Abstract
Objective
To describe post-traumatic stress disorder (PTSD)-related symptoms and frequent psychiatric comorbidities, treatments received, healthcare resource utilization (HRU), and healthcare costs pre- and post-PTSD diagnosis among adults in the United States.
Methods
Adults with PTSD who received a PTSD-related pharmacological treatment (selective serotonin reuptake inhibitor [SSRI], serotonin-norepinephrine reuptake inhibitor [SNRI], atypical antipsychotic [AA]) within 24 months of the first observed PTSD diagnosis (index date) were identified using MarketScan Commercial Database (2015–2020). Study outcomes were assessed during the 6-month pre-diagnosis and 24-month post-diagnosis periods. Subgroup analyses included patients treated or not treated with AAs post-PTSD diagnosis.
Results
Of the overall patients (N = 26,306; mean age at diagnosis 39.5 years; 73.3% female), 85.9% had PTSD-related symptoms and frequent psychiatric comorbidities during the 6 months pre-diagnosis. Patients treated with AAs post-PTSD diagnosis (N = 9,298) tended to have higher rates of PTSD-related symptoms and comorbidities at diagnosis than those not treated with AAs (N = 7,011). Following diagnosis, the most commonly observed first-line treatments were SSRI (67.4%), AA (23.4%), and SNRI (22.6%). The rate of PTSD-related symptoms and comorbidities, psychotherapy and pharmacological treatments received, HRU, and healthcare costs increased during the 6 months post-diagnosis relative to the 6 months pre-diagnosis and then declined over time during the 24 months post-diagnosis.
Conclusions
The PTSD diagnosis was associated with increased rates of symptoms and frequent psychiatric comorbidities, psychotherapy and pharmacological treatments received, HRU, and healthcare costs, pointing to increased patient monitoring. Within 6 to 12 months after the PTSD diagnosis, these outcomes tended to reduce, perhaps as patients were obtaining targeted and effective care.
Introduction
Post-traumatic stress disorder (PTSD) is a debilitating psychiatric condition that may develop after exposure to traumatic events, such as physical/sexual abuse, combat, accidents, and natural disasters [Citation1]. Symptoms of PTSD are complex, with the four core symptom clusters including intrusion symptoms (e.g. flashbacks or traumatic nightmares associated with the traumatic event), persistent avoidance of stimuli (e.g. external reminders and/or distressing memories, thoughts or feelings associated with the traumatic event), negative alterations in cognition and mood (detachment or negative emotions, guilt or shame), and alterations in arousal and reactivity (e.g. irritable behavior and angry outbursts) [Citation2]. Patients with PTSD have been shown to experience poor physical health [Citation3,Citation4], high rates of comorbidities (including anxiety, depression, and substance abuse) [Citation5], impaired psychosocial functioning [Citation6,Citation7], higher risk of incarceration [Citation8], increased suicidal attempts [Citation6,Citation9], and reduced quality of life [Citation10]. Studies in different care settings have suggested that PTSD may be associated with increased risks of hospitalization, longer hospital stays, and more mental health and outpatient visits compared with those without PTSD [Citation11,Citation12]. In the United States (US), excess direct healthcare costs attributable to PTSD in the civilian population has been estimated at $66.0 billion ($13,016 per individual), which is likely an underestimation as this amount only included those who were diagnosed with PTSD and interacted with the healthcare system [Citation13].
In the US, lifetime prevalence of PTSD has been estimated at 3.4–8.0% among civilians and 7.7–13.4% among veterans [Citation14]; however, PTSD is an underdiagnosed condition, either because it remains undiagnosed (e.g. if patients are unaware of or do not want to share the symptoms) or is misdiagnosed with other psychiatric disorders [Citation15–17]. Due to the heterogeneous nature of PTSD with its complex symptomology and extensive comorbidities, differentiating PTSD-related symptoms from those of other psychiatric disorders can be challenging and often relies on patient disclosure of the traumatic event(s) [Citation18]. However, patients may be reluctant to disclose their trauma history owing to reasons such as shame, fear of stigma, or avoidance of re-experiencing the details of the event [Citation19], which may lead to delayed diagnosis or misdiagnosis. One US primary care center study found that approximately half of patients with diagnostic interview–determined PTSD were first misdiagnosed to have depression, as originally documented in the electronic medical records [Citation16]. The underdiagnosis of PTSD may also be attributed to other factors such as the lack of trauma care awareness or training among primary care physicians, particularly within the civilian population [Citation20–22].
