Racial/ethnic differences in acute and longer-term posttraumatic symptoms following traumatic injury or illness.

BACKGROUND: Racial/ethnic differences in mental health outcomes after a traumatic event have been reported. Less is known about factors that explain these differences. We examined whether pre-, peri-, and post-trauma risk factors explained racial/ethnic differences in acute and longer-term posttraumatic stress disorder (PTSD), depression, and anxiety symptoms in patients hospitalized following traumatic injury or illness. METHODS: PTSD, depression, and anxiety symptoms were assessed during hospitalization and 2 and 6 months later among 1310 adult patients (6.95% Asian, 14.96% Latinx, 23.66% Black, 4.58% multiracial, and 49.85% White). Individual growth curve models examined racial/ethnic differences in PTSD, depression, and anxiety symptoms at each time point and in their rate of change over time, and whether pre-, peri-, and post-trauma risk factors explained these differences. RESULTS: Latinx, Black, and multiracial patients had higher acute PTSD symptoms than White patients, which remained higher 2 and 6 months post-hospitalization for Black and multiracial patients. PTSD symptoms were also found to improve faster among Latinx than White patients. Risk factors accounted for most racial/ethnic differences, although Latinx patients showed lower 6-month PTSD symptoms and Black patients lower acute and 2-month depression and anxiety symptoms after accounting for risk factors. Everyday discrimination, financial stress, past mental health problems, and social constraints were related to these differences. CONCLUSION: Racial/ethnic differences in risk factors explained most differences in acute and longer-term PTSD, depression, and anxiety symptoms. Understanding how these risk factors relate to posttraumatic symptoms could help reduce disparities by facilitating early identification of patients at risk for mental health problems.

Web-Based Problem-solving Training With and Without Peer Support in Veterans With Unmet Mental Health Needs: Pilot Study of Feasibility, User Acceptability, and Participant Engagement.

BACKGROUND: eHealth tools have the potential to meet the mental health needs of individuals who experience barriers to accessing in-person treatment. However, most users have less than optimal engagement with eHealth tools. Coaching from peer specialists may increase their engagement with eHealth. OBJECTIVE: This pilot study aims to test the feasibility and acceptability of a novel, completely automated web-based system to recruit, screen, enroll, assess, randomize, and then deliver an intervention to a national sample of military veterans with unmet mental health needs; investigate whether phone-based peer support increases the use of web-based problem-solving training compared with self-directed use; and generate hypotheses about potential mechanisms of action for problem-solving and peer support for future full-scale research. METHODS: Veterans (N=81) with unmet mental health needs were recruited via social media advertising and enrolled and randomized to the self-directed use of a web-based problem-solving training called Moving Forward (28/81, 35%), peer-supported Moving Forward (27/81, 33%), or waitlist control (26/81, 32%). The objective use of Moving Forward was measured with the number of log-ins. Participants completed pre- and poststudy measures of mental health symptoms and problem-solving confidence. Satisfaction was also assessed post treatment. RESULTS: Automated recruitment, enrollment, and initial assessment methods were feasible and resulted in a diverse sample of veterans with unmet mental health needs from 38 states. Automated follow-up methods resulted in 46% (37/81) of participants completing follow-up assessments. Peer support was delivered with high fidelity and was associated with favorable participant satisfaction. Participants randomized to receive peer support had significantly more Moving Forward log-ins than those of self-directed Moving Forward participants, and those who received peer support had a greater decrease in depression. Problem-solving confidence was associated with greater Moving Forward use and improvements in mental health symptoms among participants both with and without peer support. CONCLUSIONS: Enrolling and assessing individuals in eHealth studies without human contact is feasible; however, different methods or designs are necessary to achieve acceptable participant engagement and follow-up rates. Peer support shows potential for increasing engagement in web-based interventions and reducing symptoms. Future research should investigate when and for whom peer support for eHealth is helpful. Problem-solving confidence should be further investigated as a mechanism of action for web-based problem-solving training. TRIAL REGISTRATION: ClinicalTrials.gov NCT03555435; http://clinicaltrials.gov/ct2/show/NCT03555435.

Psychometric properties of the dissociative symptoms scale (DSS) in Italian outpatients and community adults.

