Service Use and Self-Reported Symptoms Among Persons With Positive PTSD Screens and Serious Mental Illness
Abstract
Objective:
Although many studies have reported higher rates of trauma exposure and posttraumatic stress disorder (PTSD) among persons with severe mental illness, the screening, diagnosis, and treatment of PTSD in public mental health centers remain at a suboptimal level and PTSD is often overlooked and untreated. This study used routine PTSD screening and service use data in electronic medical records to determine the association of PTSD, psychiatric symptoms, and service use in a sample of individuals with serious mental illness in a community-based treatment setting.
Methods:
The sample included 1,834 active clients between January 2007 and November 2010 who were screened for PTSD and who completed the 24-item Behavior and Symptom Identification Scale (BASIS-24). Service data included services provided a year before and a year after the screening date.
Results:
PTSD was associated with more severe psychiatric symptoms and increased no-show rates but not with increased service use or use of high-intensity services. PTSD likelihood interacted with race in accounting for elevated scores among African Americans on the psychosis domain of the BASIS-24.
Conclusions:
PTSD screening is feasible and recommended in service environments and may contribute significantly to better understanding of racial-ethnic and other differences in service use and diagnostic practices.
Posttraumatic stress disorder (PTSD) is a psychiatric disorder that arises from exposure to traumatic life events and is defined by symptoms of re-experiencing the traumatic event, hyperarousal, and avoidance of stimuli associated with the trauma (1). In the general population, PTSD has been found to be associated with an increased likelihood of endorsing one or more psychotic symptoms, particularly positive psychotic symptoms (delusions and visual and auditory hallucinations), after adjustment for sociodemographic characteristics and psychiatric and general medical comorbidity (2). PTSD in the general population is also linked to poorer general health, morbidity, and increased likelihood of seeking medical services and more intensive services (3–7). Population-based studies documenting the health care costs of individuals with PTSD in general health care settings have found increased costs for those scoring ≥45 points on the PTSD Checklist (PCL), indicating probable PTSD, compared with those scoring below 45 (8).
For people with severe mental illness, PTSD is associated with other complicating conditions, such as substance abuse, increased use of general medical services, and impaired social functioning (9–12). Over the past two decades, much research interest has focused on trauma exposure and PTSD and their interactions with serious mental illnesses such as schizophrenia, bipolar disorder, and severe major depression (13,14). Whereas rates of trauma exposure in the general population are reported to be around 50%, and lifetime rates of PTSD are reported between 8% and 13% (15–19), the rates found among people with severe mental illness are much higher. Reported trauma exposure rates are as high as 98% in this population (20–25), and reported PTSD rates vary between 19% and 43% (10,11,14,20,26–28).
Although many studies have reported higher rates of trauma exposure and PTSD among persons with severe mental illness, documentation of PTSD in medical records remains remarkably low (29,30). In two studies, the rate of chart diagnosis was 2% (20,27); in another, 5% (31). The source of the discrepancy between what research diagnoses reveal and what clinicians document in the chart is not clear. One suggested explanation is that the clinical chart diagnosis is driven by reimbursement needs, and because PTSD is not considered a major mental illness, it is not reimbursable at the same rate as schizophrenia, bipolar disorder, or major depression and therefore is not reliably recorded (32). Another possible explanation for the gap is the inadequate assessment of trauma exposure and PTSD and the lack of evidence-based treatment for this population in typical clinical settings (32).
