Evidence-based Synthesis Program 

(ESP)

Screening for Post-Traumatic 

Stress Disorder in Primary Care

A Systematic Review of the Evidence

Michele Spoont, PhD

Investigator/Psychologist

Center for Chronic Disease Outcomes Research

Minneapolis VA Healthcare System

National Center for PTSD, Pacific Islands Division

June 2013
Evidence-based Synthesis Program 

(ESP)

Acknowledgements

Co-Authors/Collaborators

o Nancy Greer, PhD

o Shannon Kehle-Forbes, PhD

o Paul Arbisi, PhD

o Laura Meis, PhD

o Steven Fu, MD

o Indulis Rutks, BS

o Tim Wilt, MD 

- Director, Minneapolis ESP 

Expert Panel/Reviewers

o Andrew Pomerantz, MD

 Discussant

o Naomi Breslau, PhD

o Rachel Kimerling, PhD

o Edward Post, MD, PhD, FACP

o Annabel Prins, PhD

o Paula Schnurr, PhD
Evidence-based Synthesis Program 

(ESP)

Disclosure

This report is based on research conducted by the Evidence-based 

Synthesis Program (ESP) Center located at the Minneapolis VA Healthcare 

System, Minneapolis, MN funded by the Department of Veterans Affairs, 

Veterans Health Administration, Office of Research and Development, 

Quality Enhancement Research Initiative (QUERI). The findings and 

conclusions in this document are those of the authors who are responsible 

for its contents; the findings and conclusions do not necessarily represent 

the views of the Department of Veterans Affairs or the United States 

government. Therefore, no statement in this article should be construed 

as an official position of the Department of Veterans Affairs. No 

investigators have any affiliations or financial involvement (e.g., 

employment, consultancies, honoraria, stock ownership or options, expert 

testimony, grants or patents received or pending, or royalties) that conflict 

with material presented in the report.
Evidence-based Synthesis Program 

(ESP)

VA Evidence-based Synthesis (ESP)

Program Overview

• Sponsored by VA Office of R&D and Quality Enhancement 

Research Initiative (QUERI).

• Established to provide timely and accurate 

syntheses/reviews of healthcare topics identified by VA 

clinicians, managers and policy-makers, as they work to 

improve the health and healthcare of Veterans. 

• Builds on staff and expertise already in place at the 

Evidence-based Practice Centers (EPC) designated by AHRQ. 

Four of these EPCs are also ESP Centers: 

o Durham VA Medical Center; VA Greater Los Angeles Health Care 

System; Portland VA Medical Center; and Minneapolis VA Medical 

Center. 
Evidence-based Synthesis Program 

(ESP)

• Provides evidence syntheses on important clinical practice 

topics relevant to Veterans, and these reports help:

o Develop clinical policies informed by evidence, 

o Implementation of effective services to improve patient 

outcomes and to support VA clinical practice guidelines and 

performance measures, and 

o Guide the direction for future research to address gaps in 

clinical knowledge.

• Broad topic nomination process – e.g. VACO, VISNs, field – 

facilitated by ESP Coordinating Center (Portland) through 

online process: 

 http://www.hsrd.research.va.gov/publications/esp/TopicNomination.cfm
Evidence-based Synthesis Program 

(ESP)

• Steering Committee representing research and operations 

(PCS, OQP, ONS, and VISN) provides oversight and guides 

program direction.

• Technical Expert Panel (TEP)

o Recruited for each topic to provide content expertise.

o Guides topic development; refines the key questions.

o Reviews data/draft report.

• External Peer Reviewers & Policy Partners

o Reviews and comments on draft report

• Final reports posted on VA HSR&D website and disseminated 

widely through the VA. 

http://www.hsrd.research.va.gov/publications/esp/reports.cfm
Evidence-based Synthesis Program 

(ESP)

Screening for Post-Traumatic Stress 

Disorder (PTSD) in Primary Care: A 

Systematic Review

January, 2013

Full-length report available on ESP website:

http://www.hsrd.research.va.gov/publications/esp/ptsd-screening.cfm 
Evidence-based Synthesis Program 

(ESP)

Background

• PTSD among Veterans

o 430,000 Veterans enrolled in VA carry a PTSD diagnosis

o Lifetime prevalence among OEF/OIF/OND veterans ~ 17%

• Chronic PTSD is very disabling and is associated with 

increased morbidity and mortality

o Increased rates of suicide, hospitalization, poverty, 

unemployment.

o Greater prevalence of numerous chronic diseases (e.g., 

cardiovascular disease, arthritis, insulin resistance, etc.).

o Earlier age of onset of chronic diseases and greater all cause 

mortality.
• The VA/ DoD Clinical Practice Guideline for 

Management of Post-Traumatic Stress 

(2010):

The evidence supporting screening with validated 

scales like the PC-PTSD is II-2. Screening can 

successfully increase the identification of PTSD in the 

screened population. 
Evidence-based Synthesis Program 

(ESP)

• Screening Program

• Purpose: To increase the detection of unrecognized disease in 

people who may not otherwise be identified as having the disease.

