Posttraumatic Stress, Functional Impairment and Service Utilization After Injury: A Public Health Approach
By Expert 48043
PTSD and Comorbid Disorders
Variations in rates of PTSD development have been reported ranging from less than 5% in European survivors of unintentional injuries (eg, motor vehicle crashes, job-related injuries) to 10% to 40% among injured survivors of both intentional (eg, injuries associated with human malice such as physical assaults) and unintentional injuries treated within the acute care setting in the United States, England, and Australia.
Prospective cohort studies suggest that increased symptomatic distress at the time of the trauma, female gender, and a history of emotional disturbance or trauma are consistent predictors of the development of PTSD symptoms in the wake of traumatic injury. Some but not all prior investigation suggests that increasing injury severity might be associated with greater posttraumatic symptomatic distress. One investigation suggests that stimulant intoxication at the time of the traumatic injury might be associated with increased PTSD symptom levels in the year after the injury; alcohol intoxication did not appear to predict or protect against PTSD symptom development.
Depressive symptoms have been shown to frequently co-occur with PTSD in injured trauma survivors. Furthermore, like with other trauma-exposed veterans, refugees, and civilian trauma exposed populations, injured patients with high levels of PTSD and/or depressive symptoms experience somatic symptom amplification. Traumatic bereavement is another clinical syndrome that can occur among injured trauma survivors who experienced the loss of a loved one. Finally, between 20% and 55% of traumas hospitalized on surgical wards are either intoxicated at the time of admission and/or meet diagnostic criteria for current/lifetime substance abuse or dependence.
Data was derived from a prospective cohort study of 101 randomly selected survivors of intentional and unintentional injuries who were hospitalized in the trauma surgery service of an academic level 1 trauma center. Approximately three fourths of the randomly selected patients either had high levels of PTSD/depressive symptoms and/or alcohol/stimulant intoxication at the time of the acute care admission.
Acute Care Screening and Diagnostic Considerations
Injured patients with high levels of acute posttraumatic distress infrequently receive chart-recorded psychiatric diagnoses, in-depth evaluations, or treatment in the acute care medical setting. These findings are consistent with previous reports regarding the detection and treatment of substance abuse disorders in acute care. Although recurrent alcohol use among trauma patients is known to increase the risk of injury recurrence and effective brief interventions exist, acute care providers have been slow to implement routine screening and intervention.
The DSM-IV now contains multiple diagnoses that capture aspects of the symptomatic suffering of injured trauma survivors. Each diagnostic category has advantages and disadvantages when considered in the context of the acute care medical setting. For instance, with regard to PTSD, the symptoms are ubiquitous among injured trauma survivors; however, patients in acute care are frequently symptomatic before the one-month PTSD time duration criteria. The DMS-IV attempted to rectify this problem by including the syndrome of acute stress disorder (ASD) that can be diagnosed between two days and one month after the trauma. Acute stress disorder like PTSD includes intrusive, avoidant, and arousal symptom clusters. Acute stress disorder, however, also requires that the patient experience three dissociative symptoms such as derealization, depersonalization, and amnesia. The difficulty with this requirement in the acute care setting is that common clinical experience, such as receiving opiate analgesics and loss of consciousness that can serve to cloud consciousness and thus make the reporting and assessment of dissociate phenomena challenging. Furthermore, two recent investigations have challenged the notion that the assessment of dissociative symptoms at the time of the trauma add to the prediction of subsequent PTSD; both of these prospective cohort studies with injured trauma survivors demonstrated that PTSD symptoms assessed early on in the days and weeks postinjury were the most parsimonious predictors of PTSD symptom development over the course of the year after injury.
From the vantage point of pragmatic trauma center providers, an entirely new symptom cluster to screen for above and beyond urine and blood toxicologies, PTSD and depressive symptoms, and physical pain raises feasibility and acceptability issues. Requiring pragmatically oriented acute care providers to identify multiple posttraumatic symptom clusters with varying time courses might serve to distract these front-line clinicians from the essential task of screening for trauma survivors at risk. In the acute care medical setting diagnostic clarity and simplification can only serve to enhance multidisciplinary efforts targeting the mental health component of injury control.
PTSD and Functioning and Quality-of-Life Outcomes
Functional status refers to the ability to actively participate in relationships and to perform physically and in specified roles (eg, at work, at home or at school). Investigations of PTSD symptoms have consistently shown an association between the symptoms or posttraumatic stress disorder and impairments in functioning and quality-of-life outcomes.
Three different prospective cohort studies have identified that PTSD is independently associated with a broad spectrum of functional impairment and diminished quality of life among trauma survivors. “Zatzick et al.” followed 101 injured trauma survivors over the course of the year after their injury and assessed functional outcomes with the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). One year after the trauma, patients with PTSD, when compared with patients without PTSD, demonstrated marked functional impairment and diminished well-being. Patients with PTSD demonstrated 10- to 40-point diminishments on the SF-36 subscales; the magnitude of this difference is equivalent to having one or more chronic diseases such as diabetes or arthritis. PTSD remained a strong independent predictor of impairments in the role physical and emotional functioning, pain, vitality, social function, and general and mental health SF-36 domains, even after adjusting for injury type and severity, demographic, and clinical characteristics. Only in the physical function domain did the comparisons between patients with and without PTSD not achieve statistical significance. Thus, at one year after injury, functional impairment was most strongly associated with PTSD.
