Cover of Evidence reviews for organisation and delivery of care for people with PTSD

Evidence reviews for organisation and delivery of care for people with PTSD

Post-traumatic stress disorder

Evidence review I

NICE Guideline, No. 116

Authors

.

London: National Institute for Health and Care Excellence (NICE); .
ISBN-13: 978-1-4731-3181-1
Copyright © NICE 2018.

Organisation and delivery or care for people with PTSD

This evidence report contains information on 1 review relating to the treatment of PTSD.

  • Review question 7.1 Which service delivery models are effective at meeting the needs of adults, children and young people with clinically important post-traumatic stress symptoms?

Review question 7.1 Which service delivery models are effective at meeting the needs of adults, children and young people with clinically important post-traumatic stress symptoms?

Introduction

The committee agreed that by conducting an evidence review on the clinical and cost effectiveness of service delivery models for people with PTSD, that the recommendations should improve the care that people with PTSD currently receive, reinforce current best practice and help to reduce variation in clinical practice as provision is variable or non-existent in some cases.

Summary of the protocol (PICO table)

Please see Table 1 for a summary of the population, intervention, comparison and outcomes (PICO) characteristics of this review.

Table 1. Summary of the protocol (PICO table).

Table 1

Summary of the protocol (PICO table).

For full protocol, see Appendix A – Review protocols

Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual; see the methods chapter for further information. Methods specific to this review question are described in Appendix A – Review protocols.

Declarations of interest were recorded according to NICE’s 2014 and 2018 conflicts of interest policies.

Clinical evidence

Included studies

Out of 73 articles for full assessment, 31 randomised controlled trials (RCTs) were identified and included in this review. For details of article selection, please refer to Appendix C. Interventions included Technology based therapies, Collaborative Care, Engagement strategies, Information and support, Stepped care, School based therapies and Motivational enhancement strategies; these interventions are presented in separate sections below. Please refer to Appendix D for characteristics of included studies.

Excluded studies

Five RCTs were identified and excluded from this review. Excluded studies and reasons for their exclusion can be found in Appendix K.

Technology based therapies: Clinical evidence

Included studies

Eight RCTs were included; seven RCTs compared delivery of Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) via telehealth versus in-person TF-CBT (Acierno 2016; Acierno 2017; Frueh 2007; Maieritsch 2015; Morland 2014; Morland 2015; Strachen 2012). One RCT compared electronically assisted TF-CBT to standard TF-CBT (Ruggiero 2016).

Excluded studies

No RCTs were identified and excluded from this review.

Summary of clinical studies included

Table 2 and BME=Black and Minority Ethnic; CBT=Cognitive Behavioural Therapy; CPT=Cognitive Processing Therapy; DSM=Diagnostic and Statistical manual of Mental disorders; ICD= International statistical Classification of Diseases and related health problems; N=Number of participants; NR=Not reported; PTSD=Post-Traumatic Stress Disorder; RCT=randomised controlled trial; TF-CBT =Trauma-Focused Cognitive Behavioural Therapy; TMH=Tele-Mental Health; VTC=Video Teleconferencing

1Acierno 2016; 2Acierno 2017; 3Frueh 2007; 4Maieritsch 2015; 5Morland 2014; 6Morland 2015; 7Strachen 2012;

Table 3 provide a brief summary of the included studies, and evidence from these are summarised in the clinical GRADE evidence profiles below (Table 4 and Table 5).

See also the literature search strategy in appendix B, study selection flow chart in appendix C, clinical evidence tables in appendix D, forest plots in appendix E and full GRADE tables in appendix F.

Table 2. Summary of included studies: Telehealth versus in-person TF-CBT.

Table 2

Summary of included studies: Telehealth versus in-person TF-CBT.

Table 3. Summary of included studies: Technology based TF-CBT versus standard TF-CBT.

Table 3

Summary of included studies: Technology based TF-CBT versus standard TF-CBT.

See appendix D for full evidence tables.

Quality assessment of clinical studies included in the evidence review

The clinical evidence profiles for this review (tele-health TF-CBT versus In-person TF-CBT and Technology supported TF-CBT versus standard TF-CBT) are presented in Table 4 and Table 5.

Table 4. Summary clinical evidence profile: Telehealth TF-CBT versus In-person TF-CBT.

Table 4

Summary clinical evidence profile: Telehealth TF-CBT versus In-person TF-CBT.

Table 5. Summary clinical evidence profile: Technology based TF-CBT versus standard TF-CBT.

Table 5

Summary clinical evidence profile: Technology based TF-CBT versus standard TF-CBT.

See appendix F for full GRADE tables.

Collaborative Care: Clinical evidence

Included studies

Seven RCTs were included, these studies compared collaborative care programs to treatment as usual (TAU) (Battersby 2013; Browne 2013; Fortney 2015; Meredith 2016; Schnurr 2013; Zatzick 2013; Zatzick 2017).

Excluded studies

One RCT was identified and excluded from this review, details of this study are presented in Appendix K.

Summary of clinical studies included

See also the literature search strategy in appendix B, study selection flow chart in appendix C, clinical evidence tables in appendix D, forest plots in appendix E and full GRADE tables in appendix F.

Table 6 provides a brief summary of the included studies, and evidence from these are summarised in the clinical GRADE profile below (Table 7).

See also the literature search strategy in appendix B, study selection flow chart in appendix C, clinical evidence tables in appendix D, forest plots in appendix E and full GRADE tables in appendix F.

Table 6. Summary of included studies: Collaborative Care.

Table 6

Summary of included studies: Collaborative Care.

Quality assessment of clinical studies included in the evidence review

The clinical evidence profiles for this review (collaborative care versus TAU) are presented in Table 7.

Table 7. Summary clinical evidence profile: Collaborative care verse TAU.

Table 7

Summary clinical evidence profile: Collaborative care verse TAU.

Engagement strategies: Clinical evidence

Included studies

Seven RCTs were included; six RCTs compared Engagement strategies to TAU (Dorsey 2014; Rosen 2013; Stecker 2014; Watts 2015; Zatzick 2015; Rosen 2017) and one RCT compared Engagement strategies to Trauma informed care (TIC) (Tecic 2011)

Excluded studies

No RCTs were identified and excluded from this review.

Summary of clinical studies included

Table 8 and BME=Black and Minority Ethnic; CBT=Cognitive Behavioural Therapy; N=Number of participants; DSM=Diagnostic and Statistical manual of Mental disorders; ICD= International statistical Classification of Diseases and related health problem; NR=Not Reported; PTSD=Post-Traumatic Stress Disorder; TAU=Treatment as usual

1 Dorsey 2014; 2Rosen 2013; 3Stecker 2014; 4Watts 2015; 5Zatzick 2015; 6Rosen 2017;

Table 9 provide a brief summary of the included studies, and evidence from these are summarised in the clinical GRADE profiles below (Table 10 and Table 11).

