Coping with serious accidental injury: a one-year follow-up study

Return to work during first year after intensive care treatment and the impact of demographic, clinical and psychosocial factors

OBJECTIVES

To describe work participation in survivors during first year after intensive care unit discharge and examine the impact of selected demographic, clinical and psychosocial factors on return to work 12 months after discharge.

RESEARCH METHODOLOGY/DESIGN

A predefined sub-study (prospective cohort study) of a randomised controlled trial.

SETTING

A Norwegian single-centre university hospital. Medical and surgical adult intensive care survivors, working/on sick leave before admission, in the intensive care unit ≥24 h, were included.

MAIN OUTCOME MEASURES

Return to work three, six and 12 months after discharge, and impact of age, pre-existing comorbidities, previous serious life events, coping ability, hope and social support on return to work 12 months after discharge.

RESULTS

Included were 284 patients, with mean age 47 years (SD 13.9) and 47 % women. One year after discharge, 69 % were back at work. In the regression analysis, with working at 12 months (yes/no) as the dependent variable, 178 patients, completing questionnaires at three as well as 12 months, were included. Lower age (OR 0.96, 95 % CI [0.93-0.99]), lower pre-existing comorbidities (OR 0.65, 95 % CI [0.43-0.97]), previous serious life events (OR 6.53, 95 % CI [2.14-19.94]), and greater hope at three months (OR 1.09, 95 % CI [1.01-1.17]) were all independently associated with higher odds of returning to work.

CONCLUSION

Following intensive care, age, pre-existing comorbidities, experience of previous serious life events and hope all have a significant impact on return to work, and are important variables to consider during intensive care treatment and rehabilitation.

IMPLICATIONS FOR CLINICAL PRACTICE

Attention must be paid to patients with prior working capability to ensure return to work after intensive care treatment. Older adults with pre-existing comorbidities might benefit from early, individualised rehabilitation to regain previous working capacity. In addition, there is also a need to support patients' hope during and after critical illness.

Adversity Interpreted: A Scoping Review of Adversity Appraisal Measurement

Although evidence suggests that individuals' appraisals (i.e., subjective interpretations) of adverse or traumatic life events may serve as a mechanism accounting for differences in adversity exposure and psychological adjustment, understanding this mechanism is contingent on our ability to reliably and consistently measure appraisals. However, measures have varied widely between studies, making conclusions about how best to measure appraisal a challenge for the field. To address this issue, the present study reviewed 88 articles from three research databases, assessing adults' appraisals of adversity. To be included in the scoping review, articles had to meet the following criteria: (1) published no earlier than 1999, (2) available in English, (3) published as a primary source manuscript, and (4) included a measure assessing for adults' (over the age of 18) subjective primary and/or secondary interpretations of adversity. Each article was thoroughly reviewed and coded based on the following information: study demographics, appraisal measurement tool(s), category of appraisal, appraisal dimensions (e.g., self-blame, impact, and threat), and the tool's reliability and validity. Further, information was coded according to the type of adversity appraised, the time in which the appraised event occurred, and which outcomes were assessed in relation to appraisal. Results highlight the importance of continued examination of adversity appraisals and reveal which appraisal tools, categories, and dimensions are most commonly assessed for. These results provide guidance to researchers in how to examine adversity appraisals and what gaps among the measurement of adversity appraisal which need to be addressed in the future research.

Posttraumatic stress disorder prevalence in medical populations: A systematic review and meta-analysis

OBJECTIVE

PTSD is increasingly recognized following medical traumas although is highly heterogeneous. It is difficult to judge which medical contexts have the most traumatic potential and where to concentrate further research and clinical attention for prevention, early detection and treatment. The objective of this study was to compare PTSD prevalence in different medical populations.

METHODS

A systematic review of the literature on PTSD following medical traumas was conducted as well as a meta-analysis with final pooled result and 95% confidence intervals presented. A meta-regression was used to investigate the impact of potential effect modifiers (PTSD severity, age, sex, timeline) on study effect size between prevalence studies.

RESULTS

From 3278 abstracts, the authors extracted 292 studies reporting prevalence. Using clinician-administered reports, the highest 24 month or longer PTSD prevalence was found for intraoperative awareness (18.5% [95% CI=5.1%-36.6%]) and the lowest was found for epilepsy (4.5% [95% CI=0.2%-12.6%]). In the overall effect of the meta-regression, only medical events or procedures emerged as significant (p = 0.006) CONCLUSION: This review provides clinicians with greater awareness of medical contexts most associated with PTSD, which may assist them in the decision to engage in more frequent, earlier screening and referral to mental health services.

