Wietse Tol and colleagues discuss some of the key challenges for implementation of new WHO guidelines for stress-related mental health disorders in low- and middle-income countries.
Please see later in the article for the Editors' Summary
The relationship between acute care clinical indicators in the first severe Pediatric traumatic brain injury (TBI) Guidelines and outcomes have not been examined. We aimed to develop a set of acute care guideline-influenced clinical indicators of adherence and tested the relationship between these indicators during the first 72 hours after hospital admission and discharge outcomes.
Retrospective multicenter cohort study
Five regional pediatric trauma centers affiliated with academic medical centers.
Children under 17 years with severe TBI (admission Glasgow coma scale (GCS) score ≤ 8, ICD-9 diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head abbreviated injury severity score ≥ 3) who received tracheal intubation for at-least 48 hours in the intensive care unit (ICU) between 2007 -2011 were examined.
Measurements and Main Results
Total percent adherence to the clinical indicators across all treatment locations (pre-hospital [PH], emergency department [ED], operating room [OR], and intensive care unit [ICU]) during the first 72 hours after admission to study center were determined. Main outcomes were discharge survival and Glasgow outcome scale (GOS) score.
Total adherence rate across all locations and all centers ranged from 68-78%. Clinical indicators of adherence were associated with survival (aHR 0.94; 95 % CI 0.91, 0.96). Three indicators were associated with survival: absence of PH hypoxia (aHR 0.20; 95% CI 0.08, 0.46), early ICU start of nutrition (aHR 0.06; 95% CI 0.01, 0.26), and ICU PaCO2 >30 mm Hg in the absence of radiographic or clinical signs of cerebral herniation (aHR 0.22; 95% CI 0.06, 0.8). Clinical indicators of adherence were associated with favorable GOS among survivors, (aHR 0.99; 95% CI 0.98, 0.99). Three indicators were associated with favorable discharge GOS: all OR CPP >40 mm Hg (aRR 0.64; 95% CI 0.55, 0.75), all ICU CPP > 40mm Hg (aRR 0.74; 95% CI 0.63, 0.87), and no surgery (any type; aRR 0.72; 95% CI 0.53, 0.97).
Acute care clinical indicators of adherence to the Pediatric Guidelines were associated with significantly higher discharge survival and improved discharge GOS. Some indicators were protective, regardless of treatment location, suggesting the need for an interdisciplinary approach to the care of children with severe TBI.
pediatrics; trauma; brain injury; indicators; outcomes; injury
Rationale: Prior studies have found that cognitive dysfunction is common in intensive care unit (ICU) survivors. Yet, relatively little is known about potentially modifiable risk factors for longer-term post-ICU cognitive impairment.
Objectives: To determine if in-hospital acute stress symptoms were associated with impaired 12-month cognitive functioning among ICU survivors.
Methods: We prospectively enrolled 150 nontrauma patients without cognitive impairment or a dementia diagnosis who were admitted to an ICU for more than 24 hours. Patients were interviewed before hospital discharge and again via telephone at 12 months post-ICU.
Measurements and Main Results: Demographics and clinical information were obtained through medical record reviews and in-person interviews. In-hospital acute stress symptoms were assessed with the Posttraumatic Stress Disorder Checklist-Civilian Version. Twelve-month post-ICU cognition was assessed with the modified Telephone Interview for Cognitive Status. Follow-up interviews were completed with 120 (80%) patients. Patients’ mean age at hospitalization was 48.2 years (SD, 13.7). In unadjusted analyses, a greater number of in-hospital acute stress symptoms was associated with significantly greater impairment in 12-month cognitive functioning (β, −0.1; 95% confidence interval, −0.2 to −0.004; P = 0.04). After adjusting for patient and clinical factors, in-hospital acute stress symptoms were independently associated with greater impairment in 12-month cognitive functioning (β, −0.1; 95% CI, −0.2 to −0.01; P = 0.03).
Conclusions: In-hospital acute stress symptoms may be a potentially modifiable risk factor for greater impairment in cognitive functioning post-ICU. Early interventions for at-risk ICU survivors may improve longer-term outcomes.
critical care; acute stress symptoms; cognitive impairment
This investigation aimed to advance posttraumatic stress disorder (PTSD) risk prediction among hospitalized injury survivors by developing a population-based automated screening tool derived from data elements available in the electronic medical record (EMR).
