A Randomized Stepped Care Intervention Trial Targeting Posttraumatic Stress Disorder for Surgically Hospitalized Injury Survivors

Overview

Journal Ann Surg

Specialty General Surgery

Date 2012 Dec 11

PMID 23222034

Citations 105

Authors

Douglas Zatzick

Gregory Jurkovich

Frederick P Rivara

Joan Russo

Amy Wagner

Jin Wang

Chris Dunn

Sarah Peregrine Lord

Megan Petrie

Stephen S OConnor

Wayne Katon

Affiliations

Soon will be listed here.

Abstract

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

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

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

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

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

Trial Registration: clinicaltrials.gov identifier: NCT00270959).

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References

Craske M, Stein M, Sullivan G, Sherbourne C, Bystritsky A, Rose R . Disorder-specific impact of coordinated anxiety learning and management treatment for anxiety disorders in primary care. Arch Gen Psychiatry. 2011; 68(4):378-88. PMC: 3074172. DOI: 10.1001/archgenpsychiatry.2011.25. View

Grieger T, Cozza S, Ursano R, Hoge C, Martinez P, Engel C . Posttraumatic stress disorder and depression in battle-injured soldiers. Am J Psychiatry. 2006; 163(10):1777-83. DOI: 10.1176/ajp.2006.163.10.1777. View

ODonnell M, Holmes A, Creamer M, Ellen S, Judson R, McFarlane A . The role of post-traumatic stress disorder and depression in predicting disability after injury. Med J Aust. 2009; 190(S7):S71-4. DOI: 10.5694/j.1326-5377.2009.tb02474.x. View

Kessler R, Berglund P, Demler O, Jin R, Merikangas K, Walters E . Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005; 62(6):593-602. DOI: 10.1001/archpsyc.62.6.593. View

Rivara F, Grossman D, Cummings P . Injury prevention. First of two parts. N Engl J Med. 1997; 337(8):543-8. DOI: 10.1056/NEJM199708213370807. View

Zatzick D, Roy-Byrne P, Russo J, Rivara F, Droesch R, Wagner A . A randomized effectiveness trial of stepped collaborative care for acutely injured trauma survivors. Arch Gen Psychiatry. 2004; 61(5):498-506. DOI: 10.1001/archpsyc.61.5.498. View

Hoge C, McGurk D, Thomas J, Cox A, Engel C, Castro C . Mild traumatic brain injury in U.S. Soldiers returning from Iraq. N Engl J Med. 2008; 358(5):453-63. DOI: 10.1056/NEJMoa072972. View

Holbrook T, Hoyt D, Coimbra R, Potenza B, Sise M, Anderson J . Long-term posttraumatic stress disorder persists after major trauma in adolescents: new data on risk factors and functional outcome. J Trauma. 2005; 58(4):764-9. DOI: 10.1097/01.ta.0000159247.48547.7d. View

Zatzick D, Roy-Byrne P, Russo J, Rivara F, Koike A, Jurkovich G . Collaborative interventions for physically injured trauma survivors: a pilot randomized effectiveness trial. Gen Hosp Psychiatry. 2001; 23(3):114-23. DOI: 10.1016/s0163-8343(01)00140-2. View

10.

Zatzick D, Jurkovich G, Rivara F, Wang J, Fan M, Joesch J . A national US study of posttraumatic stress disorder, depression, and work and functional outcomes after hospitalization for traumatic injury. Ann Surg. 2008; 248(3):429-37. DOI: 10.1097/SLA.0b013e318185a6b8. View

11.

Shih R, Schell T, Hambarsoomian K, Belzberg H, Marshall G . Prevalence of posttraumatic stress disorder and major depression after trauma center hospitalization. J Trauma. 2010; 69(6):1560-6. PMC: 3071627. DOI: 10.1097/TA.0b013e3181e59c05. View

12.

Bryant R, Harvey A, Dang S, Sackville T, Basten C . Treatment of acute stress disorder: a comparison of cognitive-behavioral therapy and supportive counseling. J Consult Clin Psychol. 1998; 66(5):862-6. DOI: 10.1037//0022-006x.66.5.862. View

13.

Kessler R, Sonnega A, Bromet E, Hughes M, Nelson C . Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995; 52(12):1048-60. DOI: 10.1001/archpsyc.1995.03950240066012. View

14.

Bryant R, ODonnell M, Creamer M, McFarlane A, Clark C, Silove D . The psychiatric sequelae of traumatic injury. Am J Psychiatry. 2010; 167(3):312-20. DOI: 10.1176/appi.ajp.2009.09050617. View

15.

Tunis S, Stryer D, Clancy C . Practical clinical trials: increasing the value of clinical research for decision making in clinical and health policy. JAMA. 2003; 290(12):1624-32. DOI: 10.1001/jama.290.12.1624. View

16.

Zatzick D, Rivara F, Jurkovich G, Russo J, Trusz S, Wang J . Enhancing the population impact of collaborative care interventions: mixed method development and implementation of stepped care targeting posttraumatic stress disorder and related comorbidities after acute trauma. Gen Hosp Psychiatry. 2011; 33(2):123-34. PMC: 3099037. DOI: 10.1016/j.genhosppsych.2011.01.001. View

17.

Koepsell T, Zatzick D, Rivara F . Estimating the population impact of preventive interventions from randomized trials. Am J Prev Med. 2011; 40(2):191-8. PMC: 3042774. DOI: 10.1016/j.amepre.2010.10.022. View

18.

Shalev A, Ankri Y, Israeli-Shalev Y, Peleg T, Adessky R, Freedman S . Prevention of posttraumatic stress disorder by early treatment: results from the Jerusalem Trauma Outreach And Prevention study. Arch Gen Psychiatry. 2011; 69(2):166-76. DOI: 10.1001/archgenpsychiatry.2011.127. View

19.

Zatzick D, Jurkovich G, Fan M, Grossman D, Russo J, Katon W . Association between posttraumatic stress and depressive symptoms and functional outcomes in adolescents followed up longitudinally after injury hospitalization. Arch Pediatr Adolesc Med. 2008; 162(7):642-8. DOI: 10.1001/archpedi.162.7.642. View

20.

Zatzick D, Rivara F, Nathens A, Jurkovich G, Wang J, Fan M . A nationwide US study of post-traumatic stress after hospitalization for physical injury. Psychol Med. 2007; 37(10):1469-80. DOI: 10.1017/S0033291707000943. View