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What are the most practical primary care screens for post-traumatic stress disorder?
The 4-item Primary Care Post-Traumatic Stress Disorder screen (PC-PTSD) is a simple and effective tool to identify symptoms of post-traumatic stress disorder (PTSD) in primary care patients (strength of recommendation [SOR]: B, 1 good-quality prospective cohort study and 1 good-quality retrospective cohort study). The 7-item Breslau screen also predictably identifies patients with PTSD symptoms (SOR: B, 1 good-quality prospective cohort study).
Evidence summary
About 8% of the US population will develop symptoms of PTSD at some point in their lives—usually as the result of a traumatic event, such as combat, a natural disaster, accident, or physical or sexual assault.1 Primary care settings tend to be the principal point of contact for patients with PTSD, although such patients rarely identify themselves as suffering from the disorder.2,3
Detailed diagnostic interviews and assessments are generally impractical in primary care.4 Brief, easy-to-complete screening tools can help clinicians identify patients with primary symptoms of PTSD.4
4-item screen assesses key characteristics of PTSD
The PC-PTSD (TABLE) is a 4-item screen that assesses the underlying characteristics specific to PTSD: re-experiencing, numbing, avoidance, and hyperarousal.4 It’s designed to be understandable to patients with an eighth-grade reading level and has been validated in a Department of Veterans Affairs (VA) primary care population (N=188).4
With a cutoff score of 3, the PCPTSD has a sensitivity of 78% and specificity of 87%, compared with the gold-standard Clinician-Administered PTSD Scale (CAPS).4 Positive responses warrant further evaluation of trauma symptoms and completion of the CAPS by a mental health provider to determine whether the patient may have PTSD or other trauma-related problems.5-7
TABLE
The primary care PTSD screen (PC-PTSD)4
| In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you… |
| 1. Have had nightmares about it or thought about it when you did not want to? YES NO |
| 2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES NO |
| 3. Were constantly on guard, watchful, or easily startled? YES NO |
| 4. Felt numb or detached from others, activities, or your surroundings? YES NO |
Breslau’s short screen addresses 7 specific symptoms
Breslau’s 7-item screening scale (available at http://ajp.psychiatryonline.org/cgi/content/full/156/6/908#T2) is another empirically tested, brief, simple means of identifying PTSD symptoms in primary care patients.2 (See also: www.pubmedcentral.nih.gov/articlerender.fcgifiartid=1484617.) Each item addresses a specific symptom.
The screen has been validated in a VA primary care clinic (N=134). With a cutoff score of 4, it has a sensitivity of 85% and specificity of 84%, yielding a positive predictive value of 71% and negative predictive value of 98%.2 The likelihood of a score <3 is 0.04 and a score >5 is 13.5. Scores of 3 to 5 have an indeterminate likelihood value (1.8). Patients with a positive screen should undergo further evaluation by a mental health provider.2
Leave lengthy screens to mental health professionals
The CAPS and the civilian version of the PTSD Symptom Checklist (PCL-C), both with 17 items, are widely used as “screens” for PTSD.7 However, their length and the recommendation that they be administered by a mental health professional make them cumbersome and impractical for use in primary care.7
Recommendations
A 2007 point-of-care guide written for primary care clinicians recommends Breslau’s short screening scale and the PCPTSD screen for use in this setting.1 Both the National Center for PTSD and Department of Defense Clinical Guidelines on PTSD recommend initial and annual screening using the PC-PTSD, PTSD Brief Screen, or Short Screening Scale for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) PTSD.8
Acknowledgements
The opinions and assertions contained herein are the private views of the authors and not to be construed as official, or as reflecting the views of the United States Air Force Medical Service or the United States Air Force at large.
1. Ebell MH. Screening instruments for post-traumatic stress disorder. Am Fam Physician. 2007;76:1848-1849.
2. Kimerling R, Ouimette P, Prins A, et al. Brief report: utility of a short screening scale for DSM-IV PTSD in primary care. J Gen Intern Med. 2006;21:65-67.
