Yale study looks at sub threshold PTSD co morbidity risks

According to research, veterans who do not have full blown PTSD but who experience some symptoms are at a heightened risk for depression, suicide and substance abuse. They could benefit from screening and treatment in clinical settings but are overlooked.

That was the takeaway of a Yale-university led study, published in the World Psychiatry Journal’s June issue. The research looked at 1,484 veterans nation-wide ranging in age from 20 to 94 with a median age of 64 and found that 22.1 percent experienced “sub threshold” PTSD while eight percent met the DSM-5 criteria for a PTSD diagnosis.

In addition, these veterans (who did not meet the criteria for diagnosis) had a 20 percent chance of developing major depression compared to four percent without sub threshold PTSD.

Twelve percent reported having suicidal thoughts in contrast to three percent of people not having symptoms.

“We found three, four, five times higher rates of some disorders with vets with sub threshold PTSD,” said Robert Pietrzak, Ph.D., MPH, senior study author and Yale University School of Medicine clinical psychologist.

He is also the director of the Translational Psychiatric Epidemiology Laboratory at the Clinical Neurosciences Division of the U.S. Department of Veterans Affairs National Center for PTSD.

Pietrzak said that he was struck by the “sheer prevalence,” of the problem shown in the study’s results.

For example, the reported past-month prevalence of subthreshold PTSD was 13.5 percent, which is significantly higher than the past-month diagnosed PTSD rate of 4.5.

“These are people living in communities who have never sought treatment and are often overlooked,” he said.

Pietrzak’s colleague, John H. Krystal, M.D., said that he “sadly” was not surprised by the results.

“My clinical experience working with veterans from the Vietnam War, the Gulf War, and the current conflicts suggested that for every veteran with PTSD, there are several who have symptoms associated with PTSD but do not meet the full criteria for the disorder,” he said.

Krystal is director of the Clinical Neuroscience Division at the VA National Center for PTSD.

The study author emphasized that doctors should be questioning patients about their symptoms, whether short or long term.

“Clinicians should be vigilant in monitoring and potentially treating sub threshold symptoms in those that have experienced any form of trauma, whether they are veterans or civilians,” Pietrzak said.

He pointed out that only one in five veterans use the VA system for care. Therefore, non-VA settings such as a primary care physician’s office could administer a one-page screening assessment during every visit to track the presence and severity of symptoms such as concentration and memory problems, negative thoughts and feelings, flashbacks and nightmares.

The research indicated that veterans with sub threshold PTSD had worse functioning than those with no or very few symptoms.

“There’s an opportunity for prevention and early intervention,” he said. “Sub threshold PTSD is a trigger for other mental health problems. Assessment could uncover if there is an issue and lead to treatment,” Pietrzak said.

“After combat experience, people may experience a range of symptoms. If they have few symptoms and can function reasonably well in their families and jobs, it does not mean that they will develop the full spectrum of PTSD,” Krystal added.

“On the other hand, if they are bothered by these symptoms, they should know that there are ways to manage them effectively through counseling, psychotherapy or medications. You do not need to have full blown PTSD to benefit from help,” Krystal said

Therapy can’t change what happened but it can help veterans to “change their interpretation and life narrative,” in order to move on, Pietrzak added. “There’s a thing called post traumatic growth. We have a saying: Fix what’s wrong. Build what’s strong.”