SCREENING

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.

BOX 6-1

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?

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, 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.

CONSIDERATIONS REGARDING SCREENING IN THE DEPARTMENT OF DEFENSE AND THE DEPARTMENT OF VETERANS AFFAIRS

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.

SCREENING IN PRIMARY CARE

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.

SCREENING TOOLS

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.

TABLE 6-2

Symptom-Based Screening Scales for PTSD.

BOX 6-2

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 (more...)

DIAGNOSIS

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.

Diagnostic Interviews

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.

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.

TABLE 6-4

Symptom-Severity Instruments for PTSD.

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 scales is intended to replace a clinical assessment, but they can constitute a useful supplement to information obtained in the face-to-face encounter.

QUALITY OF LIFE, DISABILITY, AND RESILIENCE MEASURES

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).

TABLE 6-5

Quality of Life, Disability, and Resilience Measures.

Functioning can be assessed with the Medical Outcomes Study Short Form 36-item and shorter versions (such as SF-12) (McHorney et al., 1994), 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).

SUMMARY

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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