Participant retention in trauma intensive care unit (ICU) follow-up studies: a post-hoc analysis of a previous scoping review

BACKGROUND

The study aimed to synthesize participant retention-related data for longitudinal follow-up studies of survivors from trauma intensive care units (ICUs).

METHODS

Within a published scoping review evaluating ICU patient outcomes after hospital discharge, two screeners independently searched for trauma ICU survivorship studies.

RESULTS

There were 11 trauma ICU follow-up studies, all of which were cohort studies. Twelve months (range: 1-60 months) was the most frequent follow-up time point for assessment (63% of studies). Retention rates ranged from 54% to 94% across time points and could not be calculated for two studies (18%). Pooled retention rates at 3, 6, and 12 months were 75%, 81%, and 81%, respectively. Mean patient age (OR 0.85 per 1-year increase, 95% CI 0.73 to 0.99, p=0.036), percent of men (OR 1.07, 95% CI 1.04 to 1.10, p=0.002), and publication year (OR 0.89 per 1-year increase, 95% CI 0.82 to 0.95, p=0.007) were associated with retention rates. Early (3-month) versus later (6-month, 12-month) follow-up time point was not associated with retention rates.

DISCUSSION

Pooled retention rates were >75%, at 3-month, 6-month, and 12-month time points, with wide variability across studies and time points. There was little consistency with reporting participant retention methodology and related data. More detailed reporting guidelines, with better author adherence, will help improve reporting of participant retention data. Utilization of existing research resources may help improve participant retention.

LEVEL OF EVIDENCE

Level III: meta-analyses (post-hoc analyses) of a prior scoping review.

Post-traumatic stress symptoms and sense of coherence in proximity to intensive care unit discharge

BACKGROUND

Post-traumatic stress (PTS) symptoms following intensive care unit (ICU) treatment can lead to post-traumatic stress disorder and represent a severe health burden. In trauma patients, a strong sense of coherence (SOC) is associated with fewer PTS symptoms. However, this association has not been investigated in a general ICU sample.

AIMS AND OBJECTIVES

To examine the occurrence of PTS symptoms in general ICU patients early after ICU discharge and to assess possible associations between PTS symptoms and SOC, ICU memory, pain, and demographic and clinical characteristics.

DESIGN

This was a cross-sectional study.

METHODS

Adult patients aged ≥18 years admitted for ≥24 hours to five ICUs between 2014 and 2016 were recruited. PTS symptoms and SOC were measured at the ward within the first week after discharge from the ICU using the Posttraumatic Stress Scale-10 and Sense of Coherence Scale-13. Multiple linear regression analysis was used to identify associations between PTS symptoms and SOC and the selected independent variables.

RESULTS

A total of 523 patients were included (17.8% trauma patients; median age 57 years [range 18-94]; 53.3% male). The prevalence of clinically significant PTS symptoms was 32%. After adjustments for gender and age, lower SOC (P < 0.001), more ICU delusional memories (P < 0.001), greater pain interference (P < 0.001), not being a trauma patient (P = 0.02), and younger age (P = 0.03) were significantly associated with more PTS symptoms.

CONCLUSIONS

One third of patients experienced clinically relevant PTS symptoms early after discharge from the ICU. In the present study, SOC, delusional memory, pain interference, younger age, and not being a trauma patient were factors associated with more PTS symptoms.

RELEVANCE TO CLINICAL PRACTICE

Early individual follow up after ICU discharge focusing on pain relief and delusional memory may reduce PTS symptoms, with a potential of improving rehabilitation.

Measuring Adaptive Coping of Hospitalized Patients With a Severe Medical Condition: The Sickness Insight in Coping Questionnaire

OBJECTIVES

Adaptive coping strategies are associated with less psychological distress. However, there is no brief, specific, and validated instrument for assessing adaptive coping among seriously ill patients. Our objective was to examine the validity and patient-proxy agreement of a novel instrument, the Sickness Insight in Coping Questionnaire.

DESIGN

A cross-sectional design which included two related studies.

