Psychological debriefing for preventing post traumatic stress disorder (PTSD)

 

Characteristics of included studies [ordered by study ID]

Bisson 1997

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Methods	Randomisation: randomised numbers generated by computer Allocation concealment: A Exclusion after randomisation; yes ITT: no
Participants	Setting: Burns Unit. Inclusion: Consecutive admissions to Burns Unit Exclusion: Major psychiatric or physical disorder
Interventions	Comparison: Psychological debriefing (Mitchell model) versus questionnaire only Time between event and intervention: 2 - 19 days
Outcomes	PTSD scale IES HADS
Notes	Assessor blind to intervention-- yes; Intervention standardised;--yes: No intention to treat; data provided on study completers only large SDs on IES
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Bordow 1979

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Methods	Randomisation: 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)
Participants	Male inpatients after road traffic accidents
Interventions	Comparison: 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
Outcomes	Langer 22 Item Work Adjustment Traumatic Neurosis Symptoms Pleasant and Unpleasant experiences Health deterioration
Notes	Trial 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
Item	Authors' judgement	Description
Allocation concealment?	No	C - Inadequate

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Bunn 1979

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Methods	Randomisation: 'Randomly assigned' Allocation concealment - unclear (B) Exclusion after randomisation - unclear ITT; yes, but no follow up
Participants	Parents or relatives of primary victims of trauma admitted to a general hospital. Exclusions: frequent attenders
Interventions	Comparison: 20 minutes counselling versus nil Time between assessment and intervention: unclear, but probably hours or a few days
Outcomes	Gottschalk & Gleiser content analysis of anxiety (six categories) Viney and Westbrook cognitive anxiety
Notes	Assessment 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
Item	Authors' judgement	Description
Allocation concealment?	No	C - Inadequate

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Campfield 2001

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Methods	Randomisation: 'Randomly assigned' Allocation concealment: Not reported Exclusion after randomisation: no ITT: yes
Participants	Setting: 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
Interventions	Comparison: Immediate (<10hr) Critical incident stress debriefing (CISD) (Mitchell model) versus delayed CISD (>48 hrs) Time between event and intervention: <10 or >48 hrs
Outcomes	Post-traumatic Stress Diagnostic Scale (PDS)
Notes	Assessor blind to intervention: Not stated Intervention standardised
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	D - Not used

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Conlon 1999

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Methods	Randomisation: coin toss Allocation concealment: C Exclusion after randomisation; no
Participants	Setting: Hospital trauma clinic Inclusion: RTA victims 16 to 65 Exclusion; injuries requiring hospital admission
Interventions	Comparison: 30 minute debriefing versus advice leaflet and telephone number Time between event and intervention: mean 7 days, range 3 to 14
Outcomes	IES Clinician administered PTSD scale
Notes	Assessor blind to intervention: Assessment standardised:
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	No	C - Inadequate

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Dolan

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Methods	Randomisation: Allocation concealment: Unclear Exclusion after randomisation:
Participants	Setting: 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.
Interventions	Comparison: Psychological Debriefing (Mitchell/Dyregrov model) versus initial assessment
Outcomes	GHQ-28 HADS IES The Neo-5 Factor Personality Questionnaire The Defence Style Personality Questionnaire The Mast Abbreviated Injury Scale and the Injury Severity Score
Notes	Unclear assessor blind to intervention: Intervention standardised
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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Hobbs 1996

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Methods	Randomisation: Random number table Allocation concealment: not stated Exclusion after randomisation: no ITT: no
Participants	Setting: Hospital Casualty Department Inclusion: Road accident victims Exclusion: unconscious, no memory of accident, no psychological symptoms, discharged before contact Three year follow up undertaken
Interventions	Comparison: debriefing (1 hr) + leaflet to subject and GP versus screening only Time between event and intervention: 1 to 2 days
Outcomes	Brief Symptom Inventory (Global Severity Index: GSI). IES and Distressing intrusive memories (approximation for PTSD) Travel anxiety
Notes	Subjects with no psychological symptoms at assessment excluded. Intervention standardised - yes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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Lavender 1998

