Kate Johnson

April 18, 2012

April 18, 2012 (Arlington, Virginia) — Immediate psychiatric therapy for trauma patients in the emergency department (ED) may decrease the emergence of posttraumatic stress disorder (PTSD) and appears to be most effective in sexual assault victims, new research shows.

Presented here at the Anxiety Disorders Association of America (ADAA) 32nd Annual Conference, a study by investigators from Emory University in Atlanta, Georgia, showed that trauma patients who received emergency psychiatric treatment had fewer PTSD symptoms at 3 months than their counterparts who received a basic assessment.

"This is something we want to be able to transport and use wherever traumas occur and before people sleep on it — in theater, at emergencies and disasters," said Barbara Olasov Rothbaum, PhD, director of the Trauma and Anxiety Recovery Program and professor of psychiatry at Emory University School of Medicine.

"The clinical war is until you sleep on it," she explained. "We know that memories are consolidated when you sleep, so we wanted to try and catch people before."

3-Part Therapy

In the study, 137 trauma patients who presented at a level 1 trauma center were randomly assigned to receive either basic assessment of injuries (n = 68) or assessment plus a psychiatric intervention aimed at preventing the development of PTSD (n = 69).

The intervention consisted of what Dr. Rothbaum called 3 modified exposure therapies: the first one when they came into the ED, the second one 1 week later, and the final one another week later.

In the initial session, "we asked people to go back to the traumatic event, to go through it in their mind's eye and recount it out loud over and over. We tape-recorded it, and we gave them that tape to listen to. All of this happened very quickly, in about an hour, because they had already been in the ER [emergency room] for a long time and just want to go home," she said.

At this session, participants were also given an exercise to help them to process the information.

"We tried to identify some unhelpful thoughts that they might be having and work on correcting those. We helped them anticipate any avoidance — for example, if they were in a motor vehicle collision, maybe they don't want to drive again."

Home exercises were assigned and were repeated during sessions 2 and 3.

12-Week Follow-up

About two thirds of the patients in the study were women and black. The mean age was in the early 30's, said Dr. Rothbaum.

Roughly one third of the cohort consisted of rape victims, one third had been involved in motor vehicle accidents, and the final third were victims of nonsexual assault.

Patients in the intervention arm received the intervention a median of 7 hours after their trauma.

For all patients, the immediate ED assessment included the Beck Depression Inventory (BDI) and the Posttraumatic Diagnostic Scale (PDS) to assess the impact of prior traumas in their life.

"This is a multiply traumatized population, so we wanted to try to tease out PTSD to what we call the 'index' trauma that brought them into the ER, vs PTSD to prior trauma," she said.

"We did not assess PTSD [to the index trauma] when they first presented — I don't think that's valid to say somebody had PTSD within hours of a traumatic event."

Instead, the posttraumatic symptom scale (PSS-1), used to assess PTSD to the index trauma, was administered at the 4-week and 12-week follow-up sessions.

Significant Difference

The study showed that at baseline, BDI scores were similar in both groups (18.6 in the intervention group; 21.3 in the assessment group), as were PDS scores (18.9 and 19.5, respectively).

However, 4 weeks later, the BDI score had dropped in the intervention group (15.04), although it remained stable in the assessment group (21.4), a significant difference (P < .01).

Similarly, at 4 weeks, the PDS score had worsened in the assessment group (23.8) but had remained stable in the intervention group (18.9), also a significant difference (P < .05).

Also at 4 weeks, PTSD symptoms to the index trauma, measured by PSS-1 score, were significantly higher in the assessment group compared with the intervention group (24.54 vs 19.09, P < .01). This pattern persisted at 12 weeks (20.33 vs 15.47, P < .05).

When patients were divided according to the type of trauma they had experienced, the effect of the intervention was most significant in sexual assault victims, both at week 4 (P < .01) and week 12 (P < .05).

"More of them are going end up with PTSD at week 4 and week 12 if they don't get the intervention," said Dr. Rothbaum.

A much smaller effect was seen in motor vehicle accident trauma at both periods (P = .06 and P = .43, respectively). "It doesn't look like much of an effect at all for folks in nonsexual, physical assaults," she said (P = .53 and P = .44).

Novel Approach

In light of the debate over potential risks of trauma debriefing, the findings are reassuring, said Dr. Rothbaum.

"In some of the studies looking at psychological debriefing, it looks like some of the folks that got it have been doing worse at follow-up, so I think it scared everybody off early interventions."

However, she added, there are differences between her study's intervention and traditional debriefings.

"It's individual, and usually debriefing is in the group setting. Sometimes in debriefings they make everybody talk even if they don't want to, and usually debriefing is once, and ours is 3 sessions with a lot of homework in between. Hopefully, it's the difference between a therapeutic exposure and something that might not be."

She said she expects hope one day to be able to collect a clinical profile of trauma victims that will use genetics, history, and neuroendocrine response to guide treatment.

"Just like you go to the emergency room with chest pain, they're going to take all of that into account to say, 'What's the best treatment for you?' We're not at that stage for traumatic exposure, but that's where I hope that we'll be."

Unanswered Questions

Asked to comment on the findings, the session's discussant, Terence Keane, PhD, professor and vice-chair of the Department of Psychiatry at Boston University School of Medicine in Massachusetts and director of behavioral science at National Center for PTSD, said there is little concern that the type of intervention in this study could be harmful in any way.

"The treatment is to help people in graduated ways to expose themselves to these things — to accommodate to the fear," he said in an interview with Medscape Medical News.

"There's really not a lot of question about will this be harmful, but there's a lot of questions about what's the long-term effect and when to do it and where to do it — whether it's in the ER, whether it's after they go back home."

"So the thinking here with the 3-session intervention is, can it catch people right at the beginning to prevent this disorder from cascading downhill and causing years of problems, and can it help them process this experience or this set of experiences, in a way that they can get on with their lives?"

Dr. Rothbaum and Dr. Keane have disclosed no relevant financial relationships.

Anxiety Disorders Association of America (ADAA) 32nd Annual Conference. Session 318R, presented April 13, 2012.

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