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The study investigated the power of theoretically derived cognitive variables to predict posttraumatic stress disorder (PTSD), travel phobia, and depression following injury in a motor vehicle accident (MVA). MVA survivors (N = 147) were assessed at the emergency department on the day of their accident and 2 weeks, 1 month, 3 months, and 6 months later. Diagnoses were established with the Structured Clinical Interview for DSM–IV. Predictors included initial symptom severities; variables established as predictors of PTSD in E. J. Ozer, S. R. Best, T. L. Lipsey, and D. S. Weiss's (2003) meta-analysis; and variables derived from cognitive models of PTSD, phobia, and depression. Results of nonparametric multiple regression analyses showed that the cognitive variables predicted subsequent PTSD and depression severities over and above what could be predicted from initial symptom levels. They also showed greater predictive power than the established predictors, although the latter showed similar effect sizes as in the meta-analysis. In addition, the predictors derived from cognitive models of PTSD and depression were disorder-specific. The results support the role of cognitive factors in the maintenance of emotional disorders following trauma.

BackgroundSome studies suggest that early psychological treatment is effective in preventing chronic post-traumatic stress disorder (PTSD), but it is as yet unclear how best to identify trauma survivors who need such intervention. This prospective longitudinal study investigated the prognostic validity of acute stress disorder (ASD), of variables derived from a meta-analysis of risk factors for PTSD, and of candidate cognitive and biological variables in predicting chronic PTSD following assault.MethodAssault survivors who had been treated for their injuries at a metropolitan Accident and Emergency (A&E) Department were assessed with structured clinical interviews to establish diagnoses of ASD at 2 weeks (n=222) and PTSD at 6 months (n=205) after the assault. Candidate predictors were assessed at 2 weeks.ResultsMost predictors significantly predicted PTSD status at follow-up. Multivariate logistic regressions showed that a set of four theory-derived cognitive variables predicted PTSD best (Nagelkerke R2=0·50), followed by the variables from the meta-analysis (Nagelkerke R2=0·37) and ASD (Nagelkerke R2=0·25). When all predictors were considered simultaneously, mental defeat, rumination and prior problems with anxiety or depression were chosen as the best combination of predictors (Nagelkerke R2=0·47).ConclusionQuestionnaires measuring mental defeat, rumination and pre-trauma psychological problems may help to identify assault survivors at risk of chronic PTSD.

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Management of patients with primary care needs in accident and emergency department by general practitioners reduced costs with no apparent detrimental effect on outcome. These results support new role for general practitioners.

A prospective longitudinal follow-up study (n=59) of child and adolescent survivors of physical assaults and motor vehicle accidents assessed whether cognitive processes predicted posttraumatic stress symptomatology (PTSS) at 6 months post-trauma in this age group. In particular, the study assessed whether maladaptive post-traumatic appraisals mediated the relationship between initial and later post-traumatic stress. Self-report measures of PTSS, maladaptive appraisals and other cognitive processes, as well as structured interviews assessing for Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD), were completed at 2-4 weeks and 6 months post-trauma. PTSS and PTSD at 6 months were associated with maladaptive appraisals and other cognitive processes, but not demographic or objective trauma severity variables. Only maladaptive appraisals were found to associate with PTSS/PTSD after partialling out initial symptoms/diagnosis, and to mediate between initial and later PTSS. On this basis it was argued that maladaptive appraisals are involved in the development and maintenance of PTSS over time, while other cognitive processes (e.g. subjective threat, memory processes) may only have an effect in the acute phase. The implications of this study for the treatment of PTSS in youth are discussed.

Employing general practitioners in accident and emergency departments to manage patients with primary care needs seems to result in reduced rates of investigations, prescriptions, and referrals. This suggests important benefits in terms of resource utilisation, but the impact on patient outcome and satisfaction needs to be considered further.

Accident and emergency triage can be developed to identify patients with problems that are more likely to be of a primary care type, and these patients are less likely to receive an investigation, minor surgical procedure, or referral. Many patients in this category, however, receive interventions likely to support their decision to attend accident and emergency rather than general practice. This may reflect limitations in the sensitivity of triage practice or a clinical approach of junior medical staff that includes a propensity to intervene.