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Davidson TM, Espeleta HC, Ridings LE, Witcraft S, Bravoco O, Higgins K, Houchins R, Kitchens D, Manning B, Jones S, Crookes B, Hanson R, Ruggiero KJ. Implementation of a Stepped Care Program to Address Emotional Recovery among Traumatic Injury Patients. J Am Coll Surg 2023; 237:810-825. [PMID: 37815166 PMCID: PMC10914157 DOI: 10.1097/xcs.0000000000000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
BACKGROUND Annually, over 600,000 adults served in US trauma centers (≥20%) develop posttraumatic stress disorder (PTSD) and/or depression in the first year after injury. American College of Surgeons guidelines include screening and addressing mental health recovery in trauma centers. Yet, many trauma centers do not monitor and address mental health recovery, and it is a priority to learn how to implement evidence-informed mental health programs in trauma centers. STUDY DESIGN This report describes our application of the Exploration, Preparation, Implementation, Sustainment model to implement the Trauma Resilience and Recovery Program (TRRP) in 3 Level I and II trauma centers to address patients' mental health needs. TRRP is a scalable and sustainable stepped model of care-one of the few in the US-that provides early intervention and direct services after traumatic injury. RESULTS Trauma centers are well positioned to accelerate patients' mental health recovery via early identification, education, screening, and referrals to mental health agencies that provide best-practice care. We found that TRRP was acceptable to the 3 partnering trauma centers we studied. Early engagement of patient, provider, and hospital administration stakeholders enhanced buy-in during the early stages of the implementation process and promoted sustainability. Active processes to support monitoring, evaluation, and adaptation were critical. CONCLUSIONS Our work demonstrates the feasibility of implementing and adapting TRRP, a cost-efficient and sustainable stepped care intervention, in Level I and II trauma centers. Several factors should be carefully considered by trauma centers seeking to integrate behavioral health interventions into their trauma program.
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Affiliation(s)
- Tatiana M Davidson
- From the College of Nursing (Davidson, Espeleta, Ridings, Witcraft, Bravoco, Higgins, Crookes, Ruggiero), Medical University of South Carolina, Charleston, SC
- Department of Psychiatry, Medical University of South Carolina, Charleston, SC (Davidson, Espeleta, Ridings, Hanson, Ruggiero)
| | - Hannah C Espeleta
- From the College of Nursing (Davidson, Espeleta, Ridings, Witcraft, Bravoco, Higgins, Crookes, Ruggiero), Medical University of South Carolina, Charleston, SC
- Department of Psychiatry, Medical University of South Carolina, Charleston, SC (Davidson, Espeleta, Ridings, Hanson, Ruggiero)
| | - Leigh E Ridings
- From the College of Nursing (Davidson, Espeleta, Ridings, Witcraft, Bravoco, Higgins, Crookes, Ruggiero), Medical University of South Carolina, Charleston, SC
- Department of Psychiatry, Medical University of South Carolina, Charleston, SC (Davidson, Espeleta, Ridings, Hanson, Ruggiero)
| | - Sara Witcraft
- From the College of Nursing (Davidson, Espeleta, Ridings, Witcraft, Bravoco, Higgins, Crookes, Ruggiero), Medical University of South Carolina, Charleston, SC
| | - Olivia Bravoco
- From the College of Nursing (Davidson, Espeleta, Ridings, Witcraft, Bravoco, Higgins, Crookes, Ruggiero), Medical University of South Carolina, Charleston, SC
| | - Kristen Higgins
- From the College of Nursing (Davidson, Espeleta, Ridings, Witcraft, Bravoco, Higgins, Crookes, Ruggiero), Medical University of South Carolina, Charleston, SC
| | - Rachel Houchins
- Prisma Health Midlands, Level I Trauma Center, Columbia, SC (Houchins)
| | - Debra Kitchens
- Prisma Health Upstate, Level I Trauma Center, Greeneville, SC (Kitchens, Manning)
| | - Benjamin Manning
- Prisma Health Upstate, Level I Trauma Center, Greeneville, SC (Kitchens, Manning)
| | - Seon Jones
- Trident Medical Center, Level II Trauma Center, Charleston, SC (Jones)
| | - Bruce Crookes
- From the College of Nursing (Davidson, Espeleta, Ridings, Witcraft, Bravoco, Higgins, Crookes, Ruggiero), Medical University of South Carolina, Charleston, SC
| | - Rochelle Hanson
- Department of Psychiatry, Medical University of South Carolina, Charleston, SC (Davidson, Espeleta, Ridings, Hanson, Ruggiero)
| | - Kenneth J Ruggiero
- From the College of Nursing (Davidson, Espeleta, Ridings, Witcraft, Bravoco, Higgins, Crookes, Ruggiero), Medical University of South Carolina, Charleston, SC
- Department of Psychiatry, Medical University of South Carolina, Charleston, SC (Davidson, Espeleta, Ridings, Hanson, Ruggiero)
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Adams ZW, Marriott BR, Karra S, Linhart-Musikant E, Raymond JL, Fischer LJ, Bixler KA, Bell TM, Bryan EA, Hulvershorn LA. User-Guided Enhancements to a Technology-Facilitated Resilience Program to Address Opioid Risks Following Traumatic Injury in Youth: Qualitative Interview Study. JMIR Form Res 2023; 7:e45128. [PMID: 38032728 PMCID: PMC10722375 DOI: 10.2196/45128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Youth with traumatic injury experience elevated risk for behavioral health disorders, yet posthospital monitoring of patients' behavioral health is rare. The Telehealth Resilience and Recovery Program (TRRP), a technology-facilitated and stepped access-to-care program initiated in hospitals and designed to be integrated seamlessly into trauma center operations, is a program that can potentially address this treatment gap. However, the TRRP was originally developed to address this gap for mental health recovery but not substance use. Given the high rates of substance and opioid use disorders among youth with traumatic injury, there is a need to monitor substance use and related symptoms alongside other mental health concerns. OBJECTIVE This study aimed to use an iterative, user-guided approach to inform substance use adaptations to TRRP content and procedures. METHODS We conducted individual semistructured interviews with adolescents (aged 12-17 years) and young adults (aged 18-25 years) who were recently discharged from trauma centers (n=20) and health care providers from two level 1 trauma centers (n=15). Interviews inquired about reactions to and recommendations for expanding TRRP content, features, and functionality; factors related to TRRP implementation and acceptability; and current strategies for monitoring patients' postinjury physical and emotional recovery and opioid and substance use. Interview responses were transcribed and analyzed using thematic analysis to guide new TRRP substance use content and procedures. RESULTS Themes identified in interviews included gaps in care, task automation, user personalization, privacy concerns, and in-person preferences. Based on these results, a multimedia, web-based mobile education app was developed that included 8 discrete interactive education modules and 6 videos on opioid use disorder, and TRRP procedures were adapted to target opioid and other substance use disorder risk. Substance use adaptations included the development of a set of SMS text messaging-delivered questions that monitor both mental health symptoms and substance use and related symptoms (eg, pain and sleep) and the identification of validated mental health and substance use screening tools to monitor patients' behavioral health in the months after discharge. CONCLUSIONS Patients and health care providers found the TRRP and its expansion to address substance use acceptable. This iterative, user-guided approach yielded novel content and procedures that will be evaluated in a future trial.
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Affiliation(s)
- Zachary W Adams
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Brigid R Marriott
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Swathi Karra
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States
| | | | - Jodi L Raymond
- Riley Hospital for Children at Indiana University Health, Indianapolis, IN, United States
| | - Lydia J Fischer
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Kristina A Bixler
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Teresa M Bell
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Eric A Bryan
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Leslie A Hulvershorn
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States
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Lathan EC, Haynes T, Langhinrichsen-Rohling R, Sonu SC, Powers A. Primary Care Providers' Knowledge, Perceptions, and Practice of Trauma-Informed Care in a Public Health Care Setting. FAMILY & COMMUNITY HEALTH 2023; 46:209-219. [PMID: 37703510 DOI: 10.1097/fch.0000000000000376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Despite serving patients with especially high rates of trauma exposure and related sequelae, many primary care providers do not receive specialized training in the provision of trauma-informed care (TIC). This study sought to document primary care providers' baseline rates of TIC training and their knowledge, perceptions, and practice of TIC at a large, urban public hospital in the Southeastern United States. Participants (n = 67; 68.7% women; 44.8% white; Mage = 36.7 years, standard deviation [SD]age = 9.8 years) completed an online self-report survey on their TIC training status, trauma-related knowledge, perceptions, and practices, as well as burnout and secondary traumatic stress. Less than half of participants (43.3%) endorsed TIC training exposure. Participants generally had adequate levels of trauma-related knowledge (76.5% of items correct) and favorable perceptions of TIC (endorsed 89.7% of TIC-supportive statements). Most participants (86.6%) endorsed recently using trauma-informed practices, but only 47.8% reported routinely screening for trauma-related disorders. Participants who reported receiving prior TIC training scored better on knowledge items and endorsed recently using more trauma-informed practices than those who did not have training exposure. TIC training status' associations with current screening practices and perceptions of TIC were trending toward significance. TIC training status was not related to burnout, and trained participants reported greater secondary traumatic stress than those without training exposure. Results point to system-wide TIC training as a well-received, translational strategy that can enhance the trauma-informed nature of primary care provision.
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Affiliation(s)
- Emma C Lathan
- Departments of Psychiatry and Behavioral Sciences (Drs Lathan, Haynes, and Powers and Mr Langhinrichsen-Rohling), General Medicine and Geriatrics (Drs Haynes and Sonu) and General Pediatrics and Adolescent Medicine (Dr Sonu), School of Medicine, Emory University, Atlanta, Georgia
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Bruce MM, Robinson AJ, Wiebe DJ, Shults J, Richmond TS. The Contribution of Neighborhood Characteristics to Psychological Symptom Severity in a Cohort of Injured Black Men. J Racial Ethn Health Disparities 2023; 10:2284-2293. [PMID: 36085354 PMCID: PMC10454987 DOI: 10.1007/s40615-022-01407-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 08/27/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Traumatic injury is not evenly distributed by race and class in the USA. Black men are marginalized in the society, often reside in disadvantaged neighborhoods, and are at higher risk for injury mortality and ongoing physical and psychological problems following injury. Post-traumatic stress disorder (PTSD) and depressive symptom severity are among several problematic and disabling conditions faced by injury survivors. While much research has examined individual factors that lead to increased post-injury psychological symptom severity, the contribution of the social and physical environment has been relatively understudied. OBJECTIVE To examine the contribution of neighborhood characteristics to PTSD and depressive symptom severity in Black men following traumatic injury. DESIGN Prospective cohort study. Participant data were linked via GIS to neighborhood characteristics (constructs established by factor analysis) to spatially model factors associated with increased post-injury psychological symptom severity using a GEE regression analysis, adjusting for injury mechanism and severity, age, and insurance. PARTICIPANTS Four hundred fifty-one adult Black males hospitalized for traumatic injury. RESULTS The 4 constructs were neighborhood disconnectedness, concentrated disadvantage/deprivation, crime/violence/vacancy, and race/ethnicity. High depressive and PTSD symptom severity was reported by 36.8% and 30.4% of participants, respectively. Higher PTSD symptom severity was associated with crime/violence/vacancy, and higher depressive symptom severity was associated with neighborhood disconnectedness. PTSD and depressive symptom severity were associated with intentional injury mechanisms and Medicaid/no insurance. Higher injury severity was associated with depressive symptoms. CONCLUSION Neighborhood characteristics are associated with psychological symptom severity after injury.
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Affiliation(s)
- Marta M Bruce
- University of Pennsylvania School of Nursing, Claire Fagin Hall, Room 418 Curie Blvd, Philadelphia, PA, 19104, USA
- Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Andrew J Robinson
- University of Pennsylvania School of Nursing, Claire Fagin Hall, Room 418 Curie Blvd, Philadelphia, PA, 19104, USA
| | - Douglas J Wiebe
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania Perelman School of Medicine, Blockley Hall, 423 Guardian Dr, Philadelphia, PA, 19104, USA
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Justine Shults
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania Perelman School of Medicine, Blockley Hall, 423 Guardian Dr, Philadelphia, PA, 19104, USA
| | - Therese S Richmond
- University of Pennsylvania School of Nursing, Claire Fagin Hall, Room 418 Curie Blvd, Philadelphia, PA, 19104, USA.
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, 19104, USA.
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Brier ZMF, Hidalgo JE, Espeleta HC, Davidson T, Ruggiero KJ, Price M. Assessment of Traumatic Stress Symptoms During the Acute Posttrauma Period. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:239-246. [PMID: 37404969 PMCID: PMC10316216 DOI: 10.1176/appi.focus.20230001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
A substantial majority of adults in the United States will experience a potentially traumatic event (PTE) in their lifetime. A considerable proportion of those individuals will go on to develop posttraumatic stress disorder (PTSD). Distinguishing between those who will develop PTSD and those who will recover, however, remains as a challenge to the field. Recent work has pointed to the increased potential of identifying individuals at greatest risk for PTSD through repeated assessment during the acute posttrauma period, the 30-day period after the PTE. Obtaining the necessary data during this period, however, has proven to be a challenge. Technological innovations such as personal mobile devices and wearable passive sensors have given the field new tools to capture nuanced in vivo changes indicative of recovery or nonrecovery. Despite their potential, there are numerous points for clinicians and research teams to consider when implementing these technologies into acute posttrauma care. The limitations of this work and considerations for future research in the use of technology during the acute posttrauma period are discussed.
