Posttraumatic stress disorder: a primer for trauma surgeons

Trauma Resilience and Recovery Program: Addressing Mental Health in Pediatric Trauma Centers

OBJECTIVE

Approximately 225,000 children sustain injuries requiring hospitalization annually. Posttraumatic stress disorder (PTSD) and depression are prevalent among pediatric patients and caregivers post-injury. Most U.S. trauma centers do not address patients' mental health needs. Better models of care are needed to address emotional recovery. This article describes the engagement and recovery trajectories of pediatric patients enrolled in the Trauma Resilience and Recovery Program (TRRP), a stepped-care model to accelerate emotional recovery following hospitalization.

METHODS

TRRP is designed to (a) provide in-hospital education about post-injury emotional recovery and assess child and caregiver distress; (b) track mental health symptoms via a 30-day text-messaging program; (c) complete 30-day PTSD and depression phone screens; and (d) provide evidence-based treatment via telehealth or in-person services or referrals, if needed. All 154 families approached were offered TRRP services, 96% of whom agreed to enroll in TRRP. Most patients were boys (59.8%), and average age was 9.12 years [standard deviation (SD) = 5.42]. Most injuries (45.8%) were sustained from motor vehicle accidents.

RESULTS

In hospital, 68.5% of caregivers and 78.3% of children reported clinically significant distress levels. Over 60% of families enrolled in the texting service. TRRP re-engaged 40.1% of families for the 30-day screen, 35.5% of whom reported clinically significant PTSD (M = 13.90, SD = 11.42) and/or depression (M = 13.35, SD = 11.16). Most (76%) patients with clinically significant symptomology agreed to treatment.

CONCLUSIONS

Our intervention model was feasible and increased reach to families who needed services. Efforts to improve follow-up engagement are discussed, as are initial successes in implementing this model in other pediatric trauma centers.

Unveiling posttraumatic stress disorder in trauma surgeons: a national survey

BACKGROUND

The significance of posttraumatic stress disorder (PTSD) in trauma patients is well recognized. The impact trauma surgeons endure in managing critical trauma cases is unknown. The aim of our study was to assess the incidence of PTSD among trauma surgeons and identify risk factors associated with the development of PTSD.

METHODS

We surveyed all members of the American Association for Surgery of Trauma and the Eastern Association for Surgery of Trauma using an established PTSD screening test (PTSD Checklist Civilian [PCL-C]). A PCL-C score of 35 or higher (sensitivity > 85%) was used as the cutoff for the development of PTSD symptoms and a PCL-C score of 44 or higher for the diagnosis of PTSD. Multivariate logistic regression was performed.

RESULTS

There were 453 respondents with a 41% response rate. PTSD symptoms were present in 40% (n = 181) of the trauma surgeons, and 15% (n = 68) of the trauma surgeons met the diagnostic criteria for PTSD. Male trauma surgeons (odds ratio [OR], 2; 95% confidence interval [CI], 1.2-3.1) operating more than 15 cases per month (OR, 3; 95% CI, 1.2-8), having more than seven call duties per month (OR, 2.6; 95% CI, 1.2-6), and with less than 4 hours of relaxation per day (OR, 7; 95% CI, 1.4-35) were more likely to develop symptoms of PTSD. Diagnosis of PTSD was common in trauma surgeons managing more than 5 critical cases per call duty (OR, 7; 95% CI, 1.1-8). Salary, years of clinical practice, and previous military experience were predictive for neither the development of PTSD symptoms nor the diagnosis of PTSD.

CONCLUSION

Both symptoms and the diagnosis of PTSD are common among trauma surgeons. Defining the factors that predispose trauma surgeons to PTSD may be of benefit to the patients and the profession. The data from this survey will be useful to major national trauma surgery associations for developing targeted interventions.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Posttraumatic stress disorder and symptoms among American Indians and Alaska Natives: a review of the literature

PURPOSE

American Indians and Alaska Natives (AI/ANs) experience high rates of trauma and posttraumatic stress disorder (PTSD). We reviewed existing literature to address three interrelated questions: (1) What is the prevalence of PTSD and PTSD symptoms among AI/ANs? (2) What are the inciting events, risk factors, and co-morbidities in AI/ANs, and do they differ from those in the general U.S. population? (3) Are studies available to inform clinicians about the course and treatment of PTSD in this population?

