Stephen S. O'Connor

Persistence of disability 24 to 36 months after pediatric traumatic brain injury: a cohort study

This study examined the outcome of 0- to 17-year-old children 36 months after traumatic brain injury (TBI), and ascertained if there was any improvement in function between 24 and 36 months. Controls were children treated in the emergency department for an arm injury. Functional outcome 36 months after injury was measured by the Pediatric Quality of Life Inventory (PedsQL), the self-care and communication subscales of the Adaptive Behavior Assessment Scale-2nd edition (ABAS-II), and the Child and Adolescent Scale of Participation (CASP). At 36 months after TBI, those with moderate or severe TBI continued to have PedsQL scores that were 16.1 and 17.9 points, respectively, lower than at baseline, compared to the change seen among arm injury controls. Compared to the baseline assessment, children with moderate or severe TBI had significantly poorer functioning on the ABAS-II and poorer participation in activities (CASP). There was no significant improvement in any group on any outcomes between 24 and 36 months. Post-injury interventions that decrease the impact of these deficits on function and quality of life, as well as preventive interventions that reduce the likelihood of TBI, should be developed and tested.

Collaborative Care Intervention Targeting Violence Risk Behaviors, Substance Use, and Posttraumatic Stress and Depressive Symptoms in Injured Adolescents: A Randomized Clinical Trial

IMPORTANCE Violence and injury risk behaviors, alcohol and drug use problems, and posttraumatic stress disorder (PTSD) and depressive symptoms occur frequently among adolescents presenting to acute care medical settings after traumatic physical injury. OBJECTIVE To test the effectiveness of a stepped collaborative care intervention targeting this constellation of risk behaviors and symptoms in randomly sampled hospitalized adolescents with and without traumatic brain injury. DESIGN, SETTING, AND PARTICIPANTS A pragmatic randomized clinical trial was conducted at a single US level I trauma center. Participants included 120 adolescents aged 12 to 18 years randomized to intervention (n = 59) and control (n = 61) conditions. INTERVENTIONS Stepped collaborative care intervention included motivational interviewing elements targeting risk behaviors and substance use as well as medication and cognitive behavioral therapy elements targeting PTSD and depressive symptoms. MAIN OUTCOMES AND MEASURES Adolescents were assessed at baseline before randomization and 2, 5, and 12 months after injury hospitalization. Standardized instruments were used to assess violence risk behaviors, alcohol and drug use, and PTSD and depressive symptoms. RESULTS The investigation attained more than 95% adolescent follow-up at each assessment point. At baseline, approximately one-third of the participants endorsed the violence risk behavior of carrying a weapon. Regression analyses demonstrated that intervention patients experienced significant reductions in weapon carrying compared with controls during the year after injury (group × time effect, F3,344 = 3.0; P = .03). At 12 months after the injury, 4 (7.3%) intervention patients vs 13 (21.3%) control patients reported currently carrying a weapon (relative risk, 0.31; 95% CI, 0.11-0.90). The intervention was equally effective in reducing the risk of weapon carrying among injured adolescents with and without traumatic brain injury. Other treatment targets, including alcohol and drug use problems and high levels of PTSD and depressive symptoms, occurred less frequently in the cohort relative to weapon carrying and were not significantly affected by the intervention. CONCLUSIONS AND RELEVANCE Collaborative care intervention reduced the risk of adolescent weapon carrying during the year after the injury hospitalization. Future investigation should replicate this preliminary observation. If the finding is replicated, orchestrated investigative and policy efforts could systematically implement and evaluate screening and intervention procedures targeting youth violence prevention at US trauma centers. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT00619255.

Suicide in the US Army

Suicide in the US Army is a high-profile public health problem that is complex and poorly understood. Adding to the confusion surrounding Army suicide is the challenge of defining and understanding individuals/populations dying by suicide. Data from recent studies have led to a better understanding of risk factors for suicide that may be specifically associated with military service, including the impact of combat and deployment on increased rates of psychiatric illness in military personnel. The next steps involve applying these results to the development of empirically supported suicide prevention approaches specific to the military population. This special article provides an overview of suicide in the Army by synthesizing new information and providing clinical pearls based on research evidence.

