Cg26 post-traumatic stress disorder (ptsd) - information for the public

Post-traumatic stress disorder
(PTSD): the treatment of PTSD
in adults and children
Understanding NICE guidance - information for
people with PTSD, their advocates and carers,
and the public
Information about NICE Clinical Guideline 26
Post-traumatic stress disorder (PTSD): the treatment of PTSD in
adults and children
Understanding NICE guidance - information for people with PTSD,
their advocates and carers, and the public
Issue date: March 2005
To order copies
Copies of this booklet can be ordered from the NHS Response Line-
telephone 0870 1555 455 and quote reference number N0849. A
version in English and Welsh is also available, reference number N0850.
Mae fersiwn yn Gymraeg ac yn Saesneg ar gael hefyd, rhif cyfeirnod
N0850. The English and bilingual versions of this booklet are also
available from the NICE website (www.nice.org.uk/CG026publicinfo).
The NICE clinical guideline on which this information is based, 'Post-
traumatic stress disorder (PTSD): the management of PTSD in adults
and children in primary and secondary care', is available from the NICE
website (www.nice.org.uk/CG026NICEguideline). A quick reference
guide for healthcare professionals is also available from the website
(www.nice.org.uk/CG026quickrefguide), and the NHS Response Line
(reference number N0848).
National Institute for
Clinical Excellence
MidCity Place71 High HolbornLondonWC1V 6NA Published by the National Institute for Clinical ExcellenceMarch 2005Artwork by LIMA Graphics Ltd, Frimley, SurreyPrinted by Abba Litho Sales Limited, London National Institute for Clinical Excellence, March 2005. All rights reserved. This material may be freely reproduced for educational andnot-for-profit purposes within the NHS. No reproduction by or forcommercial organisations is allowed without the express writtenpermission of the National Institute for Clinical Excellence. Contents
About this information
What is PTSD?
Where can I find help and treatment?
What treatments are available for PTSD?
Will I be offered psychological treatment? I have other illnesses or problems besides PTSD. Will this affect my treatment for PTSD? Will my treatment be affected if I am seeking compensation? Will I be offered any other kind of help by healthcare professionals? What treatments are available for
young people?
Information for families and carers
How can I support a family member with PTSD? Where you can find more information
If you want to read the other versions of this guideline About this information
This information describes the guidance that the National Institute for Clinical Excellence(called NICE for short) has issued to the NHS on the treatment and care of people with post-traumatic stress disorder (PTSD). It is basedon 'Post-traumatic stress disorder (PTSD): themanagement of PTSD in adults and children inprimary and secondary care', which is a clinicalguideline produced by NICE for doctors, nursesand others working in the NHS in England andWales. Although this information has beenwritten mainly for people with PTSD, it may also be useful for family members, those who care for people with PTSD and anyoneinterested in PTSD or in healthcare in general. In this document the term 'PTSD sufferer' is used to describe someone with PTSD. This termwas chosen on the basis of a survey conductedby members of the group who wrote the NICEguideline and who have PTSD, although it isrecognised that some people with PTSD may use alternative terms.
Understanding NICE guidance - Post-traumatic stress disorder Clinical guidelines
Clinical guidelines are recommendations forgood practice. The recommendations in NICEguidelines are prepared by groups of healthworkers, people representing the views of those who have or care for someone with thecondition, and scientists. The groups look at the evidence available on the best way oftreating or managing the condition and makerecommendations based on this evidence. There is more about NICE and the way that the NICE guidelines are developed on the NICEwebsite (www.nice.org.uk). You can downloadthe booklet 'The guideline development process- an overview for stakeholders, the public andthe NHS' from the website, or you can order acopy by phoning the NHS Response Line on 0870 1555 455 (quote reference number N0472).
Understanding NICE guidance - Post-traumatic stress disorder What the recommendations cover
NICE clinical guidelines can look at differentareas of diagnosis, treatment, care, self-help or acombination of these. The areas that a guidelinecovers depend on the topic. They are laid out ina document called the scope at the start ofguideline development. The recommendations in 'Post-traumatic stressdisorder (PTSD): the management of PTSD inadults and children in primary and secondarycare', which are also described here, cover: • the care you can expect to receive from your • the information you can expect to receive • what treatment you can expect, which may include psychological therapies and drugtreatment • the services that may help you with PTSD, including specialist mental health services.