See also the literature search strategy in appendix B, study selection flow chart in appendix C, clinical evidence tables in appendix D, forest plots in appendix E and full GRADE tables in appendix F.

Table 8. Summary of included studies: Engagement strategies versus TAU.

Table 8

Summary of included studies: Engagement strategies versus TAU.

Table 9. Summary of included studies: Engagement strategies versus TIC.

Table 9

Summary of included studies: Engagement strategies versus TIC.

Quality assessment of clinical studies included in the evidence review

The clinical evidence profiles for this review (Engagement strategies versus TAU and Engagement strategies versus TIC) are presented in Table 10 and Table 11.

Table 10. Summary clinical evidence profile: Engagement strategies versus TAU.

Table 10

Summary clinical evidence profile: Engagement strategies versus TAU.

Table 11. Summary clinical evidence profile: Engagement strategies versus TIC.

Table 11

Summary clinical evidence profile: Engagement strategies versus TIC.

Information and support: Clinical evidence

Included studies

Six RCTs were included; four RCTs compared information and support to TAU (Carson 2016; Colville 2010; Jabre 2014; Samuel 2015), one RCT compared family conference with a nurse to family conference without a nurse (Garrouste-Orgeas 2016), and one RCT compared using decision aids to placebo (Mott 2014).

Excluded studies

No RCTs were identified and excluded from this review.

Summary of clinical studies included

See also the literature search strategy in appendix B, study selection flow chart in appendix C, clinical evidence tables in appendix D, forest plots in appendix E and full GRADE tables in appendix F.

Table 12, Table 13 and Table 14 and provide a brief summary of the included studies. Evidence from these are summarised in the clinical GRADE profiles below (Table 15, Table 16 and Table 17).

See also the literature search strategy in appendix B, study selection flow chart in appendix C, clinical evidence tables in appendix D, forest plots in appendix E and full GRADE tables in appendix F.

Table 12. Summary of included studies: Information and support versus TAU.

Table 12

Summary of included studies: Information and support versus TAU.

Table 13. Summary of included studies: Family conference with a nurse versus family conference without a nurse.

Table 13

Summary of included studies: Family conference with a nurse versus family conference without a nurse.

Table 14. Summary of included studies: Decision aids versus placebo session.

Table 14

Summary of included studies: Decision aids versus placebo session.

Quality assessment of clinical studies included in the evidence review

The clinical evidence profiles for this review (Information and support versus TAU, family conference with a nurse versus family conference without a nurse and Decision aids versus placebo session) are presented in Table 15, Table 16, and Table 17.

Table 15. Summary clinical evidence profile: Information and support versus TAU.

Table 15

Summary clinical evidence profile: Information and support versus TAU.

Table 16. Summary clinical evidence profile: family conference with a nurse versus family conference without a nurse.

Table 16

Summary clinical evidence profile: family conference with a nurse versus family conference without a nurse.

Table 17. Summary clinical evidence profile: Decision aids versus placebo session.

Table 17

Summary clinical evidence profile: Decision aids versus placebo session.

Stepped Care: Clinical evidence

Included studies

One RCT was included comparing stepped care of TF-CBT to standard delivery of TF-CBT (Salloum 2016).

Excluded studies

No RCTs were identified and excluded from this review.

Summary of clinical studies included

Table 18 provides a brief summary of the included study, and evidence from this study is summarised in the clinical GRADE profile below (Table 19).

See also the literature search strategy in appendix B, study selection flow chart in appendix C, clinical evidence tables in appendix D, forest plots in appendix E and full GRADE tables in appendix F.

Table 18. Summary of included studies: Stepped care versus standard TF-CBT.

Table 18

Summary of included studies: Stepped care versus standard TF-CBT.

Quality assessment of clinical studies included in the evidence review

The clinical evidence profile for this review (Stepped Care versus standard delivery of TF-CBT) is presented in Table 19.

Table 19. Summary clinical evidence profile: Stepped Care versus standard delivery of TF-CBT.

Table 19

Summary clinical evidence profile: Stepped Care versus standard delivery of TF-CBT.

School based therapies: Clinical evidence

Included studies

One RCT was included comparing TF-CBT delivered in school to standard, in-clinic delivery of TF-CBT (Jaycox 2010).

Excluded studies

No RCTs were identified and excluded from this review.

Summary of clinical studies included

Table 20 provides a brief summary of the included study, and evidence from this study is summarised in the clinical GRADE profile below (Table 21).

See also the literature search strategy in appendix B, study selection flow chart in appendix C, clinical evidence tables in appendix D, forest plots in appendix E and full GRADE tables in appendix F.

Table 20. Summary of included studies: School based TF-CBT versus in-clinic TF-CBT.

Table 20

Summary of included studies: School based TF-CBT versus in-clinic TF-CBT.

Quality assessment of clinical studies included in the evidence review

The clinical evidence profile for this review (School based TF-CBT versus In-Clinic TF-CBT) is presented in Table 21

Table 21. Summary clinical evidence profile: School based TF-CBT versus In-clinic TF-CBT.

Table 21

Summary clinical evidence profile: School based TF-CBT versus In-clinic TF-CBT.

Motivational enhancement strategies: Clinical evidence

Included studies

One RCT was included comparing Motivational enhancement tools to TAU (Murphy 2009).

Excluded studies

No RCTs were identified and excluded from this review.

Summary of clinical studies included

Table 22 provides a brief summary of the included study, and evidence from this study is summarised in the clinical GRADE profile below (Table 23).

See also the literature search strategy in appendix B, study selection flow chart in appendix C, clinical evidence tables in appendix D, forest plots in appendix E and full GRADE tables in appendix F.

Table 22. Summary of included studies: Motivational enhancement versus TAU.

Table 22

Summary of included studies: Motivational enhancement versus TAU.

Quality assessment of clinical studies included in the evidence review

The clinical evidence profile for this review (Motivational enhancement versus TAU) is presented in Table 23.

Table 23. Summary clinical evidence profile: Motivational enhancement versus TAU.

Table 23

Summary clinical evidence profile: Motivational enhancement versus TAU.

Economic evidence

Included studies

The systematic search of economic literature identified 1 study that assessed the cost effectiveness of collaborative care versus standard care for adults with clinically important post-traumatic stress symptoms (Schnurr 2013) and 1 study that assessed the cost effectiveness of stepped care versus standard care for children and young people with clinically important post-traumatic stress symptoms (Salloum 2016).

