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ABSTRACT: 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.
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).
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.
The World Health Organization Disability Assessment Schedule 2.0 was used to assess disability at 12 months after injury.
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.
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.
The Journal of Clinical Psychiatry 02/2013; 74(2):e137-43. · 5.80 Impact Factor
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ABSTRACT: Objective The first aim of this work was to conduct a rigorous longitudinal study to identify rates of delayed-onset posttraumatic stress disorder (PTSD) in a sample of patients with severe injury. The second aim was to determine what variables differentiated delayed-onset PTSD from chronic PTSD. Methods Randomly selected patients with injury who were admitted to four hospitals around Australia were recruited to the study (N = 834) and assessed in the acute care hospital, at 3 months, and at 12 months. A structured clinical interview was used to assess PTSD at each time point. Results Seventy-three patients (9%; n = 73) had PTSD at 12 months. Of these, 39 (53%) were classified as having delayed-onset PTSD. Furthermore, 22 (56%) patients with delayed-onset PTSD had minimal PTSD symptoms at 3 months (i.e., they did not have partial/subsyndromal PTSD at 3 months). The variables that differentiated delayed-onset PTSD from chronic PTSD were greater injury severity (odds ratio [OR] = 1.13; 95% confidence interval [CI] = 1.02-1.26), lower anxiety severity at 3 months (OR = 0.73; 95% CI = 0.61-0.87), and greater pain severity at 3 months (OR = 1.39; 95% CI = 1.06-1.84). Conclusions Delayed-onset PTSD occurred frequently in this sample. Approximately half of the patients with delayed-onset PTSD had minimal PTSD symptoms at 3 months; therefore, their delayed-onset PTSD could not be accounted for by a small number of fluctuating symptoms. As we move toward DSM-V, it is important that research continues to explore the factors that underpin the development of delayed-onset PTSD.
Psychosomatic Medicine 01/2013; 75(1):68-75. · 3.97 Impact Factor
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ABSTRACT: Objective
The first aim of this work was to conduct a rigorous longitudinal study to identify rates of delayed-onset posttraumatic stress disorder (PTSD) in a sample of patients with severe injury. The second aim was to determine what variables differentiated delayed-onset PTSD from chronic PTSD.Methods
Randomly selected patients with injury who were admitted to four hospitals around Australia were recruited to the study (N = 834) and assessed in the acute care hospital, at 3 months, and at 12 months. A structured clinical interview was used to assess PTSD at each time point.ResultsSeventy-three patients (9%; n = 73) had PTSD at 12 months. Of these, 39 (53%) were classified as having delayed-onset PTSD. Furthermore, 22 (56%) patients with delayed-onset PTSD had minimal PTSD symptoms at 3 months (i.e., they did not have partial/subsyndromal PTSD at 3 months). The variables that differentiated delayed-onset PTSD from chronic PTSD were greater injury severity (odds ratio [OR] = 1.13; 95% confidence interval [CI] = 1.02-1.26), lower anxiety severity at 3 months (OR = 0.73; 95% CI = 0.61-0.87), and greater pain severity at 3 months (OR = 1.39; 95% CI = 1.06-1.84).Conclusions
Delayed-onset PTSD occurred frequently in this sample. Approximately half of the patients with delayed-onset PTSD had minimal PTSD symptoms at 3 months; therefore, their delayed-onset PTSD could not be accounted for by a small number of fluctuating symptoms. As we move toward DSM-V, it is important that research continues to explore the factors that underpin the development of delayed-onset PTSD.
Psychosomatic Medicine 11/2012; · 3.97 Impact Factor
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Meaghan L O'Donnell,
Winnie Lau,
Susannah Tipping,
Alexander C N Holmes,
Steven Ellen,
Rodney Judson,
Tracey Varker,
Peter Elliot,
Richard A Bryant,
Mark C Creamer,
David Forbes
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ABSTRACT: 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.
