The role of psychological support interventions in trauma patients on mental health outcomes: A systematic review and meta-analysis

Impact of healthcare interventions on distress following acute musculoskeletal/orthopaedic injury: a scoping review of systematic reviews

BACKGROUND

Musculoskeletal injuries can cause distress, and distress is associated with delayed recovery. Numerous interventions have been developed to facilitate recovery from injury, and several systematic reviews evaluate the efficacy of these interventions for reducing psychological distress.

OBJECTIVES

This scoping review aims to map the synthesised evidence for the relationship between treatment interventions and distress-related outcomes following acute injury. The objectives were (1) to describe the types of interventions that have been evaluated in relation to distress-related outcomes following accidental injury, (2) to examine the scope of distress-related outcomes that have been measured in relation to these interventions and (3) to explore the range of clinical professions that deliver these interventions.

DESIGN

We searched nine electronic databases and grey literature (to 21 April 2022). We included any systematic review reporting on the relationship between interventions delivered in the time following injury and distress-related outcomes. Data relevant to the specific objectives of this scoping review were extracted and described using narrative synthesis.

RESULTS

From 8412 systematic reviews imported for screening, 8266 unique records were screened. 179 were selected for full-text review. 84 systematic reviews were included in the study. Interventional types were pharmacological, psychological, exercise based, physical/manual therapies, virtual reality based, multimodal and workplace based. Interventions were delivered digitally, face to face and using virtual reality by a variety of healthcare professionals, including doctors, nurses, psychologists and physiotherapists. The most frequently reported distress-related variables included anxiety, depression, post-traumatic stress disorder diagnosis.

CONCLUSION

A wide range of interventions may help to mitigate distress following acute accidental musculoskeletal or orthopaedic injury. Even interventions that were not designed to reduce distress were found to improve distress-related outcomes. In view of the important role of distress in recovery from injury, it is recommended that distress-related variables are measured as core outcomes in the evaluation of treatments for acute injuries.

Can Baseline Patient Clinical and Demographic Characteristics Predict Response to Early Posttraumatic Stress Disorder Interventions After Physical Injury?

OBJECTIVE

A growing evidence base supports stepped care interventions for the early treatment of posttraumatic stress disorder (PTSD) after physical injury. Few investigations have examined the characteristics of patients who do and do not respond to these interventions.

METHOD

This investigation was a secondary analysis that used previously collected data from three randomized clinical trials of stepped care interventions (patient N = 498). The study hypothesized that a subgroup of patients would manifest persistent PTSD symptoms regardless of randomization to intervention or control conditions, and that characteristics present at the time of baseline injury hospitalization could distinguish patients who would develop persistent symptoms from potential treatment responders. Regression analyses identified baseline patient clinical and demographic characteristics that were associated with persistent PTSD symptoms over the 6-months post-injury. Additional analyses identified treatment attributes of intervention patients who were and were not likely to demonstrate persistent symptoms.

RESULTS

A substantial subgroup of patients (n = 222, 44.6%) demonstrated persistent PTSD symptoms over time. Greater numbers of pre-injury trauma, pre-injury PTSD symptoms, elevated early post-injury PTSD symptoms, unemployment, and non-White race identified patients with persistent symptoms. Patients with ≥3 of these baseline risk characteristics demonstrated diminished treatment responses when compared to patients with <3 characteristics. Intervention patients with ≥3 risk characteristics were less likely to engage in treatment and required greater amounts of interventionist time.

CONCLUSIONS

Injured trauma survivors have readily identifiable characteristics at the time of hospitalization that can distinguish responders to PTSD stepped care interventions versus patients who may be treatment refractory.

Psychiatric sequelae and interventions in critically ill trauma survivors

PURPOSE OF REVIEW

Psychiatric disorders following trauma impact functional recovery in trauma survivors and are a significant source of disability. Although research has traditionally focused on the physical sequelae of trauma, more attention is being directed towards the significant morbidity and mortality associated with the psychologic sequelae of trauma. This review evaluates the existing literature.

RECENT FINDINGS

Use of multidisciplinary collaborative programmes in combination with psychiatric treatment and pharmacotherapy may be necessary to improve the care of trauma patients with psychiatric sequelae. Improving identification of vulnerable patients may help in the prevention and treatment of psychiatric disorders and is an area of current research initiatives.

SUMMARY

There are few interventions that have demonstrated efficacy in managing the psychiatric sequelae of trauma. The development of strategies to guide early identification of at-risk patients and recommend prevention and treatment may improve the care of trauma survivors.

Psychological and psychosocial aspects of major trauma care: A survey of current practice across UK and Ireland

Introduction

Psychological and psychosocial impacts of major trauma, defined as any injury that has the potential to be life-threatening and/or life changing, are common, far-reaching and often enduring. There is evidence that these aspects of major trauma care are often underserved. The aim of this research was to gain insight into the current provision and operationalisation of psychological and psychosocial aspects of major trauma care across the UK and Ireland.

