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PTSD NEEDS TO BE RECOGNIZED IN PRIMARY CARE --

While PTSD is widely recognized today, it often

remains undiagnosed and undertreated.

 

 

Story here... http://www.annals.org/
cgi/content/full/146/8/617

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CURRENT CLINICAL ISSUES

Posttraumatic Stress Disorder Needs to Be Recognized in Primary Care

Jennifer Fisher Wilson

Volume 146 Issue 8 | Pages 617-620

All across the country, military health centers are facing a growing wave of veterans returning from Iraq and Afghanistan who are struggling to readjust to life at home. While the changes wrought by the physical injuries of war are obvious, many veterans' lives have been changed in more subtle ways by the psychological aftereffects. Bomb blasts, gunfire, and the constant threat of danger have left an estimated 15% of veterans with chronic posttraumatic stress disorder (PTSD), a disorder that many people still stigmatize as a sign of weakness or something that veterans should just ignore or get over. However, an anonymous survey of veterans returning from active duty in Iraq or Afganistan noted PTSD as the biggest mental health problem that they were facing (1).

Ignoring PTSD can be disastrous. The disorder manifests as intrusive and unexpected re-experiencing of the initial trauma; avoidance of people, places, activities, or thoughts that trigger traumatic memories; emotional numbing; feelings of being on guard or irritable; and difficulty concentrating. Left untreated, these symptoms can put people at increased risk for suicide, car accidents, job loss, divorce, social isolation, and illness. People with PTSD often develop substance abuse and mental health comorbidities, including heavy smoking, alcohol and drug use, depression, panic disorder, anxiety, and insomnia. They are also more likely to have hypertension, asthma, and chronic pain and frequently experience unexplained symptoms, such as shortness of breath, tremor, palpitations, and nausea.

Studies of Vietnam veterans demonstrated the common co-occurrence of the symptoms of PTSD, which helped to establish it as a syndrome; the diagnosis was first officially recognized in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, in 1980. After the terrorist attacks on 11 September 2001, the diagnosis came to the forefront of civilian mental health. "September 11th brought home the reality that all Americans, not just combat veterans, were potentially vulnerable to the impact of overwhelming, traumatic life events. The key is to be sensitive to the new context for how these symptoms will appear," said Douglas P. Zatzick, MD, an associate professor in the department of psychiatry and behavioral sciences and specialist in PTSD at the University of Washington School of Medicine. An estimated 10% of female and 5% of male U.S. civilians experience PTSD over the course of their lifetimes after trauma exposure (2). Rates vary internationally from as low as 1% to higher than 30% in areas that have experienced chronic civil unrest and violence. Although PTSD can occur in anyone who survives a life-threatening situation, it is especially common in veterans because they experience the psychological trauma of war. Among veterans, those with war injuries, such as amputations, face a particularly high risk for PTSD, as do those with extensive combat experience.

While PTSD is widely recognized today, it often remains undiagnosed and undertreated. The rising demand for all health services, especially mental health services, is stretching the resources of the U.S. Department of Defense health care system and the U.S. Department of Veterans Affairs (VA) health system. A recent task force report from the American Psychological Association found that the U.S. Army and U.S. Navy have failed to fill 40% of their open positions for active duty licensed clinical psychologists, a situation that limits access to services (3). The report also found that only 10% to 20% of the military's mental health experts were trained to help veterans with PTSD.

Veterans are also reluctant to seek help. About 80% of soldiers recently discharged after returning from Iraq have not yet enrolled in the VA system (4), and veterans referred to civilian physicians frequently fail to seek follow-up health care. Diagnosing PTSD can be difficult, especially because the disorder may emerge years after the initial trauma and the symptoms may wax and wane. According to experts on PTSD, symptoms can be missed or misinterpreted as depression or other anxiety disorders. Both pharmacotherapy and psychotherapy can take many weeks to take effect, dose adjustments are often necessary, and poor adherence to PTSD treatment is common.

Available evidence strongly supports the use of selective serotonin reuptake inhibitor (SSRI) medications and psychotherapy approaches in the treatment of PTSD. This evidence is mostly from civilian studies; pharmacologic treatment studies in veteran samples are limited but are growing. The 2004 practice guidelines on PTSD from the American Psychiatric Association are based on available evidence and clinical consensus. "One treats PTSD like one would treat a medical illness, that is, the whole patient and the illness, not only the pathology of the disease. ...Treatment comprises all of the medical approaches to disease, distress, disability, and family needs," said Robert Ursano, MD, chair of the practice guidelines workgroup and chair of the department of psychiatry at the Uniformed Services University of the Health Sciences. In an effort to get a clearer picture on PTSD treatment and prognosis, the VA asked the Institute of Medicine (IOM) to convene a new committee to review the literature on the treatment methods, goals, and practices and to comment on the prognosis of PTSD. At the first meeting of the IOM committee, held earlier this year, experts discussed treatment issues and complicating factors.