If you have questions about the specific treatmentsand options covered, talk to your doctor or nurse(or another healthcare professional, depending onwhat it is you want to know). Understanding NICE guidance - Post-traumatic stress disorder How guidelines are used in the NHS
In general, healthcare workers in the NHS areexpected to follow NICE's clinical guidelines. Butthere will be times when the recommendationswon't be suitable for someone because of his orher specific medical condition, general health,wishes, or a combination of these. If you thinkthat the treatment or care you receive does notmatch the treatment or care described on thepages that follow, you should talk to yourdoctor, nurse or other healthcare professionalinvolved in your treatment.
You have the right to be fully informed and toshare in making decisions about your healthcare,and the care you receive should take account ofyour individual needs. Understanding NICE guidance - Post-traumatic stress disorder What is PTSD?
Post-traumatic stress disorder (or PTSD for short)is the name given to the psychological andphysical problems that can sometimes followparticular threatening or distressing events.
These events might include: • rape or sexual, physical or emotional abuse • other situations in which a person was very afraid, horrified, helpless, or felt that his orher life was in danger.
The trauma can be a single event or a series ofevents taking place over many months or evenyears.
Understanding NICE guidance - Post-traumatic stress disorder PTSD may affect the person directly involved in atraumatic event or situation. It may also developin members of the emergency services or infamilies of those involved in a traumatic event.
PTSD is quite common-up to a third of peoplewho have experienced a traumatic event may goon to develop PTSD and it may affect about 8%1of people at some point in their lives. It candevelop in people of any age, including children. One of the most common symptoms of PTSD ishaving repeated and intrusive distressing memoriesof the event. There may also be a feeling ofreliving (or 're-experiencing') the event through'flashbacks' or nightmares, which can be verydistressing and disorientating. There can also bephysical reactions, such as shaking and sweating. Because the memory can be very intense andupsetting, some PTSD sufferers may avoid peopleor situations that remind them of the trauma, or try to ignore the memories and avoid talkingabout the event. Some people may also forgetsignificant parts of the traumatic event. Otherpeople will think about the event constantly, whichstops them coming to terms with it (they may, forinstance, ask themselves why the event happenedto them or how it could have been prevented). 1 This figure is based on studies in adult patients in the USA andAustralia.
Understanding NICE guidance - Post-traumatic stress disorder PTSD sufferers may have emotions or feelingsthat are difficult to deal with, such as guilt orshame, or they may feel that they do notdeserve help. They may also feel anxious orirritable, and find it difficult to concentrate andsleep. For some people it can mean that doingordinary things like going to work or school orgoing out with friends becomes very difficult.
It is not uncommon to have upsetting andconfusing feelings and to experience verydistressing symptoms in the first few weeks aftera traumatic event. Sometimes these feelings passafter a few weeks or so, but if they persist formore than a month after the event, a personmay have PTSD. Some people, however, may not have animmediate reaction to a distressing event andmay develop PTSD months or even years afterthe event. It is thought that about 80-90% of PTSDsufferers also have other problems, such asdepression (which is quite common) and anxietydisorders. Some people start to use recreationaldrugs or alcohol as a way to cope, especially ifthey have had PTSD or experienced trauma for a long time. Understanding NICE guidance - Post-traumatic stress disorder Where can I find help and
treatment?
If you have experienced a trauma and havedistressing symptoms, your GP is the best placeto start. He or she should be aware of the typesof trauma associated with the development ofPTSD. When you first go to see your GP, he orshe will want to find out about your generalhealth, how you are feeling, and how life is athome, school or work. If you see your GP about distressing symptoms
in the first 4 weeks after a traumatic event,
you may be told it is very common to feel like
this and not to be alarmed. You may not be
offered any treatment at this stage, although
your GP should offer you another appointment
within 1 month. (If you do not have a further
appointment you should go back to your doctor
if you do not feel better.) However, if your
symptoms are severe, your GP should offer
you treatment straight away.
If you are a refugee or asylum seeker, you maybe asked questions during your initial healthassessment to determine if you have symptomsof PTSD. This is because refugees and asylumseekers have often experienced a major traumaand may be at risk of developing PTSD.
Understanding NICE guidance - Post-traumatic stress disorder If you are advised that you have PTSD, your GPshould give you clear information about thecommon reactions to traumatic events, howPTSD starts, the symptoms of PTSD and how itcan be treated. If your GP thinks that you need furthertreatment, you may be referred to someone who is trained and skilled in providing treatmentfor PTSD sufferers (this may be a counsellor,community psychiatric nurse, psychologist, orpsychiatrist). You may be offered an assessmentwhere you will be asked about your physical and psychological health and your social needs,and whether you have thoughts about harming yourself. Ideally you should receive all your treatmentfrom one healthcare professional, who should be appropriately trained in giving the treatment.
