Posttraumatic Stress Disorder and Health Status

Obstructive respiratory disease in U.S. veterans: Prevalence, characteristics, and health burden

OBJECTIVE

To examine the psychiatric and physical health burden of obstructive respiratory disease in a nationally representative sample of U.S. Veterans.

METHODS

Secondary data analyses were conducted using data from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of U.S. Veterans. Participants self-reported health professional-diagnosed obstructive respiratory disease (i.e., asthma, chronic bronchitis or chronic obstructive pulmonary disease). Veterans who reported obstructive respiratory disease (n = 502) were compared to veterans without this disease but with at least one or more other medical conditions-controls (n = 3169) on measures of sociodemographic, trauma, psychiatric, and physical health characteristics. Multivariable regression analyses examined independent associations between obstructive respiratory disease and psychiatric conditions and physical characteristics.

RESULTS

A total 12.5% of the sample reported a diagnosis of obstructive respiratory disease. Compared to controls, veterans with obstructive respiratory disease were more likely to be female, unmarried/partnered, lower income, residing in the Midwest, receiving VA healthcare, and had greater lifetime and childhood trauma burden. In adjusted analyses, veterans with respiratory disease had 47-91% greater odds of screening positive for current posttraumatic stress, major depressive, and generalized anxiety disorders, and had 48% greater odds of current suicide ideation. They were also more likely to have lifetime nicotine use disorder and had more medical comorbidities and more severe somatic symptoms.

CONCLUSIONS

Obstructive respiratory disease is prevalent among U.S. veterans and associated with significant mental and physical health burden. Results highlight the need for timely screening and treatment for psychiatric and medical conditions that are highly comorbid with obstructive respiratory disease in this population.

Respiratory Health Among Older Adults in Vietnam: Does Earlier-Life Military Role and War Exposure Matter?

ObjectiveWe explore how earlier-life military roles and war trauma associate with later-life respiratory health in Vietnam. Method: The population-based sample aged 60+ is from the 2018 Vietnam Health and Aging Study. Poisson and binary logistic regressions investigate correlates of overall lung health, measured as total number of four conditions, and individual conditions, with focus on earlier-life wartime experiences. Results: Exposure is associated with lung conditions. Overall, a one-standard deviation increase in exposure results in 0.529 more conditions (p ≤ .001). Association varies across military roles and is partially explained by PTSD and smoking. Civilians heavily exposed to war trauma exhibit worse lung health than similarly exposed formal and informal military personnel. Discussion: Earlier-life war exposure is an important predictor of late-adulthood respiratory health in lower- and middle-income countries. Evidence calls for attention to the long-term impacts of war on health among not only formal and informal military personnel but also civilians.

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.

Pain, Depression, and Posttraumatic Stress Disorder Following Major Extremity Trauma Among United States Military Serving in Iraq and Afghanistan: Results From the Military Extremity Trauma and Amputation/Limb Salvage Study

OBJECTIVES

Assess the burden and co-occurrence of pain, depression, and posttraumatic stress disorder (PTSD) among service members who sustained a major limb injury, and examine whether these conditions are associated with functional outcomes.

DESIGN

A retrospective cohort study.

SETTING

Four U.S. military treatment facilities: Walter Reed Army Medical Center, National Naval Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego.

PATIENTS/PARTICIPANTS

Four hundred twenty-nine United States service members who sustained a major limb injury while serving in Afghanistan or Iraq met eligibility criteria upon review of their medical records.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASUREMENTS

Outcomes assessed were: function using the short musculoskeletal functional assessment; PTSD using the PTSD Checklist and diagnostic and statistical manual criteria; pain using the chronic pain grade scale.

RESULTS

Military extremity trauma and amputation/limb salvage patients without pain, depression, or PTSD, were, on average, about one minimally clinically important difference (MCID) from age- and gender-adjusted population norms. In contrast, patients with low levels of pain and no depression or PTSD were, on average, one to 2 MCIDs from population norms. Military extremity trauma and amputation/limb salvage patients with either greater levels of pain, and who experience PTSD, depression, or both, were 4 to 6 MCIDs from population norms. Regression analyses adjusting for injury type (upper or lower limb, salvage or amputation, and unilateral or bilateral), age, time to interview, military rank, presence of a major upper limb injury, social support, presence of mild traumatic brain injury/concussion, and combat experiences showed that higher levels of pain, depression, and PTSD were associated with lower one-year functional outcomes.

