Evidence-based Synthesis Program Department of Veterans Affairs 

Health Services Research & Development Service 

January 2013 

Screening for Post-Traumatic Stress 

Disorder (PTSD) in Primary Care: 

A Systematic Review 

Prepared for: 

Department of Veterans Affairs 

Veterans Health Administration 

Quality Enhancement Research Initiative 

Health Services Research & Development Service 

Washington, DC 20420 

Prepared by: 

Evidence-based Synthesis Program (ESP) Center 

Minneapolis VA Medical Center 

Minneapolis, MN 

Timothy J. Wilt, M.D., M.P.H., Director 

Investigators: 

Principal Investigator: 

Michele Spoont, Ph.D. 

Co-Investigators: 

Paul Arbisi, Ph.D. 

Steven Fu, M.D. 

Nancy Greer, Ph.D. 

Shannon Kehle-Forbes, Ph.D. 

Laura Meis, Ph.D. 

Research Associate:
 

Indulis Rutks, B.S.
 
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Screening for Post-Traumatic Stress Disorder (PTSD) 

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

PREFACE
 

Quality Enhancement Research Initiative’s (QUERI) Evidence-based Synthesis Program 

(ESP) was established to provide timely and accurate syntheses of targeted healthcare topics 

of particular importance to Veterans Affairs (VA) managers and policymakers, as they work to 

improve the health and healthcare of Veterans. The ESP disseminates these reports throughout 

VA. 

QUERI provides funding for four ESP Centers and each Center has an active VA affiliation. The 

ESP Centers generate evidence syntheses on important clinical practice topics, and these reports 

help: 

• develop clinical policies informed by evidence, 

• guide the implementation of effective services to improve patient 

outcomes and to support VA clinical practice guidelines and 

performance measures, and 

• set the direction for future research to address gaps in clinical 

knowledge. 

In 2009, the ESP Coordinating Center was created to expand the capacity of QUERI Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of QUERI field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service 

Networks (VISN) Clinical Management Officers. The Steering Committee provides program 

oversight, guides strategic planning, coordinates dissemination activities, and develops 

collaborations with VA leadership to identify new ESP topics of importance to Veterans and the 

VA healthcare system. 

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP 

Coordinating Center Program Manager, at nicole.floyd@va.gov. 

Recommended citation: Spoont M, Arbisi P, Fu S, Greer N, Kehle-Forbes S, Meis L, Rutks I, 

Wilt TJ. Screening for Post-Traumatic Stress Disorder (PTSD) in Primary Care: A Systematic 

Review. VA-ESP Project #09-009; 2013. 

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

(ESP) Center located at the Minneapolis VA Medical Center, Minneapolis, MN funded 

by the Department of Veterans Affairs, Veterans Health Administration, Office of 

Research and Development, Quality Enhancement Research Initiative. The findings 

and conclusions in this document are those of the author(s) 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. 
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Screening for Post-Traumatic Stress Disorder (PTSD) 

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TABLE OF CONTENTS
 

EXECUTIVE SUMMARY 

Background.................................................................................................................................................... 1
 

Methods ......................................................................................................................................................... 1
 

Data Synthesis ............................................................................................................................................... 2
 

Peer Review................................................................................................................................................... 2
 

Results ........................................................................................................................................................... 2
 

Future Research............................................................................................................................................. 4
 

INTRODUCTION ............................................................................................................................................... 6
 

METHODS 

Topic Development........................................................................................................................................ 7
 

Search Strategy.............................................................................................................................................. 7
 

Study Selection.............................................................................................................................................. 7
 

Data Abstraction ............................................................................................................................................ 8
 

Quality Assessment ....................................................................................................................................... 8
 

Rating the Body of Evidence......................................................................................................................... 8
 

Data Synthesis ............................................................................................................................................. 10
 

Peer Review................................................................................................................................................. 10
 

RESULTS 

Literature Flow ............................................................................................................................................ 12
 

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)?.................................................. 13
 

Breslau’s Short Screening Scale ........................................................................................................ 13
 

Primary Care PTSD Screen (PC-PTSD)............................................................................................ 13
 

Single-item PTSD Screener (SIPS) ................................................................................................... 13
 

SPAN.................................................................................................................................................. 14
 

PTSD Checklist (PCL), PCL-6, PCL-2 ............................................................................................. 14
 

My Mood Monitor Checklist (M-3)................................................................................................... 15
 

Provisional Diagnostic Interview – 4 Anxiety (PDI-4A)................................................................... 15
 

Anxiety and Depression Detector (ADD).......................................................................................... 15
 

Generalized Anxiety Disorder Scaled (GAD-7, GAD-2) .................................................................. 15
 

Summary............................................................................................................................................ 16
 

Key Question #2. What are the psychometric properties and utility of the screening tools 

(sensitivity, specificity, likelihood ratios, predictive values, area under curve, reliability)?....................... 17
 

Breslau’s Short Screening Scale ........................................................................................................ 17
 

Primary Care PTSD Screen (PC-PTSD)............................................................................................ 19
 

Single-item PTSD Screener (SIPS) ................................................................................................... 20
 

SPAN.................................................................................................................................................. 20
 
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Screening for Post-Traumatic Stress Disorder (PTSD) 

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

 

 

 

 

PTSD Checklist (PCL)....................................................................................................................... 21
 

My Mood Monitor Checklist (M-3)................................................................................................... 23
 

Provisional Diagnostic Interview – 4 Anxiety (PDI-4A)................................................................... 24
 

Anxiety and Depression Detector (ADD).......................................................................................... 24
 

Generalized Anxiety Disorder Scale (GAD-7, GAD-2) .................................................................... 24
 

Comparative Studies .......................................................................................................................... 29
 

Summary............................................................................................................................................ 29
 

Key Question #3. What information is there about the implementability (e.g., ease 

of administration, patient satisfaction) of PTSD screening tools in primary care clinics? ......................... 32
 

Summary............................................................................................................................................ 32
 

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? ................................... 32
 

Summary............................................................................................................................................ 33
 

SUMMARY AND DISCUSSION 

Summary of Evidence by Key Question ..................................................................................................... 36
 

Limitations................................................................................................................................................... 38
 

Clinical Considerations ............................................................................................................................... 38
 

Recommendations for Future Research....................................................................................................... 39
 

REFERENCES ................................................................................................................................................... 41
 

TABLES 

Table 1. Gold Standard Structured Diagnostic Interviews for Diagnosing PTSD................................... 9
 

Table 2. Diagnostic Accuracy Terms Used in this Report...................................................................... 11
 

Table 3. Screens Used to Identify PTSD in Primary Care Clinics ........................................................ 16
 

Table 4. Characteristics of Included Studies with Level of Evidence Rating........................................ 18
 

Table 5. Screen Performance Characteristics......................................................................................... 26
 

Table 6. Studies Comparing More than One Screening Instrument....................................................... 31
 

Table 7. Evidence for a Moderating Effect of Demographic Factors on Screen Characteristics........... 35
 

FIGURE 

Figure 1. Literature Flow......................................................................................................................... 12
 

APPENDIX A.	 SEARCH STRATEGIES ............................................................................................................ 46
 

APPENDIX B.	 STUDY SELECTION AND DATA EXTRACTION FORM ....................................................... 47
 

APPENDIX C. LEVELS OF EVIDENCE .......................................................................................................... 48
 

APPENDIX D. PEER REVIEw COMMENTS/AUTHOR RESPONSES .......................................................... 50
 

APPENDIX E.	 EVIDENCE TABLE.................................................................................................................. 58
 

APPENDIX F.	 SPECIFIC ASSOCIATION OF Rce LEVEL OF EVIDENCE RATINGS TO
 

QUADAS ITEM RATINGS AS APPLIED IN THIS REVIEw .................................................. 63
 
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Screening for Post-Traumatic Stress Disorder (PTSD) 

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

EXECUTIVE SUMMARY 

BACKGROUND 

To minimize treatment delays and to maximize population reach, Veterans Affairs (VA) 

established a screening program to facilitate identification of post-traumatic stress disorder 

(PTSD) in their patients as they present in primary care clinics. Such screening programs may be 

helpful because primary care providers often have difficulty identifying PTSD in their patients 

and PTSD is frequently undertreated in the primary care setting.1,2 The premise of this type of 

screening program is to facilitate mental health treatment engagement earlier in the course of 

the illness and to engage patients in treatment who might otherwise not be identified as needing 

mental health care.3 

Recently, the Institute of Medicine (IOM) released a report examining the screening, diagnosis, 

treatment, and rehabilitation services for military Veterans and service members with PTSD in 

the Department of Veterans Affairs and the Department of Defense.3 As noted in the IOM report 

and elsewhere, successful screening programs utilize instruments that are simple, valid, precise, 

and acceptable both clinically and socially.3-5 To identify screening tools that are best suited to 

the primary care setting, this evidence synthesis report reviews the literature on the feasibility 

and diagnostic accuracy of screening tools used and evaluated with a gold standard in a primary 

care setting. 

We addressed the following 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)? 

Key Question #3. What information is there about the implementability (e.g., ease of 

administration, patient satisfaction) 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? 

METHODS 

We searched Ovid MEDLINE from 1981 to October 2012 using standard search terms 

(Appendix A). We limited the search to peer-reviewed articles involving human subjects 

and published in the English language. We also searched the National Center for PTSD’s 

Published International Literature On Traumatic Stress (PILOTS) database (http://www.ptsd. 

va.gov/professional/pilots-database/pilots-assessment.asp). A similar search strategy was used 

(Appendix A). Additional citations were identified from reference lists of relevant articles and 

existing reviews. 
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Screening for Post-Traumatic Stress Disorder (PTSD) 

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

Titles, abstracts, and articles were reviewed by researchers trained in the critical analysis of 

literature. We excluded studies that did not involve screening of adults in primary care settings in 

the United States, that did not report an evaluation of a tool for screening for PTSD, that did not 

include a gold-standard assessment of PTSD as a comparator, and that did not report outcomes 

of interest (diagnostic accuracy or information related to implementation of a screening tool). 

Qualifying gold-standard interviews used in the included studies are presented in Table 1. 

Study characteristics, patient characteristics, and outcomes were extracted by co-investigators 

under the supervision of the Principal Investigator, a VA psychologist and core investigator. 

We assessed study quality based on selected criteria from the QUality Assessment of Studies of 

Diagnostic Accuracy included in Systematic reviews (QUADAS) tool.6 We determined levels 

of evidence according to the system developed for the Rational Clinical Examination series.7 

Findings were narratively summarized. 

DATA SYNTHESIS 

We constructed evidence tables showing sample characteristics (screening sample and interview 

sample), methodological quality, gold standard (diagnostic) assessment method, and outcomes 

(sensitivity, specificity, positive and negative predictive values, area under receiver operating 

characteristic [ROC] curve, and positive and negative likelihood ratios) organized by screening 

instrument. We compiled a summary of findings for each question based on qualitative and 

semi-quantitative synthesis of the results. We identified and highlighted findings from studies 

involving Veterans and military personnel. 

PEER REVIEW 

A draft version of this report was reviewed by technical experts, as well as clinical leadership. 

Reviewer comments were addressed and our responses incorporated in the final report (Appendix 

D). 

RESULTS 

We screened 1998 titles (1302 from MEDLINE and 696 unique abstracts identified in the 

PILOTS database) and rejected 1844 because they did not meet inclusion criteria. We performed 

a more detailed review on 154 articles. With one article added from hand searching, we identified 

fifteen eligible studies that addressed one of the 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)? 

There were fifteen studies that used gold standard diagnostic clinical interviews to investigate 

twelve screening tools in primary care settings. Of those twelve tools, seven screen exclusively 

for PTSD and the remaining five screen for the psychiatric disorders commonly encountered and 

treated by primary care providers, including PTSD. Most studies had methodologic limitations 

including non-random screening, selective recruitment for diagnostic interviews, and diagnostic 
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Screening for Post-Traumatic Stress Disorder (PTSD) 

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interviews conducted with knowledge of screen results. These limited the strength of the 

evidence base and decreased our confidence in study findings. Seven of the studies used Veteran 

or military samples. 

Three of the screening tools also included in the review were truncated versions of longer 

screens. All screens were self-administered paper and pencil screening tests, and ranged from one 

to twenty-seven items. Response options for screen items ranged from dichotomous scoring (yes/ 

no) to 5 point graded frequency or severity scales. 

Key Question #2. What are the psychometric properties and utility of the 

screening tools (sensitivity, specificity, likelihood ratios, predictive values, area 

under curve, reliability)? 

Few studies examining the use of PTSD screening tools in primary care settings were of high 

quality, and only one was conducted in VA.8 The Primary Care-PTSD (PC-PTSD), which is 

the screen currently used in VA, was evaluated in three studies all of moderate methodologic 

quality.9-11 In the initial derivative study, the PC-PTSD had a sensitivity of 77% and a specificity 

of 85%, yielding positive and negative likelihood ratios of 5.1 and 0.27 respectively at the 

recommended cut-off. Across the three studies, positive likelihood ratios ranged from 3.6 to 5.1, 

and negative likelihood ratios were less than 0.30. 

The most commonly used screening tools (PC-PTSD, SPAN [Startle, Physiological arousal to 

reminders, Anger, and Numbness], PTSD Checklist, Breslau Scale) demonstrated reasonable 

performance characteristics with positive likelihood ratios generally ranging from 3.0 to 10.0 

and negative likelihood ratios between 0.20 to 0.42. Very short screens (i.e., one or two items) 

performed less well, with positive likelihood ratios less than 3.0, making them less clinically 

useful. 

