Providing equal attention: designing control groups for intensive lifestyle interventions after brain injury.

PRIMARY OBJECTIVE: Interventions are needed to address chronic health conditions, such as obesity and diabetes, faced by adults with traumatic brain injury (TBI). The objective of this narrative is to present the justification for and an exemplar of an active attention control condition as a needed comparison group in clinical trials for intensive lifestyle interventions after TBI. RESEARCH DESIGN: Narrative review. METHODS AND PROCEDURES: N/A. MAIN OUTCOMES AND RESULTS: Despite the historical use in scientific research, integration of appropriate control conditions to account for not only the placebo effect, but also to isolate the "active ingredients" of behavioural interventions, remains a challenge. This is particularly true for intensive lifestyle interventions, especially with the increasing use of mobile health (mHealth) to augment these interventions. Herein we describe the design, content, and implementation of a group-based, attention control condition, referred to as the Brain Health Group, as an exemplar active comparison to an intensive lifestyle intervention for weight-loss among individuals with TBI (GLB-TBI). CONCLUSIONS: Intervention studies should incorporate strong scientific designs and active control conditions to assess effectiveness and aid in replication. Following recommended guidelines, we provide an active control condition for future group-based intensive lifestyle interventions post-TBI.

Caregiver expectations of recovery among persons with spinal cord injury at three and six months post-injury: A brief report.

Objective: Caregivers of patients with spinal cord injury (SCI) have increased risk of depression, anxiety, and diminished quality of life. Unmet expectations for recovery may contribute to poorer outcomes.Design: Prospective, longitudinal observation study.Settings: Trauma/Critical care ICU at baseline, telephone for follow-ups.Participants: Caregivers of patients with SCI (n = 13).Interventions: None.Outcome Measures: Expectations for recovery were assessed across four primary domains identified in a review of the literature including: pain severity, level of engagement in social/recreational activities, sleep quality, and ability to return to work/school. Caregivers' forecasts of future recovery were compared to later perceived actual recovery.Results: At three months, 75% of caregivers had unmet expectations for social engagement recovery, 50% had unmet expectations for pain decrease, and 42% had unmet expectations for sleep improvement and resuming work. Rates of unmet expectations were similar at six months, with 70% of caregivers reporting unmet expectations for social engagement recovery, 50% with unmet expectations for pain decrease, and 40% with unmet expectations for sleep improvement.Conclusion: Unmet caregiver expectations for recovery could pose a risk for caregiver recovery and adjustment. Our results show that caregiver expectations merit further investigation for their link with caregiver mental health.

Ensemble machine learning prediction of posttraumatic stress disorder screening status after emergency room hospitalization.

Posttraumatic stress disorder (PTSD) develops in a substantial minority of emergency room admits. Inexpensive and accurate person-level assessment of PTSD risk after trauma exposure is a critical precursor to large-scale deployment of early interventions that may reduce individual suffering and societal costs. Toward this aim, we applied ensemble machine learning to predict PTSD screening status three months after severe injury using cost-effective and minimally invasive data. Participants (N = 271) were recruited at a Level 1 Trauma Center where they provided variables routinely collected at the hospital, including pulse, injury severity, and demographics, as well as psychological variables, including self-reported current depression, psychiatric history, and social support. Participant zip codes were used to extract contextual variables including population total and density, average annual income, and health insurance coverage rates from publicly available U.S. Census data. Machine learning yielded good prediction of PTSD screening status 3 months post-hospitalization, AUC = 0.85 95% CI [0.83, 0.86], and significantly outperformed all benchmark comparison models in a cross-validation procedure designed to yield an unbiased estimate of performance. These results demonstrate that good prediction can be attained from variables that individually have relatively weak predictive value, pointing to the promise of ensemble machine learning approaches that do not rely on strong isolated risk factors.

The role of depression and social support on readmission rates within one year of traumatic injury.

OBJECTIVE: Hospital readmission rates have become a quality metric-particularly in trauma and acute care, where up to one third of individuals with traumatic injury return to the hospital. Thus, identifying predictors of readmission is a priority in an effort to reduce readmissions. Based on previous theoretical work, this study tests the utility of social support and depression in predicting readmissions up to one year after initial injury. METHOD: Data from 180 injured individuals admitted to a large, urban Level 1 trauma center were matched to a regional readmissions database. Logistic regression was used to assess whether social support levels or positive depression screens during initial trauma visit predicted unplanned (a) readmissions or (b) emergency/urgent outpatient visits. RESULTS: Within the sample, there were 32 total readmissions and 50 total emergency outpatient encounters following initial injury. Depression continued to be a risk factor for emergency outpatient visits only (OR = 2.75). Patients with greater social integration (OR = 0.78), more guidance (advice or information; OR = 0.72) and more reliable alliance (OR = 0.72) as forms of social support were less likely to readmit. CONCLUSIONS: This study demonstrates the utility of screening for depression and social support in predicting readmission within one year after traumatic injury. Future efforts should continue emphasizing the impact of initial depression and the need for patients to have trusted individuals in their lives to whom they can turn during recovery; doing so may lower the probability that patients return to hospital. (PsycINFO Database Record

