Abstract
Objective:
Trauma exposure is widely prevalent, with over 60% of adolescents having experienced at least one traumatic event and a third of those at-high risk to develop Post-Traumatic Stress Disorder (PTSD). Data are scarce and out of date on the services children and adolescents with PTSD receive, impeding efforts to improve care and outcomes. This study examines health service use for a large and diverse sample of children and adolescents with and without a diagnosis of PTSD.
Method:
Utilizing a matched case-control study, we gathered information from four large health care systems participating in the Mental Health Research Network (MHRN). Data from each site’s electronic medical records on diagnoses, health care encounters, and demographics were analyzed. 955 4-to-18-year-olds with a diagnosis of PTSD were identified and matched on a 1:5 ratio to 4,770 controls. We compared cases to controls on frequency of service use in outpatient primary care, medical specialty care, acute care, and in mental health care. We also assessed psychotropic medication use.
Results:
Children and adolescents diagnosed with PTSD utilized nearly all physical and mental health service categories at a higher rate than controls. However, one third of children and adolescents did not receive even one outpatient mental health visit (36.86%) during the year-long sampling window.
Conclusion:
Our findings suggest that children and adolescents diagnosed with PTSD may have unmet mental health needs. They are high utilizers of health services overall, but lower utilizers of the sectors that may be most helpful in resolving their symptoms.
Keywords: PTSD, children and adolescents, health service utilization
Introduction
Approximately 25% to 30% of children are exposed to a potentially traumatic event1,2, with cumulative exposure exceeding 60% for adolescents.3,4 The most common traumas in youth (i.e., children and adolescents below the age of 18) include witnessing violence, traffic accidents, natural disasters, and physical and sexual abuse.3,5,6 Trauma exposure is linked to poor proximal outcomes during childhood including, emotion regulation difficulties, HPA Axis dysregulation, immune system dysfunction, substance abuse, suicide attempts, and development of post-traumatic stress disorder (PTSD)3,7,8,9,10 and with distal outcomes of adult health risk behavior, chronic disease, and early mortality11. Further, there is evidence suggesting that youths meeting diagnostic criteria for PTSD may be at especially high risk for these negative outcomes.12,13
Despite significant health impacts of trauma exposure and of PTSD, screening for trauma within pediatric settings is only slowly becoming routine.14 Little is known about the prevalence of PTSD in health care settings or the patterns or adequacy of care received by identified youths.15 The existing research suggests that youth with traumatic stress symptoms may show elevated rates of utilization16 across a variety of care settings (e.g., general practitioner, school, justice, child welfare) including more frequent and longer-lasting hospitalizations.17,18,19,20,21,22 While these investigations are a useful foundation, they are limited in a variety of respects. First, data on service use has largely been reliant on parent- or youth-report. Few studies utilize medical records or claims data or ask more than a single question16,23 about whether or not any services have been used during the study period – which was restricted to just the preceding 30–60 days for some studies.18,20 A key exception is the work of Seng and collegues24, which involved Medicaid data for youths with PTSD. However, these data were restricted to one state, are now more than 25 years old, and consist of an entirely female sample. Second, few previous studies use a control or comparison group. For example, studies reporting service utilization rates from the National Child Traumatic Stress Network (NCTSN) do not compare reported service rates to youth without trauma exposure. Third, the existing literature is primarily comprised of studies limited to adolescent participants16,21,22, and less is known about services for children with PTSD.
As a result, the field lacks a clear picture of the mental and physical health care service utilization patterns among children and adolescents with PTSD. These data are needed to serve as a base for outreach and quality improvement efforts for this high-risk condition. The present study seeks to address this need by conducting a case-control study of service utilization in youth with PTSD among a large, insured population.
