This chapter begins with the rationale for screening in general and then looks at screening for posttraumatic stress disorder (PTSD) specifically. After a discussion of the goals of screening for PTSD, especially in the military and veteran populations, key considerations in screening for PTSD are examined, such as when, how, and by whom screening should be conducted and the potential effect of stigma on screening. That is followed by descriptions of screening and barriers to screening in the Department of Defense (DoD), the Department of Veterans Affairs (VA), and nonmilitary settings and the different types of screening instruments that are used or are being developed. The screening section ends with a consideration of what should be done with screening results. The second part of the chapter discusses clinical assessment for and diagnosis of PTSD, including the current guidelines for diagnostic interviews and the use of various scales for diagnosing PTSD in military and veteran populations.
Screening has been defined as the examination of a generally healthy population to identify people as likely or unlikely to have a particular condition (Morrison, 1992). In light of the fact that screening is not without cost or potential damage, six criteria have been proposed for determining the acceptability of any given screening procedure (Rona et al., 2005):
- The identified condition should be an important health problem.
- The test should be clinically, socially, and ethically acceptable.
- The test should be simple, precise, and valid.
- The test should lead to reduced morbidity.
- Staffing and facilities for all aspects of the screening program must be adequate.
- Benefits of screening should outweigh potential harms.
It is inherent in those criteria that the test used should detect the condition at an early stage and that treatment at an early stage is of more benefit than treatment at a later stage (Wilson and Jungner, 1968). It is generally accepted that screening for PTSD, depression, and other mental health problems is ineffective unless it is integrated into a total management program with adequate follow-up to confirm or refute a positive screening result and adequate capability to provide appropriate treatment. An illustrative example is depression, in which screening alone without follow-up care and treatment is unlikely to improve management and is believed to be associated with an unacceptable ratio of cost to benefit (Gilbody et al., 2006; Lang and Stein, 2005; U.S. Preventive Services Task Force, 2002). Similar considerations are likely to apply to PTSD screening.
Screening is not meant to replace assessment or diagnosis, but it can serve as a decision support tool. A person who has a positive screening result should undergo a clinical assessment that can be used by a trained clinician to make appropriate diagnoses—including diagnoses of comorbid conditions, such as depression or traumatic brain injury (TBI)—and to acquire additional information that is required to plan treatment. Such an assessment should take into account the symptoms that the person is experiencing and the severity of and functional impairment associated with the symptoms. Although it is widely believed that screening for PTSD among current and former service members is important for identifying affected people and directing them to treatment as early as possible to prevent chronic suffering and maladjustment, there is no strong evidence to support this belief.
Traumas associated with military service, such as combat and sexual assault, have been associated with a high prevalence of PTSD in this population, and several factors should be considered in implementing broad screening directives in this group (Kessler et al., 1995; Skinner et al., 2000). For a screening program to be effective, adequate resources need to be in place to support it, such as appropriate personnel and time (VA and DoD, 2010). The choice of instrument, method of delivery (such as self-report vs. clinician-administered), place of delivery (such as in the theater of war vs. on the home front), and intended use of the results of the screen are all important in designing a screening program.
Many PTSD screening instruments are available. The VA/DoD guideline notes there is insufficient evidence to recommend one PTSD screening
tool over another, but several screening tools have been validated and should be considered for use: the Primary Care PTSD screen (PC-PTSD) (Prins et al., 2003), the PTSD Brief Screen (Leskin and Westrup, 1999), the Short Screening Scale for the Diagnostic and Statistical Manual-IV PTSD (Breslau et al., 1999), and the PTSD Checklist (PCL) (Blanchard et al., 1996, civilian version; Weathers et al., 1991, military version). The four-item PC-PTSD is the most widely used of those (see Box 6-1). In the DoD, the PC-PTSD screening questions are incorporated into longer surveys— the post-deployment health assessment (PDHA) and the post-deployment health reassessment (PDHRA). In DoD clinic settings, the PCL is commonly used. Before deployment, in addition to screening for PTSD itself, determination of the presence of factors that might increase a service member’s risk of PTSD may be an associated undertaking.
For those who screen positive for PTSD or when evidence suggests the presence of other disorders or comorbidities, the screening program should ensure rapid diagnostic evaluation by a trained provider that includes the assessment of other possible causes of the symptoms and issues that are important for treatment planning. The use of a structured interview may improve the validity and reliability of such an evaluation. Evaluation should address comorbidities—such as TBI, depression, other anxiety disorders,
Primary Care PTSD Screen
In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:
- Have had nightmares about it or thought about it when you did not want to?
- Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
- Were constantly on guard, watchful, or easily startled?
- Felt numb or detached from others, activities, or your surroundings?
SOURCE: VA (2012a).
alcohol or substance abuse—and the presence of risky behaviors (discussed in more detail in Chapter 8). In addition, determining the severity of symptoms, the degree and nature of functional impairments, and suicide risk are important in selecting treatment. During the evaluation, the people being evaluated should be educated regarding PTSD and other relevant diagnoses, have their treatment options explained, and participate and be in agreement with treatment decisions. The latter is key to later engagement with and adherence to treatment.
Identifying those who have established PTSD and offering them treatment is a DoD and VA priority (VA, 2002; VA and DoD, 2010). In planning a program involving screening of active-duty service members or veterans, it is important to be clear about the goals of the activity. As will be discussed below, screening in this environment is not benign. It carries financial costs, and more important, it can lead to anxiety, further testing, and in some cases change in the course of a military career, which leads to pressure for underreporting. The costs and benefits of screening and assessment must be weighed. However, there are costs of not screening and assessing; allowing a physically or mentally impaired service member to continue to serve when not battle ready may jeopardize the service member’s or the unit’s safety. Allowing problems to go undetected may compound them and lead to comorbid disorders and increased disability; it then becomes even more complicated and expensive to treat than if the initial problem had been detected and treated earlier.
The major psychologic conditions currently screened for in populations of active-duty military personnel and veterans are PTSD, depression, alcohol use disorders, sexual trauma, suicidality, and mild TBI. All those are addressed in the DoD-administered PDHA and PDHRA, discussed in detail in Chapter 4. Here, the committee focuses on PTSD, acknowledging that partial or subthreshold PTSD should not be overlooked inasmuch as it is associated with substantial functional disability (Stein et al., 1997; Walker et al., 2002).
In active-duty service members, screening can identify those who have impaired operational readiness and ideally can lead to the care necessary to restore their previous levels of functioning. In veteran populations, screening and assessment can identify diagnosable disorders and functional impairments and thereby guide treatment and lead to fulfilling lives out of the military. As covered in Chapter 5, to implement an effective early intervention and potentially eradicate a developing problem or mitigate its effect, a candidate for intervention must first be identified. Therefore, wide-scale screening of all those at risk must be implemented. It is easier to define “at risk” for some other conditions than for PTSD. For example, all persons within 35 meters of a blast are considered “at risk” for TBI, but “at risk” is much harder to determine for PTSD. There are a few screening
tools that capture PTSD and other health issues. Although the General Health Questionnaire (Goldberg, 1972) and the 10-item and 6-item Kessler scales (Kessler et al, 2002) have been used extensively worldwide for the detection of mental health disorders, those instruments do not target specific disorders.
