Workplace trauma and professional quality of Life in clinical and forensic psychiatry: the CRITIC study.

Background: Frontline staff in psychiatry need to perform at a very high professional level in order to ensure patient and community safety. At the same time they are exposed to high levels of stress and workplace trauma. This may have severe consequences for their professional quality of life. In addition, health care workers in general have higher incidence levels of childhood adversity than the general population. The CRITIC (CRITical Incidents and aggression in Caregivers) Study aims to improve increased understanding of the interaction between personal life history (childhood adversity and benevolence), individual capabilities, exposure to trauma and violence at work and Professional Quality of Life (ProQOL). Method: The Critic Study is a cross-sectional survey of these aspects in frontline, treatment and administrative staff in clinical and forensic psychiatry. We aim to include 360 participants. Participants will be asked to complete questionnaires on childhood adversity and childhood benevolence (assessing personal life history), professional quality of life, current trauma and violence exposure, current mental health (depression, anxiety and stress), coping, social support, work engagement and resilience. In this study we will examine the moderating role of adverse and benevolent childhood experiences in the association between workplace trauma exposure and professional quality of life. Finally, a theoretical model on the relationships between trauma, stress and coping in the context of professional functioning will be tested using structural equation modelling. Discussion: The CRITIC study examines which factors influence the complex relationship between childhood adversity and benevolence, and ProQOL in healthcare workers. It also aims to provide insight into the complex relationship between personal life history, individual characteristics, exposure to trauma and violence at work and ProQOL. The results can be used for designing interventions to increase resilience to trauma and to improve professional quality of life among health care professionals. Trial registration: The CRITIC study has been approved by the Medical Ethical Committee of the Erasmus Medical Centre, under trial registration number NL73417.078.20.

Posttraumatic stress disorder in people with dementia: study protocol.

Background: Posttraumatic stress disorder (PTSD) is considered an independent risk factor for dementia. Despite the (clinical) evidence that PTSD is associated with neuropsychiatric symptoms in people with dementia, studies on its prevalence and clinical manifestation are limited, and their quality is affected by the lack of a structured method to diagnose PTSD in this population. The primary aim of the current study is to validate the 'TRAuma and DEmentia' interview as a diagnostic tool for PTSD in people with dementia and to test feasibility of EMDR treatment for people with PTSD and dementia.Methods: This prospective multi-centre study is divided into two parts. In study A, 90 participants with dementia will be included to test the criterion validity, inter-rater reliability and feasibility of the 'TRAuma and DEmentia' interview. In study B, 29 participants with dementia and PTSD will receive eye movement desensitisation and reprocessing therapy by a trained psychologist, and 29 participants with dementia and PTSD will be placed on the waiting list control group.Conclusion: This study aims to improve the diagnostic process of PTSD and to assess the effects of eye movement desensitisation and reprocessing treatment in people with dementia living in Dutch care facilities.Trial registration: NL70479.068.20 / METC 20-063 / OSF registration: https://doi.org/10.17605/OSF.IO/AKW4F.

This study protocol describes a two-part study on posttraumatic stress disorder in people with dementia in Dutch care facilities.The primary aim of the study is to validate the 'TRAuma and DEmentia' interview as a diagnostic tool for posttraumatic stress disorder in people with dementia.This study aims to test the feasibility of an evidence-based treatment for people with dementia and posttraumatic stress disorder in the form of eye movement desensitisation and reprocessing therapy.

The impact of adversities across the lifespan on psychological symptom profiles in late adulthood: a latent profile analysis.

People commonly face adverse circumstances throughout life, which increases risk for psychiatric disorders, such as anxiety, depression, psychosis, and posttraumatic stress disorder (PTSD). Adversities may occur during different periods in life. Especially adversity during early periods has been suggested to put individuals at risk for adverse mental health outcomes. Here, we investigated whether timing of adversity during the prenatal period, childhood, or mid-to-late adulthood differentially impacted classification into late adulthood symptom profiles. We performed sex-stratified Latent Profile Analysis to identify latent profiles regarding anxious, depressive, psychotic, and PTSD symptoms in n = 568 Dutch famine birth cohort members (n = 294 women, n = 274 men, mean age(SD) = 72.9(0.8)). Cross-sectional late adulthood symptomatology, childhood traumatic maltreatment, and adulthood trauma were based on self-report questionnaires. Prenatal adversity was considered present when individuals were prenatally exposed to the 1944-45 Dutch famine. In both men and women we identified one anxious/depressive profile and three profiles with approximately equal severity of all symptom types within each profile, yet differentiating in overall severity (low, mild, high) between profiles. We additionally found a PTSD symptom profile in women. In men, logistic regression models showed significant associations between prenatal, childhood and adulthood adversity, and profile classification, with differential effects depending on timing and most profound effects of child maltreatment. In women, childhood and adulthood adversity significantly increased classification probability into almost all profiles, with no significant effect of prenatal adversity. These findings support a time-dependent and sex-specific impact of adversity during different periods across the lifespan on psychological health, with consequences into late adulthood.

