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

Patient characteristics associated with posttraumatic stress symptoms in intensive care unit survivors during a one-year follow-up: A multicenter study

BACKGROUND

Intensive care unit (ICU) patients are at risk of suffering from posttraumatic stress symptoms (PTSS) after ICU survival.

OBJECTIVES

To describe the prevalence of high levels of PTSS the first year after ICU admission. Further, to identify specific combinations of patient characteristics (latent classes based on pre-ICU data, demographics, and clinical characteristics), and to investigate possible associations among these classes and PTSS at 3, 6, and 12 months after ICU admission.

METHODS

Self-reported PTSS were measured with Impact of Event Scale-Revised (IES-R). PTSS and possible predictive factors (pre-ICU data, demographics, and clinical characteristics) were analyzed using descriptive statistics, latent class analysis, and linear mixed model for repeated measures.

RESULTS

High PTSS levels (IES-R ≥ 33) were reported by 14.9 % (95 % confidence interval [CI] [10.0; 21.1]), 16.7 % (95 % CI [11.5; 23.1]), and 18.4 % (95 % CI [12.9; 25.0]) of patients (sample 1, n = 174) at 3, 6, and 12 months, respectively. Three latent classes were identified (sample 2, n = 417). PTSS were significantly associated with class 2 (male with longer hospital stay) at 6 months and class 3 (age≥70, lower level of education, higher Simplified Acute Physiology Score, being mechanically ventilated) at all three measurement times.

CONCLUSIONS

The prevalence of high levels of PTSS is the greatest 12 months after ICU admission. Health professionals can use this information to be aware of specific groups of ICU patients reporting PTSS during the first year and follow up on these.

Recurrence of post-traumatic stress disorder: systematic review of definitions, prevalence and predictors

BACKGROUND

Many people will experience a potentially traumatic event in their lifetime and a minority will go on to develop post-traumatic stress disorder (PTSD). A wealth of literature explores different trajectories of PTSD, focusing mostly on resilient, chronic, recovered and delayed-onset trajectories. Less is known about other potential trajectories such as recurring episodes of PTSD after initial recovery, and to date there has been no estimate of what percentage of those who initially recover from PTSD later go on to experience a recurrence. This systematic review aimed to synthesise existing literature to identify (i) how 'recurrence' of PTSD is defined in the literature; (ii) the prevalence of recurrent episodes of PTSD; and (iii) factors associated with recurrence.

METHODS

A literature search of five electronic databases identified primary, quantitative studies relevant to the research aims. Reference lists of studies meeting pre-defined inclusion criteria were also hand-searched. Relevant data were extracted systematically from the included studies and results are reported narratively.

RESULTS

Searches identified 5,398 studies, and 35 were deemed relevant to the aims of the review. Results showed there is little consensus in the terminology or definitions used to refer to recurrence of PTSD. Because recurrence was defined and measured in different ways across the literature, and prevalence rates were reported in numerous different ways, it was not possible to perform meta-analysis to estimate the prevalence of recurrence. We also found no consistent evidence regarding predictors of PTSD recurrence.

CONCLUSION

A clear and consistent evidence-based definition of recurrence is urgently needed before the prevalence and predictors of recurrence can be truly understood.

Longitudinal changes in mental health outcomes after COVID-19 hospitalization: A prospective study

BACKGROUND

The long-term trends of COVID-19 mental sequelae remain unknown. Thus, this study aimed to survey the one-year temporal trends of PTSD and health-related quality of life of COVID-19 survivors.

METHODS

Patients hospitalized with COVID-19 were followed up at three, six, and 12 months after discharge. Patients with COVID-19 who were able to communicate and complete the questionnaires were included in the study. All participants were asked to complete the Medical Outcomes Study 36-Item Short-Form Health (SF-36) survey and the Impact of Event Scale-Revised (IES-R). The cutoff point of 24/25 of IES-R was defined as preliminary PTSD. Patients exhibiting PTSD symptoms at six months or later were regarded as "delayed patients," while those exhibiting PTSD symptoms at all the time points were "persistent patients."

RESULTS

Of the 98 patients screened between June and November 2020, 72 participated in the study. A total of 11 (15.3%) had preliminary PTSD at three months, 10 (13.9%) at six months, and 10 (13.9%) at 12 months; delayed and persistent patients were four patients (7.54%) each. Patients with preliminary PTSD had lower mental summary scores in SF-36; 47 (IQR 45, 53) for patients with preliminary PTSD and 60 (49, 64) without preliminary PTSD at three months, 50 (45, 51) and 58 (52, 64) at six months, and 46 (38, 52) and 59 (52, 64) at 12 months.

CONCLUSION

Healthcare providers should care about the courses of PTSD in COVID-19 survivors and be aware that patients with PTSD symptoms may have a lower health-related quality of life.

Patient Experiences after Physical Trauma: The Negative Effect of the COVID-19 Pandemic on Recovery

The coronavirus disease 2019 (COVID-19) pandemic generated a crisis within the healthcare system, during which acute, COVID-19-related health needs were prioritized over less urgent needs, including vulnerable subgroups. This study explored experiences of recovery among survivors of physical injuries associated with severe pain during the COVID-19 pandemic in Norway. In-depth interviews were conducted among 13 participants. Findings generated by a thematic analysis revealed that the pandemic, including the contagion control measures and interrupted healthcare, were of negative consequence for the participants' recovery experiences and mental and physical health. Despite experiencing severe pain and perceived needs for support, the participants experienced being deprioritized by the healthcare system. They experienced a reduced capacity to cope with pandemic-related stress and to perform everyday tasks, which they perceived as generating an additional burden for their loved ones. Alcohol was reported to be used in an effort to relieve the associated mental distress. As suggested by this study, injury survivors constitute a vulnerable subgroup for whom the continuity of rehabilitation services during a national crisis, as well as the integration of mental health support, can be essential for mitigating the negative impact of the crisis on recovery and for promoting optimal long-term health outcomes.

The long-term buffering effect of sense of coherence on psychopathological symptoms during the first year of the COVID-19 pandemic: A prospective observational study

The COVID-19 pandemic is a major chronic stressor affecting all societies and almost all individuals. Consequently, research demonstrated a negative impact of COVID-19 on mental health in parts of the general population. However, not all people are affected equally thus making the identification of resilience factors modulating the pandemic's impact on mental health an important research agenda. One of these factors is sense of coherence (SOC), the key component of the salutogenesis framework. The current study aimed at investigating the long-term relationship between SOC and psychopathological symptoms, and the impact of COVID-19-related rumination as its moderator. The prospective observational study assessed psychopathological symptoms and SOC before the COVID-19 outbreak in Germany (February 2020) and at six critical time points during the pandemic in an online panel (n = 1,479). Bivariate latent change score models and latent growth mixture modeling were used to analyze changes in psychopathological symptoms and SOC along with their interaction and to differentiate trajectories of COVID-19-related rumination. A model allowing for unidirectional coupling from SOC to psychopathological symptoms demonstrated best fit. In the total sample, psychopathological symptoms increased significantly over time. Previous SOC predicted later changes in psychopathological symptoms, whereby a stronger SOC was associated with a decrease in symptoms over time. The same pattern of results was evident in the high-rumination (17.2%) but not in the low-rumination group (82.8%). Our findings demonstrate that SOC is an important predictor and modulator of psychopathological symptoms during the COVID-19 pandemic, particularly in those respondents that ruminate about the pandemic.

Screening tools for predicting posttraumatic stress disorder in acutely injured adult trauma patients: A systematic review

BACKGROUND

Adult trauma patients are at risk of developing posttraumatic stress disorder (PTSD). Early intervention reduces the development of PTSD, but few trauma patients seek and obtain care. Valid and reliable screening tools are needed to identify patients at risk of developing PTSD. The objective of this review is to identify existing screening tools and evaluate their accuracy for predicting PTSD outcomes.

