19/09/2017 Delayed-onset post-traumatic stress disorder among war veterans in primary care clinics

THE BRITISH JOURNAL OF PSYCHIATRY

BrJPsychiatry.2009Jun194(6):515520. PMCID:PMC2746686
doi:10.1192/bjp.bp.108.054700 NIHMSID:NIHMS114549

Delayedonsetposttraumaticstressdisorderamongwarveteransin
primarycareclinics
B.ChristopherFrueh
TheMenningerClinicandtheMenningerDepartmentofPsychiatryandBehavioralSciences,BaylorCollegeofMedicine,Houston,Texas,
USA

AnoukL.Grubaugh,DerikE.Yeager,andKathrynM.Magruder
VeteransAffairsMedicalCenterandDepartmentofPsychiatryandBehavioralSciences,MedicalUniversityofSouthCarolina,Charleston,
SouthCarolina,USA

B.ChristopherFrueh,DepartmentofPsychology,UniversityofHawaii,200W.KawiliSt.,Hilo,HI96720,USA.Email:frueh@hawaii.edu

Received2008May8Revised2008Oct8Accepted2008Dec3.

Copyright2009,RoyalCollegeofPsychiatrists

Abstract
Background

Onlylimitedempiricaldatasupporttheexistenceofdelayedonsetposttraumaticstressdisorder(PTSD).

Aims

ToexpandourunderstandingofdelayedonsetPTSDprevalenceandphenomenology.

Method

Acrosssectional,epidemiologicaldesign(n=747)incorporatingstructuredinterviewstoobtainrelevant
informationforanalysesinamultisitestudyofmilitaryveterans.

Results

AsmallpercentageofveteranswithidentifiedcurrentPTSD(8.3%,7/84),currentsubthresholdPTSD
(6.9%,2/29),andlifetimePTSDonly(5.4%,2/37)metcriteriafordelayedonsetwithPTSDsymptoms
initiatingmorethan6monthsaftertheindextrauma.Altogetheronly0.4%(3/747)oftheentiresample
hadcurrentPTSDwithdelayedonsetsymptomsdevelopingmorethan1yearaftertraumaexposure,and
noPTSDsymptomonsetwasreportedmorethan6yearsposttrauma.

Conclusions

RetrospectivereportsofveteransrevealthatdelayedonsetPTSD(current,subthresholdorlifetime)is
extremelyrare1yearposttrauma,andtherewasnoevidenceofPTSDsymptomonset6ormoreyears
aftertraumaexposure.

Arecentsystematicreview1ofdelayedonsetposttraumaticstressdisorder(PTSD)concludedthatthereis
`noconsensusemergingastoitsprevalence'andthatstudiesdemonstratingdelayedonsetPTSDinthe
absenceofpriorsymptomsarequiterare,althoughdelayedonsetdefinedasanexacerbationor
reactivationofpriorsymptomsisrelativelycommon(38.2%ofmilitaryand15.3%ofciviliancasesof
PTSD).ScepticsofdelayedonsetPTSDhavecriticisedtheempiricaldatauponwhichitisbasedandhave
questionedtheexistenceofthephenomenon.2,3Forexample,twolargescaleepidemiologicalstudieshave
reportedzeroorextremelylowratesofdelayedonsetPTSD(01%ofallcasesofidentifiedPTSD)in
civilians4,5whereasasmallerstudyofformerprisonersofwarreportedthatonly1.4%ofallindividuals

6
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hadPTSDwithdelayedonset.6Alternatively,twootherlargescalestudieshavereportedhigherratesof
delayedonsetPTSDincivilians(0and8%)andveterans(16%and22%),althoughwithsomewhat
differentratesbetweenstudies.7,8Anumberofothersmallerstudieshavereportedawiderange(ashigh
as>60%)ofdelayedonsetPTSDinciviliansandveterans.1,914Limitationsoftheliteratureincludethe
factthatmoststudiesonlylookatrespondents'PTSDrates1or2yearsaftertheindextraumaticevent,
whichshedslittlelightononsetthatmayoccur20or30yearslater.Furtherempiricalstudiesareneededto
advanceourunderstandingoftheconcept,prevalenceandphenomenologicalfeaturesofdelayedonset
PTSD.

