PTSD Screening and Early Intervention After Physical Injury
PTSD Screening and Early Intervention After Physical Injury
Dr Zatzick and the group from the Harborview Injury Prevention and Research Center and their level 1 trauma center program at the University of Washington are to be congratulated for their excellent work on the screening and management of posttraumatic stress disorder (PTSD) in surgically hospitalized injury survivors.
This article will be highly cited in future research projects and will be mandatory reading for all of us working in trauma settings and dealing with survivors of severe injury.
Trauma is a disease. As such, it must be approached in a multidisciplinary fashion. It is unacceptable to consider that the consequences of the initial injury will become nonexistent at the moment that the body heals. The late and long-term consequences of this devastating disease include, but are not limited to, impairment in physical functioning, psychological disturbances, social disintegration, destruction of families, lack of productivity, and high social costs.
The unavailability of proven screening and treatment strategies during or immediately after the acute phase of care suggests not only lack of knowledge and understanding of the "hidden" consequences of traumatic injury but also the complete failure of the health care system in providing support mechanisms to care for mental health care issues.
The study by Zatzick et al attempted to fill some of those gaps. During a 3.5-year period, the authors screened 207 trauma patients for PTSD symptoms, once during their initial hospitalization and then early after discharge from the hospital. After the screening process, patients were randomized to a stepped collaborative care intervention or usual care control. The interventions included care management, pharmacotherapy, and cognitive behavioral therapy (CBT), which lasted for 12 months and were delivered both in the hospital and in the outpatient clinics. Behavioral activation psychotherapy and motivational interviewing were delivered early on by the care management team. Pharmacotherapy included a serotonin-specific reuptake inhibitor (SSRI) and antidepressant agent in addition to medications targeting insomnia. CBT included psychoeducation, muscle relaxation, cognitive restructuring, and graded exposure.
The authors used 2 measures to assess PTSD: Clinician-Administered PTSD Scale (CAPS) and PTSD Checklist–Civilian Version (PCL-C). The PCL-C was used as the screening tool to enroll patients in the study. Patients who scored high on the PCL-C while in the hospital were screened again, and those who scored high for a second time were randomized into the study. In addition, the authors used the Patient Health Questionnaire to assess for depressive symptoms, the AUDIT-C for alcohol use, and the Medical Outcomes Study 36-Item Short Form Health Survey, Physical Component Summary, to assess physical health and function.
They found that study patients were more likely to be female, less severely injured, intentionally injured, blood alcohol positive, younger, and had prolonged hospitalization. They reached the remarkably high rate of 75% follow-up.
From a design point of view, the authors have taught us that even when including complex stepped treatment strategies, it is possible to carry out well-designed studies. Care managers spent approximately 13 hours per year providing care to individual patients, and the intensity of care provided decreased over the course of the 12-month period. Medication compliance was more than 60%, and 77% received more than 1 session of motivational interviewing targeting alcohol use and other high-risk behaviors, a definite indirect benefit of the study, which are certainly important components in the development of a comprehensive program. Perhaps, as important, patients participating in the collaborative care program component were more likely to receive pharmacotherapy, an adequate dosage of antidepressant medication, and a medication for insomnia. With such structured treatment strategy, it is not surprising that intervention patients were very satisfied with their general health and emotional care.
PTSD researchers who oppose or have criticisms to early screening and intervention state that in many cases, early PTSD symptoms resolve or disappear over time and therefore one should wait several days or weeks to use screening tools to effectively diagnose significant PTSD symptoms. Obviously, those who believe in early screening propose it in an attempt to mitigate symptoms and the development of the disease by implementing early intervention. Although the authors have not provided us with a clear denominator in their study, which would allow them to define the baseline rate of significant early PTSD after injury, they have clearly shown that symptoms "do not go away" as many investigators, who oppose to early screening, think. In fact, in the observation group at 6 months, mean CAPS and PCL-C scores remain close to baseline (immediately postinjury) values. At 12 months, mean CAPS scores remained above 50 and mean PCL-C were approximately 45 points.