SETTING

A single university-affiliated Dutch hospital.

SUBJECTS

Hospitalized patients (study 1) and ICU-patients and proxies (study 2).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Study 1 (n = 103 hospitalized patients) addressed the Sickness Insight in Coping Questionnaire's performance relative to questionnaires addressing similar content areas. Coping subscales of the BRIEF COPE, Illness Cognition Questionnaire, and Utrecht Coping List were used as comparator measures in testing the construct validity of the Sickness Insight in Coping Questionnaire-subscales (fighting spirit, toughness, redefinition, positivism, and non-acceptance). The Sickness Insight in Coping Questionnaire had good internal consistency (0.64 ≤ α ≤ 0.79), a clear initial factor structure, and fair convergent (0.24 ≤ r ≤ 0.50) and divergent (r, ≤ 0.12) construct validity. Study 2 examined the performance of the Sickness Insight in Coping Questionnaire among 100 ICU patients and their close family members. This study showed that the Sickness Insight in Coping Questionnaire has good structural validity (confirmatory factor analyses with Comparative Fit Index > 0.90 and Root Mean Square Error of Approximation < 0.08) and moderate (r, 0.37; non-acceptance) to strong (r, > 0.50; fighting spirit, toughness, redefinition, and positivism) patient-close proxy agreement.

CONCLUSIONS

Overall, the Sickness Insight in Coping Questionnaire has good psychometric properties. ICU clinicians can use the Sickness Insight in Coping Questionnaire to gain insight in adaptive coping style of patients through ratings of patients or their close family members.

Posttraumatic stress in intensive care unit survivors - a prospective study

Aims: This study aimed to estimate the prevalence of severe Posttraumatic Stress Disorder (PTSD) symptoms and to identify factors associated with PTSD in survivors of intensive care unit (ICU) treatment following traumatic injury. Methods: Fifty-two patients who were admitted to an ICU through the emergency ward following traumatic injury were prospectively followed. Information on injury severity and ICU treatment were obtained through medical records. Demographic information and measures of acute stress symptoms, experienced social support, coping style, sense of coherence (SOC) and locus of control were assessed within one-month post-accident (T1). At the six months follow-up (T2), PTSD was assessed with the Harvard Trauma Questionnaire (HTQ). Results: In the six months follow-up, 10 respondents (19.2%) had HTQ total scores reaching a level suggestive of PTSD (N = 52), and 11 respondents (21%) had symptom levels indicating subclinical PTSD. Female, five illness factors: coma time, mechanical ventilation, sedation, benzodiazepine, pain relieving medication, and four psychological factors: symptoms of acute stress (T1), fear of death and/or feeling completely helpless and powerless in relation to the accident and/or ICU (T1), SOC (T1) and more external locus of control (T1) correlated significantly with PTSD symptoms at T2. In the linear regression analysis, female, length of sedation, dissociation (T1), hypervigilance (T1), and external locus of control predicted 58% of the variation of PTSD. Conclusions: High levels of PTSD symptoms occurred in 19.2% of respondents in six months following traumatic injury requiring ICU admission. Screening for the variables gender, length of sedation, dissociation, hypervigilance, and locus of control after ICU admission following traumatic injuries may help to predict who will develop PTSD.

Return to work following unintentional injury: a prospective follow-up study

OBJECTIVE

The aim of this study was to predict time off work following unintentional injuries due to accidents leading to hospital admission.

DESIGN

Prospective 6-month follow-up study.

SETTING

Department of Trauma Surgery of a University Hospital.

PARTICIPANTS

Consecutively recruited victims of unintentional injuries (n=221) hospitalised for a minimum of 32 h including two consecutive nights. All the participants were aged 18-65 years and were able to participate in an assessment within 30 days of the accident.

MAIN OUTCOME MEASURES

Interview-assessed number of days off work during the 6 months immediately following the accident.

RESULTS

The patients' subjective appraisals of (1) accident severity and (2) their ability to cope with the resulting injury and its job-related consequences predicted time off work following the accident beyond the impact of the objective severity of their injury and the type of accident involved.

CONCLUSIONS

The patients' subjective appraisals of the accident severity and of their ability to cope with its consequences are highly relevant for return to work after accidents. Extending the findings from previous studies on severely injured and otherwise preselected accident victims, this seems to apply to the whole spectrum of patients hospitalised with unintentional injuries.

