Randomized, Controlled Trial of Three Levels of Critical Incident Stress Intervention

The effectiveness of psychological interventions for reducing PTSD and psychological distress in first responders: A systematic review and meta-analysis

Background

First responders are faced with stressful and traumatic events in their work that may affect their psychological health. The current review examined the effectiveness of psychological interventions to treat posttraumatic stress disorder (PTSD), anxiety, depression, stress and burnout in first responders.

Methods

Four databases were searched to identify controlled studies that examined the efficacy of psychological interventions to reduce PTSD symptoms (primary outcome) in first responders (including firefighters, police/law enforcement officers, search and rescue personnel, emergency and paramedics teams). Secondary outcomes were anxiety, depression, burnout, and stress.

Results

15 studies were identified, including 10 studies that measured PTSD, 7 studies for anxiety, 10 studies for depression, 7 studies for stress and 1 for burnout. Interventions were associated with a significant reduction in PTSD (SDM = -0.86; 95% CI = -1.34 –- 0.39), depression (SDM = -0.63; 95% CI = -0.94 –-0.32), and anxiety (SDM = -0.38; 95% CI = -0.71 –-0.05) but not stress (SDM = -0.13; 95% CI = -0.51–0.25). CBT-based and clinician-delivered interventions were associated with significantly greater reductions in PTSD than other types of interventions and non-clinician interventions, but no differences were found for depression. There was evidence of moderate to high risk of bias across all studies.

Conclusions

Psychological interventions are effective in reducing PTSD, depression and anxiety symptoms but not stress in first responders. Further research is needed using high quality randomised designs over longer periods of follow-up.

The impact and experience of debriefing for clinical staff following traumatic events in clinical settings: A systematic review

Health care professionals are more frequently exposed to potentially traumatic events than individuals in other professions. Repeated trauma exposure can significantly impact both physical and mental health. In clinical settings, the term "debriefing" refers to a group meeting during which clinical events and decision-making are reviewed and discussed to improve clinical practice. The present review investigated the use of debriefing for clinical staff in clinical settings following exposure to direct and vicarious trauma. We examined whether the use of posttrauma debriefing impacts symptoms of distress and explored how clinical staff experience debriefing; we also investigated the factors that influence this experience. A systematic search of five electronic databases was conducted between August 31 and September 2, 2019. Included articles (N = 13) described the use of debriefing in clinical settings with clinical staff following a traumatic event. We assessed methodological quality and performed a narrative synthesis. Four studies found some evidence of the benefits of debriefing for reducing psychological sequelae to traumatic events. Seven studies commented on factors that clinical staff perceived to be important for the debriefing to feel helpful, including the being given the opportunity for reflection, gaining a shared experience, and having the right peer facilitator. Some evidence suggests that debriefing with staff working in clinical settings can reduce posttraumatic distress symptoms, and subjective evidence suggests that clinical staff members perceive debriefing to be useful. Due to the limited literature, no firm conclusions could be drawn, and further methodologically sound research is required.

Pre-deployment programmes for building resilience in military and frontline emergency service personnel

BACKGROUND

Military personnel and frontline emergency workers may be exposed to events that have the potential to precipitate negative mental health outcomes such as depression, symptoms of post-traumatic stress and even post-traumatic stress disorder (PTSD). Programmes have been designed to build psychological resilience before staff are deployed into the field. This review presents a synthesis of the literature on these "pre-deployment resilience-building programmes".

OBJECTIVES

The objective of this review was to assess the effectiveness of programmes that seek to build resilience to potentially traumatic events among military and frontline emergency service personnel prior to their deployment. These resilience programmes were compared to other interventions, treatment as usual or no intervention.

SEARCH METHODS

Studies were identified through searches of electronic databases including Ovid MEDLINE, Embase, PsycINFO, Web of Science and Google Scholar. The initial search took place in January 2019, with an updated search completed at the end of September 2020.

SELECTION CRITERIA

Only studies that used a randomised controlled trial (RCT)/cluster-RCT methodology were included. The programmes being evaluated must have sought to build resilience prior to exposure to trauma. Study participants must have been 18 years or older and be military personnel or frontline emergency workers.

DATA COLLECTION AND ANALYSIS

Studies that met the inclusion criteria were assembled. Data extracted included methods, participants' details, intervention details, comparator details, and information on outcomes. The primary outcomes of interest were resilience, symptoms of post-traumatic stress and PTSD. Secondary outcomes of interest included acute stress disorder, depression, social support, coping skills, emotional flexibility, self-efficacy, social functioning, subjective levels of aggression, quality of sleep, quality of life and stress. Assessment of risk of bias was also completed. A total of 28 studies were included in a narrative synthesis of results.

