Occupational health professionals and 2018 NICE post-traumatic stress disorder guidelines

Many organizations routinely require their staff to deal with traumatic situations which may increase their risk of experiencing mental health disorders such as post-traumatic stress disorder (PTSD). Such work may increase the risk of employees developing PTSD and other trauma-related mental health problems. Although around 4.5% of the general UK population experience PTSD at any point in time, increased rates have been found in both directly trauma-exposed populations such as military veterans recently deployed in combat roles (up to 17%) [1], ambulance personnel (15–23%) [2] and those indirectly exposed such as social workers (15%) [3]. Characteristic symptoms of PTSD include intrusive thoughts, nightmares, persistent perceptions of heightened current threat such as hypervigilance or an enhanced startle reaction, feeling alienated from others and distorted self-perception including blame and shame. From an occupational perspective, it is important to note that key PTSD diagnostic criteria are avoidance of activities or thoughts related to the trauma and demonstrable functional impairment when significant-related distress may not be obvious to others. The diagnosis can be made after 1 month of symptoms following the precipitating incident(s) although in many cases there is a considerable delay between the traumatic event and diagnosis. Evidence suggests that patients with PTSD often only present for help after a crisis has happened or a significant other has issued an ultimatum [4]. Given the substantial impact of PTSD on employee well-being, ability to carry out duties effectively, timely diagnosis and the treatment of any co-morbid mental health problems (often depression or substance misuse), it is key that effective treatment is arranged in order to improve outcomes for the patient and their colleagues, family members and employers. Additionally, having an understanding of how trauma may impact on mental health is especially relevant for occupational health (OH) professionals working with trauma-prone organizations who may be asked to provide advice about how employers should deal with traumatic incidents in general and what should be done after specific major incidents. Such incidents often attract public and media attention and consequently become of considerable interest to senior managers. The recently (2018) updated NICE guidelines on the management of PTSD [5] provide a range of information of relevance to most OH professionals. Many will regularly see patients who appear to have anxiety and/or depression; however, it is worth keeping in mind that people with probable PTSD may often present with such difficulties in the first instance. It is also important to recognize that patients with PTSD may frequently present with a range of medically unexplained physical symptoms such as gastrointestinal difficulties, pain syndromes or headaches. PTSD may also be at the root of more general difficulties in functioning or relationships or may be the cause of problem drinking and/or substance misuse. OH professionals who interact with patients presenting with such problems may find it insightful to ask if they have ever experienced a traumatic event, even one that occurred some time ago, after which their problems started. In the aftermath of a significant workplace trauma, it is important to recognize that whilst many people have transient distress symptoms, the majority who experience these symptoms will recover without the need for any professional intervention. Expected post-trauma symptoms may include poor sleep, rumination and anxiety. Where such symptoms last for days or weeks, and do not substantially impair day-to-day function, they should ordinarily be considered as a ‘normal reaction to an abnormal event’. However, persistent distress symptoms associated with functional impairment should raise the possibility of a PTSD diagnosis. Recognizing that most people who develop PTSD do not seek any help at all, NICE recommend the active monitoring of patients recently exposed to trauma. This may be achieved through healthcare surveillance or through the use of structured peer support which has been adopted by numerous trauma-exposed organizations such as the military, emergency services and media companies [6]. Whilst there is evidence that post-incident mental health screening can be helpful when administered by healthcare providers to the general population after disasters, it is not helpful for use within organizations [7]. Employees often fear the stigma associated with admitting distress and are concerned what impact this may have on their careers. There are however numerous ways that organizations can optimize their organizational resilience in terms of dealing with traumatic incidents most of which focus upon improving social support and junior leadership and ensuring that proactive supportive management is the norm, especially post-trauma [8]. For those who need treatment for PTSD, the 2018 NICE guidance primarily recommends offering psychological treatment, namely, trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitization and reprocessing (EMDR) although the latter is not deemed suitable for combat-related trauma because of lack of evidence. Alternatively, where the patient wishes, supported trauma-focused computerized CBT (a facilitated self-help intervention) should be considered. From the OH professional’s perspective it is important to note that NICE recommends offering treatment to people with clinically important symptoms of PTSD. It is also worth being aware that military veterans can often access bespoke and quicker referral pathways available such as the Transition, Intervention and Liaison (TIL) Service in England which is commissioned to provide an initial assessment within 2 weeks. Details are available on the Armed Forces pages on the NHS pages (https://www.nhs.uk/using-the-nhs/military-healthcare/nhs-mental-health-services-for-veterans/). For some patients, alcohol or substance misuse can be a significant co-morbid problem. Those with such difficulties should be medically assessed and relevant blood investigations arranged. NICE recommend that people should not be excluded from PTSD treatment based solely on co-morbid drug or alcohol misuse although such patients should be referred for specialist assessment and both substance misuse and PTSD treatment. Employees with PTSD who attend primary care may well be offered antidepressant medication whilst they wait to access trauma-focused CBT or EMDR. NICE supports the use of selective serotonin reuptake inhibitors, such as sertraline, or venlafaxine if the patient wishes, but drug treatments are not recommended as first-line treatment for people with PTSD. Antidepressants may be prescribed for PTSD if the person has a preference for drug treatment or if co-morbid depression is evident. Whilst some non-antidepressant medications, such as antipsychotics, may be useful for symptomatic relief, they should only be initiated in specialist settings, or after consultation with a specialist, and should only be considered as an adjunct to psychological treatment and after other drug or psychological treatments have been tried. Whilst in some ways, PTSD can be considered an anxiety-based condition, it is important to note that the use of benzodiazepines for patients with PTSD is contraindicated. OH professionals should also remain cognizant that PTSD symptoms may significantly impact upon colleagues, managers and family members. When someone is undergoing treatment for PTSD, it is likely that they will benefit from appropriate adjustments to their workload in terms of avoiding high-stress work, especially trauma-prone duties, and possibly an alteration of working hours. Given the likely impact of PTSD on concentration, irritability, attitudes to risk taking and increase in startle response, in most cases safety critical work should be avoided whilst someone is having active treatment. However, being able to remain within a supportive work environment is likely to minimize the impact of PTSD on self-esteem and self-worth and consequently increase the chance of the individual making a good recovery. However, those found to suffer with more complex presentations of PTSD, characterized by difficulties with emotional dysregulation, interpersonal difficulties or problems in relationships and substantial negative self-perceptions, may be more challenging to treat. Whilst the NICE 2018 PTSD guidelines did not examine the specific occupational management of complex PTSD, nonetheless OH professionals may have to consider whether someone with this condition can be provided with alternative work or in some cases medical retirement may be deemed appropriate. In conclusion, the new PTSD guideline is a helpful resource for OH physicians providing them with information to help ensure that people who are unfortunate enough to develop PTSD are able to access evidence-based care to optimize their chances of both recovery and being able to continue at work. The guidance is clear that although most people will recover after trauma exposure, actively monitoring for the first few weeks is the best approach in most cases. A key role for OH professionals is to identify the possibility that someone may be suffering with PTSD and to ensure that they are referred on for specialist care which is likely to include trauma-focused CBT or EMDR. Concurrent referral for any associated alcohol or substance misuse problems may also be needed. In many cases PTSD is a treatable condition which may not impair longer term occupational function; however, early identification of the condition and engaging with effective treatment, ideally prior to significant loss of confidence and self-esteem, are both key to ensuring a good outcome. All authors were part of the NICE guidance development committee but were not instructed as to how to write this editorial by NICE although we let them see the article prior to submission. NG runs a psychological health consultancy called March on Stress Ltd.