A Randomized Effectiveness Trial of Stepped Collaborative Care for Acutely Injured Trauma Survivors
Zatzick D, Roy-Byrne P, Russo J, Rivara F, Droesch R, Wagner A, Dunn C, Jurkovich G, Uehara E and Katon W;
Commented by , 24 May 2004
Aims of the study
To investigate the effectiveness of a multifaceted, stepped Collaborative Care (CC) intervention for reducing posttraumatic stress disorder as well as alcohol abuse or dependence in acutely injured trauma survivors.
Method
Participants were recruited from the population of patients admitted for acute injuries to a trauma surgical service. A sample of 121 patients meeting inclusion criteria were randomly assigned to the CC intervention or to a usual care (UC) control condition.
The CC intervention was provided in three steps during three consecutive phases:
- Phase 1 (first three months after injury) consisted mainly in trauma support activities delivered under the coordination of a case manager. During this phase, only patients with sustained high levels of distress were offered evidence-based psychopharmacological treatment and psychotherapy.
- Phase 2 (from three to six months after injury) included assessment of patients for PTSD, using the PTSD module of the Structured Clinical Interview for DSM-IV or SCID. CC was “stepped up” in that all patients with a diagnosis of PTSD were offered their choice of evidence-based psychopharmacological treatment and/or psychotherapy.
- Phase 3 (from six to twelve months after injury) consisted in relapse prevention. During this phase, only patients who remained symptomatic for PTSD continued to receive combinations of trauma support and evidence-based PTSD treatment.
At any point during the trial, patients demonstrating postinjury alcohol abuse or dependence received evidenced-based motivational interviewing (MI) interventions.
Results
In comparison to UC patients, CC patients showed significantly less symptoms, from baseline to 12 months, with regard to PTSD and alcohol abuse/dependence. At 12 months, the CC group showed no change in the rate of PTSD, while the UC group showed on average a 6% increase in comparison with baseline rates. At 12 months the CC group showed on average a decrease of 24.2% in the rate of alcohol abuse or dependence, while the UC group showed on average an increase of 12.9% in comparison with baseline rates.
Discussion
CC as described by the authors is a multifaceted approach that integrates patient education, surveillance and treatment provided by mental health professionals and other care extenders (e.g. nurses, case managers). CC is provided in primary care clinics or, as in the present study, in trauma surgical services, with the aim to help non mental health professionals provide treatment in conformity with evidence-based guidelines in psychiatry. In stepped CC, the full range of CC interventions is restricted to patients with a severe disorder persisting over time.
In recent years, Katon (who is a co-author of the present study) et al. have published the results of studies on three different CC models for depressed patients (ref. 1,2,3). In the first two models, CC was offered to all patients who had been recognized as depressive by their primary care physicians. CC resulted in more favourable outcomes in patients with major, but not minor depression. In the third model, CC was restricted to patients whose depression persisted 6 to 8 weeks after initiation of routine primary care (step 1) and who were then stepped up to CC (step 2). Cost-effectiveness was highest in the stepped CC model.
In the present study, stepped CC was tailored to fit acutely injured trauma survivors. The results represent a major contribution to a growing literature regarding the effectiveness of early mental health care interventions for trauma survivors in acute medical settings.
References
1. Katon W, VonKorff, M, Lin E, Walker E, Simon GE, Bush T, Robinson P, Russo J (1995): Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA, 273:1026-1031.
2. Katon W, Robinson P, VonKorff M, Lin E, Bush T, Ludman E, Simon GE, Walker E (1996): A multifaceted intervention to improve treatment of depression in primary care. A randomized trial. Arch Gen Psychiatry, 53: 924-932.
3. Katon W, VonKorff M, Lin E, Simon GE, Walker G, Unützer J, Bush T, Russo J, Ludman E (1999): Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomised trial. Arch Gen Psychiatry, 56: 1109-1115.