehensive risk assessment should be undertaken and an appropriate risk management plan developed.
To undertake these evaluations and to develop and share a full formulation, more than one session may be required
and should be available.
54
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Care and management should be based on the individual’s circumstances and shared decisions made. Options include:
• Treatment of comorbid conditions
• CBT with an experienced therapist if not offered already, including home based CBT if attendance at clinic is
difficult
• Structured problem solving
• Full exploration of pharmaco-therapy
• Day support to relieve carers and family members
• Referral for advice, assessment or management to tertiary centres
There should be accurate and effective communication between all healthcare professionals involved in the care
of any person with panic disorder, and particularly between primary care clinicians (General Practitioner [GP]
and teams) and secondary care clinicians (community mental health teams) if there are existing physical health
conditions that also require active management.
Monitoring and follow up
Psychological Interventions
There should be a process within each practice to assess the progress of a person undergoing CBT. The nature of
that process should be determined on a case-by-case basis.
Pharmacological Interventions
When a new medication is started, the efficacy and side-effects should be reviewed within 2 weeks of starting
treatment and again at 4, 6, and 12 weeks. Follow the Summary of Product Characteristics (SPC) with respect to
all other monitoring required.
At the end of 12 weeks an assessment of the effectiveness of the treatment should be made and a decision made
as to whether to continue or consider an alternative intervention.
If medication is to be continued beyond 12 weeks, the individual should be reviewed at 8- to 12-week intervals,
depending on clinical progress and individual circumstances.
Self-Help Interventions
Individuals receiving self-help interventions should be offered contact with primary healthcare professionals, so
that progress can be monitored and alternative interventions considered if appropriate. The frequency of such
contact should be determined on a case-by-case basis, but is likely to be between every 4 and 8 weeks.
Outcome Measures
Short, self-complete questionnaires (such as the panic subscale of the agoraphobic mobility inventory for
individuals with panic disorder) should be used to monitor outcomes wherever possible.
Interventions for panic disorder
Pharmacological compared with psychological compared with combination interventions for panic
disorder
In the care of individuals with panic disorder, any of the following types of intervention should be offered and
the preference of the person should be taken into account. The interventions that have evidence for the longest
duration of effect, in descending order are:
• Psychological therapy
• Pharmacological therapy (antidepressant medication)
• Self-help
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
55
The treatment option of choice should be available promptly.
There are positive advantages of services based in primary care (for example, lower rates of people who do not
attend) and these services are often preferred by patients.
Pharmacological interventions for panic disorder
Benzodiazepines are associated with a less good outcome in the long term and should not be prescribed for the
treatment of individuals with panic disorder.
Sedating antihistamines or antipsychotics should not be prescribed for the treatment of panic disorder.
The following must be taken into account when deciding which medication to offer:
•
•
•
•
•
•
•
•
The age of the patient
Previous treatment response
Risks
The likelihood of accidental overdose by the person being treated and by other family members if appropriate
The likelihood of deliberate self-harm, by overdose or otherwise
Tolerability
The preference of the person being treated
Cost, where equal effectiveness is demonstrated
All patients who are prescribed antidepressants should be informed, at the time that treatment is initiated,
of potential side effects (including transient increase in anxiety at the start of treatment) and of the risk of
discontinuation/withdrawal symptoms if the treatment is stopped abruptly or in some instances if a dose is missed
or, occasionally, on reducing the dose of the drug.
Patients started on antidepressants should be informed about the delay in onset of effect, the time course of
treatment, the need to take medication as prescribed, and possible discontinuation/withdrawal symptoms. Written
information appropriate to the patient’s needs should be made available.
Unless otherwise indicated, an SSRI licensed for panic disorder should be offered.
If an SSRI is not suitable or there is no improvement after a 12-week course and if a further medication is
appropriate, imipramine or clomipramine (which are not licensed for panic disorder but have been shown to be
effective in its management) may be considered.
When prescribing an antidepressant, the healthcare professional should consider the following:
Side effects on the initiation of antidepressants may be minimised by starting at a low dose and increasing the dose
slowly until a satisfactory therapeutic response is achieved.
In some instances, doses at the upper end of the indicated dose range may be necessary and should be offered
if needed.
Long-term treatment may be necessary for some people and should be offered if needed.
If the patient is showing improvement on treatment with an antidepressant, the medication should be continued
for at least 6 months after the optimal dose is reached, after which the dose can be tapered.
If there is no improvement after a 12-week course, an antidepressant from the alternative class (if another
medication is appropriate) or another form of therapy should be offered.
Patients should be advised to take their medication as prescribed. This may be particularly important with short
half-life medication in order to avoid discontinuation/withdrawal symptoms.
56
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Stopping antidepressants abruptly can cause discontinuation/withdrawal symptoms. To minimise the risk of
discontinuation/withdrawal symptoms when stopping antidepressants, the dose should be reduced gradually over
an extended period of
All patients prescribed antidepressants should be informed that, although the drugs are not associated with
tolerance and craving, discontinuation/withdrawal symptoms may occur on stopping or missing doses or,
occasionally, on reducing the dose of the drug. These symptoms are usually mild and self-limiting but occasionally
can be severe, particularly if the drug is stopped abruptly.
Healthcare professionals should inform patients that the most commonly experienced discontinuation/withdrawal
symptoms are dizziness, numbness and tingling, gastrointestinal disturbances (particularly nausea and vomiting),
headache, sweating, anxiety, and sleep disturbances.
Healthcare professionals should inform patients that they should seek advice from their medical practitioner if they
experience significant discontinuation/withdrawal symptoms.
If discontinuation/withdrawal symptoms are mild, the practitioner should reassure the patient and monitor
symptoms. If severe symptoms are experienced after discontinuing an antidepressant, the practitioner should
consider reintroducing it (or prescribing another from the same class that has a longer half-life) and gradually
reducing the dose while monitoring symptoms.
Psychological interventions for panic disorder
CBT should be used.
CBT should be delivered only by suitably trained and supervised people who can demonstrate that they adhere
closely to empirically grounded treatment protocols.
CBT in the optimal range of duration (7-14 hours in total) should be offered.
For most people, CBT should take the form of weekly sessions of 1-2 hours and should be completed within a
maximum of 4 months of commencement.
Briefer CBT should be supplemented with appropriate focussed information and tasks.
Where briefer CBT is used, it should be around 7 hours and designed to integrate with structured self-help
materials.
For a few people, more intensive CBT over a very short period of time might be appropriate.
Other interventions for panic disorder
Bibliotherapy based on CBT principles should be offered.
Information about support groups, where they are available, should be offered. (Support groups may provide
face-to-face meetings, telephone conference support groups [which can be based on CBT principles], or additional
information on all aspects of anxiety disorders plus other sources of help.)
The benefits of exercise as part of good general health should be discussed with all patients as appropriate.
NICE 2002 – Current research suggests that the delivery of cognitive behavioural therapy via a computer
interface (CCBT) may be of value in the management of anxiety and depressive disorders. This evidence is,
however, an insufficient basis on which to recommend the general introduction of this technology into the NHS.
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
57
Care of people with generalised anxiety disorder
Step 1: Recognition and diagnosis of generalised anxiety disorder (as panic disorder, see above)
Step 2: Offer treatment in primary care
The recommended treatment options have an evidence base: psychological therapy, medication, and self-help
have all been shown to be effective. The choice of treatment will be a consequence of the assessment process and
shared decision-making.
There may be instances when the most effective intervention is not available (for example, cognitive behavioural
therapy [CBT]) or is not the treatment option chosen by the patient. In these cases, the healthcare professional will
need to consider, after discussion with the patient, whether it is acceptable to offer one of the other recommended
treatments. If the preferred treatment option is currently unavailable, the healthcare professional will also have to
consider whether it is likely to become available within a useful timeframe.
If immediate management of generalised anxiety disorder is necessary, any or all of the following should be considered:
•
•
•
•
•
•
Support and information
Problem solving
Benzodiazepines
Sedating antihistamines
Self help
Benzodiazepines should not usually be used beyond 2 to 4 weeks.
In the longer-term care of individuals with generalised anxiety disorder, any of the following types of intervention
should be offered and the preference of the person with generalised anxiety disorder should be taken into account.
The interventions that have evidence for the longest duration of effect, in descending order are:
• Psychological therapy
• Pharmacological therapy (antidepressant medication)
• Self-help
The treatment option of choice should be available promptly.
There are positive advantages of services based in primary care (for example, lower rates of people who do not
attend) and these services are often preferred by patients.
Psychological Interventions
CBT should be used.
CBT should be delivered only by suitably trained and supervised people who can demonstrate that they adhere
closely to empirically grounded treatment protocols.
CBT in the optimal range of duration (16-20 hours in total) should be offered.
For most people, CBT should take the form of weekly sessions of 1-2 hours and should be completed within a
maximum of 4 months of commencement.
Briefer CBT should be supplemented with appropriate focussed information and tasks.
Where briefer CBT is used, it should be around 8-10 hours and be designed to integrate with structured
self-help materials.
58
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Pharmacological Interventions
The following must be taken into account when deciding which medication to offer:
•
•
•
•
•
•
•
•
The age of the patient
Previous treatment response
Risks
The likelihood of accidental overdose by the person being treated and by other family members if appropriate
The likelihood of deliberate self harm, by overdose or otherwise
Tolerability
The preference of the person being treated
Cost, where equal effectiveness is demonstrated
All patients who are prescribed antidepressants should be informed, at the time that treatment is initiated,
of potential side effects (including transient increase in anxiety at the start of treatment) and of the risk of
discontinuation/withdrawal symptoms if the treatment is stopped abruptly or in some instances if a dose is missed
or, occasionally, on reducing the dose of the drug.
Patients started on antidepressants should be informed about the delay in onset of effect, the time course of
treatment, the need to take medication as prescribed, and possible discontinuation/withdrawal symptoms. Written
information appropriate to the patient’s needs should be made available.
Unless otherwise indicated, an SSRI should be offered.
If one SSRI is not suitable or there is no improvement after a 12-week course, and if a further medication is
appropriate, another SSRI should be offered.
When prescribing an antidepressant, the healthcare professional should consider the following:
Side effects on the initiation of antidepressants may be minimised by starting at a low dose and increasing the dose
slowly until a satisfactory therapeutic response is achieved.
In some instances, doses at the upper end of the indicated dosage range may be necessary and should be offered
if needed.
Long-term treatment may be necessary for some people and should be offered if needed.
If the patient is showing improvement on treatment with an antidepressant, the drug should be continued for at
least 6 months after the optimal dose is reached, after which the dose can be tapered.
If there is no improvement after a 12-week course, another SSRI (if another medication is appropriate) or another
form of therapy should be offered.
Patients should be advised to take their medication as prescribed. This may be particularly important with short
half-life medication in order to avoid discontinuation/withdrawal symptoms.
Stopping antidepressants abruptly can cause discontinuation/withdrawal symptoms. To minimise the risk of
discontinuation/withdrawal symptoms when stopping antidepressants, the dose should be reduced gradually over
an extended period of time.
All patients prescribed antidepressants should be informed that, although the drugs are not associated with
tolerance and craving, discontinuation/withdrawal symptoms may occur on stopping or missing doses or,
occasionally, on reducing the dose of the drug. These symptoms are usually mild and self-limiting but occasionally
can be severe, particularly if the drug is stopped abruptly.
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
59
Healthcare professionals should inform patients that the most commonly experienced discontinuation/withdrawal
symptoms are dizziness, numbness and tingling, gastrointestinal disturbances (particularly nausea and vomiting),
headache, sweating, anxiety and sleep disturbances.
Healthcare professionals should inform patients that they should seek advice from their medical practitioner if they
experience significant discontinuation/withdrawal symptoms.
If discontinuation/withdrawal symptoms are mild, the practitioner should reassure the patient and monitor
symptoms. If severe symptoms are experienced after discontinuing an antidepressant, the practitioner should
consider reintroducing it (or prescribing another from the same class that has a longer half-life) and gradually
reducing the dose while monitoring symptoms.
Self-Help Interventions
Bibliotherapy based on CBT principles should be offered.
Information about support groups, where they are available, should be offered. (Support groups may provide
face-to-face meetings, telephone conference support groups [which can be based on CBT principles], or additional
information on all aspects of anxiety disorders plus other sources of help).
Large group CBT should be considered.
The benefits of exercise as part of good general health should be discussed with all patients as appropriate.
NICE 2002 – Current research suggests that the delivery of cognitive behavioural therapy via a computer
interface (CCBT) may be of value in the management of anxiety and depressive disorders. This evidence is,
however, an insufficient basis on which to recommend the general introduction of this technology into the NHS.
Step 3: Review and offer alternative treatment if appropriate
If, following a course of treatment, the clinician and patient agree that there has been no improvement with one
type of intervention, the patient should be reassessed and consideration given to trying one of the other types of
intervention.
Step 4: Review and offer referral from primary care if appropriate
In most instances, if there have been two interventions provided (any combination of medication, psychological
intervention, or bibliotherapy) and the person still has significant symptoms, then referral to specialist mental health
services should be offered.
If venlafaxine is being considered:
Venlafaxine treatment should only be initiated by specialist mental health medical practitioners including General
Practitioners with a Special Interest in Mental Health.
Venlafaxine treatment should only be managed under the supervision of specialist mental health medical
practitioners including General Practitioners with a Special Interest in Mental Health.
The dose of venlafaxine should be no higher than 75 mg per day.
Before prescribing venlafaxine an initial electrocardiogram (ECG) and blood pressure measurement should
be undertaken. There should be regular monitoring of blood pressure and monitoring of cardiac status as
clinically appropriate.
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Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Step 5: Care in specialist mental health services
Specialist mental health services should conduct a thorough, holistic, re-assessment of the individual, their
environment and social circumstances. This reassessment should include evaluation of:
•
•
•
•
•
•
•
Previous treatments, including effectiveness and concordance
Any substance use, including nicotine, alcohol, caffeine, and recreational drugs
Comorbidities
Day-to-day functioning
Social networks
Continuing chronic stressors
The role of agoraphobic and other avoidant symptoms.
