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Original Article |

A Randomized Effectiveness Trial of Stepped Collaborative Care forAcutely Injured Trauma Survivors FREE

Douglas Zatzick, MD; Peter Roy-Byrne, MD; Joan Russo, PhD; Frederick Rivara, MD, MPH; RoseAnne Droesch, MSW; Amy Wagner, PhD; Chris Dunn, PhD; Gregory Jurkovich, MD; Edwina Uehara, PhD; Wayne Katon, MD
[+] Author Affiliations

From the Departments of Psychiatry and Behavioral Sciences (Drs Zatzick,Roy-Byrne, Russo, Wagner, Dunn, and Katon), Pediatrics (Dr Rivara), and Surgery(Dr Jurkovich) and the Harborview Injury Prevention and Research Center (DrsZatzick, Rivara, and Jurkovich and Ms Droesch), University of Washington Schoolof Medicine, and the School of Social Work, University of Washington (Dr Uehara),Seattle.


Arch Gen Psychiatry. 2004;61(5):498-506. doi:10.1001/archpsyc.61.5.498.
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Published online

Context  Although posttraumatic stress disorder (PTSD) and alcohol abuse frequently occur among acutely injured trauma survivors, few real-world interventions have targeted these disorders.

Objective  We tested the effectiveness of a multifaceted collaborative care (CC) intervention for PTSD and alcohol abuse.

Design  Randomized effectiveness trial.

Participants  We recruited a population-based sample of 120 male and female injured surgical inpatients 18 or older at a level I trauma center.

Intervention  Patients were randomly assigned to the CC intervention (n = 59) or the usual care (UC) control condition (n = 61). The CC patients received stepped care that consisted of (1) continuous postinjury case management, (2) motivational interviews targeting alcohol abuse/dependence, and (3) evidence-based pharmacotherapy and/or cognitive behavioral therapy for patients with persistent PTSD at 3 months after injury.

Main Outcome Measures  We used the PTSD symptomatic criteria (PTSD Checklist) at baseline and 1, 3, 6, and 12 months after injury, and alcohol abuse/dependence (Composite International Diagnostic Interview) at baseline and 6 and 12 months after injury.

Results  Random-coefficient regression analyses demonstrated that over time, CC patients were significantly less symptomatic compared with UC patients with regard to PTSD (P = .01) and alcohol abuse/dependence (P = .048). The CC group demonstrated no difference (−0.07%; 95% confidence interval [CI], −4.2% to 4.3%) in the adjusted rates of change in PTSD from baseline to 12 months, whereas the UC group had a 6% increase (95% CI, 3.1%-9.3%) during the year. The CC group showed on average a decrease in the rate of alcohol abuse/dependence of −24.2% (95% CI, −19.9% to −28.6%), whereas the UC group had on average a 12.9% increase (95% CI, 8.2%-17.7%) during the year.

Conclusions  Early mental health care interventions can be feasibly and effectively delivered from trauma centers. Future investigations that refine routine acute care treatment procedures may improve the quality of mental health care for Americans injured in the wake of individual and mass trauma.

Figures in this Article

Injured survivors of individual and mass trauma receive their initialtreatment in acute care settings.1 Within 48hours after the September 11, 2001, attack on the World Trade Center, 1103physically injured survivors were triaged through 5 acute care facilitiesin Manhattan, NY.2 Each year approximately2.5 million Americans are so severely injured that they require inpatienthospital admission.3

Symptoms consistent with a diagnosis of posttraumatic stress disorder(PTSD) may develop in 10% to 40% of hospitalized injured patients in the UnitedStates.47 Approximately20% to 40% of injured patients admitted to trauma centers have current orlifetime alcohol abuse/dependence diagnoses.8 Alcoholintoxication at the time of injury is associated with an increased risk ofinjury recurrence.9

Efficacy research suggests that individuals with PTSD respond to psychotherapeuticand psychopharmacological treatments.1012 Growingrandomized clinical trial evidence suggests that early cognitive behaviortherapy (CBT) interventions delivered in the days and weeks after injury canhelp to diminish PTSD symptom development.1316 Selectiveserotonin reuptake inhibitors and tricyclic antidepressants are efficacioustreatments for PTSD.11,1721 Efficacystudies suggest that motivational interviewing (MI) interventions can decreasealcohol use across a variety of clinical populations,2225 includinginjured trauma survivors.26

Recent consensus guidelines from the National Institute of Mental Healthidentify acutely injured trauma survivors as a group at high risk for developmentof PTSD and related comorbid conditions and recommend the development of earlyevaluation procedures that are adaptable to real-world treatment settings.27 As is true for many Americans with psychiatric disorders,28 injured patients appear to receive fragmented care,and most are not engaged in mental health services at strategic postinjurypoints.29,30 Previous investigationsof psychological debriefing suggest that although this intervention may befeasibly delivered to representative samples of patients receiving acute care,31,32 debriefing interventions are noteffective in reducing PTSD symptoms and may actually be associated with pooreroutcomes.33,34

During the past decade, collaborative care (CC) has been developed asa comprehensive treatment delivery model for patients with medical and psychiatricdisorders.3543 Collaborativecare is a disease management strategy that uses multifaceted interventions(eg, combined case management, pharmacotherapy, and psychotherapy) with theaim of integrating mental health interventions into general medical care.Just as collaborative models have improved mental health outcomes for patientswith major depression and panic disorder in primary care, the introductionof CC interventions within trauma care systems may link acute injury carewith evidence-based mental health interventions. Collaborative interventionshave the potential to reduce posttraumatic symptoms and trauma recidivismwhile improving functional recovery.

We developed and tested a multifaceted CC intervention targeting PTSDand alcohol use for acutely injured trauma survivors. The primary hypothesiswas that patients receiving the CC intervention would demonstrate significantreductions in PTSD and alcohol abuse during the year after injury.

RESEARCH SETTING AND SUBJECTS

Subjects were recruited from the Harborview level I trauma center ofthe University of Washington, Seattle. Each year Harborview admits approximately5000 survivors of intentional (eg, injuries associated with human malice suchas physical assaults) and unintentional (eg, injuries associated with motorvehicle crashes and job-related injuries) injuries of all ages. Eligible patientswere English-speaking survivors of intentional and unintentional injuries,18 years and older, who lived within 50 miles of the trauma center. Harborviewtrauma registry data documenting injury, demographic, and clinical variableswere available for screening each patient admitted during the study period.The University of Washington institutional review board approved all traumaregistry analyses and informed consent procedures before the initiation ofthe study.

RECRUITMENT PROCEDURE

On weekdays from March 30, 2001, through January 10, 2002, a researchassociate downloaded an automated list of all injured patients admitted foracute injuries to Harborview's trauma surgical services. Eligible, newly admittedpatients were approached using random number assignments from a computer-generatedalgorithm. With regard to cognitive status, patients approached in the wardwere required to have a Glasgow Coma Scale score44 of15 and a score of at least 7 on the 2 Mini-Mental State Examination itemsthat assess orientation to location and date.45 Patientswith severe injuries that prevented participation were excluded from the study.Patients who had self-inflicted injuries or active psychosis, who were currentlyincarcerated, or who had recent histories of violence were also excluded.

Hospitalized inpatients received a 2-phased evaluation. First, we administeredthe PTSD Checklist Civilian Version (PCL)46 andthe Center for Epidemiological Studies Depression Scale (CES-D)47 toeach inpatient. We included patients in the study who were symptomatic withPTSD (PCL score, ≥45)48 and/or depression(CESD-D score, ≥16).49 Second, patientswho met symptomatic criteria for the study were administered the remainderof the surgical ward interview that consisted of the Composite InternationalDiagnostic Interview (CIDI) alcohol abuse/dependence modules50 andother items assessing various aspects of preevent- and event-related symptoms,functioning, and use of health care services.

Patients were randomized to the CC intervention or the usual care (UC)control condition immediately after completion of the surgical ward assessment.Randomization was stratified according to PTSD symptom levels (PCL score,≥45 vs <45), depressive symptom levels (CES-D score, ≥16 vs <16),and results of alcohol and stimulant admission toxicology (positive vs negative).

INTERVENTION

The CC intervention combined case management and psychopharmacologicaland psychotherapeutic treatments. The intervention team included a full-timemaster's level case manager, the trauma support specialist (TSS) (R.D.), andpart-time psychiatrist (D.Z.) and psychologist (A.W.) interventionists whodelivered the medication and CBT components. The intervention procedure hasbeen manualized, and the component modules have been published.5153

The intervention was designed as a stepped-care procedure. For the first6 months after injury, all CC patients received continuous case managementdelivered by the TSS. The TSS was the frontline provider in the treatmentof the injured CC patient and provided readily accessible, continuous traumasupport in the weeks and months after the injury.

