A nationwide US study of post-traumatic stress after hospitalization for physical injury

Posttraumatic stress disorder mitigation in trauma patients: An evidence-based systematic review from the Eastern Association for the Surgery of Trauma

BACKGROUND

Because of advances in trauma care, there has been increased survival among trauma patients. However, less progress has been made to address posttraumatic psychological disorders. Many trauma patients (19-42%) report emotional or psychological distress after injury, and over one in five will develop posttraumatic stress disorder (PTSD) and/or depression within the first postinjury year. We aim to establish a practice management guideline using a systematic review to provide guidance on early identification of individuals at risk for PTSD and evidence-based treatment options to assist our patients to mitigate the development of PTSD.

METHODS

Clinically relevant questions regarding screening of and intervention for PTSD in adult trauma patients with clearly defined patient Population(s), Intervention(s), Comparison(s), and appropriately selected Outcomes were determined. A systematic literature review was conducted for the period of January 1, 1996, to September 9, 2023. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation methodology. The working group reached consensus on the final evidence-based recommendations.

RESULTS

The literature search yielded 9,387 studies, of which 25 met the criteria for inclusion. Screening and interventions were mostly successful in the identification and management of acute stress disorder/PTSD. The use of cognitive behavioral therapy was the most successful therapy, especially when used with high-risk individuals.

CONCLUSION

We conditionally recommend screening to identify patients at risk for PTSD during their initial hospitalization. We strongly recommend the use of cognitive behavioral therapy for mitigation of PTSD.

LEVEL OF EVIDENCE

Systematic Review/Meta-analysis; Level II.

Bedside mental health risk screening of traumatic injury patients is enhanced by measurement of injury mechanism and social support

BACKGROUND

The American College of Surgeons now requires mental health screening and follow up for hospitalized patients in trauma centers. National estimates indicate that 20-40 % of these patients will develop posttraumatic stress disorder (PTSD) and/or depression within one year post-injury. Research has identified brief bedside screens that predict PTSD and depression post-discharge, such as the Injured Trauma Survivor Screen and Peritraumatic Distress Inventory. However, false negatives are common; almost a quarter of patients with a negative bedside risk screen may develop PTSD or depression post-discharge and may not receive appropriate follow up. As such, there is critical need to improve bedside risk-screening tools. We aimed to identify demographic, social, and trauma-related predictors of mental health symptoms among patients with negative bedside screens.

METHOD

Patients were injury survivors served by a Level I trauma center who were identified as "low risk for development of PTSD/depression" by the Injured Trauma Survivor Screen. Patient injury type and demographics were collected from the medical record.

RESULTS

Violent injuries (e.g., gunshot wound) and lower levels of available social support predicted elevated PTSD symptoms 30-days post-injury. Lower social support also was associated with increased risk for depressive symptoms 30 days post-injury.

CONCLUSION

Findings suggest that risk-screening tools may be improved by including items that capture injury mechanism and social support. Alternatively, trauma centers should consider mental health referral for patients who have experienced violent trauma or have low levels of social support, even when bedside screening tools identify them as having low mental health risk.

The diagnostic utility of the PCL-5 in a traumatically injured black population

BACKGROUND

Posttraumatic stress disorder (PTSD) is common after traumatic injury, negatively impacting recovery. Black Americans face elevated PTSD risk following traumatic injury, yet diagnostic accuracy of assessments in trauma center settings serving this population is unknown. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) exhibits strong psychometric properties but optimal cut-scores by race require examination.

METHODS

Data were combined from three ongoing projects of injured Black American adults (N = 270). Participants completed the PCL-5 and Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) six months post-injury. Receiver operating characteristic analysis determined the PCL-5's diagnostic utility against the CAPS-5. Sensitivity, specificity, predictive values, and diagnostic efficiency were calculated across cut scores.

RESULTS

Prevalence of CAPS-5 PTSD at 6-months post-injury was 34.4 %. The PCL-5 demonstrated good accuracy in detecting PTSD (AUC=.931). A PCL-5 cut-score of > 33 maximized diagnostic efficiency (89.1 %), with sensitivity of 89.1 % and specificity of 87.6 %.

CONCLUSIONS

The PCL-5 is an accurate PTSD screening tool for injured Black Americans using an appropriate threshold. Findings have implications for improving mental health care access in trauma settings serving marginalized groups.

Prediction of psychological continuing health problems based on types of injury and manner of accident in Mozambique: A population-based analysis of burns, fractures, internal injuries, and wound injuries

The long-term effects of injuries have significant implications for forensic practice. There is a dearth of research highlighting long-term psychological problems resulting from various injuries in under-researched populations like Mozambique. This study employed multiple logistic regression analyses on the 2022-2023 Mozambique Demographic and Health Survey (DHS) data to determine injury types predictive of emotional trauma, limb function loss, and chronic pain as continuing health problems. The data from the Accidents and Injury module was used for all participants. The injuries analyzed included broken bones, wounds, internal injuries, and burns. Additionally, we investigated the predictive capacity of unintentional and violent injuries on emotional trauma as a continuing health problem. The total number of injured people (whether due to traffic or non-traffic accidents) was 419. The proportion of unintentional injuries was much higher than violent injuries (86.4% vs 7.7%). Our results indicated that burn injuries were strongly associated with emotional trauma (Odds Ratio (OR) = 4.15, 95% CI: [1.24-13.84], P = 0.021), broken-bone injuries predicted both limb function loss (OR = 2.67, 95% CI: [1.17- 6.09], P = 0.02) and emotional trauma (OR = 3.73, 95% CI: [1.51-9.22], P = 0.005), internal injuries predicted chronic pain (OR = 2.52, 95% CI: [1.18-5.38], P = 0.018), and violent injuries predicted emotional trauma (OR = 4.41, 95% CI: [1.16-16.67], P = 0.03). These findings enhance comprehension of how injury types predict long-term psychological complications in Mozambique and provide valuable insights regarding the enduring consequences of various injuries in similar populations.

Emotional awareness and expression therapy (EAET) for chronic pain following traumatic orthopaedic injury and surgery: study protocol for a single-arm feasibility clinical trial

BACKGROUND

Nearly half of individuals who sustain orthopaedic trauma develop chronic pain and experience significant levels of depression and anxiety. Emotional awareness and expression therapy (EAET) is a newly developed psychological intervention designed to treat chronic pain by helping patients process psychological trauma and conflict to reduce pain. The purpose of this study is to examine the feasibility of delivering EAET to individuals who sustained traumatic orthopaedic injuries requiring surgery and who have chronic pain 6 months after hospital discharge.

METHODS AND ANALYSIS

The study will consist of a single-arm design. Thirty individuals who sustained traumatic orthopaedic injuries requiring surgery and who reported chronic pain 6 months after hospital discharge will be recruited. Participants will receive eight sessions of individually administered EAET delivered via telehealth and complete self-report questionnaires at three timepoints (pretreatment, post-treatment and 3-month follow-up). Quantitative sensory testing will also be done before and after treatment. The primary outcome of the study is feasibility (eg, per cent of eligible patients recruited and per cent of study completers) and acceptability as reported by responses to a self-report questionnaire.

ETHICS AND DISSEMINATION

This study has been approved by the Johns Hopkins Institutional Review Board. All data are expected to be collected by 2026, with results of this study to be disseminated via relevant peer-reviewed journals and scientific conferences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT05989230. Registered on 14 August 2023.

Mental health sequelae of violent injury in children: a review

In the last decade, increasing attention has been paid to the magnitude and characterization of the relationship between violent injury and mental health, with trauma centers progressively focusing on screening and intervention strategies. This review aims to characterize the mental health sequelae of violent injury on children, highlighting effective screening and intervention tools. Violent injury compared to non-violent injury incurs a greater risk for poor mental health outcomes. Risk of acute stress disorder and post-traumatic stress disorder are among the best characterized, but anxiety, depression, and substance use disorders are also correlated to violent injury in children. Mental health sequelae are pervasive, and have lasting, significant physical and psychosocial consequences. Globally, the impact of mental health sequelae of violent injury is underrecognized and undertreated. Provider awareness, and early and efficacious screening can facilitate tailored intervention strategies.

Mental health in public safety personnel with workplace injuries requiring surgery: a longitudinal population-wide administrative data study in Manitoba, Canada

OBJECTIVES

Public safety personnel (PSP) are responsible for ensuring the safety and security of communities, often putting their own lives and well-being at risk by performing dangerous and demanding work. As a result, these workers are particularly vulnerable to workplace-related physical and mental traumatic injuries. Research is needed to understand the mental health of PSP following traumatic physical injury to inform effective prevention programmes and interventions. The objective of this study was to investigate whether PSP with traumatic physical workplace injuries requiring surgery with anaesthetic have higher post-injury rates of mental disorders compared with the general population with similar non-workplace injuries.

DESIGN

Retrospective longitudinal cohort study.

SETTING

Population-based study using linked anonymised administrative data for PSP and the general population in Manitoba, Canada.

PARTICIPANTS

This study compared two groups hospitalised for a traumatic physical injury requiring surgery with anaesthetic between 1 January 2002 and 31 December 2018: (1) PSP (n=293) injured in the workplace and matched 1:5 on sex, age, geographical region and surgical procedure code with (2) individuals in the general population (GenPop) injured outside the workplace (no Workers Compensation Board claim) (n=1198).

PRIMARY AND SECONDARY OUTCOMES AND MEASURES

As planned in the study protocol, the prevalence of mental disorders including anxiety, depression and substance use was measured in the cohorts 2 years pre- and post-injury.

RESULTS

This study found an elevated unadjusted risk of depression in PSP compared with the general population in the 2 years post-injury, adjusting for pre-injury mental health (rate ratio, 1.49; 95% CI, 1.02 to 2.17; p<0.0001). After adjusting, there were no significant differences in rates between the two cohorts; however, the significant group × care interaction term for depression suggests a greater risk for PSP compared with GenPop over time.

