Psychological debriefing and prevention of post-traumatic stress. More research is needed

Ketamine as a therapeutic agent in major depressive disorder and posttraumatic stress disorder: Potential medicinal and deleterious effects

Major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) are the most common causes of emotional distress that impair an individual's quality of life. MDD is a chronic mental illness that affects 300 million people across the world. Clinical manifestations of MDD include fatigue, loss of interest in routine tasks, psychomotor agitation, impaired ability to focus, suicidal ideation, hypersomnolence, altered psychosocial functioning, and appetite loss. Individuals with depression also demonstrate a reduced behavioral response while experiencing pleasure, a symptom known as anhedonia. Like MDD, PTSD is a prevalent and debilitating psychiatric disorder resulting from a traumatic incident such as sexual assault, war, severe accident, or natural disaster. Symptoms such as recalling event phases, hypervigilance, irritability, and anhedonia are common in PTSD. Both MDD and PTSD pose enormous socioeconomic burdens across the globe. The search for effective treatment with minimal side effects is still ongoing. Ketamine is known for its anesthetic and analgesic properties. Psychedelic and psychotropic effects of ketamine have been found on the nervous system, which highlights its toxicity. In this article, the effectiveness of ketamine as a potential therapeutic for PTSD and MDD along with its mechanisms of action, clinical trials, and possible side effects have been discussed.

Peer support in anaesthesia: Development and implementation of a peer-support programme within the Royal Brisbane and Women’s Hospital Department of Anaesthesia and Perioperative Medicine

Recent years have seen a shift in culture surrounding psychological wellbeing in doctors. As suicide continues to devastate medical families, friends and colleagues across the country, and significant rates of mental health issues persist, a greater focus on doctors’ psychological health has emerged. This, coupled with mounting evidence in favour of peer support, has driven the Royal Brisbane and Women’s Hospital Department of Anaesthesia and Perioperative Medicine to implement a unique peer support programme, which has been tailored to the needs of the perioperative environment. The programme provides a peer-driven, confidential, psychological safety net for all Royal Brisbane and Women’s Hospital anaesthetic staff. It focuses on collegial support in times of stress, as well as promoting a workplace culture of understanding for staff suffering psychological strain. The benefit of a formalised programme of this kind is that while staff have the option to obtain support at any time from a responder of their choosing, they do not need to seek it out actively in the event of a critical incident when it is automatically provided to them. Consultant anaesthetists trained in psychological first aid act as responders, offering support as well as resources and psychologist referral as required. It is our hope that its success will prompt other anaesthetic departments to continue the trend towards positive health strategies for doctors and implement similar programmes.

A Case Study of the Effects of Posttraumatic Stress Disorder on Operational Fire Service Personnel Within the Lancashire Fire and Rescue Service

BACKGROUND

Lancashire Fire and Rescue Service (LFRS), the subject of this evaluative research document employs 1400 people. 80% of employees are operational firefighters and officers whom operate across a range of duty systems and support functions, providing prevention, protection and emergency response to the communities of Lancashire.

METHODS

The overarching purpose of this epidemiological study is to assess the prevalence of post-traumatic stress disorder (PTSD) amongst operational LFRS personnel and to analyse the effects upon those who may be suffering from it, whether brought about by a single traumatic event or by repeated exposure to traumatic occurrences over a period of time. A combination of primary and secondary research was carried out. Primary data was collated using two recognised clinical questionnaires and statistical analysis was conducted with the aid of the software package SPSS.

RESULTS

The findings and statistical analysis showed that out of the 100 people surveyed, 30% of respondents had signs of probable distress. Of this quota, 4% showed symptoms of PTSD. The study considers how an organisation can recognise and manage PTSD and provides recommendations to assist in better recognising and managing the associated risks.

CONCLUSION

Based upon the findings, the authors conclude that the level of PTSD within LFRS is slightly lower than those found in other studies undertaken within the Fire and Rescue Service sector. The paper provides recommendations for future studies and a series of actions for consideration by LFRS senior management to improve PTSD support services for employees.

Personal safety when visiting patients in the community

Violence towards psychiatrists has been recognised as an occupational hazard for many years. With the development of community care it is increasingly likely to be encountered outside the hospital. To maximise personal safety in the community, psychiatrists need to be working in trusts in which an infrastructure to establish and maintain safety standards is in place.