The authors showed that patients in the intervention group demonstrated marked reductions in the symptoms of PTSD over a 12-month period. More importantly, differences were also demonstrated in the intervention group regarding treatment response criteria, PTSD remission criteria, and improvements in physical function, a novel finding in studies of patients receiving stepped collaborative care intervention. The study also emphasizes that CBT, which is more labor-intensive to deliver, might be reserved for PTSD patients with more long-term and recurrent symptoms and that "easier to apply" measures should be indicated early and might reach a sustainable level of resolution, avoiding the "shotgun" approach that may not serve all.
The findings of the study by Zatzick et al are very comprehensive and conclusive. Others have also studied issues related to early screening of PTSD in the posttraumatic period, although in smaller scales. Browne et al examined the clinical utility of screening and early intervention in reducing the disability (chronic pain, PTSD, and depression) after traumatic injury. They studied 142 severely injured patients (excluded patients with traumatic brain injury) within 4 weeks postinjury. They randomized patients to a multidisciplinary intervention (received care at 1 and 3 months for pain, rehabilitation, occupational therapy, and psychological services) or usual care. They found that acute pain, posttraumatic adjustment, depression, acute trauma symptoms, and alcohol use predicted depressive symptoms and PTSD severity at 6 months. Interestingly, 24% patients of the usual care group were initially below the cutoff mark for being at risk for PTSD or depression but had a diagnosis of these diseases at 6 months. Therefore, it seems that although early intervention is useful and is associated with a decreased incidence of significant PTSD or depression symptoms at 6 months after injuries, some patients will screen negative early on and will convert to a positive screening at a later time. This observation begs the question of when early is too early to screen. Future studies should be designed to answer this important question.
The question related to which component of the stepped intervention was the most effective in reducing PTSD symptoms still remains unanswered in the study of Zatzick et al. CBT and SSRIs are recommended for the treatment of PTSD. SSRIs, such as sertraline, paroxetine, and fluoxetine, have been used effectively in randomized clinical trials with favorable results. However, the choice of treatment is arbitrary and unclear to clinicians due to the lack of specific guidelines determining when therapy escalation is appropriate. It is possible that pharmacological therapy predominates in clinical practice because of the lack of availability and accessibility of CBT for the trauma patient population as stated by Polak et al.
One meta-analysis specifically attempted to compare the effects of pharmacological approach with psychotherapeutic treatment options for PTSD. A small advantage was found in favor of CBT compared with medications. One study found higher relapse rates at 6-month follow-up in patients treated with paroxetine than with CBT, whereas another study found that patients treated with psychotherapy were markedly more asymptomatic at 6 months (58%) than patients treated with a pharmacological approach. None of these studies included a significant number of patients compared with the present study. The duration of pharmacological treatment with SSRIs (12 weeks vs 24 weeks) has also been studied. It seems that a prolonged course of pharmacological therapy is more beneficial than a shorter course, although others have found otherwise.
Another early intervention that may be added to the current treatment strategies for patients with early, severe PTSD symptoms aims at modifying memory to prevent the development of PTSD before memory consolidation. To that end, Rothbaun et al randomly assigned patients to 3 sessions of a very early intervention beginning in the emergency department and compared this to an observation-only group. They assessed posttraumatic stress reactions (PTSRs) at 4 and 12 weeks postinjury and depression at 4 weeks. They were able to assess trauma patients at 11.8 hours postinjury, on average. Patients in the intervention group had lower PTSRs at 4 and 12 weeks and lower depressive symptoms at 4 weeks. They concluded that the modified exposure intervention initiated in the emergency department within hours postinjury is a successful, safe, and feasible strategy in reducing PTSRs and depression symptoms.
Recently, Reese et al used the Primary Care PTSD screening tool on trauma patients on clinic visits after hospital discharges post–acute traumatic event. Although no intervention was planned in the study, the authors concluded that the simplified screening tool is easy to use and can be used with both, patients and families of patients.
Another unanswered question is related to the cost-effectiveness of such an intense screening and treatment approach, as proposed by the Harborview group. Until we know which components are most effective early on, proposing broad screening and a multifaceted treatment approach may be too costly for trauma centers, which are already facing too many unfunded mandates.
Finally, the experience in the current military conflict has demonstrated that mild traumatic brain injury and PTSD combined is a disease complex that needs attention, investigation, and well-defined diagnostic and treatment strategies. We hope that investigators will consider well-designed multi-institutional studies to evaluate larger number of trauma patients, which will provide us with enough information about the natural history of mild traumatic brain injury and PTSD.