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Affiliation(s)
- Zoe M F Brier
- Department of Psychological Science, University of Vermont, Burlington (Brier, Hidalgo, Price); Department of Psychiatry and Behavioral Sciences (Brier) and College of Nursing (Espeleta, Davidson, Ruggiero), Medical University of South Carolina, Charleston
| | - Johanna E Hidalgo
- Department of Psychological Science, University of Vermont, Burlington (Brier, Hidalgo, Price); Department of Psychiatry and Behavioral Sciences (Brier) and College of Nursing (Espeleta, Davidson, Ruggiero), Medical University of South Carolina, Charleston
| | - Hannah C Espeleta
- Department of Psychological Science, University of Vermont, Burlington (Brier, Hidalgo, Price); Department of Psychiatry and Behavioral Sciences (Brier) and College of Nursing (Espeleta, Davidson, Ruggiero), Medical University of South Carolina, Charleston
| | - Tatiana Davidson
- Department of Psychological Science, University of Vermont, Burlington (Brier, Hidalgo, Price); Department of Psychiatry and Behavioral Sciences (Brier) and College of Nursing (Espeleta, Davidson, Ruggiero), Medical University of South Carolina, Charleston
| | - Kenneth J Ruggiero
- Department of Psychological Science, University of Vermont, Burlington (Brier, Hidalgo, Price); Department of Psychiatry and Behavioral Sciences (Brier) and College of Nursing (Espeleta, Davidson, Ruggiero), Medical University of South Carolina, Charleston
| | - Matthew Price
- Department of Psychological Science, University of Vermont, Burlington (Brier, Hidalgo, Price); Department of Psychiatry and Behavioral Sciences (Brier) and College of Nursing (Espeleta, Davidson, Ruggiero), Medical University of South Carolina, Charleston
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Silver CM, Visenio MR, Thomas AC, Reddy S, Raven MC, Kanzaria HK, Plevin RE, Stey AM. Hospital variability in adoption of alcohol and drug screening in adult trauma patients. J Trauma Acute Care Surg 2023; 94:684-691. [PMID: 36801898 PMCID: PMC10133007 DOI: 10.1097/ta.0000000000003928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Despite recommendations to screen all injured patients for substance use, single-center studies have reported underscreening. This study sought to determine if there was significant practice variability in adoption of alcohol and drug screening of injured patients among hospitals participating in the Trauma Quality Improvement Program. METHODS This was a retrospective observational cross-sectional study of trauma patients 18 years or older in Trauma Quality Improvement Program 2017-2018. Hierarchical multivariable logistic regression modeled the odds of screening for alcohol and drugs via blood/urine test while controlling for patient and hospital variables. We identified statistically significant high and low-screening hospitals based on hospitals' estimated random intercepts and associated confidence intervals (CIs). RESULTS Of 1,282,111 patients at 744 hospitals, 619,423 (48.3%) were screened for alcohol, and 388,732 (30.3%) were screened for drugs. Hospital-level alcohol screening rates ranged from 0.8% to 99.7%, with a mean rate of 42.4% (SD, 25.1%). Hospital-level drug screening rates ranged from 0.2% to 99.9% (mean, 27.1%; SD, 20.2%). A total of 37.1% (95% CI, 34.7-39.6%) of variance in alcohol screening and 31.5% (95% CI, 29.2-33.9%) of variance in drug screening were at the hospital level. Level I/II trauma centers had higher adjusted odds of alcohol screening (adjusted odds ratio [aOR], 1.31; 95% CI, 1.22-1.41) and drug screening (aOR, 1.16; 95% CI, 1.08-1.25) than Level III and nontrauma centers. We found 297 low-screening and 307 high-screening hospitals in alcohol after adjusting for patient and hospital variables. There were 298 low-screening and 298 high-screening hospitals for drugs. CONCLUSION Overall rates of recommended alcohol and drug screening of injured patients were low and varied significantly between hospitals. These results underscore an important opportunity to improve the care of injured patients and reduce rates of substance use and trauma recidivism. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Casey M. Silver
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michael R. Visenio
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Arielle C. Thomas
- American College of Surgeons, Chicago, IL
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Susheel Reddy
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Maria C. Raven
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA
| | - Hemal K. Kanzaria
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA
| | - Rebecca E. Plevin
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Anne M. Stey
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
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Schultebraucks K, Stevens JS, Michopoulos V, Maples-Keller J, Lyu J, Smith RN, Rothbaum BO, Ressler KJ, Galatzer-Levy IR, Powers A. Development and validation of a brief screener for posttraumatic stress disorder risk in emergency medical settings. Gen Hosp Psychiatry 2023; 81:46-50. [PMID: 36764261 PMCID: PMC10866012 DOI: 10.1016/j.genhosppsych.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Predicting risk of posttraumatic stress disorder (PTSD) in the acute care setting is challenging given the pace and acute care demands in the emergency department (ED) and the infeasibility of using time-consuming assessments. Currently, no accurate brief screening for long-term PTSD risk is routinely used in the ED. One instrument widely used in the ED is the 27-item Immediate Stress Reaction Checklist (ISRC). The aim of this study was to develop a short screener using a machine learning approach and to investigate whether accurate PTSD prediction in the ED can be achieved with substantially fewer items than the IRSC. METHOD This prospective longitudinal cohort study examined the development and validation of a brief screening instrument in two independent samples, a model development sample (N = 253) and an external validation sample (N = 93). We used a feature selection algorithm to identify a minimal subset of features of the ISRC and tested this subset in a predictive model to investigate if we can accurately predict long-term PTSD outcomes. RESULTS We were able to identify a reduced subset of 5 highly predictive features of the ISRC in the model development sample (AUC = 0.80), and we were able to validate those findings in the external validation sample (AUC = 0.84) to discriminate non-remitting vs. resilient trajectories. CONCLUSION This study developed and validated a brief 5-item screener in the ED setting, which may help to improve the diagnostic process of PTSD in the acute care setting and help ED clinicians plan follow-up care when patients are still in contact with the healthcare system. This could reduce the burden on patients and decrease the risk of chronic PTSD.
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Affiliation(s)
- K Schultebraucks
- Department of Psychiatry, NYU Grossman School of Medicine, New York, USA; Department of Population Health, NYU Grossman School of Medicine, New York, USA.
| | - J S Stevens
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA; Center for Visual and Neurocognitive Rehabilitation, Atlanta Veterans' Affairs Health Care System, Atlanta, GA, USA
| | - V Michopoulos
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - J Maples-Keller
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - J Lyu
- Department of Biostatistics, Columbia University, Mailman School of Public Health, New York, NY, USA
| | - R N Smith
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Behavioral, Social and Health Education Sciences, Emory University School of Public Health, Atlanta, GA, USA
| | - B O Rothbaum
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - K J Ressler
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA; McLean Hospital, Belmont, MA, USA
| | - I R Galatzer-Levy
- Department of Psychiatry, NYU Grossman School of Medicine, New York, USA
| | - A Powers
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
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Bernard DL, O’Loughlin K, Davidson TM, Rothbaum A, Anton MT, Ridings LE, Cooley JL, Gavrilova Y, Hink AB, Ruggiero KJ. Differences in mental health engagement and follow-up among Black and White patients after traumatic injury. J Trauma Acute Care Surg 2023; 94:117-124. [PMID: 35358156 PMCID: PMC9525457 DOI: 10.1097/ta.0000000000003604] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Severe injury necessitating hospitalization is experienced by nearly three million US adults annually. Posttraumatic stress disorder and depression are prevalent clinical outcomes. The mechanisms by which programs equitably promote mental health recovery among trauma-exposed patients are understudied. We evaluated clinical outcomes and engagement among a cohort of Black and White patients enrolled in the Trauma Resilience and Recovery Program (TRRP), a stepped-care model to accelerate mental health recovery after traumatic injury. METHODS Trauma Resilience and Recovery Program is a four-step model that includes (1) bedside psychoeducation about mental health recovery following traumatic injury, (2) a text-messaging symptom tracking system, (3) a 30-day postinjury mental health screen, and (4) referrals to mental health services. Data describe 1,550 patients enrolled in TRRP within a Level I trauma center ( Mage = 40.86; SD, 17.32), 611 of whom identified as Black (74.5% male) and 939 of whom identified as White (67.7% male). RESULTS Enrollment in TRRP was nearly universal (97.9%) regardless of race or injury mechanism. Enrollment and usage of the text-message system were statistically similar between Black (35.7%) and White patients (39.5%). Trauma Resilience and Recovery Program reengaged Black and White patients at a similar rate at the 30-day postinjury follow-up. However, Black patients were more likely to report peritraumatic distress at the bedside and clinical elevations in posttraumatic stress disorder and depression on the 30-day screen. Referrals were more likely to be accepted by Black patients relative to White patients with clinically elevated symptoms. CONCLUSION Enrollment and engagement were comparable among Black and White patients served by TRRP. Data provide preliminary evidence to suggest that TRRP is feasible and acceptable and engages patients in mental health follow-up equitably. However, research that includes careful measurement of social determinants of health and long-term follow-up examining initiation, completion, and benefit from treatment is needed. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Donte L. Bernard
- Department of Psychological Sciences, University of Missouri, Columbia, MO, 65211, USA
- Department of Psychiatry and Behavioral Sciences, National Crime Victims Research and Treatment Center, Medical University of South Carolina, Charleston, SC, USA
| | - Kerry O’Loughlin
- Department of Psychiatry and Behavioral Sciences, National Crime Victims Research and Treatment Center, Medical University of South Carolina, Charleston, SC, USA
| | - Tatiana M. Davidson
- Departments of Nursing and Psychiatry and Behavioral Sciences, College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Alex Rothbaum
- Department of Psychiatry and Behavioral Sciences, National Crime Victims Research and Treatment Center, Medical University of South Carolina, Charleston, SC, USA
| | | | - Leigh E. Ridings
- Departments of Nursing and Psychiatry and Behavioral Sciences, College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - John L. Cooley
- Department of Psychological Sciences, Texas Tech University
| | - Yulia Gavrilova
- Department of Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Ashley B. Hink
- Department of Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Kenneth J. Ruggiero
- Departments of Nursing and Psychiatry and Behavioral Sciences, College of Nursing, Medical University of South Carolina, Charleston, SC, USA
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Reppucci ML, Tong S, Simon SL, Nolan MM, Jujare S, Moulton SL, Kaar JL. Factors associated with new mental health diagnoses and resource utilization among pediatric patients following trauma admission. J Pediatr Surg 2023; 58:118-124. [PMID: 36273919 DOI: 10.1016/j.jpedsurg.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/15/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Injured children are at risk for a variety of physical and emotional sequelae that may impair their ability to return to prior function. The effect of traumatic injury on mental health in children is not well characterized or understood. We sought to determine factors associated with new mental health diagnoses and/or mental health resource utilization following admission to a Level 1 pediatric trauma center for traumatic injury. METHODS A retrospective chart review of patients admitted for accidental trauma between 2016 and 2019 was performed. Demographic data, injury characteristics, new mental health diagnoses and/or mental health resource utilization following hospitalization were extracted. Patients with prior mental health diagnosis, psychotropic prescription(s), or resource utilization were excluded from this cohort. A multivariable logistic regression model was used to examine predictors of new mental health diagnoses and/or resource utilization. RESULTS The prevalence of new mental health diagnoses or resources utilization was 9.5% (363/3828). The most common diagnoses were anxiety disorders and nonbipolar depression. The most common psychotropic medication prescribed was antidepressants. Patients with new mental illness were older (odds ratio [OR] 1.1 [95% CI: 1.06, 1.12]), more likely to sustain burn injuries (OR 6.3 [4.2, 9.5]), have non-sports related injuries (OR 3.5 [2.1, 6.0]), and be pedestrian struck (OR 2.7 [1.5, 4.8]). They additionally were more likely to sustain head, neck, and spine injuries (OR 3.8 [2.9, 5.1], 2.4 [1.1, 5.5], and 2.1 [1.3, 3.3], respectively). CONCLUSIONS There are a variety of demographic and injury specific factors associated with new mental health diagnoses and/or resource utilization in children following admission for trauma. Knowledge of these risk factors may ensure patients are allocated adequate resources to promote timely access to appropriate mental health services after hospitalization. TYPE OF STUDY Retrospective comparative study LEVEL OF EVIDENCE: III.
