Routine versus ad hoc screening for acute stress following injury: who would benefit and what are the opportunities for prevention.

Nathaniel Bell,Richard K Simons,Stephen Anderson,Robert Hewko,Boris Sobolev

doi:10.1186/1752-2897-8-5

Abstract

BackgroundScreening for acute stress is not part of routine trauma care owing in part to high variability of acute stress symptoms in identifying later onset of posttraumatic stress disorder (PTSD). The objective of this pilot study was to assess the sensitivity, specificity, and power to predict onset of PTSD symptoms at 1 and 4 months using a routine screening program in comparison to current ad hoc referral practice.MethodsProspective cross-sectional observational study of a sample of hospitalized trauma patients over a four-month period from a level-I hospital in Canada. Baseline assessments of acute stress (ASD) and subsyndromal ASD (SASD) were measured using the Stanford Acute Stress Reaction Questionnaire (SASRQ). In-hospital psychiatric consultations were identified from patient discharge summaries. PTSD symptoms were measured using the PTSD Checklist-Specific (PCL-S). Post-discharge health status and health services utilization surveys were also collected.ResultsRoutine screening using the ASD (0.43) and SASD (0.64) diagnoses were more sensitive to PTSD symptoms at one month in comparison to ad hoc referral (0.14) and also at four months (0.17, 0.33 versus 0.17). Ad hoc referral had greater positive predictive power in identifying PTSD caseness at 1 month (0.50) in comparison to the ASD (0.46) and SASD (0.43) diagnoses and also at 4 months (0.67 versus 0.25 and 0.29).ConclusionsAd hoc psychiatric referral process for acute stress is a more conservative approach than employing routine screening for identifying persons who are at risk of psychological morbidity following injury. Despite known limitations of available measures, routine patient screening would increase identification of trauma survivors at risk of mental health sequelae and better position trauma centers to respond to the circumstances that affect mental health during recovery.

Highlights

Screening for acute stress is not part of routine trauma care owing in part to high variability of acute stress symptoms in identifying later onset of posttraumatic stress disorder (PTSD)
While changes to the diagnosis have been made in the recent release of the DSM-V, there remains little evidence that the acute stress disorder (ASD) diagnosis is accurately predicting longer-term PTSD
It is well established that early identification of individuals at risk for PTSD is important for minimizing psychological morbidity, [10,11] trauma centers currently rely on ad hoc referral practices for identifying those individuals who display symptoms of acute stress

Summary

Introduction

Screening for acute stress is not part of routine trauma care owing in part to high variability of acute stress symptoms in identifying later onset of posttraumatic stress disorder (PTSD). While changes to the diagnosis have been made in the recent release of the DSM-V, there remains little evidence that the ASD diagnosis is accurately predicting longer-term PTSD These critiques have implications for how clinicians identify and manage psychological health after injury. It is well established that early identification of individuals at risk for PTSD is important for minimizing psychological morbidity, [10,11] trauma centers currently rely on ad hoc referral practices for identifying those individuals who display symptoms of acute stress. This is a significant limitation because persons with mental health illnesses often do not receive treatment, [12] are less likely to see health care specialists [13] and experience emotional disabilities often in parallel with substantial physical, social, and economic disadvantages [14,15]

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Conclusion