Is Prevention Better than Cure? How Early Interventions Can Prevent PTSD


Authors

Study population

Study design

N

Timing of treatment post trauma

Treatment/s

Outcome

Adler et al. (2008)

Peacekeepers

RCT

952

Not timed to a specific event

Groups CISD vs. Survey only vs. Stress management

No overall effects

Bisson, Shepherd, Joy, Probert, & Newcombe (2004)

Burns victims

RCT

133

2–19 days

Debriefing vs. no treatment control

Debriefing groups had higher levels of PTSD at follow-up

Lee, Slade, & Lygo (1996)

Miscarriage

RCT

60

14 days

Individual counseling vs. treatment as usual

No overall effects

Marchand et al. (2006)

Armed robbery victims

RCT

75

2–22 days (first session); 1 week after that (second session)

Debriefing vs. no treatment control

No overall effects

Mayou, Ehlers, & Hobbs (2000) [3 year follow-up of Hobbs et al. (1996)]

Road traffic accident victims

RCT

160

24–48 h

Debriefing vs. no treatment control

At 3 months post-intervention: no difference between groups; at 3 years: intervention group had higher symptom levels

Rose, Brewin, Andrews, & Kirk (1999)

Violent crime

RCT

157

<1 month

Debriefing vs. education vs. assessment

No overall effects

Sijbrandij, Olff, Reitsma, Carlier, & Gersons (2006)

Adult civilian trauma

RCT

236

11–19 days

Emotional debriefing vs. educational debriefing vs. no treatment control

All groups showed similar results

Stallard et al. (2006)

Children aged 7–18, following road traffic accident

RCT

158

Within 1 month

Debriefing vs. no treatment control

Groups showed similar results

Wu et al. (2012)

Military rescuers

RCT

1,267

1 month

Cohesion debriefing vs. Debriefing vs. no treatment

Cohesion debriefing resulted in lower PTSD at follow-up





Cognitive Behavior Therapy: Early Intervention


Cognitive behavior therapy (CBT) is a well-established effective treatment for anxiety disorders in general (Olatunji, Cisler, & Deacon, 2010), and PTSD in particular (Kar, 2011). It has also been used as an early intervention for PTSD (Table 8.2). These studies show that brief early CBT both decreases initial symptoms levels, as well as prevents the long term development of PTSD. However, results are not entirely consistent. For example: in one study that compared CBT versus an assessment only control group, the CBT groups showed significantly lower PTSD symptoms at 1 week posttreatment, but by 4 months, this significant difference had disappeared (Sijbrandij et al., 2007).


Table 8.2
Early intervention for PTSD: randomized studies of CBT



























































































































Authors

Study population

N

Timing of treatment post trauma

Treatment/s

Outcome

Bisson et al. (2004)

Physically injured trauma survivors

152

5–10 weeks

CBT vs. TAU

CBT led to significantly lower PTSD symptoms at follow-up

Bryant, Moulds, Guthrie, & Nixon (2005)

Adult civilian trauma with ASD

87

Within 1 month

CBT, CBT + hypnosis, Supportive e counseling

CBT & CBT-hypnosis lead to greater treatment effects than supportive counseling; CBT-hypnosis reduced reexperiencing symptoms

Bryant (2008)

Adult civilian trauma with ASD

90

Within 1 month

Exposure vs. cognitive restructuring vs. waitlist control

Exposure based therapy leads to more significant changes than cognitive restructuring

Bryant, Sackville, Dang, Moulds, & Guthrie (1999)

Adult civilian trauma with ASD

45

Within 2 weeks

PE vs. PE + AM vs. Supportive counseling

Less chronic PTSD in PE and PE + AM groups

Bryant, Harvey, Dang, Sackville, & Basten (1998)

Adult civilian trauma with ASD

24

Within 2 weeks

CBT vs. supportive counseling

CBT leads to significantly lower PTSD at posttreatment and follow-up

Bugg, Turpin, Mason, & Scholes (2009)

Adult civilian trauma

36

Within 6 weeks

Structured writing vs. information only

No significant difference between groups at follow-up.