 Assumption 1: Recognition of the disease is possible.

 Assumption 2: Interventions exist to treat the disease or to diminish its 

adverse impact. 

 Assumption 3: Recognition of the disease can affect the course of the 

disease via appropriate interventions. 

 Assumption 4: Resources are available to diagnose the disease and to 

provide treatment. 
Evidence-based Synthesis Program 

(ESP)

Institute of Medicine. Treatment for posttraumatic 

stress disorder in military and veteran populations: Initial 

assessment. Washington, DC: The National Academies Press; 

2012. 

“Although it is widely believed that screening for PTSD among 

current and former service members is important for 

identifying affected people and directing them to treatment as 

early as possible to prevent chronic suffering and 

maladjustment, there is no strong evidence to support this 

belief”.
Evidence-based Synthesis Program 

(ESP)

• Primary Care important target for screening

o Most Veterans with MH problems are seen in Primary 

Care Clinics.

o Primary Care Providers are not very good at 

identifying PTSD.

o Primary Care patients with PTSD are often 

undertreated.

o Increase the rate of Mental Health Treatment 

uptake.

o Initiate Treatment earlier in the Illness. 
Evidence-based Synthesis Program 

(ESP)

Key Questions

• Key Question 1: 

• What tools are used to screen for PTSD in primary 

care settings, and what are their characteristics (i.e., 

length, format/administration, response scale)?

• Key Question 2: 

• What are the psychometric properties and utility of the 

screening tools (sensitivity, specificity, likelihood 

ratios, predictive values, area under curve, reliability)?
Evidence-based Synthesis Program 

(ESP)

Key Questions

• Key Question 3: 

• What information is there about the implementation 

issues (e.g., ease of administration, patient 

satisfaction) related to the use of PTSD screening tools 

in primary care clinics? 

• Key Question 4: 

• Do the psychometric properties and utility of each of 

the screening tools differ according to age, gender, 

race/ethnicity, substance abuse, or other 

comorbidities? 
Evidence-based Synthesis Program 

(ESP)

Methods

• Literature Search

o Ovid MEDLINE from 1981 to October 2012; limited to peerreviewed articles involving human subjects and published in the 

English language. 

o National Center for PTSD’s Published International Literature On 

Traumatic Stress (PILOTS) database 

(http://www.ptsd.va.gov/professional/pilots-database/pilotsassessment.asp). 

o Reference lists of relevant articles and existing reviews
Evidence-based Synthesis Program 

(ESP)

• Methods 

Inclusion Criteria: 

1. Evaluation of a tool used to screen for PTSD.

2. Gold-standard diagnostic assessment of PTSD as a 

comparator.

3. Screening of adults in a primary care setting in the United 

States. 

4. Screening sample size greater than n=50.

5. Reported outcomes of interest: 

Diagnostic/Detection accuracy

Information related to implementation of a screening tool
Evidence-based Synthesis Program 

(ESP)

Gold Standard Diagnostic Instruments

Gold Standard Description

Clinician Administered PTSD 

Scale 

(CAPS)

Structured diagnostic interview of PTSD symptoms based on DSM-IV criteria and 

some associated symptoms.

Structured Clinical Interview 

for DSM–IV 

(SCID)

Semi-structured interview that assesses major DSM-IV diagnoses. 

Mini-International 

Neuropsychiatric Interview 

(MINI)

Brief structured diagnostic interview that assesses major psychiatric disorders 

within both DSM-IV (Axis I) and ICD-10. 

PTSD Symptom Scale – 

Interview 

(PSS-I)

Semi-structured interview for the 17 symptoms used to diagnose PTSD according 

to the DSM-IV. 

