Skip to main content

Advertisement

SpringerLink
Log in

Posttraumatic stress disorder screening status is associated with increased VA medical and surgical utilization in women

  • Original Articles
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

BACKGROUND: Women with posttraumatic stress disorder (PTSD) report poor health, but associations with health care utilization are understudied.

OBJECTIVE: To determine associations between medical/surgical utilization and PTSD in female Veterans Affairs (VA) patients.

DESIGN: Prospective comparison of utilization rates between women screening positive or negative for PTSD on a mailed survey.

SUBJECTS: Women receiving care at an urban VA medical center between October 1996 and January 2000.

MEASUREMENTS: Survey responses, including a validated screen for PTSD (PCL-C), and VA utilization data through September 2002.

RESULTS: Two thousand five hundred and seventy-eight (2,578) women (78% of those eligible) completed the PCL-C; 858 (33%) of them screened positive for PTSD (PTSD+). In unadjusted models, PTSD+ women had higher rates of medical/surgical hospitalizations and surgical inpatient procedures. Among women ages 35 to 49, mean days hospitalized/100 patients/year was 43.4 (95% CI 26 to 61) for PTSD+ women versus 17.0 (16 to 18) for PTSD negative (PTSD−) women. More PTSD+ women underwent surgical procedures (P<.001). Mean annual outpatient visits were significantly higher among PTSD+ women, including: emergency department (ED) (1.1 [1.0 to 1.2] vs 0.6 [0.5 to 0.6]), primary care (3.2 [3.0 to 3.4] vs 2.2 [2.1 to 2.3]), medical/surgical subspecialists (2.1 [1.9 to 2.3] vs 1.5 [1.4 to 1.6]), ancillary services (4.1 [3.7 to 4.5] vs 2.4 [2.2 to 2.6]), and diagnostic tests (5.6 [5.1 to 6.1] vs 3.7 [3.4 to 4.0]). In multivariate models adjusted for demographics, smoking, service access, and medical comorbidities, PTSD+ women had greater likelihood of medical/surgical hospitalization (OR=1.37 [1.04 to 1.79]) and of being among the top quartile of patients for visits to the ED, primary care, ancillary services, and diagnostic testing.

CONCLUSIONS: Female veterans who screen PTSD+ receive more VA medical/surgical services. Appropriateness of that care deserves further study.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Breslau N, Kessler RC, Shilcoat HD, Schultz LR, Davis GC, Andreski PM. Trauma and posttraumatic stress disorder in the community: the 1996 Detroit area survey of trauma. Arch Gen Psychiatry. 1998;55:626–32.

    Article  CAS  PubMed  Google Scholar 

  2. Felitti VAR, Nordenberg D, Williamson DF, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experience (ACE) study. Am Prev Med. 1998;14:245–58.

    Article  CAS  Google Scholar 

  3. Shalev A, Freedman S, Peri T, et al. Prospective study of posttraumatic stress disorder and comorbid major depression following trauma. Am J Psychiatry. 1998;155:630–7.

    CAS  PubMed  Google Scholar 

  4. Walker EA, Unutzer J, Rutter C, et al. Costs of health care use by women HMO members with a history of childhood abuse and neglect. Arch Gen Psychiatry. 1999;56:609–13.

    Article  CAS  PubMed  Google Scholar 

  5. Sibai AM, Armenian HK, Alam S. Wartime determinants of arteriographically confirmed coronary artery disease in Beirut. Am J Epidemiol. 1989;130:623–31.

    CAS  PubMed  Google Scholar 

  6. Boscarino JA. Diseases among men 20 years after exposure to severe stress: implications for clinical research and medical care. Psychosom Med. 1997;59:605–14.

    Article  CAS  PubMed  Google Scholar 

  7. Hankin CS, Skinner KM, Sullivan LM, Miller DR, Frayne S, Tripp TJ. Prevalence of depressive and alcohol abuse symptoms among women VA outpatients who report experiencing sexual assault while in the military. J Trauma Stress. 1999;12:601–12.

    Article  CAS  PubMed  Google Scholar 

  8. Dobie DJ, Kivlahan DR, Maynard C, et al. Screening for post-traumatic stress disorder in female Veteran’s Affairs patients: validation of the PTSD checklist. Gen Hosp Psychiatry. 2002;24:367–74.

    Article  PubMed  Google Scholar 

  9. Sadler AG, Booth BM, Nielson D, Doebbeling BN. Health-related consequences of physical and sexual violence: women in the military. Obstet Gynecol. 2000;96:473–80.

    Article  CAS  PubMed  Google Scholar 

  10. Engel CC, Engel AL, Campbell SJ, McFali ME, Russo J, Katon W. PTSD symptoms; and precombat sexual and physical abuse in desert storm veterans. J Nervous Mental Dis. 1993;683-8.