This study investigated the psychometric properties of the Dissociative Symptoms Scale (DSS) among Italian adults from outpatient and community samples. The DSS is a self-report measure of clinically relevant dissociation in adults. An Italian translation of the DSS was administered with measures of lifetime traumatic experiences, psychoform dissociation, and somatoform dissociation to 175 psychiatric outpatients and 423 individuals from the community. The DSS scores for outpatient and community adults were significantly different and showed good internal reliability, good convergent and construct validity, and a four-factor structure (depersonalization and derealization, gaps in awareness and memory, sensory misperceptions, and cognitive and behavioral reexperiencing) that was consistent with findings from previous research. Therefore, our results support previous research showing that the DSS can be used as a screening measure to assess clinically relevant dissociative experiences.

The Dynamic Relations Among Peritraumatic Posttraumatic Stress Symptoms: An Experience Sampling Study During Wartime.

The associations among peritraumatic posttraumatic stress symptoms (P-PTSS) in the immediate aftermath of trauma exposure, including those in the posttraumatic stress disorder clusters of intrusions, avoidance, negative cognitions and mood (NCM), and arousal, might indicate mechanisms through which enduring PTSD develops. During a period of war, exposed participants (N = 181) were sent twice-daily questionnaires for 30 days via smartphone. We repeatedly assessed the predictive associations between the P-PTSS clusters over time. We performed a multilevel pathway analysis built of multiple triple sequence responses (6,221 cases) on each of the four P-PTSS clusters at a mean time lag of 12 hr (Model A) and 24 hr (Model B) for 181 participants, 85 of whom had been diagnosed with a serious mental illness. Arousal predicted intrusion in Models A and B, bA = 0.08, 95% CI [0.03, 0.12], p < .001 and bB = 0.03, 95% CI [0.00, 0.07], p = .051, respectively; and NCM in Models A and B, bA = 0.09, 95% CI [0.05, 0.12], p < .001 and bB = 0.06, 95% CI [0.03, 0.09], p < .001, respectively. Intrusion predicted arousal in Model B, bB = 0.05, 95% CI [0.01, 0.08], p = .010. NCM predicted arousal, bA = 0.10, 95% CI [0.05, 0.14], p < .001, and avoidance bA = 0.05, 95% CI [0.00, 0.11], p = .052, in Model A. Avoidance did not predict any other cluster. Arousal seemed to be acting as a hub, strengthening feedback loops to and from NCM and intrusion.

Advantages and psychometric validation of proximal intensive assessments of patient-reported outcomes collected in daily life.

OBJECTIVES: Ambulatory assessment data collection methods are increasingly used to study behavior, experiences, and patient-reported outcomes (PROs), such as emotions, cognitions, and symptoms in clinical samples. Data collected close in time at frequent and fixed intervals can assess PROs that are discrete or changing rapidly and provide information about temporal dynamics or mechanisms of change in clinical samples and individuals, but clinical researchers have not yet routinely and systematically investigated the reliability and validity of such measures or their potential added value over conventional measures. The present study provides a comprehensive, systematic evaluation of the psychometrics of several proximal intensive assessment (PIA) measures in a clinical sample and investigates whether PIA appears to assess meaningful differences in phenomena over time. METHODS: Data were collected on a variety of psychopathology constructs on handheld devices every 4 h for 7 days from 62 adults recently exposed to traumatic injury of themselves or a family member. Data were also collected on standard self-report measures of the same constructs at the time of enrollment, 1 week after enrollment, and 2 months after injury. RESULTS: For all measure scores, results showed good internal consistency across items and within persons over time, provided evidence of convergent, divergent, and construct validity, and showed significant between- and within-subject variability. CONCLUSIONS: Results indicate that PIA measures can provide valid measurement of psychopathology in a clinical sample. PIA may be useful to study mechanisms of change in clinical contexts, identify targets for change, and gauge treatment progress.

Contributions of risk and protective factors to prediction of psychological symptoms after traumatic experiences.