Assessments of coping after acquired brain injury: a systematic review of instrument conceptualization, feasibility, and psychometric properties

OBJECTIVE

To identify measures of coping styles used by patients with acquired brain injury; to evaluate the conceptualization, feasibility, and psychometric properties of the instruments; and to provide guidance for researchers and clinicians in the choice of a suitable instrument.

DESIGN

Systematic review.

RESULTS

The search identified 47 instruments, of which 14 were selected. The instruments focused on dispositional coping, situation-specific coping, or domain-specific coping. Psychometric properties were scarcely investigated. The COPE stood out in terms of psychometric properties but had low feasibility. The brief COPE, Coping Scale for Adults-short form, and Utrecht Coping List stood out in terms of feasibility, and the available psychometric properties of these instruments were good. Only the Coping With Health Injuries and Problems was used as other report.

CONCLUSION

Information on psychometric properties of coping instruments in acquired brain injury is scarcely available and limits the strength of our recommendations. For patients with mild injuries, we cautiously recommend the COPE and for patients with more severe injuries the brief COPE, Coping Scale for Adults-short form, Utrecht Coping List, and Coping With Health Injuries and Problems-other-report. Other instruments may be used to address particular issues such as coping with a specific stressful situation or illness.

Psychobiology of PTSD in the acute aftermath of trauma: Integrating research on coping, HPA function and sympathetic nervous system activity

Research on the psychobiological sequelae of trauma has typically focused on long-term alterations in individuals with chronic posttraumatic stress disorder (PTSD). Far less is known about the nature and course of psychobiological risk factors for PTSD during the acute aftermath of trauma. In this review, we summarize data from prospective studies focusing on the relationships among sympathetic nervous system activity, hypothalamic-pituitary-adrenal function, coping strategies and PTSD symptoms during the early recovery (or non-recovery) phase. Findings from pertinent studies are integrated to inform psychobiological profiles of PTSD-risk in children and adults in the context of existing models of PTSD-onset and maintenance. Data regarding bidirectional relations between coping strategies and stress hormones is reviewed. Limitations of existing literature and recommendations for future research are discussed.

Quality of life after traumatic injury: a latent trajectory modeling approach

BACKGROUND

It is largely unknown how quality of life (QoL) changes following accidental injuries. Equally, the mechanisms underlying such changes have not yet been identified in detail. This study of injured accident survivors aimed to: (1) detect a model of change which best explains the observed course of QoL, and (2) identify potential predictor variables.

METHODS

323 injured accident survivors were interviewed within 2 weeks of the trauma, and followed up at 6 and 12 months. Latent trajectory modeling was used to analyze the fit of three potential trajectories regarding the observed course of general QoL as measured by the Questions on Life Satisfaction questionnaire.

RESULTS

The trajectory model adopting a negative square-root change fitted the observed data best, meaning that shortly after the accident, general QoL decreased strongly with diminishing negative changes occurring later on. Early and prolonged QoL impairment was largely attributable to the initial level of posttraumatic stress as measured by the Clinician-Administered PTSD Scale. To a lesser extent, depressive symptoms also predicted change in subjective QoL, while injury severity showed no direct effect; rather, its impact on QoL was mediated by initial posttraumatic stress. By contrast, reduced occupational functioning was attributable to injury severity rather than psychopathology.

CONCLUSIONS

When treating injured accident survivors, clinicians should consider symptoms of posttraumatic stress and comorbid depression in order to prevent or mitigate negative changes in QoL.

The adaptation process following acute onset disability: an interactive two-dimensional approach applied to acquired brain injury

Objective:

To describe a new model of the adaptation process following acquired brain injury, based on the patient’s goals, the patient’s abilities and the emotional response to the changes and the possible discrepancy between goals and achievements.

Background:

The process of adaptation after acquired brain injury is characterized by a continuous interaction of two processes: achieving maximal restoration of function and adjusting to the alterations and losses that occur in the various domains of functioning. Consequently, adaptation requires a balanced mix of restoration-oriented coping and loss-oriented coping. The commonly used framework to explain adaptation and coping, ‘The Theory of Stress and Coping’ of Lazarus and Folkman, does not capture this interactive duality.

Relevant theories:

This model additionally considers theories concerned with self-regulation of behaviour, self-awareness and self-efficacy, and with the setting and achievement of goals.

