Posttraumatic stress disorder in a primary health care service

Abstracts

INTRODUÇÃO: O transtorno de estresse pós-traumático (TEPT) caracteriza-se pelo desenvolvimento de sintomas como a re-experienciação do evento traumático (pesadelos, idéias intrusivas, sintomas somáticos relacionados ao momento do trauma), evitação e embotamento (evitar situações, pessoas ou comportamentos que relembrem o trauma e ter dificuldade para lidar com novas situações ou sentimentos) e excitabilidade aumentada (insônia, irritação, dificuldade de concentração e um estado permanente de alerta e sobressalto). É importante saber a freqüência do transtorno numa comunidade pobre. OBJETIVO: Identificar a freqüência de TEPT e a presença de sintomas depressivos e alcoolismo em um serviço de atenção primária. METODOLOGIA: O estudo ocorreu na Unidade de Saúde Divina Providência, do Serviço de Saúde Comunitária do Grupo Hospitalar Conceição. Realizou-se uma amostragem aleatória dos pacientes que consultaram no posto. Foram aplicados instrumentos para a identificação de TEPT, sintomas depressivos, alcoolismo e perfil sociodemográfico. RESULTADOS: Dos 54 pacientes entrevistados, 83,3% eram mulheres, e a média da idade foi de 39 anos. Os sintomas depressivos severos foram identificados em 28% dos pacientes; 59% tinham o critério de TEPT e 12,5% apresentavam problemas com álcool. CONCLUSÕES: A amostra do sexo feminino foi predominante e houve uma elevada prevalência de TEPT.

Transtorno de estresse pós-traumático; atenção primária; alcoolismo

ORIGINAL ARTICLE

Posttraumatic stress disorder in a primary health care service^*

Transtorno de estrés postraumático en una unidad de salud de atención primaria

Airton Tetelbom Stein^I; Elisiane De Carli^II; Fabrício Casanova^II; Maria Simone Pan^II; Liliana Gomes Pellegrin^III

^ICoordination Assistant and Family Doctor, Grupo Hospitalar Conceição. Professor of Preventive Medicine, School of Medicine, FFFCMPA. Professor, Graduate Course in Community Health, ULBRA

^IIResident in Family and Community Medicine, Grupo Hospitalar Conceição

^IIIMedical student, FFFCMPA, and scholarship holder, FAPERGS.Medical student, FFFCMPA, and scholarship holder, FAPERGS

^{Correspondence}

ABSTRACT

INTRODUCTION: Posttraumatic stress disorder (PTSD) is characterized by the development of symptoms such as the reexperience of traumatic events (nightmares, intrusive thoughts, somatic symptoms associated with the trauma), avoidance (trying to avoid situations, people or behaviors associated with the trauma and having difficulty in dealing with new situations and feelings) and increased arousal (insomnia, irritability, difficulty in concentrating, hypervigilance and exaggerated startle response). Being aware of the frequency of PTSD in poor communities is of paramount importance.

OBJECTIVE: To identify the frequency of PTSD and the presence of depressive symptoms andalcohol abuse in a primary health care service.

METHODS: The study was carried out at the Divina Providência Health Care Service, Grupo Hospitalar Conceição. Patients seen at the service were selected randomly. PTSD, depression, alcohol abuse and the sociodemographic profile of the patients were determined.

RESULTS: Of the 54 patients included in the study, 83.3% were female; mean age was 39 years. Severe depressive symptoms were found in 28% of the patients; 59% fulfilled the criteria for PTSD diagnosis, and 12.5% had problems with alcohol.

CONCLUSIONS: The majority of patients were female, and the prevalence of PTSD was high.

Keywords: Posttraumatic stress disorder, primary health care, alcohol abuse.

RESUMEN

INTRODUCCÍON: El trastorno de estrés postraumático (TEP) se caracteriza por el desarrollo de síntomas como la retomada de la experimentación del evento traumático (pesadilla, ideas de intrusión, síntomas somáticos relacionados a la ocasión del trauma); evitación y embotamiento (evitar situaciones, personas o comportamientos que recuerden el trauma y tener dificultad para convivir con nuevas situaciones o sentimientos) y excitabilidad ampliada (insomnio, irritación, dificultad de concentración y un estado permanente de alerta y sobresalto). Es importante saber la frecuencia en una comunidad pobre.

