People affected by trauma present in a number of different settings (Solomon et. al., 1997), sometimes immediately after the trauma, and sometimes much later when they are experiencing the effects of traumatic stress, depression, anxiety or other mental health difficulties.
When trauma leads to an individual developing a post traumatic stress reaction, there is not only a huge impact on the individual, but also on their family, their workplace, the health care system and society more broadly through the cost of burden of disease.
A systematic review, conducted for the US Agency for Healthcare Research and Quality (AHRQ), evaluates the evidence available for a range of interventions to prevent the onset of, or reduce the severity of symptoms of Post-Traumatic Stress Disorder (PTSD).
This systematic review:
assessed the efficacy, comparative effectiveness, and harms of psychological, pharmacologic and emerging interventions to prevent PTSD.
A comprehensive literature search identified 2563 citations of studies that assessed either the incidence of PTSD following a traumatic event, or the symptom severity of PTSD.
From this the reviewers included 19 studies that had low to medium risk of bias. All the included studies were randomized control trials (RCTs) and compared an intervention with either waitlist, usual care, no intervention, placebo or some other intervention.
Of the included studies, 16 investigated psychological interventions such as Cognitive Behavioural Therapy (CBT), Battlemind training, CBT plus hypnosis, debriefing, psychoeducation as well as others. 2 studies assessed the efficacy of pharmacologic interventions and 1 study addressed the efficacy of collaborative care.
- As the body of evidence mainly consisted of single studies, often with small sample sizes, methodological limitations and imprecise results, the authors were unable to make a definitive conclusion regarding the efficacy of various psychological interventions in preventing PTSD or reducing PTSD symptoms.
- There was evidence that debriefing does not work to decrease the incidence of PTSD, PTSD symptom severity, depression or anxiety.
- There was insufficient evidence regarding the efficacy or pharmacologic interventions.
- There was evidence from one study to show that a stepped, collaborative care intervention for victims requiring surgical hospitalization and with PTSD symptoms led to a reduction in PTSD symptom severity at 6, 9 and 12 months after injury.
- Four studies that looked at the effectiveness of CBT demonstrated a reduction in PTSD symptom severity as well as a reduction in the symptoms of anxiety and depression.
In reporting the results of the review the authors suggested:
- For people with acute stress disorder, CBT is more effective than supporting counseling in reducing PTSD symptoms severity;
- Collaborative care produces a greater decrease in PTSD symptom severity after injury than usual care; and
- Generally, debriefing is not effective in reducing either PTSD incidence or the severity of PTSD or depressive symptoms”.
The authors of this review concluded that:
the evidence for best practices for treating trauma-exposed individuals is very limited.
It remains difficult to reach conclusions about what prevents the onset of PTSD in an individual following the incidence of a traumatic event.
Whilst this review adds to our knowledge of what interventions can impact on an individual’s response to a traumatic event, there are many other factors at play. These include
- the person’s proximity to the traumatic event,
- their mental health prior to the event,
- their personality,
- the presence of other traumatic events and stressors in their life and
- their level of social support.
There were many studies that did not meet the criteria to be included in this review. Further research funding needs to be committed to identifying effective, evidence based interventions to prevent PTSD, in children and adults.
The review was also limited in that there were no studies included that examined the traumatic experiences of terrorism, sexual assault, natural disasters or combat related trauma. This limits their applicability to the general population, especially to racial and ethnic minorities, refugees and first responders.
So what applicability does this study have for those of us who are working with people who have experienced trauma? A collaborative approach to a person’s care after a traumatic experience, as well as a therapeutic intervention that contains elements of CBT, seems likely to have the best outcomes in reducing the severity of symptoms associated with PTSD, for patients over a 6 to 12 month period after the event.
Catherine A. Forneris; Gerald Gartlehner; Kimberley A. Brownley; Bradley N. Gaynes; Jeffrey Sonis; Emmanuel Coker-Schwimmer; Daniel E. Jonas; Amy Greenblatt; Tania M. Wilkins; Carol L. Woodell; Kathleen N. Lohr. Interventions to Prevent Post-Traumatic Stress Disorder: A Systematic Review. American Journal of Preventive Medicine; 2013 44(6): 635 – 650.[PubMed abstract]
Susan D. Solomon & Jonathan R. T. Davidson. Trauma: Prevalence, impairment, service use and cost. Journal of Clinical Psychiatry;1997 58 (9)5 – 11. [PubMed abstract]