Federally qualified health centers (FQHCs) typically offer primary health care services to underresourced individuals from impoverished backgrounds, many of whom are more susceptible to trauma due to health disparities such as limited access to nutritious foods, transportation issues, education inequality, and exposure to crime.1 To address disparities and facilitate access, FQHCs are increasingly being asked to provide on-site, same day, integrated behavioral health (BH) services.2 Numerous models for these services have been advanced and multiple pathways to care have been articulated.3–5 However, assessment and treatment of trauma in FQHCs with integrated BH services are not well established, particularly in relation to other mental and physical health symptoms. The current study, illustrating the associations of trauma symptoms with poorer mental and physical health in underserved primary care BH patients, has implications for health policy and the integration of BH services in FQHCs.
Posttraumatic stress disorder (PTSD) has become a common, yet rarely identified and poorly understood, patient disorder within primary care settings.6 Posttraumatic stress disorder is characterized by exposure to a traumatic event resulting in behavioral changes involving avoidance, intrusive thoughts, hypervigilance, and negative cognitions. Environments of poverty (family or neighborhood) can be trauma-inducing as there may be prolonged exposure to traumatic events (ie, violence, constant fear, instability).7 Prevalence rates of PTSD within primary care patients range between 9% at the low end8,9 and 23% at the higher end, typically in urban settings serving patients in poverty.6 However, even in settings providing integrated care, brief assessments for PTSD—or even general trauma symptoms—are uncommon due to health care teams' lack of awareness, comfort, and training to treat trauma.10 Logistic barriers also exist including time and lack of resources. Moreover, little is known about what other mental and physical health symptoms may co-occur with primary care patients' PTSD symptoms (eg, intrusive thoughts, avoidance of reminders, changes in cognition and mood, increased arousal).
Rates of PTSD and co-occurring mental and physical health symptoms are even less understood in patients seeking low-cost or free primary health care services.6 Thus, we examined the prevalence of PTSD symptoms and co-occurring mental and physical health symptoms in patients referred for BH services at an FQHC located in a high poverty area affected by the Deepwater Horizon oil spill disaster. We also considered the degree to which co-occurring mental and physical health concerns differed among 3 groups of BH patients. At the time of referral, patients' trauma-related symptoms were briefly assessed using a validated 2-item PTSD measure (feasible in a busy clinic). Three groups were created from their response: PTSD-likely (Clinical), PTSD-possible (Subsyndromal), and PTSD-unlikely (No/Low levels of symptoms). Overall stress level and presence/absence of particular stressors were assessed concurrently as were a variety of potentially co-occurring depressive, anxious, and physical health symptoms. It was hypothesized that patients with substantial levels of PTSD symptoms would have elevated levels of other mental health and physical health symptoms. To address another gap in the literature (lack of routine strength-focused assessments), individuals' perceived resiliency was specifically assessed and was expected to be lower in patients suffering with PTSD symptoms. The degree to which the 3 patient groups differed in their perceived lack of resiliency was also explored.
Participants (n = 120) were adult patients 19 years of age and older (M = 43.4 years, SD = 12.77). The sample identified as primarily black/African American (76.7%) and female (70.8%). All participants resided either in a medium-sized city in the southern United States (83%) or in the surrounding rural countryside (17%).
The measures were chosen for brevity and ability to be easily comprehended by patients and administered efficiently by behavioral health providers (BHPs) in an FQHC setting (see Table 1).
Abbreviated Posttraumatic Stress Disorder Checklist-Civilian, 2-item version
This PTSD assessment measure consists of items 1 and 4 from the PTSD Checklist and has been used successfully in primary care settings.11,12 Patients respond on a 5-point Likert-like scale to indicate how much they have been bothered by a traumatic event over the past month.
Patients were categorized into 3 groups on the basis of calculated scores of the PCL-C2:
- PTSD-unlikely: No to low levels of symptoms as determined by a score of less than 4 (n = 32).
- PTSD-possible: Subsyndromal levels of symptoms by a score between 4 and 7 (n = 29).
- PTSD-likely: PTSD-likely levels of symptoms by a score of 8 or higher (n = 59).13 The Cronbach α for this 2-item measure was excellent (α = 0.94) for this sample.
Overall stress levels were rated on a scale of 0 to 100. Previous research indicates that stress can be reliably and validly measured via a single item.14 Patients also indicated which, if any, of 14 potential stressors were present in their life.