A comprehensive risk assessment should be undertaken and an appropriate risk management plan developed.
To undertake these evaluations and to develop and share a full formulation, more than one session may be required
and should be available.
Care and management will be based on the individual’s circumstances and shared decisions arrived at. Options include:
• Treatment of comorbid conditions
• CBT with an experienced therapist if not offered already, including home based CBT if attendance at clinic is
problematic
• Structured problem solving
• Full exploration of pharmaco-therapy
• Day support to relieve carers and family members
• Referral for advice, assessment, or management to tertiary centres
There should be accurate and effective communication between all healthcare professionals involved in the care of
any person with generalised anxiety disorder and particularly between primary care clinicians (GP and teams) and
secondary care clinicians (community mental health teams) if there are existing physical health conditions that also
require active management.
Monitoring and follow up
Psychological Interventions
There should be a process within each practice to assess the progress of a person undergoing CBT. The nature of
that process should be determined on a case-by-case basis.
Pharmacological Interventions
When a new medication is started, the efficacy and side-effects should be reviewed within 2 weeks of starting
treatment and again at 4, 6, and 12 weeks. Follow the Summary of Product Characteristics (SPC) with respect to
all other monitoring required.
At the end of 12 weeks, an assessment of the effectiveness of the treatment should be made, and a decision made
as to whether to continue or consider an alternative intervention.
If medication is to be continued beyond 12 weeks, the individual should be reviewed at 8- to 12- week intervals,
depending on clinical progress and individual circumstances.
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
61
Self-Help Interventions
Individuals receiving self-help interventions should be offered contact with primary healthcare professionals, so
that progress can be monitored and alternative interventions considered if appropriate. The frequency of such
contact should be determined on a case-by-case basis, but is likely to be between every 4 and 8 weeks.
Outcome Measures
Short, self-complete questionnaires (such as the panic subscale of the agoraphobic mobility inventory for
individuals with panic disorder) should be used to monitor outcomes wherever possible.
Interventions for Generalised Anxiety Disorder (GAD)
Pharmacological compared with psychological compared with combined interventions for GAD
If immediate management of GAD is necessary, any or all of the following should be considered:
•
•
•
•
•
•
Support and information
Problem solving
Benzodiazepines
Sedative antihistamines
Self help
Benzodiazepines should not usually be used beyond 2-4 weeks.
In the longer-term care of individuals with generalised anxiety disorder, any of the following types of intervention
should be offered and the preference of the person with generalised anxiety disorder should be taken into account.
The interventions that have evidence for the longest duration of effect, in descending order are:
• Psychological therapy
• Pharmacological therapy (antidepressant medication)
• Self-help
The treatment option of choice should be available promptly.
There are positive advantages of services based in primary care (for example, lower rates of people who do not
attend) and these services are often preferred by patients.
Pharmacological interventions for GAD
The following must be taken into account when deciding which medication to offer:
• The age of the patient
• Previous treatment response
• Risks
• The likelihood of accidental overdose by the person being treated and by other family members if
appropriate
• The likelihood of deliberate self harm, by overdose or otherwise
• Tolerability
• The preference of the person being treated
• Cost, where equal effectiveness is demonstrated
All patients who are prescribed antidepressants should be informed, at the time that treatment is initiated,
of potential side effects (including transient increase in anxiety at the start of treatment) and of the risk of
discontinuation/withdrawal symptoms if the treatment is stopped abruptly or in some instances if a dose is missed
or, occasionally, on reducing the dose of the drug.
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Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
Patients started on antidepressants should be informed about the delay in onset of effect, the time course of
treatment, the need to take medication as prescribed, and the possible discontinuation/withdrawal symptoms.
Written information appropriate to the patient’s needs should be made available.
Unless otherwise indicated, an SSRI should be offered.
If one SSRI is not suitable or there is no improvement after a 12-week course, and if a further medication is
appropriate, another SSRI should be offered.
When prescribing an antidepressant, the healthcare professional should consider the following:
Side effects on the initiation of antidepressants may be minimised by starting at a low dose and increasing the dose
slowly until a satisfactory therapeutic response is achieved.
In some instances, doses at the upper end of the indicated dosage range may be necessary and should be offered
if needed.
Long-term treatment may be necessary for some people and should be offered if needed.
If the patient is showing improvement on treatment with an antidepressant, the drug should be continued for at
least 6 months after the optimal dose is reached, after which the dose can be tapered.
If there is no improvement after a 12-week course, another SSRI (if another medication is appropriate) or another
form of therapy should be offered.
Patients should be advised to take their medication as prescribed. This may be particularly important with short
half-life medication in order to avoid discontinuation/withdrawal symptoms.
Stopping antidepressants abruptly can cause discontinuation/withdrawal symptoms. To minimise the risk of
discontinuation/withdrawal symptoms when stopping antidepressants, the dose should be reduced gradually over
an extended period of time.
All patients prescribed antidepressants should be informed that, although the drugs are not associated with
tolerance and craving, discontinuation/withdrawal symptoms may occur on stopping or missing doses or,
occasionally, on reducing the dose of the drug. These symptoms are usually mild and self-limiting but occasionally
can be severe, particularly if the drug is stopped abruptly.
Healthcare professionals should inform patients that the most commonly experienced discontinuation/withdrawal
symptoms are dizziness, numbness and tingling, gastrointestinal disturbances (particularly nausea and vomiting),
headache, sweating, anxiety, and sleep disturbances.
Healthcare professionals should inform patients that they should seek advice from their medical practitioner if they
experience significant discontinuation/withdrawal symptoms.
If discontinuation/withdrawal symptoms are mild, the practitioner should reassure the patient and monitor
symptoms. If severe symptoms are experienced after discontinuing an antidepressant, the practitioner should
consider reintroducing it (or prescribing another from the same class that has a longer half-life) and gradually
reducing the dose while monitoring symptoms.
If venlafaxine is being considered:
Venlafaxine treatment should only be initiated by specialist mental health medical practitioners including General
Practitioners with a Special Interest in Mental Health.
Venlafaxine treatment should only be managed under the supervision of specialist mental health medical
practitioners including General Practitioners with a Special Interest in Mental Health.
The dose of venlafaxine should be no higher than 75 mg per day.
Before prescribing venlafaxine an initial ECG and blood pressure measurement should be undertaken. There should
be regular monitoring of blood pressure, and monitoring of cardiac status as clinically appropriate.
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
63
Psychological interventions for GAD
CBT should be used.
CBT should be delivered only by suitably trained and supervised people who can demonstrate that they adhere
closely to empirically grounded treatment protocols.
CBT in the optimal range of duration (16-20 hours in total) should be offered.
For most people, CBT should take the form of weekly sessions of 1-2 hours and should be completed within a
maximum of 4 months of commencement.
Briefer CBT should be supplemented with appropriate focussed information and tasks.
Where briefer CBT is used, it should be around 8-10 hours and be designed to integrate with structured
self-help materials.
Other interventions for GAD
Bibliotherapy based on CBT principles should be offered.
Information about support groups, where they are available, should be offered. (Support groups may provide
face-to-face meetings, telephone conference support groups [which can be based on CBT principles], or additional
information on all aspects of anxiety disorders plus other sources of help.)
Large group CBT should be considered.
The benefits of exercise as part of good general health should be discussed with all patients as appropriate.
NICE 2002 – Current research suggests that the delivery of cognitive behavioural therapy via a computer
interface (CCBT) may be of value in the management of anxiety and depressive disorders. This evidence is,
however, an insufficient basis on which to recommend the general introduction of this technology into the NHS.
c) Risk factor/recovery
Potential harms
• Antidepressants may result in a transient increase in anxiety at the start of treatment.
• Selective serotonin reuptake inhibitors (SSRIs) may cause nausea, diarrhoea, headache, dizziness, sexual
dysfunction, asthenia, somnolence sweating, changes in blood pressure, and myoclonus.
• Potential side effects of buspirone include dizziness, headaches, nausea, nervousness, and paraesthesia.
• Stopping antidepressants abruptly can cause discontinuation/withdrawal symptoms. The most commonly
experienced discontinuation/withdrawal symptoms are dizziness, numbness and tingling, gastrointestinal
disturbances (particularly nausea and vomiting), headache, sweating, anxiety, and sleep disturbances.
• Tricyclic antidepressants (TCAs) cause, to varying degrees, anticholinergic side effects (dry mouth, blurred
vision, constipation, urinary retention, sweating), sedation, and increase in heart rate.
• Serotonin syndrome may develop following co-administration of SSRIs or SSRIs with monoamine oxidase
inhibitors (MAOIs) and is potentially life threatening.
• Venlafaxine has a broad range of side effects which can increase blood pressure at higher doses and is
associated with a high incidence of discontinuation symptoms.
• Benzodiazepines side effects include fatigue and insomnia.
d) Return to work
No stated.
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Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
8. Priority for Q-COMP
Rating criteria
Functional restoration
Does the guideline consider graded increases in activity and function?
Psychosocial factors
To what degree does the guideline consider psychosocial factors that may influence recovery?
Return to work process (vocational rehabilitation)
To what degree does the guideline consider the Return to Work Process (vocational rehabilitation)?
Risk factors for recovery
To what degree does the guideline consider Risk Factors for Recovery?
Total rating
3
1
1
2
7
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
65
Guideline for the evaluation and treatment
of injured workers with psychiatric
conditions
Contents
1.
2.
3.
4.
5.
6.
7.
Developed by ................................................................................................................................................................................... 44
Guideline status ............................................................................................................................................................................... 44
Where located/how accessed ..................................................................................................................................................... 44
Description/scope .......................................................................................................................................................................... 44
Outcomes considered .................................................................................................................................................................... 46
Agree appraisal................................................................................................................................................................................. 46
Relevance/appropriateness of use in workers’ compensation sector ............................................................................... 46
a) Functional progression ............................................................................................................................................................ 46
b) Physical/psychiatric rehabilitation ........................................................................................................................................ 56
c) Risk factor/recovery ................................................................................................................................................................ 56
d) Return to work........................................................................................................................................................................... 57
8. Priority for Q-COMP ...................................................................................................................................................................... 57
66
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
1. Developed by
Washington State Department of Labor and Industries. Guideline for the evaluation and treatment of injured workers
with psychiatric conditions. Olympia (WA): Washington State Department of Labor and Industries; 2004.6 p.
2. Guideline status
This is the current release of the guideline.
This guideline updates a previous version: Washington State Department of Labor and Industries. Guidelines for
psychiatric and psychological evaluation of injured or chronically disabled workers. Olympia (WA): Washington State
Department of Labor and Industries; 2002 Aug.10 p.
3. Where located/how accessed
National Guideline Clearinghouse www.guideline.gov
Print copies; L&I Warehouse, Department of Labor and Industries, P.O. Box 44843, Olympia,
Washington 98504-4843.
4. Description/scope
Disease/condition(s)
• Psychiatric conditions suspected of retarding recovery form an industrial injury
• Psychiatric conditions caused by an industrial injury
• Preexisting psychiatric conditions aggravated by an industrial injury
Guideline category
• Diagnosis
• Evaluation
• Management
• Treatment
Clinical speciality
• Psychiatry
• Psychology
Intended users
• Physicians
• Psychologists/ Non-physician Behavioural Health Clinicians
Guideline objectives
To assist psychologists and psychiatrists who treat injured workers for psychiatric conditions that are either the
direct result of an industrial injury or are unrelated but retarding recovery from an industrial injury.
To assist physicians who treat injured workers’ physical conditions, but who from time to time refer injured workers
to psychiatrists or psychologists for treatment of psychiatric conditions.
To assist claim managers to validate their decisions, and thus help to ensure efficient medical management of the claim.
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
67
Target population
Injured workers with diagnosed or suspected psychiatric conditions
Interventions and Practices Considered
1. Formulation of a psychiatric diagnosis
• Evaluation including review of all relevant historical information
• Classification using Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)
(or current edition)
• Standardized measuring tools, such as Rollins® or Beck® scales, and individualized visual analogue scales.
2. Identification of barriers to recovery from an industrial injury
3. Formulation of a psychiatric treatment plan that addresses each diagnosed psychiatric condition and barriers to
recovery
• Use of objectively determinable measurements of recovery
• Discussion of predictable drug interactions for recommended medications
4. Assessment of psychiatric treatment
• Progress notes
• Visual analogue scale for assessing a patient’s perception
5. Outcomes considered
Not stated.
6. Agree appraisal
•
•
•
•
•
•
Scope and Purpose
Stakeholder Involvement
Rigour of Development
Clarity and Presentation
Applicability
Editorial Independence
61%
36%
24%
36%
0%
25%
7. Relevance/appropriateness of use in workers’ compensation sector
a) Functional progression
Major recommendations
Authorization requirements
Initial psychiatric evaluation and ongoing treatment of a psychiatric condition both require prior approval from
the department or self-insured employer (WAC 296-21-270). Authorization for psychiatric treatment may be
granted for periods of 90 days or less. Subsequent authorization periods of 90 days or less are contingent on
documented progress in psychiatric treatment.
Claim managers may authorize payment for treatment of psychiatric conditions that are retarding recovery from
an industrial injury, even though the injury did not cause the psychiatric condition or aggravate a preexisting
psychiatric condition. Claim managers can also authorize payment for treatment of psychiatric conditions when
they have been caused or aggravated by an industrial injury.
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Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
If authorization for psychiatric treatment is requested following an initial psychiatric evaluation, it is the claim
manager’s responsibility to make a determination as to the relationship between the industrial injury and the
psychiatric condition based on the information provided. For this reason, it is very important for the psychiatrist or
psychologist to clearly indicate their opinion, and the basis for their opinion, whether:
• The injured worker’s psychiatric condition was not caused or aggravated by the industrial injury, but it creates a
barrier to recovery from a condition for which the department has accepted liability.
• The injured worker’s psychiatric condition was caused by the industrial injury.
• The injured worker’s psychiatric condition is a preexisting condition that was aggravated by the industrial injury.
