**Transcript of Cyberseminar**

**Spotlight on Evidence-based Synthesis Program**

**Screening for Post-Traumatic Stress Disorder (PTSD) in Primary Care: A Systematic Review**

**Presenters: Michele Spoont, PhD; Andrew Pomerantz, MD**

**June 25, 2013**

**Screening for Post-Traumatic Stress Disorder (PTSD) in Primary Care: A Systematic Review**

**June 25, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact:**mailto:michele.spoont@va.gov*

Moderator:Today’s presenter is Michele Spoont PhD, Core Investigator at the Center for Chronic Disease Outcomes Research; a Health Psychologist at the Minneapolis VA Medical Center. She is also an Assistant Professor, Departments of Psychiatry and Psychology at the University of Minnesota in Minneapolis, Minnesota. 

She is joined by Andrew Pomerantz, MD. He is the National Mental Health Director for Integrated Care for the Veterans Health Administration and an Associate Professor of Psychiatry at the Geisel School of Medicine at Dartmouth. Thank you so much both of you for joining us today. Michele, I would like to turn things over to you.

Michele Spoont:Well, thank you, Heidi. Can you hear me okay?

Moderator:We can hear you today. But it is possible to pull the phone a little bit closer to you. It may help with some people who are listening through just their computer speakers. 

Michele Spoont:Okay, is that better?

Moderator:That is better, yes, thank you.

Michele Spoont:Okay. Today, I am going to be talking about a review of screening instruments for Posttraumatic Stress Disorder in primary care. I would like to thank my co-authors Nancy Greer, Shannon Nancy Greer, Shannon Kehle-Forbes, Paul Arbisi, Laura Meis, Steven Fu, Indulis Rutks, BS, and Tim Wilt who is the director of the Minneapolis CSP. Also, our expert panel and reviewers, particularly Dr. Andrew Pomerantz who kindly agreed to be a discussant for this presentation; and Naomi Breslau, Rachel Kimerling, Ed Post, Annabel Prins, and Paula Schnurr. 

This work is done by the Evidence Synthesis Program at the Minneapolis VA healthcare system. It was funded by VA Quality Enhancement Research Initiative for QUERI. These findings are – represent the author’s view only. We have no conflicts of interest to disclose for this report. The Evidenced-Based Synthesis program is established to provide VA with reviews on topics with clinical and policy relevance. 

There are four Evidence Synthesis Program Centers at Durham, VA in Los Angeles, Portland, and here at the Minneapolis VA healthcare system. The results of these reviews are used in a number of ways in clinical, administrative, and in a research context. Anyone can nominate a topic online at the link that appears at the bottom of your screen. Proposed topics are then reviewed by a steering committee. They just select topics that have the most relevance to VA. 

For each review, a technical expert panel is established which consists of people who have expertise in the area. They help to develop a topic and to refine the key questions that are then used to guide the report. The report draft is then reviewed by the technical expert panel as well as other reviewers who have expertise or policy expertise in the area. Then they write comments on the draft which are then integrated into or revision of the report and responded to by the authors of the report. The final publication is available at the link at the bottom of your screen. 

If, for those who are interested in reading about the report that is being presented today, that full report is available at the following link. Now, as I am sure everybody knows, many Veterans have PTSD, over 430,000 Veterans who are enrolled in VA carry a PTSD diagnosis. The lifetime prevalence of PTSD among combat Veterans actually varies considerably across studies. But it is somewhere around 17 percent for the most recently deployed Veterans. 

Chronic PTSD has tremendous health, social, and economic consequences. Increased rates of suicide, poverty, unemployment, multiple chronic diseases. More recent evidence suggests earlier ages of onset of these chronic disease and greater all cause mortality. It is a very high priority area for VA.

The VA-DoD Clinical Practice Guidelines for PTSD supports screening with validated instruments like the PC-PTSD, which is used here in VA. Screening has been shown to successfully increase the identification of PTSD in those populations that are screened.

What is the purpose of screening?  Well, the purpose of screening is to increase the detection of unrecognized disease in people who might not otherwise be identified. There are a number of assumptions associated with that. First of all, you have to assume that you can recognize the disease. It is possible. 

The second is that there are interventions that exist to treat it or to diminish its adverse impact. For both the assumptions one and two, we can say that is true. We know from the guidelines and from clinical practice that there are evidence based treatments that really can help PTSD that we can recognize the disease. The last two assumptions are a little bit less clear. The third assumption is just that recognition of the disease can affect the course of the disease via appropriate interventions. This requires a population wide study of the benefits of screening. That has yet to be done. 

Assumption four, it also assumes that resources are available to diagnose and to provide treatment. In the VA this is largely true, although it can become complicated depending on how the screens are used. The Institute of Medicine recently did a review of screening programs in VA and the DoD. In terms of whether recognition of the disease affects the population, they report although it is widely believed that screening for PTSD among current and former service members is important for identifying effective 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. That remains true. It is clinic – it feels clinically evident that there is no empirical research on this topic. Why primary care?  We chose to do this in primary care for a number of reasons. Primarily because most Veterans with mental health problems are seen in primary care clinics. Also, because in mental health when screening is done, it is done differently. It is done as part of a larger diagnostic evaluation of the patient. It is kind of an established screening program really has more clinical relevance in primary care. 