Cox, Kenardy, & Hendrikz (2010)

Children, accidental injury

85

2 weeks

Web based CBT vs. waitlist control

Decrease in anxiety in treatment group

Ehlers et al. (2003)

Motor vehicle accident

96

Within 6 months

Cognitive therapy vs. self-help booklet vs. repeated assessments

Cognitive therapy resulted in fewer symptoms of PTSD and depression. Self help not useful

Freyth, Elsesser, Lohrmann, & Sartory (2010)

Civilian trauma with ASD

40

1 month

PE vs. supportive counseling (three sessions)

No difference between groups at follow-up

Foa, Hembree et al. (2005), Foa, Keane et al. (2005)

Adult female sexual assault victims

90

Within 4 weeks

4 2-h sessions CBT vs. assessment vs. supportive counseling

Less anxiety at 3 months follow-up for CBT; no significant differences at 9 months follow-up

Nixon (2012)

Physical and sexual assault victims

30

Not stated

PT vs. supportive counseling

No difference between groups at follow-up

Rothbaum et al. (2012)

Civilian trauma survivors

137

During emergency room visit

Modified prolonged exposure in ER

Less PTSD at 4 and 12 weeks follow-up

Sijbrandij (2007)

Civilian trauma survivors

143

Within 3 months

Brief CBT vs. waitlist control

Accelerated recovery in the CBT group; no difference in long term outcome

Wagner, Zatzick, Ghesquiere, & Jurkovich (2007)

Injured trauma survivors

8

Between 1 and 3 months

TAU vs. behavioral activation

Behavioral activation resulted in fewer symptoms of PTSD, but not in depression

Zehnder, Meuli, & Landolt (2010)

Children, RTA

101

7–10 days

30 min intervention vs. treatment as usual

Reduced depression and beh problems in treatment group, who were preadolescent; no effect in older children



Remaining Questions Regarding Early Interventions


Although the studies we have reviewed suggest that CBT offered close in time to a traumatic event may be effective at preventing PTSD, there remain several important questions:

First, optimal timing of early interventions remains unclear. These studies include interventions timed between several hours (Rothbaum, Meuli & Landolt 2012) or days (Zehnder et al., 2010) to a few months (Wagner et al., 2007) after the event. Knowledge of natural decline in symptoms indicates that interventions offered at 4 days and 10 weeks are dealing with different patient sets and needs.

Second, the interventions, while all falling under the umbrella of CBT, vary widely in the specific interventions included. Therefore, it is unclear which components are essential, and which may be less necessary.

Third, many of these studies have focused on patients with diagnoses of Acute Stress Disorder (ASD). A significant percentage of individuals with ASD subsequently develop PTSD, and therefore this is a vulnerable group. However, research shows that only between 30 (Creamer, O’Donnell, & Pattison, 2004) and 84 % (Bryant & Harvey, 1998) of individuals with ASD will develop PTSD, whereas between 10 (Schnyder, Moergeli, Klaghofer, & Buddeberg, 2001) and 72 % (Harvey & Bryant, 2000) of individuals with PTSD suffered from ASD. Therefore offering intervention only to those patients with ASD potentially neglects a large number of people who are at risk for PTSD.

Fourth, although it seems clear to clinicians that early interventions are important and essential, clients seem less accepting. Studies have shown that even when early interventions are readily available, a significant percentage of patients are reluctant to accept treatment (e.g., Hoge et al., 2004). Several explanations for this have been suggested, including stigma (Kim, Thomas, Wilk, Castro, & Hoge, 2010). However, a better understanding of these barriers to treatment is essential in planning acceptable, and not just effective, treatments.


The Jerusalem Trauma Outreach and Prevention Study


The Jerusalem Trauma Outreach and Prevention Study (J-TOPS) project was designed in an attempt to answer some of the questions outlined above. It will be briefly described here (Shalev, Ankri, Peleg, Israeli-Shalev, & Freedman, 2011, gives more detailed information regarding its design), and the major results presented (Shalev et al., 2012).