OBJETIVO: Identificar la frecuencia del TEP, la presencia de síntomas de depresión y alcoholismo en un servicio de atención primaria.

METODOLOGÍA: El análisis se realizó en la Unidade de Saúde Divina Providência del Servicio de Salud Comunitaria del Grupo Hospitalar Conceição. Se hizo una muestra aleatoria de los pacientes que consultaron en el Servicio. Se utilizaron los síntomas depresivos, el alcoholismo y el perfil sociodemográfico como instrumentos de la identificación del TEP.

RESULTADOS: De los 54 pacientes entrevistados 83,3% eran mujeres y el promedio de edad fue de 39 años. Se identificó síntomas depresivos severos en 28% de los pacientes, el 59% tenían el criterio de TEP y el 12,5% presentaban problemas con el alcohol.

CONCLUSIÓN: La mayoría de los pacientes entrevistados era del sexo femenino y hubo una alta prevalencia de TEP.

Palabras clave: Trastorno de estrés postraumático, atención primaria de salud, alcoholismo.

INTRODUCTION

Posttraumatic stress disorder (PTSD) gained scientific and social importance as a result of the study of war neurosis, which, in calling attention to the diagnosis, made it evident that PTSD is a psychopathology with elevated prevalence and morbidity in the general population. Recently, studies of prevalence and prognosis performed in the United States confirmed these findings and showed that, the sooner that therapeutic intervention is performed, the better the patients' prognosis.^1,2

Posttraumatic stress disorder commonly follows a chronic course, with the majority of remissions being spontaneous and occurring during the first 12 months after the onset of symptoms. If the psychopathology is not treated there will be little improvement during the subsequent period. Comorbidities include increased suicide rates, depression, hypertension, peptic ulcer and respiratory diseases. Later, Davison et al. found that childhood sexual abuse was an independent risk factor for suicide attempts.^3,4

Posttraumatic stress disorder responds to treatment, including pharmacotherapy and psychotherapy.^4,5 Despite this, research in this area is yet incipient, partly because, until recently, scales for diagnosis and monitoring were typically administered by interviewers and were therefore limited by the time required for administration and training and were dependent on the technical abilities of the interviewer. The prevalence of PTSD, particularly among poor populations is not known in our country. Taking the morbidity and social costs associated with this psychopathology into account it becomes relevant to seek to develop strategies at the primary care level and effective measures to perfect integrated and humanized care. This paper aims to alert primary health care professionals to the possibility of PTSD early diagnosis.

The objective of the current study is to identify the frequency of PTSD, depressive symptoms and alcoholism at a primary care center. Specific objectives were to test the frequency of PTSD, alcoholism and depressive symptoms among the users of a primary care center and to test for associations between PTSD, alcoholism and depression among those people identified as suffering from the disorder. The reason for estimating prevalence for depression and alcoholism and their association with PTSD is the elevated comorbidity of these health problems.

METHODOLOGY

The Divina Providência health center has existed since 1986 and is located in the Porto Alegre Zona Leste region (East Side). It cares for a registered population of 6,182 people and is part of the Serviço de Saúde Comunitária (Community Health Service) of the Grupo Hospitalar Conceição. Social problems such as violence, drug dealing, unemployment, alcoholism, lack of basic sanitation and illiteracy are all found in the neighborhood, primarily in the alleyways, where the population's living conditions are extremely vulnerable.

A systematic, randomized sample was obtained making use of the appointment registers for daily medical consultations. The second patient scheduled was selected, followed by the seventh, thus selecting two patients per period. Inclusion criteria were adults over 16 and under 80 years of age and the ability to answer the questionnaire. These patients were invited to take part in the experiment before their medical consultations. Questionnaires were administered during August and September 2003, and data was collected across both shifts at the health center. During this period, 59 patients fitted the inclusion criteria; of these, five did not answer the questionnaire claiming lack of time or commitments.

