Collaborative interventions for physically injured trauma survivors: a pilot randomized effectiveness trial

Collaborative interventions for physically injured trauma survivors:a pilot randomized effectiveness trial

Douglas F. Zatzick, M.D.a,b,*, Peter Roy-Byrne, M.D.a, Joan E. Russo, Ph.D.a,Frederick P. Rivara, M.D., MPHb, Alan Koike, M.D.c, Gregory J. Jurkovich, M.D.b,

Wayne Katon, M.D.a

aDepartment of Psychiatry and Behavioral Science, University of Washington School of Medicine, Box 359911, Seattle, WA 98104, USAbHarborview Injury Prevention and Research Center, 325 Ninth Avenue, Seattle, WA 98104, USA

cDepartment of Psychiatry, University of California–Davis, Davis, CA, USA

Abstract

Posttraumatic behavioral and emotional disturbances occur frequently among physically injured hospitalized trauma survivors. Thisinvestigation was a pilot randomized effectiveness trial of a 4-month collaborative care intervention for injured motor vehicle crash andassault victims. As surgical inpatients, intervention subjects (N516) were assigned to a trauma support specialist who provided counseling,consulted with surgical and primary care providers, and attempted postdischarge care coordination. Control subjects (N518) received usualposttraumatic care. For all participants, posttraumatic stress disorder (PTSD) and depressive symptoms, episodic alcohol intoxication, andfunctional limitations were evaluated during the hospitalization and 1 and 4 months postinjury. Study logs and field notes revealed that over75% of intervention activity occurred in the first month after the trauma. One-month post-trauma intervention subjects when compared tocontrols demonstrated statistically significant decreases in PTSD symptoms as well as a reduction in depressive symptoms. However, at the4-month assessment, intervention subjects evidenced no significant improvements in PTSD and depressive symptoms, episodic alcoholintoxication, or functional limitations. Future larger scale trials of stepped collaborative care interventions for physically injured traumasurvivors are recommended. © 2001 Elsevier Science Inc. All rights reserved.

Keywords:Collaborative care; Posttraumatic stress disorder; Physical injury; Randomized trial; Trauma surgery

1. Introduction

Over the course of their lifetimes, between 7–15% ofAmericans will experience a serious physical assault, and14–28% of Americans will experience a life-threateningaccident [1–3]. Each year, 2.5 million Americans incurinjuries so severe that they require inpatient hospitalization[4–6].

There is increasing evidence that psychiatric disordersoccur frequently among hospitalized injured trauma survi-vors [7]. In the weeks and months after a hospitalization,10–40% of traumatically injured patients may go on todevelop posttraumatic stress disorder (PTSD) and depres-sion [8–13]. In trauma survivors, PTSD and depression areassociated with enduring functional impairment and dimin-ished quality of life above and beyond the contribution of

co-morbid physical injury and medical conditions [12,14,15].

A growing body of efficacy research suggests that indi-viduals with posttraumatic psychological symptoms mayrespond to psychotherapeutic and psychopharmacologicaltreatments [16–20]. Guidelines based on this body of effi-cacy research have been formulated [21,22]. These algo-rithms, however, have yet to be translated to the “realworld” treatment of hospitalized physically injured traumasurvivors.

Three issues arise in the application of this body ofefficacy research to the treatment of trauma survivors hos-pitalized in surgical wards. First, efficacy studies conductedunder best-practice conditions assume that well-developedclinical infrastructures exist for the delivery of psychother-apeutic and psychopharmacological interventions. How-ever, little clinical infrastructure exists to facilitate the trans-lation of efficacious interventions for patients withtraumatic injuries [23] and few trauma surgery inpatientswith high levels of posttraumatic psychological distress

* Corresponding author. Tel.:11-206-341-4209; fax:11-206-731-3236.

E-mail address: [email protected] (D.F. Zatzick).

General Hospital Psychiatry 23 (2001) 114–123

0163-8343/01/$ – see front matter © 2001 Elsevier Science Inc. All rights reserved.PII: S0163-8343(01)00140-2

receive comprehensive mental health assessments or refer-rals [7,24–26]. Also, continuity of care and care coordina-tion may be problematic as physically injured patients tran-sition from inpatient wards to outpatient follow-up andcommunity rehabilitation [23].