Work-related well-being

This study aimed to investigate the different dimensions of well-being (namely, work engagement, job satisfaction, and psychological stress) and possible predictors such as personality and perceived organizational support. A cross-sectional survey design was used, with a sample of 490 ambulance personnel in the United Kingdom. Significant correlations were found between the dimensions of job satisfaction, engagement, and stress. The results also supported a hierarchical model with job satisfaction, stress, and engagement loading onto one higher order factor of work well-being. Emotional stability and perceived organizational support were identified as significant predictors of well-being. The findings suggest the importance of measuring the work-related well-being of ambulance personnel holistically and present perceived organizational support as a possible area for interventions to improve well-being.

Prevention of Post-Traumatic Stress Disorder After Trauma: Current Evidence and Future Directions

Post-traumatic stress disorder (PTSD) is a frequent, tenacious, and disabling consequence of traumatic events. The disorder's identifiable onset and early symptoms provide opportunities for early detection and prevention. Empirical findings and theoretical models have outlined specific risk factors and pathogenic processes leading to PTSD. Controlled studies have shown that theory-driven preventive interventions, such as cognitive behavioral therapy (CBT), or stress hormone-targeted pharmacological interventions, are efficacious in selected samples of survivors. However, the effectiveness of early clinical interventions remains unknown, and results obtained in aggregates (large groups) overlook individual heterogeneity in PTSD pathogenesis. We review current evidence of PTSD prevention and outline the need to improve the disorder's early detection and intervention in individual-specific paths to chronic PTSD.

The Effectiveness of EMDR in Reducing Psychological Distress in Survivors of Natural Disasters: A Review

Natural disasters affect whole communities both at an individual level as well as economically and socially. However, the impact of natural disasters on an individual’s mental health is substantial; yet, the response to one’s mental health needs after a disaster is underdeveloped. Nevertheless, the Humanitarian Assistance Programme has attempted to address these needs by providing eye movement desensitization and reprocessing (EMDR) to natural disaster survivors. This systematic review provides evidence for the effectiveness and efficacy of EMDR in the treatment of psychological distress in survivors of natural disasters. Of the 8 studies reviewed, 4 were controlled trials and 1 study part-controlled. All the studies demonstrated statistical and clinical significance in reducing posttraumatic stress disorder (PTSD) symptoms, anxiety, depression, and other distress experienced by survivors of natural disasters. In addition, 4 of the 8 studies demonstrated clinical significance after just 1 session, presenting EMDR as resource-, time-, and cost-efficient intervention. Theoretical framework, adaptation in intervention, methodological issues, and quality assessment of studies are discussed. Implications for future research and clinical practice are also discussed.

Randomized, Controlled Trial of Three Levels of Critical Incident Stress Intervention

Background:

Stress debriefing following exposure to a critical incident isbecoming more prevalent. Its aim is to prevent or minimize the development of excessive stress response symptoms that lead to loss of productivity or effectiveness in the workplace or at home. There is little evidence that any form of psychological debriefing is effective. This study evaluated the effectiveness of three intervention strategies, and attempted to correlate the symptoms with the severity of the incidentand level of intervention.

Methods:

A randomized, controlled trial of three levels of critical stress intervention was conducted in the British Columbia Ambulance Service (BCAS), in British Columbia, Canada, among paramedics and emergency medical technicians (EMTs), reporting critical incident stress. Outcomes were measured at one week (Stanford Acute Stress Reaction Questionnaire (SASRQ), the Life Impact Score (LIS), and Schedule of Recent Events (SRE)), and at three months and six months following the intervention (Impact of Events (IE), Coping Mechanisms, LIS, and SRE).

Results:

Fifty calls were received during the 26-month study period (<1 per 10,000 BCAS response calls): 23 were by third parties, but the involved EMT did not call;nine were placed by crew unwilling to participate in the study; 18 subjects enrolled, but six completed no forms. No correlation was found between severity of the incident and scores on the SASRQ, IE, or LIS, or between any of these scores. There was no consistent pattern in the stress scores over time.

Conclusion:

Requests for critical incident stress intervention were uncommon. The need for intervention may not be as great as generally is assumed. Further randomized trials, ideally multicenter studies, are indicated.

Critical Incident Stress Intervention After Loss of an Air Ambulance: Two-year Follow Up

Objective:

Following an air ambulance crash with five fatalities, critical incident stress debriefing (CISD) was provided for involved paramedics, physicians, and nurses. A study was conducted to evaluate the long-term effects of a critical incident with critical incident stress debriefing according to the Mitchell model.