CONCLUSIONS

Major limb trauma sustained in the military results in significant long-term pain and PTSD. Overall, the results are consistent with the hypothesis that pain, depression, and PTSD are associated with disability in this population.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The National Health and Resilience in Veterans Study: A Narrative Review and Future Directions

United States (U.S.) veterans are substantially older than their non-veteran counterparts. However, nationally representative, population-based data on the unique health needs of this population are lacking. Such data are critical to informing the design of large-scale outreach initiatives, and to ensure the effectiveness of service care delivery both within and outside of the Veterans Affairs healthcare system. The National Health and Resilience in Veterans Study (NHRVS) is a contemporary, nationally representative, prospective study of two independent cohorts (n = 3,157 and n = 1,484) of U.S. veterans, which is examining longitudinal changes, and key risk and protective factors for several health outcomes. In this narrative review, we summarize the main findings of all NHRVS studies (n = 82) published as of June 2020, and discuss the clinical implications, limitations, and future directions of this study. Review of these articles was organized into six major topic areas: post-traumatic stress disorder, suicidality, aging, resilience and post-traumatic growth, special topics relevant to veterans, and genetics and epigenetics. Collectively, results of these studies suggest that while a significant minority of veterans screen positive for mental disorders, the majority are psychologically resilient. They further suggest that prevention and treatment efforts designed to promote protective psychosocial characteristics (i.e., resilience, gratitude, purpose in life), and social connectedness (i.e., secure attachment, community integration, social engagement) help mitigate risk for mental disorders, and promote psychological resilience and post-traumatic growth in this population.

Posttraumatic Stress Disorder and Cancer Risk: A Nested Case-Control Study

Data regarding cancer risk for individuals who were exposed to traumatic and stressful life events are conflicting. We sought to evaluate the association between posttraumatic stress disorder (PTSD) and the risk of the four most common solid tumors: lung, breast, prostate, and colorectal cancers. We conducted four nested case-control studies using a large UK population-based database. Cases were defined as individuals with any medical code for the specific malignancy. For every case, we used incidence-density sampling to match four controls by age, sex, practice site, and both duration and calendar time of follow-up. Exposure of interest was any diagnosis of PTSD prior to cancer diagnosis. The odds ratios (ORs) and 95% confidence intervals (CIs) for cancer risk associated with PTSD were estimated using multivariable conditional logistic regression and were adjusted for smoking status, obesity, and antidepressant use. The study population included four case groups according to cancer type. There were 19,143 cases with lung cancer (74,473 matched controls), 22,163 cases with colorectal cancer (86,538 matched controls), 31,352 cases with breast cancer (123,285 matched controls), and 27,212 cases with prostate cancer (105,940 matched controls). There was no statistically significant association between PTSD and cancer risk among any of the cancer types: lung, OR = 0.73, 95% CI [0.43, 1.23]; breast, OR = 0.73, 95% CI [0.52, 1.01]; prostate, OR = 1.24, 95% CI [0.87, 1.77]; and colorectal, OR = 1.05, 95% CI [0.68, 1.62]. Our findings indicated that participants in our study with PTSD were not at increased risk of lung, breast, prostate, and colorectal cancers.

Posttraumatic stress disorder and nonadherence to medications prescribed for chronic medical conditions: A meta-analysis

BACKGROUND

Patients with posttraumatic stress disorder (PTSD) are at increased risk for adverse consequences from comorbid medical conditions. Nonadherence to medications prescribed to treat those comorbid conditions may help explain this increased risk. We sought to determine the association between PTSD and medication nonadherence and whether it varied according to the type of event inducing the PTSD.

