NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Guidelines for the Management of Conditions Specifically Related to Stress. Geneva: World Health Organization; 2013.

Cover of Guidelines for the Management of Conditions Specifically Related to Stress

Guidelines for the Management of Conditions Specifically Related to Stress.

Show details

Executive summary

Why these guidelines were developed

There are currently no suitable, evidence-based guidelines for managing problems and disorders related to stress in primary health care and other non-specialized health-care settings. Agencies working in post-conflict and natural disaster settings are increasingly interested in mental health care. This requires the development and testing of a module on the management of problems and disorders specifically related to stress.

Objectives and scope of the document

This document was developed to provide recommended management strategies for problems and disorders that are specifically related to the occurrence of a major stressful event. The recommended strategies will form the basis of a new module to be added to the WHO (2010) mhGAP Intervention Guide for use in non-specialized specialized health-care settings.

The scope of the problems covered by these guidelines is:

  • symptoms of acute stress in the first month after a potentially traumatic event, with the following subtypes:
    -

    symptoms of acute traumatic stress (intrusion, avoidance and hyperarousal) in the first month after a potentially traumatic event;

    -

    symptoms of dissociative (conversion) disorders in the first month after a potentially traumatic event;

    -

    non-organic (secondary) enuresis in the first month after a potentially traumatic event (in children);

    -

    hyperventilation in the first month after a potentially traumatic event;

    -

    insomnia in the first month after a potentially traumatic event;

  • posttraumatic stress disorder (PTSD);
  • bereavement in the absence of a mental disorder.

Who should use these guidelines

The primary audience is non-specialized specialized health-care providers working at first- and second-level health-care facilities. They include general physicians, family physicians, nurses and clinical officers. They also include those specialist medical doctors who work in areas other than mental health and substance abuse, such as paediatricians, emergency medicine physicians, obstetricians, gynaecologists and internists. A secondary audience is those tasked with the organization of health care at the district or sub-district level, including programme managers responsible for primary or non-mental health secondary care services.

How these guidelines were developed

Guideline groups: A WHO steering group comprising members from relevant WHO departments (see Annex 1) was set up in May 2011. This group established the provisional scope and selected members of the Guideline Development Group (GDG) to reflect all regions and appropriate expertise and to achieve a gender balance (see Annex 2). A larger group of external reviewers (see Annex 3) commented on the evidence profiles, draft recommendations and final documents. Their comments were considered by the GDG.

Evidence search and retrieval: The WHO Secretariat initially proposed scoping questions that were modified and agreed upon during three rounds of electronic consultation with the GDG. Further consultations with the GDG involved review of scoping questions phrased using the PICO (Population, Intervention, Comparison, Outcomes) format. Outcomes of interest were listed and the GDG voted to rank them according to importance.

By the end of July 2011 a set of scoping questions had been finalized. These were then used to guide searches for relevant systematic reviews that had been performed within the last two years and met inclusion criteria (see evidence profiles 1–21 in Annex 5 for specific inclusion and exclusion criteria). Where relevant systematic reviews (a) did not exist, (b) were not recent (had not been done within the last two years) or (c) were not of suitable quality or applicability, new systematic reviews were commissioned. For the new commissioned systematic review on medicines for PTSD, specific additional searches were carried out to identify studies in Japanese, Chinese, French, Portuguese, Russian and Spanish.

Evidence to recommendations: The WHO Handbook for Guideline Development was followed and the GRADE system for assessing quality of evidence and using evidence to inform decisions was applied to inform drafting of recommendations. For each question, an evidence profile was developed summarizing the evidence retrieved, including discussion of values, preferences, benefits, harms and feasibility. Wherever possible, the evidence retrieved was graded and GRADE tables provided. A decision table was used by the GDG during a recommendation drafting meeting in Amman, Jordan (July 2012) to agree on the quality of evidence and certainty about harms and benefits, values and preferences, feasibility and resource implications (see Annex 5 for details of each decision). The strength of the recommendation was set as either:

“Strong”: meaning that the GDG agreed that the quality of the evidence combined with certainty about the values, preferences, benefits and feasibility of this recommendation meant it should be followed in all or almost all circumstances;

or

“Standard”: meaning that there was less certainty about the combined quality of evidence and values, preferences, benefits and feasibility of this recommendation, thus there may be circumstances in which it will not apply. The word “standard” (rather than “weak” or “conditional”) was chosen to be in line with earlier WHO mhGAP guidelines and to avoid the negative connotations of the word “weak”, which could have risked biasing GDG members towards “strong” recommendations.