Pharmacotherapy


The main goals of pharmacotherapy are to reduce the core symptoms, improve resilience and quality of life, prevent relapse, and treat comorbid disorders. Physicians use a range of drugs, many of them psychiatric, to treat PTSD. Placebo-controlled studies in veterans and civilians alike indicate that SSRIs and selective norepinephrine reuptake inhibitors are the most effective and should be the first line of pharmacotherapy, according to Jonathan Davidson, MD, professor of psychiatry at Duke University Medical Center, who addressed the IOM committee. Positive results—defined as a certain percentage reduction in symptoms and improved quality of life—have occurred in up to 55% of patients treated for 3 months with fluoxetine, paroxetine, sertraline, or venlafaxine, according to some studies. The drugs provided effective treatment for PTSD in patients who had experienced trauma in a variety of situations, not just war, and did so even when the patients had other illnesses. However, the drugs sometimes took several months to achieve maximum effectiveness, and people in remission who stopped using their medication tended to have a relapse. Therefore, Davidson recommends that medication be taken for at least 9 to 12 months to maintain remission. "Three studies show high rates of relapse—up to 50% if medication is stopped within 6 to 12 months of its initiation versus 20% for those who continue treatment. This is consistent for the literature for other anxiety disorders," Davidson said.

The drugs are not effective in all people, and veterans whose PTSD has persisted for many years may be particularly treatment-resistant, according to Davidson. In the past decade, about a dozen small, placebo-controlled trials involving Vietnam veterans with PTSD found mixed results with SSRI treatments. For these and other patients with PTSD who do not respond to first-line treatments, promising second- and third-line treatments are available. The antipsychotic drugs risperidone or olanzapine, when added to SSRI treatment, achieved a therapeutic response in 4 studies involving veterans and no response in another study. Some studies of monoamine oxidase inhibitor monotherapy and tricyclic antidepressant monotherapy also showed promising effects if the medications were taken for at least 2 months. The combination of adrenergic antagonists and agonists with the antihypertensive prazosin seemed to be effective for some patients as well. Medications to treat specific comorbid conditions may also be warranted, such as buproprion for smoking cessation.

Physicians also continue to prescribe benzodiazepines for PTSD, although studies have not found any benefit from benzodiazepine therapy. However, benzodiazepines are not recommended as a principal or sole treatment for the core features of PTSD, and Davidson noted that evidence suggests they may even hinder recovery if given for any length of time in the immediate wake of a traumatic event. He recommended that physicians instead prescribe an SSRI for patients exhibiting panic attacks or other situations that would ordinarily call for a tranquilizer.

Another treatment controversy centers on early intervention to prevent PTSD. Studies have not yet found a clear benefit, and research is sparse. In 1 small study, a 10-day course of the ß-blocker propranolol started within 6 hours after trauma reduced symptoms to the same extent as placebo at 1 month, although the drug was associated with greater reduction in excessive physiologic arousal in response to trauma reminders (5). Investigators have also administered hydrocortisone to see whether it prevents the PTSD that sometimes follows septic shock. One of 9 patients from the hydrocortisone group developed PTSD compared with 7 of 11 patients from the placebo group (6).

Despite the tenuous evidence supporting preventive therapy for PTSD, many experts believe that treatment should be provided as soon as possible if PTSD symptoms or functional impairment have persisted for at least 3 weeks after trauma (7). "Early treatment of PTSD is highly recommended in order to prevent chronicity and the secondary impacts on job and family," Ursano said.


Psychotherapy


In addition to pharmacotherapy, PTSD treatment often encompasses psychotherapy as well. Experts believe that a combination of pharmacotherapy and psychotherapy probably produces the largest response rates in PTSD. However, investigation of the treatment combination in veterans is lacking. Moreover, in clinical practice, pharmacotherapy and psychotherapy are usually delivered by different clinicians. "We need to get a better handle on the relationship between psychotherapy and pharmacotherapy in the treatment of PTSD in general and in veterans," said Rachel Yehuda, PhD, director of the traumatic stress studies division at Mount Sinai School of Medicine and Bronx VA Medical Center, in a presentation to the IOM committee.

