A systematic review of predictors of posttraumatic stress disorder (PTSD) for adult road traffic crash survivors

Long-term PTSD prevalence and associated adverse psychological, functional, and economic outcomes: a 12-15 year follow-up of adults with suspected serious injury

Background: An increasing number of longitudinal studies investigates long-term PTSD, related outcomes and potential gender differences herein. However, a knowledge gap exists when it comes to studies following individual civilian trauma beyond a decade post-trauma.Objective: To investigate the long-term PTSD prevalence, associated adverse psychological, functional and economic outcomes related to (suspected) serious injury of 12-15 years ago in Dutch adults, as well as potential gender differences herein.Method: N = 194 trauma-exposed adults (34% women) admitted to an emergency department following suspected serious injury completed a follow-up assessment 12-15 years (M = 14.30, SD = 1.00) post-trauma. Participants completed assessments of clinician-rated PTSD symptom severity, as well as self-report questionnaires on psychological, functional and economic outcomes.Results: Nine participants (4.8%) fulfilled the DSM-5 diagnostic criteria for PTSD related to the index trauma of 12-15 years ago. Results showed that PTSD symptom severity (CAPS-5) was significantly associated with more severe symptoms of anxiety (HADS) and depression (QIDS), lower well-being (WHO-5) and (health-related) quality of life (WHOQOL; EQ-5D-5L), but not with alcohol use (AUDIT), productivity loss at work (iPCQ) and health care use (iMCQ). No significant gender differences in the long-term PTSD prevalence nor in its related psychological, functional and economic outcomes were found.Conclusions: Our findings underscore the long-term presence of PTSD and associated adverse psychological and functional outcomes in a proportion of adults who experienced (suspected) serious injury over a decade ago. PTSD is already widely recognized for its substantial impact in the aftermath of a trauma. The current study emphasizes the potential long-term consequences of individual civilian trauma, highlighting the importance of accurate screening and prevention for PTSD.

A comparison of the psychometric properties of a person-administered vs. automated screening tool for posttraumatic stress disorder (PTSD) in traumatically injured patients

BACKGROUND

The American College of Surgeons Committee on Trauma (ACS-CoT) mandated that trauma centers have mental health screening and referral protocols in place by 2023. This study compares the Injured Trauma Survivor Screen (ITSS) and the Automated Electronic Medical Record (EMR) Screen to assess their performance in predicting risk for posttraumatic stress disorder (PTSD) within the same sample of trauma patients to inform trauma centers' decision when selecting a tool to best fit their current clinical practice.

METHODS

This was a secondary analysis of three prospective cohort studies of traumatically injured patients (N = 255). The ITSS and Automated EMR Screen were compared using receiver operating characteristic curves to predict risk of subsequent PTSD development. PTSD diagnosis at 6-month follow-up was assessed using the Clinician Administered PTSD Scale for DSM-5.

RESULTS

Just over half the sample screened positive on the ITSS (57.7%), while 67.8% screened positive on the Automated EMR Screen. The area under the curve (AUC) for the two screens was not significantly different (ITSS AUC = 0.745 versus Automated EMR Screen AUC = 0.694, p = 0.21), similar performance in PTSD risk predication within the same general trauma population. The ITSS and Automated EMR Screen had similar sensitivities (86.5%, 89.2%), and specificities (52.5%, 40.9%) respectively at their recommended cut-off points.

CONCLUSION

Both screens are psychometrically comparable. Therefore, trauma centers considering screening tools for PTSD risk to comply with the ACS-CoT 2023 mandate should consider their local resources and patient population. Regardless of screen selection, screening must be accompanied by a referral process to address the identified risk.

Differential predictors of early- and delayed-onset post-traumatic stress disorder following physical injury: a two-year longitudinal study

Objectives

This study aimed to investigate the predictors of both early- and delayed-onset PTSD over a 2-year period following physical injuries.

Methods

Patients were recruited from a trauma center at a university hospital in South Korea (June 2015 ~ January 2021). At baseline, 1142 patients underwent comprehensive assessments including socio-demographic, pre-trauma, trauma-related, and peri-trauma evaluations. Diagnoses of acute stress disorder (ASD) and subthreshold ASD were also determined using the Clinician-administered PTSD Scale (CAPS). Follow-up assessments at three months included diagnoses of PTSD and subthreshold PTSD using CAPS, and stressful life events (SLEs), with additional evaluations at 6, 12, and 24 months. The analyzed sample comprised 1014 patients followed up at least once after the baseline and 3-month evaluations. PTSD diagnoses were categorized into early-onset (within the first six months after trauma) and delayed-onset (more than six months after trauma). Logistic regression models identified predictors for each group.

Results

Early-onset and delayed-onset PTSD were diagnosed in 79 and 35 patients, respectively. Early-onset PTSD was predicted by previous psychiatric disorders, previous traumatic events, ASD and subthreshold ASD diagnoses, and higher anxiety levels. In contrast, delayed-onset PTSD was linked to higher education, higher injury severity, and subthreshold PTSD and SLEs at 3-month follow-up.

Conclusion

Distinct predictors were found for early-onset and delayed-onset PTSD. The findings underscore the heterogeneous factors influencing the temporal development of PTSD post-trauma, and may provide valuable guidance for more targeted interventions and improved patient outcomes.

Relationship between anxiety sensitivity and post-traumatic stress symptoms in trauma-exposed adults: A meta-analysis

Given the high rate of trauma exposure among the general population, it is important to delineate the risk factors for post-traumatic stress disorder (PTSD). While historically implicated in panic disorder, anxiety sensitivity is increasingly found to play a role in PTSD. The present review investigated the size of the relationship between anxiety sensitivity and PTSD symptoms among trauma exposed adults. A systematic search on multiple electronic databases (PTSDpubs, CINAHL, MEDLINE and PsycINFO) generated a total of 1025 records, among which 52 (n = 15173) met study inclusion criteria and were included in our random effects meta-analysis. Our results indicated a medium effect size (r = .46, 95% CI =.41,.50) for the relationship between anxiety sensitivity and PTSD symptoms. There was significant between-study heterogeneity. Furthermore, sub-group analyses revealed that study design (cross-sectional vs. longitudinal) may significantly moderate the association between anxiety sensitivity and PTSD severity. No moderation effect was found for assessment of PTSD through interview versus questionnaire, interpersonal versus non-interpersonal trauma, or low versus high study quality. Such patterns of results are consistent with cognitive models of PTSD. Clinical implications, strengths and limitations of the review were discussed.

Differences in predictive factors for post-traumatic stress disorder encompassing partial PTSD and full PTSD: a cross-sectional study among individuals exposed to the November 13, 2015 Paris attacks

Background

When faced with a surge of physically injured individuals, especially following a traumatic event like an attack, frontline practitioners prioritize early triage. Detecting potential psychological injuries soon after such events remains challenging. Some individuals might develop post-traumatic stress disorder (PTSD) according to DSM-V criteria. Others may exhibit PTSD symptoms without meeting full diagnostic criteria, termed partial or sub-syndromal PTSD, a less-explored area in literature. This study aims to identify predictive factors for both full and partial PTSD.

Method

In a cohort of victims of the 2015 Paris attacks, multinomial logistic regressions explored predictive factors for partial or full PTSD status 8 to 18 months post-attacks. Analyses considered pre, peri, and posttraumatic factors chosen from literature review and univariate analysis within each group.

Results

Within the cohort, 50 individuals showed no signs of PTSD, 35 experienced partial PTSD, and 30 presented with full PTSD. After logistic regression, risk factors associated with full PTSD included a history of trauma (OR = 1.30, CI [1.02-1.66], p < 0.05), the intensity of peri-traumatic physical reactions (OR = 1.22, CI [1.09-1.36], p < 0.001), the difficulties in suppressing intrusive thoughts (OR = 1.11, CI [1.02-1.21], p < 0.013). Only the intensity of peri-traumatic physical reactions emerged as a risk factor for partial PTSD (OR = 1.13, [CI 1.02-1.24], p < 0.001).

Discussion

This study revealed that a history of trauma, the intensity of peri-traumatic physical reactions (e.g., tachycardia, trembling, flushes, numbness.), and the difficulties in suppressing intrusive thoughts constitute risk factors for the development of full PTSD. Moreover, the study identified that only the intensity of peri-traumatic physical reactions emerged as a risk factor for partial PTSD. These findings seem to underscore the significance of peri-traumatic experiences in influencing the development of post-traumatic stress symptoms.

Conclusion

This study emphasizes the significance of examining peri-traumatic reactions in PTSD development, suggesting its potential as a straightforward screening tool for post-traumatic stress disorder. It also underscores the influence of prior traumatic experiences, before de novo traumatization, in shaping vulnerability to PTSD and illuminates the crucial role of compromised control of intrusive thoughts that could perpetuate PTSD.

[Prevalence and predictors of post-traumatic stress disorder in road traffic accidents]

Introduction

trauma-related disorders following a road accident have both a health and an economic impact.

Methods

we conducted a prospective study to determine the prevalence of these disorders, and to identify risk factors in subjects victims of road accidents and hospitalized in the Department of Orthopedic Surgery and Traumatology of the University Hospital Center of Sfax-Tunisia.

