Racial/ethnic differences in acute and longer-term posttraumatic symptoms following traumatic injury or illness

Performance replication of the Hospital Mental Health Risk Screen in ethnoracially diverse U.S. patients admitted through emergency care

BACKGROUND

Patients admitted to hospitals after emergency care for injury or acute illness are at risk for later mental health problems. The American College of Surgeons Committee on Trauma Standards for care of injured patients call for mental health risk screening, and the Hospital Mental Health Risk Screen (HMHRS) accurately identified at-risk patients in a developmental study that included patients from five ethnoracial groups. Replication of these findings is essential, because initial positive results for predictive screens can fail to replicate if the items were strongly related to outcomes in the development sample but not in a new sample from the population the screen was intended for.

STUDY DESIGN

Replication of the predictive performance of the 10-item HMHRS was studied prospectively in ethnoracially diverse patients admitted after emergency care for acute illness or injury in three hospitals across the U.S.

RESULTS

Risk screen scores and follow-up mental health outcomes were obtained for 452 of 631 patients enrolled (72%). A cut score of 10 on the HMHRS correctly identified 79% of the patients who reported elevated levels of depression, anxiety, and PTSD symptoms two months post-admission (sensitivity) and 72% of the patients whose symptoms were not elevated (specificity). HMHRS scores also predicted well for patients with acute illness, for patients with injuries, and for patients who reported an Asian American/Pacific Islander, Black, Latinx, Multirace, or White identity.

CONCLUSIONS

Predictive performance of the HMHRS was strong overall and within all five ethnoracial subgroups. Routine screening could reduce suffering and health care costs, increase health and mental health equity, and foster preventive care research and implementation. The performance of the HMHRS should be studied in other countries and in other populations of recent trauma survivors, such as survivors of disaster or mass violence.

Civilians under missile attack: post-traumatic stress disorder among the Jewish and Bedouin population of Southern Israel

BACKGROUND

Over the past 20 years, Jewish and Bedouin civilians in southern Israel have faced the ongoing threat of missile attacks from Gaza, with possible mental health consequences. This study aimed to assess the prevalence of post-traumatic stress disorder (PTSD) among Jewish and Bedouin adult civilians in southern Israel in a period with few missile attacks from Gaza, and no military operations.

METHODS

The study population included 389 participants (246 Jews, 143 Bedouins) living within 40 km/25 mi from Gaza for at least 2 years and interviewed between January and March 2023 (before the ongoing war that started on October 7th, 2023). The PTSD Checklist (PCL-5) was used, with a score of 33 as a cutoff point for the presence of PTSD.

RESULTS

Compared to Jews, a significantly lower proportion of Bedouins reported accessibility to bomb shelters and siren warning systems. Overall, 20.3% of the respondents exhibited PTSD. Multivariate analysis revealed that after adjustment for demographic and household characteristics, Bedouins had a six-fold significantly higher probability of PTSD in comparison to Jews (OR 5.6, 95%CI 2.8-10.8). Compared to participants with high socioeconomic status (SES), participants with low SES had a six-fold significantly higher probability of PTSD (OR 6.0, 95%CI 2.2-16.5). Participants who did not have an alarm system had more than two-fold odds for PTSD (OR 2.3, 95%CI 1.1-5.5). Being single, living in urban areas, or having a disability significantly increased the probability of PTSD.

CONCLUSIONS

The findings of this study demonstrate a significantly higher prevalence of PTSD among the Bedouin population of Southern Israel. Several sociodemographic characteristics were associated with the increased prevalence of PTSD, the most prominent of which was low SES. Healthcare professionals and authorities should be proactive in screening for PTSD, and provide tailored treatment and support, taking into account ethnical and cultural background. Authorities should address the disparity in bomb shelter access and siren warning coverage between Bedouin and Jewish communities.

Racial discrimination increases the risk for nonremitting posttraumatic stress disorder symptoms in traumatically injured Black individuals living in the United States

Traumatic, life-threatening events are experienced commonly among the general U.S. population, yet Black individuals in the United States (i.e., Black Americans) exhibit higher prevalence rates of posttraumatic stress disorder (PTSD) and more severe symptoms than other populations. Although empirical research has noted a range of symptom patterns that follow traumatic injury, minimal work has examined the role of racial discrimination in relation to PTSD symptom trajectories. The current study assessed racial discrimination and PTSD symptom trajectories at 6 months postinjury across two separate samples of traumatically injured Black Americans (i.e. emergency department (ED)-discharged and hospitalized). Identified PTSD symptom trajectories largely reflect those previously reported (i.e., ED: nonremitting, moderate, remitting, and resilient; hospitalized: nonremitting, delayed, and resilient), although the resilient trajectory was less represented than expected given past research (ED: 55.8%, n = 62; hospitalized: 46.9%, n = 38). Finally, higher racial discrimination was associated with nonremitting, ED: relative risk ratio (RR) = 1.32, hospitalized: RR = 1.23; moderate, ED: RR = 1.18; and delayed, hospitalized: RR = 1.26, PTSD symptom trajectories. Overall, the current findings not only emphasize the inimical effects of racial discrimination but also demonstrate the unique ways in which race-related negative events can impact PTSD symptom levels and recovery across time.

