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A nationwide US study of post-traumatic stress after hospitalization for physical injury




Injured survivors of individual and mass trauma are at risk for developing post-traumatic stress disorder (PTSD). Few investigations have assessed PTSD after injury in large samples across diverse acute care hospital settings.


A total of 2931 injured trauma survivors aged 18–84 who were representative of 9983 in-patients were recruited from 69 hospitals across the USA. In-patient medical records were abstracted, and hospitalized patients were interviewed at 3 and 12 months after injury. Symptoms consistent with a DSM-IV diagnosis of PTSD were assessed with the PTSD Checklist (PCL) 12 months after injury.


Approximately 23% of injury survivors had symptoms consistent with a diagnosis of PTSD 12 months after their hospitalization. Greater levels of early post-injury emotional distress and physical pain were associated with an increased risk of symptoms consistent with a PTSD diagnosis. Pre-injury, intensive care unit (ICU) admission [relative risk (RR) 1·17, 95% confidence interval (CI) 1·02–1·34], pre-injury depression (RR 1·33, 95% CI 1·15–1·54), benzodiazepine prescription (RR 1·46, 95% CI 1·17–1·84) and intentional injury (RR 1·32, 95% CI 1·04–1·67) were independently associated with an increased risk of symptoms consistent with a PTSD diagnosis. White injury survivors without insurance demonstrated approximately twice the rate of symptoms consistent with a diagnosis of PTSD when compared to white individuals with private insurance. By contrast, for Hispanic injury survivors PTSD rates were approximately equal between uninsured and privately insured individuals.


Nationwide in the USA, more than 20% of injured trauma survivors have symptoms consistent with a diagnosis of PTSD 12 months after acute care in-patient hospitalization. Coordinated investigative and policy efforts could target mandates for high-quality PTSD screening and intervention in acute care medical settings.


Corresponding author

*Address for correspondence: Douglas Zatzick, M.D., Associate Professor, Department of Psychiatry and Behavioral Sciences, Harborview Injury Prevention and Research Center, University of Washington, School of Medicine, Box 359896, 325 Ninth Ave, Seattle, WA 98104, USA. (Email:


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A preliminary version of this manuscript was presented at the National Institute of Drug Abuse Meeting on Disasters and Substance Abuse, Bethesda, MD, USA, on 7 December 2006.