Composite International

Diagnostic Interview 

(CIDI)

Structured diagnostic interview that assesses multiple DSM-IV (Axis I) and ICD-10 

conditions. 
Evidence-based Synthesis Program 

(ESP)

Methods

• Rating the Body of Evidence for each Screening Tool

o Qualitative assessment of the strength of the current evidence base

• Data Synthesis

o Qualitative and semi-quantitative synthesis of the results for each 

question

o Identified and highlighted findings from studies involving Veterans and 

military personnel
Evidence-based Synthesis Program 

(ESP)

QUality Assessment of Studies of Diagnostic Accuracy included 

in Systematic reviews (QUADAS)*

1. Representativeness of those who were screened: Sample Size 

2. Representativeness of those who were screened: Sampling Method 

3. Representativeness of Interview Sample viz. Screening Sample 

4. Quality of Gold Standard Evaluation

5. Blind and/or Concurrent Diagnostic Evaluations

* Whiting (2003). BMC Medical Research Methodology.
Evidence-based Synthesis Program 

(ESP)

LEVELS OF EVIDENCE: Rational Clinical Examination Series* 

*Simel (2008)

RCE Level of 

Evidence 

Rating

QUADAS Item 1 

Screening Sample 

Size

QUADAS Item 2 

Selection method

QUADAS Item 3

 

Representativeness 

of Interview Sample 

viz. Screening 

Sample

QUADAS Item 4

 

Quality of gold 

standard and its 

administration

QUADAS Item 5 

Blinded/concurrent 

Diagnostic 

Evaluations

I Large Randomly selected or 

consecutive sample

All of screening sample 

or randomly selected 

representative sample

In person by trained 

diagnostician

Yes

II Small Randomly selected or 

consecutive sample

All of screening sample 

or randomly selected 

representative sample

In person by trained 

diagnostician

Yes

III Small or Large Representative sample 

or convenience/nonrepresentative sample

Random selection or

non-representative 

interview sample

In person or by 

telephone by trained 

diagnostician

Yes

IV Small Convenience/nonrepresentative sample

Non-random interview 

sample

Telephone by trained 

research assistants

No

V Not included in Systematic Review
Evidence-based Synthesis Program 

(ESP)

Search

Results 

• N=1,998 Abstracts reviewed

• Excluded n=1,844

Full Text 

Review 

• N=154 reviewed 

• Excluded n=140

Studies 

Included

• Final exclusion/hand search

• N=15 Articles
Evidence-based Synthesis Program 

(ESP)

• KEY QUESTION #1. What tools are used to screen 

for PTSD in primary care settings, and what are 

their characteristics?

a) 9 Screens evaluated with a gold standard diagnostic tool in 

primary care setting

 Also, 3 abbreviated versions of 2 of the screens

b) All self-administered

c) Number of items: 

 PTSD specific screens: 1-17 items

 5 Screens assess for multiple disorders

– 1 to 27 items for Total scale 
Evidence-based Synthesis Program 

(ESP)

Screener Screen Type # Items Response Scale Retest

Reliability*

Breslau Scale 

(Short Screening Scale for PTSD) PTSD only 7 Yes/No 0.84a

Primary Care PTSD Screen 

(PC-PTSD) PTSD only 4 Yes/No 0.83b

Single-item PTSD Screener 

(SIPS) PTSD only 1 3-pt scale:

(Not bothered, Bothered a little, Bothered a lot) 0.63c

Startle, Physiological arousal,

Anger, and Numbness 

(SPAN)

PTSD only 4 5-pt distress scale

(0 = Not at all distressing to 4 = Extremely distressing) --

PTSD Checklist 

(PCL) PTSD only 17 5-pt degree of bothered scale

(1 = Not at all to 5 = Extremely) 0.96d

My Mood Monitor 

(M-3)

Several psychiatric 

disorders

4 of 27 total items 5-pt frequency scale

(0 = Not at all to 4 = Most of the time) --

Provisional Diagnostic Interview – 

4 Anxiety 

(PDI-4A)

Several psychiatric 

disorders

1 item (+ 1 other 

symptom) of 23 total 

items

5-pt frequency scale:

(0=Never to 4= Very often) --

Anxiety and Depression Detector 

(ADD)

Anxiety disorders & 

depression

1 of 5 total items Yes/No --

Generalized Anxiety Disorders -7 

(GAD-7) Anxiety disorders 7 4-pt frequency scale:

(0=Not at all to 3= Nearly every day) 0.83e
Study Screens

Gold 

Standard

Women 

only 

sample

Military/

Veteran

s

Screening Sample

n (Response Rate %)

Interview Sample

n (Response Rate %)