In conducting assessments of the effects of trauma exposure in the theater of war, it is important to attempt to discriminate between a normative stress response and a pathologic condition that requires diagnosis and intervention. War by its nature is an extreme stressor and a life-threatening situation, and humans should be expected to react accordingly. A detailed discussion of adaptive and maladaptive responses to stress is presented in Chapter 3. The intention is not to treat a normal or adaptive stress response, which is imperative to survival, but instead to detect when it has become maladaptive and interferes with functioning. A primary purpose of the evaluation is to lead to maintaining individual service member and unit functioning and readiness.
The VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress (2010) considers that the evidence supporting screening with the PC-PTSD or three other scales is II-2—based on well-designed cohort or case–control studies rather than randomized controlled trials—and that the quality of the evidence is fair and the strength of recommendation is B, that is, the recommendation can be made on the basis of fair evidence that screening improves health outcomes and that the benefits outweigh the costs. In their review of seven PTSD guidelines, Forbes et al. (2010) note that there is a range of support for screening: the American Psychiatric Association concludes that level 1 evidence (defined as strong expert consensus) supports screening, and others, such as the British National Institute for Health and Clinical Excellence (NICE) and the Australian Guidelines, regard the evidence as weak, at the level of “good practice points” as distinct from good evidence. A key weakness in the literature is the paucity of evidence regarding the effect of screening on PTSD outcomes.
In the DoD and the VA, screening for PTSD is usually not the sole focus of a clinical assessment but is combined with screening and assessment of other conditions. The VA/DoD clinical practice guideline (2010) supports assessment of patients for psychiatric and medical conditions,
which includes “past and current psychiatric and substance use problems and treatment, prior trauma exposure, pre-injury psychological stressors, and existing social support.” The number of deployments that a person has had should also be considered. PTSD screening can be divided into premilitary trauma, peritrauma, and posttrauma screening, each having specific considerations, which are addressed below.
The Role of the Screener
As previously discussed, the results of screening tests are usually integrated into a more comprehensive assessment, and positive or negative results require interpretation by qualified professionals. Service members must give informed consent before completing the pre-deployment health assessment, PDHA, or PDHRA, and this consent states that responses on the form “may result in a referral for additional healthcare that may include medical, dental or behavioral healthcare or diverse community support services” (10 U.S.C. 136, 1074f, 3013, 5013, 8013, and Executive Order 9397). A credentialed health care provider is required to review and discuss the service member’s responses during the face-to-face part of the assessment. Physicians, physician’s assistants, nurse practitioners, and others who are medically trained to administer the PDHA and PDHRA, such as independent corpsmen and technicians, are examples of such providers. A health care provider interviews the subject and completes the second part of the assessment, documents any concerns, and makes recommendations for further treatment or referral. The provider then signs off on the PDHA or PDHRA, documenting the nature of the service provided and of the referral given and whether the service member accepted the recommendations. PDHA and PDHRA assessments are filed in the service member’s medical record and in the Defense Medical Surveillance System. A credentialed health care practitioner at the service member’s home base is expected to review the findings and ensure that follow-up occurs and that necessary appointments are scheduled (GAO, 2008).
The Effect of Stigma
Regardless of the reliability and validity of a screening instrument in ideal testing environments, as long as there is the belief that being labeled with a given condition may affect one’s future adversely, especially in the U.S. military, there will be an underreporting bias. It is only touched on here, but a more complete discussion of stigma can be found in Chapter 9. In one study that used a brigade of Army soldiers as the population of interest, service members first completed the PDHA, and then a subsample were invited to complete an anonymous survey that consisted of the same
mental health questions found on the PDHA. A comparison of the PDHA and the anonymous survey (which would not be a part of the soldiers’ records) found that the numbers of positive responses to the mental health questions overall and to the PTSD-specific questions more than doubled and in some cases quadrupled. On the PDHA, 3.3% of soldiers screened positive for PTSD, whereas on the anonymous survey, 7.7% screened positive. Of the service members that screened positive for either PTSD or depression on the anonymous survey (12.1%), 20.3% reported that they were not comfortable in reporting their answers honestly on the PDHA. The positive-screen group also indicated they were less likely to seek treatment for these issues (one-third indicated that they thought it would harm their careers) than the group that screened negative for PTSD or depression (Warner et al., 2011). Those results indicate a high level of underreporting of mental health symptoms, which may have adverse implications for the health and readiness of the armed forces. As discussed in the next section, additional specific stigma-related concerns are involved in screening before and after deployment.
Timing of Screening
One of the many considerations in screening for PTSD is when to screen. In the active-duty (and National Guard and reserve) force, screening can occur before deployment to a combat zone, during deployment in the theater of war, or after deployment. Because PTSD symptoms may not show for a number of months or years or may not be present when a service member transitions from active duty to the civilian population, screening for PTSD is also an important consideration in the VA.
There are several approaches to predeployment screening of service members, including screening before accession, basic training and boot camp, and screening prior to the actual deployment. Service members undergo a rigorous selection process to ensure physical and mental fitness. Each of the different services has its own criteria for acceptance, including minimum scores on the Armed Forces Qualification Test, minimum level of education, and policies for waivers. Basic training also serves to test physical and mental strength and abilities, and this can lead to discharges of unqualified people. Because the resulting force consists of people who have high levels of physical and mental health, the value of additional screening for PTSD symptoms in this cohort before deployment is uncertain (Hyams, 2006).
Screening just before deployment has been proposed as an additional
method of identifying persons who have disqualifying conditions and are not otherwise eliminated. However, the preponderance of evidence does not support that approach (Hyams, 2006). The pre-deployment health assessment has one mental health question: “During the past year, have you sought counseling or care for your mental health?” This question is of limited usefulness for the assessment of predeployment mental health concerns, particularly given the stigma associated with seeking mental health care or the assumption that a service member may not recognize that he or she has a mental health problem. An affirmative response to the question results in referral for an interview by a trained medical provider who may then sign a form indicating medical readiness for deployment.
One British study demonstrated that in a sample of soldiers deployed to Iraq, screening for common mental disorders, including PTSD, before deployment would not reduce morbidity or predicted PTSD (Rona et al., 2006). A prospective study of 22,630 service members enrolled in the Millennium Cohort Study found that those who reported one or more mental health disorders on a predeployment questionnaire were significantly more likely to screen positive for postdeployment PTSD symptoms (odds ratio 2.52, 95% confidence interval 2.01–3.16) (Sandweiss et al., 2011). However, this study did not assess morbidity and did not categorize service members’ fitness for duty. Categorizing service members as unfit to deploy or unfit for military duty on the basis of such an unfounded approach may have unjustified adverse implications for their lives and careers.
