Staying connected: a feasibility study linking American Indian and Alaska Native trauma survivors to their tribal communities.

The objective of this investigation was to assess the feasibility of a culturally tailored care management intervention for physically injured American Indian/Alaska Native (AI/AN) patients. The intervention was initiated at a Level I trauma center and aimed to link AI/AN patients to their distant tribal communities. Thirty AI/AN patients were randomized to the intervention or to usual care. Assessments at baseline, 3 months, and 6 months included self-reported lifetime cumulative trauma burden, Native healing requests, and symptoms of posttraumatic stress, depression, and alcohol use. Generalized estimating equations ascertained differences between groups over time. Ninety-four percent of eligible patients participated; follow-up at 3 and 6 months was 83%. Participants had high numbers of lifetime traumas (mean = 5.1, standard deviation = 2.6). No differences between the intervention and control groups were observed in posttraumatic stress symptoms, depression symptoms, or alcohol use at baseline or follow-up time points. Among intervention patients, 60% either requested or participated in traditional Native healing practices and 75% reported that the intervention was helpful. This effectiveness trial demonstrated the feasibility of recruiting and randomizing injured AI/AN patients. Future efforts could integrate evidence-based interventions and traditional Native healing into stepped collaborative care treatment programs.

Assessing barriers to care and readiness for cognitive behavioral therapy in early acute care PTSD interventions.

Cognitive Behavioral Therapy (CBT) interventions are efficacious in reducing posttraumatic stress disorder (PTSD) but are challenging to implement in acute care and other non-specialty mental health settings. This investigation identified barriers impacting CBT delivery through a content analysis of interventionist chart notes from an acute care PTSD prevention trial. Only 8.5% of all intervention patients were able to complete CBT. Lack of engagement, clinical and logistical barriers had the greatest impact on CBT entry. Treatment preferences and stigma only prevented entry when more primary barriers resolved. Patients with prior diagnosis of alcohol abuse or dependence were able to enter CBT after six months of sobriety. Based on the first trial, we developed a CBT readiness assessment tool. We implemented and evaluated the tool in a second early intervention trial. Lack of engagement emerged again as the primary impediment to CBT entry. Patients who were willing to enter CBT treatment but demonstrated high rates of past trauma or diagnosis of PTSD were also the least likely to engage in any PTSD treatment one month post-discharge. Findings support the need for additional investigations into engagement and alternative delivery strategies, including those which dismantle traditional office-based, multi-session CBT into stepped, deliverable components.

Enhancing the population impact of collaborative care interventions: mixed method development and implementation of stepped care targeting posttraumatic stress disorder and related comorbidities after acute trauma.

OBJECTIVE: The objective of the study was to develop and implement a stepped collaborative care intervention targeting posttraumatic stress disorder (PTSD) and related comorbidities to enhance the population impact of early trauma-focused interventions. METHOD: We describe the design and implementation of the Trauma Survivors Outcomes and Support study. An interdisciplinary treatment development team was composed of trauma surgical, clinical psychiatric and mental health services "change agents" who spanned the boundaries between frontline trauma center clinical care and acute care policy. Mixed method clinical epidemiologic and clinical ethnographic studies informed the development of PTSD screening and intervention procedures. RESULTS: Two hundred seven acutely injured trauma survivors with high early PTSD symptom levels were randomized into the study. The stepped collaborative care model integrated care management (i.e., posttraumatic concern elicitation and amelioration, motivational interviewing and behavioral activation) with cognitive behavioral therapy and pharmacotherapy targeting PTSD. The model was feasibly implemented by frontline acute care masters in social work and nurse practioner providers. CONCLUSIONS: Stepped care protocols targeting PTSD may enhance the population impact of early interventions developed for survivors of individual and mass trauma by extending the reach of collaborative care interventions to acute care medical settings and other nonspecialty posttraumatic contexts.

Multisite investigation of traumatic brain injuries, posttraumatic stress disorder, and self-reported health and cognitive impairments.

CONTEXT: Few large-scale, multisite investigations have assessed the development of posttraumatic stress disorder (PTSD) symptoms and health outcomes across the spectrum of patients with mild, moderate, and severe traumatic brain injury (TBI). OBJECTIVES: To understand the risk of developing PTSD symptoms and to assess the impact of PTSD on the development of health and cognitive impairments across the full spectrum of TBI severity. DESIGN: Multisite US prospective cohort study. SETTING: Eighteen level I trauma centers and 51 non-trauma center hospitals. PATIENTS: A total of 3047 (weighted n = 10 372) survivors of multiple traumatic injuries between the ages of 18 and 84 years. MAIN OUTCOME MEASURES: Severity of TBI was categorized from chart-abstracted International Classification of Diseases, Ninth Revision, Clinical Modification codes. Symptoms consistent with a DSM-IV diagnosis of PTSD were assessed with the PTSD Checklist 12 months after injury. Self-reported outcome assessment included the 8 Medical Outcomes Study 36-Item Short Form Health Survey health status domains and a 4-item assessment of cognitive function at telephone interviews 3 and 12 months after injury. RESULTS: At the time of injury hospitalization, 20.5% of patients had severe TBI, 11.7% moderate TBI, 12.9% mild TBI, and 54.9% no TBI. Patients with severe (relative risk, 0.72; 95% confidence interval, 0.58-0.90) and moderate (0.63; 0.44-0.89) TBI, but not mild TBI (0.83; 0.61-1.13), demonstrated a significantly diminished risk of PTSD symptoms relative to patients without TBI. Across TBI categories, in adjusted analyses patients with PTSD demonstrated an increased risk of health status and cognitive impairments when compared with patients without PTSD. CONCLUSIONS: More severe TBI was associated with a diminished risk of PTSD. Regardless of TBI severity, injured patients with PTSD demonstrated the greatest impairments in self-reported health and cognitive function. Treatment programs for patients with the full spectrum of TBI severity should integrate intervention approaches targeting PTSD.