I. Importance of Study
Found in the Journal of Advanced Nursing, a group of Norwegian psychologists conducted an observational longitudinal study to discover whether or not there is a relationship because Health Related Quality of Life (HRQoL), and Post-Traumatic Stress Disorder symptoms (PTSD). Mette Senneseth, Kjersti Alsaker & Gerd Karin Natvig, conducted this study. According to the journal, the aim of the study was to examine HRQoL and PTSD symptoms in the people that attend Accident and Emergency departments (A&E), due to the fact that they suffer from some type of psychosocial crisis (Alasker et al. 2011, 403). Hereafter, this is referred to as Research 1. The study done in Research 1 revealed that there has been an interest in researching one’s quality of life, and how it correlates with one’s health. The term HRQoL refers to the “effects of health, illness and treatment on QoL” (Alasker et al. 2011, 403). There have been a number of studies that suggest that traumatic life events, including, but not limited to, sexual assault and military combat, have a negative effect on HRQoL. Additionally, poor HRQoL is not only associated with PTSD symptoms, but they are related to differences and modification in HRQoL, and there is a negative correlation between the two (Alasker et al. 2011, 403). The researchers hypothesized that people who seek help at A&E, suffering from such psychosocial calamites, have lower HRQoL than the general population of Norway at the time of the study, and that the participants will have improved HRQoL after two months (Alasker et al. 2011, 403). In addition, a second hypothesis predicts that participants who have high levels of PTSD symptoms at the time of the study will have reduced symptoms after the conclusion of the study at two months.
Lastly, the third hypothesis wraps the study up by predicating that high levels of PTSD symptoms are associated to low HRQoL scores in a follow-up experiment (Alasker et al., 2011, 403). Found in the Cyber-psychology, Behavior and Social Networking Journal, a group of researchers conducted a study to compare the effects of VR-graded exposure therapy (VR-GET) versus treatment as usual (TAU) on people suffering from combat related PTSD (McLay et al. 2011, 223). Robert Mclay, Dennis Wood, Jennifer Webb-Murphy, James Spira, Mark Miederholf, Jeffery Pyne and Brenda Wiederhold conducted this study. Hereafter, this is referred to as Research 2. The doctors responsible for conducting this study found that there has only been one “randomized, controlled proof-of-concept” study that was specifically designed for Active Duty Service Members suffering from PTSD (McLay et al. 2011, 223). Also, the doctors wanted to extend the “already found research gathered” from victims of PTSD, and take the study one step further. The researchers of Research 2 hypothesized that “patients with combat-related PTSD would be more likely to experience clinically significant improvements in VR-GET than treatment as usual” (McLay et al. 2011, 224). VR-GET is a virtual reality stimulation that combines graded virtual reality exposure with “physiologic monitoring and skills training” (McLay et al. 2011, 224). Also, VR-GET promotes engagement with, rather than escaping the events and experiences that prompt a traumatic episode.
In regards to Research 1, the participants in the study had to meet three criteria before they were able to participate. During the recruitment period, the researchers found participants who were attending the A&E due to a “psychosocial crisis and who consulted a psychiatric nurse,” were 18 years of age or older, and those who were able to both read and understand Norwegian (Alasker et al. 2011, 404). A total of 113 were asked to participate in the study. Of those 113 people selected, 99 of the people participated in the baseline study, and 41 participated in both the baseline study, and the follow-up study. Aforementioned, this was an observational longitudinal study, where participants were observed repeatedly over a long period of time.
There were two types of instruments that were used for the research in Research 1. The first instrument that was used was a SF-36 Health Survey, which is a “36 item self-report questionnaire that assesses eight domains of physical and MH ranging from 1-100” (Alasker et al. 2011, 404). In this survey, the higher score reveals the best HRQoL, and the lower score reveals the poorest HRQoL (Alasker et al. 2011, 404). The second instrument that was used for this study was the Post-traumatic Symptom Scale (PTSS-10), which is a ten item self-report questionnaire that “assesses the presence and intensity of symptoms” (Alasker et al. 2011, 404). On the PTSS-10, scores range from 10 to 70, and a score of 35 or greater results in a PTSD diagnosis (Alasker et al. 2011, 404). In addition to the two questionnaires, participants were encouraged to go to consolations at the A&E. The number of consultations that each participant attended varies throughout the study.