METHODS

PubMed, PsychInfo, and ClinicalTrials.gov were searched for studies evaluating the predictive accuracy of PTSD screening tools among traumatically injured adult civilians. Eligible studies assessed patients during acute hospitalization and at least 1 month following injury to measure PTSD outcome. Eligible outcomes included measures of predictive accuracy, such as sensitivity and specificity. The Quality Assessment of Diagnostic Accuracy Studies 2 tool was used to assess the risk of bias of each study, and the strength of evidence was assessed following the Agency for Healthcare Research and Quality guidelines.

RESULTS

Forty-nine studies were included evaluating the predictive accuracy of 38 screening tools. Most tools were assessed in a single study. Questionnaire-style tools had more favorable predictive ability than diagnostic interview assessments. The Injured Trauma Survivor Screen, Posttraumatic Adjustment Screen, the PTSD Checklist for DSM-5, and the Richmond et al. tool demonstrated the most favorable predictive accuracy, with high sensitivity (75-100%) and specificity (67-94%). Common sources of bias were selection bias due to high attrition rate and using nondiagnostic tools to assess PTSD symptoms at follow-up.

CONCLUSION

Although sensitivity and specificity of PTSD predictive tools varied widely, several emerged with favorable predictive accuracy. Further research is needed to define the ability of screening and intervention to prevent PTSD in injured trauma survivors. The results of this review can inform screening tool options for screening programs and future intervention studies.

LEVEL OF EVIDENCE

Systematic review, level III.

Time course of symptoms in posttraumatic stress disorder with delayed expression: A systematic review

OBJECTIVE

To examine the hypothesis that PTSD with delayed expression in some cases occurs without subthreshold PTSD symptoms above background levels bridging the gap between the traumatic exposure(s) and the clinical diagnosis.

METHODS

We performed systematic searches of peer-reviewed papers in English referenced in Pubmed, Embase, or PsycINFO and ascertained 34 prospective studies of PTSD symptom trajectories identified by latent class growth statistical modeling. Studies with delayed and low-stable trajectories provided appropriate data for this study. We computed the difference between the delayed trajectory PTSD symptom sumscore and the low-stable PTSD sumscore at the observed points in time after the traumatic event(s).

RESULTS

In 29 study populations, the latent class growth analyses displayed delayed trajectories, and in these, we identified 110 data points (% PTSD sumscore difference/months since traumatic exposure). The median PTSD symptom sumscore was 25% higher during the initial 6 months among individuals in the delayed trajectory compared to those in low-stable trajectory. From this level, the difference widened and reached a plateau of 40-50% higher. The variation was large, and the baseline participation rate and loss to follow-up were exceeding 25% in the majority of the studies. Heterogeneity of populations, measures, and analyses precluded formal meta-analysis.

CONCLUSION

Delayed PTSD is preceded by PTSD symptoms during the first year in most cases. Still, few individuals may experience an asymptomatic delay. The results underpin the rationale for monitoring PTSD symptoms and may inform forensic assessments in that delayed PTSD without symptoms bridging the traumatic event is rare.

Neural Responsivity to Reward versus Punishment Shortly after Trauma Predicts Long-term Development of Post-Traumatic Stress Symptoms

BACKGROUND

Processing negative and positive valenced stimuli involve multiple brain regions including the amygdala and ventral striatum (VS). Post-Traumatic Stress Disorder (PTSD) is often associated with hyper-responsivity to negatively valenced, yet recent evidence also points to deficient positive valence functioning. It is yet unclear what is the relative contribution of such opposing valence processing shortly after trauma to the development of chronic PTSD.

METHODS

Neurobehavioral indicators of motivational positive vs. negative valence sensitivities were longitudinally assessed in 171 adults (87 females, age=34.19±11.47 years) at 1-, 6-, and 14-months following trauma exposure (TP1, TP2, TP3). Using a gambling fMRI paradigm, amygdala and VS functionality (activity and functional connectivity with the prefrontal cortex) in response to rewards vs. punishments were assessed with relation to PTSD severity at different time-points. The effect of valence processing was depicted behaviorally by the amount of risk taken to maximize reward.

RESULTS

PTSD severity at TP1 was associated with greater neural functionality in the amygdala (but not the VS) towards punishments vs. rewards, and fewer risky choices. PTSD severity at TP3 was associated with decreased neural functionality in both the VS and amygdala towards rewards vs. punishments at TP1 (but not with risky behavior). Explainable machine learning revealed the primacy of VS biased processing, over the amygdala, in predicting PTSD severity at TP3.

CONCLUSIONS

These results highlight the importance of biased neural responsivity to positive relative to negative motivational outcomes in PTSD development. Novel therapeutic strategies early after trauma may thus target both valence fronts.

Deep learning model of fMRI connectivity predicts PTSD symptom trajectories in recent trauma survivors

Early intervention following exposure to a traumatic life event could change the clinical path from the development of post traumatic stress disorder (PTSD) to recovery, hence the interest in early detection and underlying biological mechanisms involved in the development of post traumatic sequelae. We introduce a novel end-to-end neural network that employs resting-state and task-based functional MRI (fMRI) datasets, obtained one month after trauma exposure, to predict PTSD symptoms at one-, six- and fourteen-months after the exposure. FMRI data, as well as PTSD status and symptoms, were collected from adults at risk for PTSD development, after admission to emergency room following a traumatic event. Our computational method utilized a per-region encoder to extract brain regions embedding, which were subsequently updated by applying the algorithmic technique of pairwise attention. The affinities obtained between each pair of regions were combined to create a pairwise co-activation map used to perform multi-label classification. The results demonstrate that the novel method's performance in predicting PTSD symptoms, in a prospective manner, outperforms previous analytical techniques reported in the fMRI literature, all trained on the same dataset. We further show a high predictive ability for predicting PTSD symptom clusters and PTSD persistence. To the best of our knowledge, this is the first deep learning method applied on fMRI data with respect to prospective clinical outcomes, to predict PTSD status, severity and symptom clusters. Future work could further delineate the mechanisms that underlie such a prediction, and potentially improve single patient characterization.

Posttraumatic stress disorder symptom trajectories within the first year following emergency department admissions: pooled results from the International Consortium to predict PTSD

BACKGROUND

Research exploring the longitudinal course of posttraumatic stress disorder (PTSD) symptoms has documented four modal trajectories (low, remitting, high, and delayed), with proportions varying across studies. Heterogeneity could be due to differences in trauma types and patient demographic characteristics.

METHODS

This analysis pooled data from six longitudinal studies of adult survivors of civilian-related injuries admitted to general hospital emergency departments (EDs) in six countries (pooled N = 3083). Each study included at least three assessments of the clinician-administered PTSD scale in the first post-trauma year. Latent class growth analysis determined the proportion of participants exhibiting various PTSD symptom trajectories within and across the datasets. Multinomial logistic regression analyses examined demographic characteristics, type of event leading to the injury, and trauma history as predictors of trajectories differentiated by their initial severity and course.

RESULTS

Five trajectories were found across the datasets: Low (64.5%), Remitting (16.9%), Moderate (6.7%), High (6.5%), and Delayed (5.5%). Female gender, non-white race, prior interpersonal trauma, and assaultive injuries were associated with increased risk for initial PTSD reactions. Female gender and assaultive injuries were associated with risk for membership in the Delayed (v. Low) trajectory, and lower education, prior interpersonal trauma, and assaultive injuries with risk for membership in the High (v. Remitting) trajectory.

CONCLUSIONS

The results suggest that over 30% of civilian-related injury survivors admitted to EDs experience moderate-to-high levels of PTSD symptoms within the first post-trauma year, with those reporting assaultive violence at increased risk of both immediate and longer-term symptoms.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

Social Robots for Supporting Post-traumatic Stress Disorder Diagnosis and Treatment

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.

