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IIR 96-030 – HSR&D Study

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IIR 96-030
Post Traumatic Stress Disorder Among VA Ambulatory Care Patients
Avron Spiro III PhD MS
Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA
Bedford, MA
Funding Period: October 1997 - September 2000

BACKGROUND/RATIONALE:
Posttraumatic stress disorder (PTSD) occurs in response to an extreme traumatic stressor. It is estimated that as many as 1 million VA patients who were exposed to combat may have PTSD. VA patients with PTSD recently have been designated as a “Special Emphasis” population for which health care resources are allocated at approximately 14 times those allocated to patients without such chronic, complex, and intensive health care needs (i.e., “Basic Care” groups). Despite recognition of its substantial impact upon VA resources, the extent and means by which PTSD affects health and health care use remain unclear. This study seeks to enhance understanding of both the extent and means by which PTSD affects the health and the health care use of patients in VA ambulatory care. To meet this goal, we build on an ongoing HSR&D project, the Veterans Health Study (VHS), a prospective longitudinal study of 2,425 VA ambulatory care patients.

OBJECTIVE(S):
Posttraumatic stress disorder (PTSD) often afflicts victims of traumatic events such as combat. Growing evidence suggests that PTSD is related to poorer health status and to increased use of health care services. However, the extent of these effects and the means by which they occur remain unclear. The goal of this study is to enhance our understanding of both the extent and means by which PTSD affects the health and the health care use of patients in VA ambulatory care. To meet this goal, we built on an HSR&D service-directed project, the Veterans Health Study (VHS), a prospective longitudinal study of 2,425 male VA ambulatory care patients.

METHODS:
This project consisted of two phases. In Phase 1, we conducted clinical interviews (CAPS) assessing PTSD with 474 patients participating in the VHS at 1-year follow-up (T12). This phase validated a brief 17-item self-report PTSD screening measure (PCL-C) against a PTSD clinical interview diagnosis. We used the results of this validation study to estimate the prevalence of PTSD in VA primary care, and to propose the use of a brief measure (PRIME-MD) as a screen for PTSD in primary care. In Phase 2, we used the PCL-C to examine the impact of PTSD on health status and health care use. We tested the hypotheses that (a) PTSD has a direct effect on health status that is independent of the effects of comorbid medical conditions, depression, and alcohol use, and (b) that controlling for comorbid medical conditions, depression and alcohol use, PTSD has both a direct effect and an indirect effect (through health status) on health care utilization. These hypotheses are being tested using structural equation methods. If, as hypothesized, PTSD exerts direct and indirect effects on health services use, then both quality of care and efficiencies in health services delivery can be improved through appropriate detection, referral, and treatment of PTSD among patients in VA ambulatory care.

FINDINGS/RESULTS:
Phase I is completed. A paper was published in the American Journal of Psychiatry in December 1999 reporting our findings from the baseline survey of the Veterans Health Study, where the screening rate of PTSD (per PCL-C) was found to be 20%. We also examined the comorbidity of depression and alcohol abuse with PTSD, finding substantial overlap for the former, but little for the latter. Among the 474 patients interviewed in Phase 1, 10% were considered to have PTSD. We found that a score of 42 or higher on the PCL-C was most efficient for predicting a diagnosis of PTSD per CAPS. Using this cutpoint, the prevalence of self-reported PTSD among the VHS sample at T12 was 21% (after adjustment for sensitivity and specificity, the prevalence was 14%). This finding has been reported at several scientific meetings, and a paper has been submitted for publication. Also using these interview data, examined the PRIME-MD, a brief screening measure of mental disorders for use in primary care, as a predictor of PTSD, finding that a score of 5 had had excellent sensitivity (0.91) and acceptable specificity (0.54) for detecting current PTSD (per CAPS). This finding is being presented at several scientific meetings in the latter half of 2002. Phase II, using the validated PCL to predict the impact of PTSD on health and health care use, is currently underway. We have determined cutpoints for diagnosing current PTSD among VA primary care patients using two self-report measures, the PTSD Checklist and the PRIME-MD. These brief measures can be used to identify potential cases for more thorough psychiatric examination.

IMPACT:
As VA emphasizes quality of care in ambulatory services, allocates resources based upon special patient populations, and emphasizes the unique needs of patients with PTSD, it becomes increasingly important to understand the extent and means by which PTSD impacts health and health care use. Because PTSD is associated with decrements in health status and increased medical services use, findings from our study will inform VA administrators, policy makers, and planners. With an enhanced understanding of the role PTSD plays in the health status and health care use of ambulatory care patients, VA will be in a better position to plan for resource utilization. In addition to such practical considerations, the scientific contribution of this study resides in its demonstration that traumatic events and the reaction to such events (e.g., PTSD) can and do have long-term health effects.

PUBLICATIONS:

Journal Articles

  1. Chatterjee S, Rath ME, Spiro A, Eisen S, Sloan KL, Rosen AK. Gender differences in veterans health administration mental health service use: effects of age and psychiatric diagnosis. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2009 May 1; 19(3):176-84.
  2. Miller DR, Frayne S, Tripp TJ, Hankin CS, Skinner KM, Sullivan LM. Prevalence of depressive and alcohol abuse symptoms among women VA outpatients who report experiencing sexual assault while in the military. Journal of traumatic stress. 1999 Oct 1; 12(4):601-12.
Book Chapters

  1. Hankin C, Bosse R, Spiro A. Assessment and treatment of retirement stress. In: Innovations in Clinical Practice: A Source Book, Volume 17. Professional Resource Exchange, Inc.; 1999.


DRA: Military and Environmental Exposures
DRE: Diagnosis
Keywords: Primary care, PTSD, Screening
MeSH Terms: Stress Disorders, Post-Traumatic, Primary Health Care, Mass Screening

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