risk factors and screening chris r. brewin clinical, educational, and health psychology, university...

Risk Factors and ScreeningChris R. Brewin

Clinical, Educational, and Health Psychology,

University College LondonCamden & Islington Mental Health

and Social Care Trust

September 2008 © Chris R. Brewin

Why screen?30-40% of direct victims of terrorist attacks likely to develop a clinically diagnosable disorder within 2 yearsEffective treatment is difficult due to:

poor recognition of PTSD in the communitywide dispersion of casesprominent avoidance symptoms


Criteria for a good screening instrument

AccuracyReliabilitySimplicityPortability


Candidates for screening items

– PTSD symptoms–Other symptoms–Impairment–Risk factors


PTSD symptoms

•Can be tied to specific event? SOME•Relevant evidence base? YES•Generally applicable? YES•Easily measured? YES


Other symptoms

•Can be tied to specific event? NO•Relevant evidence base? NO•Generally applicable? YES•Easily measured? YES


Impairment

•Can be tied to specific event? ?•Relevant evidence base? NO•Generally applicable? YES•Easily measured? YES


Risk Factors

•Pre-trauma:–Female gender–Social disadvantage–Educational disadvantage–Psychiatric history–Previous trauma–Family psychiatric history


Risk Factors

•Peri-trauma:–Objective trauma severity, including loss and proximity to event–Subjective trauma severity–Dissociation–Perceived threat to life–Negative emotions


Risk Factors

•Post-trauma:–Social support–Additional life stress–Negative appraisals–Negative emotions–Thought suppression


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


Risk Factors

•Can be tied to specific event? SOME•Relevant evidence base? YES•Generally applicable? SOME•Easily measured? SOME


Systematic review of PTSD screening instruments

INCLUDED IF: published in Englishcontain 30 items or lessability to detect PTSD in adults validated against structured clinical interviewsrelevant to any type of traumaEXCLUDED IF:limited to military or specific populations


Results of search strategy

19 articles met all criteria22 datasets were reported13 separate instruments were identified, ranging from 4-30 items in lengthAll instruments consisted of posttraumatic symptoms


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


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

Trauma Screening Questionnaire YES, AT LEAST

TWICE IN THE PAST WEEK NO 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

London Bombings screening take-up

596 screened at least once1 screener returned – 4002 screeners returned – 1233 screeners returned – 514 screeners returned – 205 screeners returned – 2

Opt out117

Attended diagnostic interview364

Referred to treatment278


Primary diagnoses of patients referred to treatment

Adjustment disorder5%

Travel phobia6%

PTSD (DSM-IV or ICD-10)

69%

Complicated griefGADDepressionOther/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


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 population-based?


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?


ReferencesBrewin, 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.

risk factors and screening chris r. brewin clinical, educational, and health psychology, university...

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