Multiple session early psychological interventions for the prevention of post-traumatic stress disorder

Randomized clinical trial of peer integrated collaborative care intervention after physical injury

Objectives

The goal of the current study was to assess the effectiveness of a peer integrated collaborative care intervention for postinjury outcomes.

Methods

Injury survivors ≥18 years of age were screened for post-traumatic stress disorder (PTSD) symptoms and severe postinjury concerns; screen-positive patients were randomized to the intervention versus enhanced usual care control conditions. The collaborative care intervention included peer support and care management. The intervention also included evidence-based pharmacotherapy and psychotherapeutic elements targeting PTSD. The COVID-19 pandemic interrupted recruitment between March and June 2020; in response to the COVID-19 pandemic, the peer component of the intervention went from in-person to virtual delivery. The primary outcomes were PTSD symptoms assessed with the Diagnostic and Statistical Manual of Mental Disorders fourth edition PTSD checklist, any severe postinjury concerns, and emergency department/inpatient utilization followed over the 12 months postinjury. Secondary outcomes included patient satisfaction with emotional healthcare.

Results

A total of 450 patients were randomized to the intervention (n=225) and control (n=225) conditions; 124 patients (28%) were recruited and completed all study assessments prior to the onset of the COVID-19 pandemic, while 326 patients (72%) were recruited after and/or had one or more study follow-ups occur postpandemic onset. Mixed model regression revealed no statistically significant comparisons for any of the primary outcomes. In exploratory models that examined the impact of COVID-19, significantly improved PTSD symptoms were present at 3 months pre-COVID-19 relative to post-COVID-19. Intervention patients consistently demonstrated higher satisfaction with emotional aspects of healthcare (F(5,1652)=2.87, p=0.01).

Conclusions

The intervention demonstrated no significant improvements in primary outcomes in the intent-to-treat sample. The peer integrated collaborative care intervention contributed to higher patient satisfaction with the emotional aspects of healthcare.

Level of evidence

Level II, randomized clinical trial.

Trial registration number

NCT03569878.

A day in the life: psychological impact on emergency responders during the 22 March 2016 terrorist attacks

Introduction

Terrorist attacks can cause severe long-term mental health issues that need treatment. However, in the case of emergency responders, research is often vague on the type of stressors that emergency responders encounter. For example, in addition to the threat that they work under, studies have shown that ill-preparation adds to the stress experienced by emergency responders. However, few studies have looked into the experience of emergency responders. In this study, we looked at the experience of emergency responders during the 22 March 2016 terrorist attacks in Belgium.

Methods

We used a qualitative design, in which we interviewed different types of emergency responders. Police officers, nurses, soldiers, firefighters, and Red Cross volunteers were included. Interviews were coded by two researchers and analyzed using a thematic approach.

Results

Four large themes were developed: constant threat and chaos, frustrations with lack of preparedness and training, ethical decisions, and debriefings. In addition, although emergency responders encountered constant threat, they often felt that they were ill-prepared for such attacks. One specific example was their lack of training in tourniquet usage. Furthermore, in a disaster setting, the emergency responders had to make life-and-death decisions for which they were not always prepared. Finally, debriefings were conducted in the aftermath of the attacks. Whereas most were perceived as positive, the debriefings among police officers were viewed as insufficient.

Conclusions

Emergency responding to terrorist attacks has many different dimensions of events that can cause stress. Our study revealed that preparation is key, not only in terms of material but also in terms of ethics and debriefings.

Can stepped collaborative care interventions improve post-traumatic stress disorder symptoms for racial and ethnic minority injury survivors?

Objectives

No large-scale randomized clinical trial investigations have evaluated the potential differential effectiveness of early interventions for post-traumatic stress disorder (PTSD) among injured patients from racial and ethnic minority backgrounds. The current investigation assessed whether a stepped collaborative care intervention trial conducted at 25 level I trauma centers differentially improved PTSD symptoms for racial and ethnic minority injury survivors.

Methods

The investigation was a secondary analysis of a stepped wedge cluster randomized clinical trial. Patients endorsing high levels of distress on the PTSD Checklist (PCL-C) were randomized to enhanced usual care control or intervention conditions. Three hundred and fifty patients of the 635 randomized (55%) were from non-white and/or Hispanic backgrounds. The intervention included care management, cognitive behavioral therapy elements and, psychopharmacology addressing PTSD symptoms. The primary study outcome was PTSD symptoms assessed with the PCL-C at 3, 6, and 12 months postinjury. Mixed model regression analyses compared treatment effects for intervention and control group patients from non-white/Hispanic versus white/non-Hispanic backgrounds.

Results

The investigation attained between 75% and 80% 3-month to 12-month follow-up. The intervention, on average, required 122 min (SD=132 min). Mixed model regression analyses revealed significant changes in PCL-C scores for non-white/Hispanic intervention patients at 6 months (adjusted difference -3.72 (95% CI -7.33 to -0.10) Effect Size =0.25, p<0.05) after the injury event. No significant differences were observed for white/non-Hispanic patients at the 6-month time point (adjusted difference -1.29 (95% CI -4.89 to 2.31) ES=0.10, p=ns).

Conclusion

In this secondary analysis, a brief stepped collaborative care intervention was associated with greater 6-month reductions in PTSD symptoms for non-white/Hispanic patients when compared with white/non-Hispanic patients. If replicated, these findings could serve to inform future American College of Surgeon Committee on Trauma requirements for screening, intervention, and referral for PTSD and comorbidities.

Level of evidence

Level II, secondary analysis of randomized clinical trial data reporting a significant difference.

Trial registration number

NCT02655354.

Stress Management Skills in the Physicians Practice of Primary Care Level

Current approaches to non-specialized help with stress are set out in this article and stress management tools are provided, which are developed by WHO in the stress management handbook “Doing What Matters in Times of Stress: An Illustrated Guide”. This knowledge is especially current in the giving of first aid in emergencies, and in giving psychosocial support to patients as well, by primary care physicians, who must have effective communication skills and mutual understanding, and have experience in supporting people in difficult situations too, as it is specified in numerous WHO recommendations on mental health, in such as : «mhGAP Intervention Guide for mental, neurological and substance use disorders in nonspecialized health settings», «IASC Guidelines for mental health and psychosocial support in emergency settings»,«mhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies», «Support for Rehabilitation: Self-Management after COVID-19 Related Illness» and etc. Aim – to give the information for the distant self-learning of the primary care professionals to use the simple stress-management tools in difficult circumstances. Distance learning is built on the basis of the evidence based WHO documents and recommendations about low intensity psychological interventions. The WHO Guide has five sections, where five ideas and techniques for reducing stress are descibed, which are designed as the acquisition of five skills. The authors at the end of each section of the Guide developed algorithms of use the skills of such tools as: «Grounding», «Unhooking», «Acting according to own values», «Showing kindness», «Creating space». The psychosocial support provided by the primary care physician / facilitator / assistant lies in helping people to use guidance and apply strategies in their own lives, and it prevents the professional burnout of healthcare professionals as well. The short information about WHO guide and stress -management methods are described in sufficient details to enhance the awareness level of the primary care personnel about stress-management tools use. As the result of using the Guide will enhance the capacity of local helth care staff and non medical staff to provide the mental health services and psychosocial support during the current COVID-19 pandemic, and readiness for the future emergencies.

Risk factors for PTSD diagnosis in young victims of recent sexual assault

BACKGROUND

Sexual assault is associated with a high risk of developing PTSD. Little is known about the PTSD onset in children who have recently been victimized by sexual assault. It is important to identify children at risk for PTSD after sexual assault to prevent chronic problems and revictimization.

OBJECTIVE

The first aim of this study was to describe the development of post-traumatic stress symptoms in the four weeks after sexual assault. The second aim was to analyse whether pre-assault factors, assault-related factors, social support, and post-traumatic stress, measured at two weeks post-assault, were associated with an indication of PTSD.

METHOD

From January 2019 to March 2021, data were collected of victims aged 8-17 years (n = 51; mean age = 15.00; SD = 1.78) who had contacted a Sexual Assault Centre. Severity of post-traumatic stress symptoms was measured at two and four weeks post-assault. The study was designed to use a multivariate logistic regression analysis. The study included female victims only.

RESULTS

Most of the victims (58.8%) showed a decline in the severity of post-traumatic stress symptoms in the four weeks after sexual assault. However, 27.4% showed an increase and 13.7% showed no change in symptoms. More than two-thirds of the children (70.6%) showed severe post-traumatic stress symptoms at four weeks post-assault, i.e. had an indication of PTSD. Since only one significant difference was found, the multivariate analysis was not executed. A significant difference was found between severity of symptoms at two weeks and an indication of PTSD at four weeks (t(49) = -5.79; p < .001).

CONCLUSION

Children with high levels of post-traumatic stress at two weeks post-assault are at risk for PTSD indication at four weeks post-assault. Further research is needed to determine whether early trauma-based treatment for children with high post-traumatic stress symptoms can prevent the development of PTSD.

[The broad spectrum of psychological sequelae of accidential trauma : Typical clinical pictures and stepped-care therapy]

The somatic sequelae of accidents and violent events can vary from uninjured to fatal but the psychological impact can vary from integrity, to transient reactions up to severe and chronic trauma-related mental health disorders. In a dynamic interaction they determine the individual processing and coping in the aftermath, the mid-term and long-term outcome of medical treatment and of psychosocial rehabilitation.Appropriate consideration of the psychological sequelae of trauma requires attention and sensitization, knowledge about widespread complaints and symptoms after potential traumatic events and their typical courses over time. A careful perception of early warning signals and basic skills of clinical management are required. When more specific psychodiagnostic and psychotherapeutic interventions seem necessary, mental health specialists have to be consulted within a staged care model.

Psychological and social interventions for the prevention of mental disorders in people living in low- and middle-income countries affected by humanitarian crises

BACKGROUND

People living in 'humanitarian settings' in low- and middle-income countries (LMICs) are exposed to a constellation of physical and psychological stressors that make them vulnerable to developing mental disorders. A range of psychological and social interventions have been implemented with the aim to prevent the onset of mental disorders and/or lower psychological distress in populations at risk, and it is not known whether interventions are effective.

OBJECTIVES

To compare the efficacy and acceptability of psychological and social interventions versus control conditions (wait list, treatment as usual, attention placebo, psychological placebo, or no treatment) aimed at preventing the onset of non-psychotic mental disorders in people living in LMICs affected by humanitarian crises.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMD-CTR), the Cochrane Drugs and Alcohol Review Group (CDAG) Specialized Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), Embase (OVID), PsycINFO (OVID), and ProQuest PILOTS database with results incorporated from searches to February 2020. We also searched the World Health Organization's (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov to identify unpublished or ongoing studies. We checked the reference lists of relevant studies and reviews.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing psychological and social interventions versus control conditions to prevent the onset of mental disorders in adults and children living in LMICs affected by humanitarian crises. We excluded studies that enrolled participants based on a positive diagnosis of mental disorder (or based on a proxy of scoring above a cut-off score on a screening measure).

