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

Election-Related Post-Traumatic Stress: Evidence from the 2020 U.S. Presidential Election

The 2020 U.S. presidential election saw rising political tensions among ordinary voters and political elites, with fears of election violence culminating in the January 6 riot. We hypothesized that the 2020 election might have been traumatic for some voters, producing measurable symptoms of post-traumatic stress disorder (PTSD). We also hypothesized that negative sentiment toward the opposing party correlates with PTSD. We measured PTSD using a modified version of the PCL-5, a validated PTSD screener, for 573 individuals from a nationally representative YouGov sample. We modeled the association between affective polarization and PTSD, controlling for political, demographic, and psychological traits. We estimate that 12.5% of American adults (95% CI: 9.2% to 15.9%) experienced election-related PTSD, far higher than the annual PTSD prevalence of 3.5%. Additionally, negativity toward opposing partisans correlated with PTSD symptoms. These findings highlight a potential need to support Americans affected by election-related trauma.

Trauma-Informed Care Curricula for the Health Professions: A Scoping Review of Best Practices for Design, Implementation, and Evaluation

PURPOSE

Trauma-exposed persons often experience difficulties accessing medical care, remaining engaged in treatment plans, and feeling psychologically safe when receiving care. Trauma-informed care (TIC) is an established framework for health care professionals, but best practices for TIC education remain unclear. To remedy this, the authors conducted a multidisciplinary scoping literature review to discern best practices for the design, implementation, and evaluation of TIC curricula for health care professionals.

METHOD

The research team searched Ovid MEDLINE, Cochrane Library, Elsevier's Scopus, Elsevier's Embase, Web of Science, and the PTSDpubs database from the database inception date until May 14, 2021. Worldwide English language studies on previously implemented TIC curricula for trainees or professionals in health care were included in this review.

RESULTS

Fifty-five studies met the inclusion criteria, with medicine being the most common discipline represented. The most prevalent learning objectives were cultivating skills in screening for trauma and responding to subsequent disclosures (41 studies [74.5%]), defining trauma (34 studies [61.8%]), and understanding trauma's impact on health (33 studies [60.0%]). Fifty-one of the studies included curricular evaluations, with the most common survey items being confidence in TIC skills (38 studies [74.5%]), training content knowledge assessment (25 studies [49.0%]), participant demographic characteristics (21 studies [41.2%]), and attitudes regarding the importance of TIC (19 studies [37.3%]).

CONCLUSIONS

Future curricula should be rooted in cultural humility and an understanding of the impacts of marginalization and oppression on individual and collective experiences of trauma. Moreover, curricula are needed for clinicians in more diverse specialties and across different cadres of care teams. Additional considerations include mandated reporting, medical record documentation, and vicarious trauma experienced by health care professionals.

Screening for opioid use disorder and co-occurring depression and post-traumatic stress disorder in primary care in New Mexico

BACKGROUND

Identifying patients in primary care services with opioid use disorder and co-occurring mental health disorders is critical to providing treatment. Objectives of this study were to (1) assess the feasibility of recruiting people to screen in-person for opioid use disorder and co-occurring mental health disorders (depression and/or post-traumatic stress disorder) in primary care clinic waiting rooms in preparation for a randomized controlled trial, and (2) compare results of detecting these disorders by universal in-person screening compared to electronic health record (EHR) diagnoses.

METHODS

This cross-sectional feasibility and pilot study recruited participants from four primary care clinics, two rural and two urban, from three health care organizations in New Mexico. Inclusion criteria were adults (≥ 18 years), attending one of the four clinics as a patient, and who spoke English or Spanish. Exclusion criteria were people attending the clinic for a non-primary care visit (e.g., dental, prescription pick up, social support). The main outcomes and measures were (1) recruitment feasibility which was assessed by frequencies and proportions of people approached and consented for in-person screening, and (2) relative differences of detecting opioid use disorder and co-occurring mental health disorders in waiting rooms relative to aggregate EHR data from each clinic, measured by prevalence and prevalence ratios.

RESULTS

Over two-weeks, 1478 potential participants were approached and 1145 were consented and screened (77.5% of patients approached). Probable opioid use disorder and co-occurring mental health disorders were identified in 2.4% of those screened compared to 0.8% in EHR. Similarly, universal screening relative to EHR identified higher proportions of probable opioid use disorder (4.5% vs. 3.4%), depression (17.5% vs. 12.7%) and post-traumatic stress disorder (19.0% vs. 3.6%).

CONCLUSIONS

Universal screening for opioid use disorder, depression, and post-traumatic stress disorder was feasible, and identified three times as many patients with these co-occurring disorders compared to EHR. Higher proportions of each condition were also identified, especially post-traumatic stress disorder. Results support that there are likely gaps in identification of these disorders in primary care services and demonstrate the need to better address the persistent public health problem of these co-occurring disorders.

Characterizing primary care patients with posttraumatic stress disorder using electronic medical records: a retrospective cross-sectional study

BACKGROUND

Posttraumatic stress disorder (PTSD) has significant morbidity and economic costs. This study describes the prevalence and characteristics of patients with PTSD using primary care electronic medical record (EMR) data.

METHODS

This retrospective cross-sectional study used EMR data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). This study included 1,574 primary care providers located in 7 Canadian provinces. There were 689,301 patients that visited a CPCSSN provider between 1 January 2017 and 31 December 2019. We describe associations between PTSD and patient characteristics using descriptive statistics, chi-square, and multiple logistic regression models.

RESULTS

Among the 689,301 patients included, 8,817 (1.3%, 95% CI 1.2-1.3) had a diagnosis of PTSD. On multiple logistic regression analysis, patients with depression (OR 4.4, 95% CI 4.2-4.7, P < 0.001), alcohol abuse/dependence (OR 1.7, 95% CI 1.6-1.9, P < 0.001), and/or drug abuse/dependence (OR 2.6, 95% CI 2.5-2.8, P < 0.001) had significantly higher odds of PTSD compared with patients without those conditions. Patients residing in community areas considered the most material deprived (OR 2.1, 95% CI 1.5-2.1, P < 0.001) or the most socially deprived (OR 2.8, 95% CI 2.7-5.3, P < 0.001) had higher odds of being diagnosed with PTSD compared with patients in the least deprived areas.

CONCLUSIONS

The prevalence of PTSD in Canadian primary care is 1.3% (95% CI 1.25-1.31). Using EMR records we confirmed the co-occurrence of PTSD with other mental health conditions within primary care settings suggesting benefit for improved screening and evidence-based resources to manage PTSD.

Clinician Experiences With Telepsychiatry Collaborative Care for Posttraumatic Stress Disorder and Bipolar Disorder

OBJECTIVE

Posttraumatic stress disorder (PTSD) and bipolar disorder are common in primary care. Evidence supports collaborative care in primary care settings to treat depression and anxiety, and recent studies have evaluated its effectiveness in treating complex conditions such as PTSD and bipolar disorder. This study aimed to examine how primary care clinicians experience collaborative care for patients with these more complex psychiatric disorders.

METHODS

The authors conducted semistructured interviews with 22 primary care clinicians participating in a pragmatic trial that included telepsychiatry collaborative care (TCC) to treat patients with PTSD or bipolar disorder in rural or underserved areas. Analysis utilized a constant comparative method to identify recurring themes.

RESULTS

Clinicians reported that TCC improved their confidence in managing medications for patients with PTSD or bipolar disorder and supported their ongoing learning and skill development. Clinicians also reported improvements in patient engagement in care. Care managers were crucial to realizing these benefits by fostering communication within the clinical team while engaging patients through regular outreach. Clinicians valued TCC because it included and supported them in improving the care of patients' mental health conditions, which opened opportunities for clinicians to enhance care and address co-occurring general medical conditions. Overall, benefits of the TCC model outweighed its minimal burdens.

CONCLUSIONS

Clinicians found that TCC supported their care of patients with PTSD or bipolar disorder. This approach has the potential to extend the reach of specialty mental health care and to support primary care clinicians treating patients with these more complex psychiatric disorders.

