The attrition rate for the sample was 37%. Ten client/CM dyads had exited the study by the 12-month data collection point; the primary reasons for these exits were clinical and systems-based. Clinically, seven client's no longer needed case management services, therefore, were 'closed', that is, were no longer 'active' clients of the service. A further three clients changed case managers as a result of staff movements (either that of leaving the service or changing role functions) after a critical point in the research period and, therefore, exited the study as the effect for WA on outcome was not able to be measured for these clients.
The low responses rate of 34% was primarily a function of the large number of clients that were nominated by case managers that did not meet selection criteria. As noted in the methods section, the criterion that presented the most difficulty was that of the duration of case management service required. For the study, this was a mid- to long-term period to allow for the tracking of the therapeutic relationship (the primary variable being measured in the larger study). As clients were selected on entry to the service, CM's were required to make a judgment as to the likely term of service required. This was not always easy given the acuity of the psychopathology involved. Furthermore, in the reality of the clinical setting, the selection criteria were not uppermost in the minds of the clinicians referring the clients to the study. Attempts to address this were undertaken during the recruitment phase, for example, a large poster listing the selection criteria was designed for each team, with the request that it be prominently displayed at team meetings in which clients were allocated to case managers to aid referral. This was in addition to the planned strategies discussed in the methods section to facilitate the recruitment process. Systemic issues also impacted on the issue of eligibility as some clients referred to the study had been assigned to an interim CM only; this again made them ineligible for the purpose of measuring the therapeutic relationship as they would be changing CM's within 3 months or less.
Data on trauma/PTSD is reported for a sample group of 27 client/CM dyads (two clients withdrew their consent during baseline data collection; these data are omitted). Where applicable, data are provided for the total sample followed by the discrete results for subgroups with PTSD (n = 9) and those reporting trauma that did not meet diagnostic threshold (n = 11) total n = 20.
Presented in Table . Note that data for CM contacts and times is at 12 months and therefore only includes data for the 17 clients remaining at this point.
Client Demographic details for the whole sample in sub-groupings for trauma/PTSD (n = 27)
Co-morbidity was defined as at least one other diagnosis (excluding PTSD). The rate of co-morbidity in the whole sample (n = 27) was 30% (n = 7) with the majority having one other diagnosis; PTSD group n = 9: 44% (n = 4) all of whom had at least two other diagnoses; non-PTSD group n = 11: 17% (n = 3) all of whom had only one other diagnosis.
Demographics: case manager (n = 17)
Data is adjusted for CM's with multiple clients in the study. The majority of CM's were male (71% n = 12). The mean age was 42 years (SD= 10) range 35. The respondents had a mean of 4 years (SD = 1.2) clinical experience plus a mean of 2.5 years in mental health (SD = 1.4). Nurses comprised the largest professional discipline (71% n = 12). The remainder were Clinical Psychologists (4) and one Social Worker. The majority of CM'S had an undergraduate qualification only (59%), four had a specialised qualification in psychiatric nursing and three CM's had a higher degree at the masters' level. Fifty-three percent of respondents had post-graduate training in a related field (CBT, Counselling, Psychoeducation).
Discussion: client demographics
Levels of employment
These are high at 70% in this sample, despite the high level of respondents who completed high school. The unemployment rate in the whole of the adult service of the ACT CMHS is recorded as 34%, however, this is not adjusted for acuity or diagnosis, therefore, as the sample has a high percentage of clients with a psychotic-based illness, direct comparison cannot be made.
The high educational level reported may reflect the general profile for the ACT, which has a higher level of retention of students in secondary school with 89% of year 7 students remaining in school at year 12 compared to the national rate of 73% [29
]. However, place of schooling was not a demographic that was included in the screen, therefore, this is not a definitive explanation of reported educational levels in the sample.