The determination of optimal cut scores depends on the prevalence of PTSD in the target 

population, and whether the primary intent of the screen is to maximize identification of possible 

patients with PTSD (i.e., sensitivity) or to more precisely deploy limited clinical resources 

to follow-up positive screens (i.e., maximize specificity). The optimal cut-score for the most 

commonly used screen, the PTSD Checklist (PCL), varied across clinical settings according to 

differences in PTSD prevalence rates and sample compositions. Because the 17 item screen has 

a more graded scoring distribution, optimal cut-scores could be more precisely determined for 

a given clinical setting. In contrast, across studies, the intermediate length screens all had sharp 

drop-offs just under the recommended cut-scores. This suggests that the optimal cut score of an 

intermediate length screen is less likely to vary across populations and settings, and can therefore 

be more easily adopted by different healthcare systems. However, it also means that there is a 

steeper trade-off between sensitivity and specificity in cut-scores that differ only by one point, 

which may have significant policy and resource implications. 

Key Question #3. What information is there about the implementability (e.g., ease 

of administration, patient satisfaction) of PTSD screening tools in primary care 

clinics? 

Although most screens were constructed with brevity and ease of administration in mind, only 

three studies12-14 examined the time it took for patients to complete the screening tools and only 
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Screening for Post-Traumatic Stress Disorder (PTSD) 

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

one of these12 conducted a process evaluation to examine the impact of screen implementation on 

the clinical process. The longest screening tool (27 items) was reported to have an administration 

time of only 5-10 minutes to complete, suggesting that none of the screens posed a significant 

time burden on patients. In the one study that conducted an implementation evaluation, both 

patients and providers found use of the screening tool helpful and acceptable, and that it 

facilitated discussion of mental health issues in the clinical encounter. 

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? 

There is very little information about screen performance characteristics across demographic and 

diagnostic groups. There were two studies that examined differential performance characteristics 

of the screening tool used by VA (PC-PTSD) and in both there was weak evidence that the PCPTSD performs less well for women than for men. The reason for this is currently unknown. 

High quality studies are needed to determine if PTSD in women is missed using the cut-score 

currently employed in clinical settings. 

There is also weak evidence that the PCL performs less well for younger African American 

Veterans, although performance characteristics are still in the acceptable range. More research 

would be needed to determine whether use of the PCL in clinical settings leads to race disparities 

among younger African American Veterans. 

Although psychiatric comorbidity among Veterans with PTSD is common, there is no 

information about the impact of specific psychiatric conditions (e.g., traumatic brain injury) on 

the performance characteristics of any of the screening tools as administered in the primary care 

setting. 

FUTURE RESEARCH 

1.	 The new Diagnostic Statistical Manual-5 (DSM-5) diagnostic criteria for PTSD are soon to 

be released. Although it is unlikely that the overall performance of the screening tool used 

by VA (PC-PTSD) and other tools reviewed in this report will be appreciably altered given 

the new diagnostic criteria, the importance of PTSD detection and treatment in VA requires a 

high degree of confidence in tools used in clinical care of Veterans with PTSD. Accordingly, 

the PC-PTSD should be validated against the DSM-5 PTSD criteria. 

2.	 VA has worked to minimize healthcare disparities. Because there is weak and inconsistent 

evidence of possible variation in screen performance related to patient characteristics, more 

information is needed to determine whether screening tools for PTSD work equally well 

regardless of patient age, gender, race, ethnicity. 

3.	 Although psychiatric comorbidity is common among Veterans with PTSD, there is no 

information about whether the performance of screening tools is altered in the presence of 

specific psychiatric comorbidities as they present in primary care clinics. 

4.	 There are no studies examining the impact of mental health screening on the primary 

care encounter within the VA system, and only one implementation study was done in a 
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Screening for Post-Traumatic Stress Disorder (PTSD) 

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

community setting. It would be helpful to have more information about how PTSD screens 

can be best integrated into clinical practice. 

5.	 The success of a screening program depends on whether identification of the target condition 

in the population improves the outcome of those who have the condition.3,5 As noted in 

the IOM report,3 this is assumed to be true for PTSD but has never been proven. It would 

be helpful to know the impact on the mental and physical health of the VA population, as 

well as the financial and opportunity costs to the VA health care system of PTSD screening 

implementation. To adequately address this important clinical and research gap, a randomized 

controlled trial or methodologically sound comparative effectiveness trial of PTSD screening 

of Veterans in primary care settings is needed. 
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Screening for Post-Traumatic Stress Disorder (PTSD) 

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EVIDENCE REPORT 

INTRODUCTION 

Evidence suggests that the majority of Americans will experience a traumatic event at some 

time during their lives and that approximately 8% will subsequently develop post-traumatic 

stress disorder (PTSD).15-17 PTSD is one of the most common psychiatric sequellae of traumatic 

experiences and is characterized by an intense emotional reaction to the traumatic event, and 

followed by a persistent re-experiencing of the trauma, avoidance of things associated with 

the trauma, numbed emotional responsiveness, and increased arousal.18 Rates among military 

Veterans returning from deployments in Iraq and Afghanistan are much higher than that found in 

the general population, as high as 20% by some estimates.19 Currently, about 400,000 Veterans 

enrolled in VA carry a PTSD diagnosis.20 

Those who suffer from PTSD often have diminished functioning and a poorer quality of life as 

evidenced by elevated rates of suicide, hospital admissions, poverty, and unemployment.21-31 

Significant medical morbidity is also common among those with PTSD21,25,27-32 and several agerelated chronic medical conditions develop earlier.21 Moreover, people with PTSD have higher 

prevalence rates of problematic health behaviors, and utilize medical care at higher rates than 

those without PTSD.33-35 Although there are PTSD treatments available that have demonstrated 

effectiveness among individuals with diagnosed PTSD,36 many people who have PTSD may not 

be diagnosed and many who are diagnosed do not pursue mental health treatment. Of those who 

do seek treatment, prolonged delays are common.2,37,38 

To minimize treatment delays and to maximize population reach, VA established a screening 

program to identify PTSD in their patients as they present in primary care clinics. Such screening 

programs may be helpful because primary care providers often have difficulty identifying PTSD 

in their patients and PTSD is therefore frequently undertreated in the primary care setting.1,2 The 

premise of this type of screening program is to identify individuals needing further evaluation 

so as to facilitate mental health treatment engagement earlier in the course of the illness and to 

identify patients for treatment who might not otherwise be identified as needing mental health 

care.3 

Recently, the Institute of Medicine (IOM) released a report examining the screening, diagnosis, 

treatment, and rehabilitation services for military Veterans and service members with PTSD in 

the Department of Veterans Affairs and the Department of Defense.3 As noted in the IOM report 

and elsewhere, successful screening programs utilize instruments that are simple, valid, precise, 

and acceptable both clinically and socially.3-5 To identify screening tools that are best suited to 

primary care practice and to maximize relevance to the VA population, this evidence synthesis 

report reviews the literature on the feasibility and diagnostic accuracy of screening tools used in 

a primary care setting in the United States. 
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Screening for Post-Traumatic Stress Disorder (PTSD) 

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

METHODS 

TOPIC DEVELOPMENT 

This project was nominated by David Simel, MD, and endorsed by the Office of Mental Health 

Services. The key questions and scope were refined with input from a technical expert panel. 

The final key questions were: 

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)? 

Key Question #3. What information is there about the implementability (e.g., ease of 

administration, patient satisfaction) 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? 

SEARCH STRATEGY 

We searched Ovid MEDLINE from 1981 to October 2012 using standard search terms 

(Appendix A). The search was limited to peer-reviewed articles involving adult human subjects 

and published in the English language. A similar search strategy was used for searching the 

National Center for PTSD’s Published International Literature On Traumatic Stress (PILOTS) 

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

A). Additional citations were identified from reference lists of relevant articles and existing 

reviews. 

STUDY SELECTION 

Titles and abstracts were reviewed by researchers trained in the critical analysis of literature. 

We retrieved the full-text of potentially relevant articles for further review. We sought to 

include studies done in settings and with populations most relevant to the United States Veteran 

population. Therefore, we excluded the following: studies that did not involve screening of 

adults in primary care settings in the United States, studies that did not report an evaluation of 

a screening tool for PTSD symptoms, studies that did not include a gold-standard structured 

diagnostic clinical assessment of PTSD as a comparator, studies that did not report outcomes of 

interest (diagnostic accuracy or information related to implementation of a screening tool), and 

studies that had a screening sample size of fewer than 50 participants. Information about gold 

standard structured diagnostic interviews used as validation tools by included studies is presented 

in Table 1. There are other structured interviews that met our gold standard inclusion criteria 

(e.g., Diagnostic Interview Schedule or DIS) but were not utilized in studies meeting other 

eligibility criteria for this review and so are not included in the table. 
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Screening for Post-Traumatic Stress Disorder (PTSD) 

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DATA ABSTRACTION 

Study characteristics, screening instrument(s) used, diagnostic measures, method of 

administration, base rate of PTSD, screening sample and interview sample response rates, and 

results (sensitivity, specificity, positive and negative predictive values, positive and negative 

likelihood ratios, area under curve) were extracted from each identified study by co-investigators 

under the supervision of the Principal Investigator, a VA psychologist and core investigator. We 

noted whether the study involved specific sample populations (e.g., Veterans, women, age over 

60 years, etc.) and rated the study on the quality components of interest. The data extraction 

form is presented in Appendix B. A list of psychometric terms and how they are determined is 

included in Table 2. 

QUALITY ASSESSMENT 

We assessed the quality of studies pertaining to key questions #2 and #3 using selected criteria 

from the QUality Assessment of Studies of Diagnostic Accuracy included in Systematic reviews 

(QUADAS) tool.6 As noted on the data extraction form (Appendix B), we focused on: 1) the 

representativeness of the screening and interview samples, 2) the time lag between screening and 

diagnostic assessments, 3) the number and selection method of screened participants who were 

interviewed, and 4) whether the diagnostic interviews were conducted blind to the screening 

results. 

RATING THE BODY OF EVIDENCE 

In addition to quality ratings of individual study features, we summarized the overall quality of 

the evidence for each study using methods developed for the Journal of the American Medical 

Association Rational Clinical Examination series.7 One of five levels of evidence was assigned 

to each study based on sample size, independence and representativeness of the study samples, 

quality of the gold standard assessment procedure, and whether diagnostic assessments were 

completed blind to screening status. Definitions for each of the five levels of evidence ratings 

are presented in Appendix C, and our application of them to each study in Appendix F. Studies 

that met the lowest level of evidence (i.e., Level V) were excluded from the review. The body of 

evidence for each screening tool was evaluated qualitatively taking into account the strength of 

the current evidence base. 
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tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

ured Diagnostic Interviews for Diagnosing PTSD 

tion Scoring* Administration Time 

ed diagnostic interview of PTSD symptoms based on DSM-IV Assesses each of the 17 DSM-IV symptoms of PTSD as well as 

ct of symptoms on occupational and social functioning, validity 

nses, and five symptoms associated with PTSD (guilt, gaps in 

ss, derealization, and depersonalization).39 

Items scored for frequency (0 - 4) and in intensity (0 - 4). Symptom typically considered present if frequency > 1 and intensity > 2. 

45-60 minutes 

uctured interview that assesses major DSM-IV diagnoses. 

w is broken down into individual modules representing categories 

oses that can be administered individually.40 

Each symptom is scored as present, absent, or subthreshold. The minimum number of symptoms required to meet diagnostic criteria must be coded as present. 

Varies depending on modules administered and the number of disorders present. Generally, 1-2 hours. 

ctured diagnostic interview that assesses major psychiatric 

s within both DSM-IV (Axis I) and ICD-10. Items were developed 

iatrists both within the United States and across Europe.41 

Each symptom with the diagnosis coded as ‘yes’ or ‘no’. 

15 minutes 

uctured interview for the 17 symptoms used to diagnose PTSD 

g to the DSM-IV. Assesses presence and severity symptoms 

o a single identified traumatic event in the past 2 weeks, which 

om the 1 month time frame within the DSM-IV.42 Has also been 

 for symptoms in the last month. 

Seventeen items each scored from 0 (not at all) to 3 (5 or more time per week/very much). Symptom considered present if it receives a score of 1 or higher. 

20 minutes 

ed diagnostic interview that assesses both DSM-IV (Axis I) and 

onditions. Disorders are grouped in modules so modules of 

can be administered individually. 

Yes/No response items and items with variable response options. Diagnosis based on DSM-IV or ICD10 criteria. 

Approximately 2 hours for entire diagnostic interview. 

 scoring a gold standard assessment, the method is reported in the text of the report.
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Screening for Post-Traumatic Stress Disorder (PTSD) 

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DATA SYNTHESIS 

We constructed a study characteristics table showing sample characteristics (screening and 

interview samples) and methodological quality. We constructed an evidence table with gold 

standard diagnostic assessment tools, base rate of PTSD, and outcomes (sensitivity, specificity, 

positive and negative predictive values, area under receiver operating characteristic (ROC) curve, 

and positive and negative likelihood ratios) organized by screening instrument. We compiled a 

summary of findings for each question based on qualitative and semi-quantitative synthesis of 

the results. We identified and highlighted findings from studies involving Veterans and military 

personnel. 

PEER REVIEW 

A draft version of this report was reviewed by technical experts as well as clinical leadership. 

