Despite increased awareness of the prevalence and morbidity of psychiatric illnesses, relatively few studies have been undertaken in primary care settings in the African context. The authors determined the prevalence of trauma exposure and posttraumatic stress disorder (PTSD) in a South African township primary health care clinic and assessed associated demographic factors, comorbidity, service use, service satisfaction, and quality of life. Subjects were directly interviewed using translated, standardized instruments to assess variables described. Retrospective chart analysis assessed clinician case identification and psychotropic drug-prescribing habits. Of the 201 participants, 94% reported exposure to traumatic events (mean, 3.8). Trauma was associated with single status (p = .01), and PTSD was associated with poverty and single status (p = .04). Both sexes were equally likely to develop PTSD. PTSD (current; 19.9%), depression (37%), and somatization disorder (18.4%) were the most common diagnoses. Comorbidity with PTSD was high and included depression (75%, p < .01), somatization (35%, p < .01), and panic disorder (25%, p < .01). Levels of functional impairment were higher for subjects with PTSD, depression, and somatization than for those without (p < .05). PTSD comorbid with depression compounded impairment (p = .04). Levels of trauma, PTSD, and depression did not increase service use or dissatisfaction with services. Clinicians did not identify trauma (0%) or psychopathology (0%), and psychotropic medication was prescribed for only 1% of participants. In this population, trauma and PTSD were highly prevalent and associated with significant unidentified morbidity and comorbidity. Patients remain untreated for years in the current system of primary care consultations.
The high burden of psychiatric disease is now well known (Lopez and Murray, 1998). Anxiety and depressive disorders are consistently the most prevalent and burdensome to the health care services (Costa e Silva, 1998;Fifer et al., 1994;Kessler et al., 1994;Rumble et al., 1996;Wittchen, 1998;Zajecka, 1997). The role trauma may play in precipitating some of these disorders is interesting. Research has shown that lifetime trauma is highly prevalent in the general population (Kessler et al., 1995;McFarlane et al., 1997) and even higher in selected clinic populations (Switzer et al., 1999) with similar trends in South Africa (Marais et al., 1999;Peltzer, 1998, 1999;Seedat et al., 2000). The general health and psychiatric consequences of traumas are varied. Posttraumatic stress disorder (PTSD), depression, and substance abuse disorders are most prevalent (Acierno et al., 1997;Kessler et al., 1995;McFarlane et al., 1997) and commonly go undetected for protracted periods (Breslau et al., 1998) with associated significant impairment of functioning, increased clinic attendance, and dissatisfaction with service provision (Acierno et al., 1997;Kilpatrick et al., 1997;Resnick, 1997;Switzer et al., 1999).
Relatively little work has been done on the epidemiology of trauma and PTSD in primary care settings in the African context. Only 6% of studies are from the developing world with no single study from Africa. Populations in these settings are more likely to be traumatized and justify research in this area (de Girolamo and McFarlane, 1996). Limited data, epidemiological and clinical, from selected populations are available in South Africa.
Demographic factors seemingly associated with higher levels of trauma are female sex (Norris, 1992;Resnick et al., 1993), single marital status (Kilpatrick et al., 1997), previous assault (Acierno et al., 1997), age (late adolescence and early adulthood;Acierno et al., 1997;Breslau et al., 1998), poverty (Acierno et al., 1997;Switzer et al., 1999), and substance abuse (Breslau et al., 1998;Kessler et al., 1995;Kilpatrick et al., 1997). Physical assault and rape are most likely to be associated with PTSD (Acierno et al., 1997;Kessler et al., 1995;Resnick et al., 1993, 1997;Wittchen et al., 1998), while female sex, prior trauma exposure, poverty, family history of psychopathology, and preexisting psychopathology appear to be demographic predictors of PTSD following trauma (Acierno et al., 1997;Boardman, 1987;Breslau et al., 1998;Kessler et al., 1995;Wittchen et al., 1998).
The lifetime prevalence of PTSD in the general population is between 7.8% and 9.2% (Breslau et al., 1998;Kessler et al., 1995). High levels of comorbidity (Kessler et al., 1995;McFarlane et al., 1997) should be seen as the rule rather than the exception and may be part of the more complex neuropsychiatric sequelae of trauma (Brady, 1997).
In this study, the prevalence of trauma and PTSD in a Xhosa township primary care clinic and the associations of trauma and PTSD with demographic and clinical variables were studied. Service use and satisfaction, physician case identification, and psychotropic prescribing habits were determined.