• The injured worker’s psychiatric condition was neither caused nor aggravated by the industrial injury, nor is it
creating a barrier to recovery from a condition for which the department has accepted liability.
Elements of a comprehensive psychiatric plan
Elements of a comprehensive psychiatric treatment plan would include formulation of a psychiatric diagnosis;
identification of barriers to recovery; development of an intensive, goal-directed plan; and recommendation for
duration of therapy.
Diagnosis of a psychiatric condition
Diagnosis is an essential first step to the development of a plan for treatment of psychiatric conditions. Diagnoses
should be specific, and should use the nomenclature and numerical identification of the Diagnostic and Statistical
Manual of Mental Disorders, 4th edition (DSM-IV) (or current edition). The diagnostic section of the initial
report, and all subsequent reports, should address all five axes described in the DSM-IV (or current
edition). Diagnoses should be based on all relevant historical information. Specific inquiry should be made into the
patients´ preinjury and current medical, psychosocial, and psychological status. Whenever possible, prior medical
records should be reviewed to screen for the presence of diagnostically important information and for information
that may be useful in the creation of a treatment plan. Carefully document any pertinent positive or negative
historical information.
Consideration should be given to the use of standardized measuring tools, such as the Rollins® or Beck® scales,
and the use of individualized visual analog scales. Such measurements provide both support for diagnoses and
benchmarks against which progress in treatment can be measured.
What are the reporting requirements?
All reports should be written in a legible style that can be understood by nonmedical personnel. Each report must
contain at least a summary of subjective complaints, objective observations, assessment of progress toward
meeting goals, updated treatment plan, and DSM-IV (or current edition) axis format assessment (WAC 296-21270). The use of specific examples of a patient’s behavior may be a helpful way to communicate the effects of a
psychological condition, or the effects of treatment for such a condition.
Doctors treating psychiatric conditions allowed on a claim are required to submit progress reports to the claim
manager every sixty days (WAC 296-21-270). If temporary treatment has been authorized for an unrelated
psychiatric condition, progress reports are required to be submitted to the claim manager every thirty days
(WAC 296-20-055). (Refer to the original guideline document for information on billing codes.)
b) Physical/psychiatric rehabilitation
Formulation of a psychiatric treatment plan
The psychiatrist or psychologist evaluating a worker with a psychiatric condition should create a treatment plan
that addresses each diagnosed psychiatric condition and any identified barriers to recovery. The treatment plan
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
69
must include intensive, goal-directed treatment and include a recommended duration of treatment. The treatment
plan should be included in the evaluation report and updated throughout treatment.
Objectively determinable measurements of recovery should be identified for each condition for which treatment
is proposed. Objective measurements should be individualized so that each patient’s progress or lack of progress
will be accurately assessed. Examples of such measurements include documentation of the level of physical
activity; improved participation in physical therapy, occupational therapy, work hardening, or vocational counseling
programs; normalization of common behavior patterns such as sleep cycles and eating disorders; and changes in
medication usage. To the extent that a treatment plan may recommend medications, the plan should include a
discussion of any predictable drug interactions the recommended medications might have with medications the
worker is currently taking. (Refer to the original guideline document for an example of a treatment plan.)
Identification of the measured variable should include a description of what will be measured, the intervals and
duration during which the variable will be measured, the anticipated endpoint, and the anticipated progress to that
endpoint at each interval measurement. When appropriate, use standardized measurements such as the Rollins® or
Beck® scales to document the extent of recovery. Each variable to be measured should be explained to the injured
worker before treatment is actually commenced. If necessary, the patient should be instructed in how to complete
diaries that document such variables as pain, activity, medication use, etc.
In the event that the psychiatric treatment plan includes measurements of indicators that are outside the practice
of the psychiatrist or psychologist, prior arrangements to obtain such measurements should be made by the
psychiatrist or psychologist with the attending doctor. Such measurements should be available to the psychiatrist
or psychologist at the time each respective progress note is created. (Refer to the original guideline document for
an example of measurements arranged by the psychiatrist or psychologist and the attending doctor.)
Assessment of psychiatric treatment and recommendations
A progress note should be prepared following each clinic visit. Per WAC 296-20- 06101, legible copies of progress
notes must be submitted to the department for all treatment. The progress note should document the patient’s
interval history and should summarize any pertinent positive or negative findings. Indicators that are measured
to assess progress should be documented along with measurements obtained during the interval period. An
assessment should be made as to whether the measurements reflect the expected progress.
A visual analog scale can be a useful tool in assessing a patient´s perception. Generally, such scales consist of a 10cm horizontal line with words at opposite ends of the spectrum. Studies have shown that visual analog scales are
most accurately representative of that which they seek to measure when the horizontal line contains no arbitrary
divisions such as numbers, interval marks, etc. The patient is instructed to place a vertical mark at the point on the
line that seems most appropriate to the patient.
Should expected progress not be made, the report of the psychiatrist or psychologist should contain a discussion
concerning the postulated reasons for lack of progress. If necessary, the treatment plan should be reassessed, and
any necessary modifications made. (Refer to the original guideline document for an example of a progress note.)
c) Risk factor/recovery
Identification of barriers to recovery from an industrial injury
Each diagnosed psychiatric condition should be assessed to determine whether it is retarding a patient’s recovery
from an industrial injury. Any such barriers should be clearly identified and the report should provide an explanation
that links the psychiatric condition to an observable, measurable behavior that interferes with recovery from an
industrial injury. (Refer to the original guideline document for an example.)
Specific inquiry should be made to determine whether there are employment related risk factors that should be
addressed in a health care setting. For example, anger towards the employer, supervisor, or coworkers may need
to be addressed. Economic disincentives and employment-related loss of self-esteem can each contribute to the
failure of a worker to make expected progress in recovery. Feelings of victimization may delay a return to a normal
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Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
lifestyle. Such risk factors should be carefully identified and documented.
d) Return to work
Not discussed.
8. Priority for Q-COMP
Rating criteria
Functional restoration
Does the guideline consider graded increases in activity and function?
Psychosocial factors
To what degree does the guideline consider psychosocial factors that may influence recovery?
Return to work process (vocational rehabilitation)
To what degree does the guideline consider the Return to Work Process (vocational rehabilitation)?
Risk factors for recovery
To what degree does the guideline consider Risk Factors for Recovery?
Total rating
1
1
2
1
5
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
71
VA/DoD clinical practice guideline for the
management of post-traumatic stress
Contents
1.
2.
3.
4.
5.
6.
7.
Developed by ................................................................................................................................................................................... 73
Guideline status ............................................................................................................................................................................... 73
Where located/how accessed ..................................................................................................................................................... 73
Description/scope .......................................................................................................................................................................... 73
Outcomes considered .................................................................................................................................................................... 77
Agree appraisal................................................................................................................................................................................. 77
Relevance/appropriateness of use in workers’ compensation sector ............................................................................... 77
a) Functional progression ............................................................................................................................................................ 77
b) Physical/psychiatric rehabilitation ......................................................................................................................................104
c) Risk factor/recovery ..............................................................................................................................................................105
d) Return to work.........................................................................................................................................................................107
8. Priority for Q-COMP ....................................................................................................................................................................107
72
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
1. Developed by
Veterans Health Administration, Department of Defence. VA/DoD clinical practice guideline for the management
of post-traumatic stress. Version 1.0. Washington (DC): Veterans Health Administration, Department of Defense;
2004 Jan. Various p. [479 references]
2. Guideline status
This is the current release of the guideline.
3. Where located/how accessed
National Guideline Clearinghouse www.clearinghouse.gov
Electronic copies; Available in Portable Document Format (PDF) from the Department of Veterans Affairs Web site.
Print copies; Available from the Department of Veterans Affairs, Veterans Health Administration, Office if Quality
and Performance (10Q) 810 Vermont Ave.NW, Washington, DC 20420
The following companion documents are available:
• Various companion documents are available from the: Veterans Health Administration (VHA) Web site.
• In addition, the VHA Web site provides references to related guidelines, performance measures, and other
resources.
• Guideline for guidelines. Draft. Washington (DC): Veterans Health Administration, Department of Veterans
Affairs. Available at: VHA Web site.
Print copies: Department of Veterans Affairs, Veterans Health Administration, Office of Quality and Performance
(10Q) 810 Vermont Ave. NW, Washington, DC 20420.
4. Description/scope
Disease/condition(s)
• Post traumatic stress disorder
Guideline category
• Diagnosis
• Evaluation
• Management
• Prevention
• Treatment
Clinical speciality
• Family Practice
• Internal Medicine
• Psychiatry
• Psychology
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
73
Intended users
• Health Care Providers
• Health Plans
• Hospitals
• Managed Care Organizations
• Nurses
• Physician Assistants
• Physicians
• Psychologists/ Non-physician Behavioural Health Clinicians
Guideline objectives
To survey best practices in post-traumatic stress disorder prevention, diagnosis, and treatment and to determine
whether the evidence supports current practices, or whether the evidence suggests they should be modified
or discontinued.
Target population
Any person who is eligible for care in the Veterans Affairs or Department of Defense health care delivery system,
specifically, military men or women and veterans who have survived traumatic events.
Interventions and practices considered
1. Initial Evaluation and Triage (includes Primary Prevention)
• Education and training to promote hardiness and resiliency
• Provide realistic training
• Strengthen perceived ability to cope
• Create supportive interpersonal work environments
• Develop and maintain adaptive beliefs
• Develop workplace-specific comprehensive traumatic stress management programs
2. Screen for Post-Traumatic Stress Disorder (PTSD) symptoms
• Primary care PTSD Screen
• PTSD Brief Screen
• Short Screening Scale for Diagnostic and Statistical Manual , 4th editions (DSM IV ) PTSD
Management of Acute Stress Reaction (ASR)
1. Screen for ASR
2. Assess medical and functional status based on general appearance and screening instruments
3. Medical status including:
• History, physical examination, and a neurological examination
• Use of prescribed medications, mood or mind-altering substances, and possible biological or chemical agent
exposure
• A minimal mental status examination to assess cognitive function
• Screen for toxicity
• Radiological assessment of patients with focal neurological findings or possible head injury
• Appropriate laboratory studies to rule out medical disorders that may cause symptoms of acute stress
reactions (e.g., complete blood count [CBC] , chemistry profile, thyroid studies, human chorionic
gonadotropin [HCG], electrocardiogram, electroencephalogram)
74
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
• A focused psychosocial assessment
• Brief assessment of functioning
4. Ensure basic physical needs are met by protecting, directing, connecting with, and triaging patients.
5. Acute symptom management
• Assurance/ reassurance
• Defusing (3-phased discussion provided within hours of the crisis for purpose of assessment triage and
acute symptom mitigation)
• Mitigate fear and anxiety
• Sleep hygiene
• Re-establish routine
• Exercise and nutrition
• Bereavement
• Survivor success
• Advise about alcohol/substance abuse
• Modulate mood/irritability
6. Psychological debriefing
7. Facilitate social and Psychological support
8. Pharmacotherapy
• Propanolol
• Benzodiazepines
• Other sympatholytics
• Antidepressants
• Anticonvulscents
• Atypical antipsychotics
• Antihistamines
• Typical antipsychotics
9. Reassessment after acute intervention by evaluation of risk factors
10. Referral and consultation with mental health professionals
Management of Combat and Ongoing Operation Stress Reaction (COSR)
1. Screening for symptoms of COSR
2. Assess risk of harm to self or others
3. Identification of service members who can return to functioning in unit
4. Acute symptom management according to “PIES” principle (proximity, immediacy, expectancy, simplicity)
5. Transfer for treatment, as needed.
Management of Acute Stress Disorder (ASD) and Post-Traumatic Stress Disorder (PTSD) in
Primary Care
1. Assessment of trauma exposure, trauma-related symptoms, and dangerousness to self or others
2. Obtain medical history, physical examination, mental status examination, laboratory tests, psychological
assessment, functional assessment, and other evaluations
3. Patient education
4. Referral to Vet Centers
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Management of Acute Stress Disorder (ASD) and Post-Traumatic Stress Disorder (PTSD) in
Specialty Care
1. Mental health assessment
2. Medical history, physical examination, mental status examination, psychosocial assessment, and appropriate
lab test
3. Documentation of DSM-IV criteria in medical record
4. Patient and family education
5. Initiation of therapy for PTSD
6. Reassessment of status after therapeutic interventions
7. Follow-up in mental health and referral
Evidence-based intervention for treatment of PTSD
1. Cognitive Therapy
2. Exposure Therapy
3. Stress Inoculation Testing
4. Eye Movement Desensitization and Reprocessing
5. Imagery Rehearsal Therapy
6. Psychodynamic Therapy
7. Group Therapy
8. Dialectic Behaviour Therapy
9. Hypnosis
10. Spiritual Support
11. Acute Stress Disorder Pharmacotherapy
• Imipramine
• Propranolol
• Benzodiazepines
• Anticonvulscents
• Other antidepressants
• Other sympatholytics
• Atypical antipsychotics
• Chloral hydrate
• Typical antipsychotics (not recommended)
12. Post-traumatic stress disorder pharmacotherapy using monotherapy and/or augmented therapy for targeted
symptoms
• Selective serotonin reuptake inhibitors (SSRIs)
• Tricyclic antidepressants (TCA’s)
• Monoamine oxidase inhibitors (MAOIs)
• Sympatholytics
• Novel antidepressants
• Anticonvulscents
• Atypical antipsychotics
• Buspirone
• Non-benzodiazepines hypnotics
• Benzodiazepines (not recommended)
• Typical antipsychotics (not recommended)
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5. Outcomes considered
• Effect on treatment on Clinician Administered Post-traumatic Stress Disorder Scale (CAPS) or other measures
of post-traumatic stress disorder (PTSD)
• Effect of treatment on symptoms of PTSD
• Relapse rate in persons with PTSD
• Prevention of PTSD
• Risk factors of PTSD
• Sensitivity and specificity of screening tools for PTSD
6. Agree appraisal
•
•
•
•
•
•
Scope and Purpose
Stakeholder Involvement
Rigour of Development
Clarity and Presentation
Applicability
Editorial Independence
67%
46%
60%
92%
11%
17%
7. Relevance/appropriateness of use in workers’ compensation sector
a) Functional progression
Major recommendations
The recommendations for the management of post-traumatic stress are organized into 5 major algorithms.
