Published on in Vol 15, No 8 (2013): August

Internet-Based Early Intervention to Prevent Posttraumatic Stress Disorder in Injury Patients: Randomized Controlled Trial

Internet-Based Early Intervention to Prevent Posttraumatic Stress Disorder in Injury Patients: Randomized Controlled Trial

Internet-Based Early Intervention to Prevent Posttraumatic Stress Disorder in Injury Patients: Randomized Controlled Trial

Original Paper

1Center for Anxiety Disorders, Research Group Psychotrauma, Department of Psychiatry, Academic Medical Center, Amsterdam, Netherlands

2Department of Clinical Psychology, VU University, Amsterdam, Netherlands

3EMGO Institute for Health and Care Research, Amsterdam, Netherlands

4Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Amsterdam, Netherlands

5Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, Netherlands

6Department of Methodology and Statistics, Utrecht University, Utrecht, Netherlands

7Optentia Research Program, Faculty of Humanities, North-West University, Potchefstroom, South Africa

8Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, Netherlands

9Department of Traumatology, VU University Medical Center, Amsterdam, Netherlands

10Arq Psychotrauma Expert Group, Diemen, Netherlands

Corresponding Author:

Joanne Mouthaan, MSc

Center for Anxiety Disorders, Research Group Psychotrauma

Department of Psychiatry

Academic Medical Center

Meibergdreef 5

Amsterdam, 3356 BE


Phone: 31 208913552

Fax:31 208913664


Background: Posttraumatic stress disorder (PTSD) develops in 10-20% of injury patients. We developed a novel, self-guided Internet-based intervention (called Trauma TIPS) based on techniques from cognitive behavioral therapy (CBT) to prevent the onset of PTSD symptoms.

Objective: To determine whether Trauma TIPS is effective in preventing the onset of PTSD symptoms in injury patients.

Methods: Adult, level 1 trauma center patients were randomly assigned to receive the fully automated Trauma TIPS Internet intervention (n=151) or to receive no early intervention (n=149). Trauma TIPS consisted of psychoeducation, in vivo exposure, and stress management techniques. Both groups were free to use care as usual (nonprotocolized talks with hospital staff). PTSD symptom severity was assessed at 1, 3, 6, and 12 months post injury with a clinical interview (Clinician-Administered PTSD Scale) by blinded trained interviewers and self-report instrument (Impact of Event Scale—Revised). Secondary outcomes were acute anxiety and arousal (assessed online), self-reported depressive and anxiety symptoms (Hospital Anxiety and Depression Scale), and mental health care utilization. Intervention usage was documented.

Results: The mean number of intervention logins was 1.7, SD 2.5, median 1, interquartile range (IQR) 1-2. Thirty-four patients in the intervention group did not log in (22.5%), 63 (41.7%) logged in once, and 54 (35.8%) logged in multiple times (mean 3.6, SD 3.5, median 3, IQR 2-4). On clinician-assessed and self-reported PTSD symptoms, both the intervention and control group showed a significant decrease over time (P<.001) without significant differences in trend. PTSD at 12 months was diagnosed in 4.7% of controls and 4.4% of intervention group patients. There were no group differences on anxiety or depressive symptoms over time. Post hoc analyses using latent growth mixture modeling showed a significant decrease in PTSD symptoms in a subgroup of patients with severe initial symptoms (n=20) (P<.001).

Conclusions: Our results do not support the efficacy of the Trauma TIPS Internet-based early intervention in the prevention of PTSD symptoms for an unselected population of injury patients. Moreover, uptake was relatively low since one-fifth of individuals did not log in to the intervention. Future research should therefore focus on innovative strategies to increase intervention usage, for example, adding gameplay, embedding it in a blended care context, and targeting high-risk individuals who are more likely to benefit from the intervention.

Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 57754429; (Archived by WebCite at

J Med Internet Res 2013;15(8):e165



Posttraumatic stress disorder (PTSD) develops after trauma exposure, such as violence, disasters, and injury [1,2]. PTSD’s lifetime prevalence in adults is 7-8% [3,4], whereas the conditional prevalence rate after exposure to violence or injury ranges from 10-56% [1,3,5]. PTSD symptoms include intrusions of the traumatic event, avoidance of stimuli related to the event, emotional numbness, and hyperarousal [6]. Until now, efforts to prevent PTSD onset, for example, psychological debriefing, have been unsuccessful [7,8]. Early treatment of PTSD, or its precursor Acute Stress Disorder, with 4-5 sessions of trauma-focused cognitive behavioral therapy (CBT) was found to be effective in preventing chronic PTSD [9]. CBT consists of imaginal exposure to the traumatic incident, aimed at extinction of the original fear associations [10], and stress-management techniques and cognitive restructuring to correct irrational beliefs [11]. A recent randomized controlled trial found evidence for the effectiveness of 3 sessions of prolonged (imaginal) exposure, starting within 12 hours of the traumatic event, in counteracting later symptoms of PTSD and depression [12]. It is yet unclear whether CBT-techniques administered as a single session early intervention are effective in preventing PTSD.

