Spotting—and treating—PTSD in primary care

,; ,

Applied Evidence

Spotting—and treating—PTSD in primary care

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

PDF Download

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.

Suspect PTSD? Start with a 4-question screen

Several brief screening instruments have been developed to minimize the time required to identify patients who have (or have a high likelihood of having) PTSD.^18-20 One of the most useful is the Primary Care PTSD Screen (PC-PTSD) (TABLE 3). This 4-item test was developed for a study of 88 men and women attending general medicine and women’s health clinics at a Veterans Administration (VA) medical center.¹⁸ The questions address the reexperiencing, avoidance/numbing, and hyperarousal that are unique to PTSD.

Using a cutoff score of 3, the PC-PTSD showed 78% sensitivity and 87% specificity compared with the gold standard—the structured diagnostic interview.¹⁸ Other studies have confirmed similar results for the PC-PTSD among primary care patients in both VA and civilian primary care settings (JRF, North American Primary Care Research Group [NAPCRG] annual meeting, November 2009).²¹

Follow up with a more detailed screen or structured interview. A study in a civilian primary care setting found the PC-PTSD to have a positive predictive value (PPV) of 36.7%. Adding a second PTSD screen—the 17-item PTSD symptom checklist, civilian [PCL-C],^22-24 a self-administered test in which the patient rates the severity of a range of symptoms over a specified time period—increased the PPV to 47.3% and the negative predictive value to >99% (JRF, NAPCRG, November 2009).

VA and military settings use such a staged approach. All primary care patients in these settings undergo annual screening with the PC-PTSD, and anyone with a score of 3 or higher undergoes additional evaluation.²⁵ Such an approach might also be valuable in civilian primary care settings.

Some physicians resist the idea of a staged approach to identifying PTSD because of time constraints. This is a legitimate concern, considering that the USPSTF alone recommends nearly 100 areas for doctors to consider for screening or basic intervention.¹⁴ However, we would counter that argument by noting that PTSD often has such a profound impact on the patient’s well-being and overall health that you can’t afford not to conduct screening.

We recommend a systems-based approach, similar to scheduled HbA1C tests, for PTSD: Patients with any of the risk factors described earlier should be screened with the 4-item PC-PTSD; those with positive results on the brief screen should take the 17-item PCL-C. Nurses or other support staff can be trained to administer PTSD screening tests, with physicians following up on positive results.

TABLE 3
The 4-question Primary Care PTSD Screen

In your life, have you ever had any experience that was so frightening, horrible or upsetting that, in the past month, you:*
1. Have had nightmares about it or thought about it when you did not want to?	Yes or No
2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?	Yes or No
3. Were constantly on guard, watchful, or easily startled?	Yes or No
4. Felt numb or detached from others, activities, or your surroundings?	Yes or No
*A score of 3 or higher should prompt additional evaluation.
Source: Prins A et al. Prim Care Psychiatry. 2003.¹⁸

Positive identification of PTSD: Then what?

When screening leads to a diagnosis of PTSD—as it did for both Maureen and Dominic—the first thing you’ll need to do is provide patient education. Talk about the effects of trauma and the fact that PTSD is treatable. Answer questions directly and truthfully, but be calm and reassuring. You may also need to be somewhat directive—for example, stress the importance of adhering to a treatment plan and coming to you, rather than discontinuing treatment, if doubts or difficulties arise.

FAST TRACK

In caring for patients with PTSD, it is more important to listen empathically than to try to “fix” their problems.

An important lesson in caring for patients with PTSD is that it is more important to listen empathically than to try to “fix” their problems. It will often be necessary to provide a referral to psychotherapy—primarily cognitive behavioral therapy (CBT)—and prescribe medication, as well.

Evidence-based psychotherapeutic approaches for PTSD include stress inoculation training, trauma-focused CBT, cognitive processing therapy, eye movement desensitization and reprocessing therapy, and exposure therapy. Using typical treatment protocols, the number needed to treat (NNT) for these proven psychotherapy approaches is approximately 12.²⁶

We recommend that primary care physicians work closely with 1 or more local mental health providers skilled in an evidence-based approach to PTSD; keep in mind, however, that no single form of CBT has been found to be superior to the other approaches.²⁶

Selective serotonin reuptake inhibitors (SSRIs) are first-line agents for both the acute and long-term management of PTSD. (For fluoxetine, paroxetine, or sertraline, the NNT=4-5).^2,27 Research indicates that 12 weeks is the adequate time for a medication trial for a patient with PTSD (vs 6-8 weeks for major depression), and 12 months is the minimal length of medication treatment.^28-30