General Hospital Psychiatry 36 (2014) 589–593
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Medical illness burden is associated with greater PTSD service utilization in a nationally representative survey Rebecca K. Sripada, Ph.D. ⁎, Paul N. Pfeiffer, M.D., Marcia Valenstein, M.D., Kipling M. Bohnert, Ph.D. VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC) VA Ann Arbor Health Care System University of Michigan Department of Psychiatry
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Article history: Received 29 June 2014 Revised 11 September 2014 Accepted 12 September 2014 Keywords: National Epidemiologic Survey on Alcohol and Related Conditions NESARC Posttraumatic stress disorder Physical illness Comorbidity
a b s t r a c t Objective: Posttraumatic stress disorder (PTSD) is associated with higher rates of many medical conditions and higher use of medical health care services. Growing evidence suggests that comorbid medical illness in PTSD may in turn be associated with greater use of mental health treatment. However, no study to date has examined the impact of cumulative medical illness burden on PTSD service utilization. Method: Data come from the second wave of the National Epidemiologic Survey on Alcohol and Related Conditions. PTSD was assessed via structured interview, and cumulative medical illness burden was assessed via a survey of medical conditions. Logistic regression modeling examined associations between cumulative medical illness burden and odds of receiving PTSD treatment. Results: In the final sample of 1599 individuals with current PTSD, controlling for demographic characteristics, insurance status, psychiatric comorbidity and PTSD symptom count, higher levels of past-year medical illness were associated with increased odds of receiving past-year treatment for PTSD (odds ratio=1.10, 95% confidence interval=1.01–1.20, P=.029). Conclusions: Greater levels of medical illness are associated with increased odds of PTSD service utilization. Greater medical comorbidity may increase the need for PTSD care by exacerbating symptoms or increase contact with medical services promoting PTSD detection and treatment. Published by Elsevier Inc.
1. Introduction Posttraumatic stress disorder (PTSD) is a serious illness that causes significant psychological distress and functional impairment [1]. In addition to these effects, PTSD is associated with a greater likelihood of suffering from medical conditions and physical health problems [2]. Physical health problems associated with PTSD include circulatory disorders (such as coronary artery disease [3–6], hypertension [7–9], hyperlipidemia [8], hypercholesterolemia [6], stroke [10], angina pectoris [6] and tachycardia [6]), endocrine/metabolic disorders (including diabetes mellitus [6] and obesity [8,9,11,12]), digestive system disorders [6,13] (including stomach ulcer [6], gastritis [6] and noncirrhotic liver disease [6]), musculoskeletal diseases [8,13] including arthritis [6,9], injuries [8,13], neurologic disorders [13], respiratory diseases [13], cancer [14], chronic pain [15], sleep disorders including obstructive sleep apnea [8,9,16–18], and other chronic medical illnesses [4,19–21]. PTSD is also associated with greater levels of physical disability, even after controlling for comorbid medical and psychiatric conditions [22], and confers greater likelihood of all-cause mortality [21]. These associations are present in both veteran [8,9,13] and civilian ⁎ Corresponding author. 2800 Plymouth Road Bldg 16, Ann Arbor MI 48109. Tel.: +1 734 222 7432; fax: +1 734 222 7514. E-mail address: [email protected] (R.K. Sripada). http://dx.doi.org/10.1016/j.genhosppsych.2014.09.007 0163-8343/Published by Elsevier Inc.
[6,22] populations. Thus, a variety of medical conditions and physical disabilities appear to be more prevalent among those with PTSD. PTSD is also associated with higher use of medical services. Across settings, individuals with PTSD utilize health care services to a greater extent than individuals without PTSD [23–29], even after accounting for medical comorbidities and for service access [30]. By some estimates, individuals with PTSD have 91% higher utilization of non-mental-health services (outpatient, emergency and inpatient medical services) than those without mental disorders — a higher rate than that observed with any other mental disorder [23]. Some studies suggest that PTSD may also exacerbate the distress or impairment caused by medical problems, although this relationship may be complex. For example, in a sample of Special Operations Force personnel, PTSD symptoms mediated the impact of somatic symptoms on number of doctor’s visits and self-reported health [29]. However, controlling for medical conditions [31] or pretrauma health service usage [32] may weaken the association between PTSD and health care utilization. Thus, it is possible that PTSD symptoms themselves may not be the cause of greater health care utilization, but rather that there is an underlying mechanism linking medical problems with susceptibility to developing PTSD after trauma exposure. Such individuals may go on to require PTSD treatment. In support of this hypothesis, there is growing evidence to suggest that medical illness may prompt greater use of mental health treatment. According to the Behavioral Model of Health Service Use [33], need