Feasibility, acceptability, and effectiveness of web-based and mobile PTSD Coach: a systematic review and meta-analysis.

Background: Timely and effective interventions can alleviate or prevent the development of clinical symptomatology in trauma-exposed individuals. However, due to limited access to these interventions, and/or stigma around accessing mental health services, there is an unmet need. Internet-and mobile-based interventions may help to address this need.Aims: This review aims to (i) synthesise the evidence on feasibility, acceptability, and effectiveness of the 'PTSD Coach' intervention (both web-based and mobile applications) in trauma-exposed individuals; (ii) evaluate the quality of this research; and (iii) identify challenges and recommendations related to 'PTSD Coach' intervention delivery.Method: Systematic database searches were conducted (PubMed/MEDLINE, PsycINFO, EMBASE, PLoS, Web of Science, PTSDpubs, Scopus, and clinical trial databases). Review inclusion was based on predefined inclusion criteria, and study quality was assessed with the mixed methods appraisal and the risk-of-bias tools for randomised trials. Where feasible, meta-analytical pooling of intervention effects on posttraumatic stress symptoms (PTSS) was conducted.Results: Seventeen manuscripts reporting on 16 primary studies were included with the majority evaluating a self-managed PTSD Coach mobile application intervention. Most studies were conducted in higher-income countries and females were over-represented. For both platforms, satisfaction and perceived helpfulness were generally high but type of smart device operating system was identified as an influence. The pooled effect size in symptom severity in the intervention group compared to the comparison group was not significant (standardised mean difference =  - 0.19) (95% CI - 0.41 to - 0.03, p = .09). Heterogeneity was not significant (p = .14; I2 = 40%). No study was excluded based on quality assessment.Conclusion: Findings support the feasibility and acceptability of 'PTSD Coach' in trauma-exposed individuals. However, evidence on the effectiveness on PTSS remains limited. More research is still needed in low-middle-income countries, particularly those in which supported 'PTSD Coach' interventions are evaluated in larger and more diverse samples.

Most studies evaluated a self-managed PTSD Coach mobile application intervention in higher-income countries.Findings generally support the feasibility and acceptability of both PTSD Coach mobile application and PTSD Coach Online in trauma-exposed individuals but the evidence on the effectiveness on posttraumatic stress symptoms remains limited.More research is needed especially in low-middle-income countries where there is often limited access to the needed interventions.

Treatment of post-traumatic stress disorder in people with dementia: a structured literature review.

Post-traumatic stress disorder (PTSD) is associated with cognitive dysfunctions and is an independent risk factor for dementia. A recent study has found the prevalence of PTSD in people with dementia is 4.7%-7.8%. However, little is known about the effectiveness of PTSD treatment for people with dementia. The primary aim of the current study is to review previous studies on the treatment of PTSD in people with dementia. A structured literature review was performed using a 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' analysis in PubMed, Embase, PsycINFO and CINAHL. Two independent researchers screened titles and abstracts. The inclusion criteria were: PTSD symptoms present, diagnosis of dementia, PTSD treatment form described and effects of the treatment mentioned. Articles that matched these criteria were included and content and quality were analyzed. We included nine articles, all case reports, with a total of 11 cases. The discussed treatment options are eye movement desensitisation and reprocessing (EMDR) (n = 3), prolonged exposure (n = 1), cognitive behavioural therapy (n = 1) and pharmacological treatment (n = 4). All articles reported a positive effect of the intervention on several monitored symptoms. Evidence for positive effects and feasibility of EMDR were most reliable, and it was applied in two articles of sufficient quality published in 2018 and 2019. EMDR 'on-the-spot' was described with positive effect in one article in which three cases were discussed. The quality of included papers ranged from insufficient to sufficient. This review shows that people with PTSD and dementia can benefit from PTSD treatment. EMDR, prolonged exposure, acceptance and commitment therapy and pharmacological treatment are applicable in this population. EMDR treatment is most described in this population (n = 5) and shows positive results, and the studies are of sufficient quality (n = 3). Further research in the form of a randomised controlled trial is required to study the effectivity of different treatment interventions in this population.

