Treating Posttraumatic Stress Disorder (PTSD) in Primary Care Setting

Military members returning from deployment may experience Posttraumatic Stress Disorder (PTSD). PTSD may develop after exposure to extreme psychological trauma, defined as events that potentially cause a threat to life or physical integrity that produce fear, helplessness or horror (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, published by the American Psychiatric Association).

For reasons that are currently not understood, not everyone exposed to such trauma develops PTSD. Individuals with PTSD have these common traits:

• Frequently re-experience the traumatic event
• Experience persistent symptoms of increased arousal not present before the trauma
• Make efforts to avoid stimuli associated with the trauma
• Exhibit numbing of their general responsiveness

An individual suffering from PTSD will often first seek care from his or her primary care manager (PCM). According to theNational Center for Posttraumatic Stress Disorder (NCPTSD), nearly half of all visits caused by a behavioral health issue are to a medical clinic or provider. Of these visits, 90 percent are to PCMs. It is important for PCMs to know the implications of PTSD so that the disorder can be identified and treated. Here are some examples of these implications from NCPTSD.

PTSD affects health – Neurochemical changes in the central nervous system, sleep deprivation, risky behavior (e.g., smoking, poor nutrition, substance abuse, anger and/or violence), and psychosocial problems can result in great biological strain on individuals with PTSD. It is not surprising that these individuals report higher rates of physical problems affecting the cardiovascular, pulmonary, neurological and gastrointestinal systems. The somatic symptoms of PTSD are frequently the presenting problems in primary care consultation.

PTSD affects utilization of services – Studies show that psychiatric problems such as PTSD, anxiety, depression and anger increase medical utilization rates. Some of the identified problems include difficulty in provider-patient communication, increase in somatization, reduction of patient compliance and collaboration in medical regimens.

PTSD is under-recognized by practitioners – Studies show that as with many anxiety disorders, most patients with PTSD are not identified, and are therefore, not receiving the appropriate education, counseling, or referrals for mental-health evaluation.

What can health care providers do? – Practitioners often identify time constraints as a barrier to in-depth discussions about behavioral health issues. The NCPTSD states that “it is important to keep in mind that pressing someone into discussion of a traumatic event soon after exposure may have a detrimental effect on some traumatized individuals. Experts on traumatic stress emphasize that people have their own pace for processing trauma, and it is important for helpers to let survivors know that they should listen to and honor their own inner pace.”

PTSD is treatable and with early intervention, the severity can be reduced. The good news is that PCMs don’t have to go it alone. There are professionals who specialize in the diagnosis and treatment of PTSD. Here are some suggestions to help you in your efforts to assist these patients:

Ask about deployment – Routinely inquiring whether active duty service members or members of the National Guard and Reserve have recently returned from deployment to a combat zone can be useful in identifying those with PTSD.

Identify available resources – There are many existing resources including fact sheets, screening questionnaires, and videos on the TriWest Behavioral Health web portal or the NCPTSD Web site, www.ncptsd.va.gov. TriWest also created A Provider’s Guide to TriWest’s Behavioral Health Resources that offers a quick snapshot of the numerous behavioral health resources available to providers.

Identify a PTSD Consultant – If your patient has TRICARE, call 1-888-TRIWEST (888-874-9378) and ask for the Behavioral Health Department. Another good place to start is your local Veterans Center , which can be found at www.vetcenter.va.gov .

Establish referral procedures – Establishing these procedures ahead of time can save time and ensure quality referrals. The NCPTSD advises, “A few words indicating your awareness of their possible difficulties with stress, and supportively advising them that specialized services can be of great help, is almost always sufficient to motivate patients to accept this referral. You need not, and in most cases probably should not, attempt to take a detailed trauma history or make a diagnostic assessment of PTSD. This can be done by the PTSD clinician specialist.”

Maintain ongoing contact with the PTSD Consultant – Once the referral is made, it is important to maintain contact with the PTSD consultant. Coordination of care often results in an improvement in patient compliance.

If you have questions regarding TRICARE beneficiaries’ benefits or resources, or need further information, refer to the TriWest Behavioral Health web portal at www.triwest.com (Provider > In the Spotlight > Behavioral Health > I am a Provider) or please contact TriWest Healthcare Alliance at 888-TRIWEST (888-874-9378).

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