Disability and quality of life in post-traumatic stress disorder: impact of drug treatment

Intentional Self-Harm Among US Veterans With Traumatic Brain Injury or Posttraumatic Stress Disorder: Retrospective Cohort Study From 2008 to 2017

BACKGROUND

Veterans with a history of traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD) may be at increased risk of suicide attempts and other forms of intentional self-harm as compared to veterans without TBI or PTSD.

OBJECTIVE

Using administrative data from the US Veterans Health Administration (VHA), we studied associations between TBI and PTSD diagnoses, and subsequent diagnoses of intentional self-harm among US veterans who used VHA health care between 2008 and 2017.

METHODS

All veterans with encounters or hospitalizations for intentional self-harm were assigned "index dates" corresponding to the date of the first related visit; among those without intentional self-harm, we randomly selected a date from among the veteran's health care encounters to match the distribution of case index dates over the 10-year period. We then examined the prevalence of TBI and PTSD diagnoses within the 5-year period prior to veterans' index dates. TBI, PTSD, and intentional self-harm were identified using International Classification of Diseases diagnosis and external cause of injury codes from inpatient and outpatient VHA encounters. We stratified analyses by veterans' average yearly VHA utilization in the 5-year period before their index date (low, medium, or high). Variations in prevalence and odds of intentional self-harm diagnoses were compared by veterans' prior TBI and PTSD diagnosis status (TBI only, PTSD only, and comorbid TBI/PTSD) for each VHA utilization stratum. Multivariable models adjusted for age, sex, race, ethnicity, marital status, Department of Veterans Affairs service-connection status, and Charlson Comorbidity Index scores.

RESULTS

About 6.7 million veterans with at least two VHA visits in the 5-year period before their index dates were included in the analyses; 86,644 had at least one intentional self-harm diagnosis during the study period. During the periods prior to veterans' index dates, 93,866 were diagnosed with TBI only; 892,420 with PTSD only; and 102,549 with comorbid TBI/PTSD. Across all three VHA utilization strata, the prevalence of intentional self-harm diagnoses was higher among veterans diagnosed with TBI, PTSD, or TBI/PTSD than among veterans with neither diagnosis. The observed difference was most pronounced among veterans in the high VHA utilization stratum. The prevalence of intentional self-harm was six times higher among those with comorbid TBI/PTSD (6778/58,295, 11.63%) than among veterans with neither TBI nor PTSD (21,979/1,144,991, 1.92%). Adjusted odds ratios suggested that, after accounting for potential confounders, veterans with TBI, PTSD, or comorbid TBI/PTSD had higher odds of self-harm compared to veterans without these diagnoses. Among veterans with high VHA utilization, those with comorbid TBI/PTSD were 4.26 (95% CI 4.15-4.38) times more likely to receive diagnoses for intentional self-harm than veterans with neither diagnosis. This pattern was similar for veterans with low and medium VHA utilization.

CONCLUSIONS

Veterans with TBI and/or PTSD diagnoses, compared to those with neither diagnosis, were substantially more likely to be subsequently diagnosed with intentional self-harm between 2008 and 2017. These associations were most pronounced among veterans who used VHA health care most frequently. These findings suggest a need for suicide prevention efforts targeted at veterans with these diagnoses.

Health-Related Quality of Life and Costs of Posttraumatic Stress Disorder in Adolescents and Young Adults in Germany

BACKGROUND

Posttraumatic stress disorder (PTSD) is one of the psychopathological consequences of sexual and/or physical abuse. The economic burden is assumed to be high, whereas health-related quality of life and education is negatively affected. This study aims to determine health care costs, health-related quality of life, and educational interruption in adolescents and young adults with PTSD after sexual and/or physical abuse in Germany.

METHODS

This analysis used data of 87 participants aged 14-21 years of a randomized controlled trial. Health care utilization, health-related quality of life (EQ-5D-5L), sick leave days, productivity, and delay or failure to achieve educational aims were assessed. Health care costs from a payer perspective were calculated using unit costs for the year 2014.