Methods:

Six months following the incident, empirically designed questionnaires were mailed to all transport paramedics and directly involved medical staff, and a random sample of both nurses from the dispatch/receiving institution and paramedics from around the province. Twenty-four months post-incident, all members of the transport paramedics completed the Impact of Events Scale and the General Health Questionnaires.

Results:

There were no differences between groups on any scores, except for disturbed sleep patterns, bad dreams, and the need for personal counseling being greater among transport paramedics at one day. There was no correlation between how well the deceased individuals were known, amount of debriefing, and symptom severity. A trend was seen for those with pre-existing stress management routines to have less severe symptoms at six months (p = 0.07). At two years, 16% of transport paramedics still had significant abnormal behavior.

Conclusion:

CISD did not appear to affect the severity of stress symptoms, whereas having pre-existing stress management strategies may. These findings give justification for proceeding to a randomized, controlled trial of different levels of critical incident stress intervention.

An Evaluation of a Police Debriefing Programme: Outcomes for Police Officers Five Years after a Police Shooting

To evaluate the effectiveness of a debriefing programme to reduce traumatic stress in a police organisation, officers involved in a shooting were surveyed by questionnaire, five years after the event. The results showed that 79 per cent of 57 officers had not received debriefing, despite its mandatory status. Those who had received debriefing had higher post-traumatic stress disorder (PTSD) scores; however, regression of PTSD and health scores, on stress perceptions, social support, other trauma, and debriefing, showed that debriefing had no significant effect. These results support those of other controlled studies suggesting that debriefing does not mitigate PTSD and may exacerbate symptoms. A number of limitations of the present study are discussed in terms of suggestions for urgent evaluation of such programs in organisational settings.

Workplace violence on workers caring for long-term institutionalized schizophrenic patients in Taiwan

It has been noted that workplace violence most frequently occurs in psychiatric settings. The purpose of this study was to explore the workplace violence, including violence situation, victims' feeling, and the prevention strategies, on workers caring for long-term institutionalized schizophrenic patients in Taiwan. We conducted a face-to-face, in-depth, and semi-structured interview with 13 health care workers suffering from physical violence and/or sexual harassment by patients in 2002. First, the interviews were taped and/or paper-notes recorded, then transcribed, organized, and analyzed. Results found that all of the victims alleged they did not receive enough post-incident support, and more than a half of the victims could not call others for help during the violence. To avoid further attack, most victims offered prevention strategies which were considered valuable for establishing guidelines. However, some victims regarded workplace violence as inevitable and part of the job. The most common situations of workplace violence were during routine ward inspections, especially when the victims were alone. The most serious psychological harm was post-traumatic stress disorder (PTSD). In conclusion, we recommended a re-engineering of the organization to a supportive and safe working environment for prevention of workplace violence in the study hospital.

Postnatal Debriefing Interventions to Prevent Maternal Mental Health Problems After Birth: Exploring the Gap Between the Evidence and UK Policy and Practice

BACKGROUND

Postnatal mental health problems range from transient psychological problems to depression, anxiety, psychosis, and post-traumatic stress disorder (PTSD). Debriefing is a structured psychological intervention to prevent postnatal psychological problems, particularly PTSD and depression. Many UK maternity service providers have established postnatal debriefing services, in some cases supported by policy, despite a lack of robust evidence. In this article, current evidence of the effectiveness of postnatal debriefing and the availability and current provision of debriefing offered in UK maternity services is described.

METHODS

A structured literature review was undertaken.

FINDINGS

Eight randomized controlled trials were conducted to evaluate debriefing or counseling interventions in childbirth settings, and seven studies were done to evaluate debriefing or counseling interventions provided within UK maternity services or describe the availability of such services. Results of six RCTs were that no differences in outcomes were found, one report indicated possible harm from debriefing, and two indicated a positive association related to a psychological intervention. Methodological issues might account for differing trial outcomes. No standard intervention was used in any RCTs or service interventions. Confusion apparently exists in use of the term "debriefing" in UK maternity service policy and practice. Although service evaluations showed that women valued opportunities to discuss their birth, evidence to support the content and timing of service provision and effectiveness of this was lacking.

