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DELIVERY OF SERVICES FOR PTSD
Robert A. Rosenheck MD1 and
Alan Fontana, PhD2
National Center for PTSD,
Northeast Program Evaluation Center,
West Haven, CT and
Department of Psychiatry
Yale University Medical School
Conventional research on the roots of psychopa-thology and on the efficacy
of treatment in controlled trials are only the first steps toward the ultimate
goal of health care systems: improving the health of the public at large. Health
services research picks up the baton from basic and clinical research to examine
how services are delivered, their costs, and above all, their effectiveness
in ³real world² settings. Research on the delivery of health care services can
be thought of as addressing three goals. First, service use, along with epidemiological
data on disease prevalence, is an indicator of the burden of disease on the
general population and its economic consequences. Second, studies of service
use provide information on the accessibility of services, i.e., the success
or failure of the health care system to address the needs of its target population.
Finally, studies of service use are important in simultaneously evaluating the
effec-tiveness and cost of services, i.e., their ultimate value to the public.
Severity/Burden of Disease. In an important paper from the National Co-Morbidity
Survey, Kessler et al. (1999) present information on the both the likeli-hood
and intensity of service use among Americans with various mental illnesses.
This study shows that PTSD is associated with nearly the highest rate of service
use, and by implication, the highest per-capita cost of any mental illness.
This study illus-trates the central importance of PTSD to the public¹s mental
health. In a more focused study of severe PTSD, Ford (1999) demonstrated exceptionally
high levels of service use among combat veterans meeting criteria for DESNOS.
Switzer et al. (1999), studying service use among clients with PTSD at an urban
mental health center, found 94% with a history of trauma and 42% with PTSD,
and documented espe-cially high levels of service use among those with PTSD,
as compared to others. Moving from mental health service use to general medical
service use, both Leserman et al. (1998) and Friedman and Schnurr (1995) showed
that PTSD is also associated with high levels of use of non-mental health services.
An im-portant HMO-based study (Walker et al., 1999) reported substantially increased
health care costs among patients who reported childhood trauma.
Access to Care. While some studies have focused on the high levels of service
use among people with PTSD, others have demonstrated considerable underuse of
services. Although best known for its documentation of the high prevalence of
PTSD in Vietnam Veterans, the National Vietnam Veterans Readjustment Study (Kulka
et al., 1990) also docu-mented dramatically low rates of service use among veterans
and helped stimulate the development of a national network of specialized VA
services for PTSD. Schwarz and Kowalski (1992) demonstrated that survivors of
a man-made disaster were reluctant to use mental health services because of
the fear that painful memories would be aroused, and they advo-cate special
efforts to reach out to such people. Solomon and Davidson (1997) also suggest
that while people with PTSD are high users of health care services, they are
often reluctant to use mental health services. Hankin et al. (1996) showed that
30% of a sample of non-psychiatric patients in the VA system met crite-ria for
PTSD and that the PTSD group reported more severe medical symptoms than other
veterans.
There has been considerable concern that the low rates of service use among
Vietnam veterans with PTSD reported by Kulka et al. (1990) might reflect a special
reluctance of these veterans, and especially minority veterans, to use VA services
because of their distrust of the government that sent them to war. Rosenheck
and Fontana (1995), however, found that, after controlling for other factors,
Vietnam veterans with PTSD were 1.8 times more likely than other veterans to
use VA mental health services. Further-more, minorities with PTSD were more
likely to use VA services than other veterans, even after adjusting for income
and other relevant factors (Rosenheck & Fontana, 1994), although they had similar
outcomes (Rosenheck & Fontana, 1996).
Access can be thought of as having several com-ponents: having any contact
with the health care system; obtaining adequate intensity of service; and receiving
appropriate quality of service. While there are no well-established guidelines
for the treatment of PTSD, program monitoring can allow continuous assessment
of the characteristics of treatment. In a study of clinician-client racial pairing,
Rosenheck, Fontana, and Cottrol (1995) demonstrated the use of such a quality
monitoring system and showed that African-American veterans treated for PTSD
had lower participation ratings than whites but no differ-ences in clinician-reported
outcomes. These findings
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are partially explained by the fact that participation was
lower when African-American veterans were treated by
white clinicians than when they were treated by African-
American clinicians.
Outcome, Cost, and Value. The ultimate goal of health
service delivery is improvement in health status‚‚best mea-
sured with standardized evaluation instruments that are
administered by trained research personnel at the begin-
ning of treatment and periodically thereafter. In a multi-site
12-month follow-up study of 525 VA outpatients treated for
PTSD in specialized PTSD Clinical Teams, Rosenheck and
Fontana (1996) found significant clinical improvement that
was comparable between African-American and white vet-
erans as well as equivalent use of services and client satisfac-
tion across racial groups. Unlike randomized clinical trials
that demonstrate the efficacy of services under conditions
that maximize internal validity by treating carefully se-
lected patients under highly controlled conditions, this study
documents outcomes associated with service delivery un-
der more natural, "real-world" conditions and thus has
greater external validity. While efficacy trials can tell us how
well treatments can perform under the best of circum-
stances, effectiveness studies help us understand the perfor-
mance of services as they are actually delivered by health
care providers in real-world health care systems.
The ultimate evaluation of service delivery must con-
sider its cost as well as its effectiveness. Although many
clinicians consider cost to be an extraneous preoccupation of
administrators and business executives, it is as crucial to the
determination of the value of a service as is its effectiveness.
