University Department of Psychiatry, Warneford Hospital, Oxford
Psychotherapy Department, Warneford Hospital, Oxford
Correspondence: Professor R. A. Mayou, University Department of Psychiatry, Warneford Hospital, Oxford OX37JX. Tel: (+44) 1865-226477; fax (+44) 1865-793101
Declaration of interest Grant from the Oxford Region Health Services Research Committee.
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ABSTRACT |
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Aims To evaluate the 3-year outcome in a randomised controlled trial of debriefing for consecutive subjects admitted to hospital following a road traffic accident.
Method Patients were assessed in hospital by the Impact of Event Scale (IES), Brief Symptom Inventory (BSI) and questionnaire and re-assessed at 3 months and 3 years. The intervention was psychological debriefing as recommended and described in the literature.
Results The intervention group had a significantly worse outcome at 3 years in terms of general psychiatric symptoms (BSI), travel anxiety when being a passenger, pain, physical problems, overall level of functioning, and financial problems. Patients who initially had high intrusion and avoidance symptoms (IES) remained symptomatic if they had received the intervention, but recovered if they did not receive the intervention.
Conclusions Psychological debriefing is ineffective and has adverse long-term effects. It is not an appropriate treatment for trauma victims.
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INTRODUCTION |
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We have previously described the outcome at 4 months in a randomised controlled trial of 106 patients consecutively admitted to hospital following a road traffic accident and who underwent early debriefing, mostly within 24-48 h (Hobbs et al, 1996). We concluded that psychiatric morbidity was substantial 4 months after injury, and there was no evidence that debriefing had helped; indeed, there were indications that it might have been disadvantageous. A more recent account of a series of 40 trauma clinic attenders re-assessed at 3 months following the trauma reported similar findings (Conlon et al, 1999). However, there remain many unanswered questions about debriefing interventions following road accidents and other trauma, which are of theoretical and clinical importance. We now report a 3-year follow-up of the sample on which we reported previously.
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METHOD |
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Baseline measures
Impact of Event Scale (IES) (Horowitz
et al, 1979) and Brief Symptom Inventory (BSI)
(Mayou, 1987), together with a
semi-structured interview derived from our previous research
(Mayou et al,
1993).
Injury severity was assessed separately for injuries of the head and neck, face, chest, abdomen and pelvis and extremities, and summed to the overall Abbreviated Injury Severity (AIS) score (Association for the Advancement of Automotive Medicine, 1990).
The length of stay in hospital was classified as overnight (1), under 3 days (2) and more than 3 days.
Follow-up measures
Impact of Event Scale (IES). The total score (sum of intrusion and
avoidance symptoms) was used for the main analyses.
Brief Symptom Inventory (BSI); the general symptoms index (GSI) (mean of the 53 symptoms) was used for the main analyses.
Questionnaires derived from our previous research (Mayou et al, 1993) covering:
Intervention
Subjects in the intervention group were offered a debriefing intervention
which lasted approximately one hour. It included a detailed review of the
accident, the encouragement of appropriate emotional expression, and initial
cognitive appraisal of traumatic experience: that is, an appraisal of the
subject's perceptions of the accident. The aim of the intervention was to
promote the emotional and cognitive processes which, it is believed, lead to
resolution of the trauma. The intervention ended with the research worker
giving information about common emotional reactions to traumatic experience,
stressing the value of talking about the experience rather than suppressing
thoughts and feelings, and also the importance of an early and graded return
to normal travel. Subjects were given a leaflet summarising the principles of
the intervention and which also encouraged support from family and friends; it
advised consultation with the family doctor if problems persisted. General
practitioners were informed of the study and sent a copy of the leaflet.
Statistical analyses
Scores on the IES and BSI were not normally distributed. They were
log-transformed, which normalised the distributions. Changes in these scores
over time were analysed with repeated measures analysis of variance (ANOVA).
Differences between the intervention and control groups were tested using
analysis of covariance (ANCOVA), with baseline scores as the covariates.
To investigate whether there were differential effects of the intervention,
depending on the initial severity of intrusion and avoidance symptoms,
patients were classified as to whether they had low (<24) or high (24)
initial IES scores. This cut-off point was chosen because it represented the
top 25% of the initial IES scores. Group differences were analysed with 2-way
ANCOVA, using baseline IES scores as the covariate, and intervention
v. control and high v. low initial score as the
between-subject factors.
Ratings for loss of enjoyment when driving or being a passenger, pain,
physical problems, and interference with everyday functioning at 3 years were
analysed with t-tests. ANCOVAs were used to control for the possible
effects of injury severity on the outcome measures. Ratings for financial and
insurance problems were analysed with MannWhitney U-tests,
because of very skewed distributions. Driving behaviour and driving problems
were analysed with 2-tests.
