Management of PTSD in general practice – transcript

Dr Penny Burns: So welcome my name is Penny Burns, I’m a general  practitioner with a special interest in disaster medicine. And today I’m speaking with Dr John  Cooper who’s a psychiatrist working with Phoenix Australia, and Phoenix Australia is a group  that specializes in post-traumatic mental health problems following natural disasters and accidents and violent crimes.

So as GPs we know that disasters affect a large number of Australians every year and we’re currently right in the middle of the world’s first coronavirus pandemic and  that’s on the back of horrendous summer bushfires and that’s on top of extended drought.

So how the  psychological response to these events is managed early on may affect the ability of individuals and  the community recovery. So general practitioners are in the community when these events occur  and they play a strong role in supporting the mental health care needs following disasters  supported by psychiatrists and psychologists.

The majority, the vast majority of  people are resilient and will recover from these traumatic events. However it’s very normal in the first few weeks to experience extreme distress to these extraordinary events and there’s no right or wrong way to respond.

However, if people continue to experience extreme severe distress after a week or two or three, then they may need referral on to someone else for further mental health support. Now we all have heard about PTSD, post-traumatic  stress disorder, but the more common mental health conditions following disaster are actually depression, anxiety, substance overuse, psychosomatic complaints and then of course we have occasional panic disorders and other conditions. But today we want to talk about  post-traumatic distress.

As a GP I know I’m much more comfortable dealing with depression, anxiety, as they walk through the door every day for me. But I don’t see a lot of PTSD. This recording is a  brief summary of PTSD management post-disaster and for those who’d like to further explore this  topic there’s a range of links attached for more detailed information and resources.

So welcome John, would you be able to take us through how you would identify and manage a patient presenting  with PTSD?

John: Thanks Penny. Identifying PTSD in many instances depends upon the context in  which you’re working.

Obviously as a psychiatrist having patients referred, the problem is often already well identified. But in a general practice setting I think the first and most important  issue is to have an index of suspicion if somebody has, to your knowledge, had exposure to a potentially traumatic event such as a natural disaster or bushfire or any other potentially life-threatening situations. It should be front of mind and the questions  that you use to guide the patient to describe their problems both in terms of the onset and the nature of their symptoms is really important. But again, I think the GP thinking about it in the first instance, is probably my strongest advice.

Penny: Are there particular screening tools you would  recommend? As GPs we love screening tools to help guide us.

John: Yes, look there are some very good screening instruments. There is a four or five question instrument for adults with PTSD, there is  a child trauma tool to use in younger patients and once you’ve suspected PTSD there are more  elaborate instruments such as the post-traumatic stress disorder checklist. The PCL which will go through all of the symptoms of PTSD with a severity rating and I know that they’ll also be links to those down below as well for you.

So, in terms of managing PTSD with psychological  treatments and pharmacotherapy what would be your first approach there? Well in this situation we do have a strong evidence base to draw upon in terms of informing us about effective treatments for PTSD at Phoenix Australia. We have produced the treatment guidelines for PTSD and  the third edition is currently being written as we speak, is very clear from both the  Australian guidelines and international guidelines that trauma-focused psychological  treatments are the most effective intervention to improve the symptoms of PTSD.

In fact from the guidelines in relation to medication, the recommendation with the strongest evidence is that we don’t rush into using medication first if the appropriate psychological treatments are available. So we’ve got lots of information that is freely available in the guidelines and the link to those guidelines will also be available for everybody to see and read.

With respect to the psychological treatments, we know that trauma-focused CBT and related interventions such as prolonged exposure, some of the cognitive therapies like cognitive processing therapy matched with in-vivo exposure exercises often between sessions and also EMDR,  I remember desensitization and reprocessing.

We know that effective treatments are those that help patients confront their traumatic memories, manage the distress and emotional arousal that comes with those memories and helps to address the avoidance behaviours that come in as a result of the distress that happens with the memories.

Penny: Fantastic, and I know I’ve actually used those resources and they’re really, really valuable. So if I’m a GP though in a rural area, and I’m able to access trauma-focused CBT how important is it that it’s trauma-focused?

John: It is important that it’s trauma-focused if we want to improve the symptoms of PTSD. We know that more general counselling that has an important supportive element, it might have an element of psychoeducation and it might help people deal with symptoms of distress, but if there isn’t that trauma-focused element then it’s unlikely that the patient is going to get much traction in reducing the severity of their PTSD.

Penny: And then in terms of types of medication chosen and I know we’re going to be talking about medication later on in another snippet, what type of medications does the evidence show are the best for PTSD?

The first line medication treatment for  PTSD should always be an antidepressant medication and that’s in cases where there is no comorbid depression. We use antidepressants to specifically target the PTSD symptoms. The evidence tells us that SSRI antidepressants and three in particular that have been most studied that include citrulline, fluoxetine and paroxetine, should be considered first line.

There are other studies of less quality in terms of sample size and methodology but also indicate and provide support for using a range of other antidepressants including the SSRIs and some of the older antidepressants including tricyclics.

Penny: Fantastic, thanks John and so I guess my final  question would be, what’s the natural progression of PTSD? As GPs what are we going to be expecting  to see? Are we seeing people with PTSD going on for years or is, are we, likely to actually make  an impression on this?

John: So the trajectories of PTSD can vary a lot from patient to patient.  We know that some patients are going to get better and their symptoms are going  to resolve with or without treatment.

We know that some patients have a delayed  onset of their symptoms and that’s sometimes a little more difficult to connect their presentation with their trauma exposure and we know that a minority of patients will  have a more chronic course of their illness and there will be a degree of treatment resistance in the way that things progress.

In the research that’s been done for  example, with the psychological treatments we can generalize the rule of thirds and we know  that a third are going to do very well and their PTSD will remit, we know that about a third are going to have significant improvement but might be left with some residual symptoms but there’s also that third that are probably not going to respond very well at all to our evidence-based treatments.  And it’s that group that often occupies us as psychiatrists and GPs in terms of providing that longer term support.

Penny: Fantastic, well thank you  very much John and I think I think we’ve got a bit of a snippet here now on a bit more information on how to firstly identify and how to manage PTSD and thank you for coming in. Thank you.

John: Thank you.