Whatever the cause, the screening, diagnosis, and treatment of PTSD in public mental health centers remain at a suboptimal level (32), and PTSD is mostly overlooked and untreated (9,28). After several decades of research with this population, what is still missing is a clear understanding of the interaction between trauma exposure, PTSD, and comorbid severe mental illness. Mueser and colleagues (33) proposed a model in 2002 that posited PTSD as mediating negative effects and outcomes of severe mental illness. Yet in their conclusion, they stated:
Although exposure to trauma in persons with severe mental illness is related to more severe psychiatric symptoms, substance abuse and higher use of acute care treatment services, little is understood about how these relationships are mediated. [italics added for emphasis]
Little is known about the stability of PTSD in this population, its demographic and clinical correlates and the interaction between PTSD, clinical status and service utilization. [italics added for emphasis]
Fasoli and colleagues (34) addressed the issue of predicting mental health service utilization on the basis of Andersen and Newman’s (35) model, where the amount and intensity of service use are affected by predisposing characteristics, such as age, gender, and race; enabling resources, such as easy access to and financial responsibility for care; and clinical need indicators, such as symptom severity. Among other factors, worse self-reported mental health on the Behavior and Symptom Identification Scale (BASIS-24) (36), indicating need, predicted more use of outpatient and residential services but not inpatient care. To the extent that PTSD is associated with more severe psychiatric symptoms (2), we planned to explore whether high risk of PTSD (even without a chart diagnosis) affects the service use of people with severe mental illness in a service environment.
The Study and Primary Hypotheses
In 2007, as part of a study that was funded by the National Institute of Mental Health for cognitive-behavioral therapy (CBT) for PTSD, a PTSD screening tool was introduced at Rutgers University Behavioral Health Care (RUBHC) (31) to identify patients who, in addition to having severe mental illness, were likely to have a PTSD diagnosis. Clinicians were trained in the administration and scoring of the tool. Subsequently, the PTSD screening tool became part of the routine intake assessment in both outpatient and partial-hospitalization programs at RUBHC.
Using the routine PTSD screening data in tandem with other data in RUBHC’s electronic medical record (EMR), we aimed to determine whether the finding in the general population that PTSD is associated with more severe psychiatric symptoms is confirmed in a sample of individuals with severe mental illness in a community-based treatment setting, to evaluate whether PTSD is associated with a lower rate of engagement in psychiatric treatment, and to evaluate whether PTSD is associated with increased service utilization, especially high-intensity services (that is, inpatient and partial-hospitalization services).
In addition, because recent evidence suggests that PTSD may be more common among African Americans but is frequently not recognized clinically (36–38), we examined rates of PTSD by race. Furthermore, it has been suggested that the well-documented higher rate of schizophrenia and psychosis in clinical charts of African Americans, which is not found in population surveys of African Americans (36), may be related to the lower recognition of PTSD in clinical settings (2,37–40). As a consequence, some PTSD symptoms, such as flashbacks, dissociative states, and hyperarousal, are misinterpreted as indicators of schizophrenia rather than PTSD. Therefore, we also examined the interrelationships between self-reported PTSD symptoms, self-reported psychotic symptoms, and race.
We hypothesized that PTSD would be associated with greater impairment in self-reported functioning and more severe symptoms after we controlled for demographic and clinical variables, such as diagnosis, race-ethnicity, and gender. Additional hypotheses were that clients who screened positive for PTSD would show more difficulty engaging in services, demonstrated by higher no-show rates, and show greater use of high-intensity services, including inpatient days, acute or partial-hospitalization program days, and emergency visits, compared with clients without positive screens.
Methods
Study Site
The study site was RUBHC, one of the largest mental health service organizations in New Jersey and providing services annually to approximately 11,000 individuals with severe mental illness. Available programs include an inpatient unit, outpatient services, and partial-hospitalization, screening/emergency, and mobile outreach programs and other community-based services (such as supportive housing, intensive case management, and family support services).
The data used in this study were taken from the administrative and clinical databases of RUBHC. No new data were directly collected from clients. The study received institutional review board approval from Rutgers University.
Sample
The sample included all active clients at RUBHC between January 2007 and November 2010 who were screened for PTSD after the implementation of the CBT study (31) and for whom there were electronic data from the Behavior and Symptom Identification Scale (BASIS-24 [41]), another routine screening tool used at RUBHC. We have excluded from our analysis the 201 clients who participated in the CBT study because they received the special treatment that the study was focused on and inclusion would have inflated the service use data for our analysis. Demographic and clinical data as well as the BASIS-24 results and the PTSD screening scores were available from the RUBHC EMRs. Service data included services provided a year before and a year after the screening date. However, because there was no difference between the two periods, the entire service data set was used in further analyses.