Their comments and our responses are presented in Appendix D. 
11 

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

Terms Used in this Report 

Definition Calculation Relation to other Metrics 

of a disorder within a target population. Number of true positives/total sample Impacts the predictive values (positive, negative) of 

screening; if prevalence is low, PPV decreases and NPV increases. 

used to divide the target population or test 

o true positive and negative cases. 

Ideal cut score typically based on desired sensitivity/specificity trade-off 

Increasing the cut score typically increases specificity and decreases sensitivity. 

that the screen will be positive when the 

 the disease (true positive fraction). 

True positives/(true positives + false negatives) 

Sensitivity increases with higher cut scores. Higher sensitivity results in higher LR+ and lower LR–. 

that the screen will be negative when the 

s not have the disease (true negative 

True negatives/(true negatives + false positives) 

Specificity decreases with higher cut scores. Higher specificity results in lower LR– and higher LR+. 

of positive screens that are true positives. True positives/(true positives + false 

positives) 

PPV increases with higher base rates: (Sensitivity)(base rate)/[(Sensitivity)(base rate) + (1 – specificity)(1 – base rate)]. 

of negative screens that are true negatives. True negatives/(true negatives + false 

negatives) 

NPV decreases with higher base rates: (Specificity)(1 – base rate)/[(specificity)(1 – base rate) + (1 – sensitivity) (base rate)]. 

een the probability of a positive screen 

isease is present and the probability of a 

een given the disease is not present. 

True positives/false positives Or Sensitivity/(1 – specificity) 

Likelihood ratio – positive: increases with increased sensitivity or increased specificity. 

een the probability of a negative screen 

isease is present and the probability of a 

creen given the disease is not present. 

False negatives/true negatives Or (1 – sensitivity)/specificity 

Likelihood ratio – negative: decreases with increased specificity or increased sensitivity. 

 a ROC* curve. Measures discrimination 

that do or do not have the disease using 

 cut scores. AUC=1.0 indicates perfect 

on. AUC=0.5 indicates test is no better 

 toss. 

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. 

c; ROC curve is plot of false positives on x-axis vs. true positives on y-axis. 
12 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

 

 

 

 

 

RESULTS 

We identified fifteen articles that met our inclusion criteria. These studies evaluated twelve tools 

intended to be used as screening instruments to detect PTSD. 

LITERATURE FLOW 

We screened 1998 titles (1302 from MEDLINE and 696 unique abstracts identified in the 

PILOTS database) and rejected 1844 because they did not meet eligibility criteria. We performed 

a more detailed review on 154 articles. From these, we excluded an additional 140 articles 

and added 1 article from hand searching for a total of 15 studies that addressed one of the key 

questions. We grouped the studies by screening instrument. Figure 1 details the process. 

Figure 1. Literature Flow 

Search Results: 

MEDLINE: 1302 Abstracts 

PILOTS: 696 Unique Abstracts 

TOTAL: 1998 

Excluded: 

1844 Abstracts 

Hand Search 

1 Article 

Full Text Review: 

154 Articles 

Excluded: 140 Articles 

1. Not US study 16 

2. Not primary care setting 42 

3. Not adults 1 

4. Not evaluation of screening tool 58 

5. No gold standard 20 

6. No outcomes of interest 3 

Included: 

15 Articles 
13 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

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)? 

We identified twelve screening tools that were evaluated using a gold standard structured 

diagnostic interview in a primary care setting. All were self-administered paper and pencil 

screening tests, and ranged from one to twenty-seven items. We provide a brief description of 

each of the screens evaluated by the included studies. The focus, length, response scale and testretest reliability of each screen are provided in Table 3. Although the focus of this systematic 

review is an evaluation of the literature of screening instruments for PTSD used in primary care, 

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. 

Breslau’s Short Screening Scale 

The Breslau scale was developed as a short self-report version of the National Institute of Mental 

Health DIS and the World Health Organization CIDI, version 2.1.43 The initial development 

was done using data from the Detroit Area Survey of Trauma, a random-digit-dialing survey of 

2,181 individuals, from 18 to 45 years old, living in the Detroit primary metropolitan statistical 

area. Respondents were asked to identify all traumatic events they had experienced and PTSD 

was assessed in connection with one randomly selected event from those identified. Diagnostic 

Statistical Manual-IV (DSM-IV) criterion symptoms of PTSD were evaluated in a structured 

interview and further analyses were limited to 1,830 individuals with complete data on all 

17 symptoms, 142 of whom had PTSD. Items evaluating duration and impairment were not 

included. A model with seven symptoms (five from the “avoidance and numbing” group and 2 

from the “arousal” group) was found to have higher positive predictive value and specificity than 

models with six or eight symptoms. In addition, a score of four or more was selected as the best 

overall cut point taking into consideration sensitivity (80%) and specificity (97%). In this initial 

derivation study, results were similar for men and women. 

Primary Care PTSD Screen (PC-PTSD) 

The PC-PTSD is a four item screen designed for use in primary care clinics.9

 Items are scored 

dichotomously as either 0 or 1 (no = 0; yes = 1). Each item was developed to map onto one 

of four empirically supported symptom factors proposed to underlie the construct of PTSD 

including 1) re-experiencing a traumatic event, 2) emotional numbing, 3) avoidance, and 4) 

hyperarousal.9 Respondents are asked about symptoms experienced in the past month that were 

related to a traumatic event that occurred anytime in their lifetime. The instrument was designed 

to be appropriate for those with at least an eighth grade reading level (Flesch-Kincaid grade level 

= 7.7). It has a test-retest reliability of 0.83. The PC-PTSD is the instrument used within VA 

medical centers and community-based outpatient care clinics across the United States. 

Single-item PTSD Screener (SIPS) 

The Single-item PTSD Screener (SIPS) is a single item asking respondents to indicate to what 

degree they were recently bothered by a past traumatic experience.10 The SIPS was developed 

to improve the implementation of PTSD screening in primary care clinics by providing a single, 
14 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

easy to memorize item. Candidate questions for the single item were written, discussed with 

study investigators, and then reviewed with patients to ensure the item was intuitive, clear, 

and acceptable. Candidate items were then refined and reviewed again by investigators before 

one was selected for the screen. The final selected item for the screen was, “Were you recently 

bothered by a past experience that caused you to believe you would be injured or killed?”. 

Response options include not bothered at all, bothered a little, or bothered a lot. 

SPAN 

The SPAN is a screening tool initially developed in a psychiatry clinic for the purpose of 

detecting PTSD in psychiatric populations with PTSD prevalence rates around 50%.44 The SPAN 

was derived from the Davidson Trauma Scale (DTS), a 17-item scale that assesses the DSM-IV 

PTSD criteria.45 In order to create the SPAN, the authors split a sample of 243 participants into 

derivation and replication samples with the goal of identifying seven or fewer items that could 

be used to screen for PTSD. The result was the four-item screening tool that assesses Startle, 

Physiological arousal to reminders, Anger, and Numbness (SPAN). Estimates of PPV and NPV 

in a population with a 10% PTSD base rate suggested that the SPAN may also be useful in 

settings with a lower prevalence of PTSD, such as primary care clinics.44 

PTSD Checklist (PCL), PCL-6, PCL-2 

The PTSD Checklist (PCL) is a 17-item self-report measure designed to assess severity of PTSD 

symptoms.46 Participants rate the severity of each of the DSM-IV symptoms for PTSD using a 

5-point Likert scale. The DSM-IV PTSD symptoms are grouped into clusters as follows: five reexperiencing symptoms, seven numbing/avoidance symptoms, and five hyper-arousal symptoms. 

The PCL instructs participants to rate items in relation to stressful experiences. The measure 

generally exhibits good internal consistency46 and has been demonstrated to be related to other 

self-report measures of PTSD as well as gold standard structured interviews for PTSD such 

as the CAPS. There are three versions of the PCL (original military version, PCL-M; civilian 

version, PCL-C; and specific version PCL-S) differentiated by the specificity of the index 

traumatic event used while completing the questionnaire. The PCL-M asks respondents to rate 

each item based on a single (unspecified) stressful military experience.46 The PCL-C does not 

require the specification of a worst single traumatic event; consequently, individual symptom 

ratings may be based on different stressful life events. The PCL-S requires item ratings based 

upon a single specified traumatic experience. Several coding strategies have been applied to the 

PCL that can be used to indicate probable PTSD.47,48 These include using several different cutoff 

scores, using DSM-IV criteria (e.g., reporting the requisite number of symptoms within each 

cluster at the moderate or greater level 3 or 4 on Likert scale), or using a combination of these 

two approaches (e.g., the requisite DSM-IV criteria are endorsed and the total score is above a 

specified cut point). Two short versions of the PCL were also evaluated – PCL-6 and PCL-2.49 

The two item version was created using the two items with the highest item-total correlations 

(i.e., items evaluating intrusive memories and distress with reminders of the trauma). The six 

item version was developed by using two items that correlated most highly with the total score of 

items within each of the three symptom clusters. 
15 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

My Mood Monitor Checklist (M-3) 

The My Mood Monitor checklist (M-3) is a one page, 27 item symptom screening tool for 

psychiatric disorders commonly found in and treated by primary care providers: PTSD, 

depression, bipolar disorder, and anxiety disorders (generalized anxiety disorder, panic disorder, 

obsessive compulsive disorder, and social anxiety disorder).12 In addition to disorder specific 

symptom items, the M-3 also includes four additional questions about functional impairment. 

Each of the 27 questions is rated on a frequency scale from not at all (0) to most of the time 

(4) for a period covering the previous two weeks. The scale was constructed at a sixth grade 

reading level. M-3 scoring is conducted in two steps. First, the respondent must screen positive 

on either: 1) the suicidality item or, 2) the impairment items (any of the four items rated as often 

or more than one as sometimes). If either “gateway” criterion is positive, then symptom modules 

are scored. The PTSD screening module consists of four questions assessing re-experiencing, 

avoidance, numbness and startle. 

Provisional Diagnostic Interview – 4 Anxiety (PDI-4A) 

The Provisional Diagnostic Interview – 4 Anxiety (PDI-4A) was developed to help primary care 

providers quickly screen for a range of mental health disorders commonly seen in primary care: 

attention-deficit/hyperactivity disorder, generalized anxiety disorder, major depression, mania, 

panic disorder, social phobia, PTSD, obsessive-compulsive disorder, and hypochondriasis.49 

Twenty-three items from an original pool of 85 items are included in the screening tool. The 

instrument was developed in a sample of 343 participants recruited from 21 primary care centers. 

The participants were high utilizers of primary care services -- 65% of participants had 2-5 

primary care visits in the past three months -- and over half reported functional disability in the 

same time period. The PTSD portion of the screen consists of one re-experiencing item from 

the DSM-IV definition of PTSD (“Having disturbing memories or dreams related to previous 

life-threatening events or assaults?”). If the item is rated as present at least sometimes over the 

previous week, it is scored as positive. In order for the screen to be counted as positive, however, 

the patient must also endorse at least one symptom listed in the screening instrument (for any 

disorder) reflecting in impairment in daily functioning with a frequency of at least once per 

week. 

Anxiety and Depression Detector (ADD) 

The Anxiety and Depression Detector (ADD) is a five item screening questionnaire developed 

to be used in primary care settings to assess possible panic disorder, PTSD, social phobia, 

generalized anxiety disorder, and depression.51 The questionnaire was developed as part of the 

Collaborative Care for Anxiety and Panic study, and validated in university-affiliated primary 

care clinics in two states. The performance of candidate items (two per disorder) were evaluated 

on a random selection of half of their sample and then the better performing items were evaluated 

on the remaining half. For PTSD, the two initial items were combined into a single question (i.e., 

either flashbacks or nightmares). In the final screen, each disorder is assessed by a single item. 

Generalized Anxiety Disorder Scales (GAD-7, GAD-2) 

The GAD-7 was developed as part of the Patient Health Questionnaire (PHQ) anxiety study.52 

The study enrolled patients from 15 primary care sites in 12 states. The scale was developed in 
16 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

2,149 patients and data from 591 were used to determined test-retest reliability. The seven items 

are scored on a scale of 0 (not at all) to 3 (nearly every day), with a total score of 0 to 21. A score 

of five represents mild anxiety symptoms; scores of 10 and 15 represent moderate and severe 

anxiety, respectively. The GAD-2 consists of the first 2 items of the GAD-7. These items reflect 

core anxiety symptoms. The score on the GAD-2 ranges from 0 to 6. In terms of identification 

of specific anxiety disorders, the GAD-7 and the GAD-2 were conceptualized as “first-step” 

screening tools. 

Summary 

There were twelve screening tools, ranging in length from one to twenty-seven items, which 

were used to identify possible PTSD within a primary care setting. Of those twelve, seven screen 

exclusively for PTSD and the remaining five screen for the psychiatric disorders commonly 

encountered and treated by primary care providers. 