A large nonrandomized controlled cohort study that compared screened and unscreened combat brigades deployed to Iraq showed that the combination of predeployment screening and subsequent contact with mental health services in the theater of war reduced the rate of combat stress reactions, behavioral health disorders, suicidal ideation, and occupational-duty restrictions (Warner et al., 2011). The purpose of the screening was not to keep service members from deploying but to link them to needed services in the theater of war. Predeployment screening opens the possibility of underreporting that is perhaps driven by service members’ desire not to compromise their chance of deploying. Evidence supporting that argument comes in part from a retrospective cohort study of service members deployed in support of Operation Enduring Freedom (OEF) that found that fewer than half those who received a diagnosis of a mental health disorder during the predeployment period gave an affirmative response to the pre-deployment health assessment question “During the past year, have you sought counseling or care for your mental health?” That demonstrates the low validity of this instrument for identifying service members who have diagnosed mental health disorders before deployment (Nevin, 2009).
Evidence that screening for PTSD immediately after deployment may result in underreporting compared with screening later can be seen in results of a matched study of 509 soldiers returning from Iraq. Statistically significant increases in mental health symptoms of PTSD, depression, general psychologic distress, anger, and relationship problems were found 120 days after deployment compared with the immediate integration period (Bliese et al., 2007). Because the PDHA and the PDHRA are not anonymous, such underreporting may be due to fear of delaying family reunion and interference with an allocated extended period of leave after returning from deployment (Bliese et al., 2007; DoD, 2007; McClure, 2007). Another possible explanation for lower rates of symptom reporting in the immediate reintegration period is that some symptom clusters may not be present or may not have a recognized adverse effect on functioning during this time (Bliese et al., 2007). A third possibility may be that service members’ relief at being home overshadows any mental health issues.
In a longitudinal follow-up of more than 88,000 soldiers returning from Iraq, Milliken et al. (2007) found that the rates of positive PTSD screening results were more than 50% higher in the PDHRA than in the initial PDHA. The increases were greatest in the National Guard and reserve components, in which the prevalence increased from 9% to 14%. In active-duty soldiers, the prevalence increased from 6% to 9%. However, the investigators observed a reduction in the rate of positive PTSD screening results in the PDHA sample on rescreening several months later. The implications are that PTSD symptoms in the early posttraumatic phase often resolve and that educational programs in the military promote recovery. One other important finding from the Milliken et al. study is that the rates of self-reported interpersonal problems increased substantially in the PDHRA. Inasmuch as those issues often involve spouses, there may be a case for greater involvement of spouses, partners, or close family members in some part of the screening process or for facilitating access of such people to the health care system (Milliken et al., 2007).
Screening, assessment, and diagnosis are different. Whereas screening instruments and tools are used to identify persons who are likely to have the condition of interest, in the case of PTSD, assessment and diagnosis are necessary to confirm diagnosis and plan treatment. A positive PTSD screening result on the PDHA and PDHRA is indicated by an affirmative response to two or more of the four PTSD-specific questions. From August 2010 through July 2011, a total of 231,822 active-duty service members in all services and 75,219 reserve-component members (National Guard and reserves) completed the PDHA. During the same period, 223,582 active-duty and 86,421 reserve-component members completed the PDHRA. In
all the completed surveys, 8.3% of active-duty service members screened positive for PTSD on the PDHA and 9.5% on the PDHRA, and 9.2% of reserve members screened positive on the PDHA and 16.6% on the PDHRA. When stratified by service, both active-duty and reserve Army and Marine Corps personnel had the highest rates of positive PTSD screens on the PDHA and the PDHRA. Of all active-duty service members, 5.9% were referred for additional mental health assessment by a provider (for any mental health concern indicated, not specifically PTSD) after the PDHA, but 10.9% after the PDHRA. Of all reserve-component members, 4.9% were referred for additional mental health assessment after the PDHA and 16.2% after the PDHRA. Because the percentage of referrals for any mental health concern was reported, it is impossible to know how many service members who had affirmative responses to the PTSD questions were referred. Among both active-duty and reserve-component members, the percentage of mental health referrals increased between the PDHA and the PDHRA. Furthermore, 95.9% of all active-duty service members and 94.6% of reserve-component service members who were given referrals after the PDHA had a medical visit (according to records of outpatient or inpatient visits for either mental health or physical health concerns) within 6 months of the referrals (Armed Forces Health Surveillance Center, 2011).
Screening of Veterans
In the VA, positive screenings for PTSD, depression, suicidality, or military sexual trauma (sexual assault or extreme harassment that occurred during service in the military) result in referral of the veteran to a mental health professional for evaluation. Patients referred are to receive an initial evaluation within 24 hours and a full evaluation within 14 days after referral. However, no data are available to track what happens after referral—for example, what proportion engage and complete evaluations, enter and complete treatment, continue or return to active duty, or are discharged. A recent analysis of 125,729 Operation Iraqi Freedom (OIF) and OEF veterans screened for military sexual trauma in VA primary care and mental health clinics found that 15.1% of women and 0.7% of men reported military sexual trauma and that such trauma was associated with increased odds of PTSD, depression, and other mental health disorders (Kimerling et al., 2010).
Given that an estimated 90% of patients who have received mental health diagnoses are seen in primary care (Gebhart and Neeley, 1996) and that persons who receive diagnoses of PTSD are more likely to seek
medical care than mental health care (VA, 2002), screening for PTSD in primary care settings is paramount. A variety of primary care venues are available through the DoD, the VA, and private practices, each of which is discussed below. This section concludes with a brief overview of some of the challenges to implementing PTSD screening in primary care settings and how they might be overcome by using lessons learned from implementing screening for depression in primary care settings.
The Department of Defense
The DoD provides primary care through the individual services and through contracted TRICARE providers. Service members who received care in an integrated behavioral health and primary care setting had significantly reduced psychologic distress and significant improvement in clinical outcomes (Cigrang et al., 2006). One example of a successful implemented screening program that is Army-specific is the Re-Engineering Systems for Primary Care Treatment of Depression and PTSD in the Military (RESPECT-Mil) program, discussed in Chapter 4. Primary care providers are trained to screen and treat soldiers for PTSD and depression at every visit. It is an approach to establish collaboration between primary care and behavioral health professionals to overcome many of the barriers to effective management of PTSD in primary care settings in the DoD. Key elements of the program include universal primary care screening for PTSD and depression, including use of the single-item PTSD screener, developed for military primary care settings (Gore et al., 2008); brief standardized primary care diagnostic assessment for those who screen positive; and use of a nurse–care facilitator to ensure continuity of care for those who have unmet depression and PTSD treatment needs. The care facilitator assists primary care clinicians with follow-up, symptom monitoring, and treatment adjustment and enhances the primary care interface with specialty mental health services (Engel et al., 2008). Separate manuals that integrate care for PTSD with care for major depression guide the primary care clinician, behavioral health specialist, and care facilitator in their roles. As of Fall 2011, RESPECT-Mil had been implemented in 32 of 37 Army sites and in 84 primary care clinics. Since its inception, more than 1.1 million primary care visits have included screening for PTSD and depression, and approximately 13% of the screenings have been positive (DoD, 2011).