Prospective Evaluation of Posttraumatic Stress Disorder and Depression in Orthopaedic Injury Patients With and Without Concomitant Traumatic Brain Injury.

OBJECTIVES: Psychological morbidities after injury [eg, posttraumatic stress disorder (PTSD) and depression] are increasingly recognized as a significant determinant of overall outcome. Traumatic brain injury (TBI) negatively impacts outcomes of patients with orthopaedic injury, but the association of concurrent TBI, orthopaedic injury, and symptoms of PTSD and depression has not been examined. This study's objective was to examine symptoms of PTSD and depression in patients with orthopaedic trauma with and without TBI. DESIGN: Longitudinal prospective cohort study. SETTING: Urban Level I Trauma Center in the Southwest United States. PATIENTS/PARTICIPANTS: Orthopaedic trauma patients older than 18 years admitted for ≥24 hours. MAIN OUTCOME MEASUREMENTS: Questionnaires examining demographics, injury-related variables, PTSD, and depression were administered during hospitalization and 3, 6, and 12 months later. Orthopaedic injury and TBI were determined based on ICD-9 codes. Generalized linear models determined whether PTSD and depression at follow-up were associated with TBI. RESULTS: Of the total sample (N = 214), 44 (21%) sustained a TBI. Those with TBI had higher rates of PTSD symptoms, 12 months postinjury (P = 0.04). The TBI group also had higher rates of depressive symptoms, 6 months postinjury (P = 0.038). CONCLUSIONS: Having a TBI in addition to orthopaedic injury was associated with significantly higher rates of PTSD at 12 months and depression at 6 months postinjury. This suggests that sustaining a TBI in addition to orthopaedic injury places patients at a higher risk for negative psychological outcomes. The findings of this study may help clinicians to identify patients who are in need for psychological screening and could potentially benefit from intervention. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Alcohol and drug toxicology screens at time of hospitalization do not predict PTSD or depression after traumatic injury.

BACKGROUND: Identifying risk factors for the development of PTSD and depression is critical for intervention and recovery after injury. Given research linking toxicology screens and substance use and the evidenced relationship between substance misuse and distress, the current study aimed to gauge the predictive value of toxicology testing on PTSD and depression. METHODS: Patients admitted to a Level I Trauma Center (N = 379) completed the PC-PTSD, PCL-C, and PHQ-8 at baseline, 3, 6, and 12 months. RESULTS: Results showed 52% of tested patients had a positive toxicology test, 51% screened for PTSD, and 54% screened for depression. Positive drug or alcohol toxicology tests were not significantly associated with PTSD or depression. CONCLUSIONS: Toxicology testing may not meaningful predict depression or PTSD in traumatic injury patients. Future research using validated measures of problematic substance use is needed to better understand how misuse may influence the development of psychological distress.

The association between posttraumatic stress symptoms, depression, and length of hospital stay following traumatic injury.

OBJECTIVE: The present study examined the relationship between posttraumatic stress symptoms (PTSS) and depression symptoms with hospital outcome measures to explore how psychiatric factors relate to hospital length of stay (LOS). METHOD: Participants were adults admitted to a large Level I Trauma Center for longer than 24h. Depression was assessed at hospitalization using the Patient Health Questionnaire (PHQ-8), and PTSS was measured by the Primary Care PTSD Screen (PC-PTSD). Hospital outcome information was collected from the hospital's trauma registry. Pearson correlations were performed. RESULTS: 460 participants (mean age=44years, SD=16.8; 65.4% male) completed the study. Baseline PTSS and depression were significantly correlated with longer hospital LOS while controlling for demographics and injury severity (p=0.026; p=0.023). Both PTSS-positive and depression-positive groups had an average increased hospital LOS of two days. CONCLUSIONS: A significant proportion of individuals who are admitted to the hospital following trauma may be at risk for depression and PTSS, which may then increase hospital LOS. As national attention turns to reducing healthcare costs, early screenings and interventions may aid in minimizing psychiatric symptoms in trauma patients, in turn reducing the cost and outcomes associated with total hospital LOS.