Table 3. Screens Used to Identify PTSD in Primary care clinics 

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) 

NR 

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) 

NR 

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) NR 

Anxiety and Depression 

Detector (ADD) 

Anxiety 

disorders & 

depression 

1 of 5 total 

items Yes/No NR 

Generalized Anxiety Disorders 

-7 (GAD-7)* 

Anxiety 

disorders 7 

4-pt frequency scale: 

(0=Not at all to 3= Nearly every 

day) 

0.83e 

*Abbreviated screens (PCL-7, PCL-3, GAD-2) scored in the same manner as the primary screening tools; reliability of PCL-7, 

PCL-3, and GAD-2 not reported. 

a

Kimerling et al., 2006;13 test-retest interval = approximately 1 month; internal consistency = NR b

Prins et al., 2003;9 test-retest interval = 1 month; internal consistency = NR c

Gore et al., 2008;10 test-retest interval = median of 13 days; internal consistency = NA (1 item) d

Weathers et al., 1993;46 test-retest interval = 2 or 3 days; internal consistency = 0.97 e

Spitzer et al., 2006;52 test-retest interval = within 1 week; internal consistency = 0.92 
17 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

KEY QUESTION #2. What are the psychometric properties and utility 

of the screening tools (sensitivity, specificity, likelihood ratios, 

predictive values, area under curve, reliability)? 

In this section, we review the studies that examined each of the screening tools and provide their 

psychometric properties and the Level of Evidence rating in tabular form by instrument. The 

studies included in the review, their focus, and their Level of Evidence ratings are included in 

Table 4. Rationale for the Level of Evidence ratings is presented in the final column (QUADAS 

ratings) of the study characteristics table in Appendix E. Detailed findings are presented in 

Table 5. After describing the studies, we will also specifically discuss the four studies in which a 

comparison was made between screening instruments. 

Breslau’s Short Screening Scale 

The utility of the Breslau scale in VA general medicine and women’s health clinics was evaluated 

by Kimerling.13 Excluded were those with obvious cognitive impairment, a preferred language 

other than English, or an invalid telephone number. The Breslau scale was completed by 92% 

(n=237) of patients approached in the clinics. Of those, 57% (n=134) completed the Breslau a 

second time and underwent a clinician interview (CAPS) approximately one month later. The 

interview was completed in-person by trained psychologists blinded to the Breslau scale results. 

Test-retest reliability of the Breslau scale was 0.84 (p<0.001). The prevalence of PTSD in the 

interviewed sample was 25%. Likelihood ratios for cut scores of 4 or higher, 5 or higher, and 

6 or higher are presented in Table 5. Area under the ROC curve was not reported. The authors 

recommended a cut score of 4. At that score, sensitivity was 85% and specificity was 84%. 

PPV was 64%, NPV was 94%, and positive and negative likelihood ratios were 5.31 and 0.18, 

respectively. The authors noted that the sensitivity and specificity were acceptable for cut scores 

of 4, 5, and 6. Based on likelihood ratios, the authors suggested that patients with scores of 6 or 7 

should be targeted first for additional assessment. 
18 

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

luded Studies with Level of evidence Rating 

ens Gold Standard Women Only Sample Military/ Veterans Screening Sample n (Response Rate %) Interview Sample n (Response Rate %) Level of Evidence Rating# 

L-C 

SCID NP 

PTSD 

Module 

X 84 (79%) 82 (77%) IV 

L-C CAPS X X 282 (11%)* 282 (11%) III 

Breslau, 

, PCL-C CAPS 411 (53% eligible, 79% contacted) Same IV 

3 MINI 723 (54%) 647* I 

C-PTSD PSS-I X SIP: 3234 (est. 88%) PC-PTSD/PCL: 213 (NR) 213* III 

-4A SCID 343‡ ‡ IV 

lau CAPS X 258 (convenience sample) 134 (57%) III 

D-7 SCID 

965* (randomly selected from 

92% of those invited who 

completed questionnaire) 

965* (randomly selected from 

1654 who agreed) I 

L-C CIDI X X 221 (56%) 49 (randomly selected from 192 [87%] who agreed) II L-C CIDI X (partial)^ 275 (65%) 154 (randomly selected from 401 enrolled) II 

D CIDI 7,738 (61%) 569 (38% +screens) 232 (21% eligible –screens) IV 

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

TSD 

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

sion not 

fied) CAPS X 1,225 (62%) 152 (74%) with trauma 116 (75%) no trauma III 

L (version 

cified) CAPS Sample 2 women only X Sample 1: 888 (74%) Sample 2: 191 (69%) 728 (82%) 130 (68%) I 

= high quality to IV = marginal quality (see Appendix C) 

both PTSD screen and diagnostic interview 

ed with self-report instrument, 704 further screened by primary care provider, 440 additional self-report instruments, and 343 interviewed. 

Veterans 
19 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

Individuals from a family practice clinic were the focus of a second study.11 In addition to the 

Breslau scale, participants in this study completed the PCL-C, the PC-PTSD, and the SPAN. 

The study included a convenience sample of patients 18 years and older and excluded those who 

did not speak English, had gross cognitive impairment, or were medically unstable. Participants 

were asked to rate the presence of PTSD symptoms in the previous month. Screening and 

diagnostic interviews were completed on 411 patients (53% of those who originally consented 

or 79% of those contacted). The telephone interviews were conducted by experienced survey 

research personnel rather than mental health professionals. The order of administration of the 

four screening measures was randomized. The diagnostic interview (referred to as CAPSmodified because the interviewers were not mental health professionals) followed the four 

screening measures. Blinding was not reported but the screening and diagnostic interviews were 

completed in one telephone session. The gender and race distributions of study participants were 

significantly different from those in the clinic population. Specifically, there were fewer men, 

more whites, and fewer African American or other race individuals in the study population. 

The prevalence of PTSD in the sample was 32%. The overall diagnostic efficiency (area under 

the ROC curve) for the Breslau scale was 0.88. It was noted that diagnostic efficiency was 

significantly better for men than women. The optimal cut score was reported to be 4. At that 

cut score, sensitivity was 85%, specificity was 76%, PPV was 31%, NPV was 98%, positive 

likelihood ratio was 3.58 and negative likelihood ratio was 0.20. 

Primary Care PTSD Screen (PC-PTSD) 

Three studies that met criteria for the present review evaluated the PC-PTSD.9-11 In two of the 

studies, the gold standard was the CAPS;9,11 in the third study, the gold standard was the PSS-I.10 

In the initial psychometric paper, Veterans attending general medical or women’s health clinics 

were recruited.9 Those with gross cognitive impairment or a primary language other than English 

were excluded. The proportion of all eligible patients represented by those who participated in 

the study or the number of patients who were approached, but declined to participate were not 

reported. From a convenience sample of 335, 167 (50%) completed the PC-PTSD. The base 

rate of PTSD was 26% based on results from the CAPS administered by trained psychologists 

within one month of the screening tests and blinded to the screening results. At a cut score of 

3, sensitivity was 77%, specificity was 85%, PPV was 63%, NPV was 91%, positive likelihood 

ratio was 5.13, and negative likelihood ratio was 0.27. Area under the ROC curve was not 

reported. 

Freedy et al. observed a PTSD base rate of 32%.11 Details of this study are reported above. 

Area under the ROC curve for the PC-PTSD was 0.92. At a cut score of 3, sensitivity was 85%, 

specificity was 82%, PPV and NPV were 38% and 98%, respectively, and positive and negative 

likelihood ratios were 4.72 and 0.18, respectively. 

The third study recruited participants from three military health system primary care clinics.10 Of 

3,234 participants who completed the Single-item PTSD Screener (SIPS, see below) and agreed 

to further evaluation, a sampling procedure was developed to include a mix of individuals who 

responded “bothered a lot,” “not bothered,” and “bothered a little.” Of 229 who were invited and 

consented to a longer assessment involving the PC-PTSD and a structured diagnostic interview 

(PSS-I), interviews were completed in 213 (93% of those who consented; 6.6% of those who 
20 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

were initially screened). The PSS-I was administered by trained mental health professionals 

blinded to the SIPS results. Due to the sampling method, base rate could not be determined 

but was estimated by the study authors to be 9%. Although the sampling was stratified and the 

sample size was moderate for this study, they used sampling weights and propensity scores to 

extrapolate to the larger population. A cut score of 2 or more was considered optimal yielding 

91% sensitivity and 84% specificity. The PPV and NPV were 37% and 99%, respectively. The 

positive likelihood ratio was 2.89; negative likelihood ratio was not reported. Area under the 

ROC curve was 0.89. 

Single-item PTSD Screener (SIPS) 

Only one study met our inclusion/exclusion criteria that evaluated the SIPS.10 This study, as 

described above, used sampling weights and propensity scores to extrapolate findings to the 

larger population. The area under the ROC curve for the SIPS was 0.77. The optimal cut point 

for the SIPS was “bothered a little” yielding a sensitivity and specificity of 76% and 79%, 

respectively. The PPV and NPV were 26% and 97% while the positive likelihood ratio was 

2.28. The authors reported moderate to high correlations between the SIPS and other self-report 

instruments (Spearman correlations with PC-PTSD = 0.59; with PCL = 0.63). The SIPS also 

demonstrated adequate test-retest reliability (r = 0.63, n = 104; p < 0.001; median days between 

assessments = 13). The SIPS appeared to be less discriminating with a significantly lower area 

under the curve (0.77, 95% CI = 0.77-0.84) than the PC-PTSD (0.89, 95% CI = 0.84-0.94). As 

noted by Gore and colleagues, the limited range of response options for the SIPS and the fact that 

it is only a single item most likely underlie its lower reliability and validity.10 

SPAN 

Meltzer-Brody and colleagues examined the performance of the SPAN in an outpatient OB/ 

GYN clinic among English-speaking women presenting for routine annual exams.55 On an initial 

survey, patients were asked to indicate if they had experienced a severe trauma. The survey 

was completed by 76% (292/384) of patients approached. Those who reported a trauma history 

(n=88) were instructed to complete the SPAN and invited to participate in a diagnostic interview 

(the MINI). The interview was conducted in-person by a psychiatrist blinded to the SPAN 

results. Only 36% (32/88) of those invited to participate (11% of the 292 who completed the 

initial survey) completed the interview. PTSD was diagnosed in 25 of the 32 (78%). The SPAN 

performed well; the area under the ROC curve was 0.75. With the suggested cut point of 5 or 

greater, sensitivity was 72%, specificity was 71%, PPV was 90%, NPV was 42%, the positive 

likelihood ratio was 2.52, and the negative likelihood ratio was 0.39. However, the strength of 

evidence for this study is limited by the inclusion of the trauma screening question and selection 

of only those with a trauma history since the trauma screening question is part of the SPAN 

screen. 

As noted above, Freedy et al. administered multiple screening tools in a family practice clinic.11 

Participants rated the intensity of the four SPAN elements over the past month. The gold standard 

was the CAPS-modified. The author-identified optimal cut-score was 3 yielding a sensitivity 

of 76%, specificity of 72%, positive predictive value of 25%, and negative predictive value 

of 96%. Positive and negative likelihood ratios were 2.67 and 0.34, respectively. Although 3 

was identified as the optimal cut-score for both men and women, sensitivity (89% vs. 74%), 
21 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

specificity (78% vs. 72%), and the percent correctly classified (79% vs. 72%) were all higher for 

men. 

In a more carefully designed study, Yeager et al. examined the use of the SPAN in VA primary 

care clinics.8 The authors identified eligible participants from 229,780 Veterans who had made 

a primary care health care visit in a single year to one of four VA medical centers. Potential 

participants were randomly selected and invited to participate through a mailing. Female 

Veterans were oversampled by identifying all women in a single clinic and inviting participation. 

The gold standard evaluation was the CAPS with a focus on current and/or lifetime PTSD. 

The CAPS was administered over the telephone by trained clinicians within 2 months of the 

screening evaluation; the clinicians were blind to the SPAN results. Among the primary care 

patients, the screening response rate was 74% and 82% of those who completed the screening 

evaluation were interviewed. Among the female Veterans, the screening response rate was 

69% and 68% of those were interviewed. Completers were older and more likely to be white. 

Preliminary examination found no differences between the 62 women recruited and the randomly 

selected primary care sample, so they were combined for the primary analyses. The base rate of 

PSTD was 11.3%. In this high quality study, the SPAN performed well. The area under the ROC 

curve was 0.84. At the recommended cut score of 5, sensitivity and specificity were 74% and 

82%, respectively. PPV and NPV were 34% and 96%; positive and negative likelihood ratios 

were 4.09 and 0.32. 

PTSD Checklist (PCL) 

The PCL was the most widely studied instrument, and there were eight studies that investigated 

the validity of the PCL in a primary care setting. Five studies used the civilian version of the PCL 

(PLC-C),11,47,49,53,54 one used the PCL-S,9

 and two did not specify the version used.8,56 

Andrykowski et al. examined an interview version of the PCL-C (not paper and pencil) in 

82 women at least six months (6-72 months) after treatment for breast cancer (all women 

were in remission).47 PCL-C performance was assessed against the non-patient version of the 

SCID I PTSD module administered by doctoral-level students at the same time as the PCL-C. 

Interviewers were not blind to patient screening status. Of 107 women eligible for the study, 

84 consented (79%) and 82 were interviewed (77%). Current PTSD was diagnosed in 6% with 

lifetime PTSD diagnosed in another 4%. A cut score of 50 on the PCL-C yielded a sensitivity of 

60% and specificity of 99% associated with a positive predictive value of 75% and a negative 

predictive value of 97%. Positive and negative likelihood ratios were 60.0 and 0.40, respectively. 

Area under the ROC curve was not reported. 

Dobie et al. examined the PCL-C in woman Veterans seen at a single VA medical center.53 It is 

unclear what proportion was being treated in outpatient medical clinics as opposed to mental 

health clinics. Of the 2,545 women Veterans invited to participate, only 11% were included 

in the study and there was no information available regarding clinical characteristics of nonparticipants. CAPS interviews were administered by a clinician blind to the PCL-C results. 