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ACS/COT (2006). Resources for the Optimal Care of the Injured Patient: 2006. American College of Surgeons Committee on Trauma: Chicago, IL.
Babor, T. F. & Grant, M. (1989). From clinical research to secondary prevention: international collaboration in the development of the Alcohol Use Disorders Identification Test. Alcohol Health and Research World 13, 371374.
Birkmeyer, J. D., Stukel, T. A., Siewers, A. E., Goodney, P. P., Wennberg, D. E. & Lucas, F. L. (2003). Surgeon volume and operative mortality in the United States. New England Journal of Medicine 349, 21172127.
Blake, D., Weathers, F., Nagy, L., Kaloupek, D., Klauminzer, G., Charney, D. & Keane, T. (1990). Clinician-Administered PTSD Scale (CAPS). National Center for Post-Traumatic Stress Disorder, Behavioral Science Division: Boston, MA.
Blanchard, E. B., Hickling, E. J., Taylor, A. E. & Loos, W. (1995). Psychiatric morbidity associated with motor vehicle accidents. Journal of Nervous and Mental Disease 183, 495504.
Blanchard, E. B., Jones-Alexander, J., Buckley, T. C. & Forneris, C. A. (1996). Psychometric properties of the PTSD Checklist. Behaviour Research and Therapy 34, 669673.
Bonnie, R. J., Fulco, C. E. & Liverman, C. T. (eds) (1999). Reducing the Burden of Injury: Advancing Prevention and Treatment. National Academy Press: Washington, DC.
Breslau, J., Aguilar-Gaxiola, S., Borges, G., Castilla-Puentes, R. C., Kendler, K. S., Medina-Mora, M. E., Su, M. & Kessler, R. C. (2007). Mental disorders among English-speaking Mexican immigrants to the US compared to a national sample of Mexicans. Psychiatry Research 151, 115122.
Breslau, J., Kendler, K. S., Su, M., Gaxiola-Aguilar, S. & Kessler, R. C. (2005). Lifetime risk and persistence of psychiatric disorders across ethnic groups in the United States. Psychological Medicine 35, 317327.
Breslau, N., Peterson, E. L., Poisson, L. M., Schultz, L. R. & Lucia, V. C. (2004). Estimating post-traumatic stress disorder in the community: lifetime perspective and the impact of typical traumatic events. Psychological Medicine 34, 889898.
Brewin, C. R., Andrews, B. & Valentine, J. D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology 68, 748766.
Bryant, R. A., Harvey, A. G., Guthrie, R. M. & Moulds, M. L. (2000). A prospective study of psychophysiological arousal, acute stress disorder, and posttraumatic stress disorder. Journal of Abnormal Psychology 109, 341344.
Chilcoat, H. D. & Breslau, N. (1998). Investigations of causal pathways between PTSD and drug use disorders. Addictive Behaviors 23, 827840.
Cuthbertson, B. H., Hull, A., Strachan, M. & Scott, J. (2004). Post-traumatic stress disorder after critical illness requiring general intensive care. Intensive Care Medicine 30, 450455.
D'Agostino, R. B. Jr. & D'Agostino, R. B. Sr. (2007). Estimating treatment effects using observational data. Journal of the American Medical Association 297, 314316.
Dansky, B. S., Saladin, M. E., Brady, K. T., Kilpatrick, D. G. & Resnick, H. S. (1995). Prevalence of victimization and posttraumatic stress disorder among women with substance abuse disorders: comparison of telephone and in-person assessment samples. International Journal of Addictions 30, 10791099.
Ehlers, A., Mayou, R. A. & Bryant, B. (1998). Psychological predictors of chronic posttraumatic stress disorder after motor vehicle accidents. Journal of Abnormal Psychology 107, 508519.
Galea, S., Vlahov, D., Tracy, M., Hoover, D. R., Resnick, H. & Kilpatrick, D. (2004). Hispanic ethnicity and post-traumatic stress disorder after a disaster: evidence from a general population survey after September 11, 2001. Annals of Epidemiology 14, 520531.
Grieger, T. A., Cozza, S. J., Ursano, R. J., Hoge, C., Martinez, P. E., Engel, C. C. & Wain, H. J. (2006). Posttraumatic stress disorder and depression in battle-injured soldiers. American Journal of Psychiatry 163, 17771783.
Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I. & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine 351, 1322.
Holbrook, T. L., Anderson, J. P., Sieber, W. J., Browner, D. & Hoyt, D. B. (1999). Outcome after major trauma: 12-month and 18-month follow-up results from the trauma recovery project. Journal of Trauma 46, 765773.
Holbrook, T. L., Hoyt, D. B., Stein, M. B. & Sieber, W. J. (2001). Perceived threat to life predicts posttraumatic stress disorder after major trauma: risk factors and functional outcome. Journal of Trauma 51, 287293.
Hosmer, D. W. & Lemeshow, S. (1989). Applied Logistic Regression. Wiley: New York.
Kapfhammer, H. P., Rothenhausler, H. B., Krauseneck, T., Stoll, C. & Schelling, G. (2004). Posttraumatic stress disorder and health-related quality of life in long-term survivors of acute respiratory distress syndrome. American Journal of Psychiatry 161, 4552.
Katon, W., Von Korff, M., Lin, E., Walker, E., Simon, G. E., Bush, T. B., Robinson, P. & Russo, J. (1995). Collaborative management to achieve treatment guidelines: impact on depression in primary care. Journal of the American Medical Association 273, 10261031.
Katon, W., Zatzick, D., Bond, G. & Williams, J. Jr. (2006). Dissemination of evidence-based mental health interventions: importance to the trauma field. Journal of Traumatic Stress 19, 611623.
