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Topic Title
- Interventions for the Prevention of Posttraumatic Stress Disorder (PTSD) in Adults After Exposure to Psychological Trauma
Full Report
- Research Review Apr. 2, 2013
Related Products for this Topic
- Research Protocol Jun. 6, 2012
- Disposition of Comments Report Jul. 31, 2013
Executive Summary – Apr. 2, 2013
Interventions for the Prevention of Posttraumatic Stress Disorder (PTSD) in Adults After Exposure to Psychological Trauma
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Table of Contents
- Background--The Condition and Preventive Strategies
- Scope and Key Questions
- Methods
- Results
- Discussion
- Research Gaps
- Conclusions
- References
- Full Report
Background--The Condition and Preventive Strategies
Posttraumatic stress disorder (PTSD) may develop following exposure to a traumatic event. According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR),1 the essential feature of PTSD is the development of characteristic symptoms following exposure to an extreme traumatic stressor. The stressor may include having direct personal experience of an event that involves actual or threatened death or serious injury or other threat to one's physical integrity; witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate. The DSM-IV-TR also requires that the person's subjective response to the event involve intense fear, helplessness, or horror.
Some traumatic events that are directly experienced or to which individuals can be exposed include military combat, violent personal assault, being taken hostage, a terrorist attack, torture, natural or manmade disasters, and being diagnosed with a life-threatening illness.1 Psychological trauma is common and leads to PTSD in a substantial number of adults exposed to trauma. The 1990–1992 National Comorbidity Survey indicated that 60 percent of men and 51 percent of women reported experiencing at least one traumatic event in their lifetimes.2 Shortly after exposure, many people experience some symptoms of PTSD; in most people, those symptoms resolve within several weeks of the trauma. However, in approximately 10 to 20 percent, PTSD symptoms persist and are associated with impairment in functioning.3 Although approximately 50 percent of those diagnosed with PTSD improve without treatment in 1 year, 10 to 20 percent develop a chronic unremitting course.4
The 2000 National Comorbidity Survey–Replication (NCS-R) estimated lifetime prevalence of PTSD among trauma-exposed adults in the United States to be 6.8 percent (9.7% in women and 3.6% in men) and current (12-month) prevalence to be 3.6 percent (5.2% in women and 1.8% in men), or more than 7.7 million American adults per year.5-7 Some demographic or occupational groups, such as military personnel, are at higher risk of PTSD because of higher rates of exposure to trauma.
Prevention of PTSD can potentially reduce a significant burden of individual and societal suffering. Two different prevention strategies have been used. The first strategy, universal prevention, is to deliver interventions to all people exposed to a trauma, regardless of symptoms or risk of developing PTSD. The second strategy, targeted prevention, is based on the fact that although many people experience some symptoms of PTSD after trauma, only a relatively small percentage develop the psychiatric disorder of PTSD and its associated disability. The goal of targeted prevention is to identify, from among all people exposed to a trauma, those who are at high risk of developing the disorder of PTSD and then intervene only with those at high risk.
Interventions to prevent PTSD involve various psychological and pharmacological approaches; they also include emerging interventions such as approaches from complementary and alternative medicine. These interventions have been used both separately and in combination. Despite evidence that some early interventions, such as debriefing, are not effective for preventing PTSD or might even cause harm, they are still widely used. Such use indicates that uncertainty and controversy still exist within the field about providing an intervention that intuitively seems as if it should help, and that not enough consideration is given to scientific evidence when weighing intervention benefits and harms.
Scope and Key Questions
This review compares the efficacy, effectiveness, and harms of psychological, pharmacological, and emerging interventions to prevent PTSD in adults. We include studies of both universal and targeted prevention. We also address the clinical importance of effect modifiers or subgroup status that may affect the impact of traumatic exposure on specific outcomes; these include sex, comorbidities, refugee status, and military or civilian status.
Our report is limited to adults who had been exposed to a traumatic event and who received an early intervention designed to prevent progression to PTSD within the first 3 months after the trauma.
We approach each Key Question (KQ) by considering the relevant populations, interventions, comparators, outcomes, timing, and settings (PICOTS). In this review, we address the following KQs:
KQ 1: For adults exposed to psychological trauma, what is the efficacy or comparative effectiveness (or both) of early interventions to prevent PTSD or to improve health outcomes?
KQ 2: For adults exposed to psychological trauma, does timing, intensity, or dosage of intervention have an impact on the effectiveness or harms of approaches to prevent PTSD or to improve health outcomes?
KQ 3: For adults exposed to psychological trauma, how does efficacy, effectiveness, or harms of early interventions to prevent PTSD differ for characteristics of traumatic exposure or subpopulations with respect to:
- demographic groups (defined by age, ethnic and racial groups, and sex),
- psychiatric comorbidities, or
- personal risk factors for developing PTSD (e.g., having a diagnosis of acute stress disorder (ASD) vs. not having the diagnosis)?
KQ 4: For adults exposed to psychological trauma, what are the absolute and comparative risks of harms from early interventions to prevent PTSD?
Figure A depicts the analytic framework for the comparative effectiveness of psychological, pharmacological, and emerging interventions for preventing PTSD in adults after exposure to trauma.
Figure A. Analytic framework for comparative effectiveness of interventions to prevent PTSD in adults after exposure to trauma
Abbreviations: KQ = Key Question; PTSD = posttraumatic stress disorder.
Literature Search Strategy
To identify articles relevant to each KQ, we searched PubMed®, CINAHL (Cumulative Index to Nursing and Allied Health Literature), the Cochrane Library, Embase, PILOTS (Published International Literature on Traumatic Stress), International Pharmaceutical Abstracts, PsycINFO®, and Web of Science. We used either Medical Subject Headings (MeSH) or major headings as search terms when available or key words when appropriate, focusing on terms to describe the relevant populations and interventions of interest. We limited the electronic searches to English-language and human-only studies. We searched sources from January 1, 1980, to July 30, 2012. In addition, we manually searched reference lists of pertinent reviews, included trials, and background articles for relevant citations that our searches might have missed. We searched for unpublished studies using ClinicalTrials.gov, the Web site of the U.S. Food and Drug Administration, the World Health Organization's International Clinical Trials Registry Platform, GreyMatters, and OpenGrey. In addition, the Scientific Resource Center requested scientific information packets from the relevant pharmaceutical companies, asking for any unpublished studies or data relevant for this review.
We developed eligibility criteria with respect to PICOTS and study designs for each KQ. Our population of interest was adults (ages 18 or older) exposed to psychological trauma. We included psychological (e.g., cognitive behavioral therapy, cognitive processing therapy, debriefing), pharmacological (e.g., beta blockers, second-generation antidepressants), and emerging (e.g., yoga, acupuncture) interventions used to prevent PTSD. Both inactive and active comparators of interest were eligible as control interventions. Our outcomes of interest focused on the incidence of PTSD and PTSD-related symptoms; PTSD symptom severity; and quality of life, functional capacity, and other patient-relevant health outcomes. Our subgroups of interest included demographic groups (defined by age, sex, and ethnic or racial groups), populations with psychiatric comorbidities, and populations with different personal risk factors for developing PTSD.
For efficacy and comparative effectiveness, we focused on randomized controlled trials (RCTs) and prospective cohort studies. For assessment of the risk of harms, we also included retrospective controlled cohort studies. For studies to be eligible, the intervention had to be administered within 3 months of the traumatic event.
Two trained members of the research team independently reviewed all titles and abstracts for eligibility against our inclusion/exclusion criteria. We retrieved the full text of all articles included during the title and abstract review phase. If both reviewers agreed that a study did not meet the eligibility criteria, we excluded it. If the reviewers disagreed, conflicts were resolved with a third, senior team member.
Risk-of-Bias Assessment of Individual Studies
To assess the risk of bias (a threat to internal validity) of studies for major outcomes of interest, we used guidance from the AHRQ "Methods Guide for Effectiveness and Comparative Effectiveness Reviews."8 We assessed selection bias, confounding, performance bias, detection bias, and attrition bias. We included questions about adequacy of randomization, allocation concealment, similarity of groups at baseline, blinding, attrition, whether intention-to-treat (ITT) analysis was used, method of handling dropouts, and treatment fidelity. We rated the studies as low, medium, or high risk of bias. Because our primary outcome of interest was the incidence of PTSD, we adopted a threshold of 20 percent for overall attrition. For outcomes with low event rates, attrition can substantially bias findings.9