Level of 

Evidence 

Rating

Andrykowski, 

1998

PCL-C

SCID NP 

PTSD Module X 84 (79%) 72 (88%) IV

Dobie, 2002 PCL-C CAPS X X 282 (11%) 282 (11%) III

Freedy, 2010

SPAN, Breslau, 

PC-PTSD, 

PCL-C

CAPS 774 (21%) 411 (53% eligible, 79% 

contacted) IV

Gaynes, 2010 M-3 MINI 723 (54%) 647* I

Gore, 2008 SIPS, PC-PTSD PSS-I X SIP: 3234 (est. 88%)

PC-PTSD/PCL: 213 (?) 213* III

Houston, 2011 PDI-4A SCID 343‡ ‡ IV

Kimerling, 2006 Breslau CAPS X 258 (convenience sample) 134 (57%) III

Kroenke, 2007 GAD-7 SCID 965 (random selection from 

92% RR sample) 965* I

Lang, 2003 & 

Lang, 2005 PCL-C CIDI X X 211 (56%)

49 randomly selected from

192 (87%) who agreed

II

MeansChristensen, 

2006

ADD CIDI 7,738 (61%)

569 (38% +screens)

232 (21% eligible –screens) IV

Meltzer-Brody, 

2004 SPAN MINI X 292 (76%) 32 (36%) with trauma III

Prins, 2003

PC-PTSD

PCL-S CAPS X 335 (convenience sample) 167 (50%) III

Walker, 2002 PCL CAPS X 1,225 (62%) 152 (74%) with trauma

116 (75%) no trauma 

III

Yeager, 2007 SPAN, PCL CAPS (Sample 2 

women only) X Sample 1: 888 (74%)

Sample 2: 191 (69%)

728 (82%)

130 (68%)

I
Evidence-based Synthesis Program 

(ESP)

• Key Question 2: 

What are the psychometric properties and 

utility of the screening tools (sensitivity, 

specificity, likelihood ratios, predictive values, 

area under curve, reliability)?
Evidence-based Synthesis Program 

(ESP)

Disease Present Disease Absent

Test Positive True Positives

a 

False Positives

b All Positives

Test Negative False Negatives 

c 

True Negatives

d All Negatives

Total Diseased in 

Population 

Total Normal in 

Population 

Sensitivity = a/a+c 

Specificity = d/b+d 

PPV = a/a+b 

NPV = d/d+c
Evidence-based Synthesis Program 

(ESP)

• Process of Screening: Classifies those in the population into 

those who probably have the disease and those who probably do not 

have the disease. 

 Normal Diseased Screening Tool
Evidence-based Synthesis Program 

(ESP)

Probably have the disease vs. probably do not have the 

disease. 

 Presumed Normal Presumed Diseased Screening Tool
Evidence-based Synthesis Program 

(ESP)

Metric Definition

Prevalence Frequency of condition in a population.

Cut Score Divides population into positive and negative cases. 

Sensitivity Correct classification of people with the condition

Specificity Correct classification of people without the condition

Positive Predictive Value (PPV) Proportion of positive screens that are true positives.

Negative Predictive Value (NPV) Proportion of negative screens that are true negatives.

Likelihood Ratio – Positive (LR+) Ratio between the probability of a positive screen given the disease is present and 

the probability of a positive screen given the disease is not present.

Likelihood Ratio – Negative (LR-) Ratio between the probability of a negative screen given the disease is present and 

the probability of a negative screen given the disease is not present.

Area Under the Curve (AUC) Area under a Receiver Operating Characteristic curve. ROC curve plots false 

positives (x-axis) vs. true positives (y-axis).
Evidence-based Synthesis Program 

(ESP)

Metric Calculation Relation to other Metrics

Prevalence Impacts the predictive values (positive, negative) of screening; if 

prevalence is low, PPV decreases and NPV increases.

Cut Score Based on desired sensitivity/specificity

trade-off. 

Increasing the cut score typically increases specificity and 

decreases sensitivity.

Sensitivity Higher sensitivity results in higher LR+, and lower LR-.

Specificity Higher specificity results in lower LR- and higher LR+. 

Positive Predictive 

Value (PPV) Increases with higher base rates.

Negative Predictive 

Value (NPV) Decreases with higher base rates.

Likelihood Ratio – 

Positive (LR+) Increases with increased sensitivity or increased specificity. 

Likelihood Ratio – 

Negative (LR-) Decreases with increased specificity or increased sensitivity. 