Prevalence of PTSD was 36% and the area under the ROC curve was 0.86. The authors identified 

a cut score of 38 as optimal and found sensitivity was 79% as was specificity. PPV and NPV 

were 68% and 87%, respectively, while positive and negative likelihood ratios were 3.78 and 

0.26. 
22 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

In a similar study, Walker et al., selected a random sample of 1,963 female HMO members and 

mailed a questionnaire packet that included the PCL (version not specified).56 Using a traumatic 

experiences screening instrument, the Childhood Trauma Questionnaire (CTQ), women who 

screened positive for childhood sexual trauma were identified and solicited to participate in the 

study. Further, a random sample of woman who fell below the screening threshold on the CTQ 

were also contacted and asked to participate in the study. Participants were interviewed using 

the CAPS within 2 months of completing the PCL. It was not reported whether the interviews 

were face to face or conducted by telephone or whether the interviewers were blind to the PCL 

results. Of the 1,225 who completed the questionnaires 21.3% were interviewed. No information 

was provided regarding those who were interviewed and those who were not interviewed. 

Further, it is impossible to determine the base rate of PTSD in the sample since women were 

selected for interview based on screening positive for childhood sexual trauma; in the interview 

sample, 10.7% were diagnosed with PTSD. The area under the ROC curve was 0.84. At the 

author-identified optimal cut score of 30 on the PCL, sensitivity was 82%, specificity was 76%, 

PPV was 28%, and NPV was 97%. Positive and negative likelihood ratios were 3.40 and 0.24, 

respectively. 

In addition to the PC-PTSD (as noted above), men and women recruited from general medical 

and woman’s health clinics at a VA Medical Center completed the PCL-S.9

 Data were reported 

for a sub-sample of 167 participants. Both the PCL-S and the CAPS were completed in person 

with CAPS interviewers (trained psychologists) blind to the PCL-S score. The base rate of PTSD 

in the sample was 26%. Using a cut score of 48 on the PCL-S, sensitivity was determined to 

be 84% and specificity was 90%. PPV was determined to be 62% and NPV 94%. Positive and 

negative likelihood ratios were 8.40 and 0.18, respectively. Area under the ROC curve was not 

reported. 

In the first Lang et al. study, the authors examined the full PCL-C in women Veterans seeking 

care at a VA outpatient primary care clinic.54 Fifty-six percent of those eligible agreed to 

participate; 87% of those agreed to a follow up telephone interview, and 25% were randomly 

chosen to be interviewed using the PTSD section of the CIDI 2.1. The interview took place 

less than a month after the PCL-C was administered and interviewers were blind to the PCL-C 

results. The randomly selected subgroup differed from the unselected group on age, race, and 

marital status. Moreover, the mean score of the PCL-C of those interviewed was significantly 

lower than the scores of those who were not interviewed. The prevalence of PTSD was 31%. 

The diagnostic efficiency of the PCL-C as indicated by the area under the ROC curve was 0.89. 

With an identified optimal cut score of 28, sensitivity and specificity were 94% and 68%, PPV 

and NPV were 58% and 96%, and positive and negative likelihood ratios were 2.94 and 0.09, 

respectively. 

Abbreviated versions of the 17 item PCL-C (two items and six items) were examined by the 

same authors.49 The study population consisted of primary care patients from a VA clinic or 

a university-affiliated clinic. Those willing to participate completed the PCL-C and returned 

it by mail. Approximately 50% of those who agreed to participate were randomly selected 

for a diagnostic interview (CIDI 2.1). The interval between administration of the PCL-C 

and the CIDI 2.1 was not reported; interviewers were blind to the PCL-C score. It is unclear 

how representative the consented participants were of the population and how effective the 
23 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

randomization process was. The PCL-C was completed by 275 of 401 patients enrolled (65%); 

both the PCL-C and CIDI 2.1 were completed by 154 patients (37% of those enrolled). Using 

two items from the PCL the diagnostic efficiency (area under the ROC curve) was 0.88 and 

nearly identical to the AUC for the six item version (0.89). The sensitivity for the 2 item version 

using a cut score of 4 was slightly greater than for the 6 item version using a cut score of 14 

(96% versus 92%), however the specificity of the 2 item version was considerably poorer (58% 

versus 72%). Other values for the 2 item version were as follows: PPV 29%, NPV 99%, positive 

likelihood ratio 2.29, and negative likelihood ratio 0.07. Corresponding values for the 6 item 

version were 36%, 98%, 3.29, and 0.11. 

The most methodologically sound study of the PCL in primary care settings was conducted 

by Yaeger et al. in 2007.8 As described above, the authors enrolled Veterans who had made a 

primary care health care visit in a single year to one of four VA medical centers. As with the 

SPAN, the CAPS interviewers were blind to the PCL scores. The diagnostic efficiency of the 

PCL (version not specified) as determined by the area under the ROC curve was 0.88. At the 

author-identified optimal cut score of 31, the sensitivity was 81% with equal specificity. PPV and 

NPV were 35% and 97%, respectively, while positive and negative likelihood ratios were 4.31 

and 0.23. As noted on Table 5, increasing the cut score to 50, another commonly recommended 

cut score, improved false positive errors, but slightly increased the false negative rate by 3% -

more concerning for an instrument used for screening purposes. 

The PCL-C was another of the screening instruments examined by Freedy et al.11 As noted 

above, the study population included adults attending a family practice training clinic (11% of 

all patients approached or 53% of those consented participated in the study). The prevalence of 

PTSD was 32%. Overall diagnostic efficiency (area under ROC curve) was 0.93 for the PCL-C. 

At the author-identified optimal cut score of 43, sensitivity was 80%, specificity was 82%, PPV 

was 37%, NPV was 97%, positive likelihood ratio was 4.54, and negative likelihood ratio was 

0.24. 

In sum, with the exception of Yeager et al.,8 studies investigating the utility of the PCL as a 

screen for PTSD in medical settings using structured interviews as a gold standard are generally 

of limited quality. 

My Mood Monitor Checklist (M-3) 

The initial validation study of the M-3 was published in 2010.12 In the only, but well designed, 

study of the M-3, consecutive patients were approached in a university associated family 

medicine clinic. All were English speaking and mentally competent to consent to participate. Of 

those approached, 54% (n=723) agreed to participate. All who filled out the screening form were 

asked to be interviewed using the MINI by an experienced master’s level interviewer blind to 

screening status. Within one month of screening, 647 were interviewed (89%). Optimal screening 

thresholds were determined on 80% of the initial cohort and then validated on the remaining 

20%. The PTSD base rate was 6.3%. When compared with the MINI, the PTSD module (at the 

author-chosen cut score of 2) demonstrated a sensitivity of 88% and a specificity of 76%. The 

positive predictive value was 20% and the negative predictive value was 99%. Positive and 

negative likelihood ratios were 3.69 and 0.16, respectively. Area under the ROC curve was not 

reported. 
24 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

Provisional Diagnostic Interview – 4 Anxiety (PDI-4A) 

There was one study investigating the PDI-4A that met inclusion criteria.50 Participants were nonpsychotic individuals at a primary care clinic for a routine visit. PDI-4A results were evaluated 

against the SCID. Data were reported for 343 patients who completed a self-report screen and 

an interview by a primary care provider. The diagnostic interview (SCID) was administered by 

“trained raters” but whether the raters were blinded and the time interval between the PDI-4A 

and SCID were not reported. Only 17 (4.9%) participants within the sample met criteria for 

PTSD based on the SCID. Given this base rate, and with the PTSD and functioning items of 

the PTI-4A both rated at least “sometimes,” sensitivity was 71%, specificity was 72%, positive 

predictive value was 12%, and negative predictive value was 98%. The positive likelihood ratio 

was 2.54 and the negative likelihood ratio was 0.40. Area under the ROC curve was not reported. 

The authors also estimated the performance of the screening instrument in a clinic with an 8.6% 

prevalence; the estimated positive predictive value (PPV) was 18%, compared to the 12% PPV in 

the study sample. The strength of evidence for the screen is limited by the purposeful selection of 

participants based on likelihood of meeting diagnostic criteria for disorder of interest, as well as 

a non-disordered control group (i.e., a non-independent sample). 

Anxiety and Depression Detector (ADD) 

One study that examined the ADD met our inclusion criteria.51 Of 12,724 patients approached 

at university-affiliated primary care clinics, 7,738 (61%) completed the screening questionnaire, 

and 1,494 of the 7,738 people who participated screened positive for panic disorder, social 

phobia, PTSD, generalized anxiety disorder, or depression. From those who screened negative, 

1,107 patients were randomly selected. Diagnostic interviews using the CIDI by telephone, 

were completed by 569 (38%) of those who screened positive and 232 (21%) of the randomly 

selected negative screen patients (31% overall). The interviews were conducted by trained 

CIDI interviewers who were not blind to the ADD results. Of the 801 interviewed, 18.5% were 

diagnosed with PTSD with a significantly higher rate among non-whites and 38% of the sample 

screened positive for more than one disorder (24% vs. 16% of whites, p<0.01). The sensitivity, 

specificity, PPV, NPV, positive likelihood ratio, and negative likelihood ratio for the one PTSD 

item on the questionnaire (yes/no scoring) indicating possible PTSD were 62%, 83%, 48%, 89%, 

3.54, and 0.46. When a version of the questionnaire that included items related to panic disorder, 

social phobia, and PTSD was used to predict PTSD, the positive likelihood ratio decreased to 

1.47 (Table 5). The authors noted that the PTSD screen had a higher sensitivity for whites than 

non-whites (86% vs. 76%, p<0.01) but found no differences based on gender or age. Diagnostic 

status (OR=5.41, 95% CI 3.4 to 8.6) and comorbid depression (OR=1.95, 95% CI 1.3 to 3.0) 

were significant predictors of screening status for PTSD. 

Generalized Anxiety Disorder Scale (GAD-7, GAD-2) 

There was one study designed to evaluate the ability of the GAD-7 and GAD-2 to detect anxiety 

disorders, including PTSD, in primary care.14 Participants were enrolled from a research network 

of 15 primary care facilities in 12 states. Of the 2,149 patients whose responses were used to 

develop and validate the GAD-7, 1,654 (77%) agreed to a telephone diagnostic interview and 

965 of those (58%) were randomly selected. Interviews were conducted blind and within 1 

week of completing the screen. The interviews included the generalized anxiety disorder, social 
25 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

anxiety disorder, and PTSD sections of the Structured SCID. The interview sample had a slightly 

higher percentage of women (69% vs. 63%, p=0.003) and had a significantly higher GAD-7 

score (5.7 vs. 5.1, p=0.01) than those who were not interviewed. Age, race, and education were 

similar in the two groups. PTSD was diagnosed in 83 patients (8.6%). 

The sensitivity, specificity, and positive likelihood ratio values for the GAD-7 and GAD-2 

were best for generalized anxiety disorder. However, similar values were observed for other 

anxiety disorders (panic disorder, social anxiety disorder, and PTSD). At a GAD-7 cut-point 

of 8 or greater, the sensitivity, specificity, PPV, NPV, positive likelihood ratio, and negative 

likelihood ratio for identifying PTSD were 76%, 75%, 22%, 97%, 3.1, and 0.32, respectively. 

Corresponding values for the GAD-2 were 59%, 81%, 23%, 95%, 3.1, and 0.51. Because the 

intent of screens such as the GAD-7 and the GAD-2 is to detect the presence of any anxiety 

disorder, the authors ascertained the sensitivity and specificity by comparing patients with 

specific anxiety diagnoses with those who had no diagnoses.14 Despite the fact that the GAD-7 

and GAD-2 yield acceptable accuracy for the identification of multiple anxiety disorders, the 

false positive rate would be much higher if used to detect PTSD in a clinic setting. 
tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

characteristics 

Cut Points Used PTSD Base rate Sensitivity Specificity PPV NPV AUC LR+ LR

≥4 ≥5 ≥6 

32.1% 85% 

71% 54% 

76% 88% 93% 

31% 43% 49% 

98% 96% 94% 

0.88 3.58 

5.90 7.51 

0.20 0.33 0.50 

≥4 ≥5 

25% 85% 

76% 

84% 91% 

64% 74% 

94% 92% 

NR 5.31 

8.44 

0.18 0.26 

3 32.1% 85% 82% 38% 98% 0.92 4.72 0.18 2 3 4 

9% 

(estimated) 

91% 70% 47% 

84% 92% 98% 

37% 46% 71% 

99% 97% 95% 

0.89 2.89 

3.64 24.9 

NR NR NR 

3 

4* 

3 (women 

only) 

26% 

25.0% 

77% 54% 70% 

85% 93% 85% 

63% 71% 61% 

91% 86% 91% 

NR 5.13 

7.17 4.38 

0.27 0.49 0.36 

Bothered a 

little 

Bothered a lot 

9% 

(estimated) 

76% 36% 

79% 96% 

26% 49% 

97% 94% 

0.77 2.28 

9.9 

NR NR 

3 4 

32.1% 76% 

53% 

72% 85% 

25% 31% 

96% 93% 

0.84 2.67 

3.52 

0.34 0.56 

3 4 5 

Unclear 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 

3 4 5 

11.3% 77% 

75% 74% 

73% 78% 82% 

27% 30% 34% 

96% 96% 96% 

0.84 2.87 

3.41 4.09 

0.32 0.32 0.32 

26 
tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

Cut Points Used PTSD Base rate Sensitivity Specificity PPV NPV AUC LR+ LR

47 

30 40 50 

DSM-IV 

Symptom 

cluster 

Current 

PTSD: 6% 

Lifetime subsyndromal PTSD: 