RESULTS

Mean health care costs for a six-month period were 5,243€ (SE 868€). In particular, costs of inpatient stays in psychiatric hospitals, general hospitals and rehabilitation as well as child welfare institutions were high. In addition, health-related quality of life was lower due to anxiety/depression, resulting in a mean EQ-5D index and EQ-VAS score of 0.70 and 61.0, respectively. Furthermore, participants reported on average 27 sick leave days, a productivity loss of 61%, and a delay in education attainment as well as having been unable to achieve educational aims.

CONCLUSION

PTSD in adolescents and young adults is associated with a high economic burden. Health-related quality of life was substantially reduced. Furthermore, delay and productivity losses in education were observed.

CLINICAL TRIAL REGISTRATION

German Clinical Trials Register identifier: DRKS00004787; date of registration: 18th March 2013; https://www.drks.de.

Posttraumatic Stress, Somatization, and Quality of Life Among Ivorian Refugees

The present study examined the relationship between peritraumatic reactions, posttraumatic stress disorder (PTSD) symptoms, somatization, and quality of life (QoL) in a sample of refugees, two years after the 2011 Ivory Coast sociopolitical crisis. Participants were 101 Ivorian adult refugees (mean age = 31.61 years, SD = 7.84; 45.5% women) who completed several questionnaires relating to peritraumatic reactions, PTSD symptoms, somatization, and QoL. Most participants (86.1%) scored above the cutoff for probable PTSD. Peritraumatic dissociation and peritraumatic distress were significantly associated with PTSD symptoms, (r = .64, p < .001) and (r = .60, p < .001), respectively, and somatization, (r = .21, p = .038) and (r = .35, p < .001), respectively, as well as with QoL, (r = -.20, p = .045) and (r = -.21, p = .037), respectively. Similarly, QoL was significantly negatively correlated with PTSD symptoms (r = -.33, p < .001) and somatization (r = -.39, p < .001). In multivariate analyses, somatization was the strongest predictor of QoL (β = -.31, p = .003). Finally, somatization statistically mediated the association between peritraumatic distress and QoL. These findings suggest that PTSD may be frequent among Ivorian refugees, and that somatization may be an important feature of the traumatic experiences. Targeting somatization in conjunction with trauma-centered therapy may improve outcomes in sub-Saharan Africans with PTSD.

The Impact of Post-Traumatic Stress Disorder on the Burden of Migraine: Results From the National Comorbidity Survey-Replication

BACKGROUND

Post-traumatic stress disorder (PTSD) has been linked with migraine in prior studies.

OBJECTIVE

To evaluate the individual and joint burdens of migraine and PTSD in a population-based cohort.

METHODS

The National Comorbidity Survey-Replication (NCS-R) is a general population study conducted in the United States from February 2001-April 2003. PTSD and migraine were assessed, and four groups defined based on their migraine and PTSD status. The four groups included those with no migraine and no PTSD (controls, n=4535), those with migraine and without PTSD (migraine alone, n=236), those with PTSD and without migraine (PTSD alone, n=244), and those with both migraine and PTSD (mig+PTSD, n=68). Logistic and Poisson regression models were used to assess the association between dichotomous/multilevel outcome variables indicating financial, health, and interpersonal burdens and each migraine/PTSD group.

RESULTS

Compared to controls, those with Mig+PTSD were more likely to be in the low poverty index (48% vs 41%, AOR 2.16; CI: 1.10, 4.24) and were less likely to be working for pay or profit in the past week (50% vs 68%, AOR 0.42; CI: 0.24, 0.74) but not those with migraine or PTSD alone. Additionally, the number of days where work quality was cut due to physical or mental health or substance abuse in the past month was greater in all groups compared to controls: (1) migraine alone: mean 2.57 (SEM 0.32) vs mean 1.09 (SEM 0.08) days, ARR=2.39; CI: 2.19, 2.62; (2) PTSD alone: mean 2.43 (SEM 0.33) vs mean 1.09 (SEM 0.08) days, ARR=2.09; CI: 1.91, 2.29; (3) mig+PTSD: mean 8.2 (SEM 0.79) vs 1.09 (SEM 0.08) days, ARR 6.79; CI 6.16, 7.49; and was over 2.5-fold greater in those mig+PTSD than migraine alone (mean 8.0 [SEM 0.79] vs 2.6 days [SEM 0.72], ARR 2.77; CI: 2.45, 3.14). The likelihood of having difficulty getting along or maintaining a social life was also increased in all groups relative to controls: (1) migraine alone: 21% vs 5.4%, AOR 4.20; CI: 2.62, 6.74; (2) PTSD alone: 18% vs 5.4%, AOR 3.40; CI: 2.40, 4.82; (3) Mig+PTSD: 39% vs 5.4%, AOR 9.95; CI: 5.72, 17.32, and was 2-fold greater in those with Mig+PTSD as compared to those with migraine alone (AOR 2.32; CI: 1.15, 4.69).