Excluded studies

Three economic studies were reviewed at full text and excluded from this review. Two of the studies were excluded as they were non-comparative and one study because the intervention was not targeted at PTSD symptoms. Studies not included in this review with reasons for their exclusion are listed in Appendix K.

Summary of studies included in the economic evidence review

Schnurr and colleagues (2013) performed a cost consequence analysis alongside a RCT (Schnurr 2013) that compared collaborative care with standard care for veterans with PTSD in the US (N=195, n=146 at 6-month follow-up). The perspective of the analysis was that of the health service. Costs consisted of outpatient visits including intervention, outpatient pharmacy, inpatient care (including pharmacy), and fee-for-service care. National unit costs were used. The primary outcome measure of the analysis was the PTSD symptom severity, measured using the Posttraumatic Diagnostic Scale (PDS). Other outcomes included depression measured using the Hopkins Symptom Checklist-20); functioning using the SF-12; and perceived quality of PTSD care and overall care. The time horizon of the analysis was 6 months.

Collaborative care was found to result in higher total costs, although the difference in costs between the two groups was not statistically significant. In terms of outcomes, there were no significant differences between collaborative and standard care, except in perceived quality of PTSD care, where results were less favourable for collaborative care. The study is partially applicable to the UK and the NICE context as it was conducted in the US and QALY was not used as the outcome measure. The study is characterised by potentially serious limitations, including the relatively small study sample and the rather short time horizon of the analysis.

Salloum and colleagues (2016) performed a cost consequence analysis alongside a RCT (Salloum 2016) that compared stepped care with standard care for children with PTSD in the US (N=53; at 3-month follow up: n=47). The perspective of the analysis was reported to be societal and included provider, payer and parent payments including productivity losses. Costs included intervention-related costs only. National unit costs were used. The primary outcome measure of the analysis was the severity of trauma symptoms, rated using the Trauma Symptom Checklist for Young Children (TSCYC, posttraumatic stress (PTS) subscale). Secondary outcomes included the Clinical Global Impression-Severity (CGI-S), the Child Behavior Checklist (CBCL), the Diagnostic Infant and Preschool Assessment (DIPA), the Clinical Global Impression-Improvement (CGI-I), the treatment credibility and satisfaction using the ERF and the Client Satisfaction Questionnaire (CSQ), and the parents’ assessment of PTSD diagnosis. The time horizon of the analysis was 3 months.

Stepped care was found to result in significantly lower total costs. In terms of outcomes, stepped care was not inferior to standard care on all variables, except for CBCL externalizing T-scores where stepped care was found to have a lower effect (p =0.09). The study is partially applicable to the UK and the NICE context as it was conducted in the US and QALY was not used as the outcome measure. The study is characterised by potentially serious limitations, including the small study sample, the short time horizon of the analysis and the fact that only intervention-related costs were considered.

The references of included studies and the economic evidence tables are provided in Appendix H. The economic evidence profiles are shown in Appendix I.

Economic model

No economic modelling was conducted for this question because other topics were agreed as higher priorities for economic evaluation.

Resource impact

The recommendations made by the committee based on this review are not expected to have a substantial impact on resources