Service X may be twice as effective as service Y, but if it is
four times as expensive, it has only half the value. In a world
in which health care resources are scarce-as they always
are and always have been-value, the benefit obtained per
dollar spent, must be the ultimate basis for resource alloca-
tion decisions. The ultimate problem with expensive treat-
ments is that they can be provided to fewer people and thus
generate less benefit to society than less expensive treat-
ments. It is not a question of dollars versus health care, but
of using dollars in the best service of health care.
In a study that has been both very controversial and
very influential in the VA system, Fontana and Rosenheck
(1997) studied a sample of 785 veterans treated in 10 inpa-
tient programs. While outcomes were similar in long-term
Specialized Inpatient PTSD Units (SIPUs), short-term Evalu-
ation and Brief Treatment PTSD Units (EBTPUs), and Gen-
eral Psychiatry Units (GPUs), SIPU treatment was about
$18,000 more expensive per patient per year than the other
programs. By shifting to less expensive but equally effective
programs, it would thus be possible to provide equally
beneficial inpatient services to larger numbers of veterans
(Rosenheck, Fontana, & Errera, 1997).
In a similar study of outpatient treatment, Fontana and
Rosenheck (1996) compared outcomes among patients who
received high-intensity outpatient treatment and patients
who received lower-intensity treatment. Comparison on
numerous measures of health status and social adjustment
showed virtually no baseline differences between high- and
low-intensity patients and suggested no empirical basis for
their receipt of more intensive services. Even so, on most of
the measures where there were significant baseline differ-
ences, recipients of low-intensity services had more severe
problems than high-intensity patients. Additionally, there
were no differences on any outcome measure. Here too,
evidence that lower-intensity services offer greater value
(more clinical benefit per dollar) suggests an approach to
treatment that can provide benefits to larger numbers of
patients.
Endnote: Health Care Services Can Yield No Greater Benefits
than the Service Systems that Deliver Them. When a clinician
makes an error in treatment, there is both bad news and
good news. The bad news is that a patient has been deprived
of benefits that he or she might otherwise have enjoyed. The
good news is that both the patient and the clinician have a
good chance of discovering the error and fixing it. In con-
trast, when service systems malfunction, the cost to human
well-being is far greater because the problems are far more
widespread and far more difficult to detect and correct.
Only systematic research and evaluation of operating ser-
vice systems can determine: (1) when a society fails to
understand the needs of its citizens for specific services, (2)
when a service system, however unintentionally, excludes
people from obtaining the benefits of health care by imped-
ing access to appropriate services, or (3) when programs
provide either too few or too many services, or provide
inefficient services, thus wasting limited resources. Medical
care has traditionally focused its research efforts on indi-
vidual patients and illnesses, and this approach has yielded
immense benefit for humanity. However, much potential
benefit has been silently lost through the inopportune op-
eration of service delivery systems. New research methods
and perspectives are increasingly being brought into action
to correct these deficiencies.
SELECTED ABSTRACTS
FONTANA, A. & ROSENHECK, R.A. (1997). Effectiveness
and cost of the inpatient treatment of posttraumatic stress
disorder: Comparison of three models of treatment. American
Journal of Psychiatry, 154, 758-765. OBJECTIVE: This study com-
pared the outcomes and costs of 3 models of Department of
Veterans Affairs (VA) inpatient treatment for PTSD: (1) long-stay
specialized inpatient PTSD units, (2) short-stay specialized evalu-
ation and brief-treatment PTSD units, and (3) nonspecialized
general psychiatric units. METHOD: Data were drawn from 785
Vietnam veterans undergoing treatment at 10 programs across
the country. The veterans were followed up at 4-month intervals
for 1 year after discharge. Successful data collection averaged 66.1
percent across the 3 follow-up intervals. RESULTS: All models
demonstrated improvement at the time of discharge, but during
follow-up symptoms and social functioning rebounded toward
admission levels, especially among participants who had been
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treated in long-stay PTSD units. Veterans in the short-stay PTSD
units and in the general psychiatric units showed significantly
more improvement during follow-up than veterans in the long-
stay PTSD units. Greatest satisfaction with their programs was
reported by veterans in the short-stay PTSD units. Finally, the
long-stay PTSD units proved to be 82.4 percent and 53.5 percent
more expensive over 1 year than the short-stay PTSD units and
general psychiatric units, respectively. CONCLUSIONS: The
paucity of evidence of sustained improvement from costly long-
stay specialized inpatient PTSD programs and the indication of
high satisfaction and sustained improvement in the far less costly
short-stay specialized evaluation and brief-treatment PTSD pro-
grams suggest that systematic restructuring of VA inpatient
PTSD treatment could result in delivery of effective services to
larger numbers of veterans.
FONTANA, A. & ROSENHECK, R.A. (1996). Improving the
efficiency of outpatient treatment for posttraumatic stress dis-
order. Administration and Policy in Mental Health, 23, 197-210. This
article uses service utilization and outcome data from the special-
ized PTSD outpatient programs of the Department of Veterans
Affairs to illustrate a method of evaluating the required intensity
of outpatient psychiatric treatment. The analyses presented sug-
gest that PTSD treatment programs could offer intensive services
for only the first four months of treatment, followed by a reduc-
tion in intensity to an average of only one visit per month, without
loss of clinical gains. Workload projections suggest that applying
such standards under a system of regulatory control would allow
a 17 to 51 percent increase in patients treated.
