Rapid assessment of mental health of Detroit-area health care workers during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic may adversely impact the mental health of health care workers (HCWs). To address this issue, it is essential to determine levels of anxiety, depression, and traumatic stress, and sources of stress, and to identify subgroups of HCWs at a higher risk of adverse mental health outcomes during the COVID-19 pandemic. METHODS: We conducted a cross-sectional study of symptoms of mental illness in HCWs in the area surrounding Detroit, Michigan. The online survey included questions about demographics, health and clinical factors, and sources of stress. Several tools were used to assess psychiatric symptoms among HCWs, including the Perceived Stress Scale, the Patient Health Questionnaire depression scale, the Generalized Anxiety Disorder 7-item assessment, and the Posttraumatic Stress Disorder Checklist for DSM-5. The adequacy of personal protective equipment, patient resources, and training for highly contagious diseases were rated. RESULTS: The sample (N = 129) was predominantly female (51.2%) and White (65.9%), with 30.2% screening positive for clinical follow-up to assess anxiety, 20.9% for moderate to severe depression, and 16.3% for elevated traumatic stress. Differences were found by self-reported psychiatric diagnosis and chronic conditions, and role on treatment teams. CONCLUSIONS: Frontline HCWs demonstrate high levels of stress and trauma symptoms. Timely screening and accommodations may be needed during health care crises, such as the COVID-19 pandemic.

Factores de riesgo y protección del estrés traumático secundario en los cuidados intensivos: un estudio exploratorio en un hospital terciario de Madrid / Risk and protective factors of secondary traumatic stress in Intensive Care Units: An exploratory study in a hospital in Madrid (Spain)

OBJETIVO: Proponer un modelo de predictores del estrés traumático secundario. DISEÑO: Se trata de un diseño transversal descriptivo. Ámbito: El estudio se llevó a cabo en las unidades de cuidados intensivos de un hospital terciario de Madrid. PARTICIPANTES: La muestra estuvo formada por 103 profesionales sanitarios. INTERVENCIONES: Se creó una batería de cuestionarios que fue rellenada por los profesionales. Respecto al análisis de datos, se utilizó una metodología de redes y análisis de regresión jerárquica. Variables de interés: Se evaluaron variables sociodemográficas tales como género, años de experiencia y puesto, el estrés traumático secundario, la pasión por el trabajo, los estresores laborales, el esfuerzo emocional, la empatía, la autocompasión. RESULTADOS: Se establece: a) para la fatiga por compasión, los años de experiencia como factor de riesgo (β = 0,224 y p = 0,029) y la pasión armoniosa como protector (β = −0,363 y p = 0,001); b) para la sacudida de creencias, el esfuerzo emocional y la empatía como factores de riesgo (β = 0,304 y p = 0,004; β = 0,394 y p = 0,000, respectivamente) y c) para la sintomatología, los estresores laborales y la empatía como factores de riesgo (β = 0,189 y p = 0,039; β = 0,395 y p = 0,000, respectivamente) y los años de experiencia como protector (β = −0,266 y p = 0,002). CONCLUSIONES: Este modelo predictivo del estrés traumático secundario asienta factores protectores que podrían aumentarse, como la pasión armoniosa, y factores de riesgo que sería conveniente reducir, como la empatía y el esfuerzo emocional, con el fin de mejorar la calidad asistencial y de vida de los profesionales

AIM: To propose a predictive model of secondary traumatic stress. DESIGN: A descriptive cross-sectional study was carried out. Context: The study was conducted in the Intensive Care Units of a hospital in Madrid (Spain). PARTICIPANTS: The sample comprised 103 health professionals. INTERVENTIONS: A series of questionnaires were created and completed by the participants. Network analysis and multiple regression were used for data analysis. Variables of interest: Sociodemographic variables such as gender, years of experience and position, secondary traumatic stress, passion for work, work stressors, emotional effort, empathy and self-compassion were evaluated. RESULTS: The result identified the following: a) years of experience as a risk factor for compassion fatigue (β=0.224 and P=0.029), and harmonious passion as a protector (β=−0.363 and P=0.001); b) emotional effort and empathy as risk factors for shattered assumptions (β=0.304 and P=0.004; β=0.394 and P=0.000, respectively); and c), work stressors and empathy as risk factors for symptomatology (β=0.189 and P=0.039; β=0.395 and P=0.000, respectively), and years of experience as a protector (β=−0.266 and P=0.002). CONCLUSIONS: This predictive model of secondary traumatic stress identifies protective factors which could be reinforced, such as harmonious passion, and risk factors which should be reduced, such as empathy and emotional effort, with a view to promoting quality of care and quality of life among these professionals

Prescription Opioid Misuse After a Recent Sexual Assault: A Randomized Clinical Trial of a Video Intervention.

