TITLE: Critical Incident Stress Debriefing for First Responders: A Review of the Clinical Benefit and Harm

TITLE: Critical Incident Stress Debriefing for First Responders: A Review of the Clinical Benefit and Harm DATE: 12 February 2010 CONTEXT AND POLICY ISSUES: Critical incident stress debriefing (CISD) is one component of the critical incident stress management (CISM) programs, which was designed in support of emergency personnel or other populations exposed to traumatic experiences. 1 The term psychological debriefing (PD) is used interchangeably with CISD, which is a structured form of group crisis intervention comprised of seven stages used within the first two weeks following a crisis incidence. 2 PD is not a form of counseling or psychotherapy to prevent the development of post-traumatic stress disorder (PTSD), but its objective is to provide education and facilitate early help seeking, normal recovery, and personal growth. 2 Although most people who received debriefing perceived it to be helpful, 3,4 there remains a prolonged debate concerning the effectiveness and efficacy of CISD. 5,6 Collective evidence even suggests that debriefing could impede natural recovery from acute PTSD symptoms. 7 This report presents the evidence within the last five years for the clinical benefit and harm of CISD given to first responders who have been exposed to a traumatic incident. RESEARCH QUESTION: What is the evidence for the clinical benefit and harm of critical incident stress debriefing for first responders? METHODS: A limited literature search was conducted on key health technology assessment resources, including PubMed, OVID s Medline, Embase, PsycINFO, the Cochrane Library (Issue 3, 2009), University of York Centre for Reviews and Dissemination (CRD) databases, ECRI, EuroScan, international health technology agencies, and a focused Internet search. The search was limited to English language articles published between 2005 and January 2010. No filters were applied to limit the retrieval by study type. Disclaimer: The Health Technology Inquiry Service (HTIS) is an information service for those involved in planning and providing health care in Canada. HTIS responses are based on a limited literature search and are not comprehensive, systematic reviews. The intent is to provide a list of sources and a summary of the best evidence on the topic that CADTH could identify using all reasonable efforts within the time allowed. HTIS responses should be considered along with other types of information and health care considerations. The information included in this response is not intended to replace professional medical advice, nor should it be construed as a recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for which little information can be found, but which may in future prove to be effective. While CADTH has taken care in the preparation of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect. CADTH is not liable for any loss or damages resulting from use of the information in the report. Copyright: This report contains CADTH copyright material. It may be copied and used for non-commercial purposes, provided that attribution is given to CADTH. Links: This report may contain links to other information available on the websites of third parties on the Internet. CADTH does not have control over the content of such sites. Use of third party sites is governed by the owners own terms and conditions.

SUMMARY OF FINDINGS: Two randomized controlled trials (RCTs) in US soldiers and peacekeepers were identified. 8-11 No studies were indentified for the use of CISD in first-responders, such as police officers. No health technology assessments, systematic reviews and meta-analyses, controlled clinical trials, or observational studies addressing the research question were found. Randomized controlled trials The characteristics and results of the RCTs are presented in Appendix 1. Adler et al. (2009) 8 assessed psychological debriefing efficacy following year-long deployment of US soldiers to Iraq. This was a four-arm parallel RCT, where 2,297 US soldiers (mostly male) returning from a 12-month combat deployment to Iraq were randomly assigned to one of the four groups: stress education, debriefing, small group training, and large group training. debriefing is a type of PD used in the U.S. military. It has similarities to civilian models such as CISD. training takes a cognitive and skill-based approach to educating military personnel about post-deployment transition. It emphasizes safety, relationships, and common physical, social, and psychological reactions to combat. Stress education was given in PowerPoint slides, identifying normal responses during post-deployment, mental health symptoms, positive coping behaviours, and reactions that leaders should watch for in their unit members. Stress education was conducted in groups of 51-257 individuals for 40-50 minutes. debriefing was similar to most group psychological debriefing models, consisting of seven phases and the median duration of the 26 sessions was 50 minutes. training had a median duration of 39 minutes given to either large groups (126-225) or small groups (15-45) of soldiers. The 23 small training sessions and the 6 large training sessions used PowerPoint slides and discussion. Distress levels were assessed before and after interventions using the Subjective Units of Distress (SUDS) ratings. Outcomes at 4-month follow-up included PTSD (using the Posttraumatic Stress Disorder checklist; PCL scale), depression (using the Patient Health Questionnaire for Depression; PHQ-D), sleep problems (5-point scale), acceptability, perception of training, training utility, goals and atmosphere (5-point scale), and stigma associated with seeking mental health treatment (5-point scale). About 54% participants did not complete followup survey. There was no evidence of change in term of distress levels immediately before and after the interventions, and no differences between groups. At 4-month follow-up, all three interventions had lower PTSD symptoms, depression symptoms, and sleep problems than stress education for high levels of combat exposure only. There were no significant differences between groups for low levels of combat exposure. All conditions received high ratings (immediate posttraining perceptions of training) compared to stress education. There were no significant differences between groups for stigma associated with seeking mental health. The authors concluded that participants reporting high levels of combat exposure benefited from debriefing and training. Adler et al. (2008) 9 published another RCT that compared CISD with a stress management class (SMC) and a no-intervention comparison arm (survey-only; SO) for US peacekeepers deployed to Kosovo. This was a three-arm open parallel RCT of 952 soldiers, mostly male. The CISD was conducted by trained personnel and there were 13 sessions, each lasting an average Critical Incident Stress Debriefing for First Responders 2