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Affiliation(s)
- Marina L Reppucci
- Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States; Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States.
| | - Suhong Tong
- Children's Hospital Center for Research in Outcomes for Children's Surgery, Children's Hospital Colorado, Aurora, Colorado, United States
| | - Stacey L Simon
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Margo M Nolan
- Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States
| | - Swati Jujare
- Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States
| | - Steven L Moulton
- Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States; Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Jill L Kaar
- Children's Hospital Center for Research in Outcomes for Children's Surgery, Children's Hospital Colorado, Aurora, Colorado, United States; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
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10
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Bell TM, Raymond JL, Mongalo AC, Adams ZW, Rouse TM, Hatcher L, Russell K, Carroll AE. Outpatient Opioid Prescriptions are Associated With Future Substance Use Disorders and Overdose Following Adolescent Trauma. Ann Surg 2022; 276:e955-e960. [PMID: 33491972 PMCID: PMC8815331 DOI: 10.1097/sla.0000000000004769] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aims to determine if outpatient opioid prescriptions are associated with future SUD diagnoses and overdose in injured adolescents 5 years following hospital discharge. SUMMARY OF BACKGROUND DATA Approximately, 1 in 8 adolescents are diagnosed with an SUD and 1 in 10 experience an overdose in the 5 years following injury. State laws have become more restrictive on opioid prescribing by acute care providers for treating pain, however, prescriptions from other outpatient providers are still often obtained. METHODS This was a retrospective cohort study of patients ages 12-18 admitted to 2 level I trauma centers. Demographic and clinical data contained in trauma registries were linked to a regional database containing 5 years of electronic health records and prescription data. Regression models assessed whether number of outpatient opioid prescription fills after discharge at different time points in recovery were associated with a new SUD diagnosis or overdose, while controlling for demographic and injury characteristics, and depression and posttraumatic stress disorder diagnoses. RESULTS We linked 669 patients (90.9%) from trauma registries to a regional health information exchange database. Each prescription opioid refill in the first 3 months after discharge increased the likelihood of new SUD diagnoses by 55% (odds ratio: 1.55, confidence interval: 1.04-2.32). Odds of overdose increased with ongoing opioid use over 2-4 years post-discharge ( P = 0.016-0.025). CONCLUSIONS Short-term outpatient opioid prescribing over the first few months of recovery had the largest effect on developing an SUD, while long-term prescription use over multiple years was associated with a future overdose.
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Affiliation(s)
- Teresa M Bell
- Department of Surgery, University of Utah, School of Medicine, Salt Lake City, UT 84121
- Intermountain Primary Children's Hospital, Salt Lake City, UT 84113
| | - Jodi L Raymond
- Indiana University Health Riley Hospital for Children, Indianapolis, IN 46202
| | - Alejandro C Mongalo
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Zachary W Adams
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Thomas M Rouse
- Indiana University Health Riley Hospital for Children, Indianapolis, IN 46202
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202
| | - LeRanna Hatcher
- Department of Anesthesiology, Mayo Clinic College of Medicine and Science, Rochester, MN 55905
| | - Katie Russell
- Department of Surgery, University of Utah, School of Medicine, Salt Lake City, UT 84121
- Intermountain Primary Children's Hospital, Salt Lake City, UT 84113
| | - Aaron E Carroll
- Indiana University Health Riley Hospital for Children, Indianapolis, IN 46202
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202
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Lu W, Srijeyanthan J, Mueser KT, Yanos PT, Parrott JS, Siriram A, Gottlieb JD, Marcello S, Silverstein SM. Predictors of undocumented PTSD in persons using public mental health services. Psychiatry Res 2022; 317:114892. [PMID: 36257204 DOI: 10.1016/j.psychres.2022.114892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 09/28/2022] [Accepted: 10/02/2022] [Indexed: 01/05/2023]
Abstract
Individuals diagnosed with serious mental illness (SMI) have greater trauma exposure and are at increased risk for posttraumatic stress disorder (PTSD). However, PTSD is rarely documented in their clinical records. This study investigated the predictors of PTSD documentation among 776 clients with SMI receiving public mental health services, who had probable PTSD as indicated by a PTSD Checklist score of at least 45. Only 5.3% of clients had PTSD listed as a primary diagnosis, and 8.4% had PTSD as a secondary diagnosis, with a total 13.7% documentation rate. PTSD documentation rate was highest for clients with major depression (18.8%) compared to those with schizophrenia (4.1%) or bipolar disorder (6.3%). Factors that predicted a lower likelihood of having a chart diagnosis of PTSD included being diagnosed with schizophrenia/schizoaffective disorder or bipolar disorder. Factors that predicted a higher likelihood of having a chart diagnosis of PTSD included being of non-white race, being female, and experiencing eight or more types of traumatic events. Findings highlight the need for PTSD screening and trauma informed care for clients with SMI receiving public mental health services.
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Affiliation(s)
- Weili Lu
- Rutgers University, School of Health Professions, USA
| | | | | | - Philip T Yanos
- John Jay College, City University of New York, 524W 59th St., 10th Floor, New York, NY 10019, USA.
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12
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Ridings LE, Espeleta HC, Streck CJ, Davidson TM, Litvitskiy N, Bravoco O, Kassam-Adams N, Ruggiero KJ. Assessing service quality and access in trauma centers through behavioral health screening, education, and treatment after pediatric injury. J Pediatr Surg 2022; 57:632-636. [PMID: 35090719 PMCID: PMC9287491 DOI: 10.1016/j.jpedsurg.2022.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/07/2022] [Accepted: 01/12/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Over 120,000 U.S. children are hospitalized annually for traumatic injury, with approximately 20% developing acute stress disorder (ASD), posttraumatic stress disorder (PTSD), or depression. The ACS COT recommends that trauma centers address emotional recovery after injury; however, few pediatric trauma centers (PTCs) assess behavioral health symptoms. This study describes results from a survey with PTC providers assessing the landscape of behavioral health screening, education, and treatment. METHODS Trauma program leaders from 83 US Level I and II trauma centers across 36 states completed a survey assessing center characteristics and decision-making, availability, and perceptions of behavioral health resources. RESULTS Nearly half (46%) of centers provide behavioral health screens for pediatric patients, and 18% screen family members, with screens mostly conducted by nurses or social workers for ASD or PTSD. Two-thirds provide child behavioral health education and 47% provide education to caregivers/family. Two-thirds provide treatment connections, typically via referrals or outpatient clinics. Behavioral health screening, education, and treatment connections were rated as very important (M > 8.5/10), with higher ratings for the importance of screening children versus caregivers. Child maltreatment (59%), observed patient distress (53%), child substance use (52%), injury mechanism (42%) and severity (42%) were prioritized in screening decision-making. CONCLUSION Service provision varies by method, resource, and provider, highlighting the lack of a roadmap for centers to provide behavioral health services. Adoption of universal education and screening procedures in PTCs is crucial to increase access to services for injured children and caregivers. PTCs are well-positioned to offer these services. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Leigh E Ridings
- Medical University of South Carolina, College of Nursing, Charleston, SC, United States.
| | - Hannah C Espeleta
- Medical University of South Carolina, College of Nursing, Charleston, SC, United States
| | - Christian J Streck
- Medical University of South Carolina, College of Medicine, Department of Surgery, Charleston, SC, United States
| | - Tatiana M Davidson
- Medical University of South Carolina, College of Nursing, Charleston, SC, United States
| | - Nicole Litvitskiy
- Medical University of South Carolina, College of Nursing, Charleston, SC, United States
| | - Olivia Bravoco
- Medical University of South Carolina, College of Nursing, Charleston, SC, United States
| | - Nancy Kassam-Adams
- Children's Hospital of Philadelphia, Center for Injury Research and Prevention, Philadelphia, PA, United States; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Kenneth J Ruggiero
- Medical University of South Carolina, College of Nursing, Charleston, SC, United States
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13
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Abstract
Orthopaedic trauma patients have high rates of psychiatric disorders, which put them at risk for worse outcomes after injury and surgery, including worse pain. Mental health conditions, such as depression and anxiety, can affect the perception of pain. Pain can also exacerbate or contribute to the development of mental illness after injury. Interventions to address both mental health and pain among orthopaedic trauma patients are critical. Balancing safety and comfort amid a drug overdose epidemic is challenging, and many clinicians do not feel comfortable addressing mental health or have the resources necessary. We reviewed the literature on the complex relationship between pain and mental health and presented examples of scalable and accessible interventions that can be implemented to promote the health and recovery of our patients. Interventions described include screening for depression in the orthopaedic trauma clinic and the emergency department or inpatient setting during injury and using a comprehensive and evidence-based multimodal pain management regimen that blends pharmacologic alternatives to opioids and physical and cognitive strategies to manage pain.
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14
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Kumodzi T, Kassam-Adams N, Vargas L, Reilly PM, Richmond TS. Comparison of two screeners predicting the future development of depression and posttraumatic stress disorder in Black men after serious injury. Injury 2022; 53:1678-1683. [PMID: 35042600 PMCID: PMC9086140 DOI: 10.1016/j.injury.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 12/21/2021] [Accepted: 01/05/2022] [Indexed: 02/02/2023]
Abstract
Background To assess the predictive performance of two established, short clinical screeners in predicting the future development of post-injury depression and PTSD. Methods This was a prospective, cohort design with a 3-month follow-up. Black adult male trauma patients were enrolled at an urban, Level 1 trauma center. The Penn Richmond Screener and the Posttraumatic Adjustment Scale (PAS) were collected in-hospital. Participants were categorized as depressed using the Quick Inventory of Depressive Symptoms-Self Report and as positive for PTSD using the PTSD Check List - 5 (PCL-5) at 3-months post-discharge. Sensitivity, specificity, PPV and NPV of each screener were calculated. We used receiver operating curve (ROC) analyses to calculate the area under the curve (AUC) with 95% CI to assess predictive performance of each screener. Results A cohort of 623 hospitalized, injured Black men were enrolled during acute hospitalization. 503 participants (80.6%) were retained at 3-months and formed the analytic sample. Mean age was 36.8 years (SD 15.4), 53.1% of injuries were intentional; median injury severity score was 9. At 3 months, 35.3% had moderate to severe depression, 32.7% had significant PTSD symptoms, and 22.4% met criteria for both depression and PTSD. Penn Richmond Screener: sensitivity 0.68, specificity 0.56, and AUC 0.62 for PTSD, and sensitivity 0.64, specificity 0.63, and AUC 0.64 for depression. PAS: sensitivity 0.59, specificity 0.73, and AUC 0.66 for PTSD, and sensitivity 0.75, specificity 0.49, and AUC 0.62 for depression. Conclusions This study validated the performance of both screeners within the same population, allowing a direct comparison. Two predictive screeners, developed through different methods and in different countries, showed comparable predictive ability. These findings indicate that risk markers for adverse psychological consequences of traumatic injury share some core similarities across populations and countries.
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Affiliation(s)
- Trina Kumodzi
- Biobehavioral Health Sciences Department, School of Nursing, University of Pennsylvania, 418 Curie Blvd. Fagin Hall, Philadelphia, PA 19104 United States; Penn Injury Science Center, University of Pennsylvania, 418 Curie Blvd. Fagin Hall, Philadelphia, PA 19104 United States; Firearm Injury among Children and Teens Consortium, University of Michigan North Campus Research Complex, 2800 Plymouth Road, Ann Arbor, MI 48109, United States.
| | - Nancy Kassam-Adams
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Roberts Center for Pediatric Research, 2716 South Street, 13th Floor Philadelphia, PA 19146, United States; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania 2716 South Street, 13th Floor Philadelphia, PA 19146, United States.
| | - Laura Vargas
- Biobehavioral Health Sciences Department, School of Nursing, University of Pennsylvania, 418 Curie Blvd. Fagin Hall, Philadelphia, PA 19104 United States; Penn Injury Science Center, University of Pennsylvania, 418 Curie Blvd. Fagin Hall, Philadelphia, PA 19104 United States.
| | - Patrick M Reilly
- Penn Injury Science Center, University of Pennsylvania, 418 Curie Blvd. Fagin Hall, Philadelphia, PA 19104 United States; Department of Surgery, Perelman School of Medicine, University of Pennsylvania 3440 Market Street, Suite 101 Philadelphia, PA 19104, United States.
| | - Therese S Richmond
- Biobehavioral Health Sciences Department, School of Nursing, University of Pennsylvania, 418 Curie Blvd. Fagin Hall, Philadelphia, PA 19104 United States; Penn Injury Science Center, University of Pennsylvania, 418 Curie Blvd. Fagin Hall, Philadelphia, PA 19104 United States.
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15
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Hink AB, Killings X, Bhatt A, Ridings LE, Andrews AL. Adolescent Suicide—Understanding Unique Risks and Opportunities for Trauma Centers to Recognize, Intervene, and Prevent a Leading Cause of Death. CURRENT TRAUMA REPORTS 2022; 8:41-53. [PMID: 35399601 PMCID: PMC8976221 DOI: 10.1007/s40719-022-00223-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2021] [Indexed: 11/21/2022]
Abstract
Purpose of Review This provides up-to-date epidemiology of adolescent suicide and risk factors for suicide and highlights the overlap of risks for suicide and injury. It reviews signs and symptoms, and the up-to-date evidence on screening for depression, post-traumatic stress disorder (PTSD), suicide, substance abuse, and lethal means, and offers strategies of implementation in trauma centers. Recent Findings The incidence of adolescent suicide has continued to rise in the USA to 6.5 per 100,000, with notable racial disparities. The risk factors are complex, but many pre-existing risk factors and sequela after injury such as exposures to violence, suicidal behaviors, substance abuse, depression and post-traumatic stress disorder, and specific injuries including traumatic brain injury and spinal cord injury have further emerged as risks. Studies show rates of suicidality as high as 30% in the acute care setting. There are short screening instruments that can be used to universally screen for depression and suicidality in adolescent trauma patients. Step-up models of care for PTSD are promising to increase screening and services after injury. Lethal means counseling, secure firearm storage practices, and firearm safety policies can reduce the risk of suicide. Summary Suicide is the second leading cause of death in US adolescents, and trauma patients have significant risk factors for mental illness and suicidality before and after injury. Trauma centers should strongly consider screening adolescents, establish strategies for mental health support and referrals, and provide lethal means counseling to help prevent suicide.