Findings from two other prospective cohort studies corroborate and extend these data demonstrating a strong independent association between PTSD symptoms and a broad profile of functional impairment. Holbrook et al. assessed PTSD symptoms in a consecutive sample of 1,048 injured trauma survivors. Functional outcome was assessed with the quality of well-being scale that assesses mobility, physical activity, and social activity. Patients with high initial PTSD symptom levels demonstrated significantly diminished global well-being 12 and 18 months after injury hospitalization. Initial PTSD symptoms remained a significant independent predictor of diminished well-being even after adjusting for injury severity, social support, and patient demographic characteristics. In this same study, high levels of depressive symptoms in the acute care setting were also significant independent predictors of diminished well-being 12 and 18 months after the injury. “Michaels et al.” followed 140 adult inpatients prospectively for 6 months after their injury admission. High PTSD symptoms levels were strongly and independently associated with diminished SF-36 general and mental health 6 months after the injury.
Health Service Use and Help-Seeking Behaviors
Few prospective studies of injured trauma survivors have followed health service use among injured patients longitudinally. In the “Zatzick et al.” study that followed 101 injured trauma survivors prospectively, both automated trauma center data and self-reported health service use was used to assess patterns of postinjury visits assessed at one, four, and twelve months after the injury. Self-reported health service use items were adapted from a questionnaire that assessed health service use among patients undergoing cardiology evaluations and procedures.
Automated trauma center data was available to assess how many patients required recurrent inpatient admission. Over the course of the year, 21 of the 101 patients were readmitted to the trauma center. Review of medical records revealed that seven readmission were for scheduled procedures, nine readmissions were for complications of the original injury (eg, recurrent infection), and five of the trauma center readmissions were either for recurrent injuries that occurred while the patient was intoxicated or were clearly related to an undiagnosed psychiatric disorder. For instance, one patient whose original injury occurred when she lost control of her vehicle on the freeway was readmitted to the coronary care unit for a chest pain workup. The hospital discharge summary revealed no cardiac etiology for the chest pain and the patient was discharged from the hospital with a primary diagnosis of anxiety disorder not otherwise specified. Interestingly, one year after the injury, patients who had a second admission to the trauma center for any reason were significantly more likely to meet PTSD symptomatic criteria when compared with patients who had not required a recurrent trauma center admission.
Self-reports of outpatient health service use over the course of the year after the injury were characterized by marked provider heterogeneity. In the first month after the injury, 38% of patients reported visiting a surgical practitioner, 27% an ED, 23% an internist, and 7% a mental health practitioner. Over the course of the year 49% of patients reported visits to surgical outpatient providers and 48% reported visits to general medical providers. Other providers visited included internists, neurologists, obstetricians/gynecologists, nurse practitioners, and practitioners of alternative medicine.
Despite high levels of PTSD, depression, recurrent substance use, and frequent somatic complaints, few patients reported visiting mental health providers. Only 14% of patients reported visiting a mental health practitioner in the year after the trauma. Similarly, only 10% of patients whose alcohol use recurred over the year after the injury reported receiving a substance abuse referral or engaging in substance abuse treatment.
Data from the National Comorbidity Survey (NCS) suggest that patients with PTSD might not access mental health services for a variety of reason. Over 60% of NCS patients reported that they did not seek help because they did not perceive that they had a problem that required treatment. Over 50% of patients reported that they thought they could solve the problem on their own. Perceived lack of effectiveness of mental health services, situational barriers to treatment, and financial barriers were also frequently cited in the NCS as reasons for not seeking treatment among PTSD patients with perceived need.
Our research group asked a similar battery of help-seeking questions to injured trauma survivors 1 year after the injury. Approximately one third of patients reported experiencing a need for care but did not seek treatment. The most common reasons for not seeking treatment were thinking the problem would go away on its own and thinking the problem was not serious enough. Other situational, perceived, and structural barriers to care were also cited as reasons why patients with symptomatic distress did not seek treatment.
These data corroborate the observations derived from the NCS. It appears that along with structural barriers to accessing care, patients’ perceptions of PTSD symptoms contribute to the infrequent accessing of mental health services. It appears that patients have multiple evolving posttraumatic concerns after an injury of which PTSD symptoms and other psychologic symptoms constitute only a small proportion. Because, however, PTSD is independently associated with functional impairment and diminished quality of life as well as marked individual suffering, it remains an important disorder to target for treatment in traumatically injured populations.
In summary, although 50% to 75% of trauma surgery inpatients experience high levels of posttraumatic distress, depression, and/or substance abuse, few symptomatic inpatients receive in-depth evaluations or referrals. Little longitudinal psychosocial care infrastructure exists at acute care centers to facilitate the delivery of mental health evaluation or treatment. As is true for many Americans with psychiatric disorders, it appears that injured patients who suffer from PTSD receive fragmented care and are not engaged in mental health services at strategic postinjury points. Thus, symptomatic patients infrequently access mental health services after hospital discharge.