Instruments were employed to identify PTSD, depression, alcoholism and sociodemographic profile.

The instrument used for alcoholism screening was a Brazilian version of AUDIT. This version was adapted for our reality taking into account what the World Health Organization aims at investigating with each question. The AUDIT test consists of 10 questions, three related to the quantity of alcoholic beverages consumed, three on alcohol dependency and four on common problems caused by alcohol use. The questions have answers that score from 0 to 4, giving a total score of 40. The cut-off point used to define alcoholism was 8.⁶

The Beck questionnaire was used to assess the presence of depressive symptoms. This instrument measures the intensity of depressive symptoms. Scores from 0 to 9 indicate no disorder, from 10 to 15 the presence of mild depressive symptoms; from 16 to 23, moderate depressive symptoms and scores above 24 indicate severe depressive symptoms.^7,8

Sociodemographic profiles were evaluated using ABIPEME's Critério de Classificação Econômica Brasil (CCEB — Brazil Economic Classification Criteria), which estimates the purchasing power of urban families and individuals, splitting them into economic classes. The scale classifies individuals from A to E.⁹

The instrument used to test for the presence of PTSD was the Davidson Trauma Scale (DTS), in its Portuguese version: Escala Davidson de Trauma. There is no validated Portuguese version available and so a form was used that had been translated by the Hospital de Clínicas de Porto Alegre and which is used in their PTSD clinic. The scale was developed to gauge the severity and frequency of symptoms in individuals exposed to traumas.¹⁰ It is a self-administered questionnaire comprising 17 questions that correspond with the 17 DSM-IV diagnostic criteria and their groups: questions 1 to 4 relate to criteria B (intrusive reexperience); questions 5 to 11, criteria C (avoidance and numbing) and questions 12 to 17, criteria D (hyperarousal or increased excitability). Before the scale is applied the patient must meet criteria A of the DSM-IV classification: experience or witness an extremely traumatic event. Therefore all of the participants in the study were questioned as to the occurrence of major trauma during their lives. If the patient did not describe any occurrence of traumatic events, the scale was not applied. The scale can be used for diagnosis and to evaluate the efficacy of therapeutic interventions by means of serial measurements.

The traumatic events described by the patients were split into nine categories according to Axis IV of the DSM-IV ^{(appendix 1)}, which is utilized to classify psychosocial and environmental problems that may affect the diagnosis, treatment and prognosis of mental disorders. The categories are: primary support group, problems related to the social environment, educational problems, occupational problems, housing problems, economic problems, problems with access to health care services, problems related to interaction with the legal system/crime and other psychosocial and environmental problems.¹¹

The study was approved by the Grupo Hospitalar Conceição ethics committee. An informed consent form was filled out by each patient before research was begun. Information obtained in the study was appended to the patients' medical records for future follow-up.

Descriptive statistics with univariate analyses were used. The chi-square test was used to compare categorical variables and Student's t test was used to compare continuous variables. Data was analyzed using the program Epi Info 6.0.¹² The measurements of association employed were prevalence ratio confidence interval.

RESULTS

Forty-five (83.3%) of the 54 patients interviewed were women. Age varied from 16 to 78 years, with a mean of 39.3 years. Sociodemographic data according to ABIPEME revealed a predominance of social class C (44.9%), followed by class D (34.7%).

Eighty-one point five percent of those interviewed reported exposure to a traumatic event. Of these, 38.9 % had been exposed to traumas from category 1 (primary support group), 16.7% from category 9 (psychosocial and environmental problems), and 14.8% to traumas from category 5 (housing problems).

Results for depressive symptoms were as follows: 27.8% of the patients exhibited severe symptoms, 11.1% moderate symptoms and 14.8% mild. Of the 32 patients who were defined as suffering from PTSD according to the Davidson scale, 13 (40.6%) had severe depressive symptoms. Two (9.1%) of the interviewees who did not fulfill PTSD criteria exhibited mild depressive symptoms and two (9.1%) severe depressive symptoms.