The two-dimensional model:

Our model proposes the simultaneous and continuous interaction of two pathways; goal pursuit (short term and long term) or revision as a result of success and failure in reducing distance between current state and expected future state and an affective response that is generated by the experienced goal-performance discrepancies. This affective response, in turn, influences the goals set. This two-dimensional representation covers the processes mentioned above: restoration of function and consideration of long-term limitations. We propose that adaptation centres on readjustment of long-term goals to new achievable but desired and important goals, and that this adjustment underlies re-establishing emotional stability. We discuss how the proposed model is related to actual rehabilitation practice.

Posttraumatic stress symptoms and health-related quality of life: a two year follow up study of injury treated at the emergency department

BACKGROUND

Among injury victims relatively high prevalence rates of posttraumatic stress disorder (PTSD) have been found. PTSD is associated with functional impairments and decreased health-related quality of life (HRQoL). Previous studies that addressed the latter were restricted to injuries at the higher end of the severity spectrum. This study examined the association between PTSD symptoms and health-related quality of life (HRQoL) in a comprehensive population of injury patients of all severity levels and external causes.

METHODS

We conducted a self-assessment survey which included items regarding demographics of the patient, accident type, sustained injuries, EuroQol health classification system (EQ-5D) and Health Utilities Index (HUI) to measure functional outcome and HRQoL, and the Impact of Event Scale (IES) to measure PTSD symptoms. An IES-score of 35 or higher was used as indication for the presence of PTSD. The survey was completed by 1,781 injury patients two years after they were treated at the Emergency Department (ED), followed by either hospital admission or direct discharge to the home environment.

RESULTS

Symptoms indicative of PTSD were associated with more problems on all EQ-5D and HUI3 domains of functional outcome and a considerable utility loss in both hospitalized (0.23-0.24) and non-hospitalized (0.32-0.33) patients. Differences in reported problems between patients with IES scores higher or lower than 35 were largest for EQ-5D health domains pain/discomfort (82% versus 28%) and anxiety/depression (53% versus 11%) and HUI domains emotion (92% versus 33%) and pain (84% versus 38%). After adjusting for potential confounders, PTSD remained strongly associated with adverse HRQoL.

CONCLUSIONS

Among patients treated at an ED posttraumatic stress symptoms indicative of PTSD were associated with a considerable decrease in HRQoL in both hospitalized and non-hospitalized patients. PTSD symptoms may therefore raise a major barrier for full recovery of injury patients of even minor levels of severity.

The interactive effects of emotional clarity and cognitive reappraisal in Posttraumatic Stress Disorder

The goal of this investigation was to examine how emotional clarity and a specific emotion regulation strategy, cognitive reappraisal, interact to predict Posttraumatic Stress Disorder (PTSD) symptom severity and positive affect among treatment seeking military Veterans (N=75, 93% male) diagnosed with PTSD. PTSD is a highly relevant context because PTSD features include heightened stress reactivity, diminished ability to differentiate and understand emotions, and reliance on maladaptive forms of emotion regulation. We found that the combination of high levels of emotional clarity and frequent use of cognitive reappraisal were associated with (a) lesser total PTSD severity after accounting for shared variance with positive affect and the extent to which emotions are attended to (attention to emotions), and (b) greater positive affect after accounting for shared variance with total PTSD severity and attention to emotions. This is the first study to demonstrate interactive effects of emotional clarity and cognitive reappraisal.

Changes in the coping styles of spouses and the influence of these changes on their psychosocial functioning the first year after a patient's stroke

OBJECTIVE

The objective of this study was to examine the changes in spouses' coping styles that occur in the first year after a patient's stroke and the influence of these changes on the spouses' psychosocial functioning.

METHODS

A total of 211 spouses of patients with stroke were assessed at three different time points using self-reported questionnaires (at the time of the patient's admission to inpatient rehabilitation, 2 months after discharge and 1 year poststroke). We used linear mixed-model and multiple linear regression analyses to analyse the data.

RESULTS

Spouses' use of an active coping style decreased significantly in the first year poststroke. There were no significant overall changes in the use of a passive coping style. The use of a passive coping style at admission and increases in passive coping style in the first year poststroke predicted worse psychosocial functioning 1 year poststroke. The models explained between 32% and 50% of the variance in quality of life, depressive symptoms and strain.

