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Keeping on top of the proliferation of evidence regarding the prevention and management of health conditions has become a major challenge.  As a result, healthcare professionals, policy makers and service planners, along with those seeking or using services, increasingly rely on syntheses of available evidence to inform what should be provided and sought.  The International Society of Traumatic Stress Studies (ISTSS) produced the first guidelines for the prevention and treatment of posttraumatic stress disorder (PTSD) in 2000 (Foa et al., 2000) and updated these in 2009 (Foa et al., 2009). This paper describes the development of the recently published third version of the ISTSS Guidelines for the Prevention and Treatment of PTSD recommendations and position papers on complex PTSD in November 2018 (ISTSS, 2018). These publications will be complemented by the final part of the updated ISTSS Guidelines, the third edition of the “Effective Treatments for PTSD” book, due to be published at the end of 2019, with a primary goal of providing a resource for clinicians to apply the recommendations to clinical practice.

The authors of the paper are the members of the ISTSS Guidelines Committee, created by the ISTSS Board to develop the new guidelines.  A key goal was to adopt a robust methodology in keeping with internationally advocated standards (IoM, 2011), whereby specific questions were developed and independent systematic reviews undertaken to answer them, with experts following more formal processes to determine final recommendations.  Scoping questions were developed using the Population, Intervention, Comparator, and Outcomes (PICO; Schardt et al., 2007) format for the prevention and treatment of PTSD in children, adolescents and adults.  Inclusion of separate scoping questions on treatments for complex presentations of PTSD adults was considered but decided against due to issues defining Complex PTSD (CPTSD) and the virtual absence of studies specifically designed to clearly answer possible scoping questions in this area.  The Committee decided, therefore, to undertake a narrative review and prepare position papers (one for children and adolescents, and one for adults) to consider the current issues around CPTSD and make recommendations to facilitate further research. 

Systematic reviews were undertaken to answer the scoping questions and 361 randomized controlled trials were included according to the a priori agreed inclusion criteria.  Two hundred and eight meta-analyses were conducted and used to generate 125 recommendations (24 for children and adolescents, and 101 for adults) for specific prevention and treatment interventions, using an agreed definition of clinical importance and recommendation setting algorithm. There were 8 Strong, 8 Standard, 5 Low Effect, 26 Emerging Evidence, and 78 Insufficient Evidence to Recommend recommendations.

The ISTSS Guidelines represent a high-quality addition to the existing guideline recommendations available to clinicians.  Like all guidelines, the ISTSS Guidelines should be used with appropriate caution; they represent a tool to aid the prevention and treatment of PTSD rather than a document that mandates specific approaches.  The ISTSS Guidelines should stimulate research to improve the effectiveness of interventions in the future and also stimulate work to improve the methodology of guideline development.  It is hoped they will support the dissemination and implementation of evidence-based practices to reduce the impact of traumatic stress globally. Further work to develop appropriate public-facing materials, including decision aids, to facilitate this is underway.

References

Foa, E.B., Keane, T.M., & Friedman, M.J., (2000). Effective Treatments for PTSD. New York, NY: Guilford Press.

Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. (2009). Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. New York, NY: Guilford Press.

IOM (Institute of Medicine) (2011). Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.

ISTSS Prevention and Treatment Guidelines (2018) https://www.istss.org/treating-trauma/new-istss-prevention-and-treatment-guidelines.aspx

Schardt, C., Adams, M. B., Owens, T., Keitz, S., & Fontelo, P. (2007). Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Medical Informatics and Decision Making, 7, 16. doi: http://dx.doi.org/10.1186/1472-6947-7-1

Reference Article

Bisson, J. I., Berliner, L., Cloitre, M., Forbes, D., Jensen, T. K., Lewis, C., ... & Roberts, N. P. (2019). The International Society for Traumatic Stress Studies New Guidelines for the Prevention and Treatment of Posttraumatic Stress Disorder: Methodology and Development Process. Journal of Traumatic Stress.

Questions for Discussion

  1. How is it best to disseminate and implement the recommendations into practice?
  2. Is it appropriate to rely solely on RCT evidence for prevention and treatment guidelines?  What are the the potential challenges to considering other forms of evidence? 

About the Author

Jonathan I. Bisson, DM FRCPsych is Professor in Psychiatry at the Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, and Chair of the ISTSS Treatment Guidlines Committee