Cognitive Behavioral Treatment for Acute Posttrauma Distress: A Randomized, Controlled Proof-of-Concept Study Among Hospitalized Adults With Burns.

OBJECTIVE: (1) To evaluate the feasibility of conducting a randomized controlled trial (RCT) of the Safety, Meaning, Activation and Resilience Training (SMART) intervention vs nondirective supportive psychotherapy (NDSP) in an acutely hospitalized adult survivor of burn injury sample; and (2) to assess the preliminary effect of SMART on acute stress disorder (ASD), posttraumatic stress disorder (PTSD), and major depressive disorder (MDD) symptom reduction as secondary prevention. DESIGN: Proof-of-concept, parallel group RCT design. SETTING: Regional burn center. PARTICIPANTS: Acutely injured, hospitalized adult survivors of burn injury (N=50) were randomly assigned to SMART (n=28) or nondirective supportive psychotherapy (n=22). Due to dropout and missing data, final sample size was 40, SMART (n=21) and nondirective supportive psychotherapy (n=19). INTERVENTIONS: SMART is a manualized, 4-session cognitive behavioral therapy-based psychological intervention targeting ASD, PTSD, and MDD symptoms. NDSP is a manualized, 4-session protocol. MAIN OUTCOME MEASURES: Davidson Trauma Scale ([DTS]; diagnostic proxy for ASD and PTSD; clinical cutoff=40, with higher score=higher severity) and the Patient Health Questionnaire-9 ([PHQ-9]; diagnostic proxy for MDD; clinical cutoff=10, with higher score=higher severity) at pretreatment, immediate posttreatment, and 1 month posttreatment. RESULTS: At baseline, median DTS scores and PHQ-9 scores were above clinical cutoffs and did not differ across groups. At 1 week and 1 month posttreatment, median DTS and PHQ-9 scores were beneath clinical cutoffs in the SMART group; scores remained above clinical cutoffs in the NDSP group at these time points. CONCLUSIONS: It is feasible to conduct an RCT of SMART in hospitalized adult survivors of burn injury. SMART has the potential to yield clinically significant outcomes. Additional studies are needed to replicate and extend these findings.

Quality of life across medical conditions and psychological factors: implications for population health management.

PURPOSE: To identify the contributions of medical conditions and psychological distress to well-being within a non-clinical sample, stratified by age. It was predicted that medical conditions and psychological distress would be negatively associated with well-being. It was also predicted that psychological distress and medical conditions would account for significant variance in well-being. It was further predicted that psychological distress would mediate the relationship between medical conditions and well-being across the life span. METHODS: 1,424,307 employees/health plan members that completed an HRA. SEM was used to characterize relationships among medical conditions and psychological distress in predicting well-being (QoL, HRQoL, and impairments in ADLs) in five adult age groups. RESULTS: Medical conditions and psychological distress were negatively associated with well-being. As age increased, psychological distress was less associated with well-being. However, in those >75 years old, psychological distress had the largest association with well-being. All medical conditions, except cancer, were negatively associated with well-being. There were decreasing effects of medical conditions across the life span, with the exception of pulmonary disease which increased. Psychological distress mediated the relationship between medical conditions and well-being, with chronic pain having the greatest mediation across the life span. CONCLUSIONS: The analysis revealed differences in the contribution of psychological distress and medical conditions to well-being by age group. Additionally, the contribution of psychological distress was equitable to that of medical conditions, thus highlighting the importance of addressing psychological distress in medical populations for well-being. Findings suggest the relevance of age in well-being and the need for further longitudinal investigation.

Workplace Well-Being Factors That Predict Employee Participation, Health and Medical Cost Impact, and Perceived Support.