Measures
The civilian version of the PCL, developed by Blanchard and colleagues (42), was used to screen and identify cases of probable PTSD diagnosis and to assess PTSD symptom severity. The PCL includes one question for each DSM-IV-TR PTSD symptom, requiring the respondent to rate the severity of each symptom over the past month on a 5-point Likert scale (range 17–85). The PCL has good test-retest reliability and convergent validity for people with severe mental illness (43,44). A total score ≥45 was used to identify cases of probable PTSD during the initial screening (42).
The BASIS-24 is a 24-item self-report scale of functioning and symptoms (41). The scale is routinely used at RUBHC for all clients at intake. In outpatient and partial-hospitalization programs it is used midtreatment, and in acute care inpatient programs it is also used at discharge.
Statistical Analysis
We sought to determine the impact of probable PTSD on service use, no-show rates (a measure of low treatment engagement), and psychiatric symptoms and functioning (BASIS-24 scores). The data were analyzed with SAS/PC software. We compared two groups of clients: one group with PTSD screening scores ≥45, the other with scores <45. Statistics used depended on the nature of the dependent variables in question; for example, Fisher’s exact test was used for categorical data, and t tests were used for continuous data. For more complicated models examining the effect of probable PTSD on dependent variables of interest (service use, for example), multiple regression was used to control for demographic covariates (including gender, race-ethnicity, and age).
Results
Of the 1,834 clients with PTSD screening, 906 (49%) of the clients scored ≥45, and 928 (51%) scored below the cutoff of 45. Table 1 presents the demographic characteristics of the sample. In the probable PTSD group, although there were more women in the sample (1,048 versus 786) the percentage of probable PTSD was higher for men (56% versus 45%). The racial-ethnic distributions were similar for African Americans and European Americans; however, the rate of PTSD was lower among Hispanics compared with these groups. The diagnostic distributions indicated that the group with schizophrenia and other psychoses had less probable PTSD (36% versus 64%), but the reverse was true for groups with major depression, bipolar disorder, or other psychiatric diagnoses.
| Posttraumatic stress disorder | ||||||||
|---|---|---|---|---|---|---|---|---|
| Total | Probable | Not probable | ||||||
| Characteristic | N | N | % | N | % | χ2 | df | p |
| Age group | 23.2 | 2 | <.001 | |||||
| 18–34 | 501 | 248 | 50 | 253 | 51 | |||
| 35–64 | 1,268 | 607 | 48 | 661 | 52 | |||
| ≥65 | 65 | 51 | 79 | 14 | 22 | |||
| Gender | 20.3 | 1 | <.001 | |||||
| Female | 1,048 | 470 | 45 | 578 | 55 | |||
| Male | 786 | 436 | 56 | 350 | 45 | |||
| Race-ethnicity | 9.8 | 3 | .021 | |||||
| African American | 795 | 405 | 51 | 390 | 49 | |||
| Hispanic | 250 | 106 | 42 | 144 | 58 | |||
| European American | 682 | 351 | 52 | 331 | 49 | |||
| Other | 107 | 44 | 41 | 63 | 59 | |||
| Diagnosis | 52.9 | 3 | <.001 | |||||
| Schizophrenia and psychosis | 463 | 168 | 36 | 295 | 64 | |||
| Major depression | 801 | 435 | 54 | 366 | 46 | |||
| Bipolar disorder | 306 | 181 | 59 | 125 | 41 | |||
| Other | 264 | 144 | 55 | 120 | 46 | |||
The most striking finding about service use and no-shows was that partial-hospitalization services were used less by the group with probable PTSD than by those who probably did not have PTSD (Table 2). No other service use differences between groups were significant. Those with probable PTSD had significantly more no-show appointments for outpatient and partial-hospitalization services than did the group without probable PTSD.