Twelve (37.5%) of the 32 patients identified as fulfilling PTSD criteria by the Davidson scale were rated as class D, and 11 (34.4%) as class C. Table 1 shows that the frequency of PTSD was 59.3% of the sample.

Eighteen (56.3%) of the PTSD patients exhibited category 1 trauma while 15.6 % presented traumas from categories 5 and another 15.6 % from category 9. Only 12 (54.5%) of the patients without PTSD had suffered some type of trauma.

Comparing depression with the presence of a traumatic event, 25 (46.3%) did not present depression, despite 17 (68%) of those interviewed having suffered some sort of traumatic event. Taking patients with moderate and severe depression, 66.7% and 53.3%, respectively, had had a category 1 traumatic event. Table 2 demonstrates that there was no association between depression and PTSD (prevalence ratio 0.99; confidence interval 0.74-1.32).

Twenty-six of the 45 women interviewed presented depression, five (11.1%) of whom had mild depression. Six (13.3%) had moderate depression, and 15 (33.3%) had severe depression. Only three (33.3%) of the nine men interviewed presented mild depression.

Six patients fulfilled the AUDIT criteria for alcoholism, four of whom were women. Furthermore, it was identified that 66.7% of the alcoholics were from social class D and 33% from class C. It was also found that 13.3% of the alcoholic patients had severe depression and 83.3% had PTSD. Table 3 shows the relationship between social class and the presence or absence of PTSD.

Category 1 trauma classification type was the most common in both classes D and C: 47.1% and 36.4%, respectively. Fifty percent of the alcoholics had suffered a category 1 trauma and the other 50%, a category 9 trauma. Patients from class D presented 37.5% of PTSD and those from class C 34.4%. Table 4 demonstrates that there was no association between alcoholism and PTSD (p = 0.38).

DISCUSSION

The sociodemographic data on the population reveal that a majority were female and from social class D. The prevalence of PTSD among women was greater than among men. This result is consistent with studies undertaken in American cities, in which women developed PTSD at a rate of 2:1.^2,13

No statistically significant association was observed between PTSD and depression. This may have occurred as a result of beta error, i.e. lack of statistical power, taking into consideration that PTSD commonly occurs in comorbidity with other psychiatric disorders, particularly major depression. Lifetime prevalence for comorbid disorders with PTSD was approximately 48% for major depression, 22% for dysthymia, 16% for generalized anxiety disorder, 30% for simple phobia, 28% for social phobia, 73% for substance abuse and 31% for anti-social personality disorder.¹⁴ Thus, traumatic/stressor events play a relevant role in the genesis of both morbidities.

This study found evidence that several patients presenting PSTD also present alcohol consumption and this is controversial in the literature (one study found that PTSD preceded alcoholism onset while another found the opposite).^15,16 Management of such cases becomes very complex, since it is necessary to first treat the alcoholism and, then, PTSD.¹³ The conclusions of one study showed that PTSD may be a risk factor for nicotine and drug use.¹⁷

Posttraumatic Stress Disorder diagnostic criteria emerged in 1970 when two American psychiatrists began to meet with groups of veterans of the Vietnam war in Nova York. From this start, Shatan and Lifton became interested in traumatized populations and studied the literature on holocaust survivors and accident and burns victims.³ A diagnosis of PTSD is not identified at the level of general practice, principally because primary care doctors do not identify this health problem. The current study identifies that this disease is probably very common in poor communities living in urban slums and that there is a need to develop strategies to identify and effectively treat it as early as possible. In one American study at the primary care level, 83% of the patients seen at health centers reported at least one traumatic event in their lives. The most common traumas were witnessing a death, serious accidents and sexual abuse. Sexual abuse was the strongest predictor of PTSD.¹⁸ These elements described in the literature may explain the elevated prevalence of PTSD in the current study, when it is considered that the community has serious problems with violence.