Potential EMR derived PTSD risk factors with the greatest predictive utilities were identified for 878 randomly selected injured trauma survivors. Risk factors were assessed using logistic regression, sensitivity, specificity, predictive values, and receiver operator characteristic (ROC) curve analyses.
Ten EMR data elements contributed to the optimal PTSD risk prediction model including: ICD-9-CM PTSD diagnosis, other ICD-9-CM psychiatric diagnosis, other ICD-9-CM substance use diagnosis or positive blood alcohol on admission, tobacco use, female gender, non-White ethnicity, uninsured, public or veteran insurance status, E-code identified intentional injury, intensive care unit admission, and EMR documentation of any prior trauma center visits. The 10-item automated screen demonstrated good area under the ROC curve (0.72), sensitivity (0.71), and specificity (0.66).
Automated EMR screening can be used to efficiently and accurately triage injury survivors at risk for the development of PTSD. Automated EMR procedures could be combined with stepped care protocols to optimize the sustainable implementation of PTSD screening and intervention at trauma centers nationwide.
PTSD; screening; injury; EMR; information technology
Traumatic brain injury (TBI) is a significant cause of mortality and disability in children. Intracranial pressure monitoring (ICPM) and craniotomy/craniectomy (CRANI) may affect outcomes. Sources of variability in the use of these interventions remain incompletely understood.
To analyze sources of variability in the use of ICPM and CRANI.
Retrospective cross-sectional study of patients with moderate/severe pediatric TBI with the use of data submitted to the American College of Surgeons National Trauma Databank.
We analyzed data from 7140 children at 156 US hospitals during 7 continuous years. Of the children, 27.4% had ICPM, whereas 11.7% had a CRANI. Infants had lower rates of ICPM and CRANI than older children. A lower rate of ICPM was observed among children hospitalized at combined pediatric/adult trauma centers than among children treated at adult-only trauma centers (relative risk = 0.80; 95% confidence interval 0.66-0.97). For ICPM and CRANI, 18.5% and 11.6%, respectively, of residual model variance was explained by between-hospital variation in care delivery, but almost no correlation was observed between within-hospital tendency toward performing these procedures.
Infants received less ICPM than older children, and children hospitalized at pediatric trauma centers received less ICPM than children at adult-only trauma centers. In addition, significant between-hospital variability existed in the delivery of ICPM and CRANI to children with moderate-severe TBI.
Decompressive craniectomy; Intracranial pressure monitoring
There have been no studies describing post-intensive care unit (ICU) alcohol use among medical-surgical ICU survivors.
To examine alcohol use and identify potentially modifiable risk factors, such as in-hospital probable acute stress disorder, for increased alcohol use following medical-surgical ICU admission.
This longitudinal investigation included 150 medical-surgical ICU survivors. In-hospital interviews obtained baseline characteristics including pre-ICU alcohol use with the Alcohol Use Disorders Identification Test (AUDIT) and in-hospital probable acute stress disorder with the Posttraumatic Stress Disorder Checklist-civilian version. Clinical factors were obtained from medical records. Post-ICU alcohol use was ascertained via telephone interviews at 3 and 12 months post-discharge using the AUDIT. Mixed-model linear regression was used to examine potential risk factors for increased post-ICU alcohol use.
There was a significant decline in the mean AUDIT score from baseline (3.9, 95%Confidence Interval [95%CI]: 2.9, 5.0) to 3 months post-ICU (1.5, 95%CI: 1.0, 2.1) (P < 0.001 by one-way analysis of variance [ANOVA]), with a significant increase between 3 and 12 months post-ICU (2.7, 95%CI: 1.8, 3.5) (P < 0.001 by one-way ANOVA). After adjusting for patient and clinical factors, in-hospital probable acute stress disorder (beta: 3.0, 95%CI: 0.9, 5.0) and pre-ICU unhealthy alcohol use (beta: 5.4, 95%CI: 3.4, 7.4) were independently associated with increased post-ICU alcohol use.