CONCLUSIONS

Our findings indicate that, compared with a matched cohort, PSP have an increased risk of depression from the pre-injury to post-injury period following a traumatic physical workplace injury. PSP have a unique mental health trajectory following workplace injury that should be considered when developing rehabilitation strategies for this important population.

Machine learning algorithms for predicting PTSD: a systematic review and meta-analysis

This study aimed to compare and evaluate the prediction accuracy and risk of bias (ROB) of post-traumatic stress disorder (PTSD) predictive models. We conducted a systematic review and random-effect meta-analysis summarizing predictive model development and validation studies using machine learning in diverse samples to predict PTSD. Model performances were pooled using the area under the curve (AUC) with a 95% confidence interval (CI). Heterogeneity in each meta-analysis was measured using I2. The risk of bias in each study was appraised using the PROBAST tool. 48% of the 23 included studies had a high ROB, and the remaining had unclear. Tree-based models were the primarily used algorithms and showed promising results in predicting PTSD outcomes for various groups, as indicated by their pooled AUCs: military incidents (0.745), sexual or physical trauma (0.861), natural disasters (0.771), medical trauma (0.808), firefighters (0.96), and alcohol-related stress (0.935). However, the applicability of these findings is limited due to several factors, such as significant variability among the studies, high and unclear risks of bias, and a shortage of models that maintain accuracy when tested in new settings. Researchers should follow the reporting standards for AI/ML and adhere to the PROBAST guidelines. It is also essential to conduct external validations of these models to ensure they are practical and relevant in real-world settings.

Transauricular vagus nerve stimulation in preventing post-traumatic stress disorder in emergency trauma surgery patients in China: a study protocol for a multicenter, double-blind, randomised, controlled trial

INTRODUCTION

The incidence of post-traumatic stress disorder (PTSD) in emergency trauma surgery patients is 24%, emphasising the urgent need for effective early interventions and treatments. Transauricular vagus nerve stimulation (ta-VNS) modulates the autonomic nervous system by stimulating the nucleus tractus solitarius while affecting PTSD-related neural networks, including the prefrontal cortex, hippocampus and amygdala, potentially offering new options for PTSD prevention and treatment. This study aims to evaluate the efficacy and safety of ta-VNS in preventing PTSD in emergency trauma surgery patients.

METHODS AND ANALYSIS

This multicentre, double-blind, randomised controlled study aims to evaluate the incidence of PTSD in emergency trauma surgery patients receiving either ta-VNS or sham stimulation. A total of 350 participants will be randomly assigned to receive either active or sham stimulation. The active group will undergo electrical stimulation of the left cymba conchae at 30 Hz with a pulse width of 250 µs, using a 30 s on/30 s off cycle. The intensity will start at 0.4 V, increasing in 0.4 V increments until a tingling sensation is detected, and will be adjusted to the highest tolerable level without causing pain. The initial intervention will begin once informed consent is obtained and randomisation is completed in the preoperative preparation room, continuing until the surgery is finished. For the four postoperative days, the intervention will be administered two times per day in 2-h sessions each morning and evening. The sham stimulation group will follow a similar procedure without actual stimulation. The primary outcome is the incidence of PTSD evaluated on postoperative day 30, with secondary outcomes including recovery quality, sleep quality, and adverse events.

ETHICS AND DISSEMINATION

The protocol received approval from Sir Run Run Shaw Hospital, affiliated with Zhejiang University School of Medicine, on 15 October 2024 (approval number: 20240562). The study will adhere to the Declaration of Helsinki guidelines, and written informed consent will be obtained from all participants. Results will be submitted to a peer-reviewed journal for publication.

TRIAL REGISTRATION NUMBER

China Clinical Trial Registration Center (ChiCTR2400080342). Trial details: https://www.chictr.org.cn/showproj.html?proj=217809.

Randomized clinical trial of peer integrated collaborative care intervention after physical injury

Objectives

The goal of the current study was to assess the effectiveness of a peer integrated collaborative care intervention for postinjury outcomes.

Methods

Injury survivors ≥18 years of age were screened for post-traumatic stress disorder (PTSD) symptoms and severe postinjury concerns; screen-positive patients were randomized to the intervention versus enhanced usual care control conditions. The collaborative care intervention included peer support and care management. The intervention also included evidence-based pharmacotherapy and psychotherapeutic elements targeting PTSD. The COVID-19 pandemic interrupted recruitment between March and June 2020; in response to the COVID-19 pandemic, the peer component of the intervention went from in-person to virtual delivery. The primary outcomes were PTSD symptoms assessed with the Diagnostic and Statistical Manual of Mental Disorders fourth edition PTSD checklist, any severe postinjury concerns, and emergency department/inpatient utilization followed over the 12 months postinjury. Secondary outcomes included patient satisfaction with emotional healthcare.

Results

A total of 450 patients were randomized to the intervention (n=225) and control (n=225) conditions; 124 patients (28%) were recruited and completed all study assessments prior to the onset of the COVID-19 pandemic, while 326 patients (72%) were recruited after and/or had one or more study follow-ups occur postpandemic onset. Mixed model regression revealed no statistically significant comparisons for any of the primary outcomes. In exploratory models that examined the impact of COVID-19, significantly improved PTSD symptoms were present at 3 months pre-COVID-19 relative to post-COVID-19. Intervention patients consistently demonstrated higher satisfaction with emotional aspects of healthcare (F(5,1652)=2.87, p=0.01).

Conclusions

The intervention demonstrated no significant improvements in primary outcomes in the intent-to-treat sample. The peer integrated collaborative care intervention contributed to higher patient satisfaction with the emotional aspects of healthcare.

Level of evidence

Level II, randomized clinical trial.

Trial registration number

NCT03569878.

Psychiatric disorder before and after exposure to violent injury: A nationwide Norwegian register-based cohort study

Interpersonal violent injury is associated with increased risk of subsequent psychological problems, but pre-existing psychopathology may complicate this association in ways that are poorly understood. Using nationwide longitudinal registry data from Norway, we tested how psychiatric history modified the association between violent injury exposure and subsequent psychiatric disorder, and examined disorder continuity before vs. after violent injury. We identified all individuals presenting to emergency services in 2010-2018 with a violent injury, along with sex- and age-matched comparison individuals from the general population. The primary outcome was subsequent psychiatric disorder, observed through December 31, 2018, with secondary analyses examining psychiatric diagnoses pre- vs. post-injury. Of the 28,276 violence-injured patients, 20% had a history of psychiatric disorder, vs. 6% of the 282,760 comparison individuals. In Cox regression models, violence-injured patients had substantially higher rates of any subsequent psychiatric disorder when compared to matched peers (HRadj: 2.36; 95% CI: 2.29, 2.42), but this association was confounded and modified by psychiatric history. Continuity of psychiatric diagnosis before and after injury was high among violence-injured patients, but they were also more likely than the comparison group to receive a new diagnosis, potentially indicating incident onset of new psychiatric disorder associated with violence exposure. Violence-injured patients face substantial burden of psychiatric disorder, especially for substance use and mood/anxiety disorders; clinical and public health strategies are needed to address this burden, which precedes violent injury in some cases but is likely provoked by it in others.

Hybrid 1 randomized controlled trial of an integrated stepped-care mental health intervention for traumatic injury patients

BACKGROUND

Annually, nearly 3 million individuals in the US are hospitalized after experiencing a traumatic injury (e.g., serious automobile crash, gunshot wound, stab injury). Many traumatically injured patients experience a trajectory of resilience. However, 20-40 % develop mental health problems such as posttraumatic stress disorder and depression; population estimates exceed 600,000 patients annually. Most trauma centers do not provide direct services to address mental health recovery, but the 2022 American College of Surgeons guidelines have established this as a priority. Cost-effective interventions are needed that meet the needs of patients at each stage of the recovery process while achieving sustainability at the level of implementation. This protocol paper describes a study that rigorously tests the Trauma Resilience and Recovery Program (TRRP), a scalable, sustainable technology-enhanced intervention to support the mental health recovery of patients who have experienced a traumatic injury.

METHODS

We describe a randomized controlled trial with 1-year follow up of TRRP vs. enhanced usual care with 350 traumatically injured patients, including recruitment and retention procedures, assessment, implementation and fidelity monitoring, and statistical plans.

CONCLUSION

Novel components of our design include integration of technology-based elements, use of a stepped-care model, and implementation in a trauma center that did not previously have a mental health program. Data collected address the impact of TRRP and inform improvements to the model and its implementation in preparation for large-scale testing and implementation initiatives. This body of work is critical to informing the field as it continues to move toward national standards and recommendations.

TRIAL REGISTRATION

NCT05497115Clinicaltrials.gov.

Neuronal excitation-inhibition imbalance in the basolateral amygdala is involved in propofol-mediated enhancement of fear memory

Posttraumatic stress disorder (PTSD) is associated with glutamatergic neuron hyperactivation in the basolateral amygdala (BLA) brain area, while GABAergic interneurons in the BLA modulate glutamatergic neuron excitability. Studies have shown that propofol exerts its effects through potentiation of the inhibitory neurotransmitter γ-aminobutyric acid. The neuronal mechanism by which propofol anesthesia modulates fear memory is currently unknown. Here, we used optogenetics and chemogenetics to suppress glutamatergic neurons or activate GABAergic interneurons in the BLA to assess alterations in neuronal excitation-inhibition balance and investigate fear memory. The excitability of glutamatergic neurons in the BLA was significantly reduced by the suppression of glutamatergic neurons or activation of GABAergic interneurons, while propofol-mediated enhancement of fear memory was attenuated. We suggest that propofol anesthesia could reduce the excitability of GABAergic neurons through activation of GABAA receptors, subsequently increasing the excitability of glutamatergic neurons in the mice BLA; the effect of propofol on enhancing mice fear memory might be mediated by strengthening glutamatergic neuronal excitability and decreasing the excitability of GABAergic neurons in the BLA; neuronal excitation-inhibition imbalance in the BLA might be important in mediating the enhancement of fear memory induced by propofol.