Two independent reviewers assessed the risk of bias for each study; one of the two reviewers was always an experienced or senior investigator. Disagreements between the two reviewers were resolved by discussion and consensus or by consulting with a third member of the team. If medium or low risk-of-bias studies were available, we omitted from our main analyses studies deemed high risk of bias by two reviewers. Such studies would not have increased the strength of the evidence and the certainty of our conclusions. If we were able to conduct quantitative syntheses, we used high-risk-of-bias studies for sensitivity analyses. In cases in which relevant information was unclear or not reported, we attempted to contact authors to get additional or unpublished information. When successful, we used this information in the findings.
For studies that met inclusion criteria and were of low or medium risk of bias, we extracted important information into evidence tables, which included characteristics of study populations, settings, interventions, comparators, study designs, methods, and results. We did not extract complete data from studies that we rated as high risk of bias.
Data Synthesis
In general, we used a "best evidence" approach to synthesize the available evidence. That is, we prioritized the evidence to emphasize studies that provided the most solid base for conclusions. If we did not find any studies with a low or medium risk of bias rating, we present results of high risk of bias studies. Conversely, if studies with low or medium risk of bias were available, we omitted high risk of bias studies from our syntheses because of the lack of reliability of their findings.
We conducted quantitative syntheses using meta-analyses of outcomes reported by multiple studies that were sufficiently homogeneous to justify combining their results. When quantitative synthesis was not appropriate (e.g., because of clinical heterogeneity, insufficient numbers of similar studies, or insufficiency or variation in outcome reporting), we synthesized the data qualitatively.
We used random-effects models to estimate pooled effects. For continuous outcomes (e.g., scales for symptom reduction), we used weighted mean differences (WMD). If we had to combine multiple scales in one meta-analysis, we used the standardized mean difference (Cohen's d). For binary outcomes (e.g., incidence of PTSD), we calculated the relative risk (RR) between groups. For each meta-analysis, we conducted sensitivity analyses by adding studies that we rated as high risk of bias. We calculated the chi-squared statistic and the I2 statistic to assess statistical heterogeneity in effects between studies. Heterogeneity was also explored through sensitivity analyses. Quantitative pairwise meta-analyses were conducted using Stata® version 11.1.
Strength of the Body of Evidence
We graded the strength of evidence (SOE) based on the guidance established for the Evidence-based Practice Center program.10 Developed to grade the overall strength of a body of evidence, this approach incorporates four key domains: risk of bias (includes study design and aggregate quality), consistency, directness, and precision of the evidence. It also considers other optional domains that may be relevant for some scenarios, such as a dose-response association, plausible confounding that would decrease the observed effect, strength of association (magnitude of effect), and publication bias.
We specified several outcomes a priori (with input from members of a technical expert panel) as important for grading strength of the body of evidence: incidence of PTSD; incidence and severity of PTSD symptoms; measures of depression and anxiety symptoms; quality of life; return to work or duty; incidence of self-injurious or suicidal thoughts, attempts, or behaviors (including suicide); incidence of aggressive or homicidal thoughts, attempts, or behaviors (including homicide); rates of adverse events (overall or for specific events such as organ failure); mortality; and dropout rate because of adverse effects.
Two reviewers assessed each domain for each key outcome and determined an overall SOE grade based on domain ratings. For each assessment one of the two reviewers was always an experienced investigator. In the event of disagreements on the domain or overall grade, they resolved differences by consensus discussion or by consulting with a third, senior investigator. Appendix G in the main report provides the detailed rationale for SOE grades.
We assessed applicability of the evidence following guidance from the "Methods Guide for Comparative Effectiveness Reviews."11 We used the PICOTS framework to explore factors that affect applicability. Some factors identified a priori that may limit the applicability of evidence include the following: age of enrolled populations, sex of enrolled populations, race or ethnicity of enrolled populations, few studies enrolling subjects with exposure to certain types of trauma, or few studies distinguishing or reporting the type of traumatic exposure for a heterogeneous population.
Throughout the report, we use the terms "efficacy" and "comparative effectiveness." By efficacy, we mean the efficacy or effectiveness of an intervention tested against some type of inactive control (e.g., placebo or waitlist). By comparative effectiveness we mean the efficacy or effectiveness of an intervention compared with another intervention of interest. In this report, we did not distinguish between explanatory (or efficacy) and pragmatic (or effectiveness) studies.
First, we describe results of the literature searches and ratings of the risk of bias. Second, we present available evidence for each KQ, focusing on efficacy or risk of harms and then comparative effectiveness or risk of harms. Within each section, we discuss evidence on psychological interventions first, followed by studies on pharmacological interventions, and lastly by studies on emerging interventions. We give SOE grades for major outcomes on which we had any evidence at all; several specified a priori were not present in our evidence base. The main report gives detailed descriptions of included studies in text and in the evidence tables in its Appendix E.
Results of the Literature Searches
We identified 2,563 citations from searches, reviews of reference lists, and grey literature. Overall, we included 19 trials in our main analyses. Another 37 studies otherwise meeting inclusion criteria were omitted from our main analyses because of a high risk of bias. If not stated otherwise, trials described below are of medium risk of bias.
KQ 1: Efficacy and Comparative Effectiveness of Interventions To Prevent PTSD
Thirteen studies addressed efficacy.12-24 Of these, each involved psychological interventions; one study included a pharmacological intervention, and one evaluated an emerging intervention (collaborative care). These studies were conducted in15,18,23,24 and outside the United States.12-14,16,17,19-21 They included a variety of trauma-exposed populations such as victims of crime, motor vehicle accidents (MVAs), other types of accidents, intimate partner violence, sexual assault, and terrorist attacks; critically ill patients; and mothers experiencing traumatic childbirth or caring for a critically ill child. We did not find any evidence on most pharmacological interventions. In addition, we had little or no evidence about terrorist attacks, sexual assault, natural disaster, or combat.
We identified trials that reported on one or more of eight different psychological interventions: debriefing, cognitive behavioral therapy (CBT), CBT combined with hypnosis, cognitive therapy (CT), prolonged exposure therapy (PE), psychoeducation, self-help materials, and supportive counseling (SC). The two key outcomes are incidence of PTSD (i.e., preventing PTSD) and reducing the severity of PTSD symptoms. From these studies, we concluded that debriefing is not effective in preventing PTSD or reducing the severity of PTSD symptoms in civilian victims of crime, assault, or accident trauma at 6-month followup (low SOE). We had insufficient data (single study) to determine the efficacy of debriefing at 2- or 6-week or 11-month followup.
From a single study, we concluded that collaborative care (CC), a stepped combination of care management, psychopharmacology, and CBT, produces a greater decrease in PTSD symptom severity at 6, 9, and 12 months after injury than usual care (low SOE).24 However, data addressing whether groups differed in PTSD diagnosis 12 months after injury were not conclusive (insufficient SOE).
For most other interventions—namely, CBT, CBT combined with hypnosis, CT, PE, psychoeducation, self-help material, SC, and the two pharmaceuticals escitalopram (a selective serotonin reuptake inhibitor [SSRI]) and hydrocortisone—we had single studies with small treatment arms (generally fewer than 80 subjects). This paucity of information led us to conclude that the evidence was insufficient to support their efficacy for preventing PTSD or reducing PTSD symptom severity.
For studies that had assessed the efficacy of interventions in terms of reducing symptoms of anxiety and depression, we found insufficient evidence. Table A summarizes the main findings and the SOE for the efficacy of psychological, pharmacological, and emerging interventions for this section of KQ 1.
Comparative Effectiveness
Eight studies addressed the effectiveness of a psychological intervention compared with another psychological intervention.13,17,20,21,25-28 The interventions included Battlemind training, CBT, CBT combined with hypnosis, CT, PE, various forms of debriefing, and SC. One study compared psychological interventions with an SSRI.20 All these studies were conducted outside the United States and included samples exposed to a variety of traumas, such as combat, crime, physical assault, motor vehicle and other types of accidents, and terrorist attacks. We did not include studies comparing two or more medications; the one study we had identified was rated high risk of bias. We did not identify any studies that evaluated the comparative effectiveness of any emerging interventions.
Our meta-analyses of trials that compared CBT with SC in a sample of participants with ASD found that at both the end of treatment and at 6-month followup, CBT was more effective than SC in reducing the severity of PTSD symptoms as measured by the Impact of Event Scale (IES) (moderate SOE). However, at both the end of treatment and at 6-month followup, CBT was no more effective than SC for preventing PTSD (low SOE), reducing symptoms of anxiety (moderate SOE), or reducing symptoms of depression (low SOE).
