Psychological interventions for post-traumatic stress disorder (PTSD) in people with severe mental illness

BACKGROUND: Increasing evidence indicates that individuals who develop severe mental illness (SMI) are also vulnerable to developing post-traumatic stress disorder (PTSD), due to increased risk of exposure to traumatic events and social adversity. The effectiveness of trauma-focused psychological interventions (TFPIs) for PTSD in the general population is well-established. TFPIs involve identifying and changing unhelpful beliefs about traumatic experiences, processing of traumatic memories, and developing new ways of responding to cues associated with trauma. Little is known about the potential feasibility, acceptability and effectiveness of TFPIs for individuals who have a SMI and PTSD. OBJECTIVES: To evaluate the effectiveness of psychological interventions for PTSD symptoms or other symptoms of psychological distress arising from trauma in people with SMI. SEARCH METHODS: We searched the Cochrane Schizophrenia Group's Trials Study-Based Register (up until March 10, 2016), screened reference lists of relevant reports and reviews, and contacted trial authors for unpublished and/or specific outcome data. SELECTION CRITERIA: We included all relevant randomised controlled trials (RCTs) which investigated TFPIs for people with SMI and PTSD, and reported useable data. DATA COLLECTION AND ANALYSIS: Three review authors (DS, MF, IN) independently screened the titles and abstracts of all references identified, and read short-listed full text papers. We assessed risk of bias in each case. We calculated the risk ratio (RR) and 95% confidence interval (CI) for binary outcomes, and the mean difference (MD) and 95% CI for continuous data, on an intention-to-treat basis. We assessed quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and created 'Summary of findings' tables. MAIN RESULTS: Four trials involving a total of 300 adults with SMI and PTSD are included. These trials evaluated three active intervention therapies: trauma-focused cognitive behavioural therapy (TF-CBT), eye movement desensitisation and reprocessing (EMDR), and brief psychoeducation for PTSD, all delivered via individual sessions. Our main outcomes of interest were PTSD symptoms, quality of life/well-being, symptoms of co-morbid psychosis, anxiety symptoms, depressive symptoms, adverse events and health economic outcomes. 1. TF-CBT versus usual care/waiting list Three trials provided data for this comparison, however, continuous outcome data available were more often found to be skewed than unskewed, leading to the necessity of conducting analyses separately for the two types of continuous data. Using the unskewed data only, results showed no significant differences between TF-CBT and usual care in reducing clinician-rated PTSD symptoms at short term (1 RCT, n =13, MD 13.15, 95% CI -4.09 to 30.39,low-quality evidence). Limited unskewed data showed equivocal results between groups in terms of general quality of life (1 RCT, n = 39, MD -0.60, 95% CI -4.47 to 3.27, low-quality evidence), symptoms of psychosis (1 RCT, n = 9, MD -6.93, 95% CI -34.17 to 20.31, low-quality evidence), and anxiety (1 RCT, n = 9, MD 12.57, 95% CI -5.54 to 30.68, very low-quality evidence), at medium term. The only available data on depression symptoms were skewed and were equivocal across groups at medium term (2 RCTs, n = 48, MD 3.26, 95% CI -3.66 to 10.18, very low-quality evidence). TF-CBT was not associated with more adverse events (1 RCT, n = 100, RR 0.44, 95% CI 0.09 to 2.31, low-quality evidence) at medium term. No data were available for health economic outcomes. Very limited data for PTSD and other symptoms were available over the long term. 2. EMDR versus waiting listOne trial provided data for this comparison. Favourable effects were found for EMDR in terms of PTSD symptom severity at medium term but data were skewed (1 RCT, n = 83, MD -12.31, 95% CI -22.72 to -1.90, very low-quality evidence). EMDR was not associated with more adverse events (1 RCT, n = 102, RR 0.21, 95% CI 0.02 to 1.85, low-quality evidence). No data were available for quality of life, symptoms of co-morbid psychosis, depression, anxiety and health economics.3. TF-CBT versus EMDROne trial compared TF-CBT with EMDR. PTSD symptom severity, based on skewed data (1 RCT, n = 88, MD -1.69, 95% CI -12.63 to 9.23, very low-quality evidence) was similar between treatment groups. No data were available for the other main outcomes.4. TF-CBT versus psychoeducationOne trial compared TF-CBT with psychoeducation. Results were equivocal for PTSD symptom severity (1 RCT, n = 52, MD 0.23, 95% CI -14.66 to 15.12, low-quality evidence) and general quality of life (1 RCT, n = 49, MD 0.11, 95% CI -0.74 to 0.95, low-quality evidence) by medium term. No data were available for the other outcomes of interest. AUTHORS' CONCLUSIONS: Very few trials have investigated TFPIs for individuals with SMI and PTSD. Results from trials of TF-CBT are limited and inconclusive regarding its effectiveness on PTSD, or on psychotic symptoms or other symptoms of psychological distress. Only one trial evaluated EMDR and provided limited preliminary evidence favouring EMDR compared to waiting list. Comparing TF-CBT head-to-head with EMDR and brief psychoeducation respectively, showed no clear effect for either therapy. Both TF-CBT and EMDR do not appear to cause more (or less) adverse effects, compared to waiting list or usual care; these findings however, are mostly based on low to very low-quality evidence. Further larger scale trials are now needed to provide high-quality evidence to confirm or refute these preliminary findings, and to establish which intervention modalities and techniques are associated with improved outcomes, especially in the long term

