Alex Holmes

A predictive screening index for posttraumatic stress disorder and depression following traumatic injury.

Posttraumatic stress disorder (PTSD) and major depressive episode (MDE) are frequent and disabling consequences of surviving severe injury. The majority of those who develop these problems are not identified or treated. The aim of this study was to develop and validate a screening instrument that identifies, during hospitalization, adults at high risk for developing PTSD and/or MDE. Hospitalized injury patients (n = 527) completed a pool of questions that represented 13 constructs of vulnerability. They were followed up at 12 months and assessed for PTSD and MDE. The resulting database was split into 2 subsamples. A principal-axis factor analysis and then a confirmatory factor analysis were conducted on the 1st subsample, resulting in a 5-factor solution. Two questions were selected from each factor, resulting in a 10-item scale. The final model was cross-validated with the 2nd subsample. Receiver-operating characteristic curves were then created. The resulting Posttraumatic Adjustment Scale had a sensitivity of .82 and a specificity of .84 when predicting PTSD and a sensitivity of .72 and a specificity of .75 in predicting posttraumatic MDE. This 10-item screening index represents a clinically useful instrument to identify trauma survivors at risk for the later development of PTSD and/or MDE.

Illness perception and health-related quality of life in multiple sclerosis

Aims –  A number of physical and psychological factors have been shown to affect health‐related quality of life (HRQoL) in patients with multiple sclerosis (MS). Among these, the role of illness perceptions has not been established as an independent factor. This study, the first of its kind in an Australian population, aimed to use a large sample to determine the relative importance of individual factors to each domain of HRQoL, in particular the role of illness perception.

Disability After Injury: The Cumulative Burden of Physical and Mental Health

CONTEXT Injury is one of the leading contributors to the global burden of disease. The factors that drive long-term disability after injury are poorly understood. OBJECTIVE The main aim of the study was to model the direct and indirect pathways to long-term disability after injury. Specifically, the relationships between 3 groups of variables and long-term disability were examined over time. These included physical factors (including injury characteristics and premorbid disability), pain severity (including pain at 1 week and 12 months), and psychiatric symptoms (including psychiatric history and posttraumatic stress, depression, and anxiety symptoms at 1 week and 12 months). DESIGN, SETTING, AND PARTICIPANTS A multisite, longitudinal cohort study of 715 randomly selected injury patients (from April 2004 to February 2006). Participants were assessed just prior to discharge (mean = 7.0 days, SD = 7.8 days) and reassessed at 12 months postinjury. Injury patients who experienced moderate/severe traumatic brain injury and spinal cord injury were excluded from the study. MAIN OUTCOME MEASURE The World Health Organization Disability Assessment Schedule 2.0 was used to assess disability at 12 months after injury. RESULTS Disability at 12 months was up to 4 times greater than community norms, across all age groups. The development and maintenance of long-term disability occurred through a complex interaction of physical factors, pain severity across time, and psychiatric symptoms across time. While both physical factors and pain severity contributed significantly to 12-month disability (pain at 1 week: total effect [TE] = 0.2, standard error [SE] < 0.1; pain at 12 months: TE = 0.3, SE < 0.1; injury characteristics: TE = 0.3, SE < 0.1), the total effects of psychiatric symptoms were substantial (psychiatric symptoms 1 week: TE = 0.30, SE < 0.1; psychiatric symptoms 12 months: TE = 0.71, SE < 0.1). Taken together, psychiatric symptoms accounted for the largest proportion of the variance in disability at 12 months. CONCLUSIONS While the physical and pain consequences of injury contribute significantly to enduring disability after injury, psychiatric symptoms play a greater role. Early interventions targeting psychiatric symptoms may play an important role in improving functional outcomes after injury.

Stepped early psychological intervention for posttraumatic stress disorder, other anxiety disorders, and depression following serious injury

The best approach for implementing early psychological intervention for anxiety and depressive disorders after a traumatic event has not been established. This study aimed to test the effectiveness of a stepped model of early psychological intervention following traumatic injury. A sample of 683 consecutively admitted injury patients were screened during hospitalization. High-risk patients were followed up at 4-weeks postinjury and assessed for anxiety and depression symptom levels. Patients with elevated symptoms were randomly assigned to receive 4-10 sessions of cognitive-behavioral therapy (n = 24) or usual care (n = 22). Screening in the hospital identified 89% of those who went on to develop any anxiety or affective disorder at 12 months. Relative to usual care, patients receiving early intervention had significantly improved mental health at 12 months. A stepped model can effectively identify and treat injury patients with high psychiatric symptoms within 3 months of the initial trauma.

Posttraumatic stress disorder after injury: does admission to intensive care unit increase risk?

BACKGROUND This study aimed to index the prevalence of posttraumatic stress disorder (PTSD) after injury requiring intensive care unit (ICU) admission to investigate whether an ICU admission after injury increases risk for PTSD and to identify predictors of PTSD after ICU admission. METHODS A two-group (those admitted to the ICU vs. those not admitted to ICU), prospective, cohort study of 829 randomly selected injury patients from five major trauma hospitals across Australia. We collected information on factors that may increase risk for PTSD including demographic variables (gender, age, income, education, and marital status), preinjury mental health status (prior trauma, psychiatric history, and prior social support), and injury characteristics (mild traumatic brain injury, injury severity, length of hospital admission, discharge destination, pain, and perceived threat). PTSD was measured at 12 months by structured clinical interview. RESULTS ICU patients were significantly more likely to have PTSD at 12 months than trauma controls (17% vs. 7%). Stepwise logistic regressions showed that an ICU admission significantly contributed to the development of PTSD after controlling for demographic, preinjury mental health status, and injury characteristic variables. CONCLUSIONS Injury patients are three times more likely to develop later PTSD if they have an ICU admission. Given we controlled for many risk variables, it seems that an ICU admission itself may contribute to the development of PTSD. Mental health services such as screening and early intervention may be particularly useful for this population.