  11. Suris A, Lind L, Kashner TM, Borman PD, Petty F. Sexual assault in women veterans: an examination of PTSD risk, health care utilization, and cost of care. Psychosom Med. 2004;66:749–56.

    Article  PubMed  Google Scholar 

  12. Stein MB, Lang AJ, Laffaye C, Satz LE, Lenox RJ, Dresselhaus TR. Relationship of sexual assault history to somatic symptoms and health anxiety in women. Gen Hosp Psychiatry. 2004;26:178–83.

    Article  PubMed  Google Scholar 

  13. Frayne SM, Skinner KM, Sullivan LM, et al. Medical profile of women Veterans Administration outpatients who report a history of sexual assault occurring while in the military. J Womens Health Gend Based Med. 1999;8:835–45.

    Article  CAS  PubMed  Google Scholar 

  14. Wolfe J, Schnurr PP, Brown PJ, Furey J. Posttraumatic stress disorder and war-zone exposure as correlates of perceived health in female Vietnam war veterans. J Consult Clin Psychiatry. 1994;62:1235–40.

    Article  CAS  Google Scholar 

  15. Murdoch M, Nichol KL. Women veterans’ experiences with domestic violence and with sexual harassment while in the military. Arch Fam Med. 1995;4:411–8.

    Article  CAS  PubMed  Google Scholar 

  16. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Washington, DC: American Psychiatric Association; 1994.

    Google Scholar 

  17. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:1048–60.

    Article  CAS  PubMed  Google Scholar 

  18. Resnick HS, Kilpatrick DG, Dansky BS, Saunders BE, Best CL. Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. J Consult Clin Psychiatry. 1993;61:984–91.

    Article  CAS  Google Scholar 

  19. Stein MB, McQuaid JR, Pedrelli P, Lenox R, McCahill ME. Posttraumatic stress disorder in the primary care medical setting. Gen Hosp Psychiatry. 2000;22:261–9.

    Article  CAS  PubMed  Google Scholar 

  20. Schnurr PP, Friedman MJ, Sengupta A, Jankowski MK, Holmes T. PTSD and utilization of medical treatment services among male Vietnam veterans. J Nerv Ment Dis. 2000;188:496–504.

    Article  CAS  PubMed  Google Scholar 

  21. Zayfert C, Dums AR, Ferguson RJ, Hegel MT. Health functioning impairments associated with posttraumatic stress disorder, anxiety disorders, and depression. J Nerv Ment Dis. 2002;190:233–40.

    Article  PubMed  Google Scholar 

  22. Wagner AW, Wolfe J, Rotnitsky A, Proctor SP, Erickson DJ. An investigation of the impact of posttraumatic stress disorder on physical health. J Trauma Stress. 2000;13:41–55.

    Article  CAS  PubMed  Google Scholar 

  23. Weisberg RB, Bruce SE, Machan JT, Kessler RC, Culpepper L, Keller MB. Nonpsychiatric illness among primary care patients with trauma histories and posttraumatic stress disorder. Psychiatric Serv. 2002;53:848–54.

    Article  Google Scholar 

  24. Beckham JC, Moore SD, Feldman ME, Hertzberg MA, Kirby AC, Fairbank JA. Health status, somatization, and severity of posttraumatic stress disorder in Vietnam combat veterans with posttraumatic stress disorder. Am J Psychiatry. 1998;155:1565–9.

    CAS  PubMed  Google Scholar 

  25. Frayne SM, Seaver MR, Loveland S, et al. Burden of medical illness in women with depression and posttraumatic stress disorder. Arch Intern Med. 2004;164:1306–12.

    Article  PubMed  Google Scholar 

  26. Zatzick DF, Weiss DS, Marmar CR, et al. Post-traumatic stress disorder and functioning and quality of life outcomes in female Vietnam veterans. Mil Med. 1997;162:661–5.

    CAS  PubMed  Google Scholar 

  27. Zatzick DF, Marmar CR, Weiss DS, et al. Posttraumatic stress disorder and functioning and quality of life outcomes in a nationally representative sample of male Vietnam veterans. Am J Psychiatry. 1997;154:1690–5.

    CAS  PubMed  Google Scholar 

  28. Schnurr PP, Spiro A III, Paris AH. Physician-diagnosed medical disorders in relation to PTSD symptoms in older male military veterans. Health Psychol. 2000;19:91–7.

    Article  CAS  PubMed  Google Scholar 

  29. Ford JD, Campbell KA, Storzbach D, Binder LM, Anger WK, Rohlman DS. Posttraumatic stress symptomatology is associated with unexplained illness attributed to Persian Gulf War military service. Psychosom Med. 2001;63:842–9.