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

Background

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

Methods

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

Results

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

Discussion

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

Level of evidence

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

Mental Health Burden After Injury: It's About More than Just Posttraumatic Stress Disorder

OBJECTIVE

Assess the prevalence of anxiety, depression, and posttraumatic stress disorder (PTSD) after injury and their association with long-term functional outcomes.

BACKGROUND

Mental health disorders (MHD) after injury have been associated with worse long-term outcomes. However, prior studies almost exclusively focused on PTSD.

METHODS

Trauma patients with an injury severity score ≥9 treated at 3 Level-I trauma centers were contacted 6-12 months post-injury to screen for anxiety (generalized anxiety disorder-7), depression (patient health questionnaire-8), PTSD (8Q-PCL-5), pain, and functional outcomes (trauma quality of life instrument, and short-form health survey)). Associations between mental and physical outcomes were established using adjusted multivariable logistic regression models.

RESULTS

Of the 531 patients followed, 108 (20%) screened positive for any MHD: of those who screened positive for PTSD (7.9%, N = 42), all had co-morbid depression and/or anxiety. In contrast, 66 patients (12.4%) screened negative for PTSD but positive for depression and/or anxiety. Compared to patients with no MHD, patients who screened positive for PTSD were more likely to have chronic pain {odds ratio (OR): 8.79 [95% confidence interval (CI): 3.21, 24.08]}, functional limitations [OR: 7.99 (95% CI: 3.50, 18.25)] and reduced physical health [β: -9.3 (95% CI: -13.2, -5.3)]. Similarly, patients who screened positive for depression/anxiety (without PTSD) were more likely to have chronic pain [OR: 5.06 (95% CI: 2.49, 10.46)], functional limitations [OR: 2.20 (95% CI: 1.12, 4.32)] and reduced physical health [β: -5.1 (95% CI: -8.2, -2.0)] compared to those with no MHD.

CONCLUSIONS

The mental health burden after injury is significant and not limited to PTSD. Distinguishing among MHD and identifying symptom-clusters that overlap among these diagnoses, may help stratify risk of poor outcomes, and provide opportunities for more focused screening and treatment interventions.

Neuroanatomical Risk Factors for Posttraumatic Stress Disorder in Recent Trauma Survivors

BACKGROUND

Low hippocampal volume could serve as an early risk factor for posttraumatic stress disorder (PTSD) in interaction with other brain anomalies of developmental origin. One such anomaly may well be the presence of a large cavum septum pellucidum (CSP), which has been loosely associated with PTSD. We performed a longitudinal prospective study of recent trauma survivors. We hypothesized that at 1 month after trauma exposure the relation between hippocampal volume and PTSD symptom severity will be moderated by CSP volume, and that this early interaction will account for persistent PTSD symptoms at subsequent time points.

METHODS

One hundred seventy-one adults (87 women, average age 34.22 years [range, 18-65 years of age]) who were admitted to a general hospital's emergency department after a traumatic event underwent clinical assessment and structural magnetic resonance imaging within 1 month after trauma. Follow-up clinical evaluations were conducted at 6 (n = 97) and 14 (n = 78) months after trauma. Hippocampal and CSP volumes were measured automatically by FreeSurfer software and verified manually by a neuroradiologist (D.N.).

RESULTS

At 1 month after trauma, CSP volume significantly moderated the relation between hippocampal volume and PTSD severity (p = .026), and this interaction further predicted symptom severity at 14 months posttrauma (p = .018). Specifically, individuals with a smaller hippocampus and larger CSP at 1 month posttrauma showed more severe symptoms at 1 and 14 months after trauma exposure.

CONCLUSIONS

Our study provides evidence for an early neuroanatomical risk factors for PTSD, which could also predict the progression of the disorder in the year after trauma exposure. Such a simple-to-acquire neuroanatomical signature for PTSD could guide early management as well as long-term monitoring.

A longitudinal study of ICD-11 PTSD and complex PTSD in the general population of Israel

The ICD-11 includes two trauma disorders: Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD). CPTSD is a disorder comprised of PTSD and Disturbance in Self-Organization (DSO) symptoms. Evidence supports the construct validity of PTSD and CPTSD, however, the temporal stability of these constructs has rarely been tested. This study examined the diagnostic stability of PTSD and CPTSD, and the temporal associations between PTSD and DSO symptoms over a period of one-year. Data were collected from a nationally representative sample of Israeli adults (n = 1,003) and one year later a random half of this sample were reassessed (n = 543). There were no statistically significant changes in rates of PTSD (6.7%, 5.3%) and CPTSD (4.9%, 3.7%) over time. Latent variable cross-lagged analysis indicated that PTSD and DSO symptoms were stable over time and that DSO symptoms predicted subsequent PTSD symptoms. Results suggest that ICD-11 PTSD and CPTSD are stable constructs in the general population over a period of one year. We discuss the possibility that these findings are influenced by the specific cultural context of Israel. Additionally, given the stability and influence of DSO symptoms we discuss the potential value of psychological therapies that directly address these symptoms.

Prevalence of post-traumatic stress disorder symptoms in adult critical care survivors: a systematic review and meta-analysis

Background

As more patients are surviving intensive care, mental health concerns in survivors have become a research priority. Among these, post-traumatic stress disorder (PTSD) can have an important impact on the quality of life of critical care survivors. However, data on its burden are conflicting. Therefore, this systematic review and meta-analysis aimed to evaluate the prevalence of PTSD symptoms in adult critical care patients after intensive care unit (ICU) discharge.

Methods

We searched MEDLINE, EMBASE, LILACS, Web of Science, PsycNET, and Scopus databases from inception to September 2018. We included observational studies assessing the prevalence of PTSD symptoms in adult critical care survivors. Two reviewers independently screened studies and extracted data. Studies were meta-analyzed using a random-effects model to estimate PTSD symptom prevalence at different time points, also estimating confidence and prediction intervals. Subgroup and meta-regression analyses were performed to explore heterogeneity. Risk of bias was assessed using the Joanna Briggs Institute tool and the GRADE approach.

Results

Of 13,267 studies retrieved, 48 were included in this review. Overall prevalence of PTSD symptoms was 19.83% (95% confidence interval [CI], 16.72–23.13; I² = 90%, low quality of evidence). Prevalence varied widely across studies, with a wide range of expected prevalence (from 3.70 to 43.73% in 95% of settings). Point prevalence estimates were 15.93% (95% CI, 11.15–21.35; I² = 90%; 17 studies), 16.80% (95% CI, 13.74–20.09; I² = 66%; 13 studies), 18.96% (95% CI, 14.28–24.12; I² = 92%; 13 studies), and 20.21% (95% CI, 13.79–27.44; I² = 58%; 7 studies) at 3, 6, 12, and > 12 months after discharge, respectively.

Conclusion

PTSD symptoms may affect 1 in every 5 adult critical care survivors, with a high expected prevalence 12 months after discharge. ICU survivors should be screened for PTSD symptoms and cared for accordingly, given the potential negative impact of PTSD on quality of life. In addition, action should be taken to further explore the causal relationship between ICU stay and PTSD, as well as to propose early measures to prevent PTSD in this population.

Trial registration

PROSPERO, CRD42017075124, Registered 6 December 2017.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2489-3) contains supplementary material, which is available to authorized users.