Note: A list of abbreviations is provided at the end of the “Major Recommendations” field.
Core module - initial evaluation and triage
Primary prevention
A. Education and training to promote hardiness and resiliency
Objective
Prepare individuals and groups for exposure to traumatic experiences in ways that minimize the likelihood of
development of post traumatic stress disorder (PTSD) and other trauma-related problems.
Recommendations
1. In high-risk occupations for which probability of trauma exposure is moderate or high, efforts should be
undertaken to increase psychological resilience of workers to the negative effects of trauma exposure. (Working
Group Consensus)
B. People at-risk for developing stress symptoms after trauma
Objective
Identify persons at risk for developing a traumatic stress disorder (PTSD) after trauma exposure.
Recommendations
1. Persons exposed to trauma should be assessed for known risk factors for developing PTSD – both pre-trauma
risks and post-trauma risks. (Brewin, Andrews, & Valentine, 2000)
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2. The trauma type, nature, and severity should be assessed. (Brewin et al., 1999; Bryant et al., 2000; Harvey &
Bryant, 2000; Mellman et al., 2001)
3. Assessment of existing social supports and ongoing stressors is important. (Litz et al., 2002)
4. Patients with Acute Stress Disorder (ASD) warrant careful clinical attention, as they are at high-risk for
developing PTSD. (Birmes et al., 2001; Brewin et al., 1999; Bryant et al., 2000, Harvey & Bryant, 2000;
Mellman et al., 2001; Murray, Ehlers, & Mayou, 2002)
5. Patients with dissociative symptoms may also warrant careful clinical attention. (Brewin et al., 1999; Murray,
Ehlers, & Mayou, 2002
C. Screen for PTSD symptoms
Objective
Identify possible cases of PTSD.
Recommendations
1. All new patients should be screened for symptoms of PTSD (Breslau et al., “Previous exposure,” 1999; Leskin &
Westrup, 1999; Prins et al. 1999; Taubman-Ben-Ari et al., 2001) initially and then on an annual basis or more
frequently if clinically indicated due to clinical suspicion, recent trauma exposure (e.g., major disaster), or history
of PTSD.(Working Group Consensus)
2. Patients should be screened for symptoms of PTSD using paper and pencil or computer-based screening tools.
3. No studies are available that compare the benefits of one PTSD screening tool versus another. However, the
following screening tools have been validated and should be considered for use:
• Primary Care PTSD Screen (PC-PTSD)
• PTSD Brief Screen
• Short Screening Scale for DSM IV PTSD
(Breslau et al. “Previous exposure,” 1999; Leskin & Westrup, 1999; Prins et al., 1999)
4. There is, as yet, insufficient evidence to recommend special screening or differing PTSD treatment for members
of any cultural or racial groups. (Frueh, Brady & de Arellano , 1998; Frueh et al., 1997; Frueh, Smith, & Libet,
1996; Ortega & Rosenheck, 2000; Penk et al., 1989; Rosenheck & Fontana, 1996; Trent et al., 2000)
D. Are trauma related symptoms present?
Objective
Identify people exposed to trauma who are at risk for developing an acute stress reaction (ASR), acute stress
disorder (ASD), or post-traumatic stress disorder (PTSD).
Recommendations
1. Individuals who are presumed to have symptoms of PTSD or who are positive for PTSD on the initial 4-item
screening should receive specific assessment of their symptoms.
2. Useful information may include details such as time of onset, frequency, course, severity, level of distress,
functional impairment, and other relevant information.
3. The elapsed time since the exposure to trauma is very important in assessing the risk of developing PTSD and
determining the appropriate intervention. See the original guideline document for definitions of stress-related
disorders and syndromes that will help providers select the appropriate treatment algorithm.
E. Normalization for asymptomatic survivors and responders
Objective
Help trauma survivors and responders who are NOT themselves experiencing signs or symptoms recognize that
these reactions in others are common in the aftermath of trauma and do not signify personal inadequacy, health
problems, mental illness, or other enduring negative consequences.
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Recommendations
1. Pre- and post-trauma education should include helping asymptomatic trauma survivor or responder understand
that the acute stress reactions of other people are common and do not indicate personal failure or weakness,
mental illness, or health problems. The responders should be taught the simple words and measures that will
support quick recovery, rather than push survivors towards a persisting disorder. (Working Group Consensus);
2. Education should include sufficient review of the many ways that post traumatic problems can present,
including symptoms in the ASD/PTSD spectrum, behavioral problems with family and friends, occupational
problems, and alcohol or other substance misuse/abuse.
3. Provide education and access information to include the following:
• Begin with clear statement about ASR being normal, common, and expectable responses to trauma; the
reliance on self and buddy management, and other available resources if stress symptoms persist or worsen.
• Maximize positive expectation of mastery.
• Demystify PTSD (before listing symptoms) and emphasize the human brain and mind´s natural resiliency
(e.g., our forefathers/mothers, generations ago survived very bad situations or we wouldn´t be here, and we
can survive also).
• Painful memories sometimes get stuck, through no fault of the sufferer. Such memories cause real biological
changes that can cause physical change and illness elsewhere in the body. Many of these changes can be
reversed. All can be compensated for by developing new brain skills, aided by medication when appropriate.
• Professionals with special skills and capabilities (including some religious pastors and mental health
professionals, other medical people, and others with special training and supervision) can intervene to
reverse this process.
• Resolving developing symptoms and problems
Module a1 - acute stress reaction (asr)
Assessment
A. Trauma exposure
Definition
Traumatic events are events that cause a person to fear that he or she may die or be seriously injured or harmed.
These events also can be traumatic when the person witnesses them happening to others. Such events often
create feelings of intense fear, helplessness, or horror for those who experience them. Among the common kinds of
traumatic events are:
•
•
•
•
•
•
•
•
Combat in a war zone
Rape or other sexual assault
Natural disaster (e.g., hurricanes, floods, or fires)
Child physical and/or sexual abuse
Domestic violence (battering)
Motor vehicle accidents
Exposure to the sudden or unexpected death of others
Sudden life-threatening physical illness (e.g., heart attack or cancer)
B. Screen for ASR
Objective
Identify individuals who may be at risk for endangering themselves or others due to emotional distress or
functional incapacity.
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Recommendations
1. Identification of a patient with ASR symptoms is based on observation of behavior and function.
2. There is no evidence to support any specific screening tool.
3. Individuals exhibiting the following responses to trauma should be screened for ASR:
• Physical: exhaustion, hyperarousal, somatic complaints (gastrointestinal [GI], genitourinary [GU],
musculoskeletal [MS], cardiovascular [CV], respiratory, nervous system [NS]), conversion disorder symptoms
• Emotional: anxiety, depression, guilt/hopelessness
• Behavioral: avoidance, problematic substance use
• Cognitive/mental: amnestic or dissociative symptoms, hypervigilance, paranoia, intrusive re-experiencing.
C. Dangerousness to self or others
Objective
Protect individuals who may be at risk for endangering themselves or others due to emotional distress or
functional incapacity.
Recommendations
1. Acute medical issues should be addressed to preserve life and avoid further harm:
• ABC´s (Maintain: Airways, Breathing, Circulation)
• Substance intoxication or withdrawal
• Danger to self or others: suicidal, homicidal behavior
• Self-injury or mutilation
• Inability to care for oneself
2. A safe private, and comfortable environment should be arranged for continuation of the evaluation.
• Establish a working treatment alliance with the patient
• Maintain a supportive, nonblaming nonjudgmental stance throughout the evaluation
• Help with the removal of any ongoing traumatic event
• Minimizing further traumas that may arise from the initial traumatic event
• Assess and optimize social supports
3. Legal mandates should be followed:
• Reporting of violence, assault
• Confidentiality for the patient
• Mandatory testing
• Attend to chain of evidence in criminal cases (e.g., rape, evaluation)
• Involuntary Commitment procedures if needed
4. Carefully consider the following potential interventions to secure safety:
• Find safe accommodation and protecting against further trauma
• Voluntary Admission
• Restraint/seclusion only if less restrictive measures are ineffective
• Forced medications
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D. Assess medical and functional status based on general appearance and screening instruments
Recommendations
1. Medical status should be obtained for all persons presenting with symptoms to include:
• History, physical examination, and a neurological examination
• Use of prescribed medications, mood or mind-altering substances, and possible biological or chemical
agent exposure
• A minimal mental status examination to assess cognitive function
2. The history and physical examination findings should lead the provider to other assessments as clinically
indicated. There is no test for acute stress reaction, so testing is directed towards detection of associated
medical conditions. Assessment may include:
• Screen for toxicology if the symptom presentation indicates
• Radiological assessment of patients with focal neurological findings or possible head injury
• Appropriate laboratory studies to rule out medical disorders that may cause symptoms of acute stress
reactions (e.g., complete blood count [CBC], chemistry profile, thyroid studies, human choriogonadotropin
[HCG}, electrocardiogram [EKG], electroencephalography [EEG])
3. A focused psychosocial assessment should be performed including active stressors, losses, current social
supports, basic needs (e.g. housing, food, financial resources).
4. A brief assessment of function based on general appearance and behavior should be completed to evaluate:
1) objectively impaired function; 2) subjectively impaired function; 3) baseline level of function (LOF) vs.
current LOF; and 4) family and relationship functioning.
The approach to triage in the immediate response to traumatic exposure for service members with symptoms
during Ongoing Military Operations may vary markedly from the management of civilians exposed to traumatic
events. Combat and Operational Stress Reactions (COSR) management is targeted to preserve the fighting
force and return the service member (SM) to functional status.
See module A2 - Management of Combat and Operational Stress Reaction (COSR)
E. Assess preexisting psychiatric and medical conditions
Recommendations
1. Assessment of patients with preexisting psychiatric conditions to identify the vulnerable, high-risk individuals
and groups
2. Referral to mental health specialty when indicated or emergency hospitalization if needed.
F. Risk factors for developing ASD/PTSD
Recommendations
1. Individuals exposed to trauma should be screened for one or more of the following risk factors for developing
ASD/PTSD.
Pre-traumatic factors:
•
•
•
•
Ongoing life stress
Lack of social support
Preexisting psychiatric disorder
Other pre-traumatic factors including: female gender, low socioeconomic status, lower level of education, lower
level of intelligence, race (Hispanic, Japanese, other ethnic minority), reported abuse in childhood, report of
other previous traumatization, report of other adverse childhood factors, family history of psychiatric disorders,
poor training or preparation for the traumatic event
• Peri-traumatic or trauma related factors:
• Severe trauma
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•
•
•
•
•
Type of trauma (interpersonal traumas such as torture, rape, or assault convey high risk of PTSD)
High perceived threat to life
Age at trauma (school age youth, 40–60 years of age)
Community (mass) trauma
Other peri-traumatic factors including: history of peri-traumatic dissociation and interpersonal trauma
Post-traumatic factors:
•
•
•
•
•
Ongoing life stress
Lack of social support
Bereavement
Major loss of resources
Other post-traumatic factors including children at home and female with distressed spouse
Triage and treatment
G. Ensure basic physical needs are met
Objective
Ensure trauma-exposed persons with acute stress symptoms have their basic needs met.
Recommendations
1. Acute intervention should ensure that the following needs are met: Basic Needs:
•
•
•
•
•
•
•
Safety/security/survival
Food, hydration, clothing, and shelter
Sleep
Medication (i.e., replace medications destroyed/lost)
Orientation
Communication with family, friends, and community
Protection from ongoing threats/toxins/harm
Psychological First Aid:
•
•
•
•
•
•
82
Protect survivors from further harm
Reduce physiological arousal
Mobilize support for those who are most distressed
Keep families together and facilitate reunion with loved ones
Provide information, foster communication and education
Use effective risk communication techniques
Clinical Guidelines for the Queensland Workers’ Compensation Scheme Psychiatric Conditions
H. Acute symptom management
Recommendations
1. Symptoms treatment should be provided after basic needs are met (e.g., sleep, normalization, and other
nonpharmacological modalities).
2. Apply a series of specific psychological interventions (individually or in a group) to reduce acute stress
symptoms and to address both general recovery and specific symptoms (e.g., breathing/relaxation treatment).
Individual psychological interventions may include:
• Assurance/reassurance
• Defusing (3-phased discussion provided within hours of the crisis for purpose of assessment triage and
acute symptom mitigation)
• Mitigate fear and anxiety
• Sleep hygiene
• Reestablish routine
• Exercise and nutrition
• Bereavement
• Survivor success
• Advise about alcohol/substance use
• Modulate mood/irritability
Group psychological interventions:
• Groups may be effective vehicles for providing trauma-related education, training in coping skills, and
increasing social support especially in the context of multiple group sessions.
• Group participation should be voluntary.
3. Peoples´ reaction to ASR varies. Some want and feel a need to discuss the event, and some have no such need.
Respect individual and cultural preferences in the attempt to meet their needs as much as possible. Allow normal
recovery, and monitor.
4. Consider a short course of medication for some individuals targeted for specific symptoms (e.g., sleep
disturbance). [See Annotation M ]
I. Psychological debriefing
Objective
Reduce risk for development of PTSD following traumatic event.
Recommendation
Individual:
1. 1. Recommend against psychological debriefing as a viable means of reducing acute post-traumatic distress
(ASR or ASD) or progression to PTSD. (Hobbs et al., 1996; Mayou, Ehlers, & Hobbs, 2000; Bisson et al.,
1997 Group:
2. 1. There is insufficient evidence to recommend for or against conducting structured group debriefing.
3. 2. Compulsory repetition of traumatic experiences in a group may be counterproductive.