The severity of perceived stress associated with community violence exposure and its role in future posttraumatic stress: findings from a longitudinal study of U.S. adolescents

BACKGROUND

Community violence exposure (CVE) in adolescence is associated with poorer mental health although the situational factors that may impact on this relationship remain relatively unexplored. The present study aimed to investigate if the degree of perceived stress during CVE has an effect on future posttraumatic stress disorder (PTSD) symptoms in youth, and if this association differs between females and males.

METHODS

Data were analyzed from 760 U.S. adolescents (mean age = 14.00 years), who participated in two surveys, one year apart. Information about CVE (witnessing violence and violence victimization) and the stress severity associated with it was collected in the first survey, whereas data on PTSD symptoms were obtained in the second survey. Generalized Linear Models were used to examine the associations that were also adjusted for ethnicity, age and socioeconomic status.

RESULTS

The results showed a longitudinal association between CVE-related stress and future PTSD symptoms, with students who had higher levels of perceived stress during CVE (witnessing or victimization) reporting higher PTSD symptom levels subsequently. There was no interaction between sex and CVE-related stress and PTSD symptoms, although females reported more PTSD symptoms.

CONCLUSIONS

The severity of the perceived stress associated with CVE should be regarded as a potentially important prognostic factor for identifying those who might develop PTSD symptoms after CVE and this may facilitate early intervention and treatment for those exposed to community violence.

Polyethylene Glycol-Fusion Repair of Peripheral Nerve Injuries

Axons successfully repaired with polyethylene glycol (PEG) fusion tecnology restored axonal continuity thereby preventing their Wallerian degeneration and minimizing muscle atrophy. PEG fusion studies in animal models and preliminary clinical trials involving patients with digital nerve repair have shown promise for this therapeutic approach. PEG fusion is safe to perform, and given the enormous potential benefits, there is no reason not to explore its therapeutic potential.

Evaluatıon of forensic medical aspects of medical interventions and damages caused by unauthorized persons

BACKGROUND

Medical interventions are procedures that are conducive to creating danger on people's life and body immunity due to their characteristics. We aimed to raise awareness and make contributions by revealing the fact that serious bodily and mental harms occur due to medical interventions by the ones who do not have the authority to perform.

METHODS

We evaluated 210 cases appealled to our institution between the years of 2017 and 2022 who suffered damage after medical interventions by people who do not have any authorization or license. The damages that occurred in the cases were evaluated in terms of medical and legal aspects. Analysis of the data were done with SPSS 25.0 for Windows and the statistical alpha significance level were accepted as p < 0.05.

RESULTS

76.7% of the cases were women, 87.1% were young individuals under the age of 40 Of the medical interventions, 91.9% were for aesthetic/cosmetic purposes (laser epilation, tattoo removal, botox, dermapen, cold lipolysis), 8.1% were for therapeutic purposes (bone setter intervention, tooth extraction/prosthesis, intramuscular injection, cupping pull) was found. It was found that 87.1% of the medical interventions were performed in beauty salons, 12.9% in hairdressers, home, medical markets, pharmacies and dental clinics.

CONCLUSIONS

All over the world and in our country, serious bodily and mental injuries occur in people after medical interventions by unauthorized persons. Therefore, it is necessary to see this situation as an important problem, and raise awareness in the society to make legal arrangements.

The impact of perceived injustice on pain and psychological outcomes after traumatic injury: a longitudinal analysis

ABSTRACT

Individuals' appraisals regarding the injustice of their pain or physical injury have emerged as a significant risk factor for worse physical and psychological outcomes. Injustice appraisals are defined by perceptions of external blame for pain or injury and viewing pain or injury as a source of irreparable loss. To date, research on the impact of injustice appraisal has been primarily cross sectional, and existing longitudinal studies have examined injustice appraisals at only 2 time points in the context of rehabilitation treatment. This study examined the trajectory of injustice appraisals in 171 patients admitted for traumatic injury at admission, as well as 3, 6, and 12 months after discharge and examined injustice appraisals as a potential moderator of recovery after injury. Findings can be summarized as follows: First, injustice perception was largely stable in the 12 months after hospital discharge. Second, elevated injustice perception was associated with decreased recovery in pain intensity and depressive symptomatology over the study period but did not moderate changes in pain catastrophizing or posttraumatic stress symptomatology over time. This study is the first naturalistic prospective analysis of injustice appraisal following trauma admission within the American healthcare system. Findings indicate that injustice appraisals do not naturally decrease in the aftermath of traumatic injury and may be a risk factor for poorer physical and psychological recovery. Future research should examine additional sociodemographic and psychosocial factors that may contribute to elevated injustice appraisal, as well as ways of addressing the potential deleterious impact of injustice appraisals in treatment settings.

History of Racial Discrimination by Police Contributes to Worse Physical and Emotional Quality of Life in Black Americans After Traumatic Injury

BACKGROUND

Black Americans are more likely than their White counterparts to experience traumatic injury and worse functional outcomes. Unfair police treatment has been identified as one specific form of racial discrimination potentially driving these deleterious outcomes. The aim of the investigation was to better understand the relationship between experiences of discrimination by police and trauma-specific quality of life outcomes, including PTSD symptom severity, in Black Americans following traumatic injury.

METHOD

Traumatically injured Black American adults (N = 53) presenting to a level 1 trauma center completed a measure of police and law enforcement discrimination at baseline, and quality of life and PTSD were assessed 6 months later.

RESULTS

Stepwise regressions results showed more frequent discrimination by police and law enforcement significantly predicted lower emotional and physical well-being 6 months after injury. Further, more frequent police discrimination resulted in more severe PTSD symptoms by 6 months after injury.

CONCLUSIONS

Findings underscore that following an injury not specifically related to discrimination by police, patients' historical, negative police experiences contributed to worse physical and emotional recovery in the present. These findings, in unison with prior investigations, reveal the need to consider patients' history of negative police experiences as a social determinant of health in their recovery.

A comparison of the psychometric properties of a person-administered vs. automated screening tool for posttraumatic stress disorder (PTSD) in traumatically injured patients

BACKGROUND

The American College of Surgeons Committee on Trauma (ACS-CoT) mandated that trauma centers have mental health screening and referral protocols in place by 2023. This study compares the Injured Trauma Survivor Screen (ITSS) and the Automated Electronic Medical Record (EMR) Screen to assess their performance in predicting risk for posttraumatic stress disorder (PTSD) within the same sample of trauma patients to inform trauma centers' decision when selecting a tool to best fit their current clinical practice.

METHODS

This was a secondary analysis of three prospective cohort studies of traumatically injured patients (N = 255). The ITSS and Automated EMR Screen were compared using receiver operating characteristic curves to predict risk of subsequent PTSD development. PTSD diagnosis at 6-month follow-up was assessed using the Clinician Administered PTSD Scale for DSM-5.

RESULTS

Just over half the sample screened positive on the ITSS (57.7%), while 67.8% screened positive on the Automated EMR Screen. The area under the curve (AUC) for the two screens was not significantly different (ITSS AUC = 0.745 versus Automated EMR Screen AUC = 0.694, p = 0.21), similar performance in PTSD risk predication within the same general trauma population. The ITSS and Automated EMR Screen had similar sensitivities (86.5%, 89.2%), and specificities (52.5%, 40.9%) respectively at their recommended cut-off points.

CONCLUSION

Both screens are psychometrically comparable. Therefore, trauma centers considering screening tools for PTSD risk to comply with the ACS-CoT 2023 mandate should consider their local resources and patient population. Regardless of screen selection, screening must be accompanied by a referral process to address the identified risk.

Engaging and following physical injury survivors at risk for developing posttraumatic stress disorder symptoms: A 25 site US national study

INTRODUCTION

Early intervention for patients at risk for Posttraumatic Stress Disorder (PTSD) relies upon the ability to engage and follow trauma-exposed patients. Recent requirements by the American College of Surgeons Committee on Trauma (College) have mandated screening and referral for patients with high levels of risk for the development of PTSD or depression. Investigations that assess factors associated with engaging and following physically injured patients may be essential in assessing outcomes related to screening, intervention, and referral.

METHODS

This investigation was a secondary analysis of data collected as part of a United States level I trauma center site randomized clinical trial. All 635 patients were ages ≥18 and had high PTSD symptom levels (i.e., DSM-IV PTSD Checklist score ≥35) at the time of the baseline trauma center admission. Baseline technology use, demographic, and injury characteristics were collected for patients who were followed up with over the course of the year after physical injury. Regression analyses were used to assess the associations between technology use, demographic and injury characteristics, and the attainment of follow-up outcome assessments.

RESULTS

Thirty-one percent of participants were missing one or more 3-, 6- or 12-month follow-up outcome assessments. Increased risk of missing one or more outcome assessments was associated with younger age (18-30 versus ≥55 Relative Risks [RR] = 1.78, 95 % Confidence Interval [CI] = 1.09, 2.91), lack of cell phone (RR = 1.32, 95 % CI = 1.01, 1.72), no internet access (RR = 1.47, 95 % CI = 1.01, 2.16), public versus private insurance (RR = 1.47, 95 % CI = 1.12, 1.92), having no chronic medical comorbidities (≥4 versus none, RR = 0.28, 95 % CI = 0.20, 0.39), and worse pre-injury mental health function (RR = 0.99, 95 % CI = 0.98, 0.99).

CONCLUSIONS

This multisite investigation suggests that younger and publicly insured and/or uninsured patients with barriers to cell phone and internet access may be particularly vulnerable to lapses in trauma center follow-up. Clinical research informing trauma center-based screening, intervention, and referral procedures could productively explore strategies for patients at risk for not engaging and adhering to follow-up care and outcome assessments.

Clinical practice guideline recommendations to improve the mental health of adult trauma patients: protocol for a systematic review

INTRODUCTION

Mental disorders are common in adult patients with traumatic injuries. To limit the burden of poor psychological well-being in this population, recognised authorities have issued recommendations through clinical practice guidelines (CPGs). However, the uptake of evidence-based recommendations to improve the mental health of trauma patients has been low until recently. This may be explained by the complexity of optimising mental health practices and interpretating CGPs scope and quality. Our aim is to systematically review CPG mental health recommendations in the context of trauma care and appraise their quality.