DISCUSSION

It might be appropriate to consider offering women an opportunity to discuss their childbirth experience and to differentiate this discussion from the offer of a formal debriefing, which is unsupported by evidence. IMPLICATIONS FOR PRACTICE/CONCLUSION: Midwives and other health care professionals who provide opportunities for women to talk about childbirth should be clear about terms used to describe the intervention, as well as the purpose and content of this. Differentiating between women who perceive their experience of childbirth as traumatic and those who develop symptoms of PTSD (for whom specific treatment may be required) is important. All health care professionals should be aware of the signs and symptoms of mental health problems after birth, which may include depression, anxiety, or psychosis in addition to PTSD.

Community mental health response to crisis

Mental health is seen as an important aspect in the community response to crisis and disaster. Research offers limited guidance to what interventions are likely to be effective in preventing postdisaster mental health problems. This article reviews recommended elements of mental health responses to community disasters. Different factors influencing response are illustrated by using 9/11 and Hurricane Katrina as examples. Clinical suggestions for community planning and actions of individual psychologists conclude the article.

Disseminating early interventions following trauma

Dissemination of effective early interventions following trauma is necessary to ensure the provision of the best possible care in a timely manner. To achieve this, agreement from all key stakeholders is required regarding the messages to be disseminated and the means of dissemination. This article is based on a National Institute of Mental Health sponsored symposium on the dissemination of early interventions at the 21st annual meeting of the International Society for Traumatic Stress Studies in Toronto in 2005. The current knowledge base regarding the effectiveness and dissemination of early interventions (defined here as those that are begun within the first 3 months after exposure) following trauma for children, adolescents, and adults is considered.

Debriefing after critical incidents for anaesthetic trainees

This survey investigated the need, and the availability, of debriefing after critical incidents for training anaesthetists. A cross-sectional postal survey of all Australian anaesthetic trainees was conducted in May 2002. Four hundred and nineteen responses were analysed (response rate 64%). Debriefing after a critical incident was perceived by most trainees to be useful, however 36% (n = 149) had never been debriefed. Trainees ranked their preferred content for a debriefing as 'anaesthetic issues' followed by the 'psychological impact of the incident' 'patient issues' and 'surgical issues'. Almost half of respondents reported that they did not feel supported by their anaesthetic department after a negative outcome incident. Trainees who had debriefings were more likely to feel supported by senior colleagues. Debriefing after critical incidents should be an integral part of the supervision of anaesthetic trainees.

A randomised controlled trial to determine the effectiveness of an early psychological intervention with children involved in road traffic accidents

OBJECTIVE

To determine whether an early intervention using a psychological debriefing format is effective in preventing psychological distress in child road traffic accident survivors.

DESIGN

Randomised controlled trial.

SETTING

Accident and Emergency Department, Royal United Hospital, Bath.

SUBJECTS

158 children aged 7-18. Follow-up assessment completed eight months post accident with 132 (70/82 of the experimental group and 62/76 in the control group).

MAIN OUTCOME MEASURES

Self-completed measures of psychological distress; fulfilment of diagnostic criteria for post-traumatic stress disorder.

RESULTS

Children in both groups demonstrated considerable improvements at follow-up. The early intervention did not result in any additional significant gains.

CONCLUSIONS

Although children in this study made significant improvements it is unclear whether these are better or worse than natural recovery rates. The specific intervention did not result in additional gains although the structured assessment provided for both groups may have been helpful in reducing subsequent pathology.

Disaster Care: Psychological Considerations

Disasters are tragic events that disrupt the normal functioning ofa community and overwhelm personal and community resources. The people who experience or simply witness traumatic events can be affected emotionally and develop a range of physical and emotional responses, which in turn can produce psychological, social, and physiological dysfunction. The challenge for health care providers is to recognize the range of emotions and to be able to identify when professional help is indicated. This article provides an overview of the human stress response and describes sources of stress that follow disasters, acute stress disorder, post-traumatic stress disorder, and interventions and resources used to care for victims after disasters.

Early Psychosocial and Pharmacological Interventions After Traumatic Events

1. There is no evidence to suggest that routine provision of single-session psychological interventions after traumatic events prevents the development of psychological sequelae. Some such evidence exists regarding multiple-session, cognitive-behavioral interventions. 2. There is no evidence to suggest that routine use of pharmacological agents prevents development of psychological sequelae in traumatized individuals. 3. Given the current evidence base, development of stepped-care programs focusing on education, screening, and treatment is warranted. 4. Currently, the main role of mental health professionals early on is to ensure emotionally supportive systems of care are in place, which will help identify individuals who appear most distressed so evidence-based interventions can be offered.

