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Psychological therapy is better than debriefing for PTSD

BMJ 2005; 330 doi: http://dx.doi.org/10.1136/bmj.330.7493.689-a (Published 24 March 2005) Cite this as: BMJ 2005;330:689
  1. Susan Mayor
  1. London

    People with post-traumatic stress disorder (PTSD) should be offered psychological treatment rather than drug treatment or the widely used practice of debriefing. This is the recommendation of a guideline for the NHS in England and Wales published this week.

    The guideline, from the National Institute for Clinical Excellence, says that up to 30% of people who experience an exceptionally threatening or catastrophic event may develop the disorder. The most characteristic symptom is reliving aspects of the traumatic event in a vivid and distressing way, including flashbacks, nightmares, and repetitive and distressing intrusive images or other sensory impressions from the event.

    After reviewing all the available evidence, including unpublished data from drug trials, the group that developed the guideline took the unusual step of recommending against a common practice used to treat the disorder. They advised that people who experience a traumatic event should not be given brief, single-session interventions, often termed debriefing.

    The facilitator of the guideline's development, Stephen Pilling, a clinical psychologist and coordinator of London's National Collaborating Centre for Mental Health, explained: “We found little evidence of benefit from a single psychological intervention in people with PTSD [post-traumatic stress disorder], and some evidence of harm.”

    He said that debriefing may not allow enough time for people to work adequately through the traumatic event and associated emotional and psychological feelings. “PTSD is associated with incomplete processing of a traumatic event, so effective therapy needs to allow a person to fully process what happened.”

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

    Mr Pilling said, “The key factor that makes these treatments effective is that they are structured psychological treatments that focus specifically on the traumatic event, in contrast to other more general therapies, such as counselling.”

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

    Mr Pilling said, “We were not able to find very convincing evidence for efficacy of drug treatment in PTSD. So, in contrast to US guidelines, which recommend use of SSRI [selective serotonin reuptake inhibitor] antidepressants as first line treatment, we advised against this.” He added that the guideline group had reviewed unpublished as well as published trials to reach the decision.

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

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

    NICE's guideline on the management of post-traumatic stress disorder is available at www.nice.org.uk