Psychosomatics 44:479-484, December 2003
© 2003 The Academy of Psychosomatic Medicine
Somatic, Posttraumatic Stress, and Depressive Symptoms Among Injured Patients Treated in Trauma Surgery
Douglas F. Zatzick, M.D.,
Joan E. Russo, Ph.D., and
Wayne Katon, M.D.
Received Sept. 4, 2002; revision received Feb. 18, 2003; accepted March 12, 2003. From the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine; and the Harborview Injury Prevention and Research Center, Seattle. Address correspondence to Dr. Zatzick, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Harborview Medical Center, 325 Ninth Ave., Seattle, WA 98104-2499; dzatzick{at}u.washington.edu (e-mail).
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ABSTRACT
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Few investigations have examined the course of somatic complaints among acutely injured trauma survivors. Posttraumatic stress disorder (PTSD), depressive, and somatic symptoms were assessed in trauma surgery inpatients (N=73) interviewed while hospitalized and again 12 months after their injury. Somatic symptoms occurred frequently and were significantly greater in patients with higher levels of PTSD and depressive symptoms, even after the analyses were adjusted for injury severity and medical comorbidity. These findings, when considered in conjunction with data documenting the heterogeneity of treatment providers visited after traumatic injury, suggest that the development of early screening and intervention procedures should incorporate assessments of physical symptoms.
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INTRODUCTION
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Over the past two decades, the study of unexplained symptoms has evolved into a vigorous area of inquiry in general medical settings.1,2 Studies in primary care have established a clear link between the number of somatic symptoms and the risk of having comorbid depressive and anxiety disorders.2,3 Screening instruments and procedures have been developed for patients with high levels of unexplained symptoms who are treated in primary care.4,5 Recent commentary has encouraged the expansion of the study of symptoms to domains of medical practice beyond primary care.1
Each year, approximately 37 million Americans visit emergency departments after sustaining traumatic physical injuries.6 Seven percent of these patients are so severely injured that they require inpatient hospitalization. In the United States, the trauma care system is the service delivery sector in which injured trauma survivors receive their treatment. A trauma care system is an organized and coordinated effort in a defined geographic area that is designated to deliver care to injured trauma victims.6 This care begins immediately after the injury and includes paramedic and ambulance service, emergency department triage, inpatient surgical hospitalization, outpatient surgical and medical visits, and, ultimately, community rehabilitation. Trauma centers are acute care hospitals that are designed to treat emergent medical complications related to physical injury.
Between 10% and 40% of injured trauma survivors experience posttraumatic stress disorder (PTSD) over the course of the year after injury.7 Previous reports with veteran and civilian patients suggest that PTSD is associated with increased somatic complaints.8–11
Few investigations have longitudinally assessed the course and predictors of physical symptoms among populations of patients who receive care within trauma care systems after an injury. The goal of this study was to understand the interrelationships between somatic complaints and symptoms of PTSD and depression in a cohort of injured trauma survivors. In a cross-sectional analysis, we determined if high levels of PTSD and depressive symptoms 1 year after injury were related to a greater number of somatic complaints 1 year after injury. In a longitudinal analysis, we assessed whether high levels of PTSD and depressive symptoms at the time of surgical ward hospitalization predicted the persistence of somatic complaints 1 year later. Also, since early screening and intervention procedures need to be linked to an understanding of patient-provider interactions,12 the investigation identified patterns of surgical, emergency department, primary care, and mental health service utilization over the course of the year after the injury.
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METHOD
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Study Setting and Participants
The study procedures have been described in detail in previous reports.7 Patients included in the study were survivors of intentional and unintentional injuries hospitalized on the trauma surgical services of a level 1 trauma center. Patients were English speaking and between the ages of 14 and 65; adolescent patients 14 and older were included in the investigation because they are routinely hospitalized with adults on trauma surgical services. Informed consent was obtained from participants after the study procedures had been fully explained; for participants ages 14–17, adolescent assent and parental consent were obtained.
Newly admitted trauma surgery inpatients were randomly approached for participation by using numerical assignments from a random numbers table. Of the 156 patients approached in the surgical ward by the research associate, 29 (19%) declined participation, and 10 (6%) consented to but did not finish the interview (eight subjects were transferred or discharged before completion, and two subjects declined ongoing participation). Participants who did not enroll or complete the interview (N=39) did not differ significantly from completers (N=117) with regard to demographic or injury characteristics. Sixteen subjects were recruited into a pilot intervention protocol, leaving 101 participants for the longitudinal investigation. The investigation achieved a 12-month follow-up rate of 72% (N=73). Patients who did not complete the 12-month interview were significantly more likely to be male ( 2=4.8, df=1, p<0.05), assault survivors (2=6.1, df=1, p<0.05), and have annual incomes less than $15,000 (2=5.9, df=1, p<0.05).
