Summary of the impact

Research at Sheffield has changed UK and international clinical guidelines for the treatment of post-traumatic stress disorder and has ensured that more appropriate treatments target people who have been traumatised. The Sheffield studies revealed the limitations and ineffectiveness of a commonly adopted clinical approach reliant on psycho-education and self-help. These studies concluded, on the basis of three randomised control trials of self-help provision, that despite the provision of information being valued by patients, it had no direct effect on relieving symptoms or enhancing quality of life or functioning. These research findings have directly contributed to good practice guidance for public health, disaster management and relief, and responding to terrorism and conflict.

Underpinning research

Lifetime exposure to traumatic events is common (39-67%) and many (8-46%) go on to develop post-traumatic stress disorder (PTSD). This is a psychological condition constituting traumatic flashbacks and the re-experiencing of memories of the event, disruption of sleep and arousal, future avoidance of the trauma situation, disrupted and dysfunctional cognitions and personal relationships, and elevated anxiety and depression. The National Institute for Health and Clinical Excellence (NICE) estimate that there are 150k new cases p.a., which cost the NHS £47m in treatments. The factors that predict PTSD following traumatic events, together with interventions designed to ameliorate its adverse effects, have been the focus for research at the University of Sheffield during the last fifteen years.

Professors Turpin (Psychology) and Mason (Northern General Hospital Accident & Emergency Department (A&E) and School of Health and Related Research (ScHARR) have overseen a series of studies (1996 onwards) designed to predict psychological adverse effects of trauma following A&E admission, plus early interventions intended to ameliorate or prevent psychological after- effects. The first studies [R2,R3] concerned the prediction of PTSD and its aftermath on social functioning and employment [R1], by the routine screening and follow up of A&E attenders in Sheffield. These findings helped to define the scale of the problem (7-14% PTSD, 14 & 9% clinically anxious or depressed) and also encouraged the development of interventions specifically targeted at large numbers of patients that might reduce the future prevalence of PTSD in A&E attenders. The latter approach was based on the widespread use of psycho-education and guided self-help treatments for mild to moderate anxiety and/or depression, which had been demonstrated as effective within clinical trials.

Three specific interventions (2002-8) were examined, consisting of the provision of patient information leaflets [R4], self-help booklets [R5] and "writing therapy" [R6]. They were evaluated by three independent Randomised Control Trials (RCTs), together involving over 500 high-risk patients, to assess the impacts of each intervention on symptoms, functioning and quality of life. The research took place at the A&E Department, the Northern General Hospital funded through the Trent Strategic Health Authority.

Overall, studies demonstrated that the majority of patients recovered fully from trauma, with a gradual reduction in symptom severity over six to eight months. For those within the intervention arms of these trials, the provision of psycho-education or self-management booklets was generally considered helpful and worthwhile by participants. However, this had no significant effect on the rate of decline in self-reported symptoms when compared to a waiting-list control. Indeed, there was some indication that the provision of information leaflets might actually raise the occurrence of reported PTSD and depression symptoms.

These results are important for the design of treatments and management of post-trauma patients, and have helped to clarify a number of therapeutic assumptions for which there was no pre- existing evidence base. Whereas self-help and psycho-education have an important role to play in the treatment of mild to moderate depression and anxiety, these studies delineate the lack of specific therapeutic impact on PTSD. The trial results have been cited in numerous clinical guidelines that caution practitioners on relying on self-help strategies for PTSD and recommend instead, based on the Sheffield research, that patients whose PTSD symptoms do not decline within four weeks of trauma should be offered a full therapeutic course of trauma-related, exposure-based Cognitive Behaviour Therapy, rather than relying on self-help. Nevertheless, psycho-education should continue to be offered, since patients value being informed about their condition, it provides some psychosocial support, and may also promote help-seeking in patients who do not experience natural recovery and who would benefit from a more intensive form of therapy.

References to the research

Details of the impact

International and National Clinical Guidelines

Major systematic reviews and international clinical guidelines for the prevention and treatment of PTSD published since 2005 have referred directly to the Sheffield research concerning the ineffectiveness of self-help.

The studies are cited by IMPACT (2008) [S1], the Dutch equivalent to NICE, as regards disasters, cautioning against the use of psycho-education and psychological debriefing, and also by EUTOPA [S2], an EC funded European Network for Psycho-social Aftercare in Case of Disaster. Turpin was invited to join this network, gave a keynote address at its Amsterdam meeting in 2008 and coordinated its working group on psycho-education at the subsequent meeting in Cologne in 2011. Finally, the studies are cited by the European Network for Traumatic Stress [S3], which produces the TENTS guidelines.