CONCLUSION

The present study indicates that spouses' passive coping style is maladaptive poststroke when used in the acute as well as in the chronic phase. Use of an active coping style decreases in the first year poststroke, but these decreases do not predict psychosocial outcomes.

The long-term prediction of return to work following serious accidental injuries: a follow up study

BACKGROUND

Considerable indirect costs are incurred by time taken off work following accidental injuries. The aim of this study was to predict return to work following serious accidental injuries.

METHOD

121 severely injured patients were included in the study. Complete follow-up data were available for 85 patients. Two weeks post trauma (T1), patients rated their appraisal of the injury severity and their ability to cope with the injury and its job-related consequences. Time off work was assessed at one (T2) and three years (T3) post accident. The main outcome was the number of days of sick leave taken due to the accidental injury.

RESULTS

The patients' appraisals a) of the injury severity and b) of their coping abilities regarding the accidental injury and its job-related consequences were significant predictors of the number of sick-leave days taken. Injury severity (ISS), type of accident, age and gender did not contribute significantly to the prediction.

CONCLUSIONS

Return to work in the long term is best predicted by the patients' own appraisal of both their injury severity and the ability to cope with the accidental injury.

The effect of post-injury depression on return to pre-injury function: a prospective cohort study

BACKGROUND

Millions of people seek emergency department (ED) care for injuries each year, the majority for minor injuries. Little is known about the effect of psychiatric co-morbid disorders that emerge after minor injury on functional recovery. This study examined the effect of post-injury depression on return to pre-injury levels of function.

METHOD

This was a longitudinal cohort study with follow-up at 3, 6 and 12 months post-injury: 275 adults were randomly selected from those presenting to the ED with minor injury; 248 were retained over the post-injury year. Function was measured with the Functional Status Questionnaire (FSQ). Psychiatric disorders were diagnosed using the Structured Clinical Interview for DSM-IV-TR disorders (SCID).

RESULTS

During the post-injury year, 18.1% [95% confidence interval (CI) 13.3-22.9] were diagnosed with depression. Adjusting for clinical and demographic covariates, the depressed group was less likely to return to pre-injury levels of activities of daily living [odds ratio (OR) 8.37, 95% CI 3.78-18.53] and instrumental activities of daily living (OR 3.25, 95% CI 1.44-7.31), less likely to return to pre-injury work status (OR 2.37, 95% CI 1.04-5.38), and more likely to spend days in bed because of health (OR 2.41, 95% CI 1.15-5.07).

CONCLUSIONS

Depression was the most frequent psychiatric diagnosis in the year after minor injury requiring emergency care. Individuals with depression did not return to pre-injury levels of function during the post-injury year.

Determinants of return to work in patients with hand disorders and hand injuries

INTRODUCTION

Return to work (RTW) in patients with hand disorders and hand injuries is determined by several determinants not directly related to the physical situation. Besides biomedical determinants, work-related and psychosocial determinants may influence RTW as well. This study is conducted to investigate the influence of these potential determinants on RTW in patients with hand disorders and hand injuries.

METHODS

Included 91 patients who were operatively treated for a hand disorder or a hand injury, and who were employed prior to surgery. Patients answered several questionnaires on the aforementioned categories. Potential determinants significantly related to RTW in a univariate analysis were entered in a logistic regression for the total group and the acutely injured patients separately.

RESULTS

Pain, accident location, job independence and symptoms of post-traumatic stress disorder (PTSD) were univariately associated with RTW. Pain was a determinant for late RTW in the total group and accident location and symptoms of PTSD in the acutely injured group.

CONCLUSION

Pain, accident location and symptoms of PTSD were most important in resuming work in hand injured patients or in patients with a hand disorder. These findings may indicate that attention should be paid to the treatment of pain, and to the development of symptoms of PTSD during rehabilitation. It may be necessary to make extra efforts aimed at RTW in patients who sustained their injury on the job.