Area Under the Curve 

(AUC)

Parametric and nonparametric methods 

available depending on assumptions

Shows trade-off between sensitivity and specificity, not necessarily 

how test performs at cut score to be used in practice.
Evidence-based Synthesis Program 

(ESP)

1. Intermediate Length Screens

2. PCL

3. Short and non-PTSD specific screens
Screen Author, 

Year

Cut 

Points 

Used

PTSD

Base rate Sensitivity Specificity PPV NPV AUC LR+ LR

-

Breslau Freedy 

2010

≥4

 

≥5

32.1%

84.5%

 

70.7%

76.4%

 

88.0%

31.3%

 

42.9%

97.5%

 

95.9%

0.88

3.58

 

5.90

0.20

 

0.33

Kimerling

2006

≥4

 

≥5

25%

85%

 

76%

84%

 

91%

64%

 

74%

94%

 

92%

--

5.31

 

8.44

0.18

 

0.26

PC-PTSD Freedy 

2010

3 32.1% 85% 82% 38% 98% 0.92 4.72 0.18

Gore 

2008

2 

 

3 

 4

21% 

91%

 

70%

 

47%

84%

 

92%

 

98%

37%

 

46%

 

71%

99%

 

97%

 

95%

0.89

2.89

 

3.64

 

24.9

--

 

--

 

--

Prins 

2003

3 

 

4 

 

3 (women)

24.5%

 

 

 

25.0%

78%

 

54%

 

70%

87%

 

93%

 

85%

65%

 

71

%

 

61%

92%

 

86%

 

91%

--

6.00

 

7.17

 

4.38

0.25

 

0.49

 

0.36

SPAN Freedy 

2010

3 

 432.1%

76%

 

53%

72%

 

85%

25%

 

31%

96%

 

93%

0.84

2.67

 

3.52

0.34

 

0.56

Meltzer-

Brody 

2004

 

3 

 

4 

 5

8.6% clinic 

patients

 

28.4% with 

trauma 

history

80%

 

76%

 

72%

29%

 

43%

 

71%

80%

 

83%

 

90%

28%

 

33%

 

42%

0.75

1.12

 

1.33

 

2.52

0.70

 

0.56

 

0.39

Yeager 

2007

 

3 

 

4 

 5

11.3%

77%

 

74%

 

74%

73%

 

78%

 

82%

27%

 

30%

 

34%

96%

 

96%

 

96%

0.84

2.87

 

3.41

 

4.09

0.32

 

0.32

 

0.32
Screen Author, 

Year

Cut 

Points 

Used

PTSD

Base rate Sensitivity Specificity PPV NPV AUC LR+ LR

-

Breslau Freedy 

2010

≥4

 

≥5

32.1%

84.5%

 

70.7%

76.4%

 

88.0%

31.3%

 

42.9%

97.5%

 

95.9%

0.88

3.58

 

5.90

0.20

 

0.33

Kimerling

2006

≥4

 

≥5

25%

85%

 

76%

84%

 

91%

64%

 

74%

94%

 

92%

--

5.31

 

8.44

0.18

 

0.26

PC-PTSD Freedy 

2010

3 32.1% 85% 82% 38% 98% 0.92 4.72 0.18

Gore 

2008

2 

 

3 

 4

21% 

91%

 

70%

 

47%

84%

 

92%

 

98%

37%

 

46%

 

71%

99%

 

97%

 

95%

0.89

2.89

 

3.64

 

24.9

--

 

--

 

--

Prins 

2003

3 

 

4 

 

3 (women)

24.5%

 

 

 

25.0%

78%

 

54%

 

70%

87%

 

93%

 

85%

65%

 

71%

 

61%

92%

 

86%

 

91%

--

6.00

 

7.17

 

4.38

0.25

 

0.49

 

0.36

SPAN Freedy 

2010

3 

 432.1%

76%

 

53%

72%

 

85%

25%

 

31%

96%

 

93%

0.84

2.67

 

3.52

0.34

 

0.56

Meltzer-

Brody 

2004

 

3 

 

4 

 5

8.6% clinic 

patients

 

28.4% with 

trauma 

history

80%

 

76%

 

72%

29%

 

43%

 

71%

80%

 

83%

 

90%

28%

 

33%

 

42%

0.75

1.12

 

1.33

 

2.52

0.70

 

0.56

 

0.39

Yeager 

2007

 

3 

 

4 

 5

11.3%

77%

 

74%

 

74%

73%

 

78%

 

82%

27%

 

30%

 

34%

96%

 

96%

 

96%

0.84

2.87

 

3.41

 

4.09

0.32

 

0.32

 