9% 

100% 

60% 60% 60% 

83% 93% 99% 97% 

24% 33% 75% 60% 

100% 

97% 97% 97% 

NR 5.88 

8.57 60.0 20.0 

0.00 0.43 0.40 0.41 

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 

43 46 

32.1% 80% 

75% 

82% 88% 

37% 44% 

97% 96% 

0.93 4.54 

6.11 

0.24 0.29 

2 item 6 item 

17 item – 30 17 item – 50 

16% 96% 

92% 96% 54% 

58% 72% 59% 94% 

29% 36% 30% 62% 

99% 98% 99% 92% 

0.88 0.89 0.90 0.90 

2.29 3.29 2.34 9.00 

0.07 

0.11 

0.07 0.49 

28 30 40 50 

31% 94% 

78% 61% 39% 

68% 71% 94% 94% 

58% 55% 80% 75% 

96% 86% 82% 22% 

0.89 2.94 

2.69 

10.17 

6.50 

0.09 0.31 0.41 0.65 

48 26% 84% 90% 62% 94% NR 8.40 0.18 

ed 

30 45 50 

NA 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 

ed 

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 

27 
tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

Cut Points Used PTSD Base rate Sensitivity Specificity PPV NPV AUC LR+ LR

2 6.3% PTSD 

35% any 

disorder 

88% 76% 20% 99% NR 3.69 0.16 

PTSD item 

and functioning 

item both 

rated at least 

sometimes 

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

n 

PTSD item 

only (Yes/No) 

3 items 

(1 specific to 

PTSD) 

18.5% 18.5% 

62% 96% 

83% 35% 

48% 27% 

89% 97% 

NR 3.54 

1.47 

0.46 

0.11 

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 

egative predictive value; AUC = area under ROC curve; LR+ = positive likelihood ratio; LR- = negative likelihood ratio; NA = not applicable; NR = not reported 

ted the PC-PTSD; base rate in that group was 24.5% 

28
29 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

Comparative Studies 

There were four studies that compared screening instruments for PTSD (Table 6).8-11 Two of the 

studies, were given Level III evidence ratings.9,10 Although both Freedy et al.11 and Yeager et al.8 

compared the SPAN and PCL within their studies, one study only reported SPAN statistics up to 

a cut score of 4,11 which was not the optimal score in the second study.8 Nonetheless, the SPAN 

performed similarly in those two studies at that cut score despite differences in the study designs. 

In both studies, the PCL slightly outperformed the other instruments as evidenced by higher 

AUC statistics; however, the difference was likely not clinically meaningful. 

The PCL-S and PC-PTSD comparison in the Prins et al. study is limited by the use of a small 

convenience sample.9 The PCL-S outperformed the PC-PTSD as might be expected by a longer 

screening tool; however, the PC-PTSD was found to have good clinical utility with a positive 

likelihood ratio of 5.13 and a negative ratio of 0.27. 

The focus of the Gore et al. study was to identify a single item screening question that could be 

used by primary care providers as the first stage in a multi-step assessment process.10 Although 

both the PC-PTSD and PCL-C were given to the interview sample, the PCL-C was used for 

validation purposes only and no statistical comparisons of the single item screen to the PCL-C 

were made. As would be expected, the performance of the four item PC-PTSD was better than 

that of the single item SIP. 

Summary 

Although there is limited information regarding the implementation of PTSD screens in primary 

care settings, what information does exist suggests that such screening can be done efficiently 

and that it can have a positive impact on the clinical process and is acceptable to both patients 

and providers. Six of the studies employed samples of Veterans or military personnel, and all of 

these were evaluating PTSD-specific screening tools. Screening tools functioned in a clinically 

useful fashion per likelihood ratio statistics in both Veteran and community samples. However, 

no study included both sample types, so there is no information as to whether a particular screen 

is better able to detect PTSD in a Veteran or a community sample. Screen length, at least up to 27 

items, can be readily administered in most clinical settings prior to patients’ appointments. 

As can be seen in Table 4, only three of the fifteen studies were methodologically rigorous 

enough to warrant Level I ratings (i.e., they had 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). Two, from 

the same investigator, met criteria for a Level II rating. Four were rated Level IV due to lack of 

independence of diagnostic interviewers (i.e., not blind to screening status), selective sampling 

of interviewees or both. Studies with Level IV ratings often overestimate the performance of the 

screens they aim to evaluate, thereby limiting our confidence in the strength of their findings. 

Performance of the very brief screening tools for PTSD (those of one or two items) had the 

least discriminative power and had steep trade-offs in sensitivity and specificity between their 

limited response options resulting in no clear optimal cut score. Comparisons of the intermediate 

length screens were limited by the lack of comparative studies of sufficient rigor. Only one study 
30 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

directly compared intermediate length screens and that study suffered from uncorrected sampling 

bias and interviews not blind to screen outcomes. 

Of the intermediate screens, the PCL-6 item had the smallest evidence base, and was evaluated in 

only one study, which limits the generalizability of those findings. Across studies, there is weak 

evidence that the clinical utility of the Breslau scale and PC-PTSD are likely comparable, and 

some indication that both the Breslau scale and the PC-PTSD discriminate better than the SPAN. 

However, direct comparisons of these scales in a rigorously controlled study would be necessary 

to increase confidence in these findings. 

The PCL is the most widely studied of the screens, although only one study had sufficient rigor 

to warrant a Level of Evidence rating of I8 and two studies by the same author were rated as 

Level II.49,54 Across studies, using 50 as a cut score was associated with negative likelihood ratios 

of 0.5 or greater, indicating that the post-screen odds of not having PTSD given a negative screen 

were no better than what might be assumed given population prevalence rates. That is, there 

would a significant risk of false negative rates, indicating that this often used cut-score is too 

high even for a Veteran population. 

The optimal cut-score for the most commonly used screen, the PTSD Checklist (PCL), 

varied across clinical settings according to differences in PTSD prevalence rates and sample 

compositions. Because the 17 item screen has a more graded scoring distribution, optimal 

cut-scores could be more precisely determined for a given clinical setting. In contrast, across 

studies, the intermediate length screens all had sharp drop-offs just under the recommended cutscores. This suggests that the optimal cut score of an intermediate length screen is less likely 

to vary across populations and settings, and can therefore be more easily adopted by different 

healthcare systems. However, it also means that there is a steeper trade-off between sensitivity 

and specificity in cut-scores that differ only by one point, which may have significant policy and 

resource implications. 

We also examined the performance of five scales that screened for multiple conditions, including 

PTSD (ADD, PDI-4A, M-3, GAD-7, GAD-2). None of these more general screens were assessed 

in Veteran samples. Of the general screens, only the M-3, GAD-7, and GAD-2 were evaluated 

with sufficient rigor to evaluate their potential utility to screen for PTSD. The GAD-7 was 

superior to the GAD-2 in terms of its accuracy in detecting PTSD among primary care patients.14 

The likelihood ratios for the detection of PTSD, both positive and negative, for the M-3 indicated 

that the M-3 performed better than the GAD-7 at identifying probable cases of PTSD.12,14 
tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

ore than One Screening Instrument 

n Cut Score PTSD Base rate Sensitivity Specificity PPV NPV AUC (SE or 95% CI) LR+ LR

SD 3 

32.1% 

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

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

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

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

SD 

2 3 9% 

(estimated) 

91% 70% 

84% 92% 

37% 46% 

99% 97% 

0.89 

(0.84-0.94) 

2.89 3.64 NR 

 a little 

a lot 

76% 36% 

79% 96% 

26% 49% 

97% 94% 

0.77 

(0.70-0.84) 

2.28 9.90 NR 

SD 3 

26% 

77% 85% 63% 91% NR 5.13 0.27 

S 48 84% 90% 62% 94% NR 8.4 0.18 

 

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 

ot 

d) 

31 43 

81% 67% 

81% 90% 

35% 47% 

97% 96% 0.88 (0.018) 

4.31 6.97 

0.23 0.36 

= high quality to IV = marginal quality (see Appendix C)

ctive value; NPV = negative predictive value; AUC = area under ROC curve; LR+ = positive likelihood ratio; LR- = negative likelihood ratio

 for non-random sampling, therefore LR parameters cannot be directly determined. 

31
32 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

KEY QUESTION #3. What information is there about the 

implementability (e.g., ease of administration, patient satisfaction) of 

PTSD screening tools in primary care clinics? 

Although not all studies reported the time it took for patients to complete the screen that was the 

focus of the study, those that did indicated that briefer screens took no more than five minutes,13 

and the longest screen (27 item M-3) was reported to have taken patients only five to ten minutes 

to complete.14 This suggests that none of the screens posed a significant time burden when used 

in a primary care setting. 

Only one study conducted a process evaluation of screen implementation in their clinics.12 

Both patients and providers were administered questionnaires following the post-screening 

medical appointment regarding: 1) the logistical aspects of screen administration/review and 2) 

whether there was any change in the patient-provider interaction in the appointment immediately 

following screening. In terms of screen administration, only 1% of patients reported that they 

had insufficient time to complete the 27 item screen prior to their appointment. Of the clinicians 

who reviewed the screen results, 83% reported that they were able to review the results in under 

one minute. Most patients (70%) talked to their providers about their feelings and symptoms and 

63% felt that the screening process facilitated that discussion. Of patients who were eventually 

diagnosed with a mental health condition, 75% felt that the screening process facilitated 

discussion of mental health issues with their providers. Most primary care providers (80%) 

reported that reviewing screen results facilitated discussion of feelings and emotional symptoms 

with their patients, and none found it too cumbersome. 

Summary 

Only three studies evaluated logistical or experiential aspects of using a screening tool in 

clinical practice. There was no evidence regarding readability, speed of administration, ease of 

interpretability, or patient satisfaction for the remainder of the instruments and no comparative 

studies of these implementation issues. 

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? 

There were six studies that evaluated whether a screening tool demonstrated demographicdependent variation in screen validity or utility, and only four of the six studies did so 

systematically. All four studies that evaluated potential differences systematically examined screen 

performance characteristics for men vs. women. Only two examined the potential modifying effect 

of age or race (Table 7);8,51 no studies examined the effect of specific psychiatric comorbidities. 

Gore (2008) used demographic based propensity scores to compare the odds of PTSD diagnoses 

within response strata and found little evidence that demographic factors considered collectively 

affected screen performance; however, the authors note that with a sample of fewer than 

300 people that they were insufficiently powered to adequately assess differences in screen 

performance between subgroups.10 Consequently, this adds little to the evidence base regarding 
33 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

potential demographic differences in screen performance. Similarly, Kimerling (2006) reported 

that the operating characteristics (i.e., sensitivity and specificity) for men and women were 

“similar” for the Breslau scale, but since no comparative statistics were presented, this study was 

also not included in the review of evidence for Key Question #4.13 

Of the studies that systematically examined gender differences in screen utility, findings were 

mixed. Freedy et al. reported that the PCL, Breslau, and PC-PTSD (but not the SPAN) were 

better able to detect PTSD in men than in women across all indices (Table 7).11 Although this 

did not impact the optimal cut scores recommended for the Breslau scale or the PC-PTSD, they 

found that the optimal PCL cut score for men was different than for women (46 vs. 43). Given 

how close these cut scores are, it is unlikely that the utility of the PCL would differ for men vs. 

women in a clinical setting. More importantly, the sample used in the study was significantly 

different from that of the patient population from which it was drawn in that patients who 

were female and those who were white were more likely to participate in the study. Since no 

adjustments were made for this selection bias, it is unclear how this might have affected the 

results. Prins (2003) similarly found that the PC-PTSD was better able to detect PTSD among 

men vs. women Veterans, but this study also suffered from significant methodological limitations 

and, additionally, was based on a fairly small convenience sample.9 

In contrast, Means-Christensen (2006) reported that the performance of the ADD was comparable 

for men and women, but that it was less able to discriminate cases vs. non-cases among non-whites 

than among whites (76% vs. 86%).51 Unfortunately, no other statistical information was provided, 

and it is unclear whether this difference has meaningful clinical significance. 

In the most methodologically rigorous study to examine demographic differences in screen 

performance, Yeager (2007) found that both the SPAN and PCL performed similarly for men as 

for women Veterans.8 Although there was no primary effect of race in performance of either screen 

in this study, the performance of the PCL (but not the SPAN) was significantly different for white 

vs. African American Veterans among the younger cohort. Specifically, they examined potential 

race differences in AUCs for the SPAN and PCL within three age strata and found significant race 

differences for the PCL in the youngest (≤ 49 yr) cohort, but not in the older groups (50-64 yr or 

65 yr +). For those Veterans younger than 50, the PCL was a much better discriminator of PTSD 

among white Veterans (AUC=0.99), than among African American Veterans (AUC=0.81). 

Although PTSD is associated with significant psychiatric comorbidity, there were no studies that 

examined whether the utility of a screening tool was affected by the presence of other mental 

health disorders. 

Summary 

There is very limited evidence regarding potential variation in the performance of screening tools 

by age, gender or race, and no information about how specific psychiatric comorbidities might 

affect the performance of the screening tools. Of the studies that were adequately powered to 

determine whether screen utility varied by demographic or clinical factors, only one was of high 

quality. Given this, our findings must be considered provisional. 