According to the official RESPECT-Mil website (DoD, 2011), “The US Army Medical Command has directed wide implementation of RESPECT-Mil in Army primary care facilities. Tri-service implementation is in the planning stages.” During FY 2012–2016, as the DoD phases in its primary care model of the patient-centered medical home—that is, a health care setting model with goals of providing comprehensive primary care for all
family members and facilitating partnerships between the patient, the physician, and members of the patient’s family (if appropriate) (Patient-Centered Primary Care Collaborative, 2007)—it plans to use RESPECT-Mil as the basis of its delivery of behavioral health care.
The U.S. Air Force initiated the Behavioral Health Optimization Program (BHOP) to integrate behavioral health and primary care services administered by the Air Force Medical Service (U.S. Air Force, 2011). It has resulted in increased availability of behavioral health services for families, as well as service members, and reduced stigma by making behavioral health care a routine part of primary medical care. In surveys of BHOP patients, 97% indicated that they were satisfied or very satisfied with their care. Not only were there statistically significant reduced levels of psychologic distress, but fewer than 10% of patients had to be referred to more intensive, specialty care services, and this suggests that integrated providers are able to manage the needs of most mental health patients in the primary care setting (Air Force Medical Operations Agency, 2011).
The Navy has integrated behavioral health and primary care services through deployment health clinics. Staff include primary care providers, psychologists, psychiatrists, social workers, and certified medical assistants. The Navy has also piloted the Behavioral Health Integration Project, whose purpose is to ensure continuity of care by placing mental health providers in primary care facilities. Mental health providers serve as consultants to the primary care providers and “provide sailors with short, focused assessments, brief interventions, skill training, and behavioral change plans” (Weinick et al., 2011).
The Department of Veterans Affairs
The VA uses annual universal mental health screening for veterans who are seen in the VA as part of its primary care preventive-health assessment process (Kirchner, 2011; Zeiss and Karlin, 2008). The VA is increasingly using mental health professionals to work as an integral part of primary care teams. In FY 2010, 155,554 veterans were seen by mental health staff deployed in primary care clinics—an increase of 102% from FY 2008 (Schoenhard, 2011). The VA policy is to screen every patient who is seen in VA primary care settings for PTSD, military sexual trauma, depression, and problem drinking, usually during the first appointment. Screenings for depression and problem drinking are repeated annually for as long as the veteran uses VA services. Military sexual trauma is screened for only once unless new data are entered into the record that indicate the need for additional screenings. PTSD screening is repeated annually for the first 5 years and every 5 years thereafter (VA, 2010).
To screen for PTSD, the VA uses the four-item PC-PTSD screen. In
2005, the definition of a positive screen changed from two or more affirmative responses to any three or more affirmative responses to the four questions (VA, 2005). The purpose of the change was to maximize efficiency (0.85) while reducing the number of false positives (Calhoun et al., 2010; Prins et al., 2003, 2004). Positive screenings for PTSD or depression also result in an additional screening for suicidality.
In addition to screening in VA health facilities, veterans seen in any of the approximately 300 Vet Centers are screened for PTSD and sexual trauma. Counseling is provided on site for those conditions, and veterans can be referred to VA mental health services as needed. Of the 191,000 veterans seen at Vet Centers in 2011, 39% were not seen at a VA medical facility (Batres, 2011).
The Private Sector
In the private sector (non-DoD and non-VA settings), veterans may be seen in primary care settings either with funding provided by TRICARE or with no military-related connection or funding. Veterans who have private insurance may choose to be seen by providers in the private sector. It has been estimated that 90% of patient visits for a mental health disorder in the private sector are to primary care providers as opposed to mental health providers, so it is likely that clinicians, especially those who have veteran patients, will encounter patients who have mental health needs (VA, 2002). However, because there are no PTSD clinical practice guidelines for the private sector specific to people who have service-related PTSD, integration of screening for service-related PTSD into private-sector primary care faces several challenges.
Challenges to Screening in Primary Care
First, primary care clinicians may not be aware of the adverse effects of PTSD on physical health (Schnurr and Jankowski, 1999). Second, many primary care providers do not have much experience in dealing with PTSD and its consequences and may find it difficult to bring up to a patient whose chief concern is seemingly unrelated. Third, with increased patient loads and cost constraints, lack of clinician time can be serious; many providers do not have or take the time to discuss with patients issues that may not be directly visible or may not seem related to the primary presenting health complaints. Fourth, if a primary care provider wants to screen for PTSD or trauma, selection of the best screening tool can be confusing (VA, 2002). The 2010 VA/DoD guideline endorses screening, but, although it does not offer specific guidance on which of the more than 20 screens and assessment tools should be used, the VA preferentially uses the four-item PC-PTSD
Screen and the DoD also uses these questions in its regular screening practices (PDHA, PDHRA) and the PCL in clinical settings. Fifth, primary care clinicians may have knowledge gaps concerning both PTSD and VA resources for its care. A recent study of nonmilitary, rural primary care providers is illustrative. Over a 6-month period, the providers saw about 1,200 OEF and OIF veteran patients and 3,600 of their family members. Many of the patients had mental health problems. Substantial gaps in knowledge of mental health disorders are suggested by the fact that providers lacked knowledge of PTSD and were unaware of VA resources. Only 20% of the providers rated their mental health treatment skills as high, and only about 8% reported that they had adequate knowledge of current mental health treatment strategies (Boscarino et al., 2010).
Other obstacles to screening in primary care settings are persistent provider and patient attitudes regarding mental health and traumatic experiences. Concerns about upsetting, retraumatizing, or offending a patient and not knowing what to do with the results of screening contribute to a reluctance of primary care providers to screen for trauma and PTSD in their patients. Some patients may not want to be reminded of their experience because of the painful memories it evokes, shame about what happened, or a belief that the provider will not be able to help them even if they disclose, but others may not be aware of what PTSD is or that it is a maladaptive response. Some research has suggested that patients who have a history of trauma are willing to disclose such information in a primary care setting, but will not typically disclose their trauma history spontaneously (VA, 2002).
Lessons from Screening for Depression in Primary Care
Screening for major depressive disorder as an accepted and routine part of primary care practice has depended on a number of developments, which are illustrative for integrating screening for and management of PTSD in primary care practice. These are of particular concern in practices outside the DoD and the VA systems. The adoption of screening for PTSD in the private sector will require a number of barriers to be addressed, including those described below.