We developed Trauma TIPS, a brief self-guided Internet intervention based on established CBT techniques. Trauma TIPS aims to decrease acute levels of distress, anxiety, and arousal, known to predict PTSD [13], and to prevent the onset of PTSD symptoms by providing information on successful coping, instructions for self-exposure to fearful situations, and stress management techniques. The exponential growth of global Internet use contributes to the feasibility of e-mental health interventions, which are considered a cost-effective alternative to traditional interventions [14]. Although both self-guided and therapist-assisted Internet-based CBT programs have been successful in the treatment of PTSD [15], there is a great lack of study into whether these programs may prevent PTSD. Preliminary evidence from one previous study on the efficacy of a self-guided Internet-based psychoeducational program for injured children and their parents showed greater anxiety reductions in children who had completed the program compared to those who had not [16].

Our study examined whether Trauma TIPS prevents the onset of PTSD symptoms in injury patients compared to care as usual. In addition, we evaluated whether Trauma TIPS prevented symptoms of depression and anxiety and led to a decrease in mental health care utilization during the first year after injury.

Trial Design

This study was an assessor-blinded randomized controlled trial (RCT; ISRCTN57754429) comparing a brief Internet-based early psychological intervention with a care-as-usual control group in two trauma centers (see Multimedia Appendix 1 for the CONSORT E-HEALTH Checklist of the trial).


Injury patients transported by ambulance or helicopter to the level 1 trauma centers of the Academic Medical Center (AMC) and VU University Medical Center (VUmc) in Amsterdam, the Netherlands, were eligible for inclusion. These patients were suspected to suffer from possible severe injuries that required specialized acute medical care. Inclusion criteria were age 18 years or older, proficiency in Dutch, and having experienced a potential traumatic event (cf. Criterion A1 DSM-IV PTSD diagnosis) [6]. According to this criterion, the person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others. Exclusion criteria were the injury resulting from deliberate self-harm ; organic brain condition, psychotic disorder, bipolar disorder, or depression with psychotic features (cf. DSM-IV) [6]; moderate to severe traumatic brain injury (TBI) (according to a Glasgow Coma Score [17] less than 13); and permanent residency outside the Netherlands.


Trauma TIPS [18] (for screenshots see Multimedia Appendices 2 and 3) was created and is owned by the authors from the Research Group Psychotrauma [19]. It is based on CBT techniques of psychoeducation, stress management/relaxation techniques, and in vivo exposure. It consists of 6 steps, including introduction to the program and basic operating instructions; assessments of acute anxiety and arousal using Visual Analogue Scales (VAS) at pre- and postintervention; video features of the trauma center’s surgical head explaining the procedures at the center and the purpose of the program, and of 3 patient models sharing their experiences after their injury; a short textual summary of 5 coping tips for common physical and psychological reactions after trauma; audio clips with instructions for stress management techniques; contact information for program assistance or professional help for enduring symptoms; and a Web forum for peer support. The introduction page shows the logos of the academic hospitals involved in the study, as well as the logos of the funders of the study. The full design and content of the intervention are described elsewhere [19,20]. Total duration of the program was approximately 30 minutes. Care as usual, available to patients from both groups, consisted of incidental, nonstructured talks with trauma center staff or with a patient’s general practitioner (GP), either directly following injury or during the course of the trial.

Study Procedures

The local institutional review boards provided medical ethical approval. Patients were contacted in hospital or via telephone within 72 hours post injury to assess eligibility and to schedule a baseline assessment. Informed consent was obtained face-to-face directly prior to the baseline assessment at approximately 1 week post injury. Patients were randomly allocated to (1) the Trauma TIPS intervention or (2) a control group with no intervention, but access to care as usual. Randomization was performed by a research member independent of data collection in a 1:1 ratio by a computerized program, TENALEA Clinical Trial Data Management System (NKI/AVL Biometrics department, Amsterdam), using random block sizes (with maximum block size 6), stratified by study center. Intervention group patients received personal log-in codes for the intervention’s website, along with instructions to perform the intervention at will, but at least once within the first month. Electronic and telephone reminders were sent to encourage (early) log-in, but patients were free to access the intervention as they pleased, to underscore the intervention’s voluntary nature and self-guiding principles. Research assistants visited patients with a laptop in case of hospitalization or a lack of Internet or computer access. Follow-up assessments were scheduled at 1, 3, 6, and 12 months post injury. The assessments took place at the AMC’s Center for Anxiety Disorders, at bedside in the hospital, or at the private home of the patient. Patients were asked not to share information about the randomization to the assessors, to ensure that they were blind to the allocated interventions. No reimbursement was given.


Trained assessors at the master’s and doctoral levels performed the data collection. The main outcome measure was PTSD symptom severity on the Clinician-Administered PTSD Scale (CAPS) [21]. The structured interview assesses the frequency and intensity (ranging from 0-4) of the 17 DSM IV symptoms of PTSD (total scores range from 0-136). Scores are added to represent PTSD symptom severity or a diagnosis. The internal consistency of the Dutch translation of the CAPS is good to excellent [22]. Presence of a PTSD diagnosis was computed using the established rule of Weathers et al [23].

The Mini International Neuropsychiatric Interview (MINI-Plus, version 5.0) [24], a semistructured clinical interview, was used to obtain DSM IV diagnoses of major depressive disorders (MDD) and anxiety disorders other than PTSD. Each module starts with screening questions, which, if positive, lead to a further examination of the disorder’s criteria.