MAIN RESULTS

All 28 included studies compared an experimental resilience building intervention versus a control or no intervention. There was a wide range of therapeutic modalities used, including cognitive behavioural therapy (CBT) informed programmes, biofeedback based programmes, stress-management programmes, mindfulness and relaxation programmes, neuropsychological-based programmes, and psychoeducational-informed programmes. The main outcomes are specified here, secondary outcomes such as depression, social support, coping skills, self-efficacy, subjective levels of aggression and stress are reported in text. No studies reported on the following pre-specified outcomes; acute stress disorder, emotional flexibility, social functioning, quality of sleep and quality of life. Resilience Eight studies reported resilience as an outcome. We narratively synthesised the data from these studies and our findings show that five of these interventions had success in building resilience in their respective samples. Two of the studies that reported significant results utilised a CBT approach to build resilience, while the other three successful programmes were mindfulness-based interventions. Symptoms of post-traumatic stress Our narrative synthesis of results included eight studies. Two of the eight studies produced significant reductions in symptoms of post traumatic stress compared to controls. These interventions used neuropsychological and biofeedback intervention models respectively. PTSD caseness Four studies reported PTSD caseness as an outcome. Our narrative synthesis of results suggests that evidence is mixed as to the effectiveness of these interventions in reducing clinical diagnosis of PTSD. One study of a neuropsychology-orientated Attention Bias Modification Training (AMBT) programme had success in reducing both symptoms of post-traumatic stress and numbers of participants receiving a diagnosis of PTSD. A stress-management programme reported that, when baseline differences in rates of pre-deployment mental health issues were controlled for, participants in the control condition were at 6.9 times the risk of a diagnosis of PTSD when compared to the intervention group. Given the diversity of intervention designs and theoretical orientations used (which included stress-management, neuropsychological and psychoeducational programmes), a definitive statement on the efficacy of pre-deployment programmes at reducing symptoms of post-traumatic stress and PTSD cannot be confidently offered.

AUTHORS' CONCLUSIONS

While a number of evaluations of relevant programmes have been published, the quality of these evaluations limits our ability to determine if resilience-building programmes 'work' in terms of preventing negative outcomes such as depression, symptoms of post-traumatic stress and diagnoses of PTSD. Based on our findings we recommend that future research should: a) report pre-/post-means and standard deviation scores for scales used within respective studies, b) take the form of large, RCTs with protocols published in advance, and c) seek to measure defined psychological facets such as resilience, PTSD and stress, and measure these concepts using established psychometric tools. This will provide more certainty in future assessments of the evidence base. From a clinical implications point of view, overall there is mixed evidence that the interventions included in this review are effective at safe guarding military personnel or frontline emergency workers from experiencing negative mental health outcomes, including PTSD, following exposure to potentially traumatic events. Based on this, practitioners seeking to build resilience in their personnel need to be aware of the limitations of the evidence base. Practitioners should have modest expectations in relation to the efficacy of resilience-building programmes as a prophylactic approach to employment-related critical incident traumas.

A review of workplace mental health interventions and their implementation in public safety organizations

OBJECTIVE

Workplace mental health is relevant to public safety organizations due to the exposure that many public safety personnel (PSP) have to psychological trauma in the course of their daily work. While the importance of attending to PSP mental health has been established, the implementation of workplace mental health interventions is not as well understood. This scoping review describes workplace mental health interventions and their implementation in public safety organizations.

METHODS

English published primary studies with any publication date up to July 3, 2020 were considered. JBI methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews was followed.

RESULTS

89 citations met inclusion criteria out of the 62,299 found. Articles and reports found were largely published within the last decade, most frequently from Western nations, and most often applied to police, followed by firefighters. The focus of interventions was commonly stress management and resilience, and a frequent implementation strategy was multi-session group training. Comprehensive quality improvement initiatives, a focus on supervisors and managers, and interventions across primary, secondary, and tertiary prevention, were infrequent.

CONCLUSION

Public safety organizations are frequently reporting on stress management and resilience interventions for police and firefighters, implemented through multi-session group training. A focus across a range of PSP, including paramedics, corrections officers, and emergency dispatchers, using implementation strategies beyond group training, is suggested. This area of research is currently expanding, with many studies published within the past decade; ongoing evaluation of the quality of interventions and implementation strategies is recommended.

