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Posttraumatic Stress Disorder in Veterans and Military Personnel: Epidemiology, Screening, and Case Recognition Margaret A. Gates New England Research Institutes, Inc., Watertown, Massachusetts Darren W. Holowka, Jennifer J. Vasterling, Terence M. Keane, and Brian P. Marx VA Boston Healthcare System, Boston, Massachusetts and Boston University School of Medicine Raymond C. Rosen New England Research Institutes, Inc., Watertown, Massachusetts Posttraumatic stress disorder (PTSD) is a psychiatric disorder that affects 7– 8% of the general U.S. population at some point during their lifetime; however, the prevalence is much higher among certain subgroups, including active duty military personnel and veterans. In this article, we review the empirical literature on the epidemiology and screening of PTSD in military and veteran populations, including the availability of sensitive and reliable screening tools. Although estimates vary across studies, evidence suggests that the prevalence of PTSD in deployed U.S. military personnel may be as high as 14 –16%. Prior studies have identified trauma characteristics and pre- and posttrauma factors that increase risk of PTSD among veterans and military personnel. This information may help to inform prevention and screening efforts, as screening programs could be targeted to high-risk populations. Large-scale screening efforts have recently been implemented by the U.S. Departments of Defense and Veterans Affairs. Given the prevalence and potential consequences of PTSD among veterans and active duty military personnel, development and continued evaluation of effective screening methods is an important public health need. Keywords: epidemiology, military personnel, posttraumatic stress disorder, screening, veterans Posttraumatic stress disorder (PTSD) is a psychiatric condition that is experienced by a subset of individuals after exposure to an event that involved life threat and elicited feelings of fear, helplessness, and/or horror in the individ- ual. PTSD is characterized by several interre- lated symptom clusters including reexperienc- ing symptoms (e.g., intrusive thoughts, recur- rent dreams, flashbacks, distress and physiologic reactivity upon exposure to trauma cues), avoidance and emotional numbing symp- toms (e.g., avoidance of traumatic reminders, anhedonia, detachment from others, restricted emotional experiences, sense of foreshortened future), and hyperarousal symptoms (e.g., sleep difficulties, irritability and anger, concentration problems, hypervigilence, exaggerated startle) (American Psychiatric Association, 2000). Ac- tive duty military personnel and veterans are two highly vulnerable, at-risk groups for devel- opment of PTSD (Dohrenwend et al., 2006; Hoge, Auchterlonie, & Milliken, 2006; Hoge et al., 2004). The true prevalence of PTSD among veterans and service members is controversial (Burkett & Whitley, 1998; McHugh & Treisman, 2007; McNally, 2006, 2007; Sundin, Fear, Iversen, This article was published Online First March 5, 2012. Margaret A. Gates and Raymond C. Rosen, New England Research Institutes, Inc., Watertown, Massachusetts; Darren W. Holowka, Jennifer J. Vasterling, Terence M. Keane, and Brian P. Marx, National Center for PTSD, VA Boston Healthcare System, and Department of Psychiatry, Boston University School of Medicine. This work was funded by U.S. Department of Defense Awards W81XWH-08-2-0102 and W81XWH-08-2-0100. Correspondence concerning this article should be ad- dressed to Margaret A. Gates, New England Research Institutes, Inc., 9 Galen Street, Watertown, MA 02472. E-mail: [email protected] Psychological Services In the public domain 2012, Vol. 9, No. 4, 361–382 DOI: 10.1037/a0027649 361

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Posttraumatic Stress Disorder in Veterans and Military Personnel:Epidemiology, Screening, and Case Recognition

Margaret A. GatesNew England Research Institutes, Inc., Watertown,

Massachusetts

Darren W. Holowka,Jennifer J. Vasterling, Terence M. Keane,

and Brian P. MarxVA Boston Healthcare System, Boston,

Massachusetts and Boston University Schoolof Medicine

Raymond C. RosenNew England Research Institutes, Inc., Watertown, Massachusetts

Posttraumatic stress disorder (PTSD) is a psychiatric disorder that affects 7–8% of thegeneral U.S. population at some point during their lifetime; however, the prevalence ismuch higher among certain subgroups, including active duty military personnel andveterans. In this article, we review the empirical literature on the epidemiology andscreening of PTSD in military and veteran populations, including the availability ofsensitive and reliable screening tools. Although estimates vary across studies, evidencesuggests that the prevalence of PTSD in deployed U.S. military personnel may be ashigh as 14–16%. Prior studies have identified trauma characteristics and pre- andposttrauma factors that increase risk of PTSD among veterans and military personnel.This information may help to inform prevention and screening efforts, as screeningprograms could be targeted to high-risk populations. Large-scale screening efforts haverecently been implemented by the U.S. Departments of Defense and Veterans Affairs.Given the prevalence and potential consequences of PTSD among veterans and activeduty military personnel, development and continued evaluation of effective screeningmethods is an important public health need.