We assessed self-reported PTSD severity with the Impact of Event Scale-Revised (IES-R) [25]. The 22 items are scored on a 5-point scale, from 0 (not at all) to 4 (extremely). Total scores range from 0-88 with higher scores representing more severe symptoms. The IES-R shows high internal consistency [25,26].

Self-reported severity of depressive and anxiety symptoms was assessed using the Hospital Anxiety and Depression Scale (HADS) [27]. The item scores in the two subscales of depression (7 items) and anxiety (7 items) range from 0-3 (total scores per subscale ranging from 0-21). Higher scores indicate greater symptomatology. The test-retest reliability of the 2 scales is high [28].

The Trimbos/iMTA questionnaire for Costs associated with Psychiatric illness (TiC-P) [29] was used to evaluate direct and indirect health costs. Direct costs include contacts with mental health professionals (eg, GP, psychologist, social worker), medication use, and admissions for mental health problems. Indirect costs were calculated as production losses due to psychological problems by the Short Form Health and Labour Questionnaire (SF-HLQ) [30].

At the beginning and after completion of Trauma TIPS, patients indicated acute anxiety and arousal levels from 0 (no anxiety or arousal) to 100 (worst anxiety or arousal) on two online VASs [19,20].

Website activity was recorded to evaluate usage characteristics, such as number of log-ins and total amount of login time.

Sample Size

To demonstrate a difference of at least 5.5 points on the CAPS between the groups at 12 months, equivalent to a small to medium effect size of Cohen’s d=.35, 134 patients or more per condition were required (Cronbach alpha=.05, power=80%, SD 16) [31]. Anticipating possible attrition of study participants, we included 150 patients per condition.


Differences in baseline characteristics between the study groups, patients lost to follow-up vs patients not lost to follow-up and patient groups with varying intervention usage were tested using independent sample t tests and chi-square tests (Bonferroni adjusted P=.005). Missing data were imputed using general purpose multivariate imputation procedure (ICE: sequential regression imputation method), creating 50 different datasets. All analyses were performed using these 50 datasets and then pooled by combining the individual results. Due to their positive skewness, CAPS and IES-R values were square root transformed. Stata version 11.2 was used for all repeated measures analyses of PTSD symptoms (CAPS, IES-R) and depressive and anxiety symptoms (HADS-A, HADS-D). The effects of time of measurement, group, and the group-by-time interaction were analyzed with linear mixed models. For all regression models, a robust variance estimator was used. Estimated values (adjusted) and 95% confidence intervals (CIs) are presented throughout the paper unless otherwise specified. Finally, as a post hoc analysis, we applied latent growth mixture modelling (LGMM) [32,33] to explore possible latent subgroups within the two groups by use of the software Mplus (Version 6.11) [34] using a Bayesian estimator [35,36]. Across all analyses, two-tailed tests are reported with Cronbach alpha=.05.

Baseline Characteristics

Recruitment and follow-up took place from September 2007 to June 2010. Figure 1 shows the flow of patients through the trial. Participants were significantly older (mean age 43.8, SD 15.9) than patients who refused participation (mean age 40.1, SD 16.3, P=.01). Table 1 shows the baseline characteristics of participants. There were no differences in baseline characteristics or attrition rate between the study groups. Patients lost to the 12-month follow-up were more often unmarried than patients who were not lost to follow-up (P=.001).

Intervention Usage

Most intervention group patients logged in to the intervention’s website once (n=63, 41.7%). Fifty-four patients (35.8%) logged in multiple times (mean 3.6, SD 3.5, median 3, IQR 2-4). Thirty-four patients (22.5%) did not log in (ie, nonusers) and provided the following reasons: not interested anymore (2), occupied with rehabilitation (1), too busy (1), on holiday (1), too much on my mind (1), tired (1), difficulty concentrating (1), postconcussion symptoms (1), broken back (1), husband deceased (1), or no explanation (22). The average number of log-ins for the entire group was 1.7 (SD 2.5). The average login time was 20.8 minutes (SD 26.3). There were no differences in attrition or outcome measures between nonusers (n=34) and users of the intervention (n=117), or between patients with a single log-in (n=63) versus multiple log-ins (n=54). The only differences were that more nonusers than users had a non-Dutch cultural background (P=.003) and that patients with multiple log-ins were significantly older (mean age 48.0, SD 14.6) than those with a single log-in (mean age 39.6, SD 14.1, P=.001).

From pre- to postintervention, the majority of intervention group patients reported no change in acute anxiety (55.9%, n=38) and arousal (63.2%, n=43) on the VASs. Seven patients reported an increase (10.3%), and 23 (33.8%) and 18 (26.5%) patients reported a reduction in anxiety and arousal respectively.