(You may wish to ask what experience theyhave.) If you see more than one person aboutyour PTSD, there should be a clear writtenagreement about who is monitoring yourtreatment and care. You, and your family and carers if appropriate, should be able to see this agreement.
Understanding NICE guidance - Post-traumatic stress disorder All healthcare professionals should treat youwith respect, sensitivity and understanding, andexplain PTSD and its treatment to you simplyand clearly.
If your first language is not English, you
should be offered an interpreter if you need
one and the healthcare professional treating
you should be sensitive to your cultural needs.
You should still be offered the same standard
of care as any other patient, and told about
all the treatments available to you.
Questions you might like to ask healthcare
professionals about PTSD.
• Can you provide information for my family? If you are having trouble sleeping you mayalso want to ask your healthcare professionalfor advice about this.
Understanding NICE guidance - Post-traumatic stress disorder What treatments are
available for PTSD?
There are a number of treatments for PTSD that are helpful. Most involve psychologicaltreatment, but medication can also be helpfulfor adults.
Many PTSD sufferers have had the symptoms for many months and sometimes years, buttreatment can still be helpful. You should beoffered treatment regardless of when thetraumatic event happened. If you havedeveloped symptoms recently you may get better with little or no treatment. Your healthcare professional should give you enough information about the effectivetreatments for PTSD for you to decide if youwant to have treatment or not, and whichtreatment you might prefer. Your ownpreference for a particular treatment isimportant and your healthcare professionalshould support your choice where possible. See 'What treatments are available for youngpeople' on page 29 for information abouttreatment for children and young people.
Understanding NICE guidance - Post-traumatic stress disorder Will I be offered psychological
treatment?
Depending on what your symptoms are andwhen you developed PTSD, you may be offeredpsychological treatments that are specific forPTSD sufferers. These are: • trauma-focused cognitive behavioural therapy Trauma-focused CBT
This is a psychological treatment for PTSD based on cognitive behavioural therapy (CBT).
CBT focuses on a person's distressing feelings,thoughts (or 'cognitions') and behaviour and helps to bring about a positive change. Intrauma-focused CBT, the treatment concentratesspecifically on the memories, thoughts andfeelings that a person has about the traumatic event. Understanding NICE guidance - Post-traumatic stress disorder If you are offered this treatment, yourhealthcare professional will encourage and help you to gradually recall and think about the trauma. This can be done in various waysincluding listening to recordings of your ownaccount of the trauma. You will be given help to cope with any emotional distress andbehavioural problems that may arise duringtreatment. As the painful and traumatic memories begin todecrease, you may be encouraged and helped tostart activities that you have been avoiding sincethe trauma, such as driving a car if you haveavoided driving since an accident. Eye movement desensitisation and reprocessing
(EMDR)
This is another psychological treatment for PTSD, in which a healthcare professional willhelp you to look at your memories of the trauma(including all of the negative thoughts, feelingsand sensations experienced at the time of theevent). EMDR aims to change how you feelabout these memories and helps you to havemore positive emotions, behaviour andthoughts. Understanding NICE guidance - Post-traumatic stress disorder During EMDR, you will be asked to concentrateon an image connected to the traumatic eventand the related negative emotions, sensationsand thoughts, while paying attention tosomething else, usually the therapist's fingersmoving from side to side in front of your eyes.
After each set of eye movements (about 20 seconds), you should be encouraged to let go of the memories and discuss the imagesand emotions you experienced during the eye movements. This process is repeated, thistime with a focus on any difficult, persistingmemories. Once you feel less distressed aboutthe image, you should be asked to concentrateon it while having a positive thought relating to it. It is hoped that through EMDR you canhave more positive emotions, thoughts andbehaviour in the future.
Understanding NICE guidance - Post-traumatic stress disorder If you have developed PTSD within 3 months of
a traumatic event you should be offered trauma-
focused CBT. Depending on how you are feeling,
a course of treatment is likely to be 8-12 sessions
lasting for 60-90 minutes each. If your symptoms
are severe, treatment may be started in the first
month after the trauma and may take only
4 or 5 sessions. A delay in beginning treatment
should not affect the success of the treatment.
Trauma-focused CBT should normally be
provided on an individual outpatient basis,
which means that you will go to a hospital
or clinic for your appointments but will not
have to stay overnight.
