June 2008, New York – Posttraumatic stress disorder and depression are extremely common a full year after hospitalization for injury and are associated with up to a nearly sixfold increased likelihood of failure to return to work, according to the largest-ever U.S. study evaluating the multiple impacts of trauma.
The implications of these new findings from the National Study of Costs and Outcomes of Trauma (NSCOT) are profound. With an estimated 2.5 million hospital admissions for injury per year in the United States, the NSCOT data would suggest 500,000 of these patients will have debilitating posttraumatic stress disorder (PTSD) 1 year later, Dr. Douglas F. Zatzick said at the annual meeting of the American Surgical Association.
The economic, social, and health costs of this problem are such that screening for early signs of PTSD and depression should become routine during the acute hospitalization of all trauma patients, regardless of injury severity, according to Dr. Zatzick, a psychiatrist at the University of Washington, Seattle.
He reported on 2,707 NSCOT participants hospitalized for injuries requiring surgery at 69 U.S. hospitals, including 18 level 1 trauma centers. The patients, who were followed for 1 year, represented the broad spectrum of trauma with the exception of burn injuries, an exclusion criterion.
One year post injury, 20.7% of subjects met diagnostic criteria for PTSD using the validated 17-item PTSD checklist. An additional 6.6% met criteria for depression using the Center for Epidemiologic Studies Depression Scale, and 4.9% had both psychiatric disorders.
Forty-five percent of patients employed preinjury had not returned to work after 1 year. The rate varied significantly depending upon whether a patient had neither psychiatric disorder, one, or both (see box).
In a multivariate analysis adjusting for injury severity, premorbid psychiatric disorders, and preinjury health status and functioning, having either PTSD or depression was an independent risk factor associated with a 3.2-fold greater likelihood of failure to return to work than for those with neither disorder. Patients with both depression and PTSD were at a 5.6-fold increased risk.
A similar stepwise relationship was observed between the number of psychiatric diagnoses present and other measures of functional impairment that were collected in the study, including return to usual activities as well as physical and mental health status as assessed using the Short Form 36, Dr. Zatzick continued.
The prevalence of PTSD and depression was similar in patients treated at level 1 trauma centers and those treated at community hospitals. So were adjusted return-to-work rates.
Col. John B. Holcomb, USA, commented that the prevalence of PTSD and depression documented in NSCOT is “exactly the same” as what he and others have found in both military and civilian trauma populations.
His advice to his civilian colleagues: “Just screen everybody. I don’t think PTSD is related to your family or work status. And we find it’s not related to severity of injury; what we would consider a minor injury the patient may consider a major injury,” said Dr. Holcomb, commander of the U.S. Army Institute of Surgical Research, Brooke Army Medical Center, San Antonio.
NSCOT copresenter Dr. Gregory J. Jurkovich said the responsibility for screening for psychiatric morbidity in injured patients must fall mainly on the country’s major trauma centers.
“They have really become the linchpin of managing trauma patients, much more so than community hospitals, and that will become even more true as regionalization of trauma care continues.
“But with that status as the centerpiece of care comes the responsibility for broad-based care involving collaborative effort between psychiatrists, psychologists, rehabilitation specialists, and others,” said Dr. Jurkovich, professor of surgery at the University of Washington and chief of trauma services at Harborview Medical Center, both in Seattle.
PTSD can’t be formally diagnosed until at least 1 month after the traumatic event. The strongest predictor of subsequent PTSD is development of an acute stress disorder during the hospitalization. This acute stress response is marked by the same three classes of symptoms that define PTSD, including intrusive symptoms such as flashbacks and nightmares, avoidance behavior, and hyperarousal as evidenced by insomnia.
Other indicators of increased likelihood of PTSD in trauma patients include a history of more than four prior hospitalizations for trauma, female gender, and a positive urine toxicology screen, Dr. Jurkovich said.
Prevention and treatment of PTSD are “somewhat problematic” and warrant far more research, he noted. One theory holds that the disorder results from imprinting of the trauma in patients with elevated catecholamines at the time of injury. Consistent with this theory is the finding that trauma patients who are more tachycardic are at increased risk for later PTSD. But prophylactic β-blocker therapy has proved ineffective. Moreover, the use of selective serotonin reuptake inhibitors in patients with PTSD has been disappointing.
In NSCOT, other independent predictors of failure to return to work 1 year after injury included the degree of residual physical impairment, effectiveness of pain management, socioeconomic status, poor social support, age, and education level.
Study participants were followed for 1 year and represented a broad spectrumof trauma. DR. ZATZICK