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16
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Bulger E, Johnson P, Parker L, Moloney KE, Roberts MK, Vaziri N, Seo S, Nehra D, Thomas P, Zatzick D. Nationwide Survey of Trauma Center Screening and Intervention Practices for Posttraumatic Stress Disorder, Firearm Violence, Mental Health, and Substance Use Disorders. J Am Coll Surg 2022; 234:274-287. [PMID: 35213489 PMCID: PMC10234338 DOI: 10.1097/xcs.0000000000000064] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) symptoms, firearm violence events, alcohol and drug use problems, and major depression and suicidal ideation are endemic among patients admitted to US trauma centers. Despite increasing policy importance, the current availability of screening and intervention services for this constellation of conditions in US trauma centers is unknown. STUDY DESIGN Trauma program staff at all Level I and Level II trauma centers in the US. (N = 627) were contacted to complete a survey describing screening and intervention procedures for alcohol and drug use problems, PTSD symptoms, depression and suicidality, and firearm violence. Additional questions asked trauma centers about the delivery of peer interventions and information technology capacity for screening and intervention procedures. RESULTS Fifty-one percent of trauma centers (n = 322) responded to the survey. More than 95% of responding sites endorsed routinely screening and/or intervening for alcohol use problems. Routine services addressing PTSD were less common, with 28% of centers reporting routine screening. More than 50% of sites that screened for PTSD used previously established trauma center alcohol use services. Programmatic screening and intervention for firearm injury sequelae was occurring at 30% of sites. CONCLUSION Alcohol screening and intervention is occurring frequently at US trauma centers and appears to be responsive to American College of Surgeons Committee on Trauma verification requirements. Routine screening and intervention services for PTSD and firearm injury were occurring less frequently. Regular national surveys may be a key element of tracking progress in national mental health and substance use screening, intervention, and referral policy.
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Affiliation(s)
- Eileen Bulger
- Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | - Peyton Johnson
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - Lea Parker
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
- Department of Psychology, Drexel University College of Arts and Sciences, Philadelphia, PA
| | - Kathleen E Moloney
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - Michelle K Roberts
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA
- Department of Anthropology, University of Kentucky College of Arts and Sciences, Lexington, KY
| | - Natalie Vaziri
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - Sara Seo
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - Deepika Nehra
- Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | - Peter Thomas
- Powers Pyles Sutter & Verville PC, Washington, DC
| | - Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
- Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle, WA
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17
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"Did You Think You Would Die?": Fear of Death and Its Relationship to the Development of Posttraumatic Stress Disorder After Traumatic Injury. J Am Acad Orthop Surg 2022; 30:e272-e278. [PMID: 34669650 DOI: 10.5435/jaaos-d-20-01438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 09/12/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Patient-specific factors may influence posttraumatic stress disorder (PTSD) development and warrant further examination. This study investigates potential association between patient-reported fear of death at the time of injury and development of PTSD. METHODS Over 35 months, 250 patients were screened for PTSD at their first posthospitalization clinic visit and were asked "Did you think you were going to die from this injury?" (yes or no). PTSD screening was conducted using the PTSD checklist for DSM-5 questionnaire. A score ≥33 was considered positive for PTSD, and patients were offered ancillary psychiatric services. Retrospectively, medical records were reviewed for baseline demographics and injury information. RESULTS Forty-three patients (17%) indicated a fear of death. The mean age was 46 years, with patients who feared death being younger (36 versus 48, P < 0.001), and 62% were male. The most common mechanisms of injury were motor vehicle or motorcycle collisions (30%) and ground-level falls (21%). Gunshot wounds were more common among patients who feared death from trauma (44% versus 7%, P < 0.001). PTSD questionnaires were completed a median of 26 days after injury, with an average score of 12.6. PTSD scores were higher for patients with fear of death (32.7 versus 8.5), and these patients required more acute interventions (47% versus 7%), both P < 0.001. After multivariable logistic regression, patients who thought that they would die from their trauma had >13 times higher odds of developing PTSD (odds ratios: 13.42, P < 0.0001). Apart from positive psychiatric history (OR: 5.46, P = 0.001), no factors (ie, age, sex, mechanism, or any injury or treatment characteristic) were predictive of positive PTSD scores on regression. DICUSSION Patients who reported fear of death at the time of injury were 13 times more likely to develop PTSD. Simply asking patients whether they thought that they would die at the time of injury may prospectively identify PTSD risk. LEVEL OF EVIDENCE Prognostic Level II.
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18
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Zatzick D, Moloney K, Palinkas L, Thomas P, Anderson K, Whiteside L, Nehra D, Bulger E. Catalyzing the Translation of Patient-Centered Research Into United States Trauma Care Systems: A Case Example. Med Care 2021; 59:S379-S386. [PMID: 34228020 PMCID: PMC8263139 DOI: 10.1097/mlr.0000000000001564] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND The expedient translation of research findings into sustainable intervention procedures is a longstanding health care system priority. The Patient-Centered Outcomes Research Institute (PCORI) has facilitated the development of "research done differently," with a central tenet that key stakeholders can be productively engaged throughout the research process. Literature review revealed few examples of whether, as originally posited, PCORI's innovative stakeholder-driven approach could catalyze the expedient translation of research results into practice. OBJECTIVES This narrative review traces the historical development of an American College of Surgeons Committee on Trauma (ACS/COT) policy guidance, facilitated by evidence supplied by the PCORI-funded studies evaluating the delivery of patient-centered care transitions. Key elements catalyzing the guidance are reviewed, including the sustained engagement of ACS/COT policy stakeholders who have the capacity to invoke system-level implementation strategies, such as regulatory mandates linked to verification site visits. Other key elements, including the encouragement of patient stakeholder voice in policy decisions and the incorporation of end-of-study policy summits in pragmatic comparative effectiveness trial design, are discussed. CONCLUSIONS Informed by comparative effectiveness trials, ACS/COT policy has expedited introduction of the patient-centered care construct into US trauma care systems. A comparative health care systems conceptual framework for transitional care which incorporates Research Lifecycle, pragmatic clinical trial and implementation science models is articulated. When combined with Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE), employed as a targeted implementation strategy, this approach may accelerate the sustainable delivery of high-quality patient-centered care transitions for US trauma care systems.
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Affiliation(s)
- Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - Kathleen Moloney
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - Lawrence Palinkas
- Department of Children, Youth and Families, USC Suzanne Dworak-Peck School of Social Work, Los Angeles, CA
| | - Peter Thomas
- Powers Pyles Sutter and Verville PC, Washington, DC
| | - Kristina Anderson
- The Koshka Foundation and Department of Psychiatry and Behavioral Sciences
| | | | - Deepika Nehra
- Surgery, University of Washington School of Medicine, Seattle, WA
| | - Eileen Bulger
- Surgery, University of Washington School of Medicine, Seattle, WA
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Zatzick D, Jurkovich G, Heagerty P, Russo J, Darnell D, Parker L, Roberts MK, Moodliar R, Engstrom A, Wang J, Bulger E, Whiteside L, Nehra D, Palinkas LA, Moloney K, Maier R. Stepped Collaborative Care Targeting Posttraumatic Stress Disorder Symptoms and Comorbidity for US Trauma Care Systems: A Randomized Clinical Trial. JAMA Surg 2021; 156:430-474. [PMID: 33688908 DOI: 10.1001/jamasurg.2021.0131] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle.,Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle
| | - Gregory Jurkovich
- Department of Surgery, UC Davis School of Medicine, Sacramento, California
| | - Patrick Heagerty
- Department of Biostatistics, University of Washington School of Public Health, Seattle
| | - Joan Russo
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
| | - Doyanne Darnell
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
| | - Lea Parker
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle.,Department of Psychology, Drexel University College of Arts and Sciences, Philadelphia, Pennsylvania
| | - Michelle K Roberts
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle.,Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle
| | - Rddhi Moodliar
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle.,Department of Psychology, University of California, Los Angeles
| | - Allison Engstrom
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
| | - Jin Wang
- Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle
| | - Eileen Bulger
- Department of Surgery, University of Washington School of Medicine, Seattle
| | - Lauren Whiteside
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle
| | - Deepika Nehra
- Department of Surgery, University of Washington School of Medicine, Seattle
| | - Lawrence A Palinkas
- Department of Children, Youth and Families, USC Suzanne Dworak-Peck School of Social Work, Los Angeles, California
| | - Kathleen Moloney
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
| | - Ronald Maier
- Department of Surgery, University of Washington School of Medicine, Seattle
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Rahmat S, Velez J, Farooqi M, Smiley A, Prabhakaran K, Rhee P, Khan M, Dornbush R, Ferrando S, Smolin Y. Post-traumatic stress disorder can be predicted in hospitalized blunt trauma patients using a simple screening tool. Trauma Surg Acute Care Open 2021; 6:e000623. [PMID: 33880413 PMCID: PMC7993304 DOI: 10.1136/tsaco-2020-000623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) has debilitating psychiatric and medical consequences. The purpose of this study was to identify whether PTSD diagnosis and PTSD symptom scale score (PTSD severity) could be predicted by assessing peritraumatic experiences using a single question or screening tools at different time points in patients hospitalized after admission to the hospital after significant physical trauma, but with stable vitals (level II trauma). METHODS Patients completed the 'initial question' and the National Stressful Events Survey Acute Stress Disorder Scale (NSESSS) at 3 days to 5 days after trauma (NSESSS-1). The same scale was administered 2 weeks to 4 weeks after trauma (NSESSS-2). The Posttraumatic Stress Disorder Symptoms Scale Interview for DSM-5 (PSSI-5) was administered 2 months after trauma. PTSD diagnosis and PTSD severity were extracted from the PSSI-5. Linear multivariate regression analyses were used to establish whether scores for NSESSS-1 or NSESSS-2 predicted PTSD diagnosis/PTSD severity. Non-linear multivariate regression analyses were performed to better understand the relationship between NSESSS-1/NSESSS-2 and PTSD diagnosis/PTSD severity. RESULTS A single question assessing the experience of fear, helplessness, or horror was not an effective tool for determining the diagnosis of PTSD (p=0.114) but can be a predictor of PTSD severity (p=0.039). We demonstrate that administering the NSESSS after either 3 days to 5 days (p=0.008, p<0.001) or 2 weeks to 4 weeks (p=0.039; p<0.001) can predict the diagnosis of PTSD and PTSD severity. Scoring an NSESSS above 14/28 (50%) increases the chance of experiencing a higher PTSD severity substantially and linearly. DISCUSSION Our initial question was not an effective predictor of PTSD diagnosis. However, using the NSESSS at both 3 days to 5 days and 2 weeks to 4 weeks after trauma is an effective method for predicting PTSD diagnosis and PTSD severity. Additionally, we show that patients who score higher than 14 on the NSESSS for acute stress symptoms may need closer follow-up. LEVEL OF EVIDENCE Level III, prognostic.
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Affiliation(s)
- Saad Rahmat
- Department of Psychiatry and Behavioral Sciences, Westchester Medical Center, Valahlla, NY, USA
| | - Jessica Velez
- Department of Surgery, Westchester Medical Center Health Network, Valhalla, New York, USA
| | - Muhammad Farooqi
- Department of Psychiatry and Behavioral Sciences, New York Medical College, Valhalla, New York, USA
| | - Abbas Smiley
- Department of Surgery, New York Medical College, Valhalla, New York, USA
| | - Kartik Prabhakaran
- Department of Surgery, Westchester Medical Center Health Network, Valhalla, New York, USA
- Department of Surgery, New York Medical College, Valhalla, New York, USA
| | - Peter Rhee
- Department of Surgery, Westchester Medical Center Health Network, Valhalla, New York, USA
- Department of Surgery, New York Medical College, Valhalla, New York, USA
| | - Maria Khan
- New York Medical College, St. Vincent's Medical Center, Yonkers, New York, USA
| | - Rhea Dornbush
- Department of Psychiatry and Behavioral Sciences, New York Medical College, Valhalla, New York, USA
| | - Stephen Ferrando
- Department of Psychiatry and Behavioral Sciences, New York Medical College, Valhalla, New York, USA
| | - Yvette Smolin
- Department of Psychiatry and Behavioral Sciences, New York Medical College, Valhalla, New York, USA
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21
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Schultebraucks K, Chang BP. The opportunities and challenges of machine learning in the acute care setting for precision prevention of posttraumatic stress sequelae. Exp Neurol 2021; 336:113526. [PMID: 33157093 PMCID: PMC7856033 DOI: 10.1016/j.expneurol.2020.113526] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/28/2020] [Accepted: 10/30/2020] [Indexed: 11/25/2022]
Abstract
Personalized medicine is among the most exciting innovations in recent clinical research, offering the opportunity for tailored screening and management at the individual level. Biomarker-enriched clinical trials have shown increased efficiency and informativeness in cancer research due to the selective exclusion of patients unlikely to benefit. In acute stress situations, clinically significant decisions are often made in time-sensitive manners and providers may be pressed to make decisions based on abbreviated clinical assessments. Up to 30% of trauma survivors admitted to the Emergency Department (ED) will develop long-lasting posttraumatic stress psychopathologies. The long-term impact of those survivors with posttraumatic stress sequelae are significant, impacting both long-term psychological and physiological recovery. An accurate prognostic model of who will develop posttraumatic stress symptoms does not exist yet. Additionally, no scalable and cost-effective method that can be easily integrated into routine care exists, even though especially the acute care setting provides a critical window of opportunity for prevention in the so-called golden hours when preventive measures are most effective. In this review, we aim to discuss emerging machine learning (ML) applications that are promising for precisely risk stratification and targeted treatments in the acute care setting. The aim of this narrative review is to present examples of digital health innovations and to discuss the potential of these new approaches for treatment selection and prevention of posttraumatic sequelae in the acute care setting. The application of artificial intelligence-based solutions have already had great success in other areas and are rapidly approaching the field of psychological care as well. New ways of algorithm-based risk predicting, and the use of digital phenotypes provide a high potential for predicting future risk of PTSD in acute care settings and to go new steps in precision psychiatry.