Recommendations

The guidelines have separate recommendations for children, adolescents and adults. For the purpose of these guidelines, adolescents are 10–19 years old while children are younger than 10 years old.

All recommendations come with remarks (see main body of this report). For example, the remarks note that even in instances where there is no recommendation for treatment, all individuals presenting with a potential mental health problem should be fully assessed to exclude physical causes of the problem. Similarly, the remarks refer to previous WHO mhGAP Guidelines (2010) recommendations, such as the recommendation to make available psychological first aid to people who have recently been exposed to a potentially traumatic event. Also, the remarks emphasize applying mhGAP general principles of care, such as good communication and mobilizing social support.

Overall, these remarks help communicate that people who suffer mental health problems should not be ignored and that certain practical steps can be taken, even in cases when there are no (new) recommendations for the management of problems and disorders specifically related to stress.

Acute traumatic stress symptoms (re-experiencing, avoidance, hyperarousal) after a potentially traumatic recent event (recommendations 1–4)

Recommendation 1

  1. Cognitive-behavioural therapy (CBT) with a trauma focus should be considered in adults with acute traumatic stress symptoms associated with significant impairment in daily functioning.
    Strength of recommendation: standard
    Quality of evidence: moderate
  2. On the basis of available evidence, no specific recommendation can be made about stand-alone problem-solving counselling, eye movement desensitization and reprocessing (EMDR), relaxation or psycho-education for adults with acute traumatic stress symptoms associated with significant impairment in daily functioning in the first month after a potentially traumatic event.
    Strength of recommendation: not applicable
    Quality of evidence: very low

Recommendation 2

On the basis of available evidence, no specific recommendation can be made on early psychological interventions (covering problem-solving counselling, relaxation, psycho-education, eye movement desensitization and reprocessing (EMDR) and cognitive-behavioural therapy (CBT)) for children and adolescents with acute traumatic stress symptoms associated with significant impairment in daily functioning.

Strength of recommendation: not applicable

Quality of evidence: very low

Recommendation 3

Benzodiazepines and antidepressants should not be offered to adults to reduce acute traumatic stress symptoms associated with significant impairment in daily functioning in the first month after a potentially traumatic event.

Strength of recommendation:

  • For benzodiazepines: strong
  • For antidepressants: standard

Quality of evidence: very low

Recommendation 4

Benzodiazepines and antidepressants should not be offered to reduce acute traumatic stress symptoms associated with significant impairment in daily functioning in children and adolescents.

Strength of recommendation: strong

Quality of evidence: very low

Insomnia after a potentially traumatic recent event (recommendations 5–8)

Recommendation 5

Relaxation techniques (e.g. progressive muscle relaxation or cultural equivalents) and advice about sleep hygiene (including advice about psychostimulants, such as coffee, nicotine and alcohol) should be considered for adults with acute (secondary) insomnia in the first month after exposure to a potentially traumatic event.

Strength of recommendation: standard

Quality of evidence: very low

Recommendation 6

On the basis of available evidence, no specific recommendation can be made for early psychological interventions in children and adolescents with acute (secondary) insomnia in the first month after a potentially traumatic event.

Strength of recommendation: not applicable

Quality of evidence: low

Recommendation 7

Benzodiazepines should not be offered to adults with insomnia within the first month after a potentially traumatic event.

Strength of recommendation: standard

Quality of evidence: moderate

Recommendation 8

Benzodiazepines should not be offered to children and adolescents with acute (secondary) insomnia within the first month after a potentially traumatic event.