DATA COLLECTION AND ANALYSIS

We calculated standardised mean differences for continuous outcomes and risk ratios for dichotomous data, using a random-effects model. We analysed data at endpoint (zero to four weeks after therapy) and at medium term (one to four months after intervention). No data were available at long term (six months or longer). We used GRADE to assess the quality of evidence.

MAIN RESULTS

In the present review we included seven RCTs with a total of 2398 participants, coming from both children/adolescents (five RCTs), and adults (two RCTs). Together, the seven RCTs compared six different psychosocial interventions against a control comparator (waiting list in all studies). All the interventions were delivered by paraprofessionals and, with the exception of one study, delivered at a group level. None of the included studies provided data on the efficacy of interventions to prevent the onset of mental disorders (incidence). For the primary outcome of acceptability, there may be no evidence of a difference between psychological and social interventions and control at endpoint for children and adolescents (RR 0.93, 95% CI 0.78 to 1.10; 5 studies, 1372 participants; low-quality evidence) or adults (RR 0.96, 95% CI 0.61 to 1.50; 2 studies, 767 participants; very low quality evidence). No information on adverse events related to the interventions was available. For children's and adolescents' secondary outcomes of prevention interventions, there may be no evidence of a difference between psychological and social intervention groups and control groups for reducing PTSD symptoms (standardised mean difference (SMD) -0.16, 95% CI -0.50 to 0.18; 3 studies, 590 participants; very low quality evidence), depressive symptoms (SMD -0.01, 95% CI -0.29 to 0.31; 4 RCTs, 746 participants; very low quality evidence) and anxiety symptoms (SMD 0.11, 95% CI -0.09 to 0.31; 3 studies, 632 participants; very low quality evidence) at study endpoint. In adults' secondary outcomes of prevention interventions, psychological counselling may be effective for reducing depressive symptoms (MD -7.50, 95% CI -9.19 to -5.81; 1 study, 258 participants; very low quality evidence) and anxiety symptoms (MD -6.10, 95% CI -7.57 to -4.63; 1 study, 258 participants; very low quality evidence) at endpoint. No data were available for PTSD symptoms in the adult population. Owing to the small number of RCTs included in the present review, it was not possible to carry out neither sensitivity nor subgroup analyses.

AUTHORS' CONCLUSIONS

Of the seven prevention studies included in this review, none assessed whether prevention interventions reduced the incidence of mental disorders and there may be no evidence for any differences in acceptability. Additionally, for both child and adolescent populations and adult populations, a very small number of RCTs with low quality evidence on the review's secondary outcomes (changes in symptomatology at endpoint) did not suggest any beneficial effect for the studied prevention interventions. Confidence in the findings is hampered by the scarcity of prevention studies eligible for inclusion in the review, by risk of bias in the studies, and by substantial levels of heterogeneity. Moreover, it is possible that random error had a role in distorting results, and that a more thorough picture of the efficacy of prevention interventions will be provided by future studies. For this reason, prevention studies are urgently needed to assess the impact of interventions on the incidence of mental disorders in children and adults, with extended periods of follow-up.

Early Hypnotic Intervention After Traumatic Events in Children

Post-traumatic stress disorder is a debilitating condition that can develop after exposure to any potentially traumatic event (natural disaster, physical assault, and car accident). This study focused on four pediatric patients presenting with an early stress response after a motor vehicle accident who were offered early therapeutic and a preventive management by hypnotherapy shortly after exposure to the traumatic event. All patients improved after one or several sessions of hypnosis. The results indicate that hypnotherapy can immediately help patients during the early period following a traumatic event.

Improving mental health and physiological stress responses in mothers following traumatic childbirth and in their infants: study protocol for the Swiss TrAumatic biRth Trial (START)

INTRODUCTION

Emergency caesarean section (ECS) qualifies as a psychological trauma, which may result in postnatal post-traumatic stress disorder (PTSD). Maternal PTSD may not only have a significant negative impact on mother-infant interactions, but also on long-term infant development. The partner's mental health may also affect infant development. Evidence-based early interventions to prevent the development of postpartum PTSD in mothers are lacking. Immediately after a traumatic event, memory formation is vulnerable to interference. There is accumulating evidence that a brief behavioural intervention including a visuospatial task may result in a reduction in intrusive memories of the trauma.

METHODS AND ANALYSIS

This study protocol describes a double-blind multicentre randomised controlled phase III trial testing an early brief maternal intervention including the computer game 'Tetris' on intrusive memories of the ECS trauma (≤1 week) and PTSD symptoms (6 weeks, primary outcome) of 144 women following an ECS. The intervention group will carry out a brief behavioural procedure including playing Tetris. The attention-placebo control group will complete a brief written activity log. Both simple cognitive tasks will be completed within the first 6 hours following traumatic childbirth. The intervention is delivered by midwives/nurses in the maternity unit.The primary outcome will be differences in the presence and severity of maternal PTSD symptoms between the intervention and the attention-placebo control group at 6 weeks post partum. Secondary outcomes will be physiological stress and psychological vulnerability, mother-infant interaction and infant developmental outcomes. Other outcomes will be psychological vulnerability and physiological regulation of the partner and their bonding with the infant, as well as the number of intrusive memories of the event.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Human Research Ethics Committee of the Canton de Vaud (study number 2017-02142). Dissemination of results will occur via national and international conferences, in peer-reviewed journals, public conferences and social media.

TRIAL REGISTRATION NUMBER

NCT03576586.

Couple and family therapies for post-traumatic stress disorder (PTSD)

BACKGROUND

Post-traumatic stress disorder (PTSD) refers to an anxiety or trauma- and stressor-related disorder that is linked to personal or vicarious exposure to traumatic events. PTSD is associated with a range of adverse individual outcomes (e.g. poor health, suicidality) and significant interpersonal problems which include difficulties in intimate and family relationships. A range of couple- and family-based treatments have been suggested as appropriate interventions for families impacted by PTSD.

OBJECTIVES

The objectives of this review were to: (1) assess the effects of couple and family therapies for adult PTSD, relative to 'no treatment' conditions, 'standard care', and structured or non-specific individual or group psychological therapies; (2) examine the clinical characteristics of studies that influence the relative effects of these therapies; and (3) critically evaluate methodological characteristics of studies that may bias the research findings.

SEARCH METHODS

We searched MEDLINE (1950- ), Embase (1980- ) and PsycINFO (1967- ) via the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) to 2014, then directly via Ovid after this date. We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library. We conducted supplementary searches of PTSDPubs (all available years) (this database is formerly known as PILOTS (Published International Literature on Traumatic Stress)). We manually searched the early editions of key journals and screened the reference lists and bibliographies of included studies to identify other relevant research. We also contacted the authors of included trials for unpublished information. Studies have been incorporated from searches to 3 March 2018.

SELECTION CRITERIA

Eligible studies were randomised controlled trials (RCTs) of couple or family therapies for PTSD in adult samples. The review considered any type of therapy that was intended to treat intact couples or families where at least one adult family member met criteria for PTSD. It was required that participants were diagnosed with PTSD according to recognised classification systems.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures prescribed by Cochrane. Three review authors screened all titles and abstracts and two authors independently extracted data from each study deemed eligible and assessed the risk of bias for each study. We used odds ratios (OR) to summarise the effects of interventions for dichotomous outcomes, and standardised mean differences (SMD) to summarise post-treatment between-group differences on continuous measures.

MAIN RESULTS

We included four trials in the review. Two studies examined the effects of cognitive behavioural conjoint/couple's therapy (CBCT) relative to a wait list control condition, although one of these studies only reported outcomes in relation to relationship satisfaction. One study examined the effects of structural approach therapy (SAT) relative to a PTSD family education (PFE) programme; and one examined the effects of adjunct behavioural family therapy (BFT) but failed to report any outcome variables in sufficient detail - we did not include it in the meta-analysis. One trial with 40 couples (80 participants) showed that CBCT was more effective than wait list control in reducing PTSD severity (SMD -1.12, 95% CI -1.79 to -0.45; low-quality evidence), anxiety (SMD -0.93, 95% CI -1.58 to -0.27; very low-quality evidence) and depression (SMD -0.66, 95% CI -1.30 to -0.02; very low-quality evidence) at post-treatment for the primary patient with PTSD. Data from two studies indicated that treatment and control groups did not differ significantly according to relationship satisfaction (SMD 1.07, 95% CI -0.17 to 2.31; very low-quality evidence); and one study showed no significant differences regarding depression (SMD 0.28, 95% CI -0.35 to 0.90; very low-quality evidence) or anxiety symptoms (SMD 0.15, 95% CI -0.47 to 0.77; very low-quality evidence) for the partner of the patient with PTSD. One trial with 57 couples (114 participants) showed that SAT was more effective than PFE in reducing PTSD severity for the primary patient (SMD -1.32, 95% CI -1.90 to -0.74; low-quality evidence) at post-treatment. There was no evidence of differences on the other outcomes, including relationship satisfaction (SMD 0.01, 95% CI -0.51 to 0.53; very low-quality evidence), depression (SMD 0.21, 95% CI -0.31 to 0.73; very low-quality evidence) and anxiety (SMD -0.16, 95% CI -0.68 to 0.36; very low-quality evidence) for intimate partners; and depression (SMD -0.28, 95% CI -0.81 to 0.24; very low-quality evidence) or anxiety (SMD -0.34, 95% CI -0.87 to 0.18; very low-quality evidence) for the primary patient. Two studies reported on adverse events and dropout rates, and no significant differences between groups were observed. Two studies were classified as having a 'low' or 'unclear' risk of bias in most domains, except for performance bias that was rated 'high'. Two studies had significant amounts of missing information resulting in 'unclear' risk of bias. There were too few studies available to conduct subgroup analyses.

AUTHORS' CONCLUSIONS

There are few trials of couple-based therapies for PTSD and evidence is insufficient to determine whether these offer substantive benefits when delivered alone or in addition to psychological interventions. Preliminary RCTs suggest, however, that couple-based therapies for PTSD may be potentially beneficial for reducing PTSD symptoms, and there is a need for additional trials of both adjunctive and stand-alone interventions with couples or families which target reduced PTSD symptoms, mental health problems of family members and dyadic measures of relationship quality.

Effect of Brief Cognitive Behavioral Counseling and Debriefing on the Prevention of Post-traumatic Stress Disorder in Traumatic Birth: A Randomized Clinical Trial

OBJECTIVE

Planning to promote the health of mothers in postpartum is important in all countries. This study aimed to determine the effectiveness of two counseling method on prevention of post-traumatic stress after childbirth.

METHODS

In this clinical trial, 193 of mothers who had experienced a traumatic birth were randomly assigned to three groups. Participants were assessed using IES_R questionnaire at 4-6 weeks and 3 months after delivery.

