The detection and treatment of posttraumatic distress and substance intoxication in the acute care inpatient setting

Mental health conditions in older multimorbid patients presenting to the emergency department for acute cardiac symptoms: Cross-sectional findings from the EMASPOT study

BACKGROUND

This study aimed to (1) examine the proportion of patients presenting to an emergency department (ED) for acute cardiac symptoms with comorbid mental health conditions (MHCs) comprising current depression, generalized anxiety disorder, and panic disorder; (2) compare cardiac patients with and without MHCs regarding sociodemographic, medical, and psychological characteristics; and (3) examine recognition and treatment rates of MHCs.

METHODS

Multimorbid patients, aged ≥50 years, presenting to an inner-city ED with acute cardiac symptoms including chest pain, dyspnea, and palpitations, completed validated self-report instruments assessing MHCs and a questionnaire collecting psychosocial and medical information. In addition, routine medical data were extracted from the electronic health record.

RESULTS

A total of 641 patients were included in the study. Mean (±SD) age was 68.8 (±10.8) years and 41.7% were female. Based on screening instruments, 28.4% of patients were affected with comorbid MHCs. Patients reported clinically significant symptoms of depression (23.3% PHQ-9 ≥10), generalized anxiety disorder (12.2% GAD-7 ≥10), and panic disorder (4.7% PHQ-PD). Patients with MHCs were more likely to be younger, female, lower educated, and unemployed. The presence of MHCs was associated with higher cardiac symptom burden and subjective treatment urgency as well as more psychosocial distress (PHQ-stress) and impaired quality of life (SF-12v2). Of all patients, 15.6% were identified with new or unrecognized MHCs.

CONCLUSIONS

MHCs are prevalent in nearly one-third of patients presenting with cardinal cardiac symptoms. Thus, the ED visit offers an opportunity to identify and refer patients with MHCs to appropriate and timely care after exclusion of life-threatening conditions.

Substance use and posttraumatic stress disorder symptoms in trauma center patients receiving mandated alcohol screening and brief intervention

In an effort to integrate substance abuse treatment at trauma centers, the American College of Surgeons has mandated alcohol screening and brief intervention (SBI). Few investigations have assessed trauma center inpatients for comorbidities that may impact the effectiveness of SBI that exclusively focuses on alcohol. Randomly selected SBI eligible acute care medical inpatients (N=878) were evaluated for alcohol, illegal drugs, and symptoms consistent with a diagnosis of posttraumatic stress disorder (PTSD) using electronic medical record, toxicology, and self-report assessments; 79% of all patients had one or more alcohol, illegal drug, or PTSD symptom comorbidity. Over 70% of patients receiving alcohol SBI (n=166) demonstrated one or more illegal drug or PTSD symptom comorbidity. A majority of trauma center inpatients have comorbidities that may impact the effectiveness of mandated alcohol SBI. Investigations that realistically capture, account for, and intervene upon these common comorbid presentations are required to inform the iterative development of college policy targeting integrated substance abuse treatment at trauma centers.

Collaborative care interventions in general trauma patients

Collaborative care is a disease management strategy that aims to simultaneously target medical/surgical (eg, physical injury) and psychiatric (eg, posttraumatic stress disorder [PTSD] and depression) conditions. Collaborative care interventions hold promise for the delivery of mental health interventions in acute care as they can incorporate frontline trauma center providers, such as social workers and nurses, into early mental health services delivery and can link trauma center care to outpatient services. Initial randomized clinical trial evidence suggests that collaborative care interventions that incorporate evidence-based motivational interviewing targeting alcohol use, as well as pharmacotherapy and psychotherapy targeting PTSD, may reduce both alcohol and PTSD symptoms among injured trauma surgery patients. Trials conducted to date thus suggest that early mental health interventions can be feasibly and effectively delivered from trauma centers. Future collaborative care investigations that refine routine acute care treatment procedures and target acute care policy mandates can improve the quality of mental health care for Americans injured in the wake of individual and mass trauma.