The TSS began treatment with each injured CC patient at the bedsidein the surgical ward. Prior investigation suggested that case management facilitatedengagement in mental health intervention among ethnically diverse low-incomepatients.54 In previous studies, injured traumasurvivors demonstrated multiple posttraumatic concerns (eg, physical health,work, and finance) that extended beyond PTSD and alcohol-related symptoms.55,56 Thus, to engage injured patients,the TSS elicited, tracked, and targeted for improvement each injured patient'sunique constellation of posttraumatic concerns.

The TSS coordinated care across surgical inpatient, primary care outpatient,specialty mental health, and community service settings. With the other membersof the intervention team, the TSS developed a comprehensive postinjury careplan that simultaneously addressed the medical and psychosocial complicationsof the injury and coordinated linkages to primary care and community services.In these activities, the TSS interfaced with patients and their families,surgical and primary care providers, staff at community agencies, and outsidemental health care professionals. The case management pager was covered bymembers of the intervention team 24 hours a day, 7 days a week, to providecare that was responsive to the spontaneous questions and needs of injuredpatients.57 These combined trauma support activitiesestablished a therapeutic alliance that facilitated the delivery of evidence-basedinterventions for alcohol abuse and PTSD.

All patients with positive alcohol toxicology test results on admission,or who at any point during the trial demonstrated postinjury alcohol abusethat could be considered hazardous and risked injury recurrence, receivedthe evidence-based MI intervention.26,52,58 TheTSS was trained by the team's expert MI consultant (C.D.) to deliver MI targetingalcohol abuse in trauma wards.59 The MI interventionconsisted of an initial surgical ward session followed by as-needed boostersessions. The surgical ward session lasted approximately 30 minutes, and thefollow-up booster sessions had variable lengths ranging from 10 to 60 minutes.The intervention components included feedback about inpatient blood alcoholtoxicology test results, exploration of the pros and cons of alcohol consumption,discussion of the importance of change, clarification of specific goals foralcohol use, and negotiation of action plans to bring about change. Any patientwho requested MI booster sessions received them; patients who had exacerbationsof alcohol use were also offered booster sessions.

Patients who demonstrated high levels of immediate posttraumatic distress(eg, severe anxiety, pain, and/or insomnia) received early psychiatric evaluations.53 Because immediate posttraumatic distress can spontaneouslyresolve in the weeks and months after injury, only patients with sustainedhigh levels of early distress were offered evidence-based PTSD pharmacologicalinterventions (eg, selective serotonin reuptake inhibitors) in the first 3months after the event. Sustained high levels of distress were operationalizedas (1) objectively observed high levels of distress such as extreme emotionalreactions (eg, fear, rage, and dissociation) that lasted at least 24 hoursand were so severe as to limit verbal interchanges and/or (2) sustained subjectivedistress lasting days that prompted repetitive patient requests for more intensivetreatment. Based on these criteria, 4 (7%) of the 59 CC patients receivedPTSD pharmacological intervention before the 3-month postinjury time point.

Three months after the injury, each CC patient was administered theStructured Clinical Interview for DSM-IV PTSD moduleby the case manager.60 All patients who receiveda PTSD diagnosis at this assessment were given their preference of CBT, pharmacotherapy,or combined treatment. Evidence-based PTSD treatments were delivered by theteam's expert psychotherapy and pharmacotherapy consultants. The CBT interventionincluded psychoeducation, muscle relaxation, cognitive restructuring, andgraded exposure.13,51 The psychopharmacologicalintervention consisted of an initial psychiatric evaluation and medicationtargeting PTSD.61,62

When care for PTSD was stepped up at the 3-month postinjury point, theTSS provided education about the diagnosis and facilitated the entry of patientsinto evidence-based treatments. During the evidence-based PTSD intervention,the TSS had the key role of performing brief assessments of adherence to medicationtherapy and symptom relapse, outside scheduled psychotherapy or medicationsessions.

The stepped-care procedure included relapse prevention and communityintegration components. From 6 to 12 months after the injury, all patientswho remained symptomatic with PTSD and/or demonstrated evidence of alcoholabuse/dependence or alcohol consumption behaviors that risked injury recurrencereceived combinations of ongoing trauma support and evidence-based MI andPTSD treatments. In this phase of the protocol, the TSS remained in contactwith the patient and periodically reassessed symptoms, function, and rehabilitation.

The collaborative team members maintained detailed logs documentingthe nature and duration of all intervention activities.56 Thecollaborative team held weekly meetings to review cases and protocol procedures.

USUAL CARE

Patients assigned to the control condition received care as usual. Previousinvestigations have documented that injured trauma survivors typically receivecare from a heterogeneous group of clinicians including surgical practitioners,emergency department caregivers, and primary care providers.63 Acuteposttraumatic distress is infrequently detected and treated in the surgicalinpatient setting,64 and less than 15% of injuredtrauma survivors report receiving specialty mental health and/or substance-relatedcare during the year after injury.52,63 Inthis investigation all patients received a list of community referrals immediatelyafter their surgical ward assessment; 21% of UC controls (11 of the 53 withself-report health service utilization data) endorsed 1 or more visits withmental health specialty providers (ie, at the doctoral level) during the courseof the year after injury.

INTERVIEWS AND MEASURES

The principal investigator, a consultation liaison psychiatrist (D.Z.),oversaw the training procedure for the surgical ward and telephone follow-upinterviews. A research associate made morning rounds with the principal investigatorduring an initial 1-month pilot phase and then for the following 3 monthsof active protocol recruitment. During this period all recruitment, consent,and interview procedures were observed and critiqued by the principal investigator.Training of research associates for structured clinical assessments and telephoneinterviews included the use of practice interviews and manuals. These interviewswere monitored for reliability by the principal investigator and senior coinvestigators.

Posttraumatic Stress Disorder

Symptoms consistent with a diagnosis of PTSD were assessed with thePCL, a 17-item self-report questionnaire that elicits graded responses (range,1-5) for the intrusive, avoidant, and arousal PTSD symptom clusters.46 A series of investigations have demonstrated thereliability and validity of the PCL across trauma-exposed populations.46,48,6568

Responses are recorded on a scale from "not at all" (grade 1) through"moderately" (grade 3) to "extremely" (grade 5). Symptoms consistent withthe DSM-IV diagnosis were determined by adherenceto the recommended algorithm that considers a score of 3 or greater a symptomand follows the diagnostic rules requiring at least 1 intrusive symptom, 3avoidant symptoms, and 2 arousal symptoms.46,69 Symptomsof PTSD were assessed in reference to the index injury (eg, "How botheredhave you been by repeated, disturbing memories, thoughts, or images of theevent in which you were injured?"). We used the PCL to screen for symptomsin the surgical ward and to reassess for PTSD at the 1-, 3-, 6-, and 12-monthtelephone follow-up interviews.

Alcohol and Substance Use

The DSM-IV diagnoses of alcohol abuse and dependencewere assessed with the CIDI Alcohol module.70 TheCIDI, a structured diagnostic interview developed by the World Health Organizationand the US Alcohol, Drug Abuse, and Mental Health Administration, has establishedreliability and validity for the DSM diagnoses ofalcohol abuse/dependence.70 The CIDI alcoholabuse/dependence modules were administered at baseline in the surgical wardand again 6 and 12 months after the injury. The baseline CIDI assessed alcoholconsumption behaviors during the 12 months before the injury, whereas the6- and 12-month telephone follow-up CIDI evaluations assessed each preceding6-month period.

Alcohol and stimulant (amphetamine and cocaine) intoxication at thetime of admission to the hospital was assessed with toxicology screens. Becauseopiates and benzodiazapines are frequently administered to trauma patients,only stimulant results were included as positive results of drug screens.

Injury Severity and Medical Comorbidities

We determined injury severity from the medical record International Classification of Disease, Ninth Version, Clinical Modification (ICD-9-CM)71 codesusing the Abbreviated Injury Scale and Injury Severity Score.72 Comorbidchronic medical conditions were also derived from ICD-9-CM diagnostic codes. Eleven conditions, including diabetes, hypertension,chronic liver and renal diseases, carcinomas, ischemic heart disease, degenerativenervous conditions, stroke, epilepsy, obesity, and coagulation defects wereincluded.73

STATISTICAL ANALYSES

To assess the representativeness of the study sample, we first comparedthe characteristics of patients included in the investigation with the characteristicsof all injured patients admitted to Harborview during the study period whomet study eligibility criteria. We also compared baseline data for patientsin the CC and UC conditions.

We used mixed-effects random-coefficient regression models with theintent-to-treat sample to determine whether patients in the 2 groups manifesteddifferent patterns of PTSD and alcohol symptom change over time. Longitudinaldata collected prospectively from injured trauma survivors is characterizedby correlated intraindividual observations, missing data, and dropouts.4 Mixed-effects random-coefficient regression methodswere selected because of their superior ability to model longitudinal datawith these characteristics.74 The procedureuses maximum likelihood estimates to evaluate treatment group, time, and treatmentgroup × time interaction effects. Baseline symptom status, age, sex,medical comorbidity, and injury severity were used as covariates in all theseregression procedures.