METHODS

Prospective observational cohort or cross-sectional studies relating PTSD and nonadherence among adults prescribed medications for a chronic medical illness were identified by searching MEDLINE, EMBASE, PsycINFO, the Cochrane Library, CINAHL, SCOPUS, and the PILOTS Database and by hand-searching bibliographies from selected articles. Individual estimates of odds ratios were pooled using random effects meta-analysis with inverse variance weighting. Articles were pooled separately according to whether PTSD was induced by a medical versus non-medical event.

OUTCOMES

Sixteen articles comprising 4483 patients met eligibility criteria. The pooled effect size of the risk of PTSD to medication nonadherence was OR 1.22 (95% CI, 1.06-1.41). Among the 6 studies of medical event-induced PTSD, the OR was 2.08 (95% CI, 1.03-4.18); p = 0.04. Among the 8 studies in which PTSD was not induced by a medical event, the OR was 1.10 (95% CI, 0.99-1.24); p = 0.09.

INTERPRETATION

Patients with PTSD were more likely to be nonadherent to medications prescribed for chronic medical conditions - an association that may exist specifically when PTSD was induced by a medical event. Medications may serve as aversive reminders among survivors of acute medical events, magnifying avoidance behaviors characteristic of PTSD.

FUNDING

NHLBI.

Medicinal versus Recreational Cannabis Use among Returning Veterans

BACKGROUND

Although increasing rates of cannabis use and cannabis use disorder (CUD) are well-documented among veterans, little is known about their use of cannabis specifically for medicinal purposes. The present study characterizes such use and compares veterans reporting cannabis use for medicinal (n = 66) versus recreational (n = 77) purposes on (a) sociodemographic factors, (b) psychiatric disorders (posttraumatic stress disorder [PTSD], major depressive disorder [MDD], and CUD), (c) other substance use, (d) reasons for cannabis use and cannabis-related problems, and (e) physical and mental health.

METHODS

Participants were veterans deployed post 9/11/2001 recruited from a Veterans Health Administration (VHA) facility (N = 143; mean [SD] age = 30.0 [6.6]; mean [SD] deployments = 1.7 [1.1]) who reported past-year cannabis use.

RESULTS

The most frequently endorsed conditions for medicinal cannabis (MC) use were anxiety/stress, PTSD, pain, depression, and insomnia. In logistic regression analyses adjusted for frequency of cannabis use, MC users were significantly more likely (OR = 3.16) to meet criteria for PTSD than recreational cannabis (RC) users. Relative to RC users, MC users reported significantly greater motivation for using cannabis to cope with sleep disturbance as well as significantly poorer sleep quality and worse physical health.

CONCLUSIONS

Veterans who use cannabis for medicinal purposes differ significantly in sleep, physical and mental health functioning than veterans who use cannabis for recreational purposes. PTSD and sleep problems may be especially relevant issues to address in screening and providing clinical care to returning veterans who are using cannabis for medicinal purposes.

Evidence-based Treatments for Military-related Posttraumatic Stress Disorder in a Veterans Affairs Setting

Posttraumatic stress disorder (PTSD) can have a significant negative impact on the physical, emotional, and mental health of individuals. This article discusses the prevalence, risk factors, and diagnostic criteria for PTSD. Given the high incidence of PTSD in the Veteran population, much attention has been given to assessment and treatment issues. Treatment options for PTSD, including the 2 most effective treatments, prolonged exposure and cognitive processing therapy, are discussed. Special issues concerning the treatment of Veterans are also reviewed.

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.

Chronic obstructive lung disease and posttraumatic stress disorder: current perspectives

Background

Several studies have reported on the co-occurrence of chronic obstructive pulmonary disease (COPD) and psychiatric conditions, with the most robust evidence base demonstrating an impact of comorbid anxiety and depression on COPD-related outcomes. In recent years, research has sought to determine if there is a co-occurrence between COPD and posttraumatic stress disorder (PTSD) as well as for associations between PTSD and COPD-related outcomes. To date, there have been no published reviews summarizing this emerging literature.

