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IIR 15-103 – HSR&D Study

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IIR 15-103
Validation of the PTSD Primary Care Screen
Michelle Jeri Bovin PhD
VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA
Boston, MA
Funding Period: January 2017 - May 2019

BACKGROUND/RATIONALE:
Given the high prevalence of posttraumatic stress disorder (PTSD) in Veterans, VA mandates that all Veterans be screened for PTSD annually for the first five years after military separation and every five years thereafter, unless the Veteran has had a PTSD diagnosis entered in his/her medical record in the past year (Vista Clinical Reminder User Manual, 2007). Screening typically takes place in primary care because most patients who have received mental health diagnoses are seen there. Currently, VA uses the Primary Care PTSD screen (PC-PTSD) to identify Veterans with probable PTSD. This 4-item questionnaire is based on the PTSD diagnostic criteria included in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). In 2013, the DSM-5 was introduced, which included several significant revisions to the PTSD diagnosis. In response, the PC-PTSD was updated to add (1) a trauma-specific stem that reflects changes made to PTSD Criterion A and (2) a new item that reflects the revisions made to the PTSD symptom criteria. The new instrument, the PC-PTSD-5, therefore reflects the new knowledge the field possesses about PTSD. Despite this, VA continues to use the old version until a valid cutoff for the PC-PTSD-5 is established. Although initial pilot data for the PC-PTSD-5 indicate it is psychometrically sound, it has not yet been compared with a gold standard PTSD diagnostic interview, such as the Clinician Administered PTSD Scale for DSM-5 (CAPS-5), in a VA primary care setting.

OBJECTIVE(S):
The objectives of the study are to: (a) establish a cutpoint for the PC-PTSD-5 in a primary care Veteran sample by validating it against the CAPS-5; (b) explore whether the optimally sensitive cutpoint for the PC-PTSD-5 varies by gender, race, ethnicity, age, military sexual trauma (MST) status, traumatic brain injury (TBI), and psychiatric comorbidity; and (c) gather initial data on the acceptability of the PC-PTSD-5 to Veterans.

METHODS:
We conducted a two-session psychometric study of the PC-PTSD-5 using a consecutive sample of primary care treatment seeking Veterans. Across two sites (Boston and Palo Alto), 495 male and female Veterans completed session 1 of the study. During this session, participants completed several self-report measures on demographic characteristics, potentially traumatic experiences, and psychiatric disorders. Within 30 days of session 1 (M = 12.04 days; SD = 7.79 days), 429 of these Veterans participated in session 2 of the study (86.7% retention rate). Participants first completed the PC-PTSD-5 and a PC-PTSD-5 acceptability questionnaire. They were then interviewed by a doctoral-level clinician, blind to the PC-PTSD-5 results, using the CAPS-5.

FINDINGS/RESULTS:
Of the 429 participants who returned for session 2 of the study, 399 (16.1% female) had complete data on both the PC-PTSD-5 and the CAPS-5. According to the CAPS-5 2/23SEV rule (Weathers et al., 2018), 16.5% (n = 66) met criteria for PTSD.

To address our primary aim, we used signal detection analyses. Results indicated that whereas the cutoff score that best balanced optimal sensitivity ( [1] = .84) with adequate specificity (.79) was 3, the cutoff score with optimal efficiency ( [.5] = .63) was 4.

To address our secondary aim, we conducted additional signal detection analyses to determine if the optimal cutoff score on the PC-PTSD-5 varied across different Veteran subgroups of interest. Overall, subgroups tended to display the same pattern of results as the total sample, such that a cutoff of 3 was optimally sensitive, and a cutoff of 4 was optimally efficient. However, there was some variation. For example, among men (n = 334; 14.4% with PTSD), the optimally efficient cutoff score was 4 ( [.5] = .64) and the optimally sensitive cutoff score was 3 ( [1] = .85). However, among women (n = 64), who had a significantly higher rate of PTSD (28.1%), a cutoff score of 5 was optimally efficient ( [.5] = .61), although a cutoff score of 3 was still optimally sensitive ( [1] = .80).

To address our third aim, we examined the responses participants provided on the PC-PTSD-5 acceptability questionnaire. Results indicated that most participants found the PC-PTSD-5 questions easy/very easy to understand (n = 400; 93.5%); found the PC-PTSD-5 questions easy/very easy to answer (n = 352; 82.1%); and found the instructions for the instrument clear/very clear (n = 413; 96.5%). Furthermore, most participants indicated that they would be comfortable/very comfortable answering these questions at a primary care appointment (n = 352; 82.2%). Participants indicated that, in general, they would prefer to be asked these questions by their primary care provider (as opposed to filling out a questionnaire on their own or telling a nurse or another primary care doctor).