Method
WesoughttoexaminedelayedonsetPTSDinalargemultisitestudyconductedwithmilitaryveteransin
primarycareclinics.UsingthissamplewehadpreviouslyexaminedPTSDprevalenceandcorrelates,
reportingaPTSDpointprevalence(currentPTSD)of11.5%,15currentsubthresholdPTSDpoint
prevalenceof4.6%,16andthatveteransintheoldestgroup(age65,6.3%)hadonethirdthePTSD
prevalenceofthoseinthemiddleagedgroup(ages4564,18.6%),despitehigherratesofcombat
exposure.17Posttraumaticstressdisorderinthissamplewaspositivelyassociatedwithavarietyof
comorbidpsychiatricdisorders,malegender,warzoneservice,age<65years,notworking,lessformal
educationandreducedfunctioning.15

GiventhatPTSDsymptomsmaywaxandwaneovertime,13itwasdeemedrelevanttoexaminedelayed
onsetofcurrentPTSDsymptomsthataresubsyndromal(i.e.`subthresholdPTSD')ornowinremission
(e.g.`lifetimePTSDonly').Thus,inthepresentstudyweconductednewanalyseswiththissamplein
ordertoaddressseveralimportantquestions.

a.AmongveteransidentifiedwithPTSD,whatistheprevalenceof`delayedonset'?
b.AmongveteransidentifiedwithcurrentsubthresholdPTSDandlifetimePTSDonly,whatisthe
prevalenceof`delayedonset'?
c.AmongveteransidentifiedwithdelayedonsetcurrentPTSD,subthresholdPTSDandlifetimePTSD
only,whatdoesthetimecourseofsymptomonsetlooklike(e.g.aretherecasesofPTSDonsetmore
than5,10,20yearsposttrauma)?
d.IfratesofdelayedonsetPTSDsymptomsarehighenoughtopermitadditionalanalyses,arethere
relevantpredictors(e.g.ethnicity,age,education)orcorrelates(e.g.otherpsychiatricsymptomsor
disorders,healthstatus,disability,healthcareserviceuse)thatcanbeidentified?

AnswerstothesequestionswillcarryimplicationsfortheevidencebaserelevanttomanagingPTSD
disabilityclaimsandclinicalserviceneeds.

Studydesignandprocedures
DatawerepartofalargercrosssectionalstudyconductedonarandomsampleofveteransatfourUS
VeteransAffairsMedicalCenters'primarycareclinics.15Studyparticipantswererandomlyselectedfrom
amasterlistofpatientsduringthefiscalyear1999ateachoftheVeteransAffairsprimarycaresites.
Consentingparticipantswereprovidedwithasemistructuredclinicassessmentandwithin2monthswere
administeredastructuredtelephoneinterviewbymaster'slevelclinicianstrainedandsupervisedbya
licensedclinicalpsychologist.Studymeasureswerereadaloudtoallparticipantsbecausemanywere
unabletoreadthembecauseofvisionproblemsorinsufficientliteracyskills.Additionally,usingavailable
medicalcharts,weconducteda12monthretrospectivereviewofeachparticipant'sVeteransAffairs
treatment.Initialexclusionarycriteriaincludedthepresenceofdementiarelatedsymptoms,andbeingage
80orolder.Afterprovidingacompletedescriptionofthestudytotheparticipants,writteninformed
consentwasobtained.Thisstudywasconductedwithfullapprovalfromrelevantinstitutionalreview
boards.

