Disability after trauma

B. H. Green

University of Liverpool and Cheadle Royal Hospital, 100 Wilmslow Road, Cheadle, Cheshire SK8 3DG, UK

That post-traumatic stress disorder (PTSD) is not associated with disability and that its clinical importance ‘may be questionable’ are huge claims and somewhat counterintuitive. For Neal et al (2004) to come to such counterintuitive conclusions would require a very strong piece of research. Unfortunately, since their paper does not seem to offer a sound methodology or results, the force and the validity of their conclusions is debatable.

Six years (on average) after a traumatic event the armed services personnel they study report high levels of disability. From the paper it appeared that the authors thought that the association was not mediated via diagnoses of PTSD, depression or alcohol dependence on statistical grounds (although these disorders were all frequently present in the 70 armed services personnel referred to the PTSD unit). The presence of high scores on the Beck Depression Inventory (BDI) accounted for a ‘high proportion of the variability’. In other words, diagnoses did not account for variability but ‘depression consequent upon trauma’ did. It is difficult to understand how the findings of relatively high disability 6 years (on average) after a trauma associated with depressive scores on the BDI cannot be linked to the diagnoses found at interview, as the conclusion of the abstract section clearly implies.

There are several problems with the study design. There is no control group. All the interviews were conducted by a single individual, a nurse, who was presumably not masked to the origin of the patients. The Structured Clinical Interview for DSM–IV (SCID) is not primarily intended as an instrument to detect PTSD. An easily administered alternative to the SCID might have been the Short Post-traumatic Stress Disorder Rating Interview (SPRINT) (Connor & Davidson, 2001) which has solid psychometric properties. There is perhaps an over-reliance otherwise on self-report questionnaires.

The study also fails to refer to relevant literature. A study published in 2001 by Tucker et al recruited 307 patients with PTSD and was both double-blind and placebo-controlled. This found a significant reduction in disability, as measured by the same Sheehan Disability Scale, after 12 weeks of treatment with paroxetine (Tucker et al, 2001).

At this point I must state my own interest in that I have written court reports on PTSD, but on joint solicitors’ instructions or single solicitor’s instructions for claimants or defendants. However, with regard to the authors – although one would like to believe in their independence – surely it is not credible for there to be no declaration of interest stated when all three authors are employed either directly or indirectly by the Ministry of Defence?

Declaration of interest B.H.G. has written numerous personal injury and clinical negligence medico-legal reports and is Editor of Psychiatry On-Line.

REFERENCES

Connor, K. M. & Davidson, J. R. (2001) SPRINT: a brief global assessment of post-traumatic stress disorder. International Clinical Psychopharmacology, 16, 279 -284.[Medline]

Neal,l. A., Green, G. & Turner, M. A. (2004) Post-traumatic stress and disability. British Journal of Psychiatry, 184, 247 -250.[Abstract/Free Full Text]

Tucker, P., Zaninelli, R., Yehuda, R. et al (2001) Paroxetine in the treatment of chronic posttraumatic stress disorder: results of a placebo-controlled, flexible-dosage trial. Journal of Clinical Psychiatry, 62, 860 -868.[Medline]


 

Author’s reply

L. A. Neal

King’s College, London and the Institute of Psychiatry and The Priory Hospital, Heath House Lane, Stapleton, Bristol BS16 1EQ, UK

Declaration of interest At the time of data collection, L.A.N. was employed by the UK Ministry of Defence. At the time of submission of the publication, he had no links with the Ministry.

We accept that our findings require confirmation from further studies. However, human intuition has often been shown to be incorrect in the face of scientific research and perhaps ought not to be taken too seriously. A good example of this is the recent history of psychological debriefing to prevent PTSD (Rose et al, 2003).

The finding that the categorical measures of depression (according to DSM–IV) did not concur with the continuous measure of depression (according to the BDI), in terms of predicting disability, may be evidence for the unreliability of the way we categorise psychiatric disorder, in terms of individual functioning. This is a possible area for further investigation.

The study was a cross-sectional survey examining the within-subject variability and relationships between variables. It has not been explained how a control group would add anything to the findings. The origin of the subjects was not a variable in the study design and it has not been explained why the assessor should have been masked to this information. The SCID is the most widely used and the most thoroughly researched clinical interview format for PTSD (Wilson & Keane, 1997). The SPRINT is one of numerous other measures of PTSD. A search on the National Center for PTSD database showed 127 hits for the SCID and 3 hits for the SPRINT. The use of self-report questionnaires as continuous variables was integral to study design and was not an ‘over-reliance’.

The study by Tucker et al (2001) does not tell us anything about the relative contribution of PTSD, depression or alcohol dependence to disability, which was central to our hypothesis. Paroxetine is effective in the treatment of depression as well as PTSD.

Employment by the Ministry of Defence does not introduce an obvious partisan interest in this study. On the one hand, the Ministry might benefit from showing that PTSD does not cause disability, but on the other hand, if PTSD has little relevance, then the need to employ military psychiatrists may be questionable. Either way, the employing organisation can hardly be said to have been concealed by the authors from Dr Green.

REFERENCES

Rose, S., Bisson, J. I. & Wessely, S. C. (2003) A systematic review of single-session psychological interventions (‘debriefing’) following trauma. Psychotherapy and Psychosomatics, 72, 176 -184.[CrossRef][Medline]

Tucker, P., Zaninelli, R., Yehuda, R., et al (2001) Paroxetine in the treatment of chronic posttraumatic stress disorder: results of a placebo-controlled, flexible-dosage trial. Journal of Clinical Psychiatry, 62, 860 -868.[Medline]

Wilson, P. W. & Keane, T. M. (1997) Assessing Psychological Trauma and PTSD. London: Guilford Press.





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