PTSD in Primary Care
PTSD in Primary Care
Abstract & Commentary
Source: Stein MB, et al. Posttraumatic stress disorder in the primary care setting. Gen Hosp Psychiatry 2000;22:261-269.
Posttraumatic stress disorder (ptsd) occurs in 2-5% of the general population, but little is known regarding its prevalence in the primary care setting. PTSD is especially important in several medical subspecialty samples, including burn victims, surgical trauma patients, and survivors of adult respiratory distress syndrome. A recent study conducted in an HMO found that 38.6% of patients referred for mental health services met DSM-IV criteria for PTSD. The symptoms of PTSD are grouped in clusters. DSM-IV Criteria A requires experiencing or witnessing an event that involved actual or threatened death, or serious injury, with a feeling of intense fear, helplessness, or horror. Criteria B involve re-experiencing the event (i.e., intrusive recollections, distressing dreams, or feeling as if the event was recurring), psychological distress, and/or physiological reactivity upon exposure to stimuli representing the event. Criteria C include avoidance of relevant stimuli and emotional numbing (e.g., avoiding thoughts, activities, places, or people and detachment from others). Finally, Criteria D highlights persistent symptoms of arousal (e.g., difficulty with sleep, hypervigilance, exaggerated startle response). However, PTSD most often is present in a primary care setting with depression, anxiety, physical complaints (e.g., pain, aches, tension), and insomnia, much more often than a consolidated capsule of PTSD symptoms. Increased health care use is common.
The current study included 368 attendees of a community primary care clinic in San Diego, Calif. Participants completed a short set of questionnaires and were asked to complete a follow-up phone interview. The PTSD checklist—Civilian Version (PCL-C)—consists of 17 items linked with DSM-IV criteria for PTSD, with a scale from 1 (not at all) to 5 (extremely); total score from 17-85.1 The study arbitrarily required a score of 4 or above on the following criteria for a positive screen: 1) two Criteria B items; 2) one Criteria C; and 3) one Criteria D. Of the 368, 33 screened positive and 19 were subsequently positive by the phone interview using the Composite International Diagnostic Interview—Short Form (CIDI-SF);2 of the 331 negative by the PCL-C, a random sample of 167 were offered the CIDI-SF interview—113 completed it and only 10 were positive by the CIDI-SF.
No significant differences were found between those who were interviewed compared to those not interviewed. Mean PCL-C scores were 29, with a standard deviation of 12. Overall, 65% of patients reported a history of a traumatic exposure, particularly an accident (19%), witnessing of severe injury/death (15%), molestation (12%), rape (9%), and fire/flood/disaster (9%) being most common. Using the criteria above, the prevalence rate of PTSD (by CIDI-SF) was 11.8% (18), including 11 with comorbid depression and seven with general anxiety disorder. Sensitivity (ability to detect a true positive) of the PCL-C was 0.32 and specificity (ability to detect a true negative) was 0.91. Of those with PTSD, 39% had missed at least one day of work in the past 30 days compared to 5.4% of controls. PTSD patients suffered three times the amount of disability on a structured instrument in terms of work functioning, family/home responsibilities, and social life. Hospitalization for medical problems in the past six months occurred in 16.7% of the PTSD patients and 1.4% of the controls. Limitations include a small sample size, assessment at only one clinic, and potential bias by patients who refused to complete the CIDI-SF, or who were unable to be contacted on follow-up. One important conclusion by Stein and colleagues was that lower cut-off criteria (and/or a score) may be necessary to increase the sensitivity of the PCL-C.
Comment by Donald M. Hilty, MD
As with most illnesses, early intervention is of paramount importance. Acute stress disorder’ (ASD) is used to characterize symptoms occurring in the first four weeks after a trauma. It is critical to make the diagnosis of ASD and immediately begin treatment to prevent a chronic course (i.e., PTSD). One key predictor is the patient’s response in the days immediately after the event: those who are significantly upset and able to talk about it have a more positive outcome than those who are either completely overwhelmed or have repressed the event. ASD and PTSD are best treated with a biopsychosocial plan, including crisis intervention to decrease immediate distress, psychoeducation about the process of recovery, peer and group counseling (in selected cases), individual therapies, and medication. Thus far, only one medication, sertraline (Zoloft), has been approved for PTSD, but it is likely that the other selective serotonin reuptake inhibitors (SSRIs) are equally effective. Sertraline has been shown to reduce re-experiencing, physiological reactivity, and arousal. Other medications used, but not yet studied in controlled trials, include anticonvulsants (e.g., Tegretol, which appears to decrease re-experiencing the trauma), anti-anxiety medications (e.g., Buspar or benzodiazepines, for arousal), and other antidepressants. Since a patient with PTSD often has comorbid major depression, general anxiety, panic attacks, and phobias, treatments are generally carried out in mental health settings.
Methods of identification and management, which are available and tailored to primary care, are sorely needed. The PCL-C is an excellent option that with more study can provide a numeric score with high sensitivity and specificity similar to some other scales (e.g., the Beck Depression Inventory, which has a sensitivity and specificity of approximately 0.8 for detecting depression in primary care).
References
1. Weathers FW, et al. PCL-C for DSM-IV. National Center for PTSD-Behavioral Sciences Division. Boston. 1994.
2. Kessler RC, et al. The World Health Organization Composite International Diagnostic Interview Short Form (CIDI-SF). Int J Methods Psychiatric Res 1998; 7:171-185.
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