Views of nursing staff on the use of physical restraint

A postal questionnaire survey was employed in regional secure and psychiatric intensive care units in England and Wales, in respect of mental health nurses' training in the use of physical restraint. The nurses' views were sought relating to their last experience of implementing the procedure. Whilst most nurses (n = 259, 96.3%) reported positive outcomes in so far that the incident was brought under control, the views of the aftereffects of the procedure were of concern and ambivalence. The literature suggests that service users did not necessarily hold the same positive views. A range of alternatives, which were consistent with the literature, was made by staff to improve intervention in the management of violence. Negative aspects relating to the use of physical restraint were also highlighted. They included procedural, injury, clinical and management issues. Some respondents also expressed concerns about the negative attitudes of their colleagues. The findings of this aspect of the survey highlights that the therapeutic value of physical restraint can only be achieved with appropriate monitoring and with emphasis on psychological intervention in the prevention and management of violence.

Single-session early psychological interventions following traumatic events

Single-session early psychological interventions became widely advocated during the 1980s and 1990s as a way to prevent the development of psychological sequalae following traumatic events. There have now been 13 randomised controlled trials of single-session interventions within 1 month of a traumatic event. Notwithstanding their methodological shortcomings and clinical heterogeneity, the results are neutral overall in terms of clinical effectiveness. Possible explanations include a failure to encourage individuals' personal coping mechanisms and defence mechanisms and that insufficient time was allowed for habituation to intense exposure to occur. With the present evidence, the routine use of single-session interventions following traumatic events cannot be justified. This does not mean that there should be nothing offered, as many individuals involved in traumatic events clearly have emotional needs. Hopefully, future research will identify alternative forms of early intervention that prove useful to those individuals who would otherwise develop more significant psychological difficulties.

Critical incident stress management (CISM): benefit or risk for emergency services?

BACKGROUND

Critical incident stress management (CISM) has become a common practice in modern emergency services. Described in 1983 as critical incident stress debriefing (CISD), CISM was originally marketed to help emergency personnel deal with ostensibly stressful situations they would encounter as a part of their work.

OBJECTIVE

To review the status of the medical and psychological literature regarding the efficacy and safety of CISM.

METHODS

Several pertinent databases were accessed and searched for scientific articles pertaining to CISM. These were subsequently analyzed for methodology and pertinence to the study topic.

RESULTS

Numerous scientific articles were found concerning CISM. Several high-quality studies were identified, but many other studies lacked adequate methodology sufficient for use in an evidence-based medicine approach. Others were from trade magazines, non-refereed journals, and obscure mental health journals. Several meta-analyses and randomized controlled trials (RCTs) were found. Overall, these studies show that, at best, CISM has no effect on preventing psychiatric sequelae following a traumatic event, particularly post-traumatic stress disorder (PTSD). Furthermore, several studies report possible paradoxical worsening of stress-related symptoms in patients and personnel receiving CISM.

CONCLUSIONS

Despite the limitations of the existing literature base, several meta-analyses and RCTs found CISM to be ineffective in preventing PTSD. Several studies found possible iatrogenic worsening of stress-related symptoms in persons who received CISM. Because of this, CISM should be curtailed or utilized only with extreme caution in emergency services until additional high-quality studies can verify its effectiveness and provide mechanisms to limit paradoxical outcomes. It should never be a mandatory intervention.

Interventions for post-traumatic stress disorder and psychological distress in emergency ambulance personnel: a review of the literature

A literature review was carried out to establish the extent of the literature on interventions for psychological distress and post-traumatic stress disorder in emergency ambulance personnel. A total of 292 articles were identified. Of these, 10 were relevant to this review. The primary intervention used with this population was critical incident stress debriefing, although there was some debate in the literature about the effectiveness of this intervention and the quality of the research conducted. More high quality research is needed on critical incident stress debriefing before being confident of its effectiveness.

Research on psychiatric outcomes and interventions subsequent to disasters: a review of the literature

Tragic events such as those of September 11, 2001, underscore the increasingly prominent role that psychiatrists play in aiding survivors, emergency workers, and broader communities to cope with disaster. The present review was undertaken to identify whether there exists a scientific basis for the practice of psychiatry in the aftermath of disasters. Most of the extensive literature over the past 30 years suggests that disasters have psychopathological consequences as well as medical and social ones. Pre-existing mood and anxiety disorders, although surprisingly not psychotic illness, appear to be risk factors for further psychopathology after a disaster. Thus, both acute psychopharmacological and psychotherapeutic interventions at disaster sites may prevent long-term sequelae, although their efficacy remains uncertain. Future controlled treatment trials are needed to determine the optimal treatment strategy.