Australia has six state and two territory governments and a federal level government, with differing levels of political responsibility for services. That of health service delivery rests at the state and territory level, and there is currently no central data collection point for employment status for persons with a mental illness in a treatment context. However, two national surveys [39
] provide some insight into this, each reporting higher rates on unemployment (approximately 30%) across genders for persons with a mental illness. A further survey on employment in persons with psychosis [41
] reported that 85% (n = 980) had their main source of income from government payments. The general unemployment rate for the ACT is 5% compared to that of 6% nationally [29
The issue of unemployment in person with a mental illness in Australia is complex, and influenced by several factors such as access to employment-related services, stigma amongst employers and society generally, and systemic issues such as availability of vocational and rehabilitation services in mental health service delivery systems. Underpinning all of these factors is the influence of a federally-funded social welfare system that supports unemployed persons to varying degrees [29
Primary psychiatric diagnosis
This was the major differentiating demographic factor between the two groups, with a greater number of clients in the non-PTSD groups diagnosed with schizophrenia. Whilst Mueser [6
] found that diagnosis was the only demographic variable associated with a diagnosis of PTSD, the current sample is too small to draw any conclusions. Given the small body of research in this setting, it is difficult to be definitive about associations between comorbid psychiatric diagnoses and PTSD. As discussed below, there are many complex issues involved in any attempts to infer causality between trauma/PTSD and the development and course of other mental illnesses [8
] and the area requires greater research.
Data: trauma/PTSD profile
Rates of trauma and PTSD n = 27
Twenty clients (74%) reported exposure to at least one traumatic event; seven clients (26%) reported no experience of a traumatic event in their lifetime. Sixty-seven percent of respondents identified multiple traumatic events; two reported exposure to a single event only. The mean number of events reported was four (SD = 2.3). Nine clients from the total sample (33%) met diagnostic criteria for PTSD. Eleven clients (41%) reported trauma symptomatology that did not meet diagnostic threshold for current PTSD. Only one patient had a formal diagnosis of PTSD in their medical record.
The data pertinent to trauma symptomatology detailed below relates to the 20 persons who reported experiencing a traumatic event in their lifetime, this includes those meeting diagnostic criteria for PTSD (n = 9), and those reporting trauma but who did not meet diagnostic criteria for PTSD (n = 11). The 7 clients who did not report any lifetime trauma are excluded from this section, but are included in the subsequent outcome section.
Number of events (n = 20)
The total number of traumatic events reported by clients was 77; the CM reported a total of 21. Paired samples t-test showed significant difference for the mean number of reported events between CM M = 1.0, SD = 1.12 and Clients M = 3.8, SD = 2.4 t (19), p< .0005.
PTSD group (n = 9)
clients reported a total of 45 traumatic events (M = 5, SD = 2.95); the CM reported a total of 14 (M = 1.55, SD = 1.13) or 31 % of the events reported by the patient. The majority of CM's (78% (7)) – knew about the patient's exposure to trauma; two CM's (22%) reported no knowledge of the patient's trauma. Only one CM reported that the client was receiving treatment for trauma/PTSD.
Non- PTSD group (n = 11)
clients reported a total of 32 events (M = 3, SD = 1.30); CM's reported a total of 6 (M = .54, SD = .93) events or 19% of those reported by the client. The majority of CM's 64% (7) had no knowledge of the client's reported exposure to trauma.
Type of event
Table shows the reported events. The three most frequently were Serious Accident, Physical Assault and Sexual Assault, however, the combination of the different types of sexual assault (childhood and adulthood) makes this the most frequently reported type of trauma across the groups. Fifty-five percent (11) of clients reported sexual assault before the age of eighteen, of these 58% (7) also reported adult sexual assault.
Categories of traumatic events from the PDS screen as reported by clients (n = 20)
PTSD group n = 9
78% (7) of the respondents reported childhood sexual assault; 53% (5) also reported adult sexual assault (3 females, 2 males). Non- PTSD group n = 11: 36% (4) reported childhood sexual assault; of these, 50% (2) also reported adult sexual assault (1 female, 1 male).
Trauma with the most effect
Interpersonal assault, physical and sexual, was the type of trauma nominated by 45% (9) of respondents as the type of trauma that 'bothered them the most'. The second highest rating trauma nominated was that of a 'serious accident or explosion' the remaining categories were unequally distributed amongst the remaining types of trauma. Eleven clients (55% n = 20) reported that the event nominated by them as the one that 'bothered them the most' happened more than 5 years ago.
Symptom details for the B C D criteria are shown in tables and .