Main Outcomes

Table 2 shows the results of the intention-to-treat analyses for PTSD, anxiety, and depressive symptoms. Mixed-model analysis of PTSD symptom severity of the CAPS showed a significant effect of time (P<.001), but no significant group differences over time (12-month follow-up, Internet intervention group: estimated means 13.0, 95% CI 11.2 - 14.8; control group: estimated means 13.0, 95% CI 11.4 - 14.6, P=.63). On the mixed-model analysis of self-reported PTSD symptoms (IES-R), we found a similar significant time effect (P<.001) and no group differences over time (12-month follow-up, Internet intervention group: estimated means 7.6, 95% CI 6.4 - 8.7; control group: estimated means 7.8, 95% CI 6.4 - 9.2, P=.76). Figure 2 presents the estimated CAPS and IES-R means over time. For depressive and anxiety symptoms, we found no effects of time or group over time in mixed-model analyses (12 month HADS-D, Internet intervention group: estimated means 3.3, 95% CI 2.4 - 4.2; control group: estimated means 3.0, 95% CI 2.2 - 3.7, P=.72; 12 month HADS-A, Internet intervention group: estimated means 4.1, 95% CI 3.5 - 4.8; control group: estimated means 3.7, 95% CI 3.0 - 4.3, P=.53).

PTSD was diagnosed in 9.2% of patients at 1 month (n=21), 7.6% at 3 months (n=14), 7.5% at 6 months (n=11), and 4.5% at 12 months (n=6). MDD was diagnosed in 7.6% of patients at 1 month (n=17), 2.7% at 3 months (n=5), 7.6% at 6 months (n=11), and 6.8% at 12 months (n=9). Ten patients (4.4%) were diagnosed with an anxiety disorder at 1 month, 11 patients (6.0%) at 3 months, 14 patients (9.7%) at 6 months, and 10 patients (7.6%) at 12 months. chi-square analyses showed no group differences in prevalence of any of the psychiatric diagnoses.

Mental health care utilization at 12 months was similar for both groups, such as visits to a GP (P=.35), company doctor (P=.95), mental health specialists (P=.52), hospital admissions (P=.70), or medication use (P=.57).The groups also did not differ with respect to employment status (P=.70), working hours (P=.89), and work absence (P=.81). Due to the absence of significant group differences, the direct and indirect costs for mental health use were not calculated.

Completer Analyses

In completers-only analyses (n=117 intervention group and n=149 control group patients), excluding nonusers (n=34), results were similar to the intention-to-treat results for all outcome measures.

Latent Subgroups

Post hoc LGMM analyses of self-reported PTSD symptoms (IES-R) revealed two latent subgroups per study group based on PTSD symptom severity at baseline, resulting in a low symptomatic control subgroup (n=94) and intervention subgroup (n=105), and a high symptomatic control subgroup (n=15) and intervention subgroup (n=20). The main difference between the groups was the slope of the high symptomatic subgroups, which showed a significant decrease in the intervention subgroup (P<.001), but not in the control subgroup (P=.32). Table 3 shows the outcomes of the LGMM analyses.

Table 1. Participant characteristics at baseline.
CharacteristicInternet intervention n=151Control with usual care n=149P valuea
Age in years, mean (SD)
44.18 (15.76)43.49 (16.00).54
Sex (male), n (%)
89 (58.9)91 (61.1).73
Post-high school education, n (%)
37 (24.7)43 (29.1).71
Unemployed, n (%)
41 (27.5)29 (19.5).13
Married/cohabitating, n (%)
82 (54.3)81 (54.4).54
Dutch cultural background, n (%)
127 (84.1)122 (83.0).88
Prior traumatic events, mean (SD)
2.99 (2.42)2.93 (2.20).80
Hospital admission, n (%)
100 (66.7)105 (70.9).46
Days hospitalized, mean (SD)
5.30 (8.02)4.57 (7.36).20
ICU admission, n (%)
13 (8.7)13 (8.8).97
Injury Severity Score, mean (SD)
10.45 (8.59)10.21 (9.87).33
Glasgow Coma Scale, mean (SD)
14.48 (1.91)14.72 (1.42).08
Traumatic event, n (%)


Traffic accident99 (65.6)105 (70.5)

Work-related accident12 (7.9)16 (10.7)

Fall28 (18.5)13 (8.7)

Interpersonal violence/physical abuse2 (2.3)5 (3.4)

Other10 (6.6)10 (6.7)
Psychological assessment tools, mean (SD)

Impact of Event Scale—Revised17.60 (16.82)21.22 (19.09).15

Hospital Anxiety and Depression Scale—Depression3.69 (3.50)4.13 (4.26).09

Hospital Anxiety and Depression Scale—Anxiety4.36 (3.90)4.87 (4.33).21

aIndependent t test for difference between groups for continuous measures and chi-square test for differences between groups in categorical characteristics.

Figure 1. Flow of participants through the trial.
View this figure
Table 2. Outcomes of intention-to-treat linear mixed models for PTSD, depressive, and anxiety symptoms.a
OutcomeInternet intervention
Control with usual care n=149TimeGroupGroup x Time
Clinician-assessed PTSD symptoms (CAPS)

1 month follow-up17.7 (16.7 to 18.7)20.2 (19.1 to 21.3)

3 month follow-up14.3 (13.2 to 15.5)16.8 (15.1 to 18.6)

6 month follow-up14.5 (13.2 to 15.8)15.7 (14.3 to 17.1)

12 month follow-up13.0 (11.2 to 14.8)13.0 (11.4 to 14.6)

Patient-reported PTSD symptoms (IES-R)


1 month follow-up10.6 (9.6 to 11.7)12.4 (11.1 to 13.7)

3 month follow-up9.7 (8.0 to 11.4)11.8 (10.1 to 13.5)