Because the knowledge base comprises largely single studies with small sample sizes, we concluded that the evidence was insufficient to determine the comparative effectiveness of most of the psychological interventions in preventing PTSD or reducing PTSD symptom severity.
Only one study compared psychological interventions (CT and PE) with a medication (escitalopram, an SSRI). Because of methods limitations, we could not draw any conclusions about the comparative effectiveness of an SSRI and a psychological intervention.
Table B summarizes the main findings and the SOE for the comparative effectiveness of psychological and pharmacological interventions for this section of KQ 1.
KQ 2: Impact of Timing, Intensity, and Dosing
The evidence is scarce on the impact of timing, intensity, and dosing on the effectiveness or risk of harms of interventions used to prevent PTSD. Overall, studies addressed timing and dosing questions;29-32 two were rated as high risk of bias.30,31 We found no studies on the impact of intensity of intervention for any psychological or emerging interventions. Table C summarizes the main findings and the SOE for KQ 2 for incidence of PTSD and PTSD symptom severity.
One RCT addressed the impact of timing of a psychological intervention.29 Immediate debriefing (within 10 hours) compared with late debriefing (after 48 hours) led to significantly fewer posttraumatic symptoms that victims experienced (insufficient SOE). No evidence was available on the impact of timing for any other psychological, pharmacological, or emerging interventions or any other outcomes.
In one RCT, dosing of sedation (light vs. deep) in critically ill patients did not affect posttraumatic symptoms, depression, or anxiety (insufficient evidence).32 We did not find any eligible evidence on the effect of dosing for any other pharmacological or emerging interventions to prevent PTSD.
|Intervention, Population
|Abbreviations: CISD = critical incident stress debriefing; N = entire sample; PTSD = posttraumatic stress disorder; SOE = strength of evidence.
|Debriefing (CISD) timing (early vs. late),
Robbery victims29
PTSD symptom severity
|Inconclusive, single trial (N=77)
|Pharmacological sedation depth (light vs. deep)
Critically ill patients32
Incidence of PTSD
|Inconclusive, single trial (N=137)
KQ 3: Subgroups
Evidence is also sparse on whether the effect of early interventions differs among groups defined by sociodemographic characteristics, psychiatric diagnoses and comorbidities, personal risk factors for developing PTSD, or types of trauma. Eight studies met our inclusion criteria for subgroup analyses,12,17,18,21,28,29,33,34 but we rated two as high risk of bias.33,34 Table D summarizes the main findings and the SOE for KQ 3 for two main categories of outcomes—the numbers of PTSD symptoms and depression symptoms. We report the outcomes in terms of whether the subgroup characteristic, such as sex, modified the effect of any intervention(s)—that is, whether individuals in the intervention and control subgroups did or did not differ at various followup measurements.
Two trials reported consistent results that effects of early psychological interventions on PTSD symptoms were similar for men and women.17,29 However, because neither trial reported the magnitude of the estimated effect or its precision, we graded the SOE as low.
One trial tested the effect of a debriefing intervention—critical incident stress debriefing (CISD)—in subgroups with a history of either depression or child abuse, but it did not report magnitude or precision of effects (SOE insufficient in all cases).17
One trial reported that the severity of trauma exposure did not modify the effect of Battlemind training among United Kingdom returning military service members (insufficient SOE).28
One trial reported that PE reduced symptoms of PTSD among survivors of sexual assault but not physical assault or motor vehicle accidents (SOE insufficient).18
Two trials provided inconsistent findings on whether baseline severity of PTSD symptoms modified the effect of two different psychological interventions (SOE insufficient).12,21
|Subgroup; Intervention: Population
|a Personal risk factor for PTSD.
Abbreviations: CBT = cognitive behavioral therapy; CISD = critical incident stress debriefing; N = entire sample; n = subset of sample; PE = prolonged exposure therapy; PTSD = posttraumatic stress disorder; SOE = strength of evidence; UK = United Kingdom.
|Demographic groups: sex; CBT, CISD; Crime victims17,29
|Incidence of PTSD
|No evidence
|PTSD symptom severity
|The effect of CBT or CISD did not differ between men and women; 2 trials (N=234), consistent findings
|Type of trauma; PE, Mixed civilian trauma18
|Incidence of PTSD
|Inconclusive, single trial (N=137)
|PTSD symptom severity
|Inconclusive, single trial (N=137)
|Psychiatric diagnosis: previous depression; Debriefing; Crime victims17
|Incidence of PTSD
|No evidence
|PTSD symptom severity
|Inconclusive, single trial (N=157)
|History of child abusea; psychoeducation vs. debriefing combined with psychoeducation; Crime victims17
|Incidence of PTSD
|No evidence
|PTSD symptom severity
|Inconclusive, single trial (N=157)
|Severity of baseline distressa; Debriefing, self-help workbook; Crime victims, women with breast cancer12,21
|Incidence of PTSD
|No evidence
|PTSD symptom severity
|Inconsistent findings, 2 trials (N=285); 1 trial reported that debriefing increased PTSD symptoms among those with high baseline PTSD arousal symptoms; and 1 trial reported that a self-help workbook decreased PTSD symptoms to a greater extent in those with high baseline PTSD symptom severity
|Severity of combat exposurea; UK military service members28
|Incidence of PTSD
|No evidence
|PTSD symptom severity
|Inconclusive, single trial (n=2,443)
KQ 4: Risk of Harms
Little evidence exists addressing either the general or the comparative risks of harms from early interventions to prevent PTSD. Four studies assessed harms;21,32,35,36 two were rated as high risk of bias.21,32 For most interventions, no evidence was available. Table E summarizes the main findings and the SOE for KQ 4.
A three-armed RCT (low risk of bias) considered absolute risk of greater severity of PTSD symptoms in patients presenting to an outpatient psychiatric clinic after psychological trauma.21 In a subgroup of patients with early hyperarousal, those receiving emotional debriefing experienced higher PTSD severity at 6 weeks than those not receiving such debriefing. The investigators did not find this difference in this subgroup at either 2 weeks or 6 months or in any other subgroups (insufficient evidence). We found no other trials of psychological or pharmacological interventions that provided information on risks of early interventions.
One randomized open-label trial considered comparative risk of harms from light versus deep sedation for patients requiring mechanical ventilation.32 The two groups did not differ with regard to rates of mortality (either during their stays in the intensive care unit or in their overall hospitalization) or in the incidence of adverse events (organ dysfunction, hypertension, and tachycardia) (insufficient evidence).
|Intervention, Population
|Abbreviations: N = entire sample; PTSD = posttraumatic stress disorder; SOE = strength of evidence.
|Emotional debriefing vs. no debriefing, Civilian, medical trauma21
|PTSD symptom severity
|For subgroup with hyperarousal, inconclusive, single trial (N=236), inconsistent findings at different assessment intervals
|Pharmacological sedation (light vs. deep),
Critically ill patients32
|Inconclusive, single trial (N=137)
|Incidence of adverse events
|Inconclusive, single trial (N=137)
High-Risk-of-Bias Studies
Table 7 in the main report presents a summary of the study designs, prevention type (i.e., universal or targeted), study comparisons, results, and methodological shortcomings of the 37 studies we rated as high risk of bias. In most cases, we had data from studies of either low or medium risk of bias, and we did not include these high-risk-of-bias studies in our analyses. For some interventions, however, we found only high-risk-of-bias studies. We summarize their findings in the main report.
Key Findings and Strength of Evidence
In this comprehensive comparative effectiveness review (CER), we conducted a systematic review of the efficacy, comparative effectiveness, and harms of psychological, pharmacological, and emerging interventions for the prevention of PTSD in adults exposed to psychological trauma. Overall, for most interventions and outcomes of interest, evidence was either entirely lacking or insufficient to draw conclusions. In addition, in the available body of evidence, the majority of eligible studies were fraught with methodological shortcomings and were rated as high risk of bias. Consequently, we are able to draw only a few conclusions with some degree of certainty:
- CC is effective at reducing the severity of PTSD symptoms for civilian victims of injuries requiring inpatient surgical admission at 6-month, 9-month, and 12-month followup (low SOE, one RCT).
- Debriefing is not effective in reducing either the incidence of PTSD or severity of PTSD or depressive symptoms in civilian victims of crime, assault, or accident trauma at 6-month followup (low SOE, two RCTs).
- In individuals with ASD, a meta-analysis found that adults who received CBT had greater reductions in severity of PTSD symptoms than those who received SC (moderate SOE, three RCTs). Differences between CBT and SC with respect to preventing PTSD (low SOE, three RCTs), reducing the severity of depression symptoms (low SOE, three RCTs), or reducing the severity of anxiety symptoms (moderate SOE, three RCTs) also favored CBT; results, however, did not reach statistical significance.
- The effectiveness of psychological interventions to prevent PTSD does not differ between men and women (low SOE).
For many interventions we did not have sufficient evidence to draw conclusions about either efficacy or comparative effectiveness. How available results from some head-to-head studies might be extrapolated to comparisons with other interventions remains unclear. Consistent with other reviews,37-39 we also concluded that psychological debriefing is not useful for preventing PTSD. One of these reviews also concluded that debriefing could actually be harmful to participants and should cease;38 we cannot confirm this conclusion from our evidence base.