Second, between 20–55% of patients hospitalized ontrauma surgery services suffer from comorbid substanceabuse or dependence [27–29]. A single effectiveness trial ofmotivational interviewing suggests that this intervention canreduce alcohol consumption and injury recurrence amonghospitalized trauma survivors [30]. Clinical guidelines de-veloped for the treatment of PTSD acknowledge the com-plexities of addressing substance-related comorbidity [21,22]. A literature review, however, revealed no clinicaleffectiveness trials that have targeted both posttraumaticdistress and comorbid substance abuse symptoms in injuredtrauma survivors.

Finally, PTSD and related comorbidities occur within thebroader context of trauma survivors’ posttraumatic illnessexperience [13]. Physically injured trauma survivors ex-press multiple financial, social, legal and health relatedconcerns; these concerns appear to evolve over the course ofposttraumatic recovery [13]. Recent re-conceptualizationsof the patient-physician relationship suggest that a “patient-centered” approach to treatment that incorporates patients’perspectives is an inherent goal of clinical medicine [31–33].

Previous investigation suggests that collaborative inter-ventions can improve clinical outcomes for patients withcomplex, comorbid presentations, while flexibly integratingpatients’ perspectives into the delivery of care [34,35]. Col-laborative care is a disease management strategy that seeksto find the optimal roles for primary care providers, special-ists and allied health professionals in the delivery of care forpatients with chronic conditions and psychiatric disorders.Essential elements of collaborative care include the provi-sion of medical support services such as case management,active sustained follow-up that promotes continuity of caredelivery, and shared patient-provider treatment planning.Collaborative interventions typically employ multifacetedtreatments (e.g., combining psychopharmacological andpsychotherapeutic interventions). Recent randomized clini-cal trials have documented the effectiveness of collaborativecare models for patients with depressive and anxiety disor-ders in primary care [36–38].

The goal of this investigation was to develop and imple-ment a collaborative intervention that targeted the spectrumof posttraumatic behavioral and emotional disturbances af-flicting physically injured trauma survivors. The pilot studyaimed to establish the feasibility of delivering the interven-tion and assessing outcomes in surgical wards and outpa-tient settings. Because of the novelty of the intervention andthe few detailed accounts characterizing inpatient traumasurgical and outpatient posttraumatic health service deliv-ery, the investigation employed descriptive methods in or-der to better depict the processes of care associated with the

pilot intervention [39]. The effectiveness of the collabora-tive intervention was tested in a randomized design thatcompared intervention patients with control subjects receiv-ing usual posttraumatic care.

2. Methods

2.1. Participants and procedure

The UC Davis Medical Center is the only level I traumacenter in inland Northern California. Between 2,500–3,000physically injured trauma survivors are admitted to thetrauma surgery service each year. Approximately 70% ofpatients admitted are victims of motor vehicle crashes (i.e.,automobile, motorcycle, bicycle or pedestrian versus mo-torized vehicle) or violent assaults (i.e., stabbings, gunshots,or physical assault).

Patients included in the study were hospitalized motorvehicle crash or assault survivors between the ages of 14–65, who were English speaking. Adolescent patients wereincluded in this effectiveness trial as they are routinelyhospitalized with adults on the UC Davis trauma surgicalservice. Patients who sustained severe injuries (i.e., Maxi-mum Abbreviated Injury Scale (AIS) score$5 [40]), wereexcluded from the protocol.

All informed consent procedures were approved by theUC Davis Institutional Review Board prior to the studyinitiation, and all patients recruited into the protocol gavetheir informed consent. The consent form described thestudy in detail, including the 4-month duration of the inter-vention.

On weekdays over a 4-month period, research associatesreviewed the list of all newly admitted patients to the UCDavis trauma surgery service. Potential subjects were ran-domly selected for approach by the research associate usingnumerical assignments derived from a random numberstable.