6 month follow-up8.2 (6.9 to 9.6)9.8 (8.1 to 11.5)

12 month follow-up7.6 (6.4 to 8.7)7.8 (6.4 to 9.2)

Anxiety symptoms (HADS-A)

1 month follow-up4.6 (3.9 to 5.2)4.8 (4.1 to 5.5)

3 month follow-up4.0 (3.5 to 4.5)4.3 (3.8 to 4.9)

6 month follow-up3.9 (3.2 to 4.6)4.6 (3.7 to 5.4)

12 month follow-up4.1 (3.4 to 4.8)3.7 (3.0 to 4.3)

Depressive symptoms (HADS-D)


1 month follow-up3.6 (3.2 to 4.0)4.1 (3.5 to 4.6)

3 month follow-up3.5 (3.0 to 4.0)3.9 (3.4 to 4.5)

6 month follow-up4.1 (3.5 to 4.8)4.5 (3.6 to 5.4)

12 month follow-up3.3 (2.4 to 4.2)3.0 (2.2 to 3.7)

aData are expressed as mean (95% CI).

Figure 2. Trends in observed PTSD symptom severity (CAPS and IES-R) per intervention group.
View this figure
Table 3. Outcomes of latent growth mixture modeling analyses for self-reported PTSD severity (IES-R).
Latent subgroupsInternet interventionControl with usual care
nmean (95% CI)Pnmean (95% CI)P
Low symptomatic subgroup


9.0 (6.9 to 11.1)<.001
14.9. (11.4 to 18.5)<.001
-1.0 (-1.4 to -0.4)<.001
-1.4 (-1.9 to -0.8)<.001
High symptomatic subgroup


41.2 (35.0 to 50.3)<.001
42.9 (30.1 to 55.6)<.001
-3.6 (-5.2 to -2.1)<.001
0.6 (-2.7 to 3.9).32

Principal Findings

In this paper, we presented the results of a randomized clinical trial comparing a self-guided Internet-based prevention program vs usual care in the prevention of PTSD symptoms in injury patients. PTSD symptoms decreased over time without a significant difference between the Internet intervention group and the control group. Moreover, there were no differences between groups with respect to the number of PTSD and MDD diagnoses and with respect to the severity of depression and anxiety at 12 months. An important finding is that participants were reluctant to use the intervention. In fact, one in five patients in the intervention group lacked any exposure to the intervention. Based on these results, there are currently no indications that offering a voluntary, information-based prevention program via the Internet to unselected injury victims is useful in preventing PTSD symptoms.

The low adherence rates were comparable to those found in similar self-help Internet-based interventions [37]. In part, this nonusage was a consequence of a deliberate design choice to allow patients freedom in performing the intervention, having learned from adverse effects of debriefing interventions found previously to be noneffective or even harmful [7,13]. However, in order to induce changes in behavior and affect, true exposure to an intervention is necessary, which entails accessing the intervention website, staying on the intervention website to actually use it, and revisiting the intervention website, in case of a repetitive design [38]. As possible reasons for dropping out of or not adhering to online treatment programs, previous studies reported time constraints, lack of motivation, technical or computer-access problems, depressive episode or physical illness, the lack of face-to-face contact, a preference for taking medication, perceived lack of treatment effectiveness, improvement in condition, and burden of the program [37]. Strategies to increase uptake of Trauma TIPS may be a more structured peer-support forum, more interactive elements to the intervention, such as quizzes or knowledge questions, automated feedback on the acute anxiety and arousal assessments, or monetary incentive [38-40]. Moreover, a more strict approach to intervention adherence for inclusion in our study (eg, a minimum number of log-ins or log-in time required for participation) may have resulted in greater benefits. However, note that we found no differences in outcomes between users and nonusers or between participants with single versus multiple use. Finally, it is possible that the idea of a computerized program did not match the acute needs of the injury victims, resulting in some of them not using it. Previous studies investigating needs of victims after the September 11, 2001, terrorist attacks and the 2005 London bombings showed that only very few people (< 1%) reported a need for professional mental health support in the acute posttrauma phase, and most (71-87%) turned to loved ones or others for support [41,42].

Another explanation for not finding a significant effect of the intervention may be the low overall PTSD symptom level. Only 9.2% of patients developed PTSD at 1 month, which decreased to 4.5% at 12 months. Beforehand, we expected that 19% of participants would have developed PTSD at 3 months [31]. This unexpectedly low PTSD incidence left little room for symptom improvement for the whole group. Additionally, the relatively low symptom levels may have caused participants to experience little personal incentive to access and use the intervention. Support for this comes from our post hoc subgroup analyses that suggested that the Trauma TIPS intervention was effective in reducing PTSD symptoms in individuals with high initial symptom levels. Because this subgroup was small (n=20), these results must be interpreted with caution.

Internet interventions may not be suitable for all individuals. Common points of criticism are that the mainly information-driven formats pose a disadvantage to people with lesser reading or language skills, do not meet the needs of the elderly or persons with limited computer skills or experience, and that it is difficult to appeal to a culturally diverse audience in a single format, as possibly illustrated in our sample of more nonusers having a non-Dutch cultural background [37]. On the other hand, the rapid developments in Internet applications, especially via mobile technology, provide more possibilities to reach populations who were earlier underserved in eHealth care [43,44].


