Douglas Zatzick

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

BACKGROUND Injured survivors of individual and mass trauma are at risk for developing post-traumatic stress disorder (PTSD). Few investigations have assessed PTSD after injury in large samples across diverse acute care hospital settings. METHOD A total of 2931 injured trauma survivors aged 18-84 who were representative of 9983 in-patients were recruited from 69 hospitals across the USA. In-patient medical records were abstracted, and hospitalized patients were interviewed at 3 and 12 months after injury. Symptoms consistent with a DSM-IV diagnosis of PTSD were assessed with the PTSD Checklist (PCL) 12 months after injury. RESULTS Approximately 23% of injury survivors had symptoms consistent with a diagnosis of PTSD 12 months after their hospitalization. Greater levels of early post-injury emotional distress and physical pain were associated with an increased risk of symptoms consistent with a PTSD diagnosis. Pre-injury, intensive care unit (ICU) admission [relative risk (RR) 1.17, 95% confidence interval (CI) 1.02-1.34], pre-injury depression (RR 1.33, 95% CI 1.15-1.54), benzodiazepine prescription (RR 1.46, 95% CI 1.17-1.84) and intentional injury (RR 1.32, 95% CI 1.04-1.67) were independently associated with an increased risk of symptoms consistent with a PTSD diagnosis. White injury survivors without insurance demonstrated approximately twice the rate of symptoms consistent with a diagnosis of PTSD when compared to white individuals with private insurance. By contrast, for Hispanic injury survivors PTSD rates were approximately equal between uninsured and privately insured individuals. CONCLUSIONS Nationwide in the USA, more than 20% of injured trauma survivors have symptoms consistent with a diagnosis of PTSD 12 months after acute care in-patient hospitalization. Coordinated investigative and policy efforts could target mandates for high-quality PTSD screening and intervention in acute care medical settings.

A national US study of posttraumatic stress disorder, depression, and work and functional outcomes after hospitalization for traumatic injury.

Objective:To examine factors other than injury severity that are likely to influence functional outcomes after hospitalization for injury. Summary Background Data:This study used data from the National Study on the Costs and Outcomes of Trauma investigation to examine the association between posttraumatic stress disorder (PTSD), depression, and return to work and the development of functional impairments after injury. Method:A total of 2707 surgical inpatients who were representative of 9374 injured patients were recruited from 69 hospitals across the US. PTSD and depression were assessed at 12 months postinjury, as were the following functional outcomes: activities of daily living, health status, and return to usual major activities and work. Regression analyses assessed the associations between PTSD and depression and functional outcomes while adjusting for clinical and demographic characteristics. Results:At 12 months after injury, 20.7% of patients had PTSD and 6.6% had depression. Both disorders were independently associated with significant impairments across all functional outcomes. A dose-response relationship was observed, such that previously working patients with 1 disorder had a 3-fold increased odds of not returning to work 12 months after injury odds ratio = 3.20 95% (95% confidence interval = 2.46, 4.16), and patients with both disorders had a 5–6 fold increased odds of not returning to work after injury odds ratio = 5.57 (95% confidence interval = 2.51, 12.37) when compared with previously working patients without PTSD or depression. Conclusions:PTSD and depression occur frequently and are independently associated with enduring impairments after injury hospitalization. Early acute care interventions targeting these disorders have the potential to improve functional recovery after injury.

Psychiatric and substance use disorders as risk factors for low birth weight and preterm delivery.

OBJECTIVE We examined the associations between psychiatric and substance use diagnoses and low birth weight (LBW), very low birth weight (VLBW), and preterm delivery among all women delivering in California hospitals during 1995. METHODS This population‐based retrospective cohort analysis used linked hospital discharge and birth certificate data for 521,490 deliveries. Logistic regression analyses were conducted to assess the associations between maternal psychiatric and substance use hospital discharge diagnoses and LBW, VLBW, and preterm delivery while controlling for maternal demographic and medical characteristics. RESULTS Women with psychiatric diagnoses had a significantly higher risk of LBW (adjusted odds ratio [OR] 2.0; 95% confidence interval [CI] 1.7, 2.3), VLBW (OR 2.9; 95% CI 2.1, 3.9), and preterm delivery (OR 1.6; 95% CI 1.4, 1.9) compared with women without those diagnoses. Substance use diagnoses were also associated with higher risk of LBW (OR 3.7; 95% CI 3.4, 4.0), VLBW (OR 2.8; 95% CI 2.3, 3.3), and preterm delivery (OR 2.4; 95% CI 2.3, 2.6). CONCLUSION Maternal psychiatric and substance use diagnoses were independently associated with low birth weight and preterm delivery in the population of women delivering in California in 1995. Identifying pregnant women with current psychiatric disorders and increased monitoring for preterm and low birth weight delivery among this population may be indicated.

