risk factors and screening chris r. brewin clinical, educational, and health psychology, university...
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September 2008© Chris R. Brewin Criteria for a good screening instrument Accuracy Reliability Simplicity PortabilityTRANSCRIPT
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
September 2008 © Chris R. Brewin
Criteria for a good screening instrument
AccuracyReliabilitySimplicityPortability
September 2008 © Chris R. Brewin
Candidates for screening items
– PTSD symptoms–Other symptoms–Impairment–Risk factors
September 2008 © Chris R. Brewin
PTSD symptoms
•Can be tied to specific event? SOME•Relevant evidence base? YES•Generally applicable? YES•Easily measured? YES
September 2008 © Chris R. Brewin
Other symptoms
•Can be tied to specific event? NO•Relevant evidence base? NO•Generally applicable? YES•Easily measured? YES
September 2008 © Chris R. Brewin
Impairment
•Can be tied to specific event? ?•Relevant evidence base? NO•Generally applicable? YES•Easily measured? YES
September 2008 © Chris R. Brewin
Risk Factors
•Pre-trauma:–Female gender–Social disadvantage–Educational disadvantage–Psychiatric history–Previous trauma–Family psychiatric history
September 2008 © Chris R. Brewin
Risk Factors
•Peri-trauma:–Objective trauma severity, including loss and proximity to event–Subjective trauma severity–Dissociation–Perceived threat to life–Negative emotions
September 2008 © Chris R. Brewin
Risk Factors
•Post-trauma:–Social support–Additional life stress–Negative appraisals–Negative emotions–Thought suppression
September 2008 © Chris R. Brewin
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
September 2008 © Chris R. Brewin
Risk Factors
•Can be tied to specific event? SOME•Relevant evidence base? YES•Generally applicable? SOME•Easily measured? SOME
September 2008 © Chris R. Brewin
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
September 2008 © Chris R. Brewin
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
September 2008 © Chris R. Brewin
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
September 2008 © Chris R. Brewin
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
September 2008 © Chris R. Brewin
Primary diagnoses of patients referred to treatment
Adjustment disorder5%
Travel phobia6%
PTSD (DSM-IV or ICD-10)
69%
Complicated griefGADDepressionOther/not stated
September 2008 © Chris R. Brewin
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
September 2008 © Chris R. Brewin
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?
September 2008 © Chris R. Brewin
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?
September 2008 © Chris R. Brewin
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.