Alcohol use decreases in the early aftermath of medical-surgical ICU admission and then increases significantly by one year post-ICU. Interventions for unhealthy alcohol use among medical-surgical ICU survivors that take into account comorbid psychiatric symptoms are needed.
critical care; alcohol use disorders; acute stress disorder; outcome assessment (health care)
Outcomes after pediatric traumatic brain injury (TBI) are related to pre-treatment factors including age, injury severity, and mechanism of injury, and may be positively affected by treatment at trauma centers relative to non-trauma centers. This study estimated the proportion of children with moderate to severe TBI who receive care at trauma centers, and examined factors associated with receipt of care at adult (ATC), pediatric (PTC), and adult/pediatric trauma centers (APTC), compared with care at non-trauma centers (NTC) using a nationally representative database. The Kids' Inpatient Database was used to identify hospitalizations for moderate to severe pediatric TBI. Pediatric inpatients ages 0 to 17 years with at least one diagnosis of TBI and a maximum head Abbreviated Injury Scale score of ≥3 were studied. Multinomial logistic regression was performed to examine factors predictive of the level and type of facility where care was received. A total of 16.7% of patients were hospitalized at NTC, 44.2% at Level I or II ATC, 17.9% at Level I or II PTC, and 21.2% at Level I or II APTC. Multiple regression analyses showed receipt of care at a trauma center was associated with age and polytrauma. We concluded that almost 84% of children with moderate to severe TBI currently receive care at a Level I or Level II trauma center. Children with trauma to multiple body regions in addition to more severe TBI are more likely to receive care a trauma center relative to a NTC.
brain injury; pediatrics; trauma; trauma center
To identify risk factors for posttraumatic stress disorder (PTSD) and depressive symptoms after medical-surgical intensive care unit (ICU) admission.
This longitudinal investigation included 150 medical-surgical ICU patients. We assessed acute stress and post-ICU PTSD symptoms with the PTSD Checklist-civilian version and post-ICU depressive symptoms with the Patient Health Questionnaire-9. Mixed-model linear regression ascertained associations between patient and clinical characteristics and repeated measures of post-ICU PTSD and depressive symptoms.
The prevalences of substantial PTSD and depressive symptoms were 16% and 31% at 3 months post-ICU and 15% and 17% at 12 months post-ICU, respectively. In-hospital substantial acute stress symptoms (beta: 16.9, 95%Confidence Interval [95%CI]: 11.4, 22.4) were independently associated with increased post-ICU PTSD symptoms. Lifetime history of major depression (beta: 2.2, 95%CI: 0.1, 4.2), greater prior trauma exposure (beta: 0.5, 95%CI: 0.2, 0.9) and in-hospital substantial acute stress symptoms (beta: 3.5, 95%CI: 0.8, 6.2) were independently associated with increased post-ICU depressive symptoms.
In-hospital acute stress symptoms may represent a modifiable risk factor for psychiatric morbidity in ICU survivors. Early interventions for at-risk ICU survivors may improve longer-term psychiatric outcomes.
posttraumatic stress disorder; depression; critical care; intensive care; outcome assessment (health care)
Employee attitudes towards change are critical for health care organizations implementing new procedures and practices. When employees are more positive about the change they are likely to behave in ways that support the change, whereas when employees are negative about the change they will resist the changes.
This study examines how perceived person-job (demands–abilities) fit influences attitudes towards change following an externally-mandated change. Specifically, we propose that perceived person-job fit moderates the negative relationship between individual job impact and attitudes towards change.
We examined this issue in a sample of Level I trauma centers facing a regulatory mandate to develop an alcohol screening and brief intervention (SBI) program. A survey of 200 providers within 20 trauma centers assessed perceived person-job fit, individual job impact, and attitudes towards change approximately one year after the mandate was enacted.
Providers who perceived a better fit between their abilities and the new job demands were more positive about the change. Further, the impact of the alcohol SBI program on attitudes towards change was mitigated by perceived fit, where the relationship between job impact and change attitudes was more negative for providers who perceived a worse fit as compared to those who perceived a better fit.
Successful implementation of changes to work processes and procedures requires provider support of the change. Management can enhance this support by improving perceived person-job fit through ongoing training sessions that enhance providers’ abilities to implement the new procedures.