3. Screen for PTSD symptoms. PTSD core annotation E. Available at: www.oqp.med.va.gov/cpg/PTSD/PTSD_cpg/content/core/annoC.htm. Accessed April 15, 2008.
4. Prins A, Ouimette P, Kimerling R, et al. The primary care PTSD screen (PC-PTSD): development and operating characteristics. Prim Care Psychiatry. 2003;9:9-14.
5. Ouimette P, Wade M, Prins A, et al. Identifying PTSD in primary care: comparison of the primary care-PTSD screen (PC-PTSD) and the general health questionnaire-12 (GHQ). J Anxiety Disord. 2008;22:337-343.
6. National Center for PTSD. Screening for PTSD in a primary care setting. Available at: www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_screen_disaster.html. Accessed April 15, 2008.
7. Griffin MG, Uhlmansiek MH, Resick PA, et al. Comparison of the posttraumatic stress disorder scale versus the clinician-administered posttraumatic stress disorder scale in domestic violence survivors. J Trauma Stress. 2004;17:497-503.
8. VA/DoD clinical practice guideline for the management of post-traumatic stress. Version 1.0; January 2004. Available at: www.guideline.gov/summary/summary.aspx?ss=15&doc_id=5187. Accessed April 15, 2008.
The 4-item Primary Care Post-Traumatic Stress Disorder screen (PC-PTSD) is a simple and effective tool to identify symptoms of post-traumatic stress disorder (PTSD) in primary care patients (strength of recommendation [SOR]: B, 1 good-quality prospective cohort study and 1 good-quality retrospective cohort study). The 7-item Breslau screen also predictably identifies patients with PTSD symptoms (SOR: B, 1 good-quality prospective cohort study).
Evidence summary
About 8% of the US population will develop symptoms of PTSD at some point in their lives—usually as the result of a traumatic event, such as combat, a natural disaster, accident, or physical or sexual assault.1 Primary care settings tend to be the principal point of contact for patients with PTSD, although such patients rarely identify themselves as suffering from the disorder.2,3
Detailed diagnostic interviews and assessments are generally impractical in primary care.4 Brief, easy-to-complete screening tools can help clinicians identify patients with primary symptoms of PTSD.4
4-item screen assesses key characteristics of PTSD
The PC-PTSD (TABLE) is a 4-item screen that assesses the underlying characteristics specific to PTSD: re-experiencing, numbing, avoidance, and hyperarousal.4 It’s designed to be understandable to patients with an eighth-grade reading level and has been validated in a Department of Veterans Affairs (VA) primary care population (N=188).4
With a cutoff score of 3, the PCPTSD has a sensitivity of 78% and specificity of 87%, compared with the gold-standard Clinician-Administered PTSD Scale (CAPS).4 Positive responses warrant further evaluation of trauma symptoms and completion of the CAPS by a mental health provider to determine whether the patient may have PTSD or other trauma-related problems.5-7
TABLE
The primary care PTSD screen (PC-PTSD)4
| In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you… |
| 1. Have had nightmares about it or thought about it when you did not want to? YES NO |
| 2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES NO |
| 3. Were constantly on guard, watchful, or easily startled? YES NO |
| 4. Felt numb or detached from others, activities, or your surroundings? YES NO |
Breslau’s short screen addresses 7 specific symptoms
Breslau’s 7-item screening scale (available at http://ajp.psychiatryonline.org/cgi/content/full/156/6/908#T2) is another empirically tested, brief, simple means of identifying PTSD symptoms in primary care patients.2 (See also: www.pubmedcentral.nih.gov/articlerender.fcgifiartid=1484617.) Each item addresses a specific symptom.