of 88.1 ± 25.2 minutes. The SMC was a combination of didactic instruction and group discussion, lasting about 63.7 ± 22.0 minutes per session. The no-intervention, SO, group received repeated survey administration only. Follow-up surveys were conducted for three periods (T2, T3, T4), following the pre-intervention (T1) survey. T2 occurred during the last month of deployment (October and November of 2002), T3 occurred 3-4 months following redeployment (January and February 2003) and T4 occurred 8-9 months following redeployment (September to November 2003). At the end of the study, 676 (71%) participants did not complete follow-up survey. The outcome variables included PTSD (using the PCL scale), depression (using the Center for Epidemiological Studies Depression scale, CES-D), aggressive behaviors (using the Conflict Tactics Scale, CTS), alcohol consumption (using the Alcohol Users Disorder Identification Test, AUDIT), perception toward organizational support (using the Perceived Organizational Support scale, POS), and subjective evaluation of intervention (using the Subjective Units of Distress Scale, SUDS). The data were collected solely based on self-report, because, as stated by the authors, clinical interviews were not feasible given the sample size and difficulties working with operational units. There were no significant differences between groups for PCL, CES-D, CTS, and POS variables at all time points. Soldiers in the CISD group evaluated the intervention more positively than those in the other two groups. For the subgroup of soldiers with highest exposure to mission stressors, the CISD condition slightly improved PCL, CTS, and POS scores, but also had slightly higher AUDIT scores than the other two conditions. Soldiers reported that they liked CISD more than the SMC. The authors concluded that, overall, CISD has no clear positive effects, but it has no strong negative effects either. Limitations The evidence was limited due to the study populations and design. In both RCTs, there was potential bias in reporting since it relied on the self-report measures instead of clinical interview. In addition, there was no true control, loss of follow-up was relatively high, and the effects of interventions were small. The participants in the second RCT were peacekeepers who might be exposed to relatively low stressors; and, in fact, many soldiers in that study did not need secondary prevention. CONCLUSIONS AND IMPLICATIONS FOR DECISION OR POLICY MAKING: Two RCTs were identified that compared CISD to other interventions in US soldiers and peacekeepers. No studies were found examining CISD for first responders such as police officers. Evidence from the identified RCTs indicated that CISD has no clear positive or negative effects compared to the other interventions although it received positive evaluation. One study expressed concern that CISD might have long-term negative impacts such as alcohol problems or higher distress level when provided to individuals exposed to higher stressors. Both studies suggested that CISD groups who were exposed to higher levels of combat exposure showed improvement in PTSD, depressive, and sleep symptoms than control, but no difference was reported with lower levels of exposure. Given the prolonged controversy and debate concerning the efficacy of CISD, the current limited evidence does not permit conclusions regarding its benefit and harm. Critical Incident Stress Debriefing for First Responders 3

PREPARED BY: Khai Tran, MSc, PhD, Research Officer Emmanuel Nkansah, BEng, MLS, MA, Information Specialist Health Technology Inquiry Service Email: htis@cadth.ca Tel: 1-866-898-8439 Critical Incident Stress Debriefing for First Responders 4

REFERENCES: 1. Malcolm AS, Seaton J, Perera A, Sheehan DC, Van Hasselt VB. Critical Incident Stress Debriefing and Law Enforcement: An Evaluative Review. Brief Treatment and Crisis Intervention. 2005;5(3):261-78. 2. Regel S. Post-trauma support in the workplace: the current status and practice of critical incident stress management (CISM) and psychological debriefing (PD) within organizations in the UK. Occup Med (Oxf) [Internet]. 2007 Sep [cited 2010 Jan 18];57(6):411-6. Available from: http://occmed.oxfordjournals.org/cgi/reprint/57/6/411 3. Theophilos T, Magyar J, Babl FE, Paediatric Research in Emergency Department. Debriefing critical incidents in the paediatric emergency department: current practice and perceived needs in Australia and New Zealand. Emerg Med Australas. 2009 Dec;21(6):479-83. 4. Tan H. Debriefing after critical incidents for anaesthetic trainees. Anaesth Intensive Care. 2005 Dec;33(6):768-72. 5. Robinson R. Reflections on the debriefing debate. Int J Emerg Ment Health. 2008;10(4):253-9. 6. Mitchell JT. From controversy to confirmation: crisis support services for the twenty-first century. Int J Emerg Ment Health. 2008;10(4):245-52. 7. Bryant RA. Early intervention for post-traumatic stress disorder. Early Intervention in Psychiatry. 2007;1(1):19-26. 8. Adler AB, Bliese PD, McGurk D, Hoge CW, Castro CA. debriefing and battlemind training as early interventions with soldiers returning from iraq: Randomization by platoon. J Consult Clin Psychol. 2009;77(5):928-40. 9. Adler AB, Litz BT, Castro CA, Suvak M, Thomas JL, Burrell L, et al. A group randomized trial of critical incident stress debriefing provided to U.S. peacekeepers. J Trauma Stress. 2008 Jun;21(3):253-63. 10. Devilly GJ, Annab R. A randomised controlled trial of group debriefing. J Behav Ther Exp Psychiatry. 2008 Mar;39(1):42-56. 11. Devilly GJ, Varker T. The effect of stressor severity on outcome following group debriefing. Behav Res Ther. 2008 Jan;46(1):130-6. Critical Incident Stress Debriefing for First Responders 5