Clinical evidence statements

Technology based intervention
Telehealth versus in-person TF-CBT
  • Data from very low quality evidence (7 RCTs; N=569) showed lower self-reported PTSD symptoms with Telehealth as compared to in-person care post-treatment, this was statistically significant, but not clinically important at 12 and 26 week time-points. At 52 weeks follow up, in-person therapy showed significantly lower self-reported PTSD symptoms.
  • Data from very low quality evidence (3 RCTs; N=300) showed a statistically significant improvement (but not clinically important), improvement in clinician rated PTSD symptomology with Telehealth as compared to in-person therapy post-treatment, at 12 and 26 week follow-up.
  • Data from very low quality evidence (5 RCTs; N=324) showed no significant difference in symptoms of depression with telehealth as compared to in-person therapy at post-treatment, at 12, 26 and 52 week follow-up.
  • Data from very low quality evidence (1 RCT; N=23) showed no significant difference in symptoms of anxiety with telehealth as compared to in-person therapy at post-treatment.
  • Data from very low quality (5 RCTs; N=673) evidence showed no significant difference in the number of participants who completed a set number of therapy sessions between Telehealth and in-person TF-CBT.
  • Data from very low quality evidence (1 RCT; N=21) showed no significant difference in the levels of patient satisfaction between those who received telehealth and those who received in-person TF-CBT.
Technology supported TF-CBT versus standard TF-CBT
  • Data from very low quality evidence (1 RCT; N=26) showed those who received technology supported TF-CBT had clinically importantly reduced PTSD symptomology post-treatment as compared to those who received standard TF-CBT, which was statistically significant.
  • Data from very low quality evidence (1 RCT; N=26) showed no difference in symptoms of depression post treatment between those who received technology supported TF-CBT and those who received standard TF-CBT.
Collaborative Care
Collaborative care versus Treatment as usual
  • Data from very low quality evidence (5 RCTs; N=72-803) showed significantly lower self-reported symptoms of PTSD with collaborative care as compared to TAU at 26, 39 and 52 week follow up. The difference was clinically important at 39 and 52 weeks.
  • Data from very low quality evidence (1 RCT; N=355) showed no significant difference in clinician rated PTSD symptomology with collaborative care as compared to TAU.
  • Data from very low quality evidence (5 RCTs; N=66-803) showed no difference in self-reported symptoms of depression between collaborative care and TAU post-treatment, at 4.3, 13 or 26-week follow up. Data from one study showed a significant difference at 39 and 52-week follow up.
  • Data from very low quality evidence (2 RCTs; N=460) showed the mean number of psychotherapy sessions attended by those in the collaborative care intervention was significantly higher than those in TAU.
  • Data from very low quality evidence (2 RCTs; N=460) showed the number of participants completing a set number of psychotherapy sessions was significantly higher in those receiving collaborative care as compared to those receiving TAU.
  • Data from very low quality evidence (2 RCTs; N=460) showed no difference in adherence to medication with collaborative care as compared to TAU.
Engagement strategies
Engagement strategies versus Treatment as usual
  • Data from low quality evidence (2 RCTs; N=395) showed significantly lower self-reported PTSD symptoms with engagement strategies as compared to TAU at 13-week follow up; however, this was not considered clinically important. There was no difference at all other time-points.
  • Data from low quality evidence (2 RCTs; N=651) showed the mean number of psychotherapy sessions was generally higher in those receiving engagement strategies as compared to TAU, but this was not statistically significant.
  • Data from very low quality evidence (1 RCT; N=128) showed the number of participants who arrived at a treatment choice was significantly higher in those who received engagement strategies as compared to TAU.
  • Data from very low quality evidence (1 RCT) showed the number of participants seeking PTSD treatment was significantly higher in those who received engagement strategies as compared to TAU.
  • Data from very low quality evidence (single-RCT analyses; N=209-273) showed the number of participants who completed a set number of psychotherapy sessions was significantly higher in those who received engagement strategies as compared to TAU.
  • Data from very low quality evidence (1 RCT; N=121) showed the number of people using the website (afterdeployment.org) was significantly higher in those who received engagement strategies as compared to TAU; however, there was no significant difference in the mean time spent using the website.
Engagement strategies versus Trauma informed care
  • Data from low quality evidence (1 RCT; N=62-65) showed no significant difference in symptoms of PTSD with engagement strategies as compared to TIC (at 26-, 52- and 78-week follow-up).
  • Data from low quality evidence (1 RCT; N=60-66) showed no significant difference in symptoms of depression or anxiety with engagement strategies as compared to TIC (at 26-, 52- and 78- week follow-up).
Information and Support
Information and support versus Treatment as usual
  • Data from very low quality evidence (2 RCTs; N=513) showed the number of people scoring >30 on IES was significantly lower with information and support as compared to TAU at 22-52 week follow-up.
  • Data from very low quality evidence (1 RCT; N=71) showed no difference in levels of PTSD symptoms with information and support as compared to TAU at 32-week follow-up.
  • Data from very low quality evidence (2 RCTs; N=513) showed the number of people scoring 8 or above on the HADS-D questionnaire was significantly lower with information and support as compared to TAU at 22-52 week follow-up.
  • Data from very low quality evidence (2 RCTs; N=383) showed no difference in symptoms of depression (HADS) with information and support as compared to TAU at 13-32 week follow-up.
  • Data from very low quality evidence (2 RCTs; N=513) showed no significant difference in the number of people scoring 8 or above on the HADS-A questionnaire with information and support as compared to TAU at 22-52 week follow-up.
  • Data from low quality evidence (2 RCTs; N=383) showed a significant difference in reported levels of anxiety with information and support as compared to TAU; however, this was not considered clinically important at 13-32 week follow-up.
  • Data from low quality evidence (1 RCT; N=570) showed no difference in discontinuation (for any reason) at study/treatment endpoint with information and support as compared to TAU.
Family conference with a nurse versus family conference without a nurse
  • Data from low quality evidence (1 RCT; N=86) showed no significant difference in the number of participants scoring 22 or above on IES-R at 13 week follow up with a family conference with a nurse or a family conference without a nurse.
  • Data from very low quality evidence (1 RCT; N=86) showed no significant difference in the number of participants scoring 8 or above on HADS-D questionnaire at 13 week follow up with a family conference with a nurse or a family conference without a nurse.
  • Data from very low quality evidence (1 RCT; N=86) showed no significant difference in the number of participants scoring 8 or above on HADS-A questionnaire at 13 week follow up with a family conference with a nurse or a family conference without a nurse.
Decision aid session versus placebo session
  • Data from very low quality evidence (1 RCT; N=20) showed no significant difference in the number of participants completing over 9 psychotherapy sessions between those who received a decision aids session as compared to those receiving a placebo session.
Stepped Care
Stepped care TF-CBT versus standard delivery of TF-CBT
  • Data from very low quality evidence (1 RCT; N=53) showed no significant difference in symptoms of PTSD as measured by TSCYCC with stepped care as compared to TAU at endpoint or 13-week follow-up.
  • Data from very low quality evidence (1 RCT; N=53) showed significantly fewer symptoms of PTSD as measured by CGI with stepped care as compared to TAU at endpoint and 13-week follow-up.
School based Therapies
School based therapy versus in-clinic therapy
  • Data from very low quality evidence (1 RCT; N=71) showed significantly fewer symptoms of PTSD with clinic based TF-CBT as compared to school based therapy at 43-week follow-up.
  • Data from very low quality evidence (1 RCT; N=71) showed no significant difference in reported levels of depression between school based therapy as clinic based therapy at 43-week follow-up.
  • Data from very low quality evidence (1 RCT; N=118) showed the number of children completing therapy sessions was significantly higher in the school based therapy sessions as compared to clinic-based sessions; this data should be regarded with caution due to the methodology discrepancies between interventions.
Motivational enhancement strategies
Motivational enhancement strategies versus Trauma informed care
  • Data from very low quality evidence (1 RCT; N=114) showed the number of participants who completed therapy sessions was not significantly different between those who received motivational enhancement or TIC.

Economic evidence statements

Collaborative care
  • Evidence from 1 US economic evaluation conducted alongside a RCT (N=195, n=146 at 6-month follow-up) suggests that collaborative care is unlikely to be a cost-effective model of delivery of care for adults with clinically important post-traumatic stress symptoms. This evidence is partially applicable to the UK context and is characterised by potentially serious methodological limitations.
Stepped care
  • Evidence from 1 US economic evaluation conducted alongside a RCT (N=53; at 3-month follow up: n=47) suggests that stepped care is likely to be a cost-effective model of delivery of care for children with clinically important post-traumatic stress symptoms. This evidence is partially applicable to the UK context and is characterised by potentially serious methodological limitations.

The committee’s discussion of the evidence

Interpreting the evidence
The outcomes that matter most

Critical outcomes were measures of PTSD symptom improvement on validated scales and prevention of PTSD (as measured by the number of people with a diagnosis or scoring above clinical threshold on a validated scale at endpoint or follow-up). Quality of life, access to treatment and uptake of treatment were also critical outcomes, although data for these outcomes was limited. The committee considered healthcare utilization, satisfaction/preference, anxiety about treatment, and symptoms of a coexisting condition (including anxiety and depression) as important but not critical outcomes. This distinction was based on the primacy of preventing PTSD and of improving access to effective treatment, whilst acknowledging that broader measures may be indicators of a general pattern of effect. Generally change scores were favoured over final scores as although in theory randomisation should balance out any differences at baseline, this assumption can be violated by small sample sizes. The committee also expressed a general preference for self-rated PTSD symptomatology over clinician-rated measures, however, in considering service delivery interventions (relative to pharmacological interventions) a greater emphasis was placed on triangulating effects on self-rated PTSD symptomatology with clinician-rated outcome measures, given that the latter but not the former could be blinded.