Results

a total of sixty-ten subjects were included in this study. The prevalence of acute stress disorder was 37.1% and was associated with female sex, low educational level, previous medical and surgical history, passivity during the accident, severity of injuries and the presence of anxious and depressive symptoms. Post-traumatic stress disorder was observed in 40% of subjects and was associated with urban residential environment, passivity during the accident and anxious and depressive symptoms. Low scores for functional coping strategies and high scores for dysfunctional coping strategies were significantly associated with both disorders. Low educational level, urban residential environment, high levels of anxiety and depression, and denial coping strategy appear to be independent risk factors for acute stress and post-traumatic stress disorder.

Conclusion

It is therefore important to determine the profile of people at greater risk of post-traumatic stress disorder, to enable early diagnosis in victims of road accidents.

The importance of self-regulation and mental health for effective recovery after traffic injuries: A comprehensive network analysis approach

OBJECTIVE

Traffic injuries significantly impact people's psychological, physical and social wellbeing, and involve complex self-regulation responses. Psychological impacts are seldom recognized and addressed holistically. This study employs network analysis to investigate the interconnectedness between different dimensions that influence mental health vulnerability and recovery after traffic injuries.

METHODS

120 adults with mild-to-moderate traffic injuries and 112 non-injured controls were recruited. The network investigation employed two main approaches. Four cross-sectional networks examined the interrelationships between self-regulation responses (cognitive and autonomic) and various health dimensions (psychological, physical, social) over time (1, 3, 6, 12 months). Three predictive networks explored influences of acute self-regulation responses (1 month) on long-term outcomes. Network analyses focused on between-group differences in overall connectivity and centrality measures (nodal strength).

RESULTS

An overall measure of psychological wellbeing consistently emerged as the most central (strongest) node in both groups' networks. Injured individuals showed higher overall connectivity and differences in the centrality of self-regulation nodes compared to controls, at 1-month and 12-months post-injury. These patterns were similarly observed in the predictive networks, including differences in cognitive and autonomic self-regulation influences.

CONCLUSIONS

Network analyses highlighted the crucial role of psychological health and self-regulation, in promoting optimal wellbeing and effective recovery. Post-traffic injury, increased connectivity indicated prolonged vulnerability for at least a year, underscoring the need of ongoing support beyond the initial improvements. A comprehensive approach that prioritizes psychological health and self-regulation through psychologically informed services, early psychological screening, and interventions promoting cognitive and autonomic self-regulation is crucial for mitigating morbidity and facilitating recovery.

TRIAL REGISTRATION

IMPRINT study, ACTRN 12616001445460.

What Are the Predictors of Post-traumatic Stress Disorder Among Road Traffic Accident Survivors: A Systematic Review

ABSTRACT

Traffic accidents put tremendous burdens on the psychosocial aspects of communities. Post-traumatic stress disorder (PTSD), after an accident, is one of the most prevalent and incapacitating psychiatric conditions worldwide. In this systematic review, we aimed to investigate the predictors of PTSD in traffic accident victims. Primary search was conducted in November 2021 and updated in 2023. Studies were excluded if they used any analysis except regression for predictors. Cumulatively, primary and update searches retrieved 10,392 articles from databases, and of these, 87 studies were systematically reviewed. The predictors were categorized into sociodemographics, pretrauma, peritrauma, and post-trauma factors. The PTSD assessment time varied between 2 weeks and 3 years. Being a woman, having depression and having a history of road traffic accidents pretraumatically, peritraumatic dissociative experiences, acute stress disorder diagnosis, rumination, higher injury severity, and involvement in litigation or compensation after the trauma were significant predictors of PTSD.

Cohort Profile: The China Severe Trauma Cohort (CSTC)

BACKGROUND

We sought to establish a prospective hospital-based cohort, featuring detailed multidimensional data of trauma patients with active follow-ups, which can be a reliable data source for all studies focusing on the effects or underlying mechanistic pathways of environmental and biological factors on multiple interested trauma-related outcomes, particularly the incidence and trajectory of trauma-related psychopathology, in a Chinese population.

METHODS

The China Severe Trauma Cohort (CSTC) enrolled all traumatized individuals aged 12 to 80 years admitted to the Trauma Center of West China Hospital between March 1st, 2020 and July 8th, 2022. The bio-sample and detailed questionnaire data were collected at recruitment, and phone/internet follow-ups were scheduled at 1, 3, 6, and 12 months after the baseline. Long-term health outcomes are planned to be obtained from administrative databases through data linkage.

RESULTS

A total of 2,500 trauma patients were enrolled (response rate = 87.1%) with an average age of 46.01 years, and most of the participants were males (62.6%). The proportions of participants with blood and fecal sample collected at baseline were 93.8% and 66.3%, respectively. As of August 31st, 2022, the follow-up rate was 90.0%, 77.0%, 76.5%, and 89.0% for 1-, 3-, 6-, and 12-month follow-ups, respectively. Fall/wrench (47.6%) and traffic accident (26.2%) were the top causes of current trauma. The most common psychopathology at recruitment was sleep disturbance (39.4%), followed by depression (22.6%), anxiety (18.2%), and acute stress reaction (7.8%), all of which showed recovering trajectories during the follow-up period, particularly the first 3 months after baseline.

CONCLUSION

CSTC provides a platform with multidimensional data to study both short-term and long-term trauma-related health consequences, prompting early identification and intervention for individuals with high risk of health decline after trauma exposures.

Ketamine as a therapeutic agent in major depressive disorder and posttraumatic stress disorder: Potential medicinal and deleterious effects

Major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) are the most common causes of emotional distress that impair an individual's quality of life. MDD is a chronic mental illness that affects 300 million people across the world. Clinical manifestations of MDD include fatigue, loss of interest in routine tasks, psychomotor agitation, impaired ability to focus, suicidal ideation, hypersomnolence, altered psychosocial functioning, and appetite loss. Individuals with depression also demonstrate a reduced behavioral response while experiencing pleasure, a symptom known as anhedonia. Like MDD, PTSD is a prevalent and debilitating psychiatric disorder resulting from a traumatic incident such as sexual assault, war, severe accident, or natural disaster. Symptoms such as recalling event phases, hypervigilance, irritability, and anhedonia are common in PTSD. Both MDD and PTSD pose enormous socioeconomic burdens across the globe. The search for effective treatment with minimal side effects is still ongoing. Ketamine is known for its anesthetic and analgesic properties. Psychedelic and psychotropic effects of ketamine have been found on the nervous system, which highlights its toxicity. In this article, the effectiveness of ketamine as a potential therapeutic for PTSD and MDD along with its mechanisms of action, clinical trials, and possible side effects have been discussed.

The role of post-trauma stress symptoms in the development of chronic musculoskeletal pain and disability: A systematic review

BACKGROUND AND OBJECTIVE

Traumatic injuries are amongst the leading causes of death and disability in the world across all age groups. This systematic review aimed to (1) describe the role of post-traumatic stress symptoms (PTSS) on the development of chronic pain and/or pain-related disability following musculoskeletal trauma and (2) report pain and or pain-related disability by injury severity/type.

DATABASE AND DATA TREATMENT

Electronic databases were searched, from inception to 31 November 2021 and updated on 10 May 2022, to identify studies in which: participants were adults aged ≥16 years sustaining any traumatic event that resulted in one or more musculoskeletal injuries; an outcome measure of PTSS was used within 3 months of a traumatic event; the presence of pain and/or pain-related disability was recorded at a follow-up of 3 months or more. Two reviewers independently screened papers and assessed the quality of included studies.

RESULTS

Eight studies were included. Owing to between-study heterogeneity, the results were synthesized using a narrative approach. Five studies investigated the relationship between PTSS and pain. Participants with PTSS were more likely to develop persistent pain for at least 12 months post-injury. Six studies assessed the relationship between PTSS and pain-related disability. The results suggest that patients with PTSS had significantly higher disability levels for at least 12 months post-injury.

CONCLUSION

Findings from this comprehensive systematic review support a clear relationship between PTSS post-injury and future pain/disability, with the potential importance of certain PTSS clusters (hyper-arousal and numbing).

SIGNIFICANCE

The findings of this systematic review indicate an association between PTSS reported within 3 months of a traumatic musculoskeletal injury and the development of longer-term pain and disability. The PTSS clusters of 'hyper-arousal' and 'numbing' appear to be of particular importance in this relationship.

PROSPERO REGISTRATION NUMBER

CRD42021285243.

Development of posttraumatic stress disorder and depression after open globe injury in adults

PURPOSE

To investigate the prevalence of posttraumatic stress disorder (PTSD) and depression after open globe injury in adults.

METHODS

A total of 95 participants, 43 adult patients with open globe injury and 52 age-sex similar subjects (control group), were included in this cross-sectional study. Age, gender, education level, occupation, accident history, psychiatric history, trauma type, cause of trauma, and visual acuity were recorded. One to six months after trauma, PTSD and depression symptoms of the participants were evaluated with the Posttraumatic Stress Disorder Questionnaire-Civil Version Scale (PTSD-S) and Beck Depression Inventory (BDI), respectively.

RESULTS

Patients with open globe injury had a higher PTSD-S total score than the control group, but not significant (23.67 ± 20.41 vs. 18.56 ± 13.13, p = 0.580). Patients with eye trauma exhibited a much higher prevalence of PTSD compared to the control group (20.9% vs. 3.8%, p = 0.010). Patients with trauma had a significantly higher BDI total score than the control group (12.47 ± 10.08 vs. 7.69 ± 6.10, p = 0.015). Also, patients had a higher rate of depression symptoms than controls (25.6% vs. 7.7%, p = 0.017). A significant positive correlation was observed between PTSD-S and BDI scores in the trauma group (r = 0.720, p < 0.001).

