Study 1
Zatzick and colleagues (2014) conducted a randomized clinical trial to evaluate the effectiveness of a stepped collaborative care intervention in reducing violence and injury risk behaviors (i.e., weapon carrying), alcohol and drug use problems, and posttraumatic stress disorder (PTSD) and depressive symptoms in injured adolescents. To be eligible for treatment, participants had to be between the ages of 12 to 18 and admitted to the University of Washington’s Harborview Medical Center, a level I trauma center, through the inpatient surgical ward or emergency department for 24 hours or longer between March 1, 2008, and October 31, 2009. Adolescent survivors of intentional and unintentional traumatic physical injuries and/or traumatic brain injuries were eligible for the study. However, adolescents with severe injuries that prevented participation or those with self-inflicted intentional injuries were excluded. Additional exclusions included adolescents who were non-English speaking or those who had two parents who were non-English speaking. Adolescents approached in the surgical ward were evaluated with the Glasgow Coma Scale and were required to have a cumulative score of 15 at the time of the evaluation, indicating mild brain injury. Adolescent patients were also required to score at least 7 out of 10, indicative of normal, on the two Mini-Mental State Examination items that assess orientation to location and date. Those who did not meet these requirements were excluded from the study. Assent was obtained from all participants and both adolescent assent and parental consent were obtained for patients younger than 18 years old.
Participants were randomly assigned to the intervention group (n = 59) and control group (n = 61). Those in the intervention group spent on average 13.1 hours receiving stepped collaborative care intervention services with most services (75 percent) being rendered within six months after the injury. Those in the control group received the usual care and services generally delivered to all those who are admitted to the level I trauma center. Usual postinjury care included routine outpatient surgical, primary care, and emergency department visits. Specialty mental health services were occasionally provided.
On average, study participants were 15 years old, 38 percent identified as nonwhite, 62 percent identified as white, and 25 percent identified as female. They had an average injury severity score of 15.7 and stayed in the hospital an average of 6 days. There were no statistically significant differences in demographic characteristics or injuries between the intervention and control groups. There were also no statistically significant differences between intervention and control group patients in any risk behaviors, such as weapon carrying (32.8 percent), alcohol and drug use (44.2 percent), high levels of PTSD symptoms (17.5 percent), and high levels of depressive symptoms (10.0 percent).
There were four outcomes of interest measured at 12 months after injury: 1) weapon carrying, 2) alcohol or drug use, 3) high-level PTSD symptoms, and 4) high-level depressive symptoms. All patients received evaluations of each outcome measure, in addition to functional impairments and health service use, at baseline in the emergency department or surgical ward before randomization, and again 12 months after discharge during telephone follow-up interviews.
Ten items from the National Longitudinal Study of Adolescent Health were used to assess a full spectrum of adolescent violence and injury risk behaviors. The Composite International Diagnostic Index was used to assess adolescent alcohol abuse and dependence criteria. The Alcohol Use Disorders Identification Test, a 3-item self-report screening measure used for early identification of problem alcohol use in the acute care setting, was used to augment the Composite International Diagnostic Index. Posttraumatic stress symptoms were assessed through the adolescent version of the University of California, Los Angeles, PTSD Reaction Index (PTSD-RI) for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The 9-item Patient Health Questionnaire (PHQ-9) depression screen was used to assess depressive symptoms. Previously developed items assessing postinjury health service use were administered at baseline and at the 12-month follow-up interview. Insurance status, length of hospital and intensive care unit stays, and other clinical characteristics were abstracted from the trauma registry and electronic medical records.
Poisson regression analyses with robust error variances were used to test the impact of the intervention on weapon carrying, substance use problems, and PTSD and depressive dichotomous outcomes a year after the injury occurred. The study authors did not conduct subgroup analyses.