Association between posttraumatic stress, depression, and functional impairments in adolescents 24 months after traumatic brain injury

The degree to which postinjury posttraumatic stress disorder (PTSD) and/or depressive symptoms in adolescents are associated with cognitive and functional impairments at 12 and 24 months after traumatic brain injury (TBI) is not yet known. The current study used a prospective cohort design, with baseline assessment and 3-, 12-, and 24-month followup, and recruited a cohort of 228 adolescents ages 14-17 years who sustained either a TBI (n = 189) or an isolated arm injury (n = 39). Linear mixed-effects regression was used to assess differences in depressive and PTSD symptoms between TBI and arm-injured patients and to assess the association between 3-month PTSD and depressive symptoms and cognitive and functional outcomes. Results indicated that patients who sustained a mild TBI without intracranial hemorrhage reported significantly worse PTSD (Hedges g = 0.49, p = .01; Model R(2) = .38) symptoms across time as compared to the arm injured control group. Greater levels of PTSD symptoms were associated with poorer school (η(2) = .07, p = .03; Model R(2) = .36) and physical (η(2) = .11, p = .01; Model R(2) = .23) functioning, whereas greater depressive symptoms were associated with poorer school (η(2) = .06, p = .05; Model R(2) = .39) functioning.

Compulsive cell phone use and history of motor vehicle crash

PURPOSE Few studies have examined the psychological factors underlying the association between cell phone use and motor vehicle crash. We sought to examine the factor structure and convergent validity of a measure of problematic cell phone use, and to explore whether compulsive cell phone use is associated with a history of motor vehicle crash. METHODS We recruited a sample of 383 undergraduate college students to complete an online assessment that included cell phone use and driving history. We explored the dimensionality of the Cell Phone Overuse Scale (CPOS) using factor analytic methods. Ordinary least-squares regression models were used to examine associations between identified subscales and measures of impulsivity, alcohol use, and anxious relationship style, to establish convergent validity. We used negative binomial regression models to investigate associations between the CPOS and motor vehicle crash incidence. RESULTS We found the CPOS to be composed of four subscales: anticipation, activity interfering, emotional reaction, and problem recognition. Each displayed significant associations with aspects of impulsivity, problematic alcohol use, and anxious relationship style characteristics. Only the anticipation subscale demonstrated statistically significant associations with reported motor vehicle crash incidence, controlling for clinical and demographic characteristics (relative ratio, 1.13; confidence interval, 1.01-1.26). For each 1-point increase on the 6-point anticipation subscale, risk for previous motor vehicle crash increased by 13%. CONCLUSIONS Crash risk is strongly associated with heightened anticipation about incoming phone calls or messages. The mean score on the CPOS is associated with increased risk of motor vehicle crash but does not reach statistical significance.

A cross-sectional investigation of the suicidal spectrum: typologies of suicidality based on ambivalence about living and dying.

OBJECTIVE The aim of this study was to determine the validity of assigning suicidal individuals into differing typologies of suicidality based on their reported wish to live and wish to die. METHODS One hundred five inpatients who reported suicidal ideation in the previous 48 hours completed a battery of assessments during inpatient psychiatric hospitalization. An algorithm was used to assign participants into 1 of 3 typologies of suicide: wish to live, ambivalent, or wish to die. Discriminant function analysis and group classification were used to predict group membership, followed by multiple analysis of variance and follow-up contrasts to measure between-group differences. MAIN RESULTS Group classification resulted in 76% accuracy for predicting typology of suicidality based on scores from suicide-specific measures. Self-perceived risk of suicide and hopelessness were the strongest variables at differentiating between the 3 groups. Patients in the wish to die typology were less likely to report having never made a suicide attempt. CONCLUSIONS Creating typologies of suicidality may prove useful to clinicians seeking to better differentiate among suicidal patients within a limited period of assessment.

Time to Remission for Depression with Collaborative Care Management (CCM) in Primary Care.