Primary care providers are – tend not to be very good at identifying PTSD. The primary care patients are often undertreated. The hope with the screening program is that you increase the rate of mental health treatment engagement. That hopefully, by so doing, you can increase the treatment earlier in the disease. Hopefully, thereby avoid the secondary and tertiary consequences of untreated PTSD. These are the key questions that we established. 

Our first key question is well, what were the tools?  What are the screening tools used to identify PTSD in primary care settings?  What are their characteristics?  What kinds of tools are used?  The second key question was really probably the one that is greater interest to most people, which are what are the psychometric properties of those screening tools?  

Our third key question is what information is there about the implementation of those screening tools in primary care clinics?  Our last is are there, or is there evidence for differential precision of these screening tools depending on the composition of the population in which it is administered?  In other words in terms of age, or gender, race, ethnicity, or a specific co-morbidity. 

To do this evidence synthesis report we reviewed the literature using two databases. We used Medline and the National Center for PTSD‘s published international literature on traumatic stress or the Pilot’s database. We started back in 1981 and went through October of 2012. Limiting only to English language and human subjects. 

These were the inclusion criteria that we used for the studies. It had to be evaluation of the screening tool for PTSD that was used to screen for this condition. It could be other conditions too, but it had to specifically be focusing on PTSD. There had to be a gold standard diagnostic assessment of PTSD as the comparator. We only looked at those studies that screened adults in primary care settings in the United States. The screening sample had to be greater than 50. Outcomes of interest had to include the providing information related to the precision of the instrument. Or related to the implementation of an instrument in the primary care setting. Of the screening – of the articles that met our inclusion criteria, these were the gold standards that were used. Others were potentially permissible. 

For example, the diagnostic interview schedule. But it was not used in any of the studies that met our inclusion criteria. To evaluate the studies that met our inclusion criteria, we did a qualitative assessment of the strength of the studies. Then integrated that information. To evaluate the studies, we used a systematic approach to evaluate study quality using the Quality Assessment of Studies of Diagnostic Accuracy and System Reviews or the QUADAS criteria. We only used a few of the items that were relevant to this particular topic. 

These primarily focused on sample sized, both of the screening sample and of the interview sample. The method of sampling for screening and for the interview whether the quality of the gold standard and whether the interview or diagnostic standard was evaluated in a blind and concurrent fashion. The importance of this is that if the screening sample is small or it is selected in non-random fashion that limits the generalizability of the findings. Many of the studies we found only interviewed positive screens or non-random selection. This introduces bias primarily by making the screen look as though it functions better than it does. 

Then we integrated these QUADAS ratings and items with the rational clinical exam series levels of evidence ratings to come up with a summary rating for each study. We integrated those two rating systems in this manner. Level I – studies that were given a level I rating had large samples that were randomly selected. The interview samples were very comprehensive or appropriately reflective of the screening sample. The gold standard was done in a blind fashion by a trained diagnostician. 

You can read for yourself the variation. The level III ratings down here could either have a small sample size or a lower rating on either two or three; either the selection methods could have a lower rating on one of these. Or it could have a large sample size. Both of these were rated lower. That resulted in the level III rating. Level IV rating, only one of these, the one I through IV QUADAS items could have been given a good rating. 

The other three had to be rated low. The level V rating studies were not included in the study. Because they were thought to be too methodologically poor. We reviewed almost 2,000 abstracts. This, we excluded 1,800 of them. We reviewed then 154 full text articles, most of which were then excluded resulting in 15 articles that were included in this review. Our results; what tools are used to screen for PTSD?  Well, there were nine screens that were evaluated with a gold standard tool in a primary care setting. 

Two of those screens, they were three abbreviated versions of them. Those were also included in the review. All of these were self-administered paper and pencil tests. Items range from one through 27. We included scales that were not PTSD specific if one of the goals of the study was to evaluate its ability to detect PTSD in a primary care setting using a gold standard. These are the screens that were identified by the included studies that met our inclusion criteria. As you can see, these screens are PTSD specific. 

But the last four screens actually assess for a variety of disorders. These studies are listed here in the attendant screens. Only a few of the studies evaluated more than one screen. Looking at the level of evidence  ratings, you can see that very – only a few studies have level I evidence rating. Only one of those involved the PTSD specific screen. 

Moderator:Michele, I am sorry to interrupt. Michele, I am sorry  to interrupt. 

Michele Spoont:Yes.

Moderator:Would it be possible to speak up a little bit louder?  We are getting some comments from the audience.

Michele Spoont:Alright.

Moderator:Thank you.