Contactinformationofparticipantswhocompletedonsiteclinicassessmentswassenttotheprimarysite,
whereclinicians(master'slevelandabove)telephonedthemtoadministerstructuredinterviews.Theuse
oftelephoneinterviewsofpotentialtraumavictimstoassessfortraumaticeventexposureandPTSD
symptoms,usingawiderangeofinstruments,hasbeenrelativelywidespreadinepidemiologicalresearch
18
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overthepast15years, withstrongpsychometricpropertiesandvirtuallynostatisticaldifferencesinrates
ofeithertraumaexposureorPTSDdiagnoseswhencomparedwithtraditionalfacetofaceinterviews,
includingsamplesofelderlyadults.19

Participants
Atotalof1198randomlyidentifiedveterans(knowntobealive)wereapproachedforstudyparticipation.
Ofthissample,885veterans(74%)providedaninformedconsenttoparticipateduringtheclinicinterview.
Asaresultofmissingfollowuptelephoneinterviewdata,ourfinalsamplewasreducedto747veterans.
Theaverageage(s.d.)ofthefinalfullsample(n=747)was61.23years(s.d.=11.81),witharangefrom
25.50to81.12years.DemographiccharacteristicsforthesamplearesummarisedinTable1.

Conceptualdefinitionof`delayedonset'
Thereisanotablelackofclarityregardingtheconceptualdefinitionof`delayedonset'.Merelybecausea
disorderisrecognisedmanyyearsaftertheaetiologicaleventisnotevidencethatonsetofthedisorderwas
`delayed'.IthasbeennotedthatPTSDdiagnosedmorethan6monthsafteratraumaticeventmayindicate
delayedtreatmentorseekingofdisabilitybenefits,delayedonsetofanysymptomsofPTSD(identifiedas
`definition1'byAndrewsetal)1,ordelayedonsetofthefulldisordersuchthatachangeinoneortwo
symptomsaltersPTSDdiagnosticstatus(identifiedas`definition2'byAndrewsetal).Anotherissueisthe
actualtimeintervalfromtraumaticexposuretoonset,with`delayedonset'countingasanyPTSDonset
thatoccursfrom7monthsto50ormoreyearsposttrauma.Thus,thereisdefinitionalandconceptual
ambiguityinDSMIV20thataffectsourunderstandingofdelayedonsetPTSD.Infact,Spitzeretal3have
proposedrevisedPTSDdiagnosticcriteriaforDSMV,changingtheonsetcriterion(criterionE)toreadas
either`thesymptomsdevelopwithinaweekoftheevent'or`ifdelayedonset,theonsetofsymptomsis
associatedwithaneventthatisthematicallyrelatedtothetraumaitself(e.g.,onsetofsymptomsinarape
survivorwheninitiatingasexualrelationship)'.

Measures
TheTraumaAssessmentforAdultsSelfReportVersion(TAA)21assessesthelifetimeprevalenceof
trauma(bothmilitaryandnonmilitary)andhasbeenwidelyusedtoscreencommunityandmedical
populationsfortraumahistory,findingtraumaprevalenceratessimilartothoseofotherlargescale
studies.22ThissurveyprovideddatatocategoriseindividualsaseithermeetingorfailingtomeetDSMIV
PTSD'straumaexposurecriterionA.

TheClinicianAdministeredPTSDScale(CAPS)23wasadministeredtothoseparticipantswhoendorseda
traumaticeventontheTAA.TheCAPSisastructuredclinicalinterviewthatmeasurestheintensityand
frequencyofthe17DSMIVPTSDsymptoms.TheCAPShasexcellentpsychometricpropertiesand
utilityformakingPTSDdiagnoses.22Forthepresentstudy,theCAPSwasusedtomakeclassificationsof
currentPTSDandsubthresholdPTSD.Participantsweredesignatedashaving`currentPTSD'iftheymet
criterionAontheTAA,andcriteriaB,CandDontheCAPS,withclinicallysignificantdistressor
impairmentandadurationofallCAPSsymptomsgreaterthan1monththepresenceofsymptomswas
basedonthe`frequency1/intensity2'CAPSscoringrule.23,24ForcurrentsubthresholdPTSD,the
algorithmwasbasedonapriordefinition,25whichrequiresendorsementofthecriterionAandcriterionB
symptomclusters,meetingdiagnosticcriteriaforeitherthecriterionCorcriterionDsymptomcluster,and
endorsementofclinicallysignificantdistressandimpairment.Amutuallyexclusivecategoryforlifetime
PTSDonlywasdesignatedforthosewhometPTSDcriteriaatsomepriorpointintheirlife,butdidnot
currentlymeetcriteriaforthedisorderorforsubthresholdPTSD.Interraterreliabilityanalysesona
randomsampleofinterviews(approximately8%)showedraterswere100%concordantforPTSD
diagnosesontheCAPS.