Brief Screening Measures Acceptable to Primary Care Clinicians
Evidence that screening leads to the identification of those who have previously undiagnosed PTSD and that this identification leads to improved outcomes in primary care settings is required before any PTSD screening program can be implemented. Validation is required both for initial (onetime) screening and for any recommendation for repeated screening, such
as annually, as is the current policy in the VA. For private-sector (non-DoD and non-VA) practice, a two-step screening process—such as the use of the two-question Patient Health Questionnaire-2 (Kroenke et al., 2003) and the full Patient Health Questionnaire-9 (Kroenke et al., 2001) as the second step for major depressive disorder—has not been similarly defined for service-related PTSD. Given that current service members and veterans will usually make up a small portion of the total practice patient population and may not identify themselves as a veteran, a simple two-step process might involve, as the first step, questions like “Have you ever served in the U.S. military?”, and then if the response is affirmative, a question from the PC-PTSD instrument like “Have you ever had any experience that was so frightening, horrible, or upsetting that, in the last month, you …?” Such an approach requires validation of effectiveness before it can be recommended. Because national guidelines and quality metrics are not available for PTSD screening in the private sector, it is unlikely for clinicians in settings outside the DoD and the VA to perform this type of screening routinely. The committee could find no specific information or data on routine PTSD screening in the private sector. Perhaps a question that should be investigated in the private sector is whether the addition of screening for PTSD to screening for major depressive disorder in nonmilitary and non-VA primary care settings provides improved outcomes, possibly with only marginal increases in cost and effort compared with screening for major depression alone. This might occur through the addition of PTSD screening and management to established primary care depression programs or the de novo implementation of such combined PTSD and major depression screening and management programs.
Accessibility of Treatment to Primary Care Clinicians
Selective serotonin reuptake inhibitors provide primary care clinicians with a treatment option for depression that has been effective in some PTSD patients and in some communities. Telemedicine options may provide additional treatment strategies for primary care clinicians. However, guidelines for PTSD management are few and do not exist specifically for primary care physicians practicing outside the DoD and the VA. Measures and criteria specifically for evaluating and monitoring primary care practice performance regarding care for PTSD have not been developed.
This section addresses the types of PTSD screening instruments that are most commonly used. The instruments can be used to assess exposure to trauma or to assess the presence of PTSD symptoms that are related
to trauma. Some of the instruments listed in Tables 6-1 and 6-2 are more commonly used in research than in clinical care, and some of the longer instruments, such as the 201-item Deployment Risk and Resiliency Inventory, involve the use of only a subset of questions. Longer screening instruments have not been found to have any advantage over shorter ones (Brewin, 2005), and there is no evidence that one validated screening tool is superior to another (VA and DoD, 2010). The selection of a screening instrument depends ultimately on the goal of the screening (for example, clinical versus research settings or brief screening versus assessment of all symptoms). Although the screens have been validated to greater or smaller degrees, it is important to note that they cannot replace the knowledge of a trained clinician or leader (such as a first sergeant or chaplain) in detecting signs and symptoms of stress. Below, the section describes screening instruments used to screen for trauma exposure, symptom-based instruments, screens for stress reactions, novel technologies for screening, and biomarkers. The American Psychiatric Association is expected to release an update of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 2013. Changes to the diagnostic criteria will also affect screening instruments used (see Box 6-2).
TABLE 6-1 Instruments for Screening for Exposure to Trauma
Abusive Violence Scale
Hendrix and Schumm, 1990
Childhood Trauma Questionnaire
Bernstein et al., 2003
Combat Exposure Index
Janes et al., 1991
Combat Exposure Scale
Keane et al., 1989
Comprehensive Trauma Inventory
Hollifield et al., 2005
Deployment Risk and Resilience Inventory
King et al., 2003
Graves Registration Duty Scale
Sutker et al., 1994
Harvard Trauma Questionnaire
Mollica et al., 1992
Life Events Checklist of the Clinician-Administered PTSD Scale
Blake et al., 1995
Military Stress Scale
Watson et al., 1988
Posttraumatic Diagnostic Scale
Foa et al.,1997
Sexual Experiences Questionnaire-DoD
Fitzgerald et al., 1999
Vietnam Era Stress Inventory-Specific Stressor Subscale
Wilson and Krause., 1980
War Events Scale
Unger et al., 1998
War Zone Stress Scale
King et al., 1995
Women’s Wartime Stressor Scale
Wolfe et al., 1993
TABLE 6-2 Symptom-Based Screening Scales for PTSD
|Beck Anxiety Inventory-Primary Care||Mori et al., 2003|
|Primary Care PTSD Screen||Prins et al., 2003|
|Short Screening Scale for PTSD||Breslau et al., 1999|
|Trauma Screening Questionnaire||Brewin et al., 2002|
|PTSD Brief Screen||Leskin and Westrup, 1999|
|PTSD Checklist (PCL)-Civilian and Military versions||Blanchard et al., 1996 (Civilian); Weathers et al., 1991 (Military)|
|Posttraumatic Adjustment Scale||O'Donnell et al., 2008|
|M-3 Checklist||Gaynes et al., 2010|
|Single item PTSD Screener||Gore et al., 2008|
|Five-item Primary Care Anxiety Screener||Means-Christensen et al., 2006|
|Anxiety and Depression Detector||Means-Christensen et al., 2006|
|Two-item and six-item PCL||Lang and Stein, 2005|
|Short Post-Traumatic Stress Disorder Rating Interview||Connor and Davidson, 2001|
|Post-Deployment Health Assessment||DoD, 1998; current DD form2796, 2008|
|Post-Deployment Health Reassessment||DoD, 2005; current DD form2900, 2008|
There are a number of self-reporting screens for exposure to trauma (Fitzgerald et al., 1999; Hendrix and Schumm, 1990; Janes et al., 1991; Keane et al., 1989; King et al., 1995, 2003; Sutker et al., 1994; Unger et al., 1998; Watson et al., 1988; Wilson and Krause, 1980; Wolfe et al., 1993). Trauma-exposure instruments may be limited to one type of event, such as military or combat-related trauma, or to a comprehensive list of events, including childhood trauma. Other trauma-exposure screening scales include the Childhood Trauma Questionnaire (Bernstein et al., 2003), which exists in long (70-item) and short (28-item) forms; the Comprehensive Trauma Inventory, a 104-item scale developed in refugee populations (Hollifield et al., 2005); and the Harvard Trauma Questionnaire (Mollica et al., 1992). Exposure to nonmilitary trauma can be assessed through interviews, such as those using the life events checklist of the Clinician-Administered PTSD Scale (CAPS) and the Posttraumatic Diagnostic Scale (Foa et al., 1997). A
Changes in Diagnostic Criteria for PTSD in the Diagnostic and Statistical Manual-V and Effect on Screening
Major revisions of the Diagnostic and Statistical Manual occur at variable intervals. Changes in the newest edition, DSM-V, are being piloted (see discussion in Chapter 2). Because some of the proposed changes, such as elimination of the A2 criterion (the person’s response involved intense fear, helplessness, or horror), have direct effects on many of the questions in current screening instruments, these instruments will probably change to reflect the updates. For example, on the PDHA and PDHRA, the screening questions for PTSD begin with “Have you ever had any experience that was so frightening, horrible, or upsetting that in the past month you …?” Thus, it will be necessary to update guidelines around screening, especially with regard to preferred instruments. The proposed change from a three-pronged to a four-pronged model (see Chapter 2) may also affect current popular screening instruments, such as the four-item PC-PTSD screen (on which the PDHA and the PDHRA are based), in which each question seeks to elicit symptoms related to each of the main criteria. The proposed addition of four symptoms (anger and aggressive behavior, erroneous self- or other-blame regarding the cause or consequences of trauma, pervasive negative emotional states, and reckless and self-destructive behavior) to the current 17 may also require revision of current screening instruments. It may, therefore, become nec-essary to update guidelines around screening, especially with regard to preferred instruments, instrument items, and scoring.
representative list of questionnaires relevant to military service is shown in Table 6-1. Some of the questionnaires may have application only to particular groups, such as women, sexual trauma survivors, Vietnam-era veterans, or grave registration personnel.