    Article  CAS  PubMed  Google Scholar 

  30. Walker EA, Katon W, Russo J, Ciechanowski P, Newman E, Wagner AW. Health care costs associated with posttraumatic stress disorder symptoms in women. Arch Gen Psychiatry. 2003;60:369–74.

    Article  PubMed  Google Scholar 

  31. Calhoun PS, Bosworth HB, Grambow SC, Dudley TK, Beckham JC. Medical service utilization by veterans seeking help for posttraumatic stress disorder. Am J Psychiatry. 2002;159:2081–6.

    Article  PubMed  Google Scholar 

  32. Kimerling R, Clum GA, Wolfe J. Relationships among trauma exposure, chronic posttraumatic stress disorder symptoms, and self-reported health in women: replication and extension. J Trauma Stress. 2000;13:115–28.

    Article  CAS  PubMed  Google Scholar 

  33. Ford JD, Schnurr PP, Friedman MJ, Green BL, Adams G, Jex S. Posttraumatic stress disorder symptoms, physical health, and health care utilization 50 years after repeated exposure to a toxic gas. J Trauma Stress. 2004;17:185–94.

    Article  PubMed  Google Scholar 

  34. Friedman MJ, Schnurr PP. The relationship between trauma, post-traumatic stress disorder, and physical health. In: Friedman MJ, Charney DS, Deutch AY, eds. Neurobiological and Clinical Consequences of Stress: From Normal Adaption to PTSD. Philadelphia: Lippincott-Raven; 1995;507–24.

    Google Scholar 

  35. Deykin EY, Keane TM, Kaloupek D, et al. Posttraumatic stress disorder and the use of health services. Psychosom Med. 2001;63:835–41.

    Article  CAS  PubMed  Google Scholar 

  36. Smith MV, Rosenheck RA, Cavaleri MA, Howell HB, Poschman K, Yonkers KA. Screening for and detection of depression, panic disorder, and PTSD in public-sector obstetric clinics. Psychiatric Serv. 2004;55:407–14.

    Article  Google Scholar 

  37. Lecrubier Y. Posttraumatic stress disorder in primary care: a hidden diagnosis. J Clin Psychiatry. 2004;65(suppl 1):49–54.

    PubMed  Google Scholar 

  38. Grossman LS, Willer JK, Stovall JG, McRae SG, Maxwell S, Nelson R. Underdiagnosis of PTSD and substance use disorders in hospitalized female veterans. Psychiatric Serv. 1997;48:393–5.

    CAS  Google Scholar 

  39. Dobie DJ, Kivlahan DR, Maynard C, Bush KR, Davis TM, Bradley KA. Posttraumatic stress disorder in female veterans: association with self-reported health problems and functional impairment. Arch Intern Med. 2004;164:394–400.

    Article  PubMed  Google Scholar 

  40. Bradley KA, Bush KR, Davis TM, et al. Binge drinking among female Veterans Affairs patients: prevalence and associated risks. Psychol Addict Behav. 2001;15:297–305.

    Article  CAS  PubMed  Google Scholar 

  41. Weathers F, Ford J. Psychometric properties of the PTSD checklist (PCL-C, PCL-S, PCL-M, PCL-PR). In: Stamm BH, ed. Measurement of Stress, Trauma, and Adaptation. Lutherville, MD: Sidran Press; 1996.

    Google Scholar 

  42. Cowper DC, Kubal JD, Maynard C, Hynes DM. A primer and comparative review of major U.S. mortality databases. Ann Epidemiol. 2002;12:462–8.

    Article  PubMed  Google Scholar 

  43. Berwick DM, Murphy JM, Goldman PA, Ware JE, Barsky AJ, Weinstein MC. Performance of a five-item mental health screening test. Med Care. 1991;29:169–76.

    Article  CAS  PubMed  Google Scholar 

  44. Russell M, Martier SS, Sokol RJ, et al. Screening for pregnancy risk-drinking. Alcohol Clin Exp Res. 1994;18:1156–61.

    Article  CAS  PubMed  Google Scholar 

  45. Bush KR, Kivlahan DR, Davis TM, et al. The TWEAK is weak for alcohol screening among female Veterans Affairs outpatients. Alcohol: Clin Exp Res. 2003;27:1971–8.

    Article  Google Scholar 

  46. Escalona R, Achilles G, Waitzkin H, Yager J. PTSD and somatization in women treated at a VA primary care clinic. Psychosomatics. 2004;45:291–6.

    Article  PubMed  Google Scholar 

  47. Marshall RP, Jorm AF, Grayson DA, O’Toole BI. Posttraumatic stress disorder and other predictors of health care consumption by Vietnam veterans. Psychiatric Serv. 1998;49:1609–11.