Methods

A cross-sectional online survey, open to health professionals working in major trauma network hospitals was undertaken. The survey had 69 questions across six sections: Participant Demographics, Psychological First Aid, Psychosocial Assessment and Care, Assessing and Responding to Distress, Clinical Psychology Services, and Major Trauma Keyworker (Coordinator) Role.

Results

There were 102 respondents from across the regions and from a range of professional groups. Survey findings indicate a lack of formalised systems to assess, respond and evaluate psychological and psychosocial aspects of major trauma care, most notably for patients with lower-level distress and psychosocial support needs, and for trauma populations that don't reach threshold for serious injury or complex health need. The findings highlight the role of major trauma keyworkers (coordinators) in psychosocial aspects of care and that although major trauma clinical psychology services are increasingly embedded, many lack the capacity to meet demand.

Conclusion

Neglecting psychological and psychosocial aspects of major trauma care may extend peritraumatic distress, result in preventable Years Lived with Disability and widen post-trauma health inequalities. A stepped psychological and psychosocial care pathway for major trauma patients and their families from the point of injury and continuing as they move through services towards recovery is needed. Research to fulfil knowledge gaps to develop and implement such a model for major trauma populations should be prioritised along with the development of corresponding service specifications for providers.

Are trauma surgical societies adequately addressing mental health after injury?

BACKGROUND

Survivors of physical trauma, their home caregivers, and their medical providers all have an increased risk of developing psychological distress and trauma-related psychiatric disease. The purpose of this study was to describe the frequency and change over time of trauma society research presentations regarding mental health to identify opportunities for growth.

METHODS

Archives from 2018 to 2020 from the American Association for the Surgery of Trauma, the Eastern Association for the Surgery of Trauma, and the Western Trauma Association were reviewed. The studies that measured mental illness, psychosocial distress, and other psychosocial factors were assessed: for (1) the use of patient-reported outcome measures ; (2) the association of psychosocial variables with outcomes; and (3) the interventions investigated. Change over time was assessed using χ2 analysis.

RESULTS

Of 1,239 abstracts, 57 (4.6%) addressed at least 1 mental health-related factor. Mental health was more frequently studied over time (2018 [3.2%]; 2019 [3.5%]; 2020 [7.7%]; P = .003). The most frequently measured factors were post-traumatic stress disorder, quality of life, general mental health, and depression. Seventeen (29.8%) abstracts addressed substance abuse, most commonly opioid abuse. Seven (12.3%) abstracts measured mental health in caregivers or medical providers. Patient-reported outcome measures were used in 32 studies (56.1%). Two-thirds of studies reported findings suggesting that mental illness impairs trauma-related outcomes. Only 5 (8.8%) investigated interventions designed to reduce adverse outcomes.

CONCLUSION

Although academic discussion of mental health after trauma increased from 2018 to 2020, the topic remains a limited component of annual programs, patient-reported outcome measures remain underutilized, and intervention studies are rare.

Psychological and psychosocial aspects of major trauma care in the United Kingdom: A scoping review of primary research

Introduction

More people are surviving major trauma, often with life changing injuries. Alongside physical injury, many survivors of major trauma experience psychological and psychosocial impacts. Presently, there is little guidance at the UK national level for psychological and psychosocial aspects of major trauma care. Set in the context of the regional model of major trauma care implemented in the UK in 2012, the purpose of this review was to identify and bring together primary research about psychological and psychosocial aspects of major trauma care in the UK to produce an overview of the field to date, identify knowledge gaps and set research priorities.

Methods

A scoping review was undertaken. Seven electronic databases (MEDLINE, Cochrane Library, CINAHL, Embase, PsycINFO, SocINDEX with Full Text and PROSPERO) were searched alongside a targeted grey literature search. Data from included studies were extracted using a predefined extraction form and underwent bibliometric analysis. Included studies were then grouped by type of research, summarised, and synthesised to produce a descriptive summary and overview of the field.

Results

The searches identified 5,975 articles. Following screening, 43 primary research studies were included in the scoping review. The scoping review, along with previous research, illustrates that psychological and psychosocial impacts are to be expected following major trauma. However, it also found that these aspects of care are commonly underserved and that there are inherent inequities across major trauma care pathways in the UK.

Conclusion

Though the scoping review identified a growing body of research investigating psychological and psychosocial aspects of major trauma care pathways in the UK, significant gaps in the evidence base remain. Research is needed to establish clinically effective psychological and psychosocial assessment tools, corresponding interventions, and patient-centred outcome measures so that survivors of major trauma (and family members or carers) receive the most appropriate care and intervention.