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Methods	Randomisation: Computer generated Allocation concealment: Adequate Exclusion after randomisation: No
Participants	Setting: 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.
Interventions	Comparison: 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:
Outcomes	HADS
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Lee 1996

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Methods	Randomisation: Alternate randomisation by odd and even numbers given by nurse recruiting (not the person treating) Allocation concealment: C Exclusion after randomisation: yes ITT: no
Participants	Setting: Gynaecology ward Inclusion: consecutive admissions with first episode of completed miscarriage, aged 18 or over Exclusion: no current psychiatric or psychological disorder
Interventions	Comparison: Psychological debriefing (Dyregov, Mitchell model) of 1 hr versus Questionnaire assessment only Time between event and intervention: 2 weeks
Outcomes	HADS, IES
Notes	Outcome caseness not given by intervention group. No PTSD criteria
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	No	C - Inadequate

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Litz 2004

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Methods	Randomisation: 'Randomly assigned' Allocation concealment: Not yet known Exclusion after randomisation: Not yet known
Participants	Setting: US arm Inclusion: Platoons deployed on peacekeeping mission Exclusion: None reported
Interventions	Comparison: Critical incident stress debriefing (CISD) (Mitchell model) versus stress education versus survey only Time between event and intervention: Not reported
Outcomes	Post traumatic stress (PCL); Depression (CES-D), General well-being (GHQ); Aggressive behaviour; Marital satisfaction; Perceived Organisational Support; Morale.
Notes	Assessor blind to intervention: Unclear Assessment standardised:
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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Priest 2003

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Methods	Randomisation: 'Randomised' Allocation concealment: Adequate Exclusion after randomisation: No
Participants	Setting: 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
Interventions	Comparison: Standardised debriefing (Mitchell model) versus standard post-natal care TIme between event and intervention: Within 72 hours of delivery
Outcomes	Depression; PTSD using DSMIV
Notes	Assessor blind to intervention: Done but not tested
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Rose 1999

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Methods	Randomisation: computer generated list by statistician Allocation concealment: yes Exclusion after randomisation: no ITT: yes
Participants	Setting: 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
Interventions	Comparison: Debriefing (Dyregov, Mitchell model):1 hr versus Education only (30 minutes) Control: Assessment only
Outcomes	PSS IES BDI
Notes	Only 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
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Sijbrandij 2002

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Methods	Randomisation: Randomised using computer Allocation concealment: Adequate Exclusion after randomisation: Yes
Participants	Setting: Trauma outpatient clinic Inclusion: Single traumatic event, 18 years or more and proficient in Dutch Exclusion: suicidal ideation, already treated for effects of trauma
Interventions	Comparison: Emotional debriefing versus the psychoeducational debriefing versus no debriefing Time between event and intervention: Approximately 2 weeks
Outcomes	SI-PTSD HADS-D HADS-A PDEQ
Notes	Assessor blind to intervention: Done but not tested
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Small 2000

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Methods	Randomisation: Computer generated telephone ransomisation Allocation concealment: Adequate Exclusion after randomisation: Unclear
Participants	Setting: 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
Interventions	Comparison: 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.
Outcomes	EPDS SF-36
Notes	No baseline measures
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Stevens 1996

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Methods	Randomisation: 'randomly assigned' Allocation concealment; opaque sealed envelopes (B) Exclusion after randomisation; yes ITT: no
Participants	Casualty 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
Interventions	Comparison: debriefing versus questionnaires Time between event and intervention; <24 hrs
Outcomes	PTSD (DSM-III). BDI. Spielberger IES
Notes	Losses to follow up not by group. PTSD and other psychiatric disorders grouped together Intention to treat: no Intervention standardised: yes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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 BDI: Beck Depression Inventory
IES; Impact of Events Scale
ITT: Intention to treat
HAD: Hospital Anxiety and Depression Scale
PSS: Post-traumatic Stress DIsorder Symptom Scale
PTSD: Post traumatic stress disorder
EPDS: Edinburgh Postnatal Depression Score
SF-36: 36 Item Short-form Health Survey