In regards to Research 2, “participants for the study were all Active Duty Service Members who had been diagnosed by a military mental health professional as having PTSD” related to military combat (McLay et al. 2011, 224). At the end of the baseline assessment, those who were qualified to participate in he study were asked to draw a piece of paper out of an envelop, making the selection of treatment completely random, and giving the participants an equal chance of choosing either treatment. There were a total of twenty people that participated in this study; ten assigned to the VR-GET and another ten assigned to TAU (McLay et al. 2011, 225).
The two methods of Research 2 consisted of the VR-GET and the TAU. The participants that were assigned for the VR-GET had a sequence of sessions that consisted of different activities. First, the therapist would meet with the participant and discuss their trauma history. In the second session, participants were asked to reveal their more traumatic stories of their military combat and tours. In later sessions, the participant used the virtual reality helmet to relive their most traumatic events, based off of the information that was gathered about them in the earlier sessions. In each session, the participants were observed on their ability to face their fears and anxieties (McLay et al. 2011, 225). “Participants assigned to TAU could receive any of the regular services available to them at the NMCSD and NHCP. These two facilities offer full spectrum of PTSD treatment, including, but not limited to, cognitive processing therapy, prolonged exposure, and group therapy” (McLay et al. 2011, 225).
The researchers for Research 1 used the two self-report questionnaires to gather their data. In addition, the researchers processed the data using statistical analysis with the help of SPSS16 Processor for Windows (Oslo, Norway). The researcher for this study wants to compare the results of the two surveys with the general population of Norway, and to succeed with that, they used SF-36 data through the Norwegian Coordinated Living Conditions Survey from 2002, consisting of 5131 people (Alasker et al. 2011, 405).
In Research 2, it was found that participants in the baseline study had lower norm-based scores in all eight HRQoL domains in comparison to the general population of Norway. In the follow-up study, two months later, the “participants still had lower norm-based scores than the general population of Norway, but participants had improved their HRQoL in five of the eight domains from the baseline study to the follow-up study” (Alasker et al. 2011, 406).
In regard to the PTSS-10 questionnaire in Research 1, among the participants in the baseline study, 79% of them had a PTSS-10 score that was 35, expressing high levels of PTSD symptoms (Alasker et al. 2011, 406). At the follow-up, “59% of the participants had a PTSS-10 score that was 35, which shows high levels of PTSD symptoms, which can indicate a risk of developing PTSD” (Alasker et al. 2011, 406).
The researchers for Research 2 aimed to identify which of the VR-GET or TAU would yield a greater percentage of participants with a “clinically meaningful reduction in PTSD” (McLay et al. 2011, 225). The researcher succeeded in deepening their research by investigating the “difference in CAPS scores at an initial assessment and then at the post-treatment assessment in VR-GET versus TAU” (McLay et al. 2011, 226). The CAPS is a “rating scale for PTSD that corresponds with the 17 symptoms of PTSD” (McLay et al. 2011, 226). Participants were classified according to whether or not they had a 30% of larger reduction of their PTSD based on the results of their CAPS. ii. Analysis Results
Taking a look at Research 1, and the question concerning whether or not there is a link between PTSD symptoms and HRQoL, researchers looked at the differences in SF-36 scores between PTSS-10 subgroups in a follow-up study
(Alasker et al. 2011, 406). “The PTSS-10 high scoring and low scoring subgroups at the 2-month follow-up differed in all eight of the HRQoL domains in the follow up study” (Alasker et al. 2011, 406). In addition, the PTSS-10 low scoring participants had improved HRQoL in six out of the eight domains (Alasker et al. 2011, 407).
In regards to Research 2, all ten of the participants assigned to the VR-GET were assessed with the CAPS at the post-assessment. Seven out of the ten participants showed an improvement of 30% or more on the CAPS. On the other hand, out of the ten participants that were assigned to the TAU, one did not complete a CAPS assessment. Nevertheless, one out of the nine returning participants receiving the TAU revealed more than a 30% improvements on the CAPS (McLay et al. 2011, 226). “There was no significant difference between VR-GET and TAU average CAPS scores both before and after the treatments, but there was indeed a significant difference in the average CAPS score over the course of the entire treatment” (McLay et al. 2011, 226).