OBJECTIVE: Traumatic experiences cause considerable suffering and place a burden on society due to lost productivity, increases in suicidality, violence, criminal behavior, and psychological disorder. The impact of traumatic experiences is complicated because many factors affect individuals' responses. By employing several methodological improvements, we sought to identify risk factors that would account for a greater proportion of variance in later disorder than prior studies. METHOD: In a sample of 129 traumatically injured hospital patients and family members of injured patients, we studied pre-trauma, time of trauma, and post-trauma psychosocial risk and protective factors hypothesized to influence responses to traumatic experiences and posttraumatic (PT) symptoms (including symptoms of PTSD, depression, negative thinking, and dissociation) two months after trauma. RESULTS: The risk factors were all significantly correlated with later PT symptoms, with post-trauma life stress, post-trauma social support, and acute stress symptoms showing the strongest relationships. A hierarchical regression, in which the risk factors were entered in 6 steps based on their occurrence in time, showed the risks accounted for 72% of the variance in later symptoms. Most of the variance in PT symptoms was shared among many risk factors, and pre-trauma and post-trauma risk factors accounted for the most variance. CONCLUSIONS: Collectively, the risk factors accounted for more variance in later PT symptoms than in previous studies. These risk factors may identify individuals at risk for PT psychological disorders and targets for treatment.

Psychotic-like experiences, symptom expression, and cognitive performance in combat veterans with posttraumatic stress disorder.

Apparent psychotic symptoms are often associated with posttraumatic stress disorder (PTSD), but these symptoms are poorly understood. In a sample of 30 male Vietnam combat veterans with severe and chronic PTSD, we conducted detailed assessments of psychotic symptom endorsement, insight, symptom severity, neurocognitive function, and feigning. Two thirds of the subjects endorsed a psychotic item but did not believe that the experiences were real. Those endorsing psychotic items were higher in PTSD severity, general psychopathology, and dissociation but not depression, functional health, cognitive function, or feigned effort. Severity of psychotic symptoms correlated with dissociation, combat exposure, and attention but not PTSD, depression, or functional health. Those endorsing psychotic items scored higher on a screen but not on a detailed structured interview for malingering. Endorsement of psychotic experiences by combat veterans with PTSD do not seem to reflect psychotic symptoms or outright malingering.

Development and Initial Performance of the Hospital Mental Health Risk Screen.

BACKGROUND: Patients hospitalized after emergency care are at risk for later mental health problems such as depression, anxiety, and posttraumatic stress disorder symptoms. The American College of Surgeons Committee on Trauma standards for verification require Level I and II trauma centers to screen patients at high risk for mental health problems. This study aimed to develop and examine the performance of a novel mental health risk screen for hospitalized patients based on samples that reflect the diversity of the US population. STUDY DESIGN: We studied patients admitted after emergency care to 3 hospitals that serve ethnically, racially, and socioeconomically diverse populations. We assessed risk factors during hospitalization and mental health symptoms at follow-up. We conducted analyses to identify the most predictive risk factors, selected items to assess each risk, and determined the fewest items needed to predict mental health symptoms at follow-up. Analyses were conducted for the entire sample and within 5 ethnic and racial subgroups. RESULTS: Among 1,320 patients, 10 items accurately identified 75% of patients who later had elevated levels of mental health symptoms and 71% of those who did not. Screen performance was good to excellent within each of the ethnic and racial groups studied. CONCLUSIONS: The Hospital Mental Health Risk Screen accurately predicted mental health outcomes overall and within ethnic and racial subgroups. If performance is replicated in a new sample, the screen could be used to screen patients hospitalized after emergency care for mental health risk. Routine screening could increase health and mental health equity and foster preventive care research and implementation.

Can sudden, severe emotional loss be a traumatic stressor?

Aspects of the stressor criterion for posttraumatic stress disorder (PTSD) have been controversial since its inception, and the theoretical or empirical reasons for decisions about it have not been clear. To investigate whether sudden events involving severe emotional loss have the potential to precipitate PTSD, we assessed exposure to Criterion A stressors, sudden abandonment, sudden move or loss of home, and symptoms of PTSD and dissociation in a community sample of 427 adults. In regression analyses, models that included a severe emotional loss stressor accounted for a significant amount of additional variance in PTSD and dissociation symptoms beyond that accounted for by a model including only Criterion A stressors. The findings suggest that limiting Criterion A1 to events involving actual or threatened death or injury may be overly restrictive. Future research is needed to replicate these findings in a clinical sample and to prospectively examine the conditional probability of PTSD following these events.