4. 3. Group debriefing with preexisting groups (teams, units, Emergency Medical Teams [EMTs], co-workers,
family members) may assist with group cohesion, morale, and other important variables that have not been
demonstrated empirically. (Foa, Keane, & Friedman, 2000; Rose, Bisson, & Wessely, 2002)
5. 4. Group participation should be voluntary.
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J. Education and normalization / expectancy of recovery
Recommendation
1. All survivors should be given educational information to help normalize common reactions to trauma, improve
coping, enhance self-care, facilitate recognition of significant problems, and increase knowledge of and access
to services. Such information can be delivered in many ways, including public media, community education
activities, and written materials.
K. Facilitate social and spiritual support
Recommendation
1. Preserve an interpersonal safety zone protecting basic personal space (e.g., privacy, quiet, personal effects).
2. Provide nonintrusive ordinary social contact (e.g., a “sounding board,” judicious use of humor, small talk about
current events, silent companionship). 3. Provide opportunities for grieving for losses. Provide access to
religious/spiritual resources when sought. (Providing space and opportunities for prayers, mantras, rites and
rituals, and end-of-life care as determined important by the patient)
3. Consider providing direct spiritual care or ensuring patient access to spiritual care when sought.
Evidence
1. Consider referral for religious/spiritual counseling as indicated for patient symptoms, consistent with available
resources, and resonant with patient belief systems (Baldacchino & Draper, 2001; Bell Meisenhelder, 2002;
Calhoun et al., 2000; Humphreys et al., 2001; Nixon et al., 1999; Strawbridge et al., 1998)
2. When providing psychological first aid or primary care services, consider providing direct spiritual care or
ensuring patient access to spiritual care (Bogia & Preston, 1985; Everly, “The role of pastoral crisis,” 2000)
3. For patients who have developed PTSD, consider referral for religious/spiritual counseling as indicated for patient
symptoms, consistent with available resources, and resonant with patient belief systems (Baldacchino & Draper,
2001; Bell Meisenhelder, 2002; Calhoun et al., 2000; Humphreys et al., 2001; Nixon et al., 1999; Strawbridge et
al., 1998)
Objective
To lessen the physical, psychological, and behavioral morbidity associated with acute stress reaction, hasten the
return to full function (duty), and diminish the likelihood of chronicity
Recommendations
Summary Table – Pharmacotherapy for ASR
R*
Significant Benefit
Some Benefit
Unknown
No
Benefit/Harm
A
B
C
I
Propanolol
Benzodiazapines
Other aympatholytics
Antidepressants
Anticonvulscents
Atypical antipsychotics
Antihistamines
D
*R = Level of recommendation
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Typical antipsychotics
1. Strongly recommend providing for physical needs, sleep, normalization, and other non-pharmacological
modalities.
2. Recommend the use of medication only for individuals that do not respond to non-pharmacological treatment
as a normal recovery is expected from ASR.
3. Consider a short course of medication targeted for specific symptoms.
• Sleep disturbance/insomnia (e.g., benzodiazepines, antihistamines)
• Hyperarousal/excessive arousal/panic attacks. (e.g., benzodiazepines, propranolol [up to 10 days])
4. There is insufficient evidence to support a recommendation for preventative use of a pharmacological agent to
prevent the development of ASD or PTSD.
Evidence
1. Benzodiazepines (Mellman, Byers, & Augenstein, 1998)
2. Antihistamines
3. Propranolol (Pitman et al., 2002)
4. Pharmacotherapy prophylaxis for ASD or PTSD (Stein et al., 2000)
M. Reassessment
Objective
Identify patients with persistent traumatic stress symptoms, related dysfunction, or additional treatment needs.
Recommendations
1. Treatment response to the acute intervention should be reassessed. This should include an evaluation for the
following risk factors:
• Persistent or worsening traumatic stress symptoms (e.g., dissociation, panic, autonomic arousal,
cognitive impairment)
• Significant functional impairments (e.g. role/work, relationships)
• Dangerousness (suicidal or violent ideation, plan, and/or intent)
• Severe psychiatric comorbidity (e.g., psychotic spectrum disorder, substance use disorder or abuse)
• Maladaptive coping strategies (e.g., pattern of impulsivity, social withdrawal under stress)
• New or evolving psychosocial stressors
• Poor social supports
2. Follow-up after acute intervention to determine patient status.
• Patient does not improve or status worsens – refer to mental health provider and/or PTSD specialty
team. Recommend continued involvement of the primary care provider in the treatment. Patients with
multiple problems may benefit from a multi-disciplinary approach to include occupational therapy, spiritual
counseling, recreation therapy, social work, psychology, and/or psychiatry.
• Patient demonstrates partial improvement (e.g., less arousal, but no improvement in sleep) – consider
augmentation or adjustment of the acute intervention within 2 weeks.
• Patient recovers from acute symptoms – provide education about acute stress reaction and contact
information with instructions for available follow-up if needed.
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Follow-up
N. Referral and consultation with mental health
Objective
Provide guidance for primary care providers on optimal referral for potential PTSD patients.
Recommendations
1. Individuals who exhibit any of the following conditions should be referred to mental health:
• Failure to respond to acute supportive interventions
• Worsening of stress related symptoms
• High potential for dangerousness
• Development of ASD/PTSD
• New onset of dangerousness or maladaptive coping to stress
• Exacerbation of pre existing psychiatric conditions
• Deterioration in function
• New onset stressors, poor social supports, or inadequate coping skills.
O. Monitor and follow-up
Recommendations
1. Follow-up should be offered to those individuals who request it.
2. Follow-up should be offered to individuals and groups at high risk of developing adjustment difficulties following
exposure to major incidents and disasters, including individuals who:
• Have ASD or other clinically significant symptoms stemming from the trauma
• Are bereaved
• Have a preexisting psychiatric disorder
• Have required medical or surgical attention
• Were exposed to a major incident or disaster that was particularly intense and of long duration
Module a2 – combat and ongoing operation stress reaction (cosr)
The approach to triage in the immediate response to traumatic exposure for service members with symptoms
during Ongoing Military Operations is directed by dual sets of objectives:
Military considerations
Management of combat and operational stress reactions (COSR) during ongoing military operations is targeted to
preserve the fighting force and return the service member (SM) to functional status. Context and setting of care
delivery may vary markedly.
Military clinical objectives
1. Prevent exacerbation of symptoms/mitigate symptoms of acute stress
2. Prevent development of traumatic stress sequelae (e.g., ASD, PTSD, depressive disorders, anxiety disorders, and
substance use disorders)
3. Keep SM with his/her unit and prevent unnecessary medical evacuation
4. Return SM to duty as soon as possible
5. Maintain and enhance unit capabilities and readiness Prior to deployment and regularly thereafter, ensure
appropriate primary prevention in the form of COSR briefs are offered to combatants, providers, and the chain
of command.
NOTE: For further discussion of the key element, please see Module A1: Acute Stress Reaction.
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A. Service member with symptoms Of Combat And Operational Stress Reaction (COSR) During ongoing
military operations
Recommendations
1. Identify service member with symptoms compatible with COSR. Symptoms are not attributed to identified
medical/surgical condition requiring other urgent treatment (a service member can have COSR concurrent with
minor return-to-duty [RTD] wounds/illness)
2. Evacuate to next level of care, if unmanageable
3. Screen service member for symptoms of COSR, which include:
• Exhaustion/burnout
• Hyperarousal and anxiety
• Somatic complaints (gastrointestinal, genitourinary, musculoskeletal, cardiovascular, respiratory, nervous
system)
• Depression or guilt/hopelessness
• Conversion Disorder symptoms
• Amnestic or dissociative symptoms
• Behavioral changes
• Emotional dysregulation
• Anger/irritability
• Brief, manageable “psychotic symptoms” (e.g., hallucination due to sleep deprivation and mild “paranoia”)
4. Address the underlying cause of symptoms (e.g., sleep deprivation) in brief restoration program. Advise service
member´s Commander, chaplain, etc. on follow-up actions. Document symptoms and observations.
B. Assess risk of harm to self or others; seek collateral information about stressors, and service
member´s function, medical history, and absence or impairment on operation or mission
Objective
Obtain information to assess service member´s condition and triage for appropriate care.
Recommendations
1. Arrange for a safe and comfortable environment to continue the evaluation. Secure any weapons and explosives.
2. Medical triage to rule out:
• Neurotoxicant exposure
• Head injury
• Undetected wounds
• Acute physical illness (e.g., infectious)
3. Document symptoms of COSR, obtain collateral information from unit leaders, and assess service member´s
function, to include:
• Any changes in productivity?
• Coworker or supervisor reports of recent changes in appearance, quality of work, or relationships?
• Any tardiness/unreliability, loss of motivation, or loss of interest?
• Forgetful or easily distracted?
• Screening for substance use
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C. Can service member return to duty within hours?
Objective
Identify service members who can rapidly resume effective functioning in the unit.
Recommendations
1. Consider the service member’s role and functional capabilities and the complexity and importance of his/her job
when determining when to return the service member to duty.
2. The continuing presence of symptoms of COSR alone should not constitute a basis for preventing a return to duty.
3. Educate and “normalize” observed psychological reactions to the chain of command.
D. Initiate acute intervention for COSR; Coordinate with service member´s unit/command; treat within
closest proximity to service member´s unit, as is logistically feasible
Objective
Initiate acute symptom management.
Recommendations
1. Maintain sense of unit integrity:
• Normalization
• Validation
• Keep positive approach
• Set up expectation for recovery and RTD (role)
2. Keep treatment consistent with the “PIES” principle:
• Proximity: Prevention and treatment are conducted in proximity to the battlefield or the origin of the stressor.
Treatment proximate to the member´s unit where he/she can be visited by fellow military members is ideal.
Consider all options for proximate treatment; strive to maintain connection to unit to maintain unit integrity
• Immediacy: Treatment should begin as soon as tactically and logistically possible
• Expectancy: From the outset, the expectation is that the SM is experiencing a normal reaction to an
abhorrently abnormal situation and will return to duty following resolution, restitution and adaptation
• Simplicity: All modalities of prevention and treatment are simple and clearly understood. No dynamic therapy.
No medical model. The only “model” is the military model—military members caring for military members.
3. Initiate treatment:
• Treat according to SM´s prior role and not as a “patient;” avoid a hospital setting
• Assure or provide the following, as needed:
• Reunion or contact with primary group
• Respite from intense stress
• Thermal comfort
• Oral hydration
• Oral food
• Hygiene (toileting, shower, shave, and feminine)
• Sleep (to facilitate rest and restoration, use anxiolytic medication judiciously and sparingly in the acute
setting)
• Encourage talk about the event with supportive others
4. Reserve group debriefing for members of preexisting and continuing groups at appropriate time and setting.
Attendance should be voluntary and only be conducted by personnel trained in debriefing methods
5. Assign job tasks and recreational activities that will restore focus and confidence and reinforce teamwork
(limited duty)
6. Avoid further traumatic events until recovered for full duty
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7. Evaluate periodically
8. Consider using a short course of medication targeted for specific symptoms (see “Pharmacotherapy for COSR”
in the original guideline document)
E. Transfer to more definitive level of care for combat and operational stress control
Objective
Transfer service member for treatment augmentation or mental health treatment or referral.
Recommendations
1. Service members who do not respond to first line supportive interventions may warrant a transfer for
treatment augmentation or mental health treatment or referral.
2. Transfer to a more definitive level of treatment may include more intense or prolonged treatment at a Combat
Refresher Training facility. Service members should be prepared for the transfer with continued positive
expectation of recovery from their symptoms and return to normal level of functioning.
3. Ensure that casualties being transferred due to other medical conditions (wounded in action) receive psychoeducation relating to anticipated psychological changes, provide positive expectations, and offer support prior
to departure from the area of responsibility.
Module B: acute stress disorder (asd) and post-traumatic stress disorder (ptsd) in primary care
A. Assessment of trauma exposure related symptoms
Recommendations
Assessment in Primary Care
1. Patients who are presumed to have symptoms of PTSD or who are positive for PTSD on the initial screening
should receive specific assessment of their symptoms. (For a list of “Common Symptoms After Exposure to
Trauma or Loss,” see Table B-1 in the original guideline document.)
2. A thorough assessment of the symptoms is necessary for accurate diagnosis, rating the severity of the disorder,
and making correct clinical decisions. (Lagomasino, Daly, & Stoudemire , 1999; Williams & Shepherd, 2000);
3. Consider self-administered checklists to ensure systematic, standardized, and efficient review of the patient´s
symptoms.
4. Useful information may include details such as time of onset, frequency, course, severity, level of distress,
functional impairment, and other relevant information.
B. Assessment of trauma exposure
Recommendations
1. Assessment of the trauma exposure should include:
• History of exposure to traumatic event(s)
• Nature of the trauma
• Severity of the trauma
• Duration and frequency of the trauma
• Age at the time of the trauma
• Patient´s reaction at time of trauma (e.g., helplessness, horror, and fear)
• Existence of multiple traumas
2. When assessing trauma exposure, the clinician must consider the patient´s ability to tolerate the recounting of
traumatic material, since it may exacerbate PTSD symptoms.
3. The assessment should be performed cautiously, especially in situations where the trauma source is still present
and the patient perceives himself or herself to be in danger.
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C. Assessment of dangerousness to self or others
Recommendation
1. All patients with ASD/PTSD should be assessed for safety and dangerousness including current risk to self or
others, as well as historical patterns of risk:
• Suicidal or homicidal ideation, intent (plan), means (e.g., weapon, excess medications), history (e.g., violence
or suicide attempts), behaviors (e.g., aggression, impulsivity), comorbidities (substance abuse, medical
conditions) (Breslau at al., 2000; Bullman & Kang, 1994; Ferrada-Noli et al., 1998; Kaslow et al., 2000;
Marshall et al., 2001; Prigerson & Slimack,
• 1999; Swanson et al., 2002
• Family and social environment – including risks to the family (Seng, 2002; Swanson et al., 2002)
• Ongoing health risks or risk-taking behavior (Acierno et al., 1996; Hutton et al., 2001)
• Medical/psychiatric comorbidities or unstable medical conditions (Davidson et al., 1991; Farrell & Ganzini,
1995; Weisberg et al., 2002)
• Consider potential to jeopardize mission in operational environment (Working Group Consensus)
D. Obtain medical history, physical examination, mental status examination (MSE), and
laboratory tests
Objective
Obtain comprehensive patient data in order to reach a working diagnosis.
