46

Screening for Post-Traumatic Stress Disorder (PTSD) 

in Primary Care: A Systematic Review Evidence-based Synthesis Program

APPENDIX A. SEARCH STRATEGIES

I. Ovid MEDLINE

Search Strategy:

1 exp mass screening/ or screen*.mp. 

2 exp Stress Disorders, Post-Traumatic/ 

3 (posttraumatic stress or posttraumatic stress disorder* or post-traumatic stress disorder* or 

ptsd).mp. 

4 combat disorder*.mp. or exp Combat Disorders/)

5 or/2-4 

6 1 and 5 

7 limit 6 to (english language and humans and yr=”1981 -Current”) 

II. PILOTS Database

Search textword “screen*”

With Limits: 

English language

1980 -2012

And Descriptor categories:

“self report instruments, adults” or “self report instruments”, “ptsd assessment instruments”, 

“dissociation assessment instruments”, “acute stress disorder assessment instruments”, 

“assessment instruments” or ”assessment”
47

tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

DY SELECTION AND DATA EXTRACTION FORM 

47

check if Backgroundpaper

First Author Year

2004

Inclusion eligibility? Y N

 Penn Inv IeS DTI DeS Miss. Scale SPAN IDcL Pc-PTSD Other 

Response Rates: Screening Sample: Interview Sample:

nsitivity (%) Specificity (%) PPV NPV + LR - LR ROCd' ROC

c-stat

(AUC) 

Other

Outcomes 

dministered PTSD Scale (cAPS) Administration Notes: (e.g., study design different from single cohort, Info on ease of administration, 

ational Neuropsychiatric Interview Face-to-Face unique scoring method, etc.)

ive international diagnostic interview (cIDI) Telephone 

nterview Schedule (DIS)

ed Clinical Interview for DSM-IV Disorders (ScID-I). Telehealth 

Medical Age 60+ TBI Minorities Sexual

nce Abuse Vietnam only OEF/OIF Other (note) 

QUADAS Eval Sample broadly representative of those who would be screened? Y NTime b/w screen and dx interview: ___________ months Is it considered "concurrent"? Y NDid whole/ random sample have dx interview? 

Whole Random (%?) 

 Random Group Different from Total Group? Y NWere diagnostic interviews conducted blindly? Y NWas screen cut score confirmed on a separate or split sample?Y NWas relevant clinical data available for interpretation of screen (like would be in clinic)? Y NWere reasons for withdrawals or refusals in the study 

explained? Y N

y/(1-specificity) -LR= (1-sensitivity)/specificity

at least 2.0 and LR- of 0.5 or less.

Diagnostic (Gold Standard) Test 

Positive Negative

tive: a (true positive) b (false positive) PPV=a/(a+b) 

ative: c (false negative) d (true negative) NPV=d/(c+d) 

Sens=a/(a+c) Spec=d/(b+d) 
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Screening for Post-Traumatic Stress Disorder (PTSD) 

in Primary Care: A Systematic Review Evidence-based Synthesis Program

APPENDIX C. LEVELS OF EVIDENCE 

Based on Criteria for the Rational Clinical Examination Series (Simel 

2008)7

Level I Evidence 

Independent, blind comparison of sign or symptom results with a “gold standard” of anatomy, 

physiology, diagnosis, or prognosis among a large number of consecutive patients suspected of 

having the target condition. 

Independent: neither the test result nor the gold standard result are used to select patients 

for the study. 

Blind: test and gold standard each applied and interpreted without knowledge of the result 

of the other. 

Gold Standard: the results of biopsy, angiography, autopsy, xray, sonogram, physiologic 

study, follow-up, therapeutic response, etc. that establish the true anatomy, physiology, 

diagnosis or outcome of the target condition. 

Target Condition: the anatomic or physiologic state, disease, syndrome, prognosis or 

therapeutic response that the sign or symptom is designed to identify. 

Large Numbers: sufficient numbers of patients to have narrow confidence limits on the 

resulting sensitivity, specificity, or likelihood ratio. 

Level II Evidence 

Independent, blind comparison of sign or symptom results with a “gold standard” among a small 

number of consecutive patients suspected of having the target condition. 

Small Number: insufficient numbers of patients to have narrow confidence limits on the 

resulting sensitivity, specificity, or likelihood ratio. (N.B. You should note that the definition 

of “small” is relative and depends on the size of all extant studies. For example, if you have 

several studies of many hundreds of patients, then a study of only 80 patients might be 

considered small.) 

Level III Evidence 

Independent, blind comparison of signs and symptoms with a “gold standard” among nonconsecutive patients suspected of having the target condition. The short-coming here is 

restricting the study sample to a subset of patients who both underwent and generated definitive 

results on both the sign or symptom and the application of the gold standard. The results overestimate accuracy. 

Level IV Evidence 

Non-independent comparison of signs and symptoms with a “gold standard” among “grab” 

samples of patients who obviously have the target condition plus, perhaps, normal individuals. 

