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Management of Mental Health Sequelae in Trauma Patients2020

Type: New Practice Management Guideline (PMG)
Category: Injury Prevention
Committee Liaison: Patrick B Murphy, MD, MPH, MSc


Team leader(s)

Statement:
Management of mental health sequelae in trauma patients. Trauma is a leading cause of death and disability. However, due to the advancements in trauma care, more and more trauma patients survive their injuries. This survivorship has the unwanted consequence of patients with psychological disorders due to their traumatic events. Many trauma patients (19-42%) report emotional or psychological distress after injury and >20% of trauma patients will develop Post Traumatic Stress Disorder (PTSD) and/or depression within the first year after injury. Untreated PTSD and depression are associated with lost productivity, poor quality of life, and functional impairment.

  1. Patients with Acute Stress Disorder (ASD) and early PTSD symptoms who were treated with early intervention have a reduction of PTSD symptoms. The strongest evidence for benefit is when patients are treated with Cognitive Behavioral Therapy (CBT)
  2. At initial encounter after trauma, patients’ physical injuries tend to be the focus. Follow up appointments after
    hospital discharge also tend to focus on wound healing and other physical health.

Unfortunately, mental health screening and intervention after trauma tends to take a back seat on both patient encounters. This often leaves patients with undiagnosed and untreated PTSD and depression affecting their lives and productivity. Trauma centers are in a position to address patients’ mental well-being after a traumatic event. However, a national survey showed that only 7% of level 1 and level 2 trauma centers provided routine screening for PTSD3. While there is a growing awareness of the need to address this problem, currently there is no unified guideline in the trauma community regarding when and how to manage patients' mental well-being after a traumatic event. This may be the reason that there is a lack of screening and intervention of ASD and PTSD in trauma centers.

We are proposing a practice management guideline (PMG) as an attempt to fill that void and provide guidance on early identification of individuals at risk for mental illness as well as evidence-based treatment options to assist our patients
in overcoming their traumatic events.

Proposed PICO questions:

A. In adult trauma patients admitted to the hospital (P), should behavioral health screening (or acute stress disorder /PTSD screening) (I) be performed compared to no screening (C) to decrease chronic PTSD, recidivism rate, post injury quality of life, and hospital LOS (O).

B. In adult trauma patients admitted to the hospital (P), should behavioral health intervention (I) (ie not just screening) be done compared to "regular care" (C) (ie. no behavioral intervention) to reduce chronic PTSD, recidivism rate, post injury quality of life, and hospital LOS (O).

C. In adult trauma patients admitted to the hospital who are SCREENED POSITIVE for ASD/ PTSD/ Depression (P), should behavioral health intervention (I), be done compared to “regular care” (ie. No behavioral intervention) (C), to reduce chronic PTSD, recidivism rate, post injury quality of life, and hospital LOS (O).

D. In adult trauma patients admitted to the hospital with pre-existing mental health conditions (P), does in-hospital mental health counseling (psychiatry/ psychology) consults (I), or only outpatient vs no follow up (C) decrease post traumatic mental health complications, post injury quality of life, and recidivism(O)?

E. In adult trauma patients admitted to the hospital (P), will cognitive behavioral therapy (specific to CBT as opposed to PICO #2 which refer to ALL types of intervention) (I) compared to other therapies (C) decrease long term PTSD recidivism rate, and post injury quality of life (O)

Bibliography

1. Ruggiero KJ, Davidson TM, Anton MT, Bunnell, B, Winkelmann J, Ridings LE, Bravoco O, Crookes B, McElligot J, Fakhry SM. Patient Engagement in Technology-Enhanced, Stepped-care Intervention to address the mental health needs of Trauma Center patients. J. Am Coll Surg.2020; 231: 223-230. 2. Roberts NP, Kitchiner NJ, Kenardy J, Lewis CE, Bisson JI. Early psychological intervention following recent trauma: A systematic review and meta-analysis. Psycho-traumatology. 2019; 10: 1-19. 3. Love J, Zatzick D. Screening and intervention for comorbid substance disorders,
PTSD, depression and suicide: a trauma center survey. Psychiatr Serv 2014; 65:918-23.

Team members:
• Hassan Mashbari, MD
• Randi Smith, MD, MPH
• Lindsey Perea, DO
• Leah C. Tatebe MD FACS
• Caroline Butler, MD
• Charity Evans, MD, MS
• Kenneth J. Ruggiero, PhD
• Rishi Rattan MD FACS
• Lisa Allee MSW, LICSW
• Rev. Carol Reese
• Ashley Hink MD
• Shaikh Hai MD
•James Drew Zebley MD
•Hillary Prince MD


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