Persons injured in the 2011 terror attacks in Norway - Relationship between post-traumatic stress symptoms, emotional distress, fatigue, sleep, and pain outcomes, and medical and psychosocial factors

Purpose: The main aim was to assess long-term post-traumatic stress symptoms, emotional distress, fatigue, sleep disturbances and pain in individuals hospitalized with physical injuries after two terror attacks in Oslo in 2011, approximately three years after the events. A secondary aim was to explore the relationship between these outcomes and medical and psychosocial factors.Materials and methods: Thirty of 43 potential persons participated. Injury characteristics were collected from medical charts. Level of post-traumatic stress, emotional distress, fatigue, sleep disturbances and pain was assessed and the association with injury severity, resilience, optimism, neuroticism and extroversion, and perceived access to social support was explored.Results: Nine of 30 met criteria for full or partial PTSD, and 14 of 30 displayed clinical levels of emotional distress. Fifteen reported moderate to severe fatigue, and 16 said sleep disturbances affected their daily life. Twelve indicated that pain affected daily activities and work ability, and 15 that pain affected their quality of life. I Resilience, optimism, neuroticism, and perceived social support, were associated with outcomes, but injury severity was not. When controlling for pain, many of the psychosocial variables failed to reach significance.Conclusions: Injury severity was not associated with outcomes. On the other hand, psychosocial factors were, but seemed to be influenced by pain.Implications for rehabilitationPersons who have obtained physical injuries under extreme psychological conditions such as terror, are at high risk of poor long-term outcomes, and will often be in need of comprehensive interdisciplinary rehabilitation services.Psychological outcomes are not associated with severity of physical injury, but premorbid and current psychological variables such as resilience, optimism, personality, and access to social support are highly associated with long-term outcome.Longstanding pain seems to diminish or weaken the role of protective psychological factors and should be addressed in the rehabilitation context.

Estimating the risk of PTSD in recent trauma survivors: results of the International Consortium to Predict PTSD (ICPP)

A timely determination of the risk of post-traumatic stress disorder (PTSD) is a prerequisite for efficient service delivery and prevention. We provide a risk estimate tool allowing a calculation of individuals' PTSD likelihood from early predictors. Members of the International Consortium to Predict PTSD (ICPP) shared individual participants' item-level data from ten longitudinal studies of civilian trauma survivors admitted to acute care centers in six countries. Eligible participants (N=2,473) completed an initial clinical assessment within 60 days of trauma exposure, and at least one follow-up assessment 4-15 months later. The Clinician-Administered PTSD Scale for DSM-IV (CAPS) evaluated PTSD symptom severity and diagnostic status at each assessment. Participants' education, prior lifetime trauma exposure, marital status and socio-economic status were assessed and harmonized across studies. The study's main outcome was the likelihood of a follow-up PTSD given early predictors. The prevalence of follow-up PTSD was 11.8% (9.2% for male participants and 16.4% for females). A logistic model using early PTSD symptom severity (initial CAPS total score) as a predictor produced remarkably accurate estimates of follow-up PTSD (predicted vs. raw probabilities: r=0.976). Adding respondents' female gender, lower education, and exposure to prior interpersonal trauma to the model yielded higher PTSD likelihood estimates, with similar model accuracy (predicted vs. raw probabilities: r=0.941). The current model could be adjusted for other traumatic circumstances and accommodate risk factors not captured by the ICPP (e.g., biological, social). In line with their use in general medicine, risk estimate models can inform clinical choices in psychiatry. It is hoped that quantifying individuals' PTSD risk will be a first step towards systematic prevention of the disorder.

Clinical implications of the proposed ICD-11 PTSD diagnostic criteria

BACKGROUND

Projected changes to post-traumatic stress disorder (PTSD) diagnostic criteria in the upcoming International Classification of Diseases (ICD)-11 may affect the prevalence and severity of identified cases. This study examined differences in rates, severity, and overlap of diagnoses using ICD-10 and ICD-11 PTSD diagnostic criteria during consecutive assessments of recent survivors of traumatic events.

METHODS

The study sample comprised 3863 survivors of traumatic events, evaluated in 11 longitudinal studies of PTSD. ICD-10 and ICD-11 diagnostic rules were applied to the Clinician-Administered PTSD Scale (CAPS) to derive ICD-10 and ICD-11 diagnoses at different time intervals between trauma occurrence and 15 months.

RESULTS

The ICD-11 criteria identified fewer cases than the ICD-10 across assessment intervals (range -47.09% to -57.14%). Over 97% of ICD-11 PTSD cases met concurrent ICD-10 PTSD criteria. PTSD symptom severity of individuals identified by the ICD-11 criteria (CAPS total scores) was 31.38-36.49% higher than those identified by ICD-10 criteria alone. The latter, however, had CAPS scores indicative of moderate PTSD. ICD-11 was associated with similar or higher rates of comorbid mood and anxiety disorders. Individuals identified by either ICD-10 or ICD-11 shortly after traumatic events had similar longitudinal course.

CONCLUSIONS

This study indicates that significantly fewer individuals would be diagnosed with PTSD using the proposed ICD-11 criteria. Though ICD-11 criteria identify more severe cases, those meeting ICD-10 but not ICD-11 criteria remain in the moderate range of PTSD symptoms. Use of ICD-11 criteria will have critical implications for case identification in clinical practice, national reporting, and research.

Early risk factors for depression, anxiety and post-traumatic distress after hospital admission for unintentional injury: Multicentre cohort study

OBJECTIVE

To quantify psychological morbidity and identify baseline factors associated with depression, anxiety and post-traumatic distress symptoms up to 12 months post-injury.

METHODS

Multicentre cohort study of 668 adults, aged 16 to 70, admitted to 4 UK NHS hospital trusts. Data on injury, socio-demographic characteristics and health status was collected at recruitment. Depression, anxiety and post-traumatic distress were measured at 1, 2, 4 and 12 months post-injury. Multilevel linear regression assessed associations between patient and injury characteristics and psychological outcomes over 12 months follow-up.

RESULTS

Depression, anxiety and post-traumatic distress scores were highest 1 month post-injury, and remained above baseline at 2, 4 and 12 months post-injury. Moderate or severe injuries, previous psychiatric diagnoses, higher pre-injury depression and anxiety scores, middle age (45-64 years), greater deprivation and lower pre-injury quality of life (QoL) were associated with higher depression scores post-injury. Previous psychiatric diagnoses, higher pre-injury depression and anxiety scores, middle age, greater deprivation and lower pre-injury QoL were associated with higher anxiety scores post-injury. Traffic injuries or injuries from being struck by objects, multiple injures (≥3), being female, previous psychiatric diagnoses, higher pre-injury anxiety scores and greater deprivation were associated with higher post-traumatic distress scores post-injury.

CONCLUSION

A range of risk factors, identifiable shortly after injury, are associated with psychological morbidity occurring up to 12 months post-injury in a general trauma population. Further research is required to explore the utility of these, and other risk factors in predicting psychological morbidity on an individual patient basis.

Application of data pooling to longitudinal studies of early post-traumatic stress disorder (PTSD): the International Consortium to Predict PTSD (ICPP) project

Background: Understanding the development of post-traumatic stress disorder (PTSD) is a precondition for efficient risk assessment and prevention planning. Studies to date have been site and sample specific. Towards developing generalizable models of PTSD development and prediction, the International Consortium to Predict PTSD (ICPP) compiled data from 13 longitudinal, acute-care based PTSD studies performed in six different countries. Objective: The objectives of this study were to describe the ICPP's approach to data pooling and harmonization, and present cross-study descriptive results informing the longitudinal course of PTSD after acute trauma. Methods: Item-level data from 13 longitudinal studies of adult civilian trauma survivors were collected. Constructs (e.g. PTSD, depression), measures (questions or scales), and time variables (days from trauma) were identified and harmonized, and those with inconsistent coding (e.g. education, lifetime trauma exposure) were recoded. Administered in 11 studies, the Clinician Administered PTSD Scale (CAPS) emerged as the main measure of PTSD diagnosis and severity. Results: The pooled data set included 6254 subjects (39.9% female). Studies' average retention rate was 87.0% (range 49.1-93.5%). Participants' baseline assessments took place within 2 months of trauma exposure. Follow-up durations ranged from 188 to 1110 days. Reflecting studies' inclusion criteria, the prevalence of baseline PTSD differed significantly between studies (range 3.1-61.6%), and similar differences were observed in subsequent assessments (4.3-38.2% and 3.8-27.0% for second and third assessments, respectively). Conclusion: Pooling data from independently collected studies requires careful curation of individual data sets for extracting and optimizing informative commonalities. However, it is an important step towards developing robust and generalizable prediction models for PTSD and can exceed findings of single studies. The large differences in prevalence of PTSD longitudinally cautions against using any individual study to infer trauma outcome. The multiplicity of instruments used in individual studies emphasizes the need for common data elements in future studies.