Michele Spoont:Sorry. Our second key question is the psychometric properties of this screen. Just to give you a quick review. This involves really assessing the ability of this screen to identify that someone has PTSD given a positive screen. Or to clarify that they do not have PTSD given a negative screen. In a perfect situation, your screen would be able to perfectly differentiate those who do not have PTSD from those who do have PTSD. But that is, of course, not really what happens. All of our screens are imperfect as well as our diagnostic assessments are also imperfect. Here I just want to quickly review the terms that are going to be used. I am not going to go over this in great detail. But sensitivity and specificity are the ones people talk about most. They basically clarify how well the screen works. 

Part of the problem with looking at only sensitivity and specificity is that they are subject to differences in populations. For example, if one population has cases that are more severe than in another population, the screen will appear to work better in that population where the cases are more severe. Because the sensitivity will appear to be better. In that sense, prevalence rates can be an estimate of the severity of the population. 

Although sensitivity and specificity are not directly affected by prevalence rates, they do vary according to the composition of the population. The positive and negative predictive values here reflect the proportion of positive and negative screens given the outcome of the screen. Positive predictive value is if I have a positive screen, what proportion of those positive screens are actual positive cases?  This is – these two values are very useful on the one hand but are actually very sensitive to prevalence rates of the condition in the population and so may not be the best metrics to evaluate screens. 

Likelihood ratios which are used in many areas of medicine to evaluate diagnostic or screening tools is kind of based on a Davian approach. It is basically – answer the question of how much does a positive screen change the probability from baseline that this person might have this disease?  It is a very useful single metric to sort of give a clinician an estimate as to the utility of the answer of that particular tool. 

Psychologists are very fond of using the area under the curve, which is under the curve of the receiving – receiver operating characteristic curve. It is – which is a measure of discriminability of the screen. Basically, if it is one, then it perfectly discriminates. If it is 0.5, it is discriminability is no better than chance. These are the manner in which you are able to evaluate these screens. As you can see, the positive and negative predictive values vary according to base rates directly. Sensitivity and the specificity vary actually less directly. Likelihood ratios are based on the sensitivity and specificity. 

For this next section, I am going to talk about the screening tools in the following manner. First, I will talk about the intermediate screens. Because these are the ones, the blank screens. Because these are the ones that are used most often. Then I will talk about the PCL. Because that is the one that – for which there is the most evidence. Then I will talk about the shorter and the non PTSD specific screens. 

There are three intermediate lengths. Screens that were really used across studies. That is the Breslau scale, the PC-PTSD, which is currently in use in the VA; and the SPAN. As you can see, these are the – I highlighted the most commonly used cut-scores for these screens. You can see that as the cut-score changes, how the sensitivity and specificity change. Also, how the likelihood ratios has changed; and the positive and negative predictive values changed. 

Specificity will increase because fewer of those with PTSD have a false positive screen. As you go up, this will increase. As you increase your cut-score, it will become less sensitive because you are more likely to lose people who actually have the condition. Overall, these intermediate screens perform fairly well. They tend to have likelihood ratios in the three to eight range; around anything better than a three is considered to be clinically useful. The likelihood ratio – the negative likelihood ratios are below 5.5. That is considered to be fairly useful. 

The PCL on the other hand is a much more complicated to evaluate. Because each of the studies included a variable ranges across which they have reported the metrics in terms of the screen efficacy. You can also see then the variation across these cut-scores. Fifty, which is used frequently in research studies of PTSD can have some very high likelihood ratios. It is very specific across studies. But it is less sensitive. Many positive cases are missed with a PCL of 50. 

It is probably not the best to use as a screening tool. Thirty, which is often used as a cut-score in active duty populations tends to have much better sensitivity. But its specificity is low. Well, lower in some studies than in others. As you can see in the likelihood ratios, the utility of 30 is not as good as the intermediate scales. I think one of the things to note about the PCL is that while you can say between 30 and 50, there is a clear delineation. But if you are really going to make a cut-score, do you want it at 30?  Or, do you want it at 31, or 32, or 33?  That is very difficult to discern exactly where that cut-score should be because of its continuous nature. That the variation from one number to the  – to the next, it really changes the odds almost in the negligible manner. 

Consequently what happens is that the appropriate cut-score for the PCL often has to be calibrated to the population that it is serving. Whereas that is less true with the intermediate scales where the drop off from say at three to a four is more clearly delineated. In the very short screening scales, you can see that the likelihood ratios are just less robust. That there is a greater tradeoff between the positive and negative predicted values across the screens. 

But importantly, I think that the non-specific non-PTSD specific screens are those that include assessment of other scales. There are one or two items. They can be used. They perform comparable to those that are like the PCL-6, which has been considered as a short screening tool. But they are not all that different. But they are not as good as the more intermediate length scales. 

There were only four studies that compared multiple screening instruments. That provided enough information to actually look at the differences. In the studies that better level of evidence ratings, you can see that the PCL seems to perform better than the more intermediate scales. However, you can see that the cut-scores were determined by the population in a posterior fashion. That it is unclear if you were to replicate this on a new sample using these cut-scores, if you would get the same metrics as an outcome. 

