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Posttraumatic Stress Disorder (PTSD) and related comorbidities are endemic among injured trauma survivors (Bryant et al., 2010; O'Donnell et al., 2008; Shalev et al., 1998; Zatzick et al., 2007). Given that each year approximately 30 million American civilians are seen in emergency departments after injury and 1.5-2.5 million require hospitalization for the treatment of more severe injuries including traumatic brain injury (TBI) (National Center for Injury Prevention, 2012), the American College of Surgeons now recommends PTSD screening and intervention at US trauma centers as a best practice clinical guideline (American College of Surgeons Committee on Trauma, 2006, 2014; Love & Zatzick, 2014; Zatzick et al., 2004).  Effective intervention models that serve to initially engage injured trauma survivors, use care management to address post-injury concerns, address substance use problems, and then deliver evidence-based PTSD services are a crucial element of the early mental health response to trauma exposure (Agency for Healthcare Research & Quality, 2013; Kearns, Ressler, Zatzick, & Rothbaum, 2012; Roberts, Kitchiner, Kenardy, & Bisson). If effective, the efficient delivery of technology enhanced stepped collaborative care has the potential to enhance the reach and breadth of applicability of early PTSD intervention, and ultimately population impact (Koepsell, Zatzick, & Rivara, 2011).
 
The current investigation was a randomized effectiveness trial designed to assess whether injured patients participating in a technology enhanced stepped collaborative care protocol would demonstrate reductions in PTSD symptoms when compared to patients assigned to a usual care control condition. Technology enhancements included laptops delivered by the hospital bedside to all participants upon completion of the baseline interview. Participants were told to navigate the bookmarked home-page (www.afterdeployment.org) and were encouraged to connect with family via email or social media. Participants were aware of the laptop usage being tracked using a software monitoring program, with the majority of patients visiting social media sites. Along with the website, participants who owned Smartphones were asked to download the LifeArmor Smartphone app, created by the same agency as the AfterDeployment website (Defense Department’s National Center for Telehealth & Technology (T2), 2010). The continued technological enhancements for those participants randomized to intervention were walked through the AfterDeployment website one-on-one with the interventionist. The website and app were used simultaneously as the stepped measurement-based intervention was delivered.
 
Acutely injured trauma survivors admitted to the intensive and critical care inpatient wards of Harborview Medical Center, a Level I Trauma Center in Seattle, Washington who screened positive on an automated electronic medical record PTSD screen were randomized to the collaborative care intervention (n=60) or usual care control (n=61) condition. The automated screen, designed to be implementable with any robust EMR, identified patients with ≥ 3 of 10 elements related to risk of PTSD development, including: 1) EMR PTSD ICD diagnosis, 2) any other comorbid ICD psychiatric diagnosis, 3) any ICD substance use disorder, tobacco use or positive BAC on admission, 4) any chronic ICD medical comorbidities, 5) injury (E) code indicative of an intentional injury, 6) ICU admission during the current hospitalization, 7) any EMR documentation of prior trauma center inpatient hospitalizations, and 8-10) demographic characteristics including female sex, non-White ethnicity, and low income or veterans insurance status (Russo, Katon, & Zatzick, 2013). The stepped measurement-based intervention included care coordination, psychopharmacology, and psychotherapy elements embedded within care management assisting patients with the transition from inpatient to outpatient care. PTSD symptoms were assessed at baseline, 1-, 3-, and 6-months post-injury using the PTSD Check List–Civilian version (PCL-C) (Weathers, Litz, Herman, Huska, & Keane, 1994).
 
Longitudinal analyses using mixed effects random coefficient regression models indicated the information technology assisted collaborative care intervention was associated with modest PTSD symptom reductions (unadjusted regression, group by time interaction, F2,204 = 2.95, p = .055, ns, adjusted regression group by time interaction, F2,204 = 3.06, p = .049) and substantially less provider delivery time (median of 2.25 hours (interquartile range=1.57 hours) over previous trials (Zatzick et al., 2013).  At the six month post-injury time point 45% of intervention patients versus 30% of control patients demonstrated a ≥ 10 point reduction from baseline on the PCL-C (NNT = 6.5).
 
The intervention tested was multifaceted and the study was not designed to determine which components were specifically associated with reduction in PTSD symptoms. Future studies could test specific components of the intervention (e.g., pharmacotherapy, CBT elements, information technology enhancements) or attempt to factor out individual components of the intervention. Additionally, future early PTSD intervention studies that combine efficiencies in treatment introduced by information technology enhancements with more in-depth understanding of post-injury recovery trajectories (Galatzer-Levy et al., 2013; Osenbach et al., 2014) could simultaneously enhance PTSD treatment effects and early intervention efficiency, thus optimizing overall population impact.
 

Reference Article 

Zatzick, D., O'Connor, S. S., Russo, J., Wang, J., Bush, N., Love, J., . . . Van Eaton, E. (2015). Technology-Enhanced Stepped Collaborative Care Targeting Posttraumatic Stress Disorder and Comorbidity After Injury: A Randomized Controlled Trial. Journal of Traumatic Stress, 28(5), 391-400. doi: 10.1002/jts.22041

 

Discussion Questions

 

  1. How does the stepped information technology enhanced collaborative care intervention serve to enhance the breadth of applicability/reach of early PTSD interventions?
  2. What are the advantages of the delivery of cognitive behavioral therapeutic elements embedded within routine care management?
  3. How does the capacity of the American College of Surgeons’ to mandate broad reach PTSD intervention strategies impact the decision to field efficacy, effectiveness and implementation spectrum early intervention trials targeting PTSD in acute care medical settings?