Prior to a formal PTSD diagnosis, patients may receive no treatment or may receive treatments for symptoms of PTSD without PTSD-specific management, which may lead to suboptimal outcomes. PTSD-specific clinical management of patients with PTSD may help to reduce the overall disease burden and often involves careful assessment of the nature of the trauma and provision of trauma-focused psychotherapy and/or pharmacological treatments [Citation9,Citation23,Citation24]. The only two approved medications for treating PTSD in the US (i.e. paroxetine and sertraline) are both selective serotonin reuptake inhibitors (SSRIs) [Citation25]. The US Department of Veterans Affairs (VA) and the Department of Defense (DoD) clinical practice guideline recommends paroxetine, sertraline, and venlafaxine (a serotonin-norepinephrine reuptake inhibitor [SNRI]) for the treatment of PTSD [Citation25], whereas the American Psychological Association guideline additionally recommends fluoxetine (an SSRI) [Citation26]. The VA/DoD guideline has also noted that other SSRI and SNRI agents as well as medications of other classes such as atypical antipsychotics (AAs) and anticonvulsants may be used given different considerations are made for each medication and patient circumstances [Citation25]. A prior US study has reported frequent off-label medication use in routine clinical practice given the limited approved options for PTSD [Citation27]. Additional medications may also be used to treat PTSD-related symptoms that may not be routinely addressed but may have emerged during the course of PTSD [Citation18,Citation27], which can lead to polypharmacy.
A recent study has suggested that patients who are suspected to have PTSD but do not have a formal diagnosis may experience a similar disease burden to those with a PTSD diagnosis but may lack clinical management targeted for PTSD [Citation28]. Yet, little is known regarding the role of a formal PTSD diagnosis may have in the journey of patients with PTSD over time. To address this research gap, the current study was conducted to describe adults diagnosed with PTSD in the US and understand the PTSD-related symptoms and frequent psychiatric comorbidities, psychotherapy and pharmacological treatments received, healthcare resource utilization (HRU; including inpatient days and outpatient services), and healthcare costs pre- and post-PTSD diagnosis.
Methods
Study design
A retrospective database analysis was conducted that identified adults with diagnosed PTSD in the US who received a PTSD-related pharmacological treatment (i.e. SSRI, SNRI, AA) within 24 months of the first observed PTSD diagnosis. The index date was defined as the date of the first observed PTSD diagnosis. The pre-diagnosis period was defined as the 6-month period prior to the index date, and the post-diagnosis period was defined as the 24-month period following the index date ().
Figure 1. Study design. AA, atypical antipsychotic; PTSD, post-traumatic stress disorder; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor.
Data source
Data from the IBM® MarketScan® Commercial database covering the period between October 1, 2015, and September 30, 2020, were used. The database consists of employer- and health plan-sourced medical and drug data for beneficiaries, including employees, their spouses, and dependents who are covered by employer-sponsored private health insurance. The database contains records of inpatient services, inpatient admissions, outpatient services, prescription drug claims, and information on long-term care and other medical care. Medical claims are linked to outpatient prescription drug claims and person-level enrollment information. Data on standard demographic variables such as age and gender are included – race/ethnicity information is not available. Data are de-identified and comply with the requirements of the Health Insurance Portability and Accountability Act; therefore, no review by an institutional review board was required per Title 45 of CFR, Part 46.101(b)(4) [Citation29].
Sample selection and subgroups
The sample selection flowchart is presented in Supplementary Figure S1. Adult patients were included in the overall sample if they 1) had at least 2 diagnoses of PTSD on distinct dates (International Classification of Diseases, Tenth revision [ICD-10 CM]: F43.1); 2) had continuous health plan enrollment 6 months prior to and 24 months following the index date; and 3) had at least one prescription fill for a PTSD-related treatment (i.e. SSRI, SNRI, AA) during the 24-month post-diagnosis period.
The current study also sought to understand the patient characteristics and circumstances in which AAs may be used in practice. Despite not being preferred by treatment guidelines [Citation25], AAs are sometimes used off label to treat PTSD [Citation27]; thus, understanding the drivers of AA use for patients with PTSD may help inform management decisions. Subgroup analyses were thus conducted to describe patients who had at least one prescription fill for an AA observed during the post-diagnosis period (i.e. the patients treated with AAs subgroup) and those without an AA prescription fill during the same period (i.e. the patients not treated with AAs subgroup). Potential differences in patient characteristics at diagnosis between the subgroups were assessed using standardized differences (≥0.10 indicates important differences).
Measures and outcomes
Study measures and outcomes included patient demographics (e.g. age, gender), clinical and treatment characteristics (e.g. PTSD-related symptoms and frequent psychiatric comorbidities, PTSD-related pharmacological and non-pharmacological treatments), as well as HRU and total healthcare costs.
Pharmacological treatments considered included SSRI, SNRI, and AA in either monotherapy or combination therapy and augmenting agents (i.e. medications that may be prescribed in addition to the SSRI, SNRI, and/or AA agents to address symptoms of PTSD, including benzodiazepines, anticonvulsants, serotonin modulators, antidepressants, antianxiety agents, and antihypertensives).
