Understanding Posttraumatic Stress Disorder: An Expert Interview With Doug Zatzick, MD

Laurie Barclay, MD


November 11, 2008

Cognitive-behavioral therapy (CBT) is the posttraumatic stress disorder (PTSD) treatment with the best evidence base supporting its use. Good response rates have been documented in relatively uncomplicated cases without substance use comorbidity, multiple medical comorbidities, ongoing exposure to recurrent traumatic and stressful life events, and other competing demands. Evidence-based PTSD treatments have yet to be adequately tested in more complex trauma-exposed populations.

Laurie Barclay, MD

Editor's Note:
At the annual meeting of the American Neurological Association held in Salt Lake City, Utah, September 21-24, 2008, PTSD was one of the featured topics. Deployment of US troops to Iraq and Afghanistan over the past 5 years has resulted in combat injury, often complicated by PTSD. Even in civilian populations, PTSD following recent hurricanes and other natural disasters -- not to mention in cases of multiple trauma following motor vehicle and other severe accidents or injury -- poses unique challenges in the treatment and delivery of healthcare services.

To give an overview of PTSD, from the epidemiology to the clinical challenges of identifying and treating patients, Laurie Barclay, MD, on behalf of Medscape, interviewed Doug Zatzick, MD, Associate Professor and Director, Attending Consult Services, University of Washington at Harborview Medical Center in Seattle, Washington. Dr. Zatzick has recently published his research on functional sequelae and interventions appropriate to patients with PTSD in level I trauma centers.

Dr. Barclay: How prevalent is PTSD in the United States and worldwide; how is the prevalence changing with time; and what are the demographics?

Dr. Zatzick: According to the National Comorbidity Survey in 1995,[1] which is one of the best studies of PTSD prevalence in the United States to date, 5% to 10% of US civilians have PTSD at some point during their lifetime (approximately 5% of men and 10% of women). In the population of injured trauma survivors, in whom I do most of my research, about 20% have symptoms consistent with PTSD. We have a paper this month in the Annals of Surgery[2] showing that at 12 months after injury, a little over 20% of injured trauma survivors hospitalized at US level I trauma centers had symptoms consistent with PTSD and about 6% had depression. Both disorders were independently associated with significant impairments across all functional outcomes, including physical function (activities, such as climbing stairs and getting around in the community), social function (interacting with family and friends), and returning to work and productive activity.

There have been many studies of worldwide prevalence of PTSD. In a study of one group of returning veterans of the current Central Asian conflicts, incidence of symptoms consistent with a current diagnosis of PTSD was about 11% to 18%.[3]

Worldwide, there have been a lot of studies in conflict areas where the incidence of PTSD is much, much higher.[4] For civilians in conflict-ridden areas, the incidence of PTSD is very high because of the high prevalence of exposure to recurrent traumatic life events.

Dr. Barclay: What are the clinical challenges involved in diagnosing and managing PTSD overall?

Dr. Zatzick: I work at a level I trauma center that is also an inner-city safety-net hospital. Therefore, I often consult on injured patients, low-income ethnically diverse patients, and first-generation Americans who have immigrated to the United States after experiencing major trauma in their countries of origin. So, for example, in the setting of an outpatient visit for PTSD after a motor vehicle accident in which there were no severe injuries or extreme incidents, such as the death of another person. If such patients are medically stable, with no major preexisting medical or psychiatric problems, and was not exposed to multiple recurrent traumatic events before the injury, and has a good support system and reasonable life circumstances, they should do very well with CBT for PTSD, especially if they are motivated for treatment. Examples of types of CBT for PTSD include exposure and cognitive processing therapy. Medications, particularly the selective serotonin reuptake inhibitors (SSRIs), may also be effective in some patients, although there have been some recent questions about their efficacy in PTSD.

The challenges in management of PTSD are more complicated in alternative real-world scenarios, such as an acute trauma center or combat zone. For example, when an accident survivor has undergone surgery, is being managed in the intensive care unit, has opiates on board for pain, and will be undergoing months of rehabilitation, that's complicated. There are multiple, competing demands on their time that push the patient in directions where they may not be ready to get psychotherapy, and addressing PTSD in this setting is much more difficult.

In a disaster zone, for example, if the patient has been evacuated, is a refugee and can't get to [a pharmacy] for a prescription, and can't get to a therapist's office because even finding a therapist is a major challenge...

Dr. Barclay: How effective are currently available treatments for PTSD?

