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The wife of a 25-year-old Veteran* sees their family physician, concerned about her husband. He recently released from the Canadian Forces (CF), and she reports that he is not coping well. He has difficulty sleeping, seems irritable, and has angry outbursts. During military service he was deployed twice to combat theatres. Both times he returned home “not the same man.” He worked “outside the wire,” managing acutely injured combatants. Their patrol was struck by an improvised explosive device, severely injuring several soldiers and killing 2. While he was still serving, she had urged him to speak to his medical officer, but he denied having problems. The family physician encourages her to book another appointment and bring her husband. She also contacts the Operational Stress Injury and Support program (OSISS). The OSISS peer-support coordinator encourages the Veteran to follow up with his family physician.
After history, physical examination, and appropriate investigations, the family physician rules out other physical conditions and suspects posttraumatic stress disorder (PTSD). The Veteran remains sceptical, but with motivational interviewing agrees to a referral for mental health assessment and follow-up visits with the family physician. The physician urges him to call Veterans Affairs Canada (VAC), and with his consent sends a referral letter to the local VAC District Office. He is referred on to a VAC Operational Stress Injury Clinic, where he is diagnosed and treated for PTSD, in collaboration with his family physician. The OSISS peer-support coordinator maintains contact with the Veteran and his family. The Veteran applies for a disability award.
Posttraumatic stress disorder secondary to military psychological trauma occurs in a substantial number of Veterans, and they might present to family physicians with complex physical and psychiatric comorbidities.1 The current and lifetime prevalences of PTSD among serving CF members are about 2.8% and 7.2%, respectively.2 In a sample of Canadian peacekeeping Veterans receiving pensions after being diagnosed with medical conditions, a 1-month prevalence of probable PTSD of 10.3% was reported.3 In samples of US military members, following deployment to Iraq and Afghanistan the rates of PTSD were estimated to be between 11% and 17% compared with a baseline rate of 5% before deployment.4 In a sample of UK military members, the reported rates were considerably lower at 4.8%.5
While service-related PTSD is often diagnosed during military service, some Veterans might not seek help until after releasing from service.6 Presentations of military-related PTSD are often complex. Veterans might present indirectly with emotional, behavioural, or addiction concerns, or with unrelated, less stigmatizing somatic problems such as physical complaints.6 Two factors in the history should trigger the physician to consider PTSD in the differential diagnosis: previous exposure to psychological trauma and presence of any PTSD symptoms. Patients with PTSD present with 3 symptom clusters: reexperiencing, avoidance and numbing, and hyperarousal symptoms.1
Understanding military culture and the nature of military deployments is essential to detecting PTSD and establishing a trusting therapeutic alliance. Potentially traumatic events (PTEs) experienced by those in the military can differ from those experienced by the general community. In the general community, PTEs typically involve rape, motor vehicle accidents, assault, natural disasters, or terrorism. Military PTEs also include combat, imprisonment, torture, witnessing atrocities, comrades being wounded or killed, or rescue missions following natural disasters.7 Military personnel are more likely to be exposed to psychological trauma than the general public are.8 Patients with PTSD are prone to presenting with somatic symptoms1 and are high users of health care resources.3 Family physicians should screen for possible PTSD in former military members.
Delays in accessing care might contribute to the functional impairment often associated with PTSD. “Macho” military identity and fear of stigmatization are barriers to seeking treatment, especially at an early stage when symptoms might be more likely to respond to treatment.9
Box 16,10,11 suggests an approach for family physicians seeing previously undiagnosed Veterans. The signs and symptoms of PTSD are nonspecific, so initially the differential diagnosis of presenting symptoms might include both physical and mental disorders.12 Check for physical, psychological, and social symptoms, inquire about exposure to military psychological trauma, then work through the differential diagnosis.13 While no physical condition explains full-spectrum PTSD,14 the condition might not be apparent initially owing to avoidance or to reluctance to discuss service-related events early in a therapeutic relationship. Comorbid physical and mental health conditions are common in PTSD and many have overlapping symptoms.
|Features suggesting possibility of PTSD|
|Primary Care PTSD Screen (positive if patient answers yes to any 3 items)|
|History and physical examination|
Family physicians can screen efficiently for PTSD using short instruments, such as the 4-item Primary Care PTSD Screen (Box 16,10,11).13 The instrument has a sensitivity of 78% and specificity of 87% for PTSD in patients who endorse 3 or more items.13 Patients who have a positive screening result should be assessed for PTSD using diagnostic criteria from the Diagnostic and Statistic Manual of Mental Disorders.11 Patients whose symptoms do not meet full diagnostic criteria for PTSD might still experience substantial functional impairment.15
Family physicians play important roles in treating Veterans with PTSD by initiating medications to reduce symptoms, making referrals, improving functioning and quality of life, assisting with treatment compliance, monitoring progress, and facilitating psychotherapy. Although PTSD can be treated by family physicians, involving a multidisciplinary team of health professionals working within a shared care model can be very helpful, especially if the family physician does not feel adequately trained or does not have the time to provide psychotherapy. Also, PTSD in one family member can have considerable effects on the health of others, who might also need assessment and treatment.