In addition to the selection bias of Level III, these studies restrict their samples to the obvious, 

“black or white” presentations (sometimes even selected on the basis of their gold standard 

result) that don’t need a clinical examination (other than pattern recognition), and exclude the 
49

Screening for Post-Traumatic Stress Disorder (PTSD) 

in Primary Care: A Systematic Review Evidence-based Synthesis Program

“shades of gray” that comprise the clinical spectrum of early as well as late, mild as well as 

severe, and other but commonly confused conditions. The results greatly over-estimate accuracy. 

Level V Evidence 

Non-independent comparisons of signs and symptoms with a standard of uncertain validity 

(which may even “incorporate” the sign or symptom result in its definition) among “grab” 

samples of patients plus, perhaps, normals. In addition to the biases of Level IV, these studies 

often include the sign or symptom result as part of a “lead standard,” resulting in a self-fulfilling 

prophesy. The results extravagantly over-estimate accuracy. 
50

tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

R REVIEW COMMENTS/AUTHOR RESPONSES

RESPONSE

 methods for this review clearly described? 

hensive review with a wealth of very useful information.

ars to be a literature synthesis of the feasibility and diagnostic accuracy of PTSD 

tings. This could be slightly clarified in the introduction, rather than the broad 

g tools in general, since issues of screening effectiveness and clinical efficiency 

he report.

ons are clearly stated, but could avoid using “etc.” in KQ #1 and 2, and instead 

stics reviewed, and for KQ#2, list the specific psychometric properties of interest. 

lity issue fits better in KQ#2 than it would in KQ#1 or as a separate question, 

eparately on page 18, and does not map to the levels of evidence framework 

agnostic accuracy (psychometric properties and utility) in KQ#2.

vels of evidence need to be clearer, especially in the discrimination of levels II 

ng for level III, “patients who both underwent and generated definitive results on 

 application of the gold standard” is not clear. I am wondering if this is an allusion 

-up or administration of one part of the testing protocol is dependent of results 

col (e.g. administering the gold standard first, and then the screen to all cases 

escribed in Simel). I’m also wondering if this may be an editing glitch, since this 

 level IV, and this kind of non-independence would be more of a Level IV issue.

study from Level II to Level III is the use of non-consecutive patients that are 

r other than eligibility for screening that would result in a non-representative 

sults do not reliably over estimate accuracy, as stated on p. 48. The effect of 

ple was selected and the ways in which they differ from the target population. 

elines include: exclusion of patients with comorbid conditions or symptoms that 

y but would likely be present in the target population; studies in specialty settings 

pression is narrowed; or just non-consecutive and non-random selection of the 

pronounced violations of sampling assumptions, such as case control studies, 

1. Thank you2. We have modified the statement of the objective of the review.3. We have modified KQ1 and 2 as suggested. We agree that the implementation processes of screening would have best been covered in a separate question and have done so to improve clarity of the findings. 4. The descriptions of levels of evidence were taken from instructions for preparing a Rational Clinical Examination article.4a. We agree that the shortcoming for Level III is verification bias – selection of patients for verification rather than inclusion of consecutive patients. We also agree that the section of text was mistakenly repeated in the summary 4b. We agree that selection bias is one of the main differences between Level II and Level III studies. We have clarified our application of these ratings in Appendix F. 

nder KQ#2 could be more complete and detailed. Not all psychometric properties 

ntly reported, including key indicators of diagnostic accuracy such as likelihood 

ds of a positive test. If only sensitivity and specificity are reported, it is important 

n the sample. This may be a minor issue, since most (but not all) of this 

t clear why some specific statistics are pulled out in the text and that the type of 

tely consistent across measures, so the reader does not get a clear critique of 

creener.

5. We have now made the text more consistent throughout.Thank you
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tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

RESPONSE

e clearly described through the three key questions:

 screen for PTSD in primary care settings, and what are their characteristics 

etric properties and utility of the screening (operating characteristics) and their 

ation) in primary care clinics?

roperties and utility of each of the screening tools differ according to age, gender, 

other comorbidities? 

creening tools used and validated in primary care.

not always logical, accurate or clearly described 

e of the US were excluded was not provided. Discussion of how Veterans in VA 

ns in primary care was not addressed. Perhaps there are reasons why screening 

differ in VA versus civilian primary care. Greater rationale for the inclusion/

ed. 

did not include PTSD items (e.g., GAD-7)? Was study selection based on 

dard in a primary care setting? If yes, other non-PTSD screens may need to be 

Q)

1. We have addressed these points in the report.1a. We included only studies done in the United States because of greater relevance to the care of US Veterans.There were no studies that compared screen efficiency or effectiveness across both Veteran and non-Veteran samples. It may be that a given screen performs better in one population vs. another or for PTSD associated with one type of trauma vs. another; however, given the absence of evidence this would be purely speculative on our part. Available evidence suggests that PTSD is under-recognized in non-Veteran primary care settings (c.f. Graves, 2011) suggesting that, from a healthcare system perspective, screening for PTSD might also facilitate further mental health evaluation and treatment among non-Veterans assuming available mental health resources. As to whether screening practices/recommendations do or should differ in Veteran vs. non-Veteran primary care settings is a matter of policy and resource availability not screen characteristics and so is beyond the scope of this review. We have clarified the rationale for inclusion/exclusion of studies.1b. We state that we included screens for multiple psychiatric disorders or multiple anxiety disorders if there was a study that investigated the ability of the screen to identify PTSD in a primary care setting. No other screens identified in our literature search process were eligible for inclusion. 