One limitation of our study was missing data due to patient dropout or failure to complete self-report instruments. We do not know to what extent attrition may have biased our results, although besides marital status, we found no differences between participants and dropouts. In addition, our sample may not have been fully representative of the entire level 1 trauma center population, since we excluded patients with moderate-severe TBI, who did not master the Dutch language, or who were unable to meet our time requirements for logging in.


As a clinical implication of our study, future comparable Internet-based early interventions should be aimed at individuals with high initial symptoms. These individuals may be accurately identified within the first weeks following trauma with early screening tools for PTSD [45-47]. Stepped care programs for acutely traumatized individuals have recently shown to be feasible [48]. The results of our study show that an e-mental health approach could well be a first step in the acute aftercare of highly distressed trauma victims, since Trauma TIPS was indeed effective in a latent subgroup of participants experiencing high levels of PTSD symptoms at baseline. For those victims whose symptoms remain, our self-guided early intervention could be followed by more specialized or traditional curative face-to-face treatment as part of a blended care strategy [49].

Future studies may determine the effectiveness of applying interventions such as Trauma TIPS to individuals with high levels of distress. They may also evaluate whether incorporation of strategies to increase adherence, for instance a motivating interviewing module or increasing the fun by adding serious gaming components to Trauma TIPS, may increase its effectiveness.

In conclusion, our study found no evidence for preventing the development of PTSD symptoms by offering a voluntary, information-based prevention program via the Internet to unselected injury trauma victims. Future research may focus on innovative strategies to increase intervention usage and targeting high-risk individuals who are more likely to benefit from the intervention.


We acknowledge the contributions of Susanne van Buschbach, MSc, Nina A. van der Togt, MSc, and Hendrieke B. Bolding, MSc, and the entire Trauma TIPS interview team for research assistance and data collection, and the participants in the study for their efforts in providing the study data. Funding for this study was provided by the Netherlands Organization for Health Research and Development (ZonMw), Grant no. 62300038, and by the Achmea Foundation for Victims and Society (Stichting Achmea Slachtoffer en Samenleving). The role of the funders in the study was limited to providing financial support to conduct the trial and to oversee the general progress of the trial. Publication costs were covered by the Open Access Fund of the Netherlands Organization for Scientific Research (NWO).

Conflicts of Interest

None declared.

Multimedia Appendix 1

CONSORT-EHEALTH checklist V1.6.2 [42].

PDF File (Adobe PDF File), 991KB

Multimedia Appendix 2

Screenshot of the Trauma TIPS internet intervention: video feature of the trauma center’s surgical head.

JPG File, 62KB

Multimedia Appendix 3

Screenshot of the Trauma TIPS internet intervention: video features of patient models.