IMPACT:
Study results will have both immediate and long-term implications for VA. Our identification of a valid cutoff score for the PC-PTSD-5 will have an immediate impact on VA's ability to accurately identify and treat Veterans with PTSD. In addition, the data obtained provides pertinent information on how to optimize PTSD screening in VA, which we are working to disseminate.

PUBLICATIONS:

Journal Articles

  1. Lee DJ, Bovin MJ, Weathers FW, Palmieri PA, Schnurr PP, Sloan DM, Keane TM, Marx BP. Latent factor structure of DSM-5 posttraumatic stress disorder: Evaluation of method variance and construct validity of novel symptom clusters. Psychological assessment. 2019 Jan 1; 31(1):46-58.
  2. Kimerling R. Sexual Assault and Women's Health: Universal Screening or Universal Precautions?. Medical care. 2018 Aug 1; 56(8):645-648.
  3. Moshier SJ, Bovin MJ, Gay NG, Wisco BE, Mitchell KS, Lee DJ, Sloan DM, Weathers FW, Schnurr PP, Keane TM, Marx BP. Examination of posttraumatic stress disorder symptom networks using clinician-rated and patient-rated data. Journal of abnormal psychology. 2018 Aug 1; 127(6):541-547.
  4. Babson KA, Wong AC, Morabito D, Kimerling R. Insomnia Symptoms Among Female Veterans: Prevalence, Risk Factors, and the Impact on Psychosocial Functioning and Health Care Utilization. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2018 Jun 15; 14(6):931-939.
  5. Kilbourne AM, Schumacher K, Frayne SM, Cypel Y, Barbaresso MM, Nord KM, Perzhinsky J, Lai Z, Prenovost K, Spiro A, Gleason TC, Kimerling R, Huang GD, Serpi TB, Magruder KM. Physical Health Conditions Among a Population-Based Cohort of Vietnam-Era Women Veterans: Agreement Between Self-Report and Medical Records. Journal of women's health (2002). 2017 Nov 1; 26(11):1244-1251.
  6. Kimerling R. No Mission Too Difficult: Responding to Military Sexual Assault. American journal of public health. 2017 May 1; 107(5):642-644.
  7. Shaw JG, Asch SM, Katon JG, Shaw KA, Kimerling R, Frayne SM, Phibbs CS. Post-traumatic Stress Disorder and Antepartum Complications: a Novel Risk Factor for Gestational Diabetes and Preeclampsia. Paediatric and perinatal epidemiology. 2017 May 1; 31(3):185-194.
  8. Sternke LM, Serpi T, Spiro A, Kimerling R, Kilbourne AM, Cypel Y, Frayne SM, Furey J, Huang GD, Reinhard MJ, Magruder K. Assessment of a Revised Wartime Experiences Scale for Vietnam-Era Women: The Health of Vietnam-Era Women's Study (HealthViEWS). Women's health issues : official publication of the Jacobs Institute of Women's Health. 2017 Jul 1; 27(4):471-477.
  9. Bovin MJ, Wolf EJ, Resick PA. Longitudinal Associations between Posttraumatic Stress Disorder Severity and Personality Disorder Features among Female Rape Survivors. Frontiers in psychiatry. 2017 Feb 2; 8(1):6.
  10. Zimmerman L, Lounsbury DW, Rosen CS, Kimerling R, Trafton JA, Lindley SE. Participatory System Dynamics Modeling: Increasing Stakeholder Engagement and Precision to Improve Implementation Planning in Systems. Administration and policy in mental health. 2016 Nov 1; 43(6):834-849.
  11. Gutner CA, Galovski T, Bovin MJ, Schnurr PP. Emergence of Transdiagnostic Treatments for PTSD and Posttraumatic Distress. Current psychiatry reports. 2016 Oct 1; 18(10):95.
  12. Rosenbaum DL, Kimerling R, Pomernacki A, Goldstein KM, Yano EM, Sadler AG, Carney D, Bastian LA, Bean-Mayberry BA, Frayne SM. Binge Eating among Women Veterans in Primary Care: Comorbidities and Treatment Priorities. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2016 Jul 1; 26(4):420-8.


DRA: Mental, Cognitive and Behavioral Disorders
DRE: Diagnosis, TRL - Applied/Translational
Keywords: Clinical Diagnosis and Screening, Ethnicity/Race, Gender Differences, PTSD
MeSH Terms: none

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