Appendix 1: Characteristics and Results of the RCTs Study / Objectives Adler et al.; 2009 8 To assess the psychological debriefing efficacy following year-long deployment of US soldiers to Iraq Interventions, comparators / Duration psychological debriefing (BPD): group size 20-33; median duration 50 min; 7 phases Small group training (SBT): group size 15-45; median duration 39 min Large group training (LBT): group size 126-225; median duration 39 min Stress education (SE): group size 51-257; duration 40-50 min Population Effectiveness Subjective evaluation US soldiers returning from a 12-month combat deployment to Iraq Randomization: 2,297 (586 BPD; 565 SBT; 618 LBT; 528 SE) Immediate postsession: 2,188 571 BPD; 559 SBT; 559 LBT; 499 SE); lost 109 4-month followup: 1,060 (271 BPD; 272 SBT; 274 LBT; 243 SE); total lost 1,237 Immediate postintervention response Distress (used Subjective Units of Distress; SUDS): no differences before and after intervention or between groups Follow-up PTSD (used 17-item PCL checklist) Depression (used Patient Health Questionnaire for Depression; PHQ-D) Sleep problems (5- point scale) All three conditions had lower PTSD, depression and sleep problem symptoms than SE for high levels of combat exposure only; no significant Immediate postintervention response Acceptability, perception of training, training utility, goals and atmosphere (5- point scale): more positive for conditions than SE; higher ratings for SBT than LBT Stigma associated with seeking mental health (5-point scale): no significant differences between groups; LBT had lower stigma levels than SE at high levels of combat Adverse Effects No adverse events associated with debriefing or training Conclusion Participants reporting high levels of combat exposure benefit from debriefing and training Critical Incident Stress Debriefing for First Responders 6

Study / Objectives Adler et al.; 2008 9 ; three-arm open parallel RCT To compare CISD with a stress management class (SMC) and a no-intervention comparison arm (survey-only; SO) provided to US peacekeepers Interventions, comparators / Duration CISD: conducted by trained personnel (mental health officers, mental health specialists); procedures of Everly & Michell; audio tape recorded; sessions between 48 to 148 minutes long SMC: combination of didactic instruction and group discussion; sessions between 44 to 110 minutes long SO: repeated survey administrations only Population Effectiveness Subjective evaluation US Army peacekeepers deployed to Kosovo Pre-intervention: 952 (312 CISD; 359 SMC; 281 SO) 1 st Post- Deployment: 614 (203 CISD; 232 SMC; 179 SO); lost 338 2 nd Post- Deployment: 276 (75 CISD; 122 SMC; 79 SO); total lost 676 differences between groups for low levels of combat exposure Overall PTSD (used 17-item PCL checklist): no differences between groups Depression (used CES-D scale): no differences between groups Aggression (used CTS): no difference between groups Perceived organizational support (used POS scale): no difference between groups Alcohol (used AUDIT): CISD slightly higher scores than the other two arms, but not significant More positive evaluation about the training for CISD than SMC Adverse Effects No adverse events associated with any of the interventions Conclusion Soldiers reported that they preferred CISD more than the other two interventions although there were no significant differences in the outcome measures between groups. For soldiers exposed to potentially traumatizing events, CISD slightly improved PTSD, aggression, and perceived organizational support, but more alcohol problems. Four stages of evaluation up to 9 months followup Exposure to mission stressors and PTE: CISD slightly improved PCL Critical Incident Stress Debriefing for First Responders 7

Study / Objectives Interventions, comparators / Duration Population Effectiveness Subjective evaluation Adverse Effects Conclusion scores, improved CTS scores, higher POS, and slightly higher AUDIT scores relative to other two arms AUDIT: Alcohol Users Disorder Identification; BPD: psychological debriefing; CES-D: Center for Epidemiological Studies-Depression scale; CISD: critical incidence stress debriefing; CTS: Conflict Tactics Scale; LBT: large training; PCL: Posttraumatic stress Disorder Checklist; POS: Perceived organizational support; PTE: potentially traumatizing events; PTSD: post-traumatic stress disorder; RCT: randomized controlled trial; SBT: small training; SE: stress education; SMC: stress management class; SO: survey-only; SUDS: Subjective Units of Distress Critical Incident Stress Debriefing for First Responders 8