June is PTSD Awareness Month. So I decided to dip into the research to get a sense of how “aware” people are about PTSD. One thing I discovered: awareness is likely insufficient for the changes needed to adequately address the problem that many with PTSD do not recognize they have a behavioral health condition that requires treatment to avoid short- and long-term problems. Ideally, everyone should be able to recognize someone who is traumatized and, as with suicide, talk with them in an empathic manner to encourage them to get help. According to Professor Anthony F. Jorm of the University of Melbourne, this is not PTSD awareness, it’s PTSD literacy, and it applies to every DSM-5 diagnosis (see Jorm et al., 1997 for more).
One aspect of the larger behavioral health literacy movement is recognition. That is, when presented one or more scenarios in various formats (verbal, written, or acted out), how many people can correctly identify; a) whether or not a behavioral health condition is present, b) the specific disorder, and c) a proper treatment.
Interestingly, recognition rates depend in part on the putative cause, even when the exact same symptoms are presented. Merritt, Tharp, and Furnham (2014) surveyed various on-line communities in the U.K and Ireland. Each respondent was presented with one of six possible scenarios with the exact same symptom presentation (which meet full criteria). The only difference was the gender of the victim and or the cause; seeing a friend killed in combat, electrocution burns suffered at work, or rape suffered at work.
Overall, 81.5% of respondents (N=2,945) said “Yes, this is a mental health problem.” Significantly less (67%) correctly identified the condition as PTSD in answer to an open-ended question. Rates depended on the associated event; 82.5% for seeing a friend killed in combat, 69% for the work-related electrocution, and 49% for rape at work. A similar pattern occurred for those with training in recognizing mental health conditions; 92%, 93%, and 80%. Again, all symptoms were the same every scenario. Across all subgroups, the combat scenario was 4.5 times more likely to be judged as causing mental health symptoms than the rape.
While PTSD may be better recognized when the sufferer has had military experience, people may not be attributing symptoms to PTSD from other causes than combat. Given base rates and conditional risk, this is especially troubling. Since rape occurs more often than combat and more often results in PTSD, we can expect that for every new case of PTSD from combat, we’ll get 15 from sexual assault. The suggestion here is that PTSD literacy might benefit from a focus on the various potential causes for PTSD (other than combat) as well as the likelihood that these causes will result in PTSD.
On a positive note, 76.7% of participants indicated that the victim should “see a psychologist or counsellor.” While the researchers did not inquire what respondents thought treatment would entail, other studies have delved into this. Tsai et al., (2018) surveyed a national convenience sample (N=523) and found that only 30% could correctly select psychotherapy from a short list when asked for the most effective PTSD treatment. When later prompted to identify an effective medication and psychotherapy from short lists of possibilities, 26% and 14.5%, respectively, answered correctly, antidepressants, and exposure-based therapy. The likelihood of a correct answer did not differ between those who did and did not screen positive for PTSD based on the PCL-5. Additionally, Tsai and colleagues assessed general attitudes and concerns about PTSD. They found that a large majority (76-93%) agreed there should be more federal spending for PTSD treatment, awareness, research, and training for professionals. While this might suggest respondents held a favorable attitude towards those with PTSD, around 1:3 believed a) PTSD sufferers are more dangerous than the general population, and b) are often violent. This may explain why 76% endorsed restricted access to firearms for those with PTSD. Here, too, there was no significant difference in response rates between those who did and did not screen positive for PTSD. Tsai and colleagues also asked respondents several general knowledge items about most people with PTSD. For example, 37% believe you must directly experience a trauma in order to develop PTSD. Nearly 1:4 (23%) don’t realize that many with PTSD turn to alcohol or drugs in order to cope. About 29% think that most people with PTSD do not recover. And around 27% believe that most with PTSD seek treatment. Nearly half (49%) believe people with PTSD should “get over” their trauma. Similarly, around 1:4 agree with that idea that PTSD sufferers should not talk about their trauma. These results may explain why a significant percentage of people do not seek – or encourage – treatment.
In another sample of 301 people who screened positive for PTSD, Harik, Matteo, Hermann, and Hamblen (2016) found a similar level of PTSD literacy: around 1:4 believed that certain events that normally can cause trauma couldn’t; 38% misidentified PTSD symptoms; and 62% erroneously thought certain treatments that are not effective for PTSD were. In some instances, this ignorance may work in favor of people seeking treatment. For example, a majority of respondents believed that divorce can cause PTSD and that addiction is part of it. However, in other instances the low literacy about PTSD could harm sufferers. For example, most believed that support groups were an effective treatment.