The screen has been validated in a VA primary care clinic (N=134). With a cutoff score of 4, it has a sensitivity of 85% and specificity of 84%, yielding a positive predictive value of 71% and negative predictive value of 98%.2 The likelihood of a score <3 is 0.04 and a score >5 is 13.5. Scores of 3 to 5 have an indeterminate likelihood value (1.8). Patients with a positive screen should undergo further evaluation by a mental health provider.2
Leave lengthy screens to mental health professionals
The CAPS and the civilian version of the PTSD Symptom Checklist (PCL-C), both with 17 items, are widely used as “screens” for PTSD.7 However, their length and the recommendation that they be administered by a mental health professional make them cumbersome and impractical for use in primary care.7
Recommendations
A 2007 point-of-care guide written for primary care clinicians recommends Breslau’s short screening scale and the PCPTSD screen for use in this setting.1 Both the National Center for PTSD and Department of Defense Clinical Guidelines on PTSD recommend initial and annual screening using the PC-PTSD, PTSD Brief Screen, or Short Screening Scale for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) PTSD.8
Acknowledgements
The opinions and assertions contained herein are the private views of the authors and not to be construed as official, or as reflecting the views of the United States Air Force Medical Service or the United States Air Force at large.
The 4-item Primary Care Post-Traumatic Stress Disorder screen (PC-PTSD) is a simple and effective tool to identify symptoms of post-traumatic stress disorder (PTSD) in primary care patients (strength of recommendation [SOR]: B, 1 good-quality prospective cohort study and 1 good-quality retrospective cohort study). The 7-item Breslau screen also predictably identifies patients with PTSD symptoms (SOR: B, 1 good-quality prospective cohort study).
Evidence summary
About 8% of the US population will develop symptoms of PTSD at some point in their lives—usually as the result of a traumatic event, such as combat, a natural disaster, accident, or physical or sexual assault.1 Primary care settings tend to be the principal point of contact for patients with PTSD, although such patients rarely identify themselves as suffering from the disorder.2,3
Detailed diagnostic interviews and assessments are generally impractical in primary care.4 Brief, easy-to-complete screening tools can help clinicians identify patients with primary symptoms of PTSD.4
4-item screen assesses key characteristics of PTSD
The PC-PTSD (TABLE) is a 4-item screen that assesses the underlying characteristics specific to PTSD: re-experiencing, numbing, avoidance, and hyperarousal.4 It’s designed to be understandable to patients with an eighth-grade reading level and has been validated in a Department of Veterans Affairs (VA) primary care population (N=188).4
With a cutoff score of 3, the PCPTSD has a sensitivity of 78% and specificity of 87%, compared with the gold-standard Clinician-Administered PTSD Scale (CAPS).4 Positive responses warrant further evaluation of trauma symptoms and completion of the CAPS by a mental health provider to determine whether the patient may have PTSD or other trauma-related problems.5-7
TABLE
The primary care PTSD screen (PC-PTSD)4
| In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you… |
| 1. Have had nightmares about it or thought about it when you did not want to? YES NO |
| 2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES NO |
| 3. Were constantly on guard, watchful, or easily startled? YES NO |
| 4. Felt numb or detached from others, activities, or your surroundings? YES NO |
Breslau’s short screen addresses 7 specific symptoms
Breslau’s 7-item screening scale (available at http://ajp.psychiatryonline.org/cgi/content/full/156/6/908#T2) is another empirically tested, brief, simple means of identifying PTSD symptoms in primary care patients.2 (See also: www.pubmedcentral.nih.gov/articlerender.fcgifiartid=1484617.) Each item addresses a specific symptom.