When significant interaction or main effects were detected by the random-coefficientregressions, post hoc logistic regressions for each follow-up assessment pointwere performed. On the basis of these logistic regressions, we calculatedthe average rates of PTSD and alcohol abuse/dependence at each assessmentpoint for the CC and UC groups adjusted for the covariates. These adjustedaverage proportions are presented in our figures. To interpret any significantstatistical interactions of treatment with time, we used logistic regressionsto calculate adjusted probabilities of PTSD and alcohol abuse/dependence foreach patient at each assessment. Next, changes in the adjusted probabilitiesfrom baseline to the 6- and 12-month assessments were calculated along withtheir 95% confidence intervals (CIs). Finally, we used 2-tailed unpaired t tests to examine the differential rates of change inthe adjusted probabilities across time for the treatment groups. Significantdifferences in the CC and UC groups would indicate differences in the ratesof change in adjusted probabilities over time.

PATIENT CHARACTERISTICS

A total of 2610 surgical inpatients underwent screening for the investigationduring the 10-month study (Figure 1).Injured trauma survivors recruited into the investigation did not significantlydiffer from all patients admitted to Harborview surgical services during thestudy period with regard to injury type (intentional injury, 21% vs 19%; χ21 = 0.18; P = .67), Injury SeverityScore (mean, 10.8 [SD, 6.6] vs 10.8 [SD, 9.4]; t2157 = 0.01; P = .99), sex (percentage female,33% vs 27%; χ21 = 1.2; P =.27), or alcohol toxicology test status (percentage with positive results,28% vs 28%; χ22 = 1.88; P =.39). On average, study patients were younger (mean age, 38.7 years [SD, 14.8years] vs 41.7 years [SD, 18.2 years]; t2509 = 0.01; P = .07) and significantly less likelyto have 1 or more chronic medical conditions (14% vs 26%; χ21 = 6.9; P = .01) when compared with the populationof trauma center patients.

Place holder to copy figure label and caption
Figure 1.

Patient flow through the clinicaltrial. Percentages have been rounded and may not total 100.

Graphic Jump Location

Injured patients included in the investigation (n = 120) were heterogeneouswith regard to demographic and clinical characteristics (Table 1). Sixty-six percent of patients were white; 12%, AfricanAmerican; 10%, Hispanic; 8%, Native American; and 5%, Asian. Thirty-six percentof patients had individual incomes less than $15 000 per year; 34%, from$15 000 to $40 000 per year; and 30%, greater than $40 000per year. Eleven percent of patients reported not having a permanent homeor living situation. Less than 10% of patients had positive findings for stimulantson admission, and the number of patients with stimulant-positive results wasnot significantly different across the 2 groups. Twelve (48%) of the 25 patientswho met DSM-IV symptomatic criteria for PTSD in thesurgical ward had comorbid alcohol abuse/dependence. Although the proportionsof CC and UC patients with positive alcohol admission toxicologic findingswere similar, stratification based on this crude screen failed to evenly distributepatients with regard to alcohol abuse/dependence (Table 1).

Table Graphic Jump LocationTable 1. Baseline Demographic, Injury, and Clinical Characteristicsof Patients Randomized to the Collaborative Care Intervention vs Usual Care47,50,46,75
PARTICIPATION IN THE COLLABORATIVE INTERVENTION

The stepped-care procedure involved gradually decreasing case managertime intensity during the weeks and months after the injury and graduallyincreasing time commitments from doctoral-level practitioners. The case managerbegan each intervention with a bedside visit, and during the course of theyear spent an average of 10.7 hours (SD, 9.8 hours; median, 7.6 hours; range,1-56 hours) with each CC patient. On average, the case manager spent 4.3 hours(SD, 2.9 hours) with each patient in the first month after the injury, 3.1hours (SD, 3.65 hours) per patient from months 1 through 3, 2.0 hours (SD,3.4 hours) per patient from months 4 to 6, and 1.3 hours (SD, 3.2 hours) perpatient during months 7 to 12 after injury. Thirty (51%) of 59 CC patientsreceived the brief MI intervention targeting alcohol abuse, and more thanhalf of these patients received 1 or more MI booster sessions during the year.

At the 3-month assessment with the Structured Clinical Interview for DSM-IV, 12 (24%) of 50 CC patients received a diagnosisof PTSD. Evidence-based pharmacotherapy and psychotherapy were offered tothese patients. Almost all of the intervention time (38.9 [95.8%] of 40.6total hours) of the expert doctoral-level therapist was spent delivering acourse of CBT (range, 5-12 sessions) to 5 CC patients from 3 to 12 monthsafter injury.

In total, the psychiatrist participated in the evaluation and/or treatmentof 38 (64%) of the 59 CC patients (average time per patient, 2.7 hours; SD,3.4 hours; median, 0.67 hours; range, 0.1-14.5 hours). The psychiatrist participatedin an average of 0.60 visits of 30 to 60 minutes' duration in the first 3months (SD, 1.00; range, 0-5), and 1.0 visits from months 3 to 12 (SD, 2.1;range, 0-8). With regard to patient-related telephone calls, in the first3 months the psychiatrist averaged 1.0 telephone contacts per patient (SD,1.9; range, 0-9 calls), and from 3 to 12 months, 1.4 telephone contacts (SD,2.3; range, 0-9). In the first 3 months immediately after the injury, thepsychiatrist evaluated 22 (37%) of 59 CC patients for high levels of immediateposttraumatic distress, pain, insomnia, or other injury-related complications.Also, for 4 (7%) of 59 patients, no in-person evaluation was performed; however,the psychiatrist participated in care coordination/referral activities withsurgical and primary care providers. Twenty (34%) of the 59 CC patients wereoffered PTSD pharmacotherapy; 10 (50%) of these 20 patients accepted and maintainedtheir medication regimes.

INTERVENTION OUTCOMES

The random regression procedure showed a significant treatment group× time interaction effect for PTSD (Table 2). The intervention effect coincided with the initiationof evidence-based medication and psychotherapy interventions at 3 months (Figure 2). The significant treatment group× time interaction was due to treatment group differences in the adjustedrates of change in PTSD for the CC and UC groups. At 6 months, the CC andUC groups had trend level differences in rates of change from baseline (t118 = 1.83; P = .07).The CC group had on average a 5.5% increase in the rate of PTSD (95% CI, 0.1%-10.8%),whereas the UC group had on average twice the rate of increase in the first6 months (12.0%; 95% CI, 7.3%-16.7%). However, at 12 months, the differencesin rates of PTSD from baseline were statistically different (t118 = 2.40; P = .02), with theCC group showing no change in the rate of PTSD (a decrease of 0.07%; 95% CI,−4.2%to 4.3%) and the UC group showing on average a 6% increase in the rate ofPTSD during the year (95% CI, 3.1%-9.3%).

Table Graphic Jump LocationTable 2. Random-Coefficient Regression Results for PTSD and AlcoholAbuse/Dependence46,50
Place holder to copy figure label and caption
Figure 2.

Percentage of patients who met DSM-IV symptomatic criteria for posttraumatic stress disorder(PTSD) during the year after injury. Symptoms consistent with a diagnosisof PTSD were assessed with the PTSD Checklist Civilian Version.46 Percentagesare adjusted for injury severity, sex, age, chronic illness, baseline PTSD,and baseline alcohol abuse/dependence. Baseline PTSD was assessed in the surgicalward (n = 120). Follow-up rates were 88% at 1 month, 86% at 3 months, 86%at 6 months, and 83% at 12 months.

Graphic Jump Location

A significant treatment group × time interaction effect was observedfor CIDI-diagnosed alcohol abuse/dependence (Table 2). The intervention appears to have maintained reductionsof alcohol consumption beyond 6 months (Figure3). The significant treatment group × time interaction wasdue to treatment group differences in the adjusted rates of change in alcoholabuse/dependence for the CC and UC groups. At 6 months, the CC and UC groupshad significantly different rates of change from baseline (t118 = 3.37; P = .001). The CCgroup had on average a 20.4% decrease in the rate of alcohol abuse/dependence(95% CI, −14.3% to −26.5%), whereas the UC group had on averageonly a 7% decrease (95% CI, −2.8% to −12.2%). At 12 months, thedifferences in rates of alcohol abuse/dependence were also statistically different(t118 = 11.53; P<.001),with the CC group showing on average a decrease in the rate of alcohol abuse/dependenceof 24.2% during the year (95% CI, −19.9% to −28.6%) and the UCgroup showing on average a 12.9% increase in the rate of alcohol abuse/dependenceduring the year (95% CI, 8.2%-17.7%).

Place holder to copy figure label and caption
Figure 3.

