PTSD is common in a population of patients with major trauma. One year after trauma 23% of our sample had an IES-score of 35 or higher, indicating probable PTSD. At two years after trauma the prevalence rate of probable PTSD was 20%. Female gender and comorbid disease were strong predictors of probable PTSD one year following injury, whereas head injury and injury of the extremities <3 were strong independent predictors of this disorder at two year follow-up. Of the patients with probable PTSD at one year follow-up 79% had persistent PTSD symptoms a year later.
The prevalence rates that we found in our study are comparable to those found by Kreis et al. [29
] and Soberg et al. [11
], who reported prevalence rates of 23% and 19% respectively regarding trauma victims with severe injuries (ISS
15). However, neither Kreis et al. [29
] nor Soberg et al. [11
] used the IES to assess PTSD, which may have affected the PTSD prevalence rates that were found.
Holbrook et al. [10
] did use the IES to assess prevalence of probable PTSD regarding a sample of trauma patients, yet they found a higher prevalence rate of 32% at 18 months follow-up. This difference in prevalence rate might be explained by differences in patient populations.
A second explanation for the differences in prevalence rates of probable PTSD may be the IES cut-off point that was used. Holbrook et al. [10
] used an IES-score greater than 24 to identify patients with probable PTSD, whereas in the current study a cut off of 35 was used. When we applied a similar IES cut-off point of 24, the prevalence rate of probable PTSD one year following trauma increased to 36%. At two years follow-up the prevalence rate of probable PTSD increased to 26%. These prevalence rates are in the same range as reported by Holbrook et al. Evidence suggests it is important to use a high IES cut-off score that incurs a high specificity to avoid over diagnosing of PTSD in a comprehensive population with a relative low PTSD prevalence [21
The existence of PTSD symptoms was measured with the IES rather than Clinician-Administered PTSD Scale for DSM-IV (CAPS). Important to note is that the IES is a self-report questionnaire that measures only two of the three main PTSD symptoms, namely intrusion and avoidance. Hyperarousal, the third main PTSD symptom, is not measured by the IES. The IES is not a diagnostic tool, i.e., it is not designed to diagnose mental disorders according to the DSM-IV (the fourth edition of the diagnostic and statistical manual for psychiatric disorders). Consequently, cases that in the current study were identified as having PTSD symptoms might not meet the DSM-IV criteria of clinical PTSD, and inversely. The use of different diagnostic instruments may be a methodological reason for differences in prevalence rates between studies. Presumably, the fact that in this study the IES has been used, and consequently PTSD symptoms excluding hyperarousal symptoms have been assessed may have resulted in a relatively high rate of probable PTSD.
In this study, a quarter of the sample met criteria for a moderate TBI, and another 20% met criteria for a severe TBI. TBI can have serious effects on communication and cognition, and the presence of severe TBI will impact upon any assessment of PTSD. Moreover, a large prospective cohort investigation of injured trauma survivors with TBI in the United States found an elevated risk of PTSD among patients with mild TBI as more than one in five (22%) was diagnosed with PTSD at one year follow up [31
Our study focused on a single stressor, i.e., injury, whereas PTSD generally originates from cumulative exposure to traumatic stressors. The presence of traumatic stressors also influences the probability of spontaneous remission from PTSD [32
]. This means that the level of other traumatic stressors may affect to a large extent the prevalence rates that were found. At long-term follow-up (>1 year) PTSD prevalence rates from 5% [9
] to 32% [10
] have been reported regarding trauma patients. This variety in PTSD prevalence rates can therefore be explained by differences in exposure to traumatic stressors other than injury.
To identify subgroups at risk for long-term probable PTSD, risk factors for the development of probable PTSD one and two year following injury were assessed. The results of our study indicate a strong association between female gender and probable PTSD. This association is in line with findings in the general literature [34
] and has been reported by other studies on PTSD following injuries [10
]. In literature several explanations were found for these gender differences in PTSD risk, such as women’s stronger perceptions of threat and loss of control and higher levels of peritraumatic dissociation, as well as gender-specific acute psychobiological reactions to trauma [34
]. Another independent predictor of probable PTSD at one year follow-up was the presence of one or more co-morbid diseases. Severity of the injury, reflected by the ISS, was not significantly associated with probable PTSD. This is in accordance with findings from previous studies [11
]. However, a limitation of our study is that the comorbidity measure is very simple, since it groups comorbidities into none, one or more than one. No distinction was made whether the comorbidities are related to pre-existing psychiatric disorders and/or substance abuse. If this distinction was made, it would shed more light on the relation between different types of co-morbidity and PTSD.
Furthermore, peritraumatic processing, social support, peritraumatic dissociation or other predictors of PTSD were not included in this study [39
Pre-hospital trauma care, i.e., the presence of helicopter or other physician staffed EMS teams at the scene of the accident was not significantly associated with probable PTSD at either one or two years follow-up. Dispatch is based on the apparent seriousness of a distress call or trauma mechanism, or based on patients’ condition as assessed by ambulance personnel at the scene of the accident. In other words, helicopter or other physician staffed EMS teams attend to the most severe cases and specific trauma mechanism. Our hypothesis was that cases with pre-hospital trauma care at the scene may be more prone to develop PTSD. The finding that pre-hospital care was not significantly associated with PTSD may be explained by the finding that trauma mechanism, disturbance of vital parameters or severity of injury are not significantly associated with probable PTSD.
The results of this study may not be generalizable to young male major trauma patients, because respondents who were willing to participate in the study were significantly older and significantly more likely to be female.
A strength of this study was that it did not focus solely on prevalence rates of probable PTSD, but also addressed the course of probable PTSD at long-term follow-up. Previous research on the course of PTSD revealed that patients experience symptoms for one year or longer [41
]. The flowchart depicting injury patients with and without symptoms at one and two years following injury allowed us to gain insight into the development of probable PTSD over time in a sample of severely injured trauma patients. The flowchart showed that PTSD symptoms fluctuate over time; patients meet criteria or cut-off at some time points, and at other points they fell just below, but that the majority of patients with probable PTSD at one year follow-up still meet the IES criterion for PTSD at two years follow-up. This indicates that many patients might suffer from prolonged effects of PTSD.
Most likely PTSD symptoms occur during the first year after the accident, rather than between year one and two after the injury. However, in the current study baseline information on PTSD symptoms was not gathered. As a result, the course of probable PTSD in the first year after the injury could not be analyzed, nor does this study provide information about pre-existing PTSD.