OnsetofPTSDsymptomswasestablishedviaitem18ontheCAPSinterview,whichinquireswhenthe
respondentfirststartedhavingendorsedPTSDsymptoms,expressedintermsofthenumberofmonths
aftertheindextraumaticeventthatsymptomsstarted.Thus,thisdefinitionisconsistentwithAndrewet
al's1`definition1'ofdelayedonsetsinceitdoesnotaskaboutfullPTSDcriteria,butratheronsetofany
`PTSDsymptoms'.Assuch,itrepresentsaconservativeinterpretationofthe`delayedonset'PTSD
1
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subtype.Also,asrecommended1weexpresstherateofdelayedonsetPTSDastheproportionofthose
withPTSD(orsubthresholdPTSDorlifetimePTSDonly,asthecasemaybe).Thisstudywasdesignedso
thatitwouldhavemetAndrewsetal'scriteriaforinclusionintheirrecentsystematicreviewofprevalence
studiesondelayedonsetPTSD.

Othermeasuresandinterviewsincludedintheparentstudyofpotentialrelevancetothecurrentstudywere
theShortFormHealthSurvey(SF36),27PostTraumaticStressDisorderChecklistCivilian(PCLC),28
andMiniInternationalNeuropsychiatricInterview(MINI).29Wealsoconductedanexaminationof
electronicmedicalrecordsforthe12monthsprecedingstudyinitiationforeachconsentingparticipant,via
researchpersonnelmaskedtothediagnosticstatusofparticipants,whichincludedmedicalandpsychiatric
diagnoses/conditionsandVeteransAffairshealthcareserviceuseintheyearprecedingstudyparticipation.

Overviewofanalyticstrategies
Analyseswereconductedwithveteransinthissampleto:

a.identifyprevalenceofdelayedonsetcurrentPTSD
b.identifyprevalenceofdelayedonset`subthresholdPTSD'(basedon`current'symptoms)and
`lifetimePTSDonly'(pasthistoryofthedisorder,butnotcurrentlymeetingcriteriaforeithercurrent
PTSDorcurrentsubthresholdPTSD)
c.examinethetimecourseofonsetforcurrentPTSD,subthresholdPTSDandlifetimePTSDonlyin
identifiedcasesand
d.ifcellsizespermitted,examinerelevantpredictors(e.g.ethnicity,age,education)andcorrelates(e.g.
otherpsychiatricsymptomsordisorders,healthstatus,disability,healthcareserviceuse)ofdelayed
onsetinordertoenhanceourunderstandingofthephenomenon.

Results
AsmallpercentageofveteranswithidentifiedcurrentPTSD(8.3%,7/84),subthresholdPTSD(6.9%,
2/29),andlifetimePTSDonly(5.4%2/37)metcriteriafordelayedonsetPTSD.Table2showsthe
frequencydistributionoftemporalonsetofPTSDfromtheindextraumaticeventonly3of747(0.4%)
veteranshadcurrentPTSDwithdelayedonsetofsymptomsdevelopingmorethan1yearafterthetrauma,
andthesewereat4yearsposttraumafortwoindividualsandat6yearsposttraumafortheother
individual.Oneofthesewasafemalewithchildhoodsexualabuseandnocombatexposure.Thetwo
participantswithdelayedonsetsubthresholdPTSDhadreportedonsetsof9and16monthsposttrauma.
BecausethenumberofdelayedonsetcurrentPTSD,subthresholdPTSD,andlifetimePTSDonlycases
wassolow(seven,twoandtworespectively),secondaryanalysesrelatedtopredictorsandcorrelatesof
delayedonsetwasnotconsideredfeasible.However,severaldescriptiveobservationscanbemade
regardingthesevenindividualswithdelayedonsetcurrentPTSD:sixreportedmultipletraumaticevents
sixwereWhitesixweremalefivewerereceivingVeteransAffairsserviceconnecteddisability
paymentsfivewerewithinthe4564agegroup,onlyonewas65yearsofageandtwowerenotrelated
tocombatexposure.