Objectives

The primary objective of this review was to determine if there is adequate evidence to support a co-occurrence between PTSD and COPD. Secondary objectives were to: 1) determine if there are important clinical considerations regarding the impact of PTSD on COPD management, and 2) identify targeted areas for further research.

Methods

A structured review was performed using a systematic search strategy limited to studies in English, addressing adults, and to articles that examined: 1) the co-occurrence of COPD and PTSD and 2) the impact of PTSD on COPD-related outcomes. To be included, articles must have addressed some type of nonreversible obstructive lung pathology.

Results

A total of 598 articles were identified for initial review. Upon applying the inclusion and exclusion criteria, n=19 articles or abstracts addressed our stated objectives. Overall, there is inconclusive evidence to support the co-occurrence between PTSD and COPD. Studies finding a significant co-occurrence generally had inferior methods of identifying COPD; in contrast, studies that utilized more robust COPD measures (such as a physician exam) generally failed to find a relationship. Among studies that examined the impact of PTSD on COPD-related outcomes, there was more consistent evidence that PTSD affects the perception of respiratory symptom burden and management. In addition, methods for measuring an important confounder (smoking) were generally lacking.

Conclusion

There is inconclusive evidence to support the co-occurrence of COPD and PTSD. There was stronger evidence implicating PTSD as an important comorbidity impacting COPD management. Further research is needed to: 1) determine whether or not COPD and PTSD are likely to be comorbid, and 2) further elucidate the mechanisms connecting PTSD and COPD-related outcomes.

PTSD is negatively associated with physical performance and physical function in older overweight military Veterans

This study examines the effect of posttraumatic stress disorder (PTSD) on function and physical performance in older overweight military Veterans with comorbid conditions. This is a secondary data analysis of older Veterans (mean age = 62.9 yr) participating in a physical activity counseling trial. Study participants with PTSD (n = 67) and without PTSD (n = 235) were identified. Self-reported physical function (36-item Short Form Health Survey) and directly measured physical performance (mobility, aerobic endurance, strength) were assessed. Multivariate analyses of variance controlling for demographic factors and psychiatric disorders demonstrated significant physical impairment among those with PTSD. PTSD was negatively associated with self-reported physical function, functioning in daily activities, and general health (p < 0.01). Those with PTSD also performed significantly worse on tests of lower-limb function (p < 0.05). Despite being significantly younger, Veterans with PTSD had comparable scores on gait speed, aerobic endurance, grip strength, and bodily pain compared with Veterans without PTSD. This study provides preliminary data for the negative association between PTSD and physical function in older military Veterans. These data highlight the importance of ongoing monitoring of physical performance among returning Veterans with PTSD and intervening in older overweight Veterans with PTSD, whose physical performance scores are indicative of accelerated risk of premature functional aging.

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.

PTSD is a chronic, fluctuating disorder affecting the mental quality of life in older adults

OBJECTIVES

Examine the longitudinal course of posttraumatic stress disorder (PTSD) in older adults and its influence on mental health quality of life (MHQoL).

DESIGN

Evaluation performed at baseline, and 3 and 6 months postrandomization as part of a longitudinal trial.

PARTICIPANTS AND SETTINGS

A total of 1,185 participants, with a mean (±SD) age of 73.53 (±5.98) years, at seven primary care sites (including five Veterans Affairs clinics), were divided into four groups, namely, no trauma (n = 661), trauma only (n = 319), partial PTSD (n = 114), and PTSD (n = 81), based on reports of trauma and associated PTSD symptoms.

MEASUREMENTS

The prevalence of comorbid depression, anxiety, and alcohol use disorders, assessed using the Diagnostic and Statistical Manual, Fourth Edition, criteria and changes in MHQoL, as assessed by the Short Form-36 mental component score.

RESULTS

At baseline, the PTSD group had higher frequencies of comorbid depression and anxiety disorders and worse MHQoL than the other groups. Both chronic (participants diagnosed with PTSD at all three assessments) and fluctuating (participants moving to or from one of the other groups) trajectories of course were observed during the follow-up period, which appeared to be separate from that of the comorbid disorders. Even after accounting for those comorbid disorders, PTSD had an independent association with poorer MHQoL at multiple time points, especially in men, whereas trauma without PTSD symptoms (trauma only) had better MHQoL.