FORD, J.D. (1999). Disorders of extreme stress following
war-zone military trauma: Associated features of posttraumatic
stress disorder or comorbid but distinct syndromes? Journal of
Consulting and Clinical Psychology, 67, 3-12. Disorders of extreme
stress not otherwise specified (DESNOS) and PTSD were found
to be comorbid but distinct among military veterans seeking
inpatient PTSD treatment: 31 percent qualified for both condi-
tions, 29 percent were diagnosed PTSD only, 26 percent were
classified DESNOS only, and 13 percent met criteria for neither.
PTSD diagnosis was associated with elevated levels of war-zone
trauma exposure and witnessing atrocities and with impairment
on the Mississippi Scale for Combat-Related PTSD and the Penn
Inventory. DESNOS classification (but not PTSD) was associated
with (a) early childhood trauma and participation in war-zone
atrocities, (b) extreme levels of intrusive trauma reexperiencing,
(c) impaired characterological functioning (object relations), and
(d) use of intensive psychiatric services. PTSD and DESNOS may
be comorbid but distinct posttraumatic syndromes and, as such,
warrant careful clinical and scientific investigation.
FRIEDMAN, M.J. & SCHNURR, P.P. (1995). The relation-
ship between trauma, post-traumatic stress disorder, and physi-
cal health. In M.J. Friedman, D.S. Charney, & A.Y. Deutch (Eds.),
Neurobiological and clinical consequences of stress: From normal adap-
tation to post-traumatic stress disorder (pp. 507-524). Philadelphia:
Lippincott-Raven. First we review the literature on the physical
health outcomes associated with traumatic events. Despite the
extensive literature suggesting that exposure to stressful events
may be associated with adverse health outcomes, much less has
been written on the medical and somatic consequences of expo-
sure to extreme stress. Nonetheless, reviewers have suggested
that physical health may be severely and chronically impaired
following traumatic experiences. Second, we review the litera-
ture on the physical health outcomes associated with PTSD. We
argue that PTSD is an important mediator through which trauma
may be related to adverse outcomes. Third, we review biological
and psychological correlates of PTSD that might predispose
affected individuals toward increased risk for medical problems.
[Adapted from Text]
HANKIN, C.S., ABUEG, F.R., GALLAGHER-THOMPSON,
D.E., & LAWS, A. (1996). Dimensions of PTSD among older
veterans seeking outpatient medical care: A pilot study. Journal
of Clinical Geropsychology, 2, 239-246. We examined PTSD arising
from a variety of stressors among a sample (n = 30) of male
veterans 60 years of age or older seeking outpatient medical
treatment. 30 percent of this nonpsychiatric sample satisfied
criteria for lifetime PTSD. We compared PTSD and nonPTSD
groups along the following dimensions: health care utilization,
somatic complaints, alexithymia, and developmental timing of
trauma occurrence. We found no significant differences between
groups for demographics, military history, health care utiliza-
tion, or alexithymia. The PTSD-positive group reported signifi-
cantly more chest pain, arthritis, and greater frequency and
distress from trauma occurring in adolescence.
KESSLER, R.C., ZHAO, S., KATZ, S.J., KOUZIS, A.C., FRANK,
R.G., EDLUND, M.J., & LEAF, P. (1999). Past-year use of outpa-
tient services for psychiatric problems in the National
Comorbidity Survey. American Journal of Psychiatry, 156, 115-123.
OBJECTIVE: The authors present nationally representative de-
scriptive data on 12-month use of outpatient services for psychi-
atric problems. They focused on the relationship between DSM-
III-R disorders [including PTSD] and service use in four broadly
defined service sectors as well as the distribution of service use in
multiple service sectors. METHOD: Data from the National
Comorbidity Survey were examined. RESULTS: Summary mea-
sures of the seriousness and complexity of illness were signifi-
cantly related to probability of use, number of sectors used, mean
number of visits, and specialty treatment. One-fourth of the
people in outpatient treatment were seen in multiple service
sectors, but no evidence was found of multisector offset in num-
ber of visits. CONCLUSIONS: Use of outpatient services for
psychiatric problems appears to have increased over the decade
between the early 1980s and early 1990s, especially in the self-
help sector. Aggregate allocation of treatment resources was
related to need, highlighting the importance of making provi-
sions for specialty care in the triage systems currently evolving as
part of managed care.
KULKA, R.A., SCHLENGER, W.E., FAIRBANK, J.A.,
HOUGH, R.L., JORDAN, B.K., MARMAR, C.R., & WEISS, D.S.
(1990). Trauma and the Vietnam War generation: Report of findings
from the National Vietnam Veterans Readjustment Study. New York:
Brunner/Mazel. Chapter IX presents findings on the patterns of
use of services for physical and mental health problems. Separate
analyses are provided for a number of subtypes of mental and
physical health services. Only one significant difference was
found between male Vietnam theater and era veterans in their use
of VA facilities for physical health care. Among women, more
differences were found between Vietnam theater and era veter-
ans. Overall, theater veterans with PTSD, a service-connected
physical disability (SCPD), or a lifetime diagnosis of substance
dependence or abuse were more likely to have used VA services
for physical health problems than their counterparts without
these conditions. Vietnam theater veterans as a group (both men
and women) were more likely to have used the VA for mental
health services than their era veteran counterparts. The data
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suggests that Vietnam theater veterans-especially those ex-
posed to high levels of war-zone stress‚‚have made greater use
of mental health care resources than their era veteran and civilian
counterparts. White/other Hispanic subgroups used all mental
health resources in much the same way as the total population of
theater veterans. Male and female theater veterans with PTSD
were significantly more likely than theater veterans without this
disorder to have ever used any type of formal mental health
service. Yet, the findings also indicate that three-eighths of male
and one-quarter of female Vietnam theater veterans with current
PTSD have never seen a health professional about a mental health
problem. Since PTSD is a major and debilitating psychiatric
disorder, a considerable unmet need for mental health services
probably remains. [Adapted from Text]
LESERMAN, J., LI, Z., DROSSMAN, D.A., & HU, Y.J.B.
