Engaging and following physical injury survivors at risk for developing posttraumatic stress disorder symptoms: A 25 site US national study.

INTRODUCTION: Early intervention for patients at risk for Posttraumatic Stress Disorder (PTSD) relies upon the ability to engage and follow trauma-exposed patients. Recent requirements by the American College of Surgeons Committee on Trauma (College) have mandated screening and referral for patients with high levels of risk for the development of PTSD or depression. Investigations that assess factors associated with engaging and following physically injured patients may be essential in assessing outcomes related to screening, intervention, and referral. METHODS: This investigation was a secondary analysis of data collected as part of a United States level I trauma center site randomized clinical trial. All 635 patients were ages ≥18 and had high PTSD symptom levels (i.e., DSM-IV PTSD Checklist score ≥35) at the time of the baseline trauma center admission. Baseline technology use, demographic, and injury characteristics were collected for patients who were followed up with over the course of the year after physical injury. Regression analyses were used to assess the associations between technology use, demographic and injury characteristics, and the attainment of follow-up outcome assessments. RESULTS: Thirty-one percent of participants were missing one or more 3-, 6- or 12-month follow-up outcome assessments. Increased risk of missing one or more outcome assessments was associated with younger age (18-30 versus ≥55 Relative Risks [RR] = 1.78, 95 % Confidence Interval [CI] = 1.09, 2.91), lack of cell phone (RR = 1.32, 95 % CI = 1.01, 1.72), no internet access (RR = 1.47, 95 % CI = 1.01, 2.16), public versus private insurance (RR = 1.47, 95 % CI = 1.12, 1.92), having no chronic medical comorbidities (≥4 versus none, RR = 0.28, 95 % CI = 0.20, 0.39), and worse pre-injury mental health function (RR = 0.99, 95 % CI = 0.98, 0.99). CONCLUSIONS: This multisite investigation suggests that younger and publicly insured and/or uninsured patients with barriers to cell phone and internet access may be particularly vulnerable to lapses in trauma center follow-up. Clinical research informing trauma center-based screening, intervention, and referral procedures could productively explore strategies for patients at risk for not engaging and adhering to follow-up care and outcome assessments.

Can stepped collaborative care interventions improve post-traumatic stress disorder symptoms for racial and ethnic minority injury survivors?

Objectives: No large-scale randomized clinical trial investigations have evaluated the potential differential effectiveness of early interventions for post-traumatic stress disorder (PTSD) among injured patients from racial and ethnic minority backgrounds. The current investigation assessed whether a stepped collaborative care intervention trial conducted at 25 level I trauma centers differentially improved PTSD symptoms for racial and ethnic minority injury survivors. Methods: The investigation was a secondary analysis of a stepped wedge cluster randomized clinical trial. Patients endorsing high levels of distress on the PTSD Checklist (PCL-C) were randomized to enhanced usual care control or intervention conditions. Three hundred and fifty patients of the 635 randomized (55%) were from non-white and/or Hispanic backgrounds. The intervention included care management, cognitive behavioral therapy elements and, psychopharmacology addressing PTSD symptoms. The primary study outcome was PTSD symptoms assessed with the PCL-C at 3, 6, and 12 months postinjury. Mixed model regression analyses compared treatment effects for intervention and control group patients from non-white/Hispanic versus white/non-Hispanic backgrounds. Results: The investigation attained between 75% and 80% 3-month to 12-month follow-up. The intervention, on average, required 122 min (SD=132 min). Mixed model regression analyses revealed significant changes in PCL-C scores for non-white/Hispanic intervention patients at 6 months (adjusted difference -3.72 (95% CI -7.33 to -0.10) Effect Size =0.25, p<0.05) after the injury event. No significant differences were observed for white/non-Hispanic patients at the 6-month time point (adjusted difference -1.29 (95% CI -4.89 to 2.31) ES=0.10, p=ns). Conclusion: In this secondary analysis, a brief stepped collaborative care intervention was associated with greater 6-month reductions in PTSD symptoms for non-white/Hispanic patients when compared with white/non-Hispanic patients. If replicated, these findings could serve to inform future American College of Surgeon Committee on Trauma requirements for screening, intervention, and referral for PTSD and comorbidities. Level of evidence: Level II, secondary analysis of randomized clinical trial data reporting a significant difference. Trial registration number: NCT02655354.

Stepped collaborative care versus American College of Surgeons Committee on Trauma required screening and referral for posttraumatic stress disorder: Clinical trial protocol.