Trauma and its consequences in Iran: cross-cultural adaption and validation of the Global Psychotrauma Screen in a representative sample.

BACKGROUND: Potentially traumatic events may lead to the development of a wide range of adverse psychological responses, including symptoms of anxiety, depression, and (complex) posttraumatic stress disorder (PTSD). Despite the high prevalence of potentially traumatic events in Iran, there is no population data nor evidence-based instrument to screen for cross-diagnostic psychological responses to trauma. The Global Psychotrauma Screen (GPS) is a transdiagnostic self-report instrument for the detection of trauma-related symptoms, as well as risk and protective factors related to the impact of potentially traumatic events. OBJECTIVE: The present study seeks to 1) translate and cross-culturally adapt the GPS in the Persian (Farsi) language and 2) examine the psychometric properties of the Persian GPS. METHOD: The translation and adaptation were performed using the Sousa and Rojjanasrirat (2011) method. A pilot study (n = 30) was carried out to test the content validity and test-retest reliability of the GPS. Next, in a representative sample (n = 800) of residents of Kermanshah City, the GPS, the General Health Questionnaire (GHQ) and the PTSD Checklist for DSM-5 (PCL-5) were administered. Construct validity of the Persian GPS was assessed using exploratory and confirmatory factor analysis. Additionally, we evaluated the convergent validity and internal consistency of the GPS. RESULTS: Exploratory and confirmatory factor analyses indicated a three-factor model as the best solution with factors representing 1) Negative Affect, 2) Core PTSD symptoms and 3) Dissociative symptoms. The GPS total symptom score had high internal consistency and high convergent validity with related measures. A GPS total symptom cut-off score of nine was optimal for indicating a probable PTSD diagnosis based on the PCL-5. About half (52%) of the current sample met criteria for probable PTSD. CONCLUSIONS: The current findings suggest that the GPS can be effectively adapted for use in a non-Western society and, specifically, that the Persian GPS represents a useful, reliable and valid tool for screening of trauma-related symptoms in Iran.

Text mining to improve screening for trauma-related symptoms in a global sample.

Previous studies showed that textual information could be used to screen respondents for posttraumatic stress disorder (PTSD). In this study, we explored the feasibility of using language features extracted from short text descriptions respondents provided of stressful events to predict trauma-related symptoms assessed using the Global Psychotrauma Screen. Texts were analyzed with both closed- and open-vocabulary methods to extract language features representing the occurrence of words, phrases, or specific topics in the description of stressful events. We also evaluated whether combining language features with self-report information, including respondents' demographics, event characteristics, and risk factors for trauma-related disorders, would improve the prediction performance. Data were collected using an online survey on a cross-national sample of 5048 respondents. Results showed that language data achieved the highest predictive power when both closed- and open-vocabulary features were included as predictors. Combining language data and self-report information resulted in a significant increase in performance and in a model which achieved good accuracy as a screener for probable PTSD diagnosis (.7 < AUC ≤ .8), with similar results regardless of the length of the text description of the event. Overall, results indicated that short texts add to the detection of trauma-related symptoms and probable PTSD diagnosis.

Acute stress reactivity and intrusive memory development: a randomized trial using an adjusted trauma film paradigm.

