Posted on 06/04/2008 8:20:46 PM PDT by neverdem
BRUCE JANCIN (Denver Bureau)
Article Outline • Copyright
NEW YORK — Posttraumatic stress disorder and depression are extremely common a full year after hospitalization for injury and are associated with up to a nearly sixfold increased likelihood of failure to return to work, according to the largest-ever U.S. study evaluating the multiple impacts of trauma.
The implications of these new findings from the National Study of Costs and Outcomes of Trauma (NSCOT) are profound. With an estimated 2.5 million hospital admissions for injury per year in the United States, the data would suggest 500,000 of these patients will have debilitating posttraumatic stress disorder (PTSD) 1 year later, Dr. Douglas F. Zatzick said at the annual meeting of the American Surgical Association.
The economic, social, and health costs of this problem are such that screening for early signs of PTSD and depression should become routine for all trauma patients, regardless of injury severity, according to Dr. Zatzick, a psychiatrist at the University of Washington, Seattle.
He reported on 2,707 NSCOT participants hospitalized for injuries requiring surgery at 69 U.S. hospitals, including 18 level 1 trauma centers. The patients, who were followed for 1 year, represented the broad spectrum of trauma with the exception of burn injuries, an exclusion criterion.
One year post injury, 20.7% of subjects met diagnostic criteria for PTSD using the validated 17-item PTSD checklist. Another 6.6% met criteria for depression using the Center for Epidemiologic Studies Depression Scale, and 4.9% had both psychiatric disorders. Forty-five percent of patients who were employed preinjury had not returned to work after 1 year. The rate varied significantly depending on whether a patient had neither psychiatric disorder, one, or both. (See graphic.)
In a multivariate analysis adjusting for injury severity, premorbid psychiatric disorders, and preinjury health status and functioning, having either PTSD or depression was an independent risk factor associated with a 3.2-fold greater likelihood of failure to return to work than for those with neither disorder. Patients with both depression and PTSD were at a 5.6-fold increased risk.
A similar stepwise relationship was observed between the number of psychiatric diagnoses present and other measures of functional impairment collected in the study, including return to usual activities as well as physical and mental health status as assessed using the Short Form 36, Dr. Zatzick continued.
The prevalence of PTSD and depression was similar in patients treated at level 1 trauma centers and those treated at community hospitals, as were adjusted return-to-work rates.
Surgeons in the audience were quick to recognize the scope of the problem but cognizant of their own limitations in assessing and managing psychiatric disorders.
“As a trauma community, we are largely ignoring this problem currently,” said Dr. David B. Hoyt, professor of surgery and chief of the division of trauma, burns, and critical care at the University of California, San Diego. “It's hard to get psychiatric consults for inpatient trauma patients … Who will be available to help manage this complicated problem?”
Col. John B. Holcomb, USA, commented that the prevalence of PTSD and depression documented in NSCOT is “exactly the same” as that found in both military and civilian trauma populations.
“Just screen everybody,” Dr. Holcomb, commander of the U.S. Army Institute of Surgical Research, Brooke Army Medical Center, San Antonio, advised his civilian colleagues. “PTSD is [not] related to your family or work status. And we find it's not related to severity of injury; what we would consider a minor injury the patient may consider a major injury.”
NSCOT copresenter Dr. Gregory J. Jurkovich said the responsibility for broad-based care would entail a collaborative effort between psychiatrists, psychologists, rehabilitation specialists, and others.
He noted that the disorder can't be formally diagnosed until at least 1 month after the traumatic event. The strongest predictor of subsequent PTSD is development of an acute stress disorder during the hospitalization. This acute stress response is marked by the same three classes of symptoms that define PTSD: intrusive symptoms such as flashbacks and nightmares, avoidance behavior, and hyperarousal as evidenced by insomnia, inability to concentrate, and an exaggerated startle response.
Other indicators of increased likelihood of PTSD in trauma patients include having more than four prior hospitalizations for trauma, female gender, and a positive urine toxicology screen, said Dr. Jurkovich, professor of surgery at the University of Washington and chief of trauma services at Harborview Medical Center, both in Seattle.
I bet John Edwards and his trial lawyer cronies would all love for this to happen. Just think of all the myriad ways they could then rake doctors and nurses over the coals.
Depending on how you define PTSD, nearly every normal person is likely to “suffer” from it. We all go through trauma in our lives and we all continue to remember it for years afterwards. But it is a normal part of life and should be considered such. I hate this disbilitation of America. When a schoolkid dies these days, no matter why, the schools pull out all stops to comfort kids on the assumption that all are traumatized. There seems to be little distinction between sorrow and trauma, between regret and trauma, and between melancholy and trauma. Apparently we are all supposed to be happy and (I was going to write “gay”) mellow no matter what happens.
Bad things happen. We probably all have flashbacks, some pleasant, some not so. But they are not abnormal or signs of mental illness. Nor are they reasons to avoid normal life and responsibilities. Adults do things anyway, whether or not they feel like it. We are becoming a generation of wimps. /rant off ;o)
“When a schoolkid dies these days, no matter why, the schools pull out all stops to comfort kids on the assumption that all are traumatized.”