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RESULTS |
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There were no significant differences between follow-up patients who had
received the debriefing intervention and controls in terms of age, gender,
marital status, social class, driver v. passenger, vehicle type,
length of hospital stay, severity of injury, history of emotional problems and
initial emotional response to the accident. However, when types of injury were
considered separately, it was found that the intervention group had more
severe injuries of their extremities (mean severity 1.33 v. 0.71,
t(59)=2.22, P=0.030). There was no difference between
intervention (27%) and control groups (29%) in the proportion of patients
classified as having high initial scores (2(1,61)=0.42,
P=0.84).
Post-traumatic symptoms at 3 years
Intrusion and avoidance symptoms as measured by the IES were lower at the
3-year follow-up than at initial assessment: F(1,59)=6.33, P=0.015.
The ANCOVA did not show a significant effect of intervention on IES scores at
3 years: F(1,58)=2.03, P=0.16.
Outcome according to initial IES scores
We then examined the possibility of differential effects of the
intervention on patients with high and low initial IES scores (see
Table 1 and
Fig. 1). The ANCOVA of IES
scores at 3 years showed a significant effect of intervention: F(1,56)=4.91,
P=0.031; and a significant interaction of intervention and IES group
(high v. low initial scores): F(1,56)=4.29, P=0.043. For
those with low initial scores, there were no differences between intervention
and control patients, but the intervention group had a significantly worse
outcome among those who had high initial scores (t(14)=2.56,
P=0.023; observed difference 0.74, 95% CI for difference 0.11-1.28).
Patients with high scores who received the intervention still showed symptoms,
whereas those who did not receive the intervention improved and had scores
comparable with those of patients with low initial scores at follow-up.
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In order to examine the course of the worse outcome of treated patients with high initial IES scores, outcome at 4 months was included in a further ANCOVA (Fig. 1). The results again showed an effect of intervention (F(1,52)=7.32, P=0.009) and an interaction between intervention and IES group (F(1,52)=5.46, P=0.023). The results indicated that the negative effects of the intervention on patients with high initial IES scores were already present at 4 months post-intervention and were maintained at follow-up.
We next tested whether the worse outcome at 3 years of the high IES scores who had received the intervention was due to differences in the severity of their injuries. Intervention patients with high initial IES scores had more severe injuries (2.0 v. 1.2, t(15)=3.29, P=0.005) and stayed marginally longer in hospital (2.2 v. 1.4, t(15)=1.80, P=0.092). When the injury severity for different body parts was considered separately, it emerged that the intervention group had more severe injuries to their extremities (1.6 v. 0.3, t(15)=2.99, P=0.009). Analyses of covariance tested whether any of these variables could account for the higher IES scores of the intervention group at 3 years. This was not the case. In all instances, the intervention factor remained at least marginally significant (all P <0.07).
There was a marginal association between overall injury severity and IES scores at 3 years (r=0.23, P=0.076), but no significant associations with hospital stay (r=0.20) or severity of injuries to the extremities (r=0.18).
Other psychological outcomes
Other psychiatric symptoms
Table 1 shows the results of
the GSI score of the BSI. In contrast to the IES results, there was no overall
improvement from the initial assessment to the 3-year follow-up on this
measure (P>0.40). The ANCOVA of 3-year follow-up scores,
controlling for baseline scores, showed a significant effect of intervention
(F(1,57)=5.21, P=0.026). Patients in the intervention group reported
more severe psychiatric symptoms at follow-up (observed difference 0.08; 95%
CI for difference 0.009-0.15).
The difference between the groups at 3 years remained at least marginally significant when the severity of injury of the extremities, overall injury severity or hospital stay were statistically controlled by ANCOVA (all P<0.07). When the sub-scales of the BSI were considered separately, the intervention group had significantly higher scores (P<0.03) at 3 years for anxiety, depression, obsessivecompulsive problems, and hostility.
Travel anxiety
There were no differences between the groups in driving behaviour: one
patient in each group had given up driving as a result of the accident. The
groups did not differ in terms of enjoyment of driving (t(57)=0.37).
However, people in the intervention group enjoyed being a passenger less than
those in the control group (t(54)=2.87, P=0.006; observed
difference 0.82, 95% CI for difference 0.25-1.40).
Other outcomes
Pain
At the 3-year follow-up, those in the intervention group reported more
severe pain (t(59)=3.19, P=0.002, observed difference=0.72,
95% CI for difference 0.27-1.17) (see Table
1). The effects were the same when mean severity of injury, length
of hospital stay, or injuries of extremities were controlled in analyses of
covariance (all P<0.007). Whether or not a patient had high
initial IES scores did not have any effect on pain at 3 years.