Several short symptom-based screening scales are used to detect possible PTSD. The VA/DoD guideline (2010) notes that a symptom-driven scale that is cued to a particular event is more attractive to clinic staff, who may not be able to address a person’s entire life history of trauma at the first visit. Those scales, which are listed in Table 6-2, are the seven-item Beck Anxiety Inventory-Primary Care (Mori et al., 2003), the four-item PC-PTSD (Prins et al., 2003), the seven-item Short Screening Scale for PTSD (Breslau et al., 1999), the four-item SPAN (Davidson, 2002), and the 10-item Trauma Screening Questionnaire (Brewin et al., 2002). All those assess symptoms that follow any type of trauma and can be completed in
less than 4 minutes. The PC-PTSD is the most widely used screen in active-duty military (with PDHA and PDHRA screens) and veteran populations. Its introductory statement is as follows: “[In your life,] have you ever had any experience that was so frightening, horrible, or upsetting that, in the last month, you …?” The PDHA and PDHRA contain detailed questions about exposure to trauma in the course of military service and then frames the PC-PTSD symptom screen questions in the context of “any experience” (it could be related to either military or civilian life).
The 17-item PCL has separate formats for military and civilian situations (Blanchard et al., 1996; Weathers et al., 1991). Additional scales include the PTSD Brief Screen (Leskin and Westrup, 1999); the 17-item symptom subscale of the Posttraumatic Diagnostic Scale; the Posttraumatic Adjustment Scale, a 10-item self-rating based on pretraumatic, peritrau-matic, and posttraumatic symptoms (O’Donnell et al., 2008); the M-3 Checklist, a 27-item screener for several disorders, including PTSD (Gaynes et al., 2010); the Single-Item PTSD Screener developed in the military primary care setting (Gore et al., 2008), which did not perform as well as the widely used four-item PC-PTSD; and the five-item primary care anxiety screener and Anxiety and Depression Detector (Means-Christensen et al., 2006). Lang and Stein have refined the PCL to shorter two-item and six-item screening options in primary care, and they have both performed adequately (Lang and Stein, 2005).
Stress Reactions: The Best Screen Is a Good First Sergeant
Related to screening for PTSD is screening for stress reactions. Identification of persons who are likely to have PTSD may be based on instruments or on personal knowledge and experience of a person. Instruments used to screen for stress reactions include the Perceived Stress Scale (Cohen et al., 1983), the Sheehan Perceived Stress Scale (Sheehan et al., 1990), the Posttraumatic Diagnostic Scale (Foa et al., 1997)—which are not used specifically in military or veteran populations—and the recently developed Response to Stressful Experiences Scale, which was developed by using active-duty and veteran populations (Johnson et al., 2011).
There has been an effort to identify service members who might be having reactions that decrease their combat readiness, but no scale has been developed for this purpose. It has been proposed that medics or embedded leaders who know their soldiers, airmen, sailors, or marines are in the best position to make such an informal assessment (“the best screen is a good first sergeant”). The idea is for the embedded leaders not to serve as counselors but to be trained to recognize and respond appropriately to signs that may be associated with stress reactions in service members for
whom they are responsible. The emerging screens may elicit warning signs by asking questions like these:
- Has the service member exhibited or described a decline in operational readiness? Has he or she been forgetful, had problems falling or staying asleep during operational pauses, or displayed extreme emotional responses, such as excessive crying or excessive anger or violence?
- Has the service member been cut off or withdrawn from others? Does he or she appear depressed or overwhelmed? Has he or she withdrawn from friends, the squad, or the platoon? Does he or she appear numb or emotionally dazed?
- Is the service member a danger to himself or herself or to others?
If a service member is a danger to himself or herself or to others, he or she should be referred immediately to a credentialed provider. If he or she makes suicidal statement or comments or threatens others, he or she should be referred. And a service member should be referred to a credentialed provider if his or her condition worsens or does not improve after 4 days of psychologic first aid.
Event-triggered screening occurs at prescribed times and currently occurs before deployment, immediately after deployment (with the PDHA), and 3-6 months after deployment (with the PDHRA). Routine screening for disruptive emotional reactions after exposure to combat operational stressors has recently been adopted. It should be performed by the medic or embedded leader that knows the service members as described above. Target stress-exposed groups include
- All wounded personnel who require medical attention and all per-sonnel who were in direct contact (defined as visual contact) with a seriously wounded or killed unit comrade;
- All personnel who were directly involved in actions that resulted in deaths or serious injuries of civilians, including women and children;
- All personnel who killed enemy combatants in close contact and had direct visual contact with the enemy before or after killing;
- All personnel who were involved in a combat or mob incident in which they believed or feared that they would die; and
- All personnel who meet screening criteria for TBI.
The use of computing and information technology tools for increasing availability, promoting access, and improving acceptance (reducing stigma) of screening and other clinically relevant services has evolved substantially during OEF and OIF, but research to document their efficiency and efficacy is still in its infancy. Computing and information technology applications include Internet-based mental health resources, social media, mobile applications, virtual worlds, and virtual reality. Some tools being used to screen for PTSD have been launched online (for example, afterdeployment.org, myhealth.va.gov, and braveheartveterans.org) or as mobile applications (for example, PTSD Coach and Mood Tracker). Such anonymous screening and education options may provide users with self-assessment results that can be used to instigate or encourage a self-referral to a provider for care. They may offer a safe and nonstigmatizing “first point of contact” for those who do not make initial direct contact with a service provider or clinic. In addition to anonymous screening, computing and information technology can provide options for delivering psychoeducational information, providing “common sense” advice, and promoting peer-group interaction. Such approaches may help to address the numerous challenges that exist for the DoD and the VA with regard to the growing need for health services in the military and veteran populations.
The Integrated Mental Health Strategy was launched in September 2010 to review computing and information technology resources and included more than 290 publically accessible technology resources in several categories: DoD, VA, and commercial websites; social media applications; mobile applications; and call centers. Each of those has advantages and gaps. Some more detailed examples of mobile applications and websites that offer screening or self-assessment for PTSD or related symptoms are described below.