Itemised PTSD symptoms for Criteria B, C, D, reported at 2–5 times per week
Number and severity of symptoms for the 3 clusters – Median-split
Symptomatology specifiers (E criterion)
All clients in both groups met the chronic symptom duration criteria (all had experienced the symptoms for more than 3 months). PTSD group n = 9: The majority of clients (89% (8)) in this group had 'acute' onset of symptoms, with only one client showing 'delayed' onset. Non- PTSD group n = 11: In contrast, these clients were almost equally divided between the acute and delayed onset categories.
Impairment of functioning (F criterion)
PTSD group n = 9
The majority of respondents – 67% (6) – met the 'severe' impairment criteria (7–9 functional areas of life effected). Two respondents met the criterion for 'moderate' impairment (3–6 areas effected); and one demonstrated 'mild' impairment (1–2 areas effected).
Non- PTSD group n = 11
Forty-five percent of respondents (5) showed no impairment; thirty-six percent (4) met the 'severe impairment' criteria, with one respondent in each of the remaining categories. Independent samples t-test showed significant difference in mean levels of impairment between the two groups. PTSD (M = 8, SD = 2.3), non-PTSD (M = 4, SD = 4), t (16) 2.8, p.014). Eta squared = 0.30 indicating a large effect size (Cohen).
Discussion: trauma/PTSD profile
Findings from this profile have particular importance for CMHS and underscore the importance of trauma assessment as a routine part of entry assessment to the service as indicated below.
Chronicity of trauma
Despite the lengthy service contact and the historical nature of the trauma, PTSD symptomatology was still current and largely unknown to treating clinicians and was, therefore, chronic in nature. Chronicity of PTSD is associated with co-morbidity; the longer the history of PTSD, the greater the chance of an individual developing a comorbid disorder [16
]. This finding highlights the importance of trauma assessment in clients with major mental illness and the hidden impact that undiagnosed and untreated trauma/PTSD may have on the course and treatment of comorbid psychiatric illness [16
This phenomenon (another feature of PTSD) is also evident in the current study, with most clients in the PTSD group demonstrating double the trauma exposure to those of the non-PTSD Group. This finding is particularly relevant to clinicians in CMHS as multiplicity of trauma exposure is also predictive of PTSD within general and psychiatric populations [3
]. Ipso facto, clients with multiple trauma experiences are more likely to have PTSD; therefore, screening for trauma is important in alerting clinicians to the possibility that PTSD symptomatology may be present in clients being treated for another primary psychiatric diagnosis.
Types of traumatic events
The pattern of events reported, although consistent with that of other studies, is quite different to that of the Australian population as reported in the findings from the NSMHW [28
]; the top three categories of events in that study were 'witnessing someone being killed', 'being involved in a life-threatening accident' and 'being involved in a natural disaster'. Sexual assault (defined as rape or sexual molestation in the above survey) was comparatively small – approximately 12% (n = 10 641). These findings distinguish the 'uniqueness' of the trauma profiles in the different populations and underscore the potential reasons for the increased levels of PTSD seen in treatment populations in CMHS as discussed in a subsequent section of this article.
The currency of the symptomatology and impairment reported as arising from the traumatic event is of interest given the chronicity of the trauma experienced. The data in table showed that in the PTSD group in particular, the reports of symptomatology are clearly not an aberration or a 'one-off' experience, but a persistent experience of negative feelings and emotions associated with the trauma. Again, this is an important finding given that the trauma was largely unknown to health professionals and therefore, untreated.
Also of interest is the symptom cluster showing the greatest effect in the PTSD group -that of the 'Avoidance/Numbing' criterion. Breslau [42
] notes that this has previously been the least met criterion in the PTSD symptomatology clusters and, therefore, the most critical to the diagnosis.