Recommendations
1. All patients should have a thorough medical and psychiatric history (Lagomasino, Daly, & Stoudemire, 1999;
Williams & Shepherd, 2000), with particular attention paid to the following:
• Baseline functional/mental status
• Past medical history
• Medications, to include herbal and over-the-counter (OTC) drugs
• Past psychiatric history, to include prior treatment, past hospitalization for depression or suicidality, and
substance use disorders
• Current life stressors
If trauma exposure is recent (<1 month) particular attention should be given to the following:
•
•
•
•
Exposure to/environment of trauma
Ongoing traumatic event
Exposure, perhaps ongoing, to environmental toxin
Ongoing perceived threat
2. All patients should have a thorough physical examination. On physical examination, particular attention should
be paid to the neurological exam and stigmata of physical/sexual abuse, self-mutilation, or medical illness. Note
distress caused by or avoidance of diagnostic tests/examination procedures.
3. All patients, particularly the elderly, should have a Mental Status Examination (MSE) to include assessment of
the following:
• Appearance and behavior
• Language/speech
• Thought process (loose associations, ruminations, obsessions) and content (delusions, illusions, and
hallucinations)
• Mood (subjective)
• Affect (to include intensity, range, and appropriateness to situation and ideation)
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• Level of Consciousness (LOC)
• Cognitive function
4. All patients should have routine laboratory screening tests including thyroid stimulating hormone (TSH),
Complete Metabolic Panel, Hepatitis, human immunodeficiency virus (HIV), and human choriogonadotropin
(HCG) (for females). Also consider CBC, urinalysis (UA), toxicology ethanol (Tox EtoH) panel and other tests, as
clinically indicated. (Lagomasino, Daly & Stoudemire, 1999; Williams & Shepherd, 2000)
5. Other assessments may be considered (radiology studies, EKG, and EEG), as clinically indicated. (Lagomasino,
Daly & Stoudemire, 1999)
6. All patients should have a narrative summary of psychological assessments to include work/school, family,
relationships, housing, legal, financial, unit/community involvement, and recreation, as clinically appropriate.
E. Assessment of functioning
Recommendation
1. Assessment of global function should be obtained, such as the Global Assessment of Function (GAF) scale or
the SF-36. (Working Group Consensus)
F. Assessment of risk factors
(See under Risk Factors/Recovery below)
G. Are there clinical significant symptoms suggestive of PTSD or ASD?
Recommendations
1. Primary care providers should formulate a presumptive diagnosis of stress related disorder consistent with
Diagnostic and Statistical Manual of Mental Disorders (4th edition) criteria for ASD and PTSD.
2. Primary care providers should consider initiating treatment or referral based on a working diagnosis of stress
related disorder.
3. Patients with difficult or complicated presentation of the psychiatric component should be referred to mental
health specialty for diagnosis and treatment.
Evidence for all Recommendations:
H. Patient education
Objective
Help trauma survivors cope with ASD/PTSD by providing information that may help them manage their symptoms
and benefit from treatment.
Recommendation
1. Trauma survivors should be educated about PTSD symptoms, other potential consequences of exposure to
traumatic stress, practical ways of coping with traumatic stress symptoms, processes of recovery from ASD/
PTSD, and the nature of treatment. (Working Group Consensus)
I. Coexisting severe medical conditions
Objective
Improve management of PTSD symptoms when they are complicated by the presence of a medical or psychiatric
comorbidity.
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Recommendations
1. Primary care providers should recognize that medical disorders/symptoms, mental disorders, and psychosocial
problems commonly coexist with PTSD and should screen for them during the evaluation and treatment of
PTSD. (Working Group Consensus)
2. Consider the existence of comorbid conditions when deciding whether to treat patients in the primary care
setting or refer them for specialty mental health care. (Working Group Consensus)
J. Concurrent PTSD and substance abuse
Objective
Improve the management of PTSD symptoms when they are complicated by a concurrent substance abuse
problem.
Recommendations
1. Substance use patterns of clients with trauma histories or PTSD should be routinely assessed (see the VA/DoD
Clinical Practice Guideline for the Management of Substance Use Disorders) (Working Group Consensus)
2. Substance abusers should be routinely screened for trauma exposure and PTSD. (Dansky et al., 1997)
3. Integrated PTSD-Substance Abuse Treatment should be considered. (Working Group Consensus)
4. Substance-abusing patients with PTSD should be educated about the relationships between PTSD and
substance abuse, referred for concurrent PTSD treatment, or provided with integrated PTSD/Substance Abuse
treatment. (Working Group Consensus; Najavits, 2002; Ouimette et al., 1998)
5. Substance Abuse-PTSD patients should receive follow-up care that includes a continued focus on PTSD issues.
(Ouimette et al., 2000)
K. Referral to mental health specialty
Objective
Provide guidance for primary care providers on optimal referral for PTSD patients.
Recommendations
1. Primary care providers should consult with a mental health provider and/or a PTSD Specialty Team for all
patients with acute or chronic stress disorders.
2. Primary care providers should continue to be involved in the treatment of patients with acute or chronic stress
disorders.
3. Treatment for patients with ASD or acute or chronic PTSD should involve a multidisciplinary team approach
to include occupational therapy (OT), spiritual counseling, recreation therapy, social work, psychology, and/or
psychiatry.
4. Patients with clinically significant symptoms or comorbidities to PTSD, including chronic pain, insomnia, anxiety,
and depression, should receive treatment for those complicating problems.
5. Case management should be provided, as indicated, to address high utilization of medical resources.
6. Consider referral for alternative care modalities as indicated for patient symptoms, consistent with available
resources, and resonant with patient belief systems.
Evidence for all recommendations:
L. Treatment in primary care
Recommendations
ALL PATIENTS with Stress Related Disorders
1. A supportive and collaborative treatment relationship or therapeutic alliance should be developed and
maintained with patients with ASD/PTSD inclusive of their input in treatment planning.
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2. Primary care providers should routinely provide the following services for all patients with stress related
disorders, especially those who are reluctant to seek specialty mental health care:
• Supportive counseling
• PTSD-related education
• Regular follow-up and monitoring of symptoms
• Early recognition of PTSD
3. Primary care providers should consider consultation with mental health providers for patients with ASD/PTSD
who warrant a mental health referral but may be reluctant or refuse it.
4. Primary care providers should take leadership in convening a collaborative team for patients with PTSD. Team
members may include the primary care providers, mental health specialists, chaplains, pastors, social worker,
occupational or recreational therapists, Vet Centers, family support centers, exceptional family member
programs, VA benefit counselors, peer-support groups, and others. ASD
5. Because ASD does not occur in all people who later develop PTSD, consider treatment for acutely traumatized
people with ASD, with severe PTSD symptoms as well as for those who are incapacitated by acute
psychological or physical symptoms.
6. Patients with ASD should be monitored for development of PTSD (Brewin et al., 1999; Bryant et al., 1998).
The use of validated PTSD symptom measure such as the PTSD Checklist should be considered (see Appendix
D in the original guideline document).
7. Primary care providers should consider the pharmacological management of disruptive symptoms (e.g., sleep)
(see “Pharmacotherapy for ASD” in the original guideline document).
8. Brief intervention (4 to 5 sessions) of cognitive behavioral therapy (CBT) is an effective early intervention
for patients with ASD (Bryant et al., 1998; Foa et al., 1995). In addition to targeted brief interventions, some
trauma survivors may benefit from follow-up provision of ongoing counseling or treatment.
PTSD
9. All patients with PTSD should have a specific primary care provider assigned to coordinate their overall health
care.
10. Pharmacological management of PTSD or related symptoms may be initiated based on a presumptive diagnosis
of PTSD. Long-term pharmacotherapy will be coordinated with other intervention once the patient has been
referred to a mental health clinic (see “Pharmacotherapy for PTSD” in the original guideline document).
11. Primary care providers should perform a brief PTSD symptom assessment at each visit. The use of a validated
PTSD symptom measure, such as PTSD Checklist, should be considered (see Appendix D in the original
guideline document).
12. Primary care providers should assess patients with PTSD for associated high-risk behaviors (e.g., smoking,
alcohol/drug abuse, HIV, and hepatitis risks) and comorbid medical and psychiatric illnesses.
M. Referral to vet centers
Objective
Provide timely mental health services to veterans in need of support.
Recommendations
1. Veterans with symptoms of PTSD should have an initial assessment of needs.
2. Veterans who are dangerous to self or others should be referred to the local Veterans Affairs Medical Center
(VAMC) or nearest emergency room.
3. Veterans who are seeking to have basic needs met should be referred to the VA Homeless Coordinator or
community resources for food, shelter, or emergency financial assistance.
4. Veterans who are eligible for Vet Center services should have an indepth psychological history taken, including a
comprehensive military history and treatment plan.
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5. Treatment plans in the Vet Center may include individual, family, or group therapy. Veterans can receive medical
treatment or medication management at the Vet Center by a psychiatrist, registered nurse (RN), or advanced
registered nurse practitioner (ARNP) or be referred to the local VAMC, Community Based Outpatient Clinic
(CBOC), or community resources.
6. Veterans who are eligible for Vet Center services should be made aware of the Center resources and referred if
the patient desires.
N. Assess duty/work responsibilities and patient´s fitness (in relation to military operation)
Recommendations
1. The determination of when to return a service member to duty should take into consideration the individual´s
service member´s role, the complexity and importance of his or her job, and the service member´s functional
capabilities.
2. The continuing presence of symptoms of PTSD should not be considered as the sole basis for preventing a return
to duty.
Module c management of ptsd in mental health speciality care
A. Patient presenting to mental health with suspected PTSD symptoms
Recommendations
Assessment in Mental Health Specialty
1. Mental health clinicians should obtain a comprehensive diagnostic assessment that includes, but is not limited to,
the symptoms that characterize PTSD.
2. Routine use of self-administered checklists may ensure systematic, standardized, and efficient review of
the patient´s symptoms and history of trauma exposure (see Appendix C [PCL-C] in the original guideline
document).
3. The assessment should also include review of other salient symptoms (guilt, dissociation, derealization,
depersonalization, reduction, and awareness of surrounding) that impact on treatment decisions. Structured
psychiatric interviews, such as the clinician administered PTSD scale (CAPS), may be considered. For discussion
see CORE Module Annotation D, and Module B – Management of ASD and PTSD in Primary Care Annotations
A and B
B. Obtain medical history, physical examination, mse, psychosocial assessment, and appropriate lab
tests
See Module B: Management of ASD & PTSD in Primary Care, Annotation D, E and F.
C. Does Patient Meet DSM-IV Criteria For ASD/PTSD?
Objective
Diagnose ASD/PTSD by DSM-IV criteria.
Recommendation
1. Diagnostic criteria should be documented in the medical record.
D. Educate patients and family about treatment options; develop collaborative and interdisciplinary
treatment plan
See Module B: Management of ASD & PTSD in Primary Care, Annotation H.
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E. Initiate Therapy for PTSD
See Intervention Module.
F. PTSD with other Comorbid Symptoms (Addiction, Substance Use Disorder [SUD], Psychosis, Bipolar)
See Module B: Management of ASD & PTSD in Primary Care, Annotation I & J.
G. Reassess PTSD Symptoms; diagnostic status, functional status; quality of life; additional treatment
needs; patient preferences
Objective
Assess patient status following therapeutic intervention to determine future direction.
Recommendations
1. Follow-up status of patients with PTSD should be monitored at least every three months. Use interview and
questionnaire methods to assess PTSD symptoms and function.
• Diagnostic status and symptom severity
• Functional status/health-related quality of life
• Psychosocial treatment needs
• Patient preferences
• Therapy adherence
• Adverse treatment effects
H. Follow-up in mental health
Recommendations
1. If patient does not improve or status worsens, consider one of the following treatment modification options:
• Continued applications of the same modality at intensified dose and/or frequency
• Change to a different treatment modality
• Apply adjunctive therapies
• Increase level of care (e.g., referral facility, partial hospitalization, inpatient hospitalization, residential care)
• Consider a referral to adjunctive services for treatment for comorbid disorders or behavioral abnormalities
(e.g., homelessness, domestic violence, or aggressive behavior)
2. If patient demonstrates partial (insufficient) remission, consider one of the following treatment
modification options:
• Continue the present treatment modality to allow sufficient time for a full response
• Continue applications of the same modality at intensified dose and/or frequency
• Change to a different treatment modality
• Apply adjunctive therapies
• Increase level of care (e.g., referral facility, partial hospitalization, inpatient hospitalization, residential care)
• Consider a referral to adjunctive services for treatment of comorbid disorders or behavioral abnormalities
(e.g., homelessness or domestic violence)
3. If patient demonstrates improved symptoms and functioning but requires maintenance treatment:
• Continue current course of treatment
• Consider stepping down the type, frequency, or dose of therapy Transition from intensive psychotherapy to
case management contacts
• Transition from individual to group treatment modalities
• Discuss patient status and need for monitoring with the primary care provider
• Consider a referral to adjunctive services for treatment of disorders or behavioral abnormalities (e.g.,
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•
•
•
•
homelessness or domestic violence)
If patient demonstrates remission from symptoms and there are no indications for further therapy:
Discontinue treatment
Educate the patient about indication and route of future care access
Monitor by primary care for relapse/exacerbation.
I. Referral
Objective
Treat symptoms, support function, and alleviate suffering in those patients with PSTD who are unwilling, unable, or
unsuitable for treatment in a mental health setting.
Recommendations
1. Evaluate psychosocial function and refer for psychosocial services, as indicated. Available resources include, but
are not limited to chaplains, pastors, Family Support Centers, Exceptional Family Member Programs, VA benefit
counselors, occupational or recreational therapists, Vet Centers, and peer-support groups.