Discrepancy in caregiving expectations predicts problematic alcohol use among caregivers of trauma injury patients six months after ICU admission.

This prospective study examined the influence of caregiving variables on the development of problematic alcohol use among family members of patients admitted to an urban Level I trauma center. Data were collected from 124 caregivers 48 hrs after initial hospitalization of their family member. The final sample included 81 participants (24.6% male; Mage = 47.8) who completed their follow-up assessment at 6 months. Hierarchical linear and logistic regression analyses assessed increases in consumption and odds of a positive screen for problematic alcohol use in association with caregiver burden, actual time spent in the caregiving role, and caregiving differential (i.e., anticipated time spent caregiving at baseline in relation to actual time caregiving at 6 months). At 6 months, 24.7% of caregivers screened positive for problematic alcohol use. Results uniquely highlighted caregiving differential as a significant predictor of both increases in general alcohol consumption (ΔR2 = .06, p < .01) and odds of screening positive for problematic alcohol use at 6 months (Odds Ratio = 1.05, 95% CI [1.02-1.09]). More specifically, our adjusted model found that providing 10% more time caregiving, relative to expectations at baseline, was associated with an increase in the probability of problematic alcohol use by 22% (95% CI: 8-37%) at 6 months. These results suggest that a discrepancy in expectations regarding anticipated time caregiving and actual time caregiving, rather than solely the amount of caregiving or perceived caregiver burden, may be an important predictor of caregiver alcohol use 6 months after a family member's ICU hospitalization. (PsycINFO Database Record

Severity of traumatic injuries predicting psychological outcomes: A surprising lack of empirical evidence.

Despite widespread beliefs that trauma severity is related to levels of posttraumatic stress symptoms (PTSS), the empirical evidence to support such beliefs is lacking. In the current study we examined Injury Severity Score (ISS), a medical measure of event severity for physical injuries, in a sample of 460 patients admitted to a Level 1 Trauma Center. Results revealed no significant relationship between ISS and PTSS, depression, pain, and general physical and mental health at baseline, three months, and six months post-injury. However, at 12 months post-injury, ISS significantly predicted depression, pain, and physical health, but was unrelated to PTSS. The effect sizes of these relationships were small and would not remain significant if any adjustments for multiple comparisons were employed. We conclude that the relationship between ISS and PTSS is, at best, weak and inconsistent. The results are discussed in the broader picture of event severity and psychological outcomes.

Secondary traumatic stress in emergency medicine clinicians.

Previously called Secondary Traumatic Stress (STS), secondary exposure to trauma is now considered a valid DSM-5 Criterion A stressor for posttraumatic stress disorder (PTSD). Previous studies have found high rates of STS in clinicians who treat traumatically injured patients. However, little research has examined STS among Emergency Medicine (EM) physicians and advanced practice providers (APPs). The current study enrolled EM providers (N = 118) working in one of 10 hospitals to examine risk factors, protective factors, and the prevalence of STS in this understudied population. Most of the participants were physicians (72.9%), Caucasian (85.6%), and male (70.3%) with mean age of 39.7 (SD = 8.9). Overall, 12.7% of the sample screened positive for STS with clinical levels of intrusion, arousal, and avoidance symptom clusters, and 33.9% had at least one symptom cluster at clinical levels. Low resilience and a history of personal trauma were positively associated with positive STS screens and STS severity scores. Borderline significance suggested that female gender and spending ≥10% of one's time with trauma patients could be additional risk factors. Findings suggest that resilience-building interventions may be beneficial.

The effect of depressive symptoms on social support one year following traumatic injury.

BACKGROUND: Depression is a common mental health outcome after traumatic injury, negatively impacting physical outcomes and increasing the cost of care. Research shows that the presence and quality of support is a leading protective factor against depression post-injury; however, research is vague on the directional effects of both factors over the course of recovery. METHODS: 130 patients admitted to a Level I Trauma Center were recruited to a prospective study examining overall outcomes one-year after injury. Effects of social support and depression at baseline and 12-months post-injury were examined using correlational and cross-lagged path model analyses. Additional follow-up analyses were conducted for depression on specific types of social support. RESULTS: Findings replicated previous research suggesting depression and social support were inversely related. Initial depression at time of traumatic injury was predictive of social support 12-months after their injury, but initial social support levels did not significantly predict depression at 12-months. Additionally, initial depression significantly predicted attachment, social integration, reassurance of worth, and guidance 12-months later. LIMITATIONS: Findings of the analyses are limited by lack of experimentation and inability to control for other related variables. CONCLUSIONS: Findings of the present study support the notion that initial depression predicts poorer social support in recovery, in lieu of prevailing theory (i.e., initial support buffers against later depression) in a sample of trauma patients. These findings highlight the need for medical staff to target specific factors during inpatient stay, such as addressing depressive symptoms and preparing family members and caregivers prior to discharge.