pants were excluded, why was the Lange et al, (2003) study included? There were 

gold standard interview. 

n that gold standards are equivalent. This may not be an accurate assumption. 

ecognize that there are different scoring algorithms within gold standards. For 

t scoring rules for the CAPS and the selection of one over another will surely impact 

g rules are rarely presented in studies, but the importance of this should not be 

1c. We excluded studies with fewer than 50 patients in the screening population.1d. We identified the gold standard diagnostic tool used in each study and noted where scoring for the gold standard differed from the scoring method described in Table 1. We agree that different gold standard instruments or scoring rules could alter the findings in a given study. As the reviewer notes, scoring rules are rarely presented in studies, as was true in the vast majority of studies included in this review. While we do not think that variation in gold standard instrumentation or scoring would appreciably alter the overall findings of the review, we have included a statement of that possibility in our limitations section. 
52

tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

RESPONSE

stem that asks about traumatic events. This is inaccurately reflected in the descrip

re asked about symptoms experienced in response to a traumatic event in the past 

a primary care sample in the original Meltzer-Brody study. It was “developed in a 

etecting PTSD in psychiatric populations with PTSD prevalence around 50%” (p14). 

ed in settings with a lower prevalence, like primary care, and yes, it was tested in 

al., study, but it was not developed/validated in primary care. 

at there are three different versions of the PCL, and three different scoring options 

are represented in the studies reviewed, and information on scoring algorithms is 

PCL as a single screen and does not mention how scoring options may impact diag

atic for the accuracy and validity of the review.

ear why the GAD-7/GAD-2 is included in the review. The screen does not include 

 in primary care

d to report on test-retest reliability

e for briefer versions of the PCL, test-retest reliability cannot be assumed to be the 

sented as well?

2a. This has been clarified.2b. We include the SPAN because there was a study that tested it in primary care setting as noted above. 2c. We have clarified which version of the PCL was used in each study. However, while there are different versions of the PCL and different scoring approaches to the instrument (e.g., symptoms/symptom cluster, total score, etc.), we believe that the importance of these differences is greatly attenuated when the PCL is used as a screening tool rather than as a diagnostic tool, a tool to assess symptom change in treatment, or as a means to estimate population prevalence rates (see Wilkins et al., 2011). Because the function of a screening tool is to identify individuals in need of further evaluation, all PTSD screening tools have lower discriminability than one would expect from a diagnostic tool. The more relevant scoring issue is cut-score, and we made efforts to include information about multiple cutscores when studies provided that information. Accordingly, we do not feel that the accuracy or the validity of the review has been compromised. 2d. As stated above, we included screens if there was a study that investigated the ability of the screen to identify PTSD in a primary care setting. Although the GAD-7 or GAD-2 may not be specific to PTSD, whether it performs better or worse than a PTSD-specific screen was an empirical question we thought worth considering given an appropriate gold standard and study design. 3a. References have been added to Table (see footnotes).3b. We have noted this on Table 3.3c. Internal consistency has been noted on Table 3 where reported (see footnotes).

but further justification is needed for the decisions the authors chose to make, 

rans given the target audience of this report. The absence of this content makes 

 p. 30 that there is no information as to whether a given screen performs better in 

he absence of such information may be of limited relevance.

We have clarified the inclusion and exclusion criteria. Our literature search yielded no studies comparing the performance of screening tests in Veteran and non-Veteran samples. We have now highlighted results of studies in Veterans in the discussion to make it more relevant for the target audience of the report. 
53

tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

RESPONSE

ise of screening for PTSD is “to facilitate mental health treatment engagement 

s and 2) to engage patients in treatment who might otherwise not be identified...” 

akes to identify PTSD screeners for primary care (pc) settings and evaluate them, 

e questions were formulated, which address evidence on the utility (and relative 

y to answer them are perhaps too narrowly formulated. This is especially the 

the fact that the studies that have evaluated PTSD screeners in pc have not  in engaging mental health workers more effectively, in terms of reaching patients 

 evaluation of the studies that evaluated PTSD screeners in pc: their design, 

work—the evaluation of screening (by any means) for mental health delivery, and 

health--- remains to be done.

Thank you. We agree, that there is important work that remains to be done involving the impact of screen use on the delivery of mental health care and on health outcomes. We included this in our recommendations. 

in our synthesis of the evidence? 

as. Thank you

Thank you

e some problematic statements about the PC-PTSD and PCL. 

ins et al., 2003)

one VA Health Care Facility, not two different VA’s in California. 

person, not over the phone

he use of blind interviews was “not reported”. The assumption was made, 

t blind (versus not reported), and the study was given a level IV rating. Although 

erviewers were indeed blind. Perhaps “not-reported” findings can be followed-up 

e. 

s assumed that interviewers were not blind to the screen results because they 

y as the diagnostic interview. But, what was the order of administration? Did 

screen results (cutoff scores for screens)? 

ger et all study is not clear. In the study, the PCL is described as “a series of 17 

 of PTSD resulting from military experiences taking place within the past month”. 

used. 