Discussion
Resultsshowthat8.3%ofthoseidentifiedwithcurrentPTSDmetcriteriafordelayedonsetusinga
conservativedefinitionoftheconstruct.Further,6.9%ofthoseidentifiedwithcurrentsubthresholdPTSD
and5.4%ofthoseidentifiedwithlifetimePTSDonlymetcriteriafordelayedonset.Consistentwiththe
conclusionsofarecentreview1thesefindingsindicatethatdelayedonsetPTSDoccurs,butisrareinthis
large,representativesampleofveterans.OnemightexpectthatPTSD,especiallydelayedonsetPTSD,
wouldbemoreprevalentinolderveteransifdelayedonsetiscommongiventhelongertimeforonsetto
occur.Infact,aswehavepreviouslyreported,PTSDratesamongtreatmentseekingveteransare
substantiallylowerinthe65agegrouprelativetothe4564agegroup,17andcurrentresultsshowonly
oneoftheveteransreportingdelayedonsetcurrentPTSDasolderthan64.BecausePTSDsymptomsmay
waxandwaneovertime,13weexaminedonsetofsubthresholdPTSDsymptomstolearnwhetherthere
mightbealargenumberofveteranswithdelayedonsetPTSDsymptomslurkingjustbeneaththe
thresholdforfullPTSD.Thiswasnotfoundtobethecase,suggestingthattherearefewveteranswith
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delayedonsetsymptomsofsubthresholdPTSDwhoarelikelytodevelopfulldelayedonsetPTSDbythe
waxingofafewsymptomsinthefuture.

Prevalence,temporaldistributionanddefinitions
TheDSMIVdefines`delayedonset'PTSDasonsetoccurringat6ormoremonthsafterindextrauma
exposure,awidetimeframe.Therefore,examinationofthefrequencydistributionoftemporalonsetof
currentPTSD,subthresholdPTSDandlifetimePTSDonlyrelativetotheindextraumaticeventis
instructive.Over90%ofcurrent(77/84)andsubthreshold(27/29)casesofPTSDreportedsymptom
developmentwithinthefirstmonthaftertheindextraumaticevent,whereasonly0.4%(3/747)ofthe
entiresampledevelopedcurrentPTSDwithsymptomsdevelopingmorethan1yearafterthetrauma(that
is,3.6%(3/84)ofthosewithcurrentPTSD).Further,therewasnoPTSDsymptomonsetforanygroup
(currentPTSD,subthresholdPTSD,lifetimePTSDonly)reportedmorethan6yearsposttrauma.In
combination,thesedataindicatethatPTSDsymptomonset6ormoreyearsaftertraumaexposureamong
veteranseitherdoesnotoccurorisexceedinglyrare.Oneimplicationifthesefindingsarereplicatedisthat
thedramaticrecentincreaseinthenumberofUSVietnamveteransseekingVeteransAffairsdisability
paymentsforPTSD29cannotbeexplainedastheresultofagrowingnumberofnewcasesof`delayed
onset'PTSD.Thus,thesedatahaveimplicationsforoneaspectofthecurrentdiscussion29regarding
VeteransAffairsPTSDdisabilityadministrativetrendsandpolicies.