CONCLUSIONS

These findings support the need for those who treat migraine patients to be aware of the comorbidity with PTSD, as these patients may be particularly prone to adverse financial, health, and interpersonal disease burdens.

PTSD and TBI co-morbidity: scope, clinical presentation and treatment options

PRIMARY OBJECTIVE

To summarize the literature on post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) and their co-morbidity, focusing on diagnosis, clinical symptoms and treatment issues relevant to the clinician.

RESEARCH DESIGN

Review of the literature.

METHODS AND PROCEDURES

Pubmed searches were performed using the terms post-traumatic stress disorder, traumatic brain injury, sleep, cognitive, depression, anxiety, treatment and combinations of these terms. Those articles relevant to the objective were included.

MAIN OUTCOMES AND RESULTS

This study presents pathophysiological, neuroimaging and clinical data on co-morbid PTSD and TBI. It reviews associated conditions, emphasizing the impact of cognitive and sleep problems. It summarizes the emerging literature on treatment effectiveness for co-morbid PTSD and TBI, including psychotherapy, pharmacotherapy and cognitive rehabilitation.

CONCLUSIONS

Both PTSD and TBI commonly occur in the general population, both share some pathophysiological characteristics and both are associated with cognitive impairment and sleep disruption. PTSD and TBI present with a number of overlapping symptoms, which can lead to over-diagnosis or misdiagnosis. Both conditions are associated with co-morbidities important in diagnosis and treatment planning. More research is needed to elucidate what treatments are effective in PTSD and TBI co-morbidity and on factors predictive of treatment success.

Post-Traumatic Stress Symptoms in Post-ICU Family Members: Review and Methodological Challenges

Family members of intensive care unit (ICU) patients are at risk for symptoms of post-traumatic stress disorder (PTSD) following ICU discharge. The aim of this systematic review is to examine the current literature regarding post-ICU family PTSD symptoms with an emphasis on methodological issues in conducting research on this challenging phenomenon. An extensive review of the literature was performed confining the search to English language studies reporting PTSD symptoms in adult family members of adult ICU patients. Ten studies were identified for review published from 2004 to 2012. Findings demonstrate a significant prevalence of family PTSD symptoms in the months following ICU hospitalization. However, there are several methodological challenges to the interpretation of existing studies and to the conduct of future research including differences in sampling, identification of risk factors and covariates of PTSD, and lack of consensus regarding the most appropriate PTSD symptom measurement tools and timing.

Assessment of the Psychosocial Predictors of Health-Related Quality of Life in a PTSD Clinical Sample

Although a wide array of the scientific literature explores the links between posttraumatic stress disorder (PTSD) symptoms, coping strategies, and social support and health-related quality of life (HRQoL) as an outcome variable, their connections remain unclear. It is unknown whether PTSD symptom severity, coping strategies, and social support explain each a unique portion of variance of HRQoL of individuals with PTSD. In the current study, based on pretreatment results of a broader study assessing a specific intervention for PTSD, 94 individuals with PTSD were screened for psychiatric disorders and completed several questionnaires concerning social support, coping strategies, PTSD symptoms, and HRQoL. Coping strategies, social support, and PTSD all appeared to be predictors of HRQoL; however, PTSD seemed to constitute the major predictor among these variables. Indeed, coping strategies and social support did not explain a unique share of variability of HRQoL beyond that of PTSD symptomatology. A causal pathway integrating these variables should be tested in future studies.