Kessler, R. C., Sonnega, A., Bromet, E., Hughs, M. & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry 52, 10481060.
Koren, D., Arnon, I. & Klein, E. (1999). Acute stress response and posttraumatic stress disorder in traffic accident victims: a one-year prospective, follow-up study. American Journal of Psychiatry 156, 367373.
Koren, D., Hemel, D. & Klein, E. (2006). Injury increases the risk for PTSD: an examination of potential neurobiological and psychological mediators. CNS Spectrums 11, 616624.
Krug, E. G., Sharma, G. K. & Lozano, R. (2000). The global burden of injuries. American Journal of Public Health 90, 523526.
Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R. & Weiss, D. S. (1990). Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study. Brunner/Mazel: New York, NY.
MacKenzie, E. J. (2001). Measuring disability and quality of life postinjury. In Injury Control: A Guide to Research and Program Evaluation (ed. Rivara, F. P., Cummings, P., Koepsell, T. D., Grossman, D. C. and Maier, R. V.), pp. 250269. Cambridge University Press: Cambridge.
MacKenzie, E. J., Rivara, F. P., Jurkovich, G. J., Nathens, A. B., Frey, K. P., Egleston, B. L., Salkever, D. S. & Scharfstein, D. O. (2006). A national evaluation of the effect of trauma-center care on mortality. New England Journal of Medicine 354, 366378.
Maes, M., Delmeire, L., Mylle, J. & Altamura, C. (2001). Risk and preventive factors of post-traumatic stress disorder (PTSD): alcohol consumption and intoxication prior to a traumatic event diminishes the relative risk to develop PTSD in response to that trauma. Journal of Affective Disorders 63, 113121.
Marshall, G. N. & Orlando, M. (2002). Acculturation and peritraumatic dissociation in young adult Latino survivors of community violence. Journal of Abnormal Psychology 111, 166174.
Marshall, G. N. & Schell, T. L. (2002). Reappraising the link between peritraumatic dissociation and PTSD symptom severity: evidence from a longitudinal study of community violence survivors. Journal of Abnormal Psychology 111, 626636.
Mayou, R., Bryant, B. & Duthie, R. (1993). Psychiatric consequences of road traffic accidents. British Medical Journal 307, 647651.
Mayou, R., Tyndel, S. & Bryant, B. (1997). Long-term outcome of motor vehicle accident injury. Psychosomatic Medicine 59, 578584.
Mellman, T. A., David, D., Bustamante, V., Fins, A. I. & Esposito, K. (2001). Predictors of post-traumatic stress disorder following severe injury. Depression and Anxiety 14, 226231.
Mellman, T. A., Ramos, J., David, D., Williams, L. & Augenstein, J. S. (1998). Possible inhibition of early PTSD symptoms by alcohol intoxication. Depression and Anxiety 7, 145.
Michaels, A. J., Michaels, C. E., Zimmerman, M. A., Smith, J. S., Moon, C. H. & Peterson, C. (1999). Posttraumatic stress disorder in injured adults: etiology by path analysis. Journal of Trauma 47, 867873.
Nathens, A. B., Jurkovich, G. J., Cummings, P., Rivara, F. P. & Maier, R. V. (2000). The effect of organized systems of trauma care on motor vehicle crash mortality. Journal of the American Medical Association 283, 19901994.
New Freedom Commission on Mental Health (2003). Achieving the Promise: Transforming Mental Health Care in America. DHHS: Rockville, MD.
O'Donnell, M. L., Creamer, M., Bryant, R. A., Schnyder, U. & Shalev, A. Y. (2003). Posttraumatic disorders following injury: an empirical and methodological review. Clinical Psychology Review 23, 587603.
O'Donnell, M. L., Creamer, M., Elliott, P., Atkin, C. & Kossmann, T. (2005). Determinants of quality of life and role-related disability after injury: impact of acute psychological responses. Journal of Trauma 59, 13281335.
O'Donnell, M. L., Creamer, M. & Pattison, P. (2004). Posttraumatic stress disorder and depression following trauma: understanding comorbidity. American Journal of Psychiatry 161, 13901396.
Ozer, E. J., Best, S. R., Lipsey, T. L. & Weiss, D. S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychological Bulletin 129, 5273.
Parslow, R. A., Jorm, A. F. & Christensen, H. (2006). Associations of pre-trauma attributes and trauma exposure with screening positive for PTSD: analysis of a community-based study of 2,085 young adults. Psychological Medicine 36, 387395.
Pole, N., Best, S. R., Metzler, T. & Marmar, C. R. (2005). Why are hispanics at greater risk for PTSD? Cultural Diversity and Ethnic Minority Psychology 11, 144161.
Roy-Byrne, P. P., Craske, M. G., Stein, M. B., Sullivan, G., Bystritsky, A., Katon, W., Golinelli, D. & Sherbourne, C. D. (2005). A randomized effectiveness trial of cognitive-behavioral therapy and medication for primary care panic disorder. Archives of General Psychiatry 62, 290298.
Rubin, D. (1987). Multiple Imputation for Nonresponse in Surveys. Wiley: New York.
Ruef, A. M., Litz, B. T. & Schlenger, W. E. (2000). Hispanic ethnicity and risk for combat-related posttraumatic stress disorder. Cultural Diversity and Ethnic Minority Psychology 6, 235251.
Santos, M., Russo, J. & Zatzick, D. (2003). Ethnocultural variations in immediate posttraumatic distress [Abstract]. In Proceedings of the 19th Annual Meeting of the International Society for Traumatic Stress Studies, Chicago, IL, p. 126.