The quality of the evidence
Technology based therapies

All interventions included in the review were assessed for risk of bias using the Cochrane Risk of Bias tool. In addition, the evidence in the pairwise comparisons was assessed using the GRADE methodology. The quality of the evidence was all considered either low or very low quality. The committee agreed that evidence was generally downgraded due to a lack of blinding of participants, in many cases assessors were also not blinded, or outcomes were based on self-report. There was a high loss to follow up throughout and often studies were small in size, and data imprecise. The committee also wished to highlight the high level of heterogeneity observed across some of the outcomes. The quality for individual comparisons are outlined below.

Telehealth

The data were considered very low quality due to lack of blinding of personnel and participants. Although the included studies were generally small in size, seven studies were included in total on PTSD symptomology, and results suggest a non-significant difference between telehealth and in person delivery, at least at endpoint and shorter-term follow-ups (up to 6 months). Therefore the evidence was considered convincing, and recommendations to be considered.

There was some discussion over the fact that the studies on Telehealth were all on US Military veterans, however the committee agreed that the findings were nevertheless relevant to a general UK PTSD population

Technology supported TF-CBT versus standard TF-CBT

No recommendation was made as data was provided from one very low quality study. The study included 26 participants, the type of trauma was unclear, randomisation methods were unclear, and both assessors and participants were aware of treatment allocation.

Collaborative Care

The data was considered very low quality, assessors and participants were not blinded to treatment allocation, randomisation methods were often unclear and heterogeneity was high or very high across different outcomes. Data for PTSD symptomology was consistent across studies and time-points; however large degrees of inconsistency were observed for the number of participants completing therapy sessions.

Engagement Strategies

Data was considered either low or very low quality due to lack of blinding of assessors and participants, unclear randomisation methods and high heterogeneity. Six studies reported data on PTSD and depression symptomology, and data were consistent across studies and across time-points. The data on mean number of sessions attended and on the number of participants completing the intervention were less consistent.

Stepped Care

The evidence presented was seen to be encouraging by the committee; however, only one study was identified for this section and the outcomes were considered as very low quality due to small sample size, lack of blinding and unclear randomisation and allocation methods.

School based therapies

The committee agreed not to recommend school based therapies, as the evidence related to one small, very low quality study. The outcomes were considered very low quality due to small sample size, lack of blinding and unclear randomisation. The study was conducted on children who had a shared trauma, and may not be relevant in other non-shared trauma environments. In addition, the data was considered to be at high risk of bias due to large differences in follow up.

Motivational enhancement strategies

The committee agreed not to recommend motivational enhancement, as it was from evidence relating to one small, low quality study. The evidence was considered very low quality due to lack of blinding of participants, randomisation and allocation methods were unclear. In addition the committee discussed the risk of reporting bias due to the way data were presented in the article.

Benefits and harms
Technology based therapies
Telehealth

The committee concluded that there were a reasonable number of studies with a significant sample size and that the studies consistently showed non-inferiority for trauma focused CBT delivered by video consultation.

The committee agreed that offering video consultation would facilitate uptake of services. People with PTSD can be quite avoidant of treatment and therefore offering treatment remotely may make therapy more accessible to those who are not comfortable being in a clinical setting. They pointed out that it could also improve access to people who are house bound and those living in remote communities or where there are challenges in travelling to services.

However, the committee was moderately concerned that telehealth might become the preferred choice to reduce cost if it were to be offered on a routine basis. They agreed that telehealth should then be considered where clinically appropriate, and where it is preferred by the person with PTSD. They also revised recommendations in the access to care section to highlight how video consultation can be considered as a modification to the method and mode of delivery of treatment interventions. Based on their clinical expertise, the committee pointed out that in some situations it may be important that the person with PTSD and therapist develop a working relationship face to face first, and then go onto use telehealth as an option of care, taking into consideration the person’s preferences.

The committee also discussed that video consultation may be clinically inappropriate in some situations: when there are language barriers; where the person has no access to IT equipment; and when people have co-morbidities (for example, in people with a substance misuse problem which may not be picked up via video conferencing facilities). They also noted that in cases where the location of the trauma is the home, video consultation from there would also not be clinically appropriate, and so there was some level of clinical judgment required to establish when face-to-face intervention would be more appropriate, and always taking into account the person’s preferences.

Whilst there was some discussion over the fact that studies on telehealth were all on US Military veterans, the committee believed that the findings were nevertheless relevant to a general UK PTSD population

Technology supported trauma focused CBT versus standard trauma focused CBT

No recommendation was made as evidence related to one very low quality study.

Collaborative Care

The committee discussed how although the data was supportive of collaborative care, this should really be regarded as a principle of good clinical practice. Co-ordinated care where there is collaboration across health care professionals should be carried out whenever required. Nonetheless, the committee also pointed out that although this should be at the core of good clinical practice, they were aware of inconsistent co-ordinated care in mental health departments across the UK. Therefore, although a specific recommendation was not developed, the committee reinforced the principles of collaboration of care in the recommendations contained under planning treatment (section 1.6 of the short guideline).

Engagement Strategies

The committee did not recommend specific engagement strategies, although the evidence comparing engagement strategies to TAU highlighted the importance of encouraging people to engage with services. Therefore, the committee agreed it was important to have systems and strategies in place to help people engage with care. It was discussed that people with PTSD as a group often avoid seeking help, and therefore this was of particular importance. The committee agreed that these engagement strategies were to be reinforced in the recommendations contained under access to care (section 1.3 of the short guideline).

Stepped Care

The committee noted that the evidence presented was encouraging. However, only one study was identified and so they agreed not to recommend stepped care. The committee agreed that this was an area for further research as stepped care approaches might address the challenges inherent to providing individual psychotherapies, by making less intensive forms of treatment more easily available to people who might benefit from them (see Appendix L).

School based therapies

The committee agreed that school based therapies should not be recommended as the evidence related to one small, very low quality study, and the data were at high risk of bias. They also noted that this was a collective trauma event and therefore may not be appropriate in single traumatic event. However, based on their clinical expertise and by consensus it was decided that although school based therapies could not be recommended on their own, they would be included within the delivery options, when discussing therapy provision as a whole. The evidence presented was from a study that looked at PTSD from a collective trauma event, and it was deemed that this may be the most appropriate time for school based therapies. The evidence supported school therapy as a viable option which can be considered in some circumstance.

Motivational enhancement strategies

Motivational enhancement was not recommended as the evidence related to only one small, low quality study.