| Posttraumatic stress disorder | |||||
|---|---|---|---|---|---|
| Probable (N=906) | Not probable (N=928) | ||||
| Service | M | SD | M | SD | p |
| All services | 112.3 | 124.7 | 122.4 | 147.2 | ns |
| Inpatient | 3.4 | 9.2 | 3.7 | 8.8 | ns |
| Outpatient | 66.6 | 64.6 | 64.3 | 61.1 | ns |
| Partial hospitalization | 38.6 | 39.7 | 58.3 | 55.4 | <.001 |
| Residential | 3.7 | 3.8 | 3.8 | 3.9 | ns |
| No-shows | |||||
| Outpatient | 10.6 | 16.1 | 7.6 | 11.5 | <.001 |
| Partial hospitalization | 26.7 | 38.9 | 20.9 | 36.5 | <.001 |
a
Means represent average service contacts per individual in the year before and the year after the screening date and are adjusted for diagnosis, race-ethnicity, gender, and age.
Although not shown in Table 2, diagnosis and race-ethnicity also had significant main effects; appointment no-shows were more frequent among African Americans and European Americans with probable PTSD compared with those from the same racial-ethnic groups without probable PTSD. Persons in any of the three most severe diagnostic groupings (schizophrenia, major depression, and bipolar disorder) had higher no-show rates if they also were classified as probably having PTSD.
Tables 3 and 4 present the results of six regression analyses, one for each of the six BASIS-24 domain scores, with each regression examining probable PTSD as a predictor and controlling for diagnosis, race-ethnicity, age, and gender. Bonferonni corrections were used to account for multiple tests. Table 3 shows that PTSD was associated with increased symptomatology across all six domains of the BASIS-24, with controls for clinical and demographic variables. Significant main effects were also found for the interpersonal, emotional lability, and psychosis subscales (p<.001 for all). In addition, African Americans reported more severe symptoms than European Americans, and women reported more emotional lability and depression than men did (p<.001; data not shown in table). There were no significant effects for age.
| Posttraumatic stress disorder | ||||
|---|---|---|---|---|
| Probable (N=906) | Not probable (N=928) | |||
| Subscale | LSM | SD | LSM | SD |
| Depression | 2.05 | 1.00 | 1.31 | 1.00 |
| Interpersonal | 1.82 | 1.10 | 1.51 | 1.10 |
| Self-harm | .53 | .70 | .21 | .70 |
| Emotional lability | 2.06 | 1.10 | 1.35 | 1.10 |
| Psychosis | 1.96 | 1.00 | .56 | 1.00 |
| Substance abuse | .76 | .90 | .45 | .90 |
a
Possible scores range from 0 to 4, where 4 is the most impaired. Significance tests controlled for diagnosis, race-ethnicity, gender, and age. For all six subscales, between-group differences were significant at p<.001.
| Subscale | Posttraumatic stress disorder | ||||||
|---|---|---|---|---|---|---|---|
| Probable (N=906) | Not probable (N=928) | ||||||
| African American | European American | African American | European American | Race-ethnicity × PTSDb | |||
| F | df | p | |||||
| Depression | 2.13 | 2.00 | 1.22 | 1.39 | 7.03 | 1 1,259 | .048 |
| Interpersonal | 1.96 | 1.68 | 1.55 | 1.38 | .93 | 1 1,268 | ns |
| Self-harm | .61 | .44 | .22 | .24 | 4.82 | 1 1,254 | ns |
| Emotional lability | 2.33 | 1.94 | 1.37 | 1.34 | 8.69 | 1 1,262 | .020 |
| Psychosis | 1.62 | .90 | .70 | .42 | 15.07 | 1 1,258 | <.001 |
| Substance abuse | .84 | .88 | .50 | .55 | .01 | 1 1,235 | ns |
a
Possible scores range from 0 to 4, where 4 is most impaired.
b
Adjusted for six regression tests
Table 4 presents the results of the same six regression analyses described above for the PTSD × race-ethnicity interaction. This interaction was statistically significant in three domains (depression, emotional lability, and psychosis). The most robust effect was associated with psychosis. Comparisons of the four means constituting the PTSD × race-ethnicity interaction (p<.001) indicated that self-reported psychosis was significantly higher among African Americans with probable PTSD compared with African Americans without probable PTSD and compared with European Americans regardless of their PTSD group (Figure 1).