A total of 105 patients were assessed for study partici-pation (Fig. 1). Of the 57 patients approached for the pro-tocol, 8 patients refused participation. Eleven subjects com-pleted the interview but were discharged before they couldbe enrolled in the clinical trial. The 11 patients dischargedprior to randomization had decreased total hospital lengthsof stay (LOS) (Mean LOS53.6, SD51.96), when comparedto control (Mean LOS55.6, SD510.6) and intervention(Mean LOS510.6, SD59.9) subjects. There were no sig-nificant differences in age [F(1,43)5 0.001,P5.97], gender[x2(2)5 1.0, P5.60], or injury type [x2(2)5.73, P5.69]between the 34 patients enrolled in the intervention trial andthe 11 patients who were discharged prior to randomization.The investigation achieved over 75% 4-month follow-upand 88% of patients had data from at least two time points.

Thirty-four subjects were randomized; 16 subjects wereassigned to the collaborative care intervention, and 18 sub-jects were assigned to the usual care control. Random group

115Zatzick et al. / General Hospital Psychiatry 23 (2001) 114–123

assignments were allocated in the following manner. Whenresearch associates completed enrolling a new surgical in-patient into the study they notified the project’s researchcoordinator. The project coordinator independently random-ized new patients in blocks of six to the intervention orcontrol group, thereby ensuring that research associatesconducting follow-up telephone interviews remainedblinded to patient group assignments. When a new inter-vention patient was recruited into the study, the projectcoordinator notified the trauma support specialist by pager.

2.2. Intervention development and implementation

Collaborative interventions characteristically combinecontinuous medical support services with active sustainedfollow-up and shared patient-provider treatment planning.On the surgical ward each patient was assigned to a traumasupport specialist who met each intervention patient at the

bedside. The trauma support specialists were instructed todevelop a therapeutic relationship and follow patients for 4months through primary care outpatient appointments andcommunity rehabilitation. Three clinicians with advanceddegrees and extensive experience with the surgical inpatienttreatment milieu (i.e., two consultation liaison psychiatristsand one trauma clinical nurse specialist) volunteered theirtime as the trauma support specialists for the pilot study.

To establish a basis for collaborative problem definitionand shared patient-provider treatment planning, the traumasupport specialists were instructed to elicit and track pa-tients’ posttraumatic concerns [13]. Thus on the surgicalward and at follow-up interviews patients were asked, “Ofall the things that have happened to you since you wereinjured, what concerns you the most?” Patients’ posttrau-matic concerns were incorporated into joint problem defi-nition and the trauma support specialists were instructed tointervene on behalf of the patients in the resolution of these

Fig. 1. Patient flow through protocol.

116 Zatzick et al. / General Hospital Psychiatry 23 (2001) 114–123

concerns whenever possible. For instance, if pain was apatient’s primary concern on the surgical ward then thetrauma support specialist would engage the patient’s wardnurse or inpatient surgical team in a collaborative efforttargeting pain control.

A psychotherapy module specifically targeting posttrau-matic distress and substance use was also developed as partof the multifaceted collaborative intervention. The traumasupport specialists received a 4 htraining in brief, psycho-educational interventions targeting PTSD symptoms andmotivational enhancement techniques targeting alcohol anddrug use [41–45]. A consultant provided initial didacticinstruction in these specific intervention techniques andsubsequently observed and critiqued the trauma supportspecialists’ implementation of the interventions with hospi-talized patients. The psychoeducational component of theintervention began with a review of the traumatic event,followed by a discussion of related emotions, cognitions,and possible future posttraumatic symptoms, and closedwith suggested coping strategies including algorithms forcontacting the support specialist. The motivational enhance-ment techniques focused on the evaluation of readiness tochange and implementation of a motivational interview tar-geting posttraumatic alcohol and drug use.

The trauma support specialists were instructed to main-tain detailed logs and field notes in order to document thespectrum of collaborative intervention activity [46]. Thesedata were presented to and reviewed by other members ofthe multidisciplinary intervention team during weekly caseconferences.

2.3. Interview administration and measures

All 34 participants were administered a 1-h interviewwhile hospitalized. Patients were re-interviewed over thetelephone at 1 month, and 4 months, after the traumaticinjury. The interviews included questions regarding pa-tients’ sociodemographic characteristics, prior trauma, cur-rent psychological distress, substance use and functionalstatus.