Posttraumatic distress and physical functioning: a longitudinal study of injured survivors of community violence

This study examines the cross-lagged relationships between posttraumatic distress symptoms and physical functioning, using a sample of 413 persons who were hospitalized for injuries resulting from community violence. Posttraumatic distress was assessed at 1 week, 3 months, and 12 months postinjury, and posttraumatic physical functioning was assessed at 3 months and 12 months. Structural equation modeling was used to assess the prospective relationship between posttraumatic distress symptoms and physical functioning while controlling for demographic characteristics and objective measures of injury severity. Results indicate that posttraumatic distress and physical functioning are reciprocally related. Individuals with high levels of psychological distress at 1 week posttrauma have worse physical functioning at 3 months. Psychological distress at 3 months was not significantly associated with subsequent change in physical functioning at 12 months. Individuals with poor physical functioning at 3 months had higher than expected levels of psychological distress at 12 months. These findings demonstrate a reciprocal relationship between physical and mental health following traumatic injury. Interventions targeting physical recovery may influence subsequent mental health, and therapies aimed at improving early mental health may also have long-term benefits for physical recovery.

Nationwide survey of alcohol screening and brief intervention practices at US Level I trauma centers

BACKGROUND

In 2007, the American College of Surgeons (ACS) Committee on Trauma implemented a requirement that Level I trauma centers must have a mechanism to identify patients who are problem drinkers and the capacity to provide an intervention for patients who screen positive. Although the landmark alcohol screening and brief intervention (SBI) mandate is anticipated to impact trauma practice nationwide, a literature review revealed no studies that have systematically documented SBI practice pre-ACS requirement.

STUDY DESIGN

Trauma programs at all US Level I trauma centers were contacted and asked to complete a survey about pre-ACS requirement trauma center SBI practice.

RESULTS

One hundred forty-eight of 204 (73%) Level I trauma centers responded to the survey. More than 70% of responding centers routinely used laboratory tests (eg, blood alcohol concentration) to screen patients for alcohol and 39% routinely used a screening question or standardized screening instrument. Screen-positive patients received a formal alcohol consult or had an informal alcohol discussion with staff members approximately 25% of the time.

CONCLUSIONS

The investigation observed marked variability across Level I centers in the percentage of patients screened and in the nature and extent of intervention delivery in screen-positive patients. In the wake of the ACS Committee on Trauma requirement, future research could systematically implement and evaluate training in the delivery of evidence-based alcohol interventions and training in development of trauma center organizational capacity for sustained delivery of SBI.

Psychiatric disorders in patients presenting to the Emergency Department for minor injury

BACKGROUND

Thirty-five percent of all Emergency Department (ED) visits are for physical injury.

OBJECTIVES

To examine the proportion of patients presenting to an ED for physical injury with a history of or current Axis I/II psychiatric disorders and to compare patients with a positive psychiatric history, a negative psychiatric history, and a current psychiatric disorder.

METHODS

A total of 275 individuals were selected randomly from adults presenting to the ED with a documented anatomic injury but with normal physiology. Exclusion criteria were: injury in the previous 2 years or from medical illness or domestic violence; or reported treatment for major depression or psychoses. Psychiatric history and current disorders were diagnosed using the Structured Clinical Interview for the Diagnostic and Statistical Manual Disorders, 4th edition (DSM-IV), a structured psychiatric interview. Three groups (positive psychiatric history, negative psychiatric history, current psychiatric disorder) were compared using Chi-square and analysis of variance.

RESULTS

The sample was composed of men (51.6%) and women (48.4%), with 57.1% Black and 39.6% White. Out of this sample, 103 patients (44.7%) met DSM-IV criteria for a positive psychiatric history (n = 80) or a current psychiatric disorder (n = 43). A past history of depression (24%)exceeded the frequency of a history of other disorders (anxiety, 6%; alcohol use/abuse, 14%; drug use/abuse, 15%; adjustment, 23%; conduct disorders, 14%). Current mood disorders (47%) also exceeded other current diagnoses (anxiety, 9%; alcohol, 16%; drug, 7%; adjustment, 7%; personality disorders, 12%). Those with a current diagnosis were more likely to be unemployed (p <.001) at the time of injury.

CONCLUSIONS

Psychiatric comorbid disorders or a positive psychiatric history was found frequently in individuals with minor injury. An unplanned contact with the healthcare system (specifically an ED) for treatment of physical injury offers an opportunity for nurses to identify patients with psychiatric morbidity and to refer patients for appropriate therapy.

