Screening,Brief Intervention,and Referral to Treatment to Prevent Post-Traumatic Stress Disorder After Gunshot Wounds

Screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based prevention model that was originally developed as an easy-to-administer method to identify, reduce, and deter substance abuse in hospitalized patients. Its adaptation to prevent the ill-effects that arise after traumatic injury has been limited. Specifically, application of the SBIRT model to post-traumatic stress disorder (PTSD) can potentially reduce the progression of acute stress symptoms after injury.

PTSD is a negative mental health consequence of trauma that effects up to 30% of injured patients. ¹ It is associated with severe physical and mental morbidity, including heightened risks of substance or alcohol abuse and other mental health problems (ie, depression and anxiety). With this in mind, the objective of this study was to assess the effectiveness of a newly adapted SBIRT model for reducing PTSD among hospitalized patients with gunshot wounds (GSWs). We hypothesized that administration of a brief screening and intervention for PTSD during index hospitalization for firearm injury paired with thorough follow-up is an effective method for reducing PTSD symptoms over time.

We conducted a prospective study using a convenience sample of adult patients (18-65 years of age) who presented to an urban level 1 trauma center for management of gunshot wounds. Individuals who sustained self-inflicted injuries were excluded from the study as were pregnant women and incarcerated persons. Consented study participants were randomized into two arms—an intervention group (INT) or treatment as usual group (TAU). All study participants were asked to complete validated post-traumatic stress disorder (PTSD Checklist for DSM-5, PCL-5) assessment. PCL-5 scores range from 0 to 80; a cut-point score of 31-33 usually indicates a diagnosis of PTSD. In addition, the INT group received a newly developed brief SBIRT Intervention for Trauma Patients (SITP) which was created using a multidisciplinary approach combining input from psychiatry, trauma surgery, public health, and the Screening, Brief Intervention, and Referral to Treatment (SBIRT) toolbox development data. Follow-up assessments were done for both groups at 30 days and 3 months following the index hospitalization for injury.

Participant demographics, injury characteristics, and clinical outcomes were obtained. Quantitative data analysis was conducted to determine a reduction in PTSD symptoms over time and between INT and TAU groups. Mean PCL-5 scores were compared using Student’s t-tests and one-way analysis of variance (ANOVA), as appropriate.

A convenience sample of 169 patients was approached for participation in our study and 46 were consented, yielding an initial participation rate of 26%. The majority of our participants were male (N = 42, 91.3%) and black (N = 40, 86.9%). Our mean age was 30.5 years, and mean injury severity score was (ISS) 15.2. Mean ICU length of stay (LOS) for the 25 (54%) patients who required admission was 6.96 days, whereas mean total LOS was 12.57 days. On average, participants took <20 minutes to complete the initial PTSD screen. After randomization, there were no differences between the INT and TAU groups with regards to race, gender, age, or injury severity. One-month post-hospital discharge, INT and TAU patients had similar physical healing scores. However, the INT arm showed a reduction in PTSD symptoms between one and three-month follow-up as opposed to TAU arm which showed an increase in symptoms (53.24→49.83 compared to 42.42→46.86, respectively, P< .001).

Previous studies have shown a lack of psychological screening in level 1 trauma centers in the United States.^1,2 Jaramillo et al suggests that a tool that is both comprehensive and brief can work to overcome barriers to systematic screening in high-stress trauma settings. ¹ Topitzes and colleagues created a specific Trauma Screening, Brief Intervention, and Referral to Treatment (T-SBIRT) in a level one trauma center as one such solution. T-SBIRT proved to be both a feasible and effective method of screening for PTSD among adults in the emergency department (ED) but was limited in that it did not explicitly prove effectiveness at reducing the mental health consequences associated with trauma.^3,4

Our study addresses this current gap. After implementing a similar and multidisciplinary-derived, trauma-informed tool (SITP) at Grady Memorial Hospital, an urban, level 1 trauma center, our results support previous findings; the SITP (an adapted SBIRT model to help prevent PTSD) proves easy to administer and effective. ³ The SITP can be administered in <20 minutes, and study participants who received the intervention showed reduced symptoms of PTSD at 3 months compared to those in the TAU group.

Trauma patients are more likely to suffer from symptoms of depression and PTSD following their injury, disrupting the healing process and lowering health-related quality of life. ¹ In addition, PTSD is associated with worse physical, mental, and social health. Patients with PTSD have been shown to have worse health outcomes, increased drug and alcohol dependence, and increased homelessness and housing insecurity. In striving for better health outcomes for trauma patients, the SITP shows promising efforts to reduce such symptoms, improving health-related quality of life. Limitations to this study include the small sample size and short study period. This data only represents admitted gunshot victims being treated at one urban level 1 trauma center, which may lead to low external validity. Future research will look to expand the reach of this tool to other trauma patients beyond gunshot victims and to other trauma centers to determine utility in different patient populations. Last, we look to understand the barriers to recruitment and retention of at-risk individuals who would benefit the most from this promising novel treatment.