Cost effectiveness and resource use

The committee considered the existing economic evidence, which was exclusively derived from studies conducted in the US. One US study conducted alongside a RCT indicated that collaborative care was unlikely to be a cost-effective model of delivery of care for adults with clinically important post-traumatic stress symptoms. On the other hand, another US study conducted alongside a RCT suggested that stepped care was likely to be a cost-effective model of delivery of care for children and young people with clinically important post-traumatic stress symptoms. The committee noted that both studies were characterised by potentially serious limitations, comprising a small study size and a short time horizon. Moreover, the committee noted that both studies were conducted in the US, where resource use, organisation of services and unit costs are different from those in the UK. Therefore, they considered all available economic evidence to be only partially applicable to the UK.

The committee expressed the view that modifying the delivery of trauma focused CBT using remote video consultation, text messages, emails or telephone contacts where it is preferred by the patient and is clinically appropriate may save resources without compromising the therapeutic outcome, in particular in remote areas where therapists need to travel longer distances to deliver trauma focused CBT in person.

The committee were concerned that video consultation might be introduced purely as a cost saving measure and not take into account the potential for additional therapeutic and engagement benefit in some situations of face to face consultation for this reason the recommendation was worded to require both patient preference and clinical appropriateness.

It was highlighted that in some situations, telehealth was provided in specialised clinics, not in the person’s home, and these situations are unlikely to provide any benefit to those who have accessibility issues. It may be easier for a patient to access a local specialised telehealth clinic than a regional specialist PTSD clinic.

Other factors the committee took into account

The committee considered the person’s preference to be an important factor when developing recommendations.

The committee also discussed how little high-quality evidence there is to support trauma-informed care and agreed that it should be prioritised as an areas for further research (see Appendix L).

References for included studies

    Technology based interventions

    • Acierno 2016

      Acierno R, Gros DF, Ruggiero KJ, et al. (2016) Behavioral activation and therapeutic exposure for posttraumatic stress disorder: A noninferiority trial of treatment delivered in person versus home-based telehealth. Depression and anxiety 33(5), 415–23 [PubMed: 26864655]

    • Acierno 2017

      Acierno R, Knapp R, Tuerk P, et al. (2017) A non-inferiority trial of Prolonged Exposure for posttraumatic stress disorder: In person versus home-based telehealth. Behaviour Research and Therapy 89, 57–65 [PMC free article: PMC5222772] [PubMed: 27894058]

    • Frueh 2007

      Frueh BC, Monnier J, Yim E, et al. (2007) A randomized trial of telepsychiatry for post-traumatic stress disorder. Journal of telemedicine and telecare 13, 142–147 [PubMed: 17519056]

    • Maieritsch 2015

      Maieritsch KP, Smith TL, Hessinger JD, et al. (2016) Randomized controlled equivalence trial comparing videoconference and in person delivery of cognitive processing therapy for PTSD. Journal of telemedicine and telecare 22(4), 238–43 [PubMed: 26231819]

    • Morland 2014

      Morland L, Mackintosh M-A, Greene C, et al. (2014) Cognitive processing therapy for posttraumatic stress disorder delivered to rural veterans via telemental health: a randomised noninferiority clinical trial. Journal of Clinical Psychiatry 75, 470–476 [PubMed: 24922484]

    • Morland 2015

      Morland LA, Mackintosh MA, Rosen CS, et al. (2015) telemedicine versus in-person delivery of cognitive processing therapy for women with posttraumatic stress disorder: A randomized non-inferiority trial. Depression and Anxiety 32, 811–820 [PubMed: 26243685]

    • Ruggiero 2016

      Ruggiero K, Adams Z, Danielson C, et al. (2016) Technology-based tools to enhance quality of care in mental health treatment. (Final progress report)

    • Strachen 2012

      Strachan M, Gros DF, Ruggiero KJ, et al. (2012) An Integrated Approach to Delivering Exposure-Based Treatment for Symptoms of PTSD and Depression in OIF/OEF Veterans: Preliminary Findings. Behavior Therapy 43, 560–569 [PubMed: 22697444]

    Collaborative Care

    • Battersby 2013

      Battersby MW, Beattie J, Pols RG, et al. (2013) A randomised controlled trial of the Flinders Program™ of chronic condition management in Vietnam veterans with co-morbid alcohol misuse, and psychiatric and medical conditions. Australian & New Zealand Journal of Psychiatry 47(5), 451–62 [PubMed: 23307806]

    • Browne 2013

      Browne AL, Appleton S, Fong K, et al. (2013) A pilot randomized controlled trial of an early multidisciplinary model to prevent disability following traumatic injury. Disability and rehabilitation 35(14), 1149–63 [PubMed: 23083416]

    • Fortney 2015

      Fortney JC, Pyne JM, Kimbrell TA, et al. (2015) Telemedicine-based collaborative care for posttraumatic stress disorder: A randomized clinical trial. JAMA Psychiatry 72, 58–67 [PubMed: 25409287]

    • Meredith 2016

      Meredith LS, Eisenman DP, Han B, et al. (2016) Impact of Collaborative Care for Underserved Patients with PTSD in Primary Care: a Randomized Controlled Trial. Journal of General Internal Medicine 31, 509–517 [PMC free article: PMC4835392] [PubMed: 26850413]

    • Schnurr 2013

      Schnurr PP, Friedman MJ, Oxman TE, et al. (2013) RESPECT-PTSD: re-engineering systems for the primary care treatment of PTSD, a randomized controlled trial. Journal of general internal medicine 28, 32–40 [PMC free article: PMC3539037] [PubMed: 22865017]

    • Zatzick 2013

      Zatzick D and McFadden C (2013) Integrating Information Technology Advancements Into Early PTSD Interventions. Available at https:​//clinicaltrials.gov (In progress)

    • Zatzick 2017

      Zatzick D, Russo J, Thomas P, et al. (2017) Patient-Centred Care Transiotions after Injury Hospitalization: A comparative effectiveness Trial. Psychiatry, 1–16

    Engagement Strategies

    • Dorsey 2014

      Dorsey S, Pullmann MD, Berliner L, et al. (2014) Engaging foster parents in treatment: A randomized trial of supplementing Trauma-focused Cognitive Behavioral Therapy with evidence-based engagement strategies. Child abuse & neglect 38(9), 1508–20 [PMC free article: PMC4160402] [PubMed: 24791605]

    • Rosen 2013

      Rosen CS, Tiet QQ, Harris AH, et al. (2013) Telephone monitoring and support after discharge from residential PTSD treatment: a randomized controlled trial. Psychiatric services (Washington, D.C.), 64, 13–20 [PMC free article: PMC6540753] [PubMed: 23117443]

    • Rosen 2017

      Rosen CS, Azevedo KJ, Tiet QQ, et al. (2017) An RCT of Effects of Telephone Care Management on Treatment Adherence and Clinical Outcomes Among Veterans With PTSD. Psychiatric Services 68(2), 151–8 [PubMed: 27745535]