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Affiliation(s)
- Katharina Schultebraucks
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, NY, United States of America; Data Science Institute, Columbia University, New York, NY, United States of America.
| | - Bernard P Chang
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, NY, United States of America
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22
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Laban G, Ben-Zion Z, Cross ES. Social Robots for Supporting Post-traumatic Stress Disorder Diagnosis and Treatment. Front Psychiatry 2021; 12:752874. [PMID: 35185629 PMCID: PMC8854768 DOI: 10.3389/fpsyt.2021.752874] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/27/2021] [Indexed: 12/13/2022] Open
Abstract
Post-Traumatic Stress Disorder (PTSD) is a severe psychiatric disorder with profound public health impact due to its high prevalence, chronic nature, accompanying functional impairment, and frequently occurring comorbidities. Early PTSD symptoms, often observed shortly after trauma exposure, abate with time in the majority of those who initially express them, yet leave a significant minority with chronic PTSD. While the past several decades of PTSD research have produced substantial knowledge regarding the mechanisms and consequences of this debilitating disorder, the diagnosis of and available treatments for PTSD still face significant challenges. Here, we discuss how novel therapeutic interventions involving social robots can potentially offer meaningful opportunities for overcoming some of the present challenges. As the application of social robotics-based interventions in the treatment of mental disorders is only in its infancy, it is vital that careful, well-controlled research is conducted to evaluate their efficacy, safety, and ethics. Nevertheless, we are hopeful that robotics-based solutions could advance the quality, availability, specificity and scalability of care for PTSD.
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Affiliation(s)
- Guy Laban
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom
| | - Ziv Ben-Zion
- Tel-Aviv Sourasky Medical Center, Sagol Brain Institute Tel-Aviv, Wohl Institute for Advanced Imaging, Tel-Aviv, Israel.,Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv, Israel.,Departments of Comparative Medicine and Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, United States.,The Clinical Neurosciences Division, VA Connecticut Healthcare System, United States Department of Veterans Affairs, National Center for Posttraumatic Stress Disorder, West Haven, CT, United States
| | - Emily S Cross
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom.,Department of Cognitive Science, Macquarie University, Sydney, NSW, Australia
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23
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Schultebraucks K, Bittlinger M, Cato K, Chang BP. Early Screening in the Emergency Department for Posttraumatic Sequelae After Acute Medical Events: The Potential of Prognostic Models and Computer-Aided Approaches. Psychiatr Ann 2021. [DOI: 10.3928/00485713-20201204-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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24
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Addressing Behavioral Health Concerns in Trauma: Using Lean Six Sigma to Implement a Depression Screening Protocol in a Level I Trauma Center. Qual Manag Health Care 2020; 29:218-225. [PMID: 32991539 DOI: 10.1097/qmh.0000000000000266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with physical injuries or chronic conditions may be impacted by mental health conditions, which significantly affect their participation and progress in treatment. The Patient Health Questionnaire-2 (PHQ-2) depression screening can identify patients who are at greatest risk for depression to provide better whole-person care. OBJECTIVE The quality improvement project objective was to identify and design a process that would result in the PHQ-2 depression screening for admitted trauma patients with a minimum 75% completion rate. METHODS Lean Six Sigma (LSS) process design methodology, DMADV (define, measure, analyze, design, and verify), drove process improvement. Medical records from before (December 2018 through February 2019) and after (March 2019 through May 2019) the intervention were evaluated using frequencies, percentages, χ, and multivariable logistic regression to determine the effectiveness of the intervention. RESULTS PHQ-2 document location was imperative to successful compliance, which increased from 60.74% (78 of 128) to 80.56% (87 of 108). Specifically, weekend compliance increased from 42.9% (18 of 42) to 82.8% (24 of 29). CONCLUSION LSS DMADV methodology helped health care professionals design a process to facilitate compliance with the PHQ-2 depression screening protocol in trauma patients. Adherence with this screening can help increase the number of behavioral health consultations, which in turn improves the treatment of traumatic injury survivors.
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25
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Livingston WS, Fargo JD, Gundlapalli AV, Brignone E, Blais RK. Comorbid PTSD and Depression Diagnoses Mediate the Association of Military Sexual Trauma and Suicide and Intentional Self-Inflicted Injury in VHA-Enrolled Iraq/Afghanistan Veterans, 2004-2014. J Affect Disord 2020; 274:1184-1190. [PMID: 32663949 DOI: 10.1016/j.jad.2020.05.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 04/09/2020] [Accepted: 05/10/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Exposure to military sexual trauma (MST) in veterans is associated with suicidal ideation. Previous research suggests there are mechanisms of this association, including posttraumatic stress disorder (PTSD) and depression. Research has yet to examine whether comorbid PTSD and depression mediate the association of MST and suicide and intentional self-inflicted injury, and whether this comorbidity confers a greater risk for suicide relative to PTSD-only and depression-only. The current study addressed this gap in our knowledge. METHODS Screening results identifying MST exposure, PTSD and depression diagnoses, suicide and intentional self-inflicted injury, and demographic covariates in 435,690 Iraq/Afghanistan veterans were extracted from Veterans Health Administration (VHA) medical records. Veterans were included if they attended VHA from 2004-2014. Mediation was tested with path analyses. RESULTS Suicide and intentional self-inflicted injury was observed in 16,149 (3.71%) veterans. The indirect effect of suicide and intentional self-inflicted injury, given a positive screen for MST, was highest among veterans with comorbid PTSD and depression diagnoses (indirect effect=3.18%, 95% confidence interval [CI] [3.01%, 3.32%]), with smaller probabilities observed for both PTSD-only (indirect effect=-0.18%, 95% CI [-0.20%, -0.14%]) and depression-only (indirect effect=0.56%, 95% CI [0.51%, 0.62%]; ps<.05). LIMITATIONS Data were limited to VHA-enrolled Iraq/Afghanistan veterans. CONCLUSIONS To reduce suicide risk among veterans with a history of MST, treatments may be most effective if they target comorbid PTSD and depression. Future research should examine the mechanisms through which comorbid PTSD and depression result in heightened risk for suicide and intentional self-inflicted injury.
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Affiliation(s)
- Whitney S Livingston
- Utah State University, Department of Psychology, 2810 Old Main Hill, Logan, UT 84321, USA; Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, 500 Foothill Dr., Salt Lake City, UT 84148, USA
| | - Jamison D Fargo
- Utah State University, Department of Psychology, 2810 Old Main Hill, Logan, UT 84321, USA; Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, 500 Foothill Dr., Salt Lake City, UT 84148, USA
| | - Adi V Gundlapalli
- Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, 500 Foothill Dr., Salt Lake City, UT 84148, USA; University of Utah School of Medicine, Departments of Internal Medicine and Biomedical Informatics, 30 N. 1900 E., Salt Lake City, UT 84132, USA
| | - Emily Brignone
- Utah State University, Department of Psychology, 2810 Old Main Hill, Logan, UT 84321, USA; Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, 500 Foothill Dr., Salt Lake City, UT 84148, USA
| | - Rebecca K Blais
- Utah State University, Department of Psychology, 2810 Old Main Hill, Logan, UT 84321, USA; Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, 500 Foothill Dr., Salt Lake City, UT 84148, USA.
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26
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Ruggiero KJ, Davidson TM, Anton MT, Bunnell B, Winkelmann J, Ridings LE, Bravoco O, Crookes B, McElligott J, Fakhry SM. Patient Engagement in a Technology-Enhanced, Stepped-Care Intervention to Address the Mental Health Needs of Trauma Center Patients. J Am Coll Surg 2020; 231:223-230. [PMID: 32335320 PMCID: PMC7491334 DOI: 10.1016/j.jamcollsurg.2020.03.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/21/2020] [Accepted: 03/23/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Annually, post-traumatic stress disorder, depression, or both, develop in the first year after injury in more than 400,000 adults treated in US trauma centers (≥20%). Yet, few trauma centers monitor and address mental health recovery, and there is limited evaluation and high structural variability across existing programs. More research is needed to guide efforts to establish such programs and to inform national standards and recommendations. STUDY DESIGN This article describes patient engagement in a stepped-care service to address patients' mental health needs. Trauma-activation patients admitted to our Level I trauma center for at least 24 hours were approached before discharge. Patients were provided education in person at the bedside (step 1), symptom monitoring via a 30-day text-messaging tool (step 2), telephone screening approximately 30 days post injury (step 3), and, when appropriate, mental health treatment referrals and treatment (step 4). RESULTS We approached and educated 1,122 patients (56%) on the floor during a 33-month period. Of these, 1,096 patients (98%) enrolled in our program and agreed to 30-day follow-up mental health screening. We reached 676 patients for the 30-day screen, 243 (36%) of these patients screened positive for post-traumatic stress disorder and/or depression. Most of the 243 patients who graduated to step 4 accepted treatment referrals (68%) or were already receiving services from a provider (7%). Home-based telemental health was preferred by 66% of patients who accepted referrals. CONCLUSIONS This work demonstrates the feasibility of an evidence-based, technology-enhanced, stepped-care intervention to address the mental health needs of trauma center patients. Strategies to reach a higher percentage of patients in follow-up are needed. We recommend trauma centers test and adopt broad-based approaches to ensure optimal long-term patient outcomes.
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Affiliation(s)
- Kenneth J Ruggiero
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, SC.
| | - Tatiana M Davidson
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, SC
| | - Margaret T Anton
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, SC
| | - Brian Bunnell
- Department of Psychiatry and Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Jennifer Winkelmann
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, SC
| | - Leigh E Ridings
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, SC
| | - Olivia Bravoco
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, SC
| | - Bruce Crookes
- Department of Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC
| | - James McElligott
- Medical University of South Carolina Center for Telehealth, Medical University of South Carolina, Charleston, SC; South Carolina Telehealth Alliance, Medical University of South Carolina, Charleston, SC
| | - Samir M Fakhry
- Department of Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC
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27
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Jacoby SF, Rich JA, Webster JL, Richmond TS. 'Sharing things with people that I don't even know': help-seeking for psychological symptoms in injured Black men in Philadelphia. ETHNICITY & HEALTH 2020; 25:777-795. [PMID: 29607675 PMCID: PMC6167172 DOI: 10.1080/13557858.2018.1455811] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 03/06/2018] [Indexed: 05/29/2023]
Abstract
Objectives: Psychological distress is common in survivors of traumatic injury, yet across United States' trauma systems, it is rare that standard injury care integrates psychological evaluation and professional mental healthcare. The purpose of this study was to explore help-seeking for psychological symptoms in injured Black men living in Philadelphia. Design: A subset of a cohort of 551 injured Black men admitted to a Trauma Center in Philadelphia participated in qualitative interviews that explored their perceptions of psychological symptoms after injury and the factors that guided their decision to seek professional mental health help. Data from 32 participants were analyzed for narrative and thematic content. Results: Three overarching themes emerged: (1) facilitators of help-seeking, (2) barriers to help-seeking, and (3) factors underlying the decision not to consider professional help. Five participants felt that their injury-related psychological distress was severe enough to merit professional help despite any perceived barriers. Seventeen participants identified systemic and interpersonal obstacles to professional help that prevented them from seeking this kind of care. These included: financial constraints, limited access to mental healthcare services, and fear of the judgments of mental healthcare professionals. Ten participants would not consider professional help; these men perceived a lack of need and sufficiency in their existing social support networks. Conclusions: Research is needed to inform or identify interventions that diminish the impact of barriers to care, and identify from whom, where, and how professional mental health help might be more effectively offered to injured Black men in recovery environments like Philadelphia.
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Affiliation(s)
- Sara F. Jacoby
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Claire M. Fagin Hall, 418 Curie Blvd, Philadelphia, PA 19104, USA
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - John A. Rich
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, 3215 Market Street, Philadelphia, PA 19104, USA
| | - Jessica L. Webster
- Department of Biobehavioral Sciences, School of Nursing, University of Pennsylvania, Claire M. Fagin Hall, 418 Curie Blvd, Philadelphia, PA 19104, USA
| | - Therese S. Richmond
- Department of Biobehavioral Sciences, School of Nursing, University of Pennsylvania, Claire M. Fagin Hall, 418 Curie Blvd, Philadelphia, PA 19104, USA
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA 19104, USA
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A Survey of Trauma Surgeon Perceptions of Resources for Patients With Psychiatric Comorbidities. J Surg Res 2020; 256:31-35. [PMID: 32683053 DOI: 10.1016/j.jss.2020.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 04/04/2020] [Accepted: 06/16/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Psychiatric illness is an independent risk factor for trauma and recidivism and is often comorbid in the trauma population. There is no current standard for the delivery of mental health services in trauma care. The purpose of this study was to gauge trauma surgeon perceptions of needed and currently available resources for this patient population at level 1 trauma centers in the United States. MATERIALS AND METHODS A 10-question survey was developed to capture the estimated volume of psychiatric patients admitted to level 1 trauma centers, their available psychiatric services, and perceived need for resources. It was sent to 27 trauma surgery colleagues at different level 1 trauma centers across the United States using a public survey tool. Descriptive analyses were performed. RESULTS Twenty-two of 27 trauma surgeons responded (81% response rate). Ten centers (48%) estimated admitting 1-5 patients with preexisting serious mental illness weekly, whereas others admitted more. Eight (36%) reported not having acute situational support services available. Ten respondents (46%) did not know how many psychiatric consultants were available at their institution. Twelve surgeons (55%) reported no designated outpatient follow-up for psychiatric issues. Sixteen trauma surgeons (73%) stated that expanded psychiatric services are needed at their trauma center. CONCLUSIONS Trauma patients frequently present with preexisting serious mental illness and many struggle with psychological sequelae of trauma. Over half of the surveyed surgeons reported no outpatient follow-up for these patients, and almost three quarters perceived the need for expansion of psychiatric services. In addition to a lack of resources, these findings highlight an overlooked gap in high-quality patient-centered trauma care.