RESULTS

Debriefing and brief cognitive behavioral counseling (CBC) significantly improved the symptoms of postpartum traumatic stress disorder. After 3 months, CBC had a significant effect on the symptoms.

CONCLUSION

Screening of traumatic childbirth, implementation of supportive care, and early counseling prior to the initiation of post-traumatic stress are recommended.

TRIAL REGISTRATION NUMBER

IRCT2015072522396N2. http://en.search.irct.ir/view/24735 .

Collaborative care model for treatment of persistent symptoms after concussion among youth (CARE4PCS-II): Study protocol for a randomized, controlled trial

Background

Currently, there is limited evidence to guide intervention and service delivery coordination for youth who suffer a concussion and subsequently experience persistent post-concussive symptoms (PCS) (Lumba-Brown et al. JAMA Pediatr 172(11):e182853, 2018; Lumba-Brown A et al. JAMA Pediatr 172(11):e182847, 2018). We have developed a collaborative care intervention with embedded cognitive-behavioral therapy, care management, and stepped-up psychotropic medication consultation to address persistent PCS and related psychological comorbidities. The CARE4PCS-II study was designed to assess whether adolescents with persistent symptoms after sports-related concussion will demonstrate better outcomes when receiving this collaborative care intervention compared to a usual care (control) condition.

Methods/design

This investigation is a randomized comparative effectiveness trial to receive intervention (collaborative care) or control (usual care). Two hundred sports-injured male and female adolescents aged 11–18 years with three or more post-concussive symptoms that persist for at least 1 month but less than 9 months after injury will be recruited and randomized into the study. The trial focuses on the effects of the intervention on post-concussive, depressive, and anxiety symptoms measured 3, 6, and 12 months after baseline.

Discussion

The CARE4PCS II study is a large comparative effectiveness trial targeting symptomatic improvements in sports injured adolescents after concussion. The study is unique in its adaptation of the collaborative care model to a broad spectrum of primary care, sports medicine, and school settings. The investigation incorporates novel elements such as the delivery of CBT through HIPAA complaint video conferenceing technology and has excellent widespread dissemination potential should effectiveness be demonstrated.

Trial registration

ClinicalTrials.gov, NCT03034720. Registered on January 27, 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3662-3) contains supplementary material, which is available to authorized users.

Multiple session early psychological interventions for the prevention of post-traumatic stress disorder

BACKGROUND

The prevention of long-term psychological distress following traumatic events is a major concern. Systematic reviews have suggested that individual psychological debriefing is not an effective intervention at preventing post-traumatic stress disorder (PTSD). Over the past 20 years, other forms of intervention have been developed with the aim of preventing PTSD.

OBJECTIVES

To examine the efficacy of psychological interventions aimed at preventing PTSD in individuals exposed to a traumatic event but not identified as experiencing any specific psychological difficulties, in comparison with control conditions (e.g. usual care, waiting list and no treatment) and other psychological interventions.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO and ProQuest's Published International Literature On Traumatic Stress (PILOTS) database to 3 March 2018. An earlier search of CENTRAL and the Ovid databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to May 2016). We handsearched reference lists of relevant guidelines, systematic reviews and included study reports. Identified studies were shared with key experts in the field.We conducted an update search (15 March 2019) and placed any new trials in the 'awaiting classification' section. These will be incorporated into the next version of this review, as appropriate.

SELECTION CRITERIA

We searched for randomised controlled trials of any multiple session (two or more sessions) early psychological intervention or treatment designed to prevent symptoms of PTSD. We excluded single session individual/group psychological interventions. Comparator interventions included waiting list/usual care and active control condition. We included studies of adults who experienced a traumatic event which met the criterion A1 according to the Diagnostic and Statistical Manual (DSM-IV) for PTSD.

DATA COLLECTION AND ANALYSIS

We entered data into Review Manager 5 software. We analysed categorical outcomes as risk ratios (RRs), and continuous outcomes as mean differences (MD) or standardised mean differences (SMDs), with 95% confidence intervals (CI). We pooled data with a fixed-effect meta-analysis, except where there was heterogeneity, in which case we used a random-effects model. Two review authors independently assessed the included studies for risk of bias and discussed any conflicts with a third review author.

MAIN RESULTS

This is an update of a previous review.We included 27 studies with 3963 participants. The meta-analysis included 21 studies of 2721 participants. Seventeen studies compared multiple session early psychological intervention versus treatment as usual and four studies compared a multiple session early psychological intervention with active control condition.Low-certainty evidence indicated that multiple session early psychological interventions may be more effective than usual care in reducing PTSD diagnosis at three to six months' follow-up (RR 0.62, 95% CI 0.41 to 0.93; I2 = 34%; studies = 5; participants = 758). However, there was no statistically significant difference post-treatment (RR 1.06, 95% CI 0.85 to 1.32; I2 = 0%; studies = 5; participants = 556; very low-certainty evidence) or at seven to 12 months (RR 0.94, 95% CI 0.20 to 4.49; studies = 1; participants = 132; very low-certainty evidence). Meta-analysis indicated that there was no statistical difference in dropouts compared with usual care (RR 1.34, 95% CI 0.91 to 1.95; I2 = 34%; studies = 11; participants = 1154; low-certainty evidence) .At the primary endpoint of three to six months, low-certainty evidence indicated no statistical difference between groups in reducing severity of PTSD (SMD -0.10, 95% CI -0.22 to 0.02; I2 = 34%; studies = 15; participants = 1921), depression (SMD -0.04, 95% CI -0.19 to 0.10; I2 = 6%; studies = 7; participants = 1009) or anxiety symptoms (SMD -0.05, 95% CI -0.19 to 0.10; I2 = 2%; studies = 6; participants = 945).No studies comparing an intervention and active control reported outcomes for PTSD diagnosis. Low-certainty evidence showed that interventions may be associated with a higher dropout rate than active control condition (RR 1.61, 95% CI 1.11 to 2.34; studies = 2; participants = 425). At three to six months, low-certainty evidence indicated no statistical difference between interventions in terms of severity of PTSD symptoms (SMD -0.02, 95% CI -0.31 to 0.26; I2 = 43%; studies = 4; participants = 465), depression (SMD 0.04, 95% CI -0.16 to 0.23; I2 = 0%; studies = 2; participants = 409), anxiety (SMD 0.00, 95% CI -0.19 to 0.19; I2 = 0%; studies = 2; participants = 414) or quality of life (MD -0.03, 95% CI -0.06 to 0.00; studies = 1; participants = 239).None of the included studies reported on adverse events or use of health-related resources.

AUTHORS' CONCLUSIONS

While the review found some beneficial effects of multiple session early psychological interventions in the prevention of PTSD, the certainty of the evidence was low due to the high risk of bias in the included trials. The clear practice implication of this is that, at present, multiple session interventions aimed at everyone exposed to traumatic events cannot be recommended. There are a number of ongoing studies, demonstrating that this is a fast moving field of research. Future updates of this review will integrate the results of these new studies.

Trauma and Public Mental Health: A Focused Review

Psychological trauma has developed into a very common concept in the scientific community, in mental health care, as well as in popular language and mass media. The purpose of this article is to show the relevance of the discipline of traumatic stress studies to the field of public mental health by examining central concepts and findings concerning trauma and its aftermath and examining implications for public mental health. Attention is paid to the diagnosis of posttraumatic stress disorder (PTSD) and the construct of resilience as well as to specific areas of public mental health activities. A public mental health perspective will help to develop preventive approaches to trauma and extend the impact of various forms of interventions. It will also make clear that trauma care will have to consider the community and the society at large.

Intrusive memories of trauma: A target for research bridging cognitive science and its clinical application

Intrusive memories of a traumatic event can be distressing and disruptive, and comprise a core clinical feature of post-traumatic stress disorder (PTSD). Intrusive memories involve mental imagery-based impressions that intrude into mind involuntarily, and are emotional. Here we consider how recent advances in cognitive science have fueled our understanding of the development and possible treatment of intrusive memories of trauma. We conducted a systematic literature search in PubMed, selecting articles published from 2008 to 2018 that used the terms "trauma" AND ("intrusive memories" OR "involuntary memories") in their abstract or title. First, we discuss studies that investigated internal (neural, hormonal, psychophysiological, and cognitive) processes that contribute to intrusive memory development. Second, we discuss studies that targeted these processes using behavioural/pharmacological interventions to reduce intrusive memories. Third, we consider possible clinical implications of this work and highlight some emerging research avenues for treatment and prevention, supplemented by new data to examine some unanswered questions. In conclusion, we raise the possibility that intrusive memories comprise an alternative, possibly more focused, target in translational research endeavours, rather than only targeting overall symptoms of disorders such as PTSD. If so, relatively simple approaches could help to address the need for easy-to-deliver, widely-scalable trauma interventions.

Psychiatric Symptoms and Clinical Diagnosis in High School Students Exposed to the Sewol Ferry Disaster

BACKGROUND

Two hundred and fifty 11th grade students and teachers from Danwon High School drowned, during a school trip, in the Sewol Ferry Disaster. The goal of this study was to investigate the experiences of the psychiatrists who volunteered and provided psychiatric services to the students at Danwon High School.

METHODS

From the second day to the 138th day after the disaster, pro bono psychiatrists provided post-disaster interventions to the 10th and 12th-grade Danwon High School students who did not attend the trip. Officially, 167 psychiatrists conducted outreach in approximately 550 encounters. The study questionnaires were distributed retrospectively to psychiatric volunteers who conducted outreach at Danwon High School. We surveyed the pro bono psychiatrists about their experiences, including the students' chief complaints, psychiatric problems, clinical diagnoses, and psychiatrists' treatment recommendations.

RESULTS

We reached 72 (43.1%) of the 167 volunteers, and they reported on 212 (38.6%) of the 550 encounters. The common chief complaints were mental health problems, companion problems, and family problems. The most frequent psychiatric symptoms were anxiety (76.89%), depressive mood (51.42%), and concentration difficulty (50.94%). The most frequent clinical diagnoses of the students were normal reaction (41.04%), acute stress disorder (24.53%), adjustment disorder (17.92%), anxiety disorders (9.43%), and posttraumatic stress disorder (6.60%). More than half of the students needed "additional counseling/therapy" (41.04%) or "referral to psychiatric treatment" (14.15%).

CONCLUSION

During the acute aftermath of the Sewol Ferry Disaster, volunteer psychiatrists were able to provide services. These services included psychiatric assessments, crisis counseling, psychological first aid, and referrals for ongoing care. More than half of the students were perceived to have a psychiatric diagnosis, and a substantial proportion of students needed further treatment. Future research should focus on the short- and long-term effects of psychiatric interventions and the characterization of post-disaster mental health needs and service provision patterns.