The less, the Freedy study was done in a civilian population. It was perhaps a little bit less well controlled study. The cut-scores are a little different. It is unclear that it was truly representative of that particular population. In this case, the PCL did not seem to perform better than the PC-PTSD. But given the methodologic variation, it is hard to interpret that. Overall the AUC statistics suggests that other than the very short SIPS, which is essentially a one question; does it both you a little or a lot?  That the AUC statistics suggests that most of these screens are clinically useful. The performance of the moderate length screens appears to be comparable. If we went back, we could see that there is maybe a little weak evidence that the span performs a little less well in the primary care setting. 

How it performs in other settings, we cannot really answer by these – by this review. The PCL. While it seems to work better, longer scales are often better than intermediate length scales. However, the cut-score is quite variable and graded. You really would need to calibrate it appropriately to a particular population. In that sense these intermediate length screens, the ones that are four, or five, six questions might be more transferrable across context. 

The non-PTSD specific screens are less precise. But they may also be clinically useful, particularly if you have the resources to evaluate multiple, in this case anxiety or depression symptoms. Then provide treatment for those patients who end up having a disorder. Our third key question is what information was there about implementation issues?  Really there was extremely little information. Almost none of the studies reported how long it took to take the screens. Or how they might have affected the clinical setting. Those that did report suggested that they only took about five minutes. 

The longest one, which was 27 items was reported to take only ten minutes to fill out. Only the Gaynes study, which reported on the M-3 screen provided the only process evaluation of any of the screens. Given that it was the longest screen, it is in some ways useful and potentially applicable to the other screens in the sense that only one percent of the patients reported that they did not have time to fill it out before their appointments. 

Most of the providers were able to review the results in less than a minute. I assume because not that many patients had positive screens. Most of the patients felt like it facilitated a discussion of mental health with their primary care providers. That was particularly true of those with mental health conditions. I think most of the providers  in that study reported that they felt that it was helpful to facilitate conversations with their patients about mental health issues that required treatment to referral. None of the providers in that study felt that inclusion of this multi-disorder 27 items screen impaired their ability to provide primary care to their patients. 

The last key question has to deal with the psychometric properties of the screen relative to particular subpopulations. Very few studies actually evaluated the precision or utility of the screen in sub-populations. Or if they did, not all of them actually provided any information about it. The most important thing I would like to point out there is that in – and this is really best illustrated by the Prins Sidel study – is that the utility of the PC-PTSD was different between men and women. It appeared to work better for men. It had better sensitivity, better specificity; much higher positive likelihood of ratio; much lower negative likelihood ratio. 

I realize this needs to be replicated. But it was also true in the Freedy study where it worked better for men than for women in terms of the likelihood ratios here as well. The only screen that did not show – intermediate screen that did not show the difference by gender in the Freedy study was the SPAN. That seemed to be comparable although less well performing than the other screens in that particular study. On the other hand, the Yeager study that did not – they did not find any difference. This was the most – the best controlled study. I think they did not look at the PC-PTSD. But for the SPAN, they also found no difference. 

Both studies that looked at the SPAN found no difference. They did not find a difference with the PCL and the Yeager study either. The Means-Christenson study of the anxiety and depression detectors; which is a multi-illness detector. They did not find any race differences. Yeager did not find any differences by race in terms of the main effect. But they did find an age by race difference for the PCL in terms of its ability to screen for PTSD. More specifically, the PCL worked less well for African-American men who were under the age of 50 than it did for older or white Veterans. 

I think that is something that really needs to be evaluated. Most of the studies did not look at these kind of differences. None of the studies looked at the utility of these screening tools in specific populations. For example, among Veterans who have traumatic brain injury or specifically substance misuse. Now, I know that there are studies that look at PTSD in substance abusing populations. But they were not done in the primary care setting. It is unclear  how people who are seeking treatment for substance misuse might differ from these particular primary care samples. 

To summarize, there is limited evidence looking at screens by age, gender and race. None that looked at specific co-morbidities in the primary care setting. There is weak evidence that the PC-PTSD and the Breslau scale performed better in men than women. The SPAN does not appear to have that difference. Although overall, it seems to have performed slightly less well than those scales. The PCL does not have any gender differences either, but there is weak evidence that the PCL may perform less well for younger African-American Veterans. 

Overall, while there is insufficient information about the potential benefits or harms of screening for PTSD on the health of Veterans in the primary care setting. Potential harms are misdiagnosis or mis-deployment of resources; or increased pursuit of disability potentially. Benefits might be getting people into care earlier and avoiding chronic course of the disease and all the secondary health and economic consequences of chronic PTSD. 