ns et al., 2003 study is also not clear. However, a correction to the article was 

e PCL-S (Prins & Ouimette, 2004, Primary Care Psychiatry, 9, p151). The review 

were screened and interviewed. That is incorrect, 167 participants completed 

 

1a. This has been corrected.1b. Thank you for clarifying this.1c. Thank you for providing this additional information. Given this clarification, we have now determined that this study should have a rating of Level III.2a. We assumed that interviews were not blind not because of their timing relative to administration of the screen, but rather because non-blind evaluations may be biased (similar to RCTs), and so the absence of a clear statement indicating that diagnostic interviews were conducted blindly in most cases means that they were not. However, as suggested by this reviewer, we sent an email to Dr. Freedy requesting further information, but have not received a response in the more than one month since the email was sent. 3a. We have clarified that no version was specified in this study.3b. We have clarified that the PCL-S was used in this study. We have replaced the data from the original paper with the data presented in the Corrigendum.

of bias in any of the decision or text. Thank you.

Thank you.
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tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

RESPONSE

published studies that we may have overlooked?

he PC-PTSD performs adequately in VA substance use populations (p. 37, item 

ictive Behaviors 31(11).

We are familiar with the Kimerling (2006) study but did not include it in this review because the study sample was that of patients who were receiving substance abuse treatment and not those presenting in primary care clinics. 

sary to include studies done on MH population and instruments that are not 

cally the GAD-7

As noted previously, we included screens if there was a study that investigated the ability of the screen to identify PTSD in a primary care setting. 

ncluding the importance of spectrum effects (e.g., age, race, etc), bias, and 

 (2010). The diagnostic accuracy of the PTSD Checklist: A critical review. Clinical 

cpr.2010.06.012.

man, S.B. (2011). Synthesis of the psychometric properties of the PTSD Checklist 

 versions. Depression and Anxiety. doi: 10.1002/da.20837.

Thank you for sharing these references. These reviews provide excellent background information on the PCL but do not focus on studies conducted in primary care. 

t I think it will surprise readers in its presentation of studies they may not know 

 complete in several respects:

ns et al. 2003 study that reports critically important information about the PCL. 

 2003 report due to a software problem regarding the handling of missing data. 

 to be based on the 2004 correction.

ues (2010) comparing the SPAN and the PC-PTSD may have been overlooked.

 ask authors for data needed to include the paper in the analysis. Was there any 

information that could have allowed an excluded paper to be included? If not, I 

is strategy if it possibly could yield additional studies to include in the review

Thank you. We have addressed your concerns.1. We have updated the report based on the Corrigendum.2. We reviewed this excellent paper but it did not meet our inclusion criteria. Subjects in that study were part of the MidAtlantic MIRECC post-deployment registry and consisted of Veterans who served in the military after to September 11, 2001. According to the authors, “Eligible Veterans were recruited through mailings, advertisements, and clinician referrals”. As such, it was not eligible for this review. 3. We did not exclude studies because of missing information. As noted in the Literature Flow (Figure 1) studies were excluded if the study setting, population, or purpose did not meet our inclusion criteria.

ing scales in primary care. Thank you.

ggestions or comments below. If applicable, please indicate the page and line numbers from the draft report.

t point, and the authors may want to specifically refer to the need for studies of 

Thank you for this suggestion. We have now made our recommendations more specific. 

e screening is meant to “Identify PTSD,” or to facilitate treatment engagement 

o need further evaluation and possibly treatment for PTSD. Similar issue in 

nd of page 5. Screening is not necessarily correlated with reducing delays for 

 concern from PTSD teams is that PC refers too many patients because of a 

esources needed to reduce access delays (though screening can lead to earlier 

ervention earlier in the course of an individual’s illness). These issues do receive 

sideration” paragraph on page 38.

Thank you for this feedback. We clarified the statement on page to indicate that screens are intended to facilitate detection of a condition (in this case PTSD), not to identify it directly. We agree that screening is not correlated with treatment; however, the purpose of screening programs is to increase the rate of treatment, particularly among those early in the course of the illness as you note. The concern you raise about too many patients having positive screens and the effect of this on limited clinical resources is an important one. This suggests that from a clinical standpoint the screen used by VA is too sensitive as it is currently employed; however, altering the screen cut score to address this has clear policy implications that may be difficult to resolve. 
55

tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

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valuating traumatic experiences are not likely to be clinically useful given the high 

events and the much lower conditional probability of developing PTSD (IOM, 

n of screens that include a trauma probe versus those that don’t has not been 

clusion of a trauma exposure question will decrease the number of false 

search could compare screens with and without a trauma probe. 

t screening for military sexual trauma is not warranted? 

wo items) performed less well than longer screens with positive likelihood ratios 

nically useful” p. 3 PLUS, “Screens not specific to PTSD but for which there was 

 the screen to detect PTSD performed less well than those that focused on the 

7

he use of the SIPS or multi-purpose screens with only 1 or 2 items relevant to 

reens seem to be better but the threshold for acceptable length is not clear. If 

ize instruments that are simple, valid, precise, and acceptable both clinically 

PTSD screens should be evaluated along these dimensions. For example, future 

ence and ease of administration based on number of items, reading level, 

ality studies examining the performance of the PC-PTSD in a primary care 

e can be contacted for clarification on the QUADAS ratings, and subsequent 

 

