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Management eBrief no. 66

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Management eBriefs
Issue 66May 2013

Screening for Post-Traumatic Stress Disorder (PTSD) in Primary Care: A Systematic Review


VA has implemented a screening program to identify Veterans with post-traumatic stress disorder (PTSD) during primary care visits, with the goal of initiating treatment earlier in the disease course, and ensuring delivery of mental healthcare to Veterans with this disorder. Investigators with VA's Evidence-based Synthesis Program at the Minneapolis VAMC conducted a systematic review to identify the feasibility and diagnostic accuracy of PTSD screening tools used and evaluated with a gold standard clinical interview in primary care settings. After screening nearly 2,000 articles from 1981 through October 2012, they identified 15 studies that addressed the following key questions.

Question #1
What tools are used to screen for PTSD in primary care settings, and what are their characteristics (i.e., length, format/administration, response scale)?

  • Twelve screening tools were identified from 15 studies. Seven tools focused exclusively on PTSD. All were self-administered screening tests with 1 to 27 items. Response options ranged from dichotomous scoring (yes/no) to 5-point graded frequency or severity scales.
Note: Most studies had methodological limitations affecting the strength of the evidence, which decreased confidence in study findings. Seven of the studies used Veteran or military samples.

Question #2
What are the psychometric properties and utility of the screening tools (i.e., sensitivity, specificity, likelihood ratios, predictive values, area under curve, reliability)?

  • Few studies examining the use of PTSD screening tools in primary care settings were of high quality, and only one was conducted within the VA. The Primary Care-PTSD (PC-PTSD) — the screen currently used in VA — was evaluated in three studies, all of moderate quality. Across the three studies, positive likelihood ratios ranged from 3.6 to 5.1, and negative likelihood ratios were less than 0.30.
  • The most commonly used screening tools (PC-PTSD, SPAN [Startle, Physiological arousal to reminders, Anger, and Numbness], PTSD Checklist [PCL], Breslau Scale) demonstrated reasonable performance characteristics with positive likelihood ratios. Very short screens (i.e., one or two items) performed less well, making them less clinically useful.
  • The determination of optimal cut scores (scores that separate test takers into categories, such as those with likely PTSD and those who are less likely to have it) depends on the prevalence of PTSD in the target population, and whether the primary intent of the screen is to maximize identification of possible patients with PTSD (i.e., sensitivity) or to more precisely deploy limited clinical resources to follow-up positive screens (i.e., maximize specificity). Moderate length screens (e.g., PC-PTSD) have a steeper trade-off between sensitivity and specificity across cut-scores; however, cut-scores differed little across settings.

Question #3
What information is there about the implementability (e.g., ease of administration, patient satisfaction) of PTSD screening tools in primary care clinics?

  • Only three studies examined the time it took patients to complete screening tools. Of those reported, the longest screening tool (27 items) took 5-10 minutes, suggesting that none of the screens posed a significant time burden on patients.
  • In the one study that conducted an implementation evaluation, both patients and providers found the screening tool helpful and acceptable, and that it facilitated discussion of mental health issues during the primary care appointment.

Question #4
Do the psychometric properties and utility of each of the screening tools differ according to age, gender, race/ethnicity, substance abuse, or other comorbidities?

  • There were two studies that examined differential performance characteristics of the screening tool used by VA (PC-PTSD), and in both there was weak evidence that it performs less well for women than men. High-quality studies are needed to determine if PTSD in women is missed using the cut-score currently employed in clinical settings.
  • There is weak evidence that the PCL performs less well for younger African-American Veterans, although performance characteristics are still in the acceptable range. More research is needed to determine whether use of the PCL in clinical settings leads to race disparities.
  • Although psychiatric comorbidity among Veterans with PTSD is common, there is no information about the impact of specific psychiatric conditions (e.g., traumatic brain injury) on the performance characteristics of any of the screening tools as administered in the primary care setting.

Future Research
The new Diagnostic and Statistical Manual 5 (DSM-5) criteria for PTSD are soon to be released. Although it is unlikely that the overall performance of the screening tools reported here will be appreciably altered given the new diagnostic criteria, the importance of PTSD detection and treatment in VA requires a high degree of confidence in tools used in clinical care. Accordingly, the PC-PTSD should be validated against the DSM-5 PTSD criteria. In addition, because there is weak and inconsistent evidence of possible variation in screen performance related to patient characteristics, more information is needed to determine whether screening tools for PTSD work equally well regardless of patient age, gender, race, or ethnicity. Also, there are no studies examining the impact of mental health screening on the primary care encounter within the VA healthcare system, and only one implementation study was done in a community setting. It would be helpful to have more information about how PTSD screens can best be integrated into clinical practice.

A Cyberseminar session on this ESP Report will be held on Tuesday, June 25, 2013 at 12:00pm (ET). Register here.




This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers — and to disseminate these reports throughout VA.

Reference

Spoont M, Arbisi P, Fu S, Greer N, Kehle-Forbes S, Meis L, Rutks I, Wilt TJ. Screening for Post-Traumatic Stress Disorder (PTSD) in Primary Care: A Systematic Review. VA-ESP Project #09-009; 2013.

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This Management eBrief is a product of the HSR&D Evidence Synthesis Program (ESP). ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.


This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of the HSR&D Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers - and to disseminate these reports throughout VA.

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