Last updated January 31, 2023

Screening and Intervention for Mental Health Disorders and Substance Use and Misuse in the Acute Trauma Patient

Key Points

Substance Misuse & Intervention

  • Resilience, recovery, delayed onset, and chronic distress are the four major trajectories of mental health wellness following trauma.
  • Trauma-informed care is a care approach intended to improve patient engagement, adherence to best practices for treatment, and patient outcomes.
  • Population-based studies suggest that mental health and substance use disorders work in a combined manner to increase the risk of a patient’s recurrent hospitalization and mortality after an index injury.
  • Alcohol and substance use problems are prevalent and increasing among trauma patients. They are associated with increased mortality, complications, need for critical care, increased length of stay, and cost of care.
  • Trauma centers participate in nationwide screening and intervention programs for substance use problems.
  • Screening and intervention programs improve outcomes related to substance use problems.
  • A best practice is to have an SBIRT clinician, someone with patient care responsibilities who has been given extra training in screening, brief intervention, or both.
  • Clinical supervision resources include someone with additional training and expertise in psychology or psychiatry.
  • Each trauma center develops a written policy and procedure for SBIRT service provision within their health system as a best practice.
  • Develop a therapeutic rapport with the patient prior to the screening questions to improve the outcomes with the SBIRT screening process.
  • Harm reduction intervention, often a focus of brief interventions in trauma centers, is an evidence-based practice for reducing substance use and related harms that does not require complete abstinence.
  • Medication-assisted therapy, plus behavioral treatment or counseling, is increasingly recognized as a best practice intervention for opioid use disorder.
  • A diagnosed substance use disorder is chronic, and relapse is common.

Postinjury Mental Health Care

  • PTSD and depression are prevalent and increasing among trauma patients, and these conditions significantly impact the patient’s quality of life.
  • The ACS-COT recently incorporated mental health screening and standardized protocols for referral to services in the 2022 Resources for Optimal Care of the Injured Patient.
  • Validated screening instruments are available for adult and pediatric hospitalized patients.
  • Models of care and efficacy of specific types of interventions to reduce distress are still emerging.
  • ACS verification standards state that all trauma centers must have a protocol to screen patients at high risk for psychological sequelae with a process for referral to a mental health provider.
  • Additional trauma programs include brief assessment and intervention, in addition to screening, as a part of care for the injured patient.
  • Develop screening protocols only in the context of adequate treatment and referral protocols.
  • Screening is an effort to determine patient risk for longterm trauma-related psychological distress that needs further assessment and intervention, not a process to establish a mental health diagnosis.
  • Best practice includes a brief risk screening (optimally between 2–5 minutes) with the trauma patient at bedside.
  • Establish and inform patients of the limits of confidentiality within the trauma center before screening.
  • It is recommended that trauma centers choose screening measures that are validated for the population with traumatic injury to assess for PTSD- and depressionrelated symptoms.
  • A positive screen for PTSD and/or depression needs to trigger a patient referral to the appropriate mental health professional for a more in-depth assessment.
  • Screening in the pediatric population needs to include special considerations for age, developmental level, and language ability when choosing screening tools, and the impact of parental distress.
  • Conduct hospital-based mental health screening early postinjury to determine patient risk for nonremitting postinjury mental health concerns.
  • Consider development of a mental health referral/resource base simultaneously with implementation of the screening process to promote more effective program functioning.
  • Models for postinjury mental health care programs vary in their approach to identify patients for screening, referral for consultation, and type of treatment provided.
  • Consider the resources available at the trauma center to identify the model appropriate for trauma center implementation.

Additional Mental Health Considerations for Trauma Centers

  • Hospital-based violence intervention programs (HVIP) provide care to blunt and penetrating injury survivors.
  • Psychological distress is higher in patients who experience trauma from assault compared to those experiencing trauma unrelated to violence.
  • HVIPs and posttrauma mental health programs can be integrated and collaborate to offer mental health services to those at great risk for posttrauma mental health psychological distress.
  • Consider ways for your trauma program to implement ongoing education and awareness of mental health concerns and brief interventions.
  • Educate trauma team members about best practices for trauma-informed care and ways to incorporate mental health approaches into their practice.
  • Potential funding for a trauma psychologist position includes revenue generated from inpatient and outpatient direct face-to-face services, virtual care, and research grants.
  • It is recommended that trauma centers, when feasible, use selective screening to identify individuals at risk for suicidal ideation who would not otherwise have been detected.
  • A best practice is to recommend that any mental health/psychiatric treatment in the hospital include both suicide screening and intervention for trauma patients during hospitalization.
  • The Joint Commission and Suicide Prevention Resource Center have guidance and discharge planning for positive suicide screening interventions.
  • Implement system-level preventative measures, such as trauma-informed care practices, to reduce the impact of medical trauma.
  • Some factors placing individuals at increased risk of Persistent Complex Bereavement Disorder include poor social support, loss of child or spouse, seeing the body in cases of violent death, and dependency on the deceased.1 Identify these patients and refer for treatment.

Implementation and Integration of the Best Practices Guidelines

  • An interdisciplinary workgroup, guided by trauma leadership, needs to perform a gap analysis and create an action plan.
  • Performance measures are selected to monitor practice changes.
  • The action plan is revised as needed, and guideline implementation is monitored until practice changes are sustained.
  • Trauma program leaders need to establish collaborative relationships with the facility’s billing and financial team to identify the billing requirements and operational process for mental health and substance misuse screening.
  • The trauma program must ensure that the requirements for Health Information Portability and Accountability Act (HIPAA) are met when implementing the mental health and substance misuse best practices guideline.
  • The trauma program may explore opportunities to integrate the mental health and substance misuse guideline document into the EMR.

Recommendation Grading

Overview

Title

Screening and Intervention for Mental Health Disorders and Substance Use and Misuse in the Acute Trauma Patient

Authoring Organizations

Publication Month/Year

January 10, 2023

Document Type

Guideline

Country of Publication

US

Document Objectives

A new best practice guideline is available to help healthcare professionals screen trauma patients for mental health disorders and substance misuse.

Inclusion Criteria

Male, Female, Adolescent, Adult, Older adult

Health Care Settings

Emergency care, Hospital, Operating and recovery room

Intended Users

Medical techologist technician, nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Management

Diseases/Conditions (MeSH)

D015813 - Substance Abuse Detection, D009104 - Multiple Trauma

Keywords

surgery, screening, Mental health, acute trauma, substance use