Group therapy in primary care settings for the treatment of posttraumatic stress disorder: A systematic literature review

OBJECTIVE

This systematic review aims to summarize existing literature on group therapy for the treatment of post-traumatic stress disorder (PTSD) in primary care.

METHOD

A PRISMA systematic literature review was performed through February 26, 2022 identifying existing studies of group trauma therapy in primary care. Articles were included if they discussed group trauma therapy for primary care patients. Bias was assessed based on sample sizes and presence of control groups. Results are presented as a weighted average of the engagement rate and a qualitative description of overlapping study traits.

RESULTS

Four studies of group PTSD treatment within primary care were identified with 70 total patients completing group treatment. The weighted treatment engagement rate was 65%. Each utilized distinct group trauma treatment models and reported significant patient improvements in PTSD symptoms on standardized trauma symptom scales.

DISCUSSION

Group trauma therapy models are available and can be disseminated within primary care settings. Limitations include both the small number of studies and participants.

CONCLUSION

There have been few studies of group therapy for PTSD in primary care, but these could represent a promising and scalable approach to meet the high need for trauma treatment. Further research is needed regarding implementation feasibility and impact.

A prospective examination of health care costs associated with posttraumatic stress disorder diagnostic status and symptom severity among veterans

Posttraumatic stress disorder (PTSD) is associated with increased health care costs; however, most studies exploring this association use PTSD diagnostic data in administrative records, which can contain inaccurate diagnostic information and be confounded by the quantity of service use. We used a diagnostic interview to determine PTSD diagnostic status and examined associations between PTSD symptom severity and health care costs and utilization, extracted from Veteran Health Administration (VHA) administrative databases. Using a nationwide longitudinal sample of U.S. veterans with and without PTSD (N = 1,377) enrolled in VHA health care, we determined the costs and utilization of mental health and non-mental health outpatient, pharmacy, and inpatient services for 1 year following cohort enrollment. Relative to veterans without PTSD, those with PTSD had higher total health care, B = 0.47; mental health clinic care, B = 0.72; non-mental health clinic care, B = 0.30; and pharmacy costs, B = 0.72, ps < .001. More severe PTSD symptoms were associated with mental health clinic care costs, B = 0.12; non-mental health clinic care costs, B = 0.27; and higher odds of inpatient, B = 0.63, and emergency service use, B = 0.39, p < .001-p = .012. These findings indicate that veterans' PTSD status, determined by a clinician-administered semistructured diagnostic interview, was associated with higher health care costs and increased use of mental health and non-mental health clinic services. The findings also suggest that more severe PTSD is associated with increased costs and utilization, including costly emergency and inpatient utilization.

Somatic symptoms and associations with common psychological diagnoses: a retrospective cohort study from Norwegian urban general practice

BACKGROUND

Patients with mental health problems often present with somatic symptoms when visiting their general practitioner (GP). Somatic presentations may challenge correct diagnosing of mental health disorders in general practice, where most of these disorders are treated.

OBJECTIVE

Explore the associations between common psychological diagnoses and somatic symptom diagnoses in Norwegian urban general practice.

METHODS

A retrospective cohort study including electronic medical data from 15 750 patients aged 16-65 years from 35 GPs in six GP offices in Oslo, Norway, during 12 months in 2014-2015. We explored prevalences and associations between anxiety-, depression-, and stress-related diagnoses, and somatic symptom diagnoses.

RESULTS

Patients with anxiety-, depression- and stress-related diagnoses had a mean number of 2.9±3.6 somatic symptom diagnoses during the 12 months, compared to 1.9±2.5 for patients without any psychological diagnoses (P < 0.001). The mean number of somatic symptoms was significantly higher for the different psychological diagnoses viewed separately, for both sexes and different age groups. There was an increase in probability for anxiety, depression, or stress-related diagnoses with an increasing number of somatic symptom diagnoses during the 12 months. We found a significant increase in somatic symptom diagnoses from ICPC-2 chapters: General and unspecified, digestive, cardiovascular, musculoskeletal, neurological, urological, female genital disorders and social problems. Associated symptom patterns were different for each of the included psychological diagnoses.

CONCLUSIONS

This study shows that patients with anxiety, depression- and stress-related diagnoses present with increased and characteristic somatic symptoms compared to patients without these diagnoses in general practice.

Association of PTSD with COVID-19 testing and infection in the Veterans Health Administration

Posttraumatic stress disorder (PTSD) is associated with coronavirus disease 2019 (COVID-19) risk factors, such as hypertension and obesity. Associations between PTSD and COVID-19 outcomes may affect Veterans Health Administration (VA) services, as PTSD occurs at higher rates among veterans than the general population. While previous research has identified the potential for increased PTSD prevalence resulting from COVID-19 as a public health concern, no known research examines the effect of pre-existing PTSD on COVID-19 test-seeking behavior or infection. This study aimed to evaluate pre-existing PTSD as a predictor of COVID-19 testing and test positivity. The sample consisted of 6,721,407 veterans who sought VA care between March 1, 2018 and February 29, 2020. Veterans with a previous PTSD clinical diagnosis were more likely to receive COVID-19 testing than veterans without PTSD. However, among those with available COVID-19 test results (n = 168,032), veterans with a previous PTSD clinical diagnosis were less likely to test positive than veterans without PTSD. Elevated COVID-19 testing rates among veterans with PTSD may reflect increased COVID-19 health concerns and/or hypervigilance. Lower rates of COVID-19 test positivity among veterans with PTSD may reflect increased social isolation, or overrepresentation in the tested population due to higher overall use of VA services. As the COVID-19 pandemic continues, the identification of patient-level psychiatric predictors of testing and test positivity can facilitate the targeted provision of medical and mental health services to individuals in need.

High prevalence of somatisation in ICD-11 complex PTSD: A cross sectional cohort study

BACKGROUND

While research demonstrates that somatisation is highly correlated with post-traumatic stress disorder (PTSD), the relationship between International Classification of Diseases 11th edition (ICD-11) PTSD, complex PTSD (CPTSD) and somatisation has not previously been determined.

OBJECTIVE

To determine the relationship between frequency and severity of somatisation and ICD-11 PTSD/CPTSD.

METHOD

This cross-sectional study included 222 individuals recruited to the National Centre for Mental Health (NCMH) PTSD cohort. We assessed rates of Patient Health Questionnaire 15 (PHQ-15) somatisation stratified by ICD-11 PTSD/CPTSD status. Path analysis was used to explore the relationship between PTSD/CPTSD and somatisation, including number of traumatic events, age, and gender as controls.

RESULTS

70% (58/83) of individuals with CPTSD had high PHQ-15 somatisation symptom severity compared with 48% (12/25) of those with PTSD (chi-square: 95.1, p value <0.001). Path analysis demonstrated that core PTSD symptoms and not disturbances in self organisation (DSO) symptoms were associated with somatisation (unstandardised coefficients: 0.616 (p-value 0.017) and - 0.012 (p-value 0.962) respectively.

CONCLUSIONS

Individuals with CPTSD have higher somatisation than those with PTSD. The core features of PTSD, not the DSO, characteristic of CPTSD, were associated with somatisation.

Access and attitudinal barriers to engagement in integrated primary care mental health treatment for rural populations

PURPOSE

Compared to urban areas, rural populations are less likely to engage in mental health care. Using data from the Study to Promote Innovation in Rural Integrated Telepsychiatry, we examined the effect of rurality on engagement in mental health treatment as well as the role of potential mediators.

METHODS

Data were obtained from medical records and surveys. We defined rurality using the rural-urban commuting area codes. Baseline mediators included the Endorsed and Anticipated Stigma Inventory and the Assessment of Perceived Access to Care. Engagement outcomes included number of psychotherapy visits and self-reported medication use. We used path analysis to examine the relationship between rurality and engagement and the influence of mediating variables.