Percentage of patients who met DSM-IV criteria for alcohol abuse/dependence during theyear after injury. Alcohol abuse/dependence was assessed with the CompositeInternational Diagnostic Interview.50 Percentagesare adjusted for injury severity, sex, age, chronic illness, and baselinealcohol abuse/dependence (ie, abuse or dependence in the year before the injury).Preinjury assessment occurred during surgical ward interview (n = 120). Follow-uprates were 86% at 6 months and 83% at 12 months.

Graphic Jump Location

This investigation establishes the feasibility of delivering a multifacetedCC intervention to acutely injured trauma survivors. We successfully recruited,intervened with, and followed up a representative sample of injured traumasurvivors, some of whom had alcohol abuse/dependence and acute posttraumaticdistress. Early case management intervention successfully engaged acutelytraumatized patients, a population that in the past has demonstrated a reluctanceto participate in ongoing mental health interventions.7678 TheCC intervention differed from previous trials of debriefing in that earlycase management activities established an ongoing relationship with patients,who were later offered evidence-based treatment.

The investigation demonstrated that a stepped CC delivery model effectivelyreduces alcohol abuse/dependence during the year after injury. At 6 and 12months after the injury, clinically and statistically significant reductionsin alcohol use were apparent for patients who received the CC intervention.

For PTSD, CC patients demonstrated essentially no change in symptomsduring the course of the year, whereas UC patients manifested a significantworsening of symptoms. Early evaluation and supportive intervention was notassociated with reductions in PTSD for patients in the CC condition. Preventionof the development of PTSD in CC patients relative to UC patients coincidedwith the initiation of evidence-based PTSD medication and CBT treatments 3months after injury.

There are a number of possible explanations for the CC intervention'srelatively small PTSD treatment effect. The investigation was limited by aninitial screening procedure that recruited some patients with minimal PTSDsymptoms. Also, previous investigations of injured trauma survivors hospitalizedat level I trauma centers in the United States suggest that this patient populationexperiences multiple recurrent traumatic life events, including a substantialburden of traumatic injuries requiring hospitalization, some of which followan index injury admission.4,9,26,7981 Ourinvestigation is limited in that we did not specifically assess PTSD in relationto these multiple prior and subsequent traumatic life events. It may be thatthe CC intervention buffers CC patients from the full symptomatic impact ofrecurrent traumatic life events, relative to UC patients. These preliminaryobservations will require more refined study in future investigations.

There are other important considerations in interpreting the resultsof this investigation. The design of this study builds on a series of effectivenesstrials for depressive and anxiety disorders delivered in real-world treatmentsettings.3742,82 Thetrade-offs relevant to the effectiveness approach apply to the current investigation.83 Because this was a multifaceted intervention, itdid not yield information regarding which components of the treatment areefficacious. For instance, although PTSD prevention was temporally associatedwith the initiation of evidence-based treatments, we cannot rule out the possibilitythat continuing trauma support activities also contributed to the preventionof PTSD. Finally, as is typical of many effectiveness trials, we relied onsymptom screens and lay interviews rather than clinician-administered diagnosticassessments.

This investigation contributes to a developing literature regardingearly intervention for posttraumatic distress in acutely traumatized patients.A stepped CC intervention furthers the delivery of high-quality posttraumaticcare by tailoring treatment needs to the individual trauma survivor whiledelivering evidence-based mental health interventions.57 Collaborativecare is a multifaceted disease management strategy into which future psychotherapeuticand pharmacological advances for the treatment of PTSD can be incorporated.84,85 Future larger-scale CC trials shouldassess functional outcome improvements and the cost-effectiveness of the intervention.86

The September 11, 2001, attack on American civilians provides an additionalimpetus for the ongoing development of multifaceted acute care mental healthscreening and intervention procedures. Injured trauma survivors triaged throughacute care in the immediate aftermath of a mass attack represent a high-risksubgroup of patients who are rapidly transported to central points of contactwithin the health care system.87 Commentariesthat have followed the September 11 attack suggest that the health care systemin the United States should be better prepared for mass civilian trauma.27,88 Future investigations that refineroutine acute care evaluation and treatment procedures have the potentialto improve the quality of mental health care for Americans injured in thewake of individual and mass trauma.

Corresponding author: Douglas Zatzick, MD, University of WashingtonSchool of Medicine, Box 359911, Harborview Medical Center, 325 Ninth Ave,Seattle WA 98104 (e-mail: dzatzick@u.washington.edu)

Submitted for publication August 15, 2003; final revision received December15, 2003; accepted January 20, 2004.

This study was supported by grant 1K08 MH01610 from the National Instituteof Mental Health, Rockville, Md; grant 1R03 HS11372 from the Agency for HealthcareResearch and Quality, Rockville; and grant CCR303568 from the Centers forDisease Control and Prevention, Atlanta, Ga.

A preliminary version of this study was presented at the Annual Meetingof the Robert Wood Johnson Clinical Scholars Program; November 22, 2003; FtLauderdale, Fla.