Posttraumatic Stress, Depressive Emotions, and Satisfaction With Life After a Road Traffic Accident

BACKGROUND

The psychological response of injured people after traffic accidents includes stress and depression.

PURPOSE

To assess orthopaedic patients' stress, depression, and satisfaction with life after traffic accidents in Greece.

METHODS

Descriptive, longitudinal, correlational study. Patients' background factors, injury severity, scores on the Impact of Events Scale-Revised (IES-R), the Center for Epidemiologic Studies Depression (CES-D) Scale, and the Satisfaction With Life Quality (SWLQ) Scale were recorded. The principles of the Declaration of Helsinki were applied.

RESULTS

In total, 60 patients participated in this study during hospitalization following a road traffic accident and 40 patients at 6 months after. Participants were mostly men (75%) with severe injuries (50%). The IES-R score at 6 months was significantly lower than during hospitalization. One out of 3 people had a CES-D score, which is considered of clinical significance. The SWLQ scores were considered high.

CONCLUSION

As posttraumatic stress and depression seem to affect a considerable percentage of people involved in road traffic accidents in Greece, these individuals should be assessed for posttraumatic stress and depression while still hospitalized.

Risk Factors of Delayed Onset Posttraumatic Stress Disorder in Chronically Critically Ill Patients

The main aim of this study was to investigate factors associated with a delayed-onset posttraumatic stress disorder (PTSD) after the intensive care unit (ICU) treatment of patients with a chronic critical illness (CCI). Patients (n = 97) with critical illness polyneuropathy or critical illness myopathy were interviewed via the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. The diagnosis of the acute stress disorder was assessed within 1 month (t1), the diagnosis of PTSD at 3 (t2) and 6 (t3) months after transfer from the acute care ICU to the post-acute ICU. Patients showing a delayed-onset or persistent course of PTSD were subsumed in one group; 24.7% (n = 24) showed a delayed-onset PTSD. Significant risk factors were as follows: the severity of the medical illness, the perceived fear of dying at the ICU, the number of traumatic memories from the ICU, and the presence of a coronary heart disease. Every fourth patient with CCI showed a delayed-onset PTSD up to 6 months after the ICU treatment. Markers for a delayed-onset PTSD should already be assessed at the time of discharge from the ICU.

Depressive, anxiety and post-traumatic stress disorders at six years after occupational injuries

The aim of this study is to determine the prevalence rates of depressive, anxiety and PTSDs, and the risk factors for psychological symptoms at 6 years after occupational injury. This longitudinal study followed workers who were occupationally injured in 2009. Psychological symptoms and return to work were assessed at 3 and 12 months after injury. Injured workers who had completed the initial questionnaire survey at 3 or 12 months after injury were recruited. A self-administered questionnaire was mailed to the participants. For workers with high Brief Symptom Rating Scale and Post-traumatic Symptom Checklist scores, an in-depth psychiatric evaluation was performed using the Mini-international Neuropsychiatric Interview. A total of 570 workers completed the questionnaire (response rate, 28.7%). Among them, 243 (42.6%) had high psychological symptom scores and were invited for a phone interview; 135 (55.6%) completed the interview. The estimated rates of major depression and post-traumatic stress disorder (PTSD)/partial PTSD were 9.2 and 7.2%, respectively, and both these rates were higher at 6 years after injury than at 12 months after injury (2.0 and 5.1%). After adjustment for family and social factors, the risk factors for high psychological scores were length of hospitalization immediately after injury, affected physical appearance, repeated occupational injuries, unemployment, and number of quit jobs after the injury. At 6 years after occupational injury, the re-emergence of psychiatric disorders was observed. Relevant factors for poor psychological health were severity of injury and instability of work. Periodic monitoring of psychological and physical health and economic stability are warranted.

Psychological Distress following Injury in a Large Cohort of Thai Adults

INTRODUCTION

Injury and psychological distress are public health priorities because of their high occurrence in the population. This study examines the longitudinal effects of injury characteristics on psychological distress.

METHODS

Study participants were enrolled distance learning Thai adults (N = 42,785 at 2013 follow-up) residing nationwide. We analysed 2009 and 2013 data. Injury questions included injury prevalence, causes and levels of severity. Distress was measured using the standard Kessler-6. To assess the risk for post-injury distress, we used multinomial logistic regression investigating psychological distress in 2013 as an outcome including injury categories in both 2009 and 2013 as predictors, adjusted for sociodemographic factors.

RESULTS

Overall injury was predictive of psychological distress. Both types of injury (traffic and non- traffic) associated with increasing psychological distress. Those that had experienced both types of injuries in the previous year had higher odds of developing psychological distress compared to those who experienced just one type. In 2013, adjusted psychological distress odds ratios were 1.46 [95% Confidence Interval 1.14-1.87] for traffic injury only; 1.26 [1.13-1.40] for non-traffic injury only; and 2.71 [2.19-3.35] for both traffic and non-traffic injuries. Increasing frequency of injury and increasing injury severity were also linked to elevated psychological distress among our Thai cohort members.

CONCLUSIONS

Our results revealed a significantly high risk of psychological distress following injury. With increasing occurrence of injury, especially traffic injuries in low and middle income countries such as Thailand, future policies should not only focus on physical care but also address psychological distress as an important consequence of injury.

Contributions of risk and protective factors to prediction of psychological symptoms after traumatic experiences

OBJECTIVE

Traumatic experiences cause considerable suffering and place a burden on society due to lost productivity, increases in suicidality, violence, criminal behavior, and psychological disorder. The impact of traumatic experiences is complicated because many factors affect individuals' responses. By employing several methodological improvements, we sought to identify risk factors that would account for a greater proportion of variance in later disorder than prior studies.

METHOD

In a sample of 129 traumatically injured hospital patients and family members of injured patients, we studied pre-trauma, time of trauma, and post-trauma psychosocial risk and protective factors hypothesized to influence responses to traumatic experiences and posttraumatic (PT) symptoms (including symptoms of PTSD, depression, negative thinking, and dissociation) two months after trauma.

RESULTS

The risk factors were all significantly correlated with later PT symptoms, with post-trauma life stress, post-trauma social support, and acute stress symptoms showing the strongest relationships. A hierarchical regression, in which the risk factors were entered in 6 steps based on their occurrence in time, showed the risks accounted for 72% of the variance in later symptoms. Most of the variance in PT symptoms was shared among many risk factors, and pre-trauma and post-trauma risk factors accounted for the most variance.

CONCLUSIONS

Collectively, the risk factors accounted for more variance in later PT symptoms than in previous studies. These risk factors may identify individuals at risk for PT psychological disorders and targets for treatment.

Posttraumatic stress in intensive care unit survivors - a prospective study

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

Increased co-morbidity of depression and post-traumatic stress disorder symptoms and common risk factors in intensive care unit survivors: a two-year follow-up study

OBJECTIVE

To investigate the long-term psychological impact of intensive care unit (ICU) hospitalization, as well as to establish risk factors which successfully discriminate patients at higher risk.