Dr Zatzick and the group from the Harborview Injury Prevention and Research Center and their level 1 trauma center program at the University of Washington are to be congratulated for their excellent work on the screening and management of posttraumatic stress disorder (PTSD) in surgically hospitalized injury survivors.
This article will be highly cited in future research projects and will be mandatory reading for all of us working in trauma settings and dealing with survivors of severe injury.
Trauma is a disease. As such, it must be approached in a multidisciplinary fashion. It is unacceptable to consider that the consequences of the initial injury will become nonexistent at the moment that the body heals. The late and long-term consequences of this devastating disease include, but are not limited to, impairment in physical functioning, psychological disturbances, social disintegration, destruction of families, lack of productivity, and high social costs.
The unavailability of proven screening and treatment strategies during or immediately after the acute phase of care suggests not only lack of knowledge and understanding of the "hidden" consequences of traumatic injury but also the complete failure of the health care system in providing support mechanisms to care for mental health care issues.
The study by Zatzick et al attempted to fill some of those gaps. During a 3.5-year period, the authors screened 207 trauma patients for PTSD symptoms, once during their initial hospitalization and then early after discharge from the hospital. After the screening process, patients were randomized to a stepped collaborative care intervention or usual care control. The interventions included care management, pharmacotherapy, and cognitive behavioral therapy (CBT), which lasted for 12 months and were delivered both in the hospital and in the outpatient clinics. Behavioral activation psychotherapy and motivational interviewing were delivered early on by the care management team. Pharmacotherapy included a serotonin-specific reuptake inhibitor (SSRI) and antidepressant agent in addition to medications targeting insomnia. CBT included psychoeducation, muscle relaxation, cognitive restructuring, and graded exposure.
The authors used 2 measures to assess PTSD: Clinician-Administered PTSD Scale (CAPS) and PTSD Checklist–Civilian Version (PCL-C). The PCL-C was used as the screening tool to enroll patients in the study. Patients who scored high on the PCL-C while in the hospital were screened again, and those who scored high for a second time were randomized into the study. In addition, the authors used the Patient Health Questionnaire to assess for depressive symptoms, the AUDIT-C for alcohol use, and the Medical Outcomes Study 36-Item Short Form Health Survey, Physical Component Summary, to assess physical health and function.
They found that study patients were more likely to be female, less severely injured, intentionally injured, blood alcohol positive, younger, and had prolonged hospitalization. They reached the remarkably high rate of 75% follow-up.
From a design point of view, the authors have taught us that even when including complex stepped treatment strategies, it is possible to carry out well-designed studies. Care managers spent approximately 13 hours per year providing care to individual patients, and the intensity of care provided decreased over the course of the 12-month period. Medication compliance was more than 60%, and 77% received more than 1 session of motivational interviewing targeting alcohol use and other high-risk behaviors, a definite indirect benefit of the study, which are certainly important components in the development of a comprehensive program. Perhaps, as important, patients participating in the collaborative care program component were more likely to receive pharmacotherapy, an adequate dosage of antidepressant medication, and a medication for insomnia. With such structured treatment strategy, it is not surprising that intervention patients were very satisfied with their general health and emotional care.
PTSD researchers who oppose or have criticisms to early screening and intervention state that in many cases, early PTSD symptoms resolve or disappear over time and therefore one should wait several days or weeks to use screening tools to effectively diagnose significant PTSD symptoms. Obviously, those who believe in early screening propose it in an attempt to mitigate symptoms and the development of the disease by implementing early intervention. Although the authors have not provided us with a clear denominator in their study, which would allow them to define the baseline rate of significant early PTSD after injury, they have clearly shown that symptoms "do not go away" as many investigators, who oppose to early screening, think. In fact, in the observation group at 6 months, mean CAPS and PCL-C scores remain close to baseline (immediately postinjury) values. At 12 months, mean CAPS scores remained above 50 and mean PCL-C were approximately 45 points.
The authors showed that patients in the intervention group demonstrated marked reductions in the symptoms of PTSD over a 12-month period. More importantly, differences were also demonstrated in the intervention group regarding treatment response criteria, PTSD remission criteria, and improvements in physical function, a novel finding in studies of patients receiving stepped collaborative care intervention. The study also emphasizes that CBT, which is more labor-intensive to deliver, might be reserved for PTSD patients with more long-term and recurrent symptoms and that "easier to apply" measures should be indicated early and might reach a sustainable level of resolution, avoiding the "shotgun" approach that may not serve all.