Method
Settings and Sources of Data
Data were drawn from a larger study on the health care service utilization of youths with anxiety diagnoses (see Weersing et al. for additional details). This parent study pulled data from four health care systems participating in the Mental Health Research Network (MHRN): Kaiser Permanente Northwest (KPNW) based in Portland, OR; Henry Ford Health Systems (HFHS) based in Detroit, MI; Kaiser Permanente Northern California (KPNC) based in Oakland, CA; and Kaiser Permanente Hawaii (KPHI) based in Honolulu. These harmonized data included electronic health records (EHR) from the health systems and insurance claims data for members of each health system. The Institutional Review Boards for each health system approved data use and research activities for this project.
Participants
The sample for our larger parent study was created from two years of patient data (Year 1 1/1/13–12/31/13; Year 2 1/1/14–12/31/14). The following inclusion criteria were used to select a sample of qualifying youths: (a) age 4.0–17.9 in the analysis window, (b) at least one health contact in Year 1, (c) at least 10 months of health plan enrollment in Year 2, and (d) no long-term institutionalization in Year 2 (> 30 days). For the current project, youths were identified as cases if they had an ICD-9 diagnostic code for PTSD (309.81) in Year 1. Youths without an anxiety or PTSD diagnosis in Year 1 who received a diagnosis of anxiety or PTSD in Year 2 were excluded from the sample. To create a comparison group, youth with PTSD were matched with a 1:5 ratio to control peers using four sociodemographic indices: age, gender (male/female), number of quarters of enrollment in Year 1, and prescription drug coverage (yes/no; yes = coverage for at least the final quarter of Year 1 and all covered months of Year 2). Control youths did not meet criteria for PTSD nor for any other anxiety diagnoses in the original parent study sample in either Year 1 or Year 2.
Measures of Health Care Utilization
Service use data was derived from department and provider specialty information along with procedure codes in Year 2. Presence (yes/no), frequency (number of visits), and type of service use were assessed in: outpatient primary care (pediatrics, family medicine, internal medicine), medical specialty care (neurology, cardiology, gastroenterology), acute care (emergency room, urgent care), and mental health care by setting (outpatient, inpatient) and by type of service (any psychotherapy, individual/family therapy, group therapy). Psychotropic medication use (yes/no) was coded as present in Year 2 if a pharmacy dispense was recorded for one or more classes of agent: beta-blockers, benzodiazepines, monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), serotonin norepinephrine reuptake inhibitors (SNRIs), selective serotonin reuptake inhibitors (SSRIs), other anxiolytics, other antidepressants, and other sleep-aids (sedative, hypnotics). Medication management / brief counseling visits were coded as yes/no.
Control Variables
Demographic characteristics were derived from each site’s virtual data warehouse (VDW) and included gender (male/female), age as a continuous variable, insurance type (primarily commercial, any Medicaid, other), and a composite variable for race/ethnicity (White Non-Hispanic, African-American Non-Hispanic, Asian Non-Hispanic, Hispanic, Other Non-Hispanic [Multi-Racial, Native American, Pacific Islander/Hawaiian, Other], and unknown). Psychiatric control variables included comorbid diagnoses of depression, bipolar disorder, attention deficit hyperactivity disorder (ADHD), disruptive behavior disorders, pervasive developmental disorders and autism spectrum disorders, and substance use disorder. Physical health control variables were also assessed, including asthma, allergy disorders and reactions, gastrointestinal disorders, and sleep disorders.
Statistical Analyses and Data Analytic Plan
Bivariate analyses were conducted to probe for significant differences between PTSD and control youths on non-matched sociodemographic characteristics, psychiatric comorbidities, and physical health conditions. Significant variables identified through these analyses were included as covariates in all subsequent analyses. Conditional logistic regression models were used to estimate the association between the presence of a PTSD diagnosis and whether a service was accessed at all during the sampling window. Conditional negative binomial regression models were used to estimate the associations of PTSD status on number of visits for each type of service.
Results
Participant Characteristics
Across sites, 955 youths diagnosed with PTSD were identified as meeting qualifying criteria and matched on a 1:5 ratio to 4,770 control youths who were not diagnosed with PTSD or any anxiety disorders. The final analytic sample consisted of 5,725 youths from 4 sites. The sample consisted mostly of female (69.21%) adolescents (M = 14.23, SD = 2.80) and was diverse, with less than half (42.62%) identifying as White Non-Hispanic and 31.52% identifying as Hispanic. The majority of families had commercial insurance (70.58%).