Critical Incident Stress Management (CISM): a statistical review of the literature

Crisis intervention has emerged over the last 50 years as a proven method for the provision of urgent psychological support in the wake of a critical incident or traumatic event. The history of crisis intervention is replete with singular, time-limited interventions. As crisis intervention has evolved, more sophisticated multicomponent crisis intervention systems have emerged. As they have appeared in the extant empirically-based literature, their results have proven promising. A previously published paper narratively reviewed the Critical Incident Stress Management (CISM) model of multicomponent crisis intervention. The purpose of this paper was to offer a statistical review of CISM as an integrated multicomponent crisis intervention system. Using the methodology of meta-analysis, a review of eight CISM investigations revealed a Cohen's d of 3.11. A fail-safe number of 792 was similarly obtained.

The World Trade Center attack. Helping the helpers: the role of critical incident stress management

Healthcare and prehospital workers involved in disaster response are susceptible to a variety of stress-related psychological and physical sequelae. Critical incident stress management, of which critical incident stress debriefing is a component, can mitigate the response to these stressors. Critical incident stress debriefing is a peer-driven, therapist-guided, structured, group intervention designed to accelerate the recovery of personnel. The attack on the World Trade Center, and the impact it may have on rescue, prehospital, and healthcare workers, should urge us to incorporate critical incident stress management into disaster management plans.

Effectiveness of psychological debriefing

OBJECTIVE

To identify literature concerning the effectiveness of psychological debriefing (PD) and analyse results according to different criteria of success and different uses of the intervention format.

METHOD

Literature search was made in databases PubMed, PsycInfo and Psychlit. Twenty-five studies were selected for a thorough description. Forty-two studies provided additional information.

RESULTS

Results indicate that, in general, debriefing does not prevent psychiatric disorders or mitigate the effects of traumatic stress, even though people generally find the intervention helpful in the process of recovering from traumatic stress. The intervention holds potential as a screening procedure, and there may be economic arguments for continued use. When used with adherence to traditional descriptions of treatment group, events, group format, leadership and time spent, a preventive effect emerges. No tendency according to timing was found.

CONCLUSION

Current uses of PD are problematic. The concept needs to be redefined, and the scope of application must be revised. The objectives for use need to be clarified.

Effect of timing of critical incident stress debriefing (CISD) on posttraumatic symptoms

Seventy-seven civilian employees who were victims of robbery were randomly assigned to either an immediate (< 10 hr) or delayed (> 48 hr) debriefing group, using the J. Mitchell (1983) CISD protocol. Scores on the Posttraumatic Stress Diagnostic Scale were obtained at 4 time intervals: debrief, 2 and 4 days post-debrief, and 2 weeks postrobbery. The number and severity of symptoms did not differ at debrief, but were lower for the immediate than for the delayed group at each subsequent time interval. The number and severity of symptoms declined across time intervals; however, although this reduction was pronounced for the immediate group it was minimal for the delayed group. The results supported use of immediate debriefing with this type of incident and victim.

Psychological debriefing: controversy and challenge

OBJECTIVE

The efficacy of psychological debriefing following potentially traumatising events has become extremely controversial. This review aims to identify the issues underlying this controversy and their theoretical, social and political ramifications which are important in other areas of psychiatry and the social sciences.

METHOD

The historical background to the debriefing debate and the (largely negative) results of recent randomised controlled trials (RCTs) are reviewed.

RESULTS

Despite the negative results of recent RCTs, psychological debriefing remains the most widely used structured intervention following potentially traumatising events, designed to reduce the incidence of long-term psychiatric morbidity. The clinical relevance these trials and their applicability in vivo is questioned. There are implicit difficulties in conducting rigorous randomised controlled trials of group debriefing, and such trials may be unachievable.

CONCLUSIONS

Demonstrating the efficacy of debriefing or other preventive interventions presents major challenges to investigators and it is unlikely the controversy will be resolved in the near future.