BACKGROUND AND OBJECTIVES: Prescription opioid (PO) misuse is increasing and is associated with overdose. Individuals who experienced a recent sexual assault are at risk for increased substance use, yet limited interventions target PO misuse after sexual assault. The current study examined the efficacy of video interventions on PO misuse after sexual assault. METHODS: Adolescent girls and women (n = 154) were recruited in the context of a sexual assault medical forensic exam in the emergency department. Effects of a prevention of post-rape stress (PPRS) video and a pleasant imagery and relaxation instruction (PIRI) video were compared with treatment as usual (TAU) during a sexual assault medical forensic exam on PO misuse. Participants reported if they had used POs for non-medical purposes since the sexual assault at 1.5 month follow-up. RESULTS: Results from a logistic regression analysis indicated that participants with a prior sexual assault were less likely to misuse prescription opioids 1.5 months after the assault in the PIRI condition compared with TAU. There were no main effects for video condition and no interactions for the PPRS condition on PO misuse. DISCUSSION AND CONCLUSIONS: Providing the PIRI video, or teaching other types of mindfulness or relaxation exercises, may be warranted as a secondary prevention for individuals during the sexual assault medical forensic exam for those with a prior sexual assault history. SCIENTIFIC SIGNIFICANCE: This research provides an initial examination of the impact of mindfulness skills recently after traumatic event exposure on PO misuse. (Am J Addict 2019;28:376-381).

Age moderates the relationship between source of social support and mental health in racial minority lesbian, gay, and bisexual youth.

We examined the relationship between source of social support and mental health (and the moderating impact of age) in 64 low socioeconomic status, racial minority lesbian, gay, and bisexual adolescents/young adults. Social support from family ( ß = -.302, p = .03; ß = -.364, p = .008), but not friends or significant others, was independently related to posttraumatic stress disorder and depression symptoms, respectively. Family social support was associated with lower posttraumatic stress disorder and depression symptoms in participants aged 16-19 years, while friend social support was associated with lower symptoms for participants aged over 20 years. Friend social support was also associated with lower posttraumatic stress disorder symptoms in participants aged 16-17 years. Interventions should target age-appropriate sources of social support.

The impact of a statewide trauma-informed child welfare initiative on children's permanency and maltreatment outcomes.

This article presents findings of a state-wide trauma informed child-welfare initiative with the goal of improving well-being, permanency and maltreatment outcomes for traumatized children. The Massachuetts Child Trauma Project (MCTP), funded by the Administration of Children and Families, Children's Bureau was a multi-year project implementing trauma-informed care into child welfare service delivery. The project's implementation design included training and consultation for mental health providers in three evidence-based treatments and training of the child-welfare workforce in trauma-informed case work practice. The learning was integrated between child-welfare and mental health with Trauma Informed Leadership Teams which included leaders from both systems and the greater community. These teams developed incremental steps toward trauma-informed system improvement. This study evaluated whether MCTP was associated with reductions in child abuse and neglect, improvements in placement stability, and higher rates of permanency during the first year of implementation. Children in the intervention group had fewer total substantiated reports of maltreatment, including less physical abuse and neglect than the comparison group by the end of the intervention year. However, children in the intervention group had more maltreatment reports (substantiated or not) and total out-of-home placements than did their counterparts in the comparison group. Assignment to MCTP, however, was not associated with an increase in kinship care or adoption. Overall, the results are promising in reinforcing the importance of mobilizing communities toward improvements in child-welfare service delivery.

Outcomes of psychotherapeutic and psychoeducative group interventions for children exposed to intimate partner violence.