Journal of Traumatic Stress 04/2012; 25(2):125-33. · 2.72 Impact Factor
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ABSTRACT: Reexperiencing symptoms are a key feature of posttraumatic stress disorder (PTSD). This study investigated the pattern of reexperiencing symptoms in non-PTSD posttraumatic disorders. This study recruited 1084 traumatically injured patients during hospital admission and conducted follow-up assessment 12 months later (N = 817, 75%). Twelve months after injury, 22% of patients reported a psychiatric disorder they had never experienced prior to the traumatic injury. One-third of patients with a non-PTSD disorder satisfied the PTSD reexperiencing criteria. Whereas patients with a non-PTSD disorder were more likely to experience intrusive memories, nightmares, psychological distress and physiological reactivity to reminders, only patients with PTSD were likely to experience flashback memories (OR: 11.41, 95% CI: 6.17-21.09). The only other symptom that was distinctive to PTSD was dissociative amnesia (OR: 4.50, 95% CI: 2.09-9.71). Whereas intrusive memories and reactions are common across posttraumatic disorders, flashbacks and dissociative amnesia are distinctive to PTSD.
Journal of psychiatric research 06/2011; 45(6):842-7. · 3.72 Impact Factor
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ABSTRACT: 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.
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.
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.
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.
The Journal of trauma 09/2010; 69(3):627-32. · 2.48 Impact Factor
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ABSTRACT: Traumatic injury affects millions of people each year. There is little understanding of the extent of psychiatric illness that develops after traumatic injury or of the impact of mild traumatic brain injury (TBI) on psychiatric illness. The authors sought to determine the range of new psychiatric disorders occurring after traumatic injury and the influence of mild TBI on psychiatric status.
In this prospective cohort study, patients were drawn from recent admissions to four major trauma hospitals across Australia. A total of 1,084 traumatically injured patients were initially assessed during hospital admission and followed up 3 months (N=932, 86%) and 12 months (N=817, 75%) after injury. Lifetime psychiatric diagnoses were assessed in hospital. The prevalence of psychiatric disorders, levels of quality of life, and mental health service use were assessed at the follow-ups. The main outcome measures were 3- and 12-month prevalence of axis I psychiatric disorders, levels of quality of life, and mental health service use and lifetime axis I psychiatric disorders.
Twelve months after injury, 31% of patients reported a psychiatric disorder, and 22% developed a psychiatric disorder that they had never experienced before. The most common new psychiatric disorders were depression (9%), generalized anxiety disorder (9%), posttraumatic stress disorder (6%), and agoraphobia (6%). Patients were more likely to develop posttraumatic stress disorder (odds ratio=1.92, 95% CI=1.08-3.40), panic disorder (odds ratio=2.01, 95% CI=1.03-4.14), social phobia (odds ratio=2.07, 95% CI=1.03-4.16), and agoraphobia (odds ratio=1.94, 95% CI=1.11-3.39) if they had sustained a mild TBI. Functional impairment, rather than mild TBI, was associated with psychiatric illness.
A significant range of psychiatric disorders occur after traumatic injury. The identification and treatment of a range of psychiatric disorders are important for optimal adaptation after traumatic injury.
American Journal of Psychiatry 03/2010; 167(3):312-20. · 12.54 Impact Factor
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ABSTRACT: The requirement that trauma survivors experience fear, helplessness or horror (Criterion A2) as a part of their posttraumatic stress disorder (PTSD) diagnosis was introduced into DSM-IV. The imminent re-definition of PTSD in DSM-V highlights the need for empirical studies to validate the utility of the A2 requirement. We aimed to identify (i) how often A2 was associated with PTSD (B-F criteria) at 3 months after trauma and (ii) what was the peritraumatic emotional experience for those who met PTSD criteria but were A2 negative. In a prospective design cohort study we assessed the peritraumatic emotional experience of 535 injury patients in four Australian hospitals. These patients were followed up 3 months later and assessed for PTSD using a structured clinical interview. The majority of those who developed PTSD (B-F criterion) at 3 months met A2 criteria. A substantial minority, however (23%), did not meet A2 criteria. Those PTSD patients who were A2 negative fell into three groups: (i) those who experienced subthreshold levels of A2; (ii) those who experienced intense peritrauma emotional responses other than fear, helplessness or horror; and (iii) those who were amnesic to their peritrauma emotional experience. These findings do not support the inclusion of A2 as diagnostic requirement for DSM-V.