Our primary outcome measures were prevention of PTSD as a DSM-IV-TR disorder (defined as incidence of PTSD) and reduction of PTSD symptom severity. Most of the studies we reviewed, however, determined PTSD symptom scores without establishing the incidence of PTSD. Whether such findings can be extrapolated reliably to differences in the incidence of PTSD remains unclear on the basis of our results.
Overall, two major limitations characterize this body of evidence. First, for many interventions, the evidence was insufficient on the efficacy, comparative effectiveness, or risk of harms of interventions. Despite our eligibility criteria, including observational studies for effectiveness and harms, we could not draw conclusions for or against benefits and harms for the majority of our interventions of interest. Even when studies assessing the effectiveness of an intervention were available, they often did not assess harms. Although lack of evidence cannot be equated with lack of effectiveness or harms, incautious use of interventions without proven net benefit has the potential to cause more harms than benefits.38
Second, available evidence frequently showed shortcomings in study methods. Of 56 studies meeting our eligibility criteria, we rated 37 as high risk of bias using standard criteria and only 3 as low risk of bias. Studies assessed as high risk of bias have significant flaws of various types (stemming from serious errors in design, conduct, or analysis) that may invalidate their results. Consequently, the evidence base for most of the major outcomes we sought to review was insufficient to draw conclusions. The SOE grades for only a few outcomes for only a few interventions could be rated as low or moderate, indicating reasonable confidence in effect estimates of those studies.
Which early psychological or pharmacological interventions would be most effective and least harmful in preventing PTSD among alladults exposed to trauma cannot be specified from our results. Among adults exposed to trauma who meet criteria for ASD, however, our findings support the use of brief CBT interventions over SC for reducing PTSD symptom severity, although the SOE supporting this conclusion is low. Our results did not identify any class of drugs that has been shown to be effective in preventing PTSD.
We found that being male or female did not modify the effect of early intervention among crime victims (low SOE), suggesting that clinicians may not need to take the sex of a patient into consideration when choosing a preventive intervention for crime victims. Whether that observation would generalize to other types of trauma is unclear. We found no evidence about which early interventions are more or less effective for other subgroups of interest.
Evidence addressing the absolute risks or comparative risks of harms from early interventions intended to prevent PTSD was similarly insufficient.
The included studies covered diverse populations exposed to a wide range of traumas and not diagnosed with PTSD, but the findings may not generalize to survivors of terrorist attack, natural disaster, sexual assault, or combat who were underrepresented or unrepresented. In addition, there were too few data to assess whether outcomes differed according to type of trauma or specific demographic factors such as age, since only adults over age 18 years were studied. Many of the included studies were conducted outside the United States with civilian populations (not U.S. military abroad), but there were too few data to analyze whether cross-cultural differences in setting or intervention delivery systems had any impact on outcome. Generally, the findings reflect interventions that were representative of those used in the treatment of PTSD, outcomes that were derived using clinically meaningful and valid measures, and settings that provided real-world context; but, because there is no accepted "usual clinical care" model for preventing PTSD in trauma victims, we cannot draw conclusions about the applicability of the findings to primary care or any other specific setting in which trauma victims present for care. Finally, with respect to the comparative effectiveness of two or more treatments, our meta-analyses indicated some benefit of CBT over SC in reducing PTSD severity in trauma victims who met criteria for ASD.25-27 However, because individuals with ASD constitute the minority of those who later develop PTSD,40-43 these findings may not generalize to the broader population of individuals at risk for developing PTSD.
Research Gaps
The most striking finding from this review is the paucity of high-quality evidence to address each of the four Key Questions. As a result of the small number of studies of low or moderate risk of bias that assessed different interventions, no findings from the included studies could be graded as high SOE. With respect to differences between interventions in PTSD-specific benefits, we had only one finding with moderate SOE (that CBT is more effective than SC in reducing symptoms of PTSD for individuals with ASD) and one with low SOE (that collaborative care produces a greater decrease in PTSD symptom severity after injury compared with usual care). All other findings for incidence of PTSD or PTSD symptom severity were graded as having insufficient strength of evidence.
Specific and important methodological flaws that we identified included the following:
- Inadequate randomization procedures
- High rates of attrition
- Inadequate statistical approaches for data analysis (e.g., lack of ITT analysis, or lack of statistical adjustment for significant between-group differences at baseline)
An important task of systematic reviews is to assess whether design and conduct of included studies provide adequate protection against bias. The methodological shortcomings of many studies conducted to test interventions to prevent PTSD substantially limit our confidence that results accurately reflect the truth. Therefore, the focus of this report is on evidence from studies rated as having low or medium risk of bias.
Future studies on early interventions to prevent PTSD should institute procedures to avoid or minimize these methodological problems if possible. Adequate and concealed methods of randomization should be relatively easy to implement. Statistical consultation can help investigators use more appropriate methods than "completers analysis" or "last observation carried forward" for handling missing data.
Minimizing attrition, however, may be more difficult to achieve, for multiple reasons. Adults exposed to trauma may have difficulty building the commitment required for long-term followup because their first contact with the research team occurs at a time when they are likely to be highly distressed. Survivors who are exposed to traumas that disrupt community infrastructure, such as natural disasters, are likely to be highly mobile and difficult to locate for followup interviews. Specific protocols for minimizing attrition in studies of traumatized populations may help maintain high rates of followup.44
Among the 19 studies that we included and rated as low or medium risk of bias, there was frequently insufficient or no evidence to address KQ 2 (timing and dose of intervention), KQ 3 (effectiveness in subgroups), or KQ 4 (harms). Future research can fill the gaps in multiple ways. For KQ 2, future studies could evaluate the comparative effectiveness of the same intervention given at different time intervals after exposure to trauma, while incorporating inactive control interventions. For studies in which the timing of the intervention is not explicitly randomized, investigators could measure the time between trauma exposure and intervention and carry out preplanned subgroup analyses by time to intervention. Investigators could also attempt to recruit sample sizes that provide sufficient power to detect prespecified group-by-intervention interaction effects. All the following subgroups could be considered: (1) demographic groups: sex, race, or ethnicity; (2) types of trauma; and (3) severity of trauma and severity of baseline distress. In examining harms or unintended side effects of both psychological and pharmacological treatments, researchers should identify potential adverse effects before starting their study and use or adapt validated instruments to measure adverse effects.
Psychological first aid has gained rapid acceptance as a universal intervention for people in the acute aftermath of trauma, but no studies of this intervention met inclusion criteria for our review. Although psychological first aid was not designed as an intervention to reduce the incidence of PTSD, it may have beneficial or adverse effects on mental health among trauma survivors.45,46 Rigorous studies of psychological first aid should be conducted.
One key research gap for studies of targeted prevention is the limited ability to identify people who are at high risk of developing PTSD shortly after they have been exposed to trauma. The development of a clinical prediction rule to identify, shortly after exposure to trauma, the relatively small percentage of such individuals who will develop PTSD would be an enormous help to the field.
We recommend that additional work be devoted to developing a clinical prediction rule based on inclusion of key variables that, together, are highly predictive of PTSD. Those variables could include pretrauma factors, event characteristics, and peri-event responses. An ideal prediction rule would have strong ability to discriminate between people who do or do not develop PTSD, be composed of a relatively small number of variables that can be measured easily and quickly, and produce results that are easily interpretable by health care providers who interact with survivors shortly after they are exposed to trauma. After a clinical prediction rule has been derived and validated in populations exposed to a variety of trauma types, it should be evaluated, in a randomized trial, to determine whether use of the rule, in concert with an intervention to reduce the incidence of PTSD, results in reduced incidence of PTSD. We believe that this is a promising approach to realizing the potential of targeted strategies for preventing PTSD.
Evidence supporting the efficacy of most interventions used to prevent PTSD is lacking. If available in a given setting, brief trauma-focused CBT might be the preferable choice for reducing PTSD symptom severity in adults with ASD; CC may be helpful for reducing PTSD symptom severity post-injury; and debriefing is not an effective prevention intervention.
