Fighting the battle against PTSD
How to detect and treat mental illness in returning veterans
By Jessica Berthold
From the September ACP Hospitalist, copyright © 2008 by the American College of Physicians
Despite film portrayals to the contrary, the typical post-traumatic stress disorder (PTSD) patient doesn’t spend his days tunneling under bed sheets, shooting with his index finger at the foot of the bed.
Instead, a typical case might involve a veteran who works a solitary job where he is able to avoid people, said Barry Fisher, MD, medical director of the behavioral medicine clinic at Highland Drive VA Hospital in Pittsburgh. The man may be socially withdrawn; he may not sleep well and feel tired all the time. But his condition slips under the radar of the outside world.
Test yourself on post-traumatic stress disorder and other mental health presentations in this month’s MKSAP Quiz.
“Then he has a heart attack, and that triggers anxiety, which in turn brings back memories of other traumatic events,” said Dr. Fisher. “So now he and the hospital staff are not only dealing with the heart attack, but with a patient who meets the full criteria for PTSD.”
Such instances may become more common given the recent uptick in soldiers returning from Afghanistan and Iraq with PTSD. Pentagon data indicate that, in 2007, there was a 50% rise in PTSD cases compared with the previous year, while a recent RAND Corp. study found that 20% of returning soldiers (totaling 300,000 troops) have PTSD or depression.
Illustration by David Cutler
While the military screens soldiers for mental health problems at least twice within six months of returning from combat, PTSD can show up several months or years after a person leaves the battlefield, experts said. By that point, the veteran may have left the military health system and be receiving health benefits through an employer or spouse’s plan.
As such, internists in community and Veterans Affairs (VA) hospitals alike must be able to spot and treat PTSD in patients, even when the disorder isn’t immediately apparent.
PTSD in VA hospitals
In the course of treating Iraq war veterans for amputations and chronic wound infections, Robert Dalton, ACP Member, a hospitalist at the Gainesville, Fla. VA Medical Center, has run across several patients with PTSD. Though already diagnosed, they plainly needed more treatment, he said.
“Predominantly, they had an inability to sleep and high anxiety,” Dr. Dalton said. “It was clear they still had some of the classic symptoms and needed some better medication management, like dosage adjustments.”
More often than not, family members spoke up on behalf of the patients, he added.
“I’d be treating a patient with IV antibiotics, and he might casually request something to help him sleep better,” Dr. Dalton said. “But the parent or spouse would take it further and request that he have a psychiatric consult.”
A VA hospitalist might also encounter PTSD in a patient admitted for problems related to alcohol or drug use, as substance abuse is very common among PTSD sufferers, experts said.
One Iraq veteran with alcoholism recently admitted to the Pittsburgh VA had taken too much Tylenol for pain management, which combined with the person’s drinking caused liver failure, noted Lawrence Gerber, ACP Member, a hospitalist whose colleague managed the patient. After being treated for his liver toxicity, the patient was referred to a psychiatrist for suspected PTSD and depression, he said.
A VA hospitalist’s main responsibility regarding a PTSD patient is ensuring that the person gets an in-hospital psychiatric consultation if he is doing poorly, Dr. Gerber noted. If the patient’s medication needs adjustment, the hospitalist must ensure he or she will get follow-up care once discharged, Dr. Dalton said.
PTSD in community hospitals
Mentally ill individuals often neglect their physical health, and so frequently show up at community hospitals for things like overdose, substance abuse, infection complications and chronic disease, noted Edward Arsura, FACP, chief of medicine at Richman University Medical Center in Staten Island, N.Y.
A PTSD sufferer may, for example, drink heavily and contract pneumonia, thus ending up in the hospital. After treating the pneumonia and taking some lab tests, a physician may detect the alcohol problem and arrange for a social worker to speak to the patient, Dr. Arsura said.
“We wouldn’t necessarily send this person to Psychiatry. Pair this with not asking about the military history, and the patient would just move through the system, and the true nature of his illness—the PTSD that drove him to drink—wouldn’t be identified,” Dr. Arsura said.
While community hospitals often screen for depression, they don’t typically screen for PTSD or ask patients whether they have been in the military, said Dr. Arsura, a former VA hospitalist in Salem, Va.
“Do I routinely review the diagnostic criteria for PTSD and ask myself whether the clinical presentation is a manifestation of PTSD? No, I don’t,” Dr. Arsura said. “If a person is manifesting certain behaviors, I do, of course, refer him or her to Psychiatry. But we don’t check the PTSD symptoms on a systematic basis, and that is probably something we should change.”