    CAS  Google Scholar 

  48. Fagan J, Galea S, Ahern J, Bonner S, Vlahov D. Relationship of self-reported asthma severity and urgent health care utilization to psychological sequelae of the September 11, 2001 terrorist attacks on the World Trade Center among New York City area residents. Psychosom Med. 2003;65:993–6.

    Article  PubMed  Google Scholar 

  49. Zhang W, Ross J, Davidson JR. Posttraumatic stress disorder in callers to the Anxiety Disorders Association of America. Depress Anxiety. 2004;19:96–104.

    Article  PubMed  Google Scholar 

  50. Andreski P, Chilcoat H, Breslau N. Post-traumatic stress disorder and somatization symptoms: a prospective study. Psychiatry Res. 1998;79:131–8.

    Article  CAS  PubMed  Google Scholar 

  51. van der Kolk BA, Pelcovitz D, Roth S, Mandel FS, McFarlane A, Herman JL. Dissociation, somatization, and affect dysregulation: the complexity of adaptation to trauma. Am J Psychiatry. 1996;153:83–93.

    PubMed  Google Scholar 

  52. Friedman MJ, Schnurr PP. The relationship between trauma, post-traumatic stress disorder, and physical health. In: MJ F, ed. Neurobiological and Clinical Consequences of Stress: From Normal Adaptation to PTSD. Philadelphia: Lippincott-Raven Publishers; 1995:507–24.

    Google Scholar 

  53. Skinner KM, Sullivan LM, Tripp TJ, et al. Comparing the health status of male and female veterans who use VA health care: results from the VA women’s health project. Women Health. 1999;29:17–33.

    Article  CAS  PubMed  Google Scholar 

  54. Asch SM, McGlynn EA, Hogan MM, et al. Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Ann Intern Med. 2004;141:938–45.

    Article  PubMed  Google Scholar 

  55. Friedman MJ. Acknowledging the psychiatric cost of war. N Engl J Med. 2004;351:75–7.

    Article  CAS  PubMed  Google Scholar 

  56. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004;351:13–22.

    Article  CAS  PubMed  Google Scholar 

  57. Hoff RA, Rosenheck RA. The use of VA and non-VA mental health services by female veterans. Med Care. 1998;36:1524–33.

    Article  CAS  PubMed  Google Scholar 

  58. Foa EB, Meadows EA. Psychosocial treatments for posttraumatic stress disorder: a critical review. Ann Rev Psychol. 1997;48:449–80.

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Mental Illness Research, Education and Clinical Center, University of Washington School of Medicine, Seattle, WA, USA

    Dorcas J. Dobie MD, Daniel R. Kivlahan PhD & Andrew C. David

  2. Veterans Affairs Puget Sound Health Care System, University of Washington School of Medicine, Seattle, WA, USA

    Dorcas J. Dobie MD, Charles Maynard PhD, Daniel R. Kivlahan PhD, Kay M. Johnson MD, MPH, Tracy Simpson PhD, Andrew C. David & Katharine Bradley MD, MPH

  3. Departments of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA

    Dorcas J. Dobie MD, Daniel R. Kivlahan PhD, Tracy Simpson PhD & Andrew C. David

  4. Health Services Research and Development, University of Washington School of Medicine, Seattle, WA, USA

    Charles Maynard PhD & Katharine Bradley MD, MPH

  5. Epidemiology Research and Information Center, University of Washington School of Medicine, Seattle, WA, USA

    Charles Maynard PhD

  6. Center of Excellence in Substance Abuse Treatment and Education, University of Washington School of Medicine, Seattle, WA, USA

    Daniel R. Kivlahan PhD

  7. Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA

    Kay M. Johnson MD, MPH & Katharine Bradley MD, MPH

  8. Women’s Trauma Recovery Program, University of Washington School of Medicine, Seattle, WA, USA

    Tracy Simpson PhD

Authors
  1. Dorcas J. Dobie MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Charles Maynard PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Daniel R. Kivlahan PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kay M. Johnson MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Tracy Simpson PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Andrew C. David
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Katharine Bradley MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Dorcas J. Dobie MD.

Additional information

The authors have no conflicts of interest to declare.

This study is supported by grants from the Department of Veterans Affairs: Health Services Research and Development Service (GEN-97-022) and Epidemiology Research and Information Center (LIP 61-114). Dr. Bradley is additionally supported by a National Institutes of Alcoholism and Alcohol Abuse award (K23AA00313) and was a Robert Wood Johnson Generalist Physician Faculty Scholar at the time this work was completed. The views in this manuscript are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Dobie, D.J., Maynard, C., Kivlahan, D.R. et al. Posttraumatic stress disorder screening status is associated with increased VA medical and surgical utilization in women. J GEN INTERN MED 21 (Suppl 3), S58–S64 (2006). https://doi.org/10.1111/j.1525-1497.2006.00376.x

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1111/j.1525-1497.2006.00376.x

Key words

Search

Navigation