Randomised controlled trial of midwife led debriefing to reduce maternal depression after operative childbirth

OBJECTIVE

To assess the effectiveness of a midwife led debriefing session during the postpartum hospital stay in reducing the prevalence of maternal depression at six months postpartum among women giving birth by caesarean section, forceps, or vacuum extraction.

DESIGN

Randomised controlled trial.

SETTING

Large maternity teaching hospital in Melbourne, Australia.

PARTICIPANTS

1041 women who had given birth by caesarean section (n= 624) or with the use of forceps (n= 353) or vacuum extraction (n= 64).

MAIN OUTCOME MEASURES

Maternal depression (score >/=13 on the Edinburgh postnatal depression scale) and overall health status (comparison of mean scores on SF-36 subscales) measured by postal questionnaire at six months postpartum.

RESULTS

917 (88%) of the women recruited responded to the outcome questionnaire. More women allocated to debriefing scored as depressed six months after birth than women allocated to usual postpartum care (81 (17%) v 65 (14%)), although this difference was not significant (odds ratio=1.24, 95% confidence interval 0.87 to 1.77). They were also more likely to report that depression had been a problem for them since the birth, but the difference was not significant (123 (28%) v 94 (22%); odds ratio=1. 37, 1.00 to 1.86). Women allocated to debriefing had poorer health status on seven of the eight SF-36 subscales, although the difference was significant only for role functioning (emotional): mean scores 73.32 v 78.98, t= -2.31, 95% confidence interval -10.48 to -0.84).

CONCLUSIONS

Midwife led debriefing after operative birth is ineffective in reducing maternal morbidity at six months postpartum. The possibility that debriefing contributed to emotional health problems for some women cannot be excluded.

Psychological debriefing for road traffic accident victims. Three-year follow-up of a randomised controlled trial

BACKGROUND

Psychological debriefing is widely used for trauma victims but there is uncertainty about its efficacy. We have previously reported a randomised controlled trial which concluded that at 4 months it was ineffective.

AIMS

To evaluate the 3-year outcome in a randomised controlled trial of debriefing for consecutive subjects admitted to hospital following a road traffic accident.

METHOD

Patients were assessed in hospital by the Impact of Event Scale (IES), Brief Symptom Inventory (BSI) and questionnaire and re-assessed at 3 months and 3 years. The intervention was psychological debriefing as recommended and described in the literature.

RESULTS

The intervention group had a significantly worse outcome at 3 years in terms of general psychiatric symptoms (BSI), travel anxiety when being a passenger, pain, physical problems, overall level of functioning, and financial problems. Patients who initially had high intrusion and avoidance symptoms (IES) remained symptomatic if they had received the intervention, but recovered if they did not receive the intervention.

CONCLUSIONS

Psychological debriefing is ineffective and has adverse long-term effects. It is not an appropriate treatment for trauma victims.

Brief psychological interventions ("debriefing") for trauma-related symptoms and the prevention of post traumatic stress disorder

OBJECTIVES

To assess the effectiveness of brief psychological debriefing for the management of psychological distress after trauma, and the prevention of post traumatic stress disorder.

SEARCH STRATEGY

Electronic searching of MEDLINE, EMBASE, PsychLit, PILOTS, Biosis, Pascal, Occ.Safety and Health, CDSR and the Trials Register of the Depression, Anxiety and Neurosis group. Hand search of Journal of Traumatic Stress. Contact with leading researchers.

SELECTION CRITERIA

The inclusion criteria for all randomized studies was that they should focus on persons recently (one month or less) exposed to a traumatic event, should consist of a single session only, and that the intervention involve some form of emotional processing/ventilation by encouraging recollection/reworking of the traumatic event accompanied by normalisation of emotional reaction to the event.

DATA COLLECTION AND ANALYSIS

8 trials fulfilled the inclusion criteria. Quality was generally poor. Data from two trials could not be synthesised.

MAIN RESULTS

Single session individual debriefing did not reduce psychological distress nor prevent the onset of post traumatic stress disorder (PTSD). Those who received the intervention showed no significant short term (3-5 months) in the risk of PTSD (pooled odds ratio 1.0, 95% ci 0.6-1.8). At one year one trial reported that there was a significantly increased risk of PTSD in those receiving debriefing (odds ratio 2.9, 95% ci 1.1-7.5). The pooled odds ratio for the two trials with follow ups just included unity (odds ratio 2.0, 95% ci 0.9-4.5). There was also no evidence that debriefing reduced general psychological morbidity, depression or anxiety.