Person-job fit; attitudes toward change; organizational change; trauma centers
Ethnoracial minority status contributes to an increased risk for posttraumatic stress disorder (PTSD) after trauma exposure, beyond other risk factors. A population-based sampling frame was used to examine the associations between ethnoracial groups and early PTSD symptoms while adjusting for relevant clinical and demographic characteristics. Acutely injured trauma center inpatients (N = 623) were screened with the PTSD Checklist. American Indian and African American patients reported the highest levels of posttraumatic stress and preinjury cumulative trauma burden. African American heritage was independently associated with an increased risk of higher acute PTSD symptom levels. Disparities in trauma history, PTSD symptoms, and event related factors emphasize the need for acute care services to incorporate culturally competent approaches for treating these diverse populations.
To test the effectiveness of a stepped care intervention model targeting posttraumatic stress disorder (PTSD) symptoms after injury.
Few investigations have evaluated interventions for injured patients with PTSD and related impairments that can be feasibly implemented in trauma surgical settings.
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 one-, three-, six-, nine-, and twelve-months after the index injury admission.
Regression analyses demonstrated that over the course of the year after injury, intervention patients had significantly reduced PTSD symptoms when compared to controls (group by time effect, CAPS, F(2, 185) = 5.50, P < 0.01; PCL-C, F(4, 185) = 5.45, P < 0.001). Clinically and statistically significant PTSD treatment effects were observed at the six-, nine-, and twelve-month post-injury assessments. Over the course of the year after injury, intervention patients also demonstrated significant improvements in physical function (MOS SF-36 PCS main effect, F(1, 172) = 9.87, P < 0.01).
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 United States trauma centers. (Trial Registration: clinicaltrials.gov identifier: NCT00270959)
In 2005 the American College of Surgeons passed a mandate requiring that Level I trauma centers have a mechanism to identify patients who are problem drinkers and have the capacity to provide an intervention for patients who screen positive. The aim of the Disseminating Organizational Screening and Brief Intervention Services (DO-SBIS) cluster randomized trial is to test a multilevel intervention targeting the implementation of high quality alcohol screening and brief intervention (SBI) services at trauma centers.
Twenty sites selected from all US Level I trauma centers were randomized to participate in the trial. Intervention site providers receive a combination of workshop training in evidence-based motivational interviewing (MI) interventions and organizational development activities prior to conducting trauma center-based alcohol SBI with blood alcohol positive injured patients. Control sites implement care as usual. Provider MI skills, patient alcohol consumption, and organizational acceptance of SBI implementation outcomes are assessed.
The investigation has successfully recruited provider, patient, and trauma center staff samples into the study and outcomes are being followed longitudinally.
When completed, the DO-SBIS trial will inform future American College of Surgeons’ policy targeting the sustained integration of high quality alcohol SBI at trauma centers nationwide.
Acute care medical trauma centers; Injury; Alcohol; Screening and brief intervention; American College of Surgeons
In an effort to integrate substance abuse treatment at trauma centers, the American College of Surgeons has mandated alcohol screening and brief intervention (SBI). Few investigations have assessed trauma center inpatients for comorbidities that may impact the effectiveness of SBI that exclusively focuses on alcohol. Randomly selected SBI eligible acute care medical inpatients (N=878) were evaluated for alcohol, illegal drugs, and symptoms consistent with a diagnosis of posttraumatic stress disorder (PTSD) using electronic medical record, toxicology, and self-report assessments; 79% of all patients had one or more alcohol, illegal drug, or PTSD symptom comorbidity. Over 70% of patients receiving alcohol SBI (n=166) demonstrated one or more illegal drug or PTSD symptom comorbidity. A majority of trauma center inpatients have comorbidities that may impact the effectiveness of mandated alcohol SBI. Investigations that realistically capture, account for, and intervene upon these common comorbid presentations are required to inform the iterative development of College policy targeting integrated substance abuse treatment at trauma centers.
