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Psychological debriefing for preventing post traumatic stress disorder (PTSD)

  1. Suzanna C Rose1,*,
  2. Jonathan Bisson2,
  3. Rachel Churchill3,
  4. Simon Wessely4

Editorial Group: Cochrane Depression, Anxiety and Neurosis Group

Published Online: 22 APR 2002

Assessed as up-to-date: 2 DEC 2001

DOI: 10.1002/14651858.CD000560


How to Cite

Rose SC, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000560. DOI: 10.1002/14651858.CD000560.

Author Information

  1. 1

    Berkshire Healthcare NHS Trust, UK., Berkshire Traumatic Stress Service, Reading, Berks, UK

  2. 2

    Cardiff University, Department of Psychological Medicine, Cardiff, UK

  3. 3

    University of Bristol, Academic Unit of Psychiatry, Community Based Medicine, Bristol, Avon, UK

  4. 4

    Guy's, King's & St Thomas School of Medicine & Institute of Psychiatry, Academic Dept of Psychological Medicine, London, UK

*Suzanna C Rose, Berkshire Traumatic Stress Service, Berkshire Healthcare NHS Trust, UK., Erleigh Road Clinic, 25 Erleigh Road, Reading, Berks, RG1 5LR, UK. suzanna.rose@berkshire.nhs.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 22 APR 2002

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Characteristics of included studies [ordered by study ID]
Bisson 1997

MethodsRandomisation: randomised numbers generated by computer
Allocation concealment: A
Exclusion after randomisation; yes
ITT: no


ParticipantsSetting: Burns Unit.
Inclusion: Consecutive admissions to Burns Unit
Exclusion: Major psychiatric or physical disorder


InterventionsComparison: Psychological debriefing (Mitchell model)
versus questionnaire only
Time between event and intervention: 2 - 19 days


OutcomesPTSD scale
IES
HADS


NotesAssessor blind to intervention-- yes; Intervention standardised;--yes:
No intention to treat; data provided on study completers only
large SDs on IES


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate

Bordow 1979

MethodsRandomisation: First 30 non randomly assigned to waiting list control: Next 40 allocated by 'random preset order' to brief or extended intervention
Allocation concealment: not stated (B)
Exclusion after randomisation: no
ITT; yes (probably - no formal data on follow up)


ParticipantsMale inpatients after road traffic accidents


InterventionsComparison:
Extended (minimal emotional support (1 hr) + practical and social support (max 10 hrs)
versus Brief "minimal emotional support" (1hr)
Time between event and intervention: up to 1 wk


OutcomesLanger 22 Item
Work Adjustment
Traumatic Neurosis Symptoms
Pleasant and Unpleasant experiences
Health deterioration


NotesTrial of brief versus extended therapy (no randomly allocated control condition)
No standard deviations for continuous measures; no cut offs for categorical measures. Not included in meta analysis


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?NoC - Inadequate

Bunn 1979

MethodsRandomisation: 'Randomly assigned'
Allocation concealment - unclear (B)
Exclusion after randomisation - unclear
ITT; yes, but no follow up


ParticipantsParents or relatives of primary victims of trauma admitted to a general hospital.
Exclusions: frequent attenders


InterventionsComparison:
20 minutes counselling
versus nil
Time between assessment and intervention: unclear, but probably hours or a few days


OutcomesGottschalk & Gleiser content analysis of anxiety (six categories)
Viney and Westbrook cognitive anxiety


NotesAssessment took place within minutes of end of intervention
Assessments based on interpretation of five minute verbal samples.
Interventions standardised: no
Subjects were not primary victims


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?NoC - Inadequate

Campfield 2001

MethodsRandomisation: 'Randomly assigned'
Allocation concealment:
Not reported
Exclusion after randomisation:
no
ITT: yes


ParticipantsSetting: Trauma Clinic
Inclusion: Civilian victims of robbery in the workplace
Exclusion: Victims of robberies involving physical injury, guns and those already receiving treatment for the effects of trauma