Keywords: epidemiology, military personnel, posttraumatic stress disorder, screening, veterans

Posttraumatic stress disorder (PTSD) is apsychiatric condition that is experienced by asubset of individuals after exposure to an eventthat involved life threat and elicited feelings offear, helplessness, and/or horror in the individ-ual. PTSD is characterized by several interre-lated symptom clusters including reexperienc-

ing symptoms (e.g., intrusive thoughts, recur-rent dreams, flashbacks, distress andphysiologic reactivity upon exposure to traumacues), avoidance and emotional numbing symp-toms (e.g., avoidance of traumatic reminders,anhedonia, detachment from others, restrictedemotional experiences, sense of foreshortenedfuture), and hyperarousal symptoms (e.g., sleepdifficulties, irritability and anger, concentrationproblems, hypervigilence, exaggerated startle)(American Psychiatric Association, 2000). Ac-tive duty military personnel and veterans aretwo highly vulnerable, at-risk groups for devel-opment of PTSD (Dohrenwend et al., 2006;Hoge, Auchterlonie, & Milliken, 2006; Hoge etal., 2004).

The true prevalence of PTSD among veteransand service members is controversial (Burkett& Whitley, 1998; McHugh & Treisman, 2007;McNally, 2006, 2007; Sundin, Fear, Iversen,

This article was published Online First March 5, 2012.Margaret A. Gates and Raymond C. Rosen, New England

Research Institutes, Inc., Watertown, Massachusetts; DarrenW. Holowka, Jennifer J. Vasterling, Terence M. Keane, andBrian P. Marx, National Center for PTSD, VA BostonHealthcare System, and Department of Psychiatry, BostonUniversity School of Medicine.

This work was funded by U.S. Department of DefenseAwards W81XWH-08-2-0102 and W81XWH-08-2-0100.

Correspondence concerning this article should be ad-dressed to Margaret A. Gates, New England ResearchInstitutes, Inc., 9 Galen Street, Watertown, MA 02472.E-mail: [email protected]

Psychological Services In the public domain2012, Vol. 9, No. 4, 361–382 DOI: 10.1037/a0027649

361

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Rona, & Wessely, 2010; Young, 1995), in partbecause of concerns over possible overdiagno-sis related to patients seeking secondary gain(Department of Veterans Affairs Office of In-spector General, 2005; McHugh & Treisman,2007). However, recent, large-scale studies in-dicate that PTSD may be a highly prevalentdisorder among U.S. service men and womenreturning from current military deployments,with prevalence estimates as high as 14–16%(Hoge et al., 2004; Hoge, Terhakopian, Castro,Messer, & Engel, 2007; Milliken, Auchterlonie, &Hoge, 2007; Tanielian & Jaycox, 2008). Impor-tantly, prior studies may actually underestimatethe true number of military personnel and veteranssuffering from PTSD and other trauma-relateddisorders, because of stigma and potential neg-ative consequences associated with disclosingmental health difficulties (e.g., compromisingone’s military career, delays in returning home)(Hoge et al., 2004). Nonetheless, on the basis ofthe available research findings, PTSD has beenreferred to as one of the “signature injuries” ofactive duty service men and women who aredeployed to Afghanistan for Operation Endur-ing Freedom (OEF) or Iraq for Operation IraqiFreedom (OIF) (Testimony of Jason Altmire,2007).

PTSD is associated with numerous deleteri-ous outcomes for veterans and active duty ser-vice personnel, and the costs of PTSD to theindividual, their immediate family, and societyat large are substantial. In addition to the emo-tional and cognitive symptoms of PTSD, indi-viduals with PTSD are more likely to experi-ence marital and family problems (Jordan et al.,1992), job instability (Smith, Schnurr, & Rosen-heck, 2005), legal difficulties (Kulka et al.,1990), and physical health problems (Bosca-rino, 2004; O’Toole, Catts, Outram, Pierse, &Cockburn, 2009). Veterans with a history ofPTSD have a higher risk of cardiovascular, re-spiratory, gastrointestinal, infectious, nervoussystem, and autoimmune disorders (Boscarino,1997, 2004; Hoge et al., 2007; Kubzansky,Koenen, Spiro, Vokonas, & Sparrow, 2007) andare more likely to experience anxiety, depres-sion, substance abuse, and other psychiatric dis-orders (Kulka et al., 1990; Long, MacDonald, &Chamberlain, 1996). Some studies also havereported a higher risk of suicidal ideationamong veterans with PTSD (Jakupcak et al.,2009; Pietrzak, Goldstein et al., 2009). PTSD