BEYOND PAIN AND DISABILITY: THE LASTING EFFECTS OF TRAUMA ON LIFE AFTER INJURY

BACKGROUND

The impact of traumatic injury likely extends beyond direct physical consequences and lasts well beyond the acute injury phase. Data collection is sparse after hospital discharge, however. In this observational study, we hypothesized that sequelae of injury would last at least 6 months and sought to prospectively determine patient reported physical, emotional, and social outcomes during this post-injury period.

METHODS

We surveyed patients admitted to our Level I trauma center (7/2019-10/2020) regarding baseline functioning and quality of life after injury, using the PROMIS-29 instrument, a primary care PTSD screen (PC-PTSD-5), and questions on substance use, employment, and living situation. Patients were re-surveyed at 6 months. PROMIS-29 scores are reported as t-scores compared to the U.S. population. Differences between groups were analyzed using chi square, signed-rank, and t-tests, with paired tests used for changes over time.

RESULTS

362 patients completed the baseline, 130 of whom completed 6-month follow-up. Those completing the 6-month survey were similar ages (43.3 ± 17.8 vs 44.4 ± 19.0, p = 0.57), mechanism (24.7% vs 28.0% shot or stabbed, p = 0.61), and severities (median ISS 9 vs 9, p = 0.15) as those who only completed the baseline. 55.0% reported being hospitalized for an injury previously. Patients reported decreases in ability to participate in social roles and activities (mean t-score 51.4 vs 55.3, p = 0.011) and increases in anxiety (53.8 vs 50.5, p = 0.011) and depression (51.0 vs 48.7, p = 0.025). 26.2% screened positive for PTSD at 6 months. Employment decreased at 6 months, with 63.9% reporting being "occasionally" employed or unemployed at 6 months, vs 44.6% pre-injury (p < 0.001).

CONCLUSION

The effects of injury extend beyond pain and disability, impacting several realms of life for at least 6 months following trauma. These data support the development of screening and intervention protocols for post-injury patients.

LEVEL OF EVIDENCE

III, prospective observational.

Stepped Collaborative Care Targeting Posttraumatic Stress Disorder Symptoms and Comorbidity for US Trauma Care Systems: A Randomized Clinical Trial

Importance

To date, few multisite investigations have evaluated early interventions for injured patients with posttraumatic stress disorder (PTSD) symptoms.

Objective

To simultaneously assess the effectiveness and implementation of a brief stepped collaborative care intervention targeting PTSD and comorbidity.

Design, Setting, and Participants

A stepped-wedge cluster randomized clinical trial was conducted at 25 US level I trauma centers. Participants included hospitalized survivors of physical injury who underwent a 2-step evaluation for PTSD symptoms. Patients reporting high levels of distress on the PTSD Checklist (PCL-C) were randomized (N = 635) per the stepped-wedge protocol to enhanced usual care control (n = 370) or intervention (n = 265) conditions. The study was conducted from January 4, 2016, through November 2018. Data analysis was performed from November 4, 2019, to December 8, 2020.

Interventions

The Trauma Survivors Outcomes and Support collaborative care intervention included proactive injury case management that assisted patients transitioning from hospital inpatient to outpatient and community settings. The intervention also integrated evidence-based pharmacotherapy and psychotherapeutic elements targeting PTSD symptoms and comorbidity.

Main Outcomes and Measures

The primary study outcome was PTSD symptoms assessed with the PCL-C at baseline in the surgical ward and at 3, 6, and 12 months postinjury. Secondary outcomes included depressive symptoms, alcohol use, and physical function. Subgroup analyses examined the effect of baseline risk factors for enduring PTSD and quality of protocol implementation on study outcomes. Primary statistical analyses were conducted using the intent-to-treat sample.

Results

A total of 327 men (51.5%) were included in analysis; mean (SD) age was 39.0 (14.2) years. The investigation attained follow-up of 75% to 80% of the participants at 3 to 12 months. The intervention lasted a mean (SD) of 122 (132) minutes. Mixed model regression analyses revealed statistically significant changes in PCL-C scores for intervention patients compared with control patients at 6 months (difference, -2.57; 95% CI, -5.12 to -0.03; effect size, 0.18; P < .05) but not 12 months (difference, -1.27; 95% CI, -4.26 to 1.73; effect size, 0.08; P = .35). Subgroup analyses revealed larger PTSD treatment effects for patients with 3 or more baseline risk factors for enduring PTSD and for patients, including firearm injury survivors, treated at trauma centers with good or excellent protocol implementation. Intervention effects for secondary outcomes did not attain statistical significance.

Conclusions and Relevance

A brief stepped collaborative care intervention was associated with significant 6-month but not 12-month PTSD symptom reductions. Greater baseline PTSD risk and good or excellent trauma center protocol implementation were associated with larger PTSD treatment effects. Orchestrated efforts targeting policy and funding should systematically incorporate the study findings into national trauma center requirements and verification criteria.