More information is needed on a population level. It would be great to have more information about the performance of these screens in specific populations. Either by race or to really clarify whether or how severe this gender difference is. Whether there is a way to eliminate that difference. The evidence base needs to be expanded on these characteristics. It seems that the fewer number of the items on the screen as is true for my psychometric scales; the greater there is a tradeoff of sensitivity and specificity for each point on the screen. It grades less well. However, on the other hand, from a – as a screening tool that might be better. 

The intermediate length screens might be better as a screening tool. Because the fine gradations and the longer PCL might actually make it less useful as an initial screening tool in the primary care setting. Because it will need to then be calibrated to each clinical contact. Screens that consist of one or two questions really do not balance that sensitivity with specificity or the likelihood ratios to really be as useful as the screens that are somewhat longer. Because either you capture almost everybody; in which case you have a lot of false positives. Or you miss a large number of people. Because there are only a couple of screens. You cannot differentiate among the population sufficiently. 

There is a still a need for a study to examine the impact of screening on the clinical process and primary care. There was only one process evaluation that was done. None has been done in the VA to really examine if we do these screens, how does that effect our ability to improve the health of Veterans overall?  How does it affect, help the primary care appointments play out?  

How does it?  What is the best way to use the screens?  How do we best then integrate the mental health within the primary care with positive screens?  It is already being done. But we do not know what the best process method is. The non-PTSD screens might have some clinical utility in primary care settings. But if you identify multiple diseases, you then  have to have the follow up necessary to make use of those screens meaningful.

There are a number of limitations in this review. There were a lot of different gold standards that were used. That really limited our ability to compare studies and we acknowledged that this is a limitation of the review. Screening tool use is really contextually dependent and we could not really look at that. What the tradeoff is between capturing all potential cases versus limiting the number of cases for follow up are really policy decisions that depend on the resources available and the preferences of the institution. 

I also would like to note that with now the implementation of DSM-5, all of these screens are going to be needing to be re-evaluated. Currently, the National Center for PTSD is reevaluating the PC-PTSD, the PCL, and the CAPS. This work is being done by Brian Marx, Frank Weathers,  and Annabel Prins primarily running evaluation studies. It is my understanding that the CAPS-5 and the PCL-5 are complete. That the PC-PTSD-5 is currently being evaluated using the MINI. That it will now have five questions. 

I am open to questions. We are actually...  I think it is up to Andy as a discussant at this point.

Moderator:  Yeah, let us turn things over to Andy for a couple of minutes. Then we will take questions. 

Andrew Pomerantz:Okay, thanks, if you cannot hear me, let me know that you did not hear that. You cannot let me know. Just a couple of points. This is – this is really important work. I will tell you why. The main issue is that we know that the VA is transitioning to a population based healthcare system that really emphasizes prevention, early identification. Screening is part and parcel to an early identification of illness and prevention of complications, and morbidity. 

One of the assumptions that Michele mentioned at the beginning, number four was that screening assumes that resources are available. That I think is the biggest issue. Really is why this is so important. We know in the VA that we have good evidence based treatments that are effective for PTSD. We also know that an awful lot of people who not may get into those programs. Many patients who are referred into them, do not really engage in treatment. It becomes really incumbent on us to develop ways to maximize the productivity of those programs. 

Our PTSD clinical teams are really swamped in many places. Because they get so many referrals directly from primary care. Who, patients who do not know what they have been referred for. Or maybe they do not even have PTSD. Maybe they do, but they have not really engaged in the shared decision making process. Or even have the concepts that tells them before a referral what they might be getting themselves into. 

We know that not very many of our patients make it through a complete course of treatment, which means that an awful lot of time in the PTSD programs is spent on patients who either do not show up. Or maybe show up for one session or maybe two sessions. Two or three sessions of evidence-based psychotherapy for PTSD may be better – may be worse than no sessions at all. 

As Michele mentioned, primary care is where most mental disorders, and particularly PTSD first present. Mental disorders including PTSD or they are generally undertreated in primary care. To a great extent, it is one of the focal points of our primary care mental health integration program, which is now putting mental health providers into the interdisciplinary pact as part of the team. Both through collocated collaborating providers as well as people doing telephone care management for mental disorders. 

Primary care presently screens for PTSD with the PTSD PC that was mentioned. Anxiety disorder screening is not generally prevalent throughout the VA in primary care. Although it is in mental health programs. We also screen for at risk and problem alcohol use as well as depression. 

An ideal screen for us looking from the primary care perspective would be one that really can have a fairly decent sensitivity. But also from the perspective of mental health providers, good specificity. In programs that have a well-developed primary care men1tal health integration presence, a lot of screen – positive screens are referred to the mental health providers in the team. 

That can be a good thing or not. Because often even those providers are overwhelmed in the facilities that have automatically generated evaluations by the mental health providers and primary care. There are a lot of positive screens. We cannot really do a good job of doing a second pass evaluation on absolutely everybody who screens positives. I mean, we are doing the best we can. But it is just another reason why we need some screens that are short enough to be tolerable. I noticed that the implementation issues were not a problem, which is good. Short enough to really screen, but also long enough to help particularly those programs that do not have available mental health expertise readily at hand. 

