Abstract
Background: The aim of this review was to assess the quality of international treatment guidelines for post-traumatic stress disorder (PTSD), and identify differences between guideline recommendations, with a focus on the treatment of nightmares. Methods: Guidelines were identified through electronic searches of MEDLINE, CINAHL, PubMed, Embase and Science Direct, as well as web-based searches of international guideline repositories, websites of psychiatric organisations and targeted web-searches for guidelines from the three most populous English-speaking countries in each continent. Data in relation to recommendations were extracted and the AGREE II criteria were applied to assess for quality. Results: Fourteen guidelines, published between 2004–2020, were identified for inclusion in this review. Only five were less than 5 years old. Three guidelines scored highly across all AGREE II domains, while others varied between domains. Most guidelines consider both psychological and pharmacological therapies as first-line in PTSD. All but one guideline recommended cognitive behavioural therapy (CBT) as first-line psychological treatment, and selective serotonin reuptake inhibitors (SSRIs) as first-line pharmacological treatment. Most guidelines do not mention the targeted treatment of nightmares as a symptom of PTSD. Prazosin is discussed in several guidelines for the treatment of nightmares, but recommendations vary widely. Most PTSD guidelines were deemed to be of good quality; however, many could be considered out of date. Recommendations for core PTSD symptoms do not differ greatly between guidelines. However, despite the availability of targeted treatments for nightmares, most guidelines do not adequately address this. Conclusions: Guidelines need to be kept current to maintain clinical utility. Improvements are most needed in the AGREE II key domains of ‘applicability’, ‘rigour of development’ and ‘stakeholder involvement’. Due to the treatment-resistant nature of nightmares, guideline development groups should consider producing more detailed recommendations for their targeted treatment. More high-quality trials are also required to provide a solid foundation for making these clinical recommendations for the management of nightmares in PTSD.
Highlights
Post-traumatic stress disorder (PTSD) is a debilitating mental condition that can significantly impact the sufferer’s quality of life [1,2,3]
Database searching was supplemented by web-based searches of guideline repositories. The latter was an additional step in an attempt to systematically capture any country-specific guidelines that were not listed in a guideline repository and may have otherwise been missed due to the search engine’s algorithm preferencing already identified guidelines
The search strategy identified a total of 133 records, of which, 14 guidelines matched the criteria for inclusion in this review
Summary
Post-traumatic stress disorder (PTSD) is a debilitating mental condition that can significantly impact the sufferer’s quality of life [1,2,3]. There appears to be few recommendations for the treatment of nightmares in guidelines, even though there are targeted treatments available, such as image rehearsal therapy (IRT) and pharmacotherapies including prazosin, terazosin and some atypical antipsychotics [13,14]. The aim of this review was to assess the quality of international treatment guidelines for post-traumatic stress disorder (PTSD), and identify differences between guideline recommendations, with a focus on the treatment of nightmares. Three guidelines scored highly across all AGREE II domains, while others varied between domains Most guidelines consider both psychological and pharmacological therapies as first-line in PTSD. Prazosin is discussed in several guidelines for the treatment of nightmares, but recommendations vary widely.
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