Concerning Research 1’s first hypothesis, participants of the study reported lower HRQoL compared to the general population of Norway in all eight HRQoL domains (Alasker et al. 2011, 408). In regards to the second hypothesis, participants in Research 1 reported high levels of PTSD symptoms at the time of the baseline experiment. Furthermore, PTSS-10 scores did improve from the time of the baseline experiment to the follow-up. The results show that PTSD symptoms decrease for people suffering from a psychosocial crisis in the 2 months after attending the A&E (Alasker et al. 2011, 408). Lastly, concerning the questions if there is a link between the level of PTSD symptoms and HRQoL in the follow-up study, the researchers found that a “high level of PTSD symptoms after a two month period were linked to lower HRQoL” (Alasker et al. 2011, 408).
Results for Research 2
Strengths and Weaknesses
In regards to Research 1, there are many strengths and lurking variables that should be pointed out. One strength of the study was that they progress of the study was completely up to the participant. The participant had the option as to how may consultations they wanted to attend, and the varied decisions led to different results. Another strength of the study was that they used instruments that were both appropriate to the study, and reliable. On the contrary, there were several confounding variables in Research 1 that must be acknowledged. First, there is no evidence that anyone in this trial was on any sort of anti-depressant or medication that would affect his or her scores on the SF-36 and the PTSS-10. Also, there are so many different traumatic events that would cause someone to show symptoms of PTSD. The study should limit its participants to those who experienced similar types of trauma.
As for Research 2, there were also strengths and weaknesses to the study. As for its strengths, the doctors did a good job through their selections process to select a small group of people who were highly qualified for this study. Also, the exam that was used to measure the severity of the participants PTSD was based off of seventeen symptoms of PTSD, whereas the instrument used in Research 1 (PTSS-10) only focused on ten symptoms of PTSD. Lastly, the ten-week span of the study was appropriate in yielding results. Just like any other study, there are confounding variables that need to be identified for Research 2. Although the goal was to get the participants in for a reassessment at the conclusion of the study (ten weeks), reassessment for some did not occur until as far as 36 weeks. With that being said, participants have plenty of time to have a relapse, or more time in combat that can result in more severe PTSD. iii. Future Directions
The researchers of Research 1 suggest that a “randomized control trial with a control group is needed to investigate the effect of the psychosocial interactions that are given to this group” (Alasker et al. 2011, 407). In addition, they suggest that it is crucial to get more, information about the long term effects of acute crisis intervention on PTSD symptoms and HRQoL “given by psychiatric nurses to participants” (Alasker et al. 2011, 410).
The researchers of Research 2 also have some suggestions for further directions of this research. It was stated that other studies on the topic of virtual reality therapy on PTSD victims, improvements in symptoms aren’t visible until sometimes three months after treatment. For future studies there needs to be a longer wait time for the follow-ups so that there can be the most accurate results. In addition, the journal states that careful monitoring of the participants is also something that needs to be done more thorough in the future because a participants overall health, aside from PTSD, must be taken into consideration when the researchers are making observations and conclusions about the participants (McLay et al. 2011, 226).
Mette Senneseth, Kjersti Alsaker, Gerd Karin Natvig. (2011). Health-related Quality of Life and Post-Traumatic Stress Disorder Symptoms in Accident and Emergency Attenders Suffering From Psychosocial Crises: a Longitudinal Study, Journal of Advanced Nursing 68(2), 402-414. Retrieved from http://web.ebscohost.com.rocky.iona.edu:2048/ehost/pdfviewer/pdfviewer?sid=6c7164f6-d4f6-4ce6-8a46-f1ad579caf63%40sessionmgr15&vid=5&hid=24
Robert N. Mclay, Dennis P. Wood, Jennifer A. Webb-Murphy, James L. Spira, Mark D. Wiederhold, Jeffery M. Pyne, Brenda K. Wiederhold. (2011). A Randomized, Control Trial of Virtual Reality-Graded Exposure Therapy for Post-Traumatic Stress Disorder in Active Duty Service Members with Combat-Related Post-Traumatic Stress Disorder. Cyberpsychology, Behavior, and Social Networking Volume 14, Issue 4. Retrieved from http://web.ebscohost.com.rocky.iona.edu:2048/ehost/pdfviewer/pdfviewer?sid=61603dcf-c639-423e-8f1e-365db0b36d61%40sessionmgr13&vid=4&hid=24