2.3.1. Posttraumatic stress disorder symptomsLevels of PTSD symptoms were assessed using the ci-

vilian version of the Post-Traumatic Stress Disorder Check-list (PCL-C) [47]. The PCL-C is a 17-item self-report ques-tionnaire that elicits graded responses [1–5] for theintrusive, avoidant, and arousal PTSD symptom clusters.Responses are recorded on a scale from “not at all” (1) to“extremely” (5). To assess PTSD symptom levels amongphysically injured inpatients, we modified the surgical wardadministration of the measure by asking hospitalized sub-jects, “How bothered have you been by these experiencessince the event that brought you to the hospital.” In a studyof motor vehicle crash survivors, Blanchard et al. [48]reported a correlation of 0.93 between PCL total score andthe Clinician-Administered PTSD Scale (CAPS); Blanchard

et al., report that a cutoff score of 45 or greater has asensitivity of 0.95 and specificity of 0.86 when compared tothe CAPS. The instrument has been used in an interviewformat with medically ill breast cancer patients [49].

2.3.2. Depressive symptomsWe used the Center for Epidemiological Studies Depres-

sion Scale (CES-D), a 20-item self-report instrument tomeasure levels of depressive symptoms [50]). The measurehas good internal consistency and convergent validity [50]and CES-D has been used in an interview format amonghospitalized stroke survivors [51]. Response format is afour-point scale (0–3) used to indicate frequency of expe-riencing symptoms in the past week; responses range from“rarely or none of the time” (less than one day) to “most orall of the time” (5–7 days. A score of 16 or greater has beensuggested as cutoff indicative of high depressive symptomlevels [52].

In the current investigation, the scale was modified so asto assess patients’ posttraumatic depressive symptoms. Inthe surgical ward, patients were asked “How often you havefelt this way since the event that brought you to the hospi-tal?” At the 1-month and 4-month assessment points, par-ticipants were asked “how often have you felt this wayduring the past month?” In a subsample of patients themodified (past month) and standard (past week) versions ofthe CES-D were administered during the same telephoneinterview. The two versions of the scale were correlated atthe r5.79 level.

2.3.3. Peritraumatic dissociationThe Peritraumatic Dissociative Experiences Question-

naire (PDEQ) measures dissociative experiences at the timeof the traumatic event [53]. We used the 8-item interviewversion of the instrument that includes experiences ofchange in sense of time, feelings of unreality, and feelingsof disorientation. Across several studies, the measure hasbeen demonstrated to be internally consistent and evidencesupports its convergent, discriminant, and predictive valid-ity [54].

2.3.4. Prior traumaTo assess prior traumatic life events we used a modified

version of the traumatic event inventory that accompaniesthe Composite International Diagnostic Interview (CIDI),PTSD module as developed for the National ComorbiditySurvey (NCS) [3]. Participants are asked if any of a seriesof traumatic events have ever happened to them. We mod-ified the inventory by asking “For each event, please tell meif it has happened to you before the event in which you wereinjured.”

2.3.5. Alcohol and drug useAlcohol and drug use at the time of the traumatic event

was assessed with blood alcohol and urine toxicologyscreens. Because alcohol intoxication is a risk factor for


recurrent traumatic injury [55,56], we assessed patient self-reports of drinking to the point of intoxication. A singlequestion from the Addiction Severity Index (ASI), [57] wasmodified to read “How many days in the past 30 have youdrank enough to feel the effects, that is three or more drinksat one sitting?” Because responses to this variable werehighly positively skewed, we dichotomized the responsesinto “any days,” versus “no days,” of drinking to the pointof intoxication in the past month.

2.3.6. Functional limitationsLimitations in physical functioning were assessed with a

modified version of the Physical Components Summary(PCS) of the Medical Outcomes Study 12-Item Short-FormHealth Survey (also see reference [13]). The 12 item PCShas established reliability and validity [58].

