In the Journals

Stepped care effective for PTSD after natural disaster

Analysis of simulated treatment suggested efficacy and cost-effectiveness of a stepped care intervention for PTSD after a natural disaster when compared with usual care.

“One potential reason for the persistence of mental health conditions, including PTSD, after disasters could be the lack of effective triage to appropriate levels of care,” Gregory H. Cohen, MPhil, MSW, of the department of epidemiology, Boston University School of Public Health, and colleagues wrote. “Although mental health care delivery efforts in the wake of disaster exposures often include psychological first aid — a universal intervention — and [Skills for Psychological Recovery (SPR)], a moderate-strength intervention targeting distressed individuals, evidence from stepped care case-finding models suggests that the most efficient and effective population approach may be screening and triage to the appropriate level of care followed by ongoing systematic reevaluation.”

To assess efficacy of stepped care for PTSD after a natural disaster, researchers conducted simulated treatment scenarios among 2,642,713 simulated agents living in areas of New York City affected by Hurricane Sandy. Simulated treatment began 4 weeks after landfall of Hurricane Sandy and ended 2 years later. The stepped care intervention referred agents with PTSD to cognitive behavioral therapy and those without PTSD to SPR, an evidence-based therapy to reduce distress and improve coping and functioning. Agents who received usual care were referred to SPR.

Agents were initialized with a PTSD prevalence of 4.38%, with distributions of sex and age comparable with population estimates in areas of New York City affected by Hurricane Sandy.

Stepped care was associated with a greater reach than usual care and was superior for reducing PTSD prevalence in the full population. Researchers noted an absolute benefit at 6 months (risk difference = –0.004; 95% CI, –0.004 to –0.004), which improved through 1.25 years (risk difference = –0.015; 95% CI, –0.015 to –0.014).

Relative benefits of stepped care were evident at 6 months (risk ratio = 0.905; 95% CI, 0.898-0.913), with continued improvement through 1.75 years (risk ratio = 0.615; 95% CI, 0.609-0.662).

Absolute benefit of stepped care was stronger among agents with PTSD, which was evident at 3 months (risk difference = –0.006; 95% CI, –0.007 to –0.005) and increased through 1.5 years (risk difference = –0.338; 95% CI, –0.342 to –0.335).

Compared with usual care, the incremental cost-effectiveness of stepped care was $3,428.71 to $6,857.68 per disability-adjusted life year avoided and $0.8 to $1.61 per PTSD-free day.

“This study has shown in a simulation that [stepped care] for early treatment of PTSD after a disaster was associated with greater reach, treatment effectiveness and cost-effectiveness relative to the more universally applied interventions that resemble our [usual care] condition. Accordingly, these results provide further proof of concept for the [stepped care] approach to treating PTSD after a disaster, and they warrant further study and application in real-world settings,” the researchers concluded. – by Amanda Oldt

Disclosures: The authors report no relevant financial disclosures.

Analysis of simulated treatment suggested efficacy and cost-effectiveness of a stepped care intervention for PTSD after a natural disaster when compared with usual care.

“One potential reason for the persistence of mental health conditions, including PTSD, after disasters could be the lack of effective triage to appropriate levels of care,” Gregory H. Cohen, MPhil, MSW, of the department of epidemiology, Boston University School of Public Health, and colleagues wrote. “Although mental health care delivery efforts in the wake of disaster exposures often include psychological first aid — a universal intervention — and [Skills for Psychological Recovery (SPR)], a moderate-strength intervention targeting distressed individuals, evidence from stepped care case-finding models suggests that the most efficient and effective population approach may be screening and triage to the appropriate level of care followed by ongoing systematic reevaluation.”

To assess efficacy of stepped care for PTSD after a natural disaster, researchers conducted simulated treatment scenarios among 2,642,713 simulated agents living in areas of New York City affected by Hurricane Sandy. Simulated treatment began 4 weeks after landfall of Hurricane Sandy and ended 2 years later. The stepped care intervention referred agents with PTSD to cognitive behavioral therapy and those without PTSD to SPR, an evidence-based therapy to reduce distress and improve coping and functioning. Agents who received usual care were referred to SPR.

Agents were initialized with a PTSD prevalence of 4.38%, with distributions of sex and age comparable with population estimates in areas of New York City affected by Hurricane Sandy.

Stepped care was associated with a greater reach than usual care and was superior for reducing PTSD prevalence in the full population. Researchers noted an absolute benefit at 6 months (risk difference = –0.004; 95% CI, –0.004 to –0.004), which improved through 1.25 years (risk difference = –0.015; 95% CI, –0.015 to –0.014).

Relative benefits of stepped care were evident at 6 months (risk ratio = 0.905; 95% CI, 0.898-0.913), with continued improvement through 1.75 years (risk ratio = 0.615; 95% CI, 0.609-0.662).

Absolute benefit of stepped care was stronger among agents with PTSD, which was evident at 3 months (risk difference = –0.006; 95% CI, –0.007 to –0.005) and increased through 1.5 years (risk difference = –0.338; 95% CI, –0.342 to –0.335).

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Compared with usual care, the incremental cost-effectiveness of stepped care was $3,428.71 to $6,857.68 per disability-adjusted life year avoided and $0.8 to $1.61 per PTSD-free day.

“This study has shown in a simulation that [stepped care] for early treatment of PTSD after a disaster was associated with greater reach, treatment effectiveness and cost-effectiveness relative to the more universally applied interventions that resemble our [usual care] condition. Accordingly, these results provide further proof of concept for the [stepped care] approach to treating PTSD after a disaster, and they warrant further study and application in real-world settings,” the researchers concluded. – by Amanda Oldt

Disclosures: The authors report no relevant financial disclosures.