Psychiatry Research 03/2010; 176(2-3):257-60. · 2.52 Impact Factor
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ABSTRACT: To conduct a descriptive study investigating the effect of access to motor vehicle accident (MVA) compensation on recovery outcomes at 24 months after injury.
Longitudinal cohort study conducted in two Level 1 trauma hospitals in Victoria, Australia. Participants were 391 randomly selected injury patients with moderate-to-severe injuries. Compensable and non-compensable patients were compared at 24 months after injury on a number of health outcomes.
Health outcomes at 24 months, including anxiety and depression severity, quality of life and disability.
Medical records identified two groups of compensation patients: MVA-compensable and non-compensable patients. After controlling for baseline variables, the MVA-compensable patients, at 24 months, had higher levels of post-traumatic stress disorder, anxiety and depression, and were less likely to have returned to their pre-injury number of work hours. However, some patients in the non-compensable group had accessed other forms of compensation (eg, private health care or compensation for victims of crime). When these were removed from the non-compensable group, the differences between MVA-compensable and non-compensable groups all but disappeared.
Our findings do not support previous research showing that access to compensation is associated with poor recovery outcomes. The relationship between access to compensation and health outcomes is complex, and more high-level research is required.
The Medical journal of Australia 03/2010; 192(6):328-33. · 2.81 Impact Factor
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ABSTRACT: To examine the relationship between psychological response to injury at 1 week and 3 months, and disability at 12 months.
Multisite, longitudinal study.
802 adult patients admitted to trauma services at four Australian hospitals from 13 March 2004 to 21 February 2006 were assessed before discharge and followed up at 3 and 12 months.
Disability, measured with the 12-item version of the World Health Organization Disability Assessment Schedule II.
Logistic regression identified the degree to which high levels of depression and post-traumatic stress disorder (PTSD) at 1 week and at 3 months predicted disability at 12 months. After controlling for demographic variables and characteristics of the injury, patients with PTSD or subsyndromal PTSD at 1 week were 2.4 times more likely, and those with depression at 1 week were 1.9 times more likely to have high disability levels at 12 months. PTSD at 3 months was associated with 3.7 times, and depression at 3 months with 3.4 times the risk of high disability at 12 months.
PTSD and depression at 1 week and at 3 months after injury significantly increased the risk of disability at 12 months. Routine assessment of symptoms of depression and PTSD in patients who have been physically injured may facilitate triage to evidence-based treatments, leading to improvement in both physical and psychological outcomes.
The Medical journal of Australia 05/2009; 190(7 Suppl):S71-4. · 2.81 Impact Factor
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ABSTRACT: Preliminary evidence suggests that injury survivors are at increased risk for having experienced traumatic events before their injury or having a lifetime psychiatric history. We aimed to extend the previous research by examining in the same sample whether trauma history or lifetime psychiatric history represented risk pathways to injury for intentional or unintentional injury survivors. We also aimed to describe the co-occurrence between trauma history and psychiatric history in unintentionally injured survivors.
In this multisited study, randomly selected injury survivors admitted to five trauma services in three states of Australia (April 2004 to February 2006) completed two structured clinical interviews that assessed their history of traumatic life events and lifetime psychiatric disorder (n = 1,167). chi analyses were conducted to compare the lifetime prevalence of traumatic events and psychiatric history for intentional and unintentional injury with population norms.
Both intentional and unintentional injury survivors were at increased risk for reporting all types of trauma and reporting all measured psychiatric diagnoses compared with population norms. The majority of unintentional injury survivors with a psychiatric history were likely to have a trauma history.
In this study, we identified that prior trauma or prior psychiatric illness may represent risk for injury in both intentionally and unintentionally injured survivors. The results highlight the need for injury-care services to address mental health issues in injury patients as part of routine care.
The Journal of trauma 03/2009; 66(2):470-6. · 2.48 Impact Factor
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ABSTRACT: 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.
Journal of Consulting and Clinical Psychology 01/2009; 76(6):923-32. · 4.85 Impact Factor
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ABSTRACT: Previous studies investigating the relationship between acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) have reported mixed findings and have been flawed by small sample sizes and single sites. This study addresses these limitations by conducting a large-scale and multisite study to evaluate the extent to which ASD predicts subsequent PTSD.