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factors such as poor medical and mental health additively interact with predisposing characteristics and enabling resources to predict service utilization. Several studies have indeed demonstrated that medical conditions lead to greater mental health usage. For instance, poor health is associated with greater likelihood/intensity of mental health care use in National Guard service members [34], primary care patients [35] and VA patients [36], even after adjusting for predisposing, need-based and enabling factors. This relationship appears to hold true for individuals with PTSD [26,37–39], though not in all cases [40]. These associations may persist after controlling for combat exposure [38] and level of PTSD symptomatology [26]. Though the link between medical illness and general mental health care appears to be robust, few studies have investigated the relationship between medical illness and PTSD care specifically. Furthermore, though there is growing interest in the relationship between medical illness and mental health treatment, no study to date has examined this relationship in a nonveteran PTSD sample. Additionally, few studies have examined the cumulative impact of multiple medical conditions on health service utilization. Thus, the current study was designed to assess the relationship between medical illness burden and PTSD service utilization in a nationally representative study. We hypothesized that greater medical illness burden would be associated with greater PTSD treatment utilization, even after controlling for variables that are associated with greater use of health care services. 2. Material and methods 2.1. Sample Data come from the second wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). The NESARC is a two-wave population-based face-to-face survey targeting the adult (18 years and older) civilian population of the United States. The first wave (Wave 1) was conducted from 2001 to 2002, and the second wave (Wave 2) was conducted from 2004 to 2005. A total of 34,653 individuals (86.7% of the original sample) completed Wave 2 [41]. The US Census Bureau and US Office of Management and Budget reviewed the NESARC research protocol and provided full ethical approval. The current study was exempt from institutional review board review because NESARC data are deidentified and publically available. Further detail on the NESARC can be found elsewhere [41,42]. For the present investigation, the sample is the subset of individuals in Wave 2 with current PTSD. The NESARC employed the Alcohol Use Disorder and Associated Disabilities Interview Schedule — DSM-IV (AUDADIS-IV) version, a fully structured diagnostic interview for use by experienced interviewers without clinical training [43]. The PTSD diagnosis derived from AUDADIS-IV has good test–retest reliability (κ= 0.77) and good internal consistency (α= .84) [44]. The PTSD module is closely modeled on the National Institute of Mental Health’s Diagnostic Interview Schedule and the World Health Organization Composite International Diagnostic Interview, which has high concordance with the Clinician-Administered PTSD Scale [45]. The PTSD module began with an inventory of 33 traumatic events that operationalize the DSM-IV stressor criterion. Respondents who had experienced multiple traumatic events were asked to select the worst (“the most distressing”) traumatic event from the list of events they endorsed. Dichotomous DSM-IV criterion symptoms and other criteria that define the disorder, including the subjective response to the event, duration and impairment, were asked in connection with the worst (or single) event. Computerized algorithms that applied the DSM-IV diagnostic definition were used to define cases with current PTSD. From the sample of participants who met criteria for a lifetime diagnosis of PTSD (n=2811), we selected for current PTSD by excluding individuals who indicated that they were not currently experiencing PTSD symptoms. Thus, we excluded individuals who responded affirmatively to the
question, “Since that time bof PTSD onset N BEGAN, have all of those reactions gone away completely?” or to the question, “Since that MOST RECENT time bof PTSD symptoms N BEGAN, have ALL of those reactions gone away completely?” The final sample consisted of 1599 individuals with current PTSD. 2.2. Medical illness burden The NESARC assessed for the past-year presence of 17 medical conditions: arteriosclerosis, hypertension, diabetes, cirrhosis, noncirrhotic liver disease, angina pectoris, tachycardia, myocardial infarction, hypercholesterolemia, heart disease, stomach ulcer, human immunodeficiency virus, AIDS, other sexually transmitted infections, gastritis, arthritis and stroke. Cumulative disease burden was calculated as the sum of all medical conditions (e.g., [31,46]). We counted only the diagnoses that participants stated had been confirmed by a physician. 2.3. Sociodemographic measures Sociodemographic measures included age, sex, race/ethnicity, educational level, marital status and type of health insurance. 2.4. Mental health treatment seeking Respondents were classified as seeking mental health treatment for PTSD in the past year if they answered affirmatively to the question, “Did you go anywhere or see anyone to get help for your b PTSDN reactions in the past 12 months?” All mental health treatment utilization questions in the NESARC were disorder-specific. 2.5. Emergency department utilization Number of emergency department visits was determined from the following question: “In the last 12 months, how many times did you receive medical care or treatment in a hospital emergency room?” 2.6. PTSD symptom count Symptom severity was not directly assessed in the NESARC; therefore, we used PTSD symptom count as a proxy for PTSD severity. Symptom count was generated by summing the number of reexperiencing, avoidance and hyperarousal symptoms endorsed by the participant. 2.7. Statistical analysis Weighted descriptive (i.e., means and percentages) and regression analyses were conducted using Taylor Series Linearization, which takes into account the complex survey design of the NESARC. Logistic regression modeling was performed to examine associations between cumulative medical illness burden and the odds of receiving treatment for PTSD. In addition, models were adjusted for sociodemographic variables that have previously been found to be associated with PTSD [47] and service utilization [27]. The first model estimated the unadjusted, bivariate relationship between medical illness burden and the likelihood of receiving PTSD services. The second model adjusted for age group, sex and race/ethnicity. The third model was an elaboration of the two previous models, with additional adjustment for educational attainment, marital status, insurance status, psychiatric comorbidity and PTSD symptom count. An additional sensitivity analysis adjusted for number of emergency room visits as a proxy for medical service utilization. Logistic regression calculates odds ratios (ORs) as the measure of strength of association, and 95% confidence intervals (CIs) are presented to aid interpretation. In a postestimation step, the method of plotting fractional polynomials was used to further examine the hypothesized association between the number of co-occurring medical conditions and the likelihood of PTSD treatment, especially with regard to potential