Estimating the risk of PTSD in recent trauma survivors: results of the International Consortium to Predict PTSD (ICPP)

A timely determination of the risk of post-traumatic stress disorder (PTSD) is a prerequisite for efficient service delivery and prevention. We provide a risk estimate tool allowing a calculation of individuals' PTSD likelihood from early predictors. Members of the International Consortium to Predict PTSD (ICPP) shared individual participants' item-level data from ten longitudinal studies of civilian trauma survivors admitted to acute care centers in six countries. Eligible participants (N=2,473) completed an initial clinical assessment within 60 days of trauma exposure, and at least one follow-up assessment 4-15 months later. The Clinician-Administered PTSD Scale for DSM-IV (CAPS) evaluated PTSD symptom severity and diagnostic status at each assessment. Participants' education, prior lifetime trauma exposure, marital status and socio-economic status were assessed and harmonized across studies. The study's main outcome was the likelihood of a follow-up PTSD given early predictors. The prevalence of follow-up PTSD was 11.8% (9.2% for male participants and 16.4% for females). A logistic model using early PTSD symptom severity (initial CAPS total score) as a predictor produced remarkably accurate estimates of follow-up PTSD (predicted vs. raw probabilities: r=0.976). Adding respondents' female gender, lower education, and exposure to prior interpersonal trauma to the model yielded higher PTSD likelihood estimates, with similar model accuracy (predicted vs. raw probabilities: r=0.941). The current model could be adjusted for other traumatic circumstances and accommodate risk factors not captured by the ICPP (e.g., biological, social). In line with their use in general medicine, risk estimate models can inform clinical choices in psychiatry. It is hoped that quantifying individuals' PTSD risk will be a first step towards systematic prevention of the disorder.

Internet-based cognitive and behavioural therapies for post-traumatic stress disorder (PTSD) in adults

BACKGROUND

Therapist-delivered trauma-focused psychological therapies are an effective treatment for post-traumatic stress disorder (PTSD). These have become the accepted first-line treatments for the disorder. Despite the established evidence-base for these therapies, they are not always widely available or accessible. Many barriers limit treatment uptake, such as the limited number of qualified therapists to deliver the interventions, cost, and compliance issues, such as time off work, childcare, and transportation, associated with the need to attend weekly appointments. Delivering cognitive behavioural therapy (CBT) on the Internet is an effective and acceptable alternative to therapist-delivered treatments for anxiety and depression. However, fewer Internet-based therapies have been developed and evaluated for PTSD, and uncertainty surrounds the efficacy of Internet-based cognitive and behavioural therapy (I-C/BT) for PTSD.

OBJECTIVES

To assess the effects of I-C/BT for PTSD in adults.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Group's Specialised Register (CCMDCTR) to June 2016 and identified four studies meeting the inclusion criteria. The CCMDCTR includes relevant randomised controlled trials (RCT) from MEDLINE, Embase, and PsycINFO. We also searched online clinical trial registries and reference lists of included studies, and contacted researchers in the field to identify additional and ongoing studies. We ran an update search on 1 March 2018, and identified four additional completed studies, which we added to the analyses along with two that were previously awaiting classification.

SELECTION CRITERIA

We searched for RCTs of I-C/BT compared to face-to-face or Internet-based psychological treatment, psychoeducation, wait list or care as usual. We included studies of adults (aged over 16 years or over), in which at least 70% of the participants met the diagnostic criteria for PTSD, according to the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD).

DATA COLLECTION AND ANALYSIS

We entered data into Review Manager 5 software. We analysed categorical outcomes as risk ratios (RRs), and continuous outcomes as mean differences (MD) or standardised mean differences (SMDs), with 95% confidence intervals (CI). We pooled data with a fixed-effect meta-analysis, except where heterogeneity was present, in which case we used a random-effects model. Two review authors independently assessed the included studies for risk of bias; any conflicts were discussed with a third author, with the aim of reaching a unanimous decision.

MAIN RESULTS

We included 10 studies with 720 participants in the review. Eight of the studies compared I-C/BT delivered with therapist guidance to a wait list control. Two studies compared guided I-C/BT with I-non-C/BT. There was considerable heterogeneity among the included studies.Very low-quality evidence showed that, compared with wait list, I-C/BT may be associated with a clinically important reduction in PTSD post-treatment (SMD -0.60, 95% CI -0.97 to -0.24; studies = 8, participants = 560). However, there was no evidence of a difference in PTSD symptoms when follow-up was less than six months (SMD -0.43, 95% CI -1.41 to 0.56; studies = 3, participants = 146). There may be little or no difference in dropout rates between the I-C/BT and wait list groups (RR 1.39, 95% CI 1.03 to 1.88; studies = 8, participants = 585; low-quality evidence). I-C/BT was no more effective than wait list at reducing the risk of a diagnosis of PTSD after treatment (RR 0.53, 95% CI 0.28 to 1.00; studies = 1, participants = 62; very low-quality evidence). I-C/BT may be associated with a clinically important reduction in symptoms of depression both post-treatment (SMD -0.61, 95% CI -1.17 to -0.05; studies = 5, participants = 425; very low-quality evidence). Very low-quality evidence also suggested that I-C/BT may be associated with a clinically important reduction in symptoms of anxiety post-treatment (SMD -0.67, 95% CI -0.98 to -0.36; studies = 4, participants = 305), and at follow-up less than six months (MD -12.59, 95% CI -20.74 to -4.44; studies = 1, participants = 42; very low-quality evidence). The effects of I-C/BT on quality of life were uncertain (SMD 0.60, 95% CI 0.08 to 1.12; studies = 2, participants = 221; very low-quality evidence).Two studies found no difference in PTSD symptoms between the I-C/BT and I-non-C/BT groups when measured post-treatment (SMD -0.08, 95% CI -0.52 to 0.35; studies = 2, participants = 82; very low-quality evidence), or when follow-up was less than six months (SMD 0.08, 95% CI -0.41 to 0.57; studies = 2, participants = 65; very low-quality evidence). However, those who received I-C/BT reported their PTSD symptoms were better at six- to 12-month follow-up (MD -8.83, 95% CI -17.32 to -0.34; studies = 1, participants = 18; very low-quality evidence). Two studies found no difference in depressive symptoms between the I-C/BT and I-non-C/BT groups when measured post-treatment (SMD -0.12, 95% CI -0.78 to 0.54; studies = 2, participants = 84; very low-quality evidence) or when follow-up was less than six months (SMD 0.20, 95% CI -0.31 to 0.71; studies = 2, participants = 61; very low-quality evidence). However, those who received I-C/BT reported their depressive symptoms were better at six- to 12-month follow-up (MD -8.34, 95% CI -15.83 to -0.85; studies = 1, participants = 18; very low-quality evidence). Two studies found no difference in symptoms of anxiety between the I-C/BT and I-non-C/BT groups when measured post-treatment (SMD 0.08, 95% CI -0.78 to 0.95; studies = 2, participants = 74; very low-quality evidence) or when follow-up was less than six months (SMD -0.16, 95% CI -0.67 to 0.35; studies = 2, participants = 60; very low-quality evidence). However, those who received I-C/BT reported their symptoms of anxiety were better at six- to 12-month follow-up (MD -8.05, 95% CI -15.20 to -0.90; studies = 1, participants = 18; very low-quality evidence).None of the included studies reported on cost-effectiveness or adverse events.

AUTHORS' CONCLUSIONS

While the review found some beneficial effects of I-C/BT for PTSD, the quality of the evidence was very low due to the small number of included trials. Further work is required to: establish non-inferiority to current first-line interventions, explore mechanisms of change, establish optimal levels of guidance, explore cost-effectiveness, measure adverse events, and determine predictors of efficacy and dropout.

Mechanisms of change for interventions aimed at improving the wellbeing, mental health and resilience of children and adolescents affected by war and armed conflict: a systematic review of reviews

Despite increasing research and clinical interest in delivering psychosocial interventions for children affected by war, little research has been conducted on the underlying mechanisms of change associated with these interventions. This review aimed to identify these processes in order to inform existing interventions and highlight research gaps. A systematic review of reviews was conducted drawing from academic databases (PubMed, PILOTS, Cochrane Library for Systematic Reviews) and field resources (e.g. Médecins Sans Frontières and the Psychosocial Centre of the International Federation of Red Cross and Red Crescent Societies), with extracted data analysed using Thematic Content Analysis. Thirteen reviews of psychosocial or psychological interventions for children and adolescents (< 25 years old) affected by war, armed conflict or political violence were identified, covering over 30 countries worldwide. Qualitative analysis identified 16 mechanisms of change, one of which was an adverse mechanism. Themes included protection from harm, play, community and family capacity building, strengthening relationships with caregivers, improved emotional regulation, therapeutic rapport, trauma processing, and cognitive restructuring; with the adverse mechanism relating to the pathologising of normal reactions. However, only 4 mechanisms were supported by strong empirical evidence, with only moderate or poor quality evidence supporting the other mechanisms. The poor quality of supporting evidence limits what can be inferred from this review's findings, but serves to highlight clinically informed mechanisms of change for existing and widely used non-specialist interventions in the field, which urgently need rigorous scientific testing to inform their continued practice.

Multiple memory systems, multiple time points: how science can inform treatment to control the expression of unwanted emotional memories

Memories that have strong emotions associated with them are particularly resilient to forgetting. This is not necessarily problematic, however some aspects of memory can be. In particular, the involuntary expression of those memories, e.g. intrusive memories after trauma, are core to certain psychological disorders. Since the beginning of this century, research using animal models shows that it is possible to change the underlying memory, for example by interfering with its consolidation or reconsolidation. While the idea of targeting maladaptive memories is promising for the treatment of stress and anxiety disorders, a direct application of the procedures used in non-human animals to humans in clinical settings is not straightforward. In translational research, more attention needs to be paid to specifying what aspect of memory (i) can be modified and (ii) should be modified. This requires a clear conceptualization of what aspect of memory is being targeted, and how different memory expressions may map onto clinical symptoms. Furthermore, memory processes are dynamic, so procedural details concerning timing are crucial when implementing a treatment and when assessing its effectiveness. To target emotional memory in its full complexity, including its malleability, science cannot rely on a single method, species or paradigm. Rather, a constructive dialogue is needed between multiple levels of research, all the way 'from mice to mental health'.This article is part of a discussion meeting issue 'Of mice and mental health: facilitating dialogue between basic and clinical neuroscientists'.