Understanding the neurobiological and cognitive processes underlying the development of posttraumatic stress disorder (PTSD) and its specific symptoms may facilitate preventive intervention development. Severe traumatic stress and resulting biological stress system activations can alter contextual memory processes. This may provide a neurobiological explanation for the occurrence of intrusive memories following trauma. Investigating the associations between temporal aspects and individual variation in peri- and post-traumatic hypothalamic pituitary adrenal (HPA) axis and sympathetic nervous system (SNS) stress reactivity and memory processing may increase our understanding of intrusive symptom development. The experimental trauma film paradigm is commonly used for this purpose but lacks robust SNS and HPA axis activation. Here, we performed an RCT to investigate the effect of an adjusted trauma film paradigm containing an added brief psychosocial stressor on HPA and SNS stress reactivity throughout the experiment and intrusive memory frequency in the following week in healthy males (N = 63, mean age = 22.3). Secondary, we investigated effects on film-related declarative memory accuracy and intrusion-related characteristics, and associations between acute HPA and SNS stress reactivity, film-related memory, glucocorticoid receptor functioning and intrusion frequency and characteristics. Participants were randomized to the socially-evaluated cold pressor test (seCPT n = 29) or control condition (warm water n = 34) immediately prior to a trauma film. Linear Mixed Models revealed increased acute SNS and cortisol reactivity, lower recognition memory accuracy and more intrusions that were more vivid and distressing during the following week in the seCPT compared to control condition. Linear regression models revealed initial associations between cortisol and alpha amylase reactivity during the experimental assessment and subsequent intrusions, but these effects did not survive multiple comparison corrections. Thus, with this adjustment, we increased the translational value of the trauma film paradigm as it appears to elicit a stronger stress response that is likely more comparable to real-life trauma. The adapted paradigm may be useful to investigate individual variation in biological and cognitive processes underlying early post-trauma PTSD symptoms and could advance potential preventive interventions.

Efficacy of immersive PTSD treatments: A systematic review of virtual and augmented reality exposure therapy and a meta-analysis of virtual reality exposure therapy.

BACKGROUND: Virtual reality exposure therapy (VRET) and augmented reality exposure therapy (ARET) are digitally assisted psychotherapies that potentially enhance posttraumatic stress disorder (PTSD) treatment by increasing a patient's sense of presence during exposure therapy. This study aimed to systematically review current evidence regarding the efficacy of VRET and ARET as PTSD treatment. METHODS: A systematic electronic database search, a systematic quality assessment and two meta-analyses were conducted in accordance with PRISMA guidelines. RESULTS: Eleven studies on the efficacy of VRET for PTSD (n = 438) were found, but no studies on the efficacy of ARET. The majority of VRET studies were of a low quality and had heterogeneous results. Meta-analyses showed VRET outperformed waitlist control (standardized mean difference -0.64 (95% CI -1.05 to -0.22)) while no significant difference was found between VRET and active treatment conditions (standardized mean difference -0.25 (95% CI -0.77 to 0.27)). CONCLUSION: VRET was superior to waitlist control groups and as effective as other psychotherapies. However, the results showed considerable heterogeneity due to the low number of studies and variety of VRET methods. VRET may be an effective alternative to current treatments and shows promise for the treatment of PTSD patients that have not responded to previous treatment. Future research should focus on high quality RCTs, including information on side effects and adverse events, with sufficient numbers of participants. This study recognizes a research gap regarding the efficacy of ARET, while it may have potential for PTSD treatment.

Exploring the impact of work-related potential traumatic events among Dutch psychiatrists.

Psychiatrists are frequently exposed to work-related potential traumatic events (PTEs). A survey was sent to the members of the Dutch Society of Psychiatrists of which 250 questionnaires were eligible for analysis. At least one work-related PTE was reported by 196 (78.4%) of the respondents, of which 177 described the PTE. Witnessing or experiencing verbal aggression (29.2%), physical violence (29.2%) or completed suicide (26.8%) were the most common PTEs. This survey implies that psychiatrists frequently experience work-related PTEs, often with a significant emotional impact. The majority of respondents considered current support as insufficient.

The oxytocinergic system in PTSD following traumatic childbirth: endogenous and exogenous oxytocin in the peripartum period.