FINDINGS

Rural participants were less likely to initiate psychotherapy (OR = 0.49; adjusted P = .036), although rurality was not associated with number of psychotherapy sessions or medication use. Rurality was associated with a small elevation in negative beliefs about mental health, but this potential mediator was not associated with engagement. Rurality was negatively associated with lower perceived need for treatment (OR = 0.67, adjusted P = .040), which was in turn positively associated with initiating psychotherapy (OR = 1.99, adjusted P = .001).

CONCLUSIONS

Neither rurality itself nor the potential mediators had a large effect on engagement. Federally Qualified Health Centers offering colocated and/or integrated mental health care appear to be mostly mitigating rural-urban disparities in mental health engagement. Improving rates of psychotherapy initiation for rural patients should remain a policy goal.

Association between Job-Related Factors and Work-Related Anxiety, and Moderating Effect of Decision-Making Authority in Korean Wageworkers: A Cross-Sectional Study

Among the factors causing workers' anxiety, job-related factors are important since they can be managed. Therefore, this study aimed to analyze the association between work-related anxiety and job-related factors among Korean wageworkers using data from the Fifth Korean Working Conditions Survey. Participants were 13,600 Korean wageworkers aged <65 years. We analyzed the association between job-related factors and work-related anxiety, and the moderating effect of decision-making authority. "Meeting precise quality standards," "Solving unforeseen problems on your own," "Complex tasks," "Learning new things," "Working at very high speed," and "Working to tight deadlines" were positively associated with work-related anxiety. "Monotonous tasks" was negatively associated with work-related anxiety. The odds ratio (OR) of "Complex tasks" was higher in the group that had insufficient decision-making authority (OR 3.92, 95% confidential interval (CI) 2.40-6.42) compared to that with sufficient decision-making authority (OR 2.74, 95% CI 1.61-4.67). The risk of work-related anxiety was higher when the workers experienced time pressure, carried out tasks with high mental and physical demands, and dealt with unpredictable situations. This association was more pronounced when decision-making authority was insufficient.

Disturbed Sleep Connects Symptoms of Posttraumatic Stress Disorder and Somatization: A Network Analysis Approach

Posttraumatic stress disorder (PTSD) and physical health problems, particularly somatic symptom disorder, are highly comorbid. Studies have only examined this co-occurrence at the disorder level rather than assessing the associations between specific symptoms. Using network analysis to identify symptoms that act as bridges between these disorders may allow for the development of interventions to specifically target this comorbidity. We examined the association between somatization and PTSD symptoms via network analysis. This included 349 trauma-exposed individuals recruited through the National Centre for Mental Health PTSD cohort who completed the Clinician-Administered PTSD Scale for DSM-5 and the Patient Health Questionnaire-15. A total of 215 (61.6%) individuals met the DSM-5 diagnostic criteria for PTSD. An exploratory graph analysis identified four clusters of densely connected symptoms within the overall network: PTSD, chronic pain, gastrointestinal issues, and more general somatic complaints. Sleep difficulties played a key role in bridging PTSD and somatic symptoms. Our network analysis demonstrates the distinct nature of PTSD and somatization symptoms, with this association connected by disturbed sleep.

Risk for Mental Disorders Associated With Sexual Assault: A Meta-Analysis

Sexual assault (SA) is a common form of trauma that is associated with numerous deleterious outcomes. Understanding the relative prevalence of psychiatric diagnoses in people who have been sexually assaulted versus people who have not been assaulted could help to prioritize assessment and intervention efforts, but there has been no quantitative review of this topic. A search of PsychINFO, ProQuest Digital Dissertations and Theses, and Academic Search Premier for articles dated between 1970 and 2014 was conducted, and unpublished data were obtained. Eligible studies used diagnostic interviews to assess Diagnostic and Statistical Manual of Mental Disorders diagnoses in both individuals experiencing adolescent/adult and/or lifetime SA and unassaulted individuals. The search yielded 171 eligible effects from 39 studies representing 88,539 participants. Meta-regression was used to aggregate the prevalence of psychiatric diagnoses in sexually assaulted and unassaulted samples as well as calculate odds ratios reflecting the difference between these prevalence estimates. Results indicated that most disorders were more prevalent in survivors of SA, and depressive disorders and posttraumatic stress disorder (PTSD) were especially prevalent. Disorder-specific differences in odds ratios were observed as a function of sample type, type of comparison group, and time frame of SA. Service providers should be prepared to address depressive disorders and PTSD in survivors of SA, and interventions that prevent the development of these disorders are especially needed.

Treating Post-traumatic Stress Disorder with a Prolonged Exposure Protocol Within Primary Care Behavioral Health: A Case Example

Posttraumatic stress disorder (PTSD) is a debilitating condition that impacts anywhere from 2 to 39% of primary care patients. Research suggests overall health, instances of hospitalizations, emergency room visits, and utilization of primary care services are impacted by a diagnosis of PTSD. Evidenced based treatments such as cognitive process therapy and prolonged exposure (PE) are available in specialty mental health but pose many barriers to treatment and implementation into primary care. This case study serves as the first known case example with an ethnic minority civilian, examining the treatment of PTSD within the Primary Care Behavioral Health Model using the brief (5 visits), PE protocol for primary care (PE-PC). PTSD was assessed using the PCL-5. Additional variables were assessed and tracked with the following tools: PHQ-9 (depressive symptoms), GAD-7 (anxiety symptoms), QLES-SF (quality of life), and the AAQ-2 (psychological flexibility) pre/post treatment, 6 months post-treatment and 9 months post-treatment. The patient reported clinically significant decreases in symptoms of PTSD, depression, and anxiety symptoms. Additionally, the patient's scores on quality of life and psychological flexibility improved. Brief, exposure-based treatment for PTSD can be delivered within the PCBH model. This treatment may result in improved quality of life and has the potential to reduce health care costs. This case encourages the treatment of PTSD within primary care, increasing access to care for patients. Future research is needed to further investigate this protocol in primary care with underserved, civilian populations and to explore patient attitudes toward brief treatment for PTSD in a primary care setting.

Study to promote innovation in rural integrated telepsychiatry (SPIRIT): Rationale and design of a randomized comparative effectiveness trial of managing complex psychiatric disorders in rural primary care clinics

OBJECTIVE

Managing complex psychiatric disorders like PTSD and bipolar disorder is challenging in Federally Qualified Health Centers (FQHCs) delivering care to U.S residents living in underserved rural areas. This protocol paper describes SPIRIT, a pragmatic comparative effectiveness trial designed to compare two approaches to managing PTSD and bipolar disorder in FQHCs.

INTERVENTIONS

Treatment comparators are: 1) Telepsychiatry Collaborative Care, which integrates consulting telepsychiatrists into primary care teams, and 2) Telepsychiatry Enhanced Referral, where telepsychiatrists and telepsychologists treat patients directly.

METHODS

Because Telepsychiatry Enhanced Referral is an adaptive intervention, a Sequential, Multiple Assignment, Randomized Trial design is used. Twenty-four FQHC clinics without on-site psychiatrists or psychologists are participating in the trial. The sample is patients screening positive for PTSD and/or bipolar disorder who are not already engaged in pharmacotherapy with a mental health specialist. Intervention fidelity is measured but not controlled. Patient treatment engagement is measured but not required, and intent-to-treat analysis will be used. Survey questions measure treatment engagement and effectiveness. The Short-Form 12 Mental Health Component Summary (SF-12 MCS) is the primary outcome.

RESULTS

A third (34%) of those enrolled (n = 1004) are racial/ethnic minorities, 81% are not fully employed, 68% are Medicaid enrollees, 7% are uninsured, and 62% live in poverty. Mental health related quality of life (SF-12 MCS) is 2.5 standard deviations below the national mean.

DISCUSSION

We hypothesize that patients randomized to Telepsychiatry Collaborative Care will have better outcomes than those randomized to Telepsychiatry Enhanced Referral because a higher proportion will engage in evidence-based treatment.