Demographic and Clinical Differences
The matching algorithm was successful in that youths diagnosed with PTSD and control youths showed no significant differences on age and gender (Ps > .98). Compared to control youths, those diagnosed with PTSD were more likely to be White Non-Hispanic, Black, or Hispanic, while non-diagnosed control youths were more likely to be Asian. Further, youths diagnosed with PTSD were more likely to have Medicaid than control youths (who were more likely to have commercial insurance) and were more likely to have been diagnosed with both comorbid mental health diagnoses (depression, bipolar disorders, oppositional defiant disorder/conduct disorder, attention deficit/hyperactivity disorder, substance use, and Autism Spectrum Disorders/Pervasive Developmental Disorders) and comorbid physical health diagnoses (allergies, asthma, gastrointestinal diseases, and sleep disorders and problems; see Table 1). Subsequent analyses included all of these significant differences as control variables when comparing youths diagnosed with PTSD and control youths.
Table 1.
Participant sociodemographic and clinical characteristics
| PTSD | Control | P value | |||
|---|---|---|---|---|---|
| n | % | n | % | ||
| Total Patients | 955 | 100.00% | 4770 | 100.00% | |
| Gender | |||||
| Male | 294 | 30.79% | 1470 | 30.82% | 0.9843 |
| Female | 661 | 69.21% | 3300 | 69.18% | |
| Age | |||||
| 4–7 yrs | 24 | 2.51% | 115 | 2.41% | 0.9950 |
| 8–12 yrs | 214 | 22.41% | 1070 | 22.43% | |
| 13–17 yrs | 717 | 75.08% | 3585 | 75.16% | |
| Race/Ethnicity | <.0001 | ||||
| White NH | 407 | 42.62% | 1853 | 38.85% | 0.0257 |
| Black/African-American NH | 117 | 12.25% | 398 | 8.34% | 0.0002 |
| Asian NH | 30 | 3.14% | 748 | 15.68% | <.0001 |
| Hispanic, all races | 301 | 31.52% | 1296 | 27.17% | 0.0053 |
| Unknown / missing | 31 | 3.25% | 259 | 5.43% | 0.0004 |
| Other (analytic category) | 69 | 7.23% | 216 | 4.53% | 0.0059 |
| Multi-Racial | 43 | 4.50% | 127 | 2.66% | |
| Native Hawaiian/Pacific Islander | 20 | 2.09% | 62 | 1.30% | |
| Native American | 6 | 0.63% | 23 | 0.48% | |
| Insurance type | <.0001 | ||||
| Commercial | 674 | 70.58% | 3789 | 79.43% | <.0001 |
| Any Medicaid | 203 | 21.26% | 690 | 14.47% | <.0001 |
| Other | 78 | 8.17% | 291 | 6.10% | 0.0167 |
| Other comorbid mental health diagnoses | |||||
| Depression | 364 | 38.12% | 123 | 2.58% | <.0001 |
| Bipolar Disorders | 158 | 16.54% | 22 | 0.46% | <.0001 |
| ODD / CD | 81 | 8.48% | 22 | 0.46% | <.0001 |
| ADHD | 211 | 22.09% | 188 | 3.94% | <.0001 |
| Substance use | 75 | 7.85% | 40 | 0.84% | <.0001 |
| ASD / PDD | 21 | 2.20% | 26 | 0.55% | <.0001 |
| Comorbid physical health diagnoses | |||||
| Allergy disorder and reactions | 167 | 17.49% | 635 | 13.31% | 0.0007 |
| Asthma | 205 | 21.47% | 536 | 11.24% | <.0001 |
| Gastrointestinal diseases | 39 | 4.08% | 92 | 1.93% | <.0001 |
| Sleep disorders and problems | 78 | 8.17% | 48 | 1.01% | <.0001 |
Overall Health Care Utilization
Service use.