The findings of the study by Zatzick et al are very comprehensive and conclusive. Others have also studied issues related to early screening of PTSD in the posttraumatic period, although in smaller scales. Browne et al examined the clinical utility of screening and early intervention in reducing the disability (chronic pain, PTSD, and depression) after traumatic injury. They studied 142 severely injured patients (excluded patients with traumatic brain injury) within 4 weeks postinjury. They randomized patients to a multidisciplinary intervention (received care at 1 and 3 months for pain, rehabilitation, occupational therapy, and psychological services) or usual care. They found that acute pain, posttraumatic adjustment, depression, acute trauma symptoms, and alcohol use predicted depressive symptoms and PTSD severity at 6 months. Interestingly, 24% patients of the usual care group were initially below the cutoff mark for being at risk for PTSD or depression but had a diagnosis of these diseases at 6 months. Therefore, it seems that although early intervention is useful and is associated with a decreased incidence of significant PTSD or depression symptoms at 6 months after injuries, some patients will screen negative early on and will convert to a positive screening at a later time. This observation begs the question of when early is too early to screen. Future studies should be designed to answer this important question.
The question related to which component of the stepped intervention was the most effective in reducing PTSD symptoms still remains unanswered in the study of Zatzick et al. CBT and SSRIs are recommended for the treatment of PTSD. SSRIs, such as sertraline, paroxetine, and fluoxetine, have been used effectively in randomized clinical trials with favorable results. However, the choice of treatment is arbitrary and unclear to clinicians due to the lack of specific guidelines determining when therapy escalation is appropriate. It is possible that pharmacological therapy predominates in clinical practice because of the lack of availability and accessibility of CBT for the trauma patient population as stated by Polak et al.
One meta-analysis specifically attempted to compare the effects of pharmacological approach with psychotherapeutic treatment options for PTSD. A small advantage was found in favor of CBT compared with medications. One study found higher relapse rates at 6-month follow-up in patients treated with paroxetine than with CBT, whereas another study found that patients treated with psychotherapy were markedly more asymptomatic at 6 months (58%) than patients treated with a pharmacological approach. None of these studies included a significant number of patients compared with the present study. The duration of pharmacological treatment with SSRIs (12 weeks vs 24 weeks) has also been studied. It seems that a prolonged course of pharmacological therapy is more beneficial than a shorter course, although others have found otherwise.
Another early intervention that may be added to the current treatment strategies for patients with early, severe PTSD symptoms aims at modifying memory to prevent the development of PTSD before memory consolidation. To that end, Rothbaun et al randomly assigned patients to 3 sessions of a very early intervention beginning in the emergency department and compared this to an observation-only group. They assessed posttraumatic stress reactions (PTSRs) at 4 and 12 weeks postinjury and depression at 4 weeks. They were able to assess trauma patients at 11.8 hours postinjury, on average. Patients in the intervention group had lower PTSRs at 4 and 12 weeks and lower depressive symptoms at 4 weeks. They concluded that the modified exposure intervention initiated in the emergency department within hours postinjury is a successful, safe, and feasible strategy in reducing PTSRs and depression symptoms.
Recently, Reese et al used the Primary Care PTSD screening tool on trauma patients on clinic visits after hospital discharges post–acute traumatic event. Although no intervention was planned in the study, the authors concluded that the simplified screening tool is easy to use and can be used with both, patients and families of patients.
Another unanswered question is related to the cost-effectiveness of such an intense screening and treatment approach, as proposed by the Harborview group. Until we know which components are most effective early on, proposing broad screening and a multifaceted treatment approach may be too costly for trauma centers, which are already facing too many unfunded mandates.
Finally, the experience in the current military conflict has demonstrated that mild traumatic brain injury and PTSD combined is a disease complex that needs attention, investigation, and well-defined diagnostic and treatment strategies. We hope that investigators will consider well-designed multi-institutional studies to evaluate larger number of trauma patients, which will provide us with enough information about the natural history of mild traumatic brain injury and PTSD.
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