Saxe, G., Stoddard, F., Courtney, D., Cunningham, K., Chawla, N., Sheridan, R., King, D. & King, L. (2001). Relationship between acute morphine and the course of PTSD in children with burns. Journal of the American Academy of Child and Adolescent Psychiatry 40, 915921.
Schelling, G., Kilger, E., Roozendaal, B., de Quervain, D. J., Briegel, J., Dagge, A., Rothenhausler, H. B., Krauseneck, T., Nollert, G. & Kapfhammer, H. P. (2004). Stress doses of hydrocortisone, traumatic memories, and symptoms of posttraumatic stress disorder in patients after cardiac surgery: a randomized study. Biological Psychiatry 55, 627633.
Schnyder, U., Moergeli, H., Klaghofer, R. & Buddeberg, C. (2001). Incidence and prediction of posttraumatic stress disorder symptoms in severely injured accident victims. American Journal of Psychiatry 158, 594599.
Shalev, A. Y., Freedman, S., Peri, T., Brandes, D., Sahar, T., Orr, S. P. & Pitman, R. K. (1998). Prospective study of posttraumatic stress disorder and depression following trauma. American Journal of Psychiatry 155, 630637.
Shalev, A. Y., Peri, T., Canetti, L. & Schreiber, S. (1996). Predictors of PTSD in injured trauma survivors: a prospective study. American Journal of Psychiatry 153, 219225.
Shaw, R. J., Robinson, T. E. & Steiner, H. (2002). Acute stress disorder following ventilation. Psychosomatics 43, 7476.
Simon, G. E., Von Korff, M., Piccinelli, M., Fullerton, C. S. & Ormel, J. (1999). An international study of the relation between somatic symptoms and depression. New England Journal of Medicine 341, 13291335.
Taubman-Ben-Ari, O., Rabinowitz, J., Feldman, D. & Vaturi, R. (2001). Post-traumatic stress disorder in primary-care settings: prevalence and physician's detection. Psychological Medicine 31, 555560.
The Johns Hopkins Health Services Research and Development Center (1989). Determining Injury Severity from Hospital Discharges: A Program to Map ICD-9CM Diagnoses into AIS and ISS Severity Scores. The Johns Hopkins University Press: Baltimore, MD.
Unutzer, J., Katon, W., Callahan, C. M., Williams, J. W. Jr., Hunkeler, E., Harpole, L., Hoffing, M., Della Penna, R. D., Noel, P. H., Lin, E. H., Arean, P. A., Hegel, M. T., Tang, L., Belin, T. R., Oishi, S. & Langston, C. (2002). Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. Journal of the American Medical Association 288, 28362845.
Ursano, R. J., Fullerton, C. S., Epstein, R. S., Crowley, B., Kao, T., Vance, K., Craig, K. J., Dougall, A. L. & Baum, A. (1999). Acute and chronic posttraumatic stress disorder in motor vehicle accident victims. American Journal of Psychiatry 156, 589595.
Verger, P., Dab, W., Lamping, D. L., Loze, J. Y., Deschaseaux-Voinet, C., Abenhaim, L. & Rouillon, F. (2004). The psychological impact of terrorism: an epidemiologic study of posttraumatic stress disorder and associated factors in victims of the 1995–1996 bombings in France. American Journal of Psychiatry 161, 13841389.
Wang, P. S., Lane, M., Olfson, M., Pincus, H. A., Wells, K. B. & Kessler, R. C. (2005). Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Archives of General Psychiatry 62, 629640.
Ware, J. E., Snow, K. K. & Kosinski, M. (1993). SF-36 Health Survey: Manual and Interpretation Guide. The Health Institute, New England Medical Center: Boston, MA.
Weathers, F. W., Huska, J. A. & Keane, T. M. (1991). The PTSD Checklist – Civilian Version. The National Center For PTSD, Boston VA Medical Center: Boston MA.
Wells, K. B., Burnam, M. A., Leake, B. & Robbins, L. N. (1988). Agreement between face-to-face and telephone-administered version of the depression section of the NIMH Diagnostic Interview Schedule. Journal of Psychiatric Research 22, 207220.
Wells, K. B., Sherbourne, C., Schoenbaum, M., Duan, N., Meredith, L., Unutzer, J., Miranda, J., Carney, M. F. & Rubenstein, L. V. (2000). Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. Journal of the American Medical Association 283, 212220.
Zatzick, D., Jurkovich, G. J., Gentilello, L. M., Wisner, D. H. & Rivara, F. P. (2002 a). Posttraumatic stress, problem drinking and functioning 1 year after injury. Archives of Surgery 137, 200205.
Zatzick, D., Kang, S. M., Muller, H. G., Russo, J. E., Rivara, F. P., Katon, W., Jurkovich, G. J. & Roy-Byrne, P. (2002 b). Predicting posttraumatic distress in hospitalized trauma survivors with acute injuries. American Journal of Psychiatry 159, 941946.
Zatzick, D. & Roy-Byrne, P. (2006). From bedside to bench: how the epidemiology of clinical practice can inform the secondary prevention of PTSD. Psychiatric Services 57, 17261730.
Zatzick, D., Roy-Byrne, P., Russo, J., Rivara, F., Droesch, R., Wagner, A., Dunn, C., Jurkovich, G., Uehara, E. & Katon, W. (2004). A randomized effectiveness trial of stepped collaborative care for acutely injured trauma survivors. Archives of General Psychiatry 61, 498506.
Zou, G. (2004). A modified Poisson regression approach to prospective studies with binary data. American Journal of Epidemiology 159, 702706.

A nationwide US study of post-traumatic stress after hospitalization for physical injury



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