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nonlinearity of the relation [48]. All analyses were conducted using Stata Version 11 (StataCorp Stata Statistical Software: Release 11; StataCorp LP, College Station, TX, 2009). 3. Results Table 1 presents demographic characteristics of the final sample, which consisted of 1599 individuals with current PTSD. Of those individuals, 385 (24.1%) sought mental health treatment for PTSD within the past year. The mean number of medical conditions in the full sample was 1.5. Seventy-one percent of the sample was female, 49% was under the age of 45, 71% was white, 84% had graduated high school, 56% was married or cohabiting, and 87% had health insurance. 3.1. Logistic regressions Table 2 depicts results from the logistic regression models estimating the association between cumulative medical disease burden and the odds of receiving past-year PTSD services. In the unadjusted model, greater number of medical diagnoses was associated with greater likelihood of receiving past-year PTSD treatment (OR=1.08, 95% CI= 1.00–1.16, P=.043). This relationship held after adjusting for age group, sex and race/ethnicity (Model 2, OR=1.11, 95% CI=1.00–1.12, P=.009) and after further adjusting for educational attainment, marital status, insurance status, past-year psychiatric comorbidity and PTSD symptom count (Model 3, OR=1.10, 95% CI=1.01–1.20, P=.029). Thus, for each additional medical condition, there was a 10% increase in the odds of receiving treatment for PTSD. This relationship was unchanged after adjusting for number of past-year emergency department visits. In a postestimation step, the method of plotting fractional polynomials was used to examine potential nonlinearity in the association Table 1 Characteristics of the NESARC sample of individuals with current PTSD, total and by PTSD service utilization status (n=1599) Total
Past-year PTSD service utilization Yes
n Total Age group (years) 18–29 30–44 45–64 ≥65 Sex Male Female Race/ethnicity White, non-Hispanic Black, non-Hispanic Hispanic, any race Other Education Less than high school High school graduate Some college Marital status Married/cohabitating Divorced/separated/ widowed Never married Health insurance Uninsured Insured Past-year psychiatric comorbidity Yes No Medical condition mean (S.E.)
Weighted % n
No Weighted % n
Weighted %
1599 100
385 24.1
1214 75.9
223 538 655 183
59 131 182 22
16.2 31.4 46.8 5.5
173 407 473 161
15.8 33.4 37.9 12.9
419 28.7 1180 71.3
90 26.1 295 73.9
329 885
29.6 70.4
941 337 244 77
71.2 13.0 10.1 5.7
241 55 69 20
74.5 9.5 9.4 6.7
700 282 175 57
70.1 14.1 10.4 5.4
287 436 876
16.3 28.1 55.6
70 14.8 82 22.4 233 62.8
217 354 643
16.8 29.9 53.2
733 556
56.2 27.5
178 56.9 135 28.1
555 421
56.0 27.3
310
16.3
72
238
16.7
15.9 32.9 40.1 11.1
15.1
194 12.6 1405 87.4
31 9.3 354 90.7
163 13.6 1051 86.4
1079 65.5 520 34.5 1599 1.5 (0.05)
309 75.9 76 24.1 385 1.7 (0.11)
770 62.1 444 37.9 1214 1.5 (0.06)
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between the number of medical conditions and past-year PTSD treatment. Fig. 1 depicts the fractional polynomial plot of the predicted probability of PTSD treatment in the past year by number of medical conditions. With the exception at the higher end of the medical comorbidity distribution, where sparse data created wide confidence bounds, the figure depicts a relatively consistent linear increase in the predicted probability of PTSD treatment with each additional medical condition. 4. Discussion We examined the relationship between cumulative medical illness burden and PTSD health service utilization in a nationally representative sample and found that greater medical illness burden in individuals with PTSD increased the likelihood of past-year mental health service utilization. This is consistent with prior research linking medical health problems to increased mental health treatment seeking [26,34,35,37–39,49]. To our knowledge, this is the first demonstration of this linkage in a civilian sample and the first to show an association between medical illness burden and treatment for PTSD specifically, rather than with general mental health care. These findings also indicate that greater medical illness burden might increase the need for PTSD care among those in the general population with the disorder. Our results suggest that greater PTSD service utilization is related to the general burden of poor medical health. Previous research suggests that the cumulative burden of multiple medical conditions may be more significant than the type of medical conditions present. For example, a recent meta-analysis of the relationship between depression and mortality found that depression-related mortality did not differ across medical disease groups [50]. The authors suggested that the association between depression and mortality may be better explained by generic mechanisms, such as biological dysregulation and lifestyle factors, rather than by disorder-specific mechanisms [50]. The same may well be true for PTSD. Further research is needed to assess the impact of individual conditions versus cumulative disease burden on PTSD symptomatology. There are several potential mechanistic explanations