If you have had PTSD for more than 3 months
you should be offered a course of trauma-
focused psychological treatment (trauma-focused
CBT or EMDR). These treatments should normally
be provided on an individual outpatient basis.
If you have experienced a single trauma, a
course of treatment is likely to be 8-12 sessions,
usually lasting for 60-90 minutes each.
It may be necessary to have more than 12 sessions of treatment if you have experiencedthe traumatic death of a relative or friend, if thetrauma has resulted in a long-term problem ordisability, or if you have lived through a series of traumatic events.
Understanding NICE guidance - Post-traumatic stress disorder General information about psychological
treatment
Sessions should take place at regular intervals(usually at least once a week if you havedeveloped PTSD recently). During treatment you will be asked about yourmemories of the trauma, but you may not beasked to talk about it in the first few weeks.
When the trauma is discussed you may beoffered a slightly longer session (of about 90 minutes). Healthcare professionals shouldunderstand that it will be difficult and stressfulfor you to talk about the trauma, and shouldoffer support so that the treatment is not too upsetting. If you miss an appointment your healthcareprofessional may contact you to see how you are feeling and ask why you didn't go.
You should not usually be offered treatments on their own that have not been designed or properly tested for people who haveexperienced trauma. These include relaxationtherapy, hypnotherapy, supportive therapy, non-directive therapy, systemic psychotherapy andpsychodynamic therapy.
Understanding NICE guidance - Post-traumatic stress disorder Is psychological treatment suitable for everyone
with PTSD?
Psychological treatments designed for PTSDsufferers have been shown to be an effectiveway of helping most people feel better, but thisdepends on when the traumatic event occurred,when you developed PTSD, and how you arefeeling.
You should not normally be offered a single
session of psychological therapy (often called
'debriefing') immediately after a traumatic event
such as a major disaster, because research has
shown this is not very helpful and may make you
feel worse later. Instead, you should be offered
practical support and information about how to
cope over the following weeks.
What if I don't feel better after psychological
treatment?
Your healthcare professional may suggest you try a different psychological treatment, or offeryou a course of medication while you are havingthe therapy.
Understanding NICE guidance - Post-traumatic stress disorder Questions you could ask your healthcare
professional if you do not feel better after
psychological treatment.
• I had expected to feel differently from how I am feeling now. Can we discuss how I amgetting on? • Do we need to look at different types of treatment or do we need to extend theperiod of treatment? Will I be offered medication?
Medication may help to treat adults with PTSD but for most people it is not as helpful as trauma-focused psychological treatment.
Healthcare professionals should usually offer you psychological treatment before medication,but you may also be offered medication if: Understanding NICE guidance - Post-traumatic stress disorder • it would be very difficult for you to start psychological treatment because of threat offurther trauma (for example, violence athome), or • psychological treatment has not helped you.
You may be offered medication in addition to
psychological treatment if the psychological
treatment is not helping you or if you have
depression.
See page 30 for information on the use ofmedication for children and young people. What kind of medication can be used to treat
PTSD?
The medication offered should be anantidepressant because, even if you are notsuffering from depression, this type ofmedication has been shown to help people with PTSD. There are different types ofantidepressants, but research has shown that thefollowing can be effective for PTSD sufferers: • paroxetine (a selective serotonin reuptake • mirtazapine (a new kind of antidepressant) Understanding NICE guidance - Post-traumatic stress disorder • amitriptyline (a tricyclic antidepressant) • phenelzine (a monoamine oxidase inhibitor, Paroxetine and mirtazapine can be prescribedfor PTSD by your GP, but generally amitriptylineand phenelzine should only be prescribed forPTSD under the supervision of a mental healthspecialist2. With phenelzine, there are somespecific cautions and advice about diet that youshould be given on an advice card when themedicine is first prescribed. You should discussthese with your doctor.
What should I know about the medication?
Before you start taking antidepressantmedication your healthcare professional should give you information about possible side effects. You should be told that when youfirst take antidepressants, particularly SSRIs,there is the possibility of symptoms such asanxiety, agitation, thoughts about suicide, andfeeling as if you can't sit or stand still (called'akathisia'). You should be advised to contactyour healthcare professional immediately if 2 Paroxetine is the only drug listed with a current UK product licence forPTSD at the date of publication (March 2005).
Understanding NICE guidance - Post-traumatic stress disorder you have any of these side effects and they aredistressing in any way.
Whichever medication you are taking, youshould be told that you may experienceunpleasant symptoms when you stop taking themedication (see page 24), miss doses or reducethe dose. These symptoms are usually mild, butcan sometimes be severe, and occur morefrequently with paroxetine than with the otherantidepressants mentioned in this booklet.