METHODS AND ANALYSIS

We will identify CPG through a search strategy applied to Medline, Embase, CINAHL, PsycINFO and Web of Science databases, as well as guidelines repositories and websites of trauma associations. We will target CPGs on adult and acute trauma populations including at least one recommendation on any prevention, screening, assessment, intervention, patient and family engagement, referral or follow-up procedure related to mental health endorsed by recognised organisations in high-income countries. No language limitations will be applied, and we will limit the search to the last 15 years. Pairs of reviewers will independently screen titles, abstracts, full texts, and carry out data extraction and quality assessment of CPGs using the Appraisal of Guidelines Research and Evaluation (AGREE) II. We will synthesise the evidence on recommendations for CPGs rated as moderate or high quality using a matrix based on the Grading of Recommendations Assessment, Development and Evaluation quality of evidence, strength of recommendation, health and social determinants and whether recommendations were made using a population-based approach.

ETHICS AND DISSEMINATION

Ethics approval is not required, as we will conduct secondary analysis of published data. The results will be disseminated in a peer-reviewed journal, at international and national scientific meetings. Accessible summary will be distributed to interested parties through professional, healthcare quality and persons with lived experience associations. PROSPERO REGISTRATION NUMBER: (ID454728).

Improved follow-up care for gun violence survivors in the Trauma Quality of Life Clinic

Background

Outpatient follow-up represents a crucial opportunity to re-engage with gun violence survivors (GVS) and to facilitate positive health outcomes. Current outpatient models for firearm-related injuries and trauma care are inconsistent and unstandardized across trauma centers. This project describes the patient population served by the multidisciplinary Trauma Quality of Life (TQoL) Clinic for GVS. Also of primary interest was the outpatient follow-up services used by patients prior to their clinic appointment. Subsequent referrals placed during Clinic, as well as rate of attendance, was a secondary aim.

Methods

This was a descriptive retrospective analysis of a quality improvement project of the TQoL Clinic. Data were extracted from the electronic medical record and were supplemented with information from the trauma registry and the hospital-based violence intervention program database. Descriptive statistics characterized the patient population served. A Χ2 analysis was used to compare no-show rates for the TQoL Clinic against two historical cohorts of trauma clinic attendees.

Results

Most attendees were young (M=32.0, SD=1.8, range=15-88 years), Black (80.1%), and male (82.0%). Of the 306 total TQoL Clinic attendees, 82.3% attended their initial scheduled appointment. Most non-attendee patients rescheduled their appointments (92.1%), and 89.5% attended the rescheduled appointment. TQoL Clinic demonstrated a significantly lower no-show rate than the traditional trauma clinic model, including after the implementation of the hospital's inpatient violence intervention program (χ2(2)=75.52, p<0.001).

Conclusion

The TQoL Clinic has demonstrated improved outpatient follow-up to address the comprehensive needs of GVS. Trauma centers with high gunshot wound volume should consider the implementation of the multidisciplinary TQoL Clinic model to increase access to care and to continue partnership with violence intervention programs to address health outcomes in those most at risk of future morbidity and mortality.

Level of evidence

Therapeutic/care management, level III.

Trajectories of post-traumatic stress in sepsis survivors two years after ICU discharge: a secondary analysis of a randomized controlled trial

BACKGROUND

Post-traumatic stress has been identified as a frequent long-term complication in survivors of critical illnesses after sepsis. Little is known about long-term trajectories of post-traumatic stress and potentially modifiable risk factors following the ICU stay. Study objective was to explore and compare different clinical trajectories of post-traumatic stress symptoms in sepsis survivors up to two years after discharge from ICU.

METHODS

Data on post-traumatic stress symptoms by means of the Post-traumatic Symptom Scale (PTSS-10) were collected in sepsis survivors at one, six, 12 and 24 months after discharge from ICU. Data on chronic psychiatric diagnoses prior ICU were derived from the primary care provider's health records, and data on intensive care treatment from ICU documentation. Trajectories of post-traumatic symptoms were identified ex post, discriminating patterns of change and k-means clustering. Assignment to the trajectories was predicted in multinomial log-linear models.

RESULTS

At 24 months, all follow-up measurements of the PTSS-10 were completed in N = 175 patients. Three clusters could be identified regarding clinical trajectories of PTSS levels: stable low symptoms (N = 104 patients [59%]), increasing symptoms (N = 45 patients [26%]), and recovering from symptoms (N = 26 patients [15%]). Patients with initially high post-traumatic symptoms were more likely to show a decrease (OR with 95% CI: 1.1 [1.05, 1.16]). Females (OR = 2.45 [1.11, 5.41]) and patients reporting early traumatic memories of the ICU (OR = 4.04 [1.63, 10]) were at higher risk for increasing PTSS levels.

CONCLUSION

Post-traumatic stress is a relevant long-term burden for sepsis patients after ICU stay. Identification of three different trajectories within two years after ICU discharge highlights the importance of long-term observation, as a quarter of patients reports few symptoms at discharge yet an increase in symptoms in the two years following. Regular screening of ICU survivors on post-traumatic stress should be considered even in patients with few symptoms and in particular in females and patients reporting traumatic memories of the ICU.

Can stepped collaborative care interventions improve post-traumatic stress disorder symptoms for racial and ethnic minority injury survivors?

Objectives

No large-scale randomized clinical trial investigations have evaluated the potential differential effectiveness of early interventions for post-traumatic stress disorder (PTSD) among injured patients from racial and ethnic minority backgrounds. The current investigation assessed whether a stepped collaborative care intervention trial conducted at 25 level I trauma centers differentially improved PTSD symptoms for racial and ethnic minority injury survivors.

Methods

The investigation was a secondary analysis of a stepped wedge cluster randomized clinical trial. Patients endorsing high levels of distress on the PTSD Checklist (PCL-C) were randomized to enhanced usual care control or intervention conditions. Three hundred and fifty patients of the 635 randomized (55%) were from non-white and/or Hispanic backgrounds. The intervention included care management, cognitive behavioral therapy elements and, psychopharmacology addressing PTSD symptoms. The primary study outcome was PTSD symptoms assessed with the PCL-C at 3, 6, and 12 months postinjury. Mixed model regression analyses compared treatment effects for intervention and control group patients from non-white/Hispanic versus white/non-Hispanic backgrounds.

Results

The investigation attained between 75% and 80% 3-month to 12-month follow-up. The intervention, on average, required 122 min (SD=132 min). Mixed model regression analyses revealed significant changes in PCL-C scores for non-white/Hispanic intervention patients at 6 months (adjusted difference -3.72 (95% CI -7.33 to -0.10) Effect Size =0.25, p<0.05) after the injury event. No significant differences were observed for white/non-Hispanic patients at the 6-month time point (adjusted difference -1.29 (95% CI -4.89 to 2.31) ES=0.10, p=ns).

Conclusion

In this secondary analysis, a brief stepped collaborative care intervention was associated with greater 6-month reductions in PTSD symptoms for non-white/Hispanic patients when compared with white/non-Hispanic patients. If replicated, these findings could serve to inform future American College of Surgeon Committee on Trauma requirements for screening, intervention, and referral for PTSD and comorbidities.

Level of evidence

Level II, secondary analysis of randomized clinical trial data reporting a significant difference.

Trial registration number

NCT02655354.

Emergency Department and Inpatient Utilization Reductions and Cost Savings Associated With Trauma Center Mental Health Intervention: Results From a 5-year Longitudinal Randomized Clinical Trial Analysis

OBJECTIVE

To identify and refer patients at high risk for the psychological sequelae of traumatic injury, the American College of Surgeons Committee on Trauma now requires that trauma centers have in-place protocols. No investigations have documented reductions in utilization and associated potential cost savings associated with trauma center mental health interventions.

BACKGROUND

The investigation was a randomized clinical trial analysis that incorporated novel 5-year emergency department (ED)/inpatient health service utilization follow-up data.

METHODS

Patients were randomized to a mental health intervention, targeting the psychological sequelae of traumatic injury (n = 85) versus enhanced usual care control (n = 86) conditions. The intervention included case management that coordinated trauma center-to-community care linkages, psychotropic medication consultation, and psychotherapy elements. Mixed model regression was used to assess intervention and control group utilization differences over time. An economic analysis was also conducted.

RESULTS

Over the course of the 5-year intervention, patients demonstrated significant reductions in ED/inpatient utilization when compared with control patients [ F (19,3210) = 2.23, P = 0.009]. Intervention utilization reductions were greatest at 3 to 6 months (intervention 15.5% vs control 26.7%, relative risk = 0.58, 95% CI: 0.34, 1.00) and 12 to 15 months (intervention 16.5% vs control 30.6%, relative risk = 0.54, 95% CI: 0.32, 0.91) postinjury time points. The economic analysis suggested potential intervention cost savings.

CONCLUSIONS

Mental health intervention is associated with significant reductions in ED and inpatient utilization, as well as potential cost savings. These findings could be productively integrated into future American College of Surgeons Committee on Trauma policy discussions.

Stepped collaborative care versus American College of Surgeons Committee on Trauma required screening and referral for posttraumatic stress disorder: Clinical trial protocol

BACKGROUND

Each year in the US, approximately 1.5-2.5 million individuals are so severely injured that they require inpatient hospital admissions. The American College of Surgeons Committee on Trauma (College) now requires that trauma centers have in place protocols to identify and refer hospitalized patients at risk injury psychological sequelae. Literature review revealed no investigations that have identified optimal screening, intervention, and referral procedures in the wake of the College requirement.

METHODS

The single-site pragmatic trial investigation will individually randomize 424 patients (212 intervention and 212 control) to a brief stepped care intervention versus College required mental health screening and referral control conditions. Blinded follow-up interviews at 1-, 3-, 6-, and 12-months post-injury will assess the symptoms of PTSD and related comorbidity for all patients. The emergency department information exchange (EDIE) will be used to capture population-level automated emergency department and inpatient utilization data for the intent-to-treat sample. The investigation aims to test the primary hypotheses that intervention patients will demonstrate significant reductions in PTSD symptoms and emergency department/inpatient utilization when compared to control patients. The study incorporates a Rapid Assessment Procedure-Informed Clinical Ethnography (RAPICE) implementation process assessment.