InterventionsComparison:
Immediate (<10hr) Critical incident stress debriefing (CISD) (Mitchell model) versus delayed CISD (>48 hrs)
Time between event and intervention:
<10 or >48 hrs


OutcomesPost-traumatic Stress Diagnostic Scale (PDS)


NotesAssessor blind to intervention:
Not stated
Intervention standardised


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearD - Not used

Conlon 1999

MethodsRandomisation: coin toss
Allocation concealment: C
Exclusion after randomisation; no


ParticipantsSetting: Hospital trauma clinic
Inclusion: RTA victims 16 to 65
Exclusion; injuries requiring hospital admission


InterventionsComparison:
30 minute debriefing
versus advice leaflet and telephone number
Time between event and intervention: mean 7 days, range 3 to 14


OutcomesIES
Clinician administered PTSD scale


NotesAssessor blind to intervention:
Assessment standardised:


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?NoC - Inadequate

Dolan

MethodsRandomisation:
Allocation concealment:
Unclear
Exclusion after randomisation:


ParticipantsSetting: Hospital trauma clinic
Inclusion: those presenting with life-threatening or near life-threatening experiences e.g. RTA, assault, housefirem industrial accident.
Exclusions: serious head injury, those too unwell to co-operate, those with no memory of the trauma. Those injured through sports injury, self-harm, DIY, fights or heavy alcohol intoxication at the time.


InterventionsComparison:
Psychological Debriefing (Mitchell/Dyregrov model) versus initial assessment


OutcomesGHQ-28
HADS
IES
The Neo-5 Factor Personality Questionnaire
The Defence Style Personality Questionnaire
The Mast
Abbreviated Injury Scale and the Injury Severity Score


NotesUnclear assessor blind to intervention:
Intervention standardised


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

Hobbs 1996

MethodsRandomisation: Random number table
Allocation concealment: not stated
Exclusion after randomisation: no
ITT: no


ParticipantsSetting: Hospital Casualty Department
Inclusion: Road accident victims
Exclusion: unconscious, no memory of accident, no psychological symptoms, discharged before contact
Three year follow up undertaken


InterventionsComparison: debriefing (1 hr) + leaflet to subject and GP
versus screening only
Time between event and intervention: 1 to 2 days


OutcomesBrief Symptom Inventory (Global Severity Index: GSI).
IES and Distressing intrusive memories (approximation for PTSD)
Travel anxiety


NotesSubjects with no psychological symptoms at assessment excluded.
Intervention standardised - yes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

Lavender 1998

MethodsRandomisation:
Computer generated
Allocation concealment:
Adequate
Exclusion after randomisation:
No


ParticipantsSetting: Hospital postpartum ward
Included: Primigravidas with singleton pregnancies and cephalic presentations who were in spontaneous labout at term and proceeded to normal vaginal delivery of a healthy baby.
Excluded: Those with 3rd degree perineal tear, manual removal of the placenta, baby admitted to special care baby unit and women requiring high dependency care.


InterventionsComparison: interactive interview when women were encouraged to spend as much time as necessary discussing their labour, asking questions and exploring their feelings versus
Time between event and intervention:


OutcomesHADS


Notes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate

Lee 1996

MethodsRandomisation: Alternate randomisation by odd and even numbers given by nurse recruiting (not the person treating)
Allocation concealment: C
Exclusion after randomisation: yes
ITT: no


ParticipantsSetting: Gynaecology ward
Inclusion: consecutive admissions with first episode of completed miscarriage, aged 18 or over
Exclusion: no current psychiatric or psychological disorder


InterventionsComparison: Psychological debriefing (Dyregov, Mitchell model) of 1 hr
versus Questionnaire assessment only
Time between event and intervention: 2 weeks


OutcomesHADS, IES


NotesOutcome caseness not given by intervention group. No PTSD criteria


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?NoC - Inadequate

Litz 2004

MethodsRandomisation:
'Randomly assigned'
Allocation concealment:
Not yet known
Exclusion after randomisation:
Not yet known


ParticipantsSetting:
US arm
Inclusion:
Platoons deployed on peacekeeping mission
Exclusion:
None reported


InterventionsComparison:
Critical incident stress debriefing (CISD) (Mitchell model) versus stress education versus survey only
Time between event and intervention:
Not reported


OutcomesPost traumatic stress (PCL); Depression (CES-D), General well-being (GHQ); Aggressive behaviour; Marital satisfaction; Perceived Organisational Support; Morale.