(1998). Selected symptoms associated with sexual and physical
abuse history among female patients with gastrointestinal dis-
orders: The impact on subsequent health care visits. Psychologi-
cal Medicine, 28, 417-425. BACKGROUND: Despite a growing
literature pointing to the deleterious health effects of sexual and
physical abuse history, few studies provide evidence about which
medical symptoms are most affected. The aim of this paper is to
determine the impact of sexual and physical abuse history on a
selected set of medical symptoms, and to test how such abuse,
medical symptoms and functional disability may affect subse-
quent health care visits. METHODS: We studied 239 women from
a referral-based gastroenterology clinic; follow-up data were
available on 196 of these women. All women were interviewed
about sexual and physical abuse history. RESULTS: Women with
abuse history, particularly those with severe abuse, were much
more likely to report somatic symptoms related to panic (e.g.,
palpitations, numbness, shortness of breath), depression (e.g.,
difficulty sleeping, loss of appetite), musculoskeletal disorders
(e.g., headaches, muscle aches), genito-urinary disorders (e.g.,
vaginal discharge, pelvic pain, painful intercourse), skin distur-
bance (e.g., rash) and respiratory illness (e.g., stuffy nose). Fur-
thermore, we found that the severity of abuse history, somatic
symptoms and functional disability predicted 30 percent of the
variance in health care visits during the subsequent year, and that
the effect of abuse severity on visits was explained by abused
women having more somatic symptoms and functional disabil-
ity. CONCLUSIONS: Patients' reports of abuse history, somatic
symptoms and functional disability appear to be important fac-
tors in explaining the number of health care visits among a clinic
sample of women with gastrointestinal disorders.
ROSENHECK, R.A. & FONTANA, A. (1994). Utilization
of mental health services by minority veterans of the Vietnam
era. Journal of Nervous and Mental Disease, 182, 685-691. This study
sought to identify differences in utilization of mental health
services among members of five minority groups who served in
the military during the Vietnam era. Data on utilization of mental
health services from five different types of provider (Veterans
Affairs [VA] and non-VA mental health providers, nonpsychiatrist
physicians, clergy, and self-help groups) were obtained from a
national survey of Vietnam era veterans (the National Vietnam
Veterans Readjustment Study) along with information on
sociodemographic characteristics, health status, income, and
health insurance coverage. Chi-square tests and multivariate
logistic regression analyses were used to compare use of various
services among whites, blacks, Puerto Rican Hispanics, Mexican
Hispanics, and others. Black veterans and Mexican Hispanic
veterans were significantly less likely than white veterans to have
used non-VA mental health services or self-help groups, after
adjusting for health status and other factors. There were no
differences between ethnocultural groups in use of VA mental
health services, or services provided by nonpsychiatrist physi-
cians or clergy, even after adjustment was made for health and
economic factors. Although military service during the Vietnam
conflict may have alienated many minority veterans from the
federal government, the reluctance of minorities to use non-VA
mental health services does not extend to the VA system. Further
studies are needed to clarify the reasons for less non-VA service
use among some minority groups.
ROSENHECK, R.A. & FONTANA, A. (1995). Do Vietnam-
era veterans who suffer from posttraumatic stress disorder
avoid VA mental health services? Military Medicine, 160, 136-142.
It has been suggested that Vietnam veterans who suffer from
PTSD avoid Department of Veterans Affairs (VA) health services
because their experiences in the military engendered a profound
distrust of the Federal Government and its institutions. Data from
a national survey of 1,676 veterans who served during the Viet-
nam era show that veterans with PTSD were 9.6 times more likely
than other veterans to have used VA mental health services; but
only 3.3 times more likely to have used non-VA services. After
controlling for other factors, veterans suffering from PTSD were
1.8 times more likely than other veterans to have used VA
services, but were no more likely to have used non-VA services.
Contrary to conventional belief, veterans with PTSD show a
preference for VA compared to non-VA mental health services.
ROSENHECK, R.A. & FONTANA, A. (1996). Ethnocultural
variations in service use among veterans suffering from PTSD.
In A.J. Marsella, M.J. Friedman, E.T. Gerrity, & R.M. Scurfield
(Eds.), Ethnocultural aspects of posttraumatic stress disorder: Issues,
research, and clinical applications (pp. 483-504). Washington: Ameri-
can Psychological Association. Empirical studies conducted in
recent decades have suggested that ethnocultural minorities
make less use of both physical and mental health services than
other Americans. In this report, we extend our examination of
ethnocultural factors in the treatment of combat-related PTSD
through a detailed examination of treatment received by veterans
who came to VA for help with psychological problems related to
their war zone experiences. Data for this study were derived from
structured interviews conducted as part of the national evalua-
tion of the implementation of the Department of Veterans Affairs
PTSD Clinical Teams (PCT) Program. The sample included 3,879
Whites (70.8 percent), 918 African Americans (16.8 percent), 249
Puerto Rican Hispanics (4.5 percent), 195 Mexican Hispanics (3.6
percent), 124 American Indians (2.3 percent), and 110 others (2.0
percent). There were no differences in the ethnocultural propor-
tions of veterans who had made prior use of at least one type of
psychiatric or substance abuse service, nor were there any differ-
ences in prior use of specialized PTSD services, in overall satisfac-
tion with VA services, or in clinical improvement in the majority
of domains. Although differences between Whites and minorities
were not found in overall use of services, there are clear differ-
ences among ethnocultural minority groups in use of specific
mental health services. First, the differences may reflect epide-
miologic differences in the type or severity of the disorders for
which ethnocultural groups seek help. Second, differences in
service use and outcome may reflect differences in receptiveness
or responsiveness to the treatments offered, whether
ethnoculturally or socioeconomically determined. Third, there
may be differences among groups that are attributable to the way
providers treat them, either by providing different amounts or
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types of services or by providing a different quality of services.