Our findings highlight the inherent difficulties of conducting research on prevention interventions—difficulties that are often more challenging for mental-health-related research than for research on medical or other health-related issues. Our body of evidence was highly limited because of the paucity of methodologically sound studies. Although disappointing, our findings underscore the need for ongoing research efforts in the field of PTSD prevention. Our findings lead us to conclude that developing a clinical prediction algorithm to identify those who are at high risk of developing PTSD after trauma exposure is perhaps a more crucial next step in the field of PTSD prevention than continuing to study which interventions are more effective than others. The ability to identify people most at risk for developing PTSD and then to evaluate the effectiveness of prevention interventions in those individuals should be the focus of future clinical and research efforts.
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV-TR. American Psychiatric Publishing, Inc.; 2000.
- Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995 Dec;52(12):1048-60. PMID: 7492257.
- Norris F, Sloane LB. The epidemiology of trauma and PTSD. In: Friedman MJ, Keane TM, Resick PA, eds. Handbook of PTSD: Science and practice. New York, NY: Guilford Press; 2007:78-98.
- Fletcher S, Creamer M, Forbes D. Preventing post traumatic stress disorder: are drugs the answer? Aust N Z J Psychiatry. 2010 Dec;44(12):1064-71. PMID: 21080102.
- Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005 Jun;62(6):593-602. PMID: 15939837.
- National Comorbidity Survey. NCS-R appendix tables: Table 1. Lifetime prevalence of DSM-IV/WMH-CIDI disorders by sex and cohort. Table 2. Twelve-month prevalence of DSM-IV/WMH-CIDI disorders by sex and cohort. 2007. www.hcp.med.harvard.edu/ncs/publications.php.
- National Institutes of Mental Health. The numbers count: Mental disorders in America. www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml. Accessed on October 12, 2012.
- Agency for Healthcare Research and Quality. Methods guide for effectiveness and comparative effectiveness reviews AHRQ. Rockville, MD: August 2011. Chapters available at www.effectivehealthcare.ahrq.gov.
- Higgins JP, Green S (eds). Cochrane Handbook for Systematic Reviews of Interventions. The Cochrane Collaboration; 2011.
- Owens DK, Lohr KN, Atkins D, et al. AHRQ series paper 5: Grading the strength of a body of evidence when comparing medical interventions—Agency for Healthcare Research and Quality and the Effective Health-Care Program. J Clin Epidemiol. 2010 May;63(5):513-23. PMID: 19595577.
- Atkins D, Chang S, Gartlehner,G,et al. Chapter 6: Assessing the applicability of studies when comparing medical interventions Agency for Healthcare Research and Quality. In: Methods Guide for Effectiveness and Comparative Effectiveness Reviews. AHRQ Publication No. 11-EHC019-EF. Rockville, MD. Available at: http://www.effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayProduct&productID=603
- Beatty LJ, Koczwara B, Rice J, et al. A randomised controlled trial to evaluate the effects of a self-help workbook intervention on distress, coping and quality of life after breast cancer diagnosis. Med J Aust. 2010 Sep 6;193(5 Suppl):S68-73. PMID: 21542450.
- Bryant RA, Mastrodomenico J, Felmingham KL, et al. Treatment of acute stress disorder: a randomized controlled trial. Arch Gen Psychiatry. 2008 Jun;65(6):659-67. PMID: 18519824.
- Gamble J, Creedy D, Moyle W, et al. Effectiveness of a counseling intervention after a traumatic childbirth: a randomized controlled trial. Birth. 2005 Mar;32(1):11-9. PMID: 15725200.
- Melnyk BM, Alpert-Gillis L, Feinstein NF, et al. Creating opportunities for parent empowerment: program effects on the mental health/coping outcomes of critically ill young children and their mothers. Pediatrics. 2004 Jun;113(6):e597-607. PMID: 15173543.
- O'Donnell ML, Lau W, Tipping S, et al. Stepped early psychological intervention for posttraumatic stress disorder, other anxiety disorders, and depression following serious injury. J Trauma Stress. 2012 Apr;25(2):125-33. PMID: 22522725.
- Rose S, Brewin CR, Andrews B, et al. A randomized controlled trial of individual psychological debriefing for victims of violent crime. Psychol Med. 1999 Jul;29(4):793-9. PMID: 10473306.
- Rothbaum BO, Kearns MC, Price M, et al. Early Intervention May Prevent the Development of Posttraumatic Stress Disorder: A Randomized Pilot Civilian Study with Modified Prolonged Exposure. Biol Psychiatry. 2012 Jul. PMID: 22766415.
- Ryding EL, Wiren E, Johansson G, et al. Group counseling for mothers after emergency cesarean section: a randomized controlled trial of intervention. Birth. 2004 Dec;31(4):247-53. PMID: 15566336.
- Shalev AY, Ankri YLE, Israeli-Shalev Y, et al. Prevention of posttraumatic stress disorder by early treatment: results from the Jerusalem Trauma Outreach and Prevention Study. Arch Gen Psychiatry. 2012 Feb;69(2):166-76. PMID: 21969418.
- Sijbrandij M, Olff M, Reitsma JB, et al. Emotional or educational debriefing after psychological trauma. Randomised controlled trial. Br J Psychiatry. 2006 Aug;189:150-5. PMID: 16880485.
- Weis F, Kilger E, Roozendaal B, et al. Stress doses of hydrocortisone reduce chronic stress symptoms and improve health-related quality of life in high-risk patients after cardiac surgery: a randomized study. J Thorac Cardiovasc Surg. 2006 Feb;131(2):277-82. PMID: 16434254.
- Wong EC, Marshall GN, Miles JN. Randomized controlled trial of a psychoeducational video intervention for traumatic injury survivors. Los Angeles, CA: RAND Corporation; Under review.
- Zatzick D, Jurkovich G, Rivara F, et al. A randomized stepped care intervention trial targeting posttraumatic stress disorder for surgically hospitalized injury survivors. Seattle, WA: University of Washington; In press. p. 1-29.
- Bryant RA, Harvey AG, Dang ST, et al. Treatment of acute stress disorder: a comparison of cognitive-behavioral therapy and supportive counseling. J Consult Clin Psychol. 1998 Oct;66(5):862-6. PMID: 9803707.
- Bryant RA, Moulds M, Guthrie R, et al. Treating acute stress disorder following mild traumatic brain injury. Am J Psychiatry. 2003 Mar;160(3):585-7. PMID: 12611847.
- Bryant RA, Moulds ML, Guthrie RM, et al. The additive benefit of hypnosis and cognitive-behavioral therapy in treating acute stress disorder. J Consult Clin Psychol. 2005 Apr;73(2):334-40. PMID: 15796641.
- Mulligan K, Fear NT, Jones N, et al. Postdeployment Battlemind training for the U.K. armed forces: A cluster randomized controlled trial. J Consult Clin Psychol. 2012;80(3):331-41. PMID: 22409642.
- Campfield KM, Hills AM. Effect of timing of critical incident stress debriefing (CISD) on posttraumatic symptoms. J Trauma Stress. 2001 Apr;14(2):327-40. PMID: 11469160.
- Frappell-Cooke W, Gulina M, Green K, et al. Does trauma risk management reduce psychological distress in deployed troops? Occup Med (Lond). 2010 Dec;60(8):645-50. PMID: 20889815.
- Tecic T, Schneider A, Althaus A, et al. Early short-term inpatient psychotherapeutic treatment versus continued outpatient psychotherapy on psychosocial outcome: a randomized controlled trial in trauma patients. J Trauma. 2011 Feb;70(2):433-41. PMID: 21057336.
- Treggiari MM, Romand JA, Yanez ND, et al. Randomized trial of light versus deep sedation on mental health after critical illness. Crit Care Med. 2009 Sep;37(9):2527-34. PMID: 19602975.
- Adler AB, Bliese PD, McGurk D, et al. Battlemind debriefing and battlemind training as early interventions with soldiers returning from iraq: Randomization by platoon. J Consult Clin Psychol. 2009 Oct;77(5):928-40. PMID: 19803572.
- Krauseneck T, Padberg F, Roozendaal B, et al. A ß-adrenergic antagonist reduces traumatic memories and PTSD symptoms in female but not in male patients after cardiac surgery. Psychol Med. 2010;40(5):861-9. PMID: 19691871.
- Adler AB, Litz BT, Castro CA, 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. PMID: 18553407.
- Carlier IVE, Lamberts RD, Van Uchelen AJ, et al. Disaster-related post-traumatic stress in police officers: a field study of the impact of debriefing. Stress Medicine. 1998;14(3):143-8.
- Barboza K. Critical incident stress debriefing (CISD): Efficacy in question. NSPB. 2005;3(2):49-70.
- Rose S, Bisson JI, Churchill R, et al. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews [Online version]. 2009(2):Art. No.: CD000560.
- van Emmerik AA, Kamphuis JH, Hulsbosch AM, et al. Single session debriefing after psychological trauma: a meta-analysis. Lancet. 2002 Sep 7;360(9335):766-71. PMID: 12241834.
- Bryant RA, Friedman MJ, Spiegel D, et al. A review of acute stress disorder in DSM-5. Depress Anxiety. 2011 Sep;28(9):802-17. PMID: 21910186.
- Fuglsang AK, Moergeli H, Schnyder U. Does acute stress disorder predict post-traumatic stress disorder in traffic accident victims? Analysis of a self-report inventory. Nord J Psychiatry. 2004;58(3):223-9. PMID: 15204210.
- Bryant RA, Creamer M, O'Donnell M, et al. The capacity of acute stress disorder to predict posttraumatic psychiatric disorders. J Psychiatr Res. 2012 Feb;46(2):168-73. PMID: 22088925.
- Bryant RA, Creamer M, O'Donnell ML, et al. A multisite study of the capacity of acute stress disorder diagnosis to predict posttraumatic stress disorder. J Clin Psychiatry. 2008 Jun;69(6):923-9. PMID: 18422396.
- Scott CK, Sonis J, Creamer M, et al. Maximizing follow-up in longitudinal studies of traumatized populations. J Trauma Stress. 2006 Dec;19(6):757-69. PMID: 17195975.
- Everly Jr. GS, Suzanne BP, Dianne K, et al. Introduction to and Overview of Group Psychological First Aid. Brief Treatment and Crisis Intervention. 2006;6(2):130.
- Schafer A, Snider L, van Ommeren M. Psychological first aid pilot: Haiti emergency response. Intervention. 2010;8(3):245-54.
Full Report
This executive summary is part of the following document: Gartlehner G, Forneris CA, Brownley KA, Gaynes BN, Sonis J, Coker-Schwimmer E, Jonas DE, Greenblatt A, Wilkins TM, Woodell CL, Lohr KN. Interventions for the Prevention of Posttraumatic Stress Disorder (PTSD) in Adults After Exposure to Psychological Trauma. Comparative Effectiveness Review No. 109. (Prepared by the RTI-UNC EPC under Contract No. 290-2007-10056-I.) AHRQ Publication No. 13-EHC062-EF. Rockville, MD: Agency for Healthcare Research and Quality; April 2013.