Comorbidity, suicidal or homicidal thoughts, and social support problems including dysfunctional family relationships are indicators to consider inpatient treatment or referral for psychiatric care.16 Posttraumatic stress disorder increases the possibility of suicidal thoughts,15 and comorbid depression further increases suicide risk.17 During initial PTSD assessment, male war Veterans might be angry and report violent thoughts and aggressive behaviour, including homicidal thoughts.18,19
Stabilization before initiating trauma-focused psychotherapy is critical to minimizing exacerbation of pre-existing comorbid conditions such as depression and substance abuse.
Initially, stabilize patients by managing acute symptoms. Improve current functioning with psychoeducation, medication, and anxiety management training. While a firm diagnosis is being established, manage “treatable symptoms” of anxiety, depression, and insomnia, and provide supportive psychotherapy. Once the diagnosis is established, family physicians can assist in educating patients about psychiatric medication and psychotherapy, establishing treatment expectations, and introducing the importance of collaborative care with psychiatry.
For most patients, first-line treatment includes selective serotonin reuptake inhibitors, such as paroxetine and sertraline, and serotonin-norepinephrine reuptake inhibitors, such as venlafaxine,1 which can be initiated by primary care physicians. Referral should be considered for patients with partial response at optimum doses or with difficulty tolerating first-line treatment. Next choice of medications could include a different class of antidepressant; combining 2 antidepressants of different class, such as adding mirtazapine or bupropion to a selective serotonin reuptake inhibitor or venlafaxine; or augmentation with atypical antipsychotics, such as risperidone or olanzapine, or anticonvulsants.1,13 Close monitoring of potential side effects, especially in the early stages, is essential when considering augmentation or combination strategies.
Once acute symptoms stabilize, patients are more able to engage in and benefit from psychotherapy20 and more likely to accept referral. Specialized psychological trauma clinics use multidisciplinary teams to manage PTSD in collaboration with family physicians. In addition, peer-support programs, like OSISS21 in Canada, can play a valuable role in encouraging medication and treatment compliance.22
Although some family physicians provide psychotherapy to patients with PTSD, for physicians without specific training it might be appropriate to refer patients to therapists who have experience with military PTSD. Prolonged exposure and cognitive behavioural therapy are considered first-line treatment. In prolonged exposure, the patient reiterates the traumatic event during planned treatment sessions until the memory no longer provokes substantial anxiety. Both conditioned fear and cognitive distortions associated with PTSD are addressed during cognitive behavioural therapy. Use of eye movement desensitization and reprocessing for PTSD is supported by evidence1,16; patients are instructed to imagine painful traumatic memories and associated negative cognition such as guilt and shame while visually focusing on the rapid movement of the clinician’s finger.13
There is considerable evidence that patients with PTSD continue to demonstrate improvement with pharmacotherapy up to 36 weeks of treatment. Those who discontinue medication can relapse within 6 months and, therefore, long-term treatment might be recommended.1 It is generally recommended that patients continue medication for at least 1 year. Although remission is not always possible, with treatment patients with PTSD demonstrate substantial symptom reduction and improved quality of life. Complete remission is achieved in 30% to 50% of cases.1,13
The CF provides serving personnel with a comprehensive array of services to assist with mental health issues, including a reorganized multidisciplinary primary care system, specialized Operational Trauma Stress Support Centres, and programs reducing barriers to mental health care. Canadian Forces personnel have access to general duty medical officers, medical technicians, nurses, physicians, psychologists, psychiatrists, and social workers in theatres of operation and at home in Canada.
A previous installment of Veteran Health Files described the array of programs, services, and benefits available to eligible CF and RCMP Veterans and their families experiencing effects of operational stress injuries.23 Veterans Affairs Canada welcomes collaboration with family physicians in providing Veterans and their families with optimum physical, mental, and social health care.
Resources for physicians
Resources for patients
Veteran Health Files is a quarterly series in Canadian Family Physician coordinated by Veterans Affairs Canada. The series explores situations experienced by family physicians caring for Veterans of military service. For further information on this series, contact Dr Jim Thompson, Veterans Affairs Canada Head Office, Charlottetown, PEI; e-mail ac.cg.cca-cav@ehcrehcer-hcraeser
*The case presented is fictitious.
The opinions expressed are those of the authors and not necessarily Veterans Affairs Canada, the Department of National Defence, or the Canadian Forces.