Transcript PPT, 0.11MB

Risk Factors and Screening
Chris R. Brewin
Clinical, Educational, and Health
Psychology,
University College London
Camden & Islington Mental Health
and Social Care Trust
Why screen?
30-40% of direct victims of terrorist attacks
likely to develop a clinically diagnosable
disorder within 2 years
Effective treatment is difficult due to:
poor recognition of PTSD in the
community
wide dispersion of cases
prominent avoidance symptoms
September 2008
© Chris R. Brewin
Criteria for a good
screening instrument
Accuracy
Reliability
Simplicity
Portability
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© Chris R. Brewin
Candidates for screening
items
– PTSD symptoms
–Other symptoms
–Impairment
–Risk factors
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© Chris R. Brewin
PTSD symptoms
•Can be tied to specific event?
•Relevant evidence base?
•Generally applicable?
•Easily measured?
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© Chris R. Brewin
SOME
YES
YES
YES
Other symptoms
•Can be tied to specific event?
•Relevant evidence base?
•Generally applicable?
•Easily measured?
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© Chris R. Brewin
NO
NO
YES
YES
Impairment
•Can be tied to specific event?
•Relevant evidence base?
•Generally applicable?
•Easily measured?
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?
NO
YES
YES
Risk Factors
•Pre-trauma:
–Female gender
–Social disadvantage
–Educational disadvantage
–Psychiatric history
–Previous trauma
–Family psychiatric history
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Risk Factors
•Peri-trauma:
–Objective trauma severity, including loss
and proximity to event
–Subjective trauma severity
–Dissociation
–Perceived threat to life
–Negative emotions
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Risk Factors
•Post-trauma:
–Social support
–Additional life stress
–Negative appraisals
–Negative emotions
–Thought suppression
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General conclusions on risk
factors
•Demographic and pre-trauma risk factors
are easy to measure but are weak predictors
•Peri- and post-trauma risk factors are
harder to measure, but are stronger
predictors. This makes them more suitable
for clinical than screening purposes. A small
number of objective indices could underpin
an approximate screening process
•Little is known about how to improve
prediction by combining risk factors
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© Chris R. Brewin
Risk Factors
•Can be tied to specific event?
•Relevant evidence base?
•Generally applicable?
•Easily measured?
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© Chris R. Brewin
SOME
YES
SOME
SOME
Systematic review of PTSD
screening instruments
INCLUDED IF:
published in English
contain 30 items or less
ability to detect PTSD in adults validated
against structured clinical interviews
relevant to any type of trauma
EXCLUDED IF:
limited to military or specific populations
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Results of search strategy
19 articles met all criteria
22 datasets were reported
13 separate instruments were identified,
ranging from 4-30 items in length
All instruments consisted of posttraumatic
symptoms
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Findings of review
•Mean diagnostic efficiency was 86.6%,
suggesting efficiency ceiling reached
•Most performed well because cut-off scores
were calculated post hoc or prevalence low
•Simpler and shorter measures performed as
well if not better than longer instruments
•Only the IES and TSQ had been tested
within 1 year of a trauma and cross-validated
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Screening after the London
Bombings
• Very brief questionnaire including:
– 10-item Trauma Screening Questionnaire
– 2 depression items
– 1 travel phobia item
– Increased drinking or smoking?
– Other worrying sign?
• Diagnostic interview offered if score >5 on
TSQ or any other items answered positively
• If children in family additional screeners sent
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Trauma Screening Questionnaire
YES, AT LEAST TWICE
IN THE PAST WEEK
1. Upsetting thoughts or memories about
the event that have come into your
mind against your will
2. Upsetting dreams about the event
3. Acting or feeling as though the event
were happening again
4. Feeling upset by reminders of the event
5. Bodily reactions when reminded of the event
6. Difficulty falling or staying asleep
7. Irritability or outbursts of anger
8. Difficulty concentrating
9. Heightened awareness of potential dangers
to yourself and others
10. Being jumpy or being startled at something
unexpected
NO
London Bombings screening take-up
596 screened at least once
Opt out
117
1 screener returned
2 screeners returned
3 screeners returned
4 screeners returned
5 screeners returned
–
–
–
–
–
400
123
51
20
2
Attended diagnostic interview
364
Referred to treatment
278
Primary diagnoses of patients
referred to treatment
Adjustment disorder
5%
Travel phobia
6%
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PTSD (DSM-IV
or ICD-10)
69%
© Chris R. Brewin
Complicated grief
GAD
Depression
Other/not stated
Guideline Recommendations
•Little point in early screening (first 6 weeks).
Studies needed of most appropriate time.
•Little point in using ASD as a predictor
•Further studies of screening needed to
establish value of risk factors rather than
symptoms
•Further studies of population-wide screening
needed
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Additional points for discussion
•Urgent intervention will be handled by
existing services. Register and contact details
need to be established at an early stage for
later screening and follow-up?
•A few objective indices (traumatic loss,
proximity to the event) should be recorded to
act as a crude measure of risk?
•Screening should be register- or populationbased?
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Additional points for discussion
•Is outreach always necessary to deliver
services where they are needed and who will
undertake this?
•Should screening measures be suitable for the
non-specialist (and for web-based screening?)
•Are existing symptom-based instruments
adequate and what additional research needs
to be done?
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References
Brewin, C.R. (2005). Systematic review of screening
instruments for the detection of posttraumatic stress disorder
in adults. Journal of Traumatic Stress, 18, 53-62.
Brewin, C.R. et al. (2002). A brief screening instrument for
posttraumatic stress disorder. British Journal of Psychiatry,
181, 158-162.
Brewin, C.R. et al. (2008). Promoting mental health following
the London bombings: A screen and treat approach. Journal of
Traumatic Stress, 21, 3-8.
Whalley, M.G. & Brewin, C.R. (2007). Mental health following
terrorist attacks. British Journal of Psychiatry, 190, 94-96.
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© Chris R. Brewin