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A lot of people are afraid of heights. Not me, I'm afraid of widths.
So sad to watch what's happening to that state, and KNOW it's the harbinger for the nation, as Buchanan states. At the rate the current Washington 'leaders' are propelling us, it's hard to concur with Buchanan's timetable...we won't be able to hold out until 2040.
Good luck to you and your generation, Kev. I won't be around to help you fend off the socialists. Hope you find some patriots to help you.
When the one you love becomes a memory, that memory becomes a treasure.
Bill, that is the problem. Presented is a real world case that is being ignored. Regardless of how someone is politically aligned, these are irrefutable facts that even the the most left-winged person cannot deny, yet will. The evolution of the original Constitution was not some ill-contrived ideal, rather based upon experience. Who would ever think they'd see a Civil War again? It is not out of our realm.
Last edited by kjrice; 06-30-2009 at 11:17 PM.
A lot of people are afraid of heights. Not me, I'm afraid of widths.

subset: commoncrawl


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ACHICA > Artisan Chairs > Barista End Table
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Barista End Table
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Material: Frame - Solid Rubber Wood; Filling - Foam and Dacron; Fabric - 100% Full Grain Cow Leather in Laguna Brown
Dimensions: H55 x D45cm
Care Instructions: Fixed cover. Dust regularly. Dab spills immediately with a soft, clean cloth. Do not use polishes, preservers, or leather soaps to clean. Light scratches may be rubbed out by the natural heat of your finger. Avoid direct sunlight and heat to protect the leather. Wipe wood with a soft, dry cloth. Avoid direct sunlight and heat to protect wood finish.
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Universal Fit
Audeo Phonak PFE112 Revision II Earphones
" From my point of view these are excellent, both in terms of sound and isolation, plus they look extremely elegant. I am not a 'golden ear' and can't really say much about the harmonics and sound spectrum as I'm really a complete noob here. However even for me I think I'd like a bit more punchy and powerful bass. Nevertheless the sound is basically music to the ears. I..." --iXpertMan
EB92 In-Ear MicroFit Monitors
"NOTE: THIS MAY ALSO BE REFERRED TO AS THE KICKER PHENOM. THE PART NUMBER SHOWN FOR THE KICKER PHENOM PHONES I HAVE IS EB92S As I contemplated giving these a go, I became aware that there was one thing that I wasn't too thrilled about. No mic or controls. I am a person constantly on the go, so most of my listening doesn't get done off of my Fiio amp, but just straight..." --MadMusicJunkie


text: Cut your breast meat up into thin jerky strips. Season them with Hi Mountain Jerky & Cure Kit. wrap it up tight and let marinate for at least 24 hours. Put your oven on the lowest setting possible. Get some jerky racks that you can put in the oven. lay the strips on the racks and pop them into the oven. Open the oven door so it stays open and has a gap of about 8-10 inches. Keep rotating the meat about every 45 min for about 2 hours or however long you want to. I like my jerky real tough and chewy so i keep mine in a little longer. It works just like a dehydrater but doesnt take up the time required with one. use this seasoning here.


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Skull Earbuds
These fabulous "Skull" ear buds are sure to get noticed. A fun way to accessorize your MP3 player, PDA or laptop. your ears Works with devices such as: Portable gaming systems, MP3 players, PDAs and Laptop computers Compatible with a standard 3.5 mm headphone socket Includes two sets of soft silicone tips. Hip, cute and practical..what more could you want ?
Auvio In-ear Headphones
In-ear design reduces outside noise to improve audio quality Enhances bass provides deep, rich lows Specially designed 1/8" plug fits recessed headphone jacks, iPhone compatible Includes 3 difference sized silicone tips to fit all ear


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The complex political and economic relationship between the United States and China--the largest U.S. creditor--is expected to be a top priority for either President Barack Obama or GOP candidate Mitt Romney after the November elections. U.S.-China relations are marked by economic imbalances, compounded by what both candidates allege to be Chinese currency manipulation and unfair trade practices. At the same time, China's foreign policy is increasingly assertive, particularly with regard to contested territories in the South China Sea.
The Obama administration has consistently brought complaints against China's trade practices at the World Trade Organization. At the same time, the administration has expanded the U.S. presence in Asia--both diplomatically and militarily--to check China's rise in the region. Romney has accused Obama of not taking a hard enough line against China, specifically on issues of currency and trade. He said he would immediately confront the currency manipulation issue upon taking office.


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So, how bad does this game suck?
So, how bad does this game suck?
Last call for alcohol.
Skyrim is no doubt the game of the year. No question. So much fun. I chose Argonian.
dragons are a cool edition.. also the 'shouts' that they put in are hella ****ing dope.. I only have the sprint and force push so far, but it makes for a completely different dynamic.. along with the changes to the casting system.. this should most definitely be a candidate for game of the year.. I do have a couple small gripes, like at least so far, I prefer Oblivion's map style, and there's not athletics or acrobatics skills, so there's no jumping or running abnormally high or fast (which I enjoyed).. but overall this is a big upgrade over Oblivion
Skyrim should be named co game of the year with Witcher 2. I doubt there's going to be a game better than these 2 by years end. Battlefield 3 was great, but not this level. MW3 was trash and and a blatant copy and paste of MW2. LA Noire, great but not at this level. Same with Deus Ex. Never played Portal 2, not my kind of game. Haven't gotten around to Assassins Creed yet but doesn't sound like a GOTY from reviews.