FIGURE 1. Psychosis domain score for African and European Americans with serious mental illness, by race-ethnicity and likelihood of having PTSDa
aAs measured on the 24-item Behavior and Symptom Identification Scale, where possible scores range from 0 to 4, with higher scores indicating greater impairment.
Discussion
The first hypothesis tested in this study—that clients who screen as probably having PTSD would have more severe psychiatric symptoms than those who screen as probably not having PTSD—was confirmed. Consistent with existing literature (20), in this study, clients with probable PTSD, compared with those without probable PTSD and with controls for clinical and demographic variables, reported more severe psychiatric symptoms, as well as more impaired functioning, across all six domains of the BASIS-24. Compared with clients without probable PTSD, those with probable PTSD reported more interpersonal problems, more substance abuse, more depression, more self-harm, increased mood instability, and elevated psychosis.
The second hypothesis, regarding engagement in services, as measured by the frequency of no-show events, also was supported by the data. Clients with probable PTSD were more likely to miss appointments and thus not receive recommended treatment compared with those without probable PTSD.
Finally, our third hypothesis—that the probable PTSD group would have increased use of high-intensity services, including inpatient days, acute or partial-hospitalization program days, and emergency visits—was not supported by the data. This hypothesis was based on the assumption that people with significant trauma would be more impaired and therefore require more services, particularly the more intensive services (such as inpatient or partial-hospitalization services). The results of the study showed, however, that the probable PTSD group used slightly more outpatient services but significantly fewer partial-hospitalization and inpatient days. It is not clear whether this finding was due to the clients’ own choice or the inability of the system to provide services that are appropriate for clients with trauma and PTSD in addition to their serious mental illness. The reduced level of services overall may replicate earlier findings that documented lack of appropriate trauma-informed services (9).
The interaction between race-ethnicity, probable PTSD, and the symptom domains of the BASIS-24, especially the psychosis domain, was intriguing. African Americans with co-occurring probable PTSD showed more self-reported psychosis symptoms than did African Americans without probable PTSD and showed more psychosis than European Americans, regardless of the PTSD status of the latter. This interaction was evident even though there was also a main effect of race-ethnicity alone on the psychosis domain score. A smaller interaction effect was evident for the emotional lability and depression domains.
These findings suggest that self-reported or clinician-documented psychotic symptoms may be elevated for African Americans with comorbid PTSD, compared with European Americans regardless of PTSD status and with African Americans without PTSD. The implications for the well-documented higher rates of diagnosis of psychosis (36) among African Americans are intriguing and call for additional focused research.
Conclusions
In summary, the study showed the value of screening for PTSD and traumatic events in a general psychiatric population, particularly because chart diagnoses of PTSD are rarely documented in the EMR, most likely because services for PTSD are reimbursed at a lower level than those for the major mental illnesses. The study also suggested that the high rates of diagnosis of psychosis among African Americans may be associated with an increased risk for PTSD. Because a subset of PTSD symptoms overlaps with psychotic symptoms, the study suggests the importance of carefully assessing traumatic history and symptoms before making a diagnosis of psychotic disorder, particularly schizophrenia.
Footnote
Partial funding for this study was provided by grant R01 MH064662 from the National Institute of Mental Health.
References
1.
Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994
2.
Sareen J, Cox BJ, Goodwin RD, et al: Co-occurrence of posttraumatic stress disorder with positive psychotic symptoms in a nationally representative sample. Journal of Traumatic Stress 18:313–322, 2005
3.
Kessler RC: Posttraumatic stress disorder: the burden to the individual and to society. Journal of Clinical Psychiatry 61(suppl 5):4–14, 2000
4.
Flett RA, Kazantzis N, Long NR, et al: Traumatic events and physical health in a New Zealand community sample. Journal of Traumatic Stress 15:303–312, 2002
5.