HRU was reported in categories and included inpatient admissions, inpatient days, days with outpatient services, and days with emergency department services. Total healthcare costs included medical costs (i.e. costs related to inpatient, outpatient, and emergency department visits) and pharmacy costs.
Statistical analyses
Study outcomes were assessed for the 6-month pre-diagnosis period, at the time of the diagnosis, and for the 24-month post-diagnosis period. The 6-month pre-diagnosis period was chosen to assess potential changes in patient and clinical characteristics that might have prompted a formal PTSD diagnosis. To assess the longer-term patient journey after receiving a diagnosis and observe changes in study outcomes over time, outcomes were assessed per 6-month window in the 24-month post-diagnosis period (i.e. at 0–6 months [including the diagnosis date], 6–12 months, 12–18 months, and 18–24 months).
Study outcomes were summarized using descriptive statistics consisting of means, standard deviation, and medians for continuous variables, as well as frequency count and percentages for categorical variables. Statistical comparisons of study outcomes in 0–6 vs 18–24 months post-diagnosis were conducted using Chi-square tests for PTSD-related symptoms and frequent psychiatric comorbidities and treatments received; and Wilcoxon’s signed rank tests for HRU and costs. Results are reported for the overall sample, patients treated with AAs, and patients not treated with AAs, separately.
All analyses were conducted using the Statistical Analysis System (SAS) Enterprise Guide, Version 7.1 (SAS, Cary, North Carolina, USA) and Stata Statistical Software, Version 16.1 (Stata, College Station, Texas, USA).
Results
A total of 26,306 treated adults with PTSD were included in the overall sample; of those, 35.3% (N = 9,295) were treated with AAs and 64.7% (N = 17,011) were not treated with AAs during the post-diagnosis period.
Patient characteristics
presents the demographic and clinical characteristics of patients in the overall sample and in the subgroups of patients treated or not treated with AAs. Overall, patients had a mean age of 39.5 years at diagnosis, 73.3% were female, and 51.5% were covered by preferred provider organization health plan. During the 6-month pre-diagnosis period, 85.9% of patients presented with PTSD-related symptoms and frequent psychiatric comorbidities, including mental, behavioral, and neurodevelopmental disorders (69.7%), physiological symptoms or reactions (58.1%), general health symptoms (23.6%), substance use (16.3%), and cognitive symptoms (10.0%).
Table 1. Patient characteristics.
At the time of the diagnosis, 40.6% of patients in the overall sample had a diagnosis for depression, 30.1% had anxiety disorders, 7.4% had bipolar disorders, 7.4% had substance use/abuse, and 2.6% had suicidal thoughts or actions. The rates of these PTSD-related symptoms and frequent psychiatric comorbidities at diagnosis were numerically higher in the subgroup of patients treated with AAs than those not treated with AAs during the post-diagnosis period ().
For the first PTSD-related pharmacological treatment following the PTSD diagnosis, 67.4% of patients in the overall sample received an SSRI, 23.4% received an AA, and 22.6% received an SNRI. Combination treatment of SSRI, SNRI, and/or AA were observed in 13.0% of patients and augmenting agents in the first regimen were observed in 74.6% of patients overall (). Among patients in the overall sample, the time to first treatment was generally short, with 43.9% receiving their first pharmacological treatment regimen within 15 days of the PTSD diagnosis and 77.0% within 90 days. Of those receiving an AA as their first treatment regimen (N = 6,148), 30.9% and 60.1% received the AA within 15 and 90 days of the diagnosis, respectively. Overall, 25.0% of patients remained on the first treatment regimen received during the post-diagnosis period; other patients either switched regimen (52.6%) or received no further treatment (22.4%).
A portion of patients in the overall sample had also received a PTSD-related pharmacological or non-pharmacological treatment during the 6 months prior to their PTSD diagnosis (43.6% received SSRI, 17.3% received SNRI, 15.4% received AA, 50.9% received psychotherapy). Among patients who eventually received an AA during the post-diagnosis period, 39.4% were receiving an AA prior to the PTSD diagnosis, and 66.1% received an AA as the first treatment regimen in the post-diagnosis period. Overall, among those with at least 1 prescription fill for an AA during the post-diagnosis period, the most frequently used AA agents were quetiapine (17%), aripiprazole (14%), olanzapine (5%), and lurasidone (5%).
