Secondary prevention for posttraumatic stress and related symptoms among women whohave experienced a recent sexual assault: A systematic review and meta-analysis

Early Intervention after Rape to prevent post-traumatic stress symptoms (the EIR-study): an internal pilot study of a randomized controlled trial

BACKGROUND

Rape is one of the trauma incidents with the highest risk of subsequent post-traumatic stress disorder. Early interventions, such as prolonged exposure therapy (PE), have shown promise in preventing PTSD following a sexual assault. The primary objective of this internal pilot trial was to examine the feasibility of the EIR study protocol, which used modified prolonged exposure therapy (mPE) as a preventive intervention after rape.

METHODS

This parallel two-arm clinical pilot study involved three sexual assault centers (SACs) in Trondheim, Oslo, and Vestfold, with data collected between June 2022 and March 2023. Women seeking assistance at one of these three SACs within 72 h after rape or attempted rape received acute medical treatment and forensic examinations. Women who wanted further psychosocial treatment were, if eligible and consenting, recruited to complete baseline assessments and a clinical interview before being randomized to one of two study arms. The intervention group prescribed up to five sessions of modified PE (mPE) in addition to treatment as usual (TAU), starting within the first 14 days after the rape incident, followed by weekly sessions. The other group received TAU. The present pilot evaluation is based on 22 participants, i.e., nine mPE + TAU and 13 TAU alone. Primary outcomes were predefined progression criteria regarding recruitment, retention, intervention implementation, a harm reporting system, and applying biological measurements and actigraphy.

RESULTS

During the 6-month recruitment period, 235 women visited the three SACs. After eligibility screening and consent, 22 (9.4%) women were randomized. Three months later, 14 (63.6%) participants completed the final assessments. Intervention implementation was successful using trained SAC personnel to deliver mPE. The harm reporting system was used according to the study's plan, and adverse and serious adverse events were detected during the trial. The biological measurements and actigraphy had substantial missing data but were still considered usable for statistical analyses.

CONCLUSION

It may be feasible to conduct a full-scale RCT of early intervention after rape by comparing mPE + TAU to TAU alone. Minor design refinements were made to the protocol to enhance the main study outcome.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05489133. Registered on 15 July 2022, retrospectively.

Web-Based Screening, Brief Intervention, and Referral to Treatment for Traumatic Stress and Alcohol Misuse Among Survivors of Sexual Assault and Intimate Partner Violence: Usability and Acceptability Study

BACKGROUND

Recent survivors of intimate partner violence (IPV) and sexual assault (SA) are at a high risk for traumatic stress and alcohol misuse. IPV and SA survivors face barriers to services for traumatic stress and alcohol misuse and have low service utilization rates. One way to increase access to services for this population is the use of web-based screening, brief intervention, and referral to treatment (SBIRT), an evidence-informed approach for early identification of traumatic stress and alcohol and drug misuse and connecting individuals to treatment.

OBJECTIVE

This study aims to assess the usability and acceptability of a web-based SBIRT called CHAT (Choices For Your Health After Trauma) tailored to address traumatic stress and alcohol misuse following past-year IPV, SA, or both.

METHODS

Phase 1 involved gathering feedback about usability and acceptability from focus groups with victim service professionals (22/52, 42%) and interviews with past-year survivors of IPV, SA, or both (13/52, 25%). Phase 2 involved gathering feedback about the acceptability of an adapted version of CHAT in an additional sample of recent survivors (17/52, 33%). Survey data on history of IPV and SA, posttraumatic stress disorder symptoms, alcohol and drug use, and service use were collected from survivors in both phases to characterize the samples. Qualitative content and thematic analyses of the interviews and focus group data were conducted using a coding template analysis comprising 6 a priori themes (usability, visual design, user engagement, content, therapeutic persuasiveness, and therapeutic alliance).

RESULTS

Six themes emerged during the focus groups and interviews related to CHAT: usability, visual design, user engagement, content, therapeutic persuasiveness, and therapeutic alliance. Phase 1 providers and survivors viewed CHAT as acceptable, easy to understand, and helpful. Participants reported that the intervention could facilitate higher engagement in this population as the web-based modality is anonymous, easily accessible, and brief. Participants offered helpful suggestions for improving CHAT by updating images, increasing content personalization, reducing text, and making users aware that the intervention is confidential. The recommendations of phase 1 participants were incorporated into CHAT. Phase 2 survivors viewed the revised intervention and found it highly acceptable (mean 4.1 out of 5, SD 1.29). A total of 4 themes encapsulated participant's favorite aspects of CHAT: (1) content and features, (2) accessible and easy to use, (3) education, and (4) personalization. Six survivors denied disliking any aspect. The themes on recommended changes included content and features, brevity, personalization, and language access. Participants provided dissemination recommendations.

