I. Coexisting Severe Mental Conditions

OBJECTIVE

Improve management of PTSD symptoms when they are complicated by the presence of a medical or psychiatric comorbidity.

BACKGROUND

Comorbid medical and psychiatric conditions are important to recognize, because they can modify clinical determinations of prognosis, patient or provider treatment priorities, and setting where PTSD care will be provided. Patients with PTSD have been found to frequently report physical symptoms and to utilize high levels of medical care services. Providers should also expect that 50 to 80 percent of patients with PTSD have one or more coexisting mental disorders. Some comorbid medical or psychiatric conditions may require early specialist consultation, in order to assist in determining treatment priorities. In some cases, these disorders may require stabilization before (or in concert with) initiating PTSD treatment.

RECOMMENDATIONS:

1. Primary care providers should recognize that medical disorders/symptoms, mental disorders, and psychosocial problems commonly coexist with PTSD and should screen for them during the evaluation and treatment of PTSD.
2. Consider the existence of comorbid conditions when deciding whether to treat patients in the primary care setting or refer them for specialty mental health care.

DISCUSSION

Comorbid conditions and psychosocial problems of greatest interest to the primary care provider include:

1. Medical conditions: Some medical disorders may restrict PTSD treatment options (e.g., dementia limits psychotherapeutic options; cardiac conduction problems may limit some pharmacotherapeutic options; and disorders that restrict mobility may limit ability to attend weekly treatment sessions). It is generally best to maximize medical management of these conditions first and then focus on PTSD treatment.
2. Substance use disorders: Patients with PTSD frequently use alcohol and other substances in maladaptive ways to cope with their symptoms. (Approximately 40 to 50 percent of PTSD patients treated in the VA have current substance use problems. Effective PTSD treatment is extremely difficult in the face of active substance use problems unless substance use disorders are also treated. Most often, attempts to address substance problems should proceed concurrently with the direct management of PTSD. However, in cases when the substance use is severe, substance use may require initial treatment and stabilization before progressing to PTSD care (e.g., patient requires detoxification from opiates) (See annotation J - Concurrent PTSD and Substance Abuse).
3. Psychiatric disorders: In addition to substance use disorders, other commonly occurring mental disorders that co-exist with PTSD include: major depression, dysthymia, panic disorder, obsessive-compulsive disorder, and agoraphobia. Treatment of these disorders often occurs concurrently with therapy for PTSD, but on occasion they will take precedence. These disorders have evidence-based therapies that may pose additional effective treatment options. Comorbid disorders that are less common with PTSD, but not rare, include psychotic disorders and bipolar disorder, and somatization or medically unexplained physical symptoms. Practitioners should be alert to comorbid eating disorders, such as bulimia, particularly in women.
4. Personality disorders: Personality disorders are long-term problems of coping that begin in childhood or adolescence and are often associated with past abuse or neglect and recurrent relationship problems. These patterns often result in poor adherence to prescribed PTSD management and the primary care provider may require early assistance and advice from the mental health care provider.
5. Psychosocial problems: Associated behavior problems and psychosocial deficits commonly present in patients with chronic PTSD include:
   • Homelessness
   • Suicidality
   • Domestic violence or abuse
   • Explosive aggression
   • Chronic pain, medically unexplained symptoms, and “somatization”

The clinician will need to determine the best strategy for prioritizing and treating multiple disorders. One key decision concerns whether these disorders should be treated concurrently or consecutively. Another choice point is whether PTSD and its psychiatric comorbidities should be treated in the primary care setting or referred to specialty mental health care. A number of guidelines or principles should be considered in making these treatment decisions:

• Integrated care models have several advantages, where the physical and mental health needs of patients are addressed in a single setting by a multidisciplinary provider team.
• In systems where integrated care models do not exist, consultation and comprehensive assessment by a mental health provider are recommended.
• In general, referral to specialty mental health is indicated if a patient with PTSD has comorbid mental disorders that are severe or unstable. (Examples include: patients whose depression is accompanied by suicidality, patients with substance dependence disorder, and patients with concurrent psychotic or bipolar disorder.) If the patient is referred to mental health for treatment of PTSD, then it is usually best for the mental health provider to provide comprehensive treatment for all mental disorders.
• Primary care clinicians may decide to refer for specialized psychiatric care at any point, depending on how comfortable they are in treating PTSD, the particular needs and preferences of the patient, and the availability of other services.

A number of logistical, provider, and resource restrictions may also influence the decision about how to best provide treatment for patient’s comorbid disorders. Factors to consider when developing the most appropriate treatment plan include:

• Local resource availability (mental health, primary care, integrated care, vet centers, other)
• Level of provider comfort and experience in treating psychiatric comorbidities
• Patient preferences
• The need to maintain a coordinated continuum of care for chronic comorbidities
• Availability of resources and time in engaging in the treatment of the diseases

For patients referred to specialty mental health care, it is important to preserve the continuity of care by ensuring ongoing communication with the primary care provider and to coordinate care when multiple providers are involved.