Outreach and Screening for Persistent Psychological Reactions after the 2005 London Bombings: the NHS Trauma Response Programme

Chris BrewinClinical, Educational & Health PsychologyUniversity College LondonTraumatic Stress Clinic, Camden & Islington NHS Foundation Trust

Three phases of the psychosocial response to emergencies

• Phase 1

Focus: immediate safety and survival. Leads: emergency services, Red Cross

• Phase 2

Focus: more broadly on practical and emotional support of a variety of affected groups including survivors, the bereaved, witnesses, first responders. Leads: FEMA, state and local government

• Phase 3

Focus: minority with persistent mental health problems. Leads: state and local government, mental health providers

Help-seeking after terrorist attacks

•Direct victims are at high risk of persistent disorder

•PTSD rates of 20% are likely after 2 years

•Individuals without previous experience of mental health

services avoid treatment

•Delayed onset and delayed help-seeking will mean new

victims continue to come forward for two years and longer

•Little is known about how to deliver mental health

interventions, who takes them up, and whether they are

effective

NHS clinician-led proposal for a screening team and additional treatment resources

• There will be substantial longer-term mental health needs after 7/7 and most will remain unmet if normal referral channels are relied upon

• Existing posttraumatic stress services have long waiting lists and will not be able to respond to increased demand in a timely way

• There is a need for a dedicated team to efficiently coordinate outreach and screening, as well as for additional resources to deliver evidence-based psychological treatment quickly in existing specialist centres

Outreach strategy

• In addition to normal referral channels:

– Lists of injured sought from Emergency Departments– Police wrote to people on their witness list– Occupational health departments sent members of

emergency services who wanted separate treatment– London primary care and family physicians written to by

U.K. Department of Health– NHS Direct helpline– General mass media campaign

Outline procedure of the Trauma Response Programme funded by the Department of Health

Brief screener

Follow up Diagnostic interview

Treatment

Screening

• Very brief questionnaire including:– Trauma Screening Questionnaire (TSQ)– 2 validated depression items– 1 new travel phobia item– Increased smoking/drinking– Other cause for concern

• Diagnostic interview offered if score >5 on TSQ or any other items answered positively

• Additional screeners for children

Diagnostic interview

• SCID-I modules for PTSD, MDD & Specific Phobia• Previous psychiatric history• Current alcohol or drug problems• Is the person recovering naturally?• Decision made to continue monitoring (send further

screening questionnaires at 3-monthly intervals), refer back to service providers they are already in contact with, refer for alcohol/drug work, or refer for brief specialist trauma treatment

Treatment

• Fast-tracked into trauma-focused cognitive-behaviour therapy or EMDR

• Programme funding enabled additional therapists to be recruited with expertise in trauma work

• Primarily at 3 specialist traumatic stress treatment centres in London

• Supervision provided by centre staff• Posttraumatic Diagnostic Scale (PDS) and Beck

Depression Inventory (BDI) used by all centres

Characteristics of those referred to the Programme and the nature of their involvement

• 910 people received information about the programme

• 596 of these were screened

• 75% of this sample personally witnessed the effects of the bombings

• 32% of this sample were injured

• 363 received a detailed clinical assessment

• 304 judged to need treatment

• Posttraumatic stress disorder (PTSD) was the most common psychological condition

Referrals to Programme

0

20

40

60

80

100

120

140

160

180

200

Jul-0

5

Aug

-05

Sep

-05

Oct

-05

Nov

-05

Dec

-05

Jan-

06

Feb

-06

Mar

-06

Apr

-06

May

-06

Jun-

06

Jul-0

6

Aug

-06

Sep

-06

Oct

-06

Nov

-06

Dec

-06

Jan-

07

Feb

-07

Mar

-07

Apr

-07

May

-07

Jun-

07

Jul-0

7

Aug

-07

Sep

-07

Referrals to treatment (% of assessments)

0

10

20

30

40

50

60

70

80

90

100

Jul-0

5

Aug

-05

Sep

-05

Oct

-05

Nov

-05

Dec

-05

Jan-

06

Feb

-06

Mar

-06

Apr

-06

May

-06

Jun-

06

Jul-0

6

Aug

-06

Sep

-06

Oct

-06

Nov

-06

Dec

-06

Jan-

07

Feb

-07

Mar

-07

Apr

-07

May

-07

Jun-

07

Jul-0

7

Aug

-07

Sep

-07

Primary diagnoses of patients referred to treatment

Adjustment disorder6%

Travel phobia7%

PTSD (DSM-IV or ICD-X)69%

Complicated grief

GAD

Depression

Other/not stated

Treatment activity in the programme – DSM-IV PTSD

No. of sessionsTreatment duration

(weeks)

Mean 11.96 (SD = 11.46) 24.71 (SD = 22.78)

Range 0-59 0-96

Median 9 18

• Majority of individuals who finished treatment received Cognitive Behaviour Therapy (61%), Eye Movement Desensitisation and Reprocessing (10%) or both (18%)

Treatment outcome in the programme – DSM-IV PTSD

Individuals showing clinically significant change in:• Posttraumatic symptoms: 66% of 104 treatment

completers• Depression symptoms: 56% of 104 treatment

completers

Treatment gains were maintained at one yearResults as good as randomised controlled trials of

cognitive-behaviour therapy for PTSD in the scientific literature

Lessons learned from users

• The Trauma Response Programme delivered effective treatment and was found acceptable and appropriate

• Programme familiarity and usage low among individuals who had been written to about the Programme by a third party. A substantial minority of these experienced bombings-related psychopathology, and attributed failure to use Programme to lack of knowledge about it

• They wouldn’t have minded contact details being passed to National Health Service by other organisations

• Family doctors tended to be unhelpful or unaware of services

Lessons learned from NHS staff

• Normal referral pathways for mental health care were relatively inflexible and were likely to actively hinder access to care for many survivors

• Outreach was possible but greatly hindered by institutional barriers to disclosing who had been affected, particularly through misunderstanding of the Data Protection Act

• More clarity needed in who ‘owned’ the project and was responsible for its success, and about how to make financial decisions in the absence of earmarked resources

• Referral outside the Programme to other areas of the U.K. was difficult

Conclusions

• The usual problems in identifying people with persistent mental health needs after major disaster were present after July 2005

• The outreach programme identified many affected people but without a register we cannot know how many did not receive information about it

• People who did receive evidence-based treatment appeared to benefit substantially

• There is much work to do in improving the financial and organisational arrangements for meeting mental health needs after future disasters and terrorist attacks

References

• Brewin, C.R., Fuchkan, N., Huntley, Z., Robertson, M., Thompson, M., Scragg, P., d’Ardenne, P., & Ehlers, A. (2010). Outreach and screening following the 2005 London bombings: Usage and

outcomes. Psychological Medicine, 40, 2049-2057.• Brewin, C.R., Rose, S., Andrews, B., Green, J., Tata, P., McEvedy, C.,

Turner, S.W., & Foa, E.B. (2002). A brief screening instrument for posttraumatic stress disorder. British Journal of Psychiatry, 181, 158-162.

• Brewin, C.R., Scragg, P., Robertson, M., Thompson, M., d’Ardenne, P., & Ehlers, A. (2008). Promoting mental health following the London bombings: A screen and treat approach. Journal of Traumatic Stress, 21, 3-8.

• Whalley, M.G. & Brewin, C.R. (2007). Mental health following terrorist attacks. British Journal of Psychiatry, 190, 94-96.