AlthoughthesedataonprevalenceandtemporaldistributionofdelayedonsetPTSDareimportant,theydo
notclarifytheambiguityintheDSMIVdefinitionof`delayedonset'orspeaktothemeaningofdifferent
temporalonsets(e.g.onsetat7months,4yearsand50yearsarecurrentlyclassifiedtogether),exceptto
indicatethatlateronsetiseitherrareornonexistent.Further,asaresultofsmallcellsizes,other
phenomenologicalfeaturesorcorrelatesofdelayedonsetPTSDarenotsatisfactorilyaddressedbythe
currentdata.Observationallywenotedthatinamajority(fiveofseven)ofindividualswithdelayed
onsetcurrentPTSDtheveteranswere:maleWhitereceivingdisabilitybenefitswithinthe4564age
groupandreportingmultipletraumaticevents.SincemostpeoplewithdelayedonsetPTSDinthissample
hadhadmultipletraumaticeventexposures,perhapsPTSDrelatedtoanindextrauma(nearlyalways
reportedascombat,whencombatexposurewaspresent)isactivatedbysubsequentexposure,orincreases
vulnerabilitytosubsequentstressorsortraumaticcues.EitherwouldbeconsistentwithSpitzeretal's3
proposedrevisionstoDSMVcriteriathatdelayedonsetbe`associatedwithaneventthatisthematically
relatedtothetrauma'.Unfortunately,thedatawerenotobtainedinthecurrentstudythatwouldallowusto
examineprecipitatingfactorsforonset,andthisissuethereforeremainsanopenquestion.

Cohorteffects
ThefindingthatPTSDismorecommoninyoungerveteranssuggestsapossiblecohorteffect,whichraises
thequestionofwhethertherewillbehigherratesofdelayedonsetinfuturegenerationsofmilitary
veterans.Apreviousfindingfromthissample17wasthatveterans65yearsofagereportlowerPTSDand
bettermentalhealththanthoseunder65.Otherstudieshavealsofoundevidenceofcohorteffects,with
lowerratesofPTSDamongSecondWorldWarveterans30relativetostudiesofVietnamveterans.Several
possibleexplanationsmayaccountforthisfinding.First,peoplemaybecomemorepsychologically
healthyastheyage(e.g.amaturationalageingprocess).Second,olderveteransmaybelesslikelyto
acknowledgepsychiatricsymptomsthatexist(e.g.asocioculturalcohorteffectrelatedto`selfreliance'or
perceptionsregardingstigmaformentalillness).Third,veteranswithpsychiatricproblemsmaybeless
likelytosurvivetoadvancedage(e.g.amortalityeffect).Last,youngerveteransmaybemoresensitiveto
andmorelikelytoreportpsychiatricsymptomsbasedonchangingsocialexpectations(e.g.evolving
interpretationsandperceptionsofpsychiatricillnessesorasociallearningeffect).31Thisfitswithgeneral
internationaltrendstowardshigherlevelsofpsychiatricdisabilityamongyoungergenerations,aswellas
disorderspecificnuancessuchasthefindingthat`flashbacks',whichareacommonsymptomamong
recentcombatveterans,areconspicuouslyabsentamongveterans'symptomreportspriortotheVietnam
War.32ThereislittlebasisfromthecurrentdatatoexpectsignificantratesoffuturedelayedonsetPTSDin
thoseyoungerveteranscurrentlywithoutPTSDsymptomsinthissample.However,onemightwonder
whetherdelayedonsetPTSD,like`flashbacks',ispossiblyaculturallyboundexpressionlikelytobecome
moreprevalentinthefuture.
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Limitations
Thisstudyhasimportantlimitationsinherentinthecrosssectional,retrospectivenatureofitsdesign.
Certainly,thereisreasontobeconcernedaboutthepotentialforinstabilityofrecallandvariousmemory
biases.1,3335Thus,recallorreportbiascannotbeexcludedintheascertainmentofcombatexperiences,
PTSDsymptomseverityorthetimeofonsetforPTSDsymptoms.Datashowthatmilitaryveterans'
reportsofcombatexposureandothermilitaryhazardscanchangeovertime36andmayevenbesubjectto
exaggeration.37Further,recallforsymptomonsetthatmayhaveoccurredaslongas40or50yearsagois
likelytoinvolveacertaindegreeofimprecision.Weacknowledgethisasanimportantlimitationofthis
study,asitisformoststudiesreportingonpasttraumaexposuresordelayedonsetPTSD.However,as
Andrewsetal1note,therearealsodisadvantagestoprospectivestudies,giventhat`individualsmayhave
hadonsetsofPTSDafteroneassessmentthatthenremittedbeforethenext'.Inotherwords,manyexisting
longitudinalPTSDstudieshavesignificantflawswithregardtoprecisionofonsetestimates.Forexample,
ina20yearlongitudinalstudy,veterans(n=214)wereassessedatfourtimepoints(1year,2years,3
yearsand20yearspostcombat)witha17yeargapbetweentimepointthreeandtimepointfour.14Thus,
itisnotclearwhenPTSDonsetsaftertimepointthreeoccurred,andthesamplewassoheavily
pathologicalatthestudyoutset(61%ofthesamplehadahistoryofcombatstressreactions,45%met
criteriaforPTSDattimepointone)thatgeneralisabilityisaconcern.Thus,thereremainsalargegapin
theknowledgebaseregardingdelayedonsetPTSD,especiallyamongveteransandexistingstudiesmay
evencontributetopotentialmisconceptionsabouttheprevalenceofdelayedonsetPTSD.