There is weak evidence that the clinical utility of the PC-PTSD differs depending on patients’ sex, 

and no information if it functions equally well among patients of different ages or racial, ethnic or 
34 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

socioeconomic backgrounds. For the Breslau scale the findings are similar, but were reported in only 

one study of limited quality. There is weak evidence that the performance of the SPAN does not vary 

by patient gender, age or race. The PCL appears to function comparably for men as it does for women, 

but there is weak evidence that Veterans who are younger than 50 and African American may not be 

identified as having PTSD as accurately by the PCL than Veterans who are white and/or older. 

There was no information regarding the impact of psychiatric comorbidity on the performance 

characteristics of any of the screening tools. 
tress Disorder (PTSD) in Primary Care: A Systematic Review Evidence-based Synthesis Program

ating effect of Demographic Factors on Screen characteristics 

 

Cut 

Score 

M W 

PTSD 

Base Rate 

Sensitivity 

M W 

Specificity 

M W 

AUC 

M W 

LR+ 

M W 

LRM W 

D 3 3 

32.1% 

M: 20.0% 

W: 35.8% 

100% 83% 87% 83% * 7.69 4.88 0.00 0.20 

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

46 43 86% 79% 95% 81% * 17.2 4.11 0.15 0.27 

 

4 4 100% 83% 78% 77% * 4.55 3.61 0.00 0.22 

20.4% 

Whites: 15.5% 

Non-whites: 23.9% 

M: 19.1% 

W: 18.2% 

NR Whites: 86% Non-whites: 76% NR NR NR 

D 3 

24.5%^ 

M: 25% 

W: 24% 

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

5 6 11.3% Blacks:13.5%; 

Whites:10.0% 

M: 11.9% 

W: 9.1%, 

NR NR No gender or race differences NR NR 

t 

) 

31 43 NR NR No gender or race differences NR NR 

Ratio; AUC = area under ROC curve; NR = Not reported 

= high quality to IV = marginal quality (see Appendix C) 

alues not reported 

35
36 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

SUMMARY AND DISCUSSION 

SUMMARY OF EVIDENCE BY KEY QUESTION 

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)? 

Screening tools that focus on evaluating traumatic experiences are not likely to be clinically 

useful given the high population prevalence of traumatic events and the much lower conditional 

probability of developing PTSD.3,15,38 Consequently, all screening tools reviewed in this report 

were those that evaluated PTSD symptoms. There is a limited number of studies examining 

screening tools for PTSD symptoms in primary care that examined their utility using “gold 

standard” structured diagnostic interviews. Most of these studies had significant methodologic 

limitations which limits the strength of the evidence and our confidence in these findings. 

Common limitations included non-random screening, selective recruitment for diagnostic 

interviews, and diagnostic interviews conducted with knowledge of screen results. Half of 

the studies used Veteran or military samples, and in these samples the following tools were 

evaluated: PCL (and its abbreviated versions), PC-PTSD, Breslau scale, SPAN, and SIP. 

There were twelve screening tools that were used to detect PTSD, and validated using a gold 

standard structured diagnostic interview, in a primary care setting. Three of the screening tools 

were truncated versions of longer screens also included in the review. Five of the screening tools 

were used to screen for multiple disorders. All screens were self-administered paper and pencil 

screening tests, and ranged from one to twenty-seven items. Response options for screen items 

ranged from dichotomous scoring (yes/no) to 5 point graded frequency or severity scales. 

Key Question #2. What are the psychometric properties and utility of the 

screening tools (sensitivity, specificity, likelihood ratios, predictive values, area 

under curve, reliability)? 

Of the screens for which area under the curve (AUC) statistics were reported, AUCs ranged from 

0.75 to 0.93. No AUC statistics were available for the PDI-4A, ADD or M-3. Performance of the 

moderate length screens (PC-PTSD, Breslau scale, SPAN) were comparable, though there was 

very weak evidence that the SPAN performed less well than the PC-PTSD or the Breslau scales. 

However, there were no high quality studies examining the performance of the PC-PTSD in a 

primary care setting. 

The optimal cut-score for the most commonly used screen, the PTSD Checklist (PCL), 

varied across clinical settings according to differences in PTSD prevalence rates and sample 

compositions. Because the 17 item screen has a more graded scoring distribution, optimal 

cut-scores could be more precisely determined for a given clinical setting. In contrast, across 

studies, the intermediate length screens all had sharp drop-offs just under the recommended cutscores. This suggests that the optimal cut score of an intermediate length screen is less likely 

to vary across populations and settings, and can therefore be more easily adopted by different 

healthcare systems. However, it also means that there is a steeper trade-off between sensitivity 
37 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

and specificity in cut-scores that differ only by one point, which may have significant policy and 

resource implications. 

Screens not specific to PTSD but for which there was a study that evaluated the ability of the 

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

exclusively. In some clinical settings, this might be preferable, as “false positives” on non-PTSD 

specific screens may reflect psychiatric symptomatology requiring further evaluation. 

Key Question #3. What information is there about the implementability (e.g., ease 

of administration, patient satisfaction) of PTSD screening tools in primary care 

clinics? 

Only two studies evaluated logistical or experiential aspects of using a screening tool in 

clinical practice. One of these evaluated the time patients took to fill out the longest screen and 

determined that the time investment was only between 5-10 minutes and could be completed 

prior to the start of the medical appointment. Only one study evaluated the impact of screen 

use on the process of care and found that it facilitated discussion of mental health issues with 

primary care providers. There was no evidence regarding readability, speed of administration, 

ease of interpretability, or patient satisfaction for the remainder of the instruments and no 

comparative studies of these implementation issues. 

Only three studies reported the time it took for patients to fill out the screening instruments, 

and only one systematically explored patients’ and providers’ experiences of screening tool 

implementation.12 In the study that evaluated implementation of screening, both patients and 

providers reported that pre-appointment mental health screening facilitated discussion of mental 

health issues in the subsequent primary care encounter. Most providers (80%) reported that the 

screen was helpful in their interactions with their patients. The authors reported that this 27 item 

screen of multiple psychiatric conditions common seen in primary care patients took patients 

only 5 minutes to complete, and that only 1% of patients felt that they had insufficient time to 

complete it prior to their appointment. 

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? 

There was very limited information regarding the modifying effect of patient demographic 

characteristics or clinical comorbidities on screen performance. 

Of the studies that were available, there was weak evidence that the clinical utility of the PCPTSD may be better for men vs. women, and no information as to whether its performance 

characteristics vary as a function of patient age, race, or ethnicity. Similarly, there is weak 

evidence that the performance of the SPAN does not vary by patient gender, age, or race. The 

PCL appears to function comparably for men as it does for women, but there is weak evidence 

that Veterans who are younger than 50 and African American may not be identified as having 

PTSD as accurately by the PCL than Veterans who are white and/or older. There was no evidence 

of screen performance characteristics among other minority groups. More information is needed 

as to whether screens, particularly the PC-PTSD, work equally well regardless of patient age, 
38 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

gender, race, or ethnicity so as to ensure that VA’s screening program does not contribute to 

treatment disparities. 

There was no information regarding the impact of specific psychiatric comorbidities on the 

performance characteristics of any of the screening tools in the primary care setting. 

LIMITATIONS 

There are a limited number of studies examining screening tools for PTSD in primary care that 

examined their utility using “gold standard” structured diagnostic interviews. Most studies had 

significant methodologic limitations which limits our confidence in these findings. Confidence 

in these findings is also somewhat limited because of variation in what studies used as a “gold 

standard.” Although all “gold standard” interviews were based on the same diagnostic criteria, 

the specific interviews used, the scoring rules for the interviews, and the skill of the interviewers 

differed across studies. This variation may have subtly altered the performance characteristics of 

the screens across studies. 

The appropriate balance of sensitivity and specificity of a screening tool depends on the purpose 

of the tool and the health care policy underlying its use. Consequently, the effectiveness of a 

particular screening tool depends on the precision with which the cut score is optimized given 

the population prevalence of the target condition and the intent of the screening program. This 

contextually-specific balance could not be assessed in the current review. 

CLINICAL CONSIDERATIONS 

Use of PTSD screening tools can improve detection of PTSD among primary care patients. 

While widely implemented, no randomized controlled trials evaluating the benefits and harms 

of screening and subsequent treatment of PTSD have been conducted. Such studies, particularly 

among individuals seen in primary care clinics, are needed. 

The primary potential harm to the patient of screening for PTSD is the potential for misdiagnosis 

which could lead to labeling and potential harms of treatment. The principal harm to the health 

care system is that limited mental health resources become used to evaluate patients with 

potential PTSD diagnoses, some of whom are subsequently found not to have PTSD, leaving 

fewer resources available to provide treatment. On the other hand, there is also potential harm in 

not screening for PTSD and thereby missing cases that may benefit from detection and treatment. 

Not only is there a missed opportunity to treat an often debilitating illness that causes significant 

suffering, but there may also be a risk of allowing untreated illness to contribute to secondary 

medical and mental health problems. Determining the most useful instrument and the optimal cut 

score for that instrument would help to balance these potential harms. 

Six studies used Veteran samples exclusively. Two enrolled only female Veterans. Four evaluated 

some version of the PCL, two evaluated the PC-PTSD, and the SIPS, Breslau scale, and SPAN 

were each evaluated in single studies. The evidence suggests that the PCL, PC-PTSD, Breslau 

scale and SPAN all perform at least as well in Veteran as in non-Veteran samples. Given the 

limited number of studies evaluating each screening tool and the lack of studies comparing the 
39 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

performance of a screen in samples with and without Veterans, there was insufficient evidence 

to determine whether screens were better at detecting possible PTSD among Veterans vs. nonVeterans. 

Currently, the VA uses the PC-PTSD, which is short, easy to administer and has good 

psychometric properties. As with many shorter screens, the PC-PTSD has a steeper gradient of 

endorsement between cut-scores than the PCL, which may result in either an over- or undersensitive screening tool depending on the cut-score selected and the population in which it is 

used. For longer screens, such as the PCL, cut-scores can be more carefully “calibrated” to the 

target population. However, the PCL also contains many items that may be endorsed by Veterans 

who have mental health concerns other than PTSD. Because of this, the specificity of the PCL 

is comparable to that of the more general GAD-7 when cut-scores lower than the mid-forties 

are used; however, use of a higher score lowers the screen’s sensitivity. Whether use of the PCL 

rather than the PC-PTSD would improve screening accuracy is unknown. 

An alternative would be a two-staged screening approach such as that used by two of the studies 

in the review. For example, in the study by Meltzer-Brody (2004), patients were first screened 

for traumatic experiences prior to receiving the SPAN.54 However, the performance of the SPAN 

was not appreciably better than in other studies without the traumatic experiences inquiry. A twostage screening approach was also used by Gaynes (2010).12 In that study, symptom scales of 

the M-3 were only scored if patients endorsed either functional impairment or suicidality items. 

Perhaps this is the reason that the likelihood ratios for the M-3 tended to be better than those for 

other very short screens. 

Within the coming year, the new Diagnostic Statistical Manual for mental disorders will be 

released (www.dsm5.org/Pages/Default.aspx). The proposed diagnostic criteria for PTSD 

overlap considerably with those in the currently used DSM-IV, but differ sufficiently that the 

performance of PTSD screening tools such as those covered in this review will need to be 

evaluated relative to the new criteria. 

RECOMMENDATIONS FOR FUTURE RESEARCH 

1.	 The new DSM-5 diagnostic criteria for PTSD are soon to be released. Although it is unlikely 

that the overall performance of the screening tool used by VA (PC-PTSD) and other tools 

reviewed in this report will be appreciably altered given the new diagnostic criteria, the 

importance of PTSD detection and treatment in VA requires a high degree of confidence 

in tools used in clinical care of Veterans with PTSD. Accordingly, the PC-PTSD should be 

validated against the DSM-5 PTSD criteria. 

2.	 VA has worked to minimize healthcare disparities. Because there is weak and inconsistent 

evidence of possible variation in screen performance related to patient characteristics, more 

information is needed to determine whether screening tools for PTSD work equally well 

regardless of patient age, gender, race, ethnicity. 

3.	 Although psychiatric comorbidity is common among Veterans with PTSD, there is no 

information about whether the performance of mental health screening tools, such as the PC-
40 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

PTSD, are altered in the presence of specific psychiatric comorbidities (e.g., traumatic brain 

injury). 

4.	 There are no studies examining the impact of mental health screening on the primary 

care encounter within the VA system, and only one implementation study was done in a 

community setting. It would be helpful to have more information about how PTSD screens 

can be best be integrated into clinical practice. 

5.	 The success of a screening program depends on whether identification of the target condition 

in the population improves the outcome of those who have the condition.3,5 As noted in the 

IOM report,3

 this is assumed to be true for PTSD but has never been proven. It would be 

helpful to know if implementation of screening for PTSD has had a positive impact on the 

mental and physical health of the VA population, as well as the financial and opportunity 

costs to the VA health care system of PTSD screening implementation. To adequately address 

this important clinical and research gap, a randomized controlled trial or methodologically 

sound comparative effectiveness trial of PTSD screening of Veterans in primary care settings 

is needed. 
41 

Screening for Post-Traumatic Stress Disorder (PTSD) 

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

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screening test for post-traumatic stress disorder. Psychiatry Res. 1999;88(1):63-70. 

45.	 Davidson JR, Book SW, Colket JT, et al. Assessment of a new self-rating scale for posttraumatic stress disorder. Psychol Med. 1997;27(1):153-60. 