1a. The statement that you reference was meant to clarify the scope of the review. On the other hand, we agree that whether screen performance would be improved with inclusion of a traumatic exposure item(s) is a worthy empirical question. 1b. No. It simply clarifies the scope of the review. 2a. We agree with the reviewer’s conclusion that the available evidence suggests that screens longer than 2 items perform better.2b. We did not find any information that any of the screening tools used in the studies cited in this review were unacceptable to patients or administrators. The longest screening tool (27 items) was reported to take patients only 10 minutes to complete, suggesting that none of the screens would be administratively burdensome. However, given the absence of comparative information about patient or provider preferences regarding screening tools, further research would be needed to make definitive statements about these issues.3a. We have updated the information from one of the studies mentioned and adjusted the quality assessment. We contacted the author of another study for clarification but did not receive a response. We did not find anything requiring clarification in the third study.

n important guide for both practice and research. It is well done is so many 

by additions to the text and tables. It also needs to be cleaned for typos, some 

20 the paragraph on the PCL says in one place that there were 2 studies and in 

shows 3, and the paragraph mentions an additional study by Kimerling (2006) 

Specific recommendations are as follows:

 the quality assessment ratings were determined. Although detail is provide 

e the crosswalk between the QUADAS evaluation questions in Appendix B, 

each study in Appendix E, and the level of evidence rating. In fact, I don’t see the 

DAS criteria and the QUADAS questions in Appendix B.

ntativeness is about whether the full range of patients to whom a test would be 

. It appears that sample representativeness—and not spectrum inclusiveness—

tudies for the report. The fact that a study had one site is mentioned in a couple 

vant to evaluating quality according to the QUADAS or RSES systems.

ppears to be missing information. RCES level 1 evidence requires that neither 

s used to select patients. Yeager’s study, which was rated at the highest level, 

mple of participants from 4 sites, whereas Andrykowski’s study is described as 

ancer.” 

x C and elsewhere in the text: it should be “Rational” not “Rationale” Clinical 

Thank you. We have corrected the typos and clarified the additional studies cited in the paragraph on the PC-PTSD.1. Thank you for pointing this out. We have now included an additional table in our appendices (Appendix F) that clarifies the relationship between the individual QUADAS ratings and the overall Level of Evidence ratings. Now that we have included the crosswalk table in the report, we hope that study ratings have been clarified. The Andrykowski study was rated as a Level IV because the diagnostic interviews were not conducted blind to patient screening status. We have corrected the typo.
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tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

RESPONSE

ocument was printed, even though it appeared fine on the screen. Also, I 

h reason the 122 excluded studies ruled out.

he test-retest interval for each study.

tandard measure used for each study and if relevant how it was scored, e.g., the 

of detail in the text about studies varies unsystematically. For example, there 

he sample used in the Prins 2003 study and a lot of information on p. 22 about 

 study.

ere discussed but the Table 4 lists 3. Freedy 2010 is excluded.

inferences that are drawn when relevant information is missing. For example, 

, the report says that it is unclear whether CAPS interviewers were blind to PCL 

elsewhere the report specifically states that lack of blinding was a major flaw of 

t blinding is not the same thing as lack of blinding. Regardless, things like this 

ing authors for missing information. 

se of shading to indicate different screens does not provide enough clarity or 

uthors could use a separate leftmost column to indicate the screen, with the 

e right:

Cutpoints

xx

xx

xx

xx

udies of both Veterans and non-Veterans, can any more be said about whether 

population to the other?

ently used for screening in both VA and DoD settings, can any more be said 

study comparing it with other screening instruments?

2. We have added the number of studies for each exclusion reason.3. We have added this information to Table 3 (see footnotes).4. We have added the gold standard measure to Table 4. Studies did not typically report how the measure was scored.5. We have reviewed this and standardized the amount of text.6. We have added Freedy 2010 to the discussion of the SPAN studies.7. As noted above, we have obtained information from one author and another author did not respond to our inquiry. 8. Thank you for the suggestion. We have modified the table. 9. A comment about Veterans vs. non-Veterans has been added to the discussion.10. Our primary recommendation is for VA (and DoD) to evaluate whether use of the screen has improved health outcomes for Veterans and to examine the impact of its use on the healthcare system. 

mendation 3 on p. 38. There is plenty of evidence about how screening tools work 

es because comorbidity is the rule rather than the exception in PTSD. What is 

er there is differential performance as a function of comorbidity.

ion 4 is unclear or perhaps is not clearly worded. There is evidence about 

n Veterans.

11. Thank you for the suggestion. We have reworded the statement and clarified our point. 12. We agree that this point needs rewording as well, and incorporated the intended point elsewhere. 

iew of the literature on screening among Veterans of other countries. Can we 

Can we learn anything from DoD screening?