CONCLUSION

An increased prevalence of PTSD and depression was observed in adults after open globe injury. The significant relationship between PTSD-S and BDI scores indicates that patients with open globe injuries should be questioned in terms of both symptoms. For patients with open globe trauma, a holistic approach with psychosocial assessment in addition to physical intervention would be beneficial.

Traumatic stress in Egyptian doctors during COVID-19 pandemic

COVID-19 pandemic has heavily burdened healthcare systems throughout the world, causing substantial mental distress to medical professionals. We aim to investigate the associated traumatic stress in a sample of practicing physicians in Egypt during the COVID-19 pandemic. This cross-sectional study assessed depression, and Post-traumatic stress disorder (PTSD) among a sample of Egyptian physicians using an electronic survey. It included demographic and practice-related data, PTSD Checklist - Civilian Version (PCL-C) and the nine-item Patient Health Questionnaire (PHQ-9). Of the 124 respondents, 66.9% were at high risk for depression and 37.9% met criteria for diagnosis of PTSD. Female gender and perceived work-related stress were significantly associated with PTSD. PTSD and depression severity scores were positively correlated. These findings highlight the importance of timely mental support and intervention for medical workers.

Dynamic changes in brain structure in patients with post-traumatic stress disorder after motor vehicle accident: A voxel-based morphometry-based follow-up study

Objectives

To investigate the dynamic changes of emotional and memory-related brain regions in post-traumatic stress disorder (PTSD) patients and trauma-exposed subjects, who experienced motor vehicle accident (MVA).

Materials and methods

Functional Magnetic Resonance imaging (fMRI) and general data were collected from trauma victims who had experienced MVA within 2 days, and their social support and coping style were evaluated. The PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5) is used for screening and diagnosis. Subsequently, 17 PTSD patients and 23 car accident trauma-exposed individuals completed a second fMRI scan at 2 months. Data were analyzed by using voxel-based morphometry (VBM) to examine the volume changes of relevant brain regions. Correlation analysis was used to assess the correlation between the regions of interest (ROIs) and the total scores on the clinical scales. Subsequently, the relationship between the total PCL-5 scores and the individual dimensions of the Simplified Coping Style Questionnaire (SCSQ) and the Social Support Rate Scale (SSRS) was studied.

Results

In comparison with the control group, the results showed a reduction in right SFG volume in the PTSD group at 2 months. Similarly, a comparison within the PTSD group revealed a reduction in the left STG volume at 2 months. Compared with the control group, PTSD patients showed a more negative coping style and worse performance in objective and subjective support. In addition, the total PCL-5 scores were negatively associated with positive coping, objective support, and subjective support.

Conclusion

The occurrence of PTSD may be related to reduced volume of the right SFG and left STG, and that patients with PTSD receive less social support and tend to cope in a negative manner in the face of stressful events. These results suggest that within 2 months of the MVA, changes in gray matter volume have occurred in some brain regions of those suffering from PTSD. We believe the results of our study will provide useful insights into the neuropsychological mechanisms underlying PTSD.

Anxiety, Depression, and Post-Traumatic Stress Disorder (PTSD) Symptomatology According to Gender in Health-Care Workers during the COVID-19 Pandemic in Peru Shortened Title: "Psychological Impact of the Pandemic on Women"

OBJECTIVE

The current study will evaluate the association that the COVID-19 pandemic has had with health-care workers and identify the factors that influenced the female gender being more affected.

METHODS

This is a cross-sectional study conducted in two hospitals in Arequipa (a Peruvian city). The participants were health-care workers. We applied a questionnaire with sociodemographic information and three scales: the Generalized Anxiety Disorder-7, the Patient Health Questionnaire-9, and the Primary Care Post-Traumatic Stress Disorder (PTSD) Screen for DSM-5. The main outcomes were anxiety, depression, and PTSD scores. The exposure of interest was gender. The scores of the scales were estimated by medians and percentiles 25-75 (p25-p75), and we used linear regression to estimate the crude and adjusted coefficients and their respective confidence intervals at 95% (CI 95%).

RESULTS

There were 109 participants, and 43.1% were women. The anxiety, depression, and PTSD median (p25-p75) scores in the study population were 6 (2-11), 6 (2-10), and 1 (0-3), respectively. The adjusted analysis showed that the female sex had 4.48 (CI 95% 2.95-6.00), 4.50 (CI 95% 2.39-6.62), and 1.13 (CI 95% 0.50-1.76) higher points on average for the scales of anxiety, depression, and PTSD symptoms in comparison to males, respectively.

CONCLUSIONS

Female health-care workers showed increased scores of mental health issues in comparison to male health-care workers.

Latent classes of posttraumatic stress disorder among survivors of the Bam Earthquake after 17 years

BACKGROUND

The purpose of this study was to identify latent classes of the severity of post-traumatic stress disorder (PTSD) among the survivors of the earthquake in Bam, south-eastern Iran, 17 years after the disaster. The most influential predictor variables of PTSD classes were also investigated.

METHODS

Eight hundred survivors of the Bam earthquake who were at least four years old in that disaster were selected by multistage sampling. The PTSD Checklist-Civilian Version was used. Latent class analysis was performed to identify subgroups of people with different PTSD symptom profiles. Latent class regression analysis was used to explore the influence of demographic and traumatic variables on each class membership.

RESULTS

We found three latent classes of PTSD, with the following profiles emerging: Low Symptom (56.6% of the participants), Moderate Symptom (23.5%), and Severe Symptom (19.9%). Old age [OR = 2.20, 95% CI = (1.46, 3.32)], physical injury [OR = 1.95, 95% CI = (1.24, 3.06)], being trapped under the rubble [OR = 1.81, 95% CI = (1.15, 2.86)], and death of a family member [OR = 1.86, 95% CI = (1.12, 3.09)] were positive risk factors for PTSD and increased the chance of being in classes having more severe symptoms. Having a high educational level was a negative risk factor [OR = 0.86, 95% CI = (0.67, 1.11)].

CONCLUSIONS

The severity of PTSD 17 years after the earthquake shows that natural disasters such as earthquakes have long-term consequences, and earthquake survivors must have psychological support and long term health care. After any catastrophic earthquake, governments should establish psychology and psychotherapy centers for earthquake victims, and these centers should support earthquake victims for a sufficiently long time.

The Association Between Sleep Disturbance and Health Outcomes in Chronic Whiplash-Associated Disorders: A Series of Mediation Analyses

OBJECTIVES

To investigate the association between sleep disturbance and clinical features of chronic whiplash-associated disorders. We also aimed to use a bootstrapped mediation analysis approach to systematically examine both direct and indirect pathways by which sleep disturbance may affect chronic pain and functional status.

METHODS

One hundred and sixty-five people (63% female) with chronic whiplash-associated disorders and not taking medications for sleep disturbance completed questionnaires evaluating sleep disturbance, pain intensity, pain interference, disability, physical and mental health quality of life, stress, anxiety, depression, pain catastrophizing, and posttraumatic stress severity.

RESULTS

Greater sleep disturbance was associated with increased duration of symptoms, higher levels of pain and disability, higher levels of emotional distress and pain catastrophizing, and functional impairment (reduced health-related quality of life). Mediation analyses demonstrated that sleep disturbance influenced chronic pain intensity and interference through both direct and indirect associations inclusive of stress, anxiety and pain catastrophizing. Similarly, sleep disturbance was associated with higher levels of disability and poor health-related quality of life, both directly and also through its negative association with pain intensity and interference.

DISCUSSION

Sleep disturbance in chronic WAD was associated with worse health outcomes and demonstrated both direct and indirect effects on both chronic pain and function.

Estimating Risk of Chronic Pain and Disability Following Musculoskeletal Trauma in the United Kingdom

IMPORTANCE

Serious traumatic injury is a leading cause of death and disability globally, with most survivors known to develop chronic pain.

OBJECTIVE

To describe early variables associated with poor long-term outcome for posttrauma pain and create a clinical screening tool for this purpose.

DESIGN, SETTING, AND PARTICIPANTS

This was a prospective cohort study at a major trauma center hospital in England. Recruitment commenced in December 2018 and ceased in March 2020. Participants were followed up for 12 months. Patients aged 16 years or older who were hospitalized because of acute musculoskeletal trauma within the preceding 14 days were included. Data were analyzed from March to December 2021.

EXPOSURE

Acute musculoskeletal trauma requiring admittance to a major trauma center hospital.

MAIN OUTCOMES AND MEASURES

A poor outcome was defined as Chronic Pain Grade II or higher and measured at both 6 months (primary time point) and 12 months. A broad range of candidate variables potentially associated with outcomes were used, including surrogates for pain mechanisms, quantitative sensory testing, and psychosocial factors. Univariable models were used to identify the variables most likely to be associated with poor outcome, which were entered into multivariable models. A clinical screening tool (nomogram) was derived from 6-month results.

