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Post-Traumatic Stress Disorder

How Common Is PTSD In Primary Care Settings?

Research suggests PTSD is under-recognized and under-treated.

Post Traumatic Stress Disorder, or PTSD, is a now well-recognized condition, unfortunately largely thanks to the activism of veteran groups as well as increasing gender-based sexual violence awareness. We have a sense that trauma is fairly common, but how common is PTSD, actually?

The authors of the current study in the journal the Harvard Review of Psychiatry, Spottswood, Davydow, and Huang (2017), conducted a systematic meta-analysis to address the question of how common PTSD is, by reviewing data from PTSD statistics in primary care settings. There were careful to avoid poor quality studies, excluded studies which reported on the same data sets, and used similar methods to cull through publications to identify reports with reliable data for analysis.

Of 10,614 titles screened, the authors ultimately included 41 studies for review. There were various approaches used to diagnose PTSD, and a range of prevalance rates in different study groups. For example, some studies used the Structured Clinical Interview, some the Clinician-Adminstered PTSD Scale, and several other reliable and validated tools.

Overall, the average point prevalence (the percentage of people with a condition a given point in time) of PTSD in primary care settings was 12.5%., and in veterans in primary care settings was 24.5%. The lifetime prevalence for PTSD ranged from 14.5% to 48.8% depending on the study.

Risk factors included: being female, for civilian populations; being male, in veteran populations; prior known exposure to violence.

These findings are important because they show higher rates than prior epidemologic surveys, such as the National Comorbidity Survey Replication, which reported that the lifetime prevalance of PTSD in the US is 6.8% and annual prevalence is 3.5% - much lower rates that indicated by the current systematic meta-review.

Aside from from supporting the notion that PTSD is more common that generally though in the general civilian population, there are other implications of these findings. Notably, there needs to be a higher index of suspicion for PTSD in primary care and related settings, a standardized approach to screening and diagnosis, and more consistent approaches to treatment. Failure to recognize this common condition results in unrecognized and unremitting suffering - both for those diagnosed with PTSD, and the many people close to them in their lives, given the terrible impact PTSD often has on relationships.

As has been the case with depression in primary care settings, addressing PTSD in particular and mental health more broadly is required in order to provide proper care for patients, their loved ones, and society in general.

In addition, given my own experience as a psychiatrist, I expect that after PTSD is given proper attention, we will begin to look at how many other psychiatric conditions are under-recognized in primary care settings, including dissociative disorders, somatoform disorders, illness anxiety disorders, eating disorders, substance use disorders (e.g. "alcoholism") and others.

Unfortunately, in my experience as a practicing psychiatrist, many primary care encounters miss crucial opportunities to help people. This is partially due to gaps in training, and partially due to primary care providers being over-worked and having insufficient time to provide comprehensive assessment and care. In addition, it is often challenging from a psychological, emotional and economic point of view to present patients with information they don't want to hear - not the best recipe for getting top ratings on Yelp or ZocDoc.

For example, I've had many clients tell me they discussed very high levels of alcohol use with their medical providers, only to be given superficial advice to cut-back, without substantive diagnostic efforts or discussion of the underlying issues and health risks associated with heavy drinking. The level of denial is striking - and I believe PTSD has some parallels due to persistent issues with shame and avoidance surrounding trauma and its sequelae.

Primary care providers can institute basic screening among their patients, and follow-up in more detail if indicated. PTSD should be on the radar, as over 10% of patients in primary care settings appear to have PTSD at any given time.

References

Spottswood M, Davydow DS, Huang H. (2017). The Prevalence of Posttraumatic Stress Disorder in Primary Care: A Systematic Review. Harvard Review of Psychiatry, May 26.

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