PURPOSE: This study tested relationships between health and well-being best practices and 3 types of outcomes. DESIGN: A cross-sectional design used data from the HERO Scorecard Benchmark Database. SETTING: Data were voluntarily provided by employers who submitted web-based survey responses. SAMPLE: Analyses were limited to 812 organizations that completed the HERO Scorecard between January 12, 2015 and October 2, 2017. MEASURES: Independent variables included organizational and leadership support, program comprehensiveness, program integration, and incentives. Dependent variables included participation rates, health and medical cost impact, and perceptions of organizational support. ANALYSIS: Three structural equation models were developed to investigate the relationships among study variables. RESULTS: Model sample size varied based on organizationally reported outcomes. All models fit the data well (comparative fit index > 0.96). Organizational and leadership support was the strongest predictor (P < .05) of participation (n = 276 organizations), impact (n = 160 organizations), and perceived organizational support (n = 143 organizations). Incentives predicted participation in health assessment and biometric screening (P < .05). Program comprehensiveness and program integration were not significant predictors (P > .05) in any of the models. CONCLUSION: Organizational and leadership support practices are essential to produce participation, health and medical cost impact, and perceptions of organizational support. While incentives influence participation, they are likely insufficient to yield downstream outcomes. The overall study design limits the ability to make causal inferences from the data.

Sustained Long-Term Effectiveness of an Energy Management Training Course on Employee Vitality and Purpose in Life.

PURPOSE: Programs designed to sustainably improve employee well-being are urgently needed but insufficiently researched. This study evaluates the long-term effectiveness of a commercial well-being intervention in a worksite setting. DESIGN: A pre/postintervention repeated analysis with follow-up at 6, 12, and 18 months. SETTING: Office-based worksites (for-profit, nonprofit, and mixed work-type; n = 8). PARTICIPANTS: One hundred sixty-three employees with a mean age of 47 (11) years (57% female). INTERVENTION: A 2.5-day group-based behavioral program emphasizing vitality and purpose in life (PiL). MEASURES: Rand Medical Outcomes Survey (MOS) 36-Item Short Form (SF-36) with a focus on vitality (primary outcome), Ryff PiL Scale, Center for Epidemiologic Studies Depression Scale, Profile of Mood States, Rand MOS Sleep Scale, physical activity, body weight, blood pressure, and blood measures for glucose and lipids at baseline, 6, 12, and 18 months. ANALYSIS: General linear models with repeated measures for mean values at baseline and follow-up. RESULTS: At 18-month follow-up, sustained improvements were observed for vitality, general health, and mental health domains of SF-36 and PiL (P < .001 for all measures). Sleep, mood, vigor, physical activity, and blood pressure were also improved at 18 months (P < .05 for all measures). CONCLUSIONS: An intensive 2.5-day intervention showed sustained improvement in employee quality of life, PiL, and other measures of well-being over 18 months.

Effectiveness of an Energy Management Training Course on Employee Well-Being: A Randomized Controlled Trial.

PURPOSE: Programs focused on employee well-being have gained momentum in recent years, but few have been rigorously evaluated. This study evaluates the effectiveness of an intervention designed to enhance vitality and purpose in life by assessing changes in employee quality of life (QoL) and health-related behaviors. DESIGN: A worksite-based randomized controlled trial. SETTING: Twelve eligible worksites (8 randomized to the intervention group [IG] and 4 to the wait-listed control group [CG]). PARTICIPANTS: Employees (n = 240) at the randomized worksites. INTERVENTION: A 2.5-day group-based behavioral intervention. MEASURES: Rand Medical Outcomes Survey (MOS) 36-item Short-Form (SF-36) vitality and QoL measures, Ryff Purpose in Life Scale, Center for Epidemiologic Studies questionnaire for depression, MOS sleep, body weight, physical activity, diet quality, and blood measures for glucose and lipids (which were used to calculate a cardiometabolic risk score) obtained at baseline and 6 months. ANALYSIS: General linear mixed models were used to compare least squares means or prevalence differences in outcomes between IG and CG participants. RESULTS: As compared to CG, IG had a significantly higher mean 6-month change on the SF-36 vitality scale ( P = .003) and scored in the highest categories for 5 of the remaining 7 SF-36 domains: general health ( P = .014), mental health ( P = .027), absence of role limitations due to physical problems ( P = .026), and social functioning ( P = .007). The IG also had greater improvements in purpose in life ( P < .001) and sleep quality (index I, P = .024; index II, P = .021). No statistically significant changes were observed for weight, diet, physical activity, or cardiometabolic risk factors. CONCLUSION: An intensive 2.5-day intervention showed improvement in employee QoL and well-being over 6 months.

The Avalanche Hypothesis and Compression of Morbidity: Testing Assumptions through Cohort-Sequential Analysis.