Several types of psychotherapy are used to treat PTSD. Cognitive behavioral therapy focuses on changing the distressing thought processes that have an effect on feelings and behaviors. Exposure therapy focuses on confronting traumatic memories. Anxiety management focuses on managing episodes that trigger these memories. Eye movement desensitization reprocessing combines re-experiencing with eye movements or other forms of rhythmic stimulation to modify response to traumatic memories.

Most of the evidence for psychotherapy efficacy in PTSD comes from civilian studies. The research on veterans is sparse, consisting of just a handful of mostly small trials. Little is known about the effects of the PTSD psychotherapy treatments that are actually in use at VA clinics, Yehuda said, mostly because it is hard to convince veterans to participate in a randomized trial when they can receive treatment regardless of their participation in research. "Incentivizing a veteran to participate in a treatment trial where they might be randomized to an inert treatment when they can receive the same treatment without participation, usually by the same VA clinician, is very difficult to do. It is not like asking a patient to participate in a cancer therapy treatment trial, where the patient would not otherwise have access to a new therapy," she said. "As a result, we lack the information about the efficacy of PTSD treatments in war veterans."

The randomized trials in the PTSD literature also often fail to represent real treatment situations because they include only select, ideal patients. For instance, people with alcoholism are often excluded from PTSD trials, but alcoholism is a common comorbid condition in patients with PTSD. "Before treatment policy is formalized, it is necessary to understand the extent to which interventions that have been studied in research patients, who are sometimes free of the kinds of comorbidities that treatment-seeking veterans have, will work on more complicated, and possibly more symptomatic, veterans. If blinded randomized trials are too difficult to perform at a VA, then maybe we can learn more from de-identified VA electronic medical records to track symptoms and treatment responses. This requires trying to use the magnificent VA data resources for information that goes beyond service utilization." Yehuda said.


Complicating Factors in PTSD


Treatment of PTSD in veterans is complicated by other factors. Injuries specific to the war in Iraq and Afghanistan might mean that veterans with PTSD require different interventions than those for civilians. For instance, traumatic brain injury, which can cause severe headaches, mood swings, and long-lasting cognitive and behavioral problems, has been called the signature wound of this war. Fifty-nine percent of blast-exposed patients at Walter Reed Army Medical Center have traumatic brain injury (2), and as of 4 November 2006, blasts were the most common cause of injury among the more than 22,600 U.S. soldiers wounded in the conflicts in Iraq, Afghanistan, and other locations. Researchers have noted that traumatic brain injury might change the manifestations of PTSD, and physicians may need to adjust treatment accordingly.

Compensation claims may interfere with the way in which veterans report treatment response. According to some experts, the current system of providing monthly compensation to veterans with PTSD encourages some patients to exaggerate symptoms and rewards patients for staying sick (8). Data in a 2005 report from the Inspector General of the VA show that this could be a problem in some cases: Between 1999 and 2004, the number of veterans receiving compensation for PTSD grew nearly 7 times as fast as the number of veterans receiving benefits for disabilities in general (9). Veteran PTSD benefit payments in 2004 were $4.3 billion, up from $1.7 billion in 1999, with the increase coming largely from Vietnam veterans seeking treatment decades after their combat experiences, according to the report. "An alternative model would be to also incentivize veterans who take aggressive steps to prevent and treat mental health symptoms or maintain treatment gains," Yehuda said.

Whether today's mental health services for veterans are adequate is an ongoing question. Readjustment counseling services and mental health assessment and treatment are provided to veterans who seek them at individual VA centers and in specialized PTSD programs throughout the United States. However, the growing needs of military personnel have placed a strain on the current military health services system. Access to care can be poor—waiting lists are long, clinics are hard to reach, hours are limited, and the referral process is unreliable, according to a report from the American Psychological Association (3). Access is particularly difficult for service members who are transitioning from active duty to veteran status and for U.S. National Guard and Reserve personnel who live far from military bases. The military has reported that it is trying to make mental health care more readily available, including increasing funding for mental health care, forming specialized treatment centers in locations across the United States, and making plans to integrate primary care and mental health care in its medical facilities and community-based outpatient clinics so that more veterans receive the help that they need.