Patient Health Questionnaire 15-item Scale (PHQ-15—physical health screener)15
As the somatic module of the larger Patient Health Questionnaire (PHQ), the PHQ-15 assesses patients' self-reported somatic symptoms. For the current study, patients reported how often they had problems with headaches, chest pains, dizziness, or trouble sleeping across the past 30 days. Each symptom was considered independently.
Patient Health Questionnaire 9-item Scale (PHQ-9—depression screener)13
As the 9-question depression module of the larger PHQ, the PHQ-9 is used to assess self-reported symptoms of depression over the last 2 weeks. The Cronbach α for the PHQ-9 was 0.86 in the current sample. The ninth item is used to determine suicide risk; it reads “thoughts that you would be better off dead or of hurting yourself.” As per protocol, patients endorsing this item received an immediate on-site risk assessment and more intensive care as warranted.
Generalized Anxiety Disorder 7-item Scale (GAD-7)
This is a 7-item scale on which patients indicate how often they were bothered by anxiety-type symptoms over the past month. The GAD-7 had excellent internal consistency (Cronbach α = 0.92) in previous work and performed well in the current sample with Cronbach α = 0.88.16
Connor-Davidson Resilience Scale-2 (CD-RISC2)
This 2-item measure was adapted from the 25-item Connor-Davidson Resilience Scale.17 Participants provided ratings on their self-perceived adaptability and ability to recover from setbacks. The scale has been validated in multiple samples and performed well in the current sample, Cronbach α = 0.84.18
All patients who participated in this study initially presented to the FQHC for physical health reasons and were then referred to a BHP through their primary care team. No patient was referred on the basis of trauma exposure or symptoms, and all patients specifically referred because of a current acute crisis were excluded from the current study. Patients were typically seen by a BHP immediately following their primary care appointment. Behavioral health providers were members of the health clinic's integrated medical team and included licensed clinical psychologists, licensed social workers, and clinical and counseling psychology doctoral students. Behavioral health providers assessed patients using the stress continuum scale, PCL-C2, PHQ-9, GAD-7, and CD-RISC-2 as part of a functional analysis conducted at initial contact. Patients also indicated the presence/absence of a list of stressors and/or physical symptoms. For patients with low literacy, assessment items were read aloud and/or explained.
The brief functional assessment was completed in roughly 10 minutes and informed subsequent intervention strategies. All patients participated in a 20- to 30-minute therapeutic intervention that occurred immediately postassessment. Of note, given the brevity of BH treatment in primary care, interventions provided were not specifically trauma-focused. Common interventions included motivation interviewing, behavioral activation, and diaphragmatic breathing. Some patients chose to continue with additional intervention sessions at the FQHC; others were referred to an outside mental health facility that offers long-term services including psychiatric treatment. On-site integrated health assessment and intervention services took place as part of the Mental and Behavioral Health Capacity Project—Alabama. Patients were provided an information sheet about the project prior to consent. All data were deidentified by the clinical staff prior to analysis. Study protocols were approved by an institutional review board; ethical procedures were followed throughout.
In the current study, 96.5% of the BHP-referred patients endorsed a stress level of 50 or above. In fact, the modal stress level reported by patients was 100 out of 100 (n = 37), followed by 80 (n = 25) and 70 (n = 16). Eight of 14 stressors were endorsed as problematic by 25% or more of the sample (see Table 2). Second, it was expected that greater than 25% of this sample would screen positive for a full PTSD assessment as per the 2-item criteria (PTSD-possible or PTSD-likely). This hypothesis was fully supported as 73.3% (n = 88) of patients scored 4 or more out of 10 on the PCL-C2 in reference to a self-selected traumatic event. Third, correlation analyses reveled that greater PTSD symptoms were associated with higher levels of co-occurring stress, depression, and anxiety along with reduced resiliency as predicted (see Table 3).
Mean differences in overall stress were considered among the 3 PTSD groups. As shown in Table 4, the PTSD-likely group's mean was significantly higher than both the PTSD-unlikely and PTSD-possible group means. The PTSD-unlikely and PTSD-possible groups did not differ significantly. Of note, post hoc comparisons indicated that both the PTSD-possible group and the PTSD-likely group were more likely to specifically endorse access to health care as a stressor than the PTSD-unlikely group. Significant group differences were also found for patients' reports of financial stressors. Interestingly, the PTSD-possible group endorsed significantly more financial stressors than patients in the other 2 groups, including the PTSD-likely group.