It makes them informed referrals to the PTSD clinical teams. I think that the tools, it looks like you covered most of the – most of the tools that I am familiar with. You mentioned the MINI a few times. A lot of the MINI has been incorporated in the behavioral health lab software, which is part of the care management assessments in many places. Again, for us it all – and we really have not given a whole lot of thought until like 20 minutes ago to the age, gender, and other possible disparities between different populations. But I think I need to look more closely at that. 

Certainly for us it all comes down to the property, the sensitivity of specificity. This is a great step forward towards better understanding what kinds of screens can be done effectively in primary care that can lead to meaningful follow up care. Because we all know that screening without available follow up care, it does not do a whole lot of good. There is a lot more I could say but I will wait and see if there are any things in the questions that come up. 

Moderator:Great, and thank you Andy. We do have several pending questions here. I am just going to start at the top and work my way down. For the audience, if you do have a question, please use the Q&A screen. Go to webinar to submit that into us. The Q&A screen is located on the dashboard on the right-hand side of your screen. Just click on that orange arrow at the upper right-hand corner, if it has collapsed against the side of your monitor. The first question I have here. Are there estimates of sensitivity and specificity of the screening instrument?

Michele Spoont:I am not sure if I understand the question. Can you repeat that, please?

Moderator:Yeah. Are there estimates of sensitivities and specificity of the screening instrument?

Michele Spoont:Well, I listed in these studies what the sensitivity and specificity are. I mean, there is not kind of a general estimate independent of the context that is evaluated. Because sensitivity and specificity really I think as I mentioned initially. Although they are not really affected by the prevalence rates in the same way as positive and negative predictive value, they are effected by the composition of the population. 

For example, if I have a population of people where there is PTSD. But it is always very mild, for example. Then the sensitivity of the same screening instrument will be lower than a different population in which the severity of the condition is worse. The ability to detect whether the condition is present depends in large part on how severe the illness is in the population in which you are looking at the screen characteristics. 

While that does not exactly go with the prevalence rates, it is sort of – the prevalence rates can actually be a proxy for that. There is not sort of a global estimate. You really have to look at it within context – a long answer.

Moderator:Okay, and great, thank you. The next question; do contravening or contrary exist for the negative IOM reports?  

Michele Spoont:Negative IO...?  You mean in terms of – I mean, the IOM report is extremely long. I am not sure. You mean, in terms – I guess I am not entirely clear on the question.

Moderator:Okay.

Michele Spoont:Perhaps that...

[Crosstalk] 

Moderator:Ralph, if you want to send in a further description on your question there, I can get back to that. The next question I have here. Do you have a reference for RCE Level of Evidence Rating scale?

Michele Spoont:Yeah. I think I – that is my – Simel. Yes, I would have to...  I do not have it on the top of my hands. But it is David Simel at Durham developed that. I believe it is in 2005. I do not have it on my – at my fingertips. But it is part of the rational and clinical exam series. Any RCE article will have that Level of Evidence rating. It will be in their references. I would be happy to send that to whoever asked that question.

Moderator:Okay, and great, thank you. The next question; was there any literature that discussed the difference between which provider administered the tool?  For example, physician versus nurse; which discipline is the usual one to administer the tool?

Michele Spoont:Well, I think that is really an excellent question. You mean in terms of the screen or the follow up interview. Most of the screens were done not by a physician. But I think there is a great deal of variability in terms of how the final diagnosis were done. There were no studies that compared that. That were included in our – that met our inclusion criteria. That was one way in which the gold standards differed quite a bit across studies. Some were done by phone. 

Others were, mostly were done in person. But some were done in phones. Some were done by psychologists. Others were done by trained research assistants. I suspect that the ability to do the diagnosis varied quite a bit depending on who did the final diagnosis. The screen since they were paper and pencil assessments, I do not think who administered those. That it mattered that much. 

Moderator:Okay, great, thank you. I had a couple of people who sent in questions similar to the next one here. I am interested in screening spouses of Korean Vietnam era Veterans to uncover Veterans who may have sub-clinical PTSD. In order to educate caregivers that may emerge at end of life. Is there a screening tool that may be more effective for screening spouses for behaviors that they may have observed from their Veteran?

Michele Spoont:I know of no proxy screens. What it sounds like those questions are – are there tools that can be used to help people identify PTSD in their spouses?  Short of administering one of these screens to their spouses, which I really do not recommend. I do not know of any screens that could be – that are developed for the purpose of saying does your husband do X?  Which I think is what the question is about.

Andrew Pomerantz:This is Andy. The attritions given the population that is being asked about. I just want to add that there are a number of caregiver documents. Caregiver screens that ask about caregiver perceptions of what is going on. Just through the use of those, it will often lead down the road of evaluating for PTSD. Based on more general things.

Moderator:Great, thank you. The next question here. How about suicide prevention?  Will diagnosis and prescription of PTSD help?

