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The World Health Organization (WHO) and the United Nations High Commissioner for Refugees has recently released new guidelines to train primary care health workers how to treat acute traumatic stress in people following a major traumatic event. Developed by the WHO's Department of Mental Health and Substance Abuse and a WHO Steering Group first established in 2011, the Guidelines for the Management of Conditions Specifically Related to Stress are intended as an evidence-based approach to the management of problems and disorders specifically related to acute stress.
According to the executive summary provided with the guidelines, the problems covered include:
-symptoms of acute traumatic stress (intrusion, avoidance and hyperarousal) in the first month after a potentially traumatic event;
-symptoms of dissociative (conversion) disorders in the first month after a potentially traumatic event;
-nonorganic enuresis (bedwetting) in the first month after a potentially traumatic event (in children);
-hyperventilation in the first month after a potentially traumatic event;
-insomnia in the first month after a potentially traumatic event;
The new guidelines are primarily intended for primary and secondary care health including physicians, nurses, clinical officers and all medical specialists working outside the area of mental health. Programme managers responsible for primary or non-mental health secondary services are also included.
Along with the guidelines are a series of recommendations relating to the effectiveness of different types of treatment for traumatic stress. Cognitive Behaviour Therapy (CBT) is endorsed as being moderately effective in treating symptoms of traumatic stress in adults. Other treatments, including eye movement desensitization and reprocessing (EMDR), standalone problem solving counseling, relaxation training and psychoeducation are not endorsed because the evidence for their effectiveness is not as strong. No treatment recommendations were made about use of any of the established treatment methods for treating children or adolescents dealing with traumatic stress. The guidelines also recommend against the use of benzodiazepines and antidepressants for treating traumatic stress in adults, children or adolescents.
For treating PTSD (chronic traumatic stress persisting longer than six months), there appears to be moderate support for use of individual CBT and EMDR in treating symptoms. Other other treatment methods such as group CBT and relaxation training appear to be less effective. Individual CBT can also be effective for children and adolescents though other treatments such as EMDR and group CBT had less evidence for their effectiveness. The guidelines also recommended against the use of antidepressants, especially SSRIs and tricyclic antidepressants, in either children or adults unless other methods have been shown to be ineffective.
The guidelines also recommend against the use of structured psychological interventions for treating simple bereavement that does not meet the criteria for a mental disorder (DSM-V bereavement disorder diagnoses were not included). For treatment of enuresis related to traumatic stress in children, caregivers need to be warned against using punishment on children since there is no evidence that this is effective. With hyperventilation related to acute stress, folk remedies such as breathing into a paper bag is not effective, whether for children or adults.
Though this is only a sample of the treatment recommendations in the 273-page report, the new guidelines are intended to overcome problems with pre-existing guidelines that were developed for industrialized countries with comprehensive health-care systems. Developing evidence-based guidelines for treatment also means that treatment providers need to be competent, including training in psychological first aid and CBT with a trauma focus. Due to the weak evidence supporting the effectiveness of psychological or psychiatric treatment for children dealing with acute stress (within one month of the traumatic event), the guidelines do not include any treatment recommendations at this time.
Along with the treatment recommendations are a comprehensive review of the clinical research that went into preparing the guidelines. Highlighting the lack of strong evidence for many of the treatments that are often used for adults and children experiencing traumatic stress, the guidelines also stress the need for new research to fill some of the critical gaps. The guidelines also highlight what not to use to avoid making the trauma worse for patients. That includes different types of medication and forcing psychological counseling on bereaved patients who should be simply allowed to grieve in peace.
Finally, the new guidelines outlines WHO plans to monitor how the new recommendations are put into practice. Working with mental health agencies around the world, the WHO has also attracted research funds from governmental and non-governmental organizations to improve the quality of treatment services available. The WHO is planning to review their recommendations and evidence base within the next five years.
To download the new Guidelines (PDF)
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