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A randomised controlled trial of psychological debriefing for victims of road traffic accidents

^a Warneford Hospital, Oxford OX3 7JX, ^b John Radcliffe Hospital, Oxford OX3 9DU

Correspondence to: Dr Hobbs.

Psychiatric problems are common after major or minor road accidents. ^{1 2 3 4} Mayou et al found that one fifth of victims developed an acute stress reaction and one quarter displayed psychiatric problems within the first year.¹ Long term psychiatric problems were mainly mood disorder (10%), phobic travel anxiety (20%), and post-traumatic stress disorder (11%). Interest has been stimulated in preventive interventions, especially routine psychological "debriefing." Although widely used after trauma, no randomised controlled trials of debriefing have been reported, and debriefing may sometimes increase distress.⁵ This randomised controlled study aimed to test whether a single debriefing could reduce post-traumatic psychopathology in road accident victims.

Subjects, methods, and results

The subjects were victims of road accidents admitted consecutively to the John Radcliffe Hospital. We excluded those who could not remember the accident and those with no psychological symptoms, who are at low risk of later problems. Others were excluded because they had been discharged or were not available when the researcher came to visit them. Eight people refused to participate. Those who agreed were allocated randomly to intervention or control group using a random number table. All subjects were screened initially using a semistructured interview based on previous research and two standard self report questionnaires, the impact of events scale for specific post-traumatic symptoms and the brief symptom inventory, which generates a global emotional distress score.

Interventions were undertaken within 24-48 hours of the accident in most cases; they comprised an hour's debriefing combining a review of the traumatic experience, encouragement of emotional expression, and promotion of cognitive processing of the experience. Advice was provided about common emotional reactions, the value of talking about the experience, and early graded return to normal road travel. All experimental subjects received an information leaflet consolidating this advice and encouraging the support of family and friends. Both groups were reassessed by interview and the self report questionnaires at four months.

The intervention group (n = 54) had a higher mean injury severity score and longer hospital stay than the controls (n = 52), but there was no significant difference in baseline post-traumatic or other psychiatric symptoms. It proved difficult to interview patients during brief admissions to busy wards. Despite intensive efforts, follow up data were not obtained from 22% of the intervention group and 6% of controls. Non-respondents did not differ on baseline characteristics.

Neither group showed a significant reduction in specific post-traumatic symptoms, mood disorder, anxiety, the self reported measures, interview ratings of intrusive thoughts or travel anxiety, or clinical diagnosis of posttraumatic stress disorder or phobic anxiety (table 1). The intervention group had a worse outcome (P <0.05) on two subscales of the brief symptom inventory, however, and a (non-significantly) poorer outcome in terms of emotional distress.

Table 1--Baseline data and assessment of road accident
victims before and after psychological intervention
-------------------------------------------------------------------
                                                         Non-
                                     Intervention    intervention
                                         group           group
                                        (n = 54)*       (n = 52)+
-------------------------------------------------------------------
Baseline assessment
Sex
No of men                                  31              35
No of women                                23              17
Median age (years) (range)             29 (18-67)      26 (17-69)
No of drivers                              47              45
No of passengers                            7               7
No in car                                  35              36
No on motorcycle                           14              13
No in lorry or van                          5               3
Median score on injury severity
 scale (range)                        6.04 (1-33)     4.19 (1-19)
Median No of days' interval between
 accident and interview (range)       1.9  (1-9)      1.9  (1-10)
Median No of days' hospital stay
 (range)                              7.7  (1-88)     3.7  (<1-18)
Mean (SD) score on impact of
 events scale                        15.13 (14.82)   15.30 (12.35)
Mean (SD) emotional distress score    0.50 (0.53)     0.42 (0.32)
Follow up assessment
Mean (SD) emotional distress score    0.62 (0.78)     0.38 (0.43)
Mean (SD) score on impact of
 events scale                        15.97 (15.32)   12.87 (14.22)
No with distressing intrusive
 memories                                   9               5
Mean (SD) travel anxiety score         1.8  (1.68)    1.6  (1.7)
No with travel anxiety                     18              16
-------------------------------------------------------------------
*n = 42 for follow up assessment.
+n = 49 for follow up assessment.

Comment

The study showed the practical difficulties of offering an early psychological intervention to road accident victims. Despite the small numbers and lack of complete follow up data, the findings are clinically convincing. Psychiatric morbidity was substantial four months after injury, with no evidence that debriefing had helped--and, indeed, indications that it might have been disadvantageous.

Several explanations are possible: rapid discharge from hospital necessitated very early intervention and some patients were still too numbed or distressed to be receptive; the intervention did not seem relevant to subjects expecting an uneventful recovery; a single intervention was inadequate for major emotional problems; and early interventions may disturb natural psychological "defences" against fear and distress.

We believe that later psychological intervention might better reduce psychiatric morbidity and that selective interventions designed to address specific emerging problems--for example, phobic avoidance of road travel--would be more effective than generalised psychological debriefing. Identifying patients at risk after discharge would, however, require effective collaboration between hospitals and general practitioners.

Funding: Oxford regional research fund.

Conflict of interest: None.

1. Mayou R, Bryant B, Duthie R. Psychiatric consequences of road traffic accidents. BMJ 1993;307:647-51.
2. Malt UF, Olafsen OM. Psychological appraisal and emotional response to physical injury: a clinical, phenomenological study of 109 adults. Psych Medicine 1992;10:117-34.
3. Blanchard EB, Hickling EJ, Mitnick N, Taylor AE, Loos WR, Buckley TC. The impact of severity of physical injury and perception of life threat in the development of post-traumatic stress disorder in motor vehicle accident victims. Behav Res Ther 1995;33:529-34. [Medline]
4. Koopman C, Classen C, Cardena C, Spiegel D. When disaster strikes, acute stress disorder may follow. Journal of Traumatic Stress 1995;8:29-46. [Medline]
5. Raphael B, Meldrum L, McFarlane AC. Does debriefing after psychological trauma work? Time for randomised controlled trials. BMJ 1995;310:1479-80. [Free Full Text]

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