CONCLUSIONS

PTSD had chronic and fluctuating courses, with negative effects on MHQoL, while partial PTSD might represent a transitional state, underscoring the need to better identify and treat PTSD at any phase in later life.

Validation of the Pittsburgh Sleep Quality Index Addendum for posttraumatic stress disorder (PSQI-A) in U.S. male military veterans

Sleep disturbances are core symptoms of posttraumatic-stress disorder (PTSD), yet they bear less stigma than other PTSD symptoms. Given the growing number of returning military veterans, brief, valid assessments that identify PTSD in a minimally stigmatizing way may be useful in research and clinical practice. The study purpose was to evaluate the psychometric properties of the Pittsburgh Sleep Quality Index Addendum for PTSD (PSQI-A), and to examine its ability to identify PTSD cases among U.S. male military veterans. Male military veterans (N = 119) completed the PSQI-A, as well as measures of sleep quality, combat exposure, posttraumatic stress, depression, and anxiety. Veterans with PTSD had higher PSQI-A identified disruptive nocturnal behaviors than veterans without PTSD. The PSQI-A had good internal consistency and convergent validity with sleep quality, combat exposure, PTSD symptoms, depression, and anxiety. A cutoff score ≥ 4 provided an area under the curve = .81, with 71% sensitivity, 82% specificity, and 60% positive and 83% negative predictive value for a clinical diagnosis of PTSD; correct classification was 74%. The PSQI-A is a valid measure to possibly detect PTSD among male military veterans. Assessment of disruptive nocturnal behaviors may provide a cost-effective, nonstigmatizing approach to PTSD screening without directly probing for trauma exposure(s).

Effects of chronic posttraumatic stress disorder on metabolic risk, quality of life, and stress hormones in aging former refugee children

It is still unclear whether the association between traumatic stress and physical disease is mediated by posttraumatic stress disorder (PTSD). Therefore, we examined the long-term consequences of PTSD on cardiovascular risk, stress hormones, and quality of life in a sample of former refugee children who were severely traumatized more than six decades ago. In 25 subjects with chronic PTSD and 25 trauma-controlled subjects, we measured the variables of metabolic syndrome supplemented by the ankle-brachial index and highly sensitive C-reactive protein. Quality of life was assessed using the 36-item Short-Form Health Survey. Cortisol, adrenocorticotropin-releasing hormone (ACTH), and dehydroepiandrosterone (DHEA) were measured using the low-dose-dexamethasone suppression test. In addition, salivary cortisol was assessed at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. We found a significant group effect between participants with and without PTSD regarding quality of life but not in any metabolic parameter including the ankle-brachial index or cortisol, ACTH, and DHEA in plasma before and after dexamethasone or salivary cortisol. The postulated association between traumatic stress and physical illness does not appear to be mediated by PTSD in this population. Nevertheless, the search for subgroups of PTSD patients with childhood traumatization leading to different metabolic and endocrine long-term consequences in aging PTSD patients is needed.

Long-term effectiveness of collaborative depression care in older primary care patients with and without PTSD symptoms

OBJECTIVE

Depressed patients with comorbid post-traumatic stress disorder (PTSD) are more functionally impaired and may take longer to respond to depression treatment than patients without PTSD. This study examined the long-term effects of PTSD on depression severity, treatment response, and health care costs among older adults.

METHODS

Patients were recruited from 18 primary care clinics in five states. A total of 1801 patients aged 60 years or older with major depression or dysthymia were randomized to Improving Mood Promoting Access to Collaborative Treatment (IMPACT) collaborative care or usual care. The study included 191 (10.6%) subjects who screened positive for PTSD. Depression severity, assessed by the Hopkins Depression Symptom Checklist, was used to estimate depression-free days (DFDs) over 24 months. Total health care costs included inpatient, outpatient, and pharmacy costs.