Birth experiences can be traumatic and may give rise to PTSD following childbirth (PTSD-FC). Peripartum neurobiological alterations in the oxytocinergic system are highly relevant for postpartum maternal behavioral and affective adaptions like bonding and lactation but are also implicated in the response to traumatic events. Animal models demonstrated that peripartum stress impairs beneficial maternal postpartum behavior. Early postpartum activation of the oxytocinergic system may, however, reverse these effects and thereby prevent adverse long-term consequences for both mother and infant. In this narrative review, we discuss the impact of trauma and PTSD-FC on normal endogenous oxytocinergic system fluctuations in the peripartum period. We also specifically focus on the potential of exogenous oxytocin (OT) to prevent and treat PTSD-FC. No trials of exogenous OT after traumatic childbirth and PTSD-FC were available. Evidence from non-obstetric PTSD samples and from postpartum healthy or depressed samples implies restorative functional neuroanatomic and psychological effects of exogenous OT such as improved PTSD symptoms and better mother-to-infant bonding, decreased limbic activation, and restored responsiveness in dopaminergic reward regions. Adverse effects of intranasal OT on mood and the increased fear processing and reduced top-down control over amygdala activation in women with acute trauma exposure or postpartum depression, however, warrant cautionary use of intranasal OT. Observational and experimental studies into the role of the endogenous and exogenous oxytocinergic system in PTSD-FC are needed and should explore individual and situational circumstances, including level of acute distress, intrapartum exogenous OT exposure, or history of childhood trauma.

The spectral fingerprint of sleep problems in post-traumatic stress disorder.

STUDY OBJECTIVES: Sleep problems are a core feature of post-traumatic stress disorder (PTSD). The aim of this study was to find a robust objective measure for the sleep disturbance in patients having PTSD. METHODS: The current study assessed EEG power across a wide frequency range and multiple scalp locations, in matched trauma-exposed individuals with and without PTSD, during rapid eye movement (REM) and non-REM (NREM) sleep. In addition, a full polysomnographical evaluation was performed, including sleep staging and assessment of respiratory function, limb movements, and heart rate. The occurrence of sleep disorders was also assessed. RESULTS: In patients having PTSD, NREM sleep shows a substantial loss of slow oscillation power and increased higher frequency activity compared with controls. The change is most pronounced over right-frontal sensors and correlates with insomnia. PTSD REM sleep shows a large power shift in the opposite direction, with increased slow oscillation power over occipital areas, which is strongly related to nightmare activity and to a lesser extent with insomnia. These pronounced spectral changes occur in the context of severe subjective sleep problems, increased occurrence of various sleep disorders and modest changes in sleep macrostructure. CONCLUSIONS: This is the first study to show pronounced changes in EEG spectral topologies during both NREM and REM sleep in PTSD. Importantly, the observed power changes reflect the hallmarks of PTSD sleep problems: insomnia and nightmares and may thus be specific for PTSD. A spectral index derived from these data distinguishes patients from controls with high effect size, bearing promise as a candidate biomarker.

Oxytocin receptor gene methylation in male and female PTSD patients and trauma-exposed controls.

Oxytocin receptor gene (OXTR) DNA-methylation levels have been associated with trauma-exposure, mood- and anxiety disorders, and social processes relevant to posttraumatic stress disorder (PTSD). We hypothesized that OXTR methylation may play a role in the neurobiological underpinnings of PTSD. In the current study, we compared OXTR methylation between PTSD patients (n = 31, 14 females) and trauma-exposed controls (n = 36, 19 females). Additionally, the association between OXTR methylation and PTSD symptom severity and amygdala reactivity to an emotional faces task was assessed, as a neural hallmark of PTSD. DNA-methylation was investigated in the CpG island located at exon 3 of the OXTR, previously associated with OXTR expression. We observed a significant interaction between PTSD-status, sex and CpG-position on methylation levels. Post-hoc testing revealed that methylation levels at two specific CpG-sites were significantly higher in PTSD females compared to female trauma-exposed controls and PTSD males (CpGs Chr3:8809437, Chr3:8809413). No significant differences in methylation were observed between male PTSD patients and controls. Furthermore, within PTSD females, methylation in these CpG-sites was positively associated with anhedonia symptoms and with left amygdala responses to negative emotional faces, although this was no longer significant after stringent correction for multiple-comparisons. Though the modest size of the current sample is an important limitation, we are the first to report on OXTR methylation in PTSD, replicating previously observed (sex-specific) associations of OXTR methylation with other psychiatric disorders.

[The effects of severe and very severe injuries]. / Gevolgen van ernstige en zeer ernstige letsels.

- The effects of severe injuries can be charted using the International Classification of Functioning, Disability and Health (ICF) model and the burden of disease model, in which the burden of disease is expressed in 'disability-adjusted life years' (DALYs). - Severe accidents cause 10 DALYs per 1000 people, which is comparable with the burden of disease of mood disorders and lung cancer.- In the Netherlands, severe injury victims are often males aged < 40 years, who are often injured in road traffic accidents. - The average hospital stay after a severe injury is one month, after which almost 75% of the patients are discharged home, while one quarter subsequently stay in rehabilitation facilities for 3-6 months. More than half return to their original employment. - Patients with thoracic and abdominal injuries recover relatively well, whereas injuries of the lower extremities, brain and spinal cord give a relatively poor prognosis. Comorbidity increases the chance of a less good recovery. Older people who survive an accident recover relatively well.