for the association between medical conditions and PTSD. One possible link is shared etiology. For instance, trauma may cause physical injury in addition to leading to the development of PTSD [51]. Furthermore, it is well recognized that psychiatric disorders cause somatic symptoms in addition to psychological distress (e.g. [52]). Some have suggested that individuals with PTSD may consciously or unconsciously somaticize their stress in lieu of discussing or presenting to treatment with psychological symptoms [20,25], though this may not explain associations with certain medical conditions. Another explanation that has arisen to describe the pervasive medical burden associated with PTSD is the concept of allostatic load. Allostatic load is the cumulative wear and tear on the body that is caused by chronic stress [53]. Several researchers have posited that PTSD may cause biological changes that lead to medical conditions through increased allostatic load. For instance, PTSD may negatively impact cardiovascular reactivity, autonomic hyperarousal, disturbed sleep physiology, adrenergic dysregulation, altered thyroid function or altered hypothalamic–pituitary–adrenal activity, leading to downstream medical illness [54]. In support of this hypothesis, some studies suggest that the link between PTSD and medical disease burden strengthens over time, such that PTSD is associated with a greater number of medical conditions the longer one has had PTSD [31,55]. Thus, PTSD may confer lasting abnormalities in physical function. Conversely, medical illness may worsen PTSD. For instance, physical symptoms have been associated with more severe PTSD [56], and it is plausible that medical illness could add to the burden of distress or functional impairment caused by PTSD symptoms. Medical illness may also decrease tolerance for PTSD symptoms. Additional support for a shared underlying mechanism comes from the fact that treating medical illness may impact mental health. For example, treating obstructive sleep
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Table 2 ORs and CIs estimating associations between medical comorbidity and past-year treatment for PTSD Model 1a
Medical comorbidity a b c
Model 2b
P
OR
95% CI
1.08
1.00–1.16
.043
OR
95% CI
1.11
1.03–1.21
.009
Model 3c
P
OR
95% CI
1.10
1.01–1.20
.029
Model 1 is unadjusted. Model 2 is adjusted for age group, sex and race/ethnicity. Model 3 is adjusted for age, sex, race/ethnicity, education, marital status, insurance status, past-year psychiatric comorbidity and symptom count.
0
.1
.2
.3
.4
.5
.6
apnea with medical interventions (continuous positive airway pressure) reduces symptoms of PTSD [57,58]. Thus, medical illness and PTSD may have a synergistic relationship that exacerbates both physical and psychological ill health. Another potential explanation linking medical comorbidity to PTSD treatment is the issue of access. Participating in medical treatment may improve detection of mental health problems and referral for treatment [34]. Additionally, the experience of previously navigating the health care system for the treatment of medical conditions may enable individuals to access mental health care with greater confidence. Thus, previous experience may facilitate mental health care use in individuals with medical conditions. Future work should explore the ways in which medical comorbidity increases the need for care or facilitates access to care. There are several limitations to the current study. Though we controlled for PTSD symptom count in our analyses, we were not able to measure severity of PTSD from the information provided by the AUDADIS-IV; thus, conclusions regarding symptom severity as a potential factor influencing the relationship between medical illness and PTSD treatment remain speculative. Similarly, we analyzed cumulative illness burden via a count of medical illnesses but could not assess severity of medical illness. Additionally, the NESARC survey used retrospective data, potentially reducing the accuracy of recall. Furthermore, the cross-sectional design of this study prevents any determination of causality in the relationship between medical illness burden and mental health service utilization. An additional limitation of our study is that the PTSD treatment utilization measure was dichotomous. Alternative measures of mental health utilization, such as those derived from electronic medical records, could provide richer data and potentially provide more information on the association between medical illness and mental health treatment utilization.
Predicted PTSD Treatment
P
0
2
4
6
8
Number of Medical Conditions 95% CI
Predicted PTSD Treatment
Fig. 1. Predicted probability of PTSD treatment in the past year by number of medical conditions.
5. Conclusions We undertook an investigation of the link between cumulative pastyear medical illness burden and past-year PTSD service utilization and found that, controlling for demographic characteristics and insurance status, medical illness burden was associated with increased likelihood of PTSD service use. Medical illness burden may improve access to care or increase the need for care. Given that those who seek treatment are likely to have a number of medical conditions, PTSD treatment providers should assess for medical needs and make appropriate referrals. Additionally, outreach efforts may be particularly needed to reach individuals with PTSD who are otherwise in good health or who do not access medical care on a regular basis. Acknowledgments The NESARC was conducted and funded by the National Institute on Alcohol Abuse and Alcoholism, with supplemental support from the National Institute on Drug Abuse. We thank the National Institute on Alcohol Abuse and Alcoholism and the US Census Bureau field representatives who administrated the NESARC interviews and made it available for researchers. Writing of this manuscript was supported by the Department of Veterans Affairs Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, the Veterans Affairs Ann Arbor Health Care System and the Veterans Affairs Serious Mental Illness Treatment Resource and Evaluation Center, and the Department of Veterans Affairs, Health Services Research and Development Service Grant CDA 11-245 (KMB). References [1] APA. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: Author; 2013. [2] Pacella ML, Hruska B, Delahanty DL. The physical health consequences of PTSD and PTSD symptoms: a meta-analytic review. J Anxiety Disord 2013;27:33–46. [3] Boscarino JA, Chang J. Electrocardiogram abnormalities among men with stressrelated psychiatric disorders: implications for coronary heart disease and clinical research. Ann Behav Med 1999;21:227–34. [4] Kang HK, Bullman TA, Taylor JW. Risk of selected cardiovascular diseases and posttraumatic stress disorder among former World War II prisoners of war. Ann Epidemiol 2006;16:381–6. [5] Kubzansky LD, Koenen KC, Spiro III A, Vokonas PS, Sparrow D. Prospective study of posttraumatic stress disorder symptoms and coronary heart disease in the Normative Aging Study. Arch Gen Psychiatry 2007;64:109–16. [6] Pietrzak RH, Goldstein RB, Southwick SM, Grant BF. Medical comorbidity of full and partial posttraumatic stress disorder in US adults: results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Psychosom Med 2011; 73:697–707. [7] Pratt L, Gonzalez A, Kotov R, Luft BJ. PTSD and risk for hypertension: a longitudinal analysis in WTC responders. Compr Psychiatry 2013;54:e33. [8] Frayne SM, Chiu VY, Iqbal S, Berg EA, Laungani KJ, Cronkite RC, et al. Medical care needs of returning veterans with PTSD: their other burden. J Gen Intern Med 2011;26:33–9. [9] Pugh MJ, Finley EP, Copeland LA, Wang CP, Noel PH, Amuan ME, et al. Complex comorbidity clusters in OEF/OIF veterans: the polytrauma clinical triad and beyond. Med Care 2014;52:172–81. [10] Lambiase MJ, Kubzansky LD, Thurston RC. Prospective study of anxiety and incident stroke. Stroke 2014;45:438–43. [11] Mitchell KS, Aiello AE, Galea S, Uddin M, Wildman D, Koenen KC. PTSD and obesity in the Detroit neighborhood health study. Gen Hosp Psychiatry 2013;35:671–3. [12] Kubzansky LD, Bordelois P, Jun HJ, Roberts AL, Cerda M, Bluestone N, et al. The weight of traumatic stress: a prospective study of posttraumatic stress disorder symptoms and weight status in women. JAMA Psychiatry 2014;71:44–51.
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Medical illness burden is associated with greater PTSD service utilization in a nationally representative survey Rebecca K. Sripada, Ph.D. ⁎, Paul N. Pfeiffer, M.D., Marcia Valenstein, M.D., Kipling M. Bohnert, Ph.D. VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC) VA Ann Arbor Health Care System University of Michigan Department of Psychiatry
a r t i c l e
i n f o
Article history: Received 29 June 2014 Revised 11 September 2014 Accepted 12 September 2014 Keywords: National Epidemiologic Survey on Alcohol and Related Conditions NESARC Posttraumatic stress disorder Physical illness Comorbidity
a b s t r a c t Objective: Posttraumatic stress disorder (PTSD) is associated with higher rates of many medical conditions and higher use of medical health care services. Growing evidence suggests that comorbid medical illness in PTSD may in turn be associated with greater use of mental health treatment. However, no study to date has examined the impact of cumulative medical illness burden on PTSD service utilization. Method: Data come from the second wave of the National Epidemiologic Survey on Alcohol and Related Conditions. PTSD was assessed via structured interview, and cumulative medical illness burden was assessed via a survey of medical conditions. Logistic regression modeling examined associations between cumulative medical illness burden and odds of receiving PTSD treatment. Results: In the final sample of 1599 individuals with current PTSD, controlling for demographic characteristics, insurance status, psychiatric comorbidity and PTSD symptom count, higher levels of past-year medical illness were associated with increased odds of receiving past-year treatment for PTSD (odds ratio=1.10, 95% confidence interval=1.01–1.20, P=.029). Conclusions: Greater levels of medical illness are associated with increased odds of PTSD service utilization. Greater medical comorbidity may increase the need for PTSD care by exacerbating symptoms or increase contact with medical services promoting PTSD detection and treatment. Published by Elsevier Inc.
1. Introduction Posttraumatic stress disorder (PTSD) is a serious illness that causes significant psychological distress and functional impairment [1]. In addition to these effects, PTSD is associated with a greater likelihood of suffering from medical conditions and physical health problems [2]. Physical health problems associated with PTSD include circulatory disorders (such as coronary artery disease [3–6], hypertension [7–9], hyperlipidemia [8], hypercholesterolemia [6], stroke [10], angina pectoris [6] and tachycardia [6]), endocrine/metabolic disorders (including diabetes mellitus [6] and obesity [8,9,11,12]), digestive system disorders [6,13] (including stomach ulcer [6], gastritis [6] and noncirrhotic liver disease [6]), musculoskeletal diseases [8,13] including arthritis [6,9], injuries [8,13], neurologic disorders [13], respiratory diseases [13], cancer [14], chronic pain [15], sleep disorders including obstructive sleep apnea [8,9,16–18], and other chronic medical illnesses [4,19–21]. PTSD is also associated with greater levels of physical disability, even after controlling for comorbid medical and psychiatric conditions [22], and confers greater likelihood of all-cause mortality [21]. These associations are present in both veteran [8,9,13] and civilian ⁎ Corresponding author. 2800 Plymouth Road Bldg 16, Ann Arbor MI 48109. Tel.: +1 734 222 7432; fax: +1 734 222 7514. E-mail address: [email protected] (R.K. Sripada). http://dx.doi.org/10.1016/j.genhosppsych.2014.09.007 0163-8343/Published by Elsevier Inc.