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29
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Richmond TS, Wiebe DJ, Reilly PM, Rich J, Shults J, Kassam-Adams N. Contributors to Postinjury Mental Health in Urban Black Men With Serious Injuries. JAMA Surg 2020; 154:836-843. [PMID: 31166596 DOI: 10.1001/jamasurg.2019.1622] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Physical injury is associated with postinjury mental health problems, which typically increase disability, cost, recidivism, and self-medication for symptoms. Objective To determine risk and protective factors across the life span that contribute to depression and posttraumatic stress symptom severity at 3 months after hospital discharge. Design, Setting, and Participants This prospective cohort study used a 3-month postdischarge follow-up of patients who had been treated at an urban, level 1 trauma center in the Northeastern United States. Men with injuries who were hospitalized, self-identified as black, were 18 years or older, and resided in the Philadelphia, Pennsylvania, region were eligible and consecutively enrolled. Those who were experiencing a cognitive dysfunction or psychotic disorder, hospitalized because of attempted suicide, or receiving current treatment for depression or posttraumatic stress disorder (PTSD) were excluded. Data were collected from January 2013 to October 2017. Data analysis took place from January 2018 to August 2018. Exposures A serious injury requiring hospitalization; adverse childhood experiences, childhood neighborhood disadvantage, and preinjury physical and mental health; and emotional resources, injury intent, and acute stress responses. Main Outcomes and Measures Depression and PTSD symptom severity were assessed with the Quick Inventory of Depressive Symptoms-Self-report and the PTSD Check List-5. The a priori hypothesis was that risk and protective factors are associated with depression and PTSD symptom severity. The analytic approach was structural equation modeling. Results A total of 623 black men were enrolled. Of these, 502 participants (80.6%) were retained at 3-month follow-up. Their mean (SD) age was 35.6 (14.9) years; 346 (55.5%) had experienced intentional injuries, and the median (range) Injury Severity Score was 9 (1-45). Of the 500 participants with complete primary outcome data, 225 (45.0%) met the cut point criteria for mental health diagnoses at 3 months. For both mental health outcomes, the models fit the data well (depression: root mean square error of approximation [RMSEA], 0.044; comparative fit index [CFI], 0.93; PTSD: RMSEA = 0.045; CFI = 0.93), and all hypothesized paths were significant and in the hypothesized direction. Outcomes were associated with poor preinjury health (standardized weights: depression, 0.28; P < .001; PTSD, 0.17; P = .02), acute psychological reactions (depression, 0.34; PTSD, 0.38; both P < .001), and intentional injury (depression, 0.16; PTSD, 0.24; both P < .001). Acute psychological reactions were associated with childhood adversity (depression, 0.33; PTSD, 0.36; both P < .001). A history of prior mental health challenges (depression, 0.70; PTSD, 0.70; both P < .001) and psychological or emotional health resources (depression, -0.22; PTSD, -0.23; both P = .003) affected poor preinjury health, which was in turn associated with acute psychological reaction (depression, 0.44; PTSD, 0.42; both P < .001). Conclusions and Relevance The intersection of prior trauma and adversity, prior exposure to neighborhood disadvantage, and poorer preinjury health and functioning are important, even in the midst of acute medical care for traumatic injury. These results support the importance of trauma-informed health care and focused assessment to identified patients with injuries who are at highest risk for poor postinjury mental health outcomes.
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Affiliation(s)
- Therese S Richmond
- Biobehavioral Health Sciences Department, School of Nursing, University of Pennsylvania, Philadelphia.,Penn Injury Science Center, University of Pennsylvania, Philadelphia
| | - Douglas J Wiebe
- Penn Injury Science Center, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Patrick M Reilly
- Penn Injury Science Center, University of Pennsylvania, Philadelphia.,Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - John Rich
- Department of Health Policy & Management, School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Justine Shults
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nancy Kassam-Adams
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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30
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A validated predictive algorithm of post-traumatic stress course following emergency department admission after a traumatic stressor. Nat Med 2020; 26:1084-1088. [PMID: 32632194 DOI: 10.1038/s41591-020-0951-z] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 05/22/2020] [Indexed: 12/23/2022]
Abstract
Annually, approximately 30 million patients are discharged from the emergency department (ED) after a traumatic event1. These patients are at substantial psychiatric risk, with approximately 10-20% developing one or more disorders, including anxiety, depression or post-traumatic stress disorder (PTSD)2-4. At present, no accurate method exists to predict the development of PTSD symptoms upon ED admission after trauma5. Accurate risk identification at the point of treatment by ED services is necessary to inform the targeted deployment of existing treatment6-9 to mitigate subsequent psychopathology in high-risk populations10,11. This work reports the development and validation of an algorithm for prediction of post-traumatic stress course over 12 months using two independently collected prospective cohorts of trauma survivors from two level 1 emergency trauma centers, which uses routinely collectible data from electronic medical records, along with brief clinical assessments of the patient's immediate stress reaction. Results demonstrate externally validated accuracy to discriminate PTSD risk with high precision. While the predictive algorithm yields useful reproducible results on two independent prospective cohorts of ED patients, future research should extend the generalizability to the broad, clinically heterogeneous ED population under conditions of routine medical care.
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31
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Ridings LE, Anton MT, Winkelmann J, Davidson TM, Wray L, Streck CJ, Ruggiero KJ. Trauma Resilience and Recovery Program: Addressing Mental Health in Pediatric Trauma Centers. J Pediatr Psychol 2020; 44:1046-1056. [PMID: 31298276 DOI: 10.1093/jpepsy/jsz053] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 05/23/2019] [Accepted: 06/03/2019] [Indexed: 02/03/2023] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | - Lauren Wray
- Department of Psychiatry and Behavioral Sciences, National Crime Victims Center, Medical University of South Carolina
| | - Christian J Streck
- Department of Surgery, College of Medicine, Medical University of South Carolina
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Anton MT, Ridings LE, Gavrilova Y, Bravoco O, Ruggiero KJ, Davidson TM. Transitioning a technology-assisted stepped-care model for traumatic injury patients to a fully remote model in the age of COVID-19. COUNSELLING PSYCHOLOGY QUARTERLY 2020. [DOI: 10.1080/09515070.2020.1785393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Margaret T. Anton
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Leigh E. Ridings
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Yulia Gavrilova
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Olivia Bravoco
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Kenneth J. Ruggiero
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Tatiana M. Davidson
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, SC, USA
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Heggeness LF, Bean CAL, Kalmbach DA, Ciesla JA. Cognitive risk, coping-oriented substance use, and increased avoidance tendencies among depressed outpatients: A prospective investigation. J Clin Psychol 2020; 76:2249-2263. [PMID: 32478424 DOI: 10.1002/jclp.22978] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The present study was designed to assess the interplay between depressive cognition, coping-oriented substance use, and future behavioral disengagement tendencies. Cognitive risk subtypes examined include brooding rumination, attributional bias (internal/stable/global), and dysfunctional attitudes. METHOD Individuals were recruited from outpatient treatment settings and met criteria for a unipolar depressive disorder (N = 70; 66% female; 81% White; Mage = 31; SDage = 13.2). Participants completed self-report measures of brooding rumination, attributional style, dysfunctional attitudes, coping-oriented substance use, and behavioral disengagement tendencies following a 3-week period. RESULTS Brooding rumination, stable attributional style, and dysfunctional attitudes were positively associated with later behavioral disengagement tendencies. Coping-oriented substance use moderated associations between both internal attributional style, as well as dysfunctional attitudes onto later behavioral disengagement. CONCLUSIONS With regard to stress-related avoidance, subsyndromal substance use may play a detrimental role among cognitively vulnerable, depressed outpatients when said drug or alcohol use serves as a means of coping.
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Affiliation(s)
- Luke F Heggeness
- Department of Psychological Sciences, Kent State University, Kent, Ohio
| | | | - David A Kalmbach
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health System, Detroit, Michigan
| | - Jeffrey A Ciesla
- Department of Psychological Sciences, Kent State University, Kent, Ohio
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Scheuer H, Engstrom A, Thomas P, Moodliar R, Moloney K, Walen ML, Johnson P, Seo S, Vaziri N, Martinez A, Maier R, Russo J, Sieber S, Anziano P, Anderson K, Bulger E, Whiteside L, Heagerty P, Palinkas L, Zatzick D. 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. Contemp Clin Trials 2020; 91:105970. [PMID: 32119926 PMCID: PMC9677945 DOI: 10.1016/j.cct.2020.105970] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/18/2020] [Accepted: 02/22/2020] [Indexed: 11/18/2022]
Abstract
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).
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Affiliation(s)
- Hannah Scheuer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 325 Ninth Ave., Box 359911, Seattle, WA 98104, United States of America.
| | - Allison Engstrom
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 325 Ninth Ave., Box 359911, Seattle, WA 98104, United States of America.
| | - Peter Thomas
- Powers Pyles Sutter & Verville PC, 501 M Street, NW, Seventh Floor, Washington, DC 20005, United States of America.
| | - Rddhi Moodliar
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 325 Ninth Ave., Box 359911, Seattle, WA 98104, United States of America.
| | - Kathleen Moloney
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 325 Ninth Ave., Box 359911, Seattle, WA 98104, United States of America.
| | - Mary Lou Walen
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 325 Ninth Ave., Box 359911, Seattle, WA 98104, United States of America.
| | - Peyton Johnson
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 325 Ninth Ave., Box 359911, Seattle, WA 98104, United States of America.
| | - Sara Seo
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 325 Ninth Ave., Box 359911, Seattle, WA 98104, United States of America.
| | - Natalie Vaziri
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 325 Ninth Ave., Box 359911, Seattle, WA 98104, United States of America.
| | - Alvaro Martinez
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 325 Ninth Ave., Box 359911, Seattle, WA 98104, United States of America.
| | - Ronald Maier
- Department of Surgery, University of Washington School of Medicine, 410 9th Ave., Seattle, WA 98104, United States of America.
| | - Joan Russo
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 325 Ninth Ave., Box 359911, Seattle, WA 98104, United States of America.
| | - Stella Sieber
- Molecular Genomics Core/Microarray Group, National Institute of Environmental Health Sciences, P.O. Box 12233, Mail Drop D2-04, Durham, N.C 27709, United States of America.
| | - Pete Anziano
- Shepherd Center, 2020 Peachtree Road NW, Atlanta, GA 30309-1465, United States of America.
| | - Kristina Anderson
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 325 Ninth Ave., Box 359911, Seattle, WA 98104, United States of America; The Koshka Foundation, United States of America.
| | - Eileen Bulger
- Department of Surgery, University of Washington School of Medicine, 410 9th Ave., Seattle, WA 98104, United States of America.
| | - Lauren Whiteside
- Department of Emergency Medicine, University of Washington School of Medicine, 325 9th Ave., Seattle, WA 98104, United States of America.
| | - Patrick Heagerty
- Department of Biostatistics, University of Washington School of Public Health, 1705 NE Pacific St., Seattle, WA 98195, United States of America.
| | - Lawrence Palinkas
- Department of Children, Youth and Families, USC Suzanne Dworak-Peck School of Social Work, 669 W 34(th) St., Los Angeles, CA 90089, United States of America.
| | - Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 325 Ninth Ave., Box 359911, Seattle, WA 98104, United States of America.
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Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) in Pragmatic Clinical Trials of Mental Health Services Implementation: Methods and Applied Case Study. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2020; 46:255-270. [PMID: 30488143 PMCID: PMC7427407 DOI: 10.1007/s10488-018-0909-3] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pragmatic clinical trials of mental health services are increasingly being developed to establish comparative effectiveness, influence sustainable implementation, and address real world policy decisions. However, use of time and resource intensive qualitative methods in pragmatic trials may be inconsistent with the aims of efficiency and cost minimization. This paper introduces a qualitative method known as Rapid Assessment Procedure-Informed Clinical Ethnography (RAPICE) that combines the techniques of Rapid Assessment Procedures with clinical ethnography. A case study is presented to illustrate how RAPICE can be used to efficiently understand pragmatic trial implementation processes and associated real world policy implications.
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Life After Trauma: A Survey of Level 1 Trauma Centers Regarding Posttraumatic Stress Disorder and Acute Stress Disorder. J Trauma Nurs 2020; 26:223-233. [PMID: 31503192 DOI: 10.1097/jtn.0000000000000451] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patients admitted to Level 1 trauma centers in the United States are rarely assessed for or educated about the potentially devastating effects of acute stress disorder (ASD) or posttraumatic stress disorder (PTSD). This descriptive research was conducted to describe current levels of assessment and education of ASD and PTSD in Level 1 trauma centers in the United States. The aims of this article are to (1) determine the extent to which Level 1 trauma centers in the United States assess and educate patients and providers about ASD and PTSD and (2) identify clinical staff who administer assessments and provide educational resources. A web-based survey was distributed to the trauma program managers and trauma medical directors of 209 adult and 70 pediatric Level 1 trauma centers in the United States. For PTSD, 26 (25.00%) adult and 17 (36.17%) pediatric centers had an assessment protocol for use with trauma patients. For ASD, 13 (12.50%) adult and 13 (27.66%) pediatric centers utilized an assessment protocol for use with trauma patients. For PTSD, 12 (12.37%) adult and 8 (20.00%) pediatric centers offered educational protocols for use with trauma patients. Seven (7.22%) adult and 7 (17.50%) pediatric centers maintain educational protocols for ASD in trauma patients. Fewer centers had assessment or educational protocols targeting formal and informal caregivers. This study was limited to Level 1 trauma centers in the United States. Results indicate that trauma patients are rarely assessed for or educated about the potential effects of PTSD or ASD. Formal and informal caregivers are also assessed and educated at low rates. Assessment, education, and incidence of PTSD and ASD should be included as universally measured health outcomes across trauma centers.