MacKenzie  EJHoyt  DBSacra  JCJurkovich  GJCarlini  ARTeitelbaum  SDTeter  H  Jr National inventory of hospital trauma centers. JAMA. 2003;2891515- 1522
PubMed Link to Article
Centers for Disease Control and Prevention, Rapid assessment of injuries among survivors of the terrorist attackon the World Trade Center—New York City, September 2001. MMWR Morb Mortal Wkly Rep. 2002;511- 5
PubMed
Bonnie  RJFulco  CELiverman  CT Reducing the Burden of Injury: Advancing Preventionand Treatment.  Washington, DC National Academy Press1999;
Zatzick  DFKang  SMMuller  HGRusso  JERivara  FPKaton  WJurkovich  GJRoy-Byrne  P Predicting posttraumatic distress in hospitalized trauma survivorswith acute injuries. Am J Psychiatry. 2002;159941- 946
PubMed Link to Article
Blanchard  EBHickling  EJTaylor  AELoos  W Psychiatric morbidity associated with motor vehicle accidents. J Nerv Ment Dis. 1995;183495- 504
PubMed Link to Article
Holbrook  TLAnderson  JPSieber  WJBrowner  DHoyt  DB Outcome after major trauma: 12-month and 18-month follow-up resultsfrom the Trauma Recovery Project. J Trauma. 1999;46765- 773
PubMed Link to Article
Michaels  AJMichaels  CEMoon  CHSmith  JSZimmerman  MATaheri  PAPeterson  C Posttraumatic stress disorder after injury: impact on general healthoutcome and early risk assessment. J Trauma. 1999;47460- 467
PubMed Link to Article
Soderstrom  CASmith  GSDischinger  PCMcDuff  DRHebel  JRGorelick  DAKerns  TJHo  SMRead  KM Psychoactive substance use disorders among seriously injured traumacenter patients. JAMA. 1997;2771769- 1774
PubMed Link to Article
Rivara  FPKoepsell  TDJurkovich  GJGurney  JGSoderberg  R The effects of alcohol abuse on readmission for trauma. JAMA. 1993;2701962- 1964
PubMed Link to Article
Shalev  AYBonne  OEth  S Treatment of posttraumatic stress disorder: a review. Psychosom Med. 1996;58165- 182
PubMed Link to Article
Solomon  SDGerrity  ETMuff  AM Efficacy of treatments for posttraumatic stress disorder. JAMA. 1992;268633- 638
PubMed Link to Article
Foa  EBMeadows  EA Psychosocial treatments for posttraumatic stress disorder: a criticalreview. Annu Rev Psychol. 1997;48449- 480
PubMed Link to Article
Bryant  RAHarvey  AGDang  STSackville  TBasten  C Treatment of acute stress disorder: a comparison of cognitive-behavioraltherapy and supportive counseling. J Consult Clin Psychol. 1998;66862- 866
PubMed Link to Article
Bryant  RAMoulds  MGuthrie  RNixon  RD Treating acute stress disorder following mild traumatic brain injury. Am J Psychiatry. 2003;160585- 587
PubMed Link to Article
Foa  EBHearst-Ikeda  DPerry  KJ Evaluation of a brief cognitive-behavioral program for the preventionof chronic PTSD in recent assault victims. J Consult Clin Psychol. 1995;63948- 955
PubMed Link to Article
Ehlers  AClark  DHackmann  AMcManus  FFennell  MHerbert  CMayou  R A randomized controlled trial of cognitive therapy, a self-help booklet,and repeated assessments as early interventions for posttraumatic stress disorder. Arch Gen Psychiatry. 2003;601024- 1032
PubMed Link to Article
Brady  KPearlstein  TAsnis  GMBaker  DRothbaum  BSikes  CRFarfel  GM Efficacy and safety of sertraline treatment of posttraumatic stressdisorder: a randomized controlled trial. JAMA. 2000;2831837- 1844
PubMed Link to Article
Hidalgo  RBDavidson  JRT Selective serotonin reuptake inhibitors in post-traumatic stress disorder. J Psychopharmacol. 2000;1470- 76
PubMed Link to Article
Connor  KMSutherland  SMTupler  LAMalik  MLDavidson  JR Fluoxetine in post-traumatic stress disorder: randomised, double-blindstudy. Br J Psychiatry. 1999;17517- 22
PubMed Link to Article
Davidson  JPearlstein  TLondborg  PBrady  KTRothbaum  BBell  JMaddock  RHegel  MTFarfel  G Efficacy of sertraline in preventing relapse of posttraumatic stressdisorder: results of a 28-week double-blind, placebo-controlled study. Am J Psychiatry. 2001;1581974- 1981
PubMed Link to Article
Marshall  RDBeebe  KLOldham  MZaninelli  R Efficacy and safety of paroxetine treatment for chronic PTSD: a fixed-dose,placebo-controlled study. Am J Psychiatry. 2001;1581982- 1988
PubMed Link to Article
Project MATCH Research Group, Matching alcoholism treatments to client heterogeneity: Project MATCHposttreatment drinking outcomes. J Stud Alcohol. 1997;587- 29
PubMed
Chick  JLloyd  GCrombie  E Counseling problem drinkers in medical wards: a controlled study. BMJ. 1985;290965- 967
PubMed Link to Article
Heather  NRollnick  SBell  ARichmond  R Effects of brief counselling among male heavy drinkers identified ongeneral hospital wards. Drug Alcohol Rev. 1996;1529- 38
Link to Article
Miller  WRSovereign  RGKrege  B Motivational interviewing with problem drinkers, II: the Drinker'sCheck-up as a preventive intervention. Behav Psychother. 1988;16251- 268
Link to Article
Gentilello  LMRivara  FPDonovan  DMJurkovich  GJDaranciang  EDunn  CWVillaveces  ACopass  MRies  RR Alcohol interventions in a trauma center as a means of reducing therisk of injury recurrence. Ann Surg. 1999;230473- 480
PubMed Link to Article
National Institute of Mental Health, Mental Health and Mass Violence: Evidence-Based EarlyPsychological Intervention for Victims/Survivors of Mass Violence: A Workshopto Reach Consensus on Best Practices.  Washington, DC National Institute of Mental Health2002;
Satcher  D Mental Health: A Report of the SurgeonGeneral.  Rockville, Md US Dept of Health and Human Services1999;
Chesnut  RMCarney  NMaynard  HPatterson  PMann  NCHelfand  M Rehabilitation for Traumatic Brain Injury.  Rockville, Md Agency for Healthcare Policy and Research1999;
Horowitz  LKassam-Adams  NBergstein  J Mental health aspects of emergency medical services for children: summaryof a consensus conference. Acad Emerg Med. 2001;81187- 1196
PubMed Link to Article
Bisson  JIJenkins  PLAlexander  JBannister  C Randomised controlled trial of psychological debriefing for victimsof acute burn trauma. Br J Psychiatry. 1997;17178- 81
PubMed Link to Article
Hobbs  MMayou  RHarrison  BWorlock  P A randomised controlled trial of psychological debriefing for victimsof road traffic accidents. BMJ. 1996;3131438- 1439
PubMed Link to Article
Rose  SBisson  J Brief early psychological interventions following trauma: a systematicreview of the literature. J Trauma Stress. 1998;11697- 710
PubMed Link to Article
van Emmerik  AKamphuis  JHHulsbosch  AMEmmelkamp  P Single session debriefing after psychological trauma: a meta-analysis. Lancet. 2002;360766- 771
PubMed Link to Article
Wagner  EHAustin  BTVon Korff  M Organizing care for patients with chronic illness. Milbank Q. 1996;74511- 543
PubMed Link to Article
Von Korff  MJGSchaefer  JCurry  SJWagner  EH Collaborative management of chronic illness. Ann Intern Med. 1997;1271097- 1102
PubMed Link to Article
Katon  WVon Korff  MLin  ESimon  GWalker  EUnutzer  JBush  TRusso  JLudman  E Stepped collaborative care for primary care patients with persistentdepression: a randomized trial. Arch Gen Psychiatry. 1999;561109- 1115
PubMed Link to Article
Katon  WVon Korff  MLin  EUnutzer  JSimon  GWalker  ELudman  EBush  T Population-based care of depression: effective disease management strategiesto decrease prevalence. Gen Hosp Psychiatry. 1997;19169- 178
PubMed Link to Article
Katon  WVon Korff  MLin  EWalker  ESimon  GEBush  TBRobinson  PRusso  J Collaborative management to achieve treatment guidelines: impact ondepression in primary care. JAMA. 1995;2731026- 1031
PubMed Link to Article
Katon  WRutter  CLudman  EVon Korff  MLin  ESimon  GBush  TWalker  EUnutzer  J A randomized trial of relapse prevention of depression in primary care. Arch Gen Psychiatry. 2001;58241- 247
PubMed Link to Article
Roy-Byrne  PKaton  WCowley  DRusso  J A randomized effectiveness trial of collaborative care for patientswith panic disorder in primary care. Arch Gen Psychiatry. 2000;58869- 876
PubMed Link to Article
Wells  KBSherbourne  CSchoenbaum  MDuan  NMeredith  LUnutzer  JMiranda  JCarney  MFRubenstein  LV Impact of disseminating quality improvement programs for depressionin managed primary care: a randomized controlled trial. JAMA. 2000;283212- 220
PubMed Link to Article
Unutzer  JKaton  WCallahan  CMWilliams  JW  JrHunkeler  EHarpole  LHoffing  MPenna  RD DellaNoel  PHLin  EHArean  PAHegel  MTTang  LBelin  TROishi  SLangston  CIMPACT  Investigators Collaborative care management of late-life depression in the primarycare setting: a randomized controlled trial. JAMA. 2002;2882836- 2845
PubMed Link to Article
Teasdale  GJennet  B Assessment of coma and impaired consciousness: a practical scale. Lancet. 1974;281- 84
PubMed Link to Article
Folstein  MFFolstein  SEMcHugh  PR "Mini-Mental State": a practical method for grading the cognitive stateof patients for the clinician. J Psychiatr Res. 1975;12189- 198
PubMed Link to Article
Weathers  FFord  J Measurement of Stress, Trauma and Adaptation: PsychometricReview of PTSD Checklist (PCL-C, PCL-S. PCL-M, PCL-PR)  Towson, Md Sidran Press1996;250- 261
Radloff  LS The CES-D Scale: a self-report depression scale for research in thegeneral population. Appl Psychol Meas. 1977;1385- 401
Link to Article