PTSD-related symptoms and frequent psychiatric comorbidities pre- and post-PTSD diagnosis
Relative to the 6 months pre-diagnosis, the proportion of patients with PTSD-related symptoms and frequent psychiatric comorbidities increased during the first 6 months post-diagnosis (including the PTSD diagnosis date) and decreased over time during the post-diagnosis period (0–6 vs 18–24 months post-diagnosis: all p < 0.001; ). For example, the proportion of patients with mental, behavioral, and neurodevelopmental disorders increased from 69.7% at 0–6 months pre-PTSD diagnosis to 86.3% at 0–6 months post-diagnosis and then decreased over time during the post-diagnosis period to 73.2% at 6–12 months, 69.8% at 12–18 months, and 68.5% at 18–24 months. The proportion of patients with selected PTSD-related symptoms and frequent psychiatric comorbidities, including anxiety disorders, depression, and suicidal thoughts or actions, was lower during the 18–24 months relative to the 0–6 months post-diagnosis; similar trends were observed in the overall sample and subgroups (all p < 0.001; ).
Figure 2. PTSD-related symptoms and frequent psychiatric comorbidities pre- and post-PTSD diagnosis in the overall sample1. AA, atypical antipsychotic; DX, diagnosis; PTSD, post-traumatic stress disorder. 1Statistical comparisons were conducted for 0–6 vs 18–24 months post-diagnosis using Chi-square tests; all comparisons were statistically significant (p < 0.001).
Figure 3. Proportions of patients with selected PTSD comorbidities at 0–6 months and 18–24 months post-PTSD diagnosis in the overall sample and subgroups1. AA, atypical antipsychotic; DX, diagnosis; PTSD, post-traumatic stress disorder. 1 Statistical comparisons were conducted for 0–6 vs 18–24 months post-diagnosis using Chi-square tests, separately for the overall sample, the patients treated with AAs subgroup, and the patients not treated with AAs subgroup; all comparisons were statistically significant (p < 0.001).
Treatments received pre- and post-PTSD diagnosis
The proportion of patients in the overall sample who had psychotherapy visits increased from 50.9% at 0–6 months pre-PTSD diagnosis to 86.0% at 0–6 months post-diagnosis and then decreased over time during the post-diagnosis period to 65.0% at 6–12 months, 58.6% at 12–18 months, and 55.9% at 18–24 months (0–6 vs 18–24 months post-diagnosis: p < 0.001; ). During the first 6 months post-diagnosis, median psychotherapy visits were 8.0 in the overall sample, 10.0 in patients treated with AAs, and 7.0 in patients not treated with AAs. The percentage decrease in median psychotherapy visits from start to end of the post-diagnosis period was 35.0% in the overall sample. Similar trends were observed in the subgroups, with a percentage decrease in median psychotherapy visits of 24.2% in patients treated with AAs and 41.5% in patients not treated with AAs.
Figure 4. Treatments received pre- and post-PTSD diagnosis1. AA, atypical antipsychotic; PTSD, post-traumatic stress disorder; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor. 1 Statistical comparisons were conducted for 0–6 vs 18–24 months post-diagnosis using Wilcoxon’s signed rank tests, separately for the overall sample, the patients treated with AAs subgroup, and the patients not treated with AAs subgroup; all comparisons were statistically significant (p < 0.001).
The proportion of patients receiving a PTSD-related pharmacological treatment (including SSRI, SNRI, AA, and augmenting agents) increased at the time of the PTSD diagnosis and decreased over time during the post-diagnosis period (0–6 vs 18–24 months post-diagnosis: p < 0.001; ). Patients on average received 1.8 PTSD-related pharmacological treatments and 2.9 augmenting agents during the post-diagnosis period.
HRU and healthcare costs pre- and post-PTSD diagnosis
The proportions of patients in the overall sample who had one or more inpatient admission increased from 12.9% at 0–6 months pre-PTSD diagnosis to 14.4% at 0–6 months post-diagnosis and decreased over time during the post-diagnosis period to 8.5% at 6–12 months, 8.1% at 12–18 months, and 8.0% at 18–24 months; the percentage decrease from start to end of the post-diagnosis period was 44.3%. Similar trends were observed in the subgroups, with a percentage decrease of 48.9% in patients treated with AAs and 36.9% in patients not treated with AAs (0–6 vs 18–24 months post-diagnosis: all p < 0.001; ). Decreases in inpatient days and outpatient service days were also seen at the 18–24 months post-diagnosis relative to the 0–6 months post-diagnosis in the overall sample and subgroups (0–6 vs 18–24 months post-diagnosis: all p < 0.001; ). The proportion of patients with days with emergency department services was low during both pre- and post-diagnosis (mean days: <1.0 [0.0%] across the overall sample and subgroups); hence, trends could not be observed.
Figure 5. HRU and healthcare costs pre- and post-PTSD diagnosis1. AA, atypical antipsychotic; DX, diagnosis; USD, United States Dollar. 1 Statistical comparisons were conducted for 0–6 vs 18–24 months post-diagnosis using Wilcoxon’s signed rank tests, separately for the overall sample, the patients treated with AAs subgroup, and the patients not treated with AAs subgroup; all comparisons were statistically significant (p < 0.001).