Racial and ethnic socioenvironmental inequity and neuroimaging in psychiatry: a brief review of the past and recommendations for the future

Neuroimaging is a major tool that holds immense translational potential for understanding psychiatric disorder phenomenology and treatment. However, although epidemiological and social research highlights the many ways inequity and representativeness influences mental health, there is a lack of consideration of how such issues may impact neuroimaging features in psychiatric research. More specifically, the potential extent to which racialized inequities may affect underlying neurobiology and impact the generalizability of neural models of disorders is unclear. The present review synthesizes research focused on understanding the potential consequences of racial/ethnic inequities relevant to neuroimaging in psychiatry. We first discuss historical and contemporary drivers of inequities that persist today. We then discuss the neurobiological consequences of these inequities as revealed through current research, and note emergent research demonstrating the impact such inequities have on our ability to use neuroimaging to understand psychiatric disease. We end with a set of recommendations and practices to move the field towards more equitable approaches that will advance our abilities to develop truly generalizable neurobiological models of psychiatric disorders.

Exploring transdiagnostic stress and trauma-related symptoms across the world: a latent class analysis

Background: Although trauma exposure is universally prevalent, the ways in which individuals respond to potentially traumatic events vary. Between-country differences have been identified as affecting the development and manifestation of transdiagnostic psychological symptoms, but it remains unclear how stress and trauma-related transdiagnostic symptoms and risk patterns differ based on geographic region.Objective: To explore whether there are distinct classes of stress and trauma-related transdiagnostic symptoms and to determine predictors of class membership in a global sample.Method: Participants (N = 8675) from 115 different countries were recruited online between 2020-2022 and completed the Global Psychotrauma Screen, which assesses stress and trauma exposure, related symptoms, and risk factors. A latent class analysis (LCA) was used to identify classes of stress and trauma-related symptoms per world region (African States, Asia-Pacific States, Eastern European States, Latin American and Caribbean States, Western European and Other States, and North America) and the total sample. Likelihood of class membership was assessed based on demographics, characteristics of the potentially traumatic event, and potential risk factors across the world regions.Results: Similar class compositions were observed across regions. A joint latent class analysis identified three classes that differed by symptom severity (i.e. high, moderate, low). Multinomial logistic regression analyses revealed several factors that conferred greater risk for experiencing higher levels of symptoms, including geographic region, gender, and lack of social support, among others.Conclusions: Stress and trauma-related symptoms seem to be similarly transdiagnostic across the world, supporting the value of a transdiagnostic assessment.

Development and Initial Performance of the Hospital Mental Health Risk Screen

BACKGROUND

Patients hospitalized after emergency care are at risk for later mental health problems such as depression, anxiety, and posttraumatic stress disorder symptoms. The American College of Surgeons Committee on Trauma standards for verification require Level I and II trauma centers to screen patients at high risk for mental health problems. This study aimed to develop and examine the performance of a novel mental health risk screen for hospitalized patients based on samples that reflect the diversity of the US population.

STUDY DESIGN

We studied patients admitted after emergency care to 3 hospitals that serve ethnically, racially, and socioeconomically diverse populations. We assessed risk factors during hospitalization and mental health symptoms at follow-up. We conducted analyses to identify the most predictive risk factors, selected items to assess each risk, and determined the fewest items needed to predict mental health symptoms at follow-up. Analyses were conducted for the entire sample and within 5 ethnic and racial subgroups.

RESULTS

Among 1,320 patients, 10 items accurately identified 75% of patients who later had elevated levels of mental health symptoms and 71% of those who did not. Screen performance was good to excellent within each of the ethnic and racial groups studied.

CONCLUSIONS

The Hospital Mental Health Risk Screen accurately predicted mental health outcomes overall and within ethnic and racial subgroups. If performance is replicated in a new sample, the screen could be used to screen patients hospitalized after emergency care for mental health risk. Routine screening could increase health and mental health equity and foster preventive care research and implementation.

Structural inequities contribute to racial/ethnic differences in neurophysiological tone, but not threat reactivity, after trauma exposure

Considerable racial/ethnic disparities persist in exposure to life stressors and socioeconomic resources that can directly affect threat neurocircuitry, particularly the amygdala, that partially mediates susceptibility to adverse posttraumatic outcomes. Limited work to date, however, has investigated potential racial/ethnic variability in amygdala reactivity or connectivity that may in turn be related to outcomes such as post-traumatic stress disorder (PTSD). Participants from the AURORA study (n = 283), a multisite longitudinal study of trauma outcomes, completed functional magnetic resonance imaging and psychophysiology within approximately two-weeks of trauma exposure. Seed-based amygdala connectivity and amygdala reactivity during passive viewing of fearful and neutral faces were assessed during fMRI. Physiological activity was assessed during Pavlovian threat conditioning. Participants also reported the severity of posttraumatic symptoms 3 and 6 months after trauma. Black individuals showed lower baseline skin conductance levels and startle compared to White individuals, but no differences were observed in physiological reactions to threat. Further, Hispanic and Black participants showed greater amygdala connectivity to regions including the dorsolateral prefrontal cortex (PFC), dorsal anterior cingulate cortex, insula, and cerebellum compared to White participants. No differences were observed in amygdala reactivity to threat. Amygdala connectivity was associated with 3-month PTSD symptoms, but the associations differed by racial/ethnic group and were partly driven by group differences in structural inequities. The present findings suggest variability in tonic neurophysiological arousal in the early aftermath of trauma between racial/ethnic groups, driven by structural inequality, impacts neural processes that mediate susceptibility to later PTSD symptoms.