Epidemiology of posttraumatic stress disorder: A prospective cohort study based on multiple nationwide Swedish registers of 4.6 million people

Helpful but not enough: exploring participants' experiences of a digital therapist-guided prolonged exposure treatment for PTSD

Background: Post-traumatic stress disorder (PTSD) can be a severe psychiatric condition, and access to timely evidence-based treatment is often limited. Prolonged exposure is recommended as first line treatment in clinical guidelines. There is limited research on how digital formats of prolonged exposure used to increase treatment availability impact user experience. Therefore, we wanted to investigate patients' experiences of prolonged exposure in a therapist-guided internet-delivered format (HOPE; Huddinge Online Prolonged Exposure), as part of an uncontrolled feasibility study.Method: Semi-structured interviews were conducted with a total of 14 participants upon their completion of HOPE.Results: Thematic analysis revealed that participants found HOPE to be helpful and effective, especially valuing the flexibility in the digital treatment format. However, a subset of participants reported that HOPE did not meet their needs entirely, indicating room for improvement and tailoring of treatment to individual preferences and needs.Conclusion: This study represents the first exploration of internet-delivered prolonged exposure therapy within a Swedish psychiatric setting, comprising participants characterized by moderate to severe PTSD and self-rated complex PTSD. The results could help guide the development of more accessible and acceptable treatments for PTSD, ultimately improving treatment quality.

Gunshot Trauma Patients Have Higher Risk of PTSD Compared With Blunt Trauma and Elective Populations: A Retrospective Comparative Study of Outpatient Orthopaedic Care

BACKGROUND

Posttraumatic stress disorder (PTSD) has been extensively studied in patients who have experienced natural disasters or military conflict, but there remains a substantial gap in knowledge about the prevalence of PTSD after civilian orthopaedic trauma, especially as related to firearms. Gun violence is endemic in the United States, especially in urban centers, and the mental impact is often minimized during the treatment of physical injuries.

QUESTIONS/PURPOSES

(1) Do patients who experience gunshot wound (GSW) trauma have higher PTSD screening scores compared with patients with blunt or other trauma (for example, motor vehicle and motorcycle accidents or stab wounds) and those with elective conditions (for example, arthritis, tendinitis, or nerve compression)? (2) Are PTSD scores correlated with pain scores in patients with GSW trauma, those with non-GSW trauma, and patients with elective orthopaedic symptoms?

METHODS

We performed a retrospective study of adults older than 18 years of age presenting to an orthopaedic clinic over an 8-month period between August 2021 and May 2022. All patients presenting to the clinic were approached for inclusion (2034 patients), and 630 new or postoperative patients answered study surveys as part of routine care. Patients were divided into three cohorts based on the orthopaedic condition with which they presented, whether gunshot trauma, blunt trauma, or elective orthopaedic symptoms. Overall, the results from 415 patients were analyzed, including 212 patients with elective orthopaedic symptoms, 157 patients with non-GSW trauma, and 46 patients with GSW trauma. Clinical data including demographic information were collected at the time of appointment and abstracted along with results from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, short screening questionnaire, which uses a 7-item scale scored from 0 to 7 (with higher scores representing worse symptoms), and from the numeric rating scale for pain (range 0 to 10). Both questionnaires were routinely administered by medical assistants at patient intake. The proportions of patients completing PTSD scoring were 45% (95) in the elective group, 74% (116) in the group with non-GSW trauma, and 85% (39) in the group with GSW trauma (p = 0.01). We compared the PTSD scores across the three groups and then dichotomized the scores as a negative versus positive screening result at a value of ≥ 4 with further comparative analysis. The correlation between pain and PTSD scores was also evaluated.

RESULTS

Patients with GSW trauma had higher mean ± SD PTSD scores compared with those who had non-GSW trauma (4.87 ± 4.05 versus 1.75 ± 2.72, mean difference 3.21 [95% CI 1.99 to 4.26]; p < 0.001) and those who presented with elective conditions (4.87 ± 4.05 versus 0.49 ± 1.04, mean difference 4.38 [95% CI 3.50 to 5.26]; p < 0.001). When dichotomized for positive or negative PTSD screening results, patients with GSW trauma had a higher risk of having PTSD (64% [25 of 39]) compared with patients with non-GSW trauma (27% [31 of 116], relative risk 2.40 [95% CI 1.64 to 3.51]; p < 0.001) and compared with patients with elective conditions (4% [4 of 95], relative risk 15.22 [95% CI 5.67 to 40.87]; p < 0.001). Pain scores were correlated with PTSD scores only for patients with non-GSW trauma (ρ = 0.37; p < 0.0001). No correlation with pain scores was present for patients with GSW (ρ = 0.24; p = 0.16) or patients with elective conditions (ρ = -0.04; p = 0.75).