RESULTS

Depressed patients with PTSD had higher depression severity than patients without PTSD symptoms at baseline. Over 2 years, intervention patients with PTSD symptoms had relatively the same benefits from collaborative care (99 more DFDs than usual care patients) as patients without PTSD (108 more DFDs than usual care) (p = 0.85). Total health care costs did not differ significantly for depressed patients with and without PTSD symptoms.

CONCLUSION

Depressed older adults with PTSD symptoms were more depressed at baseline, but collaborative care (compared to usual care) produced similar improvements in depression severity in both groups. This reduction of depression symptoms was observed for up to 12 months after the intervention ended, suggesting that long-term improvements in depression are possible with collaborative care in patients with and without PTSD symptoms.

No effect of PTSD and other psychiatric disorders on cognitive functioning in veterans with mild TBI

There has been speculation that post-traumatic stress disorder (PTSD) superimposed on mild traumatic brain injury (mTBI) may have synergistic, negative effects on cognitive functioning. The purpose of this study was to investigate differences in processing speed, executive functioning, and memory of 82 veterans with mTBI and PTSD, mTBI, and another psychiatric condition, or mTBI alone. It was hypothesized that there would be no group differences in cognitive performances. Participants completed the Trail Making Test, Stroop, Rey Complex Figure, and California Verbal Learning Test-2. There were no significant group differences on any cognitive measure. Findings suggest that PTSD and other psychiatric disorders do not necessarily have a negative exacerbating effect on processing speed, executive functioning, or memory in veterans with mTBI.

Meta-analysis of dropout rates in SSRIs versus placebo in randomized clinical trials of PTSD

Meta-analysis was conducted to examine dropout predictors and differences between SSRIs and placebo in randomized clinical trials (RCTs) of PTSD. Studies systematically located were SSRI versus placebo double blind RCTs of PTSD DSM diagnosis published between 1991 and 2008. Fourteen RCTs (n = 2815) met the inclusion criteria with an average duration of 10.8 weeks. Dropout rates were: 331 of 1111 (29.8%) among placebo arm and 513 of 1704 (30.3%) among SSRI participants. Random effects modeling showed that the dropout rates of SSRIs and placebo did not differ (OR = 1.05, 95% CI = 0.82-1.34), although favored SSRIs among civilian traumas (OR = 2.52, 95% CI = 1.11-5.7). Mixed effects modeling showed dropout was predicted by mixed trauma in the placebo arms, and duration and mean dose across treatments. With the exception of civilian trauma, SSRIs dropout rates were slightly lower than those of placebo. Formulae are available to guide the prediction of dropout.

Trauma, posttraumatic stress disorder, and physical illness: findings from the general population

OBJECTIVE

To determine in a general population sample the differential impact on physical health of exposure to traumatic experiences and posttraumatic stress disorder (PTSD). Trauma exposure and PTSD have been associated with physical illness in specific populations, such as veterans.

METHODS

Medical histories including cardiovascular, endocrine, pulmonary, and other chronic diseases were obtained from 3171 adults living in the community. They were administered the PTSD module of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), and were assigned to three groups: no trauma (n = 1440); trauma, but no PTSD (n = 1669); and trauma with subsequent PTSD (n = 62).

RESULTS

After adjustments for sociodemographic factors, smoking, body mass index, blood pressure, depression, and alcohol use disorders, subjects with trauma history had higher odds ratios (ORs) for angina pectoris and heart failure (OR = 1.2; 95% Confidence Interval [CI] = 1.1-1.3), stroke (OR = 1.2; 95 CI = 1.0-1.5), bronchitis, asthma, renal disease, and polyarthritis (ORs between 1.1 and 1.3) compared with nontraumatized participants. The PTSD positive subsample had increased ORs for angina (OR = 2.4; 95% CI = 1.3-4.5), heart failure (OR = 3.4; 95% CI = 1.9-6.0), bronchitis, asthma, liver, and peripheral arterial disease (ORs, range = 2.5-3.1).

CONCLUSIONS

Our findings suggest a strong association between PTSD and cardiovascular and pulmonary diseases. Particular diagnostic and treatment attention should be paid to physical illness in PTSD positive patients in primary care, medical, and mental health settings.