Physical problems
At the 3-year follow-up, patients in the intervention group reported having
recovered less well physically than controls (t(59)=2.33,
P=0.023, observed difference=0.38, 95% CI for difference 0.05-0.71).
Of the intervention group, 20% described major chronic health problems,
compared with 3.2% of the control group. The difference between the groups was
only partially accounted for by differences in severity of injury, because the
worse outcome for the intervention subjects remained marginally significant in
analyses of covariance controlling for mean injury severity, length of
hospital stay, or injuries of extremities (all P<0.07). Whether or
not a patient had high initial IES scores did not have any effect on the
degree of physical recovery at 3 years.
Quality of everyday life
On the overall score, patients in the intervention group reported more
impaired functioning than controls (t(54)=3.48, P=0.001;
observed difference=0.61, 95% CI for difference 0.26-0.97). The group
difference remained highly significant when severity of injury to the
extremities, overall injury severity, or length of hospital stay were
statistically controlled for with analysis of covariance (all
P<0.008). When scores on the individual ratings were considered,
significant group differences were found for home maintenance, leisure,
friends, work and hours worked.
The intervention group described greater financial problems as a result of the accident, U=279.5, Z=2.67, P=0.008. There was no effect of insurance problems on everyday life between the groups.
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DISCUSSION |
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Our debriefing intervention was carried out with individuals who were unprepared for highly stressful experiences, was relatively short and had limited internal structure. It contrasted in significant ways with the models of psychological debriefing described by Mitchell (Mitchell, 1983) and Dyregrov (Dyregrov, 1989), both of which were devised for groups of emergency services and rescue personnel, are substantially longer (2-3 hours minimum) and are conducted in a highly structured manner.
Outcomes
The first aim was to determine whether we could replicate at 3 years our
previously published report of outcome at 4 months. The findings strongly
support our earlier conclusion, that a 1-hour debriefing intervention and
written information had no benefit for a range of psychological and social
outcomes, and reinforce the conclusion that the intervention may have made
patients worse. We are now able to report a follow-up considerably longer than
is available for any other published randomised controlled trial. The
conclusions are in agreement with those of the Cochrane Review
(Wessely et al, 1998)
and in particular with the findings of the only other long-term follow-up,
which reported outcome at 13 months following acute burn injury
(Bisson et al,
1997).
Our second aim was to examine the differential effects of intervention on those with high and low initial IES scores. For patients with low IES scores, it does not seem to make any difference whether or not they receive intervention; but for patients with high scores, post-traumatic stress disorder (PTSD) symptom outcome is significantly worse if they receive the intervention.
Our other aim related to outcomes other than PTSD. It is apparent that there is an adverse outcome in the intervention group for emotional distress, subjective report of physical symptoms and physical functioning for pain, and for ratings of the main domains of everyday life. Although most of the measures were simple rating scales, the effect sizes appear to be of clinical significance.
Mechanisms
The mechanisms of the adverse effects are unclear. One may speculate that
very early exposure to the memory of the traumatic event is counter-productive
in that it may interfere with the normal cognitive processes that lead to
recovery. It is possible that the instructions led patients to ruminate
excessively about the accident rather than putting it behind them. It is also
possible that the process and recommended content of debriefing have
effects on psychological processing very different from those of the cognitive
interventions which have so far been used with apparent benefit at a somewhat
later stage after trauma. The adverse effects of the intervention may not
apply to other forms of debriefing involving later intervention or group
debriefing. However, it is difficult to see how group debriefing could be
applied to sufferers from road traffic accidents who experience different
types of accident at different times. Furthermore, as yet there is no
empirical evidence that group debriefing has positive effects on later PTSD or
other symptoms.
Clinical implications
Our results strengthen the conclusions of the Cochrane Review
(Wessely et al,
1998). Those who are most at risk of persistent PTSD and other
poor outcomes are unlikely to be helped by a short 1-hour intervention
following widely accepted debriefing principles. Indeed, our findings
strengthen the argument that such interventions are harmful.
We do not conclude, however, that those who are distressed should be denied immediate support and practical help; nor do we oppose efforts to increase recognition of significant problems in the early weeks and months after major trauma. There is also encouraging evidence that psychological treatments involving cognitive restructuring and other elements can be highly effective. We suggest immediate support and practical help, together with follow-up, to identify those with persistent problems who may benefit from extra help. Such help should be proven cognitive restructuring and behavioural techniques provided in an individualised and flexible manner.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication April 26, 1999. Revision received November 1, 1999. Accepted for publication November 10, 1999.