A 1-way, between-groups analysis of variance (ANOVA) revealed a main effect for PTSD groups on total PHQ-9 scores. As expected, the PTSD-likely group reported significantly more depressive symptoms than both the PTSD-unlikely and PTSD-possible groups. An additional 1-way ANOVA examined PTSD-group differences on question 9 of the PHQ-9, which measures suicide ideation. As expected, the PTSD-likely group's scores on this item were also significantly higher than either of the other 2 groups. Because of violation of homogeneity of variance, Welch F was calculated and reported for GAD-7 scores. A 1-way ANOVA revealed that the PTSD-possible and PTSD-likely groups reported significantly greater anxiety than the PTSD-unlikely group.
One-way ANOVA analyses also revealed significant group differences in perceived resiliency, with the PTSD-likely group's self-reported resiliency being significantly lower than that of either of the other 2 groups. Finally, the 3 PTSD groups were compared on their reports of physical health symptoms. As shown in Table 4, trends were typically in the expected direction, with the PTSD-likely group reporting significantly poorer physical health.
Exposure to trauma is associated with poor health outcomes,19 poor perceived physical health and functioning,20 and increased health care utilization.20 Limited access to health care services and repeated exposure to trauma are common experiences for patients receiving primary care services at FQHCs. Primary care providers (PCPs) believe that treatment for patients with trauma would be augmented by adding BHPs on-site, particularly in sites serving underresourced, predominantly African American and Hispanic patients who often lack access to BH services.21 Existing measures, such as the PTSD Checklist for DSM-5 (PCL-5),22 could specifically assess for PTSD symptoms and identify at-risk and/or underserved patients needing trauma-informed care. However, concerns exist about routine measuring of trauma symptoms: (1) the time duration of many PTSD measures; (2) the degree to which vulnerable patients would tolerate trauma symptom assessment during a routine visit; (3) PCPs' concerns regarding workflow changes; and (4) uncertainty surrounding what mental health care could be offered to patients, especially in settings in which the modal number of BH sessions is 1. Costs associated with adding trauma-focused assessments and specialty care are also of concern.
Cognizant of potential barriers, the current project utilized a very brief PTSD assessment with patients already referred to a BHP (during or immediately after the patient's primary care visit) to investigate the relation between PTSD symptoms and health outcomes. Of note, all primary care patients in this study were referred by 1 of many PCPs and were not referred specifically due to a trauma experience. Providers likely differed in their referral criteria; therefore, the current sample should not be considered random. Furthermore, abbreviated, self-report measures may result in less reliable and valid scores; however, the limitations of brief self-report measures need to be balanced with their feasibility and clinical utility. The 2-item PCL conducted by the BHPs was intentionally short to be sustainable in a busy environment; a more comprehensive assessment, interview, and chart review would provide more specific information about patient health and would better delineate which patients fully qualify for a PTSD diagnosis. In addition, the instruments used in the current study vary in the reporting time frame and some questions were difficult for many low-literacy patients to understand. Despite these limitations, the current study provides strategies for addressing concerns such as time constraints and changes to workflow related to routine assessment of trauma symptoms.
Of additional significance, BHPs were available on-site to work immediately with all referred primary care patients as part of a project to develop integrated care in FQHCs along the Gulf Coast,2 an area prone to disasters and noted for poverty and low access to mental health care. Having an on-site BHP addressed additional concerns PCPs identified as barriers to assessing for symptoms of posttraumatic stress (eg, lack of mental health provider resources). Access to evidence-based practices through on-site BHPs increased PCPs' willingness to assess for trauma symptoms in the BH-referred population. Readily access to care is likely to facilitate acceptance of screening in the greater patient population.23 However, the health care world is in flux: insurance options, billing codes, Electronic medical record systems, and diagnostic criteria for PTSD have all recently changed and are poised for continued alteration across time. The future of integrated BH in primary care is unclear; research such as this study indicates a need to solidify BH in this setting to meet the full needs of FQHC populations.
We anticipated that many patients referred to BH from primary care would screen positive for PTSD. The finding that 73% could be categorized as PTSD-likely or PTSD-possible was unexpected and clinically noteworthy, given previous studies have reported rates of PTSD between 9% and 23% in primary care patients.6,8,9 Furthermore, almost 50% reported a score of 8 or higher out of a possible 10 on the PCL-C2. Participants were primarily black/African American (76.7%), female (70.8%), and residents of an urban setting (83%); the urban location of this FQHC may explain higher rates of PTSD symptoms in the current sample.6,7 Findings were also obtained from one large multiclinic FQHC that serves predominantly low-income and underresourced patients in a location prone to natural disasters with limited mental health providers. This may inflate PCL-C2 scores compared with other areas; caution should be exercised when generalizing findings.
