Spotting—and treating—PTSD in primary care

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Applied Evidence

Spotting—and treating—PTSD in primary care

J Fam Pract. 2010 February;59(2):75-80

By

John R. Freedy, MD, PhD

Clive D. Brock, MD

Combat, sexual assault, and random violence have left millions of Americans with PTSD. A 4-question screen can help you determine if your patient is among them.

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References

1. US Department of Veterans Affairs. National Center for PTSD. How common is PTSD? Available at: www.ptsd.va.gov/public/pages/how-common-is-ptsd.asp. Accessed January 18, 2010.

2. Freedy JR. Post-traumatic stress disorder. In: Ebell M, ed. Evidence Based Medicine. New York: John Wiley and Sons; in press.

3. Kessler RC. Posttraumatic stress disorder: the burden to the individual and to society. J Clin Psychiatry. 2001;61:4-12.

4. Rape, Abuse & Incest National Network. Statistics. Available at: www.rainn.org/statistics. Accessed January 13, 2010.

5. RAND. Invisible wounds of war. 2008. Available at: www.rand.org/pubs/monograph/MG720. Accessed January 13, 2010.

6. Rheingold AA, Acierno R, Resnick HS. Trauma, PTSD, and health risk behaviors. In: Schnurr PP, Green BL, eds. Trauma and Health: Physical Health Consequences of Exposure to Extreme Stress. Washington, DC: American Psychological Association; 2004.

7. Brock CD, Johnson AH, Koopman RJ, et al. Difficult doctor-patient relationships that cause diagnostic and management dilemmas. J Balint Soc. 2006;33:6-10.

8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR). Washington, DC: American Psychiatric Association; 2000.

9. SJ Morewitz, ed. Domestic Violence and Maternal and Child Health. New York: Kluwer Academic/Plenum Publishers; 2007:224.

10. Freedy JR, Magruder KM, Zoller JS, et al. Traumatic events and mental health in civilian primary care: Implications for training and practice. Fam Med. In press.

11. Breslau N, Chilcoat HD, Kessler RC, et al. Previous exposure to trauma and PTSD effects of subsequent trauma: results from the Detroit Area Survey of Trauma. Am J Psychiatry. 1999;156:902-907.

12. McQuaid JR, Pedrelli P, McCahill ME, et al. Reported trauma, post-traumatic stress disorder and major depression among primary care patients. Psychol Med. 2001;31:1249-1257.

13. Freedy JR, Hobfoll SE. Traumatic Stress: From Theory to Practice. New York: Plenum Publishing; 1995.

14. Freedy JR, Monnier J, Shaw DL. Putting a comprehensive violence curriculum on the fast track. Acad Med. 2001;76:348-350.

15. US Department of Veterans Affairs. National Center for PTSD. Trauma, PTSD, and the primary care provider. Available at: http://www.ptsd.va.gov/professional/pagestrauma-ptsd-provider.asp. Accessed January 15, 2010.

16. Freedy JR, Brock CD, Blue AB, et al. The art of professionalism: being in role as the fundamental skill. J Balint Soc. 2009;37:51-54.

17. Leskin GA, Ruzek JI, Friedman MJ, et al. Effective clinical management of PTSD in primary care settings: screening and treatment options. Prim Care Psychiatry. 1999;5:3-12.

18. Prins A, Ouimette P, Kimerling R, et al. The primary care PTSD screen (PC-PTSD): development and operating characteristics. Prim Care Psychiatry. 2003;9:9-14.

19. Breslau N, Peterson EL, Kessler RC, et al. Short screening scale of DSM-IV posttraumatic stress disorder. Am J Psychiatry. 1999;156:908-911.

20. Meltzer-Brody S, Churchill E, Davidson JRT. Derivation of the SPAN, a brief diagnostic screening test for post-traumatic stress disorder. Psychiatry Res. 1999;88:63-70.

21. Kimerling R, Ouimette P, Prins A, et al. Brief report: utility of a short screening scale for DSM-IV PTSD in primary care. J Gen Intern Med. 2006;21:65-67.

22. PTSD CheckList–Civilian Version (PCL-C) Available at: www.mirecc.va.gov/docs/visn6/3_PTSD_CheckList_and_Scoring.pdf. Accessed January 18, 2010.

23. Ruggiero KJ, Del B, Scotti JR, et al. Psychometric properties of the PTSD Checklist-Civilian Version. J Trauma Stress. 2003;16:495-502.

24. Walker EA, Newman E, Dobie DJ, et al. Validation of the PTSD checklist in an HMO sample of women. Gen Hosp Psychiatry. 2002;24:375-380.

25. National Quality Measures Clearinghouse Brief Summary. Mental health: percent of eligible patients screened at required intervals for PTSD. Available at: http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?doc_id=10208. Accessed January 18, 2010.

26. Benish SG, Imel ZE, Wampold BE. The relative efficacy of bona fine psychotherapies for treating post-traumatic stress disorder: a meta-analysis of direct comparisons. Clin Psychol Rev. 2008;28:746-758.

27. Stein DJ, Ipser JC, Seedat S. Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2006;(1):CD002795.-

28. Veterans Health Administration, Department of Defense. VA/DoD clinical practice guideline for the management of post-traumatic stress. Version 1.0. Washington, DC: Veterans Health Administration, Department of Defense; January 2004. Available at: http://guidelines.gov/summary/summary.aspx?doc_id=5187&nbr=003569&string=PTSD. Accessed January 19, 2010.