Dr. Zatzick: For patients with a single episode of trauma, good social support, no severe or recurrent trauma history, and no comorbid history of substance abuse -- who are not avoiding treatment and will come to every CBT session -- the odds are that they will respond to CBT. However, the response rate may be much lower if there are a lot of complicating factors. There is some evidence that the specific serotonin uptake inhibitor class of antidepressants may also be efficacious treatments for PTSD (SSRIs), yet the evidence base is not as solid as for CBT. (See American Psychiatric Association PTSD guidelines and British NICE PTSD guidelines.)

Dr. Barclay: What are the safety and tolerability issues with currently available treatments for PTSD?

Dr. Zatzick: The SSRIs have side effects, including headache, sexual side effects, and gastrointestinal upset. Disturbed sleep is often an issue with PTSD itself, and the SSRIs may exacerbate that. There have been some studies showing that prazosin may be useful for nightmares/sleep when given with an SSRI and it is not habit-forming, but it may cause orthostatic hypotension.

Even CBT is not totally free from adverse effects because a lot of people don't like going back in their imagination and re-experiencing the event. Some patients drop out of therapy because it is so anxiety-provoking, but for those who stick it out, it's really a great treatment.

Dr. Barclay: Are there new drugs for PTSD in the pipeline, and how do you think they will compare with currently available treatments?

Dr. Zatzick: I mentioned prazosin earlier. For early PTSD interventions I would love to see a drug that would relieve pain right away and also target the anxiety symptoms of PTSD. We see a lot of people at the trauma center who are in pain, so if you can say to them, "here is a medicine that will help your pain today, and in 4-6 weeks it may also help your anxiety," that would be great. It's hard to sell starting an SSRI that won't become effective for 4-6 weeks, especially when that patient already has a lot of opiates on board. Adherence is not likely to be that good. There are other drugs, like propranolol, that work rapidly to lower blood pressure, heart rate, and autonomic response but have no effect on pain, which is the patient's primary complaint. I would like to see better molecules that simultaneously target pain and anxiety that aren't habit-forming.

Dr. Barclay: Please comment on the clinical implications of your own research in PTSD, and on directions for future research.

Dr. Zatzick: Our research, set in US level I trauma centers nationwide, is looking at PTSD and functional impairment after injury. We're trying to improve return to work and other measures of function after traumatic injury and PTSD. We've shown that PTSD can affect return to work and other functional ability after injury, and we're trying to intervene and improve people's PTSD and reduce their alcohol consumption. PTSD and depression together are really bad in terms of patients being able to return to work.

Dr. Barclay: What is the current burden of PTSD related to the Iraq and Afghanistan wars in terms of prevalence, disability, and healthcare costs?

Dr. Zatzick: I'm currently consulting on grants involving studies of veterans. There are complicated issues in veteran populations concerning being redeployed, multiple recurrent trauma, and comorbid alcohol use.

Dr. Barclay: What role does increasing treatment of active-duty combat troops with psychoactive medications play in PTSD during combat and after discharge?

Dr. Zatzick: I'm not a military psychiatrist, but if I were assigned to a combat unit, I'd be concerned about the side effects of psychoactive medications.

Dr. Barclay: Are there identified factors predisposing troops to PTSD, and are these screened for or should they be screened for before sending troops to combat?

Dr. Zatzick: Luckily, studies are now being done of the National Guard and other troops before they go to combat, so we can get a better idea of factors predisposing troops to PTSD. The big risk factor in both the Vietnam and Iraq conflicts has been shown to be physical injury. Screening for previous psychiatric disorders before deployment may be helpful.

Dr. Barclay: What future directions do you believe are important for PTSD research?

Dr. Zatzick: The genetics of PTSD are important to understand. Optimizing delivery of healthcare services, depending on the target population, is important.

A key point to study is intervention reach, meaning the ability to capture patients in a specified particular target population. If you've just been in a motor vehicle accident, for example, and you need a month of rehabilitation, it will take a while for you to get to the psychologist's or psychiatrist's office for CBT, so medications might be better in the meantime, and may have greater reach to the target population of interest.

We need to understand how to tailor the intervention to the context of the particular situation. What type of intervention can you do in the Red Cross mental health tent or in a war zone? Future research needs to address stepped collaborative care, meaning how to deal with posttraumatic concerns in their context first, such as reuniting with their family after combat, getting their home back after a hurricane, or getting your wound sewn up and getting antibiotics after a traumatic injury. This type of care management helps us build a therapeutic relationship and gets people into PTSD therapy. So step 1 is engagement, and then evidence-based PTSD treatment follows as step 2.


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