RESULTS

In total, 1590 consecutive patients were assessed for eligibility, of whom 772 were deemed eligible and 124 (80 male [64.5%]; mean [SD] age, 48.9 [18.8] years) were recruited. At 6 months, 19 of 82 respondents (23.2%) reported a good outcome, whereas at 12 months 27 of 44 respondents (61.4%) reported a good outcome. At 6 months on univariable analysis, an increase in total posttraumatic stress symptoms (odds ratio [OR], 2.09; 95% CI, 1.33-3.28), pain intensity average (OR, 2.87; 95% CI, 1.37-6.00), number of fractures (OR, 2.79; 95% CI, 1.02-7.64), and pain extent (OR, 4.67; 95% CI, 1.57-13.87) were associated with worse outcomes. A multivariable model including those variables had a sensitivity of 0.93, a specificity of 0.54, and C-index of 0.92.

CONCLUSIONS AND RELEVANCE

A poor long-term pain outcome from musculoskeletal traumatic injuries may be estimated by measures recorded within days of injury. These findings suggest that posttraumatic stress symptoms, pain spatial distribution, perceived average pain intensity, and number of fractures are good candidates for a sensitive multivariable model and derived clinical screening tool.

Psychological therapy using virtual reality for treatment of driving phobia: a systematic review

PURPOSE

Driving phobia is prevalent in injured individuals following motor vehicle crashes (MVCs). The evidence for virtual reality (VR) based psychological treatments for driving phobia is unknown. This systematic review synthesized the available evidence on the effectiveness, feasibility, and user experience of psychological treatments for driving phobia using VR.

METHODS

Three databases (PsycINFO, SCOPUS, and PubMed) were searched. Eligibility criteria included adults with clinical or sub-clinical levels of driving phobia manifesting as part of an anxiety disorder or post-traumatic stress disorder (PTSD). Primary outcomes were driving-related anxiety/fear or avoidance, PTSD symptoms and driving frequency/intensity, as well as treatment feasibility including recruitment, treatment completion and retention rates, user experience and immersion/presence in the VR program. Secondary outcomes were other health outcomes (e.g., depression) and VR technological features.

RESULTS

The 14 included studies were of low methodological quality. Clinical and methodological heterogeneity prevented quantitative pooling of data. The evidence provided in this review is limited by trials with small sample sizes, and lack of diagnostic clarity, controlled designs, and long-term assessment. The evidence did suggest that VR-based psychological interventions could be feasible and acceptable in this population.

CONCLUSIONS

For VR-based psychological interventions to be recommended for driving phobia, more high-quality trials are needed. Implications for rehabilitationVirtual reality (VR) based psychological treatments may be feasible and acceptable to patients with driving phobia.There is potential to increase accessibility to psychological therapies in patients with driving phobia following motor vehicle crashes through the use of digital psychiatry such as VR.

A randomized controlled trial of the influence of yoga for women with symptoms of post-traumatic stress disorder

Background

Survivors in motor vehicle accident (MVA) may have posttraumatic stress disorder (PTSD). Yoga is a complementary approach for PTSD therapy.

Methods

This randomized controlled trial explored whether yoga intervention has effects on reducing the symptoms of PTSD in women survived in MVA. Participants (n = 94) were recruited and randomized into control group or yoga group. Participants attended 6 45-minuite yoga sessions in 12 weeks. Depression Anxiety Stress Scales (DASS) and Impact of Events Scale-Revised (IES-R) were used to assess psychological distress.

Results

Post-intervention IES-R total score of yoga group was significantly lower than that of control group (p = 0.01). At both post-intervention and 3-months post intervention, the DASS-21 total scores of yoga group were both significantly lower than those of control group (p = 0.043, p = 0.024). Yoga group showed lower anxiety and depression level compared to control group at both post-intervention (p = 0.033, p < 0.001) and post-follow-up (p = 0.004, p = 0.035). Yoga group had lower levels of intrusion and avoidance compared to control group after intervention (p = 0.002, p < 0.001).

Conclusion

Results illustrate that yoga intervention may alleviate anxiety and depression and improve the symptoms of PTSD in women with PTSD following MVA.

Prevalence and Risk Factors of Post-Traumatic Stress Disorder in Survivors of a Cohort of Road Accident Victims in Benin: Results of a 12-Month Cross-Sectional Study

Purpose

Post-traumatic stress disorder (PTSD) is a frequent psychiatric complication in road accident survivors. However, it remains under-explored and is not taken into account in health policies in Benin. The purpose of this study was to determine the prevalence and risk factors of PTSD after a road traffic accident. This will help to improve its diagnosis and management in Benin hospitals.

Materials and Methods

An institution-based cross-sectional study was conducted from November 2020 to January 2021. Consenting victims of road traffic accidents from three hospitals across Benin, aged 18 years and above, living in the south of the country, were administered various questionnaires at 12-month follow-up. Data on PTSD were collected using a pre-tested, structured and standardized post-traumatic stress disorder questionnaire, the PTSD Checklist (specific version) (PCL-S). A logistic regression model was fitted to identify factors associated with PTSD. An adjusted odds ratio (AOR) followed by a 95% confidence interval was calculated to determine the level of significance with a p-value less than 0.05.

Results

Out of 865 patients in the cohort eligible for the 12-month follow-up, 734 (85%) participated in the study. The prevalence of PTSD was 26.43% (95% CI: 23.36–29.75). Factors associated with PTSD on multivariate analysis were female gender (adjusted odds ratio (AOR) = 2.14, 95% CI: 1.38–3.33), hospitalization (AOR = 1.87, 95% CI 1.21–2.89), negative impact of the accident on income (AOR = 4.22, 95% CI: 2.16–8.25), and no return to work (AOR = 3.17, 95% CI: 1.99–5.06).

Conclusion

The prevalence of PTSD is high in road accident survivors in Benin. The results of this study highlight the need for early diagnosis and a multidisciplinary approach to the management of PTSD patients in Benin’s hospitals.

Four Questions Nurses Can Ask to Predict PTSD 1 Year After a Motor Vehicle Crash

BACKGROUND

The role of nurses in screening for posttraumatic stress disorder is crucial in trauma units.

OBJECTIVES

To create and evaluate an easy and brief tool for nurses to predict chronic posttraumatic stress disorder 1 year after a motor vehicle crash.

METHODS

We performed a 1-year follow-up multicenter study from 2007 to 2015, including 274 patients injured in a motor vehicle crash who were hospitalized in an orthopedic trauma unit. Nurses administered the DEPITAC questionnaire. Posttraumatic stress disorder was measured by the Post-Traumatic Stress Disorder Checklist of symptoms during the first year following the crash. A multivariable logistic regression model was implemented to select items significantly associated with posttraumatic stress disorder to improve the DEPITAC questionnaire. Predictive performance to predict posttraumatic stress disorder 1 year after the motor vehicle crash was examined for these different models.

RESULTS

Of 274 patients studied, a total of 75.9% completed the questionnaire at 1 year of follow-up. We found that only two questions and two simple elements of the patient's medical record (other injury or a person dying during the crash, perception of vital threat, number of children, and length of stay in trauma) predicted posttraumatic stress disorder 1 year after a motor vehicle crash.

CONCLUSIONS

The brevity of this evaluation, simple scoring rules, and screening test performance suggest that this new screening tool can be easily administered in the acute care setting by nurses.

Revealing Unknown Benefits of Existing Medications to Aid the Discovery of New Treatments for Post‐Traumatic Stress Disorder

Objective

To systematically identify novel pharmacological strategies for preventing or treating post‐traumatic stress disorder (PTSD) by leveraging large‐scale analysis of real‐world observational data.

Methods

Using a self‐controlled study design, the association between 1399 medications and the incidence of PTSD across four US insurance claims databases covering commercially insured, Medicare eligible, and Medicaid patients was examined. A validated algorithm for identifying PTSD in claims data was used, and medications were identified by their RxNorm ingredient. Medications used to treat PTSD or its symptoms (e.g., antidepressants, antipsychotics) were excluded. Medications associated with ≥30% reduction in risk of PTSD in ≥2 databases were identified.

Results

A total of 137,182,179 individuals were included in the analysis. Fifteen medications met the threshold criteria for a potential protective effect on PTSD; six were categorized as “primary signals” while the remaining nine were considered “potential signals”. The primary signals include a beta blocker that has been previously studied for PTSD, and five medications used to treat attention‐deficit/hyperactivity disorder. The potential signals include four medications used to treat substance use disorders and five medications used to treat sleep disorders.

Discussion

The medications identified in this analysis provide targets for further research in studies that are designed to examine specific hypotheses regarding these medications and the incidence of PTSD. This work may aid in discovering novel therapeutic approaches to treat PTSD, wherein new and effective treatments are badly needed.