We chose not to include DoD studies because screening among active duty service members is complicated by limited confidentiality, potential deleterious effect of mental health diagnoses on military careers, and greater levels of stigma related to mental health conditions compared to that seen in non-active duty populations. 

ance measures, programs, quality improvement measures, patient care services, or conferences that will be directly affected by this 

ail. 

by PCL when indicated is current measure and this report is unlikely to affect that. Thank you

HI office may be able to address the impact of PTSD screening on referrals to 

e., access to care measure). And, with the new OEF4 performance measure, it 

ng and engagement with treatment (8 sessions within 14 weeks). 

content validity and predictive validity of PTSD screens will need to be evaluated 

a. 

1. We agree that evaluating the impact of screening implementation on service utilization is an important area that should be explored. 2. We agree and have now commented on the upcoming DSM-5 modifications. 
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tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

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D screening is simply an indicator of whether screening has occurred, so I think 

Thank you

dations on how this report can be revised to more directly address or assist implementation needs.

ts can be made about how the review can inform policy, guide services, support 

future research. For example:

eeded on what screen is best for detecting PTSD in VA primary care, there are 

n VA (see guidelines propose by US Preventive Services Task Force).

sitive for PTSD, CPRS presents certain follow-up options/services. Indeed, the 

ntil an option is selected. The report would be strengthened by addressing these 

mendations for additional ones. 

ship between PTSD screening and access to care, and type of care would 

c examples of what should be done is needed. For example, 

nger screens?) should be compared in VA primary care clinics and on what 

, diagnostic accuracy)? 

um effects be analyzed? Comparing AUC’s may not be the best approach.

1a. To our knowledge the USPSTF does not currently recommend routine PTSD screening. However, VA has significant clinical and political impetus for conducting routine PTSD screens on Veterans who use VA services. 1b. Although the requirement to institute a particular clinical reminder may be a result of national VA policy, how the clinical reminders are implemented varies across VISNs, Consequently, it would be less helpful to make specific recommendations about how the performance measure should be resolved. 1c. We agree. 2a. We do not recommend any particular screening tool since all have their limitations. Specific recommendations for future research are delineated. b. If what the reviewer means by “spectrum effects” is subsyndromal PTSD, then we agree that this would have implications for the criterion of a study. Comparisons of screen AUC’s across studies requires a comparable outcome criterion.

in May 2013, the relevance of the data based on DSM-IV are unclear. Data 

y not generalize to DSM-5 versions if and when such data would be available. 

sue more directly and incorporate it into their recommendations.

Agreed. We have now included comments about the relevance of the review with respect to DSM-5.
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tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

ENCE TABLE

Screen Sample

I. Age, gender, special population

II. Response Rate

Interview Sample

I. Age, gender, special population

II. Response rate

QUADAS Item Ratings

I. Representativeness

II. Quality of Gold Standard

III. Concurrent

IV. % Interviewed

V. Blind Interviews

RCE Level of Evidence

ot reported; required to be ≥18 years 

ld, English speaking, no gross cognitive 

mpairment, medically stable

74 of 3728 approached in clinic consented 

20.8%); 519 of 774 consented were contacted 67%); telephone interviews done in 411 11% of those approached in clinic, 53% of 

hose consented, 79% of those contacted for 

nterview)

I. 53% 18-44 years old, 19% 45-54 years old, 19% 

55-65 years old, 7% 66-75 years old, 1.2% ≥76 years

83% women65% white, 32% African American, 3% other45% married24% high school education or lessII. 100% of those screened

I. No (significant differences in gender 

and race from clinic population during recruitment period)

II. Fair (telephone, experienced survey 

interviewers)

III. YesIV. 79% of those who were contacted for 

interview

V. NoLevel of Evidence: IV

eterans; other screen sample characteristics 

R

37 of 258 approached (92%) were eligible and 

ompleted Breslau scale

I. Veterans

Mean age = 52 years (range 22 to 85)61% women68% white, 18% African American, 5% Hispanic, 5% 

Asian/Pacific Islander, 1% Native American, 3% other

44% married59% employedII. 57% returned for interview (significantly higher 

percentage of women in participants vs. nonparticipants)

I. Yes

II. Good (in person, trained 

psychologists)

III. Yes, approximately 1 monthIV. 57% of those who consented, 

completed Breslau scale and were eligible 

V. YesLevel of Evidence: III

1% <30 years; 24% 31-34 years old; 31% 1-50 years old; 16% 51-60 years old; 8% ≥61 

ears

male

uited from 3 military health system primary 

are clinics in Washington, DC area (service 

members, retirees, and family members) 

stimated 87.4% (3234 of approximately 3700 pproached)

E: participants first administered SIPS; 

ubgroup participated in 2nd phase of study 

PC-PTSD and structured clinical interview); 

nclear if all invited to participate in 2nd phase

I. 24% <30 years, 23% 31-34 years old, 31% 

41-50 years old, 18% 51-60 years old, 4% ≥61 years

61% maleII. 93% of those who consented to interview 

(213/229); 6.6% of those screened (213/3234)

I. Unclear; oversampled patients who 

responded “bothered a little” and “bothered a lot” to single screening question

II. Fair (unclear if in-person or 

telephone, trained mental health professionals)

