Youth, poverty, and interpersonal violence: a recipe for PTSD ============================================================= * Emily K Lenart * Tiffany K Bee * Catherine P Seger * Richard H Lewis, Jr * Dina M Filiberto * Dih-Dih Huang * Peter E Fischer * Martin A Croce * Timothy C Fabian * Louis J Magnotti * violence * wounds * penetrating * stress disorders * post-traumatic ## Introduction Substantial efforts have focused on physical rehabilitation to help speed the recovery process post-trauma. Despite intensive physical therapy, many trauma patients never return to their pre-injury status. This finding suggests there are various psychosocial factors playing a substantial role in the recovery of these patients. Several studies have found that trauma patients suffer from significant mental health–related issues, especially post-traumatic stress disorder (PTSD), after their traumatic event.1 PTSD has been shown to decrease quality of life, with many patients unable to hold jobs and maintain personal relationships after a major trauma. These patients are at high risk of substance abuse, suicide, and psychological disturbances, and are more likely to suffer from chronic pain.2 Trauma patients with PTSD have worse functional outcomes and increased social disintegration, contributing to substantial healthcare, economic, and personal costs.1 Thus, identifying and treating PTSD early has the potential to mitigate the negative impact of the disease by improving quality of life coupled with decreasing the socioeconomic cost to both the patient and society. We hypothesized that specific factors related to the patient and their trauma would be predictive of PTSD. The purpose of this study was to identify PTSD in patients post-injury and determine which risk factors could predict its subsequent development. ## Methods ### Identification of patients A prospective quality improvement project was undertaken in response to previous work performed at our institution. Consecutive patients admitted to the trauma service for >48 hours with planned follow-up in the outpatient trauma clinic between August 2019 and January 2020 were eligible for participation in the study and offered the opportunity for inclusion. Data were collected following introduction of a discharge information form and discharge teaching. Using a detailed five-question survey at their first follow-up visit post-discharge, patients were screened prospectively for PTSD. Only those patients completing all five questions comprising the survey were included in the analysis. ### Data collection and comparison Patient demographics, education level, income data, injuries and operations, mechanism of injury, severity of injury (as measured by admission injury severity score (ISS) and Glasgow Coma Scale), severity of shock (as measured by admission base excess and 24-hour transfusion requirements), and PTSD screen result were recorded. Three or more affirmative responses on the five-question survey constituted a positive screen for PTSD. Outcomes including ventilator days, and ICU and hospital length of stay were also recorded. Patients were then stratified by screen result and compared. ### Statistical analysis All data were analyzed using SAS V.9.4 (SAS Institute, Cary, NC). Normally distributed continuous variables were analyzed using the Student t-test, while nonparametric continuous variables were analyzed using the Wilcoxon rank-sum test. Categorical data were analyzed with a χ2 analysis or Fischer’s exact test where appropriate. Differences were considered statistically significant at p<0.05. Multivariable logistic regression was then performed to determine variables significantly associated with the development of PTSD in the study population. Variables exhibiting a significance less than 0.2 on univariable analysis were considered for inclusion in the full multiple regression model. The final multivariable model was constructed in a backwards stepwise fashion to identify independent predictors for the development of PTSD. Differences were considered significant at p<0.05. The area under the receiver operating curve was reported with 95% CIs. ## Results ### Study population Of the 153 surveys distributed, 145 (95%) were returned and comprised the study population. The mean time from discharge to follow-up was 15 days. The majority (71%) of the patients were male, with a median age and ISS of 32 and 14, respectively. Forty-two percent of patients suffered penetrating injuries. Of the 145 patients, 59% reported annual household incomes of