BACKGROUND: The compression of morbidity model posits a breakpoint in the adult lifespan that separates an initial period of relative health from a subsequent period of ever increasing morbidity. Researchers often assume that such a breakpoint exists; however, this assumption is hitherto untested. PURPOSE: To test the assumption that a breakpoint exists--which we term a morbidity tipping point--separating a period of relative health from a subsequent deterioration in health status. An analogous tipping point for healthcare costs was also investigated. METHODS: Four years of adults' (N = 55,550) morbidity and costs data were retrospectively analyzed. Data were collected in Pittsburgh, PA between 2006 and 2009; analyses were performed in Rochester, NY and Ann Arbor, MI in 2012 and 2013. Cohort-sequential and hockey stick regression models were used to characterize long-term trajectories and tipping points, respectively, for both morbidity and costs. RESULTS: Morbidity increased exponentially with age (P<.001). A morbidity tipping point was observed at age 45.5 (95% CI, 41.3-49.7). An exponential trajectory was also observed for costs (P<.001), with a costs tipping point occurring at age 39.5 (95% CI, 32.4-46.6). Following their respective tipping points, both morbidity and costs increased substantially (Ps<.001). CONCLUSIONS: Findings support the existence of a morbidity tipping point, confirming an important but untested assumption. This tipping point, however, may occur earlier in the lifespan than is widely assumed. An "avalanche of morbidity" occurred after the morbidity tipping point-an ever increasing rate of morbidity progression. For costs, an analogous tipping point and "avalanche" were observed. The time point at which costs began to increase substantially occurred approximately 6 years before health status began to deteriorate.

Sustained economic value of a wellness and disease prevention program: an 8-year longitudinal evaluation.

The objective of this study was to determine the sustained economic impact of a health promotion/disease prevention program delivered through a large regional health plan. This was a retrospective analysis of health risk, health claims, and cost using a mixed model factorial design for the years 2002-2009 that compared program participants to nonparticipants. All analyses were adjusted for age, sex, morbidity, and baseline health care costs as appropriate. The findings presented herein indicate a positive return on investment (ROI) for each program year with ratios ranging from a low of 1.16:1 to a high of 2.83:1. The average ROI collapsed across all 8 years was 2.02:1. The 2009 ROI approximated over $6 million in total savings. This study demonstrates the sustained economic value of a comprehensive health promotion program.

The predictive validity of the HERO Scorecard in determining future health care cost and risk trends.

OBJECTIVE: To determine the ability of the Health Enhancement Research Organization (HERO) Scorecard to predict changes in health care expenditures. METHODS: Individual employee health care insurance claims data for 33 organizations completing the HERO Scorecard from 2009 to 2011 were linked to employer responses to the Scorecard. Organizations were dichotomized into "high" versus "low" scoring groups and health care cost trends were compared. A secondary analysis examined the tool's ability to predict health risk trends. RESULTS: "High" scorers experienced significant reductions in inflation-adjusted health care costs (averaging an annual trend of -1.6% over 3 years) compared with "low" scorers whose cost trend remained stable. The risk analysis was inconclusive because of the small number of employers scoring "low." CONCLUSIONS: The HERO Scorecard predicts health care cost trends among employers. More research is needed to determine how well it predicts health risk trends for employees.

The effect of attachment style on sleep in postdeployed service members.

This study examined the effect of attachment style on subjective sleep outcomes in a population of service members (N=561 (403 male, 157 female)). Active duty, postdeployment service members completed questionnaires including two measures of adult attachment and two measures of subjective sleep. Results confirmed the central hypothesis: secure attachment style is associated with better sleep, followed by dismissing, fearful, and preoccupied, respectively. Gender differences were also found for prevalence of attachment style patterns. This is the first study incorporating attachment style and sleep outcomes within a military population, and provides the basis for future research in this area.

Return to work after burn injury: a systematic review.