The screen has been validated in a VA primary care clinic (N=134). With a cutoff score of 4, it has a sensitivity of 85% and specificity of 84%, yielding a positive predictive value of 71% and negative predictive value of 98%.2 The likelihood of a score <3 is 0.04 and a score >5 is 13.5. Scores of 3 to 5 have an indeterminate likelihood value (1.8). Patients with a positive screen should undergo further evaluation by a mental health provider.2
Leave lengthy screens to mental health professionals
The CAPS and the civilian version of the PTSD Symptom Checklist (PCL-C), both with 17 items, are widely used as “screens” for PTSD.7 However, their length and the recommendation that they be administered by a mental health professional make them cumbersome and impractical for use in primary care.7
Recommendations
A 2007 point-of-care guide written for primary care clinicians recommends Breslau’s short screening scale and the PCPTSD screen for use in this setting.1 Both the National Center for PTSD and Department of Defense Clinical Guidelines on PTSD recommend initial and annual screening using the PC-PTSD, PTSD Brief Screen, or Short Screening Scale for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) PTSD.8
Acknowledgements
The opinions and assertions contained herein are the private views of the authors and not to be construed as official, or as reflecting the views of the United States Air Force Medical Service or the United States Air Force at large.
1. Ebell MH. Screening instruments for post-traumatic stress disorder. Am Fam Physician. 2007;76:1848-1849.
2. Kimerling R, Ouimette P, Prins A, et al. Brief report: utility of a short screening scale for DSM-IV PTSD in primary care. J Gen Intern Med. 2006;21:65-67.
3. Screen for PTSD symptoms. PTSD core annotation E. Available at: www.oqp.med.va.gov/cpg/PTSD/PTSD_cpg/content/core/annoC.htm. Accessed April 15, 2008.
4. Prins A, Ouimette P, Kimerling R, et al. The primary care PTSD screen (PC-PTSD): development and operating characteristics. Prim Care Psychiatry. 2003;9:9-14.
5. Ouimette P, Wade M, Prins A, et al. Identifying PTSD in primary care: comparison of the primary care-PTSD screen (PC-PTSD) and the general health questionnaire-12 (GHQ). J Anxiety Disord. 2008;22:337-343.
6. National Center for PTSD. Screening for PTSD in a primary care setting. Available at: www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_screen_disaster.html. Accessed April 15, 2008.
7. Griffin MG, Uhlmansiek MH, Resick PA, et al. Comparison of the posttraumatic stress disorder scale versus the clinician-administered posttraumatic stress disorder scale in domestic violence survivors. J Trauma Stress. 2004;17:497-503.
8. VA/DoD clinical practice guideline for the management of post-traumatic stress. Version 1.0; January 2004. Available at: www.guideline.gov/summary/summary.aspx?ss=15&doc_id=5187. Accessed April 15, 2008.
1. Ebell MH. Screening instruments for post-traumatic stress disorder. Am Fam Physician. 2007;76:1848-1849.
2. Kimerling R, Ouimette P, Prins A, et al. Brief report: utility of a short screening scale for DSM-IV PTSD in primary care. J Gen Intern Med. 2006;21:65-67.
3. Screen for PTSD symptoms. PTSD core annotation E. Available at: www.oqp.med.va.gov/cpg/PTSD/PTSD_cpg/content/core/annoC.htm. Accessed April 15, 2008.
4. Prins A, Ouimette P, Kimerling R, et al. The primary care PTSD screen (PC-PTSD): development and operating characteristics. Prim Care Psychiatry. 2003;9:9-14.
5. Ouimette P, Wade M, Prins A, et al. Identifying PTSD in primary care: comparison of the primary care-PTSD screen (PC-PTSD) and the general health questionnaire-12 (GHQ). J Anxiety Disord. 2008;22:337-343.
6. National Center for PTSD. Screening for PTSD in a primary care setting. Available at: www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_screen_disaster.html. Accessed April 15, 2008.
7. Griffin MG, Uhlmansiek MH, Resick PA, et al. Comparison of the posttraumatic stress disorder scale versus the clinician-administered posttraumatic stress disorder scale in domestic violence survivors. J Trauma Stress. 2004;17:497-503.
8. VA/DoD clinical practice guideline for the management of post-traumatic stress. Version 1.0; January 2004. Available at: www.guideline.gov/summary/summary.aspx?ss=15&doc_id=5187. Accessed April 15, 2008.
Evidence-based answers from the Family Physicians Inquiries Network