CONCLUSIONS

The overarching goal of the investigation is to advance the sustainable delivery of high-quality trauma center mental health screening, intervention, and referral procedures for diverse injury survivors. An end-of-study policy summit will harness pragmatic trial data to inform the capacity for US trauma centers to implement high-quality acute care mental health screening, intervention and referral services for diverse injured patient populations.

TRIAL REGISTRATION

Clinicaltrials.govNCT05632770.

Psychological treatments for the management of pain after musculoskeletal injury: a systematic review and meta-analysis

ABSTRACT

Musculoskeletal injury is a leading cause of pain and disability worldwide; 35% to 75% of people experience persistent pain for months and years after injury. Psychological treatments can reduce pain, functional impairment, and psychological distress but are not widely used after injury. This systematic review and meta-analysis (PROSPERO ID: CRD42021236807) aimed to synthesize the literature testing psychological treatments for pain after musculoskeletal injury. We searched EMBASE, MEDLINE, PubMed, PsycINFO, and CENTRAL from inception to May 2022. We extracted participant, treatment, and injury characteristics and primary (eg, pain intensity, functional impairment, depression, anxiety, and PTSD symptoms) and secondary (treatment feasibility and acceptability) outcomes. Twenty-four randomized controlled trials (N = 1966) were included. Immediately posttreatment, people who received psychological treatments (versus any control) reported lower pain intensity (standardized mean differences [SMD] = -0.25, 95% confidence interval [-0.49, -0.02]), functional impairment (SMD = -0.32 [-0.55, -0.09]), and symptoms of depression (SMD = -0.46 [-0.64, -0.29]), anxiety (SMD = -0.34 [-0.65, -0.04]), and PTSD (SMD = -0.43 [-0.70, -0.15]); at 6-month follow-up, only depression symptoms were significantly lower. Included trials varied widely in treatment and injury characteristics. The certainty of evidence was low or very low for most effects and heterogeneity moderate to substantial. Most studies had risk of bias domains judged to be high or unclear. Owing to very low certainty of results, we are unsure whether psychological therapies reduce pain and functional impairment after musculoskeletal injury; they may result in improved depression immediately posttreatment and at follow-up. More research is needed to identify treatments that result in enduring effects.

Patient-Reported Outcomes Following Severe Abdominal Trauma: A Secondary Analysis of the Damage Control Laparotomy Trial

INTRODUCTION

Little is known about patient-reported outcomes (PROs) following abdominal trauma. We hypothesized that patients undergoing definitive laparotomy (DEF) would have better PROs compared to those treated with damage control laparotomy (DCL).

METHODS

The DCL Trial randomized DEF versus DCL in abdominal trauma. PROs were measured using the European Quality of Life-5 Dimensions-5 Levels (EQ-5D) questionnaire at discharge and six months postdischarge (1 = perfect health, 0 = death, and <0 = worse than death) and Posttraumatic Stress Disorder (PTSD) Checklist-Civilian. Unadjusted Bayesian analysis with a neutral prior was used to assess the posterior probability of achieving minimal clinically important difference.

RESULTS

Of 39 randomized patients (21 DEF versus 18 DCL), 8 patients died (7 DEF versus 1 DCL). Of those who survived, 28 completed the EQ-5D at discharge (12 DEF versus 16 DCL) and 25 at 6 mo (12 DEF versus 13 DCL). Most patients were male (79%) with a median age of 30 (interquartile range (IQR) 21-42), suffered blunt injury (56%), and were severely injured (median injury severity score 33, IQR 21 - 42). Median EQ-5D value at discharge was 0.20 (IQR 0.06 - 0.52) DEF versus 0.31 (IQR -0.03 - 0.43) DCL, and at six months 0.51 (IQR 0.30 - 0.74) DEF versus 0.50 (IQR 0.28 - 0.84) DCL. The posterior probability of minimal clinically important difference DEF versus DCL at discharge and six months was 16% and 23%, respectively.

CONCLUSIONS

Functional deficits for trauma patients persist beyond the acute setting regardless of laparotomy status. These deficits warrant longitudinal studies to better inform patients on recovery expectations.

Behavioral Health Screening and Follow-Up Services in Pediatric Trauma Centers Across the United States

OBJECTIVE

Over 120,000 U.S. children are hospitalized for traumatic injury annually, a major risk factor for behavioral health problems such as acute/posttraumatic stress disorder (PTSD) and depression. Pediatric trauma centers (PTCs) are well positioned to address the recent mandate by the American College of Surgeons Committee on Trauma to screen and refer for behavioral health symptoms. However, most PTCs do not provide screening or intervention, or use varying approaches. The objective of this mixed-methods study was to assess PTCs' availability of behavioral health resources and identify barriers and facilitators to service implementation following pediatric traumatic injury (PTI).

METHODS

Survey data were collected from 83 Level I (75%) and Level II (25%) PTC program managers and coordinators across 36 states. Semistructured, qualitative interviews with participants (N = 24) assessed the feasibility of implementing behavioral health education, screening, and treatment for PTI patients and caregivers.

RESULTS

Roughly half of centers provide behavioral health screening, predominantly administered by nurses for acute stress/PTSD. Themes from qualitative interviews suggest that (1) service provision varies by behavioral health condition, resource, delivery method, and provider; (2) centers are enthusiastic about service implementation including screening, inpatient brief interventions, and follow-up assessment; but (3) require training and lack staff, time, and funding to implement services.

CONCLUSIONS

Sustainable, scalable, evidence-based service models are needed to assess behavioral health symptoms after PTI. Leadership investment is needed for successful implementation. Technology-enhanced, stepped-care approaches seem feasible and acceptable to PTCs to ensure the availability of personalized care while addressing barriers to sustainability.

Early Identification of Post-Traumatic Stress Disorder in Trauma Patients: Development of a Multivariable Risk Prediction Model

BACKGROUND

The purpose of this study was to build a risk prediction model to identify trauma patients at the time of injury who are at high risk for post-traumatic stress disorder (PTSD) 1 year later.

METHODS

Patients 18+ with operative orthopedic trauma injuries were enrolled in prospective social determinants of health cohort. Data were collected through initial surveys, medical records at time of injury, and 1-year follow-up phone screenings. Univariate analysis examined associations between factors and PTSD at 1 year. The best fit multivariable logistic regression model led to a novel PTSD risk prediction tool based on weights assigned similar to the Charlson index methods.

RESULTS

Of 329 enrolled patients, 87 (26%) completed follow-up surveys; 58% screened positive for chronic PTSD. The best fit model predicting PTSD included age, insurance, violent mechanism, and 2 acute stress screening questions (AUC .89). Using these parameters, the maximum possible TIPPS index was 19. Those with PTSD at 1 year had a mean TIPPS index of 12.9 ± 4.0, compared to 5.9 ± 4.2 for those who did not (P < .001).

DISCUSSION

Traumatic injury often leads to PTSD, which can be predicted by a novel risk score incorporating age, insurance status, violent injury mechanism, and acute stress reaction symptoms. Stability in life and relationships with primary care physicians may be protective of PTSD.

LEVEL OF EVIDENCE

Diagnostic level II.

Implementation of a stepped care program to address posttraumatic stress disorder and depression in a Level II trauma center

BACKGROUND

The Trauma Resilience and Recovery Program (TRRP) is a technology enhanced model of care that includes education, screening, and service referrals to address posttraumatic stress disorder and depression following traumatic injury. TRRP has shown high rates of engagement at a Level I trauma center, but Level II centers have fewer resources and face more challenges to addressing patients' mental health needs.

METHODS

We utilized clinical administrative data to examine engagement in TRRP in a Level II trauma center with 816 adult trauma activation patients.

RESULTS

Most patients (86%) enrolled in TRRP, but only 30% completed screens during a 30-day follow-up call. Three-quarters of patients who endorsed clinically significant symptoms accepted treatment recommendations/referrals.

CONCLUSIONS

Engagement at each step of the model was lower than previously reported in a Level I center. Differences likely correspond to lower rates of mental health symptoms in the trauma patients at this setting. We discuss program adaptations that may be needed to improve patient engagement.

Racial/ethnic differences in acute and longer-term posttraumatic symptoms following traumatic injury or illness

BACKGROUND

Racial/ethnic differences in mental health outcomes after a traumatic event have been reported. Less is known about factors that explain these differences. We examined whether pre-, peri-, and post-trauma risk factors explained racial/ethnic differences in acute and longer-term posttraumatic stress disorder (PTSD), depression, and anxiety symptoms in patients hospitalized following traumatic injury or illness.

METHODS

PTSD, depression, and anxiety symptoms were assessed during hospitalization and 2 and 6 months later among 1310 adult patients (6.95% Asian, 14.96% Latinx, 23.66% Black, 4.58% multiracial, and 49.85% White). Individual growth curve models examined racial/ethnic differences in PTSD, depression, and anxiety symptoms at each time point and in their rate of change over time, and whether pre-, peri-, and post-trauma risk factors explained these differences.

RESULTS

Latinx, Black, and multiracial patients had higher acute PTSD symptoms than White patients, which remained higher 2 and 6 months post-hospitalization for Black and multiracial patients. PTSD symptoms were also found to improve faster among Latinx than White patients. Risk factors accounted for most racial/ethnic differences, although Latinx patients showed lower 6-month PTSD symptoms and Black patients lower acute and 2-month depression and anxiety symptoms after accounting for risk factors. Everyday discrimination, financial stress, past mental health problems, and social constraints were related to these differences.

CONCLUSION

Racial/ethnic differences in risk factors explained most differences in acute and longer-term PTSD, depression, and anxiety symptoms. Understanding how these risk factors relate to posttraumatic symptoms could help reduce disparities by facilitating early identification of patients at risk for mental health problems.