Strengths
Thenotedlimitationsofourcrosssectionaldesignarebalancedbyimportantstudystrengths,includinga
large,representativesampleofveteransfromVeteransAffairsprimarycareclinics,inclusionofalong
timeframeposttrauma(typically2540yearsinthissample)forpotentialPTSDonsettooccur,anduse
ofwidelyaccepted,psychometricallyrobuststructuredclinicalinterviewsforevaluatingtraumaticevent
exposureandPTSDassessment.ThisstudydesignwouldhavemetAndrewsetal's1suggestedcriteriafor
inclusionintheirsystematicreviewofprevalencestudiesondelayedonsetPTSDandthereforerepresents
ameaningfuladditiontoanimportant,yetunderstudiedandlikelymisunderstood,conceptualaspectof
PTSD.EvenifwestipulatethatcurrentestimatesofPTSDsymptomonsetinoursampleareunlikelytobe
preciselyaccurate,itseemsplausiblethatestimatesareatleastinthe`ballpark'.Notably,thereisno
recencyeffectforreportedPTSDonset,asonemightexpectgivendatathatpeoplemayforgetpast
episodesofotherpsychiatricdisorders.34Infact,theconverseappearstobetruehere,wherepeoplewith
currentPTSDrecalltheirsymptomonsetasoccurringmanyyearsbefore,shortlyaftertheindextrauma,
andpersistingchronicallytothepresenttime.Thus,ifwecollapseonsetsintothreegeneraltimeperiods
weareleftwiththeessenceofanimportantfinding:forthosewithcurrentPTSD,symptomonsetoccurs
primarilywithinthefirst6monthsaftertheindextraumaticevent(91.6%,77/84),withnoonsetoccurring
after6yearsposttrauma.Alltold,thevastmajority(96.4%,81/84)ofcurrentPTSDonsetsoccurred
withinthefirstyearposttrauma,andasimilarpatternholdsforsubthresholdPTSDandlifetimePTSD
only.Thus,PTSDsymptomonsetisremarkablyconsistentacrossourthreegroups(current,subthreshold,
lifetimeonly).Moreover,theoverallpatternofonsetandthefactthatwedidnotfindasingleincidentof
`late'delayedonsetisconsistentwiththefindingsofthemostmethodologicallyrigorouslargescale
prospectivestudieswithciviliansamples5,6andwithhistoricalperspectivesregardingpostcombat
psychiatricreactionsgainedfromexperiencewithveteransoftheFirstWorldWar.38