Development and initial validation of the Structured Interview for Self-Destructive Behaviors.

This article describes the initial validation of the Structured Interview for Self-Destructive Behaviors (SI-SDB), a brief interview assessing suicidality, self-injury, substance abuse, disordered eating, and risky sexual behaviors. Self-destructive behaviors present clinical and practical challenges for mental health treatment providers. Participants were 217 psychiatric inpatients with a wide variety of diagnoses who completed the SI-SDB and other measures of psychiatric symptoms, trauma exposure, and other childhood experiences. Internal validity analyses revealed an internally consistent measure with 2 major factors. External validity analyses indicated that the Substance Abuse and Disordered Eating scales were predictive of related psychiatric diagnoses. All scales except Substance Abuse were significantly correlated with psychiatric symptoms and childhood abuse. These findings indicate that the SI-SDB is a valid means of assessing 5 significant domains of dangerous behaviors in clinical and research settings. Further research on the reliability of reports over time, interrater consistency, and convergent validity with longer measures of the SI-SDB domains is needed.

Development and cross-validation of a veterans mental health risk factor screen.

BACKGROUND: VA primary care patients are routinely screened for current symptoms of PTSD, depression, and alcohol disorders, but many who screen positive do not engage in care. In addition to stigma about mental disorders and a high value on autonomy, some veterans may not seek care because of uncertainty about whether they need treatment to recover. A screen for mental health risk could provide an alternative motivation for patients to engage in care. METHOD: Data from samples of veterans and traumatic injury survivors were analyzed to identify mental health risk factors that are characteristics of individuals or stressors or of post-trauma, post-deployment, or post-military service resources, experiences, or responses. Twelve risk factors were strongly related to PTSD (r > .50): current PTSD, depression, dissociation, negative thinking, and emotional lability symptoms, life stress, relationship stress, social constraints, and deployment experiences of a difficult environment, concerns about life and family, perceived threat, and moral injury. Items assessing each of these risk factors were selected and their validity to prospectively predict PTSD and/or depression 6 months later was assessed in a new sample of 232 VA primary care patients. RESULTS: Twelve items assessing dissociation, emotional lability, life stress, and moral injury correctly classified 86% of those who later had elevated PTSD and/or depression symptoms (sensitivity) and 75% of those whose later symptoms were not elevated (specificity). Performance was also very good for 110 veterans who identified as members of ethnic/racial minorities. CONCLUSIONS: Mental health status was prospectively predicted in VA primary care patients with high accuracy using a screen that is brief, easy to administer, score, and interpret, and fits well into VA's integrated primary care. When care is readily accessible, appealing to veterans, and not perceived as stigmatizing, information about mental health risk may result in higher rates of engagement than information about current mental disorder status.

Peer-supported mobile mental health for veterans in primary care: A pilot study.

One in four veteran primary care patients suffers from a mental health condition; however, most do not receive any treatment for these problems. Mobile health (mHealth) can overcome barriers to care access, but poor patient engagement limits the effectiveness and implementation of these tools. Peers may facilitate patient engagement with mHealth. We designed a protocol for peers to support implementation of mobile mental health tools in primary care and tested the feasibility, acceptability, and clinical utility of this approach. Thirty-nine patients across two Veterans Affairs sites who screened positive for depression during a primary care visit and were not currently in mental health treatment were enrolled. Participants were scheduled for four phone sessions with a peer over 8 weeks and introduced to five mobile apps for a range of transdiagnostic mental health issues (stress, low mood, sleep problems, anger, and trauma). Pre/post phone interviews using quantitative and qualitative approaches assessed participants' self-reported app use, satisfaction with the intervention, symptom change (stress, anxiety, depression, insomnia), and progress with personal health goals. On average, patients reported using 3.04 apps (SD = 1.46). Per the Client Satisfaction Questionnaire, global satisfaction with the intervention was high (M = 25.71 out of 32, SD = 3.95). Pre to post participants reported significant improvements in their level of stress, based on a quantitative measure (p = .008), and 87% reported progress on at least one personal health goal. Findings support the feasibility, acceptability, and clinical utility of peer-supported mobile mental health for veterans in primary care. A randomized controlled trial of an adaptive version of this intervention is recommended. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Development of a Brief Version of the Dissociative Symptoms Scale and the Reliability and Validity of DSS-B Scores in Diverse Clinical and Community Samples.

