Implementation of a screening-based algorithm for diagnosis and treatment of mental-health problems into the therapy concept of the statutory accident insurance – FAUST II

Status:

completed 07/2011

Aims:

The objective of this project is the evaluation of a new screening-based algorithm for diagnosis and treatment of mental health problems after severe work related accidents. This algorithm is based on empirical findings of a precedent study with high risk patients after accidental trauma ("Freiburger Arbeitsunfallstudie I"). Does a systematic screening for early psychological symptoms - conducted during surgical inpatient treatment - improve detection, diagnosis and treatment of risk patients for mental health problems? The impact of this procedure on symptom courses and rehabilitation results six months after the accidents is analysed.

Activities/Methods:

The study is conducted in several emergency clinics with patients after acute work related injuries which need not less than seven days of inpatient treatment. In a control phase the screening instrument is just given to the patients without influencing the etablished management of mental health problems in the clinics (treatment as usual). In the intervention phase results of the screening instrument guide additional steps for diagnosis and treatment of mental health symptoms. All included risk patients are assessed before discharge from hospital and at six month follow-up for symptoms of posttraumatic stress disorder, anxiety and depression. Further data concerning symptom courses, treatment and rehabilitation six months after the accident are gathered directly from the statutory accident insurance services. The impact of the new algorithm concerning practice, acceptance and effects is compared with the present procedures.

Results:

The multicenter-study evaluates the psychological sequelae of accidental injury, its early identification, and systematic clinical management for risk patients. The implementation of a screening based algorithm for diagnosis and treatment of mental health problems was studied under routine conditions in 18 trauma departments. Symptom courses and 6 months’ results were compared for 3 different risk-groups – derived from patients’ results in a 10-item screening questionnaire (non-risk- ”green”, risk- “yellow” and high-risk-patients “red”) - and for 2 phases of the study (treatment as usual (TAU)/ intervention phase). In addition to symptom self-ratings “objective” data from the employer’s liability insurance were collected 6 months after the accident. Outcome and process data by patients, surgeons and employer’s liability insurance services were analysed. 1800 patients with at least 6 days of in-patient treatment were included, with a quota of 22 % risk patients in both study phases. 62 % of risk patients initially showed high PTBS scores, 40 % had depressive symdromes and 25 % showed panic-attacks. 6-months outcome for risk patients in the intervention phase was not superior compared to TAU. In both phases patients with more severe symptoms and high-risk status showed a chronic course of their PTBS and anxiety symptoms after 6 months. 50 % (phase 1) vs. 34 % (phase 2) showed high functional impairments in everday-life due to mental health problems. Compared to “non-risk-”, “risk patients” had significant and clinically relevant higher levels of psychopathology at follow-up. An analysis of the implementation process revealed practical problems at the transition from inpatient identification of risk status and actual management of subsequent diagnostic and therapeutic steps by the employer’s liability insurance services. The potential of the screening-based procedure for mental health problems could be enhanced by compensating organisational deficits and by a specific algorithm for diagnostic and therapeutic intervention. The management of mental health problems in the aftermath of severe injuries should comprise different tools within a stepped-care approach, starting with early identification in surgery departments. Existing clinical guidelines for acute traumatization should be taken into consideration. The diagnostic and therapeutic algorithm under examination is also compatible with a concept of the DGUV, the so called “Modellverfahren Psychotherapy”, which follows the idea of early diagnosis and indicative intervention for patients at risk for the development of chronic psychopathology.

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