JPG File, 67KB

  1. Rees S, Silove D, Chey T, Ivancic L, Steel Z, Creamer M, et al. Lifetime prevalence of gender-based violence in women and the relationship with mental disorders and psychosocial function. JAMA 2011 Aug 3;306(5):513-521. [CrossRef] [Medline]
  2. O'Donnell ML, Creamer M, Pattison P, Atkin C. Psychiatric morbidity following injury. Am J Psychiatry 2004 Mar;161(3):507-514. [Medline]
  3. de Vries GJ, Olff M. The lifetime prevalence of traumatic events and posttraumatic stress disorder in the Netherlands. J Trauma Stress 2009 Aug;22(4):259-267. [CrossRef] [Medline]
  4. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005 Jun;62(6):617-627 [FREE Full text] [CrossRef] [Medline]
  5. Bryant RA, O'Donnell ML, Creamer M, McFarlane AC, Clark CR, Silove D. The psychiatric sequelae of traumatic injury. Am J Psychiatry 2010 Mar;167(3):312-320. [CrossRef] [Medline]
  6. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: American Psychiatric Association; 2000.
  7. Rose S, Bisson J, Wessely S. A systematic review of single-session psychological interventions ('debriefing') following trauma. Psychother Psychosom 2003;72(4):176-184. [Medline]
  8. De Silva M, Maclachlan M, Devane D, Desmond D, Gallagher P, Schnyder U, et al. Psychosocial interventions for the prevention of disability following traumatic physical injury. Cochrane Database Syst Rev 2009(4):CD006422 [FREE Full text] [CrossRef] [Medline]
  9. Roberts NP, Kitchiner NJ, Kenardy J, Bisson JI. Systematic review and meta-analysis of multiple-session early interventions following traumatic events. Am J Psychiatry 2009 Mar;166(3):293-301. [CrossRef] [Medline]
  10. Foa EB, Kozak MJ. Emotional processing of fear: exposure to corrective information. Psychol Bull 1986 Jan;99(1):20-35. [Medline]
  11. Foa EB, Riggs DS, Gershuny BS. Arousal, numbing, and intrusion: symptom structure of PTSD following assault. Am J Psychiatry 1995 Jan;152(1):116-120. [Medline]
  12. Rothbaum BO, Kearns MC, Price M, Malcoun E, Davis M, Ressler KJ, et al. Early intervention may prevent the development of posttraumatic stress disorder: a randomized pilot civilian study with modified prolonged exposure. Biol Psychiatry 2012 Dec 1;72(11):957-963. [CrossRef] [Medline]
  13. Sijbrandij M, Olff M, Reitsma JB, Carlier IV, Gersons BP. Emotional or educational debriefing after psychological trauma. Randomised controlled trial. Br J Psychiatry 2006 Aug;189:150-155 [FREE Full text] [CrossRef] [Medline]
  14. Kaltenthaler E, Brazier J, De Nigris E, Tumur I, Ferriter M, Beverley C, et al. Computerised cognitive behaviour therapy for depression and anxiety update: a systematic review and economic evaluation. Health Technol Assess 2006 Sep;10(33):iii, xi-ixiv, 1 [FREE Full text] [Medline]
  15. Andrews G, Cuijpers P, Craske MG, McEvoy P, Titov N. Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis. PLoS One 2010;5(10):e13196 [FREE Full text] [CrossRef] [Medline]
  16. Cox CM, Kenardy JA, Hendrikz JK. A randomized controlled trial of a web-based early intervention for children and their parents following unintentional injury. J Pediatr Psychol 2010 Jul;35(6):581-592 [FREE Full text] [CrossRef] [Medline]
  17. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974 Jul 13;2(7872):81-84. [Medline]
  18. Trauma TIPS.   URL: [accessed 2013-04-05] [WebCite Cache]
  19. Mouthaan J, Sijbrandij M, Reitsma JB, Gersons BP, Olff M. Internet-based prevention of posttraumatic stress symptoms in injured trauma patients: design of a randomized controlled trial. Eur J Psychotraumatol 2011;2:8294 [FREE Full text] [CrossRef] [Medline]
  20. Mouthaan J, Sijbrandij M, Reitsma JB, Luitse JSK, Goslings JC, Olff M. Trauma TIPS: an internet-based intervention to prevent posttraumatic stress disorder in injured trauma patients. Journal of Cybertherapy and Rehabilitation 2011;4(3):331-340.
  21. Blake DD, Weathers FW, Nagy LM, Kaloupek DG, Gusman FD, Charney DS, et al. The development of a Clinician-Administered PTSD Scale. J Trauma Stress 1995 Jan;8(1):75-90. [Medline]
  22. Hovens JE, van der Ploeg HM, Klaarenbeek MT, Bramsen I, Schreuder JN, Rivero VV. The assessment of posttraumatic stress disorder: with the Clinician Administered PTSD Scale: Dutch results. J Clin Psychol 1994 May;50(3):325-340. [Medline]
  23. Weathers FW, Ruscio AM, Keane TM. Psychometric properties of nine scoring rules for the Clinician-Administered Posttraumatic Stress Disorder Scale. Psychological Assessment 1999;11(2):124-133. [CrossRef]
  24. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59 Suppl 20:22-33;quiz 34. [Medline]
  25. Weiss DS, Marmar CR. The Impact of Event Scale-Revised. In: Wilson JP, Keane TM, editors. Assessing psychological trauma and PTSD. New York: Guilford Press; 1997:399-411.
  26. Creamer M, Bell R, Failla S. Psychometric properties of the Impact of Event Scale - Revised. Behav Res Ther 2003 Dec;41(12):1489-1496. [Medline]
  27. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983 Jun;67(6):361-370. [Medline]
  28. Spinhoven P, Ormel J, Sloekers PP, Kempen GI, Speckens AE, Van Hemert AM. A validation study of the Hospital Anxiety and Depression Scale (HADS) in different groups of Dutch subjects. Psychol Med 1997 Mar;27(2):363-370. [Medline]
  29. Hakkaart-van Roijen L, van Straten A, Donker M, Tiemens B. Manual Trimbos/iMTA questionnaire for Costs associated with Psychiatric illness (TiC-P). Handleiding Trimbos/iMTA questionnaire for Costs associated with Psychiatric illness (TiC-P). Rotterdam, The Netherlands: Institute for Medical Technology Assessment, Erasmus University Rotterdam; 2002.
  30. van Roijen L, Essink-Bot ML, Koopmanschap MA, Bonsel G, Rutten FF. Labor and health status in economic evaluation of health care. The Health and Labor Questionnaire. Int J Technol Assess Health Care 1996;12(3):405-415. [Medline]
  31. Conlon L, Fahy TJ, Conroy R. PTSD in ambulant RTA victims: a randomized controlled trial of debriefing. J Psychosom Res 1999 Jan;46(1):37-44. [Medline]
  32. Preacher KJ, Wichman AL, MacCallum RC, Briggs NE. Latent Growth Curve Modeling. London: Sage; 2008.
  33. Muthén B, Muthén LK. Integrating person-centered and variable-centered analyses: growth mixture modeling with latent trajectory classes. Alcohol Clin Exp Res 2000 Jun;24(6):882-891. [Medline]
  34. Muthén LK, Muthén BO. Mplus User's Guide, Sixth edition. Los Angeles: Muthén & Muthén; 2010.   URL: [accessed 2013-08-09] [WebCite Cache]
  35. Lynch SM. Introduction to Applied Bayesian Statistics and Estimation for Social Scientists. New York: Springer; 2007.
  36. Elliott MR, Gallo JJ, Ten Have TR, Bogner HR, Katz IR. Using a Bayesian latent growth curve model to identify trajectories of positive affect and negative events following myocardial infarction. Biostatistics 2005 Jan;6(1):119-143 [FREE Full text] [CrossRef] [Medline]
  37. Christensen H, Griffiths KM, Farrer L. Adherence in internet interventions for anxiety and depression. J Med Internet Res 2009 Apr;11(2):e13 [FREE Full text] [CrossRef] [Medline]
  38. Crutzen R, Cyr D, de Vries NK. Bringing loyalty to e-Health: theory validation using three internet-delivered interventions. J Med Internet Res 2011 Sep;13(3):e73 [FREE Full text] [CrossRef] [Medline]
  39. Brouwer W, Kroeze W, Crutzen R, de Nooijer J, de Vries NK, Brug J, et al. Which intervention characteristics are related to more exposure to internet-delivered healthy lifestyle promotion interventions? A systematic review. J Med Internet Res 2011 Jan;13(1):e2 [FREE Full text] [CrossRef] [Medline]
  40. Donkin L, Christensen H, Naismith SL, Neal B, Hickie IB, Glozier N. A systematic review of the impact of adherence on the effectiveness of e-therapies. J Med Internet Res 2011 Aug;13(3):e52 [FREE Full text] [CrossRef] [Medline]
  41. Schuster MA, Stein BD, Jaycox L, Collins RL, Marshall GN, Elliott MN, et al. A national survey of stress reactions after the September 11, 2001, terrorist attacks. N Engl J Med 2001 Nov 15;345(20):1507-1512. [CrossRef] [Medline]
  42. Rubin GJ, Brewin CR, Greenberg N, Simpson J, Wessely S. Psychological and behavioural reactions to the bombings in London on 7 July 2005: cross sectional survey of a representative sample of Londoners. BMJ 2005 Sep 17;331(7517):606 [FREE Full text] [CrossRef] [Medline]
  43. Istepanaian RS, Zhang YT. Guest editorial. Introduction to the special section: 4G Health--the long-term evolution of m-Health. IEEE Trans Inf Technol Biomed 2012 Jan;16(1):1-5. [CrossRef] [Medline]
  44. Eysenbach G, CONSORT-EHEALTH Group. CONSORT-EHEALTH: improving and standardizing evaluation reports of Web-based and mobile health interventions. J Med Internet Res 2011;13(4):e126 [FREE Full text] [CrossRef] [Medline]
  45. Shalev AY, Freedman S, Peri T, Brandes D, Sahar T. Predicting PTSD in trauma survivors: prospective evaluation of self-report and clinician-administered instruments. Br J Psychiatry 1997 Jun;170:558-564. [Medline]
  46. O'Donnell ML, Creamer MC, Parslow R, Elliott P, Holmes AC, Ellen S, et al. A predictive screening index for posttraumatic stress disorder and depression following traumatic injury. J Consult Clin Psychol 2008 Dec;76(6):923-932. [CrossRef] [Medline]
  47. Sijbrandij M, Olff M, Opmeer BC, Carlier IV, Gersons BP. Early prognostic screening for posttraumatic stress disorder with the Davidson Trauma Scale and the SPAN. Depress Anxiety 2008 Dec;25(12):1038-1045. [Medline]
  48. Zatzick D, Rivara F, Jurkovich G, Russo J, Trusz SG, Wang J, et al. Enhancing the population impact of collaborative care interventions: mixed method development and implementation of stepped care targeting posttraumatic stress disorder and related comorbidities after acute trauma. Gen Hosp Psychiatry 2011;33(2):123-134 [FREE Full text] [CrossRef] [Medline]
  49. Cucciare MA, Weingardt KR, Greene CJ, Hoffman J. Current trends in using Internet and mobile technology to support the treatment of substance use disorders. Curr Drug Abuse Rev 2012 Sep;5(3):172-177. [Medline]