Measures
All 73 participants were administered a 1-hour interview while hospitalized. Patients were reinterviewed over the telephone 1 month, 4 months, and 12 months after the traumatic injury. The interviews included questions regarding patients' sociodemographic characteristics, prior trauma, current psychological distress, physical symptoms, substance use, functional status, and health service utilization.7
Physical symptoms
We used the 15-item Patient Health Questionnaire somatic symptom subscale4 to identify and follow somatic complaints. The Patient Health Questionnaire inquires about frequently expressed somatic complaints and elicits 14 of 15 symptoms required for making the DSM-IV diagnosis of somatization disorder. The Patient Health Questionnaire asks directly about pain in specific body regions (e.g., back pain, headache, stomach pain) and also includes questions that address nonspecific somatic complaints (e.g., nausea, feeling tired). The Patient Health Questionnaire has established reliability and validity.4 We used the patient screener form of the measure that dichotomizes symptomatic complaints into yes/no patient responses. Also, because two-thirds of the injured patients recruited into the study were male, we excluded the single Patient Health Questionnaire item that assesses menstrual pain.
PTSD symptoms
Levels of PTSD symptoms were assessed by using the civilian version of the PTSD Checklist.13 The PTSD Checklist is a 17-item self-report questionnaire that elicits responses graded from 1 to 5 for the intrusive, avoidant, and arousal PTSD symptom clusters. Responses are recorded on a scale from  not at all (grade=1) to extremely (grade=5). In a study of motor vehicle crash survivors, Blanchard et al.14 reported that a cutoff score of 45 or greater has a sensitivity of 0.95 and specificity of 0.86 when compared with the Clinician-Administered PTSD Scale.
Depressive symptoms
We used the Center for Epidemiological Studies Depression Scale (CES-D Scale), a 20-item self-report instrument, to measure levels of depressive symptoms. The measure has good internal consistency and convergent validity.15 Response format is a 4-point scale graded from 0 to 3 used to indicate frequency of experiencing symptoms in the past week; responses range from rarely or none of the time (less than 1 day) to most or all of the time (5–7 days).
Injury Severity and Comorbid Medical Conditions
Injury severity and location were abstracted from surgical records by using a conversion software program that transforms recognized ICD-9-CM codes into Abbreviated Injury Scale16 scores. The Abbreviated Injury Scale is a numerical scale ranging from 0 (no injury) to 6 (severe injury with high likelihood of fatality). Each ICD-9-CM injury diagnosis is assigned an Abbreviated Injury Scale severity score. The injury severity score is defined as the sum of squares of the highest Abbreviated Injury Scale score in each of the three most severely injured body regions.17
Comorbid chronic medical conditions were also derived from ICD-9-CM diagnostic codes. Eleven conditions (including diabetes, hypertension, chronic liver disease, ischemic heart disease, degenerative nervous conditions, HIV, epilepsy, obesity, and coagulation defects) previously shown to influence the course of recovery among trauma surgery inpatients were included.18
Health Care Utilization
We used self-reports of health care utilization to document the percentage of patients visiting surgical, emergency, general medical, and any other outpatient providers during the month immediately following hospital discharge. Items were adapted from a questionnaire used to assess health service utilization among patients undergoing cardiology evaluations and procedures.19 Patients who had utilized services were asked what types of practitioner(s) they had visited.
Data Analyses
Mean Patient Health Questionnaire symptom scores were tabulated for the 73 patients who completed the 12-month follow-up. We next divided patients into four groups: 1) patients with high levels of PTSD and depressive symptoms, 2) patients with high levels of PTSD symptoms only, 3) patients with high levels of depressive symptoms only, and 4) patients without high levels of PTSD/depressive symptoms. For the 12-month postinjury analyses, high PTSD symptom levels were defined as meeting symptomatic criteria B through D for DSM-IV PTSD20 on the PTSD Checklist. For the surgical ward analyses, we used the PTSD Checklist cutoff of 45 or greater to demarcate high PTSD symptom levels.14 For both the surgical ward and 12-month time points, high depressive symptoms scores were defined as CES-D Scale scores >26.21
We used analysis of covariance to compare 12-month Patient Health Questionnaire mean symptom scores across the four PTSD/depression patient groups. We adjusted for injury severity score, medical comorbidity, age, and gender in this analysis. We developed a linear regression model that used these same clinical, injury, and demographic characteristics to predict the persistence of greater Patient Health Questionnaire somatic symptom levels 12 months after the injury. The variables selected for the model were developed in accordance with previously described model selection criteria.7
Finally, in order to better understand the patient-provider and service delivery contexts in which screening and intervention procedures will be developed, we identified patterns of health service use for the cohort over the course of the year after the injury.
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RESULTS
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The demographic injury and clinical characteristics of the cohort of patients have been previously described.7 Patients were moderately severely injured (mean injury severity score=8.6, SD=7.2), with a mean age of 33.5 years (SD=12.2). In the surgical ward, 31% of the patients scored 45 or greater on the PTSD Checklist, and 42% of patients had CES-D Scale scores greater than 26.