Youths diagnosed with PTSD utilized nearly all service categories at significantly higher rates than control youths, with the exception of specialist care settings—which were utilized at relatively low rates overall (approximately 1–3%)—and urgent care, which had comparable utilization rates (9.32% vs. 6.96% respectively, P = .32; see Table 2). Youths diagnosed with PTSD were about one and a half times as likely as control youths to receive services from internal medicine (P = .004), nearly three times as likely to visit the emergency department (P < .001), and more than five times as likely to receive psychotherapy in any setting (P = .001). They were also five times as likely to receive mental health services in high-cost inpatient settings (P = .026). Youths diagnosed with PTSD also had significantly higher rates of receiving a pharmacy dispense of a targeted psychotropic medication (50.79% vs. 6.54%) and engaging in medication management/brief counseling sessions (6.70% vs. 0.44%). Importantly, although youths diagnosed with PTSD did exhibit a significantly higher utilization of mental health care than control youths, approximately a third did not receive any outpatient mental health care (36.86%) and one half did not receive a pharmacy dispense (49.21%). Of note, nearly a third (28.17%) of youth with PTSD diagnoses did not appear to receive mental health care of any kind during the sample window, with no recorded use of outpatient, inpatient, psychotherapy (any setting), or psychotropic medication use (see Table 2).
Table 2.
Service utilization for PTSD and Control youth
| PTSD | Control | OR | P value | |||
|---|---|---|---|---|---|---|
| n | % with use | n | % with use | |||
| Outpatient settings | ||||||
| Pediatrics | 762 | 79.79% | 3592 | 75.30% | 0.77 | 0.018 |
| Family medicine | 144 | 15.08% | 531 | 11.13% | 1.33 | 0.039 |
| Internal medicine | 488 | 51.10% | 1538 | 32.24% | 1.31 | 0.004 |
| Specialist care, any setting | ||||||
| Neurology | 30 | 3.14% | 54 | 1.13% | 1.03 | 0.947 |
| Cardiology | 34 | 3.56% | 90 | 1.89% | 1.36 | 0.247 |
| Gastroenterology | 17 | 1.78% | 33 | 0.69% | 1.87 | 0.364 |
| Acute care settings | ||||||
| Urgent care | 89 | 9.32% | 332 | 6.96% | 1.18 | 0.317 |
| Emergency department | 366 | 38.32% | 662 | 13.88% | 1.87 | 0.000 |
| Mental health care by setting | ||||||
| Outpatient mental health | 603 | 63.14% | 336 | 7.04% | 9.09 | 0.000 |
| Inpatient mental health | 101 | 10.58% | 11 | 0.23% | 1685.02 | 0.026 |
| Psychotherapy, any setting | 486 | 50.89% | 252 | 5.28% | 7.17 | 0.000 |
| Individual/family | 433 | 45.34% | 226 | 4.74% | 6.62 | 0.000 |
| Group therapy | 223 | 23.35% | 91 | 1.91% | 5.22 | 0.000 |
| Psychotropic use, any setting | ||||||
| Pharmacy dispense | 485 | 50.79% | 312 | 6.54% | 6.56 | 0.000 |
| Medication management / brief counseling | 64 | 6.70% | 21 | 0.44% | 4.84 | 0.000 |
| Mental health composite variables | ||||||
| Psychotropic medications only | 71 | 7.43% | 192 | 4.03% | 2.20 | <.001 |
| No mental health services | 269 | 28.17% | 4236 | 88.81% | 0.10 | <.001 |
Number of visits.