Nausea in the peri-traumatic period is associated with prospective risk for PTSD symptom development

While nausea often develops following exposure to trauma, little is known regarding the relationship between peri-traumatic nausea and prospective risk for developing posttraumatic stress disorder (PTSD). We examined the association between peri-traumatic nausea and PTSD symptom development in three independent cohorts. Participants were recruited from (1) the Emergency Departments (ED) at Grady Memorial Hospital (GMH) in Atlanta, GA, (2) from multiple other ED sites in the TRYUMPH Research Network, and (3) from the ED during evaluation for suspected acute coronary syndrome in the REACH cohort. Administration of IV ondansetron, the most predominant antiemetic used at GMH, was used as a surrogate marker for nausea in the initial GMH cohort; nausea was then directly assessed in the internal validation at GMH, and within the replication TRYUMPH Research Network and REACH cohorts. In the GMH cohort (N = 363), ondansetron administration was associated with increased 1- and 3-month posttrauma PTSD symptoms in adjusted models (all p's < 0.05). In the GMH internal validation, nausea significantly predicted 1 month (p = 0.009; n = 68) and 3 month (p = 0.029; n = 54) PTSD symptoms. In the TRYUMPH cohort (N = 1846), patient reported nausea in the ED was significantly associated with increased PTSD symptoms (p = 0.009) in adjusted models. In the REACH cohort (N = 758), peri-traumatic nausea was associated with PTSD symptom severity at the 1-month follow-up in adjusted models (p's ≤ 0.008). The current prospective data from three independent cohorts suggest that peri-traumatic nausea is a prospective predictor of PTSD symptom development. Further studies are needed to determine the mechanistic role of nausea as an intermediate phenotype of PTSD risk.

BRIGHTEN Heart intervention for depression in minority older adults: Randomized controlled trial

OBJECTIVE

Assess the effectiveness of an interdisciplinary geriatric team intervention in decreasing symptoms of depression among urban minority older adults in primary care. Secondary outcomes included cardiometabolic syndrome and trauma.

METHOD

250 African American and Hispanic older adults with PHQ-9 scores ≥ 8 and BMI ≥ 25 were recruited from 6 underserved urban primary care clinics. Intervention arm participants received the BRIGHTEN Heart team intervention plus membership in Generations, an older adult educational activity program; comparison participants received only Generations.

RESULTS

Both arms demonstrated clinically significant improvements in PHQ-9 scores at 6 months (-5 points, intervention and comparison) and 12 months (-7 points intervention, -6.5 points comparison); there was no significant difference in change scores between groups on depression or cardiometabolic syndrome at 6 months; there was a small difference in depression trajectory at 12 months (p < .001). More participants in the treatment group (70.7%) had greater than 50% reduction in PHQ-9 scores than the comparison group (56.3%; p = .036). For those with higher PTSD symptoms (PCL-C6), improvement in depression was significantly better in the intervention arm than the comparison arm, regardless of baseline PHQ-9 (p = .001). In mixed models, those with higher PTSD symptoms (β = -0.012, p = < 0.001) in the intervention arm showed greater depression improvement than those with lower PTSD symptoms (β = -0.004, p = .001).

CONCLUSIONS

The BRIGHTEN Heart intervention may be effective in reducing depression for urban minority older adults. Further research on team care interventions and screening for PTSD symptoms in primary care is warranted. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Development and refinement of a clinician intervention to facilitate primary care patient use of the PTSD Coach app

Posttraumatic stress disorder (PTSD) is common and undertreated among Veterans Affairs (VA) primary care patients. A brief primary care intervention combining clinician support with a self-management mobile app (Clinician-Supported PTSD Coach, CS-PTSD Coach) may improve patient outcomes. This study developed and refined an intervention to provide clinician support to facilitate use of the PTSD Coach app and gathered VA provider and patient qualitative and quantitative feedback on CS-PTSD Coach to investigate preliminary acceptability and implementation barriers/facilitators. VA primary care providers and mental health leadership (N = 9) completed a survey and interview regarding implementation barriers and facilitators structured according to the Consolidated Framework for Implementation Research (CFIR). Clinicians who delivered CS-PTSD Coach (N = 3) and patients (N = 9) who received it provided feedback on the intervention and implementation process. CS-PTSD Coach has high provider and patient acceptability. Important implementation factors included that CS-PTSD Coach be compatible with the clinics' current practices, have low complexity to implement, be perceived to address patient needs, and have strong support from leadership. Diverse factors related to CS-PTSD Coach delivery facilitate implementation, provide an opportunity to problem-solve barriers, and improve integration of the intervention into primary care.

Patient Preferences for Discussing Childhood Trauma in Primary Care

CONTEXT

Exposure to traumatic events is common in primary care patients, yet health care professionals may be hesitant to assess and address the impact of childhood trauma in their patients.

OBJECTIVE

To assess patient preferences for discussing traumatic experiences and posttraumatic stress disorder (PTSD) with clinicians in underserved, predominantly Latino primary care patients.

DESIGN

Cross-sectional study.

MAIN OUTCOME MEASURE

We evaluated patients with a questionnaire assessing comfort to discuss trauma exposure and symptoms using the Adverse Childhood Experiences (ACE) Study questionnaire and the Primary Care-PTSD screen. The questionnaire also assessed patients' confidence in their clinicians' ability to help with trauma-related issues. Surveys were collected at an integrated medical and behavioral health care clinic.

RESULTS

Of 178 adult patients asked, 152 (83%) agreed to participate. Among participants, 37% screened positive for PTSD, 42% reported 4 or more ACEs, and 26% had elevated scores on both measures. Primary Care-PTSD and ACE scores were strongly positively correlated (r = 0.57, p < 0.001). Most patients agreed they were comfortable being asked about trauma directly or through screening questionnaires and did not oppose the inclusion of trauma-related information in their medical record. In addition, most patients perceived their clinician as comfortable asking questions about childhood trauma and able to address trauma-related problems.

CONCLUSION

Screening is acceptable to most primary care patients regardless of trauma exposure or positive PTSD screening. Findings may aid primary care clinicians to consider screening regularly for ACEs and PTSD to better serve the health care needs of trauma-exposed patients.

The Prevalence of Posttraumatic Stress Disorder in Primary Care: A Systematic Review

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Determine the prevalence of clinician-diagnosed posttraumatic stress disorder (PTSD) in primary care patients• Identify the prevalence of questionnaire-ascertained PTSD symptoms in primary care patients OBJECTIVE: Determine the prevalence of clinician-diagnosed PTSD and questionnaire-ascertained PTSD symptoms in primary care patients.

METHODS

A systematic review of the literature using the PRISMA method, searching MEDLINE, CINAHL, Cochrane Database, PsycINFO, EMBASE, Google Scholar, and relevant book chapter bibliographies. Studies that reported on the prevalence, including point or lifetime prevalence, of PTSD ascertained using diagnostic interviews or self-report questionnaires, or from administrative data, among patients seen in primary care were deemed eligible for inclusion. We abstracted data on the PTSD assessment tool, the mean questionnaire scores/cutoff scores, the time period of PTSD symptoms, and PTSD prevalence reported.

RESULTS

Of 10,614 titles screened, 41 studies were eligible for inclusion. The included studies assessed PTSD in a total of 7,256,826 primary care patients. The median point prevalence of PTSD across studies was 12.5%. The median point prevalence in the civilian population was 11.1%; in the special-risk population, 12.5%; and in veterans, 24.5%. The point prevalence of diagnostic interview-ascertained PTSD ranged from 2% to 32.5%, and the point prevalence of questionnaire-based substantial PTSD symptoms ranged from 2.9% to 39.1%. Lifetime prevalence of diagnostic interview-ascertained PTSD ranged from 14.5% to 48.8%. The prevalence of PTSD in administrative data-based studies ranged from 3.5% to 29.2%.