Strength of recommendation: strong

Quality of evidence: very low

Enuresis after a potentially traumatic recent event (recommendation 9)

Recommendation 9

  1. Psycho-education about the negative effects of punitive responses should be given to caregivers of children with secondary non-organic enuresis in the first month after a potentially traumatic event.
    Strength of recommendation: strong
    Quality of evidence: very low
  2. Parenting skills training and the use of simple behavioural interventions (i.e. star charts, toileting before sleep and rewarding having nights without wetting the bed) should be considered. Where resources permit, alarms should be considered.
    Strength of recommendation: standard
    Quality of evidence: moderate for alarms, low or very low for other behavioural interventions

Dissociative (conversion) disorders after a potentially traumatic recent event (recommendations 10–11)

Recommendation 10

On the basis of available evidence, no specific recommendation can be made on psychological interventions for adults with symptoms of dissociative (conversion) disorders in the first month after a potentially traumatic event.

Strength of recommendation: not applicable

Quality of evidence: very low

Recommendation 11

On the basis of available evidence, no specific recommendation can be made for children and adolescents with symptoms of dissociative (conversion) disorders in the first month after a potentially traumatic event.

Strength of recommendation: not applicable

Quality of evidence: very low

Hyperventilation after a potentially traumatic recent event (recommendations 12–13)

Recommendation 12

No specific recommendation can be made on the basis of available evidence on rebreathing into a paper bag for adolescents and adults with hyperventilation in the first month after exposure to a potentially traumatic event.

Strength of recommendation: not applicable

Quality of evidence: very low

Recommendation 13

Rebreathing into a paper bag should not be considered for children with hyperventilation in the first month after a potentially traumatic event.

Strength of recommendation: standard

Quality of evidence: very low

Posttraumatic stress disorder (recommendations 14–17)

Recommendation 14

Individual or group cognitive-behavioural therapy (CBT) with a trauma focus, eye movement desensitization and reprocessing (EMDR) or stress management should be considered for adults with posttraumatic stress disorder (PTSD).

Strength of recommendation: standard

Quality of evidence: moderate for individual CBT, EMDR; low for group CBT, stress management

Recommendation 15

Individual or group cognitive-behavioural therapy (CBT) with a trauma focus or eye movement desensitization and reprocessing (EMDR) should be considered for children and adolescents with posttraumatic stress disorder (PTSD).

Strength of recommendation: standard

Quality of evidence: moderate for individual CBT, low for EMDR, very low for group CBT

Recommendation 16

Selective serotonin re-uptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) should not be offered as the first line of treatment for posttraumatic stress disorder (PTSD) in adults. SSRIs and TCAs should be considered if (a) stress management, cognitive-behavioural therapy (CBT) with a trauma focus and/or eye movement desensitization and reprocessing (EMDR) have failed or are not available or (b) if there is concurrent moderate–severe depression.

Strength of recommendation: standard

Quality of evidence: low

Recommendation 17

Antidepressants should not be used to manage posttraumatic stress disorder (PTSD) in children and adolescents.

Strength of recommendation: strong

Quality of evidence: very low

Bereavement in the absence of mental disorder (recommendations 18–21)

Recommendation 18

Structured psychological interventions should not be offered universally to (all) bereaved adults who do not meet the criteria for a mental disorder.

Strength of recommendation: strong

Quality of evidence: moderate

Recommendation 19

Structured psychological interventions should not be offered universally to (all) bereaved children and adolescents who do not meet the criteria for a mental disorder.

Strength of recommendation: strong

Quality of evidence: very low

Recommendation 20

Benzodiazepines should not be offered to bereaved adults who do not meet criteria for a mental disorder.

Strength of recommendation: strong

Quality of evidence: very low

Recommendation 21

Benzodiazepines should not be offered to bereaved children and adolescents who do not meet criteria for a mental disorder.

Strength of recommendation: strong

Quality of evidence: very low

Copyright © World Health Organization 2013.

All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob.

Requests for permission to reproduce or translate WHO publications –whether for sale or for noncommercial distribution– should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html).

Bookshelf ID: NBK159723

Views

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...