Good practice guidelines

Reviews targeting the management of PTSD within the military have cited Sheffield RCTs. The Disaster Mental Health sub-committee of the US National Biodefense Science Board used the Sheffield findings to inform its recommendations for preparedness for interventions in mental health in the event of significant disasters [S4]. In 2010, the US Department of Veterans' Affairs and the Department of Defense updated their Clinical Practice Guideline for the Management of PTSD and recommended further research into non-CBT approaches to significant PTSD before approaches such as self-help or writing therapy could be recommended [S5]. This guideline affects a significant number of Veterans in the US, with 442,000 new requests for support with PTSD in the five-year period. The guidance was also cited by the Australian Centre for Post-traumatic Mental Health [S6], and the "Guidelines for psychosocial support for uniformed workers" published by IMPACT and the Trimbos Institute [S7].

The research has been cited by several non-governmental organisations concerned with effective disaster management, such as the Turkish Red Crescent [S8] and the Belgian Red Cross [S9]. Turpin contributed to a EUTOPA study visit (2012) to Israel to look at community resilience to disasters, and to the Bangladeshi Clinical Psychology Association's annual conference (2011) on Psychological Responses to Disasters and Flooding. He has been invited to an expert panel (1st international workshop in the EUNAD project: Psychosocial Crisis Management - Assisting people with visual / hearing impairment in Disasters) in Prague (October, 2013) to discuss disaster planning for the disabled.

Commissioning guidance

A national programme in the UK since 2008, Improving Access to Psychological Therapies (IAPT), directed by the Department of Health, has seen the expansion of access to psychological therapies for common mental health problems. Although guided self-help is a commonly adopted strategy for anxiety and depression, both the IAPT implementation toolkit (2008) and Self-help Good Practice Guide (2010) recommend against self-help as a stand-alone intervention for PTSD, based on the Sheffield research. Turpin coordinated the production of the Good Practice Guide in his role as the National Advisor for Education and Training to the IAPT Programme.

Educational guidelines

The Sheffield randomised controlled trials (RCTs) have been identified in reviews and textbooks for a variety of practitioners including clinical psychologists, psychiatrists, A&E physicians, and occupational medicine practitioners. Specifically, the texts have cautioned against the efficacy and appropriateness of self-help for trauma and has been cited in, for example, within the Oxford Handbook of Traumatic Stress Disorders (Beck & Sloan, 2012), the Handbook of Evidence-based Practice in Clinical Psychology (Powers, Kayak, Cahill & Foa, 2012), International Encyclopaedia of Rehabilitation (Stone & Blouin, 2012) and a treatment review within Psychopharmacology Review (Dowd & Philip, 2008). The studies are mentioned in various on-line reviews and sources for continuing professional development for psychiatrists (for example, Hobfoll et al., Psychiatry Online, 2009). Essentially, they warn against mental health practitioners relying solely on psycho- education as an effective early intervention for PTSD.

The research has been highlighted as an example of inconsistency between patient self-report and clinical outcomes in a recent review of "Best evidence and best practice" in mental health (Newham & Page (2010) Clinical Psychology Review, 30, 127-142) and was the subject of a British Journal of Psychiatry (2006, 189, 200) editorial where it was described as "a nugget of gold", representing scientific discovery that has elements of the unexpected.

Finally, given that until very recently mental health services did not routinely collect outcome data, it is difficult to quantify the numbers of clients who may have benefited directly from this research and its impact on therapist practice. We would expect that these guidelines will have helped clinicians direct patients to more effective interventions for those 150k new cases of PTSD that present to services each year. Nevertheless, the indirect measure is the large number of clinical guidelines published across the world that have identified the research conducted at Sheffield and have cautioned against the use of self-help as an initial treatment for PTSD.

Sources to corroborate the impact

S1. Impact (Dutch knowledge and advice centre for post-disaster psychosocial care.) European Multidisciplinary Guidelines corroborate direct use of Sheffield research findings in guidance. (http://tinyurl.com/oqmpnjp).

S2. Letter of support from EUTOPA corroborates Sheffield research used as basis for guidelines.

S3. Bisson, J. et al. (2010) TENTS guidelines: development of post-disaster psychosocial care guidelines through a Delphi process. British Journal of Psychiatry, 196, 69-74.

S4. US National Biodefense Science Board (2008). Disaster Mental Health Recommendations. Page 31 corroborates use of Sheffield research in producing recommendations. (http://tinyurl.com/kppyfus)

S5. VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress (page 109) Department of Veterans' Affairs, Department of Defense. (http://tinyurl.com/ocntjz7).

S6. Australian Centre for Posttraumatic Mental Health, University of Melbourne. Integrated Literature Reviews, 2002-2012 (April 2008) PDF available.

S7. Letter of support from IMPACT confirms use of Sheffield research for the development of the `Guidelines for psychosocial support for uniformed workers' in 2012.

S8. Implementation Guidelines for Psycho-Social Support in Disasters. Turkish Red Crescent. (http://tinyurl.com/pu7jeqb).

S9. Belgian Red Cross (2011). African First Aid Materials AFRAM) Guidelines. Page 13 (reference 48) corroborates use of Sheffield findings in guidelines for management of emergency situations. PDF available.

S10. Turpin, G., et al. (2010). IAPT Good Practice Guidance on the Use of Self-Help Materials within IAPT Services (http://tinyurl.com/prb36q2)