CONCLUSIONS

PTSD is common in primary care settings. Additional research on effective and generalizable interventions for PTSD in primary care is needed.

Impact of Collaborative Care for Underserved Patients with PTSD in Primary Care: a Randomized Controlled Trial

BACKGROUND

The effectiveness of collaborative care of mental health problems is clear for depression and growing but mixed for anxiety disorders, including posttraumatic stress disorder (PTSD). We know little about whether collaborative care can be effective in settings that serve low-income patients such as Federally Qualified Health Centers (FQHCs).

OBJECTIVE

We compared the effectiveness of minimally enhanced usual care (MEU) versus collaborative care for PTSD with a care manager (PCM).

DESIGN

This was a multi-site patient randomized controlled trial of PTSD care improvement over 1 year.

PARTICIPANTS

We recruited and enrolled 404 patients in six FQHCs from June 2010 to October 2012. Patients were eligible if they had a primary care appointment, no obvious physical or cognitive obstacles to participation, were age 18-65 years, planned to continue care at the study location for 1 year, and met criteria for a past month diagnosis of PTSD.

MAIN MEASURES

The main outcomes were PTSD diagnosis and symptom severity (range, 0-136) based on the Clinician-Administered PTSD Scale (CAPS). Secondary outcomes were medication and counseling for mental health problems, and health-related quality of life assessed at baseline, 6 months, and 12 months.

KEY RESULTS

Patients in both conditions improved similarly over the 1-year evaluation period. At 12 months, PTSD diagnoses had an absolute decrease of 56.7% for PCM patients and 60.6% for MEU patients. PTSD symptoms decreased by 26.8 and 24.2 points, respectively. MEU and PCM patients also did not differ in process of care outcomes or health-related quality of life. Patients who actually engaged in care management had mental health care visits that were 14% higher (p < 0.01) and mental health medication prescription rates that were 15.2% higher (p < 0.01) than patients with no engagement.

CONCLUSIONS

A minimally enhanced usual care intervention was similarly effective as collaborative care for patients in FQHCs.

[Trauma and posttraumatic stress symptoms in patients in German primary care settings]

BACKGROUND

Primary care settings have an important gatekeeping function to detect mental diseases, including trauma and posttraumatic stress disorders.

OBJECTIVES

To assess the prevalence of trauma and posttraumatic symptoms in a first sample of northeast German primary care patients and to evaluate the diagnostic sensitivity and specificity of the general practitioners.

MATERIAL AND METHODS

Traumatic experiences and posttraumatic stress disorders (PTSD) were assessed with self-rating questionnaires in a sample of N = 400 patients from 3 primary care facilities. Additionally, knowledge and diagnostic accuracy of the general practitioners were evaluated.

RESULTS

According to the results of the patient health questionnaire (PHQ-15) data from all patients, the majority of patients questioned showed slight to moderate stress from somatic symptoms. Of the patients with complete data 7 % (n = 25) had a complete PTSD according to the results of the questionnaire, which was also identified in the medical assessment with a sensitivity of 40 %. The stress resulting from posttraumatic symptoms was closely associated with the extent of somatic complaints.

CONCLUSION

Patients with a history of trauma and posttraumatic symptoms are prevalent in primary care settings. An early diagnosis by the general practitioner can help patients to receive adequate treatment. Patients with somatoform disorders in particular should be screened for trauma and posttraumatic symptoms.

Using PTSD Coach in primary care with and without clinician support: a pilot randomized controlled trial

OBJECTIVE

This study aims to evaluate the feasibility and potential effectiveness of two approaches to using the PTSD Coach mobile application in primary care: Self-Managed PTSD Coach and Clinician-Supported PTSD Coach. This study also aims to gather preliminary data to investigate if clinician support improves the benefits of using PTSD Coach on posttraumatic stress disorder (PTSD) severity and specialty mental healthcare utilization.

METHOD

Twenty primary care veterans with PTSD symptoms were randomized to either Self-Managed PTSD Coach consisting of one 10-min session providing instructions for application use or Clinician-Supported PTSD Coach consisting of four 20-min sessions focused on setting symptom reduction goals and helping veterans fully engage with application content.

RESULTS

Research procedures and intervention conditions appear feasible as indicated by high rates of assessment and intervention retention and high clinician fidelity and satisfaction. Both treatments resulted in reductions in PTSD symptoms, with 7 Clinician-Supported PTSD Coach and 3 Self-Managed PTSD Coach participants reporting clinically significant improvements. Clinician-Supported PTSD Coach resulted in more specialty PTSD care use postintervention and possibly greater reductions in PTSD symptoms.

CONCLUSIONS

Both PTSD Coach interventions are feasible and potentially helpful. The addition of clinician support appears to increase the effectiveness of self-management alone. A larger-scale randomized controlled trial is warranted to confirm these encouraging preliminary findings.

Validation of a brief PTSD screener for underserved patients in federally qualified health centers

OBJECTIVE

The objective was to validate the reliability and efficiency of alternative cutoff values on the abbreviated six-item Posttraumatic Stress Disorder (PTSD) Checklist (PCL-6) [1] for underserved, largely minority patients in primary care settings of Federally Qualified Health Centers (FQHCs).

METHOD

Using a sample of 760 patients recruited from six FQHCs in the New York City and New Jersey metropolitan area from June 2010 to April 2013, we compared the PCL-6 with the Clinician Administered PTSD Scale (CAPS) for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. We used reliability statistics for single cutoff values on PCL-6 scores. We examined the relationship between probabilities of meeting CAPS diagnostic criteria and PCL-6 scores by nonparametric regression.

RESULTS

PCL-6 scores range between 6 and 30. Reliability and efficiency statistics for cutoff between 12 and 26 were reported. There is a strong monotonic relationship between PCL-6 scores and the probability of meeting CAPS diagnostic criteria.

CONCLUSION

No single cutoff on PCL-6 scores has acceptable reliability on both false positive and false negative simultaneously. An ordinal decision rule (low risk: 12 or less, medium risk: 13 to 16, high risk: 17 to 25 and very high risk: 26 and above) can differentiate the risk of PTSD. A single cutoff (17 or higher as positive) may be suitable for identifying those with the greatest need for care given limited mental health capacity in FQHC settings.

A Randomized Clinical Trial of Primary Care Brief Mindfulness Training for Veterans with PTSD

OBJECTIVES

Primary care (PC) patients typically do not receive adequate posttraumatic stress disorder (PTSD) treatment. This study tested if a brief mindfulness training (BMT) offered in PC can decrease PTSD severity.

METHOD

VA PC patients with PTSD (N = 62) were recruited for a randomized clinical trial comparing PCBMT with PC treatment as usual. PCBMT is a 4-session program adapted from mindfulness-based stress reduction.

RESULTS

PTSD severity decreased in both conditions, although PCBMT completers reported significantly larger decreases in PTSD and depression from pre- to posttreatment and maintained gains at the 8-week follow-up compared with the control group. Exploratory analyses revealed that the describing, nonjudging, and acting with awareness facets of mindfulness may account for decreases in PTSD.

CONCLUSION

Our data support preliminary efficacy of BMT for Veterans with PTSD. Whether PCBMT facilitates engagement into, or improves outcomes of, full-length empirically supported treatment for PTSD remains to be evaluated.

Trauma-Informed Medical Care: Patient Response to a Primary Care Provider Communication Training

Trauma exposure predicts mental disorders and health outcomes; yet there is little training of primary care providers about trauma's effects, and how to better interact with trauma survivors. This study adapted a theory-based approach to working with trauma survivors, Risking Connection, into a 6-hour CME course, Trauma-Informed Medical Care (TI-Med), to evaluate its feasibility and preliminary efficacy. We randomized four primary care sites to training or wait-list conditions; PCPs at wait-list sites were trained after reassessment. Primary care providers (PCPs) were Family Medicine residents (n = 17; 2 sites) or community physicians (n = 13; 2 sites). Outcomes reported here comprised a survey of 400 actual patients seen by the PCPs in the study. Patients, mostly minority, completed surveys before or after their provider received training. Patients rated PCPs significantly higher after training on a scale encompassing partnership issues. Breakdowns showed lower partnership scores for those with trauma or posttraumatic stress symptoms. Future studies will need to include more specific trauma-related outcomes. Nevertheless, this training is a promising initial approach to teaching trauma-informed communication skills to PCPs.

