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The Rational Clinical Examination
August 4, 2015

Does This Patient Have Posttraumatic Stress Disorder?Rational Clinical Examination Systematic Review

Author Affiliations
  • 1US Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota
  • 2Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota
  • 3University of Minnesota Medical School, Minneapolis
  • 4US Department of Veterans Affairs Evidence-based Synthesis Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
  • 5Division of General Internal Medicine, Duke University Medical School, Durham, North Carolina
  • 6Mid-Atlantic Mental Illness, Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
  • 7Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
  • 8Department of Mental Health,Durham Veterans Affairs Medical Center, Durham, North Carolina
  • 9Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Israel
  • 10Gertner Institute for Health Policy and Epidemiology,Sheba Medical Center, Tel Hashomer, Israel
JAMA. 2015;314(5):501-510. doi:10.1001/jama.2015.7877

Importance  Posttraumatic stress disorder (PTSD) is a relatively common mental health condition frequently seen, though often unrecognized, in primary care settings. Identifying and treating PTSD can greatly improve patient health and well-being.

Objective  To systematically review the utility of self-report screening instruments for PTSD among primary care and high-risk populations.

Evidence Review  We searched MEDLINE and the National Center for PTSD’s Published International Literature on Traumatic Stress (PILOTS) databases for articles published on screening instruments for PTSD published from January 1981 through March 2015. Study quality was rated using Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria.

Study Selection  Studies of screening instruments for PTSD evaluated using gold standard structured clinical diagnostic interviews that had interview samples of at least 50 individuals.

Findings  We identified 2522 citations, retrieved 318 for further review, and retained 23 cohort studies that evaluated 15 screening instruments for PTSD. Of the 23 studies, 15 were conducted in primary care settings in the United States (n = 14 707 were screened, n = 5374 given diagnostic interview, n = 814 had PTSD) and 8 were conducted in community settings following probable trauma exposure (ie, natural disaster, terrorism, and military deployment; n = 5302 were screened, n = 4263 given diagnostic interview, n = 393 were known to have PTSD with an additional 50 inferred by rates reported by authors). Two screens, the Primary Care PTSD Screen (PC-PTSD) and the PTSD Checklist were the best performing instruments. Using the same score employed by primary care clinics in the Department of Veterans Affairs to indicate a positive screen (≥3), the 4-item PC-PTSD has a sensitivity of 0.69 (95% CI, 0.55-0.81), a specificity of 0.92 (95% CI, 0.86-0.95), a positive likelihood ratio of 8.5 (95% CI, 5.6-13.0) and a negative likelihood ratio of 0.34 (95% CI, 0.22-0.48). For the 17-item PTSD Checklist, scores around 40 as indicating a positive screen, have a sensitivity of 0.70 (95% CI, 0.64-0.77), a specificity of 0.90 (95% CI, 0.84-0.93), a positive likelihood ratio of 6.8 (95% CI, 4.7-9.9) and a negative likelihood ratio of 0.33 (95% CI, 0.27-0.40).

Conclusions and Relevance  Two screening instruments, the PC-PTSD and the PTSD Checklist, show reasonable performance characteristics for use in primary care clinics or in community settings with high-risk populations. Both are easy to administer and interpret and can readily be incorporated into a busy practice setting.