Efficacy of interpersonal therapy-group format adapted to post-traumatic stress disorder: an open-label add-on trial

BACKGROUND

Post-traumatic stress disorder (PTSD) is a highly prevalent condition, yet available treatments demonstrate only modest efficacy. Exposure therapies, considered by many to be the "gold-standard" therapy for PTSD, are poorly tolerated by many patients and show high attrition. We evaluated interpersonal therapy, in a group format, adapted to PTSD (IPT-G PTSD), as an adjunctive treatment for patients who failed to respond to conventional psychopharmacological treatment.

METHODS

Research participants included 40 patients who sought treatment through a program on violence in the department of psychiatry of Federal University of São Paulo (UNIFESP). They had received conventional psychopharmacological treatment for at least 12 weeks and failed to have an adequate clinical response. After signing an informed consent, approved earlier by the UNIFESP Ethics Review Board, they received a semi-structured diagnostic interview (SCID-I), administered by a trained mental health worker, to confirm the presence of a PTSD diagnosis according to DSM-IV criteria. Other instruments were administered, and patients completed out self-report instruments at baseline, and endpoint to evaluate clinical outcomes.

RESULTS

Thirty-three patients completed the trial, but all had at least one second outcome evaluation. There were significant improvements on all measures, with large effect sizes.

CONCLUSIONS

IPT-G PTSD was effective not only in decreasing symptoms of PTSD, but also in decreasing symptoms of anxiety and depression. It led to significant improvements in social adjustment and quality of life. It was well tolerated and there were few dropouts. Our results are very preliminary; they need further confirmation through randomized controlled clinical trials.

Posttraumatic stress disorder and stress-related disorders

Posttraumatic stress disorder (PTSD) is a prevalent anxiety disorder. Symptoms present shortly after an exposure to a traumatic event, abate with time in the majority of those who initially express them, and leave a significant minority with chronic PTSD. PTSD may be treated with pharmacotherapy or psychotherapy. Treatment of the early expressions of the disorder constitutes a separate domain of theory and research. Treatment of chronic PTSD often stabilizes the condition but rarely produces stable remission. This article reviews the empirical evidence on the treatment of acute and chronic PTSD, outlines similarities and differences between PTSD and other Axis I disorders, evaluates new therapeutic approaches, and discusses the implications of current knowledge for the forthcoming DSM-V.

Year in review 2007: Critical Care--intensive care unit management

With the development of new technologies and drugs, health care is becoming increasisngly complex and expensive. Governments and health care providers around the world devote a large proportion of their budgets to maintaining quality of care. During 2007, Critical Care published several papers that highlight important aspects of critical care management, which can be subdivided into structure, processes and outcomes, including costs. Great emphasis was given to quality of life after intensive care unit stay, especially the impact of post-traumatic stress disorder. Significant attention was also given to staffing level, optimization of intensive care unit capacity, and drug cost-effectiveness, particularly that of recombinant human activated protein C. Managing costs and providing high-quality care simultaneously are emerging challenges that we must understand and meet.

Combat stress casualties in Iraq. Part 2: psychiatric screening prior to aeromedical evacuation

TOPIC

Exposure to combat-related trauma is a leading cause of posttraumatic stress disorder. Deployed military mental health practitioners serve important roles in the assessment, diagnosis, and aeromedical evacuation of psychiatric patients from the combat zone.

PURPOSE

To review the role of military mental health professionals working with psychiatric patients at a combat hospital and aeromedical staging facility in Iraq.

SOURCE OF INFORMATION

Military operating instructions, existing theoretical and research literature, and personal experiences of the authors while deployed to Iraq.

CONCLUSIONS

Psychiatric screening can help reduce risk in potentially unstable mental health patients prior to aeromedical evacuation. Civilian nurse psychotherapists and advanced practice psychiatric nurses will be needed to provide psychiatric follow-up care for the large number of military veterans returning from combat.