Original Research

Posttraumatic Stress Disorder, Depression, and Other Comorbidities: Clinical and Systems Approaches to Diagnostic Uncertainties

Overlap in the clinical presentation and significant rates of comorbidity complicate effective management of depression and PTSD, each presenting major health burdens for veterans and active-duty service members.

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Over the past decade, nationwide attention has focused on mental health conditions associated with military service. Recent legal mandates have led to changes in the DoD, VA, and HHS health systems aimed at increasing access to care, decreasing barriers to care, and expanding research on mental health conditions commonly seen in service members and veterans. On August 31, 2012, President Barack Obama signed the Improving Access to Mental Health Services for Veterans, Service Members, and Military Families executive order, establishing an interagency task force from the VA, DoD, and HHS.1 The task force was charged with addressing quality of care and provider training in the management of commonly comorbid conditions, including (among other conditions) posttraumatic stress disorder (PTSD) and depression.

Depression and PTSD present major health burdens in both military and veteran cohorts. Overlap in clinical presentation and significant rates of comorbidity complicate effective management of these conditions. This article offers a brief review of the diagnostic and epidemiologic complexities associated with PTSD and depression, a summary of research relevant to these issues, and a description of recent system-level developments within the Military Health System (MHS) designed to improve care through better approaches in identification, management, and research of these conditions.

Diagnostic Uncertainty

Both PTSD and major depressive disorder (MDD) have been recognized as mental health disorders since the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) discarded its previous etiologically based approach to diagnostic classification in 1980 in favor of a system in which diagnosis is based on observable symptoms.2,3 With the release of DSM-5 in 2013, the diagnostic criteria for PTSD underwent a substantial transformation.4 Previously, PTSD was described as an anxiety disorder, and some of its manifestations overlapped descriptively (and in many cases, etiologically) with anxiety and depressive illnesses.5

Clinicians also often described shorter-lived, developmental, formes fruste, or otherwise subsyndromal manifestations of trauma associated with PTSD. In DSM-5, PTSD was removed from the anxiety disorders section and placed in a new category of disorders labeled Trauma and Stressor-Related Disorders. This new category also included reactive attachment disorder (in children), acute stress disorder, adjustment disorders, and unspecified or other trauma and stressor-related disorders. Other major changes to the PTSD diagnostic criteria included modification to the DSM-IV-TR (text revision) trauma definition (making the construct more specific), removal of the requirement for explicit subjective emotional reaction to a traumatic event, and greater emphasis on negative cognitions and mood. Debate surrounds the updated symptom criteria with critics questioning whether there is any improvement in the clinical utility of the diagnosis, especially in light of the substantial policy and practice implications the change engenders.6

Recently, Hoge and colleagues examined the psychometric implications of the diagnostic changes (between DSM-IV-TR and DSM-5) in the PTSD definition.6 The authors found that although the 2 definitions showed nearly identical association with other psychiatric disorders (including depression) and functional impairment, 30% of soldiers who met DSM-IV-TR criteria for PTSD failed to meet criteria in DSM-5, and another 20% met only DSM-5 criteria. Recognizing discordance in PTSD and associated diagnoses, the U.S. Army Medical Command mandated that its clinicians familiarize themselves with the controversies surrounding the discordant diagnoses and coding of subthreshold PTSD.7

Adding to the problem of diagnostic uncertainty, the clinical presentation of MDD includes significant overlap with that of PTSD. Specifically, symptoms of guilt, diminished interests, problems with concentration, and sleep disturbances are descriptive of both disorders. Furthermore, the criteria set for several subthreshold forms of MDD evidence considerable overlap with PTSD symptoms. For example, diagnostic criteria for disruptive mood dysregulation disorder include behavioral outbursts and irritability, and diagnostic criteria for dysthymia include sleep disturbances and concentration problems.

Adjustment disorders are categorized as trauma and stressor-related disorders in DSM-5 and hold many emotional and behavioral symptoms in common with PTSD. The “acute” and “chronic” adjustment disorder specifiers contribute to problems in diagnostic certainty for PTSD. In general, issues pertaining to diagnostic uncertainty and overlap likely reflect the limits of using a diagnostic classification system that relies exclusively on observational and subjective reports of psychological symptoms.8,9

In a treatment environment where a veteran or active-duty patient has presented for care, in the face of these shared symptom sets, clinicians frequently offer initial diagnoses. These diagnoses are often based on perceived etiologic factors derived from patients’ descriptions of stressors encountered during military service. This tendency likely contributes to considerable inconsistencies and potential inaccuracies in diagnoses, and much of the variance can be attributed to the clinicians’ degree of familiarity with military exposures, perceptions of what constitutes trauma, and outside pressure to assign or avoid specific diagnoses.

Importantly, the phenomenologic differences between PTSD and depressive disorders increase the likelihood of poorly aligned and inconsistent treatment plans, and this lack of clarity may, in turn, compromise effective patient care. To address some of these diagnostic challenges, the VA and DoD incorporate military culture training into clinicians’ curriculum to increase provider familiarity with the common stressors and challenges of military life, mandate the use of validated measures to support diagnostic decision making, and regularly review policies that influence diagnostic practices.

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