NotesAssessor blind to intervention:
Unclear
Assessment standardised:


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

Priest 2003

MethodsRandomisation:
'Randomised'
Allocation concealment:
Adequate
Exclusion after randomisation:
No


ParticipantsSetting:
Two large maternity hospitale in Perth
Inclusion:
Women delivered at or near term
Exclusion: Insufficient English, already under psychological care, less than 18 years or with infant needing neonatal care


InterventionsComparison:
Standardised debriefing (Mitchell model) versus standard post-natal care
TIme between event and intervention:
Within 72 hours of delivery


OutcomesDepression; PTSD using DSMIV


NotesAssessor blind to intervention:
Done but not tested


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate

Rose 1999

MethodsRandomisation: computer generated list by statistician
Allocation concealment: yes
Exclusion after randomisation: no
ITT: yes


ParticipantsSetting: 2161 victims of violent crime identified from police and casualty
Inclusion: over 18
Exclusion: domestic violence, living outside study area, more than one month after crime


InterventionsComparison: Debriefing (Dyregov, Mitchell model):1 hr
versus Education only (30 minutes)
Control: Assessment only


OutcomesPSS
IES
BDI


NotesOnly 11% of those contacted agreed to intervention
Time between incident and intervention: max one month.
Most outcomes telephone, but also postal and home visits
Intervention standardised: yes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate

Sijbrandij 2002

MethodsRandomisation:
Randomised using computer
Allocation concealment:
Adequate
Exclusion after randomisation:
Yes


ParticipantsSetting:
Trauma outpatient clinic
Inclusion:
Single traumatic event, 18 years or more and proficient in Dutch
Exclusion:
suicidal ideation, already treated for effects of trauma


InterventionsComparison:
Emotional debriefing versus the psychoeducational debriefing versus no debriefing
Time between event and intervention:
Approximately 2 weeks


OutcomesSI-PTSD
HADS-D
HADS-A
PDEQ


NotesAssessor blind to intervention:
Done but not tested


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate

Small 2000

MethodsRandomisation:
Computer generated telephone ransomisation
Allocation concealment:
Adequate
Exclusion after randomisation:
Unclear


ParticipantsSetting: 908 women on postnatal ward, large Maternity Hospital, Australia
Inclusion: women who had given birth by LSCS, forceps or vacuum extraction.
Excluded: women who had not had operative births, stillbirths or those who had babies weighing <1500gms, those with insufficient english, those ill themselves, very ill babies and those whose private obstetrician refused access


InterventionsComparison: Debriefing 'provided women with the opportunity to discuss labour, birth and post-delivery events and experiences. +pamphlet on sources of other assistance of 1 hour versus Brief visit from midife to give out pamplet.


OutcomesEPDS
SF-36


NotesNo baseline measures


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?YesA - Adequate

Stevens 1996

MethodsRandomisation: 'randomly assigned'
Allocation concealment; opaque sealed envelopes (B)
Exclusion after randomisation; yes
ITT: no


ParticipantsCasualty attenders after road traffic accident, dog bite or assault
Exclusions: non English speakers, not physically fit to be interviewed; need immediate psychiatric referral, homeless, intoxicated


InterventionsComparison: debriefing versus questionnaires
Time between event and intervention; <24 hrs


OutcomesPTSD (DSM-III).
BDI. Spielberger
IES


NotesLosses to follow up not by group.
PTSD and other psychiatric disorders grouped together
Intention to treat: no
Intervention standardised: yes