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Major: Elementary Education
Year of Graduation: 2011
Graduate Program: Master's, Curriculum & Instruction, Winona State University
Please give a brief description of your current position and where you're working.
I am a resident in the Graduate Induction Program through Winona State University and the Rochester Public School District. Residents in this program teach at the elementary (K-6) level while also taking courses to earn a master's degree in Education. I will be teaching third grade at Franklin Elementary School in Rochester this year while also completing my master's degree in Curriculum and Instruction.
What path did you follow to arrive at your current job?
To earn the opportunity to be part of this program, I majored in Elementary Education during my time at St. Ben's and gained experience working with children through activities both on- and off-campus. I volunteered at a KIDSTOP location, helped at a Saturday School program, and taught a Sunday School class. I also worked at a KinderCare center and summer camp. My volunteer work as well as paid positions involving children helped set me apart during the selection process for the Graduate Induction Program.
What advice/suggestions would you have for students who might be interested in your career?
Students who are interested in teaching should take courses in Education and, most importantly, take advantage of opportunities to work with children! Any experience with children will help students learn and grow on their way to becoming passionate and effective teachers.
Students who are interested in attending graduate school in Education should search for programs like the Graduate Induction Program that allow residents to actively and consistently work with children throughout their courses.
What skills are important in your field?
The most important skills in the education field are clearly communicating and modeling ideas and expectations, actively listening to students' thoughts, and flexibly adapting plans to meet students' needs. Of course, these skills don't mean anything without a passion for education.
What activities/experiences were helpful at CSB/SJU (and elsewhere) in preparation for this career?
The most helpful activities and experiences I found were those where I was given room to be creative in how I worked with children and where I was able to observe and learn from professional educators whose ability to engage and empower children awed me. My most memorable experiences include talking with Education professors at CSB/SJU, participating in practicums and student teaching through my coursework, volunteering at a Saturday School program in St. Paul with other Bennies and Johnnies, and volunteering at KIDSTOP at an elementary school in St. Cloud. These opportunities provided a very important link for me between what I was learning in my Education courses and the real world of teaching and working with students.
What is the most satisfying/rewarding part of your job?
Since the school year is just getting started, I anticipate that the most rewarding part of my job will be watching my students grow throughout the year from children timidly stepping into third grade to children confidently leaping forward into fourth grade and beyond. Watching students finally grasp concepts they've been struggling with for weeks or light up with pride as they grow in confidence makes all the work that goes into teaching worth it.


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Latest Headlines
Paint the Town Orange: A view from the stands of the Rutgers-Syracuse game
Posted on 14 Nov 2010 by Beth Ann Clyde.
Don't call us spoiled or bandwagoners. We went to SU from 2005-09 and are proud survivors of the GROB era. "Hey everybody! Syracuse is awesome!" shouted a young Syracuse fan on his way out of Rutgers Stadium this evening. It was a rare display of innocence as Orange and Scarlet Knights fans engaged in your typical, semi-hostile, oft-profanity-laced post game back-and-forth on their way...


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As I was talking with one of the people doing an attempt at a remake of the MegaGlest MegaPack there was some discussion over the balance of factions with him and me wanting some asymmetric factions and the others obsessed with Starcraft style balance.
I was thinking about how to change things up and I was wondering a few things:
How would people feel about factions that were extra strong, something like LA Ermor in Dominions 3, and/or operated under a separate control scheme?
For instance suppose you had a faction based on the roman legion and then several barbarian factions. The Barbarians would fight somewhat like a traditional RTS faction and they would be ganging up on the Roman like faction.
The Roman faction would need to have a larger production capacity both to compete economically and to compete with the utility provided by 7 sets of unique units. But you might also wish to give them a more Roman and more realistic command structure. You might allow the player to set up hierarchies that can organize and fight as themselves, sort of like garrisons that can handle their business if you deploy appropriate unit combinations and supply lines. You could set up squads and leaders and move up the line to legions.
This is only one example of something that isn't possible in normal RTS games, most only have one control system and they rarely if ever would do something like change the faction balance to be asymmetrical.
I was just wondering how many people care to try out deviations from conventions like this, or one of the many other possibilities.


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Vida Guerra was around before it was popular to be a video model or as we affectionately call them now TWODELS.
Believe it or not she is almost 40 years old. Still looking right in a bikini though.
Thank you for the sensible critique. Me & my neighbor were just preparing to do a little research on this. We got a grab a book from our local library but I think I learned more from this post. I am very glad to see such magnificent information being shared freely out there.
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Comments are closed.


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you're all a bunch of whiners. i have paid taxes all my adult life and will until i'm dead. that's the way it is. that's the way it's always been. do you think they invented taxation 10 years ago just to piss you off? my parents, their parents and their parents parents paid taxes. if you think we can lower taxes and pay of the debt, you're just dreaming.
where do you think the funding comes from for the national parks, the interstate highway system, national defense, veteran's hospitals, the border patrol, NASA, NOAA, etc. and yes, SS and Medicare. if you don't think you NEED SS and Medicare you are either planning on death at an early age or that you can amass a nest egg of at least $2,000,000 to sustain yourself for the 20 or so years at the end of your life when you are no longer working.
you act like you get no value for your contribution. that is definitely not the case.-Paul


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Round 1 Pick 30 (S.F.): Zack Martin, OT, Notre Dame (A)
Round 2 Pick 25 (S.D.): Gabe Jackson, OG, Mississippi State (A)
Round 2 Pick 26 (N.O.): Aaron Donald, DT, Pittsburgh (A-)
Round 3 Pick 16 (NYJ): C.J. Fiedorowicz, TE, Iowa (A)
Round 3 Pick 17: Jeremy Hill, RB, LSU (B+)
Round 3 Pick 18 (CHI): Donte Moncrief, WR, Ole Miss (B)
Round 3 Pick 22 (PHI): Stanley Jean-Baptiste, CB, Nebraska (C-)
Round 3 Pick 30 (S.F.): Aaron Colvin, CB, Oklahoma (B-)
Round 3 Pick 31 (DEN): Dee Ford, OLB, Auburn (A-)
Round 4 Pick 16: Calvin Barnett, DT, Oklahoma State (A-)
Round 4 Pick 28 (CAR): Bryan Stork, C, Florida State (A)
Round 4 Pick 30 (N.E.): Max Bullough, ILB, Michigan State (B-)
Round 4 Pick 31 (DEN): A.J. McCarron, QB, Alabama (A)
Round 4 Pick 32 (SEA): Jay Prosch, FB, Auburn (A)
Round 7 Pick 19: Vinnie Sunseri, SS, Alabama (A)


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Results 11 to 19 of 19
Thread: Ballast pump advice?
I have not done a ballast system myself, but based on years of reading the forum, and having friends try it, I am going to put my vote in for #4 as well. And as folks said, if you switch sides a lot, get the X-Link system as well. I would also recommend ripping out everything and starting from scratch, as it sounds like you have already started. It seems like trying to save pieces and rework things and save money ends up causing more frustration than it is worth.
I guess I wish there were a faster impeller style pump for you guys using the giant bags. For the 1100# sacs, it is still an 11-12 minute fill time. Maybe its not that big a deal, it just sounds like a long time. Also, with the X-Link the time to swap sides should be reduced to about half as much time.Brian Roberts
2001 Outback DD
06-07-2013, 12:58 PM #12Drew
2016 Supra SA 450
2015 Supra SG 450
2012 Moomba Mojo
2008 Moomba OBV
06-07-2013, 01:10 PM #13Senior Member
- Join Date
- Apr 2010
- Location
- saskatchewan, canada
- Posts
- 331
I did number 4 last years, best investment I have made for my boat. I just "T" off the center sac into my bow sac and use 3 pumps to fill four bags, works perfect. The reversible pumps are awesome. i would recommend to anyone looking to up grade.2005 Mobius LSV
Gravity IV (750s rear, 400 mid and 650 bow)
wakeplate, perfect pass,
Not sure what stereo I have, but I have 3 amps 2 subs 6 x 6.5 mids and tweets and 4 tower speakers ( 2 x 8 inch and 2 x 6.5 and tweets)
Fuel Injected
1433 acme prop
What - plan ahead? Who does that...
I noticed a huge diff in drain time going from Rule 700's on 3/4" lines to T-1200's on 1" lines. That seemingly agonizing "is it done yet" wait disappeared. Filling same deal basically. I try to make goofy riders go last but that rarely ever works because me (regular) and daughter (goofy) are typically the first ones willing to hit the water.
I'm biased towards big fast aerators as long as they are plumbed in correctly to void priming issues. <jab>The years have been kind, it's the weekends that have done the damage.
2001 MobiusV - Slightly Modified...
Re: Ballast pump advice?
Thanks berg lol. For some of us below water line space is very difficult to come by.
Sent from my SCH-R970 using Tapatalk 2-Mark
14 Mojo - 72 hours and growing
02 Mobius LSV ---- Sold and always will be remembered as the one that started it all.
"Hey you only live once"
06-07-2013, 10:31 PM #17Member
- Join Date
- Feb 2011
- Location
- Monroe, WA
- Posts
- 74
Still no consensus
I don't really have space issues in the big XLV, but it takes a DAMN long time to fill or swap with the 1100s, and I'm even considering adding a 450 to the rider side, and having to swap that with either a T-line or another pump.
I hesitate on the reversibles because they're not that fast, burn power / have to leave boat running. Either way I'll probably end up with an X-link so maybe I'll make my goofy rider pay for that first!
It would be nice to have some legitimate testing data of the various pumps fill speed. Most of the data I've seen is flawed in some way.
-J2008 Mobius XLV | 325HP | Acme 1235| lots of ballast!
If fast is what you want, Put three new 1 inch mushroom thru the bottoms and three new tsunami 1200's for each bag, scrap the manifold and use vented loops. Put a x link between if needed. Swap all lines to one inch. Swap out drain pumps if faster draining is required. This seems like the fastest method for unrestricted fills.
Ps not the most efficient to drain bags flat, with the two pump per bag system.A Day at the Lake...Priceless
A Day in Powder...Endless
Joe V
2012 Möbius XLV~ Loaded & Exiled
2007 Outback V ~ sold