This cluster is also of particular interest for its interaction with other psychiatric symptomatology. As noted earlier, the predominant type of trauma experienced by clients with mental illness is inter-personal in nature, therefore, the avoidance of social interactions and feelings of detachment, feature large in this criterion, (as evidenced by the data), consequently, they have a high potential to lead to social isolation and reduced social networks. Social isolation and poor social networks are also a feature of several types of other mental illnesses and are a known predictor of relapse and hospitalisation [43
]. Ipso, facto, co-morbid PTSD symptomatology, particularly, that of the avoidance cluster, may increase this effect and lead to a worsening of symptoms and functioning and, ultimately, relapse and hospitalisation. The hypothesised pathway by which this occurs is illustrated in the model discussed earlier [8
Rates of PTSD
This finding is of major importance as it demonstrates a rate 26-times greater than that found in the National Survey of Mental Health and Wellbeing (NSMHWB) [28
] (using the most conservative results for rates of PTSD) and it is also consistent with findings of other studies in persons with a major mental illness in treatment settings as discussed above. If this finding was representative of CMHS Australia wide, one third of all clients in a service at a given time may have current PTSD symptomatology. There is no reason to suspect that these findings are unique to the study site, as it does not differ greatly in structure, services or client base to other services nationwide.
Potential contributory factors to the higher rates of trauma and PTSD found in clients of mainstream psychiatric services
The explanation for the finding of higher rates of trauma and PTSD in persons with major mental illness is unclear, however, it is evident from the discussion in the literature that this phenomena is not unique to the current study. Several potential factors (in addition to the role of chronicity discussed earlier) including victimisation, associations between age and type of trauma experienced, gender issues and vulnerability, substance use and the psychiatric setting have been proposed in the literature as possible explanations for the increased rates of trauma and PTSD in this population and these are briefly outlined below. In general these factors cannot be directly examined in relation to the results of the current study due to methodological limitations, but they provide a basis for exploration of this variable in future research studies in this population.
Age and type of trauma
The age at which victimisation occurs may influence later victimisation; several studies have noted the link between childhood sexual abuse and sexual and physical abuse in adulthood [3
The additional relevance of this finding to general psychiatry is that sexual victimisation in childhood is also associated with the development of psychiatric disorders (other than PTSD) in adulthood [8
]. The current study showed a large percentage of respondents reporting sexual abuse in both childhood and adulthood; victims of such trauma are more likely to develop other psychiatric disorders and be treated for such in the mental health system, therefore, treating health professionals need to be alert to this potential link to an unknown trauma history.
It has been suggested that women who have been subjected to sexual victimisation may be less aware of inherent dangers and have poorer risk recognition, therefore, are slower to remove themselves from sexually dangerous situations than are women with no history of sexual victimisation [8
], hence increasing their vulnerability to further traumatisation. Whilst this effect is greater in some women with a history of sexual victimisation and PTSD symptomatology, this influence may be concomitant with the severity of PTSD symptoms. Better risk-awareness was reported in women with greater symptom severity, particularly those of the hyper-arousal cluster, so that PTSD symptomatology may, in some instances, act as a 'buffer' for women in sexually dangerous situations as a result of increased sensitivity to cues [47
]. However, the opposite may be true for women with major mental illness, particularly those with a diagnosis of schizophrenia, who have experienced sexual victimisation. Vulnerability to re-victimisation may be exacerbated for these women as a result of the negative effect of their illness that may further compromise their social competence and decrease their ability to act positively to avert the risk or remove themselves from dangerous situations [8
]. Sample size prohibits analysis of this factor in the current sample.
The Psychiatric setting
Vulnerability issues related to assaultive violence may also be a factor inherent in the psychiatric setting [20
]; in-patient units in particular, have been the subject of a broad range of studies in relation to patient violence and the use of restraint and seclusion. However, the focus of these studies has primarily been staff and patient safety issues, the aetiology of violence, measurement issues, staff training and legislation. Even though patient to patient assault may occur, particularly in mixed gender units, few studies have examined the psychological impact of this on the individual [20
]. It has been suggested that the procedures and processes of in-patient units, particularly those related to restraint and seclusion, may also re-traumatise victims [20
]. Additionally, the experience of the mental illness itself, particularly if it involves psychosis, can result in PTSD symptomatology and/or exacerbation of previous trauma [6
]. Several clients in the current study nominated this latter stressor (being diagnosed with a mental illness, particularly psychotic-based) as a 'traumatic event'. However, as it did not meet DSM IV
criteria for a traumatic event, further assessment was not undertaken.