If you are prescribed an antidepressant, yourhealthcare professional should usually see you 2 weeks after starting the medication and afterthat on a regular basis (this will depend on howyou are feeling, but should usually be every2-4 weeks in the first 3 months, and then lessfrequently after that). This is to make sure thatthe medication is helping you and not causingany major side effects. If you are aged between 18 and 29 years you
should usually be seen 1 week after starting an
antidepressant and then regularly after that.
Whatever your age, if you have thoughts about
suicide and are thought to be at risk, you should
also be seen after 1 week and then regularly
after that.
Understanding NICE guidance - Post-traumatic stress disorder When you first start taking antidepressants(particularly SSRIs) your healthcare professionalshould ask you if you have felt very restless,anxious or agitated, and if you have hadthoughts about suicide. How long should I take the medication?
If the medication helps, you should beencouraged to continue with the treatment for at least 12 months. After this period of time the medication can be gradually reducedover 4 weeks and then stopped (for some peopleit may take longer). You may have a few mildsymptoms when stopping the medication. If thishappens, your healthcare professional shouldreassure you that this is common and check that your symptoms are not getting worse. If you experience severe symptoms whilereducing your medication, your healthcareprofessional may suggest you go back to theoriginal dose, or offer another kind of similarantidepressant, and again gradually reduce thedose while monitoring your symptoms.
Understanding NICE guidance - Post-traumatic stress disorder What happens if the medication prescribed has
not helped me?
If the medication has not been helpful, yourhealthcare professional should usually consideroffering you a different antidepressant (selectedfrom those specifically recommended for PTSD),or offer you a medicine called olanzapine inaddition to your current medication. Can medication help me with sleep problems?
If you are having trouble sleeping yourhealthcare professional may offer youmedication. This may be a sleeping tablet (for short-term use only), or one of theantidepressants (specifically recommended for PTSD) that helps with sleep. Understanding NICE guidance - Post-traumatic stress disorder If you are offered antidepressant medication
you could ask the following questions.
• How long will it take before I start to feel You should be told about possible side
effects of antidepressants, but if you are
unsure you could also ask the following
questions.
• Does this medication have any side effects? • Will the side effects affect my daily life, or • What should I do if I get any of these side • Is there a leaflet or other written material Understanding NICE guidance - Post-traumatic stress disorder I have other illnesses or problems
besides PTSD. Will this affect my
treatment for PTSD?
If you have PTSD and also have depression youshould be offered treatment for both. Usuallythe PTSD will be treated first, because depressionoften improves as the symptoms of PTSDimprove, but if you have severe depression, thedepression will usually be treated first. If healthcare professionals think that you may beat risk of harming yourself or others, they shouldtry and deal with this problem first to make sureyou are safe.
If you take recreational drugs and/or alcohol,this may affect your treatment for PTSD, sohealthcare professionals should treat any drug or alcohol problem first.
If you have other personal and relationshipproblems that have been around for a long time you should still be offered trauma-focusedpsychological treatment, but you may receivetreatment for longer than 8 sessions. Understanding NICE guidance - Post-traumatic stress disorder If you have lost a family member or friend dueto an unnatural or sudden death your emotionsmay be overwhelming, and you may have whatis sometimes called 'traumatic grief'. Your GPshould also be able to provide you withinformation about professionals who havetraining and experience in this area. But if youthink you have PTSD, it is best to see your GP. Will my treatment be affected if I am
seeking compensation?
No. Healthcare professionals should not delaytreatment or refuse to treat you because you are seeking compensation as a result of atraumatic event.
Will I be offered any other kind of
help by healthcare professionals?
In addition to any support you are receivingfrom family members and/or carers, healthcareprofessionals should give you information onwhere to get further practical and social supportif you need it. Understanding NICE guidance - Post-traumatic stress disorder What treatments are
available for young people?
If you are a child or young person you should be offered a type of psychological treatment for PTSD called 'trauma-focused cognitivebehavioural therapy (CBT)' (for more informationsee page 14). You can receive this treatment ifyou have had PTSD for a short time or a longertime. It involves talking to a healthcareprofessional about what happened and how youare feeling. If this makes you feel very upset,your healthcare professional should try tounderstand and help you to take things slowly.
If you have developed PTSD recently (within
the last month) and you feel very distressed,
you should be offered psychological treatment
(but this is not always appropriate for younger
children).