III. YesIV. 6.6% of those screenedV. YesLevel of Evidence: III
59

tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

Screen Sample

I. Age, gender, special population

II. Response Rate

Interview Sample

I. Age, gender, special population

II. Response rate

QUADAS Item Ratings

I. Representativeness

II. Quality of Gold Standard

III. Concurrent

IV. % Interviewed

V. Blind Interviews

RCE Level of Evidence

ot reported; recruited from general medical 

nd women’s health clinics at a VA facility in 

alifornia; required to have no gross cognitive 

mpairment and English speaking

umber approached for screening not reported

I. Mean age = 52 years*

34.0% male33% married43% unemployed27% high school education or lessII. 50% of those who completed screening 

(167/335); participants repeated the PC-PTSD at the interview

NOTE: all screened individuals invited to participate 

in interview

I. VA sample from 1 VA in California 

with 50% response rate

II. Good (in-person, trained 

psychologists)

III. YesIV. 50%V. YesLevel of Evidence: III

Mean age = 34 years

% female

white, 49% African-American(n=88/292) reported a traumatic event and 

ompleted the SPAN

6% (292/384 approached)

I. Mean age = 35 years

52% white, 41% African AmericanII. 11% of total sample (32/292) of total sample; 

36% of those with trauma who were invited for interview (32/88)

I. Women presenting for annual exam 

at ob/gyn clinic; n=32 completed interview

II. Good (in-person, psychiatrist)III. Not reportedIV. 11% of total sampleV. YesLevel of Evidence: III

Group 1 - Veterans (male & female)

4.1% (888/1198)

Group 2 - Female Veterans (oversample)

9.2% (191/276)

I. 79% male

63% whiteII. Group 1 - 82% of those who completed 

screen (728/888) or 61% of those approached (728/1198)

Group 2 – 68% of those who completed screen 

(130/191) or 47% of those approached (130/276)

NOTE: completers more likely to be older and 

Caucasian; final analysis (combining Groups 1 and 2) included only Caucasians and AfricanAmericans (840/1079 or 78% of those who completed screen; 840/1474 or 57% of those approached)

I. Random sample from 4 medical 

centers in southeastern US

II. Good (telephone, trained clinicians)III. Yes, within 2 monthsIV. 57% of total sampleV. YesLevel of Evidence: I
60

tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

Screen Sample

I. Age, gender, special population

II. Response Rate

Interview Sample

I. Age, gender, special population

II. Response rate

QUADAS Item Ratings

I. Representativeness

II. Quality of Gold Standard

III. Concurrent

IV. % Interviewed

V. Blind Interviews

RCE Level of Evidence

Mean age = 57 years

Caucasian, 4% African-American, 1% Asian

merican

high school education or less

E: all had diagnosis of Stage 0 to IIIA breast 

ancer, without surgery, chemotherapy, or 

adiotherapy for 6-72 months, in remission

4/107 (79%) consented; 2 later deemed 

neligible

I. Same as screen sample

II. Same as screen sampleNOTE: participants completed PCL-C and SCID NP 

PTSD during one telephone interview

I. Women in remission from breast 

cancer

II. Fair (telephone, doctoral-level 

students)

III. YesIV. 100% of those consenting; 77% of 

those invited

V. NoLevel of Evidence: IV

Mean age = 48 years

% female

white, 9% black, 15% othermarriedhigh school education or less

6% of those randomly selected for telephone 

nterview (282/1763); 11% of total pool 

282/2545)

I. Same as screening

II. Same as screeningNOTE: participants were older and more often 

divorced than eligible non-participants

I. Female Veterans (1 site)

II. Good (in-person, clinician)III. YesIV. 11% of total sampleV. YesLevel of Evidence: III

rimary care from VA or university-affiliated 

inic

pproximately 60% of patients approached in 

inic consented; 275/401 completed PCL-C 

69% [65% reported in text]) (returned by mail)

E: reported that a randomly selected half 

f those who completed consent form and 

hort set of instruments in waiting room were elected for diagnostic interview

I. Mean age = 48 years

48% male57% Caucasian53% married23% high school education or lessII. 186/401 completed CIDI (46% [44% reported in 

text])

154/401 completed PCL-C and CIDI (38% [36.5% 

reported in text])

I. Primary care clinics (VA or universityaffiliated)

II. Fair (telephone, licensed 

psychologist or research assistant)

III. Not reportedIV. 38% of enrolledV. YesLevel of Evidence: II
61

tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

Screen Sample

I. Age, gender, special population

II. Response Rate

Interview Sample

I. Age, gender, special population

II. Response rate

QUADAS Item Ratings

I. Representativeness

II. Quality of Gold Standard

III. Concurrent

IV. % Interviewed

V. Blind Interviews

RCE Level of Evidence

00% female

ans (1 site)

6% agreed to participate and returned uestionnaires (221/394) 

E: 25 of 419 survey packets were undeliverable

I. Mean age = 53 years

82% Caucasian, 12% African-American; 6% other/

unknown

39% married80% with 9-15 years of educationNOTE: interviewed women were older, more likely 

Caucasian, more likely divorced, separated, or widowed; less likely to be never married

II. 87% of those screened willing to be interviewed 

(192/221); 46% of those approached (192/419)

26% randomly selected for interview (49/192)

I. Female Veterans (1 site)

II. Fair (telephone, CIDI designed for lay 

interviewers)