2.3.7. Injury severityInjury severity was abstracted from surgical records us-

ing a conversion software program [59] that transformsrecognized International Classification of Disease NinthVersion Clinical Modification (ICD-9CM) codes into Ab-breviated Injury Scale (AIS) and subsequently injury sever-ity scores (ISS) [40]. The AIS is a numerical scale rangingfrom 0 (no injury) to 6 (severe injury with high likelihood offatality). The ISS is defined as the sum of squares of thehighest AIS score in each of the three most severely injuredbody regions [59].

2.3.8. Social supportEight items from the Medical Outcomes Study (MOS)

Social Support Survey [60] were used to assess 5 domainsof social support: emotional support, tangible support, feed-back and guidance, evaluative support, and companionshipin leisure and recreational activities.

2.4. Statistical analyses

The main outcome variables assessed were PTSD(PCL-C) and depressive (CES-D) symptoms, at risk drink-ing (ASI), and physical functioning (PCS). Outcome anal-yses were conducted for the both the intent-to-treat sampleof 34 subjects and for those subjects with complete data oneach outcome measure at all time points.

For PCL-C, CES-D, and PCS scores, the hypothesizedeffect of the intervention was tested through a mixed modelrepeated measures analysis of covariance (ANCOVAs) thatcompared mean scores on the scales across groups and atsuccessive time points. When significant group by timeinteractions resulted, post hoc ANCOVAs on the changescores were computed. A literature review suggested thatage, gender, injury severity, and admission alcohol anddrug toxicology screen results should be included in theANCOVA analyses as covariates. We used thex2 statisticand Fisher’s Exact Test to assess for group differences inself-reports of drinking alcohol to the point of intoxication.

All statistical analyses were performed with the SPSS ver-sion 10.0 software (SPSS, INC.).

3. Results

3.1. Characteristics of the sample

The intervention and control groups did not significantlydiffer on demographic, injury or clinical characteristics atthe time of the surgical ward interview (Table 1). Thirty onepercent of patients in the intervention group and 22% ofpatients in the control group were admitted after violentassaults with the remainder of patients in both groups beingadmitted after motor vehicle crashes.

Both intervention and control subjects demonstrated highlevels of PTSD and depressive symptom levels while hos-pitalized. Approximately 20% of hospitalized inpatients(N57) had PCL-C scores$45 while 79% (N527) of pa-tients had CES-D scores of$16. Patients’ surgical wardPTSD and depressive symptom levels were highly corre-lated (r5.70, P,.001). Forty-seven percent of patientsscreened positive on admission for alcohol and/or stimulantintoxication.

3.1.1. Qualitative Description of the InterventionTrauma support specialists spent an average of 92 min

(standard deviation554 min) per patient delivering the in-tervention over the course of the 4-month study (Table 2).Examination of trauma support specialist’s logs and fieldnotes revealed that 75% of the patient contact occurredbetween hospital admission and 1 month follow-up, while25% of patient contact occurred between 1 and 4 months.Virtually all of the surgical ward contact occurred as face toface counseling while after hospital discharge the vast ma-jority of contacts were over the telephone with the patient,family members and surgical and primary care providers.Review of study logs and field notes revealed that patients’posttraumatic concerns were frequently discussed duringmultidisciplinary team meetings and targeted for ameliora-tion by the trauma support specialists.

There were some difficulties implementing the collabo-rative care principles of continuous case management andactive sustained follow-up. For instance, patients with noinsurance often required intensive service coordination ef-forts targeting linkage with community agencies. Becausethese activities required time availability and flexibility ofscheduling that taxed the abilities of the highly trained,hospital based case managers, these efforts to insure conti-nuity of care frequently fell short.

3.1.2. Quantitative comparisons of the intervention andcontrol groups

Comparisons of PTSD symptom levels between the in-tervention and control groups reflected the variations in theintensity of the intervention (Fig. 2). Repeated measures


analysis of covariance revealed a significant group by timeinteraction in the intent to treat [F(2,54)5 4.5,P,.05] andcompleter [F(2,30)5 6.7, P,.01] analyses. A significantgroup effect of gender, with women demonstrating greatersymptom levels than men, [intent to treat; F(1,27)5 6.6,P,.05: completer F(1,15)5 4.9, P,.05] was also ob-served. There were no significant main effects for age,injury severity, or admission blood alcohol or urine toxicol-ogy screens.