Preventing intrusive memories after trauma via a brief intervention involving Tetris computer game play in the emergency department: a proof-of-concept randomized controlled trial

After psychological trauma, recurrent intrusive visual memories may be distressing and disruptive. Preventive interventions post trauma are lacking. Here we test a behavioural intervention after real-life trauma derived from cognitive neuroscience. We hypothesized that intrusive memories would be significantly reduced in number by an intervention involving a computer game with high visuospatial demands (Tetris), via disrupting consolidation of sensory elements of trauma memory. The Tetris-based intervention (trauma memory reminder cue plus c. 20 min game play) vs attention-placebo control (written activity log for same duration) were both delivered in an emergency department within 6 h of a motor vehicle accident. The randomized controlled trial compared the impact on the number of intrusive trauma memories in the subsequent week (primary outcome). Results vindicated the efficacy of the Tetris-based intervention compared with the control condition: there were fewer intrusive memories overall, and time-series analyses showed that intrusion incidence declined more quickly. There were convergent findings on a measure of clinical post-trauma intrusion symptoms at 1 week, but not on other symptom clusters or at 1 month. Results of this proof-of-concept study suggest that a larger trial, powered to detect differences at 1 month, is warranted. Participants found the intervention easy, helpful and minimally distressing. By translating emerging neuroscientific insights and experimental research into the real world, we offer a promising new low-intensity psychiatric intervention that could prevent debilitating intrusive memories following trauma.

Assessing Psychological Resilience: Development and Psychometric Properties of the English and Dutch Version of the Resilience Evaluation Scale (RES)

Background: Psychological resilience is a distinct factor that affects mental health outcomes after adversities. This study describes the development, validity and measurement invariance (MI) of a Dutch and English scale on psychological resilience, called the Resilience Evaluation Scale (RES). Methods: Separate online surveys with the Dutch and English version of the RES and hypothesized related measures were distributed in a Dutch- and English-speaking group, both drawn from the general population. Results: Exploratory factor analysis, using data from 522 respondents (n = 296 Dutch, n = 226 English), yielded a two-factor structure for the final 9-item RES. The factors reflected the hypothesized underlying constructs of psychological resilience: self-confidence and self-efficacy. The items and constructs of psychological resilience as measured by the RES were interpreted and conceptualized in the same way by both language groups, with the exception of one item. The RES showed good convergent validity and good internal consistency. Conclusions: The current study establishes sound psychometric properties of a new, brief, and freely available scale on psychological resilience. This study contributes to the identification and measurement of psychological resilience after adversities. The final 9-item RES may serve as a valuable instrument in research and in clinical practice.

Impact of child death on paediatric trainees

OBJECTIVE

To assess the prevalence of symptoms of acute stress reactions (ASR) and post-traumatic stress disorder (PTSD) in paediatric trainees following their involvement in child death.

DESIGN

A survey designed to identify trainees' previous experiences of child death combined with questions to identify features of PTSD. Quantitative interpretation was used alongside a χ² test. A p value of <0.05 was considered significant.

SETTING

604 surveys were distributed across 13 UK health education deaneries.

PARTICIPANTS

303/604 (50%) of trainees completed the surveys.

RESULTS

251/280 (90%) of trainees had been involved with the death of a child, although 190/284 (67%) had no training in child death. 118/248 (48%) of trainees were given a formal debrief session following their most recent experience. 203/251 (81%) of trainees reported one or more symptoms or behaviours that could contribute to a diagnosis of ASR/PTSD. 23/251 (9%) of trainees met the complete criteria for ASR and 13/251 (5%) for PTSD. Attending a formal debrief and reporting feelings of guilt were associated with an increase in diagnostic criteria for ASR/PTSD (p=0.036 and p<0.001, respectively).

CONCLUSIONS

Paediatric trainees are at risk of developing ASR and PTSD following the death of a child. The feeling of guilt should be identified and acknowledged to allow prompt signposting to further support, including psychological assessment or intervention if required. Clear recommendations need to be made about the safety of debriefing sessions as, in keeping with existing evidence, our data suggest that debrief after the death of a child may be associated with the development of symptoms suggestive of ASR/PTSD.

Screening for trauma-related symptoms via a smartphone app: The validity of Smart Assessment on your Mobile in referred police officers

To facilitate easily accessible screening for trauma-related symptoms, a web-based application called Smart Assessment on your Mobile (SAM) was developed. In this study, we examined whether SAM was able to accurately identify posttraumatic stress disorder (PTSD) and depression in adults. Eighty-nine referred police officers completed SAM, containing the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 (PCL-5) and the Depression Anxiety and Stress Scale (DASS-21), on their own device prior to a diagnostic interview where the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and Structured Clinical Interview for DSM-IV (SCID-I/P) were administered. Results showed a substantial agreement between SAM and the diagnostic interview in the assessment of PTSD and depression. An optimal trade-off between sensitivity (89%) and specificity (68%) levels was found at a cut-off score of 31 on the PTSD Checklist for DSM-5 (area under the curve = 0.845, 95% CI [0.765, 0.925], diagnostic odds ratio = 15.97). This is one of the first studies to support the validity and reliability of a mobile screener following trauma. SAM may facilitate screening for trauma-related symptoms on a large scale and could be a first step in a stepped-care model for trauma survivors to help identify individuals who need further diagnostics and care.

Reducing intrusive traumatic memories after emergency caesarean section: A proof-of-principle randomized controlled study

Preventative psychological interventions to aid women after traumatic childbirth are needed. This proof-of-principle randomized controlled study evaluated whether the number of intrusive traumatic memories mothers experience after emergency caesarean section (ECS) could be reduced by a brief cognitive intervention. 56 women after ECS were randomized to one of two parallel groups in a 1:1 ratio: intervention (usual care plus cognitive task procedure) or control (usual care). The intervention group engaged in a visuospatial task (computer-game 'Tetris' via a handheld gaming device) for 15 min within six hours following their ECS. The primary outcome was the number of intrusive traumatic memories related to the ECS recorded in a diary for the week post-ECS. As predicted, compared with controls, the intervention group reported fewer intrusive traumatic memories (M = 4.77, SD = 10.71 vs. M = 9.22, SD = 10.69, d = 0.647 [95% CI: 0.106, 1.182]) over 1 week (intention-to-treat analyses, primary outcome). There was a trend towards reduced acute stress re-experiencing symptoms (d = 0.503 [95% CI: -0.032, 1.033]) after 1 week (intention-to-treat analyses). Times series analysis on daily intrusions data confirmed the predicted difference between groups. 72% of women rated the intervention "rather" to "extremely" acceptable. This represents a first step in the development of an early (and potentially universal) intervention to prevent postnatal posttraumatic stress symptoms that may benefit both mother and child.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT02502513.

Refinement and Preliminary Testing of an Imagery-Based Program to Improve Coping and Performance and Prevent Trauma among Urban Police Officers

Police officers are regularly exposed to traumatic critical incidents. The substantial mental, behavioral, and social costs of police trauma indicate a substantial need for prevention. We have refined and enhanced a previously tested Swedish program to the harsh conditions of U.S. inner cities. The program was designed to strengthen resilience during stressful encounters and teach methods of coping after exposure, thereby preventing the emergence of maladaptive symptoms and behaviors with adverse effects on professionalism. In an uncontrolled demonstration project, junior officers were trained by senior officers to engage in imaginal rehearsal of specific dangerous situations while incorporating optimal police tactics and healthy emotional reactions. A class of 32 officers in the police academy engaged in the program, and they and the trainers reported high satisfaction with it. After their first year of field work, 22 officers were reassessed. Compared to pre-training, these officers showed significant increases in the use of positive reframing and humor and significant reductions in anxiety and alcohol use over the year. Trauma symptoms did not increase. These results offer preliminary evidence for the feasibility and effectiveness of this trauma prevention program for new police officers.

Psychotherapy and Cognitive Behavioral Therapy Supervision in Danish Psychiatry: Training the Next Generation of Psychiatrists

OBJECTIVE

Psychotherapy training is mandatory for physicians to qualify as psychiatrists in Denmark. Evidence for the effectiveness of psychotherapy has increased, and psychotherapy is increasingly included in international treatment guidelines. The authors investigated how psychiatrists in training in Denmark evaluate the opportunities to practice psychotherapy in their training and the quality of the supervision they receive in psychotherapy training, particularly for cognitive behavioral therapy (CBT).

METHOD

The authors conducted a survey regarding psychotherapy training and CBT supervision among psychiatrists in training at Danish psychiatric specialist training courses. They investigated respondents' interest and experience in psychotherapy and respondents' views on the relevance and feasibility of performing psychotherapy and receiving supervision in their psychiatry training.

RESULTS

Eighty-eight percent of the psychiatrists in training found psychotherapy to be a relevant part of their training; however, 77 % found it difficult to find time to practice psychotherapy and 44 % felt that practicing psychotherapy was a strain on their employer. Thirty-six percent and 53 %, respectively, had difficulties securing psychodynamic and CBT supervision. In CBT supervision, more than 60 % reported supervision that appeared to be below the expected CBT supervision standard and often so much below it might not qualify as CBT supervision.

CONCLUSIONS

There is a need to focus on how to better integrate psychotherapy and supervision in the Danish psychiatric training program. Good CBT supervision may be lacking, and a way to ensure high-quality supervision is required.

Support for mothers and their families after life-threatening illness in pregnancy and childbirth: a qualitative study in primary care

BACKGROUND

One in 100 women who give birth in the UK develop life-threatening illnesses during childbirth. Without urgent medical attention these illnesses could lead to the mother's death. Little is known about how the experience of severe illness in childbirth affects the mother, baby, and family.

AIM

As part of the UK National Maternal Near-miss Surveillance Programme, this study explored the experiences of women and their partners of life-threatening illnesses in childbirth, to identify the long-term impact on women and their families.

DESIGN AND SETTING

Qualitative study based on semi-structured narrative interviews. Interviews were conducted in patients' homes in England and Scotland from 2010 to 2014.

METHOD

An in-depth interview study was conducted with 36 women and 11 partners. A maximum variation sample was sought and interviews transcribed for thematic analysis with constant comparison.

RESULTS

Women's birth-related illnesses often had long-lasting effects on their mental as well as physical health, including anxiety, panic attacks, and post-traumatic stress disorder. In some cases the partner's mental health was also affected. Women often described feeling isolated. Their experiences can have a profound impact on their relationships, family life, career, and future fertility. While some women described receiving good support from their GP, others felt there was little support available for them or their families after discharge from hospital.

CONCLUSION

A near-miss event can have long-lasting and major effects on women and their families. Support in primary care, including watchful waiting for mental health impacts, can play a valuable role in helping these families come to terms with their emergency experience. The findings highlight the importance of communication between primary and secondary care.

Psychological therapies for post-traumatic stress disorder and comorbid substance use disorder

BACKGROUND

Post-traumatic stress disorder (PTSD) is a debilitating mental health disorder that may develop after exposure to traumatic events. Substance use disorder (SUD) is a behavioural disorder in which the use of one or more substances is associated with heightened levels of distress, clinically significant impairment of functioning, or both. PTSD and SUD frequently occur together. The comorbidity is widely recognised as being difficult to treat and is associated with poorer treatment completion and poorer outcomes than for either condition alone. Several psychological therapies have been developed to treat the comorbidity, however there is no consensus about which therapies are most effective.

