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The importance of psychological morbidity after major trauma, such as posttraumatic stress disorder (PTSD), is continuing to gain attention in trauma outcomes research. The Trauma Recovery Project is a large prospective epidemiologic study designed to examine multiple outcomes after major trauma, including quality of life (QoL) and PTSD. The specific objectives of the present report are to examine risk factors for PTSD and to assess the impact on QoL at the 6-, 12-, and 18-month follow-up time points in the Trauma Recovery Project population.Between December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the study. The enrollment criteria for the study included age 18 years and older, admission Glasgow Coma Scale score of 12 or greater, and length of stay > 24 hours. QoL was measured after injury using the Quality of Well-being scale, a sensitive index to the well end of the functioning continuum (range, 0 = death to 1.000 = optimum functioning). Early symptoms of acute stress reaction (SASR) at discharge were assessed using the Impact of Events Scale (score > 30 = SASR). PTSD at 6-month follow-up was diagnosed using standardized Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, criteria. Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge.PTSD was diagnosed in 32% (261 of 824) patients at 6-month follow-up. Perceived threat to life predicted PTSD onset (odds ratio [OR], 1.6;p < 0.01) and early SASR (OR, 2.2;p < 0.001). PTSD was more frequent in women (39%) than in men (29%) and in younger low-income patients. Other major risk factors were penetrating trauma (OR, 2.3;p < 0.001) and assaults (OR, 1.5;p < 0.05). PTSD had a major impact on QoL at 6-, 12-, and 18-month follow-up (Quality of Well-being scale score: 6 months, 0.576 vs. 0.658; 12 months, 0.620 vs. 0.691; 18 months, 0.620 vs. 0.700;p < 0.0001).These results provide new and provocative evidence that perceived threat to life and mechanism predict PTSD after major traumatic injury. PTSD had a prolonged and profound impact on short- and long-term outcome and QoL.