Ever dealt with children who have lost a classmate or a parent or a sibling? All may not be traumatized but ALL are affected. Making counseling available helps children deal with loss. And may just prevent another traumatic incident.
I don’t think you should do it as a matter of course. I think you should carefully watch a traumatized kid and see if he or she is showing unusual symptoms and then intervene.
This bringing counselors on for everyone at the first moment is, to my mind, a self-fulfilling prophecy: we expect you to be traumatized so you will be. It is the same principle as when a kid falls down. You as a parent often react one of two ways: You rush to the kid and cry “are you hurt?” “are you okay?” or you matter-of-factly say something like, “did you bite my floor?” Believe me, you get two different reactions from the kid most of the time.
Yes, I have dealt with traumatized kids, my own. Yes, I had classmates die. Don’t assume that every traumatic event will always result in trauma to the kid. We are more resilient than that and the way we make assumptions will have a tendency to either increase or decrease PTSD. Nightmares are a normal part of life. So are daylight flashbacks. Treat the debilitating problems but don’t assume debilitation or don’t lead people to expect themselves to be debilitated. Either way, the won’t disappoint you.
“I don’t think you should do it as a matter of course. I think you should carefully watch a traumatized kid and see if he or she is showing unusual symptoms and then intervene.”
Yes, in every case, it should be done as a matter of course. That’s the point of a crisis team, to watch and be available. If they aren’t there, they can’t watch.
It is one thing to watch. It is another to push a crisis team in someone’s face with the subliminal or not-so-subliminal message that one ought to be traumatized. A crisis team is usually over-reaction and will justify its presence one way or another.
I got caught up in a traumatic situation about fifteen years ago. The crisis teams were called in and victims were urged to vent their feelings. My husband and I went and, while we appreciated getting more details of what happened during the event, we did not feel any catharsis or anything else except being encouraged to dwell on our feelings. Several more session were called. We declined the offer after the second because it was just reliving the situation again and hearing people competing to who did the most suffering. We were the most successful in moving on from the situation compared to those who were doing the crisis team bidding. We did it by chalking our experience up to misfortune and leaving it there. Had we not been able to move on, then definitely some help should happen but these automatic crisis intervention teams tend to encourage people to get hung up on their traumas.
You may argue that children are different but I’m not so sure. Children can be amazingly resilient, even more so than adults and we need to allow their natural defenses to operate rather than enervating that instinct. Watch them, yes. Intervene when necessary. But don’t assume they can’t handle traumas by themselves.
My grandfather lost his mother at age two months. His only sibling died when he was just three years old. His father abandoned him to a maiden aunt, who later married and whose husband abused him physically until she divorced him. She raised him as a single mother from then on, in the early 1900s. Yet he grew up to be a loving husband and father to six children and never had a single problem with the law, with addictions or anything else.
My father also lost his mother early—at age four. His emotionally distant father married a widow with three children of her own, making six children in the family. The stepmother drove away his little brother. He surfaced only after a forty year absence. They treated him with contempt and, after taking all the profits from the family farm crops, they refused to lend my mother $400 after my father broke his neck. Yet my parents cared for both of them until they died.
My reason for detailing that family history is that we seem to be too quick to assume people can’t move on in their lives, yet generations have done so forever. Generally people are strong when they expect themselves to be strong and weak when they expect themselves to be weak. Bringing in the crisis teams at the first moment says to them, “we expect you to be weak.”
No bringing in the crisis team immediately is saying we care about you and if you want to talk we’re here. Not all children react the same way and provisions need to be made for those that can’t handle the situation. Glad you and yours are so resilient, not everyone is.
Where are the parents in the times of their childrens’ crises? I am my children’s crisis team and if I feel I need assistance, I will get it. I don’t want the schools interfering with that parental function. I think we both agree that sometimes help is needed but the issue is how quickly and whether it should be automatic or on an as-needed basis. I vote for as-needed. I do understand your concern about having help within reach to everyone but don’t mess with my kids without my say-so.
“but don’t mess with my kids without my say-so.”
And apparently you don’t get it. No one forces the kids to see anyone if they don’t want to. And if your kids decided to see a counselor without your “permission”, then what? Are you going to punish them for it?
No, I would not punish my kid but I would have a few words with the counselor. Sorry but schools take the in loco parentis bit too seriously. I didn’t say the kids were forced to see a counselor but having the counselors novering around from the very first moment is wrong-headed, I believe. If they showed up a week later and asked older kids if anyone wanted to talk to a counselor, fine. But too often the team is there immediately before the kids even begin to process the trauma and I think that’s way too soon. Kids have support groups, whether friends, parents or other adults in their lives that can help and should have first crack at doing so. Strangers in the mode of crisis teams should be a later resort only at need.
“Strangers in the mode of crisis teams should be a later resort only at need.”
Most times they aren’t strangers. And I’ll bow out by simply saying I don’t agree with you at all.
No problem. Reasonable people can respectfully disagree.
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