Background: Collaborative care management (CCM) has been shown to have superior outcomes to usual care (UC) for depressed patients with a fixed end point. This study was a survival analysis over time comparing CCM with UC using remission (9-item Patient Health Questionnaire [PHQ-9] score <5) and persistent depressive symptoms (PDSs; PHQ-9 score ≥10) as end points. Methods: A retrospective cohort study of 7340 patients with depression cared for at 4 outpatient primary care clinics was conducted from March 2008 through June 2013. All adult patients diagnosed with depression (International Classification of Diseases, 9th Revision [ICD-9], codes 296.2–3) or dysthymia (ICD-9 code 300.4) with an initial PHQ-9 score ≥10 were included. CCM was implemented at all clinics between 2008 and 2010. Kaplan-Meyer survival curves for time to remission and PDSs were plotted. A Cox proportional hazards model was used to adjust for expected differences between patients choosing CCM versus UC. Results: Median time to remission was 86 days (95% confidence interval [CI], 81–91 days) for the CCM group versus 614 days (95% CI, 565–692 days) for the UC group. Likewise, median duration of PDSs was 31 days (95% CI, 30–33 days) for the CCM group versus 154 days (95% CI, 138–182 days) for the UC group. In the Cox proportional hazards model, which controlled for covariates such as age, sex, race, diagnosis, and initial PHQ-9 score, CCM was associated with faster remission (hazard ratio of the CCM group [HRCCM], 2.48; 95% CI, 2.31–2.65). Conclusions: This study demonstrated that patients enrolled in CCM have a faster rate of remission and a shorter duration of PDSs than patients choosing UC.

Technology-Enhanced Stepped Collaborative Care Targeting Posttraumatic Stress Disorder and Comorbidity After Injury: A Randomized Controlled Trial

Posttraumatic stress disorder (PTSD) and its comorbidities are endemic among injured trauma survivors. Previous collaborative care trials targeting PTSD after injury have been effective, but they have required intensive clinical resources. The present pragmatic clinical trial randomized acutely injured trauma survivors who screened positive on an automated electronic medical record PTSD assessment to collaborative care intervention (n = 60) and usual care control (n = 61) conditions. The stepped measurement-based intervention included care management, psychopharmacology, and psychotherapy elements. Embedded within the intervention were a series of information technology (IT) components. PTSD symptoms were assessed with the PTSD Checklist at baseline prerandomization and again, 1-, 3-, and 6-months postinjury. IT utilization was also assessed. The technology-assisted intervention required a median of 2.25 hours (interquartile range = 1.57 hours) per patient. The intervention was associated with modest symptom reductions, but beyond the margin of statistical significance in the unadjusted model: F(2, 204) = 2.95, p = .055. The covariate adjusted regression was significant: F(2, 204) = 3.06, p = .049. The PTSD intervention effect was greatest at the 3-month (Cohens effect size d = 0.35, F(1, 204) = 4.11, p = .044) and 6-month (d = 0.38, F(1, 204) = 4.10, p = .044) time points. IT-enhanced collaborative care was associated with modest PTSD symptom reductions and reduced delivery times; the intervention model could potentially facilitate efficient PTSD treatment after injury.

Identifying outpatients with entrenched suicidal ideation following hospitalization

The purpose of this study was to identify outpatients who experience entrenched suicidal ideation following inpatient psychiatric hospitalization. Our findings suggest that the use of a suicidal ambivalence index score was helpful at discriminating those who reported significantly greater ratings of suicidal ideation across a 1-year period of time, whereas splitting patients based upon suicide attempt history yielded nonsignificant results. Similar findings resulted from a dimensional analytic approach, as well. Application of the suicidal ambivalence index may help administrators identify patients who require more intensive clinical services to resolve their suicidal ideation.

The association between the Kessler 10 and suicidality: a cross-sectional analysis

OBJECTIVE The aims of this study were to test the psychometric properties of the Kessler 10 (K10) in a clinical setting and to investigate the utility of the K10 as a means for identifying suicidality. METHODS One hundred forty-nine inpatients at an inpatient psychiatric hospital completed a battery of assessments during their inpatient hospital stay. Factor analysis provided information suggesting multiple factor loadings present within the K10. A series of t tests examined differences of group means between suicidal participants and a control group, whereas multiple regression models examined the correlation between the K10 and several suicide-specific assessments. MAIN RESULTS The K10 seems to be composed of 2 primary factors (depression and anxiety) and differentiated suicidal and nonsuicidal inpatients and was associated with several measures related to suicidality. CONCLUSIONS The observed results indicate that the K10 may be an effective screener to measure occult suicidality in a clinical setting.