Between April 2004 and April 2005, patients admitted consecutively to 4 major trauma hospitals across Australia (N = 597) were randomly selected and assessed for ASD (DSM-IV criteria) during hospital admission (within 1 month of trauma exposure) and were subsequently reassessed for PTSD 3 months after the initial assessment (N = 507).
Thirty-three patients (6%) met criteria for ASD, and 49 patients (10%) met criteria for PTSD at the 3-month follow-up assessment. Fifteen patients (45%) diagnosed with ASD and 34 patients (7%) not diagnosed with ASD subsequently met criteria for PTSD. The positive predictive power of PTSD criteria in the acute phase (0.60) was a better predictor of chronic PTSD than the positive predictive power of ASD (0.46).
The majority of people who develop PTSD do not initially meet criteria for ASD. These data challenge the proposition that the ASD diagnosis is an adequate tool to predict chronic PTSD.
The Journal of Clinical Psychiatry 05/2008; 69(6):923-9. · 5.80 Impact Factor
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ABSTRACT: In 2005, over 2 million people in the United States of America were hospitalised following non-fatal injuries. The frequency with which severe injury occurs renders it a leading cause of posttraumatic stress disorder and other trauma-related psychopathology. In order to develop a health system model of early psychological intervention for this population, we review the literature that pertains to mental health early intervention. The relevant domains include prevalence of psychopathology following traumatic injury, the course of symptoms, screening, and early intervention strategies. On the basis of available evidence, we propose a health system model of early psychological intervention following traumatic injury. The model involves screening for vulnerability within the hospital setting, follow-up screening for persistent symptoms at one month posttrauma, and early psychological intervention for those who are experiencing clinical impairment. Recommendations are made to facilitate tailoring early intervention psychological therapies to the special needs of the injury population.
Clinical Psychology Review 04/2008; 28(3):387-406. · 7.07 Impact Factor
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ABSTRACT: To examine the relationship between acute measures of a) heart rate (HR) immediately after traumatic injury, b) tonic (resting) HR at 1 week post injury, c) phasic (aroused) HR at 1 week post injury, and d) somatic symptoms of arousal in the prediction of subsequent posttraumatic stress disorder (PTSD). Fear conditioning models propose that HR reactivity shortly after trauma may predict PTSD.
In a longitudinal study, consecutive injury survivors (n = 197) admitted to a hospital trauma service were assessed within 1 week and at 12 months post injury. HR was assessed by paramedics at the site of the trauma and pulse oximetry technology at 1 week post trauma. Somatic symptoms of arousal were measured using the somatic scale on the Beck Anxiety Inventory (BAI). PTSD was assessed using the Clinician Administered PTSD Scale at 12 months.
At 12 months post injury, PTSD was diagnosed in 10% of participants. Only HR change scores (phasic - tonic HR) and BAI scores significantly predicted later PTSD.
These findings question the clinical usefulness of tonic HR as a biological marker of later PTSD. The finding that HR reactivity (phasic - tonic) predicts later PTSD has theoretical importance. The strongest predictor of later PTSD was somatic arousal.
Psychosomatic Medicine 05/2007; 69(3):256-61. · 3.97 Impact Factor
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ABSTRACT: This study aimed to identify posttraumatic stress disorder (PTSD) symptom trajectories across the first 12 months following traumatic injury. Three hundred and seven consecutively admitted injury survivors were assessed for severity of PTSD symptoms just prior to discharge, and at 3 and 12 months postinjury. Growth modeling was used to determine the curve that best fit the trajectory for each symptom cluster over the 12-month period. Individuals with 12-month PTSD showed significantly higher re-experiencing, arousal, and avoidance symptoms at eight days posttrauma relative to those without, and these symptoms escalated over time. Those without PTSD maintained their relatively low symptom levels. These findings highlight that individuals who will go onto develop PTSD have a distinctly different symptom course than those who recover.