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By Brad Locke/NEMS Daily Journal
STARKVILLE – Alex Detz hadn't originally planned to play at Mississippi State, and he sure as heck hadn't planned to play first base.
Good thing for the No. 5-ranked Bulldogs that he's doing both. Detz, a native of San Luis Obispo, Calif., has come to the rescue as starting first baseman Wes Rea battles a quad injury.
The junior college transfer is hitting .423 on the young season and has a team-best 12 RBIs.
Over his last three games, Detz is 8 of 10 at the plate with two doubles and eight RBIs.
His Bulldogs (11-0) host Saint Joseph's, an Atlantic 10 school from Philadelphia, in a four-game series starting at 4 p.m. today. Game 2 is noon Saturday, and they'll finish up with a Sunday doubleheader starting at 1 p.m.
Detz was all set to commit to Oregon State when his recruitment changed direction. He played summer ball in San Luis Obispo with State shortstop Adam Frazier two years ago, and the coach of that team, Chal Fanning, had a strong connection to MSU coach John Cohen, as the two had worked together at Missouri many years ago.
"Adam definitely had a big part in me coming here," Detz said.
position change
He was a middle infielder at Cuesta (Calif.) College, then got some work at third base during MSU's preseason drills. Before Rea was injured, MSU's coaches were looking for a good backup option at first base, and they felt Detz fit the bill.
"He's got great hands as middle infielder, and just not quite as much range as some of our other second basemen," Cohen said. "So third base and first base came into play."
Detz said it hasn't been too difficult an adjustment for him, and he's sought the help of Rea, who he called "the best defensive first baseman I've ever played with."
Detz certainly has adjusted well at the plate, where he brings a left-handed bat to the lineup.
He batted .324 at Cuesta last season. After a slow start this year – he was 1 of 10 after his first five games – Detz has rediscovered his hitting prowess.
"On the at-bats where I'm not (getting my pitches), I'm fouling the balls off that I don't want to hit and working the walks," he said. "Then the balls that they're leaving over the plate I'm able to take advantage."


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LAKE CHARLES, LA — First National Bank of Louisiana
(FNB), a local community bank with locations in Lake Charles, Sulphur, Crowley
and Lafayette, has named 30-year banking veteran Greg Webb its Market President
of Southwest Louisiana.
to joining FNB, Webb served seven years as Capital One's Southwest Louisiana
Market President.
Lake Charles native, Webb began his career with Calcasieu Marine National Bank,
which was later acquired by Hibernia National Bank and ultimately Capital One
Bank. He brings a breadth of experience developed over decades serving
customers and business owners.
attributes FNB's "unwavering" community focus as its most compelling
differentiator, and views his position as an opportunity to further strengthen
relationships with individuals and local businesses alike.
believe very strongly in personally supporting the community, and I know that
FNB shares that commitment," Webb said. "Whether it's providing avenues for
local businesses to grow, or providing students with financial education, we
share a dedication to the people of the communities we serve."
said now more than ever, local businesses in particular are relying on
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building a business, a lot hinges on your relationship with your banker," Webb
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Cox, Webb's longtime Administrative Assistant, will join in the transition and
remain integral to client relations and daily operations.
a Lake Charles resident, is married to Tammy and has two children, Kellie and Kacie.
He currently serves as Chairman of the Community Foundation of Southwest
Louisiana. The Louisiana Tech graduate was named 2009 Southwest Louisiana Chamber
of Commerce Volunteer of the Year and has served on the Profit and Loss
Association's board of directors for the past decade. He is a deacon, trustee
and member of the Finance Committee at Trinity Baptist Church.
bank with people they know and trust," said FNB Chairman, President and CEO
Randy Prather, acknowledging Webb's "people-first" approach to banking. "We're
excited to have Greg as part of our team. With his leadership and reputation,
he's going to make a tremendous difference for our bank."


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shaman wrote: what I do know is most locator calling is done without context. If you're out there long enough, you know there is a rhythm to the sounds in the morning. There is a flow. I try to figure out that flow and work with it. The crow that sounds off is already part of that flow. When I sound off, I can be subtly off from the flow and it will probably sound that way to the gobbler.
Exactly right in my humble opinion.
My preference is to use more subtle turkey talk rather than sudden loud locator calls. It is that close tom who is most likely to be pleasantly surprised to hear an out of place hen nearby. He may gobble or he may just yelp and cluck in response; many times a quick setup by the hunter yields a gobbler in short order.


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Universal Fit
Noble Audio Savant
"Overview Unlike most companies, Noble choose to not overwhelm buyers with piles of specifications, preferring instead to accurately describe the sound and allow the decision to be about subjective choices which are far more relevant to the purely personal experience of enjoying music. While specifications can help make decisions sometimes they can also influence our decisions in ways that..." --Loquah
Noble Audio Katana
" At the time this review was written, the Noble Katana Universal was listed for sale on Noble Audio's website. Here is a link to their listing of the product: https://nobleaudio.com/en/shop/universal/ Introduction The greatest thing about this hobby is that the art of manufacturing great sounding earphones continues to evolve. From the top of the line multi-driver..." --Hisoundfi
Noble Audio Kaiser K10UA universal aluminum
" I would like to Thank Noble Audio for providing me with a review sample of K10UA in exchange for my honest opinion. Manufacturer website: http://nobleaudio.com/en/shop/universal/ * click on images to expand. I would like to start this K10UA review with a quote from my Noble Savant write up posted a few months ago: "I'm pretty sure I'm gonna eat my words if I get a..." --twister6
Noble Audio FR
"Disclaimer The FR is a review sample sent from Noble Audio. The reviewer was compensated in the form of a ridiculously cool and form-fitting Noble Audio shirt. Introduction Despite humans having only a single pair of ears, many an audio enthusiast reading this review likely has more than one pair of headphones or IEMs. I myself am guilty of this. If pressed by family and..." --HideousPride
Elecom Hybrid Sealed High Resolution Corresponding Canal Earphone Black Ehp-r / Hh1000abk
"-- Elecom is an electronics manufacturer. [www.elecom.co.jp/global/] The EHP-R / HH1000A is their flagship earphone. ~ All Photos Taken By Me ~ [Product Link] (in Japanese):..." --BloodyPenguin
Noble Audio PR
"Intro: The Noble PR is one of Noble's newest set of universal IEMs, which have a cool feature that allows for you to switch between two "modes". The PR is the reference model of the new line up, the P stands for Pure, meaning it is the ultimate reference sound. "Transparent, detailed, precise. Transparency and precision are all that matters here." The R is another reference mode however it is..." --shiorisekine
Noble Audio Trident In-Ear Monitors
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Noble Audio SAGE (LOT 18, #3)
Sage follows the footsteps of the Savant and features proprietary Noble drivers that result in a more refined and capable sound. Reconfiguration of a vented port on the bass driver delivers increased low-end extension with more texture with a slight lift in overall bass response. Unique one-off design 2 proprietary balanced armature drivers per side Sensitive enough for use with smartphones...
Noble Audio Kaiser 10 (Universal)
"Nothing much to add that has not been said about this wonderful IEM. Just wanted to add a few lines. Pros: 1) Great sound. Wonderful mids, best mids I have had and very spacious. Works well with every genre and extremely coherent. 2) Great handiwork, very well finished product. 3) Very easy to drive and sounds good even from poor sources. Cons: (Expensive like most..." --Docterror
Elecom Ear Drops Series 3 Canal Type Stereo Headphone Ear Buds (Red)
Elecom Ear Drops Noise reducing earphones are the perfect companion for your iPod, mp3 player, laptop, portable DVD, MD, radio, or other audio devices, combining sleek design, premium sound quality, noise reduction, and maximum comfort. The soft silicone earbuds fit perfectly inside your ears, allowing you to comfortably enjoy your music while blocking outside noise. The new ear buds give you a...