Consequences of major burn injuries often include losing the ability to engage in basic life functions such as work or employment. As this is a developing area of importance in burn care, the goal of this study was to perform a systematic review of the burn literature to ascertain a comprehensive view of the literature and identify return to work (RTW) factors where possible. A search was conducted and peer-reviewed studies that investigated predictors and barriers of returning to work of those with burn injuries, published since 1970 and written in English, were examined. From the 216 articles initially identified in the search, 26 studies were determined to meet inclusion criteria. Across studies, the mean age was 33.63 years, the mean TBSA was 18.94%, and the average length of stay was 20 days. After 3.3 years (41 months) postburn, 72.03% of previously employed participants had returned to some form of work. Important factors of RTW were identified as burn location, burn size, treatment variables, age, pain, psychosocial factors, job factors, and barriers. This systematic review suggests multiple conclusions. First, there is a significant need for attention to this area of study given that nearly 28% of all burn survivors never return to any form of employment. Second, the RTW literature is in need of coherent and consistent methodological practices, such as a sound system of measurement. Finally, this review calls for increased attention to interventions designed to assist survivors' ability to function in an employed capacity.

Epidemiology and impact of scarring after burn injury: a systematic review of the literature.

The purpose of this study was to perform a systematic review of the existing literature on the incidence of hypertrophic scarring and the psychosocial impact of burn scars. In a comprehensive literature review, the authors identified 48 articles published since 1965 and written in English which reported the incidence and risk factors for hypertrophic scarring or assessed outcomes related to scarring. Most studies had important methodological limitations limiting the generalizability of the findings. In particular, the absence of standardized valid measures of scarring and other outcome variables was a major barrier to drawing strong conclusions. Among studies on hypertrophic scarring, the prevalence rate varied between 32 and 72%. Identified risk factors included dark skin, female gender, young age, burn site on neck and upper limb, multiple surgical procedures, meshed skin graph, time to healing, and burn severity. With regard to psychosocial outcomes, two studies compared pediatric burn survivors with a nonburn comparison group on a body image measure; neither study found differences between groups. Across studies, burn severity and location had a modest relationship with psychosocial outcome variables. Psychosocial variables such as social comfort and perceived stigmatization were more highly associated with body image than burn characteristics. To advance our knowledge of the epidemiology of scars and the burden of scars, future studies need to implement more rigorous methodologies. In particular, standardized valid measures of scarring and other outcomes should be developed. This process could be facilitated by an international collaboration among burn centers.

The impact of attachment style on posttraumatic stress disorder symptoms in postdeployed service members.

This study examined the effects of attachment style on self-reported posttraumatic stress disorder (PTSD) symptoms in a population of service members (N=561). Active duty, postdeployment service members completed anonymous questionnaires including 2 measures of adult attachment and the PTSD checklist-military as a measure of PTSD symptoms. Results confirmed the central hypothesis that attachment style was related to reported PTSD symptoms. Secure attachment style was associated with less reported PTSD symptoms and therefore may be involved in mechanisms associated with protection from developing PTSD after experiencing wartime trauma. Results were consistent when tested across continuous and dichotomous assessments that captured diagnostic criteria. This study demonstrates a significant relationship between attachment style and PTSD symptoms within a military population, potentially providing the basis for future research in this area.

Measuring coping behavior in patients with major burn injuries: a psychometric evaluation of the BCOPE.

Burn injuries involve significant physiological, psychological, and social challenges with which individuals must cope. Although the brief COPE (BCOPE) is frequently used, knowledge of its factor structure and construct validity is limited, thus limiting confidence with interpreting results. This study assessed psychometric properties of the BCOPE in hospitalized patients with burn injury. Participants had a major burn injury (n = 362). Measures assessed coping behavior and physical, psychological, and social functioning. Exploratory factorial analysis was conducted to evaluate patterns of coping strategies. To assess construct validity, the BCOPE scale scores were correlated with the distress measures across time points. Exploratory factorial analysis revealed seven factors accounting for 51% of total variance. The pattern matrix indicated four items loaded onto factor 1 (active coping = 0.47-0.80) and four onto factor 2 (avoidant coping = 0.59-0.73). The remaining factors were consistent with original scale assignments reported by Carver (Int J Behav Med 1997;4:92-100). Construct validity of BCOPE scales (active and avoidant) was demonstrated by their association with the Davidson trauma scale, short form-12, and satisfaction with appearance scale. The results indicate that the BCOPE is valid, reliable, and can be meaningfully interpreted. Research using these factors may improve knowledge about interrelationships among stress, coping, and outcome, thus building the evidence base for managing distress in this population.

Peritraumatic heart rate and posttraumatic stress disorder in patients with severe burns.

