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Abstract-Because posttraumatic stress disorder (PTSD) is both prevalent and underrecognized, routine primary care-based screening for PTSD has been implemented across the Veterans Health Administration. PTSD is frequently complicated by the presence of comorbid chronic pain, and patients with both conditions have increased symptom severity and poorer prognosis. Our objective was to determine whether the presence of pain affects diagnosis and treatment of PTSD among Department of Veterans Affairs (VA) patients who have a positive PTSD screening test. This retrospective cohort study used clinical and administrative data from six Midwestern VA medical centers. We identified 4,244 VA primary care patients with a positive PTSD screen and compared outcomes for those with and without a coexisting pain diagnosis. Outcomes were three clinically appropriate responses to positive PTSD screening: (1) mental health visit, (2) PTSD diagnosis, and (3) new selective serotonin reuptake inhibitor (SSRI) prescription. We found that patients with coexisting pain had a lower rate of mental health visits than those without pain (hazard ratio: 0.889, 95% confidence interval: 0.821-0.962). There were no significant differences in the rate of PTSD diagnosis or new SSRI prescription between patients with and without coexisting pain.
Key words: comorbidity, health services research, healthcare utilization, mental health, pain, posttraumatic stress disorder, primary care, screening, Veterans, Veterans health.
INTRODUCTION
Posttraumatic stress disorder (PTSD) is both prevalent and underrecognized in primary care. Prior to operations in Iraq and Afghanistan, the point prevalence of PTSD among Department of Veterans Affairs (VA) primary care patients was estimated at 11.5 percent and the diagnosis was recognized by the primary care provider in less than 50 percent of cases [1]. Routine screening with the 4-item Primary Care PTSD Screen (PC-PTSD) has been implemented within the VA system to facilitate early recognition of PTSD [2].
PTSD is frequently complicated by the presence of comorbid chronic pain. Studies of Veterans in all eras since Vietnam have yielded high rates of comorbidity between the two conditions [3-5]. Patients with comorbid PTSD and pain have worse symptom severity, worse prognosis and treatment outcomes, greater levels of disability, worse quality of life, greater levels of psychological distress, and worse maladaptive thinking and coping patterns [6-12]. Theoretical models have postulated underlying vulnerabilities that predispose the development of both chronic pain and PTSD [13]...