Posthoc ANCOVA analyses of the intent to treat samplerevealed two distinct time trends in PTSD symptom levels.From the time of the surgical ward admission through the

1-month follow-up, intervention subjects had significantlydecreased PTSD symptoms when compared to controls[F(1,33)5 6.8,P,.05: effect size5.99]. From the 1-monththrough the 4-month follow-up assessments, interventionpatients’ symptoms significantly increased relative to con-trols [F(1,27)5 6.1, P,.05: effect size51.75]. These re-sults did not vary substantially for the completer sample.

Comparisons of depressive symptom levels between theintervention and control groups revealed similar results(Fig. 3). The ANCOVA yielded a significant group by timeinteraction in the intent to treat [F(2,54)5 3.6,P,.05] andcompleter [F(2,32)5 5.4, P,.05] samples. There was a

Table 1Baseline demographic, injury, and clinical characteristics of patients randomized to collaborative care vs. usual care control

Characteristic Intervention(N 5 16)

Control(N 5 18)

Test statistic P

DemographicsAge (Mean, 50) 35.3 (11.2) 32.5 (13.0) t (32)5 .5 n.s.Gender (% female) 50% 33% x2 (1) 5 1.0 n.s.Education# high school 50% 67% x2 (1) 5 1.0 n.s.Income# $15,000 47% 63% x2 (1) 5 .8 n.s.White 63% 61% x2 (1) 5 0.1 n.s.Live alone (Yes, %) 44% 56% x2 (1) 5 .5 n.s.Social support 3.9 (.8) 3.6 (1.1) t (31)5 1.1 n.s.

InjuryType: motor vehicle crash (%) 69% 78% FET n.s.Severity: ISS (Mean, SD) 9.2 (6.0) 8.7 (7.0) t (32)5 .2 n.s.

ClinicalPrior trauma (CIDI) 4.1 (2.4) 4.1 (2.5) t (32)5 2.1 n.s.PCL-C 38.8 (14.7) 34.0 (8.5) t (31)5 1.5 n.s.CES-D 28.4 (12.0) 24.4 (9.4) t (32)5 1.1 n.s.PDEQ 1.6 (.6) 1.7 (.7) t (29)5 2.2 n.s.Admit blood alcohol (% positive) 13% 33% FET n.s.Admit urine toxicology (% positive) 31% 22% FET n.s.PCS 50.4 (11.8) 53.1 (8.8) t (32)5 2.8 n.s.One or more medical conditions 13% 6% FET n.s.Inpatient length of stay (days) 10.6 (9.9) 5.6 (4.7) t (32)5 2.1a 0.04Days on surgical ward prior to

study enrollment4.7 (3.4) 3.1 (1.9) t (32)5 1.4a n.s.

Social Support5 Medical Outcomes Study Social Support Scale; ISS5 Injury Severity Score; CIDI5 Composite International Diagnostic Interview;PCL-C 5 Posttraumatic Stress Disorders Checklist; CES-D5 Center for Epidemiological Studies Scale; PDEQ5 Peritraumatic Dissociative ExperiencesQuestionnaire; PCS5 Medical Outcomes Study 12-Item Short Form Physical Components Summary. Urine toxicology positive includes patients positivefor stimulants (cocaine or amphetamine).

a Hospital days are log transformed for these analyses.

Table 2Breakdown of collaborative care activity by time period post-injury

Category Surgical ward Ward dischargethrough 1 monthfollow-up

1 month follow-upthrough 4 monthfollow-up

Total time per patient (minutes: mean and standard deviation) 52 (37) 20 (23) 20 (25)Collaborative care activity (% total time)

Direct patient contact 91% 56% 84%Family contact 6% 21% 9%Interactions with care providers 5% 16% 2%Outreach and tracking — 7% 5%

Number of contacts (median, range) 1 (1–7) 2 (0–7) 2 (0–7)


significant group effect for gender in the intent to treat[women . men, F(1,27) 5 7.5, P,.05] but not thecompleter [F(1,16)5 2.7, P5.12] sample. The time trendsfor depressive symptoms also resembled the trajectories ofPTSD symptoms (Fig. 3), [Surgical ward to 1 monthANCOVA intent to Treat F(1,33)5 3.7, P5.07: effectsize50.58: completer F(1,18) 5 7 P,.05; effectsize50.58], [1 month to 4 month ANCOVA intent to treatF(1,33) 5 6.8, P,.05; effect size51.15: completerF(1,18)5 5.1, P,.05; effect size51.44].