0.32
Screen Author, Year

Cut 

Points 

Used

PTSD

Base rate Sensitivity Specificity PPV NPV AUC LR+ LRPCL Andrykowski

1998

30

40

50

DSM-IV

Current 

PTSD: 6%

Lifetime: 9%

100%

60%

60%

60%

83%

93%

99%

97%

24%

33%

75%

60%

100%

97%

97%

97%

--

5.88

8.57

60.0

20.0

0.00

0.43

0.40

0.41

Dobie 2002

38

44

50

36%

79%

68%

58%

79%

86%

92%

68%

73%

79%

87%

83%

80%

0.86

3.78

4.69

7.54

0.26

0.38

0.45

Freedy 2010

43

46

32.1%

80%

75%

82%

88%

37%

44%

97%

96%

0.93

4.54

6.11

0.24

0.29

Lang 2005

6 item

17 item – 

30

17 item – 

50

16%

92%

96%

54%

72%

59%

94%

36%

30%

62%

98%

99%

92%

0.89

0.90

0.90

3.29

2.34

9.00

0.11

0.07

0.49

Lang 2003

30

40

50

31%

78%

61%

39%

71%

94%

94%

55%

80%

75%

86%

82%

22%

0.89

2.69

10.17

6.50

0.31

0.41

0.65

Prins, 2003

(PCL-S) 48 26% 84% 90% 62% 94% -- 8.40 0.18

Walker 2002

30

45

50

--

82%

36%

21%

76%

95%

98%

28%

43%

50%

97%

93%

91%

0.84

3.40

6.59

8.57

0.24

0.68

0.81

Yeager 2007

31

44

50

11.3%

81%

63%

53%

81%

91%

95%

35%

47%

57%

97%

95%

94%

0.88

4.31

7.02

10.32

0.23

0.41

0.50
Screen Author, Year

Cut 

Points 

Used

PTSD

Base rate Sensitivity Specificity PPV NPV AUC LR+ LRPCL Andrykowski

1998

30

40

50

DSM-IV

Current 

PTSD: 6%

Lifetime: 9%

100%

60%

60%

60%

83%

93%

99%

97%

24%

33%

75%

60%

100%

97%

97%

97%

--

5.88

8.57

60.0

20.0

0.00

0.43

0.40

0.41

Dobie 2002

38

44

50

36%

79%

68%

58%

79%

86%

92%

68%

73%

79%

87%

83%

80%

0.86

3.78

4.69

7.54

0.26

0.38

0.45

Freedy 2010

43

46

32.1%

80%

75%

82%

88%

37%

44%

97%

96%

0.93

4.54

6.11

0.24

0.29

Lang 2005

6 item

17 item – 30

17 item – 50

16%

92%

96%

54%

72%

59%

94%

36%

30%

62%

98%

99%

92%

0.89

0.90

0.90

3.29

2.34

9.00

0.11

0.07

0.49

Lang 2003

30

40

50

31%

78%

61%

39%

71%

94%

94%

55%

80%

75%

86%

82%

22%

0.89

2.69

10.17

6.50

0.31

0.41

0.65

Prins, 2003

(PCL-S) 48 26% 84% 90% 62% 94% -- 8.40 0.18

Walker 2002

30

45

50

--

82%

36%

21%

76%

95%

98%

28%

43%

50%

97%

93%

91%

0.84

3.40

6.59

8.57

0.24

0.68

0.81

Yeager 2007

31

44

50

11.3%

81%

63%

53%

81%

91%

95%

35%

47%

57%

97%

95%

94%

0.88

4.31

7.02

10.32

0.23

0.41

0.50
Screen Author, Year

Cut 

Points 

Used

PTSD

Base rate Sensitivity Specificity PPV NPV AUC LR+ LRPCL Andrykowski

1998

30

40

50

DSM-IV

Current 

PTSD: 6%

Lifetime: 9%

100%

60%

60%

60%

83%

93%

99%

97%

24%

33%

75%

60%

100%

97%

97%

97%

--

5.88

8.57

60.0

20.0

0.00

0.43

0.40

0.41

Dobie 2002

38

44

50

36%

79%

68%

58%

79%

86%

92%

68%

73%

79%

87%

83%

80%

0.86

3.78

4.69

7.54

0.26

0.38

0.45

Freedy 2010

43

46

32.1%

80%

75%

82%

88%

37%

44%

97%

96%

0.93

4.54

6.11

0.24

0.29

Lang 2005

6 item

17 item – 30

17 item – 50

16%

92%

96%

54%

72%

59%

94%

36%

30%

62%

98%

99%

92%

0.89

0.90

0.90

3.29

2.34

9.00

0.11

0.07

0.49

Lang 2003

30

40

50

31%

78%

61%

39%