Mean total healthcare costs among patients in the overall sample increased from $9,882 at 0–6 months pre-PTSD diagnosis to $11,845 at 0–6 months post-diagnosis and then decreased over time during the post-diagnosis period to $9,785 at 6–12 months, $9,444 at 12–18 months, and $9,410 at 18–24 months. The majority (77.8–84.2%) of the costs were driven by medical costs, particularly inpatient and outpatient costs. The percentage decrease in total healthcare costs from start to end of post-diagnosis period was 20.1% in overall sample. Similar trends were observed in the subgroups, with a percentage decrease in total healthcare costs of 25.1% in patients treated with AAs and 11.7% in patients not treated with AAs (0–6 vs 18–24 months post-diagnosis: all p < 0.001; ).
Discussion
The current retrospective claims analysis found that prior to receiving a formal PTSD diagnosis, over 85% of adult patients with PTSD presented with PTSD-related symptoms and frequent psychiatric comorbidities, and the use of PTSD-related pharmacological treatment was also common, perhaps highlighting the pre-treatment of symptoms and comorbidities related to PTSD prior to patients receiving a formal diagnosis. Of note, the proportion of patients who experienced PTSD-related symptoms and psychiatric comorbidities pre-diagnosis could be an underestimation if the symptoms or comorbidities could not be identified in coded claims or did not fall under the categories defined in the current study, as clinical information is not available in claims data. Overall, once a PTSD diagnosis was made, the diagnosis was associated with increased rates of recorded PTSD-related symptoms and frequent psychiatric comorbidities, psychotherapy/pharmacological treatments received, and increased HRU and healthcare costs at the time of diagnosis, which may reflect the treatment initiation and monitoring process that typically follows a confirmed diagnosis of a medical condition. Shortly after the diagnosis, most patients with PTSD received pharmacological treatment (43.9% within 15 days and 77.0% within 90 days), which further points to increased clinical management of patients with PTSD that may be prompted by a formal diagnosis. Importantly, during the initial 6-month period following and including the PTSD diagnosis, the rates of PTSD-related symptoms and frequent psychiatric comorbidities, treatments received, HRU, and healthcare costs were seen to reduce over time, with statistically significant reductions in the 0–6 vs 18–24 months post-diagnosis. These observations imply that a formal PTSD diagnosis could be followed by gradual improvement of the condition, which may be due to the positive impact associated with receiving PTSD-targeted management. Thus, findings of the current study suggest that receiving a formal PTSD diagnosis may be important for patients to obtain appropriate care and potentially attain more favorable outcomes in the long term.
In the current study, the rate of PTSD-related symptoms and frequent psychiatric comorbidities at diagnosis appeared to be higher among patients treated with AAs than those not treated with AAs during the post-diagnosis period, which may suggest that disease severity could be a factor considered during treatment decisions for patients with PTSD. While the only medications approved for PTSD in the US are SSRIs (i.e. sertraline and paroxetine) [Citation25], other medications may also be used off label [Citation23,Citation27], and clinicians may consider various factors in selecting an appropriate medication such as type and severity of symptoms and comorbid conditions experienced by the individual diagnosed with PTSD [Citation23]. Findings of the current study suggest that AAs may be used for patients with more severe PTSD in clinical practice, including those with more complex symptom and comorbidity profiles. In addition, although similar trends were observed in the overall sample and subgroups pre- and post-PTSD diagnosis, patients treated with AAs relative to those not treated with AAs were observed to experience less favorable outcomes (e.g. required more treatments, incurred higher HRU and costs) 24 months after their PTSD diagnosis, suggesting that while treatment is effective for some patients, those with more severe disease may not be achieving full benefits, and additional management options are needed to further mitigate their disease burden. Future studies are needed to confirm these assumptions and guide clinical management of this patient population.
PTSD is recognized as a substantially underdiagnosed condition, and studies have shown that PTSD-related symptoms and frequent psychiatric comorbidities could be present for years after the traumatic event prior to a formal PTSD diagnosis [Citation15–17,Citation30,Citation31], during which time patients may not always receive treatments specific for PTSD. Part of the diagnostic challenges in PTSD lies in the high prevalence of psychiatric comorbidities, a number of which have considerable symptom overlap with PTSD that may confound and delay diagnosis [Citation18]. A US cross-sectional study found that nearly half of patients identified with PTSD through interview assessments had received treatments for their psychiatric symptoms such as anxiety and depression, despite only a few having received a documented PTSD diagnosis in their health records [Citation32]. A large US machine learning-based cohort study found that about 0.3% of commercially insured patients could have PTSD but did not receive a formal diagnosis and the undiagnosed patient population with PTSD was found to bear similar burden to those diagnosed with PTSD [Citation28]. Therefore, adults with undiagnosed PTSD may be experiencing PTSD-related symptoms and frequent psychiatric comorbidities but do not receive a formal PTSD diagnosis and lack the opportunity to receive appropriate PTSD-targeted management. The current study demonstrates that receiving a PTSD diagnosis could play a positive role in the journey of patients with PTSD, and that clinically recognizing a patient’s symptoms as PTSD, rather than a comorbid condition that could have related symptoms, may be an important factor in patient care.