Four large US‐based administrative claims databases were used to analyze the association between all marketed prescription medications and the outcome of incident post‐traumatic stress disorder (PTSD)

Of the 1399 medications examined, there were 15 that met the strict filtering criteria for showing consistent, moderate‐to‐strong, protective effects against the outcome

Medications fell into four main classes: (1) a beta blocker (propranolol), (2) five medications used to treat attention‐deficit/hyperactivity disorder (ADHD), (3) four medications used to treat substance use disorders and (4) five medications used to treat sleep disorders

These findings identify rational starting points for future hypothesis‐driven research to explore these associations in greater detail

Traumatic stress, depression, and non-bereavement grief following non-fatal traffic accidents: Symptom patterns and correlates

Non-fatal traffic accidents may give rise to mental health problems, including posttraumatic stress (PTS) and depression. Clinical evidence suggests that victims may also experience grief reactions associated with the sudden changes and losses caused by such accidents. The aim of this study was to examine whether there are unique patterns of symptoms of PTS, depression, and grief among victims of non-fatal traffic accidents. We also investigated associations of emerging symptom patterns with sociodemographic variables and characteristics of the accident, and with transdiagnostic variables, including self-efficacy, difficulties in emotion regulation, and trauma rumination. Participants (N = 328, Mage = 32.6, SDage = 17.5 years, 66% female) completed self-report measures tapping the study variables. Using latent class analysis (including symptoms of PTS, depression, and grief), three classes were identified: a no symptoms class (Class 1; 59.1%), a moderate PTS and grief class (Class 2; 23.1%), and a severe symptoms class (Class 3; 17.7%). Summed symptom scores and functional impairment were lowest in Class 1, higher in Class 2, and highest in Class 3. Psychological variables were similarly ordered with the healthiest scores in Class 1, poorer scores in Class 2, and the worst scores in Class 3. Different sociodemographic and accident related variables differentiated between classes, including age, education, and time since the accident. In a regression including all significant univariate predictors, trauma rumination differentiated Class 2 from Class 1, all three psychological variables differentiated Class 3 from Class 1, and difficulties with emotion regulation and trauma rumination differentiated Class 3 from Class 2. This study demonstrates that most people respond resiliently to non-fatal traffic accident. Yet, approximately one in three victims experiences moderate to severe mental health symptoms. Increasing PTS coincided with similarly increasing grief, indicating that grief may be considered in interventions for victims of traffic accidents. Trauma rumination strongly predicted class membership and appears a critical treatment target to alleviate distress.

Written Exposure Therapy for Korean Adolescents With PTSD: Four Case Studies

Research shows that cognitive behavioral therapy (CBT) is the most effective approach for treating children and adolescents with post-traumatic stress disorder (PTSD). However, evidence regarding CBT for adolescents with PTSD in Korea is lacking. Written Exposure Therapy (WET), which has the advantages of brevity and tolerability, has important clinical implications as an option for effective treatment of PTSD in the context of the Korean medical system. We aimed to examine the application of WET to adolescents through the cases of four Korean adolescents who underwent WET. The treatment experiences of the four adolescent participants with PTSD are presented, and insights based on their pre- and post-treatment research assessments are discussed. Although evidence is insufficient, our study suggests that WET can be considered a suitable treatment for adolescents who do not have a history of childhood abuse and have a relatively good support system.

Pre-trauma predictors of severe psychiatric comorbidity 5 years following traumatic experiences

BACKGROUND

A minority of persons who have traumatic experiences go on to develop post-traumatic stress disorder (PTSD), leading to interest in who is at risk for psychopathology after these experiences. Complicating this effort is the observation that post-traumatic psychopathology is heterogeneous. The goal of this nested case-control study was to identify pre-trauma predictors of severe post-traumatic psychiatric comorbidity, using data from Danish registries.

METHODS

The source population for this study was the population of Denmark from 1994 through 2016. Cases had received three or more psychiatric diagnoses (across all ICD-10 categories) within 5 years of a traumatic experience (n = 20 361); controls were sampled from the parent cohort using risk-set sampling (n = 81 444). Analyses were repeated in samples stratified by pre-trauma psychiatric diagnoses. We used machine learning methods (classification and regression trees and random forest) to determine the important predictors of severe post-trauma psychiatric comorbidity from among hundreds of pre-trauma predictor variables spanning demographic and social variables, psychiatric and somatic diagnoses and filled medication prescriptions.

RESULTS

In the full sample, pre-trauma psychiatric diagnoses (e.g. stress disorders, alcohol-related disorders, personality disorders) were the most important predictors of severe post-trauma psychiatric comorbidity. Among persons with no pre-trauma psychiatric diagnoses, demographic and social variables (e.g. marital status), type of trauma, medications used primarily to treat psychiatric symptomatology, anti-inflammatory medications and gastrointestinal distress were important to prediction. Results among persons with pre-trauma psychiatric diagnoses were consistent with the overall sample.

CONCLUSIONS

This study builds on the understanding of pre-trauma factors that predict psychopathology following traumatic experiences, by examining a broad range of predictors of post-trauma psychopathology and comorbidity beyond PTSD.

Concurrent associations of dimensions of anger with posttraumatic stress, depression, and functional impairment following non-fatal traffic accidents

BACKGROUND

Anger is associated with dysfunction following potentially traumatic events. It is still unclear to what extent different types of anger are differentially related to poor outcomes. To advance knowledge in this area, the Posttraumatic Anger Questionnaire (PAQ) was designed, measuring anger directed at (i) the justice system, (ii) other people, (iii) the self, (iv) people held accountable for the potential traumatic event, and (v) a desire for revenge to those held responsible. Preliminary evidence shows that these types of anger are distinguishable and differentially associated with posttraumatic stress (PTS). No studies have yet examined whether such findings can be generalized to victims of non-fatal traffic accidents, one of the most common potentially traumatic events.

OBJECTIVE

This study's aims were (i) to establish if the five-factor structure of the PAQ found in prior studies could be replicated, (ii) to explore whether the intensity of emerging types of anger differed, and (iii) to explore the associations of anger-types with levels of PTS, depression, and functional impairment.

METHOD

Two-hundred and fifty adults who experienced a traffic accident completed the PAQ and instruments measuring PTS, depression, and functional impairment. They also answered questions about their socio-demographic characteristics and features of the accident.

RESULTS

Confirmatory factor analysis confirmed that the PAQ measures five types of anger. Levels of anger at people held accountable were the highest. Structural equation modelling showed that both anger at others and anger at the self, but not the other three anger types, were associated with PTS, depression, and functional impairment, when controlling for the shared variance between the anger types, socio-demographic variables, and features of the accident.

CONCLUSIONS

Findings illustrate the potential importance of considering different types of anger when assessing and treating PTS following traffic accidents.

HIGHLIGHTS

Based on data from people confronted with a traffic accident, we found the Posttraumatic Anger Questionnaire (PAQ) to represent distinguishable dimensions of anger.Anger dimensions were: anger directed at (i) the justice system, (ii) other people, (iii) the self, (iv) people held accountable for the event, and (v) a desire for revenge to those held responsible.Scores on items measuring anger at people held accountable for the event were significantly higher than scores on items measuring other anger types.Anger at the self and other people were most strongly associated with posttraumatic stress, depression, and functional impairment.

Prior histories of posttraumatic stress disorder and major depression and their onset and course in the three months after a motor vehicle collision in the AURORA study

BACKGROUND

A better understanding of the extent to which prior occurrences of posttraumatic stress disorder (PTSD) and major depressive episode (MDE) predict psychopathological reactions to subsequent traumas might be useful in targeting posttraumatic preventive interventions.

METHODS

Data come from 1306 patients presenting to 29 U.S. emergency departments (EDs) after a motor vehicle collision (MVC) in the advancing understanding of recovery after trauma study. Patients completed self-reports in the ED and 2-weeks, 8-weeks, and 3-months post-MVC. Associations of pre-MVC probable PTSD and probable MDE histories with subsequent 3-months post-MVC probable PTSD and probable MDE were examined along with mediation through intervening peritraumatic, 2-, and 8-week disorders.

RESULTS

27.6% of patients had 3-month post-MVC probable PTSD and/or MDE. Pre-MVC lifetime histories of these disorders were not only significant (relative risk = 2.6-7.4) but were dominant (63.1% population attributable risk proportion [PARP]) predictors of this 3-month outcome, with 46.6% prevalence of the outcome among patients with pre-MVC disorder histories versus 9.9% among those without such histories. The associations of pre-MVC lifetime disorders with the 3-month outcome were mediated largely by 2- and 8-week probable PTSD and MDE (PARP decreasing to 22.8% with controls for these intervening disorders). Decomposition showed that pre-MVC lifetime histories predicted both onset and persistence of these intervening disorders as well as the higher conditional prevalence of the 3-month outcome in the presence of these intervening disorders.

CONCLUSIONS

Assessments of pre-MVC PTSD and MDE histories and follow-ups at 2 and 8 weeks could help target early interventions for psychopathological reactions to MVCs.

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.

Deep learning model of fMRI connectivity predicts PTSD symptom trajectories in recent trauma survivors

Early intervention following exposure to a traumatic life event could change the clinical path from the development of post traumatic stress disorder (PTSD) to recovery, hence the interest in early detection and underlying biological mechanisms involved in the development of post traumatic sequelae. We introduce a novel end-to-end neural network that employs resting-state and task-based functional MRI (fMRI) datasets, obtained one month after trauma exposure, to predict PTSD symptoms at one-, six- and fourteen-months after the exposure. FMRI data, as well as PTSD status and symptoms, were collected from adults at risk for PTSD development, after admission to emergency room following a traumatic event. Our computational method utilized a per-region encoder to extract brain regions embedding, which were subsequently updated by applying the algorithmic technique of pairwise attention. The affinities obtained between each pair of regions were combined to create a pairwise co-activation map used to perform multi-label classification. The results demonstrate that the novel method's performance in predicting PTSD symptoms, in a prospective manner, outperforms previous analytical techniques reported in the fMRI literature, all trained on the same dataset. We further show a high predictive ability for predicting PTSD symptom clusters and PTSD persistence. To the best of our knowledge, this is the first deep learning method applied on fMRI data with respect to prospective clinical outcomes, to predict PTSD status, severity and symptom clusters. Future work could further delineate the mechanisms that underlie such a prediction, and potentially improve single patient characterization.