Blanchard  EBJones-Alexander  JBuckley  TCForneris  CA Psychometric properties of the PTSD Checklist. Behav Res Ther. 1996;34669- 773
PubMed Link to Article
Williams  JW  JrPignone  MRamirez  GStellato  C Perez Identifying depression in primary care: a literature synthesis of case-findinginstruments. Gen Hosp Psychiatry. 2002;24225- 237
PubMed Link to Article
World Health Organization, Composite International Diagnostic Interview (CIDI)Version 2.1.  Geneva, Switzerland World Health Organization1997;
Wagner  A Cognitive-behavioral therapy for PTSD: applications to injured traumasurvivors. Semin Clin Neuropsychiatry. 2003;8175- 187
PubMed Link to Article
Dunn  C Brief motivational interviewing interventions targeting substance abusein the acute care medical setting. Semin Clin Neuropsychiatry. 2003;8188- 196
PubMed Link to Article
Zatzick  DFRoy-Byrne  P Psychopharmacological approaches to the management of posttraumaticstress disorders in the acute care medical sector. Semin Clin Neuropsychiatry. 2003;8168- 174
PubMed Link to Article
Miranda  JAzocar  FOrganista  KCDwyer  EAreane  P Treatment of depression among impoverished primary care patients fromethnic minority groups. Psychiatr Serv. 2003;54219- 225
PubMed Link to Article
Zatzick  DFKang  SMHinton  WLKelly  RHHilty  DMFranz  CELe  LKravitz  RL Posttraumatic concerns: a patient-centered approach to outcome assessmentafter traumatic physical injury. Med Care. 2001;39327- 339
PubMed Link to Article
Zatzick  DFRoy-Byrne  PRusso  JRivara  FPKoike  AJurkovich  GJKaton  W Collaborative interventions for physically injured trauma survivors:a pilot randomized effectiveness trial. Gen Hosp Psychiatry. 2001;23114- 123
PubMed Link to Article
Committee on Quality of Health Care in America, Crossing the Quality Chasm: A New Health System forthe 21st Century.  Washington, DC National Academy Press2001;
Gentilello  LMDonovan  DMDunn  CWRivara  FP Alcohol interventions in trauma centers: current practice and futuredirections. JAMA. 1995;2741043- 1048
PubMed Link to Article
Johnston  BDRivara  FPDroesh  RMDunn  CCopass  MK Behavior change counseling in the emergency department to reduce injuryrisk: a randomized, controlled trial. Pediatrics. 2002;110267- 274
PubMed Link to Article
First  MBSpitzer  RLGibbon  MWilliams  JBW Structured Clinical Interview for DSM-IV Axis I Disorders–Clinician Version (SCID-CV).  Washington, DC American Psychiatric Press1997;
Foa  EBKeane  TMFriedman  MJ Effective Treatments for PTSD.  New York, NY Guilford Publications2000;
Expert Consensus Panels for PTSD, The expert consensus guideline series: Treatment of Posttraumatic StressDisorder. J Clin Psychiatry. 1999;60suppl 163- 76
PubMed Link to Article
Zatzick  DRusso  JKaton  W Somatic, posttraumatic stress and depressive symptoms among injuredpatients treated in trauma surgery. Psychosomatics. 2003;44479- 484
PubMed Link to Article
Zatzick  DFKang  SKim  SLeigh  PKravitz  RDrake  CSue  SWisner  D Patients with recognized psychiatric disorders in trauma surgery: incidence,inpatient length of stay, and cost. J Trauma. 2000;49487- 495
PubMed Link to Article
Asmundson  GJFrombach  IMcQuaid  JPedrelli  PLenox  RStein  MB Dimensionality of posttraumatic stress symptoms: a confirmatory factoranalysis of DSM-IV symptom clusters and other symptommodels. Behav Res Ther. 2000;38203- 214
PubMed Link to Article
Walker  EANewman  EDobie  DJCiechanowski  PKaton  W Validation of the PTSD Checklist in an HMO sample of women. Gen Hosp Psychiatry. 2002;24375- 380
PubMed Link to Article
Dobie  DJKivlahan  DRMaynard  CBush  KRMcFall  MEpler  AJBradley  KA Screening for post-traumatic stress disorder in female Veteran's Affairspatients: validation of the PTSD Checklist. Gen Hosp Psychiatry. 2002;24367- 374
PubMed Link to Article
Walker  EKaton  WRusso  JCiechanowski  PNewman  EWagner  A Health care costs associated with posttraumatic stress disorder symptomsin women. Arch Gen Psychiatry. 2003;60369- 374
PubMed Link to Article
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition.  Washington, DC American Psychiatric Association1994;
Kessler  RCCrum  RMWarner  LANelson  CBSchulenberg  JAnthony  JC Lifetime co-occurrence of DSM-III-R alcoholabuse and dependence with other psychiatric disorders in the National ComorbiditySurvey. Arch Gen Psychiatry. 1997;54313- 321
PubMed Link to Article
Johns Hopkins Health Services Research and Development Center, Determining Injury Severity From Hospital Discharges:A Program to Map ICD-9-CM Diagnoses Into AIS and ISS Severity Scores.  Baltimore, Md Johns Hopkins University Press1989;
Committee on Injury Scaling, The Abbreviated Injury Scale, 1985 Revision.  Morton Grove, Ill American Association for the Advancement of AutomotiveMedicine1985;
MacKenzie  EJMorris  JAEdelstein  SL Effect of pre-existing disease on length of hospital stay in traumapatients. J Trauma. 1989;29757- 764
PubMed Link to Article
Gibbons  RDHedeker  DElkin  IWaternaux  CKraemer  HCGreenhouse  JBShea  MTImber  SDSotsky  SMWatkins  JT Some conceptual and statistical issues in analysis of longitudinalpsychiatric data. Arch Gen Psychiatry. 1993;50739- 750
PubMed Link to Article
Ware  JEKosinski  MKeller  SD A 12-item Short-Form Health Survey: construction of scales and preliminarytests of reliability and validity. Med Care. 1996;34220- 223
PubMed Link to Article
Weisaeth  L Acute posttraumatic stress: nonacceptance of early intervention. J Clin Psychiatry. 2001;62suppl 1735- 40
PubMed
Pitman  RKSanders  KMZusman  RMHealy  ARCheema  FLasko  NBCahill  LOrr  SP Pilot study of secondary prevention of posttraumatic stress disorderwith propranolol. Biol Psychiatry. 2002;51189- 192
PubMed Link to Article
Schwarz  EDKowalski  JM Malignant memories: reluctance to utilize mental health services aftera disaster. J Nerv Ment Dis. 1992;180767- 772
PubMed Link to Article
Smith  RSFry  WRMorabito  DJOrgan  CHJ Recidivism in an urban trauma center. Arch Surg. 1992;127668- 670
PubMed Link to Article
Poole  GVGriswold  JAThaggard  VKRhodes  RS Trauma is a recurrent disease. Surgery. 1993;113608- 611
PubMed
Sims  DWBivins  BAObeid  FNHorst  HMSorensen  VJFath  JJ Urban trauma: a chronic recurrent disease. J Trauma. 1989;29940- 947
PubMed Link to Article
Unutzer  JKaton  WWilliams  JWCallahan  CMHarpole  LHunkeler  EMHoffing  MArean  PHegel  MTSchoenbaum  MOishi  SMLangston  CA Improving primary care for depression in late life: the design of amulticenter randomized trial. Med Care. 2001;39785- 799
PubMed Link to Article
Wells  KB Treatment research at the crossroads: the scientific interface of clinicaltrials and effectiveness research. Am J Psychiatry. 1999;1565- 10
PubMed
Friedman  MJ Future pharmocotherapy for post-traumatic stress disorder: preventionand treatment. Psychiatr Clin North Am. 2002;25427- 441
PubMed Link to Article
Ehlers  AClark  D Early psychological interventions for adult survivors of trauma: areview. Biol Psychiatry. 2003;53817- 826
PubMed Link to Article
Katon  WJRoy-Byrne  PRusso  JCowley  D Cost-effectiveness and cost offset of a collaborative care interventionfor primary care patients with panic disorder. Arch Gen Psychiatry. 2002;591098- 1104
PubMed Link to Article
Zatzick  D Collaborative care for injured victims of individual and mass trauma:a health services research approach to developing early interventions. Ursano  RJFullerton  CSNorwood  AEeds.Terrorism and Disaster: Individual and Community Mental Health Interventions. New York, NY Cambridge University Press2003;189- 205
Ursano  RJ Post-traumatic stress disorder. N Engl J Med. 2002;346130- 132
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Patient flow through the clinicaltrial. Percentages have been rounded and may not total 100.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Percentage of patients who met DSM-IV symptomatic criteria for posttraumatic stress disorder(PTSD) during the year after injury. Symptoms consistent with a diagnosisof PTSD were assessed with the PTSD Checklist Civilian Version.46 Percentagesare adjusted for injury severity, sex, age, chronic illness, baseline PTSD,and baseline alcohol abuse/dependence. Baseline PTSD was assessed in the surgicalward (n = 120). Follow-up rates were 88% at 1 month, 86% at 3 months, 86%at 6 months, and 83% at 12 months.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Percentage of patients who met DSM-IV criteria for alcohol abuse/dependence during theyear after injury. Alcohol abuse/dependence was assessed with the CompositeInternational Diagnostic Interview.50 Percentagesare adjusted for injury severity, sex, age, chronic illness, and baselinealcohol abuse/dependence (ie, abuse or dependence in the year before the injury).Preinjury assessment occurred during surgical ward interview (n = 120). Follow-uprates were 86% at 6 months and 83% at 12 months.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Baseline Demographic, Injury, and Clinical Characteristicsof Patients Randomized to the Collaborative Care Intervention vs Usual Care47,50,46,75
Table Graphic Jump LocationTable 2. Random-Coefficient Regression Results for PTSD and AlcoholAbuse/Dependence46,50