CONCLUSION

In an orthopaedic clinic population, the prevalence of positive screening for PTSD was highest in the population sustaining gunshot trauma as compared with blunt or other trauma and elective orthopaedic conditions. Interestingly, pain scores correlated with PTSD screening only in the patients with non-GSW trauma. These differences suggest a substantial difference in the populations at risk of PTSD after trauma. Overall, the psychological impacts of gun trauma are poorly understood. The next step would be to prospectively study the differences and timelines of PTSD screening in patients with GSW trauma in comparison with patients with blunt or other trauma to better define the treatment needs in this population.

LEVEL OF EVIDENCE

Level III, prognostic study.

Prevalence of major depressive disorder and post-traumatic stress disorder among first-time sleep center attendees

BACKGROUND

Sleep disorders and psychiatric disorders stand in a bidirectional relationship. Sleep complaints are prominent in populations with psychiatric disorders, especially amongst people with major depressive disorder (MDD) and post-traumatic stress disorder (PTSD). Consultations at sleep clinics offer opportunities to screen psychiatric disorders and to propose primary psychiatric care.

METHODS

This descriptive study was conducted on 755 patients making their first visit to sleep clinic, with 574 seeking consultation for suspected obstructive sleep apnoea-hypopnoea syndrome (OSAHS), 139 for complaints of insomnia, and 42 for complaints of hypersomnia. The results of 387 screening scales for MDD (BDI-II) and 403 for TSPT (PCL-5) were compared according to the reason given for the consultation.

RESULTS

In the whole group, 12.1 % of patients presented a positive MDD screening and 4.9 % for PTSD. Among patients presenting with insomnia, 19.8 % had a positive screening for MDD, as compared to 9.3 % in patients presenting with suspected OSAHS (p = 0.02). Regarding PTSD, 9.7 % of patients seeking consultation because of insomnia had a positive screening, compared to 2.9 % among patients with suspected OSAHS (p = 0.03). Among patients with a positive screening for MDD, 40.5 % were not receiving antidepressant or mood stabilizer treatment.

CONCLUSION

Positive screening for MDD and PTSD are frequent in patients who attend sleep centers, especially amongst those presenting with insomnia. Nearly half of the patients with positive screening for MDD or PTSD were not receiving a dedicated pharmacological treatment. These figures emphasize systematic screening for psychiatric disorders in sleep clinics.

Refugee status and the incidence of affective psychotic disorders and non-psychotic bipolar disorder: A register-based cohort study of 1.3m people in Sweden

BACKGROUND

Refugees are at increased risk of non-affective psychotic disorders, but it is unclear whether this extends to affective psychotic disorders [APD] or non-psychotic bipolar disorder [NPB].

METHODS

We conducted a nationwide cohort study in Sweden of all refugees, non-refugee migrants and the Swedish-born population, born 1 Jan 1984-31 Dec 2016. We followed participants from age 14 years until first ICD-10 diagnosis of APD or NPB. We fitted Cox proportional hazards models to estimate hazard ratios [HR] and 95 % confidence intervals [95%CI], adjusted for age, sex and family income. Models were additionally stratified by region-of-origin.

RESULTS

We followed 1.3 million people for 15.1 million person-years, including 2428 new APD cases (rate: 16.0 per 100,000 person-years; 95%CI: 15.4-16.7) and 9425 NPB cases (rate: 63.8; 95%CI: 62.6-65.1). Rates of APD were higher in refugee (HRadjusted: 2.07; 95%CI: 1.55-2.78) and non-refugee migrants (HRadjusted: 1.40; 95%CI: 1.16-1.68), but lower for NPBs for refugee (HRadjusted: 0.24; 95%CI: 0.16-0.38) and non-refugee migrants (HRadjusted: 0.34; 95%CI: 0.28-0.41), compared with the Swedish-born. APD rates were elevated for both migrant groups from Asia and sub-Saharan Africa, but not other regions. Migrant groups from all regions-of-origin experienced lower rates of NPB.

LIMITATIONS

Income may have been on the causal pathway making adjustment inappropriate.

CONCLUSIONS

Refugees experience elevated rates of APD compared with Swedish-born and non-refugee migrants, but lower rates of NPB. This specificity of excess risk warrants clinical and public health investment in appropriate psychosis care for these vulnerable populations.

