Psychological debriefing for preventing post traumatic stress disorder (PTSD) Edited (no change to conclusions)

Abstract

Abstract
Background

Over approximately the last fifteen years, early psychological interventions, such as psychological 'debriefing', have been increasingly used following psychological trauma. Whilst this intervention has become popular and its use has spread to several settings, empirical evidence for its efficacy is noticeably lacking. This is the third update of a review of single session psychological "debriefing", first having been undertaken in 1997.

Objectives

To assess the effectiveness of brief psychological debriefing for the management of psychological distress after trauma, and the prevention of post traumatic stress disorder.

Search methods

Electronic searching of MEDLINE, EMBASE, PsychLit, PILOTS, Biosis, Pascal, Occ.Safety and Health,SOCIOFILE, CINAHL, PSYCINFO, PSYNDEX, SIGLE, LILACS, CCTR, CINAHL, NRR, Hand search of Journal of Traumatic Stress. Contact with leading researchers.

Selection criteria

The focus of RCTs was on persons recently (one month or less) exposed to a traumatic event. The intervention consisted of a single session only, and involved some form of emotional processing/ventilation, by encouraging recollection/reworking of the traumatic event, accompanied by normalisation of emotional reaction to the event.

Data collection and analysis

15 trials fulfilled the inclusion criteria. Methodological quality was variable, but the majority of trials scored poorly. Data from 6 trials could not be included the meta‐analyses. These trials are summarised in the text.

Main results

Single session individual debriefing did not prevent the onset of post traumatic stress disorder (PTSD) nor reduce psychological distress, compared to control. At one year, one trial reported a significantly increased risk of PTSD in those receiving debriefing (OR 2.51 (95% CI 1.24 to 5.09). Those receiving the intervention reported no reduction in PTSD severity at 1‐4 months (SMD 0.11 (95%CI 0.10 to 0.32)), 6‐13 months (SMD 0.26 (95%CI 0.01 to 0.50)), or 3 years (SMD 0.17 (95%CI ‐0.34 to 0.67)). There was also no evidence that debriefing reduced general psychological morbidity, depression or anxiety, or that it was superior to an educational intervention.

Authors' conclusions

There is no evidence that single session individual psychological debriefing is a useful treatment for the prevention of post traumatic stress disorder after traumatic incidents. Compulsory debriefing of victims of trauma should cease. A more appropriate response could involve a 'screen and treat' model (NICE 2005).

Author(s)

Suzanna C Rose, Jonathan Bisson, Rachel Churchill, Simon Wessely

Abstract

Plain language summary

 Psychological debriefing for preventing post traumatic stress disorder (PTSD) 

This review concerns the efficacy of single session psychological "debriefing" in reducing psychological distress and preventing the development of post traumatic stress disorder (PTSD) after traumatic events. Psychological debriefing is either equivalent to, or worse than, control or educational interventions in preventing or reducing the severity of PTSD, depression, anxiety and general psychological morbidity. There is some suggestion that it may increase the risk of PTSD and depression. The routine use of single session debriefing given to non selected trauma victims is not supported. No evidence has been found that this procedure is effective.

Author(s)

Suzanna C Rose, Jonathan Bisson, Rachel Churchill, Simon Wessely

Reviewer's Conclusions

Authors' conclusions

Implications for practice

1. At present the routine use of single session individual debriefing in the aftermath of individual trauma cannot be recommended in either military or civilian life. The practice of compulsory debriefing should cease pending further evidence. Even if further large scale trials do reveal a positive effect of debriefing that has not been detected in the trials to date, the evidence reviewed above suggest the likely treatment effect will be small.

2. We are unable to comment on the use of group debriefing, nor the use of debriefing after mass traumas. We are also unable to make recommendations about the use of debriefing in children.

3. It appears appropriate to continue to focus resources on identifying and treating those with recognisable psychiatric disorders arising after trauma, such as acute stress disorder, depression and PTSD. Emphasis should increasingly be placed on the early detection of those at risk of developing psychopatholgy and early interventions should be aimed at this group. Follow‐up assessment should increasingly viewed as important and the use of screen and treat programmes should be increasingly developed (NICE 2005). The Psychological First Aid Model (Freeman in press) may offer an alternative approach, although clearly this needs evaluation. This model proposes an individually tailored response that encompasses practical and social support, any discussion of the event is again respondent led, use of a follow‐up and, where necessary, appropriate referral to a mental health professional.

4. In terms of using the principles of evidence based practice where psychosocial interventions are used, even when (especially when) associated with clear need, high face validity and client satisfaction these should not be regarded as a substitute for evidence.

Implications for research

1. There is no information on the response of those with pre existing psychiatric disorder to psychological debriefing, since all studies used known psychiatric disorder as an exclusion.

2. Since the last issue of this review three further trials and a follow‐up have been reported, but there remains a continuing need for more randomised studies. Three areas are a particular priority. First, the efficacy of debriefing in emergency workers. Second, the efficacy of group, as opposed to individual, debriefing. Third, the efficacy of debriefing after mass disasters/traumas, although it is accepted that such studies will be difficult to undertake. Currently the reviewers are not aware of the evidence base surrounding debriefing in children.

3. There is a need towards working with predictive questionnaires with differing populations to highlight those 'at risk' (e.g. Brewin 2003, NICE 2005).

4. At present the reviewers are aware of several ongoing RCTs, the results of which will be incorporated into this review as soon as they are available.

5. There are now four published trials of longer interventions (Foa 1995a, Andre 1997, Bryant 1998a, Bisson et al, in press). Preliminary information suggests that delivering more formalised interventions over a longer period of time and aimed at those with overt distress may be worthwhile.

The results of this review contrast with the evidence for the effectiveness of psychological treatments in the management of several psychiatric disorders. Treatments that are effective in those with established disorder cannot be assumed to be effective in prevention, and the possibility of adverse effects must be remembered.

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