Michele Spoont:Well, there are many conditions that can result in suicide. But people with PTSD are certainly at an elevated risk for suicide. I think any time that you have an untreated mental illness that the risk of suicide is always higher. In that sense, screening for any of these mental health conditions. Whether it is PTSD, depression, substance misuse; psychosis really will improve the detection, or of people who are potentially suicidal.

Moderator:Great, and I received a follow up on the IOM question. They sent in here. The IOM statements that no evidence exists that defines benefit. It seems to contravene efforts to treat based on screening. 

Michele Spoont:I totally agree. I think that is because it is clinical intuition. That if you can treat somebody before they have been ill for 20 years, that your outcome is better. That the individuals’ lives are better. They are less likely to get divorced and married three times. Or lose five jobs; or be unable to hold a job. You can really improve people’s lives through treatment. 

I think clinicians have a sense for that. But there have been no studies, no empirical evidence to support that. I think one of the things that while clinical intuition is very useful and important, a real empirical study should also look at potential harms. 

I think this is done less in the mental health arena. More in the arena for example like screening for cancer. There has been sort of a renewed interest at looking at the potential downsides of screening programs for cancer. The same may be true for PTSD. We just actually do not know. 

Moderator:Okay, great, thank you. The next question; what is the level of evidence for efficacy of treatment?  Can primary care really take care of these challenging problems?

Michele Spoont:Well, there are two parts of...  That is a two part question, and I will start with part one. Yes, there is plenty of evidence for – that there are effective treatments for PTSD. I would really encourage the person who asked that question to look at the VA/DoD guidelines on the Clinical Practice Guidelines for PTSD. Or any of the other, there are a number of guidelines. They are fairly similar, but the VA/DoD Clinical Practice Guidelines for PTSD are potentially the most accessible. 

Then the second question, part of that question was can primary care treat this?  I guess I would say yes and no. primary care providers certainly are capable of prescribing pharmacotherapy for PTSD. I do not think all primary care providers have the information necessary to do that. They would require appropriate training and support to be able to do that in a way that feel comfortable and could be integrated into their clinical practice. But we are also not talking about providing treatment within the primary care setting. 

We are talking about identifying people in the primary care setting for further evaluation. The primary care mental health integrated program also involves other providers like psychologists, social workers, psychiatrists who can either provide treatment or refer to specialty PTSD clinical programs where the treatment can be provided if they are available and the patient is willing to go; which is often more of the issue than anything else.

Andrew Pomerantz:To some extent this is also the answer to this question; which I agree. It is yes and no; which is just dependent on how you define primary care. But thinking of the fully developed patient aligned care team, the answer is yes. But you can; and you may not be able to do the 12 sessions of cognitive processing therapy in primary care . In fact you really cannot do that. But there are a number of pilots as well as a couple of RCTs looking at brief manualized treatments. 

Looking at three 30 minute sessions within primary care that can be delivered by the embedded psychologists. There have been – it is an area of tremendous need. Again, to help if nothing else, filter out people who are really just kind of struggling with readjustment and trauma; versus those who need and want definitive treatment for PTSD, which we do not do in primary care. We are, and I think the last I looked, have the data. Something like 27 percent of the primary diagnosis of people seen in primary care by our integrated teams are PTSD. It’s big. It is number two second only to fresh and what our proprietors are addressing. There is a lot of work to be done. 

Moderator:Okay, great, thank you. The next question; so what should be the screen of choice for primary care?

Michele Spoont:Well, I think in the VA that any of the intermediate screen like screens would be good. There is the most information about the PC-PTSD, which is already being used. Is now almost finished revalidated for the new DSM-5 criteria. It seems to be a reasonable choice. Whether other screens for other conditions should be included is kind of a policy decision. Outside of the VA, I think that you would really have to look at what are the resources and the intentions of the screen in whatever the clinical context is.

Moderator:Okay, great, thank you. The next question here. I do not understand why the longer, more accurate screen is not the preferred questionnaire given. Especially since none of the providers indicated that it was cumbersome when added to their primary care appointments.

Michele Spoont:I missed that last part. But why are we not using a longer screen?  You mean, for the multiple conditions or the PCL?  I guess I would like. Because the process evaluation was done on the M-3, which looked across numerous mental health conditions. 

Moderator:Okay, I am not sure. The questioner could send in some further information, if they would like there. Let us move on to the next question. I am interested in the PCL specificity, sensitivity for Hispanic men under 50 years old. Is there a similar weak evidence as for African-American men?

Michele Spoont:There really, as far as the studies that met the inclusion criteria for this review, there was actually no information about the utility or precision of any of these instruments in a specifically Hispanic population. 

Moderator:Okay, thank you. The next question here is very long. I think it actually went over. But I will get through as much as we can here. Regarding screening utility, is the purpose not to over capture the target condition so that the diagnosis can be established or confirmed by follow up evaluation?  The PCL was developed specifically as a waiting room instrument that would be reviewed by a PTSD clinician later and expanded upon in a diagnostic interview. 