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validity, and diagnostic utility. San Antonio , TX: Annual Convention of the International 

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47.	 Andrykowski MA, Cordova MJ, Studts JL, Miller TW. Posttraumatic stress disorder 

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Checklist-Civilian Version (PCL-C) as a screening instrument. J Consult Clin Psychol. 

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48.	 Bliese PD, Wright KM, Adler AB, Cabrera O, Castro CA, Hoge CW. Validating the 

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49.	 Lang AJ, Stein MB. An abbreviated PTSD checklist for use as a screening instrument in 

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instrument assessing 5 additional common anxiety-related diagnoses in adult primary 

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51.	 Means-Christensen AJ, Sherbourne CD, Roy-Byrne PP, Craske MG, Stein MB. Using 

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18. 
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Screening for Post-Traumatic Stress Disorder (PTSD) 

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52.	 Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized 

anxiety disorder: the GAD-7. Arch Int Med. 2006;166(10):1092-7. 

53.	 Dobie DJ, Kivlahan DR, Maynard C, et al. Screening for post-traumatic stress disorder in 

female Veteran’s Affairs patients: validation of the PTSD checklist. Gen Hosp Psychiatry. 

2002;24(6):367-74. 

54.		 Lang AJ, Laffaye C, Satz LE, Dresselhaus TR, Stein MB. Sensitivity and specificity of 

the PTSD checklist in detecting PTSD in female veterans in primary care. J Trauma 

Stress. 2003;16(3):257-64. 

55.	 Meltzer-Brody S, Hartmann K, Miller WC, Scott J, Garrett J, Davidson J. A brief 

screening instrument to detect posttraumatic stress disorder in outpatient gynecology. 

Obstet Gynecol. 2004;104(4):770-6. 

56.	 Walker EA, Newman E, Dobie DJ, Ciechanowski P, Katon W. Validation of the PTSD 

checklist in an HMO sample of women. Gen Hosp Psychiatry. 2002;24(6):375-80. 
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 

check if Background paper 

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 N 

Time b/w screen and dx interview: ___________ months

 Is it considered "concurrent"? Y N 

Did whole/ random sample have dx interview? 

Whole Random (%?) 

 Random Group Different from Total Group? Y N 

Were diagnostic interviews conducted blindly? Y N Was screen cut score confirmed on a separate or split sample? Y N Was relevant clinical data available for interpretation of screen (like would be in clinic)? Y N 

Were 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) 

47
48 

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. 1. Thank you 

ars to be a literature synthesis of the feasibility and diagnostic accuracy of PTSD 2. We have modified the statement of the objective of the 

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

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 3. We have modified KQ1 and 2 as suggested. We agree that 

stics reviewed, and for KQ#2, list the specific psychometric properties of interest. the implementation processes of screening would have best 

lity issue fits better in KQ#2 than it would in KQ#1 or as a separate question, been covered in a separate question and have done so to 

eparately on page 18, and does not map to the levels of evidence framework improve clarity of the findings. 

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

vels of evidence need to be clearer, especially in the discrimination of levels II 4. The descriptions of levels of evidence were taken from 

instructions for preparing a Rational Clinical Examination article. 

ng for level III, “patients who both underwent and generated definitive results on 4a. We agree that the shortcoming for Level III is verification 

 application of the gold standard” is not clear. I am wondering if this is an allusion bias – selection of patients for verification rather than 

-up or administration of one part of the testing protocol is dependent of results inclusion of consecutive patients. We also agree that the 

col (e.g. administering the gold standard first, and then the screen to all cases section of text was mistakenly repeated in the summary 

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 4b. We agree that selection bias is one of the main 

r other than eligibility for screening that would result in a non-representative differences between Level II and Level III studies. We have 

sults do not reliably over estimate accuracy, as stated on p. 48. The effect of clarified our application of these ratings in Appendix F. 

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, 

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 
51 

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

RESPONSE 1. We have addressed these points in the report. 

e clearly described through the three key questions: 1a. We included only studies done in the United States 

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

ation) in primary care clinics? 

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

samples. It may be that a given screen performs better in 

roperties and utility of each of the screening tools differ according to age, gender, one population vs. another or for PTSD associated with one 

other comorbidities? type of trauma vs. another; however, given the absence 

creening tools used and validated in primary care. of evidence this would be purely speculative on our part. 

not always logical, accurate or clearly described Available evidence suggests that PTSD is under-recognized 

in non-Veteran primary care settings (c.f. Graves, 2011) 

e of the US were excluded was not provided. Discussion of how Veterans in VA suggesting that, from a healthcare system perspective, 

ns in primary care was not addressed. Perhaps there are reasons why screening screening for PTSD might also facilitate further mental health 

differ in VA versus civilian primary care. Greater rationale for the inclusion/ evaluation and treatment among non-Veterans assuming 

ed. 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 

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

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

disorders or multiple anxiety disorders if there was a study 

Q) 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. 1c. We excluded studies with fewer than 50 patients in the 

gold standard interview. 

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

screening population. 

n that gold standards are equivalent. This may not be an accurate assumption. 1d. We identified the gold standard diagnostic tool used in each 

study and noted where scoring for the gold standard differed 

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

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

from the scoring method described in Table 1. We agree that 

g rules are rarely presented in studies, but the importance of this should not be 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. 
54 

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 We are familiar with the Kimerling (2006) study but did not 

ictive Behaviors 31(11). include it in this review because the study sample was that of

patients who were receiving substance abuse treatment andnot 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 aprimary 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 consistedof Veterans who served in the military after to September 11, 2001. According to the authors, “Eligible Veterans were recruited through mailings, advertisements, and clinicianreferrals”. 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 didnot 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 facilitatedetection of a condition (in this case PTSD), not to identifyit 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 earlyin the course of the illness as you note. The concern you raise about too many patients having positive screens andthe 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

RESPONSE 

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 Thank you. We have corrected the typos and clarified the 

by additions to the text and tables. It also needs to be cleaned for typos, some additional studies cited in the paragraph on the PC-PTSD. 

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 1. Thank you for pointing this out. We have now included an 

e the crosswalk between the QUADAS evaluation questions in Appendix B, additional table in our appendices (Appendix F) that clarifies 

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

DAS criteria and the QUADAS questions in Appendix B. the overall Level of Evidence ratings. 

ntativeness is about whether the full range of patients to whom a test would be Now that we have included the crosswalk table in the 

. It appears that sample representativeness—and not spectrum inclusiveness— report, we hope that study ratings have been clarified. The 

tudies for the report. The fact that a study had one site is mentioned in a couple Andrykowski study was rated as a Level IV because the 

vant to evaluating quality according to the QUADAS or RSES systems. diagnostic interviews were not conducted blind to patient 

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

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 We have corrected the typo. 
56 

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? 

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. 

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. 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 1. We agree that evaluating the impact of screening 

e., access to care measure). And, with the new OEF4 performance measure, it implementation on service utilization is an important area that 

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

content validity and predictive validity of PTSD screens will need to be evaluated 2. We agree and have now commented on the upcoming 

a. DSM-5 modifications. 
57 

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

RESPONSE 

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. 
58 

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 

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

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

I. No (significant differences in gender 

and race from clinic population during 

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) 

years 

83% women 65% white, 32% African American, 3% other 45% married 24% high school education or less II. 100% of those screened 

recruitment period) 

II. Fair (telephone, experienced survey 

interviewers) 

III. Yes IV. 79% of those who were contacted for 

interview 

V. No Level of Evidence: IV 

eterans; other screen sample characteristics I. Veterans I. Yes 

R Mean age = 52 years (range 22 to 85) 

61% women 

II. Good (in person, trained 

psychologists) 

37 of 258 approached (92%) were eligible and 

ompleted Breslau scale 

68% white, 18% African American, 5% Hispanic, 5% 

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

44% married 59% employed 

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

completed Breslau scale and were eligible 

II. 57% returned for interview (significantly higher 

percentage of women in participants vs. nonparticipants) 

V. Yes Level of Evidence: III 

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

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

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

I. Unclear; oversampled patients who 

responded “bothered a little” and

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); 

years 

61% male II. 93% of those who consented to interview 

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

“bothered a lot” to single screening question 

II. Fair (unclear if in-person or 

telephone, trained mental health professionals) 

III. Yes IV. 6.6% of those screened V. Yes Level of Evidence: III 

nclear if all invited to participate in 2nd phase 
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 

I. Mean age = 52 years* 34.0% male 

I. VA sample from 1 VA in California 

with 50% response rate

alifornia; required to have no gross cognitive 

mpairment and English speaking 

umber approached for screening not reported 

33% married 43% unemployed 27% high school education or less II. 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 

II. Good (in-person, trained 

psychologists) 

III. Yes IV. 50% V. Yes Level of Evidence: III 

Mean age = 34 years I. Mean age = 35 years I. Women presenting for annual exam 

% female 

white, 49% African-American 

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

at ob/gyn clinic; n=32 completed interview 

(n=88/292) reported a traumatic event and 

ompleted the SPAN 

6% (292/384 approached) 

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

II. Good (in-person, psychiatrist) III. Not reported IV. 11% of total sample V. Yes Level of Evidence: III 

Group 1 - Veterans (male & female) 

4.1% (888/1198) 

I. 79% male 63% white 

I. Random sample from 4 medical 

centers in southeastern US 

Group 2 - Female Veterans (oversample) 

9.2% (191/276) 

II. 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) 

II. Good (telephone, trained clinicians) III. Yes, within 2 months IV. 57% of total sample V. Yes Level of Evidence: I 

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) 
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 I. Same as screen sample I. Women in remission from breast 

Caucasian, 4% African-American, 1% Asian- 

merican II. Same as screen sample cancer II. Fair (telephone, doctoral-level 

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 

NOTE: participants completed PCL-C and SCID NP 

PTSD during one telephone interview 

students) 

III. Yes IV. 100% of those consenting; 77% of 

those invited 

V. No Level of Evidence: IV 

Mean age = 48 years 

% female 

I. Same as screening I. Female Veterans (1 site) 

II. Good (in-person, clinician) 

white, 9% black, 15% other married high school education or less 

6% of those randomly selected for telephone 

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

282/2545) 

II. Same as screening NOTE: participants were older and more often 

divorced than eligible non-participants 

III. Yes IV. 11% of total sample V. Yes Level of Evidence: III 

rimary care from VA or university-affiliated 

inic 

I. Mean age = 48 years 48% male 

I. Primary care clinics (VA or universityaffiliated)

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 

57% Caucasian 53% married 23% high school education or less II. 186/401 completed CIDI (46% [44% reported in 

text]) 

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

reported in text]) 

II. Fair (telephone, licensed 

psychologist or research assistant) 

III. Not reported IV. 38% of enrolled V. Yes Level 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) 

I. Mean age = 53 years 82% Caucasian, 12% African-American; 6% other/ 

I. Female Veterans (1 site) II. Fair (telephone, CIDI designed for lay 

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

E: 25 of 419 survey packets were undeliverable 

unknown 

39% married 80% with 9-15 years of education NOTE: interviewed women were older, more likely 

Caucasian, more likely divorced, separated, or 

interviewers) 

III. Yes, within 1 month IV. 26% (randomly selected, n=49) V. Yes 

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) 

Level of Evidence: II 

Mean age = 41 years 

% female 

I. Not reported I. Women only; random sample of 

HMO members 

Caucasian; 6% African-American; 8% Asian, II. Overall 21% (261 of 1225 who returned II. Unclear (Not reported if face-to- 

% Hispanic, 1% Native-American 

married college graduates 

Adjusted return rate of 62% (1225/1912 

ligible) 

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 

face or telephone; qualifications of administrators not reported) 

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

maltreatment; 46% of sample without maltreatment 

V. Not reported Level of Evidence: III 

to interview (or 46% of sample) 

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

I. Mean age = 45 years 71% female 

I. One family medicine clinic, sample 

similar to overall clinic 

nd attending primary care academic family 

medicine clinic) 

4% of those approached (n=723) 

67% white, 28% black, 5% other 49% married 55% high school education or less 21% unemployed II. complete date for 89% (647/723 who consented 

II. Fair (In person or telephone, 

research assistant) 

III. Yes, within 30 days IV. 89% V. Yes Level 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% female 86% white 48% married II. 78% (343/440) 

I. One primary care clinic II. Fair (telephone, “trained rater”) III. Not reported IV. Not reported V. Not reported Level of Evidence: IV 

ot reported I. Mean age = 42 years I. More interviews among positive 

62% female screens 

1% of patients approached (7738/12724) 65% Caucasian, 16% African American, 10% II. Fair (telephone, trained CIDI 

Hispanic, 4% Asian, 5% other interviewers) 

III. Yes, median of 14 days 

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 

IV. 38% of those that screened positive; 

21% of random sample of those that screened negative 

V. No Level of Evidence: IV 

ot reported I. Mean age=47years I. Yes-15 primary care sites in 12 states 

2% (2740/2982) completed questionnaire 

69% female 81% non-Hispanic white, 7% black, 9% Hispanic, 

(part of research network) 

II. Fair (telephone, 1 of 2 mental health 

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

sed for development and validation of the 

GAD-7 

3% other 

65% married 34% high school education or less II. 77% (1654/2149) agreed to interview; 58% 

(965/1654) randomly selected for interview 

professionals) 

III. Yes, approximately 1 week IV. 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

CIFIC ASSOCIATION OF RCE LEVEL OF EVIDENCE RATINGS TO 

TINGS 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