J-TOPS consisted of two overlapping research methodologies: first, a longitudinal prospective outreach study and second, an embedded randomized controlled trial. Tracking all admissions to the Emergency Room of a large hospital in Israel, the outreach program identified, via computer, patients as suitable for the study (aged between 18 and 65, lived within the greater Jerusalem area, came to the ER as a result of a potentially traumatic event). These individuals were phoned within 2 weeks of their ER visit. This telephone interview (Telephone Interview I, or TI-1) identified whether the person had experienced a traumatic event, as per DSM (i.e., both objectively experienced an event as well as subjective responded to that event), as well as suffering from symptom levels of PTSD and depression. Figure 8.1 details the design of the study.

A217180_1_En_8_Fig1_HTML.gif


Fig. 8.1
J-TOPS study design

A second telephone interview was conducted 7 months post-trauma. At this point in time all subjects who had experienced a traumatic event were reinterviewed. In addition, 10 % of those subjects deemed not to have had experienced a traumatic event were randomly chosen and reinterviewed.

In the first telephone interview, 5,286 individuals were called, and 5,053 (94 %) agreed to participate. A large proportion of these people had not actually experienced a traumatic event, as defined in Criteria A1 and A2 of DSM IV. Of the 1996 that had experienced an event, 1,502 were considered to be sufficiently symptomatic as to warrant further investigation, and were invited to a clinical interview. Only 50 % actually attended. Of the 756 people interviewed at this stage, 397 exhibited PTSD symptoms, and were eligible for the randomized control trial. Of these, 296 (75 %) started treatment.

Participants who were invited to either the clinical interview, or to participate in the treatment trial, but did not attend, showed less symptom reduction over time. This difference between attendees and non-attendees remained significant, even when initial symptoms levels were taken into account. Thus, this study revealed that even when approached by a treatment team dedicated to outreach, the majority of recently traumatized individuals preferred not to meet with a mental health professional. However, acceptance of telephone contact was extremely high. As refusing an interview, or treatment, is clearly associated with poorer outcome, this represents a significant barrier to successful treatment.

The randomized controlled trial (Shalev et al., 2012) assessed effectiveness of three different treatment modalities. The first treatment, Prolonged Exposure (PE, Foa & Rothbaum, 1998), is a behavior based treatment that includes psychoeducation, breathing retraining, in vivo exposure, and imaginal exposure to the trauma narrative. Many studies, as described above, have demonstrated the effectiveness of PE as a treatment for both chronic PTSD as well as an early intervention. The latter, however, usually consisted of 4–5 sessions. In this study, the full protocol of 12 sessions was offered. The second treatment, cognitive therapy (CT, Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998), focuses on the negative interpretations that patients make about their trauma, themselves, and their reactions. It includes no elements of exposure, and therefore, can be compared with PE. CT been shown to be effective in treating chronic PTSD (Marks et al., 1998), although results as an early intervention were less positive (Bryant et al., 2008). In the third treatment group, patients received an SSRI in a double blind comparison with placebo. A fourth group of patients were a waitlist control. If they were symptomatic at the end of the waitlist condition, they received Prolonged Exposure. Thus, early and late interventions could be compared.

The results indicated that both PE and CT were successful in treating early symptoms. There were no significant differences between PE and CT in treatment acceptance, drop out from treatment, or its effectiveness. There were no significant difference between SSRI, placebo, and waitlist control, and all were significantly less effective than PE and CT.

This study allowed patients to refuse up to two treatment conditions within the randomization process: thus a patient could refuse PE, and then be re-randomized to one of the other conditions. This type of randomization better reflects real world clinical settings, where patients are able to choose their treatment. This study found that relatively few patients refused psychological treatments (CT: 8, 3.1 %; PE: 3, 1.2 %). However, a significantly higher number refused medication (103, 42.6 %).

The study found that early and late PE resulted in similar recovery rates.

While the majority of patients who entered the RCT presented with full PTSD or ASD symptoms, others met two out of the three necessary criteria and therefore could be said to have “partial PTSD.” When these patients with partial PTSD who received CT or PE were compared with waitlist control, no significant differences were found. This indicates that the effectiveness of PE and CT over natural recovery is only apparent in those presenting with all the symptoms of PTSD.

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Jul 18, 2017 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Is Prevention Better than Cure? How Early Interventions Can Prevent PTSD

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