 

Characteristics of excluded studies [ordered by study ID]

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Study	Reason for exclusion
Amir 1998	Non randomised group intervention
Andre 1997	Not single session; CBT
Brom 1993	Multiple sessions Time between trauma and intervention > 1 month
Bryant 1998	Sample selected on the basis of acute stress disorder - not a random sample of victims. Intervention four sessions
Carlier	Non randomised
Chemtob 1997	Non randomised. Time between trauma and intervention >1 month
Deahl 1994	Non randomised
Deahl 2000
Doctor 1994	Intervention not related to traumatic event; Intervention not debriefing (12 sessions of group counselling)
Foa 1995	Non randomised
Greenberg 1996	Not debriefing
Hytten 1989	Non randomised
Kenardy 1996	Non randomised
Matthews 1998	Non randomised
McFarlane 1988	Non randomised
Polak 1975	Crisis intervention, not debriefing
Resnick 1999	Not randomised
Richards 2001	Not an RCT
Robinson 1993	Not randomised
Saari 1996	Non randomised
Tadmor 1987	Pre trauma intervention
Viney 1985	Not debriefing

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Characteristics of ongoing studies [ordered by study ID]

Alexander 2002

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Trial name or title	Alexander 2002
Methods
Participants	120
Interventions	Psychological Intervention +// Unclear Intervention +
Outcomes
Starting date
Contact information
Notes

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Stallard 2003

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Trial name or title	Stallard 2003
Methods
Participants	276
Interventions	Trauma discussion intervention// Usual Care +//
Outcomes
Starting date
Contact information
Notes

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Comparison 1. Debriefing versus Control

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Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

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 1 PTSD diagnosis - ITT data

3

Peto Odds Ratio (Peto, Fixed, 95% CI)

Subtotals only

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1.1 Up to 3 months

1

40

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.58 [0.10, 3.26]

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1.2 3-6 months

3

278

Peto Odds Ratio (Peto, Fixed, 95% CI)

1.17 [0.70, 1.98]

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1.3 6-12 months

1

105

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.93 [0.35, 2.46]

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1.4 12 months or more

1

133

Peto Odds Ratio (Peto, Fixed, 95% CI)

2.51 [1.24, 5.09]

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 2 PTSD severity - using self-report measures

6

Std. Mean Difference (IV, Fixed, 95% CI)

Subtotals only

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2.1 Initial

5

393

Std. Mean Difference (IV, Fixed, 95% CI)

0.12 [-0.08, 0.32]

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2.2 1-4 months

5

356

Std. Mean Difference (IV, Fixed, 95% CI)

0.11 [-0.10, 0.32]

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2.3 6-13 months

3

265

Std. Mean Difference (IV, Fixed, 95% CI)

0.26 [0.01, 0.50]

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2.4 3 years

1

61

Std. Mean Difference (IV, Fixed, 95% CI)

0.17 [-0.34, 0.67]

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 3 PTSD severity - clinician rating measures

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

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3.1 3 months

1

32

Mean Difference (IV, Fixed, 95% CI)

-6.0 [-16.49, 4.49]

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 4 PTSD - self-reported symptoms

1

Peto Odds Ratio (Peto, Fixed, 95% CI)

Subtotals only

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4.1 4 months

1

106

Peto Odds Ratio (Peto, Fixed, 95% CI)

1.84 [0.60, 5.63]

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 5 Depression diagnosis - completers only

1

Peto Odds Ratio (Peto, Fixed, 95% CI)

Subtotals only

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5.1 0-1 month

1

39

Peto Odds Ratio (Peto, Fixed, 95% CI)

1.72 [0.17, 17.75]

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5.2 2-5 months

1

39

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.11 [0.01, 1.81]

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 6 Depression severity

4

Std. Mean Difference (IV, Fixed, 95% CI)

Subtotals only

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6.1 0-1 month

2

142

Std. Mean Difference (IV, Fixed, 95% CI)

0.01 [-0.33, 0.34]