A Randomized Stepped Care Intervention Trial Targeting Posttraumatic Stress Disorder for Surgically Hospitalized Injury Survivors

Objective: To test the effectiveness of a stepped care intervention model targeting posttraumatic stress disorder (PTSD) symptoms after injury. Background: Few investigations have evaluated interventions for injured patients with PTSD and related impairments that can be feasibly implemented in trauma surgical settings. Methods: The investigation was a pragmatic effectiveness trial in which 207 acutely injured hospitalized trauma survivors were screened for high PTSD symptom levels and then randomized to a stepped combined care management, psychopharmacology, and cognitive behavioral psychotherapy intervention (n = 104) or usual care control (n = 103) conditions. The symptoms of PTSD and functional limitations were reassessed at 1, 3, 6, 9, and 12 months after the index injury admission. Results: Regression analyses demonstrated that over the course of the year after injury, intervention patients had significantly reduced PTSD symptoms when compared with controls [group by time effect, CAPS (Clinician-Administered PTSD Scale): F(2, 185) = 5.50, P < 0.01; PCL-C (PTSD Checklist Civilian Version): F(4, 185) = 5.45, P < 0.001]. Clinically and statistically significant PTSD treatment effects were observed at the 6-, 9-, and 12-month postinjury assessments. Over the course of the year after injury, intervention patients also demonstrated significant improvements in physical function [MOS SF-36 PCS (Medical Outcomes Study Short Form 36 Physical Component Summary) main effect: F(1, 172) = 9.87, P < 0.01]. Conclusions: Stepped care interventions can reduce PTSD symptoms and improve functioning over the course of the year after surgical injury hospitalization. Orchestrated investigative and policy efforts could systematically introduce and evaluate screening and intervention procedures for PTSD at US trauma centers. (Trial Registration: clinicaltrials.gov identifier: NCT00270959)

Association between posttraumatic stress and depressive symptoms and functional outcomes in adolescents followed up longitudinally after injury hospitalization.

OBJECTIVE To assess the association between early posttraumatic stress disorder (PTSD) and depressive symptoms and functional and quality-of-life outcomes among injured youth. DESIGN Prospective cohort study. SETTING Combined pediatric-adult level I trauma center. PARTICIPANTS Randomly sampled adolescent injury survivors aged 12 to 18 years (N = 108) were recruited from surgical inpatient units. MAIN EXPOSURES Posttraumatic stress disorder and depressive symptom levels in the days and weeks immediately following injury. We also collected relevant adolescent demographic, injury, and clinical characteristics. MAIN OUTCOME MEASURE Multiple domains of adolescent functional impairment were assessed with the 87-item Child Health Questionnaire (CHQ-87) at 2, 5, and 12 months after injury. RESULTS The investigation attained greater than 80% adolescent follow-up at each assessment after injury. Mixed-model regression was used to assess the association between baseline levels of PTSD and depressive symptoms and subsequent functional outcomes longitudinally. High baseline PTSD symptom levels were associated with significant impairments in CHQ-87 Role/Social Behavioral, Role/Social Physical, Bodily Pain, General Behavior, Mental Health, and General Health Perceptions subscales. High baseline depressive symptoms were associated with significant impairments in CHQ-87 Physical Function, Role/Social Emotional, Bodily Pain, Mental Health, Self-esteem, and Family Cohesion subscales. CONCLUSIONS Early PTSD and depressive symptoms are associated with a broad spectrum of adolescent functional impairment during the year after physical injury. Coordinated investigative and policy efforts that refine mental health screening and intervention procedures have the potential to improve the functioning and well-being of injured youth treated in the acute care medical setting.

ICU Care Associated With Symptoms of Depression and Posttraumatic Stress Disorder Among Family Members of Patients Who Die in the ICU

BACKGROUND Psychologic symptoms of posttraumatic stress disorder (PTSD) and depression are relatively common among family members of patients who die in the ICU. The patient-level risk factors for these family symptoms are not well understood but may help to target future interventions. METHODS We performed a cohort study of family members of patients who died in the ICU or within 30 h of ICU transfer. Outcomes included self-reported symptoms of PTSD and depression. Predictors included patient demographics and elements of palliative care. RESULTS Two hundred twenty-six patients had chart abstraction and family questionnaire data. Family members of older patients had lower scores for PTSD (P = .026). Family members that were present at the time of death (P = .021) and family members of patients with early family conferences (P = .012) reported higher symptoms of PTSD. When withdrawal of a ventilator was ordered, family members reported lower symptoms of depression (P = .033). There were no other patient characteristics or elements of palliative care associated with family symptoms. CONCLUSIONS Family members of younger patients and those for whom mechanical ventilation is not withdrawn are at increased risk of psychologic symptoms and may represent an important group for intervention. Increased PTSD symptoms among family members present at the time of death may reflect a closer relationship with the patient or more involvement with the patients ICU care but also suggests that family should be offered the option of not being present.