Comparison of trauma scores and total prehospital time in the prediction of clinical course in a plane crash: Does timing matter?

OBJECTIVE

To investigate how the total prehospital time (TPT), Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), and Trauma Score-Injury Severity Score (TRISS) affect the outcome of plane crash victims from anatomical, physiological and psychological perspectives. The accuracy or strength of these scores and TPT in predicting hospitalization and surgery, sequelae development and psychiatric complications [permanent temporary disability (PoTDs)] and PTSD can allow medical professionals to direct and prioritize management efforts of the victims of mass casualties in general.

METHODS

The study was designed as a single-center retrospective study. By examining the records of victims of a plane crash transferred to the ED, AIS, ISS, TRISS and TPT were calculated on admission. The clinical severity of the patients was determined by a joint decision of five clinicians. The performances of the trauma scores on hospitalization, surgery, PTSD and PoTDs were compared. The study data were analyzed via the Mann-Whitney U test and descriptive statistical methods. Pearson's chi-square test was used for the comparison of qualitative data, and ROC analyses were employed to determine cutoff levels.

RESULTS

The AIS, ISS, and TRISS scores of the victims with an indication for hospitalization, calculated on admission to the ED, were significantly higher than those of the other victims (p = 0.001). In addition, TPT, AIS, ISS, and TRISS scores were significantly higher in hospitalized patients than in outpatients (p < 0.05). The cutoff levels for AIS and ISS were ≥ 1.50 and ≥ 4.50, respectively, while they were ≥ 123.5 min for TPT with regard to hospitalization decisions. The AIS, ISS, and TRISS scores calculated on admission for the patients who underwent surgery were significantly higher than those who did not (p = 0.001). Cutoff levels for AIS and ISS were ≥ 2.50 and ≥ 11.50, respectively, while they were ≥ 135.5 min for TPT with respect to the decision to operate on the victims.

CONCLUSIONS

It is expected that everyone who practices medicine be equipped to handle multiple casualties. As the number of people involved in mass casualties increases, diagnostic tools, workups such as laboratory and radiological studies, and prognostic markers such as trauma scores should be simpler and more user-friendly.

Infectious Disease Outbreak and Post-Traumatic Stress Symptoms: A Systematic Review and Meta-Analysis

Background: As one of the most widely researched consequence of traumatic events, the prevalence of post-traumatic stress symptoms (PTSS) among people exposed to the trauma resulting from infectious disease outbreak varies greatly across studies. This review aimed at examining the pooled prevalence of PTSS among people exposed to the trauma resulting from infectious disease outbreak, summarizing the possible causes of the inconsistencies in the current estimates. Methods: Systematic searches of databases were conducted for literature published on PubMed, EMBASE, Web of Science, the Cochrane Library, PsycArticles, and Chinese National Knowledge Infrastructure (CNKI) until 14 October 2020. Statistical analyses were performed using R software (registration number: CRD42020182366). Results: About 106 studies were included. The results showed that the pooled prevalence of PTSS among the general population exposed to the trauma resulting from infectious disease outbreak was 24.20% (95% CI: 18.54-30.53%), the pooled prevalence of PTSS among healthcare workers was 24.35% (95% CI: 18.38-1.51%), the pooled prevalence of PTSS among patients with infectious disease was 28.83% (95% CI: 18.53-44.86%), and the pooled prevalence of PTSS among suspected cases of infectious disease was 25.04% (95% CI: 18.05-34.73%). Mortality rate was a significant contributor to heterogeneity. Conclusions: Evidence suggests that PTSS were very common among people exposed to the trauma resulting from infectious disease outbreak. Health policymakers should consider both short-term and long-term preventive strategy of PTSS.

The contribution of pre-injury vulnerability to risk of psychiatric morbidity in adults injured in a road traffic crash: Comparisons with non-injury controls

People who sustain injury in a road traffic crash (RTC) have significant risk of psychiatric morbidity, but effective screening for identifying at-risk individuals soon after the RTC is lacking. We investigated whether pre-injury vulnerability can assist as an early screen to manage this risk. We recruited 120 adults who sustained physical injury in a RTC and admitted to an emergency department (ED). They were comprehensively assessed for acute and long-term presence of psychiatric disorder/morbidity and disability over 12-months after the injury, with comparisons to a non-injury control. Propensity matching based on six pre-injury vulnerability factors (age, sex, education, socioeconomic status, prior mental health, prior physical health) with the control group was used to determine membership of high vulnerability (HV) and low vulnerability (LV) injury sub-groups. Compared to the LV sub-group and controls that had similar pre-injury vulnerability, the HV sub-group had a worrying post-RTC recovery profile, with significantly higher rates of long-term psychiatric morbidity (42.2% vs. 23.1% and 15.9% respectively, p = .002) including post-traumatic stress disorder and/or depression, and poorer psychological adjustment over the 12-months. In contrast, the HV and LV sub-groups were similar in injury-related characteristics and post-injury physical (pain, fatigue, physical functioning) and participation outcomes. Findings provide preliminary evidence that pre-injury vulnerability, primarily prior mental health status, is a promising screen for early identification of people at risk of psychiatric morbidity post-RTC. It is suggested this screen could be implemented in ED to prevent chronicity and improve recovery following a traumatic injury. Further research is warranted to enhance the screen's effectiveness.

Involvement in litigation in children with PTSD following motor vehicle accident: Associations with emotional distress and treatment outcomes

OBJECTIVES

Litigation is common in the context of Post-traumatic Stress Disorder (PTSD) and mild Traumatic Brain Injury (mTBI), adding contradicting motivations to individuals' engagement in psychotherapeutic interventions. This study's main goal was to explore the relationship between litigation status and emotional distress among children with PTSD following motor vehicle accidents (MVAs). We also present preliminary findings from a pilot study on treatment efficacy for children with PTSD, with and without litigation.

METHODS

Participants included 76 children with PTSD following MVA and their main caregiving parent. The associations between litigation status (litigation involvement, litigation phase, and litigation's emotional impact) and children's global distress, PTSD, persistent post-concussion symptoms (PPCS), and sub-optimal effort, and parents' PTSD symptoms were assessed before and after intervention for PTSD. Comorbid mTBI was explored as a possible moderating factor.

RESULTS

Involvement in litigation was not related to children's and parents' pre-intervention distress, nor to the presence of mTBI or to children's effort. However, higher emotional impact of litigation on parents was associated with children's higher PPCS pre-intervention. A pilot study on intervention outcomes found an improvement both in children with and without litigation involvement. A greater decrease in PPCS following intervention was found in children of parents with higher emotional impact of litigation.

CONCLUSIONS

The emotional impact of litigation on parents should be considered while addressing children in litigation context. However, this study's preliminary findings suggest that children with litigation involvement may benefit from treatment, thus litigation should not serve solely as an exclusion criterion for psychological intervention. A larger study should further explore this issue.

Socio-demographic and trauma-related predictors of PTSD within 8 weeks of a motor vehicle collision in the AURORA study

This is the initial report of results from the AURORA multisite longitudinal study of adverse post-traumatic neuropsychiatric sequelae (APNS) among participants seeking emergency department (ED) treatment in the aftermath of a traumatic life experience. We focus on n = 666 participants presenting to EDs following a motor vehicle collision (MVC) and examine associations of participant socio-demographic and participant-reported MVC characteristics with 8-week posttraumatic stress disorder (PTSD) adjusting for pre-MVC PTSD and mediated by peritraumatic symptoms and 2-week acute stress disorder (ASD). Peritraumatic Symptoms, ASD, and PTSD were assessed with self-report scales. Eight-week PTSD prevalence was relatively high (42.0%) and positively associated with participant sex (female), low socioeconomic status (education and income), and several self-report indicators of MVC severity. Most of these associations were entirely mediated by peritraumatic symptoms and, to a lesser degree, ASD, suggesting that the first 2 weeks after trauma may be a uniquely important time period for intervening to prevent and reduce risk of PTSD. This observation, coupled with substantial variation in the relative strength of mediating pathways across predictors, raises the possibility of diverse and potentially complex underlying biological and psychological processes that remain to be elucidated with more in-depth analyses of the rich and evolving AURORA data.

Trauma-focused cognitive behavioural therapy and exercise for chronic whiplash with comorbid posttraumatic stress disorder: a randomised controlled trial

ABSTRACT

Many people with chronic whiplash-associated disorders (WAD) have also symptoms of posttraumatic stress disorder (PTSD), but this is rarely considered in usual predominantly exercise-based interventions. We aimed to investigate the effectiveness of combined trauma-focused cognitive behavioural therapy (TF-CBT) and exercise compared with supportive therapy (ST) and exercise for people with chronic WAD and PTSD. A randomised controlled multicentre trial with concealed allocation, assessor blinding, and blinded analysis was conducted. One hundred three participants with chronic WAD (>3 months and <5 years, grade II) and PTSD were randomised to TF-CBT and exercise (n = 53) or ST and exercise (n = 50). Both interventions comprised 10 weeks of TF-CBT or ST, followed by 6 weeks of exercise. Outcomes were measured at baseline, 10, 16 weeks, 6, and 12 months after randomisation. Analysis was intention to treat using linear mixed models. There was no difference between the interventions on the primary outcome of neck pain-related disability at any time point. At 16 weeks, the treatment effect on the 0 to 100 Neck Disability Index was 0.59 (95% confidence interval [CI] 5.51 to -4.33), at 6 months 1.18 (95% CI 6.15 to -3.78), and at 12 months 1.85 (95% CI 6.81 to -3.11). In addition, there was no difference between the interventions for most secondary outcomes at any time. Exceptions were in favour of TF-CBT and exercise, where improvements in PTSD symptoms were found at 16 weeks. From 16 weeks onwards, both groups achieved a clinically important improvement in neck pain-related disability. However, both groups remained moderately disabled.

