Screening and treating hospitalized trauma survivors for posttraumatic stress disorder and depression.

Traumatic injury affects over 2.6 million U.S. adults annually and elevates risk for a number of negative health consequences. This includes substantial psychological harm, the most prominent being posttraumatic stress disorder (PTSD), with approximately 21% of traumatic injury survivors developing the disorder within the first year after injury. Posttraumatic stress disorder is associated with deficits in physical recovery, social functioning, and quality of life. Depression is diagnosed in approximately 6% in the year after injury and is also a predictor of poor quality of life. The American College of Surgeons Committee on Trauma suggests screening for and treatment of PTSD and depression, reflecting a growing awareness of the critical need to address patients' mental health needs after trauma. While some trauma centers have implemented screening and treatment or referral for treatment programs, the majority are evaluating how to best address this recommendation, and no standard approach for screening and treatment currently exists. Further, guidelines are not yet available with respect to resources that may be used to effectively screen and treat these disorders in trauma survivors, as well as who is going to bear the costs. The purpose of this review is: (1) to evaluate the current state of the literature regarding evidence-based screens for PTSD and depression in the hospitalized trauma patient and (2) summarize the literature to date regarding the treatments that have empirical support in treating PTSD and depression acutely after injury. This review also includes structural and funding information regarding existing postinjury mental health programs. Screening of injured patients and timely intervention to prevent or treat PTSD and depression could substantially improve health outcomes and improve quality of life for this high-risk population. LEVEL OF EVIDENCE: Review, level IV.

Psychological Prophylaxis: An Integrated Psychological Services Program in Trauma Care.

The primary medical goals of acute care are restoration of physical health and return to physical function. However, in response to traumatic events and injuries, psychological factors are critical to one's overall recovery. Both pre-morbid psychiatric comorbidities and post-injury psychological compromise affect physical and psychological recovery in inpatient trauma populations. The Psychological Services Program (PSP), a model trauma/acute care program, addresses these critical factors in a Level 1 Trauma Center. The program routinely treats over one-quarter of the trauma patients at any given time. The incorporation of the PSP into treatment team care ensures that patients in need of mental health support can be identified and treated during their recovery. This unique model is recommended as a potential injury prevention and recovery intervention strategy for the myriad mental health comorbidities that may function as risk factors for poor post-injury adaptation and also as risk factors for possible future traumatic injury.

Proficiency of surgical faculty and residents with ethical dilemmas: is modeling enough?

OBJECTIVE: Professionalism, an Accreditation Commission for Graduate Medical Education (ACGME) competency, embraces the concept of adherence to ethical principles. Despite this, most surgical residencies do not currently include ethics as part of their core curriculum. Further, expertise in effectively managing ethical dilemmas is frequently obtained via modeling after the attending physician. This study evaluated surgical faculty (SF) and residents (SR) on their understanding of basic ethical principles and their overall confidence in translation of these principles into clinical practice. The objective was to determine if there are any differences in the overall levels of knowledge and confidence in ethics between SR and SF. DESIGN AND SETTING: Immediately before the first session of a Kamangar Grant supported monthly Ethics Forum, all SF and SR completed a Pre-Curriculum Questionnaire (PCQ) on their knowledge about ethical principles and their confidence in dealing with ethical issues. PQC contained 13 multiple-choice and true/false knowledge questions and 8 questions evaluating confidence rated on a 5-point Likert scale. PARTICIPANTS: Surgical faculty (SF) (n = 16) and SR (n = 36). Knowledge and confidence scores were compared between SR and SF, using Student t-test analysis to evaluate differences between groups. RESULTS: No significant differences were found in ethical knowledge scores between faculty and residents. Faculty confidence is higher than resident (p < 0.05). Further, female faculty confidence is higher than that of their male counterparts (p < 0.05). CONCLUSIONS: While SF are more confident in their ethical decision-making, their fundamental knowledge base in ethics is not different from that of SR. Female SF report greater self-confidence over their male counterparts. In total, SF may not possess the foundation to effectively mentor residents in appropriate ethical principles and their translation to clinical practice. This study supports the need for both SR and SF to engage in an integrated education program in ethics to promote on-going dialogue in this complex topic.

Impaired residents: identification and intervention.

PURPOSE: To describe the effect of a psychologist on faculty staff supporting impaired residents to successful program completion in general surgery. METHODS: Since 1996, the Department of Surgery has had a staff psychologist on faculty who works closely with the Trauma service. Duties include provision of patient and family therapies (representing a revenue-generating activity for the department), in-services for staff stress management, research, and community education activities. As resident performance issues have arisen, the psychologist has been instrumental in early identification of and referral for underlying issues affecting resident behavior. RESULTS: From 1996 to October 2001, 12 residents (2 with multiple referrals) have been identified with significant psychological issues impairing performance. The various psychological problems include depression, anger control issues, and addictions; required interventions have included referrals for therapeutic counseling, recommendations for career change, and therapeutic counseling combined with pharmacotherapy. Fellow residents referred 4 of the 12 residents to the psychologist for possible evaluation, and the remaining 8 had referral initiated by performance concerns. CONCLUSIONS: Significant psychological problems can impair resident performance and possible training program completion. Early identification and intervention by a professional psychologist on faculty can provide support for increased opportunity to complete residency training.

The psychological aspects of pediatric trauma: perspectives on patient, family, and provider.

Pediatric trauma engenders multi-system injury--physiological as well as psychological. Not only does injury to a child affect the patient, but also the family system within which the child functions. Professional caregivers, too, are not immune to the emotional aftermath of pediatric traumatic injury. Effective management of the pediatric trauma patient must, therefore, include an understanding of the psychological aspects of injury--for the patient, the family, and the provider. This chapter seeks to delineate these variables in an effort to promote effective identification of the emotional components of injury and facilitation of necessary interventions in promoting positive overall injury outcomes.

Turning point: rethinking violence--evaluation of program efficacy in reducing adolescent violent crime recidivism.

BACKGROUND: The link between medicine and violence prevention is self-evident, yet the literature reveals few studies that scientifically document effective interventions. The Turning Point: Rethinking Violence (TPRV) program is a unique multiagency program developed to expose, educate, and remediate first-time violent offenders and their parents regarding the real-world consequences of violence. Four key components are integrated into a 6-week, court-ordered program (14 total contact hours): the Trauma Experience (tour, video, discussions), the Victim Impact Panel (presented by parent survivors), Group Process, and Community Networking (individualized mental health referral). We hypothesize that TPRV delivers lower outcomes regarding violence recidivism (VR) when compared with standard court sentencing options (100 hours of community service) for first-time violent offenders. METHODS: The study group subjects (n = 38) met inclusion criteria and were blindly and randomly sentenced to attend the TPRV program. The control group (n = 38) were pulled from a subject pool of first-time offenders who received standard sentencing options, met the same inclusion criteria with regard to age and types of offenses, and were matched by race to the study group. Both groups were studied for VR within the year after the first violent conviction, and comparison was performed by a (2 analysis of recidivism rates. RESULTS: Results reveal a statistically significant difference between the study group and the control group for VR (p