METHODS

We searched the PubMed and Web of Science databases and a database on AI/AN health, capturing an initial sample of 77 original English-language articles published 1992–2010. After applying exclusion criteria, we retained 37 articles on prevalence of PTSD and related symptoms among AI/AN adults. We abstracted key information and organized it in tabular format.

RESULTS

AI/ANs experience a substantially greater burden of PTSD and related symptoms than U.S. Whites. Combat experience and interpersonal violence were consistently cited as leading causes of PTSD and related symptoms. PTSD was associated with bodily pain, lung disorders, general health problems, substance abuse, and pathological gambling. In general, inciting events, risk factors, and co-morbidities appear similar to those in the general U.S. population.

CONCLUSIONS

Substantial research indicates a strikingly high incidence of PTSD in AI/AN populations. However, inciting events, risk factors, and co-morbidities in AI/ANs, and how they may differ from those in the general population, are poorly understood. Very few studies are available on the clinical course and treatment of PTSD in this vulnerable population.

A randomized stepped care intervention trial targeting posttraumatic stress disorder for surgically hospitalized injury survivors

OBJECTIVE

To test the effectiveness of a stepped care intervention model targeting posttraumatic stress disorder (PTSD) symptoms after injury.

BACKGROUND

Few investigations have evaluated interventions for injured patients with PTSD and related impairments that can be feasibly implemented in trauma surgical settings.

METHODS

The investigation was a pragmatic effectiveness trial in which 207 acutely injured hospitalized trauma survivors were screened for high PTSD symptom levels and then randomized to a stepped combined care management, psychopharmacology, and cognitive behavioral psychotherapy intervention (n = 104) or usual care control (n = 103) conditions. The symptoms of PTSD and functional limitations were reassessed at 1, 3, 6, 9, and 12 months after the index injury admission.

RESULTS

Regression analyses demonstrated that over the course of the year after injury, intervention patients had significantly reduced PTSD symptoms when compared with controls [group by time effect, CAPS (Clinician-Administered PTSD Scale): F(2, 185) = 5.50, P < 0.01; PCL-C (PTSD Checklist Civilian Version): F(4, 185) = 5.45, P < 0.001]. Clinically and statistically significant PTSD treatment effects were observed at the 6-, 9-, and 12-month postinjury assessments. Over the course of the year after injury, intervention patients also demonstrated significant improvements in physical function [MOS SF-36 PCS (Medical Outcomes Study Short Form 36 Physical Component Summary) main effect: F(1, 172) = 9.87, P < 0.01].

CONCLUSIONS

Stepped care interventions can reduce PTSD symptoms and improve functioning over the course of the year after surgical injury hospitalization. Orchestrated investigative and policy efforts could systematically introduce and evaluate screening and intervention procedures for PTSD at US trauma centers. (

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT00270959).

Initial management of bereaved relatives following trauma

Emergency department (ED) staff confront death more frequently than any other specialty except oncology. These deaths are often traumatic, sudden, unexpected and occur in a younger age group. As a consequence, bereaved survivors have a greater risk of an abnormal grief reaction. [ Walters DT, Tupin JP (1991) Family grief in the emergency department. Emergency Medicine Clinics of North America 9(1): 189–206.] Whilst the severity or timing of traumatic injuries may preclude medical attempts to influence patient survival, the approach of the same resuscitation team to the bereaved before death, during resuscitation and after death may have profound influences on subsequent grief in the bereaved. Despite this, it can be argued that Emergency Medicine within the UK has given little thought and time for reflection upon how we treat the bereaved. That the care of the dying and the bereaved within the ED matters is greatly reinforced by the Scottish Government’s 2010 Consultation document on bereavement that states: ‘There is … evidence that the way [the] bereaved experience events around the time of death will influence their grief. Where health services get it right … bereaved people are supported to accept the death … Conversely if the health services get it wrong, then bereaved people may experience additional distress, and that distress will interfere with their successful transition through the grieving process’.