Friedman MJ, Schnurr PP: The relationship between trauma, post-traumatic stress disorder, and physical health; in Neurobiological and Clinical Consequences of Stress: From Normal Adaptation to Post-Traumatic Stress Disorder. Edited by Friedman MJ, Charney DS, Deutch AY. Philadelphia, Lippincott-Raven, 1995
6.
Breslau N, Davis GC: Posttraumatic stress disorder in an urban population of young adults: risk factors for chronicity. American Journal of Psychiatry 149:671–675, 1992
7.
Ullman SE, Siegel JM: Traumatic events and physical health in a community sample. Journal of Traumatic Stress 9:703–720, 1996
8.
Walker EA, Katon W, Russo J, et al: Health care costs associated with posttraumatic stress disorder symptoms in women. Archives of General Psychiatry 60:369–374, 2003
9.
Frueh BC, Buckley TC, Cusack KJ, et al: Cognitive-behavioral treatment for PTSD among people with severe mental illness: a proposed treatment model. Journal of Psychiatric Practice 10:26–38, 2004
10.
Mueser KT, Salyers MP, Rosenberg SD, et al: Interpersonal trauma and posttraumatic stress disorder in patients with severe mental illness: demographic, clinical, and health correlates. Schizophrenia Bulletin 30:45–57, 2004
11.
Switzer GE, Dew MA, Thompson K, et al: Posttraumatic stress disorder and service utilization among urban mental health center clients. Journal of Traumatic Stress 12:25–39, 1999
12.
Neria Y, Bromet EJ, Sievers S, et al: Trauma exposure and posttraumatic stress disorder in psychosis: findings from a first-admission cohort. Journal of Consulting and Clinical Psychology 70:246–251, 2002
13.
Rosenberg S, Mueser KT, Jankowski MK, et al: Trauma exposure and PTSD in people with severe mental illness. PTSD Research Quarterly 13(3):1–4, 2002
14.
Grubaugh AL, Zinzow HM, Paul L, et al: Trauma exposure and posttraumatic stress disorder in adults with severe mental illness: a critical review. Clinical Psychology Review 31:883–899, 2011
15.
Breslau N, Davis GC, Andreski P, et al: Traumatic events and posttraumatic stress disorder in an urban population of young adults. Archives of General Psychiatry 48:216–222, 1991
16.
Breslau N, Peterson EL, Poisson LM, et al: Estimating post-traumatic stress disorder in the community: lifetime perspective and the impact of typical traumatic events. Psychological Medicine 34:889–898, 2004
17.
Kessler RC, Chiu WT, Demler O, et al: Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62:617–627, 2005
18.
Kessler RC, Sonnega A, Bromet E, et al: Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry 52:1048–1060, 1995
19.
Resnick HS, Kilpatrick DG, Dansky BS, et al: Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. Journal of Consulting and Clinical Psychology 61:984–991, 1993
20.
Mueser KT, Goodman LB, Trumbetta SL, et al: Trauma and posttraumatic stress disorder in severe mental illness. Journal of Consulting and Clinical Psychology 66:493–499, 1998
21.
Hutchings PS, Dutton MA: Sexual assault history in a community mental health center clinical population. Community Mental Health Journal 29:59–63, 1993
22.
Jacobson A: Physical and sexual assault histories among psychiatric outpatients. American Journal of Psychiatry 146:755–758, 1989
23.
Lipschitz DS, Kaplan ML, Sorkenn JB, et al: Prevalence and characteristics of physical and sexual abuse among psychiatric outpatients. Psychiatric Services 47:189–191, 1996
24.
Walsh E, Moran P, Scott C, et al: Prevalence of violent victimisation in severe mental illness. British Journal of Psychiatry 183:233–238, 2003
25.
Goodman LA, Rosenberg SD, Mueser KT, et al: Physical and sexual assault history in women with serious mental illness: prevalence, correlates, treatment, and future research directions. Schizophrenia Bulletin 23:685–696, 1997
26.
Howgego IM, Owen C, Meldrum L, et al: Posttraumatic stress disorder: an exploratory study examining rates of trauma and PTSD and its effect on client outcomes in community mental health. BMC Psychiatry 5:21, 2005
27.
