Posttraumatic stress disorder in primary care: prevalence and relationships with physical symptoms and medical utilization

Exploring relations among traumatic, posttraumatic, and physical pain experiences in methadone-maintained patients

Differences in lifetime trauma exposure and screened symptoms of posttraumatic stress disorder (PTSD) were examined in methadone maintenance treatment (MMT) patients with a variety of pain experiences. Parametric and nonparametric statistical tests were performed on data obtained from 150 patients currently enrolled in MMT. In comparison to MMT patients reporting no pain in the previous week, those with chronic severe pain (CSP) (ie, pain lasting at least 6 months with moderate to severe pain intensity or significant pain interference) exhibited comparable levels of trauma involving sexual assault but reported significantly higher levels of trauma involving physical assault, number of traumatic events, and screened symptoms of PTSD. A third group, non-CSP MMT patients reporting some pain in the past week, differed significantly from the CSP group on number of traumatic events but reported comparable levels of sexual assault and physical assault. In comparison to men, women reported higher levels of sexual assault and were more likely to score above the cutoff on the PTSD screener but reported comparable levels of physical assault and number of traumatic events. Pain-related differences in trauma and screened symptoms of PTSD exist in MMT patients and may have implications for program planning and outreach efforts.

PERSPECTIVE

This article demonstrates that trauma and screened symptoms of PTSD vary as a function of sex and pain status in methadone-maintained patients. Future studies may benefit from developing and assessing interventions that address chronic pain, PTSD, and opioid dependence in MMT.

Families' perceptions of veterans' distress due to post-traumatic stress disorder-related symptoms at the end of life

OBJECTIVES

To define the frequency of post-traumatic stress disorder (PTSD)-related symptoms among veterans who are near the end of life and to describe the impact that these symptoms have on patients and their families.

METHODS

Patients had received inpatient or outpatient care from a participating VA facility in the last month of life, and one family member per patient was selected using predefined eligibility criteria. Family members then completed a telephone survey, The Family Assessment of Treatment at End-of-Life, which assessed their perceptions of the quality of the care that the patients and they themselves received during the patients' last month of life.

RESULTS

Seventeen percent of patients (89 of 524) were reported to have had PTSD-related symptoms in the last month of life. PTSD-related symptoms caused discomfort less often than pain did (mean frequency score 1.79 vs. 1.93; Wilcoxon sign rank test, P<0.001) but more often than dyspnea did (mean severity score 1.79 vs. 1.73; Wilcoxon sign rank test, P<0.001). Family members of patients with PTSD-related symptoms reported less satisfaction overall with the care the patient received (mean score 48 vs. 62; rank sum test, P<0.001). Patients who received a palliative care consult (n=49) had lower ratings of discomfort attributed to PTSD-related symptoms (mean 1.55 vs. 2.07; rank sum test, P=0.007).

CONCLUSION

PTSD-related symptoms may be common and severe among veterans near the end of life and may have a negative effect on families' perceptions of the quality of care that the veteran received.

Medical conditions and symptoms associated with posttraumatic stress disorder in low-income urban women

BACKGROUND

Epidemiological studies have consistently reported rates of posttraumatic stress disorder (PTSD) in women that are twice that of men. In men and women, PTSD has been associated with comorbid medical conditions, medical symptoms and lower self-rating of health. In low-income urban women, rates of PTSD are even more elevated than in suburban women and may be related to observed health disparities.

METHODS

In this study, 250 women seeking healthcare at an urban clinic were interviewed for a PTSD diagnosis, major depressive disorder (MDD), the experience of traumatic events, the experience of current and past common medical conditions and symptoms, and subjective rating of health. A chart review was used to assess healthcare use in the past year.

RESULTS

More current (5.2 vs. 3.8, p < 0.05) and past medical conditions (4.6 vs. 3.3, p < 0.05) were reported by women with a lifetime history of PTSD than by women without this history, after controlling for demographics and current depression. Women with lifetime PTSD also had more annual clinic appointments (5.9 vs. 3.8 p < 0.03) and were 2.4 times (p < 0.05) more likely to report lower appraisal of their physical health.