The objective of this investigation was to assess the feasibility of a culturally tailored care management intervention for physically injured American Indian/Alaska Native (AI/AN) patients. The intervention was initiated at a Level I trauma center and aimed to link AI/AN patients to their distant tribal communities. Thirty AI/AN patients were randomized to the intervention or to usual care. Assessments at baseline, 3 months, and 6 months included self-reported lifetime cumulative trauma burden, Native healing requests, and symptoms of posttraumatic stress, depression, and alcohol use. Generalized estimating equations ascertained differences between groups over time. Ninety-four percent of eligible patients participated; follow-up at 3 and 6 months was 83%. Participants had high numbers of lifetime traumas (mean = 5.1, standard deviation = 2.6). No differences between the intervention and control groups were observed in posttraumatic stress symptoms, depression symptoms, or alcohol use at baseline or follow-up time points. Among intervention patients, 60% either requested or participated in traditional Native healing practices and 75% reported that the intervention was helpful. This effectiveness trial demonstrated the feasibility of recruiting and randomizing injured AI/AN patients. Future efforts could integrate evidence-based interventions and traditional Native healing into stepped collaborative care treatment programs.
To survey US Level I trauma centers in order to assess the characteristics of child and adolescent psychosocial service delivery.
Trauma program staff at US Level I trauma centers were asked to complete a survey regarding the characteristics and quality of service delivery for youth. The presence of pediatric services and screening of injured youth for alcohol use problems and posttraumatic stress disorder (PTSD) symptoms were assessed.
150 of 202 (74%) of trauma centers responded to the survey. Substantial variability was observed in trauma center age cutoffs for pediatric and adolescent patients. Although the majority of sites endorsed having specialized pediatric, intensive care unit, and surgical services, marked differences were found in the reported percentage of youth receiving psychosocial services. Even though the majority of sites screened injured youth for alcohol use problems, variability was observed in the actual percentage of children and adolescents screened. Only 20% of sites endorsed specialized PTSD services.
Our investigation observed marked variability across trauma centers in the delivery of child and adolescent services. Future research could develop high quality pediatric psychosocial services in order to inform trauma center standards nationwide.
Quality of Care; Children; Adolescents; Psychiatry; PTSD; Alcohol
To develop and implement a stepped collaborative care intervention targeting PTSD and related co-morbidities to enhance the population impact of early trauma-focused interventions.
We describe the design and implementation of the Trauma Survivors Outcomes & Support Study (TSOS II). An interdisciplinary treatment development team was comprised of trauma surgical, clinical psychiatric and mental health services “change agents” who spanned the boundaries between front-line trauma center clinical care and acute care policy. Mixed method clinical epidemiologic and clinical ethnographic studies informed the development of PTSD screening and intervention procedures.
Two-hundred and seven acutely injured trauma survivors with high early PTSD symptom levels were randomized into the study. The stepped collaborative care model integrated care management (i.e., posttraumatic concern elicitation and amelioration, motivational interviewing, and behavioral activation) with cognitive behavioral therapy and pharmacotherapy targeting PTSD. The model was feasibly implemented by front-line acute care MSW and ARNP providers.
Stepped care protocols targeting PTSD may enhance the population impact of early interventions developed for survivors of individual and mass trauma by extending the reach of collaborative care interventions to acute care medical settings and other non-specialty posttraumatic contexts.
PTSD; stepped collaborative care; acute care; population impact; traumatic injury
Growing concern about the limited generalizability of trials of preventive interventions has led to several proposals concerning the design, reporting, and interpretation of such trials. This paper presents an epidemiologic framework that highlights three key determinants of population impact of many prevention programs: the proportion of the population at risk who would be candidates for a generic intervention in routine use, the proportion of those candidates who are actually intervened on through a specific program, and the reduction in incidence produced by that program among recipients. It then describes how the design of a prevention trial relates to estimating these quantities. Implications of the framework include: (1) reach is an attribute of a program, while external validity is an attribute of a trial, and the two should not be conflated; (2) specification of a defined target population at risk is essential in the long run and merits greater emphasis in the planning and interpretation of prevention trials; (3) with due attention to sampling frame and sampling method, the process of subject recruitment for a trial can yield key information about quantities that are important for assessing its potential population impact; and (4) exclusions during subject recruitment can be conceptually separated into intervention-driven, program-driven, and trial design–driven exclusions, which have quite different implications for trial interpretation and for estimating population impact of the intervention studied.