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Amir 1998Non randomised group intervention

Andre 1997Not single session; CBT

Brom 1993Multiple sessions
Time between trauma and intervention > 1 month

Bryant 1998Sample selected on the basis of acute stress disorder - not a random sample of victims. Intervention four sessions

CarlierNon randomised

Chemtob 1997Non randomised.
Time between trauma and intervention >1 month

Deahl 1994Non randomised

Deahl 2000

Doctor 1994Intervention not related to traumatic event;
Intervention not debriefing (12 sessions of group counselling)

Foa 1995Non randomised

Greenberg 1996Not debriefing

Hytten 1989Non randomised

Kenardy 1996Non randomised

Matthews 1998Non randomised

McFarlane 1988Non randomised

Polak 1975Crisis intervention, not debriefing

Resnick 1999Not randomised

Richards 2001Not an RCT

Robinson 1993Not randomised

Saari 1996Non randomised

Tadmor 1987Pre trauma intervention

Viney 1985Not debriefing

 
Characteristics of ongoing studies [ordered by study ID]
Alexander 2002

Trial name or titleAlexander 2002

Methods

Participants120

InterventionsPsychological Intervention +// Unclear Intervention +

Outcomes

Starting date

Contact information

Notes

Stallard 2003

Trial name or titleStallard 2003

Methods

Participants276

InterventionsTrauma discussion intervention// Usual Care +//

Outcomes

Starting date

Contact information

Notes

 
Comparison 1. Debriefing versus Control

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 PTSD diagnosis - ITT data3Peto Odds Ratio (Peto, Fixed, 95% CI)Subtotals only

    1.1 Up to 3 months
140Peto Odds Ratio (Peto, Fixed, 95% CI)0.58 [0.10, 3.26]

    1.2 3-6 months
3278Peto Odds Ratio (Peto, Fixed, 95% CI)1.17 [0.70, 1.98]

    1.3 6-12 months
1105Peto Odds Ratio (Peto, Fixed, 95% CI)0.93 [0.35, 2.46]

    1.4 12 months or more
1133Peto Odds Ratio (Peto, Fixed, 95% CI)2.51 [1.24, 5.09]

 2 PTSD severity - using self-report measures6Std. Mean Difference (IV, Fixed, 95% CI)Subtotals only

    2.1 Initial
5393Std. Mean Difference (IV, Fixed, 95% CI)0.12 [-0.08, 0.32]

    2.2 1-4 months
5356Std. Mean Difference (IV, Fixed, 95% CI)0.11 [-0.10, 0.32]

    2.3 6-13 months
3265Std. Mean Difference (IV, Fixed, 95% CI)0.26 [0.01, 0.50]

    2.4 3 years
161Std. Mean Difference (IV, Fixed, 95% CI)0.17 [-0.34, 0.67]

 3 PTSD severity - clinician rating measures1Mean Difference (IV, Fixed, 95% CI)Subtotals only

    3.1 3 months
132Mean Difference (IV, Fixed, 95% CI)-6.0 [-16.49, 4.49]

 4 PTSD - self-reported symptoms1Peto Odds Ratio (Peto, Fixed, 95% CI)Subtotals only

    4.1 4 months
1106Peto Odds Ratio (Peto, Fixed, 95% CI)1.84 [0.60, 5.63]

 5 Depression diagnosis - completers only1Peto Odds Ratio (Peto, Fixed, 95% CI)Subtotals only

    5.1 0-1 month
139Peto Odds Ratio (Peto, Fixed, 95% CI)1.72 [0.17, 17.75]

    5.2 2-5 months
139Peto Odds Ratio (Peto, Fixed, 95% CI)0.11 [0.01, 1.81]

 6 Depression severity4Std. Mean Difference (IV, Fixed, 95% CI)Subtotals only

    6.1 0-1 month
2142Std. Mean Difference (IV, Fixed, 95% CI)0.01 [-0.33, 0.34]