Substance use and misuse
This is a known clinical correlate of both PTSD and major mental illness, and may also play a role in the higher levels of trauma evidenced in this population [5
]. The decreased inhibitory effects and resultant risk taking associated with substance abuse may place the person in increasingly unsafe social and physical environments exposing them to greater risks of interpersonal violence [6
]. Levels of substance misuse are high in the PTSD and trauma groups of the current study, but again, the sample size prohibits any definitive analysis.
Implications of these contributing factors for CMHS and mainstream psychiatry
The variety of issues contributing to increased rates of trauma and PTSD identified in the preceding discussion may be distilled into three main factors all of which have important implications for public-sector service providers in mainstream psychiatry, particularly CMHS. These factors relate to the discrete sub-group of persons accessing mainstream psychiatric services, the inherent risk factors for PTSD within this group and the trauma characteristics demonstrated by this group. Increased awareness of these factors by service providers and clinicians is the first step in responding to the identified need for service provision for clients with co-morbid PTSD.
First, the nature of the population; all reported studies of PTSD in persons with a mental illness are from a treatment population of persons receiving current intervention for another mental health disorder. Given the known co-morbidity associated with PTSD, it is not unreasonable that higher rates would be found in this group of persons as they are suffering non-diagnosed PTSD, of chronic duration and, therefore, the likelihood of another mental disorder developing, for which the individual seeks treatment is increased. However, awareness of this factor by service providers not only gives a contextual awareness for interpretation of research findings in the field, but also provides them with insight into the potential service needs of their customer base and the need to include trauma/PTSD screening as a routine element of entry assessment protocols in this consumer group.
, the trauma profile of persons with a major mental illness (as reported in the literature and the results of this study) is dominated by interpersonal violence, particularly sexual victimisation and is potentially a major contributing factor to the higher rates found. Whilst women in particular are at greater risk of assaultive violence [42
], the type of the trauma experienced and the individual's perception of the trauma as 'upsetting' is known to influence the development of PTSD. This cognitive/emotional response is a known feature of sexual victimisation; for example, rape is one such event that is perceived as 'upsetting' across genders and in treatment and non-treatment populations and, as such, is strongly linked to the subsequent development of PTSD [3
]. Whilst this underscores the need for trauma screening, it also highlights the need for a sensitive and supportive environment that allows the traumatised individual to verbalise the nature of the abuse.
, whilst increased risk of PTSD following exposure to trauma in persons with a major mental illness is reported in both treatment and population surveys [6
], this risk may be incremental depending on the type and severity of mental illness experienced; in a treatment population, the nature of the illness is likely to be more acute and/or severe, therefore, individuals may be subject to greater vulnerability to the risk factors discussed earlier, including re-traumatisation and subsequent development of PTSD.
This has particular implications for the processes and procedures associated with issues of admission and management practices in hospital units, involuntary processes, the experience of mental illness itself, particular psychotic-based illness, and the impact this has on the psychological integrity of the individual. It also highlights the need for inclusive and collaborative management of substance abuse issues and those associated with residential and environmental safety in community based services.
The interaction of PTSD and other mental illness
Co-morbidity and PTSD
PTSD is strongly co-morbid with other psychiatric disorders as demonstrated in the two community surveys in America [3
] and Australia [2
]. The NSMHWB [2
] found a 12-month prevalence of co-morbidity for PTSD with at least one other Axis 1 diagnosis in 85.2% of males and 79.7% of females, whilst the National Co-morbidity survey showed 88.3% males and 79% females with at least one other psychiatric disorder [3
]. This high rate of co-morbidity was also demonstrated in the current study particularly in the PTSD group, who accounted for most of the co-morbidity in the sample, however, the sample was too small to examine gender differences.
Notwithstanding the potential influence of the above on rates of PTSD in persons with a co-morbid psychiatric diagnosis, no definitive causality chain between PTSD and other mental disorders can be identified. Although some researchers discuss the seemingly intuitive link between traumatic experiences, PTSD and the course of other mental illnesses (based on the widespread occurrence of the phenomenon), there is no definitive answer to the question at this time and the issue has not been widely studied or reported.