METHODS

The Medical Outcomes Study Short Form Survey (SF-36), the Center for Epidemiologic Studies for Depression (CES-D), and the Davidson Trauma Scale (DTS) questionnaires were obtained from 48 ICU survivors who were also interviewed and self-reported on several acknowledged risk factors.

RESULTS

A high co-morbidity between depression and post-traumatic stress disorder (PTSD) cases was observed. Both CES-D and DTS scores correlated negatively with the SF-36 mental health subscale scores; although a causative relation cannot be attributed to this finding, it indicates a potential negative impact of depression and PTSD symptoms on the patients' quality of life even at 18- to 24-month post-ICU. The most important risk factor associated with a long-term impact on quality of life, depression and PTSD was lifetime history of any psychiatric disorder.

CONCLUSIONS

During ICU admissions efforts should be made towards identifying and psychologically supporting those patients with a previous history of a psychiatric disease, as they are at considerably higher risk of suffering from the long-term psychological sequelae of ICU admission.

Early PTSD symptom trajectories: persistence, recovery, and response to treatment: results from the Jerusalem Trauma Outreach and Prevention Study (J-TOPS)

Context

Uncovering heterogeneities in the progression of early PTSD symptoms can improve our understanding of the disorder's pathogenesis and prophylaxis.

Objectives

To describe discrete symptom trajectories and examine their relevance for preventive interventions.

Design

Latent Growth Mixture Modeling (LGMM) of data from a randomized controlled study of early treatment. LGMM identifies latent longitudinal trajectories by exploring discrete mixture distributions underlying observable data.

Setting

Hadassah Hospital unselectively receives trauma survivors from Jerusalem and vicinity.

Participants

Adult survivors of potentially traumatic events consecutively admitted to the hospital's emergency department (ED) were assessed ten days and one-, five-, nine- and fifteen months after ED admission. Participants with data at ten days and at least two additional assessments (n = 957) were included; 125 received cognitive behavioral therapy (CBT) between one and nine months.

Approach

We used LGMM to identify latent parameters of symptom progression and tested the effect of CBT on these parameters. CBT consisted of 12 weekly sessions of either cognitive therapy (n = 41) or prolonged exposure (PE, n = 49), starting 29.8±5.7 days after ED admission, or delayed PE (n = 35) starting at 151.8±42.4 days. CBT effectively reduced PTSD symptoms in the entire sample.

Main Outcome Measure

Latent trajectories of PTSD symptoms; effects of CBT on these trajectories.

Results

Three trajectories were identified: Rapid Remitting (rapid decrease in symptoms from 1- to 5-months; 56% of the sample), Slow Remitting (progressive decrease in symptoms over 15 months; 27%) and Non-Remitting (persistently elevated symptoms; 17%). CBT accelerated the recovery of the Slow Remitting class but did not affect the other classes.

Conclusions

The early course of PTSD symptoms is characterized by distinct and diverging response patterns that are centrally relevant to understanding the disorder and preventing its occurrence. Studies of the pathogenesis of PTSD may benefit from using clustered symptom trajectories as their dependent variables.

Psychiatric outcome after severe cardio-respiratory failure treated with extracorporeal membrane oxygenation: a case-series

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is increasingly used to save patients with severe cardiopulmonary failure at high risk of dying, but the long-term psychiatric outcome of the treatment has not been studied.

METHODS

Twenty-eight adults who survived ECMO were subjected to psychiatric assessment 5 years after ECMO by means of interviews (MINI-Neuropsychiatric Interview and Montgomery-Åsberg Depression Rating Scale) and psychometrics [Neuroticism and social conformity (EPQ-N+L); General Health Questionnaire (GHQ), Hospital Anxiety Depression Scale; Aggression Questionnaire, Toronto Alexithymia Scale, and Giessener somatic symptom checklist (GBB)].

RESULTS

Fifteen patients (54%) suffered lifetime psychiatric disorders prior to ECMO. After ECMO, 11 subjects (39%) developed new psychiatric disorders, mostly organic mental (18%), obsessive-compulsive disorders (OCD) 15%, and/or post-traumatic stress disorders (PTSD) 11%. These 11 patients reported higher scores on Montgomery-Åsberg Depression Rating Scale (MADRS), GHQ, EPQ-N, and GBB. Disregarding the presence of psychiatric disorders at follow-up, ECMO patients reported high levels of distress, physical aggression, anger, and alexithymic traits.

CONCLUSIONS

Severe life-threatening cardiovascular or pulmonary failure with subsequent ECMO is associated with an increased prevalence of long-term psychiatric disorders and distress. Studies addressing the etiology and prevalence of psychiatric consequences after ECMO are needed.

Tachikawa project for prevention of posttraumatic stress disorder with polyunsaturated fatty acid (TPOP): study protocol for a randomized controlled trial

BACKGROUND

Preclinical and clinical studies suggest that supplementation with omega-3 fatty acids after trauma might reduce subsequent posttraumatic stress disorder (PTSD). To date, we have shown in an open trial that PTSD symptoms in critically injured patients can be reduced by taking omega-3 fatty acids, hypothesized to stimulate hippocampal neurogenesis. The primary aim of the present randomized controlled trial is to examine the efficacy of omega-3 fatty acid supplementation in the secondary prevention of PTSD following accidental injury, as compared with placebo. This paper describes the rationale and protocol of this trial.

METHODS/DESIGN

The Tachikawa Project for Prevention of Posttraumatic Stress Disorder with Polyunsaturated Fatty Acid (TPOP) is a double-blinded, parallel group, randomized controlled trial to assess whether omega-3 fatty acid supplementation can prevent PTSD symptoms among accident-injured patients consecutively admitted to an intensive care unit. We plan to recruit accident-injured patients and follow them prospectively for 12 weeks. Enrolled patients will be randomized to either the omega-3 fatty acid supplement group (1,470 mg docosahexaenoic acid and 147 mg eicosapentaenoic acid daily) or placebo group. Primary outcome is score on the Clinician-Administered PTSD Scale (CAPS). We will need to randomize 140 injured patients to have 90% power to detect a 10-point difference in mean CAPS scores with omega-3 fatty acid supplementation compared with placebo. Secondary measures are diagnosis of PTSD and major depressive disorder, depressive symptoms, physiologic response in the experiment using script-driven imagery and acoustic stimulation, serum brain-derived neurotrophic factor, health-related quality of life, resilience, and aggression. Analyses will be by intent to treat. The trial was initiated on December 13 2008, with 104 subjects randomized by November 30 2012.

DISCUSSION

This study promises to be the first trial to provide a novel prevention strategy for PTSD among traumatized people.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT00671099.

Incidence and prediction of post-traumatic stress disorder at 6 months after motor vehicle accidents in Japan

BACKGROUND

Incidence proportion of post-traumatic stress disorder (PTSD) after motor vehicle accidents (MVA) vary considerably across countries, and whether heart rate (HR) and respiratory rate (RR) immediately after MVA predict subsequent PTSD remains controversial. This study examined the incidence proportion of PTSD at 6 months after MVA in Japan, and the predictors of PTSD in MVA survivors.

METHOD

Patients with MVA-related injuries consecutively admitted to the intensive care unit of a teaching hospital in Tokyo were recruited. Six months after MVA, PTSD was diagnosed using the Clinician Administered Post-traumatic Stress Disorder Scale (CAPS).

RESULTS

Of the 300 participants, 106 completed the assessments at 6 months after MVA and PTSD was diagnosed in 7.5% of the patients. Eight of the 300 participants (2.7%) were regarded as having PTSD after imputing their CAPS score at follow-up assessment for participants who dropped out. In multivariate regression analysis, no variables were shown to be independent predictors for PTSD. HR and RR did not predict PTSD in the analysis.