Trial Registration

ClinicalTrials.gov Identifier: NCT02655354.

A Randomized Trial of Modified Prolonged Exposure to Prevent the Development of Posttraumatic Stress Disorder in Patients Hospitalized With Traumatic Injuries

Individuals who require hospitalization after traumatic injuries are at increased risk for developing posttraumatic stress disorder (PTSD); however, few early behavioral interventions have been effective at preventing PTSD within this population. The aim of this pilot study was to assess the feasibility and effectiveness of modified prolonged exposure therapy (mPE) to prevent PTSD and depression symptoms among patients hospitalized after a DSM-5 single-incident trauma. Hospitalized patients were eligible if they screened positive for PTSD risk. Participants (N = 74) were randomly assigned in a parallel-groups design to receive mPE (n = 38) or standard of care treatment (SoC; n = 36) while admitted to the hospital after a traumatic injury. Individuals randomized to the intervention condition received one (42.1%), two (36.8%), or three sessions (15.8%) of mPE, mainly depending on length of stay. There were no significant differences between groups regarding PTSD or depression severity at 1- or 3-months posttrauma, except for more PTSD diagnoses in the intervention group after 1 month, ϕ = -.326. Intervention differences were nonsignificant when we took baseline PTSD symptoms and the nonindependence of the repeated measurements within the data into account. No adverse events were reported. Overall, mPE was no more effective than SoC for hospitalized, traumatic injury survivors with a high PTSD risk. The results may point to a need for a stepped-care approach, where intervention protocols focus on first briefly treating individuals who are actively exhibiting acute stress reactions, then extensively treating those whose symptoms do not decrease over time.

A comparative effectiveness trial of an information technology enhanced peer-integrated collaborative care intervention versus enhanced usual care for US trauma care systems: Clinical study protocol

Annually approximately 2-3 million Americans are so severely injured that they require inpatient hospitalization. The study team, which includes patients, clinical researchers, front-line provider and policy maker stakeholders, has been working together for over a decade to develop interventions that target improvements for US trauma care systems nationally. This pragmatic randomized trial compares a multidisciplinary team collaborative care intervention that integrates front-line trauma center staff with peer interventionists, versus trauma team notification of patient emotional distress with mental health consultation as enhanced usual care. The peer-integrated collaborative care intervention will be supported by a novel emergency department exchange health information technology platform. A total of 424 patients will be randomized to peer-integrated collaborative care (n = 212) and surgical team notification (n = 212) conditions. The study hypothesizes that patient's randomized to peer integrated collaborative care intervention will demonstrate significant reductions in emergency department health service utilization, severity of patient concerns, post traumatic stress disorder symptoms, and physical limitations when compared to surgical team notification. These four primary outcomes will be followed-up at 1- 3-, 6-, 9- and 12-months after injury for all patients. The Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) method will be used to assess implementation processes. Data from the primary outcome analysis and implementation process assessment will be used to inform an end-of-study policy summit with the American College of Surgeons Committee on Trauma. The policy summit will facilitate acute care practice changes related to patient-centered care transitions over the course of a single 5-year funding cycle. Trial registration: (Clinicaltrials.govNCT03569878).

Systematic review and meta-analyses of randomized control trials of the effectiveness of psychosocial interventions for homeless adults

AIMS

To evaluate the effect of psychosocial interventions for homeless adults on their psychosocial outcomes.

DESIGN

A systematic review and meta-analyses were performed for critical appraisal and synthesis of the included studies.

DATA SOURCES

A systematic search of studies published before 10 September 2018 was performed using PubMed, Cochrane Library, EMBASE, PsycINFO, and CINAHL.

REVIEW METHODS

The review included randomized controlled trials conducting psychosocial interventions and assessing psychosocial outcomes for homeless adults. After systematically describing study and intervention characteristics, we conducted meta-analyses by the type of outcome and subgroup meta-analyses by the type of intervention and outcome. Fourteen studies were included in this review and 11 were included in the meta-analyses.

RESULTS

A significant effect of psychosocial interventions in reducing anxiety and enhancing mental health status among homeless adults was noted.

CONCLUSION

The meta-analyses showed that psychosocial interventions may reduce anxiety and enhance the mental health status of homeless people. Specifically, we suggest that relaxation response training may be effective in improving anxiety and mental health status and cognitive behavioural therapy may reduce anxiety.

IMPACT

Although psychosocial interventions for homeless persons have been implemented for a decade, their impact for psychosocial outcomes among homeless adults has not been evaluated. This review suggest that psychosocial interventions may improve anxiety and mental health status among homeless adults. The findings of the present study may provide directions for developing psychosocial interventions to help vulnerable homeless adults in managing psychological outcomes.