C. Screen For PTSD Symptoms

OBJECTIVE

Identify possible cases of PTSD.

BACKGROUND

Patients don’t often self-identify as suffering with PTSD, and patients with unrecognized PTSD are often difficult to treat because of poor patient/provider rapport, anger and distrust, somatization, and other trauma-related problems. Research supports the utility of brief screening tools for identifying undiagnosed cases of PTSD. Identification of PTSD may help facilitate development of rapport, suggest treatment options, and potentially improve outcomes for these patients.

RECOMMENDATIONS

1. All new patients should be screened for symptoms of PTSD initially and then on an annual basis or more frequently if clinically indicated due to clinical suspicion, recent trauma exposure (e.g., major disaster), or history of PTSD.
2. Patients should be screened for symptoms of PTSD using paper and pencil or computer-based screening tools.
3. No studies are available that compare the benefits of one PTSD screening tool versus another. However, the following screening tools have been validated and should be considered for use:
   • Primary Care PTSD Screen (PC-PTSD)
   • PTSD Brief Screen
   • Short Screening Scale for DSM IV PTSD
4. There is, as yet, Iinsufficient evidence to recommend special screening or differing PTSD treatment for members of any cultural or racial groups

DISCUSSION

The benefit of screening is well established for diseases with high prevalence. In one study (Taubman et al., 2001), 23 percent of patients presenting in the primary care setting reported exposure to traumatic events and 39 percent of those met criteria for PTSD. Screening strategies should, however, balance efficacy with practical concerns (e.g., staffing, time constraints, and current clinical practices). Brevity, simplicity, and ease of implementation should encourage compliance with recommended screening, but there is no clear evidence supporting use of one particular screening tool versus another. Care should be exercised in implementing screening to avoid social stigmatization and adverse occupational effects of positive screens.

Screening Tools:

Primary Care PTSD Screen (PC-PTSD); ( See Appendix C) Internal consistency (KR2-=.79) and test-retest reliability (r -.84) of the PC-PTSD was found as good (Prins, et al., 1999) . The operating characteristics of the screen suggest that the overall efficiency (i.e. optimal sensitivity and specificity = .87) is best when any two items are endorsed.

PTSD Brief Screen (Leskin et al., 1999): The PTSD bBrief Screen was developed using the rationally derived approach based on data from the National Comorbidity Survey. Construct validity has generally been adequate. The overall efficiency of this screen was good (.78), whereas the correlations were significantly lower or negative for other mental disorders indicating good construct validity.

Screening for Sexual Trauma:
Within the Veterans Health Administration, every new women veteran must be screened for history of sexual trauma according to public law (see screening for sexual trauma at http://www.va.gov/publ/direc/health/direct/12000008.html).

The passage of Public Law (Pub. L.) 102-585, in 1992, authorized Department of Veterans Affairs (VA) to include outreach and counseling services for women veterans who experienced incidents of sexual trauma while they served on active duty in the military. The law defines sexual trauma as sexual harassment, sexual assault, rape and other acts of violence. It further defines sexual harassment as repeated unsolicited verbal or physical contact of a sexual nature, which is threatening in nature. NOTE: This law was later amended by Pub. L. 103-452, which authorizes VA to provide counseling to men as well as women. The Veterans Millennium Health Care Act, signed on November 30, 1999, has significant implications under Section 115, Counseling and Treatment for Veterans Who Have Experienced Sexual Trauma. Provisions of Pub. L. 106-117. Section 115 are to: (1) Expand the focus on sexual trauma beyond counseling and treatment, (2) Mandate that counseling and appropriate care and services will be provided, (3) Extend the period of the program to December 31, 2004, and (4) Require a formal mechanism be implemented to report on outreach activities.

Special screening of any cultural or racial groups:
Research has centered on three broadly-defined groups: Hispanics, Blacks/African-Americans, and Whites/Caucasians in the attempt to answer two questions: first, are members of one or more groups more susceptible to developing PTSD? And second, are the symptoms shown by members of any group more severe or otherwise different from symptoms shown by other veterans with PTSD?

There are data to suggest that Blacks/African-Americans and Hispanics experience higher rates of PTSD than do Whites/Caucasians (Frueh et al., 1998; Ortega & Rosenheck, 2000). But, as Frueh and his colleagues note in a systematic review, “secondary analyses within the existing epidemiological studies suggest that differential rates of PTSD between racial groups may be a function of differential rates of traumatic stressors and other pre-existing conditions. This finding, in combination with the general paucity of empirical data and certain methodological limitations, significantly moderates the conclusions that should be reached from this body of literature.”

In terms of symptom severity and clinical course, the evidence is also mixed. Among the seven studies reviewed here, the following conclusions were reached:

• Two studies found Black/African-American veterans to be more severely affected than Hispanics or Whites/Caucasians (Frueh et al., 1996; Penk et al., 1989)
• One study found Hispanics to be more severely affected than Whites/Caucasians, but not to suffer from higher functional impairment levels than Whites (Ortega and Rosenheck, 2000)
• Three studies found no significant clinical differences between Black/African-American veterans and White/Caucasian veterans (Frueh et al., 1997; Rosenheck and Fontana, 1996; Trent et al., 2000)
• One review found no clinical differences among Hispanics, Blacks/African-Americans, and Whites/Caucasians (Frueh et al., 1998)

These results support Frueh et al. (1998) in their conclusion that: “despite the prevailing zeitgeist and clinical lore, the limited extant empirical evidence suggests that veterans of different races are more similar to each other than they are different when it comes to the clinical manifestation and response to treatment of combat-related PTSD and associated features.”