Elsevier

General Hospital Psychiatry

Volume 22, Issue 4, July–August 2000, Pages 261-269
General Hospital Psychiatry

Psychiatry and primary care
Posttraumatic stress disorder in the primary care medical setting

https://doi.org/10.1016/S0163-8343(00)00080-3Get rights and content

Abstract

Posttraumatic stress disorder (PTSD) is a prevalent disorder that adversely affects 2–5% of the general population. Little is known about PTSD in the primary care setting. The purpose of the present study was to evaluate the utility of a screening instrument for PTSD (the PCL-C) in primary care and to examine comorbidity, disability, and patterns of healthcare utilization among persons with PTSD in this setting. Adult, English-speaking patients attending for routine medical care (N=368) participated in a two-stage screening consisting of the administration of a self-report measure for posttraumatic stress disorder (the PCL-C) followed by a structured diagnostic interview. Current (1-month) prevalence of PTSD was determined, as were current comorbid disorders. Brief functional impairment and disability indices were administered, and healthcare utilization in the prior 6 months was ascertained. 11.8% (standard error 1.7%) of primary care attendees met diagnostic criteria for either full or partial PTSD. Comorbidity with major depression (61% of cases of PTSD) and generalized anxiety disorder (39%) was common, but less so with social phobia (17%) and panic disorder (6%). Substance use disorder comorbidity (22%) was also fairly common. Patients with PTSD reported significantly more functional impairment than patients without mental disorders. Patients with PTSD also made greater use of healthcare resources than not mentally ill patients. PTSD frequently is encountered in primary care, and is associated with considerable functional impairment and healthcare utilization. Comorbidity with other mood and anxiety disorders is extensive. It remains to be seen if greater awareness and more aggressive treatment of PTSD in primary care will lead to improved functioning and reduced (or more appropriate) healthcare utilization. These are topics for further study.

Introduction

Posttraumatic stress disorder (PTSD), although originally felt to be a rare phenomenon afflicting almost exclusively war veterans, has been found to be a remarkably prevalent condition affecting a diverse segment of the general population 1, 2, 3, 4. PTSD has also been noted to be common in specific medical subspecialty samples. Examples include burn victims or their parents 5, 6, surgical trauma patients 7, 8, and survivors of acute adult respiratory distress syndrome [9].

There is also considerable evidence to indicate that greater attention should be paid to the prevalence and impact of PTSD in general medical settings. A recent study in a large health maintenance organization found that 38.6% of patients referred for mental health services met DSM-IV criteria for PTSD [10]. This high percentage of people with PTSD is likely to require treatment throughout the healthcare system. Psychologic trauma, particularly sexual abuse and other forms of criminal victimization such as domestic violence, has been found in numerous studies to be associated with adverse health outcomes and increased healthcare utilization in medical patients 11, 12, 13, 14, 15. PTSD in combat veterans is associated with increased somatic complaints, poorer physical health, and greater healthcare utilization 16, 17, 18, 19, 20.

These observations suggest that it will be important to further study the occurrence and correlates of PTSD in primary care. Patients with other psychiatric disorders (e.g., depression) present more often in medical settings than in mental health clinics [21]. If true of patients with PTSD, then their attendance in primary care might represent an opportunity for identification and intervention. The goals of the present study were to 1) test the utility of a screening measure for identifying cases of PTSD in primary care, and 2) determine the prevalence, clinical correlates (including comorbidity), extent of disability, and patterns of healthcare utilization of patients with PTSD in the primary care setting.

Section snippets

Participants and procedures

Three hundred and sixty-eight attendees to a community-based, University-affiliated primary care clinic in San Diego agreed to participate in this study. This clinic is staffed by family medicine board-eligible physicians, and the patient population is ethnically diverse and predominantly middle class. Patients were approached by an undergraduate research assistant who invited them to participate in a study of “the relationship between physical and mental health.” All patients attending the

Sociodemographic characteristics of the sample

Sociodemographic characteristics of the subjects in the sample are shown in Table 1. There were no significant differences between the interviewed and uninterviewed subjects (test statistics not shown, all P>.05) with the exception of there being a slight preponderance of women in the former (χ2=4.38, df=1, P<.04).

PTSD symptoms and traumatic event types in primary care patients

The distribution of total PCL-C scores in our sample of screened primary care patients (N=367; data unavailable in one subject) is shown in Figure 2. Scores ranged from 17 (the

Discussion

Posttraumatic stress disorder (PTSD) has only in recent years become the subject of much attention by the medical community [31], in part due to the misconception that it is exclusively a disorder of war veterans. We have now come to recognize that PTSD affects a large sector of the population, particularly women 4, 32, 33. In parallel has emerged a relatively independent line of research demonstrating that childhood abuse and adult trauma (e.g., domestic violence) are associated with increased

Acknowledgements

We are grateful to Patrick J. Heagerty PhD of the Department of Biostatics at the University of Washington, Seattle, WA for statistical advice. Thanks also to the staff of the UCSD Mira Mesa Clinic for their cooperation.

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