REVIEWER'S CONCLUSIONS

There is no current evidence that psychological debriefing is a useful treatment for the prevention of post traumatic stress disorder after traumatic incidents. Compulsory debriefing of victims of trauma should cease.

Supporting nursing staff exposed to violence at work

An individual nurses risk of experiencing violence will vary related to his or her area of practice, role and work setting. The available evidence suggests that good practice in environmental design, security management and staff training may reduce but will not eliminate the probability of nurses experiencing assault. If we cannot prevent all violence then we must consider how we best support those who may be exposed to it. This paper thus explores the research on the effects of violence on nurses and critically examines the literature on staff support.

An 18-month longitudinal study of posttraumatic disorders in children who were taken hostage in their school

OBJECTIVE

The objective of our investigation was to study the course of direct and indirect posttraumatic disorders over 18 months in children after they were taken hostage in their school.

METHODS

Twenty-six young hostages were evaluated by using standardized clinical interviews and self-administered questionnaires (State and Trait Anxiety Inventory for Children [STAIC]and Revised Impact of Event Scale [IES]) 2, 4, 7, and 18 months after the event. They were compared with 21 children from the same school who were not taken hostage (indirect exposure).

RESULTS

Symptoms of acute stress were observed in 25 (96%) of the children who were directly involved in the traumatic event. After 2 months, 18 children had developed disorders according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, including 7 cases of full posttraumatic stress disorder (PTSD), 11 cases of subclinical PTSD, 3 cases of separation anxiety, 1 case of specific phobia, and 2 cases of major depressive disorder. Anxiety scores (STAIC) decreased between 2 and 4 months and then stabilized, whereas symptoms of avoidance (IES-avoidance) decreased gradually throughout the follow-up period, and symptoms of repetition (IES-intrusion) decreased less markedly. Children who were indirectly exposed to the trauma also manifested protracted posttraumatic symptomatology (two full cases of PTSD and six cases of subclinical PTSD), but their IES-intrusion scores were significantly lower at 7 months than those of children who were directly exposed, and the severity of their symptoms diminished over time. Girls tended to show a higher level of anxiety and more features of intrusion than boys. Psychological debriefing did not prevent occurrence of the disorders, but children who were not debriefed had the worst outcomes.

CONCLUSIONS

Even after a short event and even if they are not directly exposed, children under the age of 9 years can develop high rates of posttraumatic disorders that follow a protracted course despite early intervention and careful monitoring.

Individual differences in posttraumatic distress: problems with the DSM-IV model

OBJECTIVE

To evaluate the evidence concerning the role of threatening life events in accounting for clinically significant posttraumatic stress responses.

METHOD

Research was examined to review the epidemiology, evidence of dose-response relations, and individual difference factors in accounting for variations in conditions, including posttraumatic stress disorder, after exposure to threatening events.

RESULTS

The evidence is significantly discrepant from the clinical Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) model. Greater distress arises from individual differences than from event characteristics. Important individual differences that interact with threat exposures include trait negative affectivity (neuroticism); beliefs about emotions, the self, the world, and the sources and consequences of danger; and prevent acts, disorders, and intelligence. Reasons for the discrepancies between the evidence and the current model of posttraumatic distress are proposed.

CONCLUSION

In accounting for responses to threatening life events, the relatively minor contribution of event qualities compared with individual differences has significant treatment implications. Treatment approaches assuming that toxic event exposure creates a posttraumatic disorder fail to consider individual differences that could improve treatment efficacy.

PTSD in ambulant RTA victims: a randomized controlled trial of debriefing

This report examines initial distress levels, course of symptoms, incidence of posttraumatic stress disorder (PTSD), predictors of short-term outcome, and value of prophylactic counseling in a consecutive series of 40 ambulant trauma clinic attenders with minor road traffic accident (RTA) injuries. Subjects were randomly allocated to intervention and monitoring groups following assessment at a mean of 7 days posttrauma and reassessed at 3 months using a variety of standard rating scales. Seventy-five percent reported significant levels of distress at 1 week posttrauma. By 3 months this had decreased sharply to 35%, and 22% were significantly impaired by clinical assessment. Incidence of PTSD over 3 months was estimated at 19% and point prevalence at 3 months posttrauma was 9%. High initial distress, increasing age, and high levels of perceived threat were significant independent predictors of morbidity, and no significant differences in outcome were found between intervention and monitoring groups at 3 months.