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Ceniti AK, Heinecke N, McInerney SJ. Examining suicide-related presentations to the emergency department. Gen Hosp Psychiatry 2020; 63:152-157. [PMID: 30268506 DOI: 10.1016/j.genhosppsych.2018.09.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 07/17/2018] [Accepted: 09/15/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Although the Emergency Department (ED) is a frequent point of contact for individuals with suicide-related behaviour (SRB) or ideation, there is limited literature specifically examining presentations to the ED for SRB. This review examines the international literature published in North America, the United Kingdom and Australia relating to presentations to the ED for SRB, with focus on high-risk groups, screening tools used in the ED, and difficulties in classifying ED presentations of SRB. METHOD The database PubMed was searched using relevant terms, and national health care administrative data were reviewed. RESULTS Psychiatric history, substance use, and lower socioeconomic status were all found to be associated with higher rates of ED presentations for SRB. Limited research exists around ED presentations of SRB by particular high-risk groups, including lesbian, gay, bisexual, and transgender populations and Indigenous peoples. Individuals who present to EDs for SRB are often chronic users of EDs and have a high rate of repeat self-harm and death by suicide. CONCLUSION These findings suggest that EDs could serve as a focal point for suicide treatment interventions. Deepening our understanding of ED presentations for SRB could inform further development and implementation of interventions to reduce death by suicide.
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Affiliation(s)
- Amanda K Ceniti
- Arthur Sommer Rotenberg Suicide & Depression Studies Program, St. Michael's Hospital, Toronto, Ontario, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nicole Heinecke
- Arthur Sommer Rotenberg Suicide & Depression Studies Program, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Shane J McInerney
- Arthur Sommer Rotenberg Suicide & Depression Studies Program, St. Michael's Hospital, Toronto, Ontario, Canada; Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Psychiatry, St. Michael's Hospital, University Health Network & University of Toronto, Toronto, Ontario, Canada.
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Darnell D, Parker L, Engstrom A, Fisher D, Diteman K, Dunn C. Evaluation of a Level I trauma center provider training in patient-centered alcohol brief interventions using the Behavior Change Counseling Index rated by standardized patients. Trauma Surg Acute Care Open 2019; 4:e000370. [PMID: 31922018 PMCID: PMC6937416 DOI: 10.1136/tsaco-2019-000370] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 09/22/2019] [Accepted: 12/02/2019] [Indexed: 12/30/2022] Open
Abstract
Background Traumatic injury requiring hospitalization is common in the USA and frequently related to alcohol consumption. The American College of Surgeons requires that Level I and II verified trauma centers implement universal alcohol screening and brief intervention for injured patients. We examined whether Level I trauma center provider skill in patient-centered alcohol brief interventions improved after training and whether professional role (eg, nursing, social work) and education were associated with these skills. Methods We present evaluation data collected as part of training in alcohol brief interventions embedded within a larger clinical trial of a collaborative care intervention targeting posttraumatic stress disorder and related comorbidities. Sixty-five providers from 25 US Level I trauma centers engaged in a 1-day workshop, with 2 hours dedicated to training in patient-centered alcohol brief interventions followed by 6 months of weekly coaching in a collaborative care model. Providers completed standardized patient role-plays prior to and 6 months after the workshop training. The standardized patient actors rated provider quality of alcohol brief interventions immediately after each role-play using the Behavior Change Counseling Index (BECCI), a pragmatic measure designed to assess the quality of behavior change counseling, an adaptation of motivational interviewing suitable for brief healthcare consultations about behavior change. Results Seventy-two percent of providers completed both standardized patient role-play assessments. A statistically significant improvement in overall BECCI scores (t(41)=−2.53, p=0.02, Cohen’s d=−0.39) was observed among those providers with available pre–post data. Provider professional role was associated with BECCI scores at pre-training (F(3, 58)=11.25, p<0.01) and post-training (F(3, 41)=8.10, p<0.01). Discussion Findings underscore the need for training in patient-centered alcohol brief interventions and suggest that even a modest training helps providers engage in a more patient-centered way during a role-play assessment. Level of evidence Level V, therapeutic/care management.
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Affiliation(s)
- Doyanne Darnell
- Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Lea Parker
- Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Allison Engstrom
- Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Dylan Fisher
- Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Kaylie Diteman
- Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Christopher Dunn
- Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
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Jaramillo S, Suffoletto B, Callaway C, Pacella-LaBarbara M. Early Screening for Posttraumatic Stress Disorder and Depression Among Injured Emergency Department Patients: A Feasibility Study. Acad Emerg Med 2019; 26:1232-1244. [PMID: 31179590 PMCID: PMC7294865 DOI: 10.1111/acem.13816] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/03/2019] [Accepted: 06/05/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Despite the risk of developing posttraumatic stress disorder (PTSD) and associated comorbidities after physical injury, few emergency departments (EDs) in the United States screen for the presence of psychological symptoms and conditions. Barriers to systematic screening could be overcome by using a tool that is both comprehensive and brief. This study aimed to determine 1) the feasibility of screening for posttraumatic sequelae among adults with minor injury in the ED and 2) the relationship between ED screening and later psychological symptoms and poor quality of life (QOL) at 6 weeks postinjury. METHODS In the EDs of two Level I trauma centers, we enrolled injured patients (n = 149) who reported serious injury and/or life threat in the past 24 hours. Subjects completed the Posttraumatic Adjustment Scale (PAS) to screen for PTSD and depression in the ED, and 6 weeks later they completed assessments for symptoms of PTSD, depression, and trauma-specific QOL (T-QoL). RESULTS Our retained sample at 6 weeks was 84 adults (51.2% male; mean ± SD age = 33 ± 11.88 years); 38% screened positive for PTSD, and 76% screened positive for depression in the ED. Controlling for age, hospital admission, and ED pain score, regression analyses revealed that a positive ED screen for both PTSD and depression was significantly associated with 6 weeks PTSD (p = 0.027, 95% confidence interval [CI] = 0.92 to 15.14) and depressive symptoms (p = 0.001, 95% CI = 2.20 to 7.74), respectively. Further, a positive ED screen for depression (p = 0.043, 95% CI = -16.66 to -0.27) and PTSD (p = 0.015, 95% CI = -20.35 to -2.24) was significantly associated with lower T-QoL. CONCLUSIONS These results suggest that it is feasible to identify patients at risk for postinjury sequelae in the ED; screening for mental health risk may identify patients in need of early intervention and further monitoring.
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Affiliation(s)
- Stephany Jaramillo
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Brian Suffoletto
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Clifton Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Maria Pacella-LaBarbara
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Grossman DC, Choucair B. Violence And The US Health Care Sector: Burden And Response. Health Aff (Millwood) 2019; 38:1638-1645. [DOI: 10.1377/hlthaff.2019.00642] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- David C. Grossman
- David C. Grossman is senior investigator at the Kaiser Permanente Washington Health Research Institute, in Seattle
| | - Bechara Choucair
- Bechara Choucair is senior vice president and chief community health officer at Kaiser Permanente in Oakland, California
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McBain SA, Sexton KW, Palmer BE, Landes SJ. Barriers to and facilitators of a screening procedure for PTSD risk in a level I trauma center. Trauma Surg Acute Care Open 2019; 4:e000345. [PMID: 31467988 PMCID: PMC6699788 DOI: 10.1136/tsaco-2019-000345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/12/2019] [Accepted: 07/17/2019] [Indexed: 11/20/2022] Open
Abstract
Background Patients admitted to the hospital after an injury are at a greater risk for developing post-traumatic stress disorder (PTSD) due to the nature of the injury and the traumatic nature of necessary medical interventions. Many level I trauma centers have yet to implement screening protocols for PTSD risk. The goal of the study was to characterize the barriers to and facilitators of implementation of a screening procedure for PTSD risk in a level I trauma center. Methods We conducted semistructured qualitative interviews with multidisciplinary academic medical center stakeholders (N=8) including those with clinical, research, teaching, and administrative roles within an urban academic medical center’s Department of Surgery, Division of Acute Care Surgery. We analyzed the qualitative data using summative template analysis to abstract data related to participants’ opinions about implementation of a screener for PTSD. Results Participants’ general perception of screening for PTSD risk after injury was positive. Identified challenges to implementation included timing of screening, time burden, care coordination, addressing patients with traumatic brain injury or an altered mental status, and ensuring appropriate care after screening. Reported facilitators included existing psychosocial screening tools and protocols that would support inclusion of a PTSD screener, a patient-centered culture that would facilitate buy-in from providers, a guideline-driven culture, and a commitment to continuity of care. Conclusions This study offers concrete preliminary information on barriers to and facilitators of PTSD screening that can be used to inform planning of implementation efforts within a trauma center. Level of evidence Level V, qualitative.
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Affiliation(s)
- Sacha A McBain
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Mental Illness Research Education and Clinical Center (MIRECC), Central Arkansas Veterans Healthcare System, Eugene J Towbin Healthcare Center, North Little Rock, Arkansas, USA
| | - Kevin W Sexton
- Department of Surgery, Division of Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Brooke E Palmer
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Sara J Landes
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Mental Illness Research Education and Clinical Center (MIRECC), Central Arkansas Veterans Healthcare System, Eugene J Towbin Healthcare Center, North Little Rock, Arkansas, USA
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Do screening and a randomized brief intervention at a Level 1 trauma center impact acute stress reactions to prevent later development of posttraumatic stress disorder? J Trauma Acute Care Surg 2019; 85:466-475. [PMID: 29787532 DOI: 10.1097/ta.0000000000001977] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Approximately 20% to 40% of trauma survivors experience posttraumatic stress disorder (PTSD). The American College of Surgeons Committee on Trauma reports that early screening and referral has the potential to improve outcomes and that further study of screening and intervention for PTSD would be beneficial. This prospective randomized study screened hospitalized patients for traumatic stress reactions and assessed the effect of a brief intervention in reducing later development of PTSD. METHODS The Primary Care PTSD (PC-PTSD) screen was administered to admitted patients. Patients with symptoms were randomized to an intervention or control group. The brief intervention focused on symptom education and normalization, coping strategies, and utilizing supports. The control group received a 3-minute educational brochure review. Both groups completed in-hospital interviews, then 45- and 90-day telephone interviews. Follow-up collected the PTSD checklist-civilian (PCL-C) assessment and qualitative data on treatment-seeking barriers. RESULTS The PC-PTSD screen was successful in predicting later PTSD symptoms at both 45 days (β = 0.43, p < 0.001) and 90 days (β = 0.37, p < 0.001) even after accounting for depression. Correlations of the intervention with the PCL-C scores and factor score estimates did not reach statistical significance at either time point (p = 0.827; p = 0.838), indicating that the brief intervention did not decrease PTSD symptoms over time. Of those at or above the PCL-C cutoff at follow-ups, a minority had sought treatment for their symptoms (43.2%). Primary barriers included focusing on their injury or ongoing rehabilitation, financial concerns, or location of residence. CONCLUSION The PC-PTSD screen identified patients who later assess positive for PTSD using the PCL-C. The brief intervention did not reduce 45- and 90-day PTSD development. Follow-up interviews revealed lack of treatment infrastructure in the community. It will be important for trauma centers to align with community resources to address the treatment needs of at-risk patients. LEVEL OF EVIDENCE Prospective randomized controlled trial, level II.
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Bunnell BE, Davidson TM, Winkelmann JR, Maples-Keller JL, Ridings LE, Dahne J, Fakhry SM, Ruggiero KJ. Implementation and Utility of an Automated Text Messaging System to Facilitate Symptom Self-Monitoring and Identify Risk for Post-Traumatic Stress Disorder and Depression in Trauma Center Patients. Telemed J E Health 2019; 25:1198-1206. [PMID: 30730263 DOI: 10.1089/tmj.2018.0170] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background and Introduction: Comprehensive monitoring and follow-up after traumatic injury is important for psychological recovery. However, scalable services to facilitate this are limited. Automated text message-based symptom self-monitoring (SSM) may be a feasible approach. This study examined its implementation and utility in identifying patients at risk for mental health difficulties after traumatic injury. Materials and Methods: Five hundred two patients admitted to a Level I trauma center between June 20, 2016 and July 31, 2017 were offered enrollment in a text message-based SSM service. Patients who enrolled received daily text message prompts over 30 days and most participated in a mental health screening 30 days postbaseline. Results: Approximately 67% of patients enrolled in the service; of these, 58% responded to the text messages, with an average response rate of 53%. Younger patients and those with elevated peritraumatic distress were more likely to enroll. Patients with higher levels of mental health stigma, who were White, or had been in a motor vehicle collision were more likely to enroll and respond to text messages once enrolled. Patients' daily ratings of distress detected clinically elevated 30-day mental health screens with high sensitivity (83%) and specificity (70%). Discussion and Conclusions: Text message-based SSM can be implemented as a clinical service in Level I trauma centers, and patient participation may increase engagement in mental health follow-up. Further, it can inform the use of risk assessments in practice, which can be used to identify patients with poor psychological recovery who require additional screening.
