A Critical Look at Healthcare's Overlooked Mental Health Challenge
Post Traumatic Stress Disorder (PTSD) is now a well-known complication of war and a consequence of exposure to violence of any kind. Much less well-known is that PTSD can occur in survivors, family members, and caregivers of patients with critical medical illness. Recently, PTSD has been found to be associated with childbirth and traumatic injuries.
Our understanding of PTSD and how to treat it didn't begin to develop until after the Vietnam War and continues to evolve. In World War I, the term "shell shocked" was used to describe soldiers exhibiting signs of anxiety, difficulty sleeping, paranoia, and nightmares. Many were incorrectly treated for schizophrenia. During World War II, the term was replaced by "combat fatigue". Self-medication with alcohol or opioids was often the norm. Unfortunately, meaningful progress in understanding and treating PTSD didn't occur until after the Vietnam War. It has been estimated that a staggering 700,000 Vietnam War veterans suffered from various degrees of PTSD. Substance abuse, compulsive behavior, anxiety, insomnia, inability to focus or concentrate, increased anger or isolation were among some of the behavior patterns identified. The understanding and treatment of PTSD continues to evolve. What is known is that active intervention with early counseling is crucial in how well a person responds to the inciting event. It is common for those affected to minimize the traumatic event only to be later faced with symptoms that they find confusing and hard to understand. Trauma-informed care is crucial in treating those struggling with PTSD. It is essential to acknowledge that something is wrong, accept that the feelings may be due to PTSD, and adapt by seeking professional help.
So, what is PTSD? Essentially, this is a disorder of the recovery process from trauma. It is not unusual for the symptoms of PTSD to occur months and even years after the trauma is experienced when something triggers the memory of the event, making it difficult to make the connection to the primary cause. These triggering events are often random and unexpected. It is not unusual to have those suffering from these symptoms be placed on benzodiazepines or antidepressants without delving into the underlying cause. Worse yet is self-medication with alcohol or opioids. Symptoms can include but are not limited to mood swings, fear, anxiety, sadness, hopelessness, nightmares, flashbacks, trouble sleeping, intrusive thoughts, and perseveration on death and dying. Some experience substance abuse, compulsive behavior, increased anger or isolation, and the inability to focus or concentrate.
The current practice of trauma-informed care tells us that it is common to experience many of these symptoms after a traumatic event. Still, for most, they should resolve as recovery happens. Thus, PTSD exists on a spectrum, with some patients requiring no formal treatment while others need therapy and/or medication in addition to mental health support. If the symptoms persist past one month, it suggests that recovery is not occurring as it should and may require formal evaluation and management.
Cognitive behavioral therapy provided by a licensed clinical psychologist is helpful. Learning to speak about what you are feeling, journaling about your thoughts, acting, and writing are well-validated tools used in cognitive behavioral therapy to treat PTSD. Mindfulness meditation is another established technique that has been demonstrated to treat PTSD symptoms effectively. Some patients require medication along with intensive mental health support.
Approximately five million individuals annually require critical care admissions, many requiring mechanical ventilation for complications of pneumonia. Estimates suggest that as high as 40% of patients discharged from ICUs have some symptoms of PTSD. The American Academy of Family Medicine now recommends screening patients discharged from ICUs as well as their family members for PTSD. COVID-19 led to a staggering increase in the number of ICU hospitalizations; many may not realize that they are suffering from PTSD related to this illness. The recognition that pregnancy can trigger symptoms of PTSD has led to a profound introspection by the Ob-Gyn community and a realization that symptoms of PTSD should not be considered or treated as the "post-partum blues."
The massive demand for medical care caused by the pandemic has led to an unprecedented depletion of healthcare providers, estimated to be as high as 20%. Urgent care centers have become a default alternative for patients unable to be seen by their physicians. There are colossal wait times to establish care as a new patient with PCPs, that is, if you can even find one accepting patients. Even patients with established relationships with primary care providers have difficulty accessing urgent visits. Our emergency rooms are chronically overcrowded due to a lack of providers available to see patients in alternative settings.
Patients, especially children who require specialized mental health hospital beds, can wait many days in the Emergency Room. This is a far from ideal situation for those in crisis. Alcohol consumption and deaths from opioids rose above the trend during the pandemic. Fortunately, they are now beginning to fall. These findings highlight a red-flag warning of maladaptive behavior due to the ongoing trauma and isolation caused by the pandemic. Our healthcare system, especially our mental health system, is struggling to keep up with the increased demand created by the pandemic. There are no easy fixes, but the healthcare leaders of our communities, along with legislative action, will be required to remedy this ongoing crisis. This situation will not resolve on its own.
Warmly,
Dr. Michael
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