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6.2 1-4 months

3

225

Std. Mean Difference (IV, Fixed, 95% CI)

-0.00 [-0.27, 0.26]

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6.3 6-13 months

3

265

Std. Mean Difference (IV, Fixed, 95% CI)

0.33 [0.09, 0.58]

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 7 Anxiety diagnosis

1

Peto Odds Ratio (Peto, Fixed, 95% CI)

Subtotals only

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7.1 0-1 month

1

39

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.79 [0.22, 2.89]

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7.2 2-5 months

1

39

Peto Odds Ratio (Peto, Fixed, 95% CI)

1.71 [0.43, 6.79]

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 8 General Anxiety

3

Std. Mean Difference (IV, Fixed, 95% CI)

Subtotals only

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8.1 0-1 month

2

142

Std. Mean Difference (IV, Fixed, 95% CI)

-0.00 [-0.33, 0.33]

---

8.2 1-4 months

3

225

Std. Mean Difference (IV, Fixed, 95% CI)

0.03 [-0.23, 0.29]

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8.3 6-13 months

2

172

Std. Mean Difference (IV, Fixed, 95% CI)

0.25 [-0.05, 0.55]

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 9 Travel anxiety

1

Peto Odds Ratio (Peto, Fixed, 95% CI)

Subtotals only

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9.2 2-5 months

1

106

Peto Odds Ratio (Peto, Fixed, 95% CI)

1.12 [0.50, 2.53]

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 10 All psychiatric morbidity

1

Peto Odds Ratio (Peto, Fixed, 95% CI)

Subtotals only

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10.1 0-1 month

1

63

Peto Odds Ratio (Peto, Fixed, 95% CI)

2.24 [0.70, 7.19]

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10.2 2-5 months

1

63

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.70 [0.24, 2.08]

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 11 Reduced Functioning

1

Peto Odds Ratio (Peto, Fixed, 95% CI)

Subtotals only

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11.1 3 months

1

103

Peto Odds Ratio (Peto, Fixed, 95% CI)

1.53 [0.59, 3.92]

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 12 Dropout

4

444

Peto Odds Ratio (Peto, Fixed, 95% CI)

1.97 [1.23, 3.15]

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Comparison 2. Debriefing versus Educational intervention

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Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

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 1 PTSD diagnosis - ITT data

1

106

Peto Odds Ratio (Peto, Fixed, 95% CI)

1.65 [0.71, 3.83]

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1.1 6 months

1

106

Peto Odds Ratio (Peto, Fixed, 95% CI)

1.65 [0.71, 3.83]

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 2 PTSD severity - using self-report measures - completers

1

92

Mean Difference (IV, Fixed, 95% CI)

2.90 [-2.10, 7.90]

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2.1 6 months

1

92

Mean Difference (IV, Fixed, 95% CI)

2.90 [-2.10, 7.90]

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 3 Depression severity - completers

1

92

Mean Difference (IV, Fixed, 95% CI)

2.90 [-2.10, 7.90]

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3.1 6 months

1

92

Mean Difference (IV, Fixed, 95% CI)

2.90 [-2.10, 7.90]

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 4 Dropout

1

106

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.96 [0.31, 2.93]

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4.1 6 months

1

106

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.96 [0.31, 2.93]

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Comparison 3. Immediate Debriefing versus Delayed Debriefing

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Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

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 1 PTSD severity - self-report

1

77

Mean Difference (IV, Fixed, 95% CI)

-26.16 [-30.59, -21.73]

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1.1 2 weeks

1

77

Mean Difference (IV, Fixed, 95% CI)

-26.16 [-30.59, -21.73]

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Table 1. Methodological ratings for each study using Kenardy scale

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Study ID	Total score
Bisson 1997	22
Priest 2003	22
Rose 1999	19
Dolan	18
Sijbrandij 2005	17.5
Campfield 2001	15
Conlon 1999	15
Lee 1996	14
Litz 2005	14
Hobbs 1996	13
Stevens 1996	13
Bordow 1979	11
Small 2000	11
Lavender 1998	10
Bunn 1979	8

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