29. American Psychiatric Association. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Arlington, VA: American Psychiatric Association; November 2004. Available at: http://guidelines.gov/summary/summary.aspx?doc_id=5954&nbr=003920&string=PTSD. Accessed January 19, 2010.

30. National Collaborating Centre for Mental Health. Post-traumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. London, UK: National Institute for Clinical Excellence (NICE); 2005. Available at: http://guidelines.gov/summary/summary.aspx?doc_id=6850&nbr=004204&string=PTSD. Accessed January 19, 2010.

31. Dietrich AJ, Oxman TE, Burns MR, et al. Application of a depression management office system in community practice: a demonstration. J Am Board Fam Pract. 2003;16:107-114.

32. Dietrich AJ, Oxman TE, Williams JW, et al. Going to scale: re-engineering systems for primary care treatment of depression. Ann Fam Med. 2004;2:1-8.

33. Oxman TE, Dietrich AJ, Schulberg HC. Evidence-based models of integrated management of depression in primary care. Psychiatr Clin North Am. 2005;28:1061-1077.

34. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA. 1995;273:1026-1031.

35. Engel CC, Oxman T, Yamamoto C, et al. RESPECT-Mil: feasibility of a systems-level collaborative care approach to depression and post-traumatic stress disorder in military primary care. Mil Med. 2008;173:935-940.

PRACTICE RECOMMENDATIONS

• Adopt a staged screening approach to PTSD, starting with a validated 4-question screen for patients with risk factors, and following up, as needed, with a longer (17-item) symptom checklist. C

• Prescribe SSRIs as first-line medication for PTSD, augmented by other agents, if necessary, for symptom control. A

• Enhance your ability to recognize and respond to patients with PTSD through continuing education, psychotherapy, participation in a Balint group, and/or expert consultation. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

CASE. Maureen S,* a patient in her late 50s with chronic pain due to severe degenerative disc disease and early-stage chronic obstructive pulmonary disease (COPD) from years of smoking, was referred to me (JRF) 5 years ago after her physician relocated. Because of her chronic health problems, I began scheduling monthly visits. But she rarely followed through on my recommendations, whether for smoking cessation, physical therapy, pain management, or mammography screening. As I got to know Maureen, it was clear that she was chronically depressed and anxious. I began asking her why she didn’t take better care of herself.

Gradually, she provided the answers. Throughout her childhood, Maureen confided, her mother had subjected her to severe corporal punishment. From the time she was 7 until she reached her teens, Maureen’s “uncle” had sexually abused her. As an adult, she’d had a series of abusive relationships. The patient’s poor health and failure to care for herself, I suspected, were related to chronic post-traumatic stress disorder (PTSD).

CASE. Dominic T,* a 46-year-old construction worker, had always been in good health and remained active, both on the job and off. He came to my office (JRF) for the first time because he was “a little down” and suffering from insomnia.

As I examined Dominic and took a medical history, it was easy to understand why. Three months earlier, he had been involved in an industrial explosion. Dominic had sustained burns on his arms, neck, and upper torso; his buddy, who had been working beside him, died. Upon questioning the patient further, I discovered that he was also having nightmares and panic attacks, often triggered by loud noises. I suspected that he, like Maureen, suffered from PTSD.

* Patients’ names and certain details of their cases have been changed to protect their privacy.

The lifetime prevalence of PTSD in the general population is estimated at 7% to 8%, with about 10% of women and 5% of men developing the disorder at some point in their lives.¹ But in primary care settings, where patients often seek medical care related to the situations or experiences that are associated with PTSD, it is generally believed that the rates are 2 to 3 times higher.^2,3

FAST TRACK

Sexual assault is the leading cause of PTSD in women; violence, often combat-related, is the chief cause in men.

In women, rape is the leading cause of PTSD.³ Nearly 13% of US women will be sexually assaulted at some point in their lives,⁴ and 25% to 50% of them will develop PTSD as a result.³ In men, violence—often combat-related—is the No. 1 cause.³

Overall, PTSD costs an estimated $3 billion a year in lost productivity in the United States—similar to that of major depression.³ A more recent estimate, based solely on PTSD among US troops and on the assumption that 15% of those who return from deployment will develop PTSD, projects a 2-year cost of $3.98 billion for this population alone.⁵ Clearly, PTSD is not a condition we can afford to overlook.

Untreated PTSD: The impact is severe

The effect of PTSD on patients, families, and society is profound. Mental health comorbidities, including depression, other anxiety disorders, alcohol abuse, and suicidal ideation commonly complicate treatment.^2,3 PTSD is associated with functional impairment—underachievement in school and work, and relationship difficulties—and behaviors that represent health risks, such as smoking, overeating, inactivity, and nonadherence to treatment. In addition, PTSD often goes hand-in-hand with chronic conditions such as diabetes and COPD.^2,6

While patients with PTSD are often hesitant to talk about psychological symptoms, they often present with vague, and persistent, physical complaints.^2,6 Experienced primary care physicians sometimes discover that their most troubling patients—those who are chronically depressed, anxious, or preoccupied with somatization, and nearly impossible to console—may actually be suffering from chronic PTSD.^3,7

Diagnostic criteria and PTSD risks

There are 6 diagnostic criteria for PTSD (TABLE 1).⁸ In addition to 1 or multiple traumatic precipitating events, the patient must suffer from intrusive thoughts or reactions (re-experiencing), detachment or other withdrawal (avoidance/numbing), and sleep disturbance, hypervigilance, or other disturbing reactions (arousal) as a result. In addition, the symptoms must persist for 1 month or more and impair the patient’s academic, occupational, or social functioning.⁸