The  sensitivity and specificity of the PCL to PTSD would likely vary across population because the response metric is How much were you bothered by X symptom in the last month versus how often or how much did you experience it?  And thus measures distress which might not be PTSD. In studies that examine the two, there is PCL and CAPS to score those. 

Michele Spoont:Okay. Can you repeat the very first part of that?

Moderator:Regarding screening utility, is the purpose not to over capture the target condition so that the diagnosis can be established or confirmed by follow up evaluation?

Michele Spoont:Okay. There are two parts to this question. I will start with that first part. Yes, absolutely, that is the purpose of the screen, and which is to over capture so that assuming... In part, it is a policy decision. I think in VA we can safely say that is the purpose of the screen. Because you have to decide what is the cost of missing somebody who has a disorder or a condition for which you are screening?  Since we value the treatment and identification as in treatment of Veterans who have PTSD is really an important health priority for VA, we want to do that. 

On the other hand, if you over capture, you then really max out your resources in which Dr. Pomerantz alluded to earlier; which is that if you over capture too much, then you are using all of your mental health resources for follow-up evaluations. In which case, they are not available to provide the treatment. You have to make a decision based on what resources are available. The importance of the condition; how much of... Whether it is more important to capture everybody? Or whether it is okay to maximize use of your resources?  There is a tradeoff between those two things. 

The second part of the question which is involved...

[Crosstalk] 

Andrew Pomerantz:All the more reason.

Michele Spoont:Right. Exactly; and the, and then the PCL, it potentially. It has benefits for screening. I think the reason why I do not think that it is useful as a screening tool in primary care is first of all there are usually are not necessarily PTSD specialists within the primary care setting. But even if there are, the bigger problem is how do you use it?  If you -if you use a cut-score of 30, and someone has 29, are you really confident that you are a clear that they do not have PTSD?  

I would say it is really less clear because the change in odds by each point is minimal. It is really only when you jump ten points from 30 to 40, or 25 to 35, or to 50 that you really see a change in the odds of whether a positive screen means that someone has PTSD. It is – so it is fine gradation while very useful potentially for looking at outcome data. It is really less useful for a screen in a clinical context. Now it is used often as a screen to look at prevalence estimates. But there you do not have to worry about if I miss a certain number of people. Then there are no deleterious health consequences of missing those people.

I really think that the intermediate length screen have the best trade off. It is easier to decide three is a good cut point. Or five is a good point for the screen in terms of balancing the sensitivity and specificity of the tool in the population. 

Moderator:Great, thank you. The next question I have here. Can you please expand what you mean by the instrument causing harm?

Michele Spoont:Well, the instrument itself does not cause harm. Or at least I do not think so. I think once people have been traumatized, asking them that is really not what is the problem. Since they already suffered the awful thing to begin with. But there is always harm in potentially having false positives. If I tell someone they have PTSD because my screen says so. There is that much imprecision. 

For some reason my follow up assessment is not good. Then that person may get treatment that they do not need. They might be started on an antidepressant that does not help them. Or they may pursue disability which then has other negative effects for them. I think that we do not really look at that in mental health so much. It is much more obvious when you are looking at cancer screening. Where if you assess for say prostate cancer or breast cancer. You have a false positive screen, then people get surgery that they do not need. I think in – there are potential complications of any surgery. 

I think it is very obvious in that situation. But it is probably true in mental health too. I mean, some of the research I have been involved in is people really have difficulty identifying whether they themselves have PTSD. They know that they might be suffering. But they may not have a label for it. Once we provide them with a label, there are consequences for their self-concept. Then whether they believe that it is treatable. Whether they are willing to pursue treatment. The stigma associated with those diagnostic labels. But really we have not evaluated whether those harms are significant?  Or whether they are trivial?  There just really is no evidence for that.

Moderator:Okay, thank you. That actually is all of the questions that we have received. Michele, Andy, do either of you have any last remarks you would like to make before we close things out today?

Michele Spoont:I do not.

Andrew Pomerantz:Yes, probably nothing more for me except just to reaffirm that this is a big area of interest for us. Treating mental disorders, managing mental disorders in primary care so that we can protect our scarce mental health specialty resources for the people who really will engage. Who really need them, the most serious cases. Every bit of evidence that we can develop is one more carat for us. Thank you, Michele.

Michele Spoont:Thank you, Andy.

Moderator:Yes, I also want to thank both of you for taking the time to prepare and present for today’s cyber seminar. We very much appreciate it. For the audience, as you leave the session today, you will be prompted with a feedback form. If you could take a few moments to fill that out. 

We definitely read through all of the feedback. Definitely to make changes and considerations for the session from what we read there. I want to thank everyone for joining us for today’s spotlight on Evidence Based Synthesis Programs Cyber Seminar. We hope to see you at a future session. Thank you.

[END OF TAPE] 

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