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TITLE: MANAGEMENT
OF POST-TRAUMATIC STRESS
|
| Citation: |
Management
of Post-Traumatic Stress. Washington, DC: VA/DoD Clinical Practice
Guideline Working Group, Veterans Health Administration, Department
of Veterans Affairs and Health Affairs, Department of Defense,
December 2003. Office
of Quality and Performance publication 10Q-CPG/PTSD-04. |
| Completion Date: |
May 2003 |
| Release Date: |
January 2004 |
| Source(s): |
The Post -Traumatic Stress Guideline
was developed by and written for clinicians by the Department
of Veterans Affairs (VA), Department of Defense (DoD). |
| Adaptation: |
The guideline draws
from other evidence based guidelines that were available to the
Working Group: Effective Treatments for PTSD: Practice Guidelines
from the International Society for Traumatic Stress Studies.
Foa EB, Keane TM, Friedman MJ (Eds) 2000; The Expert Consensus
Guideline Series: Treatment of Posttraumatic Stress Disorder.
Foa EB, et al., 1999; and the Mental Health and Mass Violence: Evidenced-Based Early Psychological
Intervention for Victims/Survivors of Mass Violence. A Workshop
to Reach Consensus on Best Practices. National Institute of Mental
Health 2002. NIH Publication No. 02-5138. Washington, D.C.: U.S.
Government Printing Office. (www.nimh.nih.gov/research/massviolence.pdf
) |
| Guideline Status: |
This is the current
release of the guideline. An update is targeted for 2006. |
| Developer(s): |
Veterans Health Administration
(VHA), Department of Veterans Affairs (VA) and
Department of Defense (DoD) - Federal Government Agency [U.S.] |
| Funding Source: |
United States Government |
| Committee: |
The Management of Post-Traumatic
Stress Working Group
|
| Group Composition: |
The list of contributors to this guideline
includes psychiatrists, psychologists, nurses, occupational therapists,
social workers, internal medicine and primary care physicians,
and experts in the field of guideline and algorithm development. |
| Disease/Condition: |
Post-Traumatic Stress |
| Category: |
Prevention, Early Recognition,
Diagnosis and Treatment, Management; Evaluation |
| Intended Users: |
While designed for use by primary
care providers in an ambulatory care setting, the modules can
also be used to coordinate and standardize care within subspecialty
teams and as teaching tools for students and house staff. |
| Target Population: |
Any person who is eligible for
care in the VA or DoD health care delivery system. |
| Contact Person(s):
|
VA:
Harold S. Kudler, M.D.
Mental Health Coordinator, VISN 6
Durham VAMC
508 Fulton Street
Durham, NC 27705
Ph: 919-286-6933
Fax: 919-416-5832
E-mail: Harold.kudler@med.va.gov
DoD:
LTC Bruce E. Crow, Psy.D.
Chief, Department of Psychology
Madigan Army Medical Center
Department of Psychology
Tacoma, WA 98431
Ph: 253-968-4893
Fax: 253-968-3731
E-mail: bruce.crow@nw.amedd.army.mil |
|
GOALS/OBJECTIVES
- Implement
routine screening in primary care
- Standardized
initial and follow-up assessments
- Increase
prevention promote resilience
- Increase
detection of diagnosed ASR, ASD, PTSD
- Implement
evidence based intervention
- Integrate/coordinate
primary and mental health care
- Implement
routine screening for trauma and PTSD.