A first step to uncovering combat-related PTSD in a civilian hospital setting may be as simple as having a question about military service in every patient’s medical history paperwork. Beyond that, the health professional might ask a question or two about a patient’s experience in the war, if he is exhibiting symptoms that send up a warning signal.
“If you discover someone is a veteran and he is having headache and fatigue and there is no easy answer … you should ask a question or two about it.”
“If you discover someone is a veteran and he is having headache and fatigue and there is no easy answer … you should ask a question or two about it,” said Kurt Kroenke, MACP, a professor and mental illness researcher at the Regenstrief Institute in Indianapolis.
That question should get at the specific kind of experience the patient had in the war. PTSD always stems from a traumatic event which involved a real or perceived threat to the self or others, and which caused extreme distress at the time, according to Psychiatry Essentials of Primary Care, a book by Robert Schneider, FACP and James Levenson, MD.
The more intense, drawn-out and recurring the trauma, the more likely it would cause PTSD, the book says. Severe bodily injury or victimization (like torture), and the sudden loss of a loved one are also big predictors of developing PTSD, it says. Many soldiers returning from Iraq and Afghanistan have had these sorts of qualifying experiences, the RAND study found. Half of those surveyed said that a friend had been wounded or killed, 45% saw dead or seriously injured civilians, and 10% required hospitalization for injuries themselves. Indeed, exposure to combat trauma was the single best predictor of PTSD and depression, according to the RAND study.
“If you look at the symptoms of post-traumatic stress disorder in isolation, they might be considered non-specific. But our understanding of them might change if we understand that these symptoms came on following a psychologically stressful event,” said Lt. Col. Michael Jaffee, MD, director of the Defense and Veterans Brain Injury Center, at a State of the Military Health System conference last January.
The most common somatic symptoms of PTSD are fatigue, sleep disturbance, joint pain, memory loss, headache and concentration troubles, according to a 1994 study of Gulf War veterans in the Journal of Psychosomatic Research. The actual defining symptoms, which can be harder to tease out from patients, include re-experiencing the traumatic event(s), avoiding thoughts about the trauma, and being hyperaroused or “on edge.” (See sidebar “Sussing Out the Symptoms” for more detail on PTSD criteria).
“I recommend two screening questions: ‘Do you have recurrent nightmares about the trauma?’ and ‘Do you have vivid daytime memories of the trauma?’” said Wayne Katon, MD, vice chair of psychiatry and behavioral sciences at the University of Washington in Seattle, who has treated veterans. “My clinical experience is that if you don’t have one of these two, you don’t have PTSD.”
Other predisposing factors
Traumatic head injuries that cause a concussion during combat increase the risk of PTSD or depression, too. A January 2008 study in the New England Journal of Medicine found that 44% of soldiers who lost consciousness on the battlefield met the criteria for PTSD three to four months after returning from Iraq, compared with 16% who had other injuries and 9% with no injuries. The rate was 27% for those with concussion who didn’t black out.
“Being knocked unconscious on the battlefield is about as close as you can come to threatening your loss of life,” said study author Col. Charles Hoge, MD, director of psychiatry and neuroscience at Walter Reed Army Institute of Research, during a presentation last January. “There are going to be physiological stress responses, memory and coding of traumatic events in this context, and these can lead to PTSD.”
National Guard and Army Reserve soldiers, who are more likely to wind up using civilian care and insurance, are also more likely than active duty veterans to show signs of mental illness, according to a November 2007 study of Iraq war veterans in the Journal of the American Medical Association. At six months after return, the PTSD rate among active soldiers was 16.7%; for reservists, it was 24.5%. Depression rates were 10.3% and 13%, respectively.
Treating the problem
When an undiagnosed patient screens positive for PTSD, try to “normalize” the condition by explaining it, Dr. Katon said. Patients often think they are going crazy, and a diagnosis can provide relief.
“Tell him that PTSD is a common physiologic response to seeing trauma and terrible things, that it is a disorder precipitated by the stress that he has gone through,” Dr. Katon said. “At the least, the internist should see it as his or her job to do an accurate diagnosis and education of the patient.”
If you decide to refer patients for outpatient counseling, find a psychiatrist or psychologist with experience treating combat trauma, advised experts. Most psychotherapy modalities for PTSD are based on the experience of a single traumatic event, like a rape or murder, rather than the sort of repeat trauma a soldier might experience, the JAMA article noted.