The mean Patient Health Questionnaire physical symptom score was 5.5 symptoms (median=5.0, SD=3.5) 12 months after the injury. At the 12-month follow-up, 38% (N=28) of the patients had either high levels of PTSD symptoms, depressive symptoms, or both (Figure 1). Analyses of covariance revealed that patients without high PTSD or depressive symptom levels demonstrated significantly lower Patient Health Questionnaire mean scores than did patients with high levels of PTSD (F=11.7, df=1, 64, p=0.01) or patients with high levels of depressive symptoms (F=5.6, df=1, 64, p<0.05). Also, women demonstrated significantly higher symptom levels compared with men (F=8.8, df=1, 64, p<0.01).
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FIGURE 1. Interrelationships of PTSD, Depressive, and Somatic Symptoms in 73 Trauma Surgery Patients 12 Months After Physical Injurya
aPHQ=Patient Health Questionnaire.4 Somatic symptom scores represent mean scores adjusted for PTSD, depression, injury severity score, chronic medical conditions, age, and gender. High PTSD represents a PTSD Checklist score consistent with DSM-IV criteria for PTSD. High depression represents a Center for Epidemiological Studies Depression Scale score >26.
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We next developed a linear regression model that used clinical, injury, and demographic variables present at the time of the surgical ward hospitalization to predict Patient Health Questionnaire scores 12 months after injury (Table 1). The model explained a significant proportion of the variance in 12-month somatic symptoms levels (adjusted R2=0.322; F=5.6, df=7, 60, p<0.001). Female gender and patients with both high levels of PTSD and depressive symptoms had significantly higher somatic symptom levels at 12 months (Table 1). Injury severity, chronic medical conditions, and age were not associated with significantly higher symptom levels 12 months after the injury. It is interesting that in this prospective analysis, patients with only high levels of PTSD or only high levels of depression did not manifest significantly increased 12-month somatic symptoms.
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TABLE 1. Linear Regression Model Predicting Patient Health Questionnaire Somatic Symptom Scores in 73 Trauma Surgery Patients 12 Months After Physical Injury
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As seen in Table 2, in the first month after the injury 38% of patients reported visiting a surgical practitioner, 27% an emergency department, 23% a general practitioner, and 7% a mental health practitioner. Over the course of the year, 49% of patients reported visits to surgical outpatient providers, and 48% reported visits to general medical providers. Mental health providers were visited by 14% of patients over the course of the year.
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DISCUSSION
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Somatic complaints occurred frequently 1 year after injury in a representative cohort of injured trauma survivors. In both prospective and cross-sectional analyses, patients with higher levels of PTSD and depressive symptoms demonstrated the greatest number of somatic complaints 1 year after the injury. These results are consistent with prior investigations in primary care and community samples that demonstrated a strong association between anxiety and depressive disorders and an increased incidence of medically unexplained symptoms.2,3,10,11 The findings are also consistent with prior reports that suggest that when depression and anxiety are comorbid with medical conditions, somatic symptoms are amplified.2,22
Future investigations with larger samples of injured trauma survivors could productively focus on the relative contributions of anxiety and depressive symptoms, both alone and in combination, on the frequency and severity of somatic complaints. Also, because chronic PTSD is associated with the development of chronic medical conditions,23,24 future prospective cohort investigations could follow injured patients over years in order to assess the contribution of PTSD to the development of chronic diseases.
Health care utilization over the course of the year after the injury was characterized by marked provider heterogeneity. Surgical providers and generalists were seen by approximately 50% of the patients, and emergency department providers were seen by just under 30% of the patients. Less than 15% of the patients reported visits to specialty mental health providers. Other providers visited included internists, neurologists, obstetricians/gynecologists, nurse practitioners, and practitioners of alternative medicine.
The finding linking somatic complaints to PTSD and depression when considered in conjunction with the heterogeneity of postinjury providers has important implications for the evaluation and treatment of distress among injured trauma survivors. Recent investigation and commentary suggests that even the most cursory peritraumatic substance use and psychological screening procedures may be difficult to implement among pragmatically oriented trauma center providers.7,25 To the extent to which somatic symptom checklists such as the Patient Health Questionnaire constitute an extended review of physical symptoms, these instruments may have greater appeal to trauma center providers as early screening tools for posttraumatic anxiety and depressive disorders. Similarly, mental health professionals working in the acute care medical setting may be able to identify patients who are amplifying somatic complaints. In turn, the discussion of symptoms with pragmatically oriented trauma center providers may facilitate early mental health screening and intervention procedures targeting the complex of PTSD, depression, and somatic amplification.
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CONCLUSIONS
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Trauma care systems represent a new health service delivery sector for the extension of the study of physical symptoms. High levels of somatic complaints are persistent among injured trauma survivors and are associated with PTSD and depression. Future investigations within trauma care systems should test early screening and intervention procedures that incorporate assessments of physical symptoms.
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ABSTRACT
INTRODUCTION