CONCLUSIONS

These findings suggest that urban health-seeking women with PTSD experience health impairments that may cause increased morbidity and that healthcare providers should consider the health ramifications of PTSD when providing medical care to women.

System factors affect the recognition and management of posttraumatic stress disorder by primary care clinicians

BACKGROUND

Posttraumatic stress disorder (PTSD) is common with an estimated prevalence of 8% in the general population and up to 17% in primary care patients. Yet, little is known about what determines primary care clinician's (PCC's) provision of PTSD care.

OBJECTIVE

To describe PCC's reported recognition and management of PTSD and identify how system factors affect the likelihood of performing clinical actions with regard to patients with PTSD or "PTSD treatment proclivity."

DESIGN

Linked cross-sectional surveys of medical directors and PCCs.

PARTICIPANTS

Forty-six medical directors and 154 PCCs in community health centers (CHCs) within a practice-based research network in New York and New Jersey.

MEASUREMENTS

Two system factors (degree of integration between primary care and mental health services, and existence of linkages with other community, social, and legal services) as reported by medical directors, and PCC reports of self-confidence, perceived barriers, and PTSD treatment proclivity.

RESULTS

Surveys from 47 (of 58) medical directors (81% response rate) and 154 PCCs (86% response rate). PCCs from CHCs with better mental health integration reported greater confidence, fewer barriers, and higher PTSD treatment proclivity (all P < 0.05). The PCCs in CHCs with better community linkages reported greater confidence, fewer barriers, higher PTSD treatment proclivity, and lower proclivity to refer patients to mental health specialists or to use a "watch and wait" approach (all P < 0.05).

CONCLUSIONS

System factors play an important role in PCC PTSD management. Interventions are needed that restructure primary care practices by making mental health services more integrated and community linkages stronger.

A comparison of PTSD symptom patterns in three types of civilian trauma

Posttraumatic stress disorder (PTSD) is assumed to be an equivalent syndrome regardless of the type of traumatic event that precipitated it. However, the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) and previous research suggest that the clinical presentation of PTSD varies by trauma type. This study compared PTSD symptom profiles in three types of civilian trauma: sexual assault (n = 86), motor vehicle accident (n = 162), and sudden loss of a loved one (n = 185). Groups differed in overall PTSD severity and displayed distinct PTSD symptom patterns. Results suggest that different trauma types lead to unique variants of the PTSD syndrome, which may result from different etiological factors and may require different treatment approaches.

Experiences of traumatic events and associations with PTSD and depression development in urban health care-seeking women

Posttraumatic stress disorder (PTSD) is an anxiety disorder that occurs after a traumatic event and has been linked to psychiatric and physical health declines. Rates of PTSD are far higher in individuals with low incomes and who reside in urban areas compared to the general population. In this study, 250 urban health care-seeking women were interviewed for a diagnosis of PTSD, major depressive disorder, and also the experience of traumatic events. Multivariate logistic regressions were used to determine the associations between traumatic events and PTSD development. Survival analysis was used to determine if PTSD developed from assaultive and nonassaultive events differed in symptom duration. Eighty-six percent of women reported at least one traumatic event, 14.8% of women were diagnosed with current PTSD, and 19.6% with past PTSD. More than half of women with PTSD had comorbid depression. Assaultive traumatic events were most predictive of PTSD development. More than two thirds of the women who developed PTSD developed chronic PTSD. Women who developed PTSD from assaultive events experienced PTSD for at least twice the duration of women who developed PTSD from nonassaultive events. In conclusion, PTSD was very prevalent in urban health care-seeking women. Assaultive violence was most predictive of PTSD development and also nonremittance.

PTSD in Latino patients: illness beliefs, treatment preferences, and implications for care

BACKGROUND

Little is known about how Latinos with post-traumatic stress disorder (PTSD) understand their illness and their preferences for mental health treatment.

OBJECTIVE

To understand the illness beliefs and treatment preferences of Latino immigrants with PTSD.