Youths diagnosed with PTSD had a greater number of internal medicine visits (M = 3.58 vs. M = 0.77) but were otherwise comparable to control youths across outpatient medical and specialist care settings (see Table 3). The largest differences seen between these two groups were for number of psychotherapy visits and inpatient mental health admissions. Youths diagnosed with PTSD had an average of 6.23 psychotherapy visits, while control youths had 0.29, P < .001. In terms of inpatient mental health, youths diagnosed with PTSD had 0.19 admissions, on average, while control youths had a mean of 0.00 admissions, P < .001. Outpatient mental health was also significantly different among groups, with youths diagnosed with PTSD having an average of 6.65 visits and control youths 0.31 visits. Among the subset of youths who utilized these services at least once, these differences remained statistically significant for psychotherapy and outpatient visits, but not inpatient services. Among youths who accessed services at least once, those diagnosed with PTSD had an average of 12.25 psychotherapy visits, 10.53 outpatient mental health visits, and 1.84 inpatient mental health admissions while control youths had an average of 5.55 psychotherapy visits (P < .0001), 4.35 outpatient visits (P < .001), and 1.27 inpatient admissions (P =.186).
Table 3.
Service visits for PTSD and Control Youth
| PTSD | Control | P value | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| n | Visits | Visits amongst users | n | Visits | Visits amongst users | IRR | ||||||
| M | SD | M | SD | M | SD | M | SD | |||||
| Outpatient settings | ||||||||||||
| Pediatrics | 762 | 2.57 | 2.83 | 3.22 | 2.82 | 3592 | 1.75 | 1.88 | 2.32 | 1.83 | 1.08 | 0.068 |
| Family medicine | 144 | 0.36 | 1.31 | 2.37 | 2.59 | 531 | 0.17 | 0.60 | 1.53 | 1.06 | 1.21 | 0.150 |
| Internal medicine | 488 | 3.58 | 8.39 | 7.00 | 10.68 | 1538 | 0.77 | 2.48 | 2.39 | 3.91 | 1.79 | 0.000 |
| Specialist care, any setting | ||||||||||||
| Neurology | 30 | 0.07 | 0.60 | 2.20 | 2.64 | 54 | 0.02 | 0.25 | 1.98 | 1.31 | 1.35 | 0.433 |
| Cardiology | 34 | 0.06 | 0.35 | 1.62 | 0.99 | 90 | 0.04 | 0.36 | 1.91 | 1.82 | 1.47 | 0.202 |
| Gastroenterology | 17 | 0.04 | 0.31 | 2.06 | 1.20 | 33 | 0.02 | 0.25 | 2.36 | 1.93 | 0.89 | 0.825 |
| Acute care settings | ||||||||||||
| Urgent care | 89 | 0.17 | 0.73 | 1.88 | 1.57 | 332 | 0.10 | 0.41 | 1.39 | 0.79 | 1.44 | 0.016 |
| Emergency department | 366 | 0.79 | 1.47 | 2.07 | 1.73 | 662 | 0.18 | 0.54 | 1.29 | 0.81 | 1.79 | 0.000 |
| Mental health care by setting | ||||||||||||
| Outpatient mental health | 603 | 6.65 | 11.67 | 10.53 | 13.23 | 336 | 0.31 | 1.91 | 4.35 | 5.86 | 7.88 | 0.000 |
| Inpatient mental health | 101 | 0.19 | 0.85 | 1.84 | 1.97 | 11 | 0.00 | 0.06 | 1.27 | 0.47 | 17.89 | 0.000 |
| Psychotherapy, any setting | 486 | 6.23 | 13.32 | 12.25 | 16.59 | 252 | 0.29 | 1.90 | 5.55 | 6.29 | 9.85 | 0.000 |
| Individual/family | 433 | 3.81 | 8.06 | 8.40 | 10.23 | 226 | 0.20 | 1.26 | 4.13 | 4.17 | 9.79 | 0.000 |
| Group therapy | 223 | 2.27 | 7.18 | 9.70 | 12.20 | 91 | 0.09 | 1.03 | 4.76 | 5.82 | 9.90 | 0.000 |
| Psychotropic use, any setting | ||||||||||||
| Medication management / brief counseling | 485 | 0.16 | 0.98 | 2.38 | 3.05 | 312 | 0.01 | 0.11 | 1.48 | 0.68 | 7.35 | 0.000 |
Medication Use.