One venue for treatment outside the VA system is Giveanhour.com (www.giveanhour.com), a nonprofit organization of mental health professionals who provide free, confidential counseling to soldiers back from Iraq and Afghanistan. Patients are expected to volunteer for some sort of community service work down the road, in lieu of payment.
For PTSD patients with an alcohol or drug abuse problem, stress that the patient needs to get his or her substance use under control in order for the medication and/or counseling to work, said Dr. Kroenke at the Regenstrief Institute. If you are comfortable prescribing drug treatment, consider the following:
SSRIs. Selective serotonin reuptake inhibitors (SSRIs) are the medication of choice for PTSD, and they perform double duty with the depression that is often comorbid. Because there isn’t a big difference between SSRIs as far as effectiveness, a provider might choose one based on the side effects. “If a (PTSD) patient is agitated and experiencing hyperarousal, or is having trouble sleeping, then I might use a more sedating SSRI like paroxetine,” said Matthew Bair, ACP Member, who works in an Indianapolis primary care VA clinic. “In the VA system, it also depends on your formulary, and that can vary by hospital or clinic. I have also used sertraline, fluoxetine and citalopram.”
Drugs to avoid. Steer clear of the selective norepinephrine reuptake inhibitor bupropion, because it has been known to exacerbate PTSD symptoms in some patients. Some also hesitate to use benzodiazepines like alprazolam for anxiety symptoms because they can make symptoms worse and be addictive, which is an issue since PTSD patients often have substance abuse problems, experts said.
Drug combinations. The alpha-blocker prazosin may help stem nightmares in PTSD sufferers, Dr. Katon said. Trazodone and mirtazapine may also help with insomnia and nightmares, according to Psychiatry Essentials of Primary Care, usually when used with an SSRI. Anticonvulsants are sometimes used as an add-on therapy to treat irritability, while antipsychotics are used with SSRIs to suppress nightmares and flashbacks, said Dr. Fisher.
Sussing out the symptoms
Diagnosing PTSD can be tricky because patients often present with physical complaints—like sleeplessness—that appear with other illnesses. The following hallmark symptoms must have persisted for at least a month after the traumatic event to justify a diagnosis of PTSD, according to Psychiatry Essentials of Primary Care, by Robert Schneider, FACP, and James Levenson, MD (available from ACP Press at www.acponline.org/acppress):
Re-experiences. Often the easiest symptoms to recognize, these are akin to hallucinations based on very real experiences of the sensations and feelings surrounding an event; they also include nightmares, flashbacks and intrusive thoughts.
Avoidance. This is often characterized by isolating oneself, feeling emotionally numb and avoiding thoughts related to the trauma. Avoidance can be difficult to detect, because it involves the patient actively making an effort not to think about or discuss the traumatic event. (A healthy response, by contrast, would be for a patient to acknowledge the difficulty of a traumatic experience, and express that he or she has been able to cope.)
Hyperarousal. This includes jitteriness, hypervigilance, insomnia and irritability. Symptoms such as insomnia and muscle tension are tricky to diagnose because they are easily attributable to other illnesses. If a hospitalist suspects that a patient might have PTSD, s/he should move to a more formal screening mechanism, such as:
- GAD-7. Screens for four anxiety disorders, including PTSD.
- PHQ-9. The standard screen for depression, which is often comorbid with PTSD.
- Military screening questionnaire. The military uses a short, six-item questionnaire that screens for both PTSD and depression.
Here are resources for physicians and patients dealing with PTSD and depression:
Psychiatry Essentials of Primary Care, by Robert Schneider, FACP, and James Levenson, MD.
PIER module on PTSD (ACP Members only).
National Center for PTSD. Provides educational information and resources for patients, providers and families.
Post-Deployment Health Clinical Practice Guideline. Developed by the Department of Defense to assist primary care doctors evaluate and manage post-deployment patients.
PTSD Clinical Practice Guidelines. Developed by the Department of Defense.
Anxiety Disorders Association of America. A non-profit resource for clinicians, patients and the general public.
Give an Hour. A non-profit network of mental health professionals who provide free services to veterans who served in Iraq and Afghanistan.
The National Suicide Prevention Lifeline. 1-800-273-TALK (8255). Veterans should press “1” after being connected. The hotline is available 24 hours a day.
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