Academic journal article Journal of Rehabilitation Research & Development

Does Comorbid Chronic Pain Affect Posttraumatic Stress Disorder Diagnosis and Treatment? Outcomes of Posttraumatic Stress Disorder Screening in Department of Veterans Affairs Primary Care

Academic journal article Journal of Rehabilitation Research & Development

Does Comorbid Chronic Pain Affect Posttraumatic Stress Disorder Diagnosis and Treatment? Outcomes of Posttraumatic Stress Disorder Screening in Department of Veterans Affairs Primary Care

Article excerpt

INTRODUCTION

Posttraumatic stress disorder (PTSD) is both prevalent and underrecognized in primary care. Prior to operations in Iraq and Afghanistan, the point prevalence of PTSD among Department of Veterans Affairs (VA) primary care patients was estimated at 11.5 percent and the diagnosis was recognized by the primary care provider in less than 50 percent of cases [1]. Routine screening with the 4-item Primary Care PTSD Screen (PC-PTSD) has been implemented within the VA system to facilitate early recognition of PTSD [2].

PTSD is frequently complicated by the presence of comorbid chronic pain. Studies of Veterans in all eras since Vietnam have yielded high rates of comorbidity between the two conditions [3-5]. Patients with comorbid PTSD and pain have worse symptom severity, worse prognosis and treatment outcomes, greater levels of disability, worse quality of life, greater levels of psychological distress, and worse maladaptive thinking and coping patterns [6-12]. Theoretical models have postulated underlying vulnerabilities that predispose the development of both chronic pain and PTSD [13] as well as multiple ways in which the two conditions exacerbate and maintain one another [14].

Previous research has shown that co-occurrence of depression and pain is associated with a decreased likelihood that depression will be appropriately diagnosed and treated [15]. This may occur because patients or clinicians prefer to focus on managing physical symptoms [16]. Whether similar effects occur in comorbid PTSD and pain is unknown, but it is plausible given the commonalities between chronic pain and PTSD of avoidant coping style, reduced activity, and social withdrawal that may affect healthcare utilization [14]. Depression management has been the focus of considerable attention in primary care and is now principally managed by generalist providers in primary care. PTSD differs in that it has received less attention in primary care and the most effective evidence-based therapies for PTSD are typically delivered in mental health settings; however, initial diagnosis and treatment or referral usually occur in primary care. Following a positive screen and further evaluation of symptoms, current VA guidelines advise primary care providers to manage PTSD by initiating pharmacotherapy (primarily selective serotonin reuptake inhibitors [SSRIs]) and/or referring to psychotherapy [17].

Our objective was to determine whether coexisting pain affects diagnosis and treatment of PTSD among VA patients who have a positive PTSD screening test in primary care. Based on previous literature on chronic pain and comorbid depression in primary care patients [16], we hypothesized that the presence of pain would predict longer delays in PTSD evaluation and treatment outcomes following positive PTSD screenings in primary care. We evaluated time to mental health visit, time to PTSD diagnosis, and time to new SSRI prescription as our outcomes.

METHODS

This retrospective cohort study included patients receiving care within Veterans Integrated Service Network 11, the VA regional healthcare network serving Michigan, Indiana, and Illinois. Clinical and administrative data were extracted from local databases of six VA medical centers. We included patients who had a positive PTSD screening test between January 1, 2001, and January 1, 2007, and had a primary care visit within 30 days after the positive screening. We excluded patients from this analysis if they had a preexisting PTSD diagnosis (International Classification of Diseases-9th Revision [ICD-9] 309.81) or if they had no primary care visit within 30 days of the positive screening test. Outcomes that occurred up to January 1, 2008, were analyzed.

Measures

VA clinical sites included in this study used the PCPTSD to screen for PTSD in primary care clinics. The PC-PTSD was developed and validated among Veterans seen in outpatient VA primary care clinics and implemented nationally. …

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