[Adapted from Text]
ROSENHECK, R.A., FONTANA, A., & COTTROL, C. (1995).
Effect of clinician-veteran racial pairing in the treatment of
posttraumatic stress disorder. American Journal of Psychiatry, 152,
555-563. OBJECTIVE: This study explored the effect of veterans'
race and of the pairing of veterans' and clinicians' race on the
process and outcome of treatment for war-related PTSD.
METHOD: As part of the national evaluation of the PTSD Clinical
teams program of the Department of Veterans Affairs, data on
assessment of 4,726 white and black male veterans at admission
to the program and on the race and other characteristics of their
315 primary clinicians were obtained. Measures of service deliv-
ery and treatment emphasis were obtained 2, 4, 8, and 12 months
after program entry, along with clinicians' ratings of improve-
ment. RESULTS: After control for sociodemographic characteris-
tics, clinical status, and clinicians' characteristics, multivariate
analysis showed that black veterans had significantly lower
program participation ratings than white veterans on 10 of 24
measures, but no differences in clinicians' improvement ratings
were noted. Additional analyses showed that pairing of white
clinicians with black veterans was associated with lower pro-
gram participation on 4 of the 24 measures and with lower
improvement ratings on 1 of 15 measures. When treated by either
black or white clinicians, black veterans had poorer attendance
than white veterans, seemed less committed to treatment, re-
ceived more treatment for substance abuse, were less likely to be
prescribed antidepressant medications, and showed less im-
provement in control of violent behavior. CONCLUSIONS: Al-
though no differences were noted on most measures, the pairing
of black veterans with white clinicians was associated with re-
ceiving fewer services. According to some other measures, black
veterans received less attentive services regardless of the clinician's
race.
ROSENHECK, R.A., FONTANA, A. & ERRERA, P. (1997).
Inpatient treatment of war-related posttraumatic stress disor-
der: A 20-year perspective. Journal of Traumatic Stress, 10, 407-413.
These papers show that long-stay inpatient PTSD programs
provide treatment that is quite different from other programs but
that they are neither as effective, from a psychometric perspec-
tive, nor as helpful, from the veterans' subjective perspective, as
has been expected. VA treatment of PTSD is changing its focus
and is being influenced by three distinct societal forces, in addi-
tion to data from studies like these: (1) the continuing effort of
American society to come to terms with its Vietnam War experi-
ence; (2) the crisis of U.S. health care costs; and (3) the emergence
of a movement to "re-invent" government and to increase public
accountability through performance data.
SCHWARZ, E. & KOWALSKI, J.M. (1992). Malignant memo-
ries: Reluctance to utilize mental health services after a disaster.
Journal of Nervous and Mental Disease, 180, 767-772.This report
describes the reluctance of individuals exposed to a man-made
disaster to utilize formal mental health services. Measures were
obtained in an initial screening 6 months after a shooting for 24
exposed school personnel. Data from the initial screening were
compared for those who did not participate in a follow-up
screening 12 months later (n = 11) and those who did (n = 13).
Follow-up nonparticipants reported: more PTSD symptoms, es-
pecially avoidance; recall of life threat during the event; feeling
depressed; and an increase in positivity toward victims but not
about their work or mental health professionals. The authors
conclude that some individuals may avoid formal mental health
services because they serve as cues for malignant memory re-
trieval and discuss implications for service delivery.
SOLOMON, S.D. & DAVIDSON, J.R.T. (1997). Trauma:
Prevalence, impairment, service use, and cost. Journal of Clinical
Psychiatry, 58, Supplement 9, 5-11. A review of the literature on the
epidemiology of trauma reveals that traumatic events are com-
mon: most Americans experience at least one over the course of
their lives. According to recent estimates, 5 percent of men and 10
percent to 12 percent of women will suffer from PTSD sometime
in their lives, and for victims of traumas such as rape, the rate may
be as high as 60 percent to 80 percent. For at least a third of
sufferers, PTSD is a persistent condition lasting many years. Over
80 percent of persons with PTSD suffer from other psychiatric
disorders. Many also experience marital, occupational, financial,
and health problems. While trauma victims are disproportionate
users of the health care system, they are reluctant to seek mental
health treatment. Consequences of exposure to trauma are enor-
mously costly, not only to the victims, but also to our health care
system and to society as a whole.
SWITZER, G.E., DEW, M.A., THOMPSON, K.,
GOYCOOLEA, J.M., DERRICOTT, T., & MULLINS, S.D. (1999).