CONCLUSIONS

Overall, CHAT was acceptable among victim service professionals and survivors. Positive reactions to CHAT show promise for future research investigating the efficacy and potential benefit of CHAT when integrated into services for people with traumatic stress and alcohol misuse after recent IPV and SA.

Mental health of sexual assault victims and predictors of their use of support from in-house psychologists at Belgian sexual assault care centres

BACKGROUND

Sexual assault (SA) can induce a negative impact on victims' mental health. Specialised SA services generally offer medical care and a forensic examination to SA victims. However, there is a large variation in how these services provide mental health support.

OBJECTIVE

This study aims to assess mental health problems of SA victims attending the Belgian Sexual Assault Care Centres (SACCs) and identify predictors for victims' use of support from in-house psychologists.

METHOD

Health records of victims ≥ 16 years who presented within one week post-SA to one of the three Belgian SACCs between 25 October 2017 and 31 October 2019 were reviewed. An AIC-based stepwise backward binary logistic regression was used to analyse the association between victim, assault, service use and mental health characteristics and follow-up by a SACC-psychologist.

RESULTS

Of the 555 victims, more than half had a history of mental health problems. Of those assessed, over 70% showed symptoms of posttraumatic stress disorder (PTSD), depression and/or anxiety disorder. One in two victims consulted a SACC-psychologist. Victims with a mental health history (OR 1.46, p = .04), victims accompanied by a support person during acute care (OR 1.51, p = .04), and victims who were assaulted by an acquaintance in comparison to those assaulted by a stranger (OR 1.60, p = .039) were more likely to attend their appointment with the SACC-psychologist.

CONCLUSION

The study reaffirms the high mental health burden among victims attending specialised SA services, stressing the need to provide effective mental health interventions at these services and improve their longer-term use by victims. Prescheduling of appointments with an in-house psychologist in combination with phone reminders may improve the uptake of such services. Health care providers must be vigilant about potential barriers faced by victims without a mental health history or social support in attending appointments with mental health professionals.

Modified prolonged exposure therapy as Early Intervention after Rape (The EIR-study): study protocol for a multicenter randomized add-on superiority trial

BACKGROUND

Sexual assault and rape are the traumatic life events with the highest probability for posttraumatic stress disorder (PTSD), which can have devastating consequences for those afflicted by the condition. Studies indicate that modified prolonged exposure (mPE) therapy may be effective in preventing the development of PTSD in recently traumatized individuals, and especially for people who have experienced sexual assault. If a brief, manualized early intervention can prevent or reduce post-traumatic symptoms in women who have recently experienced rape, healthcare services targeted for these populations (i.e., sexual assault centers, SACs) should consider implementing such interventions as part of routine care.

METHODS/DESIGN

This is a multicenter randomized controlled add-on superiority trial that enrolls patients attending sexual assault centers within 72 h after rape or attempted rape. The objective is to assess whether mPE shortly after rape can prevent the development of post-traumatic stress symptoms. Patients will be randomized to either mPE plus treatment as usual (TAU) or TAU alone. The primary outcome is the development of post-traumatic stress symptoms 3 months after trauma. Secondary outcomes will be symptoms of depression, sleep difficulties, pelvic floor hyperactivity, and sexual dysfunction. The first 22 subjects will constitute an internal pilot trial to test acceptance of the intervention and feasibility of the assessment battery.

DISCUSSION

This study will guide further research and clinical initiatives for implementing strategies for preventing post-traumatic stress symptoms after rape and provide new knowledge about which women may benefit the most from such initiatives and for revising existing treatment guidelines within this area.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05489133. Registered on 3 August 2022.

Depression and post-traumatic stress symptoms two years post-rape and the role of early counselling: Rape Impact Cohort Evaluation (RICE) study