OBJECTIVES

To determine the efficacy of psychological therapies aimed at treating traumatic stress symptoms, substance misuse symptoms, or both in people with comorbid PTSD and SUD in comparison with control conditions (usual care, waiting-list conditions, and no treatment) and other psychological therapies.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR) all years to 11 March 2015. This register contains relevant randomised controlled trials from the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We also searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov, contacted experts, searched bibliographies of included studies, and performed citation searches of identified articles.

SELECTION CRITERIA

Randomised controlled trials of individual or group psychological therapies delivered to individuals with PTSD and comorbid substance use, compared with waiting-list conditions, usual care, or minimal intervention or to other psychological therapies.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 14 studies with 1506 participants, of which 13 studies were included in the quantitative synthesis. Most studies involved adult populations. Studies were conducted in a variety of settings. We performed four comparisons investigating the effects of psychological therapies with a trauma-focused component and non-trauma-focused interventions against treatment as usual/minimal intervention and other active psychological therapies. Comparisons were stratified for individual- or group-based therapies. All active interventions were based on cognitive behavioural therapy. Our main findings were as follows.Individual-based psychological therapies with a trauma-focused component plus adjunctive SUD intervention was more effective than treatment as usual (TAU)/minimal intervention for PTSD severity post-treatment (standardised mean difference (SMD) -0.41; 95% confidence interval (CI) -0.72 to -0.10; 4 studies; n = 405; very low-quality evidence) and at 3 to 4 and 5 to 7 months' follow-up. There was no evidence of an effect for level of drug/alcohol use post-treatment (SMD -0.13; 95% CI -0.41 to 0.15; 3 studies; n = 388; very low-quality evidence), but there was a small effect in favour of individual psychological therapy at 5 to 7 months (SMD -0.28; 95% CI -0.48 to -0.07; 3 studies; n = 388) when compared against TAU. Fewer participants completed trauma-focused therapy than TAU (risk ratio (RR) 0.78; 95% CI 0.64 to 0.96; 3 studies; n = 316; low-quality evidence).Individual-based psychological therapy with a trauma-focused component did not perform better than psychological therapy for SUD only for PTSD severity (mean difference (MD) -3.91; 95% CI -19.16 to 11.34; 1 study; n = 46; low-quality evidence) or drug/alcohol use (MD -1.27; 95% CI -5.76 to 3.22; 1 study; n = 46; low-quality evidence). Findings were based on one small study. No effects were observed for rates of therapy completion (RR 1.00; 95% CI 0.74 to 1.36; 1 study; n = 62; low-quality evidence).Non-trauma-focused psychological therapies did not perform better than TAU/minimal intervention for PTSD severity when delivered on an individual (SMD -0.22; 95% CI -0.83 to 0.39; 1 study; n = 44; low-quality evidence) or group basis (SMD -0.02; 95% CI -0.19 to 0.16; 4 studies; n = 513; low-quality evidence). There were no data on the effects on drug/alcohol use for individual therapy. There was no evidence of an effect on the level of drug/alcohol use for group-based therapy (SMD -0.03; 95% CI -0.37 to 0.31; 4 studies; n = 414; very low-quality evidence). A post-hoc analysis for full dose of a widely established group therapy called Seeking Safety showed reduced drug/alcohol use post-treatment (SMD -0.67; 95% CI -1.14 to -0.19; 2 studies; n = 111), but not at subsequent follow-ups. Data on the number of participants completing therapy were not for individual-based therapy. No effects were observed for rates of therapy completion for group-based therapy (RR 1.13; 95% CI 0.88 to 1.45; 2 studies; n = 217; low-quality evidence).Non-trauma-focused psychological therapy did not perform better than psychological therapy for SUD only for PTSD severity (SMD -0.26; 95% CI -1.29 to 0.77; 2 studies; n = 128; very low-quality evidence) or drug/alcohol use (SMD 0.22; 95% CI -0.13 to 0.57; 2 studies; n = 128; low-quality evidence). No effects were observed for rates of therapy completion (RR 0.91; 95% CI 0.68 to 1.20; 2 studies; n = 128; very low-quality evidence).Several studies reported on adverse events. There were no differences between rates of such events in any comparison. We rated several studies as being at 'high' or 'unclear' risk of bias in multiple domains, including for detection bias and attrition bias.

AUTHORS' CONCLUSIONS

We assessed the evidence in this review as mostly low to very low quality. Evidence showed that individual trauma-focused psychological therapy delivered alongside SUD therapy did better than TAU/minimal intervention in reducing PTSD severity post-treatment and at long-term follow-up, but only reduced SUD at long-term follow-up. All effects were small, and follow-up periods were generally quite short. There was evidence that fewer participants receiving trauma-focused therapy completed treatment. There was very little evidence to support use of non-trauma-focused individual- or group-based integrated therapies. Individuals with more severe and complex presentations (e.g. serious mental illness, individuals with cognitive impairment, and suicidal individuals) were excluded from most studies in this review, and so the findings from this review are not generalisable to such individuals. Some studies suffered from significant methodological problems and some were underpowered, limiting the conclusions that can be drawn. Further research is needed in this area.

Intrusive memories to traumatic footage: the neural basis of their encoding and involuntary recall

BACKGROUND

A hallmark symptom after psychological trauma is the presence of intrusive memories. It is unclear why only some moments of trauma become intrusive, and how these memories involuntarily return to mind. Understanding the neural mechanisms involved in the encoding and involuntary recall of intrusive memories may elucidate these questions.

METHOD

Participants (n = 35) underwent functional magnetic resonance imaging (fMRI) while being exposed to traumatic film footage. After film viewing, participants indicated within the scanner, while undergoing fMRI, if they experienced an intrusive memory of the film. Further intrusive memories in daily life were recorded for 7 days. After 7 days, participants completed a recognition memory test. Intrusive memory encoding was captured by comparing activity at the time of viewing 'Intrusive scenes' (scenes recalled involuntarily), 'Control scenes' (scenes never recalled involuntarily) and 'Potential scenes' (scenes recalled involuntarily by others but not that individual). Signal change associated with intrusive memory involuntary recall was modelled using finite impulse response basis functions.

RESULTS

We found a widespread pattern of increased activation for Intrusive v. both Potential and Control scenes at encoding. The left inferior frontal gyrus and middle temporal gyrus showed increased activity in Intrusive scenes compared with Potential scenes, but not in Intrusive scenes compared with Control scenes. This pattern of activation persisted when taking recognition memory performance into account. Intrusive memory involuntary recall was characterized by activity in frontal regions, notably the left inferior frontal gyrus.

CONCLUSIONS

The left inferior frontal gyrus may be implicated in both the encoding and involuntary recall of intrusive memories.

Prevention of Post-Traumatic Stress Disorder After Trauma: Current Evidence and Future Directions

Post-traumatic stress disorder (PTSD) is a frequent, tenacious, and disabling consequence of traumatic events. The disorder's identifiable onset and early symptoms provide opportunities for early detection and prevention. Empirical findings and theoretical models have outlined specific risk factors and pathogenic processes leading to PTSD. Controlled studies have shown that theory-driven preventive interventions, such as cognitive behavioral therapy (CBT), or stress hormone-targeted pharmacological interventions, are efficacious in selected samples of survivors. However, the effectiveness of early clinical interventions remains unknown, and results obtained in aggregates (large groups) overlook individual heterogeneity in PTSD pathogenesis. We review current evidence of PTSD prevention and outline the need to improve the disorder's early detection and intervention in individual-specific paths to chronic PTSD.

Evidence-Based Practice: Separating Science From Pseudoscience

Evidence-based practice (EBP) requires that clinicians be guided by the best available evidence. In this article, we address the impact of science and pseudoscience on psychotherapy in psychiatric practice. We describe the key principles of evidence-based intervention. We describe pseudoscience and provide illustrative examples of popular intervention practices that have not been abandoned, despite evidence that they are not efficacious and may be harmful. We distinguish efficacy from effectiveness, and describe modular approaches to treatment. Reasons for the persistence of practices that are not evidence based are examined at both the individual and the professional system level. Finally, we offer suggestions for the promotion of EBP through clinical practice guidelines, modelling of scientific decision making, and training in core skills.

Disaster Management: Mental Health Perspective

Disaster mental health is based on the principles of 'preventive medicine' This principle has necessitated a paradigm shift from relief centered post-disaster management to a holistic, multi-dimensional integrated community approach of health promotion, disaster prevention, preparedness and mitigation. This has ignited the paradigm shift from curative to preventive aspects of disaster management. This can be understood on the basis of six 'R's such as Readiness (Preparedness), Response (Immediate action), Relief (Sustained rescue work), Rehabilitation (Long term remedial measures using community resources), Recovery (Returning to normalcy) and Resilience (Fostering). Prevalence of mental health problems in disaster affected population is found to be higher by two to three times than that of the general population. Along with the diagnosable mental disorders, affected community also harbours large number of sub-syndromal symptoms. Majority of the acute phase reactions and disorders are self-limiting, whereas long-term phase disorders require assistance from mental health professionals. Role of psychotropic medication is very limited in preventing mental health morbidity. The role of cognitive behaviour therapy (CBT) in mitigating the mental health morbidity appears to be promising. Role of Psychological First Aid (PFA) and debriefing is not well-established. Disaster management is a continuous and integrated cyclical process of planning, organising, coordinating and implementing measures to prevent and to manage disaster effectively. Thus, now it is time to integrate public health principles into disaster mental health.

Debriefing interventions for the prevention of psychological trauma in women following childbirth

BACKGROUND

Childbirth is a complex life event that can be associated with both positive and negative psychological responses. When giving birth is experienced as particularly traumatic this can have a negative impact on a woman's postnatal emotional well-being. There has been an increasing focus on women's psychological trauma symptoms following childbirth, including the relatively rare phenomenon of post-traumatic stress disorder (PTSD), and the benefit of debriefing interventions to prevent this. In this review we examined the evidence for debriefing as a preventative intervention for psychological trauma following childbirth.

OBJECTIVES

To assess the effects of debriefing interventions compared with standard postnatal care for the prevention of psychological trauma in women following childbirth.

SEARCH METHODS

The trials registers of the Cochrane Depression, Anxiety and Neurosis Group (CCDANCTR-References and CCDANCTR-Studies) and the Cochrane Pregnancy and Childbirth Group were searched up to 4 March 2015. These registers include relevant randomised controlled trials from the following bibliographic databases: the Cochrane Library (all years to date), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). Additional searches were conducted in CENTRAL, MEDLINE, EMBASE, PsycINFO, and Maternity and Infant Care. The reference lists of all included studies were checked for additional published reports and citations of unpublished research. Experts in the field were contacted.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-randomised trials comparing postnatal debriefing interventions with standard postnatal care for the prevention of psychological trauma of women following childbirth. The intervention consisted of at least one debriefing intervention session, which had the purpose of allowing women to describe their experience and to normalise their emotional reaction to that experience.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trial quality and extracted data. Meta-analysis was conducted where there were more than two trials examining the same outcomes.