Overall, youths diagnosed with PTSD had more psychotropic medication use across all classes than control youths (most Ps < .001, see Table 4). The largest differences were seen in second generation antipsychotics (16.96% vs. 0.34%) and selective serotonin reuptake inhibitors (SSRI; 30.79% vs. 1.01%). We further examined the proportion of youth who had a psychotropic medication dispensed during the sample year but did not have any recorded use of mental health services (inpatient, outpatient, psychotherapy in any setting). These youth could have received prescriptions from non-mental health settings (e.g., pediatrics) or have been refilling prescriptions without an office visit. Rates of medication use without concomitant mental health visits were low overall (7.43%).
Table 4.
Medication Use for PTSD and Control Youth
| PTSD | Control | OR | P value | |||
|---|---|---|---|---|---|---|
| n | % with use | n | % with use | |||
| Antidepressant SSRI | 294 | 30.79% | 48 | 1.01% | 21.28 | 0.000 |
| Antidepressant SNRI | 15 | 1.57% | 0 | 0.00% | NA | NA |
| Antidepressant Other | 120 | 12.57% | 26 | 0.55% | 8.55 | 0.000 |
| Anti-Anxiety Other | 54 | 5.65% | 40 | 0.84% | 2.83 | 0.002 |
| Anticonvulsants | 68 | 7.12% | 26 | 0.55% | 5.23 | 0.001 |
| Antipsychotic 1st gen | NA | NA | NA | NA | NA | NA |
| Antipsychotic 2nd gen | 162 | 16.96% | 16 | 0.34% | 30.14 | 0.000 |
| Lithium | NA | NA | NA | NA | NA | NA |
| Sleep: Benzodiazepine | 35 | 3.66% | 26 | 0.55% | 3.84 | 0.003 |
| Sleep: Non-Benzodiazepine | NA | NA | NA | NA | NA | NA |
| Stimulants | 149 | 15.60% | 165 | 3.46% | 3.23 | 0.008 |
| ADHD: Other Medications | 93 | 9.74% | 26 | 0.55% | 15.39 | 0.000 |
Discussion
Summary of findings
Children and adolescents are exposed to potentially traumatic events at alarmingly high rates, with one-third of these youth developing symptoms of PTSD and 1–6% receiving a formal diagnosis.3,10,25 In order to better understand the health service utilization of youth diagnosed with PTSD, we examined a large and diverse sample across multiple health care settings and types of services over a two-year period. Findings reveal that youth diagnosed with PTSD utilize health services at higher rates than controls in most cases. However, they may not be receiving sufficient levels of mental health care.
As compared to controls, youth with a diagnosis of PTSD were significantly more likely to receive services from pediatric, family medicine, and internal medicine settings, psychotherapy in any setting, and outpatient mental health settings. Youths were also more likely to receive services from the high-cost emergency department and inpatient mental health settings. Youth with a diagnosis of PTSD were also much more likely to receive a pharmacy dispense and engage in medication management encounters than control youth. Despite the fact that youth diagnosed with PTSD utilized mental health services at significantly higher rates than control youth, only about two-thirds (63.14%) received outpatient mental health services, while half (50.79%) received medications. Per practice parameters26 for youth PTSD, psychotropic medications such as SSRIs can be an important adjunct to psychotherapy especially for youth with comorbid conditions or more severe symptoms, and, thus, this rate of medication dispense may indicate unmet need. Most critically, almost one-third (28.17%) of youth diagnosed with PTSD did not receive any mental health services at all during the study period, while 7.43% of youth filled prescriptions for psychotropic mediations without utilizing any other mental health services. This is problematic in terms of PTSD symptoms and impairment and for other apparently physical symptoms (e.g., stomach aches)27 that may be anxiety related. Not only does this affect youth who continue to experience symptoms without long-term relief, but it may also have negative consequences for health systems by contributing to the use of ineffective and expensive services (e.g., increased emergency department visits).