12‐hour shifts:Prevalence, views and impact

The provision of 24-hour nursing care inevitably involves shift work and flexible working, including “long days” or 12-hour shifts (Newey and Hood 2004, Lorenz 2008). However, these shift patterns have become increasingly controversial, with concerns raised over performance, fatigue, stress and patient safety. Historically, traditional shift work patterns were based on three eight-hour shifts per day (Ferguson and Dawson 2011, Estabrooks et al. 2009), but over the past 20 years there has been a tendency to move away from this pattern of working in preference for the 12-hour shift (Todd et al. 1989, McGettrick and O’Neill 2006).In the UK, many hospitals utilise 12-hour shifts primarily because managers believe it is a more cost effective way of providing 24-hour care, with lower costs and greater continuity of staffing (Estabrooks et al. 2009). Some nurses also prefer to work longer daily hours with fewer shifts, which gives them greater flexibility and more days away from work (Josten et al. 2003). As the majority of the nursing workforce is female, this may also make it easier to balance work and personal responsibilities (Messing 1997, Josten et al. 2003). However, there are increasing concerns over potential threats to patient safety and quality of care (Stimpfel and Aiken 2013), and some employers now question the benefits of such extended hours and are choosing to revert to eight-hour shifts (Geiger-Brown and Trinkoff 2010). Although the handover period has been criticised for being unproductive, with no formal ‘overlap’ 12-hour shifts can have a negative impact on opportunities for ward meetings, teaching, mentorship, teambuilding and research (Sprinks 2012). A study in the US by Stimpfel and colleagues published in 2013 found that nurses who worked shifts of 12-hours or longer were significantly more likely to report poor quality care and poor patient safety when compared to those working eight-hour shifts. Patients also reported lowersatisfaction with care in hospitals where staff worked longer shifts (Stimpfel et al. 2012).Shift work is a common feature across many industries. Fatigue associated with long shifts has been linked with disasters such as the Chernobyl nuclear accident, Three Mile Island incident and the grounding of the Exxon Valdez (Miller 2011). However, research to date is equivocal and some studies have found little differences in terms of cost or productivity (Williamson et al. 1994) or levels of fatigue (Duchon et al. 1994) by shift length. A systematic review by Smith et al. (1998) compared eight and 12-hour shifts across a broad range of industries and concluded that longer shifts increased fatigue but also led to an increase in job performance. Tucker et al. (1998) examined the effect of shift length on alertness. Their findings showed that more rest days between shifts were associated with slightly higher levels of alertness and lower levels of fatigue.In nursing, Geiger-Brown and Trinkoff (2010) reviewed studies up until 2008. In five of the seven studies reviewed, those working 12-hour shifts were significantly more fatigued. Estabrooks et al. (2009) reviewed 12 studies comparing the effect of eight and 12-hour shifts on quality of care and health care provider outcomes. They found insufficient evidence to conclude that shift length had an effect on patient or healthcare outcomes. A common question asked by health care employers and employees around shift work is “is it OK to work 12-hour shifts?” (Ferguson and Dawson 2011, p. 519). Our current study brings together findings from previously published studies and from new analysis of previously collected data, to address this question.AimThe aim of this study is to review existing data sources to identify what we know about the prevalence of 12-hour shifts in nursing and the impact on both staff and patients. Specifically, this study aims to address the following questions:What is the prevalence of 12-hour shifts in nursing?How much internal variation in shift length is there in NHS hospitals?What impact does shift length have on quality of patient care and staff experience?<br/