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.
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.
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.
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 (  = .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 (  = .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 (  = .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).
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.
External Links for this Project
Grant Number: I01HX001876-01A2
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Mental, Cognitive and Behavioral Disorders
TRL - Applied/Translational, Diagnosis
Clinical Diagnosis and Screening, Ethnicity/Race, Gender Differences, PTSD