MAIN RESULTS

We included seven trials (eight articles) from three countries (UK, Australia and Sweden) that fulfilled the inclusion criteria. The number of women contributing data to each outcome varied from 102 to 1745. Methodological quality was variable and most of the studies were of low quality. The quality of evidence for the prevalence of psychological trauma (primary outcome) and the prevalence of depression symptoms was rated low or very low, based on few studies (ranging from a single study to three studies) with high risk of bias in main domains such as performance bias, random sequence generation, allocation concealment and incomplete outcome data. The quality of evidence for the remaining outcomes (that is prevalence of anxiety, prevalence of fear of childbirth, prevalence of general psychological morbidity, health service utilization and attrition from treatment) was not assessed as data were not available.Among women who had a high level of obstetric intervention during labour and birth, we found no difference between standard postnatal care with debriefing and standard postnatal care without debriefing on psychological trauma symptoms within three months postpartum (RR 0.61; 95% CI 0.28 to 1.31; n = 425) or at three to six months postpartum (RR 0.62; 95% CI 0.27 to 1.42; n = 246). The results were based on two trials, respectively. Among women who experienced a distressing or traumatic birth, there was no evidence of an effect of psychological debriefing on the prevention of PTSD (measured by the MINI-PTSD) at four to six weeks postpartum (RR 1.15; 95% CI 0.66 to 2.01; n = 102) or at six months (RR 0.35; 95% CI 0.10 to 1.23; n = 103). The results were based on one small trial. One trial involving low-risk women who delivered healthy infants at or near term reported no significant difference between the intervention group and the control group in the proportion of women who met the diagnostic criteria for psychological trauma during the year following childbirth (RR 1.06; 95% CI 0.88 to 1.28; n = 1745). We did not find any information about attrition rates.

AUTHORS' CONCLUSIONS

We did not find any high quality evidence to inform practice, with substantial heterogeneity being found between the studies conducted to date. There is little or no evidence to support either a positive or adverse effect of psychological debriefing for the prevention of psychological trauma in women following childbirth. There is no evidence to support routine debriefing for women who perceive giving birth as psychologically traumatic.Future research should provide greater detail of the outcome measures used, and with scales for measuring psychological trauma validated against clinical diagnostic interviews. High rates of obstetric intervention in some birth settings may mean that women require improved emotional care from health professionals to reduce the risk of childbirth being experienced as traumatic. As all included trials excluded women unable to communicate in the native language of the study setting, there is no information on the response of these women to psychological debriefing. No included studies were conducted in low or middle-income countries.

Post-traumatic stress disorder--a diagnostic and therapeutic challenge

BACKGROUND

In Germany, the one-month prevalence of post-traumatic stress disorder (PTSD) is in the range of 1% to 3%. Soldiers, persons injured in accidents, and victims of domestic violence increasingly seek medical help for symptoms of emotional stress. Days lost from work and monetary compensation for emotional disturbances are markedly on the rise. The term "PTSD" is commonly used uncritically and imprecisely, with too little regard for the existing diagnostic criteria. It is at risk of turning into a nonspecific collective term for emotional stress of any kind.

METHODS

We selectively reviewed the literature in the PubMed database and pertinent journals, with additional consideration of the recommendations and guidelines of medical societies from Germany and abroad.

RESULTS

The characteristic types of reactions seen in PTSD are nightmares and an intense, repetitive, intrusive "reliving" of the traumatic event(s). Emotional traumatization manifests itself not only as PTSD but also through major effects on other mental and somatic diseases. An early, trauma-focused behavioral therapeutic intervention involving several sessions, generally on an outpatient basis, can prevent the development of PTSD. The most important components of effective treatment are a focus on the particular trauma experienced and confrontation with the patient's memories of the trauma. The best existing evidence is for cognitive therapy, behavioral therapy according to the exposure paradigm of Foa, and eye movement desensitization and reprocessing therapy. The most recent meta-analysis reveals effect strengths of g = 1.14 for all types of psychotherapy and g = 0.42 for all types of pharmacotherapy taken together (with considerable differences among psychotherapeutic methods and among drugs). The efficacy of psychodynamic therapy, systemic therapy, body-oriented therapy, and hypnotherapy has not been adequately documented in randomized controlled trials.

CONCLUSION

PTSD can be precisely diagnosed and effectively treated when the diagnostic criteria and guideline recommendations are taken into account. Referral for trauma-focused psychotherapy should be considered if the acute symptoms persist for several weeks.

First steps in using machine learning on fMRI data to predict intrusive memories of traumatic film footage

After psychological trauma, why do some only some parts of the traumatic event return as intrusive memories while others do not? Intrusive memories are key to cognitive behavioural treatment for post-traumatic stress disorder, and an aetiological understanding is warranted. We present here analyses using multivariate pattern analysis (MVPA) and a machine learning classifier to investigate whether peri-traumatic brain activation was able to predict later intrusive memories (i.e. before they had happened). To provide a methodological basis for understanding the context of the current results, we first show how functional magnetic resonance imaging (fMRI) during an experimental analogue of trauma (a trauma film) via a prospective event-related design was able to capture an individual's later intrusive memories. Results showed widespread increases in brain activation at encoding when viewing a scene in the scanner that would later return as an intrusive memory in the real world. These fMRI results were replicated in a second study. While traditional mass univariate regression analysis highlighted an association between brain processing and symptomatology, this is not the same as prediction. Using MVPA and a machine learning classifier, it was possible to predict later intrusive memories across participants with 68% accuracy, and within a participant with 97% accuracy; i.e. the classifier could identify out of multiple scenes those that would later return as an intrusive memory. We also report here brain networks key in intrusive memory prediction. MVPA opens the possibility of decoding brain activity to reconstruct idiosyncratic cognitive events with relevance to understanding and predicting mental health symptoms.

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Why only some moments within a trauma intrude while others do not is unclear.

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Neuroimaging may provide further clues as to why this is the case.

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Multivariate pattern analysis, a recent neuroimaging analysis tool, was able to predict intrusive memories.

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Those brain networks involved in intrusive memory prediction are presented.

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Multivariate pattern analysis may inform future innovation in mental health.

Pharmacological interventions for preventing post-traumatic stress disorder (PTSD)

BACKGROUND

Post-traumatic stress disorder (PTSD) is a debilitating disorder which, after a sufficient delay, may be diagnosed amongst individuals who respond with intense fear, helplessness or horror to traumatic events. There is some evidence that the use of pharmacological interventions immediately after exposure to trauma may reduce the risk of developing of PTSD.

OBJECTIVES

To assess the effects of pharmacological interventions for the prevention of PTSD in adults following exposure to a traumatic event.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Controlled Trials Register (CCDANCTR-Studies and CCDANCTR-References) (to 14 February 2014). This register contains relevant reports of randomised controlled trials from the following bibliographic databases: CENTRAL (all years); EMBASE (1974 to date); MEDLINE (1950 to date) and PsycINFO (1967 to date). We identified unpublished trials by searching the National Institute of Health (NIH) Reporter, the metaRegister of Controlled Trials database (mRCT) and the WHO International Clinical Trials Registry Platform (to December 2013). We scanned the reference lists of articles for additional studies. We placed no constraints on language and setting.

SELECTION CRITERIA

We restricted studies to randomised controlled trials (RCTs) of pharmacological interventions compared with placebo for the prevention of PTSD in adults.

DATA COLLECTION AND ANALYSIS

Two authors (TA and JI) independently assessed trials for eligibility and inclusion based on the review selection criteria. We independently extracted sample, methodological, outcome and 'Risk of bias' data, as well as the number of side effects, from each trial and entered these into a customised data extraction form. We contacted investigators for missing information. We calculated summary statistics for continuous and dichotomous variables (if provided). We did not undertake subgroup analyses due to the small number of included studies.

MAIN RESULTS

We included nine short-term RCTs (duration 12 weeks or less) in the analysis (345 participants; age range 18 to 76 years). Participants were exposed to a variety of traumas, ranging from assault, traffic accidents and work accidents to cardiac surgery and septic shock. Seven studies were conducted at single centres. The seven RCTs included four hydrocortisone studies, three propranolol studies (of which one study had a third arm investigating gabapentin), and single trials of escitalopram and temazepam. Outcome assessment measures included the Clinician-Administered PTSD Scale (CAPS), the 36-Item Short-Form Health Survey (SF-36) and the Center for Epidemiological Studies - Depression Scale (CES-D).In four trials with 165 participants there was moderate quality evidence for the efficacy of hydrocortisone in preventing the onset of PTSD (risk ratio (RR) 0.17; 95% confidence interval (CI) 0.05 to 0.56; P value = 0.004), indicating that between seven and 13 patients would need to be treated with this agent in order to prevent the onset of PTSD in one patient. There was low quality evidence for preventing the onset of PTSD in three trials with 118 participants treated with propranolol (RR 0.62; 95% CI 0.24 to 1.59; P value = 0.32). Drop-outs due to treatment-emergent side effects, where reported, were low for all of the agents tested. Three of the four RCTs of hydrocortisone reported that medication was more effective than placebo in reducing PTSD symptoms after a median of 4.5 months after the event. None of the single trials of escitalopram, temazepam and gabapentin demonstrated evidence that medication was superior to placebo in preventing the onset of PTSD.Seven of the included RCTs were at a high risk of bias. Differential drop-outs between groups undermined the results of three studies, while one study failed to describe how the allocation of medication was concealed. Other forms of bias that might have influenced study results included possible confounding through group differences in concurrent medication and termination of the study based on treatment response.

AUTHORS' CONCLUSIONS

There is moderate quality evidence for the efficacy of hydrocortisone for the prevention of PTSD development in adults. We found no evidence to support the efficacy of propranolol, escitalopram, temazepam and gabapentin in preventing PTSD onset. The findings, however, are based on a few small studies with multiple limitations. Further research is necessary in order to determine the efficacy of pharmacotherapy in preventing PTSD and to identify potential moderators of treatment effect.

Comparing screening instruments to predict posttraumatic stress disorder

BACKGROUND

Following traumatic exposure, a proportion of trauma victims develops posttraumatic stress disorder (PTSD). Early PTSD risk screening requires sensitive instruments to identify everyone at risk for developing PTSD in need of diagnostic follow-up.

AIMS

This study compares the accuracy of the 4-item SPAN, 10-item Trauma Screening Questionnaire (TSQ) and 22-item Impact of Event Scale-Revised (IES-R) in predicting chronic PTSD at a minimum sensitivity of 80%.

METHOD

Injury patients admitted to a level-I trauma centre (N = 311) completed the instruments at a median of 23 days and were clinically assessed for PTSD at 6 months. Areas under the curve and specificities at 80% sensitivity were compared between instruments.

RESULTS

Areas under the curve in all instruments were adequate (SPAN: 0.83; TSQ: 0.82; IES-R: 0.83) with no significant differences. At 80% sensitivity, specificities were 64% for SPAN, 59% for TSQ and 72% for IES-R.