The barriers to an accurate and timely PTSD diagnosis may also be attributable to the lack of disclosure of trauma history by patients [Citation19] and the limited awareness and knowledge of trauma-associated symptoms among physicians within a civilian context, including limited training and resources in trauma care [Citation20,Citation33]. As experiences of trauma become more widely recognized and stigma around disclosure of trauma reduces, more timely identification of PTSD symptoms among patients can lead to greater opportunities for early diagnosis and treatment for some patients. Findings of the current study should help raise awareness around the benefits of a formal PTSD diagnosis in regard to the conduciveness to providing more streamlined care that could result in reductions in PTSD-related symptoms and frequent psychiatric comorbidities, HRU, and healthcare costs over time. Furthermore, these findings may encourage the early recognition and acceptance of trauma and help garner attention for the need for resources that may facilitate early and accurate diagnosis of PTSD and subsequent provision of trauma-informed care.
Limitations
The findings of the current study should be considered in light of limitations. The study included a commercially insured population, and therefore the results may not be representative of the general PTSD population or individuals with public or no health insurance, as well as patients with military-based insurance. Information captured in the study was limited to that available in the commercial claims database, which does not include clinical information such as physician notes; thus, treatment lines were defined solely based on the timing of claims with PTSD-related agents and information on rationale for treatment and PTSD-severity assessments were not available. In addition, self-medication (e.g. with opioids, cannabis, alcohol) may be common among patients with PTSD [Citation34,Citation35], and the extent to which these medications or substances affect treatment use and outcome in the current study population cannot be determined. Further, the results were not stratified by gender or race/ethnicity; these factors may affect the type of trauma exposure, risk for developing PTSD, and clinical outcomes [Citation36–39], and thus future investigations on PTSD journey among patients with different gender and racial/ethnical profiles are warranted. As with all claims-based analyses, the study is subject to billing inaccuracies and missing data. Additionally, as per the design, the current study focused on adult patients diagnosed with PTSD who were treated with pharmacological treatment. As such, it was not possible to compare characteristics of adults with PTSD between those undiagnosed and diagnosed or those treated and untreated.
Conclusions
Findings from the current study highlight that adults with PTSD represent a heterogeneous population with a complex symptom and comorbidity profile, which may impact treatment decisions. Initially, a PTSD diagnosis was associated with increased rates of symptoms and frequent psychiatric comorbidities, treatments received, and increased HRU and healthcare costs, potentially due to treatment initiation and monitoring. Within 6 to 12 months after the PTSD diagnosis, PTSD-related symptoms and frequent psychiatric comorbidities, psychotherapy and pharmacological treatments received, HRU, and healthcare costs were seen to reduce over time, perhaps as patients were obtaining appropriate care.
Transparency
Declaration of funding
This study was funded by Otsuka Pharmaceutical Development & Commercialization, Inc. and Lundbeck LLC. The study sponsor was involved in several aspects of the research, including the study design, interpretation of data, writing of the manuscript, and decision to submit the manuscript for publication.
Declaration of financial/other relationships
LLD has received research grants from Alkermes, Aptinyx, Social Finance, Veterans Administration, and Westat; and consultancy fees from Boehringer Ingleheim, Otsuka, and Signant Health. JA is an employee of Otsuka Pharmaceutical Development & Commercialization, Inc. AU is an employee of Lundbeck LLC. PGS, JM, MC, and AG are employees of Analysis Group, Inc., a consulting company that has provided paid consulting services to of Otsuka Pharmaceutical Development & Commercialization, Inc. and Lundbeck LLC for the conduct of the current study. WQ was an employee of Analysis Group, Inc. at the time the study was conducted. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.
Author contributions
PGS, JM, WQ, MC, and AG contributed to study conception and design, collection and assembly of data, and data analysis and interpretation. LLD, JA, and AU contributed to study conception and design, data analysis and interpretation. All authors have provided final approval of this version to be published and agree to be accountable for all aspects of the work.
Ethical approval
Data were de-identified and comply with the patient requirements of the Health Insurance Portability and Accountability Act (HIPAA) of 1996; therefore, no review by an institutional review board was required per Title 45 of CFR, Part 46.101(b)(4) [Citation29].
Previous presentations
Part of the material in this manuscript was presented at the Psych Congress held on September 17–20, 2022, at New Orleans, LA, and at the Academy of Managed Care Pharmacy (AMCP) Annual Meeting held on March 21–24, 2023, in San Antonio, Texas, as poster presentations.