Limited financial resources, escalating mental health related costs, and opportunities for capitalizing on advances in health information technologies have brought the theme of efficiency to the forefront of mental health services research and clinical practice. In this introductory paper to the journal series stemming from the 20th NIMH Mental Health Services Research Conference, we first delineate the need for a new focus on efficiency in both research and clinical practice. Second, we provide preliminary definitions of efficiency for the field and discuss issues related to measurement. Finally, we explore the interface between efficiency in mental health services research and practice and the NIMH strategic objectives of developing improved interventions for diverse populations and enhancing the public health impact of research. Case examples illustrate how perspectives from dissemination and implementation research may be used to maximize efficiencies in the development and implementation of new service delivery models. Allowing findings from the dissemination and implementation field to permeate and inform clinical practice and research may facilitate more efficient development of interventions and enhance the public health impact of research.
efficiency; mental health; health services research; intervention development; implementation
Few clinical epidemiologic investigations have assessed whether youths exposed to a traumatic injury demonstrate elevations in the full spectrum of provider-recognized psychiatric disorders compared with unexposed, noninjured youths.
In a population-based prospective cohort study, data for children and adolescents aged ten to 19 who were enrolled in the Group Health Cooperative health plan were screened for injury visits in the index year of 2001 (N = 20,507). Psychiatric diagnoses, including anxiety and acute stress, depressive, substance use, and disruptive behavior disorders, given to these youths over the next three years (2002–2004) were documented, as were psychotropic medication prescriptions. Regression analyses assessed for an independent association between injury and psychiatric disorders and prescription of psychotropic medication.
In adjusted regression analyses, injury in the index year was independently associated with significantly increased odds of receiving a diagnosis of anxiety or acute stress (odds ratio [OR] = 1.21, 95% confidence interval [CI] = 1.02–1.44), depression (OR = 1.30, CI = 1.10–1.53), and a substance use disorder (OR = 1.56, CI = 1.21–2.00) and of receiving a psychotropic medication prescription (OR = 1.37, CI = 1.20–1.57). Youths with traumatic brain injuries also were significantly more likely to receive psychotropic medication prescriptions.
Traumatic injury was independently associated with an increased risk of receiving a full spectrum of anxiety, depressive, and substance use diagnoses among youths aged ten to 19. Population-based surveillance procedures that incorporate screening and stepped-care interventions targeting the spectrum of postinjury emotional disturbances have the potential to improve the quality of mental health care for youths treated in general medical settings.
In 2007, the American College of Surgeons (ACS) Committee on Trauma implemented a requirement that Level I trauma centers must have a mechanism to identify patients who are problem drinkers and the capacity to provide an intervention for patients who screen positive. Although the landmark alcohol screening and brief intervention (SBI) mandate is anticipated to impact trauma practice nationwide, a literature review revealed no studies that have systematically documented SBI practice pre-ACS requirement.
Trauma programs at all US Level I trauma centers were contacted and asked to complete a survey about pre-ACS requirement trauma center SBI practice.
One hundred forty-eight of 204 (73%) Level I trauma centers responded to the survey. More than 70% of responding centers routinely used laboratory tests (eg, blood alcohol concentration) to screen patients for alcohol and 39% routinely used a screening question or standardized screening instrument. Screen-positive patients received a formal alcohol consult or had an informal alcohol discussion with staff members approximately 25% of the time.
The investigation observed marked variability across Level I centers in the percentage of patients screened and in the nature and extent of intervention delivery in screen-positive patients. In the wake of the ACS Committee on Trauma requirement, future research could systematically implement and evaluate training in the delivery of evidence-based alcohol interventions and training in development of trauma center organizational capacity for sustained delivery of SBI.
Few large-scale, multisite investigations have assessed the development of posttraumatic stress disorder (PTSD) symptoms and health outcomes across the spectrum of patients with mild, moderate, and severe traumatic brain injury (TBI).
To understand the risk of developing PTSD symptoms and to assess the impact of PTSD on the development of health and cognitive impairments across the full spectrum of TBI severity.
Multisite US prospective cohort study.
Eighteen level I trauma centers and 51 non–trauma center hospitals.