Coping and quality of life after tumor surgery: personal and social resources promote different domains of quality of life

Personal and social resources facilitate the adaptation to critical life events. The present study investigates whether general self-efficacy beliefs and received social support elevate cancer patients' physical, emotional, and social well-being directly, or whether these effects are rather mediated by active or meaning-focused coping. Gastrointestinal, colorectal, and lung cancer patients were approached at 1 month and at 6 months after surgery (N=175). Structural equation models indicate that self-efficacy at 1 month after surgery exerted a positive direct effect on all three domains of health-related quality of life at 6 months after surgery, but indirect effects through active and meaning-focused coping were also observed. Initial received support elevated later emotional well-being, but not the other two quality of life domains. This effect was not mediated by coping. Results suggest the development of interventions to increase optimistic self-beliefs and coping skills in tumor-surgery patients.

Post-traumatic stress disorder in serious accidental injury: 3-year follow-up study

BACKGROUND

Long-term data on post-traumatic stress disorder (PTSD) following accidents are scarce.

AIMS

To assess and predict PTSD in people 3 years after severe accidental injury.

METHOD

Severely injured patients were recruited consecutively from the intensive care unit (n=121) and assessed within 1 month of the trauma. Follow-up interviews were conducted 6 months, 12 months and 36 months later; 90 patients participated in all four interviews. Symptoms were assessed using the Clinician-Administered PTSD Scale.

RESULTS

Post-traumatic stress disorder was diagnosed in 6% of patients 2 weeks after the accident, in 2% after 1 year and in 4% after 3 years. Robust predictors of later PTSD symptom level were intrusive symptoms shortly after the accident and biographical risk factors. There were individual changes over time between the categories PTSD, sub-threshold PTSD and no PTSD. Whereas PTSD symptom severity was low or decreased for most of the patients, some of them showed an increase or a delayed onset. Patients with persisting PTSD symptoms at 6 months and patients with delayed onset of symptoms are at risk of long-term PTSD.

CONCLUSIONS

The prevalence of PTSD was low over the whole period of 3 years.

Posttraumatic stress disorder following accidental injury: rule or exception in Switzerland?

BACKGROUND

There is still marked variability in the findings concerning psychiatric disorders associated with traumatic injury. The aim of this study was to determine the incidence of acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) following accidental injuries, and to predict the PTSD symptom level at 6 months, taking into particular consideration the role of pre-existing psychiatric morbidity and insufficient command of the local language.

METHOD

A total of 255 accident survivors who were hospitalized for at least 2 consecutive nights at a Swiss university hospital for treatment of recently acquired physical injuries were interviewed within 2 weeks of the trauma and 6 months after the accident. Patients who did not have a good command of German but were fluent in Italian, Spanish, Portuguese, Serbo-Croatian or Albanian were assessed using interpreters. The main outcome measure was the Clinician-Administered PTSD Scale.

RESULTS

Ten patients (3.9%) were diagnosed as having ASD. At 6 months, 8 patients (3.1%) had PTSD. A regression model using 12 potential predictor variables explained 40% of the variance of PTSD symptoms; mild traumatic brain injury (p < 0.001), pain (p < 0.05), ASD symptom level (p < 0.001) and emotional coping (p = 0.001) predicted higher PTSD symptom levels, while high Sense of Coherence (p < 0.05) and perceived responsibility for the accident (p < 0.01) were associated with lower PTSD symptom levels at follow-up.

CONCLUSIONS

ASD and PTSD seem to occur less frequently following accidental injuries than previously reported in the literature. Pre-existing psychiatric morbidity and lack of proficiency in the locally spoken language do not appear to play an important role in the development of PTSD.

Treating acute stress disorder and posttraumatic stress disorder with cognitive behavioral therapy or structured writing therapy: a randomized controlled trial

BACKGROUND

Writing assignments have shown promising results in treating traumatic symptomatology. Yet no studies have compared their efficacy to the current treatment of choice, cognitive behavior therapy (CBT). The present study evaluated the efficacy of structured writing therapy (SWT) and CBT as compared to a waitlist control condition in treating acute stress disorder (ASD) and posttraumatic stress disorder (PTSD).

METHODS

A randomized controlled trial was conducted at an outpatient clinic. Participants (n = 125) (a) satisfied DSM-IV criteria for ASD or PTSD, (b) were 16 years or older, (c) were sufficiently fluent in Dutch or English, (d) had no psychiatric problems except ASD or PTSD that would hinder participation or required alternative clinical care, and (e) received no concurrent psychotherapy. Treatment consisted of five 1.5-hour sessions of CBT or SWT for participants with ASD or acute PTSD and ten 1.5-hour sessions for participants with chronic PTSD. Outcome measures included the Structured Clinical Interview for DSM-IV, Impact of Event Scale, Beck Depression Inventory, State-Trait Anxiety Inventory and the Dissociative Experiences Scale.