OBJECTIVE: Previous studies have suggested a link between heart rate (HR) following trauma and the development of posttraumatic stress disorder (PTSD). This study expands on previous work by evaluating HR in burn patients followed longitudinally for symptoms of acute stress disorder (ASD) and PTSD. METHOD: Data were collected from consecutive patients admitted to the Johns Hopkins Burn Center, Baltimore, Maryland, between 1997 and 2002. Patients completed the Stanford Acute Stress Reaction Questionnaire (n = 157) to assess symptoms of ASD. The Davidson Trauma Scale was completed at 1 (n = 145), 6 (n = 106), 12 (n = 94), and 24 (n = 66) months postdischarge to assess symptoms of PTSD. Heart rate in the ambulance, emergency room, and burn unit were obtained by retrospective medical chart review. RESULTS: Pearson correlations revealed a significant relationship between HR in the ambulance (r = 0.32, P = .016) and burn unit (r = 0.30, P = .001) and ASD scores at baseline. Heart rate in the ambulance was related to PTSD avoidance cluster scores at 1, 6, 12, and 24 months. In women, HR in the ambulance was correlated with PTSD scores at 6 (r = 0.65, P = .005) and 12 (r = 0.78, P = .005) months. When covariates (gender, ß-blockers, Brief Symptom Inventory Global Severity Index score) were included in multivariate linear regression analyses, ambulance HR was associated with ASD and PTSD scores at baseline and 1 month, and the interaction of ambulance HR and gender was associated with PTSD scores at 6 and 12 months. Multivariate logistic regression results were similar at baseline and 12 months, which included an HR association yet no interaction at 6 months and a marginal interaction at 1 month. CONCLUSIONS: While peritraumatic HR is most robustly associated with PTSD symptom severity, HR on admission to burn unit also predicts the development of ASD. Gender and avoidance symptoms appear particularly salient in this relationship, and these factors may aid in the identification of subgroups for which HR serves as a biomarker for PTSD. Future work may identify endophenotypic measures of increased risk for PTSD, targeting subgroups for early intervention.

Growth curve trajectories of distress in burn patients.

Psychological adjustment after a major burn injury is a significant concern to providers and patients alike. Although efforts have been made to identify associated risk factors, little is known about heterogeneity in the levels or trajectories of adjustment in this population. This study used a novel application of Growth Mixture Modeling to identify subgroups of patients based on their longitudinal self-reported distress using the Brief Symptom Inventory (BSI). Data were drawn from the database of the Burn Model Systems project, a prospective, multisite, cohort study of major burn injury survivors. The BSI was used to assess symptoms in-hospital and at 6, 12, and 24 months postburn. Participants' T scores on the BSIs Global Severity Index provided a continuous measure of psychological distress. Analyses were conducted using participants' Global Severity Index T scores to discern distinct classes of respondents with similar trajectories across the 2-year follow-up. Results from the Growth Mixture Modeling analysis produced an ordered four-class model of psychological recovery from a major burn. Groups represented the equivalent of high, subthreshold, mild, and minimal symptom severity. Covariates significantly affected the intercept and slope of each class, as well as prediction of group assignment. These analyses demonstrate differences between individual recoveries after a major burn. Psychological distress symptoms remain largely stable over time and highlight the psychological vulnerability of this patient population.

Confirmatory factor analysis of the Short Form McGill Pain Questionnaire with burn patients.

The Short Form McGill Pain Questionnaire (SF-MPQ) is an abbreviated version of McGill Pain Questionnaire (MPQ) developed for pragmatic reasons to improve the clinical utility of the MPQ. Although the SF-MPQ has been used in more than 250 published studies, few studies have examined the core constructs it measures. The objective of this study was to evaluate in a sample with burn injuries whether the factor structure of the SF-MPQ is consistent with the theoretic pain constructs it purports to measure. Participants (n = 338) met American Burn Association's criteria for major burn injury and had a mean total body surface area burned of 14%. They were mostly male (70.1%) and Caucasian (63.4%) with an average age of 41.25 years. There were 2 primary findings. First, confirmatory factor analysis yielded fit index values demonstrating viability of a 2-factor, oblique, solution composed of sensory and affective latent constructs. These findings were consistent with previous work and the theoretic constructs. Second, results from a relatively new model consisting of 8 SF-MPQ items demonstrated potential viability for measuring similar constructs.