The Dissociative Symptoms Scale (DSS) was developed to assess moderately severe types of dissociation (depersonalization, derealization, gaps in awareness and memory, and dissociative reexperiencing) that would be relevant to a range of clinical populations, including those experiencing trauma-related dissociation. The current study used data from 10 ethnically and racially diverse clinical and community samples (N = 3,879) to develop a brief version of the DSS (DSS-B). Item information curves were examined to identify items with the most precision in measuring above average levels of the latent trait within each subscale. Analyses revealed that the DSS-B preserved the factor structure and content domains of the full scale, and its scores had strong reliability and validity that were comparable to those of scores on the full measure. DSS-B scores showed high levels of measurement invariance across ethnoracial groups. Results indicate that DSS-B scores are reliable and valid in the populations studied.

Mental health symptoms are comparable in patients hospitalized with acute illness and patients hospitalized with injury.

BACKGROUND: High rates of mental health symptoms such as depression, anxiety, and posttraumatic stress disorder (PTSD) have been found in patients hospitalized with traumatic injuries, but little is known about these problems in patients hospitalized with acute illnesses. A similarly high prevalence of mental health problems in patients hospitalized with acute illness would have significant public health implications because acute illness and injury are both common, and mental health problems of depression, anxiety, and PTSD are highly debilitating. METHODS AND FINDINGS: In patients admitted after emergency care for Acute Illness (N = 656) or Injury (N = 661) to three hospitals across the United States, symptoms of depression, anxiety, and posttraumatic stress were compared acutely (Acute Stress Disorder) and two months post-admission (PTSD). Patients were ethnically/racially diverse and 54% female. No differences were found between the Acute Illness and Injury groups in levels of any symptoms acutely or two months post-admission. At two months post-admission, at least one symptom type was elevated for 37% of the Acute Illness group and 39% of the Injury group. Within racial/ethnic groups, PTSD symptoms were higher in Black patients with injuries than for Black patients with acute illness. A disproportionate number of Black patients had been assaulted. CONCLUSIONS: This study found comparable levels of mental health sequelae in patients hospitalized after emergency care for acute illness as in patients hospitalized after emergency care for injury. Findings of significantly higher symptoms and interpersonal violence injuries in Black patients with injury suggest that there may be important and actionable differences in mental health sequelae across ethnic/racial identities and/or mechanisms of injury or illness. Routine screening for mental health risk for all patients admitted after emergency care could foster preventive care and reduce ethnic/racial disparities in mental health responses to acute illness or injury.

Acute stress disorder revisited.

Acute stress disorder (ASD) was introduced into the Diagnostic and Statistical Manual (DSM) taxonomy in 1994 to address the lack of a specific diagnosis for acute pathological reactions to trauma and the role that dissociative phenomena play both in the short- and long-term reactions to trauma. In this review, we discuss the history and goals of the diagnosis and compare it with the diagnoses of acute stress reaction, combat stress reaction, and posttraumatic stress disorder (PTSD). We also evaluate the research on the validity and limitations of ASD as a diagnosis, the relationship between peritraumatic dissociation and other symptomatology, the extent to which PTSD is predicted by previous ASD or peritraumatic dissociation, and other important issues such as impairment and risk factors related to ASD. We conclude with our recommendations for changes in DSM-5 criteria and the development of more sophisticated research that considers ASD as but one of two or possibly three common acute posttraumatic syndromes.

Chronic psychological and functional sequelae after emergent hand surgery.

