Mental health following traumatic injury: Toward a health system model of early psychological intervention
Introduction
In recent years, much information has been published about early intervention for posttraumatic stress disorder (PTSD) following traumatic events. Issues pertaining to early intervention have been explored in numerous review articles (e.g., Ehlers and Clark, 2003, McNally et al., 2003, Watson and Shaley, 2005), and books/chapters (e.g., Bisson, 2003, Bryant, 2004, Litz, 2004, Shalev, 2002b, Watson et al., 2003). Furthermore a number of best practice guidelines for early intervention following trauma have been developed (Australian Centre for Posttraumatic Mental Health, 2007, National Collaborating Centre for Mental Health, 2005, U.S. National Institute of Mental Health, 2002). Despite this, there is a paucity of literature that attempts to integrate information about early intervention and present it in a coherent model for health system application.
The aim of this review is to examine information relevant to early psychological intervention in terms of its applicability to a specific trauma population — traumatic injury survivors. This population of trauma survivors warrants a specific focus because traumatic injury is one of the leading causes of posttrauma psychopathology (Creamer et al., 2001, Kessler et al., 1995). The process of reviewing what is known about early intervention then provides a basis to present and discuss a health system model of service delivery for the identification and early treatment of posttrauma psychopathology following traumatic injury.
The traumatic stress health service model we will present is a three stepped model that involves screening injury survivors to identify those at risk for poor psychological adjustment, reassessment of those who screen as high risk at a later point in time, and early intervention for those who have persistent symptoms at one month post injury. In order to justify the model we will review the prevalence of psychopathology following injury, describe the course of symptoms over time, review screening information, and describe relevant early intervention studies.
As the “signature disorder” for trauma survivors, posttraumatic stress disorder (PTSD) is the main focus of this paper (Breslau, 1998, p. 1). It would be, however, a mistake to focus exclusively on PTSD given the frequency with which other psychopathology develops following traumatic injury (O'Donnell et al., 2004, Aug., O'Donnell et al., 2004). Although it is more difficult to determine whether other disorders (e.g., depression) are etiologically linked to a traumatic event because their diagnostic criteria do not directly require experience of a traumatic event, the finding that many psychiatric disorders are prevalent in the aftermath of trauma has implications for early posttraumatic intervention strategies.
It is important at this point to address what we mean by “traumatic injury”. Most studies that have investigated psychopathology following injury have assessed people with injuries severe enough warrant an admission to an emergency department or hospital. So the literature uses injury severity as a necessary, but not sufficient, condition to warrant classification as “traumatic injury”. It is important to note, however, that injury severity is not a good indicator of whether a person regards their injury experience as an emotionally traumatic experience. For example, characteristics about the injury such as injury severity score (ISS: Baker, O'Neil, Haddon, & Long, 1974), length of hospitalisation, or admission to an intensive care unit are not strong predictors of later PTSD (Mayou et al., 2001, O'Donnell et al., 2004, Aug., Schnyder et al., 2001, Zatzick et al., 2002). This has led some authors (e.g., Shalev, 2002a) to describe events as “potentially traumatic events”. That is, just because someone experiences an injury does not mean that they experience it as emotionally traumatic. There are many characteristics about being injured that will contribute to whether an individual experiences being injured as a traumatic event. These may include the perception of fear, helplessness or horror at the time of the injury event, the experience of invasive and painful hospital procedures, and dealing with the consequences of the injury (such as disability, disfigurement, and pain). Shalev (2002a) provides a useful distinction between the primary stressors (e.g., the motor vehicle accident), and secondary stressors (e.g., dealing with bodily disfigurement), but recognises that both sets of stressors are important contributors to whether an individual perceives their injury experience as traumatic. In this review when we make reference to traumatic injury we are really referring to injury as a potentially emotionally traumatic experience.
The traumatic injury literature is not yet at the point where it can differentiate whether some types of injury are more likely to elicit emotional traumatic responses than others. We do know from other literatures that interpersonal violence has higher rates of PTSD associated with it than non-interpersonal traumatic events (Breslau et al., 1998) so we can assume that traumatic injury as a result of assault may be more likely to lead to poorer psychological adjustment than other events such as motor vehicle accidents. Large epidemiological studies are still required to investigate in depth whether there are potentially key mechanisms inherent to certain physical injuries that increase risk of poor psychological outcomes.
Section snippets
Prevalence of psychopathology following injury
Studies using consecutive or random hospital admissions report that the prevalence of PTSD following injury ranges from 2% to 30% (Ehlers et al., 1998, O'Donnell et al., 2004, Aug., Schnyder et al., 2001, Zatzick et al., 2002) at 12 month post injury, with the majority of studies falling between 10% and 30%. The considerable variance in prevalence rates has been attributed to methodological factors, such as the use of self-report vs structured clinical interview, as well as cultural factors and
Trajectory of traumatic stress symptoms
An understanding of the course of traumatic stress symptoms is an important part of this review because it provides useful information about when early intervention should be targeted. Immediately following traumatic injury, the majority of individuals experience some posttraumatic stress symptoms. These reactions may include shock, anxiety, depression, agitation, and dissociative-like symptoms (Shalev, 2002a). These symptoms begin to look similar to PTSD and depression symptoms after one to
Screening for disorder
As the majority of individuals exposed to a traumatic experience recover without persistent emotional problems, it has been argued that the provision of trauma intervention to all trauma survivors is “impractical, inefficient, and arguably unethical” (Gray & Litz, 2005, p 191). The NICE guidelines for the treatment of PTSD (National Collaborating Centre for Mental Health, 2005) recommended that single session debriefing and educational approaches that are routinely applied to all trauma
Screening for vulnerability
Another form of screening, which has particular relevance to early intervention models, is that for vulnerability to later psychopathology. This form of screening aims to identify in the acute aftermath of trauma individuals at risk for poor emotional recovery. This is particularly important in the case of PTSD where screening for the disorder usually occurs at least one month after the traumatic event (to take into account the time criterion). Screening for vulnerability allows at risk
Early psychological intervention
Eight studies to date have examined early psychological intervention in injury survivors. These studies range from efficacy studies to more recent effectiveness trials. The majority of these studies focus exclusively on preventing and treating PTSD specifically, although some do comment on how the PTSD focused treatment affects depression symptomatology. One study also intervenes with alcohol abuse. A summary of each study is presented in Table 2.
The majority of studies use, as their screening
Developing a health service model of early psychological intervention
This review provides evidence that posttraumatic mental health conditions are a significant problem following traumatic injury and that early psychological interventions may have an important role to play. It provides modest evidence that early psychological intervention using a brief trauma-focused CBT approach is effective in the prevention and treatment of PTSD. There is less evidence to suggest that trauma-focused interventions specifically targeting PTSD will have an effect on depression
Conclusion
In conclusion, PTSD and depression are common consequences of experiencing a traumatic injury. Other anxiety disorders and substance use disorders also occur relatively frequently in this population. Poor mental health has enduring consequences in terms of quality of life, lower return to work and higher levels of disability. While the majority of individuals will recover from a traumatic injury, a significant minority will experience high acute stress symptoms which will escalate over the
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