BACKGROUND: Each year in the US, approximately 1.5-2.5 million individuals are so severely injured that they require inpatient hospital admissions. The American College of Surgeons Committee on Trauma (College) now requires that trauma centers have in place protocols to identify and refer hospitalized patients at risk injury psychological sequelae. Literature review revealed no investigations that have identified optimal screening, intervention, and referral procedures in the wake of the College requirement. METHODS: The single-site pragmatic trial investigation will individually randomize 424 patients (212 intervention and 212 control) to a brief stepped care intervention versus College required mental health screening and referral control conditions. Blinded follow-up interviews at 1-, 3-, 6-, and 12-months post-injury will assess the symptoms of PTSD and related comorbidity for all patients. The emergency department information exchange (EDIE) will be used to capture population-level automated emergency department and inpatient utilization data for the intent-to-treat sample. The investigation aims to test the primary hypotheses that intervention patients will demonstrate significant reductions in PTSD symptoms and emergency department/inpatient utilization when compared to control patients. The study incorporates a Rapid Assessment Procedure-Informed Clinical Ethnography (RAPICE) implementation process assessment. CONCLUSIONS: The overarching goal of the investigation is to advance the sustainable delivery of high-quality trauma center mental health screening, intervention, and referral procedures for diverse injury survivors. An end-of-study policy summit will harness pragmatic trial data to inform the capacity for US trauma centers to implement high-quality acute care mental health screening, intervention and referral services for diverse injured patient populations. TRIAL REGISTRATION: Clinicaltrials.govNCT05632770.

Learnings from the implementation of standardized content and processes for integrated behavioral health prevention visits.

INTRODUCTION: Integrated behavioral health (IBH) in pediatric primary care has spread significantly over the past two decades. However, a crucial component of advancing the state of science is articulating specific intervention models and their associated outcomes. Foundational to this research is the standardization of IBH interventions; however, limited scholarship exists. This is particularly true for IBH prevention (IBH-P) interventions, which pose unique challenges to standardization. The present study presents the development of a standardized IBH-P model, processes to ensure fidelity, and fidelity outcomes. METHOD: The IBH-P model was delivered by psychologists in two large, diverse pediatric primary care clinics. Extant research and quality improvement processes supported the development of standardized criteria. Fidelity procedures were developed through an iterative process, resulting in two measures: provider self-rated fidelity and independent rater fidelity. These tools assessed fidelity to IBH-P visits and comparison of self and independently rated fidelity. RESULTS: Data from both self and independent ratings indicated 90.5% of items were completed across all visits. The agreement between independent rater coding and provider self-coding was high (87.5%). DISCUSSION: Results indicated a high level of concordance between provider self-ratings and independent coder ratings of fidelity. Findings suggest that a prevention-based, universal, standardized model of care with a psychosocially complex population was feasible to develop and adhere to. Learnings generated from this study may guide other programs seeking to develop standardization interventions and fidelity processes that can ensure high-quality, evidence-based care. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Shyness and susceptibility to social influence: Stronger concordance between norms and drinking among shy individuals.

Despite a large body of work exploring associations between perceived norms and drinking and norms-based interventions for drinking, less work has examined moderators of associations between norms and drinking outcomes to determine potential sub-groups that might benefit most from brief norms-based interventions. The present study investigates shyness as a moderator of associations between drinking norms and alcohol use. We hypothesized that shyness would moderate associations between drinking norms and alcohol use such that individuals who are higher in shyness might be more sensitive to social influence and thus show stronger associations between drinking norms and alcohol use. Participants included 250 college students (70% female; 44.5% White/Caucasian) aged 18-26 (M = 21.02, SD = 2.16) who met heavy drinking criteria (4/5 drinks on one or more occasions in the past month for women/men). Participants completed measures of demographics, shyness, alcohol use, alcohol-related problems, and drinking norms remotely at baseline and one-month follow-up (N = 169). Drinking norms were negatively associated with shyness and positively associated with baseline and follow-up drinking. Shyness was negatively associated with baseline drinking but not associated with follow-up drinking. Interaction models tested longitudinal associations between shyness, descriptive drinking norms, and follow-up drinking, controlling for baseline drinking and gender. Results showed that associations between drinking norms and drinks per week were strongest among people who were higher in shyness. Individuals who are shy may be more susceptible to social influence and thus may benefit more from a norms-based drinking intervention. Future work may explore shyness as a moderator of norms-based intervention efficacy.

Selection of preclinical models to evaluate intranasal brain cooling for acute ischemic stroke.

Stroke accounts for a large proportion of global mortality and morbidity. Selective hypothermia, via intranasal cooling devices, is a promising intervention in acute ischemic stroke. However, prior to large clinical trials, preclinical studies in large animal models of ischemic stroke are needed to assess the efficacy, safety, and feasibility of intranasal cooling for selective hypothermia as a neuroprotective strategy. Here, we review the available scientific literature for evidence supporting selective hypothermia and make recommendations of a preclinical, large, animal-based, ischemic stroke model that has the greatest potential for evaluating intranasal cooling for selective hypothermia and neuroprotection. We conclude that among large animal models of focal ischemic stroke including pigs, sheep, dogs, and nonhuman primates (NHPs), cynomolgus macaques have nasal anatomy, nasal vasculature, neuroanatomy, and cerebrovasculature that are most similar to those of humans. Moreover, middle cerebral artery stroke in cynomolgus macaques produces functional and behavioral deficits that are quantifiable to a greater degree of precision and detail than those that can be revealed through available assessments for other large animals. These NHPs are also amenable to extensive neuroimaging studies as a means of monitoring stroke evolution and evaluating infarct size. Hence, we suggest that cynomolgus macaques are best suited to assess the safety and efficacy of intranasal selective hypothermia through an evaluation of hyperacute diffusion-weighted imaging and subsequent investigation of chronic functional recovery, prior to randomized clinical trials in humans.