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.

Psychiatric comorbidity and mortality after acute myocardial infarction

BACKGROUND

Prior studies of the impact of psychiatric comorbidity on outcomes after acute myocardial infarction (AMI) have frequently relied on inpatient secondary diagnosis codes. This study compared associations between psychiatric comorbidity and AMI outcomes that were derived using secondary diagnosis codes and codes captured from prior outpatient encounters.

METHODS AND RESULTS

Retrospective cohort study analyzing 21 745 patients admitted in 2004 to 2006 to Veterans Health Administration hospitals with AMI using administrative data. Psychiatric comorbidity was identified using (1) secondary inpatient diagnosis codes from the index hospitalization and (2) diagnoses from prior outpatient encounters. Outcomes included 30- and 365-day mortality and the receipt of coronary revascularization within 30 days of admission. Generalized estimating equations and Cox proportional hazards were used to adjust mortality and receipt of revascularization for demographic and clinical variables. Psychiatric disorders were identified in 2285 (10%) patients from inpatient secondary diagnosis codes and 5225 (24%) patients from prior outpatient codes. Patients with psychiatric comorbidity had higher adjusted 30- and 365-day mortality, based on outpatient codes (odds ratios, 1.19 [95% CI, 1.09 to 1.30] and 1.12 [95% CI, 1.03 to 1.22], respectively), but similar mortality based on inpatient codes (odds ratios, 0.89 [95% CI, 0.69 to 1.01] and 0.93 [95% CI, 0.82 to 1.06], respectively). In contrast, patients with psychiatric comorbidity had lower receipt of coronary revascularization based on outpatient codes (hazard ratio, 0.92; [95% CI, 0.85 to 0.99], but similar receipt based on inpatient codes (hazard ratio, 1.00 [95% CI, 0.91 to 1.10]).

CONCLUSIONS

Inpatient secondary diagnosis codes identified fewer patients with psychiatric comorbidity than prior outpatient codes. Moreover, associations with AMI outcomes differed for the 2 approaches. These findings raise potential concerns about the validity and reliability of psychiatric inpatient secondary diagnosis in estimating the impact of psychiatric comorbidities on AMI outcomes and in developing risk-adjustment models.

Dual use of VA and non-VA services among primary care patients with depression

BACKGROUND

Depression treatment requires close monitoring to achieve optimal, long-term control. Use of multiple sources of health care can affect coordination and continuity of treatment for depression.

OBJECTIVES

To assess levels of non-Veterans Health Administration (VA) use among depressed primary care patients by service type and examine patient factors associated with non-VA use.

DESIGN

Cross-sectional comparison of dual and VA-only users among depressed primary care patients. Depression was defined as PHQ-9 >or=10.

SUBJECTS

Five hundred fifty depressed patients from the baseline sample of a group-randomized trial of collaborative care for depression in ten VA primary care practices.

MEASUREMENTS

VA and non-VA outpatient utilization for physical and emotional health problems in the prior 6 months, patient demographics, and co-morbid conditions. All measures were self-reported and obtained at the baseline interview.

RESULTS

Overall, 46.8% of VA depressed primary care patients utilized non-VA care. Dual users were more likely to use acute care services (emergency room or inpatient), especially for physical health problems. Dual users of physical health services had more total visits, but fewer VA visits than VA-only users, while dual users of emotional health services had fewer total and VA visits. Factors associated with dual use were urban clinic location, having other insurance coverage, and dissatisfaction with physical health care in general.

CONCLUSIONS

Almost half of depressed primary care patients used non-VA care, with most of their non-VA use for physical rather than emotional health problems. Care management strategies for depressed patients should include communication and coordination with non-VA providers.

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.

Depression, posttraumatic stress disorder, and mortality

OBJECTIVE

To determine whether a history of depression and/or posttraumatic stress disorder (PTSD) is associated with all-cause mortality in primary care patients over an average of 2 years.