References

MacKenzie  EJHoyt  DBSacra  JCJurkovich  GJCarlini  ARTeitelbaum  SDTeter  H  Jr National inventory of hospital trauma centers. JAMA. 2003;2891515- 1522
PubMed Link to Article
Centers for Disease Control and Prevention, Rapid assessment of injuries among survivors of the terrorist attackon the World Trade Center—New York City, September 2001. MMWR Morb Mortal Wkly Rep. 2002;511- 5
PubMed
Bonnie  RJFulco  CELiverman  CT Reducing the Burden of Injury: Advancing Preventionand Treatment.  Washington, DC National Academy Press1999;
Zatzick  DFKang  SMMuller  HGRusso  JERivara  FPKaton  WJurkovich  GJRoy-Byrne  P Predicting posttraumatic distress in hospitalized trauma survivorswith acute injuries. Am J Psychiatry. 2002;159941- 946
PubMed Link to Article
Blanchard  EBHickling  EJTaylor  AELoos  W Psychiatric morbidity associated with motor vehicle accidents. J Nerv Ment Dis. 1995;183495- 504
PubMed Link to Article
Holbrook  TLAnderson  JPSieber  WJBrowner  DHoyt  DB Outcome after major trauma: 12-month and 18-month follow-up resultsfrom the Trauma Recovery Project. J Trauma. 1999;46765- 773
PubMed Link to Article
Michaels  AJMichaels  CEMoon  CHSmith  JSZimmerman  MATaheri  PAPeterson  C Posttraumatic stress disorder after injury: impact on general healthoutcome and early risk assessment. J Trauma. 1999;47460- 467
PubMed Link to Article
Soderstrom  CASmith  GSDischinger  PCMcDuff  DRHebel  JRGorelick  DAKerns  TJHo  SMRead  KM Psychoactive substance use disorders among seriously injured traumacenter patients. JAMA. 1997;2771769- 1774
PubMed Link to Article
Rivara  FPKoepsell  TDJurkovich  GJGurney  JGSoderberg  R The effects of alcohol abuse on readmission for trauma. JAMA. 1993;2701962- 1964
PubMed Link to Article
Shalev  AYBonne  OEth  S Treatment of posttraumatic stress disorder: a review. Psychosom Med. 1996;58165- 182
PubMed Link to Article
Solomon  SDGerrity  ETMuff  AM Efficacy of treatments for posttraumatic stress disorder. JAMA. 1992;268633- 638
PubMed Link to Article
Foa  EBMeadows  EA Psychosocial treatments for posttraumatic stress disorder: a criticalreview. Annu Rev Psychol. 1997;48449- 480
PubMed Link to Article
Bryant  RAHarvey  AGDang  STSackville  TBasten  C Treatment of acute stress disorder: a comparison of cognitive-behavioraltherapy and supportive counseling. J Consult Clin Psychol. 1998;66862- 866
PubMed Link to Article
Bryant  RAMoulds  MGuthrie  RNixon  RD Treating acute stress disorder following mild traumatic brain injury. Am J Psychiatry. 2003;160585- 587
PubMed Link to Article
Foa  EBHearst-Ikeda  DPerry  KJ Evaluation of a brief cognitive-behavioral program for the preventionof chronic PTSD in recent assault victims. J Consult Clin Psychol. 1995;63948- 955
PubMed Link to Article
Ehlers  AClark  DHackmann  AMcManus  FFennell  MHerbert  CMayou  R A randomized controlled trial of cognitive therapy, a self-help booklet,and repeated assessments as early interventions for posttraumatic stress disorder. Arch Gen Psychiatry. 2003;601024- 1032
PubMed Link to Article
Brady  KPearlstein  TAsnis  GMBaker  DRothbaum  BSikes  CRFarfel  GM Efficacy and safety of sertraline treatment of posttraumatic stressdisorder: a randomized controlled trial. JAMA. 2000;2831837- 1844
PubMed Link to Article
Hidalgo  RBDavidson  JRT Selective serotonin reuptake inhibitors in post-traumatic stress disorder. J Psychopharmacol. 2000;1470- 76
PubMed Link to Article
Connor  KMSutherland  SMTupler  LAMalik  MLDavidson  JR Fluoxetine in post-traumatic stress disorder: randomised, double-blindstudy. Br J Psychiatry. 1999;17517- 22
PubMed Link to Article
Davidson  JPearlstein  TLondborg  PBrady  KTRothbaum  BBell  JMaddock  RHegel  MTFarfel  G Efficacy of sertraline in preventing relapse of posttraumatic stressdisorder: results of a 28-week double-blind, placebo-controlled study. Am J Psychiatry. 2001;1581974- 1981
PubMed Link to Article
Marshall  RDBeebe  KLOldham  MZaninelli  R Efficacy and safety of paroxetine treatment for chronic PTSD: a fixed-dose,placebo-controlled study. Am J Psychiatry. 2001;1581982- 1988
PubMed Link to Article
Project MATCH Research Group, Matching alcoholism treatments to client heterogeneity: Project MATCHposttreatment drinking outcomes. J Stud Alcohol. 1997;587- 29
PubMed
Chick  JLloyd  GCrombie  E Counseling problem drinkers in medical wards: a controlled study. BMJ. 1985;290965- 967
PubMed Link to Article
Heather  NRollnick  SBell  ARichmond  R Effects of brief counselling among male heavy drinkers identified ongeneral hospital wards. Drug Alcohol Rev. 1996;1529- 38
Link to Article
Miller  WRSovereign  RGKrege  B Motivational interviewing with problem drinkers, II: the Drinker'sCheck-up as a preventive intervention. Behav Psychother. 1988;16251- 268
Link to Article
Gentilello  LMRivara  FPDonovan  DMJurkovich  GJDaranciang  EDunn  CWVillaveces  ACopass  MRies  RR Alcohol interventions in a trauma center as a means of reducing therisk of injury recurrence. Ann Surg. 1999;230473- 480
PubMed Link to Article
National Institute of Mental Health, Mental Health and Mass Violence: Evidence-Based EarlyPsychological Intervention for Victims/Survivors of Mass Violence: A Workshopto Reach Consensus on Best Practices.  Washington, DC National Institute of Mental Health2002;
Satcher  D Mental Health: A Report of the SurgeonGeneral.  Rockville, Md US Dept of Health and Human Services1999;
Chesnut  RMCarney  NMaynard  HPatterson  PMann  NCHelfand  M Rehabilitation for Traumatic Brain Injury.  Rockville, Md Agency for Healthcare Policy and Research1999;
Horowitz  LKassam-Adams  NBergstein  J Mental health aspects of emergency medical services for children: summaryof a consensus conference. Acad Emerg Med. 2001;81187- 1196
PubMed Link to Article
Bisson  JIJenkins  PLAlexander  JBannister  C Randomised controlled trial of psychological debriefing for victimsof acute burn trauma. Br J Psychiatry. 1997;17178- 81
PubMed Link to Article
Hobbs  MMayou  RHarrison  BWorlock  P A randomised controlled trial of psychological debriefing for victimsof road traffic accidents. BMJ. 1996;3131438- 1439
PubMed Link to Article
Rose  SBisson  J Brief early psychological interventions following trauma: a systematicreview of the literature. J Trauma Stress. 1998;11697- 710
PubMed Link to Article
van Emmerik  AKamphuis  JHHulsbosch  AMEmmelkamp  P Single session debriefing after psychological trauma: a meta-analysis. Lancet. 2002;360766- 771
PubMed Link to Article
Wagner  EHAustin  BTVon Korff  M Organizing care for patients with chronic illness. Milbank Q. 1996;74511- 543
PubMed Link to Article
Von Korff  MJGSchaefer  JCurry  SJWagner  EH Collaborative management of chronic illness. Ann Intern Med. 1997;1271097- 1102
PubMed Link to Article
Katon  WVon Korff  MLin  ESimon  GWalker  EUnutzer  JBush  TRusso  JLudman  E Stepped collaborative care for primary care patients with persistentdepression: a randomized trial. Arch Gen Psychiatry. 1999;561109- 1115
PubMed Link to Article
Katon  WVon Korff  MLin  EUnutzer  JSimon  GWalker  ELudman  EBush  T Population-based care of depression: effective disease management strategiesto decrease prevalence. Gen Hosp Psychiatry. 1997;19169- 178
PubMed Link to Article
Katon  WVon Korff  MLin  EWalker  ESimon  GEBush  TBRobinson  PRusso  J Collaborative management to achieve treatment guidelines: impact ondepression in primary care. JAMA. 1995;2731026- 1031
PubMed Link to Article
Katon  WRutter  CLudman  EVon Korff  MLin  ESimon  GBush  TWalker  EUnutzer  J A randomized trial of relapse prevention of depression in primary care. Arch Gen Psychiatry. 2001;58241- 247
PubMed Link to Article
Roy-Byrne  PKaton  WCowley  DRusso  J A randomized effectiveness trial of collaborative care for patientswith panic disorder in primary care. Arch Gen Psychiatry. 2000;58869- 876
PubMed Link to Article
Wells  KBSherbourne  CSchoenbaum  MDuan  NMeredith  LUnutzer  JMiranda  JCarney  MFRubenstein  LV Impact of disseminating quality improvement programs for depressionin managed primary care: a randomized controlled trial. JAMA. 2000;283212- 220
PubMed Link to Article
Unutzer  JKaton  WCallahan  CMWilliams  JW  JrHunkeler  EHarpole  LHoffing  MPenna  RD DellaNoel  PHLin  EHArean  PAHegel  MTTang  LBelin  TROishi  SLangston  CIMPACT  Investigators Collaborative care management of late-life depression in the primarycare setting: a randomized controlled trial. JAMA. 2002;2882836- 2845