[6,22] populations. Thus, a variety of medical conditions and physical disabilities appear to be more prevalent among those with PTSD. PTSD is also associated with higher use of medical services. Across settings, individuals with PTSD utilize health care services to a greater extent than individuals without PTSD [23–29], even after accounting for medical comorbidities and for service access [30]. By some estimates, individuals with PTSD have 91% higher utilization of non-mental-health services (outpatient, emergency and inpatient medical services) than those without mental disorders — a higher rate than that observed with any other mental disorder [23]. Some studies suggest that PTSD may also exacerbate the distress or impairment caused by medical problems, although this relationship may be complex. For example, in a sample of Special Operations Force personnel, PTSD symptoms mediated the impact of somatic symptoms on number of doctor’s visits and self-reported health [29]. However, controlling for medical conditions [31] or pretrauma health service usage [32] may weaken the association between PTSD and health care utilization. Thus, it is possible that PTSD symptoms themselves may not be the cause of greater health care utilization, but rather that there is an underlying mechanism linking medical problems with susceptibility to developing PTSD after trauma exposure. Such individuals may go on to require PTSD treatment. In support of this hypothesis, there is growing evidence to suggest that medical illness may prompt greater use of mental health treatment. According to the Behavioral Model of Health Service Use [33], need
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factors such as poor medical and mental health additively interact with predisposing characteristics and enabling resources to predict service utilization. Several studies have indeed demonstrated that medical conditions lead to greater mental health usage. For instance, poor health is associated with greater likelihood/intensity of mental health care use in National Guard service members [34], primary care patients [35] and VA patients [36], even after adjusting for predisposing, need-based and enabling factors. This relationship appears to hold true for individuals with PTSD [26,37–39], though not in all cases [40]. These associations may persist after controlling for combat exposure [38] and level of PTSD symptomatology [26]. Though the link between medical illness and general mental health care appears to be robust, few studies have investigated the relationship between medical illness and PTSD care specifically. Furthermore, though there is growing interest in the relationship between medical illness and mental health treatment, no study to date has examined this relationship in a nonveteran PTSD sample. Additionally, few studies have examined the cumulative impact of multiple medical conditions on health service utilization. Thus, the current study was designed to assess the relationship between medical illness burden and PTSD service utilization in a nationally representative study. We hypothesized that greater medical illness burden would be associated with greater PTSD treatment utilization, even after controlling for variables that are associated with greater use of health care services. 2. Material and methods 2.1. Sample Data come from the second wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). The NESARC is a two-wave population-based face-to-face survey targeting the adult (18 years and older) civilian population of the United States. The first wave (Wave 1) was conducted from 2001 to 2002, and the second wave (Wave 2) was conducted from 2004 to 2005. A total of 34,653 individuals (86.7% of the original sample) completed Wave 2 [41]. The US Census Bureau and US Office of Management and Budget reviewed the NESARC research protocol and provided full ethical approval. The current study was exempt from institutional review board review because NESARC data are deidentified and publically available. Further detail on the NESARC can be found elsewhere [41,42]. For the present investigation, the sample is the subset of individuals in Wave 2 with current PTSD. The NESARC employed the Alcohol Use Disorder and Associated Disabilities Interview Schedule — DSM-IV (AUDADIS-IV) version, a fully structured diagnostic interview for use by experienced interviewers without clinical training [43]. The PTSD diagnosis derived from AUDADIS-IV has good test–retest reliability (κ= 0.77) and good internal consistency (α= .84) [44]. The PTSD module is closely modeled on the National Institute of Mental Health’s Diagnostic Interview Schedule and the World Health Organization Composite International Diagnostic Interview, which has high concordance with the Clinician-Administered PTSD Scale [45]. The PTSD module began with an inventory of 33 traumatic events that operationalize the DSM-IV stressor criterion. Respondents who had experienced multiple traumatic events were asked to select the worst (“the most distressing”) traumatic event from the list of events they endorsed. Dichotomous DSM-IV criterion symptoms and other criteria that define the disorder, including the subjective response to the event, duration and impairment, were asked in connection with the worst (or single) event. Computerized algorithms that applied the DSM-IV diagnostic definition were used to define cases with current PTSD. From the sample of participants who met criteria for a lifetime diagnosis of PTSD (n=2811), we selected for current PTSD by excluding individuals who indicated that they were not currently experiencing PTSD symptoms. Thus, we excluded individuals who responded affirmatively to the
