Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations Initial Assessment (2012) / Chapter Skim
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6 Screening and Diagnosis
6 Screening and Diagnosis
Pages 195-230
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From page 195... ...
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.
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From page 196... ...
Many PTSD screening instruments are available. The VA/DoD guideline notes there is insufficient evidence to recommend one PTSD screening
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. In the DoD, the PC-PTSD screening questions are incorporated into longer surveys -- the post-deployment health assessment (PDHA)
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From page 198... ...
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.
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From page 199... ...
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 PostTraumatic Stress (2010)
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From page 200... ...
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.
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From page 201... ...
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)
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From page 202... ...
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)
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From page 203... ...
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.
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From page 204... ...
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)
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From page 205... ...
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)
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. 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.
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, 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.
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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)
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From page 209... ...
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.
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From page 210... ...
. TABLE 6-1 Instruments for Screening for Exposure to Trauma Instrument Reference 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 Blake et al., 1995 PTSD Scale 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 Wilson and Krause., 1980 Subscale War Events Scale Unger et al., 1998 War Zone Stress Scale King et al., 1995 Women's Wartime Stressor Scale Wolfe et al., 1993
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; 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 form 2796, 2008 Post-Deployment Health Reassessment DoD, 2005; current DD form 2900, 2008 Trauma Exposure 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)
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From page 212... ...
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)
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; 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)
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214 PTSD IN MILITARY AND VETERAN POPULATIONS 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 opera tional readiness?
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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.
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. 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.
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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)
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a Clinician-Administered PTSD Scale Blake et al., 1995 Structured Clinical Interview for DSM-IVa Spitzer et al., 1992 Interviewb Composite International Diagnostic Robins et al., 1988 PTSD Symptom Scale -- Interview Versiona Foa et al., 1993 PTSDa Structured Interview for Davidson et al., 1997a Diagnostic Interview Scheduleb Cottler, 2009; Robins et al., 1997 Interviewa Mini-International Neuropsychiatric Sheehan et al., 1998 a Indicates instruments that can be used to inform clinical assessment. b Indicates instruments that are used for epidemiologic and treatment outcome research.
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; the Hovens Self Rating Inventory for PTSD (Hovens et al., 2002) ; the PTSD Diagnostic Scale (Foa et al., 1997)
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Mississippi Scale -- civilian and combat versions Keane et al., 1988, McFall et al., 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 Derogatis and Cleary, 1977 Checklist 90 -- Revised 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 the SIP (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.
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(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)
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1999. Short screening scale for DSM-IV posttraumatic stress disorder.
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1997b. Assessment of a new self-rating scale for posttraumatic stress disorder.
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1997. The validation of a self-report measure of posttraumatic stress disorder: The posttraumatic diagnostic scale.
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1999. PTSD brief screen: Posttraumatic stress disorder implica tions for primary care.
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2008. Validation of the short posttraumatic stress disorder rating interview (expanded version, SPRINT-E)
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1997. Full and partial posttraumatic stress disorder: Findings from a community survey.
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1988. Differences between posttraumatic stress disorder patients with delayed and undelayed onsets.
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2008. Integrating mental health and primary care services in the Department of Veterans Affairs health care system.
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