The role of psychological support interventions in trauma patients on mental health outcomes: A systematic review and meta-analysis Christopher H. Pham, MD, Mike Fang, PhD, Jacqueline Nager, MS, Kazuhide Matsushima, MD, Kenji Inaba, MD, and Catherine M. Kuza, MD, Los Angeles, California BACKGROUND: The recovery and rehabilitation of trauma survivors may be long and challenging. Patients may be prone to psychiatric disorders, cognitive impairments, and decreased quality of life. The objective of this review was to determine whether there is a role for psy- chological interventions in reducing the incidence and severity of psychiatric sequelae in trauma survivors. METHODS: MEDLINE, PubMed, SCOPUS, and Google Scholar were searched for published articles. We searched for articles published be- tween 1990 and 2018 with adult subjects, and limited our search to articles published in English. Randomized controlled trials that evaluated various psychiatric interventions in trauma patients on the effects of psychiatric outcomes were included for analysis. The articles were independently reviewed for eligibility by two different reviewers. A meta-analysis was performed on nine studies with similar interventions, outcomes measured, and patient populations. RESULTS: Nine hundred thirty-four articles were identified [830 articles identified through database search, and 107 through article refer- ences]. Sixty-nine full-text articles were reviewed for eligibility. Of these, 33 were included for qualitative analysis. Thirteen studies evaluating the effect of cognitive behavioral therapy (CBT)-based interventions on the severity of posttraumatic stress disorder (PTSD), anxiety, and depression symptoms underwent meta-analysis. While CBT-treated patients experienced clinically signifi- cant decreases in symptom severity, there were no statistically significant differences between treatment and control groups at follow-up for PTSD, anxiety, and depression. CONCLUSION: Compared with usual care, CBT-based interventions may not be effective in decreasing or preventing PTSD, anxiety, or depression symptoms in trauma survivors. (J Trauma Acute Care Surg. 2019;87: 463–482. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.) LEVEL OF EVIDENCE: Systematic Review, level III. KEY WORDS: Trauma; psychological intervention; PTSD; anxiety; depression. T rauma is the leading cause of death for individuals 46 years or younger in the United States. 1 The emotional nature of the trauma itself, combined with a prolonged hospital stay and recovery period, make trauma patients susceptible to psychiatric sequelae. After severe traumatic injuries, some patients may de- velop psychiatric disorders. Several studies suggest that early psychotherapy or phar- macotherapy may help attenuate or prevent the development of psychiatric symptoms. 2–5 Several systematic reviews and meta-analyses have evaluated the effects of early psychological interventions on outcomes in trauma patients 6,7 and their long- term effects. 8 With respect to posttraumatic stress disorder (PSTD), specifically, a recent meta-analysis of randomized controlled trials (RCTs) 8 demonstrated that psychotherapy interventions in patients with a diagnosis of PTSD have significantly reduced PTSD symp- toms during the recovery period. 8 Specifically, exposure-based therapies reduced PTSD symptom over time. 8 The effectiveness of psychotherapy in trauma patients without an acute stress disorder (ASD) or PTSD diagnosis is unclear. 6–8 Furthermore, there are several psychological inter- ventions offered, including cognitive behavior therapy (CBT), pharmacotherapy, and collaborative care (CC); however, no one specific intervention has been demonstrated to be superior to others. 9 The main objectives of this systematic review and meta- analysis were to review the current literature on the different types of psychological interventions, performed within 1 year of the injury, in adult trauma patients, and determine their long-term effects on psychiatric symptoms and diagnoses. Meta-analyses of studies with similar study designs, interven- tions, and measured outcomes were performed to determine the effects of psychological interventions on psychiatric disorders. We hypothesized that psychological interventions (i.e., psychotherapy, CBT, etc.) reduce the incidence of PTSD, anxi- ety, and depression in adult trauma survivors. A better under- standing of psychological interventions and their efficacy can guide the development of interventions aimed at preventing and ameliorating the negative psychological sequelae of trauma. Submitted: February 12, 2019, Revised: April 10, 2019, Accepted: May 5, 2019, Pub- lished online: May 28, 2019. From the Department of Anesthesiology (C.H.P., J.N., C.M.K.), Division of Plastic and Reconstructive Surgery, Department of Surgery (C.H.P.), Keck School of Medi- cine of the University of Southern California, Los Angeles, California; Depart- ment of Population and Quantitative Health Sciences (M.F.), Case Western Reserve University School of Medicine, Cleveland, Ohio; and Department of Sur- gery (K.M., K.I.), Keck School of Medicine of the University of Southern California, Los Angeles, California. Address for reprints: Catherine M. Kuza, MD, Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Suite 3600, 1450 San Pablo St, Los Angeles, CA 90033; email: Catherine.kuza@med.usc.edu. Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com). DOI: 10.1097/TA.0000000000002371 SYSTEMATIC REVIEW J Trauma Acute Care Surg Volume 87, Number 2 463 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.