PTSD_Claims_Suppl_Materials_036542_25SEP2023.docx
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Medical writing assistance was provided by professional medical writer, Flora Chik, PhD, MWC, an employee of Analysis Group, Inc., and was funded by Otsuka Pharmaceutical Development & Commercialization, Inc. and Lundbeck LLC.
Data availability statement
The data that support the findings of this study are available from IBM. Restrictions apply to the availability of these data, which were used under license for this study. Requests for data should be made directly to IBM.
References
- National IOMH. Post-traumatic stress disorder. 2020.
- APA. Diagnostic and statistical manual of mental disorders. 5th ed. (DSM-5). Arlington (VA): American Psychiatric Publishing, 2013.
- Gupta MA. Review of somatic symptoms in post-traumatic stress disorder. Int Rev Psychiatry. 2013;25(1):86–99. doi:10.3109/09540261.2012.736367.
- Spitzer C, Barnow S, Volzke H, et al. Trauma, posttraumatic stress disorder, and physical illness: findings from the general population. Psychosom Med. 2009;71(9):1012–1017. doi:10.1097/PSY.0b013e3181bc76b5.
- Qassem T, Aly-Elgabry D, Alzarouni A, et al. Psychiatric co-morbidities in post-traumatic stress disorder: detailed findings from the adult psychiatric morbidity survey in the english population. Psychiatr Q. 2021;92(1):321–330. doi:10.1007/s11126–020–09797–4.
- Kessler RC. Posttraumatic stress disorder: the burden to the individual and to society. J Clin Psychiatry. 2000;61(5):4–12. discussion 13–14
- Pietrzak RH, Goldstein MB, Malley JC, et al. Subsyndromal posttraumatic stress disorder is associated with health and psychosocial difficulties in veterans of operations enduring freedom and iraqi freedom. Depress Anxiety. 2009;26(8):739–744. doi:10.1002/da.20574.
- Fovet T, Wathelet M, Amad A, et al. Trauma exposure and PTSD among men entering jail: a comparative study with the general population. J Psychiatr Res. 2021;145:205–212. doi:10.1016/j.jpsychires.2021.12.014.
- Sareen J. Posttraumatic stress disorder in adults: impact, comorbidity, risk factors, and treatment. Can J Psychiatry. 2014;59(9):460–467. doi:10.1177/070674371405900902.
- Pietrzak RH, Tsai J, Armour C, et al. Functional significance of a novel 7-factor model of DSM-5 PTSD symptoms: results from the national health and resilience in veterans study. J Affect Disord. 2015;174:522–526. doi:10.1016/j.jad.2014.12.007.
- Glaesmer H, Braehler E, Riedel-Heller SG, et al. The association of traumatic experiences and posttraumatic stress disorder with health care utilization in the elderly - a german population based study. Gen Hosp Psychiatry. 2011;33(2):177–184. doi:10.1016/j.genhosppsych.2010.12.006.
- Kartha A, Brower V, Saitz R, et al. The impact of trauma exposure and post-traumatic stress disorder on healthcare utilization among primary care patients. Med Care. 2008;46(4):388–393. doi:10.1097/MLR.0b013e31815dc5d2.
- Davis LL, Schein J, Cloutier M, et al. The economic burden of posttraumatic stress disorder in the United States from a societal perspective. J Clin Psychiatry. 2022;83(3):21m14116. doi:10.4088/JCP.21m14116.
- Schein J, Houle C, Urganus A, et al. Prevalence of post-traumatic stress disorder in the United States: a systematic literature review. Curr Med Res Opin. 2021;37(12):2151–2161. doi:10.1080/03007995.2021.1978417.
- Wimalawansa SJ. Post-Traumatic stress disorder: an under-diagnosed and under-treated entity. Compr. Res. J. Med. Med. Sci. 2013;1(1):1–12.
- Liebschutz J, Saitz R, Brower V, et al. PTSD in urban primary care: high prevalence and low physician recognition. J Gen Intern Med. 2007;22(6):719–726. doi:10.1007/s11606–007–0161–0.
- Mueser KT, Goodman LB, Trumbetta SL, et al. Trauma and posttraumatic stress disorder in severe mental illness. J Consult Clin Psychol. 1998;66(3):493–499. doi:10.1037/0022–006X.66.3.493.
- Brady KT, Killeen TK, Brewerton T, et al. Comorbidity of psychiatric disorders and posttraumatic stress disorder. J Clin Psychiatry. 2000;61(7):22–32.
- Kantor V, Knefel M, Lueger-Schuster B. Perceived barriers and facilitators of mental health service utilization in adult trauma survivors: a systematic review. Clin Psychol Rev. 2017;52:52–68. doi:10.1016/j.cpr.2016.12.001.