Identification and Referral of Patients at Risk for Post-traumatic Stress Disorder: A Literature Review and Retrospective Analysis

Post-traumatic stress disorder (PTSD) is a well-established psychological disorder after severe traumatic injury but remains poorly recognized. Recent changes in the “Resources for Optimal Care of the Injured Trauma Patient 2014” stress the need for comprehensive screening and referral for PTSD and depression after injury. Our purpose was to review the current PTSD literature and perform a retrospective chart review to evaluate screening at our institution. We hypothesized a lack of documentation and thus referral of these patients to mental health professionals. We performed a literature review of 43 publications of risk factors for PTSD in the civilian adult population followed by a retrospective review. Records were analyzed for basic demographics, risk factors found in the literature, and referrals to mental health providers. Risk factors included amputation, dissociative symptoms, female gender, history of mental health disorder, and peri-traumatic emotionality. Traumatic amputation status and gender were recorded in all patients. History of mental health disorder was present in 11.5 per cent patients, absent in 80.75 per cent, and not recorded in 7.75 per cent with an overall documentation of 91.75 per cent. Dissociative symptoms and peri-traumatic emotionality were recorded in 0.5 per cent and 1.0 per cent of patients, respectively. Only 13 patients of 400 (3.25%) were referred to mental health professionals. Despite extensive evidence and literature supporting risk factors for the development of PTSD, identification and treatment at our level 1 trauma center is lacking. There is a need for consistent screening among trauma centers to identify PTSD risk factors and protocols for risk reduction and referrals for patients at risk.

Psychiatric morbidity and predisposing factors in a primary care population in Madrid

OBJECTIVES

The aim of this article is to estimate the prevalence of mental disorders in patients in primary care centers in an urban area of Madrid and to study possible associated risk factors.

METHODS

Cross-sectional month prevalence was evaluated in two phases in an urban area of Madrid. The sample for the first phase included 635 individuals (aged 18-65 years), and the second phase included 320 individuals. Socio-demographic variables (age, sex, educational level, living conditions and country of origin) and clinical variables (psychiatric diagnosis and level of psychosocial stress) were studied. The instruments used for screening were the General Health Questionnaire (GHQ)-28 item questionnaire and the MULTICAGE-CAD 4test. The Mini International Neuropsychiatric Interview (M.I.N.I.) was used in the second phase (in 'possible cases' and 20% of the 'non-cases'). Prevalence was calculated using weighted logistic regression with the observed sampling fractions of the patients in study phase 2 as sample weights.

RESULTS AND CONCLUSIONS

The month prevalence of mental disorders was 31.3% (95% confidence interval (CI) = [27.6, 35.2]). Anxiety disorders were the most frequent diagnoses with a prevalence of 22.4% (95% CI = [17.8, 27.1]), followed by depressive disorders (16.6%; 95% CI = [12.9, 20.3]), substance abuse or dependence disorders (5.6%; 95% CI = [3.2, 6.9]) and posttraumatic stress disorder (PTSD; 4.4%; 95% CI = [2.0, 2.8]). Factors associated with mental disorders were the presence of stressful life events in the previous 12 months, Latin American region of origin, being woman aged 25 and 34 years and having a low education level.

Self-reported physical health associations of traumatic events in medical and dental outpatients: a cross-sectional study

The purpose of this cross-sectional study was to understand the prevalence and severity of health-related sequelae of traumatic exposure in a nonpsychiatric, outpatient sample.Self-report surveys were completed by patients seeking outpatient medical (n = 123) and dental care (n = 125) at a large, urban academic medical center.Results suggested that trauma exposure was associated with a decrease in perceptions of overall health and an increase in pain interference at work. Contrary to prediction, a history of interpersonal trauma was associated with less physical and emotional interference with social activities. A history of trauma exposure was associated with an increase in time elapsed since last medical visit. Depression and anxiety did not mediate the relationship between trauma history and medical care.Based on these results, clinical and research implications in relation to the health effects of trauma are discussed. The results suggest that routine screening for traumatic events may be important, particularly when providers have long-term relationships with patients.

Invasive coronary procedure use and outcomes among veterans with posttraumatic stress disorder: insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

BACKGROUND

Posttraumatic stress disorder (PTSD) is prevalent in the general population and US veterans in particular and is associated with an increased risk of developing coronary artery disease (CAD). We compared the patient characteristics and postprocedural outcomes of veterans with and without PTSD undergoing coronary angiography.

METHODS

This is a multicenter observational study of patients who underwent coronary angiography in Veterans Affairs hospitals nationally from October 2007 to September 2011. We described patient characteristics at angiography, angiographic results, and after coronary angiography, we compared risk-adjusted 1-year rates of all-cause mortality, myocardial infarction (MI), and revascularization by the presence or absence of PTSD.

RESULTS

Overall, of 116,488 patients undergoing angiography, 14,918 (12.8%) had PTSD. Compared with those without PTSD, patients with PTSD were younger (median age 61.9 vs 63.7; P < .001), had higher rates of cardiovascular risk factors, and were more likely to have had a prior MI (26.4% vs 24.7%; P < .001). Patients with PTSD were more likely to present for stable angina (22.4% vs 17.0%) or atypical chest pain (58.5% vs 48.6%) and less likely to have obstructive CAD identified at angiography (55.9% vs 62.2%; P < .001). After coronary angiography, PTSD was associated with lower unadjusted 1-year rates of MI (hazard ratio (HR), 0.86; 95% CI [0.75-1.00]; P = 0.04), revascularization (HR, 0.88; 95% CI [0.83-0.93]; P < .001), and all-cause mortality (HR, 0.66; 95% CI [0.60-0.71]; P < .001). After adjustment for cardiovascular risk, PTSD was no longer associated with 1-year rates of MI or revascularization but remained associated with lower 1-year all-cause mortality (HR, 0.91; 95% CI [0.84-0.99]; P = .03). Findings were similar after further adjustment for depression, anxiety, alcohol or substance use disorders, and frequency of outpatient follow-up.

CONCLUSIONS

Among veterans undergoing coronary angiography in the Veterans Affairs, those with PTSD were more likely to present with elective indications and less likely to have obstructive CAD. After coronary angiography, PTSD was not associated with adverse 1-year outcomes of MI, revascularization, or all-cause mortality.

Comorbidity of PTSD in anxiety and depressive disorders: prevalence and shared risk factors

The present study aims to assess comorbidity of posttraumatic stress disorder (PTSD) in anxiety and depressive disorders and to determine whether childhood trauma types and other putative independent risk factors for comorbid PTSD are unique to PTSD or shared with anxiety and depressive disorders. The sample of 2402 adults aged 18-65 included healthy controls, persons with a prior history of affective disorders, and persons with a current affective disorder. These individuals were assessed at baseline (T0) and 2 (T2) and 4 years (T4) later. At each wave, DSM-IV-TR based anxiety and depressive disorder, neuroticism, extraversion, and symptom severity were assessed. Childhood trauma was measured at T0 with an interview and at T4 with a questionnaire, and PTSD was measured with a standardized interview at T4. Prevalence of 5-year recency PTSD among anxiety and depressive disorders was 9.2%, and comorbidity, in particular with major depression, was high (84.4%). Comorbidity was associated with female gender, all types of childhood trauma, neuroticism, (low) extraversion, and symptom severity. Multivariable significant risk factors (i.e., female gender and child sexual and physical abuse) were shared among anxiety and depressive disorders. Our results support a shared vulnerability model for comorbidity of anxiety and depressive disorders with PTSD. Routine assessment of PTSD in patients with anxiety and depressive disorders seems warranted.