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Affiliation(s)
- Brian E Bunnell
- Biomedical Informatics Center, College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Tatiana M Davidson
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
| | - Jennifer R Winkelmann
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
| | - Jessica L Maples-Keller
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Leigh E Ridings
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
| | - Jennifer Dahne
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Samir M Fakhry
- Synergy Surgicalists, Reston Hospital Center, Reston, Virginia
| | - Kenneth J Ruggiero
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
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Why do trauma survivors become depressed? Testing the behavioral model of depression in a nationally representative sample. Psychiatry Res 2019; 272:587-594. [PMID: 30616128 DOI: 10.1016/j.psychres.2018.12.150] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 12/28/2018] [Accepted: 12/28/2018] [Indexed: 11/23/2022]
Abstract
Despite accumulated evidence linking trauma exposure to major depressive disorder (MDD), there is limited understanding as to why some trauma survivors subsequently develop MDD. The behavioral model of depression points to a negative reinforcement cycle of trauma-related avoidance and depressed mood, but no study has evaluated this framework in trauma survivors. This study tested the hypothesis that traumatic stress symptom-related interference with daily activities and with relationships and self-medicating traumatic stress symptoms with alcohol and with drugs would predict MDD onset in a nationally representative sample after controlling for established risk factors. Data were drawn from Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) using two samples: adults reporting lifetime trauma exposure but no history of MDD at Wave 1 (n = 8301) and a subset of those participants who met criteria for lifetime PTSD prior to Wave 1 (n = 1055). Younger age, female gender, a greater number of different trauma types, traumatic stress-related interference with daily activities, and self-medicating traumatic stress symptoms with alcohol significantly predicted MDD onset in both groups. Findings underscore the role of traumatic stress-related interference and self-medication in the development of MDD.
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45
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Geier TJ, Hunt JC, Nelson LD, Brasel KJ, deRoon-Cassini TA. Detecting PTSD in a traumatically injured population: The diagnostic utility of the PTSD Checklist for DSM-5. Depress Anxiety 2019; 36:170-178. [PMID: 30597679 PMCID: PMC6373876 DOI: 10.1002/da.22873] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/20/2018] [Accepted: 12/08/2018] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The posttraumatic stress disorder (PTSD) Checklist for DSM-5 (PCL-5) is among few validated measures of PTSD severity in line with the DSM-5. Validation efforts among veteran samples have recommended cut scores of 33 and 38 to indicate PTSD; cut scores vary across populations depending on factors such as trauma type. The purpose of this study was to evaluate the diagnostic utility of and identify optimal cut scores for the PCL-5 in relation to the gold standard Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) among traumatically injured individuals 6 months after discharge from a level I trauma center. METHODS A total of 251 participants completed the PCL-5 and CAPS-5 6 months after discharge from a level I trauma center following traumatic injury. Receiver operating characteristic curve analyses detailed diagnostic accuracy of the PCL-5 and identified the optimal cut score via Youden's J index. Cut scores were also broken down by intentional versus nonintentional injury. RESULTS The PCL-5 produces satisfactory diagnostic accuracy, with adequate sensitivity and specificity, in a traumatically injured population. Estimates indicate the optimal cut score as >30; the optimal cut score for intentional injuries was >34 and >22 for nonintentional injuries. CONCLUSIONS This investigation provides support for the PCL-5 in detection of PTSD among injured individuals 6 months after discharge from a level I trauma center. PCL-5 specificity and sensitivity suggest clinicians working with this population can feel confident in using this measure over more onerous structured interviews (e.g., CAPS-5). This study signifies a move toward ensuring those experiencing mental health difficulties after traumatic injury are identified and connected to resources.
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Affiliation(s)
- Timothy J Geier
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Joshua C Hunt
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lindsay D Nelson
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Karen J Brasel
- Department of Surgery, Oregon Health & Science University, Portland, Oregon
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46
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DeCou CR, Schumann ME. On the Iatrogenic Risk of Assessing Suicidality: A Meta-Analysis. Suicide Life Threat Behav 2018; 48:531-543. [PMID: 28678380 DOI: 10.1111/sltb.12368] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 05/08/2017] [Indexed: 11/27/2022]
Abstract
Previous studies have failed to detect an iatrogenic effect of assessing suicidality. However, the perception that asking about suicide may induce suicidality persists. This meta-analysis quantitatively synthesized research concerning the iatrogenic risks of assessing suicidality. This review included studies that explicitly evaluated the iatrogenic effects of assessing suicidality via prospective research methods. Thirteen articles were identified that met inclusion criteria. Evaluation of the pooled effect of assessing suicidality with regard to negative outcomes did not demonstrate significant iatrogenic effects. Our findings support the appropriateness of universal screening for suicidality, and should allay fears that assessing suicidality is harmful.
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Affiliation(s)
- Christopher R DeCou
- School of Medicine, University of Washington, Seattle, WA, USA.,Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Matthew E Schumann
- Minneapolis VA Health Care System, Minneapolis, MN, USA.,Idaho State University, Pocatello, ID, USA
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Bruce MM, Kassam-Adams N, Rogers M, Anderson KM, Sluys KP, Richmond TS. Trauma Providers' Knowledge, Views, and Practice of Trauma-Informed Care. J Trauma Nurs 2018; 25:131-138. [PMID: 29521782 PMCID: PMC5968451 DOI: 10.1097/jtn.0000000000000356] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Trauma-informed interventions have been implemented in various settings, but trauma-informed care (TIC) has not been widely incorporated into the treatment of adult patients with traumatic injuries. The purpose of this study was to examine health care provider knowledge, attitudes, practices, competence, and perceived barriers to implementation of TIC. This cross-sectional study used an anonymous web-based survey to assess attitudes, knowledge, perceived competence, and practice of TIC among trauma providers from an urban academic medical center with a regional resource trauma center. Providers (nurses, physicians, therapists [physical, occupational, respiratory]) working in trauma resuscitation, trauma critical care, and trauma care units were recruited. Descriptive statistics summarized knowledge, attitudes, practice, competence, and perceived barriers to TIC and logistic regression analyses examined factors predicting the use of TIC in practice. Of 147 participants, the majority were nurses (65%), followed by therapists (18%) and physicians (17%), with a median 3 years of experience; 75% answered the knowledge items correctly and 89% held favorable opinions about TIC. Nineteen percent rated themselves as less than "somewhat competent." All participants rated the following as significant barriers to providing basic TIC: time constraints, need of training, confusing information about TIC, and worry about retraumatizing patients. Self-rated competence was the most consistent predictor of providers' reported use of specific TIC practices. Despite some variability, providers were generally knowledgeable and held favorable views toward incorporating TIC into their practice. TIC training for trauma providers is needed and should aim to build providers' perceived competence in providing TIC.
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Affiliation(s)
- Marta M. Bruce
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nancy Kassam-Adams
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Children’s Hospital of Pennsylvania, Philadelphia, PA, USA
| | - Mary Rogers
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Kerstin Prignitz Sluys
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Red Cross University College, Stockholm, Sweden
| | - Therese S. Richmond
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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48
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Richmond TS, Foman M. Firearm Violence: A Global Priority for Nursing Science. J Nurs Scholarsh 2018; 51:229-240. [PMID: 30215887 DOI: 10.1111/jnu.12421] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE This purpose of this article is to frame firearm violence as a health and public health problem, to illustrate the magnitude of the problem, to examine factors that increase the risk to be injured by a firearm, or conversely, that confer protection, and to identify relevant priority areas for nursing science. ORGANIZING CONSTRUCT Firearm violence results in physical and psychological injuries and is a global health priority. Firearm violence is categorized as intentional (interpersonal and self-inflicted) and unintentional (interpersonal and self-inflicted) and accounts for an estimated 196,000 to 220,000 nonconflict deaths annually. METHODS We reviewed the theoretical and scientific literature to analyze the magnitude and geographic distribution of firearm violence, the factors associated with firearm injury, the consequences of firearm violence, and areas where nursing science can make an impact on prevention, outcomes, and recovery. FINDINGS Firearm violence is a significant public health problem that affects the health of individuals, families, and communities. The burdens and contributors to firearm violence vary worldwide, making it important to understand the local context of this global phenomenon. Relevant areas of inquiry span primary prevention focusing on individual and environmental risk factors; and focus on managing the physical and psychological consequences postinjury; and mitigating long-term consequences of firearm violence. CONCLUSIONS Reducing the global burden of firearm violence and improving the health and safety of individuals, families, and communities provide compelling reasons to integrate this area into nursing science. CLINICAL RELEVANCE The goals of nursing are to keep people healthy and safe and to help return those injured to their optimal levels of health and well-being. Understanding the factors that come together to injure people with a firearm in various physical, social, economic, and cultural environments positions nurses to both extend the dialogue beyond pro-gun versus anti-gun and to design and carry out rigorous studies to reduce firearm violence.
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Affiliation(s)
- Therese S Richmond
- Andrea B. Laporte Professor of Nursing, Associate Dean for Research & Innovation, Biobehavioral Health Sciences Department, School of Nursing, University of Pennsylvania, Penn Injury Science Center, Philadelphia, PA, USA
| | - Matthew Foman
- Research Assistant, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA.,Student, History and Sociology of Science Department, School of Arts & Sciences, University of Pennsylvania, Philadelphia, PA, USA
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Bunnell BE, Davidson TM, Ruggiero KJ. The Peritraumatic Distress Inventory: Factor structure and predictive validity in traumatically injured patients admitted through a Level I trauma center. J Anxiety Disord 2018; 55:8-13. [PMID: 29549879 PMCID: PMC5879025 DOI: 10.1016/j.janxdis.2018.03.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 02/16/2018] [Accepted: 03/06/2018] [Indexed: 10/17/2022]
Abstract
Peritraumatic distress is defined as the emotional and physiological distress experienced during and/or immediately after a traumatic event and is associated with the development and severity of posttraumatic stress disorder (PTSD) and related psychological difficulties. The Peritraumatic Distress Inventory (PDI) is a widely-used self-report measure for which psychometric evaluation has been limited. This study sought to assess the factor structure and predictive validity of the PDI with a clinical sample of 600 traumatically injured patients admitted to a Level I trauma center, 271 of whom completed a phone-based PTSD screening ∼30-days post-injury. The results confirmed previously proposed one- and two-factor solutions for the PDI. PDI scores predicted PTSD severity and positive PTSD screens (i.e., clinically elevated vs. non-elevated). Data suggested an optimal cutoff score of 23 (sensitivity = 71%; specificity = 73%) for predicting clinically elevated PTSD 30-days post-injury. This study provides further evidence supporting the PDI as a valid and reliable measure of peritraumatic distress and a useful clinical tool with significant prognostic value.
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Affiliation(s)
- Brian E. Bunnell
- Biomedical Informatics Center, College of Medicine, Medical University of South Carolina, 135 Cannon St., Ste. 405, MSC 200, Charleston, SC 29425
| | - Tatiana M. Davidson
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, 99 Jonathan Lucas St., MSC 160, Charleston, SC, 29425
| | - Kenneth J. Ruggiero
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, 99 Jonathan Lucas St., MSC 160, Charleston, SC, 29425
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50
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Zatzick D, Russo J, Thomas P, Darnell D, Teter H, Ingraham L, Whiteside LK, Wang J, Guiney R, Parker L, Sandgren K, Hedrick MK, Van Eaton EG, Jurkovich G. Patient-Centered Care Transitions After Injury Hospitalization: A Comparative Effectiveness Trial. Psychiatry 2018. [PMID: 29533154 DOI: 10.1080/00332747.2017.1354621] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The investigation aimed to compare two approaches to the delivery of care for hospitalized injury survivors, a patient-centered care transition intervention versus enhanced usual care. METHOD This pragmatic comparative effectiveness trial randomized 171 acutely injured trauma survivors with three or more early postinjury concerns and high levels of emotional distress to intervention (I; n = 85) and enhanced usual care control (C; n = 86) conditions. The care transition intervention components included care management that elicited and targeted improvement in patients' postinjury concerns, 24/7 study team cell phone accessibility, and stepped-up care. Posttraumatic concerns, symptomatic distress, functional status, and statewide emergency department (ED) service utilization were assessed at baseline and over the course of the 12 months after injury. Regression analyses assessed intervention and control group outcome differences over time. RESULTS Over 80% patient follow-up was attained at each time point. Intervention patients demonstrated clinically and statistically significant reductions in the percentage of any severe postinjury concerns expressed when compared to controls longitudinally (Wald chi-square = 11.29, p = 0.01) and at the six-month study time point (C = 74%, I = 53%; Fisher's exact test, p = 0.02). Comparisons of ED utilization data yielded clinically significant cross-sectional differences (one or more three- to six-month ED visits; C = 30.2%, I = 16.5%, [relative risk (95% confidence interval] C versus I = 2.00 (1.09, 3.70), p = 0.03) that did not achieve longitudinal statistical significance (F (3, 507) = 2.24, p = 0.08). The intervention did not significantly impact symptomatic or functional outcomes. CONCLUSIONS Orchestrated investigative and policy efforts should continue to evaluate patient-centered care transition interventions to inform American College of Surgeons' clinical guidelines for U.S. trauma care systems.
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