Background/Purpose:   Posttraumatic stress disorder (PTSD) has a prevalence of 11.5% in the outpatient setting and is associated with increased risk for multiple comorbid psychiatric and medical conditions. Studies have demonstrated an increased risk of incident RA in cohorts with PTSD, as well as increased pain scores in those with both RA and PTSD. We sought to examine variation in patient characteristics, medication use, pain level, and disease activity among Veterans with ankylosing spondylitis (AS) by PTSD status in a Veterans Affairs (VA) outpatient rheumatology clinic. 

Methods:   Veterans who had one or more visits at an outpatient rheumatology clinic at a single VA site between 1/1/14 and 12/31/15 were identified for inclusion by the presence of an ICD-9 or ICD-10 code for AS. Diagnosis of AS was confirmed by review of documentation by their primary rheumatologist. Chart review was conducted to collect information on PTSD by chart diagnosis, age, gender, race, pain score, medication use (including NSAIDs, synthetic DMARDs, biologics, and opiates), and disease activity measured using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) when documented by the clinician. Characteristics were compared by PTSD status using t-tests for continuous variables and Fischer’s exact test for categorical variables.

Results: Of 136 Veterans with ICD-9 or ICD-10 codes for AS, 113 had a rheumatologist diagnosis for AS and were included in the study. Of 113 Veterans, 20 (18%) had a diagnosis of PTSD. Those with PTSD were significantly younger, with a mean age of 52 ± 17 years as compared to those without PTSD, who had a mean age of 59 ± 14 years (p=0.04); both populations were mostly male and white. BASDAI was recorded for 30% with a mean score of 4.3 ± 2.0 indicating suboptimal control of disease. Those with PTSD had higher mean pain (see Table) and BASDAI scores as compared to those without PTSD, with a difference approaching statistical significance (p=0.06 for both comparisons). Prescribed medications were similar for both groups in regards to synthetic DMARDs, biologics, and opioids, although those with PTSD were significantly more likely to receive NSAIDs (p=0.03).

Conclusion:   Veterans with AS and concomitant PTSD are younger and have higher reported pain and disease activity scores compared to those without PTSD in this single site study. The documentation of disease activity by validated instruments such as the BASDAI is recommended in the 2015 Treat to Target guidelines for AS, as higher disease activity is associated with increased mortality. This study underscores the importance of identifying PTSD in patients with AS who report higher pain and disease activity. Future research should include identifying and treating concomitant mental health disorders in Veterans with AS, as other studies have shown improvement in chronic pain with treatment of PTSD. 

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/posttraumatic-stress-disorder-and-correlates-of-disease-activity-among-veterans-with-ankylosing-spondylitis/