METHODS

Patients from seven Department of Veterans Affairs medical centers completed mailed questionnaires. Depression and PTSD status were determined from patient self-report of a prior diagnosis and/or electronic administrative data. Date of death was ascertained from Veterans Health Information Systems and Technology Architecture and the Department of Veterans Affairs' Beneficiary Identification and Records Locator System.

RESULTS

Among 35,715 primary care patients, those with a history of depression without a history of PTSD (n = 6876) were at increased risk of death over an average of 2 years compared with patients with neither depression nor PTSD after adjustment for demographic variables, health behaviors, and medical comorbidity (hazard ratio (HR) = 1.17; 95% Confidence Interval (CI) = 1.06-1.28). However, patients with a history of PTSD without a history of depression (n = 748) were not at increased risk of death compared with patients with neither depression nor PTSD (HR = 0.84; 95% CI = 0.63-1.13). Patients with a history of both (n = 3762) were at increased risk of death after adjustment for demographic factors, although not after additional adjustment for health behaviors and medical comorbidity (HR = 0.90; 95% CI = 0.78-1.04).

CONCLUSIONS

In a large sample of veterans, a prior diagnosis of depression, but not PTSD, was associated with an increased risk of death over an average of 2 years after adjusting for age, demographic variables, health behaviors, and medical comorbidity.

Screening for posttraumatic stress disorder in VA primary care patients with depression symptoms

BACKGROUND

Unrecognized posttraumatic stress disorder (PTSD) is common and may be an important factor in treatment-resistant depression. Brief screens for PTSD have not been evaluated for patients with depression.

OBJECTIVE

The objective was to evaluate a 4-item screen for PTSD in patients with depression.

DESIGN

Baseline data from a depression study were used to evaluate sensitivity, specificity, and likelihood ratios (LRs) using the PTSD checklist (PCL-17) as the reference standard.

SUBJECTS

Subjects are 398 depressed patients seen in Veterans Affairs (VA) primary care clinics.

MEASURES

The Patient Health Questionnaire (PHQ) for depression, PCL-17, and 4-item screen for PTSD were used.

RESULTS

Patients had a mean PHQ score of 14.8 (SD 3.7). Using a conservative PCL-17 cut point "(>50)", the prevalence of PTSD was 37%. PCL-17 scores were strongly associated with PHQ scores (r = 0.59, P < 0.001). Among the 342 (86%) patients endorsing trauma, a score of 0 on the remaining 3 symptom items had a LR = 0.21, score of 1 a LR = .62, score of 2 a LR = 1.36, and score of 3 a LR = 4.38.

CONCLUSIONS

Most depressed VA primary care patients report a history of trauma, and one third may have comorbid PTSD. Our 4-item screen has useful LRs for scores of 0 and 3. Modifying item rating options may improve screening characteristics.

Dissemination of Methods and Results From the Veterans Health Study

The Veterans Health Study (VHS) followed a cohort of patients receiving ambulatory care in the Veterans Affairs healthcare system for up to 5 years. One of the principal aims of this study was to develop a library of methodologies including general and disease-specific health outcome questionnaires for use in monitoring the quality of healthcare and for research purposes. The cornerstone for this work is the Veterans RAND 36 and 12 Item Health Surveys (VR-36 and VR-12), a general measure developed in the VHS for measuring the physical and psychologic well-being of the patient. A comprehensive set of disease-specific assessments has also been developed as part of this study for the purposes of monitoring specific chronic conditions more commonly seen in routine ambulatory care settings. Since 1996, more than 2 million questionnaires have been administered in the VA for quality monitoring purposes, using the VR-36 and VR-12. Research studies that have used these batteries span randomized clinical trials in the VA cooperative studies program and clinical effectiveness research. Health assessments using VHS batteries are being disseminated for widespread use outside the VA. Chief among the assessments used is the VR-12, which has recently been included in the 2006 Health Plan Employer Data and Information Set (HEDIS) as part of the Medicare Health Outcomes Survey for monitoring the Medicare Advantage Program. The methods and batteries developed in the VHS are in the public domain and provide a framework for future patient monitoring using standard measures of health.