Posttraumatic stress disorder and service utilization among
urban mental health center clients. Journal of Traumatic Stress, 12,
25-39. Although the urban poor are at high risk for exposure to
trauma, community mental health clinics rarely diagnose clients
with PTSD. Failure to diagnose PTSD may undermine the effec-
tiveness of services provided. Our objectives were to (1) assess
prevalence of traumatic experiences and PTSD, and (2) examine
differences in service utilization between those who had PTSD
and those who did not. Interview data were gathered from 181
urban psychiatric outpatients. A substantial number of clients
had experienced at least one lifetime trauma (94 percent), and of
those, 42 percent had PTSD during the past year. Analyses
comparing service use between PTSD and nonPTSD clients sup-
ported our expectation that clients with PTSD would use more
mental health services, and would be less satisfied with services
than their nonPTSD counterparts.
WALKER, E.A., UNUTZER, J., RUTTER, C., GELFAND, A.,
SAUNDERS, K., VONKORFF, M., KOSS, M.P., & KATON, W.
(1999). Costs of health care use by women HMO members with
a history of childhood abuse and neglect. Archives of General
Psychiatry, 56, 609-613. BACKGROUND: Early childhood mal-
treatment has been associated with adverse adult health out-
comes, but little is known about the magnitude of adult health
care use and costs that accompany maltreatment. We examined
differences in annual health care use and costs in women with
and without histories of childhood sexual, emotional, or physical
abuse and neglect. METHODS: A random sample of 1225 women
members of a health maintenance organization completed a 22-
page questionnaire inquiring into childhood maltreatment expe-
riences as measured by the Childhood Trauma Questionnaire.
Health care costs and use data were obtained from the automated
cost-accounting system of the health maintenance organization,
including total costs, outpatient and primary care costs, and
emergency department visits. RESULTS: Women who reported
any abuse or neglect had median annual health care costs that
were $97 (95 percent confidence interval, $0.47 - $188.26) greater
than women who did not report maltreatment. Women who
reported sexual abuse had median annual health care costs that
were $245 (95 percent confidence interval, $132.32 - $381.93)
Prev Page 6 Next
greater than costs among women who did not report abuse.
Women with sexual abuse histories had significantly higher
primary care and outpatient costs and more frequent emergency
department visits than women without these histories. CON-
CLUSION: Although the absolute cost differences per year per
woman were relatively modest, the large number of women in
the population with these experiences suggests that the total costs
ADDITIONAL CITATIONS
Annotated by the Editors
BLAKE, D.D., COOK, J.D., & KEANE, T.M. (1992). Post-
traumatic stress disorder and coping in veterans who are
seeking medical treatment. Journal of Clinical Psychology, 48,
695-704.
Assessed coping and mental health treatment histories in 36
combat veteran medical patients and 38 war-era controls.
Participants with PTSD or who had sought mental health treatment
tended to use more emotional-focused coping, relative to other
participants. Among those who had sought mental health
treatment, Vietnam veterans were more likely than veterans of
earlier conflicts to have received individual treatment.
BROWN, P.J., RECUPERO, P.R., & STOUT, R. (1995).
PTSD substance abuse comorbidity and treatment utiliza-
tion. Addictive Behaviors, 20, 251-254.
Examined self-reported mental health service utilization in a
sample of 84 male and female substance abuse patients on a
substance abuse detoxification unit. Individuals with PTSD,
relative to those without PTSD, reported a greater number of
lifetime admissions for substance abuse treatment: 6.5 versus 2.8.
BRYANT, R.A. (1998). An analysis of calls to a Vietnam
veterans' telephone counselling service. Journal of Traumatic
Stress, 11, 589-596.
Analyzed the pattern of calls to an after-hours telephone crisis
line for Vietnam veterans in Australia. During the 9-week period,
274 calls involved psychiatric issues, including domestic conflict,
substance abuse, and traumatic memories. Twenty-three percent
required a referral, and 18% required an emergency referral.
DRUSS, B.G. & ROSENHECK, R.A. (1997). Use of medical
services by veterans with mental disorders. Psychosomatics,
38, 451-458.
Examined medical service use in a national sample of 44,533
veterans who had been discharged from a VA psychiatric unit
with a comorbid medical disorder. Patients were classified into
diagnostic groups on the basis of their primary discharge diagno-
sis. Relative to a comparison group of patients with disorders
including adjustment disorder and dysthymia, patients with all
types of other disorders, including PTSD, were less likely to use
medical services.
FRIEDMAN, M.J. & ROSENHECK, R.A. (1996). PTSD as a
persistent mental illness. In S.M. Soreff (Ed.), Handbook for the
treatment of the seriously mentally ill (pp. 369-389). Seattle:
Hogrefe & Huber.
Reviews findings on the persistence of PTSD and considers
evidence that PTSD can be a chronic mental illness in a subset of
cases. The authors present data on veterans with PTSD who seek
VA care, provide recommendations for treating this population,
and also comment on the treatment of chronic trauma reactions
among individuals who do not have a primary diagnosis of
PTSD.
HANSEN, T.E. & ELLIOTT, K.D. (1993). Frequent psychiatric
visitors to a Veterans Affairs medical center emergency care
unit. Hospital and Community Psychiatry, 44, 372-375.
Examined 1,144 veterans who had visited a VA Medical Center
for emergency care in order to determine the characteristics of
frequent treatment-seekers. During the one-year study, 26% were
occasional repeaters and 8% were frequent repeaters whose visits
accounted for 24% of all emergency visits. The authors suggest
that the percentage of patients with repeat visits, which was high
relative to the percentage observed in large urban non-VA
hospitals, may be due to methodological factors as well as
characteristics of veterans and their environments.