DESIGN

Semi-structured, face-to-face interviews.

PARTICIPANTS

Sixty foreign-born, Latino adults recruited from five primary care centers in New York and New Jersey and screened for PTSD.

APPROACH

Content analytic methods identified common themes, their range, and most frequent or typical responses.

RESULTS

Participants identified their primary feelings as sadness, anxiety, nervousness, and fear. The most common feeling was "sad" (triste). Other words frequently volunteered were "angry" (enojada), "nervous" (nerviosa), and "scared" (miedo). Participants viewed their PTSD as impairing health and functioning. They ascribed their somatic symptoms and their general medical problems to the "stress" from the trauma and its consequences on their lives. The most common reason participants volunteered for their work and school functioning being impaired was their poor concentration, often due to intrusive thoughts. Most expressed their desire to receive mental health treatment, to receive it within their primary care center, and preferred psychotherapy over psychotropic medications. Among participants who did not report wanting treatment, most said it was because the trauma was "in the past."

CONCLUSIONS

Clinicians may consider enquiring about PTSD in Latino patients who report feeling sad, anxious, nervous, or fearful. Our study suggests topics clinicians may include in the psychoeducation of patients with PTSD.

Lower decision threshold for doctor visits as a predictor of health care use in somatoform disorders and in the general population

OBJECTIVE

Somatization is related to elevated health care utilization (HCU) and high health care costs. However, it is unclear whether HCU in somatizers and nonsomatizers in the general population is determined by existing symptoms or by lower thresholds for doctor visits.

METHOD

A representative sample of the German general population (N=2510) was screened for psychopathology and HCU in the prior 12 months. The sample was subdivided into somatizers (n=712) and controls (n=1796), using the Patient Health Questionnaire (PHQ-15). A general tendency to visit doctors even for minor reasons was assessed. Demographic and psychopathological variables were additionally entered into regression analyses to predict HCU for the whole investigated sample and the two subsamples.

RESULTS

Higher somatization, unemployment or retirement, a lower decision threshold for doctor visits and higher posttraumatic symptomatology were consistent and unique positive predictors of HCU in the prior 12 months.

CONCLUSION

Not only symptoms per se but also a lower decision threshold for doctor visits contribute to increased HCU. Psychopathological and demographic variables can further predict HCU in somatizing persons and controls. Although somatization and reduced thresholds for doctor visits are associated, they have to be distinguished from each other and contribute independently to increased costs.

The impact of trauma exposure and post-traumatic stress disorder on healthcare utilization among primary care patients

BACKGROUND

Trauma exposure and post-traumatic stress disorder (PTSD) increase healthcare utilization in veterans, but their impact on utilization in other populations is uncertain.

OBJECTIVES

To examine the association of trauma exposure and PTSD with healthcare utilization, in civilian primary care patients.

RESEARCH DESIGN

Cross-sectional study.

SUBJECTS

English speaking patients at an academic, urban primary care clinic.

MEASURES

Trauma exposure and current PTSD diagnoses were obtained from the Composite International Diagnostic Interview. Outcomes were nonmental health outpatient and emergency department visits, hospitalizations, and mental health outpatient visits in the prior year from an electronic medical record. Analyses included bivariate unadjusted and multivariable Poisson regressions adjusted for age, gender, income, substance dependence, depression, and comorbidities.

RESULTS

Among 592 subjects, 80% had > or =1 trauma exposure and 22% had current PTSD. In adjusted regressions, subjects with trauma exposure had more mental health visits [incidence rate ratio (IRR), 3.9; 95% confidence interval (CI), 1.1-14.1] but no other increased utilization. After adjusting for PTSD, this effect of trauma exposure was attenuated (IRR, 3.2; 95% CI, 0.9-11.7). Subjects with PTSD had more hospitalizations (IRR, 2.2; 95% CI, 1.4-3.7), more hospital nights (IRR, 2.6; 95% CI, 1.4-5.0), and more mental health visits (IRR, 2.2; 95% CI, 1.1-4.1) but no increase in outpatient and emergency department visits.