History repeats itself: Impact of mental illness on violent reinjury and hospital reencounters among female victims of interpersonal violence

BACKGROUND

Violence-related reinjury impacts both patients and health care systems. Mental illness (MI) is prevalent among violently injured individuals. The relationship between preexisting MI and violent reinjury among women has not been fully characterized. Our objective was to determine if risk of hospital reencounter-violent reinjury and all-cause-was associated with preexisting MI at time of index injury among female victims of violence.

METHODS

All females (15-100 + years) presenting to a level I trauma center with violent injury (2002-2019) surviving to discharge were included (N = 1,056). Exposure was presence of preexisting MI. The primary outcome was hospital reencounters for violent reinjury and all-cause within one year (through 2020). The secondary outcome was the development of a new MI within one year of index injury. Odds of reencounter and development of new MI for those with and without preexisting MI were compared with multivariable logistic regression, stratified for interaction when appropriate.

RESULTS

There were 404 women (38%) with preexisting MI at time of index injury. Approximately 11% of patients with preexisting MI experienced violent reinjury compared to 5% of those without within 1 year ( p < 0.001). Specifically, those with MI in the absence of concomitant substance use had more than three times the odds of violent reinjury (adjusted Odds Ratio, 3.52 (1.57, 7.93); p = 0.002). Of those with preexisting MI, 64% had at least one reencounter for any reason compared to 46% of those without ( p < 0.001 ) . Odds of all-cause reencounter for those with preexisting MI were nearly twice of those without (adjusted Odds Ratio, 1.81 [1.36, 2.42]; p < 0.0001).

CONCLUSION

Among female victims of violence, preexisting MI is associated with a significantly increased risk of hospital reencounter and violent reinjury within the first year after index injury. Recognition of this vulnerable population and improved efforts at addressing MI in trauma patients is critical to ongoing prevention efforts to reduce violent reinjury.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Assessment of Traumatic Stress Symptoms During the Acute Posttrauma Period

A substantial majority of adults in the United States will experience a potentially traumatic event (PTE) in their lifetime. A considerable proportion of those individuals will go on to develop posttraumatic stress disorder (PTSD). Distinguishing between those who will develop PTSD and those who will recover, however, remains as a challenge to the field. Recent work has pointed to the increased potential of identifying individuals at greatest risk for PTSD through repeated assessment during the acute posttrauma period, the 30-day period after the PTE. Obtaining the necessary data during this period, however, has proven to be a challenge. Technological innovations such as personal mobile devices and wearable passive sensors have given the field new tools to capture nuanced in vivo changes indicative of recovery or nonrecovery. Despite their potential, there are numerous points for clinicians and research teams to consider when implementing these technologies into acute posttrauma care. The limitations of this work and considerations for future research in the use of technology during the acute posttrauma period are discussed.

Effect of Dexmedetomidine on Posttraumatic Stress Disorder in Patients Undergoing Emergency Trauma Surgery: A Randomized Clinical Trial

Importance

Posttraumatic stress disorder (PTSD) is common in people who have experienced trauma, especially those hospitalized for surgery. Dexmedetomidine may reduce or reverse the early consolidation and formation of conditioned fear memory and prevent the occurrence of postoperative PTSD.

Objective

To evaluate the effects of intraoperative and postoperative low-dose intravenous pumping dexmedetomidine on PTSD among patients with trauma undergoing emergency surgery.

Design, Setting, and Participants

This double-blind, randomized clinical trial was conducted from January 22 to October 20, 2022, with follow-up 1 month postoperatively, in patients with trauma undergoing emergency surgery at 4 hospital centers in Jiangsu Province, China. A total of 477 participants were screened. The observers were blinded to patient groupings, particularly for subjective measurements.

Interventions

Dexmedetomidine or placebo (normal saline) was administered at a maintenance dose of 0.1 μg/kg hourly from the start of anesthesia until the end of surgery and at the same rate after surgery from 9 pm to 7 am on days 1 to 3.

Main Outcomes and Measures

The primary outcome was the difference in the incidence of PTSD 1 month after surgery in the 2 groups. This outcome was assessed with the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (CAPS-5). The secondary outcomes were the pain score within 48 hours and 1 month postoperatively; incidence of postoperative delirium, nausea, and pruritus; subjective sleep quality; anxiety; and occurrence of adverse events.

Results

A total of 310 patients (154 in the normal saline group and 156 in the dexmedetomidine group) were included in the modified intention-to-treat analysis (mean [SD] age, 40.2 [10.3] years; 179 men [57.7%]). The incidence of PTSD was significantly lower in the dexmedetomidine group than in the control group 1 month postoperatively (14.1% vs 24.0%; P = .03). The participants in the dexmedetomidine group had a significantly lower CAPS-5 score than those in the control group (17.3 [5.3] vs 18.9 [6.6]; mean difference, 1.65; 95% CI, 0.31-2.99; P = .02). After adjusting for potential confounders, the patients in the dexmedetomidine group were less likely to develop PTSD than those in the control group 1 month postoperatively (adjusted odds ratio, 0.51; 95% CI, 0.27-0.94; P = .03).

Conclusions and Relevance

In this randomized clinical trial, the administration of intraoperative and postoperative dexmedetomidine reduced the incidence of PTSD among patients with trauma. The findings of this trial support the use of dexmedetomidine in emergency trauma surgery.

Trial Registration

Chinese Clinical Trial Register Identifier: ChiCTR2200056162.

Continuous peripheral nerve blocks for analgesia of ventilated critically ill patients with multiple trauma: a prospective randomized study

BACKGROUND

Sedation of ventilated critically ill trauma patients requires high doses of opioids and hypnotics. We aimed to compare the consumption of opioids and hypnotics, and patient outcomes using sedation with or without continuous regional analgesia (CRA).

METHODS

Multiple trauma-ventilated patients were included. The patients were randomized to receive an intravenous analgesia (control group) or an addition of CRA within 24h of admission. A traumatic brain injury (TBI) patients group was analyzed. The primary endpoint was the cumulative consumption of sufentanil at 2 days of admission. Secondary endpoints were cumulative and daily consumption of sufentanil and midazolam, duration of mechanical ventilation, intensive care unit (ICU) stay, and safety of CRA management.

RESULTS

Seventy six patients were analyzed: 40 (67.5% males) in the control group and 36 (72% males) in the CRA group, respectively. The median [IQR] Injury Severity Score was 30.5 [23.5-38.5] and 26.0 [22.0-41.0]. The consumption of sufentanil at 48h was 725 [465-960] μg/48h versus 670 [510-940] μg/48h (p = 0.16). Daily consumption did not differ between the groups except on day 1 when consumption of sufentanil was 360 [270-480] μg vs. 480 [352-535] μg (p = 0.03). Consumptions of midazolam did not differ between the groups. No difference was noted between the groups according to the secondary endpoints.

CONCLUSIONS

CRA does not decrease significantly sufentanil and midazolam consumption within the first 5 days after ICU admission in multiple trauma-ventilated patients. The use of peripheral nerve blocks in heavily sedated and ventilated trauma patients in the ICU seems safe.

Peer-to-Peer Trauma-Informed Training for Surgical Residents Facilitated by Psychiatry Residents

OBJECTIVE

This article describes the implementation of trauma-informed care (TIC) didactic training, using a novel, interdisciplinary peer-to-peer teaching model to improve confidence surrounding trauma-informed practices in a surgical residency program.

METHODS

Eight psychiatry residents and two medical students with a background in psychological trauma and TIC and an interest in medical education were recruited to participate in three 2-hour "train the trainer" sessions led by a national expert in TIC. Eight psychiatry residents and two medical students subsequently developed and delivered the initial TIC training to 29 surgical interns. Training included the neurobiology of psychological trauma, principles of trauma-informed care, and developing trauma-informed curricula.

RESULTS

Surgical interns reported significantly improved understanding of the physiology of trauma, knowledge of TIC approaches, and confidence and comfort with TIC and practices. Among surgical interns, understanding of the physiology of the fear response increased from 3.36 to 3.85 (p = 0.03). Knowledge of the neurobiology of trauma improved between pre- and post-training surveys (2.71 to 3.64, p = 0.006). Surgery interns also expressed an improved understanding of the connection between fear, trauma, and aggression (3.08 to 4.23, p = 0.002) from pre- to post-training surveys. Post-training knowledge of trauma-informed approaches increased from 2.57 to 4.71 (p < 0.001) and confidence in delivering TIC on the wards increased from 2.79 to 4.64 (p < 0.001).

CONCLUSION

This TIC curriculum delivered via a peer-to-peer training model presents an effective way to improve comfort and confidence surrounding TIC practices and approaches in a surgical residency training program.

Chronic Pain and Psychiatric Conditions

Introduction

Chronic pain is a common condition with high socioeconomic and public health burden. A wide range of psychiatric conditions are often comorbid with chronic pain and chronic pain conditions, negatively impacting successful treatment of either condition. The psychiatric condition receiving most attention in the past with regard to chronic pain comorbidity has been major depressive disorder, despite the fact that many other psychiatric conditions also demonstrate epidemiological and genetic overlap with chronic pain. Further understanding potential mechanisms involved in psychiatric and chronic pain comorbidity could lead to new treatment strategies both for each type of disorder in isolation and in scenarios of comorbidity.

Methods

This article provides an overview of relationships between DSM-5 psychiatric diagnoses and chronic pain, with particular focus on PTSD, ADHD, and BPD, disorders which are less commonly studied in conjunction with chronic pain. We also discuss potential mechanisms that may drive comorbidity, and present new findings on the genetic overlap of chronic pain and ADHD, and chronic pain and BPD using linkage disequilibrium score regression analyses.

Results

Almost all psychiatric conditions listed in the DSM-5 are associated with increased rates of chronic pain. ADHD and BPD are significantly genetically correlated with chronic pain. Psychiatric conditions aside from major depression are often under-researched with respect to their relationship with chronic pain.

Conclusion

Further understanding relationships between psychiatric conditions other than major depression (such as ADHD, BPD, and PTSD as exemplified here) and chronic pain can positively impact understanding of these disorders, and treatment of both psychiatric conditions and chronic pain.

