Early help for trauma stress

SINGAPORE - Most people expect to handle some stress in their lives, but nothing quite jolts the body and mind as a traumatic event.

A person is said to have gone through one if he has been in a car crash, was violently assaulted or witnessed a severe workplace injury.

In these intense moments, he might fear for his life and safety, or that of others.

In the aftermath of a traumatic event, the usual approach is to ensure the person has physically recovered.

But medical professionals here are increasingly paying attention to the mental well-being of such patients as well.

At least two hospitals here routinely screen trauma victims for prolonged signs of stress. The aim is to provide early psychological intervention, so the person is less likely to develop post-traumatic stress disorder (PTSD) in the longer term.

This debilitating condition impairs the social and occupational abilities of a person. For instance, a pedestrian in a road traffic accident may later take detours to avoid crossing any road, while a cab driver may stop driving altogether.

Research has shown that in the first 12months after a serious injury, up to three in 10 patients will develop a psychiatric disorder such as PTSD, depression, anxiety and substance use disorders.

Dr Chan Herng Nieng, a consultant at the department of psychiatry at Singapore General Hospital (SGH), said if they are left untreated, trauma patients may resort to alcohol or drugs to alleviate their distress.

In 2007, both Changi General Hospital (CGH) and KK Women's and Children's Hospital (KKH) started screening programmes using questionnaires to identify those at risk of PTSD. The mental state of trauma victims admitted through emergency departments and subsequently warded are routinely checked.

Since March 2007, more than 3,500patients have been screened at CGH, while at KKH, approximately 1,400children have been screened since June 2007.

CGH said more than half of trauma patients are screened. The rest either already have underlying psychiatric illnesses or may have been discharged or transferred before they could be screened.

At other hospitals such as SGH, trauma patients who show significant mental distress are referred by doctors who treat their physical injuries to psychologists or psychiatrists.

At Tan Tock Seng Hospital (TTSH) and National University Hospital (NUH), the severity of stress symptoms of such patients is then assessed using questionnaires.

Dr Teo Li Tserng, a consultant in trauma service at the department of general surgery at TTSH, estimated that one or two out of every 10 trauma patients will need such a referral.

Associate Professor Malcolm Mahadevan, head and senior consultant of NUH's emergency medicine department, said screening the entire trauma population may not be necessary, just like how cancer screening is recommended for only certain age groups.

He recommends screening only the high-risk group, such as those who have witnessed people dying.

Benefits of screening

The Journal Of Traumatic Stress reported in April that screening 683 patients for risk in an acute hospital in Australia correctly identified more than 85 per cent of those who went on to develop PTSD, major depressive disorder and any anxiety or affective disorder within 12 months of their trauma.

These patients were offered treatment within six weeks of the trauma. The authors also found that those in the early intervention group had a greater improvement in their screening scores over time than those in the usual care regimen.

CGH and KKH have yet to analyse how many screened patients eventually developed mental disorders, but said patients seemed to be benefiting from screening.

Since screening began at CGH, the proportion of patients who are screened and later referred to the psychiatrists has dropped, said Ms Elizabeth Ho, a counsellor at the trauma recovery and corporate solutions unit at CGH.

Last year, 1.8 per cent of screened patients needed psychiatric intervention, down from 5.5 per cent in 2009.

This drop is an indication that fewer screened patients went on to develop psychiatric disorders such as PTSD and depression, Ms Ho said.

Preliminary findings showed the majority of patients at CGH recover by the third month, she added. Seven in 10 patients report a return to their previous level of functioning by then and 85 per cent showed an improvement in anxiety and depression.

The improvement could be due to the early intervention, though it could also be due to patients' natural coping abilities, Ms Ho said.

She will share these results on Saturday at Trauma Conference 2012, a gathering on evidence-based practice approaches to crisis intervention and PTSD.

Approximately one in 10 children screened in the wards at KKH is advised to return for a follow-up consultation four to six weeks after their discharge, because either he or his family was distressed or had risk factors that required them to be closely monitored.

Of the children asked to return for therapy, nine in 10 improved after treatment and resumed their daily activities, said Dr Jasmine Pang, a senior clinical psychologist and deputy head of service at the psychosocial trauma support service.

Tell-tale signs

At CGH, patients are seen in the wards by a counsellor who assesses them and also counsels them. They are asked about symptoms such as bad dreams, irritability, sleeplessness or the feeling of reliving the event.

Though PTSD is persistent and debilitating, its three core symptoms of intrusive thoughts, hyperarousal and avoidance actually begin as normal and understandable responses to severe stress and shock.

In most cases, these symptoms disappear within a few weeks. A problem arises when the reactions become so intense and frequent that they interfere with everyday life.

Dr Chan said it is a challenge to identify children who cannot yet verbalise their distress. They may report physical ailments such as headaches and abdominal pain instead.

So at KKH, medical staff observe how children and their parents behave in the wards as part of screening in addition to interviewing them, said Dr Pang.

Some children burst into tears when recounting what happened. Parents' moods also affect their children.

Dr Pang said art, music and play may be used to help children express themselves and understand what happened to them.

Ms Ho said the screening session lets her educate patients about the reactions they can expect, teach them coping tips and prepare them to receive mental health intervention later, if necessary.

She helps patients normalise their immediate reactions and allay their fear of going insane.

Patients are also asked about the impact of past traumatic events, the support they received then and how they felt during and after the recent trauma - all of which can indicate their risk of developing PTSD.

Dr Mok Yee Ming, deputy chief of the department of general psychiatry in the Institute of Mental Health, said how vulnerable someone is to PTSD stems from an interplay of biological factors, early childhood experiences and how severe the event was.

So someone with poor relationships who has not learnt coping skills as a young child is more likely to develop PTSD, he added.

Dr Christopher Cheok, head and senior consultant at the psychological medicine department at Khoo Teck Puat Hospital, said a person's perception of how horrific the event was is a better predictor of PTSD than his physical injuries.

So a passenger who was sleeping when the accident occurred would be less traumatised than the driver who saw, heard and felt the impact of the collision, though both may have sustained similar injuries.

After a patient is discharged from CGH, the counsellor calls at the one-month and three-month marks to track his return to normal life, as indicated by his mobility, self-care, engagement in his usual activities, pain or discomfort, and anxiety or depression.

This follow-up is essential since some time may pass before symptoms arise or become unbearable, said Mr Daniel Koh, a psychologist at private counselling clinic Insights Mind Centre.

Dr Lim Yun Chin, consultant psychiatrist at Raffles Counselling Centre at Raffles Hospital, noted that others who are in contact with the patients, such as family members, employers and even lawyers, have a role to play in referring them for help.

He said: "Walk-in cases of PTSD tend to be very rare. Cases are usually picked up by general practitioners, who are getting better at recognising signs of PTSD."

One patient who benefited from the screening endured her husband's assaults for the last three years.

The 25-year-old housewife was so severely beaten in July that she was hospitalised for five days at CGH with a swollen face, torn lips and a throbbing headache. She was in low spirits, had poor sleep and flashbacks of the physical attacks, making her susceptible to PTSD.

After her discharge, she had follow-up sessions with a psychiatrist and counsellor and subsequently obtained a personal protection order against her husband.

Ms Ho taught her to pen her feelings in a journal and reconnect with friends to build her social support network.

When her family criticised her for taking the personal protection order, she calmed herself through breathing techniques and positive thoughts.

She said: "I'm not the same weak person I was. I know what I need to do to start a new life." joanchew@sph.com.sg