A validated predictive algorithm of post-traumatic stress course following emergency department admission after a traumatic stressor


Annually, approximately 30 million patients are discharged from the emergency department (ED) after a traumatic event1. These patients are at substantial psychiatric risk, with approximately 10–20% developing one or more disorders, including anxiety, depression or post-traumatic stress disorder (PTSD)2,3,4. At present, no accurate method exists to predict the development of PTSD symptoms upon ED admission after trauma5. Accurate risk identification at the point of treatment by ED services is necessary to inform the targeted deployment of existing treatment6,7,8,9 to mitigate subsequent psychopathology in high-risk populations10,11. This work reports the development and validation of an algorithm for prediction of post-traumatic stress course over 12 months using two independently collected prospective cohorts of trauma survivors from two level 1 emergency trauma centers, which uses routinely collectible data from electronic medical records, along with brief clinical assessments of the patient’s immediate stress reaction. Results demonstrate externally validated accuracy to discriminate PTSD risk with high precision. While the predictive algorithm yields useful reproducible results on two independent prospective cohorts of ED patients, future research should extend the generalizability to the broad, clinically heterogeneous ED population under conditions of routine medical care.

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Fig. 1: Variable importance for the training set.

Data availability

All requests for raw and analyzed data and related materials, including programming code, will be reviewed by our legal departments (New York University Grossman School of Medicine and Emory University School of Medicine) to verify whether the request is subject to any intellectual property or confidentiality constraints. Any data and materials that can be shared will be released via a material transfer agreement for noncommercial research purposes. Request should be addressed to the corresponding author (K.S.) or the Principal Investigators of the two study sites (K.J.R. and I.R.G.-L.).

Code availability

The programming code is based on Scikit-learn (https://scikit-learn.org/stable/) and SHAP (https://github.com/slundberg/shap) and the core algorithm can be obtained from https://github.com/KSchultebraucks/DeepSuperLearner. Requests should be addressed to the corresponding author (K.S.).


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K.S. was supported by the German Research Foundation (SCHU 3259/1–1). The study was also supported by K01MH102415 (I.R.G.-L.), R01MH094759 (C.B.N.) and R01MH094757 (K.J.R.).

Author information




I.R.G.-L., K.J.R, C.B.N., A.Y.S., C.R.M., B.O.R., V.M., T.J. and K.S. substantially contributed to the design of the study and developed the study concept. S.-M.S., I.R.G.-L., V.M., J.S.S., J.L.M.-K., C.R.G. were involved in the data collection process. K.S. developed the data analytical plan and performed data analysis. G.A.B. and I.R.G.-L. provided supervision. K.S. wrote the first draft of the manuscript and all co-authors reviewed and revised the manuscript critically for important intellectual content. All co-authors approved the version of the manuscript to be published.

Corresponding author

Correspondence to Katharina Schultebraucks.

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Competing interests

B.O.R. has funding from Wounded Warrior Project, Department of Defense Clinical Trial Grant No.W81XWH-10-1-1045, National Institute of Mental Health grant no. 1R01MH094757-01 and McCormick Foundation. B.O.R. also receives royalties from Oxford University Press, Guilford, APPI and Emory University and received advisory board payments from Genentech, Jazz Pharmaceuticals, Sophren, Nobilis Therapeutics, Neuronetics and Aptinyx. C.R.M. serves on the scientific advisory board and has equity in Receptor Life Sciences. He also serves on the PTSD advisory board for Otsuka Pharmaceutical. He receives support from the National Institute on Alcohol Abuse and Alcoholism, National Institute of Mental Health, Department of Defense, US Army Congressionally Directed Medical Research Program, the Steven & Alexander Cohen Foundation, Cohen Veterans Bioscience, Cohen Veterans Network, Home Depot Foundation, McCormick Foundation, Robin Hood Foundation and the City of New York. C.B.N. discloses the following: research/grants from National Institutes of Health and Stanley Medical Research Institute; consulting (last three years) at Xhale, Takeda, Taisho Pharmaceutical Inc., Bracket (Clintara), Fortress Biotech, Sunovion Pharmaceuticals Inc., Sumitomo Dainippon Pharma, Janssen Research & Development LLC, Magstim, Inc., Navitor Pharmaceuticals, Inc., TC MSO, Inc. and Intra-Cellular Therapies, Inc.; stockholder of Xhale, Celgene, Seattle Genetics, Abbvie, OPKO Health, Inc., Antares, BI Gen Holdings, Inc., Corcept Therapeutics Pharmaceuticals Company, TC MSO, Inc. and Trends in Pharma Development, LLC; scientific advisory boards of American Foundation for Suicide Prevention (AFSP), Brain and Behavior Research Foundation, Xhale, Anxiety Disorders Association of America (ADAA), Skyland Trail, Bracket (Clintara) and Laureate Institute for Brain Research Inc.; board of directors of AFSP, Gratitude America, ADAA and Xhale Smart, Inc.; income sources or equity of USD$10,000 or more from American Psychiatric Publishing, Xhale, Bracket (Clintara), CME Outfitters, Takeda, Intra-Cellular Therapies, Inc., Magstim and EMA Wellness; patents for the method and devices for transdermal delivery of lithium (US 6,375,990B1), the method of assessing antidepressant drug therapy via transport inhibition of monoamine neurotransmitters by ex vivo assay (US 7,148,027B2) and compounds, compositions, methods of synthesis and methods of treatment (CRF receptor binding ligand) (US 8,551,996 B2). K.J.R. performs consulting for Janssen, Verily, Alkermes and Biogen, Inc. on matters unrelated to this manuscript. I.R.G.-L. receives salary and stock options from AiCure. All other authors declare no competing interests.

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Extended data

Extended Data Fig. 1 Schematic overview of the study design.

Displayed are the basic steps of the model development and model validation.

Extended Data Fig. 2 Predictive performance in terms of discrimination and calibration.

In panel a, the ROC curve shows the specificity and the sensitivity of the predictions on the training set (blue line) and the external validation set (orange line) and is accompanied by a calibration plot for the predicted probabilities on the training set (orange line and blue bars) and the external validation set (red line and green bars) in panel b. The bars in the calibration plot in panel (b) displays the predicted probabilities in 10 bins [0, 10%], (10%, 20%],…, (90%, 100%], whereas the lines visualize the predicted probabilities in two bins (low vs. high probability).

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Supplementary Figs. 1–7, Supplementary Tables 1–10, Supplementary Discussion.

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Schultebraucks, K., Shalev, A.Y., Michopoulos, V. et al. A validated predictive algorithm of post-traumatic stress course following emergency department admission after a traumatic stressor. Nat Med 26, 1084–1088 (2020). https://doi.org/10.1038/s41591-020-0951-z

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