Repeated measures ANCOVA comparing the interven-tion and control groups’ PCS scores revealed a significanteffect of time, [intent to treat; F(2,54)5 3.6, P,.05: com-pleter F(2,32)5 4.7, P,.05] but no other main effects orinteractions. Also, no significant differences were foundwhen the two groups were compared with regard to drinkingto the point of intoxication.

To assess meaningful clinical changes we compared thedevelopment of PTSD in intervention and control subjectswho completed the study (Fig. 4). Five intervention subjectscompared to two controls had high PTSD symptom levelson the surgical ward, while seven intervention subjects and12 controls had low symptom levels. Two interventionpatients (one with a high ward PCL-C score, and one witha low PCL-C score) met symptomatic criteria for PTSD

over the course of the 4-month study. However, both controlsubjects with high ward PCL-C scores met symptomaticcriteria for PTSD, as did four of the 12 control subjects withlow PCL-C scores. Although clinically informative, thesegroup comparisons did not achieve statistical significance.

4. Discussion

The goal of this pilot intervention was to obtain data onthe feasibility and impact of delivering a multifaceted col-laborative intervention to acutely injured trauma survivors.Standardized assessment instruments were successfullyused to screen and follow posttraumatic symptomatic dis-tress, at risk drinking and functional impairment in a ran-domly selected cohort of hospitalized, physically injuredtrauma survivors. Inpatient trauma survivors manifestedhigh levels of symptomatic distress and substance intoxica-tion at the time of the surgical ward admission.

The collaborative care intervention significantly de-creased PTSD and depressive symptoms in the first monthafter the trauma. These statistically significant symptomaticimprovements were not maintained at the final 4-monthevaluation. However, the intervention appeared to be suc-cessful in both preventing the development of symptomaticdistress consistent with a diagnosis of PTSD and in reducingclinically significant distress in patients with initial highsymptom levels. There was no evidence that the interven-tion impacted posttraumatic functional limitations or pat-terns of alcohol consumption.

Fig. 2. Mean adjusted posttraumatic stress disorder checklist (PCL-C)scores for intervention (N516) and control (N518) patients. Scores areadjusted for injury severity, age, gender, and surgical inpatient bloodalcohol and urine toxicology screen results.

Fig. 3. Mean adjusted Center for Epidemiologic Studies Depression Scale(CES-D) scores for intervention (N516) and control (N518) patients.Scores are adjusted for injury severity, age, gender, and surgical inpatientblood alcohol and urine toxicology screen results.

Fig. 4. The development of symptoms consistent with a diagnosis ofposttraumatic stress disorder in intervention and control patients. Highward PTSD corresponds to PCL-C scale scores of$45 [48]. PTSD at the1- and 4- month assessments corresponds to DSM-IV intrusive, avoidant,and arousal symptom criteria.


The observed reduction and subsequent recurrence oftrauma survivors’ PTSD and depressive symptoms followedthe temporal “dosing” of the collaborative intervention. Thehospital-based interventionists were able to provide eachpatient with active sustained inpatient contact and telephonefollow-up in the days and weeks immediately following theinjury. The limitation of the hospital-based interventionbecame apparent after the first month postinjury, whencontinuous follow-up could no longer be achieved andsymptomatic distress in the intervention group recurred.These observations are consistent with the results of previ-ous collaborative intervention trials that have describedsymptomatic recurrences in depressed patients in the ab-sence of treatment maintenance protocols [37].

