Primary Care And PTSD
By Ronald J. Gebhart, M.D. and Frances L. Neeley, R.N., M.S.N., M.H.S.A.
NCP Clinical Quarterly 6(4): Fall 1996
The evolution of patient care in the Veterans Health Administration (VHA) is bringing health care providers into closer contact with each other more than at any time in the past. As VHA moves to implement primary care as its preferred method of patient management, mental health and primary care providers are finding that they have much to talk to each other about. This is particularly true in the case of patients with PTSD.
Many of these patients are seen initially in primary care clinics for a variety of healthcare reasons. A significant number of patients presenting with health concerns also suffer from PTSD, which often remains undiagnosed and untreated in medical settings, and which may have negative impact on compliance with medical treatment, response to treatment, patient satisfaction, level of health care utilization and cost. Severe illnesses and some medical procedures may be traumatic stressors which may lead to stress reactions or PTSD problems amenable to psychological care. A history of exposure to catastrophic stressors is associated with increased rates of health problems, health care utilization, morbidity, and mortality. Also, public accounts of victims of natural or other tragedies have focused attention on the need for crisis and stress intervention. These events occur everyday and victims may show up at the VA primary care provider’s doorstep. The providers may not know about the incident that triggered the symptoms. They need to know that they must ask the difficult questions anyway. The ability to recognize key symptoms of PTSD as significant components of the symptom complex is not always something that primary care providers have developed in a non-VA setting. As a result, a dialogue between mental health providers with expertise in PTSD and primary care providers must be encouraged and developed.
According to the National Ambulatory Medical Survey ( ) nearly half of all patients in which there was a primary or secondary diagnosis of a mental health disorder are seen by a medical clinic provider, 90% in primary care. One in three trauma survivors or survivors of war or physical or sexual abuse have significant undetected and untreated psychological impairment. Yet fewer than 10% of medical clinics systematically identify trauma survivors with untreated mental health problems. The observation that a high number of VHA patients have significant mental health diagnoses in addition to their medical conditions has led to discussions and collaboration between primary care providers and mental health providers as primary care teams have been set up. The exact mechanism for these liaisons varies from having a mental health professional (psychiatrist, psychiatric clinical nurse specialist, psychiatric social worker, psychologist) actually assigned to the primary care team to having mental health primary care teams that provide the majority of health care to these patients with a consultant primary care physician or physician assistant or nurse practitioner assigned to the team.
With frequent interactions between medical primary care and mental health providers, there are opportunities for each to educate and enrich the other to the mutual benefit of the patients and providers, since health outcomes can be optimized, costs can be reduced and patient satisfaction enhanced. Careful planning and developed structure are needed to assure that these interactions are valued and encouraged locally and nationally. Trauma and stress screening and treatment can be accomplished with little or no extra workload for health care providers. Formal clinical educational seminars and conferences are being discussed and planned at national levels in VHA. Some ideas proposed to assist primary care providers consist of brief self-administered screening tools, educational brochures and effective communication techniques. This training will assist the primary care provider by decreasing their time pressures and workload day, since these patients often eat away at the provider’s time with frequent visits, multiple complaints, and poor compliance with advice and treatment.
Recent attention has been focused on the role of trauma (combat, sexual, and physical) on women in the military and its long term effects. Many of these women are now coming to the VA for care. Primary care providers need to be alert to the special needs of this group of patients. Educational efforts are underway through national training programs for women veteran coordinators, primary care providers and patient health education coordinators. The proposed educational programs provide helpful changes in primary care practices that can increase the detection, enhance appropriate referrals to mental health specialists, and improve clinical management of patients with psychiatric symptoms.
Ronald J. Gebhart is Chief Consultant, Primary and Ambulatory Care in VA Headquarters, Washington, DC, and formerly Associate Chief of Staff for Ambulatory Care at Atlanta VAMC. Dr. Gebhart is an internist with a subspecialty in Infectious Diseases and has over 20 years experience in delivering primary care in outpatient settings. Frances L. Neeley is Clinical Program Manager in the Office of Primary and Ambulatory Care in VA Headquarters , Washington, DC. Ms. Neeley is formally trained as a Psychiatric Clinical Nurse Specialist and has clinical, educational and administrative experience in inpatient and ambulatory care.
|