PubMed Link to Article
Teasdale  GJennet  B Assessment of coma and impaired consciousness: a practical scale. Lancet. 1974;281- 84
PubMed Link to Article
Folstein  MFFolstein  SEMcHugh  PR "Mini-Mental State": a practical method for grading the cognitive stateof patients for the clinician. J Psychiatr Res. 1975;12189- 198
PubMed Link to Article
Weathers  FFord  J Measurement of Stress, Trauma and Adaptation: PsychometricReview of PTSD Checklist (PCL-C, PCL-S. PCL-M, PCL-PR)  Towson, Md Sidran Press1996;250- 261
Radloff  LS The CES-D Scale: a self-report depression scale for research in thegeneral population. Appl Psychol Meas. 1977;1385- 401
Link to Article
Blanchard  EBJones-Alexander  JBuckley  TCForneris  CA Psychometric properties of the PTSD Checklist. Behav Res Ther. 1996;34669- 773
PubMed Link to Article
Williams  JW  JrPignone  MRamirez  GStellato  C Perez Identifying depression in primary care: a literature synthesis of case-findinginstruments. Gen Hosp Psychiatry. 2002;24225- 237
PubMed Link to Article
World Health Organization, Composite International Diagnostic Interview (CIDI)Version 2.1.  Geneva, Switzerland World Health Organization1997;
Wagner  A Cognitive-behavioral therapy for PTSD: applications to injured traumasurvivors. Semin Clin Neuropsychiatry. 2003;8175- 187
PubMed Link to Article
Dunn  C Brief motivational interviewing interventions targeting substance abusein the acute care medical setting. Semin Clin Neuropsychiatry. 2003;8188- 196
PubMed Link to Article
Zatzick  DFRoy-Byrne  P Psychopharmacological approaches to the management of posttraumaticstress disorders in the acute care medical sector. Semin Clin Neuropsychiatry. 2003;8168- 174
PubMed Link to Article
Miranda  JAzocar  FOrganista  KCDwyer  EAreane  P Treatment of depression among impoverished primary care patients fromethnic minority groups. Psychiatr Serv. 2003;54219- 225
PubMed Link to Article
Zatzick  DFKang  SMHinton  WLKelly  RHHilty  DMFranz  CELe  LKravitz  RL Posttraumatic concerns: a patient-centered approach to outcome assessmentafter traumatic physical injury. Med Care. 2001;39327- 339
PubMed Link to Article
Zatzick  DFRoy-Byrne  PRusso  JRivara  FPKoike  AJurkovich  GJKaton  W Collaborative interventions for physically injured trauma survivors:a pilot randomized effectiveness trial. Gen Hosp Psychiatry. 2001;23114- 123
PubMed Link to Article
Committee on Quality of Health Care in America, Crossing the Quality Chasm: A New Health System forthe 21st Century.  Washington, DC National Academy Press2001;
Gentilello  LMDonovan  DMDunn  CWRivara  FP Alcohol interventions in trauma centers: current practice and futuredirections. JAMA. 1995;2741043- 1048
PubMed Link to Article
Johnston  BDRivara  FPDroesh  RMDunn  CCopass  MK Behavior change counseling in the emergency department to reduce injuryrisk: a randomized, controlled trial. Pediatrics. 2002;110267- 274
PubMed Link to Article
First  MBSpitzer  RLGibbon  MWilliams  JBW Structured Clinical Interview for DSM-IV Axis I Disorders–Clinician Version (SCID-CV).  Washington, DC American Psychiatric Press1997;
Foa  EBKeane  TMFriedman  MJ Effective Treatments for PTSD.  New York, NY Guilford Publications2000;
Expert Consensus Panels for PTSD, The expert consensus guideline series: Treatment of Posttraumatic StressDisorder. J Clin Psychiatry. 1999;60suppl 163- 76
PubMed Link to Article
Zatzick  DRusso  JKaton  W Somatic, posttraumatic stress and depressive symptoms among injuredpatients treated in trauma surgery. Psychosomatics. 2003;44479- 484
PubMed Link to Article
Zatzick  DFKang  SKim  SLeigh  PKravitz  RDrake  CSue  SWisner  D Patients with recognized psychiatric disorders in trauma surgery: incidence,inpatient length of stay, and cost. J Trauma. 2000;49487- 495
PubMed Link to Article
Asmundson  GJFrombach  IMcQuaid  JPedrelli  PLenox  RStein  MB Dimensionality of posttraumatic stress symptoms: a confirmatory factoranalysis of DSM-IV symptom clusters and other symptommodels. Behav Res Ther. 2000;38203- 214
PubMed Link to Article
Walker  EANewman  EDobie  DJCiechanowski  PKaton  W Validation of the PTSD Checklist in an HMO sample of women. Gen Hosp Psychiatry. 2002;24375- 380
PubMed Link to Article
Dobie  DJKivlahan  DRMaynard  CBush  KRMcFall  MEpler  AJBradley  KA Screening for post-traumatic stress disorder in female Veteran's Affairspatients: validation of the PTSD Checklist. Gen Hosp Psychiatry. 2002;24367- 374
PubMed Link to Article
Walker  EKaton  WRusso  JCiechanowski  PNewman  EWagner  A Health care costs associated with posttraumatic stress disorder symptomsin women. Arch Gen Psychiatry. 2003;60369- 374
PubMed Link to Article
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition.  Washington, DC American Psychiatric Association1994;
Kessler  RCCrum  RMWarner  LANelson  CBSchulenberg  JAnthony  JC Lifetime co-occurrence of DSM-III-R alcoholabuse and dependence with other psychiatric disorders in the National ComorbiditySurvey. Arch Gen Psychiatry. 1997;54313- 321
PubMed Link to Article
Johns Hopkins Health Services Research and Development Center, Determining Injury Severity From Hospital Discharges:A Program to Map ICD-9-CM Diagnoses Into AIS and ISS Severity Scores.  Baltimore, Md Johns Hopkins University Press1989;
Committee on Injury Scaling, The Abbreviated Injury Scale, 1985 Revision.  Morton Grove, Ill American Association for the Advancement of AutomotiveMedicine1985;
MacKenzie  EJMorris  JAEdelstein  SL Effect of pre-existing disease on length of hospital stay in traumapatients. J Trauma. 1989;29757- 764
PubMed Link to Article
Gibbons  RDHedeker  DElkin  IWaternaux  CKraemer  HCGreenhouse  JBShea  MTImber  SDSotsky  SMWatkins  JT Some conceptual and statistical issues in analysis of longitudinalpsychiatric data. Arch Gen Psychiatry. 1993;50739- 750
PubMed Link to Article
Ware  JEKosinski  MKeller  SD A 12-item Short-Form Health Survey: construction of scales and preliminarytests of reliability and validity. Med Care. 1996;34220- 223
PubMed Link to Article
Weisaeth  L Acute posttraumatic stress: nonacceptance of early intervention. J Clin Psychiatry. 2001;62suppl 1735- 40
PubMed
Pitman  RKSanders  KMZusman  RMHealy  ARCheema  FLasko  NBCahill  LOrr  SP Pilot study of secondary prevention of posttraumatic stress disorderwith propranolol. Biol Psychiatry. 2002;51189- 192
PubMed Link to Article
Schwarz  EDKowalski  JM Malignant memories: reluctance to utilize mental health services aftera disaster. J Nerv Ment Dis. 1992;180767- 772
PubMed Link to Article
Smith  RSFry  WRMorabito  DJOrgan  CHJ Recidivism in an urban trauma center. Arch Surg. 1992;127668- 670
PubMed Link to Article
Poole  GVGriswold  JAThaggard  VKRhodes  RS Trauma is a recurrent disease. Surgery. 1993;113608- 611
PubMed
Sims  DWBivins  BAObeid  FNHorst  HMSorensen  VJFath  JJ Urban trauma: a chronic recurrent disease. J Trauma. 1989;29940- 947
PubMed Link to Article
Unutzer  JKaton  WWilliams  JWCallahan  CMHarpole  LHunkeler  EMHoffing  MArean  PHegel  MTSchoenbaum  MOishi  SMLangston  CA Improving primary care for depression in late life: the design of amulticenter randomized trial. Med Care. 2001;39785- 799
PubMed Link to Article
Wells  KB Treatment research at the crossroads: the scientific interface of clinicaltrials and effectiveness research. Am J Psychiatry. 1999;1565- 10
PubMed
Friedman  MJ Future pharmocotherapy for post-traumatic stress disorder: preventionand treatment. Psychiatr Clin North Am. 2002;25427- 441
PubMed Link to Article
Ehlers  AClark  D Early psychological interventions for adult survivors of trauma: areview. Biol Psychiatry. 2003;53817- 826
PubMed Link to Article
Katon  WJRoy-Byrne  PRusso  JCowley  D Cost-effectiveness and cost offset of a collaborative care interventionfor primary care patients with panic disorder. Arch Gen Psychiatry. 2002;591098- 1104
PubMed Link to Article
Zatzick  D Collaborative care for injured victims of individual and mass trauma:a health services research approach to developing early interventions. Ursano  RJFullerton  CSNorwood  AEeds.Terrorism and Disaster: Individual and Community Mental Health Interventions. New York, NY Cambridge University Press2003;189- 205
Ursano  RJ Post-traumatic stress disorder. N Engl J Med. 2002;346130- 132
PubMed Link to Article

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