Salivary Oxytocin and Vasopressin Levels in Police Officers With and Without Post-Traumatic Stress Disorder.

Post-traumatic stress disorder (PTSD) is characterised by symptoms associated with maladaptive fear and stress responses, as well as with social detachment. The neuropeptides oxytocin (OT) and arginine vasopressin (AVP) have been associated with both regulating fear and neuroendocrine stress responsiveness and social behaviour. However, there is only limited evidence for dysregulated peripheral OT and AVP levels in PTSD patients. The present study aimed to investigate basal salivary OT and AVP levels in trauma-exposed male and female police officers with and without PTSD. Saliva samples were collected during rest and OT and AVP levels were determined using a radioimmunoassay. Men and women were analysed separately, having adjusted for differences in trauma history, and for hormonal contraception use in women. The results showed that male PTSD patients had lower basal salivary OT levels, and did not differ in AVP levels compared to male trauma-exposed healthy controls after adjusting for childhood emotional abuse. There were no significant differences in basal salivary OT and AVP levels in women. Our findings indicate potential dysfunctioning of the OT system in male PTSD patients. Future studies are needed to replicate these findings and to further unravel the relationship between the OT and AVP systems, sex, trauma history and PTSD.

Dexamethasone-suppressed cortisol awakening response predicts treatment outcome in posttraumatic stress disorder.

BACKGROUND: Posttraumatic stress disorder (PTSD) has been associated with several alterations in the neuroendocrine system, including enhanced cortisol suppression in response to the dexamethasone suppression test. The aim of this study was to examine whether specific biomarkers of PTSD predict treatment success in trauma-focused psychotherapy. METHODS: Data were collected in the context of a randomized controlled trial comparing two forms of trauma-focused psychotherapy. Basal cortisol and dehydroepiandrosterone sulfate levels, and the response to the dexamethasone suppression test were assessed pre-treatment in 24 PTSD patients. Treatment success was measured by pre- to post-treatment decrease in self-reported PTSD severity. RESULTS: A more suppressed cortisol curve after dexamethasone significantly predicted greater PTSD symptom decrease in trauma-focused psychotherapy, independent of the effects of gender, pre-treatment PTSD symptom severity, and trauma history. Basal early morning cortisol and dehydroepiandrosterone sulfate did not predict treatment response. LIMITATIONS: The number of participants who completed the neuroendocrine measurements was small and a significant number of participants fulfilled criteria of co-morbid major depressive disorder. CONCLUSIONS: This study suggests the use of the dexamethasone-suppression test for the cortisol awakening response as a biomarker for treatment response to trauma-focused psychotherapy. Measures of HPA-axis sensitivity appear to be an important predictor of positive clinical response in PTSD patients, and may lead to biomarker-based treatment matching in the future.

DHEAS and cortisol/DHEAS-ratio in recurrent depression: State, or trait predicting 10-year recurrence?

BACKGROUND: Major depressive disorder (MDD) has been associated with low dehydroepiandrosterone-sulphate (DHEAS), - particularly relative to high cortisol - although conflicting findings exist. Moreover, it is unclear whether low DHEAS is only present during the depressive state, or manifests as a trait that may reflect vulnerability for recurrence. Therefore, we longitudinally tested whether low DHEAS and high cortisol/DHEAS-ratio in recurrent MDD (I) reflects a trait, and/or (II) varies with depressive state. In addition, we tested associations with (III) previous MDD-episodes, (IV) prospective recurrence, and (V) effects of cognitive therapy. METHODS: At study-entry, we cross-sectionally compared morning and evening salivary DHEAS and molar cortisol/DHEAS-ratio of 187 remitted recurrent MDD-patients with 72 matched controls. Subsequently, patients participated in an 8-week randomized controlled cognitive therapy trial. We repeated salivary measures after 3 months and 2 years. We measured clinical symptoms during a 10-year follow-up. RESULTS: Remitted patients showed steeper diurnal DHEAS-decline (p<.005) and a flatter diurnal profile of cortisol/DHEAS-ratio (p<.001) than controls. We found no state-effect in DHEAS or cortisol/DHEAS-ratio throughout follow-up and no association with number of previous episodes. Higher morning cortisol/DHEAS-ratio predicted shorter time till recurrence over the 10-year follow-up in interaction with the effects of cognitive therapy (p<.05). Finally, cognitive therapy did not influence DHEAS or cortisol/DHEAS-ratio. CONCLUSIONS: Diurnal profiles of DHEAS and cortisol/DHEAS-ratio remain equally altered in between depressive episodes, and may predict future recurrence. This suggests they represent an endophenotypic vulnerability trait rather than a state-effect, which provides a new road to understand recurrent depression and its prevention. TRIAL REGISTRATION: www.isrctn.com/ISRCTN68246470.