Design of the Violence and Stress Assessment (ViStA) study: a randomized controlled trial of care management for PTSD among predominantly Latino patients in safety net health centers

Posttraumatic stress disorder (PTSD) is a common problem in primary care. Although effective treatments are available, little is known about whether such treatments are effective within the context of Federally Qualified Health Centers (FQHCs) that serve as national "safety nets" for providing primary care for low income and underinsured patients. The Violence and Stress Assessment (ViStA) study is the first randomized controlled trial (RCT) to test the impact of a care management intervention for treating PTSD in FQHCs. To develop a PTSD management intervention appropriate for lower resource FQHCs and the predominantly Latino patients they serve, formative work was conducted through a collaborative effort between researchers and an FQHC practice-based research network. This article describes how FQHC stakeholders were convened to review, assess, and prioritize evidence-based strategies for addressing patient, clinician, and system-level barriers to care. This multi-component care management intervention incorporates diagnosis with feedback, patient education and activation; navigation and linkage to community resources; clinician education and medication guidance; and structured cross-disciplinary communication and continuity of care, all facilitated by care managers with FQHC experience. We also describe the evaluation design of this five-year RCT and the characteristics of the 404 English or Spanish speaking patients enrolled in the study and randomized to either the intervention or to usual care. Patients are assessed at baseline, six months, and 12 months to examine intervention effectiveness on PTSD, other mental health symptoms, health-related quality-of-life, health care service use; and perceived barriers to care and satisfaction with care.

Mental disorders in primary care in Israel: prevalence and risk factors

OBJECTIVE

Psychiatric morbidity is common among patients in primary care services and leads to disability and increased use of medical services. Comparison of primary care and community prevalence data is of interest in relation to the health services planning for mental disorders. The aim of the present study was to measure prevalence of mental disorders in six primary care clinics in Israel and to assess risk factors for these disorders.

METHOD

Prevalence of mental disorders was measured in a sample of 2,948 primary care consecutive attendees, using two-stage stratified sampling with the General Health Questionnaire 12 (GHQ-12) and the Composite International Diagnostic Interview (CIDI).

RESULTS

A high rate (46.3%) of current mental disorders was found, with rates of current depressive episode, generalized anxiety disorder, somatization disorder, and neurasthenia being relatively high in comparison with rates in other countries. Low education was a risk factor for all categories of disorders, unemployment a risk factor for depressive disorders, and parenthood was protective for most categories of disorders.

CONCLUSIONS

High rates of mental disorders were found in this Israeli primary care sample as compared to other countries, while in the community the rates were midrange as compared to other countries, pointing to a relatively higher use of primary care services by patients with mental disorders in Israel than in other countries.

The effects of PTSD symptoms on health care resource utilization in a low-income, urban primary care setting

Individuals with posttraumatic stress disorder (PTSD) symptoms engage in greater rates of health care utilization. Existing literature is limited, however, because the number of visits to health care providers is exclusively used as an outcome. Low-income women (N = 96) screening positive for PTSD symptoms (n = 23; 23.9%) were compared to those who did not (n = 73) on a range of health care utilization outcomes obtained through a chart review. Significant PTSD symptoms were associated with more complaints per visit, ordered labs, and prescribed medications--beyond the effects of age, depression symptoms, and chronic illness. Individuals with PTSD symptoms are a challenge to primary care as currently practiced. Collaboration with mental health professionals and specific primary care procedures to diagnose and treat PTSD are needed.

Cognitive behavioral therapy for PTSD and somatization: an open trial

No treatment, to date, has been developed to improve both posttraumatic stress disorder (PTSD) and medically unexplained physical symptoms (MUPS), despite mounting evidence of high comorbidity between PTSD and MUPS. This study assessed the feasibility, acceptability, and treatment outcomes of an adapted cognitive behavioral therapy for PTSD and abridged somatization in a sample of eight participants. Fifteen percent of completers did not meet PTSD criteria after treatment completion and 62.5% improved their somatic symptoms. There was a significant difference between pre- and post-treatment depression symptoms, as well as in psychological and physical functioning measures. Results indicated a small to moderate effect size (d = 0.27-0.78) in PTSD severity scores, and moderate to large effect size in depression symptoms and psychosocial and physical functioning variables (d = 0.39-1.12). Preliminary evidence of acceptability indicates that the current CBT intervention may be suitable for Latinos individuals with PTSD and MUPS.

The relationships between posttraumatic stress disorder severity, depression severity and physical health

This study examines the relationship among posttraumatic stress disorder severity, depression severity, and subjective and objective physical health in a sample of 200 adults with posttraumatic stress disorder. Posttraumatic stress disorder severity was correlated with subjective, but not objective, health. Similarly, depression symptoms had an indirect effect on the relationship between posttraumatic stress disorder symptom severity and three measures of subjective physical health. Finally, depression symptoms had an indirect effect on the relationship between both reexperiencing and hyperarousal symptoms and subjective physical health. This research underscores the important role that posttraumatic stress disorder, particularly reexperiencing and hyperarousal symptoms, and depression may have on perceptions of physical health.

Probable Posttraumatic Stress Disorder and Psychiatric Co-morbidity among Latino Primary Care Patients in Puerto Rico

Background

The present investigation was designed to study PTSD among inner city primary care patients in Puerto Rico. Specifically, we examined the rate of probable PTSD, PTSD co-morbidity with MDD and GAD, and the association of probable PTSD and co-occurring disorders with demographic, treatment, and alcohol related factors.

Methods

We screened 3,568 patients at primary care practices serving primarily low-income patients. The presence of probable PTSD was assessed with the Primary Care PTSD screen, major depression with the PHQ-9, and generalized anxiety disorder with the GAD Q-IV.

Results

Fourteen percent of our sample screened positive for probable PTSD. Among this group, 12% met criteria for co-morbid GAD without MDD and 15.9% for co-morbid MDD with/without GAD, whereas 72% of the patients with probable PTSD did not meet criteria for co-morbidity. Over 80% of the patients with probable PTSD indicated they were not receiving mental health treatment. Multiple logistic regression findings show that there were no significant differences in demographic and alcohol related factors by PTSD status. Multinomial logistic regression analysis revealed significant differences in the use of mental health treatment among the subgroups of patients with probable PTSD. As compared to patients with only probable PTSD, the use of mental health services was 4 times higher among patients with probable PTSD and MDD and over 2 1/2 times higher among patients with probable PTSD and GAD.

Conclusion

The prevalence rate of probable PTSD in our sample was similar to the rates reported for soldiers after returning from deployment and for Latinos after the September 11 attacks. The high prevalence of probable PTSD and low use of mental health treatment among inner city primary care patients in our study, highlight the need of future research to obtain information on how to effectively target and treat Latino primary care patients in need of treatment for PTSD.

Association of life threat and betrayal with posttraumatic stress disorder symptom severity

The Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000) emphasizes life threat as the defining feature of psychological trauma. Recent theoretical and empirical work, however, indicates the need to identify and evaluate other key aspects of trauma. Betrayal has been proposed as a pertinent, distinct, and complementary factor that can explain effects of trauma not accounted for by life threat alone. This study examined the relationship between injury, perceived life threat (PLT), and betrayal with posttraumatic stress disorder (PTSD) symptom severity. Trauma-exposed college students (N = 185) completed self-report measures of trauma exposure and PTSD, as well as items regarding life threat, betrayal, and level of medical care received. In hierarchical regressions incorporating injury, PLT, and betrayal, betrayal was associated with all PTSD symptom clusters and PTSD total severity (f(2) = .08), whereas PLT was associated with hyperarousal (f(2) = .05) and PTSD total (f(2) = .03), and injury had no association with PTSD symptoms. In a revised model with trauma type as an additional variable, betrayal was associated with avoidance (f(2) = .03), numbing (f(2) = .04), and PTSD total (f(2) = .03), whereas PLT was associated with reexperiencing (f(2) = .04), hyperarousal (f(2) = .04), and PTSD total (f(2) = .03), and injury was associated with avoidance (f(2) = .03). These findings support the idea that betrayal is a core dimension of psychological trauma that may play an important role in the etiology of PTSD.

