Primary Care Needs Help to Recognize, Treat Individuals With Trauma

“Traumatic exposure and trauma-related distress and illness are not military-specific phenomena,” three psychiatrists affiliated with the Uniformed Services University of the Health Sciences (USUHS) reminded primary care physicians in the September 11 Annals of Internal Medicine.

“Yet assessment for PTSD and other trauma-related disorders is not a standard of care in emergency departments, nor in outpatient settings where many patients affected by trauma present,” they said.

Exposure to combat is a prominent risk factor for posttraumatic stress disorder (PTSD), especially among the 2.4 million troops who have served in Iraq or Afghanistan over the last decade. However, it is the trauma caused by enduring natural or man-made disasters, not to mention assaults and accidents in civilian life, that is likely to affect patients seen in emergency rooms or primary care offices, said Robert Ursano, M.D., a professor of psychiatry and neuroscience and chair of psychiatry; David Benedek, M.D., a professor of psychiatry; and Charles Engel, M.D., M.P.H., an associate professor of psychiatry at USUHS.

Ursano is a former Air Force psychiatrist, while Benedek and Engel are U.S. Army colonels on active duty.

Primary care physicians form an important component of the mental health system, Ursano told Psychiatric News. “Many more patients present with their mental health problems to primary care than to psychiatric or other mental health care resources,” he said. “Developing and improving assessment for suicidal risk and PTSD in primary care can leverage our ability to reach the broadest group of those who need care.”

PTSD can be viewed as a disorder of “impaired forgetting,” the psychiatrists indicated. “But forgetting is probably a much more important function for our brains than is remembering.”

Besides PTSD, psychiatric disorders such as depression, panic, or substance use are also associated with traumatic events, and their incidence and course vary widely from individual to individual, as is the case with other medical illnesses.

Suicide is yet another event that affects both military and civilian populations. Over the last decade of war, suicide rates in the U.S. Armed Forces, which were once below age- and gender-matched civilian rates, have risen to meet them.

“While it is tempting to focus solely on suicide rates in combat veterans, suicide remains a leading cause of death among youth and among working-age American men,” the authors noted. Thus it’s crucial that both civilians and veterans receive screening for suicidality and for depression, which often predicts suicidal ideation.

Primary care and other clinicians can simply ask patients if their lives were ever in danger or if they have ever considered harming themselves or others. Positive answers can lead to a more complete assessment of PTSD or suicidality, Ursano and colleagues pointed out.

Reminding even experienced primary care physicians and their patients about the value of trauma-informed care is useful. “All of us need reminders,” said Ursano. “Primary care physicians are very busy, have little time, and are always being told what to look for without necessarily having the tools and education on how to do so.”

The recent addition to the Medicare program of reimbursement for screening for some psychiatric disorders adds another incentive to reach out to primary care clinicians, he added.

The authors’ thoughts on trauma-informed care came just 10 days after President Obama issued an executive order directing the secretaries of Defense, Health and Human Services, Veterans Affairs, and Homeland Security to “expand suicide-prevention strategies and take steps to meet the current and future demand for mental health and substance abuse treatment services for veterans, service members, and their families.”

That effort will involve more community providers, including internists, according to Obama’s order.