Early Post-trauma Interventions in Organizations: A Scoping Review

Background

In some organizations, traumatic events via direct or indirect exposure are routine experiences. The National Institute for Health and Care Excellence reviews (2005; 2018) of post-traumatic stress disorder management in primary and secondary care did not address early interventions for trauma within emergency response organizations.

Aims

This scoping review was designed to identify research which evaluates the use of early interventions in emergency and other high-risk organizations following exposure to primary or secondary trauma and to report on the effectiveness of the early intervention models in common use.

Methods

A scoping review was conducted to examine early interventions for workers exposed to trauma, including emergency response, military, and humanitarian aid. Relevant data were extracted from the included studies and the outcomes were assessed using meta-ethnography.

Results

Fifty studies of mixed quality met the inclusion criteria for this review. A synthesis of study outcomes found that early interventions help emergency responders to manage post-incident trauma when they are delivered in a manner that (a) respects distinct organizational culture, (b) is supported by organizations and senior management, and (c) harnesses existing social cohesion and peer support systems within teams.

Conclusion

This review demonstrates that early interventions support emergency responders following exposure to trauma when these are tailored to the needs of the population, are supported by the host organization, and harness existing social cohesion and peer support processes within a team or unit. A number of recommendations for the delivery and evaluation of early interventions for psychological trauma in emergency response organizations were made.

Further validation of the psychological injury risk indicator scale

OBJECTIVE

Confirm the Psychological Injury Risk Indicator (PIRI) scale capacity to facilitate routine assessment of psychological health of workers in high-stress environments.

METHOD

A cross-sectional study compared the PIRI scale scores with two experienced clinical psychologists' assessment of defined psychological injury in 93 participants. A second, longitudinal, study assessed PIRI predictive capacity for emotional exhaustion, physical health, and work engagement in 420 participants over 14 months.

RESULTS

The PIRI scale was shown to (a) determine the degree of psychological injury in participants with high correspondence to a specialist clinical interview; and (b) predict future emotional exhaustion, physical health, and work engagement to a significantly better degree than the 12-item General Health Questionnaire and Kessler-10 measures.

CONCLUSIONS

The PIRI scale shows a valuable capacity to provide accurate routine psychological health assessment for at-risk workers in high-strain work environments.

The pain that binds us: midwives' experiences of loss and adverse outcomes around the world

Although much has been written about helping women and their families cope with loss related to childbearing, little exists in the literature to guide and support the midwives who witness these losses. We conducted qualitative interviews globally with 22 midwives from nations located on six different continents to begin exploring common themes of experiences and coping methods of midwives involved in adverse perinatal outcomes. The concept of critical incident stress (CIS) is presented as a framework for understanding practitioner reactions that occur after adverse outcomes. Implications for practice, education, and continued research are addressed.

Brief psychological interventions ("debriefing") for trauma-related symptoms and the prevention of post traumatic stress disorder

OBJECTIVES

To assess the effectiveness of brief psychological debriefing for the management of psychological distress after trauma, and the prevention of post traumatic stress disorder.

SEARCH STRATEGY

Electronic searching of MEDLINE, EMBASE, PsychLit, PILOTS, Biosis, Pascal, Occ.Safety and Health, CDSR and the Trials Register of the Depression, Anxiety and Neurosis group. Hand search of Journal of Traumatic Stress. Contact with leading researchers.

SELECTION CRITERIA

The inclusion criteria for all randomized studies was that they should focus on persons recently (one month or less) exposed to a traumatic event, should consist of a single session only, and that the intervention involve some form of emotional processing/ventilation by encouraging recollection/reworking of the traumatic event accompanied by normalisation of emotional reaction to the event.

DATA COLLECTION AND ANALYSIS

8 trials fulfilled the inclusion criteria. Quality was generally poor. Data from two trials could not be synthesised.

MAIN RESULTS

Single session individual debriefing did not reduce psychological distress nor prevent the onset of post traumatic stress disorder (PTSD). Those who received the intervention showed no significant short term (3-5 months) in the risk of PTSD (pooled odds ratio 1.0, 95% ci 0.6-1.8). At one year one trial reported that there was a significantly increased risk of PTSD in those receiving debriefing (odds ratio 2.9, 95% ci 1.1-7.5). The pooled odds ratio for the two trials with follow ups just included unity (odds ratio 2.0, 95% ci 0.9-4.5). There was also no evidence that debriefing reduced general psychological morbidity, depression or anxiety.

REVIEWER'S CONCLUSIONS

There is no current evidence that psychological debriefing is a useful treatment for the prevention of post traumatic stress disorder after traumatic incidents. Compulsory debriefing of victims of trauma should cease.