An epidemiologic approach to the development of early trauma focused intervention

Early, trauma-focused intervention development has emphasized unidirectional trajectories that begin with basic research and efficacy trials followed later by effectiveness and dissemination studies. In this article, the authors present methods derived from social and clinical epidemiology that constitute foundational research in the development of early trauma-focused intervention. They also describe how population-based practice research may serve to feed back and inform what has been conceptualized as earlier stages of intervention development such as efficacy trials. Examples of relevant epidemiologic research methods are presented to illustrate these points. The authors posit that the continued application of population-based methods may produce treatments that can be feasibly applied to the unique patient, provider, organizational, and community contexts relevant to early interventions for survivors of trauma.

Detection of co-occurring mental illness among adult patients in the New Jersey substance abuse treatment system

OBJECTIVES

We assessed the detection of mental illness in an adult population of substance abuse patients and the rate of referral for mental health treatment.

METHODS

We obtained combined administrative records from 1994 to 1997 provided by the New Jersey substance abuse and mental health systems and estimated detection and referral rates of patients with co-occurring disorders (n = 47,379). Mental illness was considered detected if a diagnosis was in the record and considered undetected if a diagnosis was not in the record but the patient was seen in both treatment systems within the same 12-month period. Predictors of detection and referral were identified.

RESULTS

The detection rate of co-occurring mental illness was 21.9% (n=10364); 57.9% (n=6001) of these individuals were referred for mental health treatment. Methadone maintenance clinics had the lowest detection rate but the highest referral rate. Male, Hispanic, and African American patients, as well as those who used heroin or were in the criminal justice system, had a higher risk of mental illness not being detected. Once detected, African American patients, heroin users, and patients in the criminal justice system were less likely to be referred for treatment.

CONCLUSIONS

There is a need to improve the detection of mental illness among substance abuse patients and to provide integrated treatment.

Primary care utilization and detection of emotional distress after adolescent traumatic injury: identifying an unmet need

OBJECTIVE

Few investigations have assessed the primary care detection of adolescent posttraumatic emotional distress after an injury. We aimed to determine (1) the level of attachment to primary care providers (PCPs) and school providers among this group of high-risk adolescents, (2) the emotional status of this population postinjury, (3) continuity of care between trauma center and community care, and (4) PCPs' detection of emotional problems in adolescents after an injury.

METHODS

This was a prospective cohort study of traumatically injured adolescents aged 12 to 18 who were admitted to a level I regional trauma center. Adolescents were screened for posttraumatic stress symptoms, depressive symptoms, and alcohol use on the surgical ward and 4 to 6 months postinjury. PCPs were contacted by telephone 4 to 6 months postinjury to assess follow-up care and the detection of emotional distress.

RESULTS

In the surgical ward, 39.4% of the adolescent patients or their parents reported no identifiable source of regular medical care. Only 24.3% of the patients had visited a PCP during the 4 to 6 months after injury. At 4 to 6 months postinjury, 30% of the adolescents were experiencing high posttraumatic stress symptom levels, 11% were experiencing high depressive symptom levels, and 17% had high levels of alcohol use. PCPs did not detect any new emotional distress or problem drinking during postinjury office visits.

CONCLUSIONS

Injured adolescents represent a high-risk pediatric population, a substantial number of whom develop mental health problems postinjury. Furthermore, almost 40% of adolescents in our study reported no source of primary care. These results suggest that referrals from trauma centers to PCPs are necessary and that an increase in awareness of and screening for adolescent emotional distress postinjury during follow-up appointments and at school should be routine components of postinjury care.

Posttraumatic Stress and Depressive Symptoms, Alcohol Use, and Recurrent Traumatic Life Events in a Representative Sample of Hospitalized Injured Adolescents and Their Parents

OBJECTIVE

Few investigations have comprehensively assessed the scope of impairment of injured adolescents presenting to acute care inpatient settings.

METHODS

Randomly sampled injured adolescent inpatients and their parents were screened for posttraumatic stress (PTS) and depressive symptoms, preinjury alcohol use, and preinjury trauma. Linear regression was used to assess which clinical, demographic, and injury characteristics were independently associated with increased levels of adolescent PTS and depressive symptoms.

RESULTS

Fifty-seven percent [corrected] of adolescent-parent dyads endorsed high levels of PTS or depressive symptoms and/or high preinjury alcohol use. Adolescent female gender, greater levels of preinjury trauma, greater subjective distress at the time of the injury, and greater parental depressive symptoms were independently associated with increased levels of adolescent PTS and depressive symptoms.

CONCLUSIONS

The adoption of early screening and intervention procedures that broadly consider the scope of impairment of injured adolescents and their family members could enhance the quality of acute care mental health service delivery.