Posttraumatic Stress Disorder in U.S. Military Primary Care: Trajectories and Predictors of One‐Year Prognosis

Abstract

We examined the longitudinal course of primary care patients in the active duty Army with posttraumatic stress disorder (PTSD) and identified prognostic indicators of PTSD severity. Data were drawn from a 6-site randomized trial of collaborative primary care for PTSD and dpression in the military. Subjects were 474 soldiers with PTSD (scores ≥ 50 on the PTSD Checklist -Civilian Version). Four assessments were completed at U.S. Army installations: baseline, and follow-ups at 3 months (92.8% response rate [RR]), 6 months (90.1% RR), and 12 months (87.1% RR). Combat exposure and 7 validated indicators of baseline clinical status (alcohol misuse, depression, pain, somatic symptoms, low mental health functioning, low physical health functioning, mild traumatic brain injury) were used to predict PTSD symptom severity on the Posttraumatic Diagnostic Scale (Cronbach's α = .87, .92, .95, .95, at assessments 1-4, respectively). Growth mixture modeling identified 2 PTSD symptom trajectories: subjects reporting persistent symptoms (Persisters, 81.9%, n = 388), and subjects reporting improved symptoms (Improvers 18.1%, n = 86). Logistic regression modeling examined baseline predictors of symptom trajectories, adjusting for demographics, installation, and treatment condition. Subjects who reported moderate combat exposure, adjusted odds ratio (OR) = 0.44, 95% CI [0.20, 0.98], or who reported high exposure, OR = 0.39, 95% CI [0.17, 0.87], were less likely to be Improvers. Other baseline clinical problems were not related to symptom trajectories. Findings suggested that most military primary care patients with PTSD experience persistent symptoms, highlighting the importance of improving the effectiveness of their care. Most indicators of clinical status offered little prognostic information beyond the brief assessment of combat exposure.

The relationship among psychopathology, religiosity, and nicotine dependence in Croatian war veterans with posttraumatic stress disorder

“…Our results showed that PTSD is a chronic disorder that does not subside with time ( 6 , 34 ). Higher combat exposure was associated with more intense re-experiencing, negativity and hyperarousal, and depression, supporting the view that it predicts PTSD persistence ( 35 ). A previous study in Croatian veterans found that all PTSD symptoms were more severe with more intense war experience, but it did not assess depression and negativity and participants were exclusively prisoners of war ( 2 ).…”

Predictors of PTSD Treatment Retention and Response: A Systematic Review

“…We created one large record for each study that included data from all associated publications. Seventy studies reported in 84 publications are included in this review: Acierno et al, 2017;Agha, 2008;Badour et al, 2012;Belsher et al, 2012;Boden et al, 2013;Bonn-Miller et al, 2013;Bray et al, 2016;Creamer et al, 2002;Currier, Holland, and Drescher, 2014;DeViva et al, 2017;Elliott et al, 2005;Engel et al, 2015;Evans et al, 2010;Evans, Cowlishaw, and Hopwood, 2009;Foa et al, 2018;Fontana and Rosenheck, 1997;Fontana and Rosenheck, 1998;Fontana, Ford, and Rosenheck, 2003;Forbes et al, 2003;Forbes et al, 2005;Forbes et al, 2008;Forbes et al, 2010;Ford, Fisher, and Larson, 1997;Fortney et al, 2015;Friedman et al, 2007;Gallegos et al, 2015;Gallegos, Streltzov, and Stecker, 2016;Garcia et al, 2011;Gilman, Schumm, and Chard, 2012;Graca, Palmer, and Occhietti, 2014;Gros et al, 2013;Gros et al, 2018;Gros, Yoder, et al, 2011;Haller et al, 2016;Hebenstreit et al, 2015;Hernandez-Tejada et al, 2014;Hobfoll et al, 2016;…”

“…Heterogeneity was substantial (I 2 = 78%) and significant (p = .01). Thirteen studies (Belsher, 2012;Bray et al, 2016;Currier, 2014;Holder et al, 2018;Jeffreys et al, 2014;López et al, 2017;McLay et al, 2016;Tiet et al, 2015;Tuerk et al, 2011;Walter et al, 2014) Korte et al, 2017, included age in a path model and found older age associated with greater severity as measured by PCL scores (coefficient = 0.37) at the midtreatment point. Bray et al, 2016, found patients 35 years and older less likely to be classified as "improvers" at discharge (OR = 0.49, 95% [CI 0.24, 0.99]).…”

“…Thirteen studies (Belsher, 2012;Bray et al, 2016;Currier, 2014;Holder et al, 2018;Jeffreys et al, 2014;López et al, 2017;McLay et al, 2016;Tiet et al, 2015;Tuerk et al, 2011;Walter et al, 2014) Korte et al, 2017, included age in a path model and found older age associated with greater severity as measured by PCL scores (coefficient = 0.37) at the midtreatment point. Bray et al, 2016, found patients 35 years and older less likely to be classified as "improvers" at discharge (OR = 0.49, 95% [CI 0.24, 0.99]). Currier, Holland, and Drescher, 2014, created a logistic regression model to predict stable low PTSD versus improving moderate PTSD at discharge; older age was associated with the latter category.…”

“…In a study of outpatient PTSD treatment, Fontana, Ford, and Rosenheck, 2003, found that more years of education was correlated with greater decrease in PTSD severity measured by the Mississippi Scale for Combat-Related PTSD at both four and 12 months (r = -0.16 and -0.26, respectively; N = 554). Bray et al, 2016, stratified results by education level; patients with a high school education or less were significantly more likely to be classified as improved at 12 months than those with some college or college graduates ( p <.05). In an RCT of PE versus PCT in female veterans and Army soldiers, Schnurr, 2016, found no difference in the percentage of patients with education beyond high school between nonresponders, responders, patients no longer meeting diagnosis criteria, and patients experiencing remission.…”