Abstract

“Because posttraumatic stress disorder (PTSD) is both prevalent and under recognized, routine primary care-based screening for PTSD has been implemented across the Veterans Health Administration. PTSD is frequently complicated by the presence of comorbid chronic pain, and patients with both conditions have increased symptom severity and poorer prognosis. Our objective was to determine whether the presence of pain affects diagnosis and treatment of PTSD among Department of Veterans Affairs (VA) patients who have a positive PTSD screening test. This retrospective cohort study used clinical and administrative data from six Midwestern VA medical centers. We identified 4,244 VA primary care patients with a positive PTSD screen and compared outcomes for those with and without a coexisting pain diagnosis. Outcomes were three clinically appropriate responses to positive PTSD screening: (1) mental health visit, (2) PTSD diagnosis, and (3) new selective serotonin reuptake inhibitor (SSRI) prescription. We found that patients with coexisting pain had a lower rate of mental health visits than those without pain (hazard ratio: 0.889, 95% confidence interval: 0.821–0.962). There were no significant differences in the rate of PTSD diagnosis or new SSRI prescription between patients with and without coexisting pain.”

Implications

For Practice

Veterans who believe they may be suffering from PTSD or chronic pain should be aware that effective treatments exist for these conditions. They should discuss their symptoms and health concerns with their primary care provider. If after screening and further evaluation veterans receive a PTSD or chronic pain diagnosis, veterans and their clinician should develop a treatment plan. Since the most effective evidence-based therapies for PTSD are usually delivered in mental health settings, after initial diagnosis and treatment, primary care physicians should refer veterans to an appropriate mental health provider. After a patient has received a positive screening test for PTSD and their symptoms have been further evaluated, clinicians should consider managing PTSD through pharmacotherapy and potentially referring patients to psychotherapy. Clinicians should be mindful that recognizing PTSD and distinguishing it from other mental disorders can be difficult even with the aid of screening tools. A prior study found that primary care providers were more likely to label patient distress as depression rather than PTSD as identified by a comprehensive diagnostic interview.

For Policy

VA and policy makers might attempt to identify and address the gap between positive PTSD screenings and follow-up treatment. To identify and address the gap, the VA and policymakers might explore patient preferences and education. Since many veterans do not readily acknowledge their PTSD symptoms or diagnosis, the VA and policy makers might evaluate the effectiveness and scalability of efforts to reduce stigma and increase patient awareness. The VA and policy makers might evaluate whether primary care providers have been given sufficient resources or how administrative procedures can be further streamlined. To reduce false results and increase the accuracy of PTSD diagnoses, the VA and policy makers might consider allocating resources to further study and refine the screening tool.

For Future Research

To improve the accuracy of the PTSD screening tool, further evaluation may be necessary to establish the predicted rate of false positives and negatives. The screening tool may need to be evaluated for its utility in the clinical setting. Researchers should also evaluate the usefulness of the PTSD screening tool for distinguishing symptoms of PTSD from other mental disorders, such as depression. A limitation of this study is that the sample only included veterans who had a positive PTSD diagnosis and a primary care visit 30 days after the positive result. Future research may look to examine the outcomes for veterans who had a positive PTSD screen and did not have a primary care visit within 30 days. Studies are also needed on veterans who did not screen positive for PTSD initially but subsequently received a PTSD diagnosis. An additional limitation is that this study was not able to account for the ongoing efforts across the VA to improve PTSD care. Future research should compare post-screening PTSD evaluation and treatment rates before and after implementation of mental health programs in primary care to further evaluate the effectiveness of the VA’s current efforts. Finally, these findings may not be generalizable to other VA health systems and veteran cohorts. Future studies should use a representative sample. Further research should replicate and extend the current analysis to explore if differences in the type of trauma and physical pain differentially affect PTSD diagnosis and health care utilization.