Risk Factors and Screening Chris R. Brewin Clinical, Educational, and Health Psychology, University College London Camden & 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 years Effective treatment is difficult due to: poor recognition of PTSD in the community wide dispersion of cases prominent avoidance symptoms

September 2008© Chris R. Brewin Criteria for a good screening instrument Accuracy Reliability Simplicity Portability

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 English contain 30 items or less ability to detect PTSD in adults validated against structured clinical interviews relevant to any type of trauma EXCLUDED IF: limited to military or specific populations

September 2008© Chris R. Brewin Results of search strategy 19 articles met all criteria 22 datasets were reported 13 separate instruments were identified, ranging from 4-30 items in length All 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 once 1 screener returned – screeners returned – screeners returned – 51 4 screeners returned – 20 5 screeners returned – 2 Opt out 117 Attended diagnostic interview 364 Referred to treatment 278

September 2008© Chris R. Brewin Primary diagnoses of patients referred to treatment

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 References Brewin, C.R. (2005). Systematic review of screening instruments for the detection of posttraumatic stress disorder in adults. Journal of Traumatic Stress, 18, Brewin, C.R. et al. (2002). A brief screening instrument for posttraumatic stress disorder. British Journal of Psychiatry, 181, 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,