There's Nothing Broken. You've Had a Whiplash, That's It: A Qualitative Study of Comorbid Posttraumatic Stress Disorder and Whiplash Associated Disorders

BACKGROUND

Posttraumatic stress disorder (PTSD) symptoms are common in chronic Whiplash associated disorders (WAD) and have been found to be associated with higher levels of pain and disability. Theoretical frameworks have suggested that PTSD and pain not only coexist, but also mutually maintain one another. Although the comorbidity has been subject to increasing quantitative research, patients' experiences of the comorbidity and symptom interaction remain largely uninvestigated using qualitative methods.

OBJECTIVE

The present study set out to explore the potential relationship of PTSD and pain in people with WAD and properly assessed PTSD after motor vehicle accidents.

METHODS

A qualitative explorative study of eight individual face-to-face semistructured interviews were conducted. Interviews were recorded and transcribed verbatim and analyzed using framework analysis.

RESULTS

Through the analysis, we developed three overarching themes. The first theme illustrated the complex and burdensome comorbidity with overlapping and transdiagnostic symptoms, whereas the second theme highlighted how several circumstances, some related to the health care system, could extend and amplify the traumatic response. The final theme illustrated symptom associations and interactions, particularly between pain and PTSD, both supporting and rejecting parts of the mutual maintenance framework.

CONCLUSIONS

These findings underlined the great complexity and variability of the comorbidity and the traumatic event, but also emphasized how experiences of psyche and soma seem closely connected in these patients. The results provide support for the importance of thorough assessment by multidisciplinary teams, minimizing distress post-injury, and a critical approach to the idea of mutual maintenance between pain and PTSD.

Head- and neck-related symptoms post-motor vehicle collision (MVC): Separate entities or two-sides of the same coin?

BACKGROUND AND AIM

Although post-motor vehicle collision (MVC) pain and symptoms are largely convergent among those with mild traumatic brain injury (mTBI) and whiplash associated disorder (WAD), and patients oftentimes report initial neck and head complaints, the clinical picture of mTBI and WAD has been primarily studied as separate conditions which may result in an incomplete clinical picture. As such, this study was conducted to explore the role of pain and post-traumatic psychological features in explaining both head and neck-related symptom variability in a cohort of post-collision patients. This is with the goal of disentangling if contributory factors are uniquely related to each diagnosis, or are shared between the two.

METHODS

Patients recruited in the very early acute phase (<72 h) returned for clinical and psychological assessment at 6 months post-accident. In order to determine which factors were unique and which ones were overlapping the same potential contributors: mean head pain, mean neck pain, female gender, number of post-collision painful body areas, PTSD, and depression were included in the regression models for both neck disability index (NDI) and Rivermead post-concussion symptoms questionnaire (RPQ).

RESULTS

Of 223 recruited participants, 70 returned for a follow-up visit (age range 18-64, mean(SD) 37.6 (11.9), 29F). This cohort primarily met the criteria for mTBI, but also fulfilled the criteria for whiplash, reinforcing the duality of injury presentation. Correlations existed between the NDI and RPQ scores (Spearman's ρ=0.66, p<0.001), however overlap was only partial. Regression analysis showed that after the removal of area-of-injury pain neck related disability (r = 0.80, p <0.001) was explained solely by number of painful body areas (ß=0.52, p <0.001). In contrast, post-concussion syndrome symptoms (r = 0.86, p<0.001) are influenced by clinical pain, painful body areas (ß=0.31, p = 0.0026), female gender (ß=0.19, p = 0.0053), and psychological factors of depression (ß=0.31, p = 0.0028) and PTSD symptoms (ß=0.36, p = 0.0013).

CONCLUSIONS

It seems that while mechanisms of neck- and head-related symptoms in post-collision patients do share a common explanatory feature, of residual body pain, they are not entirely overlapping. In that psychological factors influence post-concussion syndrome symptoms, but not post-whiplash neck disability.

Prevalence and determinants of posttraumatic stress disorder and depression among survivors of motor vehicle accidents from a hilly Indian state

BACKGROUND

Motor vehicle accidents (MVAs) are the leading cause of death and have also been proven debilitating for their survivors. In India, with poor road infrastructure and low maintenance, MVAs are quite apparent. With a significant focus of treatment on physical health, psychological consequences linked to these traumas are often neglected.

AIM

The aim of this study was to estimate the prevalence of posttraumatic stress disorder and depression, as well as the determinants of these disorders among survivors of MVAs.

MATERIALS AND METHODS

An institution-based, cross-sectional descriptive study was conducted among 250 survivors of MVA visiting a tertiary care center in Uttarakhand (India) during December 2019, recruited using total enumerative sampling. Data were collected with standardized and validated tools that consisted of sociodemographic information, Posttraumatic Stress Disorder Checklist 5, and Zung Self-Rating Depression Scale. Data were analyzed using SPSS version 23, including descriptive (frequency, percentage, mean, and mean percentage) and inferential statistics (Mann-Whitney, Kruskal-Wallis, and binary logistic regression).

RESULTS

The prevalence of posttraumatic stress disorder (PTSD) was found to be 32.4%, and mild and moderate depressions were present among 14.4% and 6.4% of the study population, respectively. Witnessing death (odds ratio [OR] = 5.52; 95% confidence interval [CI] = 0.92-3.06), loss of valuables (OR = 2.62; 95% CI = 0.78-9.04), self-blame (OR = 6.06; 95% CI = 1.15-31.91), and perceived death threat (OR = 9.98; 95% CI = 5.89-46.85) acted as determinants in the occurrence of PTSD and depression.

CONCLUSION

A considerably large proportion of the population suffered from psychiatric disorders following the trauma. These must be addressed with an urgent development of multidisciplinary teams incorporating mental health services across all hospitals' trauma units.

Prevalence of post-traumatic stress symptoms among people influenced by coronavirus disease 2019 outbreak: A meta-analysis

BACKGROUND

As one of the most widely researched consequence of traumatic events, the prevalence of post-traumatic stress symptoms among people exposed to the trauma resulting from coronavirus disease 2019 (COVID-19) outbreak varies greatly across studies. This review aimed at examining the pooled prevalence of post-traumatic stress symptoms among people exposed to the trauma resulting from COVID-19 outbreak.

METHODS

Systematic searches of databases were conducted for literature published on PubMed, EMBASE, Web of Science, the Cochrane Library, PsycArticle, and Chinese National Knowledge Infrastructure until October 14, 2020. Statistical analyses were performed using R software (PROSPERO registration number: CRD42020180309).

RESULTS

A total of 106,713 people exposed to the trauma resulting from the COVID-19 outbreak were identified in the 76 articles, of which 33,810 were reported with post-traumatic stress symptoms. The pooled prevalence of post-traumatic stress symptoms among people exposed to the trauma resulting from COVID-19 outbreak was 28.34%, with a 95% confidence interval of 23.03-34.32%. Subgroup analysis indicated that older age, male and bigger sample size were associated with higher prevalence of post-traumatic stress symptoms. After controlling for other factors, the results of meta-regression showed that the influence of gender and sample size on prevalence is no longer significant.

CONCLUSIONS

Symptoms of post-traumatic stress disorder (PTSD) were very common among people exposed to the trauma resulting from COVID-19 outbreak. Further research is needed to explore more possible risk factors for post-traumatic stress symptoms and identify effective strategies for preventing PTSD-related symptoms among people exposed to the trauma resulting from COVID-19 outbreak.

Prior sleep problems and adverse post-traumatic neuropsychiatric sequelae of motor vehicle collision in the AURORA study

STUDY OBJECTIVES

Many patients in Emergency Departments (EDs) after motor vehicle collisions (MVCs) develop post-traumatic stress disorder (PTSD) or major depressive episode (MDE). This report from the AURORA study focuses on associations of pre-MVC sleep problems with these outcomes 8 weeks after MVC mediated through peritraumatic distress and dissociation and 2-week outcomes.

METHODS

A total of 666 AURORA patients completed self-report assessments in the ED and at 2 and 8 weeks after MVC. Peritraumatic distress, peritraumatic dissociation, and pre-MVC sleep characteristics (insomnia, nightmares, daytime sleepiness, and sleep duration in the 30 days before the MVC, trait sleep stress reactivity) were assessed retrospectively in the ED. The survey assessed acute stress disorder (ASD) and MDE at 2 weeks and at 8 weeks assessed PTSD and MDE (past 30 days). Control variables included demographics, MVC characteristics, and retrospective reports about PTSD and MDE in the 30 days before the MVC.