Background: Survivors of sexual violence are at higher risk of adverse mental health outcomes compared to those exposed to other interpersonal traumas.Objective: To examine the trajectory of both post-traumatic stress disorder (PTSD) and depression as well as the role of early counselling over 24 months among rape survivors.Method: The South African Rape Impact Cohort Evaluation (RICE) study enrolled women aged 16-40 years attending post-rape care services within 20 days of a rape incident (n = 734), and a comparison group (n = 786) was recruited from primary health care. Women were followed for 24 months; the main study outcomes were depression and PTSD. Reports of early supportive counselling by the exposed group were also included. The analysis included an adjusted joint mixed model with linear splines to account for correlated observations between the outcomes.Results: At 24 months, 45.2% of the rape-exposed women met the cut-off for depression and 32.7% for PTSD. This was significantly higher than levels found among the unexposed. Although a decline in depression and PTSD was seen at 3 months among the women who reported a rape, mean scores remained stable thereafter. At 24 months mean depression scores remained above the depression cut-off (17.1) while mean PTSD scores declined below the PTSD cut-off (14.5). Early counselling was not associated with the trajectory of either depression or PTSD scores over the two years in rape-exposed women with both depression and PTSD persisting regardless of early counselling.Conclusion: The study findings highlight the importance to find and provide effective mental health interventions post-rape in South Africa.

Prevalence and risk factors for acute stress disorder in female victims of sexual assault

Sexual assault is one of the most traumatic events a person can experience. Despite this, information regarding the risk factors associated with the development of Acute Stress Disorder (ASD) in sexual assault victims is scarce. A follow-up prospective cohort study was designed to examine the prevalence and risk factors of ASD in women exposed to a recent sexual assault. A total of 156 women were treated at the Emergency Department of a university general hospital shortly after sexual assault. Sociodemographic, clinical and sexual assault-related variables were collected. The Acute Stress Disorder Interview was used to estimate the prevalence of ASD at three weeks post-SA. From the 156 victims, 66.6% (N = 104) met ASD diagnosis using DSM-5 criteria, whereas 59.6% (N = 93) met ASD diagnosis using DSM-IV criteria. The risk factors associated with the development of ASD were nationality, psychiatric history, peritraumatic dissociation and type of assault. In conclusion, the prevalence of ASD in female victims of recent sexual assault was high, affecting approximately two thirds of them. The recognition of the risk factors associated with ASD development, like peritraumatic dissociation or type of assault, may aid in the prompt detection of vulnerable women that require early and specific interventions shortly after trauma.

Health care utilization by women sexual assault survivors after emergency care: Results of a multisite prospective study

BACKGROUND

Approximately, 100,000 US women receive emergency care after sexual assault each year, but no large-scale study has examined the incidence of posttraumatic sequelae, receipt of health care, and frequency of assault disclosure to providers. The current study evaluated health outcomes and service utilization among women in the 6 weeks after sexual assault.

METHODS

Women ≥18 years of age presenting for emergency care after sexual assault to twelve sites were approached. Among those willing to be contacted for the study (n = 1080), 706 were enrolled. Health outcomes, health care utilization, and assault disclosure were assessed via 6 week survey.

RESULTS

Three quarters (76%) of women had posttraumatic stress, depression, or anxiety, and 65% had pain. Less than two in five reported seeing health care provider; receipt of care was not related to substantive differences in symptoms and was less likely among Hispanic women and women with a high school education or less. Nearly one in four who saw a primary care provider did not disclose their assault, often due to shame, embarrassment, or fear of being judged.

CONCLUSION

Most women receiving emergency care after sexual assault experience substantial posttraumatic sequelae, but health care in the 6 weeks after assault is uncommon, unrelated to substantive differences in need, and limited in socially disadvantaged groups. Lack of disclosure to primary care providers was common among women who did receive care.

Anxiety Sensitivity Prospectively Predicts Increased Acute Posttraumatic Stress and Related Symptoms After Sexual Assault

Anxiety sensitivity is a potential risk factor for posttraumatic stress symptoms (PTSS) and has been hypothesized to contribute to PTSS development. However, few prospective studies have evaluated whether anxiety sensitivity predicts PTSS. In a subsample of 48 women sexual assault survivors enrolled as part of a larger prospective observational study, elevated anxiety sensitivity measured via a brief assessment 1 week after experiencing a sexual assault was concurrently associated with PTSS at 1 week and prospectively predicted PTSS 6 weeks after the event, with small-to-medium effect sizes, η2 p = .10, even after covarying for trauma history. Heightened anxiety sensitivity at 1-week postevent also interacted with time to predict anxiety and depression both before and after sexual assault, with medium-to-large effect sizes, ηp 2 = .21- .24. This is consistent with research linking anxiety sensitivity to PTSS, but this was the first prospective study of which we are aware to demonstrate that anxiety sensitivity in the acute posttrauma period predicts PTSS among women who have recently experienced sexual assault. Future research should use the full Anxiety Sensitivity Index to replicate findings in a larger sample and explore whether targeting anxiety sensitivity could mitigate the development of PTSS in this vulnerable population.