Depression and chronic pain

Chronic pain and major depression commonly occur together. Major depression in patients with chronic pain is associated with decreased function, poorer treatment response and increased health care costs. The experience and expression of chronic pain vary between individuals, reflecting complex and changing interactions between physical, psychological and social processes. The diagnosis of major depression in patients with chronic pain requires differentiation between the symptoms of pain and symptoms of physical illness. Antidepressants and psychological therapies can be effective and should be delivered as part of a coordinated, cohesive, multidisciplinary pain management plan.

Predictors of Pain Severity 3 Months after Serious Injury

OBJECTIVE Injury is a common initiating event for persistent pain. The presentation of injured patients to hospital represents an opportunity to identify patients at high risk of persistent pain and triage them to early intervention. Although a range of physical, psychological, and social risk factors have been implicated in the transition from acute to persistent pain, these factors have not been tested concurrently in a prospective study. This study aimed to determine the degree to which pain severity at 3 months can be predicted at the time of injury and which independent factors predicted pain severity. DESIGN A large prospective cohort study was conducted recruiting patients from two trauma hospitals during their acute admission. Patients were assessed with a comprehensive battery of known and possible risk factors for persistent pain. Patients were assessed for pain severity on a visual analog scale over the past 24 hours at 3 months. RESULTS Two hundred ninety patients were recruited, and 242 were followed up at 3 months. Older age, female gender, past alcohol dependence, lower physical role function, pain severity, amount of morphine equivalents administered on the day of assessment, and pain control attitudes predicted pain severity at 3 months. The variance attributed to these factors was 22%. CONCLUSIONS Injured patients with a number of these factors may warrant increased monitoring and early triage to specialist pain services.

Trial of interpersonal counselling after major physical trauma.

Objective: The purpose of the present study was to determine if interpersonal counselling (IPC) was effective in reducing psychological morbidity after major physical trauma. Methods: One hundred and seventeen subjects were recruited from two major trauma centres and randomized to treatment as usual or IPC in the first 3 months following trauma. Measures of depressive, anxiety and post-traumatic symptoms were taken at baseline, 3 months and 6 months. The Structured Clinical Interview for DSM IV diagnoses was conducted at baseline and at 6 months to assess for psychiatric disorder. Results: Fifty-eight patients completed the study. Only half the patients randomized to IPC completed the therapy. At 6 months the level of depressive, anxiety and post-traumatic symptoms and the prevalence of psychiatric disorder did not differ significantly between the intervention and treatment-as-usual groups. Subjects with a past history of major depression who received IPC had significantly higher levels of depressive symptoms at 6 months. Conclusion: IPC was not effective as a universal intervention to reduce psychiatric morbidity after major physical trauma and may increase morbidity in vulnerable individuals. Patient dropout is likely to be a major problem in universal multi-session preventative interventions.

Use of antipsychotic medications for the management of delirium: an audit of current practice in the acute care setting

OBJECTIVE Despite delirium being common in older hospitalized people, little is known about its management. The aims of this study are (1) to describe the pharmacological management of delirium in an acute care setting as a baseline measure prior to the implementation of newly developed Australian guidelines; and (2) to determine what areas of delirium pharmacological management need to be targeted for future practical guideline implementation and quality improvement activities. METHODS A medical record audit was conducted using a structured audit form. All patients aged 65 years and over who were admitted to a general medical or orthopaedic unit of the Royal Melbourne Hospital between 1 March 2006 and 28 February 2007 and coded with delirium were included. Data on the use of antipsychotic medications for the management of delirium in relation to best practice recommendations were assessed. RESULTS Overall 174 episodes of care were included in the analysis. Antipsychotic medications were used for the management of most patients with severe behavioral and or emotional disturbance associated with delirium. There was variation in the prescribing patterns of antipsychotic agents and the documentation of medication management plans. Less than a quarter of patients prescribed antipsychotic medication were started on a low dose and very few were reviewed on a regular basis. CONCLUSION A wide range of practice is seen in the use of antipsychotic agents to manage older patients with severe symptoms associated with delirium. The findings highlight the need to implement evidence-based guideline recommendations with a focus on improving the consistency in the pharmacological management and documentation processes.

Reversal of a neurologic paraneoplastic syndrome with octreotide (sandostatin) in a patient with glucagonoma

A 69-year-old woman with classic glucagonoma syndrome had associated progressive neurologic disease manifest as dementia, ataxia, optic atrophy, and lower limb weakness. Visual evoked responses (VERs) were absent bilaterally. After an attempt at resection was unsuccessful, therapy was started with somatostatin analogue (Sandostatin, SMS 201-995). Over the ensuing 3 months, there was a decrease in the plasma glucagon level, resolution of the rash, weight gain, reversal of the dementia, and an improvement in coordination and limb weakness. Subsequent VERs revealed bilateral delayed responses.