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A Randomized Effectiveness Trial of Stepped Collaborative Care for Acutely Injured Trauma Survivors
Douglas Zatzick, MD;
Peter Roy-Byrne, MD;
Joan Russo, PhD;
Frederick Rivara, MD, MPH;
RoseAnne Droesch, MSW;
Amy Wagner, PhD;
Chris Dunn, PhD;
Gregory Jurkovich, MD;
Edwina Uehara, PhD;
Wayne Katon, MD
Arch Gen Psychiatry. 2004;61:498-506.
Context Although posttraumatic stress disorder (PTSD) and alcohol abuse frequently occur among acutely injured trauma survivors, few real-world interventions have targeted these disorders.
Objective We tested the effectiveness of a multifaceted collaborative care (CC) intervention for PTSD and alcohol abuse.
Design Randomized effectiveness trial.
Participants We recruited a population-based sample of 120 male and female injured surgical inpatients 18 or older at a level I trauma center.
Intervention Patients were randomly assigned to the CC intervention (n = 59) or the usual care (UC) control condition (n = 61). The CC patients received stepped care that consisted of (1) continuous postinjury case management, (2) motivational interviews targeting alcohol abuse/dependence, and (3) evidence-based pharmacotherapy and/or cognitive behavioral therapy for patients with persistent PTSD at 3 months after injury.
Main Outcome Measures We used the PTSD symptomatic criteria (PTSD Checklist) at baseline and 1, 3, 6, and 12 months after injury, and alcohol abuse/dependence (Composite International Diagnostic Interview) at baseline and 6 and 12 months after injury.
Results Random-coefficient regression analyses demonstrated that over time, CC patients were significantly less symptomatic compared with UC patients with regard to PTSD (P = .01) and alcohol abuse/dependence (P = .048). The CC group demonstrated no difference (–0.07%; 95% confidence interval [CI], –4.2% to 4.3%) in the adjusted rates of change in PTSD from baseline to 12 months, whereas the UC group had a 6% increase (95% CI, 3.1%-9.3%) during the year. The CC group showed on average a decrease in the rate of alcohol abuse/dependence of –24.2% (95% CI, –19.9% to –28.6%), whereas the UC group had on average a 12.9% increase (95% CI, 8.2%-17.7%) during the year.
Conclusions Early mental health care interventions can be feasibly and effectively delivered from trauma centers. Future investigations that refine routine acute care treatment procedures may improve the quality of mental health care for Americans injured in the wake of individual and mass trauma.
From the Departments of Psychiatry and Behavioral Sciences (Drs Zatzick, Roy-Byrne, Russo, Wagner, Dunn, and Katon), Pediatrics (Dr Rivara), and Surgery (Dr Jurkovich) and the Harborview Injury Prevention and Research Center (Drs Zatzick, Rivara, and Jurkovich and Ms Droesch), University of Washington School of Medicine, and the School of Social Work, University of Washington (Dr Uehara), Seattle.
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