Today, PTSD is most often treated and managed by mental health professionals, but given that veterans are often reluctant about seeking mental health care, primary care may become a more common route for PTSD treatment. Clinical guidelines have been provided for managing PTSD in primary care (7, 10, 11). As Davidson said, "The opportunities are there, and there is no reason PTSD cannot be treated effectively in primary care."

Sidebar: PTSD Diagnosis in Primary Care

Over time, people with PTSD often turn into heavy users of health care, which opens up ongoing opportunities for screening, diagnosis, and treatment. According to the VA, 90% of visits to private-sector physicians are to primary care providers. Experts on PTSD encourage physicians to ask about recent trauma or loss when patients experience the onset of overwhelming fear or anxiety or develop insomnia. Also, physicians should be alert to extreme behaviors, such as excessive working, increased drinking or smoking, or increased social isolation. "These can be signs of avoiding the angst of the trauma," said Douglas P. Zatzick, MD, a psychiatrist specializing in PTSD at University of Washington School of Medicine.

If PTSD is suspected, Zatzick advises physicians to perform a screening test. He recommends the PTSD checklist developed by the VA National Center for PTSD, among others (12). A gold standard for both military veteran and civilian trauma survivors is the Clinician-Administered PTSD Scale (CAPS) (13). The CAPS diagnostic interview provides an idea of the severity of PTSD, as well as whether it is acute or chronic.

More information on PTSD screening tools is available from the VA National Center for PTSD Web site at
 http://www.ncptsd.va.gov/ncmain/
assessment/ptsd_screening.jsp.


Author and Article Information

Potential Financial Conflicts of Interest: None disclosed.

E-mail: jenwilson@acponline.org.


References

1. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004;351:13-22. [PMID: 15229303].[Abstract/Free Full Text]

2. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:1048-60. [PMID: 7492257].[Abstract]

3. American Psychological Association Presidential Task Force on Military Deployment Services for Youth, Families and Service Members. The Psychological Needs of U.S. Military Service Members and Their Families: A Preliminary Report. Washington, DC: American Psychological Association; 2007. Accessed at http://www.apa.org/releases/MilitaryDeploymentTaskForceReport.pdf on 6 March 2007.

4. Okie S. Reconstructing lives—a tale of two soldiers. N Engl J Med. 2006;355:2609-15. [PMID: 17182985].[Free Full Text]

5. Pitman RK, Sanders KM, Zusman RM, Healy AR, Cheema F, Lasko NB, et al. Pilot study of secondary prevention of posttraumatic stress disorder with propranolol. Biol Psychiatry. 2002;51:189-92. [PMID: 11822998].[Medline]

6. Schelling G, Briegel J, Roozendaal B, Stoll C, Rothenhäusler HB, Kapfhammer HP. The effect of stress doses of hydrocortisone during septic shock on posttraumatic stress disorder in survivors. Biol Psychiatry. 2001;50:978-85. [PMID: 11750894].[Medline]

7. Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Foa EB, Kessler RC, et al. Consensus statement on posttraumatic stress disorder from the International Consensus Group on Depression and Anxiety. J Clin Psychiatry. 2000(61 Suppl 5):60-6. [PMID: 10761680].[Medline]

8. Frueh BC, Gold PB, de Arellano MA. Symptom overreporting in combat veterans evaluated for PTSD: differentiation on the basis of compensation seeking status. J Pers Assess. 1997;68:369-84. [PMID: 9107014].[Medline]

9. Review of state variances in VA disability compensation payments. Washington, DC: U.S. Department of Veterans Affairs Office of Inspector General; 2005. Accessed at http://www.va.gov/oig/52/reports/2005/VAOIG-05-00765-137.pdf on 6 March 2007.

10. Culpepper L. Social anxiety disorder in the primary care setting. J Clin Psychiatry. 2006(67 Suppl 12):31-7. [PMID: 17092194].[Medline]

11. Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Marshall RD, Nemeroff CB, et al. Consensus statement update on posttraumatic stress disorder from the international consensus group on depression and anxiety. J Clin Psychiatry. 2004(65 Suppl 1):55-62. [PMID: 14728098].[Medline]

12. Weathers FW, Huska JA, Keane TM. The PTSD checklist—civilian version. Boston National Center for PTSD, Boston Veterans Affairs Medical Center; 1991.

13. Blake D, Weathers F, Nagy L, Kaloupek D, Klauminzer G, Charney D, et al. Clinician-Administered PTSD Scale (CAPS). Boston: National Center for PTSD, Behavioral Science Division; 1990.

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Larry Scott  --