CONCLUSIONS

PTSD is associated with more hospitalizations, longer hospitalizations, and greater mental healthcare utilization in urban primary care patients. Although trauma exposure is independently associated with greater mental healthcare utilization, PTSD mediates a portion of this association.

Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population

BACKGROUND

The 7-item Generalized Anxiety Disorder Scale (GAD-7) is a practical self-report anxiety questionnaire that proved valid in primary care. However, the GAD-7 was not yet validated in the general population and thus far, normative data are not available.

OBJECTIVES

To investigate reliability, construct validity, and factorial validity of the GAD-7 in the general population and to generate normative data.

RESEARCH DESIGN

Nationally representative face-to-face household survey conducted in Germany between May 5 and June 8, 2006.

SUBJECTS

Five thousand thirty subjects (53.6% female) with a mean age (SD) of 48.4 (18.0) years.

MEASURES

The survey questionnaire included the GAD-7, the 2-item depression module from the Patient Health Questionnaire (PHQ-2), the Rosenberg Self-Esteem Scale, and demographic characteristics.

RESULTS

Confirmatory factor analyses substantiated the 1-dimensional structure of the GAD-7 and its factorial invariance for gender and age. Internal consistency was identical across all subgroups (alpha = 0.89). Intercorrelations with the PHQ-2 and the Rosenberg Self-Esteem Scale were r = 0.64 (P < 0.001) and r = -0.43 (P < 0.001), respectively. As expected, women had significantly higher mean (SD) GAD-7 anxiety scores compared with men [3.2 (3.5) vs. 2.7 (3.2); P < 0.001]. Normative data for the GAD-7 were generated for both genders and different age levels. Approximately 5% of subjects had GAD-7 scores of 10 or greater, and 1% had GAD-7 scores of 15 or greater.

CONCLUSIONS

Evidence supports reliability and validity of the GAD-7 as a measure of anxiety in the general population. The normative data provided in this study can be used to compare a subject's GAD-7 score with those determined from a general population reference group.

PTSD diagnoses, subsyndromal symptoms, and comorbidities contribute to impairments for breast cancer survivors

The clinical importance of posttraumatic stress disorder (PTSD) symptomatology for cancer patients is unclear. The association between the magnitude of cancer-related PTSD symptoms, comorbidity, and functioning is tested. Breast cancer patients (N = 74) were assessed at diagnosis/surgery, followed, and screened for cancer-related PTSD 18 months later. Participants then completed diagnostic interviews and PTSD (n = 12), subsyndromal PTSD (n = 5), and no symptom (n = 47) patient groups were identified. Posttraumatic stress disorder cases were distinguished by having experienced violent traumas and anxiety disorders predating cancer, whereas subsyndromal cases were not. Also, longitudinal data show that PTSD covarys with poorer functioning and lower quality of life among breast cancer survivors. Both PTSD and subsyndromal PTSD were associated with employment absenteeism and the seeking of mental health services.

Extended-release formulation of venlafaxine in the treatment of post-traumatic stress disorder

There is abundant evidence for abnormalities of both norepinephrine and serotonin neurotransmitter systems in post-traumatic stress disorder (PTSD). Venlafaxine extended-release formulation (venlafaxine XR) is a serotonin and norepinephrine re-uptake inhibitor with antidepressant and anxiolytic properties relevant to the pathophysiology of PTSD. Venlafaxine XR is currently approved for the treatment of panic disorder, generalized anxiety disorder and social anxiety disorder, as well as major depression in adults, based on a number of randomized, double blind, placebo-controlled clinical trials. Limited data also demonstrate that venlafaxine XR maintains a therapeutic response for more than 6 months in these anxiety disorders. Venlafaxine XR has demonstrated short- and long-term efficacy for the treatment of PTSD in two recent randomized, double-blind, placebo-controlled clinical trials, although it has not been extensively studied for PTSD, compared with other anxiety disorders. This review focuses on the potential role of venlafaxine XR in the treatment of PTSD, based on currently available evidence.