2. Provide case management, as indicated, to address high utilization of medical resources.
3. Consider psychotherapeutic interventions as appropriate for level of training and available resources.
4. For patients with severe symptoms or coexisting psychiatric problems consider referrals to:
•
•
•
•
Specialized PTSD programs
Specialized programs for coexisting problems and conditions
Partial psychiatric hospitalization or “day treatment” programs
Inpatient psychiatric hospitalization
Evidence for all Recommendations: (Working Group Consensus)
Evidence-based intervention for treatment of PTSD
Acute Stress Disorder (ASD) Pharmacotherapy
Summary table – Pharmacotherapy for ASD
R*
Significant Benefit
Some Benefit
Unknown
No
Benefit/Harm
A
B
C
I
Imipramine
Propanolol
Benzodiazepines
Other Sympatholitics
Other
Antidepressants
Anticonvulscents
Atypical
Antipsychotics
Chloral Hydrate
D
Typical Antipsychotics
Although the effectiveness of selective serotonin reuptake inhibitors (SSRIs) has been demonstrated for PTSD, it
has not been tested in ASD and therefore cannot be recommended.
Objective
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To lessen the physical, psychological, and behavioral morbidity associated with acute stress reaction, hasten the
return to full function (duty, work, social function), and diminish the likelihood of chronicity.
Recommendations
1. Recommend providing for physical needs, sleep, normalization, and other non-pharmacological modalities
(Working Group Consensus
2. Consider the use of medication for individuals that do not respond to non-pharmacological treatment (Working
Group Consensus)
3. Consider the use of imipramine to ameliorate the symptoms of ASD
4. Consider a short course of medication targeted for specific symptoms
Sleep disturbance/insomnia
•
•
•
•
•
Benzodiazepines (up to 5 days) (Gelpin et al., 1996; Mellman, Byers, & Augenstein, 1998)
Chloral hydrate (up to 5 days) (Robert et al., 1999)
Hyperarousal/excessive arousal/panic attacks
Propranolol and other anti-adrenergic agents (up to 10 days) (Pittman et al., 2002)
Imipramine (up to 7 days) (Robert et al., 1999)
• Benzodiazepines (up to 5 days) avoid short acting agent (e.g., alprazolam) (Gelpin et al., 1996; Mellman,
Byers, & Augenstein, 1998)
5. There is insufficient evidence to support a recommendation for preventative use of a pharmacological agent to
prevent the development of PTSD.
6. There is insufficient evidence to support a recommendation for PTSD pharmacotherapies for patient presenting
symptoms for less than 4 weeks.
B. Post-Traumatic Stress Disorder (PSTD) Pharmacotherapy
Summary Table for PTSD Pharmacotherapy*
R*
Significant Benefit
A
B
SSRI’s
Some Benefit
Unknown
No
Benefit/Harm
C
I
D
TCAs
MAOs
Sympatholitics
Novel
Antidepressants
Anticonvulscents
Atypical
Antipsychotics
Buspirone
Nonbenzodiazepine
Hypnotics
Benzodiazepines
Typical
Antipsychotics
*R = level of recommendation; SSRIs = selective serotonin reuptake inhibitors; TCAs = tricyclic antidepressants;
MAOIs = monoamine oxidase inhibitors.
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Objective
To minimize signs and symptoms of PTSD and maintain function.
Recommendations
Monotherapy
1. Strongly recommend selective serotonin reuptake inhibitors (SSRIs) for the treatment of PTSD. (Stein et al.,
2000)
2. Recommend tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) as second-line
treatments for PTSD. (Stein et al., 2000; Cochrane Review)
3. Consider an antidepressant therapeutic trial of at least 12 weeks before changing therapeutic regimen.
(Martenyi et al., 2002)
4. Consider a second-generation (e.g., nefazodone, trazodone, venlafaxine, mirtazapine, bupropion) in the
management of PTSD. (Hidalgo et al., 1999)
Augmented Therapy for Targeted Conditions
5. Consider prazosin to augment the management of nightmares and other symptoms of PTSD. (Raskind et al.,
2003)
6. Recommend medication compliance assessment at each visit. (Group Consensus)
7. Since PTSD is a chronic disorder, responders to pharmacotherapy may need to continue medication indefinitely;
however, it is recommended that maintenance treatment should be periodically reassessed. (Rapaport,
Endicott, & Clary, 2002)
8. There is insufficient evidence to recommend a mood stabilizer (e.g., lamotrigine) for the treatment of PTSD.
(Hertzberg et al., 1999)
9. There is insufficient evidence to recommend atypical antipsychotics for the treatment of PTSD. (Hamner et al.,
2003)
10. There is insufficient evidence to support the recommendation for a pharmacological agent to prevent the
development of PTSD.
11. Recommend against the long-term use of benzodiazepines to manage core symptoms in PTSD. (Kosten et al.,
2000)
12. Recommend against typical antipsychotics in the management of PTSD. (Stein et al., 2000)
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C. Psychotherapy interventions
Objective
Reduce symptoms severity and improve of global functioning.
Summary Table for Psychotherapy Interventions
R*
Significant Benefit
A
Cognitive
Therapy (CT)
Exposure
Therapy (ET)
Stress
Inoculation
Training (SIT)
Eye Movement
Desensitization
And
Reprocesssing
(EMDR)
Some Benefit
Unknown
No
Benefit/Harm
B
Imagery
Rehearsal
Therapy (IRT)
Psychodynamic
Therpy
Sympatholitics
Novel
Antidepressants
C
I
D
PTSD-Patient Education
*R = level of recommendation
Recommendations
1. Providers should explain to all patients with PTSD the range of available and effective therapeutic options for
PTSD. (Expert Consensus)
2. Cognitive Therapy (CT), Exposure Therapy (ET), Stress Inoculation Training (SIT), and Eye Movement
Desensitization and Reprocessing (EMDR) are strongly recommended for treatment of PTSD in military and
non-military populations. EMDR has been found to be as effective as other treatments in some studies and less
effective than other treatments in some other studies.
3. Imagery Rehearsal Therapy [IRT] and Psychodynamic Therapy may be considered for treatment of PTSD.
4. Patient education is recommended as an element of treatment of PTSD for all patients.
5. Consider Dialectical Behavioral Therapy (DBT) for patients with a borderline personality disorder typified by
parasuicidal behaviors.
6. Consider hypnotic techniques especially for symptoms associated with PTSD, such as pain, anxiety, dissociation
and nightmares, for which hypnosis has been successfully used.
7. Specialized PTSD psychotherapies may be augmented by additional problem specific methods/services and
pharmacotherapy.
8. Combination of cognitive therapy approaches (e.g., ET plus CT), while effective, has not proven to be superior
to either component alone.
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9. Specific psychotherapy techniques may not be uniformly effective across all patients. When selecting a specific
treatment modality, consideration of patient characteristics such as gender, type of trauma (e.g., combat vs.
other trauma), and past history may be warranted.
10. Patient and provider preferences should drive the selection of evidence-based psychotherapy and/or evidencebased pharmacotherapy as the first line treatment.
11. Selection of individual interventions should be based upon patient preference, provider level of skill and comfort
with a given modality, efforts to maximize benefit and minimize risks to the patient, and consideration of
feasibility and available resources.
12. Psychotherapies should be provided by practitioners who have been trained in the particular method of
treatment, whenever possible.
13. A stepped care approach to therapy administration may be considered, though supportive evidence is lacking.
*Detailed evidence tables for each therapy are included in the applicable following Discussion sections.
Note: Psychotherapy interventions are aimed at reduction of symptoms severity and improvement of global
functioning. However, the clinical relevance and importance of other outcome indicators (e.g., improvement of
quality of life, physical and mental health) are not currently well known.
A. Selection of therapy for PTSD
In clinical practice, providers and patients alike are often faced with important decisions relating to type, number,
frequency, and dose of various psychotherapies and pharmacologic therapies. Therapies may be broadly divided
into (1) evidence-based psychotherapies, (2) evidence-based pharmacotherapies, and (3) key adjunctive or
supplemental treatment modalities. Providers should explain to all patients with PTSD the range of therapeutic
options that are available and effective for PTSD. This discussion should include general advantages and
disadvantages (including side-effects) associated with each therapeutic option. In general, PTSD therapy research
has provided insufficient evidence to favor medication or evidence-based psychotherapy as a first-line treatment.
There is also insufficient evidence to suggest for or against combined medication and psychotherapy over only one
of the two approaches.
It may be helpful to add therapies using a stepped care approach, even though supporting evidence does not exist.
The use of stepped care has been advocated for many chronic conditions including hypertension, low back pain,
and depression. In stepped care, the intensity of care is augmented for patients who do not achieve an acceptable
outcome with lower levels of care. Stepped care is based on three assumptions: different people require different
levels of care; finding the right level of care often depends on monitoring outcomes; and moving from lower to
higher levels of care based on patient outcomes often offers efficient increases in overall effectiveness.
The level or intensity of care is guided by illness trajectory (degree of chronicity and current illness severity),
observed outcomes, and previously attempted therapies. Active follow-up is used to determine the level of care
each patient requires over time. In PTSD for example, the patient and provider may determine that the first-line
therapy will be psychotherapy. If, after a period of treatment, the patient is not responding adequately, the patient
may be “stepped up” in therapeutic intensity by adding a medication, such as a selective serotonin reuptake inhibitor
(SSRI) to the regimen of ongoing psychotherapy. Contrary to clinical intuition, there is no evidence indicating the
superiority of programs that combine different cognitive behavioral therapies.
B. Cognitive Therapy (CT)
Recommendations
1. CT is effective with civilian men and women exposed to combat and noncombat trauma. (Lovell, et al., 2001;
Marks et al., 1998)
2. CT is effective with military and veterans with combat- and noncombat-related PTSD. (Working Group
Consensus)
3. CT is effective for women with PTSD associated with sexual assault. (Resick et al., 2002)
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C. Exposure therapy
Recommendations
1. ET is effective in the treatment of PTSD (compared to placebo or waiting list) (Cooper & Clum, 1989; Foa et
al., 1991; Foa et al., “A comparison,” 1999; Ironson et al., 2002; Keane et al., 1989; Marks et al., 1998; Tarrier
et al., 1999)
2 ET compared to other forms of therapy show equivalent results (Foa et al., 1991; Foa et al., “A
comparison,”1999; Marks et al., 1998; Paunovic & Ost, 2001; Resnick & Nishisth, 2001; Schnurr, 2001; Tarrier
et al., 1999)
D. Stress Inoculation Training (SIT)
Recommendations
1. SIT is effective as a treatment for PTSD related to sexual assault (Foa et al., 1991; Foa et al., “A comparison,”
1999; Kilpatrick, Veronen, & Resick, 1982; Rothbaum et al., 2000)
E. Eye Movement Desensitization and Reprocessing (EMDR)
Recommendations
1. EMDR is more efficacious for PTSD than wait-list, routine care, and active treatment controls. (Chemtob, Tolin,
& van der Kolk, 2000; Davidson & Parker, 2001; Foa & Meadows, 1997; Maxfield & Hyer, 2002; Shepherd,
Stein, & Milne, 2000)
2. Eye movements are not critical to the effects of EMDR (Foa & Meadows, 1997)
3. EMDR compared with ET and CT shows mixed results (Cahill, 2000; Davidson & Parker, 2001; Foa & Meadows,
1997; Ironson et al., 2002; Lee et al., 2002; Power et al., 2002; Servan-Schrieber, 2000; Shepherd, Stein, &
Milne, 2000; Taylor, Thordarson, & Maxfield, 2002; Van Etten & Taylor, 1998)
F. Imagery Rehearsal Therapy (IRT)
Recommendations
1. IRT can be considered for treatment of PTSD (nightmare and sleep disruption in particular). (Krakow et al., 1995;
Krakow et al., “Imagery rehearsal,” 2001; Krakow et al., “Treatment of chronic nightmares,” 2001; Forbes, Phelps, &
McHugh, 2001)
G. Psychodynamic therapy
Recommendations
1. Psychodynamic psychotherapy for the treatment of PTSD (Brom, Kleber, & Defares, 1989)
2. Psychodynamic psychotherapy for patients with complex PTSD (Courtois, 1999; Roth & Batson, 1997;
Shengold, 1989)
H Patient education
Objective
Provide a therapeutic intervention that reduces the symptoms and functional impairments of PTSD.
Recommendation
1. Psychoeducation is recommended (Foa, Davidson, & Frances, 1999)
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I. Group therapy
Objective
Provide a supportive environment in which a patient with PTSD may participate in therapy with other PTSD patients.
Recommendations
1. Consider group treatment for patients with PTSD (Donovan, Padin- Rivera, & Kowaliw, 2001; Foy et al., 2000;
Rogers et al., 1999)
2. Current findings do not favor any particular type of group therapy over other types. (Foy et al., 2000)
J. Dialectical behavior therapy
1. Consider DBT for patients with a borderline personality disorder typified by parasuicidal behaviors. (Evans et al.,
1999; Hawton et al., 2000; Linehan, Heard, & Armstrong, 1993; Safer, Telch, & Agras, 2001; Telch, Agras, &
Linehan, 2001; van den Bosch et al., 2002; Verheul et al., 2003)
K. Hypnosis
Objective
A therapeutic intervention that may be an effective adjunctive procedure in the treatment of PTSD
Recommendation
1. Hypnosis may be used to alleviate PTSD symptoms. (Brom, Kleber, & Defares, 1989; Sherman, 1998)
L. Psychosocial adjunctive methods/services
Objective
Provide a therapeutic intervention that facilitates generalizing skills for coping with PTSD from clinic to home/
work/community.
Recommendations
1. Consider psychosocial rehabilitation techniques once the client and clinician identify the following kind of
problems associated with the diagnosis of PTSD: persistent high-risk behaviors, lack of self care/independent
living skills, homelessness, interactions with a family that does not understand PTSD, socially inactive,
unemployed, and encounters with barriers to various forms of treatment/rehabilitation services.