    6.2 1-4 months
3225Std. Mean Difference (IV, Fixed, 95% CI)-0.00 [-0.27, 0.26]

    6.3 6-13 months
3265Std. Mean Difference (IV, Fixed, 95% CI)0.33 [0.09, 0.58]

 7 Anxiety diagnosis1Peto Odds Ratio (Peto, Fixed, 95% CI)Subtotals only

    7.1 0-1 month
139Peto Odds Ratio (Peto, Fixed, 95% CI)0.79 [0.22, 2.89]

    7.2 2-5 months
139Peto Odds Ratio (Peto, Fixed, 95% CI)1.71 [0.43, 6.79]

 8 General Anxiety3Std. Mean Difference (IV, Fixed, 95% CI)Subtotals only

    8.1 0-1 month
2142Std. Mean Difference (IV, Fixed, 95% CI)-0.00 [-0.33, 0.33]

    8.2 1-4 months
3225Std. Mean Difference (IV, Fixed, 95% CI)0.03 [-0.23, 0.29]

    8.3 6-13 months
2172Std. Mean Difference (IV, Fixed, 95% CI)0.25 [-0.05, 0.55]

 9 Travel anxiety1Peto Odds Ratio (Peto, Fixed, 95% CI)Subtotals only

    9.2 2-5 months
1106Peto Odds Ratio (Peto, Fixed, 95% CI)1.12 [0.50, 2.53]

 10 All psychiatric morbidity1Peto Odds Ratio (Peto, Fixed, 95% CI)Subtotals only

    10.1 0-1 month
163Peto Odds Ratio (Peto, Fixed, 95% CI)2.24 [0.70, 7.19]

    10.2 2-5 months
163Peto Odds Ratio (Peto, Fixed, 95% CI)0.70 [0.24, 2.08]

 11 Reduced Functioning1Peto Odds Ratio (Peto, Fixed, 95% CI)Subtotals only

    11.1 3 months
1103Peto Odds Ratio (Peto, Fixed, 95% CI)1.53 [0.59, 3.92]

 12 Dropout4444Peto Odds Ratio (Peto, Fixed, 95% CI)1.97 [1.23, 3.15]

 
Comparison 2. Debriefing versus Educational intervention

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 PTSD diagnosis - ITT data1106Peto Odds Ratio (Peto, Fixed, 95% CI)1.65 [0.71, 3.83]

    1.1 6 months
1106Peto Odds Ratio (Peto, Fixed, 95% CI)1.65 [0.71, 3.83]

 2 PTSD severity - using self-report measures - completers192Mean Difference (IV, Fixed, 95% CI)2.90 [-2.10, 7.90]

    2.1 6 months
192Mean Difference (IV, Fixed, 95% CI)2.90 [-2.10, 7.90]

 3 Depression severity - completers192Mean Difference (IV, Fixed, 95% CI)2.90 [-2.10, 7.90]

    3.1 6 months
192Mean Difference (IV, Fixed, 95% CI)2.90 [-2.10, 7.90]

 4 Dropout1106Peto Odds Ratio (Peto, Fixed, 95% CI)0.96 [0.31, 2.93]

    4.1 6 months
1106Peto Odds Ratio (Peto, Fixed, 95% CI)0.96 [0.31, 2.93]

 
Comparison 3. Immediate Debriefing versus Delayed Debriefing

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 PTSD severity - self-report177Mean Difference (IV, Fixed, 95% CI)-26.16 [-30.59, -21.73]

    1.1 2 weeks
177Mean Difference (IV, Fixed, 95% CI)-26.16 [-30.59, -21.73]

 
Table 1. Methodological ratings for each study using Kenardy scale

Study IDTotal score

Bisson 199722

Priest 200322

Rose 199919

Dolan18

Sijbrandij 200517.5

Campfield 200115

Conlon 199915

Lee 199614

Litz 200514

Hobbs 199613

Stevens 199613

Bordow 197911

Small 200011

Lavender 199810

Bunn 19798