Witnessing violence toward a caregiver during childhood is associated with negative impact on children's health and development, and there is a need for effective interventions for children exposed to intimate partner violence in clinical as well as in community settings. The current effectiveness study investigated symptom reduction after participation in two established group interventions (one community-based psychoeducative intervention; one psychotherapeutic treatment intervention) for children exposed to intimate partner violence and for their non-offending parent. The study included 50 children-24 girls and 26 boys-aged 4-13 years and their mothers. Child and maternal mental health problems and trauma symptoms were assessed pre- and post-treatment. The results indicate that although children showed benefits from both interventions, symptom reduction was larger in the psychotherapeutic intervention, and children with initially high levels of trauma symptoms benefited the most. Despite these improvements, a majority of the children's mothers still reported child trauma symptoms at clinical levels post-treatment. Both interventions substantially reduced maternal post-traumatic stress. The results indicate a need for routine follow-up of children's symptoms after interventions.

Potential of Environmental Enrichment to Prevent Transgenerational Effects of Paternal Trauma.

Adverse experiences in early life are risk factors for the development of behavioral and physiological symptoms that can lead to psychiatric and cognitive disorders later in life. Some of these symptoms can be transmitted to the offspring, in some cases by non-genomic mechanisms involving germ cells. Using a mouse model of unpredictable maternal separation and maternal stress, we show that postnatal trauma alters coping behaviors in adverse conditions in exposed males when adult and in their adult male progeny. The behavioral changes are accompanied by increased glucocorticoid receptor (GR) expression and decreased DNA methylation of the GR promoter in the hippocampus. DNA methylation is also decreased in sperm cells of exposed males when adult. Transgenerational transmission of behavioral symptoms is prevented by paternal environmental enrichment, an effect associated with the reversal of alterations in GR gene expression and DNA methylation in the hippocampus of the male offspring. These findings highlight the influence of both negative and positive environmental factors on behavior across generations and the plasticity of the epigenome across life.

[Trauma-focused psychotherapy: Technique, area of application, and treatment outcome]. / Traumaorientierte Psychotherapie : Technik, Anwendungsmöglichkeiten und Ergebnisse.

Traumatic events may lead to trauma-related disorders such as the posttraumatic stress disorder (PTSD) and constraints in quality of life. Meanwhile, there are different trauma-focused psychotherapies that aim to prevent PTSD shortly after experiencing a traumatic event and interventions that aim to treat PTSD. In Germany, cognitive-behavioral and psychodynamic trauma-focused approaches are commonly applied. While cognitive-behavioral programs aim at early exposure with the traumatic event, psychodynamic approaches emphasize the need of a period of stabilization before undergoing exposure. With regard to empirical evidence, cognitive-behavioral programs were able to prove their efficacy most often and are recommended in national and international guidelines. The German S3 guideline PTSD is currently under revision.

Stigma, American military personnel and mental health care: challenges from Iraq and Afghanistan.

BACKGROUND: Since 2001, more than 2.5 million United States military personnel have been deployed for combat. Over one million have served multiple deployments. Combat generally involved repeated exposure to highly traumatic events. Personnel were also victims of military sexual trauma (MST), a major risk factor for psychiatric illness. Most survivors do not seek or receive mental health care. Stigma is one of the main barriers to that care. AIMS: To explore the impact of stigma on personnel with psychiatric illness, and suggest some innovative ways to potentially reduce stigma and improve care. METHODS: Cinahl and PubMed databases were searched from 2001 to 2014. RESULTS: Anonymity, the use of non-stigmatizing language, peer-to-peer, and stigma-reduction programs help military personnel receive mental health care. Technology offers the opportunity for effective and appropriate education and treatment. CONCLUSIONS: Although stigma is formidable, several innovative services are available or being developed for military victims of trauma. Commitment of resources for program development and further research to explore which interventions offer the best clinical outcomes are needed to increase efforts to combat stigma and ensure quality care.

Correlatos neurobiológicos y consecuencias clínicas de las experiencias adversas tempranas: un enfoque sistémico / Neurobiological Correlates and Clinical Consequences of Early Adverse Expriencies: A Systemic Approach