Post-traumatic stress disorder (PTSD) symptoms and alcohol and drug use comorbidity at 25 US level I trauma centers

Background

Questions regarding the extent to which post-traumatic stress disorder (PTSD) is comorbid with alcohol and drug use are particularly germane in an era when the American College of Surgeons Committee on Trauma (ACS-COT) is considering policy requiring screening, intervention and/or referral services for patients presenting with psychological sequalae of traumatic injury. Literature review revealed few multisite trauma-center-based investigations that have assessed the association between PTSD symptoms and alcohol and drug use comorbidities in injured patients.

Methods

This investigation was a secondary analysis of baseline data collected prior to randomization in a 25-site trauma center pragmatic clinical trial. All 635 patients included in the investigation had elevated PTSD symptom levels at the time of trauma center admission. Self-report questionnaire screening, laboratory toxicology results, and electronic health record data were combined to assess the frequencies of alcohol, stimulant (i.e., amphetamine and cocaine), opioid and marijuana use comorbidities for injured patients. Logistic regression was used to assess the associations between demographic and injury characteristics and alcohol and drug use comorbidity.

Results

The frequency of patients with one or more alcohol or substance use comorbidity was between 62% and 79%. Over 50% of patients were positive for one or more alcohol or cannabis comorbidity. Approximately 26% of patients were positive for stimulants and 10% for opioid comorbidity.

Discussion

This multisite investigation suggests that between 62% and 79% of hospitalized injury survivors with elevated PTSD symptoms have one or more alcohol or drug use comorbidity. Orchestrated ACS-COT policy and trauma center service delivery development should incorporate the key finding that a substantial majority of patients with high levels of psychological distress (eg, elevated PTSD symptoms) may have alcohol and drug use comorbidities.

Level of evidence

Level II (epidemiological investigation of untreated controls from a multisite randomized clinical trial)

Trial registration number

NCT02655354.

To BDZ or not to BDZ? That is the question! Is there reliable scientific evidence for or against using benzodiazepines in the aftermath of potentially traumatic events for the prevention of PTSD? A systematic review and meta-analysis

BACKGROUND

Most international guidelines suggest that benzodiazepines (BDZs) may be inefficient or iatrogenic in the aftermath of a potentially traumatic event (PTE). The goal of this study was to assess the strength of the evidence on whether the use of BDZs in the aftermath of a PTE negatively affects the incidence and severity of post-traumatic stress disorder (PTSD).

METHODS

We systematically scrutinized the ISI Web of Knowledge, MEDLINE, SCOPUS, and PTSDpubs electronic databases in addition to citation searching. We included original studies providing data about the development of PTSD in adults after BDZ administration in the aftermath of a PTE. We screened 387 abstracts and selected eight studies for the qualitative synthesis and seven for the meta-analysis. We performed two separate meta-analyses, one for randomized clinical trials (RCTs) and the other for cohort studies. Heterogeneity between studies was evaluated with Higgins I² statistic and tested using the χ². This study was registered at PROSPERO (number 127170).

RESULTS

The meta-analysis of the cohort studies showed an increased risk of PTSD in patients who received BDZs compared to those who did not (risk ratio (RR) = 1.53; 95% confidence interval (CI): 1.05-2.23) with a modest heterogeneity among studies (I² = 41.8, p = 0.143). Regarding the RCTs, the combined measure revealed a tendency toward an increased severity of the PTSD symptoms (standardized mean difference (SMD): 0.24; 95% CI: 0.32-0.79).

CONCLUSION

The studies reviewed showed a possible harmful effect of BDZs when used immediately after a PTE. However, these conclusions were based on a small number of studies of poor to moderate methodological quality.

Nationwide Survey of Trauma Center Screening and Intervention Practices for Posttraumatic Stress Disorder, Firearm Violence, Mental Health, and Substance Use Disorders

BACKGROUND

Posttraumatic stress disorder (PTSD) symptoms, firearm violence events, alcohol and drug use problems, and major depression and suicidal ideation are endemic among patients admitted to US trauma centers. Despite increasing policy importance, the current availability of screening and intervention services for this constellation of conditions in US trauma centers is unknown.

STUDY DESIGN

Trauma program staff at all Level I and Level II trauma centers in the US. (N = 627) were contacted to complete a survey describing screening and intervention procedures for alcohol and drug use problems, PTSD symptoms, depression and suicidality, and firearm violence. Additional questions asked trauma centers about the delivery of peer interventions and information technology capacity for screening and intervention procedures.

RESULTS

Fifty-one percent of trauma centers (n = 322) responded to the survey. More than 95% of responding sites endorsed routinely screening and/or intervening for alcohol use problems. Routine services addressing PTSD were less common, with 28% of centers reporting routine screening. More than 50% of sites that screened for PTSD used previously established trauma center alcohol use services. Programmatic screening and intervention for firearm injury sequelae was occurring at 30% of sites.

CONCLUSION

Alcohol screening and intervention is occurring frequently at US trauma centers and appears to be responsive to American College of Surgeons Committee on Trauma verification requirements. Routine screening and intervention services for PTSD and firearm injury were occurring less frequently. Regular national surveys may be a key element of tracking progress in national mental health and substance use screening, intervention, and referral policy.

Anxiety, depression and post-traumatic stress symptoms among injury patients and the association with outcome after injury

BACKGROUND

Injury patients are at risk for mental health problems, which could result in slower recovery and affect health-related quality of life (HRQoL), health care utilization, and return to work (RTW).

OBJECTIVE

In this study, we determined the prevalence of symptoms indicative of probable depression, anxiety, and post-traumatic stress disorder (PTSD) and their association with HRQoL, health care utilization, and RTW in adult injury patients.

METHOD

Data on unintentional injuries in adult patients were retrieved from the Dutch Injury Surveillance System (DISS) and a six-month follow-up questionnaire that included the Hospital Anxiety and Depression Scale (HADS) and Impact of Event Scale-Revised (IES-R) to assess depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms, and items on HRQoL (measured with the EQ-5D-5 L and EQ visual analogue scale), health care utilization and RTW. Logistic regression analyses assessed the association between depression, anxiety, and PTSD and HRQoL, health care utilization, and RTW.

RESULTS

At six months post-injury, 22% (n = 665/3060) of included patients had scores indicative of probable anxiety disorder (14%), depression (16%), and/or PTSD (6%). These patients had reduced EQ-5D utility scores [β: -0.26 (95% CI: -0.28, -0.23)] and were less likely to RTW [OR: 2.12 (95% CI: 1.34, 3.37)] compared to their counterparts. Both mental and physical health care utilization were significantly higher in patients with symptoms indicative of depression, anxiety, and/or PTSD.

CONCLUSIONS

In injury patients, there is a high occurrence of depression, anxiety, and PTSD symptoms, which is associated with lower HRQoL, higher health care utilization, and lower RTW rates. These results underline the importance of screening and treatment of these symptoms in this population to enhance good recovery of injury patients.

Psychological outcomes affect functional outcomes in patients with severe pelvic ring fractures

PURPOSE

To evaluate the correlation between post-traumatic functional and psychological outcomes in patients with severe pelvic ring injuries.

METHODS

Forty-four patients who sustained a completely unstable pelvic ring injury (Tile C, AO/OTA 61C) treated in our institution from 2012 to 2017 were included. A telephone interview was performed in 16 of 44 patients to evaluate pelvic functionality, using the Majeed pelvic score, and psychological evaluation, using Hamilton anxiety and depression rating scales.

RESULTS

The mean Injury Severity Score (ISS) was 27 ± 12, and mean GCS at presentation was 13 ± 4. Average time from trauma to interview was 3 years (range, 1-5 years). Mean Majeed pelvic score was 67 ± 22. Majeed sub-scores were pain 19 ± 9, work 10 ± 7, sitting 8 ± 2, sexual intercourse 3 ± 2, walking aids 11 ± 2, gait unaided 9 ± 2, walking distance 8 ± 3. Mean depression and anxiety scores were 16 ± 12 and 17 ± 14, respectively. Significant correlations were observed between functional and psychological outcomes (P < 0.005). Majeed score was negatively correlated with depressive symptoms (r = -0.721, P = 0.002) and anxiety symptoms (r = -0.756, P = 0.001). Depression and anxiety scores were positively correlated (r = 0.945, P < 0.001).

CONCLUSION

Lower functional outcomes in patients with Tile C pelvic injuries were correlated with more severe symptoms of depression and anxiety. We recommend that providers consider and treat patients' mental health condition during posttraumatic recovery.

A Rapid Ethnographic Assessment of the Impact of the COVID-19 Pandemic on Mental Health Services Delivery in an Acute Care Medical Emergency Department and Trauma Center

A rapid ethnographic assessment of delivery of mental health services to patients at a Level I trauma center in a major metropolitan hospital undergoing a COVID-19 surge was conducted to assess the challenges involved in services delivery and to compare the experience of delivering services across time. Study participants were patients and providers who interacted with or otherwise were observed by three clinicians engaged in the delivery of care within the Emergency Department (ED) and Trauma Center at Harborview Medical Center from the COVID-19-related "surge" in April to the end of July 2020. Data were collected and analyzed in accordance with the Rapid Assessment Procedures-Informed Clinical Ethnography (RAPICE) protocol. Community and institutional efforts to control the spread of the coronavirus created several challenges to providing mental health services in an acute care setting during the April surge. Most of these challenges were successfully addressed by standardization of infection control protocols, but new challenges emerged including an increase in expenses for infection control and reduction in clinical revenues due to fewer patients, furloughs of mental health services providers and peer specialists in the ED, services not provided or delayed, increased stress due to fear of furloughs or increased workload of those not furloughed, and increases in patients seen with injuries due to risky behavior, violence, and substance use. These findings illustrate the rapidly shifting nature of the pandemic, its impacts on mental health services, and the mitigation efforts of communities and healthcare systems.