Zanville H, Cattaneo, LB: Underdiagnosing and non-treatment of posttraumatic stress disorder in community mental health: a case study. Psychological Services 6:32–42, 2008
28.
Frueh BC, Grubaugh AL, Cusack KJ, et al: Disseminating evidence-based practices for adults with PTSD and severe mental illness in public-sector mental health agencies. Behavior Modification 33:66–81, 2009
29.
Mueser KT, Essock SM, Haines M, et al: Posttraumatic stress disorder, supported employment, and outcomes in people with severe mental illness. CNS Spectrums 9:913–925, 2004
30.
Cusack KJ, Grubaugh AL, Knapp RG, et al: Unrecognized trauma and PTSD among public mental health consumers with chronic and severe mental illness. Community Mental Health Journal 42:487–500, 2006
31.
Lu W, Yanos PT, Silverstein SM, et al: Public mental health clients with severe mental illness and probable posttraumatic stress disorder: trauma exposure and correlates of symptom severity. Journal of Traumatic Stress 26:266–273, 2013
32.
Frueh BC, Cousins VC, Hiers TG, et al: The need for trauma assessment and related clinical services in a state-funded mental health system. Community Mental Health Journal 38:351–356, 2002
33.
Mueser KT, Rosenberg SD, Goodman LA, et al: Trauma, PTSD, and the course of severe mental illness: an interactive model. Schizophrenia Research 53:123–143, 2002
34.
Fasoli DR, Glickman ME, Eisen SV: Predisposing characteristics, enabling resources and need as predictors of utilization and clinical outcomes for veterans receiving mental health services. Medical Care 48:288–295, 2010
35.
Andersen R, Newman JF: Societal and individual determinants of medical care utilization in the United States. Milbank Quarterly 83(4):1–28, 2005
36.
Gara MA, Vega WA, Arndt S, et al: Influence of patient race and ethnicity on clinical assessment in patients with affective disorders. Archives of General Psychiatry 69:593–600, 2012
37.
Alim TN, Graves E, Mellman TA, et al: Trauma exposure, posttraumatic stress disorder and depression in an African-American primary care population. Journal of the National Medical Association 98:1630–1636, 2006
38.
Alim TN, Feder A, Graves RE, et al: Trauma, resilience, and recovery in a high-risk African-American population. American Journal of Psychiatry 165:1566–1575, 2008
39.
Frueh BC, Smith DW, Libet JM: Racial differences on psychological measures in combat veterans seeking treatment for PTSD. Journal of Personality Assessment 66:41–53, 1996
40.
Frueh BC, Hamner MB, Bernat JA, et al: Racial differences in psychotic symptoms among combat veterans with PTSD. Depression and Anxiety 16:157–161, 2002
41.
Eisen SV, Normand SL, Belanger AJ, et al: The Revised Behavior and Symptom Identification Scale (BASIS-R): reliability and validity. Medical Care 42:1230–1241, 2004
42.
Blanchard EB, Jones-Alexander J, Buckley TC, et al: Psychometric properties of the PTSD Checklist (PCL). Behaviour Research and Therapy 34:669–673, 1996
43.
Grubaugh AL, Elhai JD, Cusack KJ, et al: Screening for PTSD in public-sector mental health settings: the diagnostic utility of the PTSD Checklist. Depression and Anxiety 24:124–129, 2007
44.
Mueser KT, Salyers MP, Rosenberg SD, et al: Psychometric evaluation of trauma and posttraumatic stress disorder assessments in persons with severe mental illness. Psychological Assessment 13:110–117, 2001
Information & Authors
Information
Published In
Cover: The Violoncellist, by Lilla Cabot Perry, 1906. Private collection.
History
Received: 2 May 2014
Revision received: 6 November 2014
Accepted: 22 December 2014
Published online: 15 April 2015
Published in print: August 01, 2015
Authors
Funding Information
The authors report no financial relationships with commercial interests.
Metrics & Citations
Metrics
Citations
Export Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
View Options
View options
PDF/EPUB
View PDF/EPUBLogin options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).