question, “Since that time bof PTSD onset N BEGAN, have all of those reactions gone away completely?” or to the question, “Since that MOST RECENT time bof PTSD symptoms N BEGAN, have ALL of those reactions gone away completely?” The final sample consisted of 1599 individuals with current PTSD. 2.2. Medical illness burden The NESARC assessed for the past-year presence of 17 medical conditions: arteriosclerosis, hypertension, diabetes, cirrhosis, noncirrhotic liver disease, angina pectoris, tachycardia, myocardial infarction, hypercholesterolemia, heart disease, stomach ulcer, human immunodeficiency virus, AIDS, other sexually transmitted infections, gastritis, arthritis and stroke. Cumulative disease burden was calculated as the sum of all medical conditions (e.g., [31,46]). We counted only the diagnoses that participants stated had been confirmed by a physician. 2.3. Sociodemographic measures Sociodemographic measures included age, sex, race/ethnicity, educational level, marital status and type of health insurance. 2.4. Mental health treatment seeking Respondents were classified as seeking mental health treatment for PTSD in the past year if they answered affirmatively to the question, “Did you go anywhere or see anyone to get help for your b PTSDN reactions in the past 12 months?” All mental health treatment utilization questions in the NESARC were disorder-specific. 2.5. Emergency department utilization Number of emergency department visits was determined from the following question: “In the last 12 months, how many times did you receive medical care or treatment in a hospital emergency room?” 2.6. PTSD symptom count Symptom severity was not directly assessed in the NESARC; therefore, we used PTSD symptom count as a proxy for PTSD severity. Symptom count was generated by summing the number of reexperiencing, avoidance and hyperarousal symptoms endorsed by the participant. 2.7. Statistical analysis Weighted descriptive (i.e., means and percentages) and regression analyses were conducted using Taylor Series Linearization, which takes into account the complex survey design of the NESARC. Logistic regression modeling was performed to examine associations between cumulative medical illness burden and the odds of receiving treatment for PTSD. In addition, models were adjusted for sociodemographic variables that have previously been found to be associated with PTSD [47] and service utilization [27]. The first model estimated the unadjusted, bivariate relationship between medical illness burden and the likelihood of receiving PTSD services. The second model adjusted for age group, sex and race/ethnicity. The third model was an elaboration of the two previous models, with additional adjustment for educational attainment, marital status, insurance status, psychiatric comorbidity and PTSD symptom count. An additional sensitivity analysis adjusted for number of emergency room visits as a proxy for medical service utilization. Logistic regression calculates odds ratios (ORs) as the measure of strength of association, and 95% confidence intervals (CIs) are presented to aid interpretation. In a postestimation step, the method of plotting fractional polynomials was used to further examine the hypothesized association between the number of co-occurring medical conditions and the likelihood of PTSD treatment, especially with regard to potential
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nonlinearity of the relation [48]. All analyses were conducted using Stata Version 11 (StataCorp Stata Statistical Software: Release 11; StataCorp LP, College Station, TX, 2009). 3. Results Table 1 presents demographic characteristics of the final sample, which consisted of 1599 individuals with current PTSD. Of those individuals, 385 (24.1%) sought mental health treatment for PTSD within the past year. The mean number of medical conditions in the full sample was 1.5. Seventy-one percent of the sample was female, 49% was under the age of 45, 71% was white, 84% had graduated high school, 56% was married or cohabiting, and 87% had health insurance. 3.1. Logistic regressions Table 2 depicts results from the logistic regression models estimating the association between cumulative medical disease burden and the odds of receiving past-year PTSD services. In the unadjusted model, greater number of medical diagnoses was associated with greater likelihood of receiving past-year PTSD treatment (OR=1.08, 95% CI= 1.00–1.16, P=.043). This relationship held after adjusting for age group, sex and race/ethnicity (Model 2, OR=1.11, 95% CI=1.00–1.12, P=.009) and after further adjusting for educational attainment, marital status, insurance status, past-year psychiatric comorbidity and PTSD symptom count (Model 3, OR=1.10, 95% CI=1.01–1.20, P=.029). Thus, for each additional medical condition, there was a 10% increase in the odds of receiving treatment for PTSD. This relationship was unchanged after adjusting for number of past-year emergency department visits. In a postestimation step, the method of plotting fractional polynomials was used to examine potential nonlinearity in the association Table 1 Characteristics of the NESARC sample of individuals with current PTSD, total and by PTSD service utilization status (n=1599) Total
Past-year PTSD service utilization Yes
n Total Age group (years) 18–29 30–44 45–64 ≥65 Sex Male Female Race/ethnicity White, non-Hispanic Black, non-Hispanic Hispanic, any race Other Education Less than high school High school graduate Some college Marital status Married/cohabitating Divorced/separated/ widowed Never married Health insurance Uninsured Insured Past-year psychiatric comorbidity Yes No Medical condition mean (S.E.)