Physical health conditions associated with posttraumatic stress disorder in U.S. older adults: results from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVES

To present findings on past-year medical conditions associated with lifetime trauma exposure and full and partial posttraumatic stress disorder (PTSD) in a nationally representative sample of U.S. older adults.

DESIGN

Face-to-face diagnostic interviews.

SETTING

Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions.

PARTICIPANTS

Nine thousand four hundred sixty-three adults aged 60 and older.

MEASUREMENTS

Logistic regression analyses adjusting for sociodemographic characteristics and psychiatric comorbidity were used to evaluate associations between PTSD status and past-year medical disorders; linear regression models evaluated associations with past-month physical functioning.

RESULTS

After adjustment for sociodemographic characteristics and comorbid lifetime mood, anxiety, substance use, attention-deficit/hyperactivity, and personality disorders, respondents with lifetime PTSD were more likely than respondents who reported experiencing one or more traumatic life events but who did not meet lifetime criteria for full or partial PTSD (trauma controls) to report being diagnosed with hypertension, angina pectoris, tachycardia, other heart disease, stomach ulcer, gastritis, and arthritis (odds ratios (ORs) = 1.3-1.8) by a healthcare professional; they also scored lower on a measure of physical functioning than controls and respondents with partial PTSD. Respondents with lifetime partial PTSD were more likely than controls to report past-year diagnoses of gastritis (OR = 1.7), angina pectoris (OR = 1.5), and arthritis (OR = 1.4) and reported worse physical functioning. Number of lifetime traumatic event types was associated with most of the medical conditions assessed; adjustment for these events reduced the magnitudes of and rendered nonsignificant most associations between PTSD status and medical conditions.

CONCLUSION

Older adults with lifetime PTSD have high rates of several physical health conditions, many of which are chronic disorders of aging, and poorer physical functioning. Older adults with lifetime partial PTSD have higher rates of gastritis, angina pectoris, and arthritis and poorer physical functioning.

The current state of intervention research for posttraumatic stress disorder within the primary care setting

Posttraumatic Stress Disorder (PTSD) is common among primary care patients and is associated with significant functional impairment, physical health concerns, and mental health comorbidities. Significant barriers to receiving adequate treatment often exist for primary care patients with PTSD. Mental health professionals operating as part of the primary care team have the potential to provide effective brief intervention services. While good PTSD screening and assessment measures are available for the primary care setting, there are currently no empirically supported primary care-based brief interventions for PTSD. This article reviews early research on the development and testing of primary care-based PTSD treatments and also reviews other brief PTSD interventions (i.e., telehealth and early intervention) that could be adapted to the primary care setting. Cognitive and behavioral therapies currently have the strongest evidence base for establishing an empirically supported brief intervention for PTSD in primary care. Recommendations are made for future research and clinical practice.

Meeting the mental health needs of low-income immigrants in primary care: a community adaptation of an evidence-based model

Low-income, uninsured immigrants are burdened by poverty and a high prevalence of trauma exposure and thus are vulnerable to mental health problems. Disparities in access to mental health services highlight the importance of adapting evidence-based interventions in primary care settings that serve this population. In 2005, the Montgomery Cares Behavioral Health Program began adapting and implementing a collaborative care model for the treatment of depression and anxiety disorders in a network of primary care clinics that serve low-income, uninsured residents of Montgomery County, Maryland, the majority of whom are immigrants. In its 6th year now, the program has generated much needed knowledge about the adaptation of this evidence-based model. The current article describes the adaptations to the traditional collaborative care model that were necessitated by patient characteristics and the clinic environment.

The forensic nursing in sexual assaults: the immunochemical diagnosis and prevention of its adverse effects

Sexual assault was a ubiquitous and serious problem in our society. The world's care centers and forensic associations, which were at the forefront of scientific research in sexual assaults, discussed the role of the Forensic Nursing in their early diagnosis and their prevention, but little has been written in literature regarding their appropriate management. This article focuses on the immunochemical laboratory investigation in diagnosis and prevention of its adverse effects in sexual assaults and the role of the Forensic Nursing played in this task. After a careful reading of all the material received from many of the care centers and the associations contacted, a Forensic Nursing Examination Program, with specific immunochemical address, is identified.

Exercise for the treatment of depression and anxiety

Depression and anxiety are the most common psychiatric conditions seen in the general medical setting, affecting millions of individuals in the United States. The treatments for depression and anxiety are multiple and have varying degrees of effectiveness. Physical activity has been shown to be associated with decreased symptoms of depression and anxiety. Physical activity has been consistently shown to be associated with improved physical health, life satisfaction, cognitive functioning, and psychological well-being. Conversely, physical inactivity appears to be associated with the development of psychological disorders. Specific studies support the use of exercise as a treatment for depression. Exercise compares favorably to antidepressant medications as a first-line treatment for mild to moderate depression and has also been shown to improve depressive symptoms when used as an adjunct to medications. While not as extensively studied, exercise has been shown to be an effective and cost-efficient treatment alternative for a variety of anxiety disorders. While effective, exercise has not been shown to reduce anxiety to the level achieved by psychopharmaceuticals.

The association of traumatic experiences and posttraumatic stress disorder with health care utilization in the elderly - a German population based study

OBJECTIVE

Traumatic experiences (TE) and posttraumatic stress disorder (PTSD) are related to impaired mental and physical health and to increased health care utilization (HCU). However, general population studies simultaneously investigating the association of TE and PTSD with HCU in the elderly are lacking to date.

METHODS

A representative sample of 1456 people aged 60-85 years from the German general population was examined using self-rating instruments for TE, PTSD, HCU and physical health (PH).

RESULTS

In regression analyses including age and gender, TE are significantly associated with increased probability of visits to specialists and to mental health professionals, and of hospitalization, but not with the frequency of HCU. Current PTSD is significantly associated with increased probability of visits to mental health professionals and of hospitalization, and with increased frequency of general practitioner visits, of specialist visits, and of visits to mental health professionals. In two mediation models, the relationships between TE and PTSD, respectively, with HCU were weakened but remained significant after including PTSD and physical morbidity, respectively.

CONCLUSION

These results indicate that both trauma and PTSD are positively associated to some indicators of HCU. Posttraumatic stress disorder has a weak mediating role in the association of TE and HCU. Physical health has a weak mediating role in the association of PTSD and HCU.

Associations between posttraumatic stress disorder and hemoglobin A1(C) in low-income minority patients with diabetes

OBJECTIVE

Posttraumatic Stress Disorder (PTSD) is prevalent among low-income minorities and is associated with poorer health. However, the association between PTSD and hemoglobin A1(C) (A1(C)) among patients with diabetes has not been fully described. The objective of this cross-sectional study was to evaluate associations between PTSD and A1(C) among low-income minorities with diabetes.

METHOD

Adults with diabetes were recruited from a network of primary care clinics. Data were obtained from surveys and electronic medical records. Lifetime PTSD symptoms were assessed using the Structured Clinical Interview-DSM-IV and depressive symptoms with the Patient Health Questionnaire-9. A1(C) was obtained from chart review.

RESULTS

Of 103 adults analyzed, 12% had lifetime full PTSD and 12% had subthreshold PTSD. On backward stepwise logistic regression, patients with any PTSD symptoms were significantly more likely to have an A1(C) >7% compared to patients without symptoms (OR(adj) 2.98, 95% CI 1.04-8.52, P=.04). An A1(C) >7% also was associated with an interaction between PTSD symptoms and longer diabetes duration (P<.05).

CONCLUSION

In this cohort of low-income minorities with diabetes, lifetime PTSD symptoms were significantly associated with an A1(C) >7%.