 

Author Biography

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The Trauma Survivors Outcomes and Support (TSOS) clinical research team is headed up by Douglas Zatzick, MD. Over the past two decades Dr. Zatzick has developed a public health approach to trauma-focused research that has emphasized clinical epidemiologic, functional outcome, and early intervention studies of posttraumatic stress disorder (PTSD) and related co-morbid conditions including depression and alcohol and drug abuse, TBI and pre-injury chronic medical conditions. From 2009 to 2012, Dr. Zatzick served as Chairperson of the National Institute of Mental Health, Services in Non-specialty Settings (NIMH, SRNS) Study Section and also served on the congressionally mandated United States Institute of Medicine four-year ongoing assessment of PTSD treatment, and the World Health Organization Stress Disorders Guideline Development Group.
 

References Cited

Agency for Healthcare Research & Quality. (2013). Psychological and pharmacological treatments for adults with posttraumatic stress disorder (PTSD) Effective Health Care Program (Vol. 92, pp. 760). Rockville, MD.
American College of Surgeons Committee on Trauma. (2006). Resources for optimal care of the injured patient. Washington DC

American College of Surgeons Committee on Trauma. (2014). Resources for optimal care of the injured patient. Washington DC

Bryant, O'Donnell, Creamer, McFarlane, Clark, & Silove. (2010). The psychiatric sequelae of traumatic injury. American Journal of Psychiatry, 167(3), 312-320. doi: appi.ajp.2009.09050617 [pii] 10.1176/appi.ajp.2009.09050617Adolescent

Defense Department’s National Center for Telehealth & Technology (T2). (2010). AfterDeployment, from www.afterdeployment.org

Galatzer-Levy, Ankri, Freedman, Israeli-Shalev, Roitman, Gilad, & Shalev. (2013). Early PTSD symptom trajectories: persistence, recovery, and response to treatment: results from the Jerusalem Trauma Outreach and Prevention Study (J-TOPS). [Randomized Controlled Trial Research Support, Non-U.S. Gov't]. PloS one, 8(8), e70084. doi: 10.1371/journal.pone.0070084

Kearns, Ressler, Zatzick, & Rothbaum. (2012). Early interventions for PTSD: A review. Depression and Anxiety, 29(10), 833-842. doi: 10.1002/da.21997

Koepsell, Zatzick, & Rivara. (2011). Estimating the population impact of preventive interventions from randomized trials. American Journal of Preventive Medicine, 40(2), 191-198. doi: 10.1016/j.amepre.2010.10.022
Love, & Zatzick. (2014). Screening and Intervention for Comorbid Substance Disorders, PTSD, Depression, and Suicide: A Trauma Center Survey. Psychiatric Services. doi: 10.1176/appi.ps.201300399

National Center for Injury Prevention. (2012). Cost of injury reports. Atlanta.

O'Donnell, Creamer, Parslow, Elliott, Holmes, Ellen, . . . Bryant. (2008). A predictive screening index for posttraumatic stress disorder and depression following traumatic injury. Journal of Consulting and Clinical Psychology, 76(6), 923-932. doi: 10.1037/a0012918

Osenbach, Lewis, Rosenfeld, Russo, Ingraham, Peterson, . . . Zatzick. (2014). Exploring the Longitudinal Trajectories of Posttraumatic Stress Disorder in Injured Trauma Survivors. Psychiatry: Interpersonal and Biological Processes, 77(4), 386-397. doi: 10.1521/psyc.2014.77.4.386

Roberts, Kitchiner, Kenardy, & Bisson. (2009). Systematic review and meta-analysis of multiple-session early interventions following traumatic events. American Journal of Psychiatry, 166(3), 293-301. doi: appi.ajp.2008.08040590 [pii] 10.1176/appi.ajp.2008.08040590

Russo, Katon, & Zatzick. (2013). The development of a population-based automated screening procedure for PTSD in acutely injured hospitalized trauma survivors. General Hospital Psychiatry, 35(5), 485-491. doi: 10.1016/j.genhosppsych.2013.04.016

Shalev, Freedman, Peri, Brandes, Sahar, Orr, & Pitman. (1998). Prospective study of posttraumatic stress disorder and depression following trauma. American Journal of Psychiatry, 155(5), 630-637. doi: 10.1176/ajp.155.5.630

Weathers, Litz, Herman, Huska, & Keane. (1994). The PTSD checklist: Reliability, validity, and diagnostic utility. Paper presented at the International Society for Traumatic Stress Studies, San Antonio.

Zatzick, Jurkovich, Fan, Grossman, Russo, Katon, & Rivara. (2007). Posttraumatic stress and depressive symptoms as predictors of adolescent functional impairment after physical injury. Archives of Pediatrics and Adolescent Medicine, in press.

Zatzick, Jurkovich, Rivara, Russo, Wagner, Wang, . . . Katon. (2013). A randomized stepped care intervention trial targeting posttraumatic stress disorder for surgically hospitalized injury survivors. Annals of Surgery, 257(3), 390-399. doi: 10.1097/SLA.0b013e31826bc313

Zatzick, Roy-Byrne, Russo, Rivara, Droesch, Wagner, . . . Katon. (2004). A randomized effectiveness trial of stepped collaborative care for acutely injured trauma survivors. Archives of General Psychiatry, 61(5), 498-506. doi: 10.1001/archpsyc.61.5.498