71%

94%

94%

55%

80%

75%

86%

82%

22%

0.89

2.69

10.17

6.50

0.31

0.41

0.65

Prins, 2003

(PCL-S) 48 26% 84% 90% 62% 94% -- 8.40 0.18

Walker 2002

30

45

50

--

82%

36%

21%

76%

95%

98%

28%

43%

50%

97%

93%

91%

0.84

3.40

6.59

8.57

0.24

0.68

0.81

Yeager 2007

31

44

50

11.3%

81%

63%

53%

81%

91%

95%

35%

47%

57%

97%

95%

94%

0.88

4.31

7.02

10.32

0.23

0.41

0.50
Screen Author, 

Year

Cut Points 

Used

PTSD

Base rate Sensitivity Specificity PPV NPV AUC LR+ LRPCL-2 Lang, 2005 4 16% 96% 58% 10% 99% 0.88 2.29 0.07 

PCL-6 Lang, 2005 14 16% 92% 72% 36% 98% 0.86 3.29 0.11

M-3

Gaynes, 

2010 2

6.3% 

PTSD

35% any 

disorder

88% 76% 20% 99% -- 3.69 0.16

PDI-4A

Houston, 

2011

PTSD item 

and 

functioning 

item both 

rated at least 

sometimes

4.9% 71% 72% 12% 98% -- 2.54 0.40

ADD

MeansChristensen 

2006

PTSD item 

only (Yes/No)

3 items

(1 specific to 

PTSD)

18.5%

62%

96%

83%

35%

48%

27%

89%

97%

--

3.54

1.47

0.46

0.11

GAD-7

Kroenke, 

2007

GAD-7 ≥8

GAD-2 ≥3

8.6%

76%

59%

75%

81%

22%

23%

97%

95%

0.83

0.80

3.1

3.1

0.32

0.51
Evidence-based Synthesis Program 

(ESP)

• Only 4 studies used multiple 

instruments in same sample and 

provided comparative statistics. 
Evidence-based Synthesis Program 

(ESP)

Author, Year 

(Sample size) 

Level of 

Evidence 

Rating#

Screen Cut

Score

PTSD

Base rate Sensitivity Specificity PPV NPV AUC(SE or 95% CI) LR+ LRFreedy, 2010

(n=411)

IV

PC-PTSD 3

32.1%

85% 82% 38% 98% 0.92 (0.028) 4.72 0.18

SPAN 4 53% 85% 31% 93% 0.84 (0.032) 3.52 0.34

PCL-C 43 80% 82% 37% 97% 0.93 (0.024) 4.54 0.24

Breslau 5 71% 88% 43% 96% 0.88 (0.029) 5.90 0.33

Gore, 2008

(n=213 PCPTSD;

n=3,234 SIPS)

III

PC-PTSD

2

3

9% 

(estimated)

91%

70%

84%

92%

37%

46%

99%

97%

0.89

(0.84-0.94)

2.89

3.64 --

SIPS

a little

a lot

76%

36%

79%

96%

26%

49%

97%

94%

0.77

(0.70-0.84)

2.28

9.90 --

Prins, 2003

(n=188)

III

PC-PTSD 3

26%

77% 85% 63% 91% -- 5.13 0.27

PCL-S 48 84% 90% 62% 94% -- 8.40 0.18

Yeager, 2007

(n=758)

I

SPAN

4

5

6 11.3%

75%

74%

73%

78%

82%

85%

30%

34%

39%

96%

96%

96%

0.84 (0.023)

3.41

4.09

4.91

0.32

0.32

0.32

PCL

31

43

81%

67%

81%

90%

35%

47%

97%

96% 0.88 (0.018)

4.31

6.97

0.23

0.36
Evidence-based Synthesis Program 

(ESP)

KQ2 Summary: 

• AUC’s ranged from 0.75-0.93.

• Performance of moderate length screens (Breslau, 

PC-PTSD, SPAN) comparable.

o Weak evidence SPAN performed less well. 

• PCL optimal cut-score varies, needs calibration.

o Intermediate length screens may be more transferable. 

• Non-PTSD specific screens less precise for PTSD, but 

this may be clinically useful. 
Evidence-based Synthesis Program 

(ESP)

• Key Question 3: 

• What information is there about the implementation issues (e.g., ease of 

administration, patient satisfaction) related to the use of PTSD screening tools 

in primary care clinics? 

1. Few studies reported implementation information.

 Shorter screens ~ 5 min. or less. Longest ~10 min.