A total of 3047 (weighted n=10 372) survivors of multiple traumatic injuries between the ages of 18 and 84 years.
Main Outcome Measures
Severity of TBI was categorized from chart-abstracted International Classification of Diseases, Ninth Revision, Clinical Modification codes. Symptoms consistent with a DSM-IV diagnosis of PTSD were assessed with the PTSD Checklist 12 months after injury. Self-reported outcome assessment included the 8 Medical Outcomes Study 36-Item Short Form Health Survey health status domains and a 4-item assessment of cognitive function at telephone interviews 3 and 12 months after injury.
At the time of injury hospitalization, 20.5% of patients had severe TBI, 11.7% moderate TBI, 12.9% mild TBI, and 54.9% no TBI. Patients with severe (relative risk, 0.72; 95% confidence interval, 0.58-0.90) and moderate (0.63; 0.44-0.89) TBI, but not mild TBI (0.83; 0.61-1.13), demonstrated a significantly diminished risk of PTSD symptoms relative to patients without TBI. Across TBI categories, in adjusted analyses patients with PTSD demonstrated an increased risk of health status and cognitive impairments when compared with patients without PTSD.
More severe TBI was associated with a diminished risk of PTSD. Regardless of TBI severity, injured patients with PTSD demonstrated the greatest impairments in self-reported health and cognitive function. Treatment programs for patients with the full spectrum of TBI severity should integrate intervention approaches targeting PTSD.
Collaborative care is a disease management strategy that aims to simultaneously target medical/surgical (e.g., physical injury) and psychiatric (e.g., PTSD and depression) conditions. Collaborative care interventions hold promise for the delivery of mental health interventions in acute care as they can incorporate front-line trauma center providers such as social workers and nurses into early mental health services delivery and can link trauma center care to outpatient services. Initial randomized clinical trial evidence suggests that collaborative care interventions that incorporate evidence-based motivational interviewing targeting alcohol use, as well as pharmacotherapy and psychotherapy targeting PTSD, may reduce both alcohol and PTSD symptoms among injured trauma surgery patients. Trials conducted to date thus suggest that early mental health interventions can be feasibly and effectively delivered from trauma centers. Future collaborative care investigations that refine routine acute care treatment procedures and target acute care policy mandates can improve the quality of mental health care for Americans injured in the wake of individual and mass trauma.
Collaborative Care; PTSD; Trauma Center; Alcohol
To review the prevalence of psychiatric syndromes in pediatric critical illness survivors as well as to summarize data on vulnerabilities and pediatric intensive care unit (PICU) exposures that may increase risk of developing these syndromes.
Medline (1966–2009), the Cochrane Library (2009, Issue 3), and PsycInfo (1967–2009) as of August 9, 2009.
Case-control, cross-sectional, prospective cohort and retrospective cohort studies, as well as randomized-controlled trials.
Hospitalization for the treatment of a critical illness.
Main Outcome Measures
Assessments of psychiatric symptoms/disorders at least once after discharge.
Seventeen studies were eligible. The most commonly assessed psychiatric disorders were posttraumatic stress disorder (PTSD) and major depression. The point prevalence of clinically significant PTSD symptoms ranged from 10%–28% (5 studies). The point prevalence of clinically significant depressive symptoms ranged from 7%–13% (3 studies). Pre-illness psychiatric and/or developmental problems and parental psychopathology were associated with vulnerability to psychiatric morbidity. Neither a child’s age nor gender consistently increased vulnerability to post-illness psychopathology. Exposure to increased severity of medical illness and PICU service-delivery characteristics (e.g., invasive procedures) were predictors of psychiatric illness in some, but not all, studies. Early post-illness psychiatric symptoms were predictors of later psychiatric morbidity.
Psychiatric morbidity appears to be a substantial problem for pediatric critical illness survivors. Future research should include more in-depth assessment of post-critical illness depressive, anxiety and psychotic symptoms, validate existing psychiatric instruments, and clarify how vulnerability factors, PICU service-delivery characteristics and severity of critical illnesses are associated with subsequent psychopathology.
intensive care units; pediatric; stress disorder; posttraumatic; depressive disorder; major; critical illness; outcome assessment (health care)