RESULTS

Prevalence estimates were 41.0% for 2-week ASD, 42.0% for 8-week PTSD, 30.5% for 2-week MDE, and 27.2% for 8-week MDE. Pre-MVC nightmares and sleep stress reactivity predicted 8-week PTSD (mediated through 2-week ASD) and MDE (mediated through the transition between 2-week and 8-week MDE). Pre-MVC insomnia predicted 8-week PTSD (mediated through 2-week ASD). Estimates of population attributable risk suggest that blocking effects of sleep disturbance might reduce prevalence of 8-week PTSD and MDE by as much as one-third.

CONCLUSIONS

Targeting disturbed sleep in the immediate aftermath of MVC might be one effective way of reducing MVC-related PTSD and MDE.

Suicide by crashing into a heavy vehicle: a focus group study of professional drivers

Professional heavy vehicle drivers can experience a traumatic event at work when suicidal drivers deliberately crash into their vehicles or a pedestrian jumps in front of them. This study adopts a qualitative approach, aiming to gain an understanding about the psychological and other consequences that these crashes have for this occupational group. We organized a semi-structured focus group meeting with six drivers who reported experiencing a deliberate crash into their vehicle. The meeting was moderated by two psychologists. The participants reported that avoiding the crash was difficult. These events can have long-lasting effects on drivers' well-being although individual differences in the response to the event and coping strategies do exist. Participation in our meeting was regarded as a positive experience. This encourages us to believe that organizing similar meetings that allow drivers under the supervision of professionals to share their own experiences with those who experienced similar events, could perhaps be one way of providing support to such drivers who experienced a traumatic event at work.

Different Patterns of Mental Health Outcomes among Road Traffic Crash Survivors: A Prospective Cohort Study

This study aimed to investigate factors associated with the symptoms of mental disorders following a road traffic crash (RTC). A prospective cohort of 200 people was followed for 6 months after experiencing an RTC. The cohort was comprised of uninjured survivors and injured victims with all levels of road traffic injury (RTI) severity. Multivariable logistic regression analyses were performed to evaluate the associations between the symptoms of depression, posttraumatic stress disorder and anxiety one and six months after the RTC, along with sociodemographic factors, health status before and after the RTC, factors related to the RTI and factors related to the RTC. The results showed associations of depression, anxiety, and posttraumatic stress disorder symptoms with sociodemographic factors, factors related to the health status before and after the RTC and factors related to the RTC. Factors related to the RTI showed associations only with depression and posttraumatic stress disorder symptoms. Identifying factors associated with mental disorders following an RTC is essential for establishing screening of vulnerable individuals at risk of poor mental health outcomes after an RTC. All RTC survivors, regardless of their RTI status, should be screened for factors associated with mental disorders in order to successfully prevent them.

Mediating Role of Anxiety and Depression in the Relationship Between Posttraumatic Stress Disorder and Aggression in Motor Vehicle Accident: A Structural Equation Modelling Approach

Objective:

This study investigated the existence of anxiety and depression mediating effect on the relationship between PTSD and aggression in the hope of providing more comprehensive and effective trauma treatment in motor vehicle accident.

Methods:

The studied population of the study consisted of motor vehicles with posttraumatic stress disorder in Kashan. Three questionnaires of post-traumatic stress disorder, Hospital Anxiety and Depression Scale (HADS) and Aggression Questionnaire (Buss & Perry, 1992) were used for data collection. In order to analyze the mediating effects of anxiety and depression on the relationship between PTSD and aggression, structural equation modeling(SEM) was performed with the maximum likelihoodratio as the method of estimation.

Results:

Evaluation of the research hypothesis model using fitness indices showed that the hypothetical model fits with the measurement model. NFI=0.96, CFI =0.95, RMSEA=0.06 and the results showed that PTSD had indirect exacerbating effects on aggression. The results also confirmed the mediating role of anxiety and depression in the relationship between post-traumatic stress disorder and aggression in motor vehicle accident.

Conclusion:

The findings demonstrate that anxiety mediates the relationship between PTSD and aggression. Therefore, this finding can help to prioritize therapeutic goals and determine therapeutic focus for mental health professionals. It is possible to reduce one's aggression by focusing on his anxiety and increasing his/her ability to handle and manage it.

Frequent Marijuana or Alcohol Use in Low-Income Emerging Adults: Impact of Adverse Life Experiences

The transition to adulthood may be especially difficult for those who use drugs and alcohol regularly. While research clearly links adverse childhood experiences (ACEs) with later substance use, many studies have explored only a limited range of ACEs, and have focused on the number instead of specific types of ACE. Objectives: The current study examined the role of ACEs on the likelihood of frequent marijuana and alcohol use among a community sample of emerging adults (N = 185). This research builds on and extends previous work by focusing on a low-income sample, examining specific types of ACEs, and expanding categories to include some less studied ACEs. Logistic regression models examined the relationships between ACEs and frequent alcohol or marijuana use. Results: The emerging adults in the current sample experienced many ACEs in childhood, and roughly a third reported frequent (defined as using once a week or more for the past 90 days) alcohol or marijuana use. ACEs associated with both frequent marijuana and alcohol use were time spent in foster care, childhood emotional abuse, and having a close family member or friend who died violently. Alcohol use was further predicted by childhood sexual abuse and witnessing a serious injury or death, while marijuana use was further predicted by childhood physical abuse. Conclusions: Findings highlight the importance of thoroughly assessing for ACEs when addressing substance use issues in young adults. The negative impact of being in foster care may be overlooked as a trauma beyond the experiences that contributed to entering care.

Effects of Neurological Disorders on Bone Health

Neurological diseases, particularly in the context of aging, have serious impacts on quality of life and can negatively affect bone health. The brain-bone axis is critically important for skeletal metabolism, sensory innervation, and endocrine cross-talk between these organs. This review discusses current evidence for the cellular and molecular mechanisms by which various neurological disease categories, including autoimmune, developmental, dementia-related, movement, neuromuscular, stroke, trauma, and psychological, impart changes in bone homeostasis and mass, as well as fracture risk. Likewise, how bone may affect neurological function is discussed. Gaining a better understanding of brain-bone interactions, particularly in patients with underlying neurological disorders, may lead to development of novel therapies and discovery of shared risk factors, as well as highlight the need for broad, whole-health clinical approaches toward treatment.

Behavioral, Physiological and EEG Activities Associated with Conditioned Fear as Sensors for Fear and Anxiety

Anxiety disorders impose substantial costs upon public health and productivity in the USA and worldwide. At present, these conditions are quantified by self-report questionnaires that only apply to behaviors that are accessible to consciousness, or by the timing of responses to fear- and anxiety-related words that are indirect since they do not produce fear, e.g., Dot Probe Test and emotional Stroop. We now review the conditioned responses (CRs) to fear produced by a neutral stimulus (conditioned stimulus CS+) when it cues a painful laser unconditioned stimulus (US). These CRs include autonomic (Skin Conductance Response) and ratings of the CS+ unpleasantness, ability to command attention, and the recognition of the association of CS+ with US (expectancy). These CRs are directly related to fear, and some measure behaviors that are minimally accessible to consciousness e.g., economic scales. Fear-related CRs include non-phase-locked phase changes in oscillatory EEG power defined by frequency and time post-stimulus over baseline, and changes in phase-locked visual and laser evoked responses both of which include late potentials reflecting attention or expectancy, like the P300, or contingent negative variation. Increases (ERS) and decreases (ERD) in oscillatory power post-stimulus may be generalizable given their consistency across healthy subjects. ERS and ERD are related to the ratings above as well as to anxious personalities and clinical anxiety and can resolve activity over short time intervals like those for some moods and emotions. These results could be incorporated into an objective instrumented test that measures EEG and CRs of autonomic activity and psychological ratings related to conditioned fear, some of which are subliminal. As in the case of instrumented tests of vigilance, these results could be useful for the direct, objective measurement of multiple aspects of the risk, diagnosis, and monitoring of therapies for anxiety disorders and anxious personalities.

Meta-synthesis of qualitative evidence in road traffic injury prevention: a scoping review of qualitative studies (2000 to 2019)

BACKGROUND

A considerable number of qualitative studies have been published in recent years on the issues that the quantitative studies have limitations on. This study aimed at performing a meta-synthesis on qualitative studies on Road Traffic Injuries (RTIs) with a scoping review approach.

METHODS

This meta-synthesis study was conducted as a scoping review in 2019. The Arkesy and O'Malley framework was applied which has six steps of identifying the research question, identifying the relevant studies, selecting the studies, charting the data, data analysis and reporting the results, and consultation exercise. The required data were gathered by searching the relevant keywords in databases of PubMed, web of knowledge, Scopus, Cochrane Library, Science Direct, Google scholar, Sid, IranMedex. Extracted data were analyzed by the Content-Analysis method.

RESULTS

Finally, 30 studies were included. Extracted data summarized in five main themes and 17 sub-themes. The main themes were: consequences (individual, family, social, financial), the needs of survivors (social support and healthcare), risk factors (general risk factors, risk factors for motorcyclists, risk factors for children and adolescents), barriers of prevention (general barriers, pre-hospital barriers, emergency, and hospital barriers), and prevention solutions (increasing safety, rules and regulations, education, increasing equipment, scientific solutions) of RTIs.

CONCLUSION

This study combined the methods of the scoping review and the meta-synthesis to mapping all qualitative studies on the RTIs, with this approach, this study provides extensive and practical information for policy-makers, managers, practitioners, and researchers in the field of RTIs. Also, by applying this approach, the gaps in the existing knowledge and areas in need of further research are identified.