Novel intervention approaches after recent exposure to trauma

Abstract

Background: The life-time incidence of exposure to traumatic events is high and can have a profound negative impact on mental health. The majority of individuals exposed to trauma will go through a process of natural recovery and experience short-lived reactions. The most widely reported long-term reactions in the traumatic stress literature are acute stress disorder (ASD) and post-traumatic stress disorder (PTSD). After intentional traumatic events, one-third of the exposed will develop PTSD in the first year. That stresses the necessity and importance of early scalable interventions to alleviate initial reactions and change the trajectory away from a chronic course. The key precursor for PTSD is exposure to a specific traumatic event which allows for early identification and intervention. Early psychological interventions based on trauma-focused cognitive behavioural therapy (CBT-T) has shown promising results, especially for those who meet the diagnostic threshold for ASD.

Aims: The general aim of this thesis was to develop and evaluate novel early psychological interventions after exposure to a potentially traumatic event(s) (PTE) in order to facilitate recovery and reduce immediate distress. The specific aims of each study in this thesis were to investigate: the feasibility, acceptability and efficacy of brief prolonged exposure (PE) provided face-to-face in the early aftermath of a potentially traumatic event in an emergency hospital setting and at an emergency department for rape victims (Studies I and II); the feasibility, acceptability and efficacy of condensed internet-delivered PE (CIPE) in the early aftermath of a potentially traumatic event (Studies III and V); and the participants experience of CIPE in the early aftermath of a potentially traumatic event (Study IV).

Methods: Five studies (I-V) that evaluated PE as an early intervention after trauma using different types of methodology in recruitment, assessment and form of delivery were conducted within this doctoral project. Study I and II investigated feasibility, acceptability and efficacy of PE delivered face-to-face within 72 hours of exposure to trauma. Study I was a randomised controlled trial (RCT) with the original aim to allocate 352 participants to three sessions of PE or non-directive support. Study II evaluated feasibility of the same face-to-face protocol for rape victims in a non-randomised pilot study (N=10). In study III, a condensed internetdelivered prolonged exposure intervention was developed and tested for feasibility, acceptability and preliminary effects in a pilot randomised trial (N=33) when provided within the first two months after exposure to trauma. Study IV (N=11) used a qualitative thematic analysis to explore participants experiences of the intervention. Study V was a randomised trial (N=102) with the aim to investigate the effectiveness of CIPE against a waiting list up to 7 weeks from baseline.

Results: In study I, we experienced problems with high attrition and low recruitment rate and the trial was terminated beforehand due to unexpected organisational changes at the recruiting site. In study II, the compliance to the intervention in terms of session attendance and homework assignments completion was high. Nevertheless, only a small proportion of patients at the recruiting clinic were eligible for the study. Study III showed that CIPE was feasible, acceptable and preliminary led to greater reductions in post-traumatic stress symptoms compared to the waiting list group. Data from study IV showed that participants found CIPE to be a demanding yet effective intervention. Participants described CIPE as a credible, tolerable and educative intervention that motivated them to engage in exposure. Imaginal exposure was perceived to be both the most important in recovery after trauma and also the most distressing one. Study V demonstrated that CIPE was more effective in reducing symptoms of post-traumatic stress than the waiting list group up to 7 weeks after baseline. The between-group effect size was in the moderate range at intervention completion after 3 weeks (bootstrapped d=0.71 [95% CI; 0.33 to 1.05]) and large at the 1-month follow up (bootstrapped d=0.83; [95% CI 0.46 to 1.19]). Results were maintained after six months. No serious adverse events associated with the intervention were found in either of the studies.

Conclusions: The results from the studies in this thesis put the light on that recruiting participants from Swedish emergency hospitals and delivering an early intervention face-toface within the first 72 hours of exposure to trauma was not as feasible as originally expected. A change in methodology was therefore necessary. The time-frame from exposure to trauma and inclusion was extended, an indicated approach to inclusion was used and the recruitment, assessment and intervention procedures were transferred to an online format (CIPE). Results indicate that CIPE was a feasible, acceptable and effective early intervention after trauma when delivered within the first two months after exposure to PTE to symptomatic individuals. CIPE could greatly increase access to this type of intervention and may prove to be a highly scalable intervention with the benefit to be used in the exact moment when needed.