If you have had PTSD for months or years
you should also be offered psychological
treatment. You should normally see your doctor
between 8 and 12 times (at least once a week).
Each meeting should usually last for 1 hour,
but when you talk about what happened to
you, the meeting should usually last for about
an hour and half. The same doctor should see
you for all of your meetings.
Understanding NICE guidance - Post-traumatic stress disorder Usually, it is important that you receive most ofyour treatment on your own with the healthcareprofessional. But your healthcare professionalmay suggest that members of your family orcarers are involved in your treatment if he or she thinks it may help. This should be agreedwith you before it happens. Healthcare professionals should tell you (and amember of your family if appropriate) that onlypsychological treatments that are designed forPTSD should be used to treat PTSD. There is littleevidence at the moment to show that othertreatments (such as play therapy, art therapy and family therapy) can help young people with PTSD. You should not usually be offered medicines totreat your PTSD, because there is not enoughsupporting evidence to recommend suchtreatments in children and young people.
Understanding NICE guidance - Post-traumatic stress disorder Information for families and
carers
How can I support a family member
with PTSD?
As a family member or a carer you can have an important role in providing practical andemotional support to someone with PTSD. If it is appropriate and the person with PTSDconsents, healthcare professionals should giveyou full information about common reactions to traumatic events, including the symptoms of PTSD and its course and treatment. How can I find support for myself?
Supporting a person with PTSD may be quitedistressing. If this is the case, and you needfurther help, healthcare professionals should besympathetic and understanding, and offer youfurther information about self-help groups,support groups and voluntary organisations. You can find information about the importantrole of carers at the website www.carers.gov.uk Understanding NICE guidance - Post-traumatic stress disorder If other members of the family have alsoexperienced the traumatic event (for example acar accident, or the death or near death, of arelative) they may also develop PTSD. If so, careand treatment should address the needs of thewhole family. Understanding NICE guidance - Post-traumatic stress disorder Where you can find more
information
If you need further information about PTSD orthe care that you are receiving, ask your doctor,nurse or other member of your healthcare team.
You can discuss the NICE guideline orinformation in this booklet with them.
If you want to read the other versions
of this guideline
There are four versions of this guideline: • the full guideline, which has all the recommendations, information on how theywere developed and the evidence on whichthey were based • the NICE guideline, which has all the • the quick reference guide, which is a summary Understanding NICE guidance - Post-traumatic stress disorder All versions of the guideline are available fromthe NICE website (www.nice.org.uk/CG026). This version and the quick reference guide arealso available from the NHS Response Line-phone 0870 1555 455 and give the referencenumber(s) of the booklets you want (N0849 forthis version, N0850 for this version in English andWelsh, and N0848 for the quick reference guide).
If you want more information about
PTSD
NHS Direct may be a good starting point forfinding out more about PTSD. You can call NHS Direct on 0845 46 47 or visit the website at www.nhsdirect.nhs.uk orwww.nhsdirect.wales.nhs.uk There may be support groups for people withPTSD in your area. Your doctor or nurse shouldbe able to give you more details. Informationabout local groups may also be available fromNHS Direct or your local library or CitizensAdvice Bureau.
Understanding NICE guidance - Post-traumatic stress disorder If you want to know about related
NICE guidance
Information for the public on the followingrelated guidance can be found on the NICEwebsite. • Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and communitycare. NICE Clinical Guideline No. 22 (December 2004). Available fromwww.nice.org.uk/CG022publicinfo • Depression: management of depression in primary and secondary care. NICE ClinicalGuideline No. 23 (December 2004). Availablefrom www.nice.org.uk/CG023publicinfo • Self-harm: The short-term physical and psychological management and secondaryprevention of self-harm in primary andsecondary care. NICE Clinical Guideline No. 16 (July 2004). Available fromwww.nice.org.uk/CG016publicinfo Understanding NICE guidance - Post-traumatic stress disorder These can also be ordered from the NHSResponse Line on 0870 1555 455. For the anxiety information quote reference numberN0764 for a version in English and N0765 for aversion in English and Welsh; for depressionquote N0767 (English) and N0768 (English andWelsh); and for self-harm quote N0626 (English)and N0627 (English and Welsh).
NICE is in the process of developing thefollowing guidance (details available fromwww.nice.org.uk): • Depression in children: identification and management of depression in children andyoung people in primary care and specialistservices. NICE Clinical Guideline. (Publicationexpected August 2005.) Understanding NICE guidance - Post-traumatic stress disorder National Institute for
Clinical Excellence

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