DISCUSSION

The results suggested that the incidence proportion of PTSD following MVA in Japan was lower than that in most developed countries, and HR and RR might not be accurate screening tools despite their importance in a fear-conditioning model of the genesis of PTSD.

Potential impact of propofol immediately after motor vehicle accident on later symptoms of posttraumatic stress disorder at 6-month follow up: a retrospective cohort study

INTRODUCTION

Critically injured patients are at risk of developing posttraumatic stress disorder (PTSD). Propofol was recently reported to enhance fear memory consolidation retrospectively. Thus, we investigated here whether administration of propofol within 72 h of a motor vehicle accident (MVA) affects the subsequent development of PTSD symptoms.

METHODS

We examined data obtained from a prospective cohort study of MVA-related injured patients, admitted to the intensive care unit of a general hospital. We investigated the effect of propofol administration within 72 h of MVA on outcome. Primary outcome was diagnosis of full or partial PTSD as determined by the Clinician-Administered PTSD Scale (CAPS) at 6 months. Secondary outcomes were diagnosis of full or partial PTSD at 1 month and CAPS score indicating PTSD at 1 and 6 months. Multivariate analysis was conducted adjusting for being female, age, injury severity score (ISS), and administration of ketamine or midazolam within 72 h of MVA.

RESULTS

Among 300 patients recruited (mean ISS, 8.0; median Glasgow Coma Scale (GCS) score, 15.0; age, 18 to 69 years), propofol administration showed a higher risk for full or partial PTSD as determined by CAPS at 6 months (odds ratio = 6.13, 95% confidence interval (CI): 1.57 to 23.85, P = 0.009) and at 1 month (odds ratio = 1.31, 95% CI: 0.41 to 4.23, P = 0.647) in the multivariate logistic regression. Multivariate regression analysis showed a trend toward adverse effects of propofol on PTSD symptom development at 6 months after MVA (β = 4.08, 95% CI: -0.49 to 8.64, P = 0.080), but not at 1 month after MVA (β = -0.42, 95% CI: -6.34 to 5.51, P = 0.890).

CONCLUSIONS

These findings suggest that using propofol in the acute phase after MVA might be associated with the development of PTSD symptoms 6 months later. However, since the design of this study was retrospective, these findings should be interpreted cautiously and further study is warranted.

Schutz- und Risikofaktoren für Traumafolgestörungen

Theoretischer Hintergrund: Schutzfaktoren und Risikofaktoren tragen zur Prognose, Indikation und Interventionsplanung bei Menschen nach traumatischen Ereignissen bei. Bisherige systematische Reviews fassen die Befunde bis maximal 2007 zusammen und fokussieren auf Posttraumatische Belastungsstörungen. Fragestellung: Systematisches Review unter Einschluss der Befunde für die Jahre 2007 bis 2010 und Berücksichtigung weiterer Traumafolgestörungen. Methode: Analyse von 13 systematischen Reviews und 29 prospektiven Originalarbeiten zu Schutz- und Risikofaktoren für Traumafolgestörungen nach Typ-I-Traumata. Ergebnisse: Es werden Befunde zu prätraumatischen (Soziodemographie, Biographie, psychische Störungen, Persönlichkeitsfaktoren), peritraumatischen (Art und Schwere des Ereignisses, psychische Verfassung während des Ereignisses, peritraumatische Reaktion) und posttraumatischen Faktoren (akute psychische Symptome, Kognitionen, Coping, Vermeidungsverhalten, soziale Unterstützung, zusätzliche Stressoren) dargestellt. Schlussfolgerungen: Vor allem peri- und posttraumatische Schutz- und Risikofaktoren eignen sich für die Vorhersage von Traumafolgestörungen.

[Post-traumatic stress disorder-related to intensive care stay: influence of sedation practices]

The stay in intensive care unit can be potentially traumatic at the origin of post-traumatic stress symptoms. The severity of post-traumatic stress symptoms is linked to the intensity and the type of traumatic memories of the intensive care stay. Sedatives and analgesics given to ventilated patients in intensive care influence the traumatic memory. The level, the duration and the type of sedation-analgesia protocol are risk factors of post-traumatic stress symptoms. Links between sedation, dissociative symptoms, delirium and post-traumatic stress symptoms are documented. Environmental and pharmacological measures are to be considered to reduce the traumatic potential risk of the intensive care. Intensive care caregivers, liaison-psychiatrist and general practitioner have each a specific role to play in the screening of the post-traumatic stress symptoms.

A Latent Growth Mixture Modeling Approach to PTSD Symptoms in Rape Victims

The research literature has suggested that longitudinal changes in posttraumatic stress disorder (PTSD) could be adequately described in terms of one universal trajectory, with individual differences in baseline levels (intercept) and rate of change (slope) being negligible. However, not everyone who has experienced a trauma is diagnosed with PTSD, and symptom severity levels differ between individuals exposed to similar traumas. The current study employed the latent growth mixture modeling technique to test for multiple trajectories using data from a sample of Danish rape victims (N = 255). In addition, the analysis aimed to determine whether a number of explanatory variables could differentiate between the trajectories (age, acute stress disorder [ASD], and perceived social support). Results concluded the existence of two PTSD trajectories. ASD was found to be the only significant predictor of one trajectory characterized by high initial levels of PTSD symptomatology. The present findings confirmed the existence of multiple trajectories with regard to PTSD symptomatology in a way that may be useful to clinicians working with this population.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Clearance of fear memory from the hippocampus through neurogenesis by omega-3 fatty acids: a novel preventive strategy for posttraumatic stress disorder?

Not only has accidental injury been shown to account for a significant health burden on all populations, regardless of age, sex and geographic region, but patients with accidental injury frequently present with the psychiatric condition of posttraumatic stress disorder (PTSD). Prevention of accident-related PTSD thus represents a potentially important goal. Physicians in the field of psychosomatic medicine and critical care medicine have the opportunity to see injured patients in the immediate aftermath of an accident. This article first briefly reviews the prevalence and associated factors of accident-related PTSD, then focuses on a conceptual model of fear memory and proposes a new, rationally hypothesized translational preventive intervention for PTSD through promoting hippocampal neurogenesis by omega-3 fatty acid supplementation. The results of an open-label pilot trial of injured patients admitted to the intensive care unit suggest that omega-3 fatty acid supplementation immediately after accidental injury can reduce subsequent PTSD symptoms.

Prevalence of posttraumatic stress disorder and major depression after trauma center hospitalization

BACKGROUND

Individuals hospitalized after physical trauma are at heightened risk for mental disorders. We examined prevalence rates of both posttraumatic stress disorder (PTSD) and major depression at 6 and 12 months in a sample of 677 individuals experiencing different types of trauma who were representative of physical trauma survivors hospitalized in Los Angeles County trauma centers. Demographic and injury-related risk factors for these disorders were also evaluated.

METHODS

Bivariate logistic regressions estimated risk for PTSD and depression at either 6 or 12 months associated with baseline risk factors.

RESULTS

At 6 months, 31% of participants met screening criteria for probable PTSD and 31% met criteria for probable depression. At 12 months, 28% and 29% met criteria for PTSD and depression, respectively. There were also high rates of comorbidity; depression and PTSD co-occurred in 21% of individuals at 6 months and in 19% of patients at 12 months. Bivariate logistic regressions indicated that preexisting disability and lower education were associated with higher odds of PTSD at either 6 or 12 months. African Americans and Hispanics had higher odds of PTSD compared with non-Hispanic Caucasians. Assault-related injury (versus accident), more severe injury, and longer hospitalizations were also associated with greater odds of PTSD. By contrast, higher odds of depression at 6 or 12 months were only associated with preexisting disability, losing consciousness, more severe injury, and longer hospitalizations.

CONCLUSIONS

Key demographic and injury characteristics may enhance identification of at-risk trauma survivors who would benefit from targeted screening, patient education, and early intervention efforts.