HOFF, R.A. & ROSENHECK, R.A. (1998). Long-term patterns
of service use and cost among patients with both psychiatric
and substance abuse disorders. Medical Care, 36, 835-843.
Used VA administrative data to examine VA service use in 9,813
inpatients and 58,001 outpatients over a 6-year interval. Among
inpatients, costs did not differ as a function of dual diagnosis.
Among outpatients, total costs over the entire observation period
were greater among dually diagnosed patients, compared with
singly diagnosed patients. Within the outpatient group, all spe-
cific types of costs except outpatient psychiatric and inpatient
medical were greater for the dually diagnosed.
MARSHALL, R.P., JORM, A.F., GRAYSON, D.A., DOBSON,
M. & O'TOOLE, B. (1997). Help-seeking in Vietnam veterans:
Post-traumatic stress disorder and other predictors. Austra-
lian and New Zealand Journal of Public Health, 21, 211-213.
Investigated factors predictive of seeking VA care among a
sample of 461 Australian Vietnam veterans. Even after adjust-
ment for numerous predictors, including physical health, non-
PTSD psychiatric disorders, predisposing characteristics, and
combat exposure, the authors found that PTSD was associated
with greater help-seeking.
MARSHALL, R.P., JORM, A.F., GRAYSON, D.A. & O'TOOLE,
B.I. (1998). Posttraumatic stress disorder and other predictors
of health care consumption by Vietnam veterans. Psychiatric
Services, 49, 1609-1611.
Assessed self-reported utilization during a 2-week period in 641
randomly sampled Australian Vietnam veterans. Using
multivariate regression to adjust for numerous variables (age,
mental health, predisposition to PTSD, military service,
repatriation, and membership in service organizations), the
authors found that PTSD was associated with an additional $79
in total health care costs. Other important predictors of cost were
depression, education, the quality of the repatriation experience,
and social support.
PRIEBE, S. & ESMAILI, S. (1997). Long-term mental sequelae
of torture in Iran-who seeks treatment? Journal of Nervous
and Mental Disease, 185, 74-77.
Assessed 34 Iranian torture victims who had emigrated to Ger-
many. Treatment-seekers differed from individuals who had not
sought treatment in many ways, including: greater anxiety, de-
pression, and PTSD symptom severity; a greater likelihood of
PTSD; poorer coping; and less knowledge of German.
RONIS, D.L., BATES, E.W., GARFEIN, A.J., BUIT, B.K.,
FALCON, S.P., & LIBERZON, I. (1996). Longitudinal patterns
of care for patients with posttraumatic stress disorder. Journal
of Traumatic Stress, 9, 763-781.
Assessed patterns of utilization of VA mental healthcare in 939
Prev Page 7 Next
patients with PTSD, 923 patients with schizophrenia, and 907
patients with major depression. The authors defined types of use
and nonuse intervals and applied their system to characterize
temporal patterns. Patients with PTSD had substantial but episodic
use. The authors discuss the implications of their findings for
understanding the long-term course of PTSD.
ROSENHECK, R.A., LEDA, C. & GALLUP, P. (1992). Combat
stress, psychosocial adjustment, and service use among home-
less Vietnam veterans. Hospital and Community Psychiatry, 43,
145-149.
Studied service use among a sample of 627 homeless male Viet-
nam combat veterans who received care from VA homelessness
programs. The authors defined combat stress and no-combat-
stress groups on the basis of intrusive symptoms during the 30
days prior to assessment. Combat stress was associated with
greater psychiatric comorbidity and service utilization, as well as
a greater likelihood of having a VA psychiatric disability. How-
ever, many homeless veterans with mental disorders received no
mental health services.
SANSONE, R.A., WIEDERMAN, M.W., & SANSONE, L.A.
(1998). Borderline personality symptomatology, experience
of multiple types of trauma, and health care utilization among
women in a primary care setting. Journal of Clinical Psychiatry,
59, 108-111.
Reviewed 12 months of medical records in 166 women who were
consecutively recruited from routine gynecological appointments
at an HMO. Multiple types of trauma was related to increased
utilization of various types: telephone contacts, physician visits,
acute prescriptions, and ongoing prescriptions. Borderline
personality disorder was related to greater levels of all types of
utilization except specialist care.
SINNERBRINK, I., SILOVE, D.M., MANICAVASAGAR,
V.L., STEEL, Z. & FIELD, A. (1996). Asylum seekers: General
health status and problems with access to health care. Medical
Journal of Australia, 165, 634-637.
Assessed 40 asylum seekers who sought assistance from a com-
munity based program for asylum seekers in Australia. The
group reported numerous medical complaints, although they
also reported better physical functioning than normative samples
of medical and psychiatric patients. Roughly half of the sample
reported poor access to medical and dental care.
TOOMEY, T.C., SEVILLE, J.L., MANN, J.D., ABASHIAN, S.W.
& GRANT, J.R. (1995). Relationship of sexual and physical
abuse to pain description, coping, psychological distress,
and health-care utilization in a chronic pain sample. Clinical
Journal of Pain, 11, 307-315.
Assessed self-reported healthcare utilization in 22 abused and 58
nonabused chronic pain patients. Although the groups did not
differ in reported pain or functional interference, the abused
group had lower self-control and perceived control over their
pain, and greater distress. The abused group was more likely than
the nonabused group to use emergency care for pain symptoms,
but the groups did not differ on other measures of utilization. The
authors suggest that prior trauma should be considered as a
factor in the development of strategies for managing chronic
pain.