PURPOSE: Several studies have shown that upper extremity trauma has serious, acute psychological effects after injury. This study's goal was to assess the psychological outcomes, including symptoms of major depression, posttraumatic stress disorder (PTSD), and other psychosocial variables, as well as the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) results, after severe hand trauma. We hypothesized that hand trauma would have persistent psychological sequelae long after the physical injury. METHODS: We performed a cross-sectional survey of 34 patients who had emergency hand surgery at a Level 1 trauma center an average of 16 months (range, 7-32 mo) earlier. The hand disability measure was the QuickDASH, and the psychological measures included the Center for Epidemiologic Studies Depression Scale, the Screen for Posttraumatic Stress Symptoms, the Medical Outcomes Study Social Support Survey Form, the Social Constraints Survey (to assess interpersonal stressors), and the Perceived Stress Scale. RESULTS: The overall QuickDASH score was 27. The mean score for PTSD was 13 (above the clinical threshold for PTSD), and 29% of respondents had high levels of both depression and PTSD. High pain scores on the QuickDASH were strongly correlated with both depression and PTSD symptoms. CONCLUSIONS: This study found high levels of psychological distress in patients after hand trauma. Hand disability was strongly related to pain, depression, and PTSD symptoms. This study shows that the psychological sequelae of hand trauma can persist long after the physical injury. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Posttraumatic stress and aggression among veterans in long-term care.

Because stresses associated with long-term care settings may exacerbate distress and aggression related to past trauma, we investigated self-report and staff reports of posttraumatic stress disorder symptoms and staff observations of verbal and physical aggression in 32 elderly males who were patients in a long-term care unit for veterans. Feelings of anger and irritability were reported by 47% of patients; levels of anger and irritability were significantly correlated with observed aggressive behaviors (r = 0.43, P < .02); and observed aggressive behaviors were significantly more frequent among those reporting past traumatic stressors (t = 2.84, P < .008). Patient-reported posttraumatic stress disorder symptoms were significantly correlated with the frequency of past traumatic stressors (r = 0.48, P < .006). Observer-reported posttraumatic stress disorder symptoms and patient reports of anger were strongly correlated (r = 0.73, P < .001). No patient or staff reports were related to level of cognitive function. These findings are consistent with the hypothesis that posttraumatic symptoms can contribute to aggressive behaviors in elderly, medically ill, and cognitively impaired patients.

Development and Validation of the Dissociative Symptoms Scale.

The Dissociative Symptoms Scale (DSS) was developed to assess moderately severe levels of depersonalization, derealization, gaps in awareness or memory, and dissociative reexperiencing that would be relevant to a wide range of clinical populations. Structural analyses of data from four clinical and five nonclinical samples ( N = 1,600) yielded four factors that reflected the domains of interest and showed good fit with the data. Sample scores were consistent with expectations and showed very good internal consistency and temporal stability. Analyses showed consistent evidence of convergent and divergent validity, and posttrauma elevations in scores and in patients with posttraumatic stress disorder provided additional evidence of construct validity. Item response theory analyses indicated that the items assessed moderately severe dissociative experiences. Overall, the results provide support for the reliability and validity of DSS total and subscale scores in the populations studied. Further work is needed to evaluate the performance of the DSS relative to structured interview measures and in samples of patients with other psychological disorders.

Development and preliminary performance of a risk factor screen to predict posttraumatic psychological disorder after trauma exposure.

OBJECTIVE: We examined data from a prospective study of risk factors that increase vulnerability or resilience, exacerbate distress, or foster recovery to determine whether risk factors accurately predict which individuals will later have high posttraumatic (PT) symptom levels and whether brief measures of risk factors also accurately predict later symptom elevations. METHOD: Using data from 129 adults exposed to traumatic injury of self or a loved one, we conducted receiver operating characteristic (ROC) analyses of 14 risk factors assessed by full-length measures, determined optimal cutoff scores, and calculated predictive performance for the nine that were most predictive. For five risk factors, we identified sets of items that accounted for 90% of variance in total scores and calculated predictive performance for sets of brief risk measures. RESULTS: A set of nine risk factors assessed by full measures identified 89% of those who later had elevated PT symptoms (sensitivity) and 78% of those who did not (specificity). A set of four brief risk factor measures assessed soon after injury identified 86% of those who later had elevated PT symptoms and 72% of those who did not. CONCLUSIONS: Use of sets of brief risk factor measures shows promise of accurate prediction of PT psychological disorder and probable PTSD or depression. Replication of predictive accuracy is needed in a new and larger sample.