- afterdeployment.org. This website was created and is maintained by the National Center for Telehealth and Technology, a component of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and part of the Military Health System. Its primary mission is to provide wellness resources for the military community. It provides extensive resources on posttraumatic stress, depression, TBI, family and friendships, and sleep. The screening section is extensive, with self-assessments covering 29 domains, including PTSD, depression, caregiver stress, mild-TBI symptom management, and sleep. The site uses the military version of the PCL to screen for PTSD, and users are given their scores following completion with recommendations for next steps (DCoE, 2012a).
- PTSD Coach. This free mobile application was created by the VA’s National Center for PTSD and the DoD’s National Center for Telehealth and Technology and is specifically designed for veterans and current service members who have or may have PTSD. It is available for both iPhone and Android smartphones and provides validated information about PTSD and its treatment and interactive tools for self-assessment, managing and tracking of symptoms (relaxation skills and coping techniques), and finding support. Any information entered is as secure as the device, but users may share data and are able to customize the tool content to integrate their own contacts, photographs, and music. This application is not intended to diagnose or treat PTSD and should not replace professional care. A PTSD Family Coach is under development (VA, 2012b).
- My HealtheVet. Screening for PTSD and other mental health conditions is available for all veterans through the VA’s My HealtheVet website (VA, 2012c). The site allows all registered users of VA health care services to access their clinical records and provides a number of wellness and health-enhancement options. On the website (Researching Your Health—Mental Health Section), any veteran (even if not registered as a user of VA services) can complete the 17 questions of the PCL, have his or her score immediately displayed and, if the screen suggests a possible problem, be advised about seeing a VA mental health professional.
- braveheartveterans.org. A number of private foundations and organizations have been involved in outreach to aid service members and veterans in accessing mental health services. The Robert R. McCormick Foundation has joined with Major League Baseball Charities to support the national Welcome Back Veterans program. BraveHeart: Welcome Back Veterans Southeast Initiative launched a website aimed at outreach to veterans in Alabama, Georgia, and South Carolina. The website uses an avatar to help users to assess themselves for PTSD and then provides assistance in finding services through a ZIP code locator (Atlanta Braves and Emory University, 2011).
Much recent discussion concerning screening for and diagnosis of PTSD has centered on the many types of potential biologic markers. Some literature has suggested that startle responses and heart rate may be useful for screening for PTSD. No validated, accurate biologic screening test for
PTSD is currently available. A more complete discussion of biomarkers can be found in Chapter 3.
The diagnosis of PTSD rests on the ability of a trained professional to establish rapport with a patient and conduct a thorough clinical interview. Supplementary information can be obtained with self-rating scales for PTSD, suicidality, depression, quality of life, disability, and resilience. Several structured interviews have been validated for the diagnosis of PTSD; these scales vary in the time needed for administration. This section describes the components of the diagnostic process mentioned earlier.
Clinical Diagnostic Assessment
The diagnosis of PTSD ultimately rests on a careful and comprehensive clinical evaluation performed by a qualified professional (a psychologist, a social worker, a psychiatrist, or a psychiatric nurse practitioner) under conditions of privacy and confidentiality (DoD, 2007; IOM, 2006). It may take some time to elicit the information necessary to conclude that a person does or does not have PTSD. As discussed in Chapter 2, many pretraumatic factors have been found to be associated with development of PTSD, and the interview should obtain these and other important details, including chief complaints; lifetime history of exposures to trauma and experience of physical injury to self or others; frequency and severity of symptoms of PTSD and other morbidity; level of function (disability); quality of life and ongoing life stressors; medical history and present health; prior psychiatric diagnosis and treatment; details of family, recreations, and supports; personal strengths and vulnerabilities; styles of coping with stress; and experiences in the military. Obtaining all that information may not be straightforward and can be accompanied by the expression of strong affect by the patient, so it may be necessary to plan more than a single intake interview. The process can be facilitated by using information from screening scales and other ratings, such as scales to measure all main PTSD symptoms, such related problems as depression, other axis I conditions (for example panic disorder, social phobia, and generalized anxiety disorder), patterns of alcohol and substance use, disability, quality of life, and resilience. In some situations, more comprehensive personality and neurocognitive assessments might be indicated. It is important to determine whether the goal is to identify and assess pathologic conditions (the severity of diagnosable disorders, such as PTSD, and common comorbid conditions, such as depression and TBI), to assess functioning, or both. If assessing pathologic conditions, the clinician
must be able to rule out some conditions that could also cause the symptoms and determine whether more than one disorder is present.
Besides helping to make an initial diagnosis, rating scales can serve as a measure of PTSD severity and as a benchmark against which future progress can be measured. For instance, use of the PCL can provide a measure of the extent of improvement during treatment, serve as a marker of remission, and highlight symptoms that may persist when others have improved.
The DSM-IV criteria for PTSD have been given previously (Chapter 2). There are a number of well-tested and valid structured interviews for the diagnosis of PTSD, although in general they are unlikely to be adopted in routine clinical practice, where the benchmark continues to remain a thorough clinical interview. All of these structured interviews are primarily research tools that can be used for clinical assessment in situations where the diagnosis in not clear. The shortest assessments take 15–30 minutes to complete, and the longer ones take 45–60 minutes. However, there is considerable variability in the time needed to complete the assessment. It depends on the choice of scale, the complexity of the case, the number and type of traumas, and the subject’s level of knowledge about PTSD. Although the VA/DoD guideline specifically mentions the use of the CAPS for diagnosis, they also state that “diagnosis of PTSD should be obtained based on a comprehensive clinical interview that assesses all the symptoms that characterize PTSD.” Table 6-3 lists the structured interviews that can be used to diagnose PTSD.
TABLE 6-3 Structured Interviews for Assessment of PTSD
|Clinician-Administered PTSD Scale (CAPS)a||Blake et al., 1995|
|Structured Clinical Interview for DSM-IVa||Spitzer et al., 1992|
|Composite International Diagnostic Interviewb||Robins et al., 1988|
|PTSD Symptom Scale-Interview Versiona||Foa et al., 1993|
|Structured Interview for PTSDa||Davidson et al., 1997a|
|Diagnostic Interview Scheduleb||Cottler, 2009; Robins et al., 1997|
|Mini-International Neuropsychiatric Interviewa||Sheehan et al., 1998|
|aIndicates instruments that can be used to inform clinical assessment.
bIndicates instruments that are used for epidemiologic and treatment outcome research.