Cost-effectiveness of trauma CT in the trauma room versus the radiology department: the REACT trial.

OBJECTIVE: To determine the cost-effectiveness of trauma room CT compared with CT performed at the radiology department. METHODS: In this randomised controlled trial, adult patients requiring evaluation in a level 1 trauma centre were included. In the intervention hospital the CT system was located within the trauma room and in the control hospital within the radiology department. Direct and indirect medical costs of the institutionalised stay and diagnostic and therapeutic procedures were calculated. RESULTS: A total of 1,124 patients were randomised with comparable demographic characteristics. Mean number of non-institutionalised days alive was 322.5 in the intervention group (95 % CI 314-331) and 320.7 in the control group (95 % CI 312.1-329.2). Mean costs of diagnostic and therapeutic procedures per hospital inpatient day were 554 for the intervention group and 468 for the control group. Total mean costs in the intervention group were 16,002 (95 % CI 13,075-18,929) and 16,635 (95 % CI 13,528-19,743) for the control group (P = 0.77). CONCLUSION: The present study showed that in trauma patients the setting with a CT system located in the trauma room did not provide any advantages or disadvantages from a health economics perspective over a CT system located in the radiology department.

Identifying persons at risk for PTSD after trauma with TSQ in the Netherlands.

In The Netherlands about 80% of the population experience a traumatic event while about 14% develop post traumatic stress disorder (PTSD). Considering this high prevalence the prevention or early treatment of posttraumatic stress is important from a health as well as cost-benefit perspective. The aim of this study was to examine whether we could identify subjects at risk of developing PTSD. We included 100 Dutch victims of different civil traumas that contacted the Victim Support Foundation. The trauma screening questionnaire (TSQ), was used as a screening tool. The results show that a cut-off score of 7 on the TSQ correctly identified most subjects with PTSD. We found a moderate positive correlation between PTSD and the severity of complaints. We also found a significant relationship between the TSQ and depression symptoms. This study indicates that the Dutch version of the TSQ is a useful instrument for identifying future cases of PTSD.

Effects of psychotherapy on regional cerebral blood flow during trauma imagery in patients with post-traumatic stress disorder: a randomized clinical trial.

BACKGROUND: Functional brain-imaging studies in post-traumatic stress disorder (PTSD) have suggested functional alterations in temporal and prefrontal cortical regions. Effects of psychotherapy on these brain regions have not yet been examined. METHOD: Twenty civilian PTSD out-patients and 15 traumatized control subjects were assessed at baseline using psychometric ratings. Cerebral blood flow was measured using trauma script-driven imagery during 99mtechnetium hexamethyl-propylene-amine-oxime single-photon emission computed tomography scanning. All 20 out-patients were randomly assigned to treatment or wait-list conditions. Treatment was brief eclectic psychotherapy (BEP) in 16 weekly individual sessions. RESULTS: At baseline, greater activation was found in the right insula and right superior/middle frontal gyrus in the PTSD group than in the control group. PTSD patients treated with BEP significantly improved on all PTSD symptom clusters compared to those on the waiting list. After effective psychotherapy, lower activation was measured in the right middle frontal gyrus, compared to the PTSD patients on the waiting list. Treatment effects on PTSD symptoms correlated positively with activation in the left superior temporal gyrus, and superior/middle frontal gyrus. CONCLUSIONS: BEP induced clinical recovery in PTSD patients, and appeared to modulate the functioning of specific PTSD-related sites in the prefrontal cortical regions.