A number of different studies have used the DSM-III-R criteria to investigate the prevalence, incidence and morbidity of PTSD and of traumatic situations. Breslau et al. found a lifelong PTSD prevalence of 11% for women and 5.5% for men, while Kessler et al. found a lifelong prevalence for the disorder of between 8 and 12% in the United States, with the average for women being twice as frequent.^1,2 These studies also found evidence that between 40 and 70% of individuals had experienced at least one major trauma in their lives, which suggests that constitutional and sociocultural factors are also involved in the development of the syndrome, in addition to the magnitude of the traumatic event. In fact, depending on the vulnerability of the individual concerned, PTSD can be caused by traumatic events that are relatively common within the community. The current study has shown a tendency towards a greater frequency of PTSD among women, in confirmation of published data.

In common with the present study, Kessler et al.¹ also observed that the rate of PTSD was higher among women (10.4%) than among men (5.0%). Australian data recently reproduced the marital status findings, but found a much smaller difference between the sexes in a 12-month prevalence study¹⁹. It is interesting to note that Australia appears to have a lower global 12-month PTSD prevalence (1.33%) than that found by a study performed in the USA (3.9%).¹⁹

There are a number of limitations to the present study, which should be taken into account before making generalizations applicable to other communities. Data collection was performed in the waiting room of a health center, which could have caused a selection bias and may explain the fact that the observed PTSD prevalence was so much greater than that found in the USA (the same applies to exposure to traumatic events). The small sample size is a further study limitation that could lead to errors when inferring prevalence. However, it is estimated that the frequency of these outcomes would be elevated in this community. The patients assessed presented an elevated frequency of severe depression, which would not be expected in primary care. Measurement bias cannot be discarded since the information imparted was not validated by psychiatric interview. Notwithstanding, this study makes it possible to raise a series of hypotheses and without doubt makes it possible to alert primary care doctors to the existence of PTSD and its comorbidity with alcoholism and depressive symptoms, in addition to the need to identify such problems early. Based on the results from this study it can be perceived that PTSD may have an elevated prevalence in poor urban communities and that health professionals and management should develop strategies to treat this morbidity with priority and develop a line of research into the subject.

Acknowledgements

We are grateful to Dr. Flávio Sanchis who contributed to the literature review and in identifying available research instruments with which to perform the study.

REFERENCES

9. Associação Brasileira dos Institutos de Pesquisa de Mercado (ABIPEME). Disponível em: www.abipeme.org.br. Acessado: 7 jul. 2004.

Received on April 24, 2004.

Revised on July 27, 2004.

Approved on August 8, 2004.

⁷

Axis IV — Psychosocial and environmental problems

Primary support group problems: for example, death of a family member, health problems in family, disruption of family by separation, divorce, or estrangement, removal from the home, remarriage of parent, sexual or physical abuse, parental overprotection, neglect of child, inadequate discipline, discord with siblings, birth of sibling.

Problems related to the social environment: for example, death or loss of friend, inadequate social support, living alone, difficulty with acculturation, discrimination, adjustment to life-cycle transition (e.g. retirement).

Educational problems: for example, illiteracy, academic problems, discord with teachers or classmates, inadequate school environment.

Occupational problems: for example, unemployment, threat of job loss, stressful work problems, difficult work conditions, job dissatisfaction, job change, discord with boss or co-workers.

Housing problems: for example, homelessness, inadequate housing, unsafe neighborhood, discord with neighbors or landlord.

Economic problems: for example, extreme poverty, inadequate finances, insufficient welfare support.

Problems with access to health care services: for example, inadequate health care services, transportation to health care facilities unavailable, inadequate health insurance.

Problems related to interaction with the legal system/crime: for example, arrest, incarceration, litigation (lawsuit/trial), victim of crime.

Other psychosocial and environmental problems: for example, exposure to disasters, war, other hostilities, discord with non-family caregivers such as counselor, social worker, or physician, unavailability of social service agencies.

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Appendix 1  — Traumatic event categories according to the DSM-IV

*

This study received grants from FAPERGS.

Publication Dates

• Publication in this collection
  13 Sept 2005
• Date of issue
  Aug 2004

History

• Received
  28 Apr 2004
• Reviewed
  27 July 2004
• Accepted
  12 Aug 2004