    • Stecker 2014

      Stecker T, McHugo G, Xie H, et al. (2014) RCT of a brief phone-based CBT intervention to improve PTSD treatment utilization by returning service members. Psychiatric Services 65, 1232–1237 [PMC free article: PMC4182109] [PubMed: 24933496]

    • Tecic 2011

      Tecic T, Schneider A, Althaus A, et al. (2011) Early short-term inpatient psychotherapeutic treatment versus continued outpatient psychotherapy on psychosocial outcome: a randomized controlled trial in trauma patients. J Trauma 70(2), 433–41[PMID: 21057336] [PubMed: 21057336]

    • Watts 2015

      Watts BV, Schnurr PP, Zayed M, et al. (2015) A randomized controlled clinical trial of a patient decision aid for posttraumatic stress disorder. Psychiatric services (Washington, D.C.) 66, 149–154 [PubMed: 25322473]

    • Zatzick 2015

      Zatzick D, O’Connor SS, Russo J, et al. (2015) Technology-Enhanced Stepped Collaborative Care Targeting Posttraumatic Stress Disorder and Comorbidity After Injury: A Randomized Controlled Trial. J Traumatic Stress 28, 391–400 [PMC free article: PMC5549940] [PubMed: 26467327]

    Information and support

    • Carson 2016

      Carson SS, Cox CE, Wallenstein S, et al. (2016) Effect of Palliative Care-Led Meetings for Families of Patients With Chronic Critical Illness: A Randomized Clinical Trial. JAMA 316, 51–62 [PMC free article: PMC5538801] [PubMed: 27380343]

    • Colvielle 2010

      Colville GA, Cream PR, Kerry SM (2010) Do parents benefit from the offer of a follow-up appointment after their child’s admission to intensive care?: An exploratory randomised controlled trial. Intensive and Critical Care Nursing 26, 146–153 [PubMed: 20347311]

    • Garrouste-Orgeas 2016

      Garrouste-Orgeas M, Max A, Lerin T, et al. (2016) Impact of proactive nurse participation in ICU family conferences: A mixed-method study. Critical care medicine 44, 1116–1128 [PubMed: 26937860]

    • Jabre 2014

      Jabre P, Tazarourte K, Azoulay E, et al. (2014) Offering the opportunity for family to be present during cardiopulmonary resuscitation: 1-Year assessment. Intensive Care Medicine 40, 981–987 [PubMed: 24852952]

    • Mott 2014

      Mott JM, Stanley MA, Street RL, et al. (2014) Increasing engagement in evidence-based PTSD treatment through shared decision-making: a pilot study. Military medicine 179, 143–149 [PubMed: 24491609]

    • Samuel 2015

      Samuel V, Colville G, Goodwin S, et al. (2015) The Value of Screening Parents for Their Risk of Developing Psychological Symptoms After PICU: A Feasibility Study Evaluating a Pediatric Intensive Care Follow-Up Clinic. Pedaitric Critical Care Medicine 16, 808–813 [PubMed: 26218258]

    Stepped Care

    • Salloum 2016

      Salloum A, Wang W, Robst J, et al. (2016) Stepped care versus standard trauma-focused cognitive behavioral therapy for young children. Journal of Child Psychology and Psychiatry 57(5), 614–22 [PMC free article: PMC4824681] [PubMed: 26443493]
      Salloum A, Swaidan V, Torres A, et al. (2016) Parents’ perception of stepped care and standard care trauma-focused cognitive behavioral therapy for young children. Journal of Child and Family Studies 25, 262–274 [PMC free article: PMC4788389] [PubMed: 26977133]

    School based therapies

    • Jaycox 2010

      Jaycox LH, Cohen JA, Mannarino AP, et al. (2010) Children’s mental health care following Hurricane Katrina: A field trial of trauma-focused psychotherapies. Journal of Traumatic Stress 23(2), 223–31 [PMC free article: PMC2860874] [PubMed: 20419730]

    Motivational enhancement strategies

    • Murphy 2009

      Murphy RT, Thompson KE, Murray M, et al. (2009) Effect of a motivation enhancement intervention on veterans’ engagement in PTSD treatment. Psychological Services 6(4), 264

Appendices

Appendix A. Review protocols

Review protocol for “Which service delivery models are effective at meeting the needs of adults, children and young people with 4 clinically important post-traumatic stress syndrome?”

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Table

Women who have been exposed to sexual abuse or assault, or domestic violence Lesbian, gay, bisexual, transsexual or transgender people

Appendix B. Literature search strategies

Search strategies for “Which service delivery models are effective at meeting the needs of adults, children and young people with clinically important post-traumatic stress symptoms?”

Clinical evidence

Database: Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R), Embase, PsycINFO

Date of last search: 31 January 2017

Database: CDSR, DARE, HTA, CENTRAL

Date of last search: 31 January 2017

Database: CINAHL PLUS

Date of last search: 31 January 2017

Health economic evidence

Note: evidence resulting from the health economic search update was screened to reflect the final dates of the searches that were undertaken for the clinical reviews (see review protocols).

Database: Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R), Embase, PsycINFO

Date of last search: 1 March 2018

Database: HTA, NHS EED

Date of last search: 1 March 2018

Appendix C. Clinical evidence study selection

Clinical evidence study selection for “Which service delivery models are effective at meeting the needs of adults, children and young people with clinically important post-traumatic stress symptoms?”

Figure 1. Flow diagram of clinical article selection for review

Appendix E. Forest plots

Forest plots for “Which service delivery models are effective at meeting the needs of adults, children and young people with clinically important post-traumatic stress symptoms?”

Technology based Therapies

Engagement Strategies

Engagement strategies versus Treatment as usual for the treatment of clinically important symptoms/PTSD

Figure 17. Engagement strategies versus Treatment as usual for the treatment of clinically important symptoms/PTSD: PTSD symptomology (self-report)

Figure 18. Engagement strategies versus Treatment as usual for the treatment of clinically important symptoms/PTSD: Mental health (SF-12, mental component) at 26 week follow up

Figure 19. Engagement strategies versus Treatment as usual for the treatment of clinically important symptoms/PTSD: Symptoms of depression (self-report)

Figure 20. Engagement strategies versus Treatment as usual for the treatment of clinically important symptoms/PTSD: Mean number of psychotherapy sessions attended

Figure 21. Engagement strategies versus Treatment as usual for the treatment of clinically important symptoms/PTSD: Number of participants who arrived at a treatment choice

Figure 22. Engagement strategies versus Treatment as usual for the treatment of clinically important symptoms/PTSD: Number of participants seeking PTSD treatment