These results contribute to the developing literature re-garding acute interventions for the treatment of psycholog-ical distress among trauma survivors. Psychological de-briefing involves emotional processing and review of atrauma during a circumscribed time period shortly after theevent has occurred. To date the results of randomized trialsof debriefing have been mixed, with reports of worse acuteand long-term psychological outcomes among patients re-ceiving the debriefing intervention [61]. The current collab-orative intervention differed from trials of debriefing in thattrauma support specialists established an ongoing relation-ship with patients. Thus, a discussion and review of thetrauma was an optional aspect of the intervention that couldevolve over the weeks and months after the event. Futuretrials of collaborative interventions should document therelational processes through which patients and providerscome to a shared agreement regarding the appropriate tim-ing of traumatic catharsis and review.

Cognitive behavioral therapists have delivered 4–5 ses-sion (7–8 h) psychotherapy interventions to select samplesof trauma survivors in outpatient mental health settings[62,63]. The current effectiveness trial differs from theseinvestigations in that a random sampling strategy was em-ployed to select a representative sample of patients from apopulation of hospitalized trauma survivors. Patients withalcohol and drug related comorbidities were included in thecurrent trial. Also, the trauma support specialists in thecurrent study spent on average 1.5 h with each patient.

Of note, one previous trial of a 3-month supportivecounseling intervention for male motor vehicle crash survi-vors reported significant symptomatic and functional im-provement in intervention patients [64]. The collaborativeintervention differed from supportive counseling in that itincorporated psychotherapeutic treatment modules that spe-cifically targeted PTSD and substance abuse comorbidities.

There are a number of important considerations in inter-preting the results of this investigation. The sample size inthis pilot investigation was small and the results will requirereplication in a larger trial. There may not have been enoughpower to detect differences in the intervention and controlgroups for the alcohol and functional outcomes. The col-laborative intervention was not manualized and therefore

was likely to be implemented with marked variability acrosstrauma support specialists.

Taken together, these limitations and results suggest thathospital based care delivered by highly trained professionalsmay not be of long enough duration or great enough inten-sity, to effect lasting therapeutic change in this population.Full-time masters level clinicians with the ability topromptly attend to surgical inpatients, as well as maintainfollow-up in the community should be introduced into thetrauma support specialist role.

Future larger trials may also need to incorporate astepped approach to the delivery of collaborative care. Priorlongitudinal descriptive investigations suggests that PTSDand depressive symptoms may spontaneously decrease in aless severely afflicted subsample of physically injuredtrauma survivors [9,10,13]. In the stepped approach, inter-vention resources are allocated at gradually increasing“doses” to patients whose symptoms do not remit afterinitial low intensity evaluation and treatment. Stepped pro-tocols may also need to incorporate a psychopharmacolog-ical treatment component for patients who prefer medica-tions and/or whose symptoms do not spontaneously remit.The stepped approach to collaborative intervention wouldalso mandate that future intervention trials include a cost-effectiveness component, so as to inform policy discussionregarding the adoption and dissemination of the interventionmodel across trauma centers [7,65].

This study contributes to an evolving body of literaturethat suggests that clinical ethnographic methods [66] canprovide a rich source of explanatory information regardingmental health outcome and intervention assessments devel-oped for novel service delivery contexts [13,39,67]. Theinformation derived from trauma support specialists’ logsand field notes may ultimately inform the development ofmanualized collaborative care interventions targeting pa-tients, providers and systems of posttraumatic health caredelivery.

In summary, no organized service delivery system existsfor physically injured trauma survivors suffering from post-traumatic behavioral and emotional disturbances. The re-sults of this investigation suggest that collaborative inter-ventions may hold promise for reducing posttraumaticsymptomatic distress. Future investigations should developand test high quality, cost-effective, stepped collaborativecare interventions that target symptomatic and functionalimpairments among injured trauma survivors.

Acknowlegments

The authors would like to thank Carol Franz, Ph.D.,Leanne Le, B.A. and Sarah Barry, B.A. for assistance withthe data collection, Sun-Mee Kang, MS for assistance withthe data analyses and Barbara MacCalla for her graphicaland editorial assistance with the final manuscript. This re-search was funded in part by grants from the UC Davis


Hibbard E. Williams Award Research Fund and NationalInstitute of Mental Health grant number 1K08 MH01610.

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Collaborative interventions for physically injured trauma survivors: a pilot randomized effectiveness trial