Futureresearch
Futureadditionallongitudinalresearchisneededtoenhanceourunderstandingoftheonsetandcourseof
PTSDinveteranandciviliantraumasurvivors,includingdefinitionalclarity,prevalence,temporal
distributionofdelayedonsetsandphenomenologicalfeaturesassociatedwithdelayedonset.Such
longitudinalepidemiologicalresearchshouldtaketheformofroutinehealthsurveillanceamongveterans
deployedtowarzonesandotherrelevantpopulations.33Findingswillhaverelevancetoongoingeffortsto
refinePTSDdiagnosticcriteriaanddevelopmentofservicesandbenefitsforveterans.

Funding
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ThisworkwaspartiallysupportedbygrantsVCR990102fromVeteransAffairsHealthServices
ResearchandDevelopment(VeteransAffairsHSR&D)toK.M.M.,grantCD207015fromVeterans
AffairsHSR&DtoA.L.G.,grantMH074468fromtheNationalInstituteofMentalHealth(NIMH)to
B.C.FandawardsfromtheMcNairFoundationandMenningerFoundation.Thisworkwasalsosupported
bytheOfficeofResearchandDevelopment,MedicalResearchService,DepartmentofVeteransAffairs.
Allviewsandopinionsexpressedhereinarethoseoftheauthorsanddonotnecessarilyreflectthoseofour
respectiveinstitutionsortheDepartmentofVeteransAffairs.

Acknowledgments
WethankCarlaSharp,Ph.D.forherhelpfulcommentsonanearlierdraftofthismanuscript,aswellasthe
thoughtfulcritiquesofthreeanonymousreviewers.

Notes
Declarationofinterest

None.

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FiguresandTables

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19/09/2017 Delayed-onset post-traumatic stress disorder among war veterans in primary care clinics

Table1
Demographicdescriptorsforparticipantsinthefullsample

Fullsample(n= CurrentPTSD(n SubthresholdPTSD(n LifetimePTSDonly(n

747) =84) =29) =37)
Gendermale,% 93.3 97.6 93.1 83.8
Ageinyears,mean(s.d.) 61.23(11.81) 57.35(10.94) 58.55(13.05) 57.42(10.56)

Maritalstatus,%
Alone 29.7 27.4 20.7 21.6
Withsomeone 70.3 72.6 79.3 78.4

Workstatus,%
Working 32.9 23.8 24.1 32.4
Notworking 67.1 76.2 75.9 67.6

a
Minoritystatus, %
White 62.7 59.5 50.0 70.3
Allother 37.3 40.5 50.0 29.7

Education,%
<thanhighschool 21.7 20.2 31.0 5.4
degree
Highschool/some 62.4 73.8 58.6 75.7
college
Collegedegreeor 15.9 6.0 10.3 18.9
postgraduate

Militaryvariables,%
Combat 50.2 85.7 67.9 72.2
Serviceconnected 45.2 60.7 37.9 73.0
disability

PTSD,posttraumaticstressdisorder
a.
WiththeexceptionofthreeveteransclassifiedasHispanicor`Other',allotherminoritymemberswereAfricanAmerican

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Table2
Frequencydistributionoftemporalonsetofcurrentposttraumaticstressdisorder(PTSD),subthreshold
PTSDandlifetimePTSDonly,fromtheindextraumaticevent

n(%)

PTSDonsetfromindextraumaticevent, CurrentPTSD(n= SubthresholdPTSD(n= LifetimePTSDonly(n=

a
months 84) 29) 37)
01 77(91.7) 27(93.1) 34(91.9)

25 0 0 1(2.7)
612 4(4.8) 1(3.4) 2(5.4)

1348 0 1(3.4) 0

4972 3(3.6) 0 0

73ormore 0 0 0

a.
Inthecompletesampletherewere86veteranswithPTSDand34withsubthresholdPTSD,29butasaresultofmissing
valuesonthedelayedonsetvariable,theresultingabovecellsizesarereported

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