Figure 23. Engagement strategies versus Treatment as usual for the treatment of clinically important symptoms/PTSD: Number of participants who completed set number of psychotherapy sessions

Figure 24. Engagement strategies versus Treatment as usual for the treatment of clinically important symptoms/PTSD: Number of people using the website

Figure 25. Engagement strategies versus Treatment as usual for the treatment of clinically important symptoms/PTSD: Mean time using the website during hospital stay

Information and support

Decision aids versus placebo session for the treatment of clinically important symptoms/PTSD

Figure 39. Decision aids versus placebo session for the treatment of clinically important symptoms/PTSD: Number completing >9 sessions

Motivational Enhancement strategies

Motivational enhancement versus trauma informed care for the treatment of clinically important symptoms/PTSD

Figure 45. Motivational enhancement versus trauma informed care for the treatment of clinically important symptoms/PTSD: Number completing sessions

Appendix F. GRADE tables

GRADE tables for “Which service delivery models are effective at meeting the needs of adults, children and young people with clinically important post-traumatic stress symptoms?”

Technology based therapies

Telehealth versus in-person TF-CBT for the treatment of clinically important symptoms/PTSD
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235/328 (71.6%)

Technology supported TF-CBT versus standard TF-CBT for the treatment of clinically important symptoms/PTSD
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Table

CI=confidence interval; PTSD=post-traumatic stress disorder; TF-CBT=Trauma-focused cognitive behavioural therapy

Collaborative Care

Collaborative care versus treatment as usual for the treatment of clinically important symptoms/PTSD
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Table

44/229 (19.2%)

Engagement Strategies

Engagement strategies versus treatment as usual for the treatment of clinically important symptoms/PTSD
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Table

60/63 (95.2%)

Engagement strategies versus trauma-informed care for the treatment of clinically important symptoms/PTSD
Image

Table

CI=confidence interval; PTSD=post-traumatic stress disorder; SMD=standard mean difference; STAI=State-Trait Anxiety Inventory; TIC=trauma informed care

Information and Support

Information and support versus Treatment as usual for the treatment of clinically important symptoms/PTSD
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Table

51/253 (20.2%)

Family conference with a nurse versus family conference without a nurse for the treatment of clinically important symptoms/PTSD
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Table

21/42 (50%)

Decision aids versus placebo session for the treatment of clinically important PTSD symptoms
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Table

4/9 (44.4%)

Stepped Care

Stepped care versus treatment as usual for the treatment of clinically important symptoms/PTSD
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Table

CI=confidence interval; CGI=Clinical Global Impression scale; MD=mean difference; SMD=standard mean difference; TAU=treatment as usual; TSCYC=Trauma Symptom Checklist for Young Children

School based therapies

School based TF-CBT versus in-clinic TF-CBT for the treatment of clinically important symptoms/PTSD
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Table

57/58 (98.3%)

Motivational enhancement therapies

Motivational enhancement versus trauma informed care for the treatment of clinically important symptoms/PTSD
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Table

42/60 (70%)

Appendix G. Economic evidence study selection

Economic evidence study selection for “Which service delivery models are effective at meeting the needs of adults, children and young people with clinically important post-traumatic stress symptoms?”

A global health economics search was undertaken for all areas covered in the guideline. The flow diagram of economic article selection across all reviews is provided in Appendix A of Supplement 1 – Methods Chapter’.

Appendix H. Economic evidence tables

Economic evidence tables for “Which service delivery models are effective at meeting the needs of adults, children and young people with clinically important post-traumatic stress symptoms?”

Collaborative care

  • Schnurr PP, Friedman MJ, Oxman TE (2013) RESPECT-PTSD: Re-engineering systems for the primary care treatment of PTSD, A randomized controlled trial. Journal of General Internal Medicine 28(1), 32–40 [PMC free article: PMC3539037] [PubMed: 22865017]

Download PDF (88K)

Stepped-care

  • Salloum A, Wang W, Robst J(2016) Stepped care versus standard trauma-focused cognitive behavioral therapy for young children. Journal of Child Psychology and Psychiatry 57(5), 614–22 [PMC free article: PMC4824681] [PubMed: 26443493]

Download PDF (87K)

Appendix I. Health economic evidence profiles

Health economic evidence profiles for “Which service delivery models are effective at meeting the needs of adults, children and young people with clinically important post-traumatic stress symptoms?”

Collaborative care

Download PDF (98K)

Stepped care

Download PDF (100K)

Appendix J. Health economic analysis

Health economic analysis for “Which service delivery models are effective at meeting the needs of adults, children and young people with clinically important post-traumatic stress symptoms?”

No health economic analysis was conducted for this review.

Appendix K. Excluded Studies

Excluded studies for “Which service delivery models are effective at meeting the needs of adults, children and young people with clinically important post-traumatic stress symptoms?”

Clinical studies

Economic studies

Appendix L. Research recommendations

Research recommendations for “Which service delivery models are effective at meeting the needs of adults, children and young people with clinically important post-traumatic stress symptoms?”

1. What is the clinical and cost effectiveness of stepped care for PTSD?

Why is this important?

PTSD is a common disorder that affects a significant number of people in the UK. While some individual psychotherapies such as trauma-focused cognitive-behavioural therapy (CBT) are effective treatments, providing this type of intervention to everyone who needs it is a challenge. It can be expensive in terms of therapist time and it may take a long time to build up a workforce to deliver it. This means that people with PTSD can face a significant wait for treatment. Additionally, a treatment that is delivered over several sessions is difficult for many people with PTSD. A randomised controlled trial looking at stepped care approaches might address these issues, by making less intensive forms of treatment more easily available to people who might benefit from them. Less intensive therapies can be undertaken at home (for example online interventions) so they are easier to access. This allows therapist time to be focused on people with more severe presentations.

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To compare a lower intensity treatment to usual care (e.g. active case management) in first instance; if efficacious, then compare to “active” therapy (i.e. intensive one-to-one therapy) in a non-inferiority RCT. Clinic vs. school or subspecialist (more...)

2. What is the clinical and cost effectiveness of trauma informed care or trauma informed approaches?

Why is this important?

A trauma-informed approach to service delivery, or trauma-informed care, has been widely adopted in the US and is becoming increasingly common in the UK. However, it covers a large range of interventions and organisational changes, and there is little high-quality evidence to support its use. If effective, it could have a substantial impact on the experience of people with PTSD, reduce the length of hospital stays and outpatient visits, improve symptoms and reduce the number of restraints used in residential care.

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TIC should be compared to ‘service as usual’, i.e. without a trauma-informed approach. Alternatively different methods of TIC could be compared to each other.