Weighted % n
No Weighted % n
Weighted %
1599 100
385 24.1
1214 75.9
223 538 655 183
59 131 182 22
16.2 31.4 46.8 5.5
173 407 473 161
15.8 33.4 37.9 12.9
419 28.7 1180 71.3
90 26.1 295 73.9
329 885
29.6 70.4
941 337 244 77
71.2 13.0 10.1 5.7
241 55 69 20
74.5 9.5 9.4 6.7
700 282 175 57
70.1 14.1 10.4 5.4
287 436 876
16.3 28.1 55.6
70 14.8 82 22.4 233 62.8
217 354 643
16.8 29.9 53.2
733 556
56.2 27.5
178 56.9 135 28.1
555 421
56.0 27.3
310
16.3
72
238
16.7
15.9 32.9 40.1 11.1
15.1
194 12.6 1405 87.4
31 9.3 354 90.7
163 13.6 1051 86.4
1079 65.5 520 34.5 1599 1.5 (0.05)
309 75.9 76 24.1 385 1.7 (0.11)
770 62.1 444 37.9 1214 1.5 (0.06)
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between the number of medical conditions and past-year PTSD treatment. Fig. 1 depicts the fractional polynomial plot of the predicted probability of PTSD treatment in the past year by number of medical conditions. With the exception at the higher end of the medical comorbidity distribution, where sparse data created wide confidence bounds, the figure depicts a relatively consistent linear increase in the predicted probability of PTSD treatment with each additional medical condition. 4. Discussion We examined the relationship between cumulative medical illness burden and PTSD health service utilization in a nationally representative sample and found that greater medical illness burden in individuals with PTSD increased the likelihood of past-year mental health service utilization. This is consistent with prior research linking medical health problems to increased mental health treatment seeking [26,34,35,37–39,49]. To our knowledge, this is the first demonstration of this linkage in a civilian sample and the first to show an association between medical illness burden and treatment for PTSD specifically, rather than with general mental health care. These findings also indicate that greater medical illness burden might increase the need for PTSD care among those in the general population with the disorder. Our results suggest that greater PTSD service utilization is related to the general burden of poor medical health. Previous research suggests that the cumulative burden of multiple medical conditions may be more significant than the type of medical conditions present. For example, a recent meta-analysis of the relationship between depression and mortality found that depression-related mortality did not differ across medical disease groups [50]. The authors suggested that the association between depression and mortality may be better explained by generic mechanisms, such as biological dysregulation and lifestyle factors, rather than by disorder-specific mechanisms [50]. The same may well be true for PTSD. Further research is needed to assess the impact of individual conditions versus cumulative disease burden on PTSD symptomatology. There are several potential mechanistic explanations for the association between medical conditions and PTSD. One possible link is shared etiology. For instance, trauma may cause physical injury in addition to leading to the development of PTSD [51]. Furthermore, it is well recognized that psychiatric disorders cause somatic symptoms in addition to psychological distress (e.g. [52]). Some have suggested that individuals with PTSD may consciously or unconsciously somaticize their stress in lieu of discussing or presenting to treatment with psychological symptoms [20,25], though this may not explain associations with certain medical conditions. Another explanation that has arisen to describe the pervasive medical burden associated with PTSD is the concept of allostatic load. Allostatic load is the cumulative wear and tear on the body that is caused by chronic stress [53]. Several researchers have posited that PTSD may cause biological changes that lead to medical conditions through increased allostatic load. For instance, PTSD may negatively impact cardiovascular reactivity, autonomic hyperarousal, disturbed sleep physiology, adrenergic dysregulation, altered thyroid function or altered hypothalamic–pituitary–adrenal activity, leading to downstream medical illness [54]. In support of this hypothesis, some studies suggest that the link between PTSD and medical disease burden strengthens over time, such that PTSD is associated with a greater number of medical conditions the longer one has had PTSD [31,55]. Thus, PTSD may confer lasting abnormalities in physical function. Conversely, medical illness may worsen PTSD. For instance, physical symptoms have been associated with more severe PTSD [56], and it is plausible that medical illness could add to the burden of distress or functional impairment caused by PTSD symptoms. Medical illness may also decrease tolerance for PTSD symptoms. Additional support for a shared underlying mechanism comes from the fact that treating medical illness may impact mental health. For example, treating obstructive sleep
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Table 2 ORs and CIs estimating associations between medical comorbidity and past-year treatment for PTSD Model 1a
Medical comorbidity a b c
Model 2b
P
OR
95% CI
1.08
1.00–1.16
.043
OR
95% CI
1.11
1.03–1.21
.009
Model 3c
P
OR
95% CI
1.10
1.01–1.20
.029
Model 1 is unadjusted. Model 2 is adjusted for age group, sex and race/ethnicity. Model 3 is adjusted for age, sex, race/ethnicity, education, marital status, insurance status, past-year psychiatric comorbidity and symptom count.
0
.1
.2
.3
.4
.5
.6
apnea with medical interventions (continuous positive airway pressure) reduces symptoms of PTSD [57,58]. Thus, medical illness and PTSD may have a synergistic relationship that exacerbates both physical and psychological ill health. Another potential explanation linking medical comorbidity to PTSD treatment is the issue of access. Participating in medical treatment may improve detection of mental health problems and referral for treatment [34]. Additionally, the experience of previously navigating the health care system for the treatment of medical conditions may enable individuals to access mental health care with greater confidence. Thus, previous experience may facilitate mental health care use in individuals with medical conditions. Future work should explore the ways in which medical comorbidity increases the need for care or facilitates access to care. There are several limitations to the current study. Though we controlled for PTSD symptom count in our analyses, we were not able to measure severity of PTSD from the information provided by the AUDADIS-IV; thus, conclusions regarding symptom severity as a potential factor influencing the relationship between medical illness and PTSD treatment remain speculative. Similarly, we analyzed cumulative illness burden via a count of medical illnesses but could not assess severity of medical illness. Additionally, the NESARC survey used retrospective data, potentially reducing the accuracy of recall. Furthermore, the cross-sectional design of this study prevents any determination of causality in the relationship between medical illness burden and mental health service utilization. An additional limitation of our study is that the PTSD treatment utilization measure was dichotomous. Alternative measures of mental health utilization, such as those derived from electronic medical records, could provide richer data and potentially provide more information on the association between medical illness and mental health treatment utilization.
Predicted PTSD Treatment
P
0
2
4
6
8
Number of Medical Conditions 95% CI
Predicted PTSD Treatment
Fig. 1. Predicted probability of PTSD treatment in the past year by number of medical conditions.
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