Two studies of psychiatric morbidity among motor vehicle accident survivors 1 year after the crash

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Abstract

We assessed the psychiatric co-morbidity associated with chronic posttraumatic stress disorder (PTSD) (1–2 years) secondary to personal injury motor vehicle accidents (MVAs) in two studies. In Study 1, we compared the results of SCID assessments for 75 treatment-seeking MVA survivors (51 with PTSD and 24 with symptoms but no PTSD). In Study 2, we compared similar results among 132 MVA survivors who had been followed prospectively for 12+ months after their accidents (19 with PTSD, 32 who had PTSD but who had remitted, and 81 who never met criteria for PTSD). We found comparable levels of current co-morbid major depression (53%), any mood disorder (62–68%), generalized anxiety disorder (26%) and any anxiety disorder (42%) for both groups of participants with chronic PTSD. These rates of co-morbidity were higher than those found in non-PTSD comparison groups with similar MVA histories.

Introduction

Personal injury motor vehicle accidents (MVAs) are a frequent occurrence in the USA and other parts of the developed world and are perhaps the leading cause of posttraumatic stress disorder (PTSD) (Norris, 1992). Over the past 5 years, more than 3-million Americans have been injured in MVAs each year (USDOT, 2000). There have been many studies over the past 10 years examining the short-term psychiatric consequences of MVAs with most of the focus on the possibility of the MVA survivor’s developing PTSD (e.g., Mayou, Bryant and Duthie, 1993, Blanchard, Hickling, Taylor and Loos, 1995, Shalev, Freedman, Peri, Brandes, Sahar, Orr and Pitman, 1998, Ursano, Fullerton, Epstein, Crowley, Kao, Vance, Craig, Dougall and Baum, 1999, Koren, Arnon and Klein, 1999, Harvey and Bryant, 1998, Frommberger, Stieglitz, Nybert, Schlickewei, Kuner and Berger, 1998). Some of these studies have included 1-year or longer prospective follow-ups (e.g., Mayou, Bryant and Duthie, 1993, Blanchard, Hickling, Vollmer, Loos, Buckley and Jaccard, 1995, Delahanty, Herberman, Craig, Hayward, Fullerton and Ursano, 1997, Freedman, Brandes, Peri and Shalev, 1999, Ehlers, Mayou and Bryant, 1998, Ursano, Fullerton, Epstein, Crowley, Kao, Vance, Craig, Dougall and Baum, 1999, Harvey and Bryant, 1999, Koren, Arnon and Klein, 1999, Jeavons, 2000, Schnyder, Moergeli, Klaghofer and Buddeberg, 2001), again usually with a focus on maintenance or remission of PTSD. A few of these follow-up studies have gone beyond assessing PTSD and also included assessment of other psychiatric disorders (Mayou, Bryant and Duthie, 1993, Mayou, Tyndel and Bryant, 1997, Ehlers, Mayou and Bryant, 1998, Koren, Arnon and Klein, 1999, Koren, Arnon and Klein, 2001, Mayou, Ehlers and Bryant, 2002).

In the earliest paper on this topic, Mayou et al., 1993 interviewed 188 of 200 emergency room (ER) attendees as a result of MVAs in Oxford, UK, using the present state examination (PSE) (Wing, Cooper, & Sartorious, 1974); 174 were re-interviewed 3 months later and 171 (91%) at 12 months. Fourteen (8.0%) met DSM-III-R criteria for PTSD at 3 months, whereas 13 (7.6%) met PTSD criteria at 1 year. Two other psychiatric problems were assessed at both follow-ups: travel anxiety, while not a DSM-IV diagnosis was present in 32 cases at 3 months (18.4%) and 26 cases at 12 months (15.2%). The PSE yields an estimate of “caseness” that is meeting PSE criteria for presence of a psychiatric disorder but without clear specification of the disorder. Thus, there were 25 cases (14.4%) at 3 months and 20 cases (11.7%) at 12 months.

Mayou et al. (1997) reported on 5-year follow-up data on 111 (59.0%) of the original Mayou et al. (1993) sample, using questionnaires to assess PTSD and travel anxiety. They found 9 cases of PTSD (8.1%) and 10 other individuals with “minor” PTSD. A total of 31 cases (28%) had travel anxiety, an increase in rate over the 1-year data.

In a second study based at the ER at Oxford, UK, Ehlers et al. (1998) were able to obtain initial questionnaire-based assessments on 1148 of 1441 MVA ER attendees (80%). At 3 months, 865 responded to follow-up questionnaires (75% of those initially assessed), as did 773 (67% of initial) at 1 year. The fractions with PTSD at 3 months were 23% and at 1 year 17%. Co-morbid conditions assessed were travel anxiety (22% at 3 months and 16% at 1 year), and general anxiety and depression as measured by the Hospital Anxiety and Depression Scale (HADS) (Zigmund & Smith, 1983) in questionnaire form. General anxiety was present in 19% of those assessed at 12 months whereas depression was present in 6%. A 3-year follow-up (Mayou et al., 2002) questionnaire assessment of PTSD was obtained on 546 (47.6% of those initially assessed) participants. Overall, 11% of those assessed still met criteria for PTSD. No co-morbidity was assessed.

The other research on co-morbidity 1 year and later after a MVA originated in Israel. Koren et al. (1999) initially assessed 99 MVA survivors who had all been admitted to the hospital for orthopedic injuries. They were able to reassess 74 (74.7%) at 1-year post-MVA, using the SCID-NP, 1.0 interview (Spitzer, Williams, Gibbon, & First, 1990b). Twenty-four (32%) met criteria for PTSD at 1 year. Sixteen of these (67%) met criteria for another concurrent psychiatric condition (11 (45.8%) with mood disorders, 5 (20.8%) with anxiety disorders). Among those 50 who were negative for PTSD at 1 year, 9 (18%) were positive for other disorders (6 (12%) mood disorders, 3 (6%) anxiety disorders). Thus, the likelihood of co-morbid diagnoses between those with and without PTSD was significant (p<0.001).

