MONTREAL - The physical burden of psychological trauma remains largely underrecognized from both a public health and clinical perspective, a panel of experts explained at the annual meeting of the International Society for Traumatic Stress Studies. And the interplay of mental and physical health should be a central consideration in prevention and treatment programs, they said.
"I think we are just beginning to peel apart the onion" of the extent to which physical illness and mental illness are comorbid, said Dr. Sandro Galea, a physician and epidemiologist affiliated with the school of public health at Columbia University, New York. Mental illness "is a key component in the onset, progression, and severity of a full range of physical illnesses, which, if factored in properly, would illustrate a dramatically greater burden of mental illness than we have currently accepted," he said.
In several ongoing studies across a wide variety of populations, Dr. Galea and his colleagues have documented "an extraordinary relationship" between posttraumatic stress disorder (PTSD) and health disorders such as vascular problems, respiratory and lung problems (including chronic obstructive pulmonary disease, tuberculosis, and emphysema), and other major illnesses such as arthritis, cancer, and diabetes, he reported.
"With few exceptions, it is pretty consistent across the board" that there is a clear association of physical health, functioning, and disability according to the presence or absence of current or lifetime PTSD, he said.
For example, recent evidence from the Detroit Neighborhood Health Study shows evidence of epigenetic and immune system dysfunction among individuals with depression and/or PTSD, compared with unaffected individuals (Proc. Natl. Acad. Sci. 2010;10720:9470-5).
"As providers, we need to be aware of this association and should think about screening for trauma in many of our patients, particularly those with chronic illness," said Dr. Beth E. Cohen of the University of California, San Francisco, and an internal medicine specialist at the San Francisco VA Medical Center. "There’s a lot of data showing [that] people do not actually get diagnosed and treated for things like PTSD for years or even decades after they start to experience these symptoms. If we were able to treat people more aggressively up front, perhaps we could prevent a lot of this."
As coinvestigator on the Heart and Soul Study, Dr. Cohen and her colleagues have documented an increased rate of cardiovascular (CVD) events among heart disease patients with a history of psychological trauma vs. those without (Arch. Gen. Psychiatry 2010;67:750-8). Over a mean of 6 years’ follow-up, there was a 44% rate of CVD events in subjects in the highest quartile of psychological trauma, compared with 36% among those in the lowest quartile, she said.
"Psychological trauma was common in this cohort of patients with heart disease," she said. In addition, greater lifetime trauma was prospectively associated with an increased risk of cardiac events, independent of psychiatric comorbidities, health behaviors, and conventional cardiac risk factors, she explained.
"Cumulative psychological trauma is a very real risk factor for cardiac disease, and patients do not have to either develop a psychiatric disorder or engage in a negative health behavior for this cardiac risk to emerge."
Both Dr. Cohen and Dr. Galea noted the importance of communication between providers of mental and medical health care.
Psychiatrists need to be aware that the psychological trauma they treat is "part of a much greater constellation of symptoms," said Dr. Galea in an interview. "One of the big challenges of medicine is that we are trained in silos. The rheumatologist doesn’t think about PTSD, and the psychiatrist doesn’t think about arthritis. I think we need to be profoundly aware that mental illness does not exist in isolation and, in fact, is linked to an inextricable part of physical function. We need to make sure that the physicians in charge of the physical symptoms realize the centrality of mental illness in that presentation."
Conversely, mental health practitioners need to be aware of their patients’ increased risk for physical illness, Dr. Cohen said. "We need to think of efforts to reduce cardiac risk in patients with psychological trauma, but given that this doesn’t seem to be driven simply by things like cholesterol or blood pressure, we really need to think outside the box in terms of what’s going on here and how we can approach it," she said in an interview.
Neither Dr. Cohen nor Dr. Galea reported any conflicts of interest.