CONCLUSION

The SPAN, TSQ and IES-R show similar accuracy in early detection of individuals at risk for PTSD, despite differences in number of items. The modest specificities and low positive predictive values found for all instruments could lead to relatively many false positive cases, when applied in clinical practice.

Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology

This revision of the 2005 British Association for Psychopharmacology guidelines for the evidence-based pharmacological treatment of anxiety disorders provides an update on key steps in diagnosis and clinical management, including recognition, acute treatment, longer-term treatment, combination treatment, and further approaches for patients who have not responded to first-line interventions. A consensus meeting involving international experts in anxiety disorders reviewed the main subject areas and considered the strength of supporting evidence and its clinical implications. The guidelines are based on available evidence, were constructed after extensive feedback from participants, and are presented as recommendations to aid clinical decision-making in primary, secondary and tertiary medical care. They may also serve as a source of information for patients, their carers, and medicines management and formulary committees.

Design, delivery, and evaluation of early interventions for children exposed to acute trauma

BACKGROUND

Exposure to acute, potentially traumatic events is an unfortunately common experience for children and adolescents. Posttraumatic stress (PTS) responses following acute trauma can have an ongoing impact on child development and well-being. Early intervention to prevent or reduce PTS responses holds promise but requires careful development and empirical evaluation.

OBJECTIVES

The aims of this review paper are to present a framework for thinking about the design, delivery, and evaluation of early interventions for children who have been exposed to acute trauma; highlight targets for early intervention; and describe next steps for research and practice.

RESULTS AND CONCLUSIONS

Proposed early intervention methods must (1) have a firm theoretical grounding that guides the design of intervention components; (2) be practical for delivery in peri-trauma or early post-trauma contexts, which may require creative models that go outside of traditional means of providing services to children; and (3) be ready for evaluation of both outcomes and mechanisms of action. This paper describes three potential targets for early intervention-maladaptive trauma-related appraisals, excessive early avoidance, and social/interpersonal processes-for which there is theory and evidence suggesting an etiological role in the development or persistence of PTS symptoms in children.

Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults

BACKGROUND

Post-traumatic stress disorder (PTSD) is a distressing condition, which is often treated with psychological therapies. Earlier versions of this review, and other meta-analyses, have found these to be effective, with trauma-focused treatments being more effective than non-trauma-focused treatments. This is an update of a Cochrane review first published in 2005 and updated in 2007.

OBJECTIVES

To assess the effects of psychological therapies for the treatment of adults with chronic post-traumatic stress disorder (PTSD).

SEARCH METHODS

For this update, we searched the Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR-Studies and CCDANCTR-References) all years to 12th April 2013. This register contains relevant randomised controlled trials from: The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). In addition, we handsearched the Journal of Traumatic Stress, contacted experts in the field, searched bibliographies of included studies, and performed citation searches of identified articles.

SELECTION CRITERIA

Randomised controlled trials of individual trauma-focused cognitive behavioural therapy (TFCBT), eye movement desensitisation and reprocessing (EMDR), non-trauma-focused CBT (non-TFCBT), other therapies (supportive therapy, non-directive counselling, psychodynamic therapy and present-centred therapy), group TFCBT, or group non-TFCBT, compared to one another or to a waitlist or usual care group for the treatment of chronic PTSD. The primary outcome measure was the severity of clinician-rated traumatic-stress symptoms.

DATA COLLECTION AND ANALYSIS

We extracted data and entered them into Review Manager 5 software. We contacted authors to obtain missing data. Two review authors independently performed 'Risk of bias' assessments. We pooled the data where appropriate, and analysed for summary effects.

MAIN RESULTS

We include 70 studies involving a total of 4761 participants in the review. The first primary outcome for this review was reduction in the severity of PTSD symptoms, using a standardised measure rated by a clinician. For this outcome, individual TFCBT and EMDR were more effective than waitlist/usual care (standardised mean difference (SMD) -1.62; 95% CI -2.03 to -1.21; 28 studies; n = 1256 and SMD -1.17; 95% CI -2.04 to -0.30; 6 studies; n = 183 respectively). There was no statistically significant difference between individual TFCBT, EMDR and Stress Management (SM) immediately post-treatment although there was some evidence that individual TFCBT and EMDR were superior to non-TFCBT at follow-up, and that individual TFCBT, EMDR and non-TFCBT were more effective than other therapies. Non-TFCBT was more effective than waitlist/usual care and other therapies. Other therapies were superior to waitlist/usual care control as was group TFCBT. There was some evidence of greater drop-out (the second primary outcome for this review) in active treatment groups. Many of the studies were rated as being at 'high' or 'unclear' risk of bias in multiple domains, and there was considerable unexplained heterogeneity; in addition, we assessed the quality of the evidence for each comparison as very low. As such, the findings of this review should be interpreted with caution.

AUTHORS' CONCLUSIONS

The evidence for each of the comparisons made in this review was assessed as very low quality. This evidence showed that individual TFCBT and EMDR did better than waitlist/usual care in reducing clinician-assessed PTSD symptoms. There was evidence that individual TFCBT, EMDR and non-TFCBT are equally effective immediately post-treatment in the treatment of PTSD. There was some evidence that TFCBT and EMDR are superior to non-TFCBT between one to four months following treatment, and also that individual TFCBT, EMDR and non-TFCBT are more effective than other therapies. There was evidence of greater drop-out in active treatment groups. Although a substantial number of studies were included in the review, the conclusions are compromised by methodological issues evident in some. Sample sizes were small, and it is apparent that many of the studies were underpowered. There were limited follow-up data, which compromises conclusions regarding the long-term effects of psychological treatment.

Myocardial Infarction - Stress PRevention INTervention (MI-SPRINT) to reduce the incidence of posttraumatic stress after acute myocardial infarction through trauma-focused psychological counseling: study protocol for a randomized controlled trial

BACKGROUND

Posttraumatic Stress Disorder (PTSD) may occur in patients after exposure to a life-threatening illness. About one out of six patients develop clinically relevant levels of PTSD symptoms after acute myocardial infarction (MI). Symptoms of PTSD are associated with impaired quality of life and increase the risk of recurrent cardiovascular events. The main hypothesis of the MI-SPRINT study is that trauma-focused psychological counseling is more effective than non-trauma focused counseling in preventing posttraumatic stress after acute MI.

METHODS/DESIGN

The study is a single-center, randomized controlled psychological trial with two active intervention arms. The sample consists of 426 patients aged 18 years or older who are at 'high risk' to develop clinically relevant posttraumatic stress symptoms. 'High risk' patients are identified with three single-item questions with a numeric rating scale (0 to 10) asking about 'pain during MI', 'fear of dying until admission' and/or 'worrying and feeling helpless when being told about having MI'. Exclusion criteria are emergency heart surgery, severe comorbidities, current severe depression, disorientation, cognitive impairment and suicidal ideation. Patients will be randomly allocated to a single 45-minute counseling session targeting either specific MI-triggered traumatic reactions (that is, the verum intervention) or the general role of psychosocial stress in coronary heart disease (that is, the control intervention). The session will take place in the coronary care unit within 48 hours, by the bedside, after patients have reached stable circulatory conditions. Each patient will additionally receive an illustrated information booklet as study material. Sociodemographic factors, psychosocial and medical data, and cardiometabolic risk factors will be assessed during hospitalization. The primary outcome is the interviewer-rated posttraumatic stress level at three-month follow-up, which is hypothesized to be at least 20% lower in the verum group than in the control group using the t-test. Secondary outcomes are posttraumatic stress levels at 12-month follow-up, and psychosocial functioning and cardiometabolic risk factors at both follow-up assessments.

DISCUSSION

If the verum intervention proves to be effective, the study will be the first to show that a brief trauma-focused psychological intervention delivered within a somatic health care setting can reduce the incidence of posttraumatic stress in acute MI patients.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01781247.

The development of a population-based automated screening procedure for PTSD in acutely injured hospitalized trauma survivors

OBJECTIVE

This investigation aimed to advance posttraumatic stress disorder (PTSD) risk prediction among hospitalized injury survivors by developing a population-based automated screening tool derived from data elements available in the electronic medical record (EMR).

METHOD

Potential EMR-derived PTSD risk factors with the greatest predictive utilities were identified for 878 randomly selected injured trauma survivors. Risk factors were assessed using logistic regression, sensitivity, specificity, predictive values and receiver operator characteristic (ROC) curve analyses.

RESULTS

Ten EMR data elements contributed to the optimal PTSD risk prediction model including International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) PTSD diagnosis, other ICD-9-CM psychiatric diagnosis, other ICD-9-CM substance use diagnosis or positive blood alcohol on admission, tobacco use, female gender, non-White ethnicity, uninsured, public or veteran insurance status, E-code identified intentional injury, intensive care unit admission and EMR documentation of any prior trauma center visits. The 10-item automated screen demonstrated good area under the ROC curve (0.72), sensitivity (0.71) and specificity (0.66).

CONCLUSIONS

Automated EMR screening can be used to efficiently and accurately triage injury survivors at risk for the development of PTSD. Automated EMR procedures could be combined with stepped care protocols to optimize the sustainable implementation of PTSD screening and intervention at trauma centers nationwide.

The neural basis of flashback formation: the impact of viewing trauma

BACKGROUND

Psychological traumatic events, such as war or road traffic accidents, are widespread. A small but significant proportion of survivors develop post-traumatic stress disorder (PTSD). Distressing, sensory-based involuntary memories of trauma (henceforth 'flashbacks') are the hallmark symptom of PTSD. Understanding the development of flashbacks may aid their prevention. This work is the first to combine the trauma film paradigm (as an experimental analogue for flashback development) with neuroimaging to investigate the neural basis of flashback aetiology. We investigated the hypothesis that involuntary recall of trauma (flashback) is determined during the original event encoding. Method A total of 22 healthy volunteers viewed a traumatic film whilst undergoing functional magnetic resonance imaging (fMRI). They kept a 1-week diary to record flashbacks to specific film scenes. Using a novel prospective fMRI design, we compared brain activation for those film scenes that subsequently induced flashbacks with both non-traumatic control scenes and scenes with traumatic content that did not elicit flashbacks ('potentials').

RESULTS

Encoding of scenes that later caused flashbacks was associated with widespread increases in activation, including in the amygdala, striatum, rostral anterior cingulate cortex, thalamus and ventral occipital cortex. The left inferior frontal gyrus and bilateral middle temporal gyrus also exhibited increased activation but only relative to 'potentials'. Thus, these latter regions appeared to distinguish between traumatic content that subsequently flashed back and comparable content that did not.

CONCLUSIONS

Results provide the first prospective evidence that the brain behaves differently whilst experiencing emotional events that will subsequently become involuntary memories - flashbacks. Understanding the neural basis of analogue flashback memory formation may aid the development of treatment interventions for this PTSD feature.