The possible link between the two broad types of disorders may be more to do with shared risk factors for PTSD and other mental health problems, such as the mood disorders, and the interplay between differential effects of specific traumas, individual risk factors and personal coping mechanisms [16
]. The full explanation may lie in a complex matrix of all of these factors differing across individuals, communities and diagnoses, but is unlikely to lie in the potential for symptom overlap between PTSD and common co-morbid diagnoses such as depression, anxiety, and dysthymia. Rather, the literature suggests that this factor, far from overstating the case for PTSD, may result in misdiagnosis if detailed trauma histories are not sought and potential PTSD diagnosis excluded [10
The potential influence of this factor cannot be ruled out of the current study given the level of documentation of respondents' trauma/PTSD profile found. Although this local finding was not unexpected, as there was no formal or standardised assessment of trauma done in the service it does, however, demonstrate the potential for diagnostic ambiguity in clients presenting with symptoms of depression, anxiety, psychosis and/or substance abuse, if trauma histories are not routinely sought.
Whilst the inter-relationship between trauma, PTSD and other mental illness is complex and largely unexamined, thus compounding attempts to explain the higher rates found in persons with other mental disorders, contemporary findings indicate that multiple traumatisation is a strong predictor of PTSD in treatment and non treatment populations regardless of the ultimate relationship [3
]. The single definitive answer that can be gleaned from the current findings and discussions on the subject, is that much more rigorous and longitudinal research is needed from an epidemiological and targeted perspective in order to achieve optimal outcomes for the commonly treated psychiatric disorders [1
Data: effect of PTSD diagnosis on client outcome
As the study sought to explore the potential effect of untreated PTSD symptomatology on client health outcomes, this section compares data for clients with PTSD to those without PTSD, and therefore, includes those clients who reported no experience of trauma either current or lifetime. The sample size was 17 (5 clients with PTSD, 12 without), the number remaining enrolled in the study at the T2 data point, the 6-month period following engagement with the service and CM. Only two of the four outcome measures used showed any significant difference for clients with PTSD – the HoNOS and the WHOQOL. Only one of these, WHOQOL, is reported in this paper for reasons discussed earlier. Data are presented in table /. Two population 'norms' were used for comparison, the first was from a similar population of clients with a major mental disorder, primarily Axis 1 diagnoses, 70% of whom had a diagnosis of Schizophrenia [55
]. That study was conducted in an Australian Community Mental Health setting and used the WHOQOL-BREF, client and CM format and, therefore, provides a suitable comparison in view of the lack of studies in clients with major mental illness and PTSD. The second comparison is that of the Australian population 'norms' for the WHOQOL [33
QOL PTSD/No PTSD diagnosis (n = 17): Client data and comparisons with community samples.
QOL PTSD/No PTSD diagnosis: CM data and comparisons with 'psychosis" sample
There were no significant correlations between client and CM ratings on any of the outcome measures used in this study.
Discussion: effect of PTSD on client outcomes
The findings on outcome are severely constrained by the short follow-up time and no definitive conclusions can be drawn from the lack of effect for PTSD Diagnosis on the other outcomes selected.
Whilst QOL is considered the most important outcome in mental health research and is central to outcomes management [56
], there is an obvious lack of literature on PTSD and quality of life in the study population with which to compare the research findings [56
]. Contemporary QOL research in PTSD stems primarily from a veteran's perspective [56
]; research of civilian trauma has focused on specific trauma-related perspectives, for example, female victims of violence [58
], victims of major trauma [59
], or persons with specific medical conditions [60
] and those involved in drug trials [57
]. Although there remains the issue of different QOL measurements used in the various studies to date, the emerging trend in anxiety research suggests that PTSD in particular, has a major negative effect on QOL [56
The results of the current study support this growing body of research, with clients and CM's both reporting data that was significantly different for those clients with PTSD than those without, in three of the four domains of QOL measured.
The impact of co-morbid PTSD on QOL in persons with another major mental illness is further evidenced in the study group when compared with a similar population with major mental illness but without PTSD. Clients with PTSD showed significantly greater impairment in physiological and psychological health than did those in the comparison group who had a psychotic illness only (considered to be one of the most disabling disorders with a lower quality of life than that reported in physical illness and the general population). In contrast, those study clients without PTSD had scores very similar to that reported for the comparison group. Additionally, the study demonstrated that for clients with and without PTSD, reported QOL was significantly worse in all domains (with the exception of that of the Environmental Domain in the non-PTSD group) when compared with that of the general Australian population.