RESULTS

At posttest and follow-up, treatment was associated with improved diagnostic status and lower levels of intrusive symptoms, depression and state anxiety, while a trend was noted for the reduction of avoidance symptoms. Treatment did not result in lower levels of trait anxiety or dissociation. No differences in efficacy were detected between CBT and SWT.

CONCLUSIONS

The present study confirmed the efficacy of CBT for ASD and PTSD and identified SWT as a promising alternative treatment.

Coping with posttraumatic stress disorder and comorbidity after myocardial infarction

OBJECTIVE

Literature on the relationship between coping strategies, posttraumatic stress after myocardial infarction (post-MI PTSD), and comorbidity is limited. This study aimed to fill this gap in literature by investigating this relationship.

METHOD

One hundred twenty patients with MI were recruited from 2 general practices and interviewed using the Posttraumatic Stress Diagnostic Scale, the General Health Questionnaire, and the COPE Scale.

RESULTS

Thirty-one percent had PTSD. Patients used acceptance-focused coping in that most of them accepted that the MI had happened and that it could not be changed. At the same time, some patients used avoidance-focused coping in that they disengaged themselves mentally and behaviorally from the traumatic effects of MI. When the variables of age, bypass surgery, mental health problems before MI, and angioplasty were held constant, the results showed that patients who used maladaptive coping strategies of emotion-focused and avoidance-focused copings tended to report more comorbid symptoms. Patients who underwent medical procedures or interventions such as bypass surgery and angioplasty tended to report more PTSD symptoms.

CONCLUSIONS

The way in which MI patients' coping strategies relate to health outcomes has been shown to be symptom-specific. Using maladaptive coping strategies does not necessarily have a significant impact on PTSD symptoms. On the other hand, medical procedures or interventions for treating MI can play a major role in maintaining PTSD symptoms for patients with MI.

Changes in cortisol and DHEA plasma levels after psychotherapy for PTSD

Post-traumatic stress disorder (PTSD) has been associated with dysregulation of the neuroendocrine system. In this study we examine the effects of psychotherapy in 21 PTSD patients, with and without coexisting depression, on the levels of six stress-related hormones: cortisol, dehydroepiandrosterone (DHEA), and dehydroepiandrosterone-sulfate (DHEA-S), prolactin, thyrotropin (TSH) and free thyroxin (fT4). The results show that after brief eclectic psychotherapy (BEP) significant changes occurred in levels of cortisol and DHEA. Responders showed an increase in cortisol and DHEA levels, while in non-responders both hormone levels decreased. Differences were only found after controlling for depressive symptoms. In conclusion, effective psychotherapy for PTSD may alter dysregulations in the Hypothalamus-pituitary-adrenal (HPA)-axis, but comorbid depressive symptoms should be taken into account.

The prevalence of post traumatic stress disorder in survivors of ICU treatment: a systematic review

OBJECTIVE

To determine the prevalence of post traumatic stress disorder in survivors of intensive care treatment.

DESIGN

Systematic literature review including Medline, Embase, CINAHL, PsycINFO and references from identified papers.

STUDY SELECTION

Studies determining the prevalence of PTSD in adult patients who had at least 24[Symbol: see text]h treatment on an intensive care unit. Independent duplicate data extraction. Study quality was evaluated in terms of study design and method and timing of PTSD assessment. DATA SYNTHESIS AND RESULTS: Of the 1472 citations identified, 30 studies meeting the selection criteria were reviewed. PTSD was diagnosed by standardised clinical interview alone in 2 studies. A self-report measure alone was used in 19 studies to measure PTSD symptomatology. The remaining 9 studies applied both standardised clinical interview and a self-report measure. The reported prevalence of PTSD was 0-64% when diagnosed by standardised clinical interview and 5-64% by self-report measure. PTSD assessments occurred 7 days to 8 years after intensive care discharge.

CONCLUSION

The true prevalence of PTSD and the optimum timing and method of PTSD assessment have not yet been determined in intensive care unit survivors. Deficiencies in design, methodology and reporting make interpretation and comparison of quoted prevalence rates difficult, and rigorous longitudinal studies are needed.