Koren et al. (2001) were able to obtain 3-year post-MVA follow-up data on 58 (78.4%) of those assessed at 1 year. If individuals acknowledged any PTSD symptom or other symptoms they were reassessed with the SCID. Ten of those with PTSD at 1 year had not remitted; furthermore, there were two cases of delayed onset PTSD among those not positive for PTSD at 1 year, for a total of 12 of 58 (20.7%) total cases of PTSD at 3 years. No information was provided on co-morbid conditions.

Thus, from the two studies with 1-year prospective follow-up data that used structured psychiatric interviews (Mayou, Bryant and Duthie, 1993, Koren, Arnon and Klein, 1999), we find only limited data on psychiatric disorders other than PTSD. Mayou et al. report 11.7% of 1 year participants are “psychiatric cases” (this may include the 7.6% who met criteria for PTSD). Koren et al. (1999) report a total of 25 (of 74, 33.8%) individuals with either a mood disorder or an anxiety disorder (other than PTSD) including 67% of those with PTSD also having a co-morbid condition. The two studies also have markedly different rates of PTSD at 1 year: (Mayou et al. found 7.6% versus 32% in Koren et al.). These differences in PTSD and in possible co-morbid conditions could be due to differences in severity of physical injury (with only a few of those in Mayou et al. admitted to hospital versus 100% in Koren et al.), differences in assessment instrument (PSE in Mayou et al. versus SCID in Koren et al.) and differences in population (UK versus Israel). The values from the large Ehlers et al. (1998) study must be taken with some caution since all assessments were conducted with questionnaire because of the large numbers of cases involved. In any event, it seems clear that there is a relative lack of detailed information about psychiatric morbidity, other than PTSD, among MVA survivors who are a year or more post-accident, and the data from the two extant studies is noticeably discrepant.

We report data on this topic from two studies conducted at our center. In the first, we examine the rate of psychiatric co-morbidity among treatment-seeking MVA survivors, who were 1–2 years post-MVA and who either met or did not meet criteria for PTSD. In the other study, we report on the 1-year prospective follow-up of a cohort of MVA survivors initially assessed about 2 months post-MVA. The 1-year co-morbidity data on this sample have not been previously examined. The prospective nature of the second study allows us to learn something about the antecedents of the 1-year co-morbid diagnoses.

Section snippets

Study 1

As mentioned above, this study involved individuals who were seeking treatment for psychological distress secondary to a MVA. Thus they are different than the samples reported by Mayou et al. (1993) and Koren et al. (1999).

Participants

Seventy-five individuals (23 male, 52 female) who had been in a personal injury MVA between 1 and 2 years earlier, who were seeking treatment for their subsequent psychological distress, and who, at a telephone screen, acknowledged some level of posttraumatic stress symptoms, were invited for a thorough evaluation. The average age of the sample was 41 years. They were on average 21.1 months post-MVA.

Procedures

Participants were individually assessed with a series of structured interviews by advanced

Results

Of the 75 individuals, 51 met criteria for PTSD, 24 met criteria for sub-syndromal PTSD or non-PTSD. The latter 24 participants formed a comparison condition for the group of interest, those with MVA-related PTSD 1–2 years post-MVA. Of these 24, 15 had met criteria for PTSD in the months immediately following the MVA, whereas 9 had never met criteria for full PTSD.1

Study 2

Study 1 revealed a noticeable level of psychiatric co-morbidity among MVA survivors with PTSD 1–2 years after the accident, especially mood disorders and anxiety disorders. However, the study has two main limitations: the sample was treatment-seeking, and the comparisons were cross-sectional, rather than longitudinal. To remedy these problems and to shed some light on the co-morbidity present a year after the accident, we have examined archival data from our center. We had assessed 158

Participants

As described above, we assessed 158 survivors of personal injury MVAs within 1–4 months post-MVA. Fifteen percent had been admitted to the hospital, 60% seen at the ER but not admitted, and 25% seen by emergency medical technicians at the accident scene but who were released or declined to go to the ER. Most saw their personal physician within the next 2 days. Six months later, 145 (91.8%) were reassessed and 132 (83.5%) were reassessed 12 months later or almost 14 months post-MVA. It is the

Results

In Table 5 are the co-morbid Axis I diagnoses for the three sub-groups at the 12-month reassessment.

Comparisons across the three sub-groups reveal a significantly greater proportion with current major depression among MVA survivors who continue to meet criteria for PTSD at the 1-year follow-up (52.6%) in comparison to those who initially had PTSD but have remitted and to those who never met criteria for PTSD. The latter two groups also differ significantly with those whose PTSD has remitted

Discussion

To us, the most striking feature of the results of these two studies is the similarity in rates of co-morbid conditions among individuals who are suffering from PTSD secondary to MVAs between 1 and 2 years after the accident. We had expected that the treatment-seeking sample in Study 1 would have higher rates of co-morbidity than those in the naturalistic follow-up of Study 2. Instead, we find very similar rates of current major depression (52.9% in Study 1, 52.6% in Study 2), any current mood

Acknowledgements

This research was supported by a grant from NIMH, MH-48476. Requests for further information should be addressed to Dr. Edward B. Blanchard, Center for Stress and Anxiety Disorders, 1535 Western Avenue, Albany, NY 12203.

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