En este artículo se ofrece una perspectiva y un panorama general acerca de los efectos y consecuencias de un amplio grupo de experiencias traumáticas tempranas, organizadas bajo el concepto abarcador de experiencias adversas tempranas y trauma de apego: abuso sexual, maltrato físico y verbal, abandono parental temprano e interacción en un ambiente familiar caótico, entre otras. Se considera un mecanismo general por el cual, las experiencias adversas generan estrés agudo o crónico que se evidencia por alterciones en la regulación del eje hipotálamo-hipófisis-suprarrenal actuando el estrés así generado como una carga alostática que genera alteraciones mente/cuerpo. Las dificultades para regular la respuesta al estrés o factores que actúan en forma independiente pueden conducir a desorganización parcial de la estructura cortical cerebral especialmente en los sistemas neuronales que procesan las emociones (sistema límbico), la memoria (hipocampo) y la capacidad de reconocer estados mentales en el propio individuo y en las personas con las cuales interactúa (teoría de la mente). Se analizan los mecanismos moleculares de resiliencia que permiten recuperarse o resistir dichas experiencias. Se menciona la importancia de reconocer un período crítico basado en el desarrollo cerebral, que podría generar una latencia en los efectos de los acontecimientos trumáticos generando vulnerabilidad y daño tanto en la infancia como durante la adolescencia o adultez joven bajo la forma de depresión, ansiedad, trsatornos de la personalidad o abuso de sustancias. El reconocimiento e investigación del trauma temprano resulta fundmental para evitar la repetición intergeneracional de las adversidades y para el desarrollo de tratamientos efectivos...

This article offers an insight and an overview of the effects and consequences of a wide range of early traumatic experiences organized within the encompassing concept of early adverse experiences and attachment trauma: sexual abuse, physical and verbal harassment, early parental abandonment and interaction in a chaotic family environment. It is considered a general mechanism by which adverse experiences generate chronic or acute stress evidenced by alterations in the regulation of the hippocampal-hypophiseal-suprarenal axis; the generated stress thus acts as an allostatic load that generates mind/body alterations. Difficulties to regulate the response to stress or factors that act independently may lead to a partial disorganization of the cerebral, cortical structure, particularly in the neuronal systems that process emotions (limbic system), memory (hippocampus) and the ability to recognize mental states within the same individual and the interacting people (theory of the mind). The author analyzes the molecular mechanisms of resilience that enable to recover from or resist to such experiences, higlighting the importance of recognizing a critical period bases on brain development, which might generate a latency in the effects of traumatic events, generating vulnerability and abuse both in the childhood as well as in the adolescence or young adulthood in the shape of depression, anxiety, personality disorders or drug abuse. The recognition and research of early trauma is key to avoid the intergenerational repetition of advesities and for the develpment of effective treatments...

[Interventions for mental health sequelae of accidents]. / Psychische Folgen von Unfällen und deren Versorgung.

Emergency psychology and psychotraumatology deal with the psychological sequelae of traumatic experiences, i.e., the prevention and early intervention of posttraumatic mental health disorders. Accidents are the most prevalent traumatic events in the general population that may result in a range of severe trauma and adjustment disorders. Accidents happen suddenly, unexpectedly, and can gravely threaten health, personal integrity, and life. The prevalence of intermittent and chronic psychiatric disorders in the aftermath of severe accidents varies between 5 and 30 %. Victims suffer from unknown and frightening posttraumatic symptoms, often irreversible handicaps as a consequence of their injuries, impairments in everyday functioning, and negative impact on the quality of life. The direct and indirect burden for society is high. Comprehensive secondary prevention, starting with early detection and early intervention of post-accident disorders, is not well established in clinical care. In case of severe accidental injuries, emergency and medical treatment has absolute priority. But all too often, severe mental health problems remain undetected in later treatment phases and therefore cannot be addressed adequately. In primary care, knowledge of specific psychodiagnostic and treatment options is still insufficient. Prejudices, denial, and fear of stigmatization in traumatized victims as well as practical constraints (availability, waiting time) in the referral to special evidence-based interventions limit the access to adequate and effective support. This overview presents the objectives, concepts, and therapeutic tools of a stepped-care model for psychological symptoms after accidental trauma, with reference to clinical guidelines.

Psychosocial care to affected citizens and communities in case of CBRN incidents: a systematic review.