Prospective Evaluation of Posttraumatic Stress Disorder in Injured Patients With and Without Orthopaedic Injury.

OBJECTIVES: The study purposes were to prospectively evaluate occurrence of posttraumatic stress (PTS) symptoms at hospital admission and 6 months later in patients with orthopaedic injury; to explore differences in PTS symptoms in those with and without orthopaedic injury; and to determine whether PTS symptoms are influenced by orthopaedic injury type. DESIGN: Prospective, longitudinal observational study. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Two hundred fifty-nine participants admitted for at least 24 hours. MAIN OUTCOME MEASUREMENTS: The Primary Care Posttraumatic Stress Disorder (PTSD) Screen (PC-PTSD) measured PTSD symptoms during hospitalization. The PTSD Checklist-Civilian Version (PCL-C) measured PTS symptoms at 6 months. RESULTS: In orthopaedic patients, 28% had PTS at 6 months, compared with 34% of nonorthopaedic patients. Odds ratios (ORs) were calculated to determine the influence of pain, physical and mental function, depression, and work status. At 6 months, if the pain score was 5 or higher, the odds of PTS symptoms increased to 8.38 (3.55, 19.8) (P < 0.0001). Those scoring below average in physical function were significantly more likely to have PTS symptoms [OR = 7.60 (2.99, 19.32), P < 0.0001]. The same held true for mental functioning and PTS [OR = 11.4 (4.16, 30.9), P < 0.0001]. Participants who screened positive for depression had a 38.9 (14.5, 104) greater odds (P < 0.0001). Participants who did not return to work after injury at 6 months were significantly more likely to have PTS [OR = 16.5 (1.87, 146), P = 0.012]. CONCLUSIONS: PTSD is common in patients after injury, including those with orthopaedic trauma. At 6 months, pain of 5 or greater, poor physical and mental function, depression, and/or not returning to work seem to be predictive of PTSD. Orthopaedic surgeons should identify and refer for PTSD treatment given the high incidence postinjury. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

The intensive care unit experience: Psychological impact on family members of patients with and without traumatic brain injury.

PURPOSE/OBJECTIVE: The intensive care unit (ICU) has been identified as a possible contributor to emotional distress. This study seeks to identify whether families of traumatic brain injury (TBI) patients in the ICU experience psychological differences as compared with non-TBI patients' family members. METHOD: Eighty-two family members in a trauma/critical care ICU were assessed at baseline and again at 3 months. The Patient Health Questionnaire 8-Item measured depression, the Primary Care PTSD Screen measured symptoms of posttraumatic stress (PTS). RESULTS: Forty of these individuals were the family members of ICU patients who had sustained a TBI; 42 of the individuals were the family members of non-TBI patients in the ICU. At baseline, 39% (33% non-TBI, 45% TBI, p = .28) of the total sample screened positive for depressive symptoms and 24.3% (26% non-TBI, 23% TBI, p = .69) screened positive for PTS symptoms. However, differences emerged between the groups at 3 months, with family members in the non-TBI group showing a significant decrease in both baseline depression and PTS symptoms. CONCLUSIONS/IMPLICATIONS: This study, to our knowledge, is the first of its kind to examine psychological differences in the ICU in those whose family members either have or do not have a TBI. Results suggest the TBI group endorsed more symptoms of depression and PTS symptoms at 3 months. Although it is unclear whether symptoms were directly related to the ICU experience or the injury itself, future research should explore the possible additive effect of postintensive care syndrome-family symptoms. (PsycINFO Database Record

Psychological factors predicting outcome after traumatic injury: the role of resilience.

BACKGROUND: Increasingly, studies have examined the psychological impact on individuals who survive a traumatic physical injury. The primary aim of this study was to determine the stability of resilience and its association with depressive symptoms. METHODS: This study included 110 adults admitted to a Level I trauma center. Resilience and depression were measured at baseline and 12 months. Injury-related variables included Glasgow Coma Scale, Injury Severity Score, etiology of injury, and type of injury. RESULTS: Analysis revealed that resilience remained stable over 12 months regardless of injury severity, etiology, or type. Negative correlations were found between baseline resilience and 12-month depression (P < .01), as well as Glasgow Coma Scale and depression (P = .001). CONCLUSIONS: Injured individuals with low resilience are more likely to be depressed at 12 months. Assessing resilience at the time of injury may be useful in identifying those at risk for depression 1 year later.