AMC: Academic Medical Center
CAPS: Clinician Administered PTSD Scale
CBT: cognitive behavioral therapy
GP: general practitioner
HADS: Hospital Anxiety and Depression Scale
HADS-A: Hospital Anxiety and Depression Scale-Anxiety subscale
HADS-D: Hospital Anxiety and Depression Scale-Depression subscale
IES-R: Impact of Event Scale-Revised
IQR: interquartile range
LGMM: latent growth mixture modeling
MDD: major depressive disorder
MINI-Plus: Mini International Neuropsychiatric Interview
PTSD: posttraumatic stress disorder
RCT: randomized controlled trial
SF-HLQ: Short Form Health and Labour Questionnaire
TBI: traumatic brain injury
TiC-P: Trimbos/iMTA Questionnaire for Costs Associated with Psychiatric Illness
VAS: Visual Analogue Scale
VUmc: VU University Medical Center

Edited by G Eysenbach; submitted 28.11.12; peer-reviewed by N Kar, A Shalev; comments to author 28.03.13; revised version received 03.05.13; accepted 10.06.13; published 13.08.13


©Joanne Mouthaan, Marit Sijbrandij, Giel-Jan de Vries, Johannes B Reitsma, Rens van de Schoot, J Carel Goslings, Jan SK Luitse, Fred C Bakker, Berthold PR Gersons, Miranda Olff. Originally published in the Journal of Medical Internet Research (, 13.08.2013.

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