Prenatal maternal PTSD as a risk factor for offspring ADHD: A register-based Swedish cohort study of 553 766 children and their mothers

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) is highly heritable, though environmental factors also play a role. Prenatal maternal stress is suggested to be one such factor, including exposure to highly distressing events that could lead to post-traumatic stress disorder (PTSD). The aim of this study is to investigate whether prenatal maternal PTSD is associated with offspring ADHD.

METHOD

A register-based retrospective cohort study linking 553 766 children born in Sweden during 2006-2010 with their biological parents. Exposure: Prenatal PTSD. Outcome: Offspring ADHD. Logistic regression determined odds ratios (ORs) with 95% confidence intervals (CIs) for ADHD in the offspring. Adjustments were made for potential covariates, including single parenthood and possible indicators of heredity measured as parental ADHD and maternal mental disorders other than PTSD. Subpopulations, excluding children with indicators of heredity, were investigated separately.

RESULTS

In the crude results, including all children, prenatal PTSD was associated with offspring ADHD (OR: 1.79, 95% CI: 1.37-2.34). In children with indicators of heredity, the likelihood was partly explained by it. Among children without indicators of heredity, PTSD was associated with offspring ADHD (OR: 2.32, 95% CI: 1.30-4.14), adjusted for confounders.

CONCLUSIONS

Prenatal maternal PTSD is associated with offspring ADHD regardless of indicators of heredity, such as parental ADHD or maternal mental disorder other than PTSD. The association is partly explained by heredity and socioeconomic factors. If replicated in other populations, preferably using a sibling design, maternal PTSD could be identified as a risk factor for ADHD.

Post-traumatic stress disorder and the risk of violent crime conviction in Sweden: a nationwide, register-based cohort study

BACKGROUND

Post-traumatic stress disorder (PTSD) has been linked to violent crime in veteran populations. However, whether there is a link between PTSD and violent crime in the general population is not known. This study aimed to investigate the hypothesised association between PTSD and violent crime in the Swedish general population and to investigate the extent to which familial factors might explain this association using unaffected sibling control individuals.

METHODS

This nationwide, register-based cohort study assessed individuals born in Sweden in 1958-93 for eligibility for inclusion. Individuals who died or emigrated before their 15th birthday, were adopted, were twins, or whose biological parents could not be identified were excluded. Participants were identified and included from the National Patient Register (1973-2013), the Multi-Generation Register (1932-2013), the Total Population Register (1947-2013), and the National Crime Register (1973-2013). Participants with PTSD were matched (1:10) with randomly selected control individuals from the population without PTSD by birth year, sex, and county of residence in the year of PTSD diagnosis for the matched individual. Each participant was followed up from the date of matching (ie, the index person's first PTSD diagnosis) until violent crime conviction or until being censored at emigration, death, or Dec 31, 2013, whichever occurred first. Stratified Cox regressions were used to estimate the hazard ratio of time to violent crime conviction ascertained from national registers in individuals with PTSD compared with control individuals. To account for familial confounding, sibling analyses were conducted, comparing the risk of violent crime in a subsample of individuals with PTSD with their unaffected full biological siblings.

FINDINGS

Of 3 890 765 eligible individuals, 13 119 had a PTSD diagnosis (9856 [75·1%] of whom were female and 3263 [24·9%] of whom were male), were matched with 131 190 individuals who did not, and were included in the matched cohort. 9114 individuals with PTSD and 14 613 full biological siblings without PTSD were also included in the sibling cohort. In the sibling cohort, 6956 (76·3%) of 9114 participants were female and 2158 (23·7%) were male. Cumulative incidence of violent crime convictions after 5 years was 5·0% (95% CI 4·6-5·5) in individuals diagnosed with PTSD versus 0·7% (0·6-0·7) in individuals without PTSD. At the end of follow-up (median follow-up time 4·2 years, IQR 2·0-7·6), cumulative incidence was 13·5% (11·3-16·6) versus 2·3% (1·9-2·6). Individuals with PTSD had a significantly higher risk of violent crime than the matched control population in the fully-adjusted model (hazard ratio [HR] 6·4, 95% CI 5·7-7·2). In the sibling cohort, the risk of violent crime was also significantly higher in the siblings with PTSD (3·2, 2·6-4·0).

INTERPRETATION

PTSD was associated with increased risk of violent crime conviction, even after controlling for familial effects shared by siblings and in the absence of SUD or a history of violent crime. Although our results might not be generalisable to less severe or undetected PTSD, our study could inform interventions that aim to reduce violent crime in this vulnerable population.

FUNDING

None.