Behaviour Research and Therapy 04/2007; 45(3):601-6. · 3.30 Impact Factor
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ABSTRACT: Cognitive models of posttraumatic stress disorder (PTSD) posit that appraisal plays an important role in the development and persistence of PTSD. This study examined posttraumatic appraisals and their relationship to the development and course of PTSD symptoms. Two hundred fifty-three injury survivors were assessed for PTSD symptoms and posttraumatic cognitions across a 12-month period. A path analytic modeling approach showed that posttraumatic appraisals were important direct and indirect predictors of later PTSD severity. The findings suggest that appraisals made in the aftermath of trauma have a significant influence on subsequent psychological adjustment.
Journal of Traumatic Stress 04/2007; 20(2):173-82. · 2.72 Impact Factor
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ABSTRACT: Recent studies have indicated that delayed-onset posttraumatic stress disorder (PTSD) (i.e., the development of PTSD more than 6 months posttrauma) is generally characterised by subsyndromal diagnoses within the first 6 months. This study sought to examine the relationship between sub-clinical levels of PTSD symptoms at 3 months posttrauma and delayed onset PTSD at 12 months in a large sample of traumatic injury survivors.
Three hundred and one consecutively admitted injury survivors were assessed at 3 and 12 months posttrauma. PTSD was diagnosed according to DSM-IV criteria, while partial and subsyndromal diagnoses were based on recent definitions developed by Mylle and Maes [Mylle, J., Maes, M., 2004. Partial posttraumatic stress disorder revisited. J. Affect. Disord. 78, 37-48].
Eight percent of participants was diagnosed with 3-month PTSD while 10% was diagnosed with 12-month PTSD. Nearly half (47%) of 12-month PTSD cases were of delayed onset. The majority of those with delayed-onset were diagnosed with partial or subsyndromal PTSD at 3 months. Ten percent of delayed onset cases did not meet partial or subsyndromal criteria.
As symptoms were not assessed at 6 months (the DSM cut-off for delayed PTSD), it could not be conclusively determined that delayed-onset cases had not developed PTSD between 3 and 6 months posttrauma.
A considerable proportion of 12-month PTSD diagnoses was delayed in onset. While most demonstrated 3-month morbidity in the form of partial and subsyndromal diagnoses, a minority did not. Thus, clinicians should consider subthreshold diagnoses as potential risk factors for delayed-onset PTSD. Future research is required to identify factors that may predict delayed-onset PTSD in trauma survivors without evidence of prior PTSD pathology.
Journal of Affective Disorders 03/2006; 90(2-3):257-61. · 3.52 Impact Factor
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ABSTRACT: The factors that determine quality of life (QOL) and disability after traumatic injury are poorly understood. This study identified the unique contributions that characteristics about the injury/hospital admission and acute psychological adjustment make in determining 12-month role-related disability and QOL.
Consecutive admissions (n = 363) to a Level I trauma service were assessed just before discharge and followed up at 12 months. Structural equational modeling was used to examine the relationships between the acute factors and 12-month outcomes.
Characteristics of the individual's injuries measured in the acute setting significantly predicted 12-month disability but only indirectly predicted 12-month QOL. An individual's acute psychological response directly predicted both the level of disability and QOL at 12 months.
Both characteristics about an individual's injury and acute psychological responses play important roles in determining later QOL and role-related disability outcomes. Trauma care systems must consider both physical and psychological injury to offer effective and comprehensive healthcare management.
The Journal of trauma 01/2006; 59(6):1328-34; discussion 1334-5. · 2.48 Impact Factor
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ABSTRACT: This study explored the relationship between mild traumatic brain injury (MTBI), amnesia, and posttraumatic stress disorder (PTSD). MTBI status and amnesia for the event were assessed in 307 consecutive admissions to a Level 1 Trauma Center. Amnesia did not always occur concurrently with MTBI: 18% of those with MTBI had full recall and over half had partial recall of the event. Just over 10% of participants developed PTSD by 12 months post-injury, with prevalence comparable across MTBI and non-MTBI groups. Non-significant differences in incidence of PTSD were apparent between those with full recall (9%), partial recall (14%) and no recall (7%). These data highlight the fact that PTSD may develop following trauma despite amnesia for the event, and illustrate the importance in both clinical and research settings of carefully examining the extent of amnesia.
Behaviour Research and Therapy 11/2005; 43(10):1383-9. · 3.30 Impact Factor