2. Client and clinician should determine whether such problems are associated with core symptoms of PTSD and, if
so, then ensure that rehabilitation techniques are used as a contextual vehicle for alleviating PTSD symptoms.
3. Psychosocial rehabilitation should occur concurrently or shortly after a course of treatment for PTSD, since
psychosocial rehabilitation is not trauma-focus.
M. Spiritual support
Objective
Reduce symptoms of PTSD and improve patient´s functioning through social and spiritual support.
Recommendation
1. Provide access to religious/spiritual resources, if sought.
Evidence
Provide opportunities to vent & defuse, to share feelings and talk (Bogia & Preston, 1985; Everly, “The role of
pastoral crisis,” 2000; Hunter, 1996)
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Abbreviation/Acronym List
ABCs Airway, breathing, circulation
AHCPR Agency for Healthcare Policy and Research
APA American Psychiatric Association
ASD Acute stress disorder
ASR Acute stress reaction
AUDIT Alcohol Use Disorders Identification Test
CAGE Alcohol abuse/dependence screening test mnemonic
CAPS Clinician Administered PTSD Scale
CBC Complete blood count
CBT Cognitive Behavioral Therapy
CCTR Cochrane Central Register of Controlled Trials
CDR Commander
CNS Central nervous system
COSR Combat and operational stress reactions
CISD Critical Incident Stress Debriefing
CT (Interventions) Cognitive Therapy
CT Computed tomography
CV Cardiovascular
DARE Database of Abstracts of Reviews of Effectiveness
DAST Drug Abuse/Dependence Screener
DBT Dialectical Behavioral Therapy
DoD Department of Defense
DSM-IV Diagnostic and Statistical Manual of Mental Disorders (4th edition)
DTE Direct Therapeutic Exposure
EBM Evidence-based medicine
EBPTU Evaluation and Brief PTSD Treatment Unit
EEG Electroencephalography
EKG Electrocardiogram
EMDR Eye Movement Desensitization and Reprocessing
EMTs Emergency Medical Teams
ESRT Emotional Self-Regulation Therapy
EtoH Ethanol
ET Exposure Therapy
FDA U. S. Food and Drug Administration
GAF Global Assessment of Function
GI Gastrointestinal
GU Genitourinary
HCG Human Choriogonadotropin
HIV Human immunodeficiency virus
IRT Image Rehearsal Therapy
LOC Level of consciousness
LOF Level of function
MAOIs Monoamine oxidase inhibitors
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MAST Michigan Alcohol Screening Test
MDD Major Depressive Disorder
MHP Mental health providers
MI Myocardial infarction
MMSE Mini-Mental State Examination
MRI Magnetic resonance imaging
MSE Mental status examination
NIMH National Institute of Mental Health
NS Nervous system
OMO Ongoing military operations
OTC Over-the-counter
PCL-C PTSD Checklist – Civilian Version
PCL-M PTSD Checklist – Military Version
PCL-S PTSD Checklist – Stressor Specific Version
PCP Primary care provider
PE Physical examination
PE (Interventions) Prolonged Exposure
PIES Proximity, Immediacy, Expectancy, Simplicity
PTSD Post-traumatic Stress Disorder
QE Quality of evidence
RCS Readjustment Counseling Services
RCT Randomized controlled trial
RTD Return-to-duty
SC Supportive Counseling
SIADH Syndrome of inappropriate antidiuretic hormone
SIPU Specialized Inpatient PTSD Unit
SIT Stress Inoculation Therapy
SM Service member
SR Strength of recommendation
SSRI Selective Serotonin Reuptake Inhibitors
SUD Substance Use Disorder
SUNY State University of New York
TCAs Tricyclic Antidepressants
TSH Thyroid Stimulating Hormone
USPSTF U.S. Preventive Service Task Force
VA Veterans Affairs
VAMC Veterans Affairs Medical Center
VHA Veterans Health Administration
b) Physical/psychiatric rehabilitation
Discussed extensively throughout “Functional Progression”
c) Risk factor/recovery
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F. Assessment of risk factors
Recommendations
1. All patients should be assessed for risk factors for developing ASD or PSTD. Special attention should be given to
post-traumatic factors (i.e., social support and functional incapacity) that may be modified by intervention.
2. Because of the high prevalence of psychiatric comorbidities in the PTSD population, assessment for depression
and other psychiatric comorbidities is warranted (see also VA/DoD Clinical Practice Guideline for the
Management of MDD and Psychotic Disorders).
3. Substance use patterns of persons with trauma histories or PTSD should be routinely assessed to identify
substance misuse or dependency (alcohol, nicotine, prescribed drugs, and illicit drugs) (see also VA/DoD Clinical
Practice Guideline for the Management of Substance Use Disorders)
Evidence
Pre-trauma
1. Prior exposure to traumatic events (Breslau et al., “Previous exposure” 1999; Brewin, Andrews, & Valentine,
2000; Dougall et al., 2000; Green et al., 2000; Maes et al., 2001; Neria, Bromet, & Marshall, 2002; Ozer et al.,
2003; Seedat & Stein, 2000; Zatzick et al., 2002)
2. Female gender (Breslau, “Gender differences,” 2002; Breslau et al., “Vulnerability,” 1999; Brewin, Andrews, &
Valentine, 2000, I; Finnsdottir & Elklit, 2002; Neria, Bromet, & Marshall, 2002; Seedat & Stein, 2000; Stretch,
Knudson, & Durand, 1998; Zatzick et al., 2002)
3. Psychiatric disorders or personality dimensions (Breslau, “Epidemiologic studies,” 2002; Brewin, Andrews, &
Valentine, 2000; Maes et al., 2001; Norris et al., 2002; Ozer et al., 2003)
4. Cognitive factors: Lower intelligence, Neurological soft signs (Brewin, Andrews, & Valentine, 2000; Gurvits et
al., 2000)
5. Parental or family history of PTSD (Yehuda et al., 1998)
6. Childhood abuse/assault (Breslau et al., “Previous exposure,” 1999; Breslau, “Epidemiologic studies,” 2002;
Brewin, Andrews, & Valentine, 2000; Neria, Bromet, & Marshall, 2002
7. Low educational level or socioeconomic status (Armenian et al., 2000; Brewin, Andrews, & Valentine, 2000;
Bromet et al., 2002; Finnsdottir & Elklit, 2002)
Peri-trauma
8. Severity of trauma; Perceived life threat (Armenian et al., 2000, II; Brewin, Andrews, & Valentine, 2000; Feehan
et al., 2001; Ozer et al., 2003; Woods, 2000)
9. Peri-traumatic dissociation (Ozer et al., 2003)
10. Youth at time of exposure (Brewin, Andrews, & Valentine, 2000; Finnsdottir & Elklit, 2002; Neria, Bromet, &
Marshall, 2002; Norris et al., 2002)
11. Biological factors such as heart rate (HR) increase (Shalev et al., “A prospective study,” 1998; Yehuda,
McFarlane, & Shalev, 1998)
Post-trauma
12. Resource loss/unemployment (Feehan et al., 2001; Norris et al., 2002)
13. Impaired social support system (Armenian et al., 2000; Brewin, Andrews, & Valentine, 2000; Gregurek et al.,
2001; Ozer et al., 2003)
14. Health problems (Norris et al., 2002)
15. On-going life stress (Brewin, Andrews, & Valentine, 2000; Norris et al., 2002)
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Potential harms
A detailed recounting of a traumatic experience may cause further distress to the patient and is not advisable
unless a provider has been trained and is able to support the patient through this experience.
Pharmacological adverse effects
Note: See Table 4 of Module 1 – Treatment Interventions for PTSD – for detailed list of drug adverse effects
and cautions.
• Selective serotonin reuptake inhibitors (SSRIs) (fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram):
nausea, headache, sexual dysfunction, hyponatremia/syndrome of inappropriate antidiuretic hormone (SIADH),
serotonin syndrome
• Tricyclic antidepressants (imipramine, amitriptyline, desipramine, nortriptyline, protriptyline, clomipramine):
anticholinergic effects, orthostatic hypotension, increased heart rate, ventricular arrhythmias
• Monoamine oxidase inhibitors (phenelzine, tranylcypromine): hypertensive crisis with drug/tyramine
interactions, bradycardia, orthostatic hypotension, insomnia
• Sympatholytics: propranolol – hypotension, bronchospasm, bradycardia; prazosin – first dose syncope
• Novel antidepressants: trazodone and nefazodone – sedation, rare priapism; venlafaxine – hypertension in
patients with preexisting hypertension;nefazodone – hepatoxicity
• Anticonvulsants: carbamazepine – leukopenia, SIADH, drowsiness, ataxia; gabapentin – sedation, ataxia;
lamotrigine - Stevens-Johnson syndrome, fatigue; topiramate – secondary angle closure glaucoma, sedation,
dizziness, ataxia; valproate – nausea/vomiting, sedation, ataxia, thrombocytopenia
• Benzodiazepines (clonazepam, lorazepam, alprazolam, diazepam): sedation, memory impairment,
ataxia, dependence
• Typical antipsychotics (chlorpromazine, haloperidol, thioridazine): sedation, orthostatic hypotension (with
chlorpromazine and thorazine), akathisia, dystonia, drug-induced parkinsonism, tardive dyskinesia , neuroleptic
malignant syndrome, QTc changes
• Atypical antipsychotics (olanzapine, quetiapine, risperidone): sedation, weight gain, neuroleptic malignant
syndrome, akathisia (at high doses), druginduced parkinsonism, especially with doses >6 mg/d
• Non-benzodiazepine hypnotics (zaleplon, zolpidem): sedation, ataxia, rebound insomnia
• Non-benzodiazepine anti-anxiety (buspirone): nausea, headache
Contraindications
• Selective serotonin reuptake inhibitors (SSRIs) (fluoxetine, paroxetine, sertraline, fluvoxamie, citalopram)
are contraindicated with MAO inhibitor use within 14 days and relatively contraindicated in patients with
hypersensitivity.
• Tricyclic Antidepressants (imipramine, amitriptyline, desipramine, nortriptyline, protriptyline, clomipramine)
are contraindicated with monoamine oxidase inhibitor (MAOI) use within 14 days, and acute myocardial
infarction within 3 months, and relatively contraindicated in patients with coronary artery disease and prostatic
enlargement. Clomipramine is contraindicated in patients with seizure disorder.
• Monoamine Oxidase Inhibitors (MAOI)(phenelzine, tranylcypromine) are contraindicated with use of all
antidepressants within 7 days of start of MAOI, except fluoxetine is 5 weeks, and use of central nervous system
stimulants and decongestants.
• Propranolol: Sinus bradycardia, congestive heart failure are contraindications.
• Novel antidepressants (bupropion, nefazodone, trazodone, venlafaxine) are contraindicated with MAOI use
within 14 days, and bupropion.
• Anticonvulsants: Carbamazepine is contraindicated in patients with bone marrow suppression, particularly
leukopenia. Gabapentin is contraindicated in those with renal impairment. Lamotrigine is contraindicated in
patients who experience increased rash with valproate (max. dose of 200 mg). Topiramate is contraindicated in
patients with hepatic impairment, and valproate with impaired liver function and thrombocytopenia.
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• Benzodiazepines (clonazepam, lorazepam, alprazolam, diazepam) should be used with caution in elderly patients
and patients with impaired liver function, and there is a risk of abuse in patients with history of substance abuse.
• Typical antipsychotics (chlorpromazine, haloperidol, thioridazine) are contraindicated in patients with
Parkinson´s disease and QTc prolongation.
• Atypical antipsychotics (olanzapine, quetiapine, risperidone) are relatively contraindicated in Parkinson´s disease.
• Non-benzodiazepine hypnotics (zaleplon, zolpidem) should be used with caution with alcohol/drug abuse history
and with caution in elderly patients with liver dysfunction.
• Non-benzodiazepine anti-anxiety (buspirone) is contraindicated with MAOI use within 14 days.
• Contraindications for Cognitive Therapy have not been empirically established, but may include psychosis,
severe brain damage, or severe intellectual impairment.
• Patients living in dangerous circumstances (e.g., domestic violence or a threatening environment) are not
candidates for Exposure Therapy until their security can be assured. Other contraindications for Exposure
Therapy have not been confirmed in empirical research, but may include health problems that preclude exposure
to intense physiological arousal, current suicidal ideation, substance abuse not in stable remission, comorbid
psychosis, or lack of motivation to undergo the treatment.
• Contraindications for Group Therapy include active psychosis, severe organicity or limited cognitive capacity,
pending litigation, or compensation seeking.
• There are a number of contraindications for using traditional hypnotic techniques in the treatment of PTSD:
• In the rare cases of individuals who are refractory or minimally responsive to suggestions, hypnotic techniques
may not be the best choice, because there is some evidence that hypnotizability is related to treatment
outcome efficacy.
• Some PTSD patients may be reluctant to undergo hypnosis, either because of religious belief or other reasons.
If the resistance is not cleared after dispelling mistaken assumptions, other suggestive techniques can be tried,
including emotional self-regulation therapy (ESRT), which is done with open eyes and uses sensory recall
exercises rather than a hypnotic induction.
• For patients who have low blood pressure or are prone to fall asleep, hypnotic procedures such as “alert hand,”
which emphasize alertness and activity rather than relaxation, may be substituted.
• Psychosocial rehabilitation techniques are contraindicated when client and clinician conclude that the problems
are resolved.
• Marriage counseling is typically contraindicated in cases of domestic violence, until the batterer has been
successfully (individually) rehabilitated.
d) Return to work
See above Can Service Member Return To Duty Within Hours.
8. Priority for Q-COMP
Rating criteria
Functional restoration
Does the guideline consider graded increases in activity and function?
Psychosocial factors
To what degree does the guideline consider psychosocial factors that may influence recovery?
Return to work process (vocational rehabilitation)
To what degree does the guideline consider the Return to Work Process (vocational rehabilitation)?
Risk factors for recovery
To what degree does the guideline consider Risk Factors for Recovery?
Total rating
4
3
2
1
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