PILOTS UPDATE
The PILOTS database contains much more than biblio-
graphical citations and abstracts. By displaying or printing
search results in the optional "long" format, you can learn
many useful details about the publications your search has
found. In this column we describe some of the fields
contained in the full PILOTS database record, and the
information they provide.
The "Affiliation" field tells you where the work de-
scribed in a publication was performed. By searching on
this field, work performed at a particular institution or in
a particular state, province, or country can be identified. By
combining this process with a subject-oriented search of
the database, it would be possible to find someone in
Colorado who knows about alcohol abuse in Vietnam War
veterans, or a Canadian expert on PTSD in adolescents.
The "Instruments" field lists the assessment instru-
ments used in the research or clinical work reported. This
information can provide some idea of the research meth-
odology or clinical strategy employed, beyond what is
implied in the title or stated in the abstract. If you have a
special interest in assessment, it can be useful in choosing
or evaluating an instrument-or in seeing who has used an
instrument that you have created. By combining a search of
the "Instruments" field with the use of appropriate De-
scriptors (such as "PTSD Assessment Instruments") you
can find publications that discuss the reliability, validity,
or psychometric properties of a particular instrument whose
use you might be considering.
We use the "Note" field to describe the relationship of
a document to other publications or presentations, and to
provide any other information that we think might be
helpful to PILOTS database users.
If the material contained in the document has been
presented elsewhere, we give the name, place, and date of
the lecture, meeting, or conference at which this happened.
If it has been published elsewhere, we give the biblio-
graphical details. You can use this information to verify
that a particular document is in fact the one you are seeking
(for example, when you know that the paper you want is
based on a poster you saw at the ISTSS conference in
Boston). Or you can use it to find a substitute for a publica-
tion that would be difficult to obtain (such as a journal
article that reports the research findings from a doctoral
dissertation). If a translation of a document has been pub-
lished, that too will be noted in the "Note" field.
Some journals, such as the Annals of the New York
Academy of Sciences, devote individual issues to specific
topics, and publish them simultaneously as books with
separate titles and ISBNs. We index contributions to these
publications as journal articles, but use the "Note" field to
give particulars of the book version.
When a journal article is published in several parts, we
list the other parts in the "Note" field. If a correction or
retraction has been published, this will be listed in there as
well. And if a comment on an article has been published,
we will note that fact and give the pertinent bibliographical
Prev Page 8 Next
information. Similarly, the entry for such a comment will
contain a reference to the publication it discusses. By
checking the "Note" field, you can determine whether you
need to examine any other publications in order to evalu-
ate the document in question.
Sometimes the references for a book chapter are not
placed at the end of the chapter, but are included in a
general reference list at the end of the book. When this is the
case, this will be reported in the "Note" field, along with
the page numbers of the references. Knowing this can help
you avoid the frustration of receiving a photocopy of a
book chapter, only to learn that you cannot look up any of
the cited references. Likewise any other material pertinent
to a book chapter or journal article is noted in this field.
When we apply the Descriptor "Literature Review" or
"Meta Analysis" to a document, we include the number of
publications referenced in the "Note" field.
Whenever in the "Note" field we mention another
document indexed in the PILOTS database, we provide the
PILOTS ID number of that publication. To find the full
PILOTS record for that document, select "All Indexes"
from the pull-down menu and type in its ID number.
While both the "Affiliation" and "Instruments" fields
can be searched using the pull-down menus provided by
the PILOTS Web interface, the "Note" field does not appear
on that menu. However, the contents of this field are
searchable through the "All Indexes" menu.
Many users of the PILOTS database find that searching
by author, descriptor, or topic satisfies their information
needs. For those whose needs are more complex, the fea-
tures described in this column can help to improve and
refine access to the traumatic stress literature.
CHANGES IN THE NATIONAL CENTER
WEB SITE
The National Center has collected a vast amount of
clinical and empirical material on trauma and PTSD. In this
10th anniversary year, we are looking at our website as an
ideal tool for disseminating this information to a wide
variety of audiences. To make it as user-friendly as pos-
sible, we are undertaking significant reconstruction of the
site. Webdesign experts from the Koop Institute at the
Dartmouth Medical School are helping us to make it easier
to navigate. To better reflect the extensive range of exper-
tise contained within the National Center's seven divi-
sions, our website will contain a significantly larger collec-
tion of information resources, including the complete con-
tents of all back issues of our newsletters, profiles of our
professional staff and their research and clinical activities,
and journal publications from National Center staff. We
will continue to offer free access to the PILOTS database
and detailed instructions for searching it. And we plan to
take advantage of continuing developments in Internet
technology to present information on PTSD in audiovisual
media as well as text form.
CLARIFICATION
There are three points that warrant clarification in my
article entitled "Research on Eye Movement Desensiti-
zation and Reprocessing (EMDR) as Treatment for PTSD
(PTSD Research Quarterly, Winter 1999, 10(1). First,
Shapiro's (1995) statement that eye "fixation" is func-
tionally equivalent to eye movement occurs on page 25,
not on page 95, of her textbook. Second, although twice
as many patients dropped out of EMDR than CBT in
Devilly and Spence's (1999) comparative trial, the rat-
ings of "treatment distress" were nearly identical for
both treatments. Third, Pitman et al. (1996) computed
correlations between treatment fidelity and six treat-
ment outcome variables. Although Pitman et al. pub-
lished only the two correlations that were significant,
the average correlation between fidelity and all six
outcome variables was r = .23.
-Richard J. McNally, Ph.D., Harvard University
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