Disasters are associated with a substantial psychosocial burden for affected individuals (including first responders) and communities. Knowledge about how to address these risks and problems is valuable for societies worldwide. Decades of research into post-disaster psychosocial care has resulted in various recommendations and general guidelines. However, as CBRN (chemical, biological, radiological, nuclear) events form a distinctive theme in emergency planning and disaster preparedness, it is important to systematically explore their implications for psychosocial care. The aim of this study is to answer two questions: 1). To what extent does psychosocial care in the case of CBRN events differ from other types of events? 2). How strong is the scientific evidence for the effectiveness of psychosocial care interventions in the context of a CBRN event? A systematic literature review was conducted. Searches were performed in Medline, PsychINFO, Embase and PILOTS. Studies since January 2000 were included and evaluated by independent reviewers. The 39 included studies contain recommendations, primarily based on unsystematic literature reviews, qualitative research and expert opinions. Recommendations address: 1) public risk- and crisis communication, 2) training, education and exercise of responders, 3) support, and 4) psychosocial counselling and care to citizens and responders. Although none of the studies meet the design criteria for effectiveness research, a substantial amount of consensus exists on aspects relevant to CBRN related psychosocial care. Recommendations are similar or complementary to general post-disaster psychosocial care guidelines. Notable differences are the emphasis on risk communication and specific preparation needs. Relevant recurring topics are uncertainty about contamination and health effects, how people will overwhelm health care systems, and the possibility that professionals are less likely to respond. However, the lack of evidence on effectiveness makes it necessary to be careful with recommendations. More evaluation research is absolutely needed.

Universal preventive interventions for children in the context of disasters and terrorism.

This review addresses universal disaster and terrorism services and preventive interventions delivered to children before and after an event. The article describes the organization and structure of services used to meet the needs of children in the general population (practice applications), examines screening and intervention approaches (tools for practice), and suggests future directions for the field. A literature search identified 17 empirical studies that were analyzed to examine the timing and setting of intervention delivery, providers, conditions addressed and outcomes, and intervention approaches and components.

Indicated and selective preventive interventions.

Exposure to traumatic events places children at risk for developing distressing, significant emotional reactions such as posttraumatic stress symptoms (PTSS). These reactions also affect long-term functional outcomes. Research on identified and potential risk factors for the development of significant, persistent PTSS is under way. Evidence for preventive interventions is in its infancy but progressing. Family-centered interventions comprising education about emotional reactions to traumatic events and focusing on communication between children and parents show promising results. Only morphine has shown sufficient evidence as a pharmacologic intervention in children. Additional research is necessary to support the establishment of gold-standard preventive practices.

Emotionally based strategic communications and societal stress-related disorders.

This article discusses the potential of emotionally based strategic communications (EBSCs) as an extension of traditional strategic communications in prevention of societal stress-related disorders. The concept of EBSCs takes into consideration dominant emotional maps of a specific sociocultural environment in which communications take place. EBSCs may have a significant potential to transform mainly negative-dominant emotional maps of targeted social groups into more positive ones, as a precondition of building a more resilient and stress-resistant social environment. A better understanding of dominant emotional maps and their conditioning may facilitate restoration of more positive emotional maps by touching the right emotions of significant parts of the targeted social groups in the right way. Dominant emotional maps of societies afflicted by economic downturns, natural disasters, conflicts etc., are typically characterized by negatively valenced emotions. Persistent negatively valenced group-based dominant emotions may be used as a quantitative statistical measure of potential stress-related disorders and post-traumatic stress disorders among respected group members. The toxic power of extreme negative emotions, attitudes, actions, and behavior might be reduced by EBSCs as a communication method for transforming negative-dominant emotional maps into more positive ones. EBSCs are conceptualized as the positively valenced stimulation of a negatively emotionally affected group by an appropriate communication strategy to minimize dominant-negative emotional maps and behavior of the targeted group.

Prevalencia de lesiones en triatletas de una liga francesa / Prevalence of injuries in triathletes from a French league