Reevaluating the association between emergency department heart rate and the development of posttraumatic stress disorder: A public health approach

BACKGROUND Preliminary investigations in select samples of trauma survivors presenting to acute care settings suggest an association between elevated emergency department heart rate (HR) and the subsequent development of posttraumatic stress disorder (PTSD). Other studies suggest no association, however. METHOD In a prospective cohort study of a population-based sample of 161 acutely injured surgical inpatients, HR was assessed at initial presentation to the emergency department. Symptoms of PTSD were assessed with the PTSD Checklist at the time of the surgical inpatient hospitalization and 1, 4-6, and 12 months postinjury. RESULTS Emergency department HR > or = 95 beats per minute (BPM) was a significant independent predictor of PTSD symptoms in analyses that adjusted for relevant injury, clinical, and demographic characteristics. This HR cutoff demonstrated modest specificity (range 60%-65%) and sensitivity (range 49%-63%) for the prediction of chronic PTSD. CONCLUSIONS We found an independent association between elevated emergency department HR > or = 95 BPM and PTSD symptoms in a representative sample of injured acute care inpatients. Future investigations that incorporate clinical epidemiologic methods in the study of acute care biological parameters have the potential to improve the quality of mental health care delivered to injured survivors of individual and mass trauma.

Multisite investigation of traumatic brain injuries, posttraumatic stress disorder, and self-reported health and cognitive impairments.

CONTEXT Few large-scale, multisite investigations have assessed the development of posttraumatic stress disorder (PTSD) symptoms and health outcomes across the spectrum of patients with mild, moderate, and severe traumatic brain injury (TBI). OBJECTIVES To understand the risk of developing PTSD symptoms and to assess the impact of PTSD on the development of health and cognitive impairments across the full spectrum of TBI severity. DESIGN Multisite US prospective cohort study. SETTING Eighteen level I trauma centers and 51 non-trauma center hospitals. PATIENTS A total of 3047 (weighted n = 10 372) survivors of multiple traumatic injuries between the ages of 18 and 84 years. MAIN OUTCOME MEASURES Severity of TBI was categorized from chart-abstracted International Classification of Diseases, Ninth Revision, Clinical Modification codes. Symptoms consistent with a DSM-IV diagnosis of PTSD were assessed with the PTSD Checklist 12 months after injury. Self-reported outcome assessment included the 8 Medical Outcomes Study 36-Item Short Form Health Survey health status domains and a 4-item assessment of cognitive function at telephone interviews 3 and 12 months after injury. RESULTS At the time of injury hospitalization, 20.5% of patients had severe TBI, 11.7% moderate TBI, 12.9% mild TBI, and 54.9% no TBI. Patients with severe (relative risk, 0.72; 95% confidence interval, 0.58-0.90) and moderate (0.63; 0.44-0.89) TBI, but not mild TBI (0.83; 0.61-1.13), demonstrated a significantly diminished risk of PTSD symptoms relative to patients without TBI. Across TBI categories, in adjusted analyses patients with PTSD demonstrated an increased risk of health status and cognitive impairments when compared with patients without PTSD. CONCLUSIONS More severe TBI was associated with a diminished risk of PTSD. Regardless of TBI severity, injured patients with PTSD demonstrated the greatest impairments in self-reported health and cognitive function. Treatment programs for patients with the full spectrum of TBI severity should integrate intervention approaches targeting PTSD.

Collaborative interventions for physically injured trauma survivors: a pilot randomized effectiveness trial

Posttraumatic behavioral and emotional disturbances occur frequently among physically injured hospitalized trauma survivors. This investigation was a pilot randomized effectiveness trial of a 4-month collaborative care intervention for injured motor vehicle crash and assault victims. As surgical inpatients, intervention subjects (N=16) were assigned to a trauma support specialist who provided counseling, consulted with surgical and primary care providers, and attempted postdischarge care coordination. Control subjects (N=18) received usual posttraumatic care. For all participants, posttraumatic stress disorder (PTSD) and depressive symptoms, episodic alcohol intoxication, and functional limitations were evaluated during the hospitalization and 1 and 4 months postinjury. Study logs and field notes revealed that over 75% of intervention activity occurred in the first month after the trauma. One-month post-trauma intervention subjects when compared to controls demonstrated statistically significant decreases in PTSD symptoms as well as a reduction in depressive symptoms. However, at the 4-month assessment, intervention subjects evidenced no significant improvements in PTSD and depressive symptoms, episodic alcohol intoxication, or functional limitations. Future larger scale trials of stepped collaborative care interventions for physically injured trauma survivors are recommended.

Psychiatric morbidity and functional impairments in survivors of burns, traumatic injuries, and ICU stays for other critical illnesses: A review of the literature

Severe burns, traumatic injuries and other critical illnesses are a substantial source of morbidity in the United States. As more patients survive these conditions, there has been increasing interest in psychiatric and functional outcomes of these individuals. In this article, we reviewed the literature on the prevalence of psychiatric conditions, with particular emphasis on posttraumatic stress disorder (PTSD) and depression, as well as functional impairments, in adult and pediatric survivors of burns, trauma and intensive care unit stays for other critical illnesses. We found that PTSD and depressive symptoms are quite prevalent in these patient groups. We also examined potential risk factors for psychiatric morbidity and impaired function in all three patient groups, and conclude that patient-specific and acute care factors, in addition to early post-acute care psychiatric symptoms, may convey risk for subsequent psychopathology and diminished function. Finally, we discussed limitations in the literature as well as possible directions for future research, particularly in clarifying risk factors for psychiatric disorders as well as potential preventative and treatment interventions that may improve outcomes.