Importantly, among primary care patients already referred to a BHP, determining probable PTSD status yielded greater knowledge about the patients' current physical health. Dizziness and chest pain, greater problems with sleeping, and headaches were specific symptoms that were significantly more likely to be endorsed by patients with elevated PTSD symptoms. Not surprisingly, given that PTSD has historically been diagnostically grouped with the anxiety disorders, both the PTSD-likely and the PTSD-possible groups self-reported more anxiety-related psychopathology. When examining depressive symptoms, the PTSD-likely group differed from the 2 other groups with a mean depression score in the severe range. However, even the PTSD-unlikely group had mean depression scores in the moderate range. Assessing and targeting symptoms of depression is an important component of integrated care. Of note, the PTSD-likely group also reported significantly more thoughts of suicide within the past 2 weeks. Our group-specific findings are consistent with research documenting the specific association of PTSD with increased suicide risk.24 Implementing brief trauma assessments might aid suicide prevention efforts with particularly vulnerable patients. As a next step, piloting a universal screening for trauma symptoms could determine whether these findings generalize to the broader primary care patient population. Greater use of and comfort with brief trauma symptom and self-harm assessments, in conjunction with universal screening for depression, are needed by both BHPs and PCPs in primary care and hospital settings.
The 3 PTSD groups also differed in endorsements of particular stressors. The PTSD-possible group had more financial problems while both the PTSD-possible and PTSD-likely groups were more likely to endorse poor access to health care services than the PTSD-unlikely group. One possible explanation for this latter finding is that patients within the PTSD-possible and PTSD-likely groups may be perceiving the health care system as failing to adequately address all aspects of their physical and mental health. It is worth noting that many of the patient endorsed stressors that are also barriers to traditional approaches to delivering mental health care; for example, financial issues and employment problems likely make it challenging to pay for standard 8- to 12-session treatment protocols in a setting devoted to mental health. Integration of mental and BH services into routine health care practice—including adoption of trauma-informed care principles—may improve access, service satisfaction, and overall well-being within vulnerable populations.
The current study is one of the first to consider how self-perceptions of resiliency might differ among patients with varying levels of PTSD symptoms. Of note, patients in the PTSD-likely group self-reported significantly reduced resiliency. Adding resiliency-enhancing strategies, such as emphasizing patients' strengths and promoting frequent self-care activities, to routine integrated health care is likely to be beneficial. Given its positive rather than symptom-centric nature, a focus on resiliency might be particularly well received by primary care patients who are typically accessing 1 same-day appointment with a BHP.
Implications for Policy & Practice
- Administration of a brief PTSD symptom screener by an on-site BHP as part of routine integrated practice provides potential solutions to common concerns regarding trauma screening (eg, time, lack of resources) that is operationally feasible and more appealing to PCPs.
- Knowledge gained via stressor and trauma screening provides useful contextual information about the physical and behavioral health symptoms of patients presenting to primary care.
- Including an assessment of resiliency might help providers focus on patients' strengths while identifying patients who need to develop enhanced coping skills.
- Finally, in the context of the DHOS and the Gulf Region Health Outreach Program, the current study illustrates the complex health needs of vulnerable FQHC patients living along the Gulf Coast. The findings emphasize the importance of mental health integration and trauma-informed health care to promote population health and community resilience in underresourced areas.
In sum, these findings highlight the link between mental and physical health, substantiate the need for interdisciplinary health teams who are trained to be trauma-sensitive, and support the importance of considering patient levels of stress and trauma in primary care settings. A broader population-based assessment of stress level, if not trauma symptoms specifically, might be best initiated in places with on-site BH services. As stress level and trauma symptom information can be obtained with 3 questions (1 on overall stress and 2 to assess for PTSD symptoms), the time involved is minimal. Routine screening for trauma symptoms—even in patients not referred to the BHP—may provide information that can enhance treatment plans. The results are also consistent with the national push for trauma-informed and patient-centered care.25 Initiating trainings on how to provide trauma-sensitive health care could benefit patients, providers, and the health care system as a whole.26
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Keywords:Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
federally qualified health centers (FQHC); primary care; PTSD; trauma-informed; vulnerable populations