|
|
INTERVENTIONS AND PRACTICES
The guideline consists of 4 modules addressing:
Management of Acute Post-Trauma Stress in the early days after
exposure to trauma in civilian (ASR) and in combat or ongoing
military operation (COSR). Each module include criteria useful
to identify persons with stress reaction who have a greater probability
of developing PTSD and who therefore would benefit from early
brief intervention. The management of ASD and PTSD in primary
care and mental health specialty includes recommendations for
pharmacology and psychotherapy interventions. |
|
OUTCOMES CONSIDERED
Early diagnosis and treatment of stress may prevent PTSD. Appropriate
treatment of patients with PTSD may increase function and quality
of life. |
|
MAJOR RECOMMENDATIONS
The guideline is presented in an algorithmic format that allows
the practitioner to follow in the recognition and treatment of
ASR, ASD and PTSD. Recommendations are made with regard to the
intent to establish verifiable treatment objectives for veterans
with PTSD that will lead to a reduction in symptoms, increase
function and quality of life. |
|
CLINICAL ALGORITHM ARE PROVIDED FOR:
|
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TYPE OF EVIDENCE
The annotations that accompany the algorithms in the guideline
indicate whether each recommendation is based on scientific data
or expert opinion. Where existing literature is ambiguous
or conflicting, or where scientific data are lacking on an issue,
recommendations are based on the expert panels opinion and clinical
experience. The guideline contains a bibliography and discussion
of the evidence supporting each recommendation. |
|
DESCRIPTION OF METHODS TO COLLECT EVIDENCE
Published, peer-reviewed, RCTs were considered to constitute
the strongest level of evidence in support of guideline recommendations.
This decision was based on the judgment that RCTs provide the
clearest, scientifically sound basis for judging comparative
efficacy. The Working Group made this decision recognizing
the limitations of RCTs, particularly considerations of generalizability
with respect to patient selection and treatment quality. Meta-analyses
that included random controlled studies were also considered
to be the strongest level of evidence, as well as reports of
evidence-based systematic reviews. A systematic search of the
literature was conducted. It focused on the best available
evidence to address each key question and ensured maximum coverage
of studies at the top of the hierarchy of study types: evidence-based
guidelines, meta analyses, and systematic reviews. When available,
the search sought out critical appraisals already performed
by others that described explicit criteria for deciding what
evidence was selected and how it was determined to be valid.
The sources that have already undergone rigorous critical appraisal
include Cochrane Reviews, Best Evidence, Technology Assessment,
and EPC reports. |
|
METHODS TO ASSESS THE QUALITY
AND STRENGTH OF THE EVIDENCE
The
Grading Scheme Used for the Guideline
Table 1. Quality of Evidence
| I |
At least one properly done RCT |
| II-1 |
Well designed controlled trial without randomization |
| II-2 |
Well designed cohort or case-control analytic study |
| II-3 |
Multiple time series, dramatic results of uncontrolled experiment |
| III |
Opinion of respected authorities, case reports, and expert committees |
|
Table 2. Overall Quality
| Good |
High grade evidence (I or II-1) directly linked to
health outcome |
| Fair |
High grade evidence (I or II-1) linked to
intermediate outcome; or
grade evidence (II-2 or II-3) directly linked to health outcome |
|
Poor
|
Level III evidence or no linkage of evidence to health outcome |
|
Table 3. Net Effect of the Intervention
| Substantial |
More than a small relative impact on a frequent condition
with a substantial burden of suffering; or
A large impact on an infrequent condition with
a significant impact on the individual patient level. |
| Moderate |
A small relative impact on a frequent condition with
a substantial burden of suffering; or
A moderate impact on an infrequent condition
with a significant impact on the individual patient level. |
| Small |
A negligible relative impact on a frequent condition
with a substantial burden of suffering; or
A small impact on an infrequent condition with
a significant impact on the individual patient level. |
| Zero or Negative |
Negative impact on patients; or
No relative impact on either a frequent condition
with a substantial burden of suffering; or an infrequent condition
with a significant impact on the individual patient level. |
Table 4. Grade of Recommendation
| A |
A strong recommendation that the intervention is always
indicated and acceptable |
| B |
A recommendation that the intervention may be useful/effective |
| C |
A recommendation that the intervention may be considered |
| D |
A recommendation that a procedure may be considered
not useful/effective, or may be harmful |
| I |
Insufficient evidence to recommend for or against -
the clinician will use clinical judgment |
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