III. Yes, within 1 monthIV. 26% (randomly selected, n=49)V. YesLevel of Evidence: II

Mean age = 41 years

% female

Caucasian; 6% African-American; 8% Asian, 

% Hispanic, 1% Native-American

marriedcollege graduates

Adjusted return rate of 62% (1225/1912 

ligible)

I. Not reported

II. Overall 21% (261 of 1225 who returned 

questionnaire) or 14% (261/1912 eligible) – See NOTE

NOTE: 305 returned questionnaires and had history 

of childhood sexual maltreatment, 152 of 204 reached (74%) agreed to interview (or 50% of those with history of maltreatment who returned questionnaires)

From sample of 250 without childhood 

maltreatment, 116 of 155 reached (75%) agreed to interview (or 46% of sample)

7 had missing PCL data; final sample was n=261

I. Women only; random sample of 

HMO members

II. Unclear (Not reported if face-toface or telephone; qualifications of 

administrators not reported)

III. Yes, within 2 monthsIV. 50% of those who reported childhood 

maltreatment; 46% of sample without maltreatment

V. Not reportedLevel of Evidence: III
62

tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

Screen Sample

I. Age, gender, special population

II. Response Rate

Interview Sample

I. Age, gender, special population

II. Response rate

QUADAS Item Ratings

I. Representativeness

II. Quality of Gold Standard

III. Concurrent

IV. % Interviewed

V. Blind Interviews

RCE Level of Evidence

ot reported (eligible patients were age 18 or 

lder, English speaking, mentally competent, nd attending primary care academic family 

medicine clinic)

4% of those approached (n=723)

I. Mean age = 45 years

71% female67% white, 28% black, 5% other49% married55% high school education or less21% unemployedII. complete date for 89% (647/723 who consented

I. One family medicine clinic, sample 

similar to overall clinic 

II. Fair (In person or telephone, 

research assistant)

III. Yes, within 30 daysIV. 89%V. YesLevel of Evidence: I

ot reported (eligible patients were age 18 or 

lder, non-psychotic, and seen in primary care 

inic)

ot reported, 343 of those who completed an 

nitial questionnaire were “qualified” for the study 

fter initial interview by investigating physician

I. Mean age = 47 years

69% female86% white48% marriedII. 78% (343/440)

I. One primary care clinic

II. Fair (telephone, “trained rater”)III. Not reportedIV. Not reportedV. Not reportedLevel of Evidence: IV

ot reported

1% of patients approached (7738/12724)

I. Mean age = 42 years

62% female65% Caucasian, 16% African American, 10% 

Hispanic, 4% Asian, 5% other

II. 867 of 1494 that screened positive (58%) agreed 

to interview; 569 (38%) completed interview

452 of random sample of 1107 that screened 

negative (41%) agreed to interview; 232 (21%) completed interview

I. More interviews among positive 

screens

II. Fair (telephone, trained CIDI 

interviewers)

III. Yes, median of 14 daysIV. 38% of those that screened positive; 

21% of random sample of those that screened negative 

V. No

Level of Evidence: IV

ot reported

2% (2740/2982) completed questionnaire 

ncluding GAD-7); of 2740, the first 2149 were 

sed for development and validation of the 

GAD-7

I. Mean age=47years

69% female81% non-Hispanic white, 7% black, 9% Hispanic, 

3% other

65% married34% high school education or lessII. 77% (1654/2149) agreed to interview; 58% 

(965/1654) randomly selected for interview

I. Yes-15 primary care sites in 12 states 

(part of research network)

II. Fair (telephone, 1 of 2 mental health 

professionals)

III. Yes, approximately 1 weekIV. 100% (this analysis based on those 

who completed GAD-7 and were interviewed) 

V. Yes

Level of Evidence: I

es of Diagnostic Accuracy included in Systematic reviews tool (Whiting 2003)6

mel 2008)7 (see Appendix C)

e who completed an initial screen)
63

tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

pecific Association of RCE Level of Evidence Ratings to

atings as Applied in this Review

S Item 1

e size of 

g sample

QUADAS Item 2

Representativeness of 

screening sample viz. target 

population/ selection method

QUADAS Item 3

Sample size/

representativeness of 

Interview sample viz. 

screening sample

QUADAS Item 4

Quality of gold standard 

and its administration

QUADAS Item 5

Blinded/concurrent 

diagnostic evaluations

Representative of target population/randomly selected or consecutive sample

All of screening sample or randomly selected representative sample

In person by trained diagnostician

Yes

Representative of target population/randomly selected or consecutive sample

All of screening sample or randomly selected representative sample

In person by trained diagnostician

Yes

rge Representative sample 

or convenience/nonrepresentative sample

Random selection or nonrepresentative interview sample

In person or by telephone by trained diagnostician

Yes

Convenience/nonrepresentative sample Non-random interview sample Telephone by trained research assistants No

Not included in Systematic Review

es of Diagnostic Accuracy included in Systematic reviews tool (Whiting 2003)6

mel 2008)7 (see Appendix C)

mple size and lower ratings on QUADAS 2 or QUADAS 3, or a larger sample size and lower ratings on both QUADAS 2 and QUADAS 3 

ng on one of the QUADAS 1-4 criteria but have lower ratings in the other 3 criteria