Half of those in the above study were Veterans. While being a Vet was associated with greater ability to recognize what constituted a trauma, it was significantly less likely to lead to recognition of an effective treatment.
It appears that efforts to increase PTSD awareness and literacy must continue among the general population as misconceptions and stigma abound. But about among those on the front lines of medical treatment? Are medical students being appropriately educated about PTSD?
Theophanous et al. (2016) surveyed 700 medical students about their attitudes towards unique military health issues – such as PTSD. The response rate was 32.8% (n=230). Regarding awareness, 38% checked “somewhat low” and 20% selected “very low.” Fewer rated their comfort level in assessing these health needs as “somewhat low” (29%) or “very low” (17%). In part, this may have had to do with exposure. Most students (74%) were in their first or second year. This may explain why 27% noted “somewhat low” exposure to military health issues, and 50% selected “very low.” Interest in learning about veteran and family health issues did not quite measure up to this lack of exposure: 31% and 13% indicated their interest was “somewhat high” and “very high”. In short, roughly 3:4 med students acknowledged low exposure to vet health, perhaps explaining why only 1:4 felt “high” comfort in assessing these issues.
As mentioned, the survey was again sent out to all 700 students after a 4-lecture series on military health issues. Interestingly, attendance matched roughly with pre-survey interest levels. In the pre-survey, 13% indicated their interest in learning about Vet health was “very high”. And attendance at each voluntary lecture ranged between 15-17%.
It would appear that PTSD awareness, literary, and training should continue with this population as well, and – more importantly – must be compulsory.
Among General Practitioners, awareness does not equal literacy. While most can recognize it, they also under-estimate it. By a factor of 10. While the national PTSD rate is around 10%, most GPs will say it’s around 1%. It’s as if they are saying, “I’ll know it if I see it, but I’m not looking for it.” This is why screening of every new patient is so important.
Given that Primary Care is the first stop for many issues among military personnel, Samuelson et al. (2013), developed a four-module, 70’ online program for providers. PTSD-related knowledge among the 73 providers increased an average of 63% from before the training and was maintained at a 30-day post check. While most indicated that after the training they felt more comfortable assessing PTSD, and nearly half said they used the content in their practice, no assessment was made about any pre-post change in diagnosing PTSD, referral, or prescription rates.
Unfortunately, I could find no meta-analytic studies of PTSD and related awareness or literacy available via PubMed or Ovid databases. As it stands, we must continue to educate the general public as well as our medical colleagues on PTSD.
For more information on the topic, you may be interested in our upcoming online training event "Assessing Military Clients for Trauma and Posttraumatic Stress Disorder" to be held on 24 July 2018.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
David Reynolds, Ph.D., is the CDP's Military Internship Behavioral Health Psychologist at Malcolm Grow Medical Clinicas and Surgery Center (MGMCSC) located on Joint Base Andrews, Maryland.
Harik, J. M., Matteo, R. A., Hermann, B. A., & Hamblen, J. L. (2016). What people with PTSD symptoms do (and do not) know about PTSD: A national survey. Depression and Anxiety, 34(4): 374-382. Doi: 10.1002/da.22558
Jorm, A. F., Korten, A. E., Jacomb, P. A., Christensen, H., Rogers, B., & Politt, P. (1997). ‘Mental health literacy’: a study of the public's ability to recognise mental disorder and their beliefs about the effectiveness of treatment. Medical Journal of Australia, 166, 182–186.
Merritt, C. J., Tharp, I. J., & Furnham, A. (2014). Trauma type affects recognition of Post-Traumatic Stress Disorder among online respondents in the UK and Ireland. Journal of Affective Disorders, 164, 123-9. Doi: 10.1016/j.jad.2014.04.013
Samuelson, K. W., Koenig, C. J., McCamish, N., Choucroun, G., Tarasovsky, G., Bertenthal, D., and Seal, K. H. (2014). Web-based PTSD training for primary care providers: a pilot study. Psychological Services, 11(2), 153-161. Doi: 10.1037/a0034855
Theophanous, C., Kalashnikova1, M., Sadler, C., Barreras, E., Fung, C. C., & Bruning, M. (2016). Educating Medical Students about Military Health: Perspectives from a Multidisciplinary Lecture Initiative. Education for Health, 29(2), 128-131. Doi: 10.4103/1357-6283.188754
Tsai, J, Shen, J., Southwick, S. M., Greenberg, S., Pluta, A., & Pietrzak, R. H. (2018). Public attitudes and literacy about posttraumatic stress disorder in U.S. adults. Journal of Anxiety Disorders, 55, 63-69. Doi: 10.1016/j.janxdis.2018.02.002