Among the many structured interviews, the CAPS (Blake et al., 1995), the Structured Clinical Interview for DSM-IV (First et al., 1995; Spitzer et al., 1992), PTSD Symptom Scale—Interview Version (PSS-I) (Foa et al., 1993), Structured Interview for PTSD (SIP) (Davidson et al., 1997a), Diagnostic Interview Schedule (DIS-IV) (Cottler, 2009; Robins et al., 1997), and Composite International Diagnostic Interview (CIDI) (Robins et al., 1988) have been noted in previous Institute of Medicine reports as potentially informing professional judgment, although they are used more often in epi-demiologic or treatment-outcome research rather than clinical assessments. The widely used Mini-International Neuropsychiatric Interview (MINI) assesses most major diagnoses, including PTSD (Sheehan et al., 1998). All the above except the CAPS, PSS-I, and SIP assess multiple diagnoses. The PSS-I and SIP can be completed in 20–30 minutes. The DIS-IV can be administered either by a trained clinician or a lay interviewer or in a computerized format; the CIDI can also be administered by a trained professional or layperson. The Short PTSD Rating Interview (SPRINT) and the extended version (SPRINT-E) are not structured interviews, but they provide a more global overview of PTSD, disability, general health, depression, and suicide risk and can be used as brief interview-based diagnostic screens (Connor and Davidson, 2001; Norris et al., 2008). For most of these instruments, the respondent must be able to identify the most bothersome trauma and link it to many of the key PTSD symptoms.
Self-Rating Symptom Scales
Among the various self-rating scales for PTSD are the PCL (Blanchard et al., 1996; Weathers et al., 1991) and the Mississippi Scale (Keane et al., 1988; McFall et al., 1990), both of which exist in civilian and military or combat versions. Additional scales include the Impact of Event Scale (Horowitz et al., 1979), which antedates DSM-III, and its revised form, which accommodates all the DSM-IV symptoms (Weiss and Marmar, 1997); the MMPI-Keane PTSD Scale (Keane et al., 1984); the Hovens Self Rating Inventory for PTSD (Hovens et al., 2002); the PTSD Diagnostic Scale (Foa et al., 1997); the Davidson Trauma Scale (Davidson et al., 1997b); the War Zone Related PTSD subscale from the SCL-90 (Derogatis and Cleary, 1977); the Los Angeles Symptom Checklist (King et al., 1995); the 26-item Penn Inventory (Hammarberg, 1992); and the 22-item Self-Rating Scale for PTSD, developed by Carlier et al. (1998) from the SIP (Davidson et al., 1997a). These scales are summarized in Table 6-4. The shortest contains 17 items, and the longest contains 49.
All scales have been tested, albeit in different populations, and there is some variability with respect to their reliability and validity. Within the VA system, the PCL is perhaps the most often used severity scale. None of the
TABLE 6-4 Symptom-Severity Instruments for PTSD
|PTSD Checklist-civilian and military versions||Blanchard et al., 1996 (civilian); Weathers et al., 1991 (military)|
|Mississippi Scale-civilian and combat versions||Keane et al., 1988, McFall etal., 1990|
|Impact of Event Scale updated for DSM-IV||Horowitz et al., 1979; Weiss and Marmar, 1997|
|MMPI-Keane PTSD Scale||Keane et al., 1984|
|Hovens Self Rating Inventory for PTSD||Hovens et al., 2002|
|PTSD Diagnostic Scale||Foa et al., 1997|
|Davidson Trauma Scale||Davidson et al., 1997b|
|War Zone Related PTSD subscale from the Symptom Checklist 90-Revised||Derogatis and Cleary, 1977|
|Los Angeles Symptom Checklist||King et al., 1995|
|26-item Penn Inventory||Hammarberg, 1992|
|22-item Self-Rating Scale for PTSD||Carlier et al., 1998, from theSIP (Davidson et al., 1997a)|
|Reactions to Stressful Experiences Scale||Johnson et al., 2011|
|PTSD Symptom Scale-Self Report Version||Foa et al., 1993|
scales is intended to replace a clinical assessment, but they can constitute a useful supplement to information obtained in the face-to-face encounter.
Several instruments have been developed that measure quality of life, functioning and disability, and resilience and are shown in Table 6-5. Among the main quality of life scales that may be used in assessing people who have PTSD are the Quality of Life Experiences Scale (Endicott et al., 1993), the EURO-QOL (EuroQol, 1990), the 100-question World Health Organization Quality of Life Assessment and an abbreviated form (WHOQOL-BREF) (Harper et al., 1998), the Quality of Life Inventory (Frisch et al., 1992), and the Manchester Short Assessment of Quality of Life (Priebe et al., 1999).
Functioning can be assessed with the Medical Outcomes Study Short Form 36-item and shorter versions (such as SF-12) (McHorney et al., 1994),
TABLE 6-5 Quality of Life, Disability, and Resilience Measures
|Medical Outcomes Study Short Form 36||Ware and Sherbourne, 1992|
|Medical Outcomes Study Short Form 12||Ware et al., 1996|
|Quality of Life Experiences Scale||Endicott et al., 1993|
|Sheehan Disability Scale||Sheehan et al., 1996|
|World Health Organization Quality of Life Assessment||WHO, 1998|
|Manchester Short Assessment of Quality of Life||Priebe et al., 1999|
|Resilience Scale||Wagnild and Young, 1993|
|Resilience Scale for Adults||Friborg et al., 2003|
|Connor Davidson Resilience Scale, 25-, 10-, and 2-item versions||Connor and Davidson, 2003 (25 item); Campbell-Sills and Stein, 2007 (10 item); Vaishnavi et al., 2007 (2 item)|
|Quality of Life Inventory||Frisch et al., 1992|
|Dispositional Resilience Scale, 45-, 30-, and 15-item forms||Bartone et al., 2008|
the Global Assessment of Function (APA, 1994), and the Sheehan Disability Scale (Sheehan, 1983).
Resilience has become the focus of greater attention in recent years, and there are a number of psychometrically valid scales that measure this construct. They include the brief five-item scale of Smith et al. (2008), the 2-, 10-, and 25-item versions of the Connor-Davidson Resilience Scale (Campbell-Sills and Stein, 2007; Connor and Davidson, 2003; Vaishnavi et al., 2007), the 25- and 14-item versions of the Resilience Scale (Wagnild and Young, 1993), the Resilience Scale for Adults (Friborg et al., 2003), and the 45-, 30-, and 15-item forms of the Dispositional Resilience Scale (Bartone et al., 2008). As is the case with the PTSD symptom scales and measures of quality of life and disability, studies have shown that resilience can improve as the result of treatment (Lavretsky et al., 2010).
Screening for PTSD is essential for identifying those who need treatment. Issues including stigma and timing of screening should be considered, in addition to the venue of screening (DoD, VA, and nonmilitary settings). Many types of screening instruments exist, but only a few are used by
the DoD and the VA. Some are based on exposure to trauma and others are symptom-based. Screening instruments may be self-administered or clinician-administered. Although screening is useful for identifying potential PTSD cases, a diagnosis can be made only on the basis of a comprehensive clinical evaluation performed by a qualified professional. Several structured interviews and symptom-based rating scales may be used for diagnosis and to determine severity of symptoms. The next chapter describes the different treatments that have been found to be effective in treating persons who have a diagnosis of PTSD.
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