Stepped Collaborative Care Targeting Posttraumatic Stress Disorder Symptoms and Comorbidity for US Trauma Care Systems: A Randomized Clinical Trial

Importance

To date, few multisite investigations have evaluated early interventions for injured patients with posttraumatic stress disorder (PTSD) symptoms.

Objective

To simultaneously assess the effectiveness and implementation of a brief stepped collaborative care intervention targeting PTSD and comorbidity.

Design, Setting, and Participants

A stepped-wedge cluster randomized clinical trial was conducted at 25 US level I trauma centers. Participants included hospitalized survivors of physical injury who underwent a 2-step evaluation for PTSD symptoms. Patients reporting high levels of distress on the PTSD Checklist (PCL-C) were randomized (N = 635) per the stepped-wedge protocol to enhanced usual care control (n = 370) or intervention (n = 265) conditions. The study was conducted from January 4, 2016, through November 2018. Data analysis was performed from November 4, 2019, to December 8, 2020.

Interventions

The Trauma Survivors Outcomes and Support collaborative care intervention included proactive injury case management that assisted patients transitioning from hospital inpatient to outpatient and community settings. The intervention also integrated evidence-based pharmacotherapy and psychotherapeutic elements targeting PTSD symptoms and comorbidity.

Main Outcomes and Measures

The primary study outcome was PTSD symptoms assessed with the PCL-C at baseline in the surgical ward and at 3, 6, and 12 months postinjury. Secondary outcomes included depressive symptoms, alcohol use, and physical function. Subgroup analyses examined the effect of baseline risk factors for enduring PTSD and quality of protocol implementation on study outcomes. Primary statistical analyses were conducted using the intent-to-treat sample.

Results

A total of 327 men (51.5%) were included in analysis; mean (SD) age was 39.0 (14.2) years. The investigation attained follow-up of 75% to 80% of the participants at 3 to 12 months. The intervention lasted a mean (SD) of 122 (132) minutes. Mixed model regression analyses revealed statistically significant changes in PCL-C scores for intervention patients compared with control patients at 6 months (difference, -2.57; 95% CI, -5.12 to -0.03; effect size, 0.18; P < .05) but not 12 months (difference, -1.27; 95% CI, -4.26 to 1.73; effect size, 0.08; P = .35). Subgroup analyses revealed larger PTSD treatment effects for patients with 3 or more baseline risk factors for enduring PTSD and for patients, including firearm injury survivors, treated at trauma centers with good or excellent protocol implementation. Intervention effects for secondary outcomes did not attain statistical significance.

Conclusions and Relevance

A brief stepped collaborative care intervention was associated with significant 6-month but not 12-month PTSD symptom reductions. Greater baseline PTSD risk and good or excellent trauma center protocol implementation were associated with larger PTSD treatment effects. Orchestrated efforts targeting policy and funding should systematically incorporate the study findings into national trauma center requirements and verification criteria.

Trial Registration

ClinicalTrials.gov Identifier: NCT02655354.

Validation of the Injured Trauma Survivor Screen: An American Association for the Surgery of Trauma multi-institutional trial

BACKGROUND

Psychological distress is common following a traumatic injury event. The Injured Trauma Survivor Screen (ITSS) was developed at a level 1 trauma center to assess for posttraumatic stress disorder (PTSD) and major depressive episode (MDE) following admission for a traumatic injury. The ITSS sensitivity and specificity were analyzed 1 to 3 and 6 to 9 months postinjury to test the validity across trauma centers.

METHOD

Four level 1 trauma centers from the East, Midwest, South, and West in the United States recruited 375 eligible adult inpatients (excluded participants included those with moderate or severe traumatic brain injury, whose injury was self-inflicted, were noncommunicative, or were non-English speaking). Baseline sample (White/Caucasian, 63.2%; male, 62.4%; mean (SD) age, 45 (17.11) years; injured by motor vehicle collision, 42.4%) measurements were conducted during index hospitalization. At first follow-up, 69.6% (n = 261) were retained; at second follow-up, 61.3% (n = 230) were retained. Measurements included the ITSS, PTSD Checklist for DSM-5, Center for Epidemiologic Studies Depression Scale-Revised, and Clinician-Administered PTSD Scaled for DSM 5.

RESULTS

At follow-up 1, the ITSS PTSD subscale had a sensitivity of 75% and specificity of 78.8%, and the MDE subscale had a sensitivity of 80.4% and specificity of 65.6%. At follow-up 2, the PTSD subscale had a sensitivity of 72.7% and specificity of 83.1%, and the MDE subscale had a sensitivity of 76.1% and specificity of 68.3%. A combined risk group using two symptom based measures administered at baseline produced increased specificity.

CONCLUSION

The nine-item ITSS continues to be an efficient and effective risk screen for PTSD and MDE following traumatic injury requiring hospitalization. This multi-institutional validation study creates a solid foundation for further exploration of the generalizability of this screen's psychometric properties in distinct populations.

LEVEL OF EVIDENCE

Prognostic study, level III.

Predicting suicidal behavior and self-harm after general hospitalization of adults with serious mental illness

Individuals with psychiatric disorders are vulnerable to adverse mental health outcomes following physical illness. This longitudinal cohort study defined risk profiles for readmission for suicidal behavior and self-harm after general hospitalization of adults with serious mental illness. Structured electronic health record data were analyzed from 15,644 general non-psychiatric index hospitalizations of individuals with depression, bipolar, and psychotic disorders admitted to an urban health system in the southwestern United States between 2006 and 2017. Using data from one-year prior to and including index hospitalization, supervised machine learning was implemented to predict risk of readmission for suicide attempt and self-harm in the following year. The Classification and Regression Tree algorithm produced a classification prediction with an area under the receiver operating curve (AUC) of 0.86 (95% confidence interval (CI) 0.74-0.97). Incidence of suicide-related behavior was highest after general non-psychiatric hospitalizations of individuals with prior suicide attempt or self-harm (18%; 69 cases/389 hospitalizations) and lowest after hospitalizations associated with very high medical morbidity burden (0 cases/3090 hospitalizations). Predictor combinations, rather than single risk factors, explained the majority of risk, including concomitant alcohol use disorder with moderate medical morbidity, and age ≤55-years-old with low medical morbidity. Findings suggest that applying an efficient and highly interpretable machine learning algorithm to electronic health record data may inform general hospital clinical decision support, resource allocation, and preventative interventions for medically ill adults with serious mental illness.

Understanding trajectories of underlying dimensions of posttraumatic psychopathology

BACKGROUND

Research suggests four modal trajectories of psychological symptoms after traumatic injury: Resilient, Chronic, Delayed Onset, Recovery. However, most studies focus on symptoms of psychiatric disorders (e.g., posttraumatic stress disorder, depression), which are limited by heterogeneity and symptom overlap. We examined trajectories of cross-cutting posttraumatic symptom dimensions following traumatic injury and predictors of trajectory membership.

METHODS

In this longitudinal study of 427 predominantly Hispanic/Latino traumatic injury survivors, posttraumatic psychopathology symptoms were assessed during hospitalization and approximately one and five months post-trauma. Using latent class growth analysis, we estimated trajectories of several posttraumatic symptom dimensions: re-experiencing, avoidance, anxious arousal, numbing, dysphoric arousal, loss, and threat. We then examined sociodemographic and trauma-related characteristics (measured during hospitalization) as predictors of trajectory membership for each dimension.

RESULTS

Four trajectories (Resilient, Chronic, Delayed Onset, Recovery) emerged for all dimensions except loss and threat, which manifested three trajectories (Resilient, Chronic, Delayed Onset). Across dimensions, membership in the Chronic (vs. Resilient) trajectory was consistently predicted by unemployment (7 of 7 dimensions), followed by older age (3/7), female sex (3/7), and assaultive trauma (2/7). For several dimensions, unemployment also distinguished between participants who presented with similar symptom levels days after trauma, but then diverged over time.

LIMITATIONS

Measures of posttraumatic symptom dimension constructs differed across assessments.

CONCLUSIONS

This study provides evidence of distinct trajectories across transdiagnostic symptom dimensions after traumatic injury. Employment status emerged as the most important predictor of trajectory membership. Research is needed to better understand the etiologies and consequences of these posttraumatic symptom dimension trajectories.

Pain, Depression, and Posttraumatic Stress Disorder Following Major Extremity Trauma Among United States Military Serving in Iraq and Afghanistan: Results From the Military Extremity Trauma and Amputation/Limb Salvage Study

OBJECTIVES

Assess the burden and co-occurrence of pain, depression, and posttraumatic stress disorder (PTSD) among service members who sustained a major limb injury, and examine whether these conditions are associated with functional outcomes.

DESIGN

A retrospective cohort study.

SETTING

Four U.S. military treatment facilities: Walter Reed Army Medical Center, National Naval Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego.

PATIENTS/PARTICIPANTS

Four hundred twenty-nine United States service members who sustained a major limb injury while serving in Afghanistan or Iraq met eligibility criteria upon review of their medical records.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASUREMENTS

Outcomes assessed were: function using the short musculoskeletal functional assessment; PTSD using the PTSD Checklist and diagnostic and statistical manual criteria; pain using the chronic pain grade scale.

RESULTS

Military extremity trauma and amputation/limb salvage patients without pain, depression, or PTSD, were, on average, about one minimally clinically important difference (MCID) from age- and gender-adjusted population norms. In contrast, patients with low levels of pain and no depression or PTSD were, on average, one to 2 MCIDs from population norms. Military extremity trauma and amputation/limb salvage patients with either greater levels of pain, and who experience PTSD, depression, or both, were 4 to 6 MCIDs from population norms. Regression analyses adjusting for injury type (upper or lower limb, salvage or amputation, and unilateral or bilateral), age, time to interview, military rank, presence of a major upper limb injury, social support, presence of mild traumatic brain injury/concussion, and combat experiences showed that higher levels of pain, depression, and PTSD were associated with lower one-year functional outcomes.

CONCLUSIONS

Major limb trauma sustained in the military results in significant long-term pain and PTSD. Overall, the results are consistent with the hypothesis that pain, depression, and PTSD are associated with disability in this population.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.