Among those youth with PTSD who did receive outpatient mental health services, the average number of outpatient sessions was 10.53. Although the session content in this sample is unknown, it is important to note that Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; an evidence-based approach to treating PTSD in youth) is typically of similar length (12–20 sessions).28 Therefore, if not already implemented, it may be possible to scale up the currently offered sessions in terms of frequency, length, and intensity to offer efficacious treatments such as TF-CBT easier than if the current session average was significantly lower.
These findings are broadly consistent with existing literature, which generally indicates that youth with trauma-exposure or PTSD tend to be high users of mental health services.17,20,22 However, this current study’s results are unique in several ways. First, we examined a broad range of health and mental health services in detail. Second, the study included a large sample of both children and adolescents clinically diagnosed with PTSD in large health systems. Third, we included a comparison group of youth not diagnosed with this disorder. Fourth, we followed youth for 2 years to identify youth with current PTSD diagnoses. Finally, in contrast to most prior studies which utilized self-reports, the current study examined electronic health records, allowing us to accurately assess service use in greater detail.
Limitations
These results should be considered in light of the limitations of the study. The study relied on clinical diagnosis of PTSD instead of standardized research assessments and may therefore be subject to either over- or under-diagnosis, as types of clinicians conferring diagnoses and assessments used may have varied. Prior research and available data suggest that under-diagnosis is more likely. PTSD is often co-morbid with and potentially overshadowed by other issues (e.g., externalizing problems), children might not meet all criteria at the time of evaluation (e.g., symptoms for less than 1 month), or the physician may not screen for traumatic events in the youth’s life and be unaware of both trauma exposure and PTSD symptoms. Miele and O’Brien29 for example, found that rates of PTSD diagnosis increased from 5.4% to 44.6% of at-risk outpatient youth when a trauma-focused interview was used. In this study, 0.18% of the qualifying sample (i.e., 955 out of 524,475 youth) was found to have a diagnosis of PTSD in their medical record. Given conservative estimates of 1% PTSD prevalence in general population studies,3,10,25 this suggests that, on average, less than every fifth child with PTSD is being identified in the current sample. Rates of PTSD in this sample were especially low for Asian youths, indicating underdiagnosis may vary by race / ethnicity. Similarly, younger children are often underdiagnosed, especially if evaluated for PTSD via criteria that are not developmentally sensitive30, indicating that the proportion of younger children in this sample may be too low as well. Additionally, findings from the present study may not generalize to other samples of youth with PTSD, especially youth with limited contact with the health care system. This might include refugee and asylum-seeking youth or youth experiencing inconsistent housing or caregiving situations, which might then extend to inconsistent contact with the health care system. Homeless and foster care youth and victims of human trafficking might be especially vulnerable, and the unique circumstances surrounding their traumatic experiences may lead to differential service utilization patterns if or when they do access care. Youths with a lower socioeconomic status (SES) background might also display differential trauma exposure and service utilization; future work might disentangle SES in a more comprehensive way, as our study was only able to use Medicaid as a proxy. Finally, it is possible that participants in this study utilized services outside of the health care system. For example, they might have used resources at school, in the justice system, or at other social services agencies.
Directions for future research
This study was, to our knowledge, the first using electronic health record data in order to examine the service utilization patterns of youth diagnosed with PTSD. Our findings provide valuable data on the pattern and adequacy of services for youth with PTSD, including the finding that youths may be overutilizing emergency services and underutilizing outpatient mental health. However, research on this health-system scale does not allow insight into why such few youths with PTSD are identified and why those that are identified might not be receiving the evidence-based treatment that would be indicated for their condition. Future research should address both the lack of identification of youth with PTSD and the quality and content of care youth diagnosed with PTSD are receiving, to better evaluate how services could address their needs in a more efficient and effective manner.
Funding source:
This study was funded through the National Institute of Mental Health, Grant number - 6U19MH092201-08, Grant Title - MENTAL HEALTH RESEARCH NETWORK II
Footnotes
Author Disclosure: The authors have no financial relationships or conflicts of interest relevant to this article to disclose.
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