Emergency room intervention to prevent post concussion-like symptoms and post-traumatic stress disorder. A pilot randomized controlled study of a brief eye movement desensitization and reprocessing intervention versus reassurance or usual care

Abstract

Up to 20% of patients presenting at an emergency room (ER) after a stressful event will for several months suffer from very diverse long-lasting symptoms and a potentially significant decline in quality of life, often described as post concussion-like symptoms (PCLS). The objectives of our randomized open-label single-center study were to assess the feasibility of psychologist-led interventions in the context of the ER and to compare the effect of eye movement desensitization and reprocessing (EMDR) with reassurance and usual care. Conducted in the ER of Bordeaux University Hospital, the study included patients with a high risk of PCLS randomized in three groups: a 15-min reassurance session, a 60-min session of EMDR, and usual care. Main outcomes were the proportion of interventions that could be carried out and the prevalence of PCSL and post-traumatic stress disorder (PTSD) three months after the ER visit.

One hundred and thirty patients with a high risk of PCLS were randomized. No logistic problem or patient refusal was observed. In the EMDR, reassurance and control groups, proportions of patients with PCLS at three months were 18%, 37% and 65% and those with PTSD were 3%, 16% and 19% respectively. The risk ratio for PCLS adjusted for the type of event (injury, non-injury) for the comparison between EMDR and control was 0.36 [95% CI 0.20–0.66].

This is the first randomized controlled trial that shows that a short EMDR intervention is feasible and potentially effective in the context of the ER.

The study was registered at ClinicalTrials.gov (NCT03194386).

Introduction

According to a 2012 national survey in France, 10.6 million people came or were taken to the emergency room (ER), several times in some cases, accounting for 18 million visits recorded that year (Vuagnat, 2013). About half of these visits are the consequence of injury and more than 90% of patients will leave the service within hours, without hospitalization (Carrasco and Baubeau, 2003). Consistent recent studies (de Leon et al., 2009; Friedland and Dawson, 2001; McLean et al., 2009; Stovner et al., 2009) reveal that 10–20% of these injured patients for several months after the event will suffer from very diverse symptoms often associated with a potentially significant decline in quality of life, delay in return to school or work activities and change in social and family relationships. Extrapolating these figures to the annual number of ER visits in France led us think that at least one million people each year could be concerned by varying degrees of difficulty in the months following an ER visit. The potential link with the initial event, often unidentified, is all the more difficult to make as these symptoms are non-specific: headaches, concentration disorders, memory problems, stress intolerance, personality change, irritability. They have been described for more than 50 years, in the context of head injury, and thus referred to as the post-concussion syndrome (PCS). Recent studies suggest that these symptoms are not specific to brain injuries and can occur for all types of trauma (Laborey et al., 2014; Lagarde et al., 2014; McLean et al., 2009; Smith-Seemiller et al., 2003), greatly expanding the size of the population concerned. They are henceforth now frequently described as post concussion-like symptoms (PCLS) (Edmed and Sullivan, 2012).

Further, the results of a study we conducted among injured patients admitted to the ER (Lagarde et al., 2014) reinforced the hypothesis that concussion-like symptoms included ones that were very similar to those of the hyperactivation and numbing dimensions of post-traumatic stress disorder (PTSD) (Diagnostic and Statistical Manual of Mental Disorders, 2013). This led us, with other authors (Edmed and Sullivan, 2012), to raise the hypothesis that PCS and PTSD partly share a causal pathway in which stress plays a key role. Another interesting result of our previous study (Lagarde et al., 2014) was that a small set of measurable factors were associated with the risk of PCS and PTSD, paving the way to the development of simple assessment tools to identify a subset of high-risk patients. Consistently, several studies conducted in the past five years noted that patients’ psychological vulnerability and stress experienced during and in the aftermath of the event that led to ER admission were the two most predictive elements of these long-lasting symptoms (Bernard et al., 2016; Lee et al., 2015; Losoi et al., 2016; Manners et al., 2016; Stein et al., 2016). These result prompted us to consider testing the feasibility and the effectiveness of stress management interventions during ER stay, with the hope of improving outcomes of injured patients, but also of all patients presenting at the ER and who experience stress either related to an event (accident or medical condition) or to the ER stay. While no result is available in the literature concerning the prevention of PCLS, studies evaluating interventions for PTSD prevention are sufficient in number and quality to identify credible modes of intervention. We identified eye movement desensitization and reprocessing (EMDR) (Bisson et al., 2013) as an intervention both promising and potentially suitable for use in the ER:, for which. Because of (i) the strong overlap between PTSD and PCLS, (ii) the importance of stress as reported in the ER in the sustained PCLS three months later, and (iii) the availability of a shortened adapted protocol (Jarero et al., 2011; Quinn, 2013; Shapiro and Laub, 2013), we decided to define a first comparison group of the trial with patients recieving the EMDR intervention by trained psychologists. We selected reassurance as a second comparison group as a small number of study reports suggest a preventive potential of reassuring patients about recovery and persistent symptoms (Absolom et al., 2007; Odeen et al., 2013; Pincus et al., 2013; Schmulson et al., 2006). This second intervention group will allow us to compare the impact of EMDR with a shorter interaction by the same trained psychologists.

We conducted a pilot randomized controlled study to assess the feasibility of psychologist-led interventions in the context of the ER and to compare the 3-month rate of PTSD and PCLS among patients presenting at the ER, assessed as being at high risk for these two syndromes and randomized in three groups: a 15-min reassurance session, a single 60-min session of EMDR, compared with usual care.