An abbreviated PTSD checklist for use as a screening instrument in primary care

Abstract

Although the importance of recognizing posttraumatic stress disorder (PTSD) in primary care has been well-established, routine screening for PTSD remains unfeasible for many primary care clinics because of the length of the available screening instruments. Thus, the purpose of this work was to develop and validate a brief screening tool for PTSD. In Study 1, four short forms of the PTSD Checklist-civilian version were identified that captured a majority of the variance in the measure. In Study 2, the performance of these short forms was evaluated in a separate sample of primary care patients. We found that both two-item and six-item versions have adequate psychometric properties for screening purposes and suggest that the selection of one version over the other depends on the specific needs of each primary care clinic.

Introduction

Many patients with emotional disorders receive their care exclusively in general medical settings (Regier et al., 1993). Recognizing the importance of increasing the rates of detection and treatment of depression in primary care, the US Preventive Services Task Force recently recommended that primary care providers routinely screen for depression (Agency for Healthcare Research and Quality, 2002). There is good reason to believe that many of the same benefits would be derived from screening for anxiety states as well. Like depression, anxiety is generally under-recognized and under-treated by general medical providers (Pini, Perkonnig, Tansella, & Wittchen, 1999).

There are a number of reasons why posttraumatic stress disorder (PTSD) is an important condition to be assessed in primary care. A significant number of patients are affected. In a national study of Israeli primary care patients, 7.5% of men and 10.5% of women were found to have PTSD (Taubman-Ben-Ari, Rabinowitz, Feldman, & Vaturi, 2001). Similarly, 11.8% of patients in a US primary care clinic were diagnosed with current PTSD (Stein, McQuaid, Pedrelli, Lenox, & McCahill, 2000). Traumatized individuals are over-represented in primary care partially because of the need for medical care for trauma-related physical injuries (Koss, Koss, & Woodruff, 1991), but chronic PTSD is associated with impaired functioning, increased medical complaints, higher long-term utilization of medical services and reduced quality of life (Kimerling & Calhoun, 1994; Koss et al., 1991; Schnurr, Friedman, Sengupta, Jankowski, & Holmes, 2000; Solomon & Davidson, 1997). Nonetheless, physicians in primary care recognize distress in only half of patients with PTSD and identify PTSD in specific much less frequently; only 2% of patients with presumptive PTSD based on a self-report measure were diagnosed with the disorder (Taubman-Ben-Ari et al., 2001).

The greatest barrier to increased screening in primary care is its feasibility for busy staff and providers. The shortest self-report measures that are validated for screening in primary care, such as the PTSD Checklist-civilian version (PCL-C) (Weathers, Litz, Huska, & Keane, 1994), take approximately 5 min to complete. If a provider is to screen for three or four mental health problems (e.g., depression, panic, PTSD, substance use disorders), the total time quickly rises to 20–30 min. Thus, if we are to advocate for increased screening in primary care (e.g., Lang & Stein, 2002), we must make available good and extremely short screening instruments.

Previous work has shown that the PCL-C has adequate psychometric properties for use with women in primary care (Dobie et al., 2002; Walker, Newman, Dobie, Ciechanowski, & Katon, 2002). The purpose of this paper is to describe the development a brief screening instrument for PTSD to be used with both men and women in primary care.