Trajectory of posttraumatic stress disorder caused by myocardial infarction: a two-year follow-up study

OBJECTIVE

A substantial proportion of patients develop posttraumatic stress disorder (PTSD) following myocardial infarction (MI). Previous research on the trajectory over time of PTSD in post-MI patients is scant and refers to self-rated posttraumatic symptoms. The aim of this study was to investigate the longitudinal course of an interviewer-rated diagnosis of PTSD and PTSD symptom severity following MI.

METHODS

Study participants were 40 patients (78% men, mean age 54 +/- 8 years) who were diagnosed with PTSD using the Clinician-administered PTSD Scale (CAPS) after an average of 5 +/- 4 months (range 2-16 months) following an index MI. After a mean follow-up of 26 +/- 6 months (range 12-36 months), 24 patients underwent a second diagnostic interview.

RESULTS

Two-thirds of patients (n = 16) still qualified for a diagnosis of PTSD at follow-up. In all 24 patients, total PTSD symptoms (p = 0.001), re-experiencing symptoms (p < 0.001), avoidance symptoms (p = 0.015), and, with borderline significance, hyperarousal symptoms (p < 0.06) had all decreased over time. However, in the subgroup of the 16 patients who had retained PTSD diagnostic status at follow-up, symptoms of avoidance (p = 0.23) and of hyperarousal (p = 0.48) showed no longitudinal decline. Longer duration of follow-up was associated with a greater decrease in avoidance symptoms (p = 0.029) and, with borderline significance, in re-experiencing symptoms (p < 0.07) across all patients.

CONCLUSION

Although PTSD symptomatology waned over time and in relation to longer follow-up, two-thirds of patients still qualified for a diagnosis of PTSD 2 years after the initial diagnosis. In post-MI patients, clinical PTSD is a considerably persistent condition.

Mental health and posttraumatic stress symptoms 2 years after severe multiple trauma: self-reported disability and psychosocial functioning

OBJECTIVES

To describe mental health and posttraumatic stress symptoms (PTSS) for patients with severe multiple trauma at 2 years postinjury. Further, objectives were to examine relationships between PTSS and factors related to the person, injury, and postinjury physical and psychosocial functioning from the time of return home to 2 years after injury. The final aim was to identify predictors of PTSS and mental health at 2 years.

DESIGN

Prospective cohort study with a 2-year follow-up.

SETTING

Hospital and community setting.

PARTICIPANTS

Patients (N=99) age 18 to 67 years with multiple trauma and a New Injury Severity Score (NISS) greater than 15 treated at a regional trauma referral center. Mean age +/- SD was 35.3+/-14.2 years; 83% were men. Mean NISS +/- SD was 34.9+/-12.7.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Postinjury psychologic distress associated with depression on the Medical Outcomes Study 36-Item Short-Form Health Survey Mental Health scale and PTSS on the Post-Traumatic Symptom Scale 10 (PTSS-10) at 2 years post injury. Self-reported physical, mental, and cognitive functioning at the return home and 1 and 2 years, and coping strategies.

RESULTS

Mean PTSS-10 score +/- SD at 2 years was 25.6+/-12.2. Twenty percent had a PTSS-High score, indicating posttraumatic stress disorder (PTSD). Twenty-seven percent had Mental Health scores indicating depression. Predictors of PTSS were sex (female), younger age, avoidant coping, pain, mental health, and cognitive functioning on the return home, which explained 70% of the variance in PTSS-10 score.

CONCLUSIONS

Twenty percent had a PTSS-High score indicating PTSD at 2 years postinjury. The personal factors sex (female), younger age, and avoidant coping and the functional factors pain, mental health, and cognitive functioning predicted PTSS at 2 years.

Posttraumatic stress, anxiety and depression symptoms in patients during the first year post intensive care unit discharge

Introduction

To study the level and predictors of posttraumatic stress, anxiety and depression symptoms in medical, surgical and trauma patients during the first year post intensive care unit (ICU) discharge.

Methods

Of 255 patients included, 194 participated at 12 months. Patients completed the Impact of Event Scale (IES), Hospital Anxiety and Depression Scale (HADS), Life Orientation Test (LOT) at 4 to 6 weeks, 3 and 12 months and ICU memory tool at the first assessment (baseline). Case level for posttraumatic stress symptoms with high probability of a posttraumatic stress disorder (PTSD) was ≥ 35. Case level of HADS-Anxiety or Depression was ≥ 11. Memory of pain during ICU stay was measured at baseline on a five-point Likert-scale (0-low to 4-high). Patient demographics and clinical variables were controlled for in logistic regression analyses.

Results

Mean IES score one year after ICU treatment was 22.5 (95%CI 20.0 to 25.1) and 27% (48/180) were above case level, IES ≥ 35. No significant differences in the IES mean scores across the three time points were found (P = 0.388). In a subgroup, 27/170 (16%), patients IES score increased from 11 to 32, P < 0.001. No differences in posttraumatic stress, anxiety or depression between medical, surgical and trauma patients were found. High educational level (OR 0.4, 95%CI 0.2 to 1.0), personality trait (optimism) OR 0.9, 95%CI 0.8 to 1.0), factual recall (OR 6.6, 95%CI 1.4 to 31.0) and memory of pain (OR 1.5, 95%CI 1.1 to 2.0) were independent predictors of posttraumatic stress symptoms at one year. Optimism was a strong predictor for less anxiety (OR 0.8, 0.8 to 0.9) and depression symptoms (OR 0.8, 0.8 to 0.9) after one year.

Conclusions

The mean level of posttraumatic stress symptoms in patients one year following ICU treatment was high and one of four were above case level Predictors of posttraumatic stress symptoms were mainly demographics and experiences during hospital stay whereas clinical injury related variables were insignificant. Pessimism was a predictor of posttraumatic stress, anxiety and depression symptoms. A subgroup of patients developed clinically significant distress symptoms during the follow-up period.

2004 Tsunami: long-term psychological consequences for Swiss tourists in the area at the time of the disaster

OBJECTIVE

Most of the data on psychological outcome and the mental health treatment available following natural disasters originate from the indigenous population of the region destroyed. Examining tourists returning from the area affected by the 2004 tsunami presents an opportunity of studying the impact of natural disasters on psychological outcome and mental health treatment in their countries of origin. The aim of the present study was to extend the current knowledge on psychiatric morbidity and potential positive outcomes, as well as subsequent mental health treatment following a natural disaster, based on the results from a sample of home-coming Swiss tourists.

METHOD

Tourists who had been potentially affected by the 2004 tsunami were assessed using the Post-traumatic Diagnostic Scale, the Hospital Anxiety and Depression Scale, and the Post-traumatic Growth Inventory. Outcome variables were related to the degree of tsunami exposure. In addition, mental health treatment before and after the tsunami was assessed.

RESULTS

Of the 342 respondents, 55 (16.8%) fulfilled the criteria of post-traumatic stress disorder (PTSD). Evidence of anxiety or depressive disorder was found in 17.8% and 8.0%, respectively. The tsunami victims who had been directly affected showed significantly more symptoms of anxiety, depression and PTSD, as well as post-traumatic personal growth, than tourists who were indirectly affected or unaffected. A total of 12.3% of untreated respondents fulfilled the criteria for PTSD and 38% of respondents who had received psychiatric treatment were still fulfilling PTSD criteria 2(1/2) years after the tsunami.

CONCLUSION

A marked percentage of respondents reported symptoms of PTSD but they remained untreated or were treated insufficiently. We recommend that tourists returning from regions affected by natural disasters be informed about PTSD and that careful screening be given to those found to be at risk of PTSD. An open-door policy of mental health services is particularly needed for tourists returning home who have been affected by large-scale disasters.