2. Gayes (2010) M-3 only process evaluation.

 Only 1% patients had insufficient time for 27 items.

 83% providers reviewed results < 1 min.

 About 2/3 patients felt it facilitated MH discussion with providers.

 Of those with MH conditions, 75% patients and 80% providers 

felt screen facilitated talk about MH issues.

 No providers felt it was too cumbersome to include in their 

practice. 
• Key Question 4: 

• Do the psychometric properties and utility of each of 

the screening tools differ according to age, gender, 

race/ethnicity, substance abuse, or other 

comorbidities? 
Author, 

Year 

Level of 

Evidence 

Rating# Screen

Cut

Score

M W

PTSD

Base Rate

Sensitivity

M W

Specificity

M W

AUC

M W

LR+

M W

LRM W

Freedy, 

2010

IV

PC-PTSD 3 3 

32.1%

 

M: 20.0%

W: 35.8%

100% 83% 87% 83% + Gender 

Difference 7.69 4.88 0.00 0.20

SPAN 3 3 89% 74% 78% 72% No difference 4.05 2.64 0.14 0.36

PCL-C 46 43 86% 79% 95% 81% + Gender 

Difference 17.2 4.11 0.15 0.27

Breslau

Scale 4 4 100% 83% 78% 77% + Gender 

Difference 4.55 3.61 0.00 0.22

MeansChristenso

n, 2006

IV

ADD 

20.4%

Whites: 

15.5%

Non-whites: 

23.9%

M≈W

-- Whites: 86%

Non-whites: 76% -- -- --

Prins, 2003

III PC-PTSD 3 

24.5% 

M: 25%

W: 24%

94% 70% 92% 84% -- 11.75 4.38 0.07 0.36

Yeager, 

2007

I 

SPAN 5 

6 

11.3%

 

Blacks:13.5% 

Whites:10.0%

 

M: 11.9%

W: 9.1%,

-- --

No gender or 

race 

differences

-- --

PCL 31

43 -- -- Age X Race Interaction -- --
Evidence-based Synthesis Program 

(ESP)

KQ4 Summary: 

• Limited evidence evaluating screens by age, gender, 

race and none looked at specific comorbidities in 

primary care.

• Weak evidence that PC-PTSD and Breslau scale 

perform better in men than women. 

• SPAN and PCL no evident gender differences.

• Weak evidence PCL less good for African American 

Men < 50 yo. 
Evidence-based Synthesis Program 

(ESP)

Summary and Recommendations: 

• Information about potential benefits and 

harms of screening for PTSD on the health 

of veterans is needed. 

• Information is needed about the 

performance of screens given specific 

comobidities (e.g., TBI).

• There is weak and inconsistent evidence of 

screen performance by gender, race, and 

age. Evidence base should be expanded. 
Evidence-based Synthesis Program 

(ESP)

• The fewer the number of items, the greater 

the trade-off of sensitivity vs. specificity for 

each point in the screen. 

• Screens that consist of 1 or 2 questions do 

not sufficiently balance sensitivity with 

specificity or LR+ with LR- to be as useful as 

slightly longer screens.
Evidence-based Synthesis Program 

(ESP)

• Longer scales, like the PCL, are finely graded 

across the scoring spectrum.

o To be useful as a screen, however, requires 

calibration to the target population. 

• Studies are needed that examine the impact 

of MH screening on the clinical processes in 

primary care clinics. 

• Non-PTSD specific screens may have some 

clinical utility in primary care settings. 
Evidence-based Synthesis Program 

(ESP)

• Limitations: 

o Variation in gold standards across studies 

limiting comparability.

o Utility of a screening tool is contextually 

dependent. This could not be assessed in the 

current review. 

o Applicability to DSM-5 requires additional 

information. 
Evidence-based Synthesis Program 

(ESP)

DSM 5 

• NCPTSD: re-validating PC-PTSD, PCL 

and CAPS.

o Brian Marx, Frank Weathers, Annabel Prins running 

evaluation studies. 

• CAPS-5 and PCL-5 are complete. 

• PC-PTSD-5 currently being validated in VA primary 

care using the MINI. More specific trauma stem to 

items may increase precision. Will have 5 questions. 
Evidence-based Synthesis Program 

(ESP)

Questions?

If you have further questions, 

feel free to contact:

Michele Spoont, PhD

michele.spoont@va.gov

The full report and cyberseminar presentation is available on the ESP website: 

http://www.hsrd.research.va.gov/publications/esp/