Objetivo: Evaluar la prevalencia de traumatismos en triatletas y buscar los factores contribuyentes implicados. Método: Se envió por correo un cuestionario anónimo sobre los casos de traumatismos durante la temporada pasada a 788 triatletas de una liga francesa. Resultados: El 52,4% de los triatletas que respondieron notificaron que habían sufrido como mínimo una lesión durante la temporada pasada y el 17% varias lesiones. El 83,5% de las lesiones se produjeron durante el entrenamiento, sobre todo corriendo (72,5%). Los casos notificados con más frecuencia fueron tendinopatías (44,5%) y lesiones musculares (35%). Las zonas anatómicas notificadas con más frecuencia fueron el tobillo (20,6%), la rodilla (18,3%), el muslo (15%), la región lumbar (12,6%) y el hombro (8,3%). El 77% de los triatletas lesionados pudieron seguir entrenando, sobre todo haciendo natación (71%) y ciclismo (61,5%), mientras que en el 85,5% de los casos tuvieron que dejar de correr. Los triatletas que habían sufrido lesiones notificaron que dedican un tiempo significativamente menor al calentamiento que los triatletas ilesos (respectivamente, 13,7min frente a 18min) (p<0,01). El tiempo dedicado a los estiramientos también era inferior en los lesionados en comparación con los ilesos (respectivamente, 8,3min frente a 10,6min) (p<0,01). Se observó la misma asociación entre el tiempo empleado en el calentamiento y el estiramiento y la prevalencia de tendinopatías. La prevalencia de lesiones musculares se asoció de manera significativa con el número de horas de entrenamiento semanales (p<0,05) y con la distancia de entrenamiento semanal nadando, haciendo ciclismo y corriendo (p<0,05). Conclusión: Las lesiones observadas en triatletas amateurs son lesiones musculoesqueléticas por «abuso», producidas sobre todo durante el entrenamiento, principalmente al correr(AU)

Objective: To assess the prevalence of trauma injuries in triathletes and look for contributing factors involved. Method: An anonymous questionnaire about trauma history during the past season was sent by post to 788 triathletes from a French league. Results: 52.4% of triathletes responding reported having been injured at least once during the past season, for 17% of them several times. 83.5% of injuries occurred during training, mostly in running (72.5%). The tendinopathies (44.5%), and muscle injuries (35%), were the most frequently reported. The anatomical sites most frequently reported were the ankle (20.6%), knee (18.3%), thigh (15%), lumbar region (12.6%) and shoulder (8,3%). 77% of injured triathletes were able to keep training, mainly in swimming (71%) and cycling (61.5%), while running was stopped in 85.5% of cases. Injured triathletes reported devote significantly less time to warm-up than uninjured triathletes (respectively 13.7min vs. 18min) (p<0.01). Time devoted to stretching was also lower for injured vs. uninjured (respectively 8.3min vs. 10.6min) (p<0.01). The same association was also found between time spent warming up and stretching and the prevalence of tendinopathies. The prevalence of muscle injuries was significantly associated with number of training hours per week (p<0.05) and weekly training distance swimming, cycling and running (p<0.05). Conclusion: Injuries encountered in amateur triathletes are musculoskeletal injuries of «overuse», occurring mainly in training, especially running(AU)

Secondary traumatic stress in nurses: a systematic review.

BACKGROUND: Is there a "cost of caring" for health care providers of traumatized patients? OBJECTIVES: The aim of this study is to review the literature on secondary traumatic stress in nurses in order to answer the following questions: What studies have been conducted on secondary traumatic stress in nurses in all clinical specialties? What instruments were used to measure secondary traumatic stress in nurses and what psychometric properties were reported? DESIGN: A systematic review. DATA SOURCES: CINAHL, PubMed, and PsycINFO databases were searched for the years 1981 to the present. Keywords used in the database searches included secondary traumatic stress, compassion fatigue, vicarious traumatization, secondary trauma, PTSD, and nurses. REVIEW METHODS: Research studies were reviewed for the following inclusion criteria: the sample included nurses, the secondary traumatic stress symptoms were measured, and the language was English. RESULTS: Seven studies were found in which researchers examined secondary traumatic stress in nurses. The samples in five of these studies consisted of all nurses, whereas in the remaining two studies, nurses were included in the samples but the results were not specifically reported for the subgroup of nurses. Presence of secondary traumatic stress was reported in forensic nurses, emergency department nurses, oncology nurses, pediatric nurses, and hospice nurses. Three instruments were identified that measured secondary traumatic stress in practitioners who care for traumatized populations: Secondary Traumatic Stress Scale, Compassion Fatigue Self Test for Helpers, and the Compassion Fatigue Scale-Revised. CONCLUSIONS: Presence of secondary traumatic stress in nurses was reported in all of the studies included in this literature review. The use of small samples and a number of different instruments to measure secondary traumatic stress symptoms, however, hindered the ability to make comparisons across studies and to draw conclusions. None of the studies conducted to date have focused on secondary traumatic stress in psychiatric nurses. Suggestions for future research and clinical implications for what can be done to protect nurses from secondary traumatic stress are addressed.