- Chung JY, Frank L, Subramanian A, et al. A qualitative evaluation of barriers to care for trauma-related mental health problems among low-income minorities in primary care. J Nerv Ment Dis. 2012;200(5):438–443. doi:10.1097/NMD.0b013e31825322b3.
- Lecrubier Y. Posttraumatic stress disorder in primary care: a hidden diagnosis. J Clin Psychiatry. 2004;65(Suppl 1):49–54.
- Cook JM, Zeber JE, Simiola V, et al. Comparisons between patients diagnosed with PTSD in primary care versus mental health care in five large civilian health care systems. J Clin Psychol Med Settings. 2021;28(2):221–228. doi:10.1007/s10880–020–09706–8.
- Ehret M. Treatment of posttraumatic stress disorder: focus on pharmacotherapy. Ment Health Clin. 2019;9(6):373–382. doi:10.9740/mhc.2019.11.373.
- Yehuda R, Hoge CW, Mcfarlane AC, et al. Post-traumatic stress disorder. Nat Rev Dis Primers. 2015;1:15057. doi:10.1038/nrdp.2015.57.
- Department of Veterans Affairs. VA/DOD clinical practice guideline for the management of posttraumatic stress disorder and acute stress disorder. 2023.
- American Psychological Association. Clinical practice guideline for the treatment of Posttraumatic Stress Disorder (PTSD) in Adults. 2017.
- Harpaz-Rotem I, Rosenheck RA, Mohamed S, et al. Pharmacologic treatment of posttraumatic stress disorder among privately insured Americans. Psychiatr Serv. 2008;59(10):1184–1190. doi:10.1176/ps.2008.59.10.1184.
- Gagnon-Sanschagrin P, Schein J, Urganus A, et al. Identifying individuals with undiagnosed post-traumatic stress disorder in a large United States civilian population - a machine learning approach. BMC Psychiatry. 2022;22(1):630. doi:10.1186/s12888–022–04267–6.
- U.S. Department of Health and Human Services. 45 CFR 46: pre-2018 requirements. https://www.hhs.gov/ohrp/regulations-and-policy/regulations/45-cfr-46/index.html#46.101. (September 19, 2023).
- Mcfarlane AC. The long-term costs of traumatic stress: intertwined physical and psychological consequences. World Psychiatry. 2010;9(1):3–10. doi:10.1002/j.2051–5545.2010.tb00254.x.
- Southwick SM, CaR M, Darnell A, et al. Trauma-related symptoms in veterans of operation desert storm: a 2-year follow-up. Am J Psychiatry. 1995;152(8):1150–1155.
- Meltzer EC, Averbuch T, Samet JH, et al. Discrepancy in diagnosis and treatment of post-traumatic stress disorder (PTSD): treatment for the wrong reason. J Behav Health Serv Res. 2012;39(2):190–201. doi:10.1007/s11414–011–9263-x.
- Green BL, Kaltman S, Frank L, et al. Primary care providers’ experiences with trauma patients: a qualitative study. Psychological Trauma: theory, Research, Practice, and Policy. 2011;3(1):37–41. doi:10.1037/a0020097.
- Goldstein RB, Smith SM, Chou SP, et al. The epidemiology of DSM-5 posttraumatic stress disorder in the United States: results from the national epidemiologic survey on alcohol and related Conditions-III. Soc Psychiatry Psychiatr Epidemiol. 2016;51(8):1137–1148. doi:10.1007/s00127–016–1208–5.
- Steenkamp MM, Blessing EM, Galatzer-Levy IR, et al. Marijuana and other cannabinoids as a treatment for posttraumatic stress disorder: a literature review. Depress Anxiety. 2017;34(3):207–216. doi:10.1002/da.22596.
- Hiscox LV, Sharp TH, Olff M, et al. Sex-based contributors to and consequences of post-traumatic stress disorder. Curr Psychiatry Rep. 2023;25(5):233–245. doi:10.1007/s11920–023–01421-z.
- Street AE, Dardis CM. Using a social construction of gender lens to understand gender differences in posttraumatic stress disorder. Clin Psychol Rev. 2018;66:97–105. doi:10.1016/j.cpr.2018.03.001.
- Roberts AL, Gilman SE, Breslau J, et al. Race/ethnic differences in exposure to traumatic events, development of post-traumatic stress disorder, and treatment-seeking for post-traumatic stress disorder in the United States. Psychol Med. 2011;41(1):71–83. doi:10.1017/S0033291710000401.
- Spoont M, Nelson D, Kehle-Forbes S, et al. Racial and ethnic disparities in clinical outcomes six months after receiving a PTSD diagnosis in veterans health administration. Psychol Serv. 2021;18(4):584–594. doi:10.1037/ser0000463.