Dr Meaghan O'Donnell
Associate Professor David Forbes
Professor Mark Creamer
Dr Alexander Holmes
Associate Professor Steven Ellen
Professor Richard Bryant
Australian Centre for Posttraumatic Mental Health
beyondblue Victorian Centre of Excellence
Project completion year
In Australia, more than 300,000 people are severely injured each year and require a hospital admission. The cost to the community in terms of human suffering and financial burden is considerable. Until very recently, the psychiatric aspect of injury and the impact of mental health on physical recovery were largely ignored. There is increasing evidence to suggest, however, that the psychological aspects of injury are of crucial importance in understanding recovery and the return to normal functioning1.
The aim of this study is to test the efficacy of early intervention telephone-administered cognitive behavioural therapy in the prevention/treatment of depression, PTSD and anxiety following traumatic injury.
The researchers hypothesise that early intervention telephone-administered CBT (TEl) will be associated with reduced symptoms of depression, PTSD and anxiety at six months post injury, relative to usual care (UC). They also expect the Telephone-Administered Early Intervention (TEI) group to have lower disability, higher quality of life, lower pain levels and less family conflict relative to UC.
This project is a randomised controlled trial (RCT) that will be conducted across multiple settings. The first setting is the acute hospital (trauma service inpatients); the second is assessment and treatment conducted in the community.
Methodology and project design
Target participants to this study are injury patients who have been admitted to the Alfred or Royal Melbourne Hospital trauma service. Screening will identify those at high risk for the development of depression and anxiety problems post injury. Psychological therapy will be targeted to those with persistent symptoms at one month post injury.
Importantly, this research targets injury patients who are mostly men (especially young men), people in the workforce (industrial and motor vehicle accidents) and women (although women are at less risk of being injured, they are at more risk to develop depression and anxiety after injury).
Measurable endpoints or outcomes:
- mental health symptom severity and caseness (including depression, anxiety, and PTSD symptoms)
- quality of life
- level of disability
- pain levels
- family coherence
- barriers to care: detailed assessment of those who refuse therapy will be collected.
The study will adopt a high methodological rigour by following CONSORT recommendations for conducting and reporting of well-designed RCTs.
Consecutively admitted injury patients at the Alfred and Royal Melbourne hospitals will be screened during their acute hospital admission to identify those at high risk of developing depression, PTSD and anxiety; those identified as high risk will be reassessed at four weeks post injury. Patients with high symptoms at four weeks will then be offered intervention and randomly assigned into telephone-administered CBT (TEl) or usual care (UC) conditions. Participants will be followed up at six and 12 months post injury. The study therefore employs a two (treatment condition) by three (assessment point) factorial design.
Telephone-administered early intervention
Those allocated to the TEl condition will have a face-to-face clinical assessment with the clinical psychologist conducting the therapy. This face-to-face assessment will allow the therapist to create a formulation of the patient’s presenting problems. This session is also expected to create rapport between therapist and patient, which will help adherence with the therapy.
The telephone-administered early intervention therapy will utilise the flexible, manual-based CBT tested in the previous study. This manual is made up of 12 modules, each of which targets a specific cluster of symptoms. The clinician will conduct a detailed assessment of the participant's symptoms and identify which modules the participant should receive. For example, participants with low mood and behavioural withdrawal will receive behavioural activation; those with symptoms of avoidance of future threat will receive graded exposure. All participants will receive the psycho-education, cognitive therapy and relapse-prevention modules. Participants will receive a minimum of six 90-minute sessions and will be offered another four sessions if they fail to cross a threshold in symptom reduction. In our previous study, the majority of patients required the full 10 sessions of therapy. For those with high pain levels, therapy sessions will be shorter but more frequent.
Those in the usual care condition will be provided with a standardised letter that suggests they contact their GP if their distress becomes unmanageable. The GP's management of the distress will be classified as usual care. Those in the usual care condition will be told that they will be offered intervention as part of the study at six months post injury. Detailed information will be collected about the usual care an individual received in the six months post injury. This will include type and duration of intervention and the individual’s satisfaction with the intervention.
The study will operate within an established stepped care, outreach model of early psychological intervention following injury. The project will screen over 700 injury patients, assess over 300 patients at four weeks for anxiety and depression symptoms, conduct in-depth clinical assessments on over 100 patients and carry out cognitive behavioural therapy on at least 42 patients.
At the end of the study, the researchers will be able to identify whether telephone-administered CBT is an efficacious way to deliver early psychological intervention. This will enable recommendations to be made about best practice processes for conducting telephone-administered therapy.
The research will result in a detailed assessment of the barriers to care for patients accessing psychological care.
1 O'Donnell ML, Holmes AC, Creamer MC, Ellen S, Judson R, McFarlane AC, Silove DM, Bryant RA: The role of post-traumatic stress disorder and depression in predicting disability after injury. Med J Aust 2009; 190(7):S71-4