often occurs in combination with persistentpostconcussive symptoms and chronic pain,complicating the diagnosis and treatment ofPTSD (Lew et al., 2009). The economic costs ofPTSD and major depression for all currentlydeployed service members could be morethan 6.2 billion dollars during only the first twoyears after return from deployment (Tanielian &Jaycox, 2008). A large proportion of these costsare expected to be attributable to lost workproductivity. Eibner and colleagues (Eibner,Ringel, Kilmer, Pacula, & Diaz, 2008) hypoth-esized that the economic burden of PTSD couldbe reduced through the proper identification ofthose with PTSD and use of evidence-basedtreatments within the first two years after anindividual’s return from war zone deployment.

In response to the recent estimates of PTSDprevalence among military personnel deployedto OEF/OIF and the associated public healthand economic consequences, the U.S. Depart-ment of Defense (DoD) and VA have increasedthe number of available mental health providersand instituted mandatory primary care screen-ings for PTSD and other associated disordersfor military personnel and veterans. In addition,the VA has developed and implemented spe-cialized programs for evidence-based treatmentof PTSD, including Cognitive Processing Ther-apy (CPT) and Prolonged Exposure (PE) ther-apy (Karlin et al., 2010). However, the provi-sion of adequate services depends upon the useof accurate and reliable screening procedures toidentify individuals either at risk for or currentlyaffected by the disorder. Continued evaluationof the current screening efforts is needed toassess their effectiveness in properly identifyingindividuals with PTSD and reducing the amountof PTSD-related suffering among veterans andactive duty military personnel.

In considering the rationale for the develop-ment and implementation of PTSD screeningprograms for armed services personnel and vet-erans, we first provide an overview of the prev-alence and etiology of PTSD in military andveteran populations, followed by a review ofcurrent screening initiatives within the DoD andVA and the available screening instruments. Weconclude by discussing potential gaps and fu-ture research needs in the area of screening forPTSD in veteran and military populations. Theprimary goal of this article is to provide anoverview of PTSD epidemiology and screening

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for clinicians and researchers, as well as toserve as a resource to guide clinicians in theselection of screening instruments and imple-mentation of screening programs.

Method

We searched the U.S. National Library ofMedicine’s PubMed database and the Psy-cINFO database for articles related to the prev-alence, epidemiology, or screening of PTSDamong armed forces personnel and veterans.We identified studies related to the prevalenceor epidemiology of PTSD in veterans and mil-itary personnel by searching for references withthe terms “posttraumatic stress disorder” or“PTSD” and “veterans,” “military,” or “com-bat” in the title or abstract, as well as “preva-lence” (n � 229) or “epidemiology,” “risk fac-tor,” or “predictor” (n � 101) in the title/abstract or subject heading. We reviewed theabstracts for the resulting articles to identifythose relevant to our topic, and we also re-viewed the references for the most relevant ar-ticles to identify additional studies of interest.

To identify articles related to screening forPTSD in veterans and active duty military per-sonnel, we searched for articles with the terms“posttraumatic” or “PTSD” in the major subjectheading, “veteran” or “military” in the subjectsfield, and “screen” in any field, which yielded177 articles. We reviewed the results to deter-mine whether the study addressed screening forPTSD and the screening measures used. Afteridentifying relevant screening measures, weperformed additional searches to locate articlesabout the measures in question, including orig-inal validation studies.

Results

Prevalence of PTSD in Veterans andMilitary Personnel

Figure 1 displays estimates of the prevalenceof lifetime (any history) and current PTSD fromstudies of active duty military personnel andveterans of the Vietnam War (Boscarino, 1995;Eisen et al., 2004; Goldberg, True, Eisen, &Henderson, 1990; Kulka et al., 1990; O’Toole etal., 2009; O’Toole et al., 1996; Stretch, 1985),Gulf War (Al-Turkait & Ohaeri, 2008; Depart-ment of National Defence, 2002; Gray, Reed,

Kaiser, Smith, & Gastanaga, 2002; Holmes,Tariot, & Cox, 1998; Ikin et al., 2004; Jones,Rona, Hooper, & Wesseley, 2006; Kang, Natel-son, Mahan, Lee, & Murphy, 2003; Lee, Ga-briel, Bolton, Bale, & Jackson, 2002; Perconte,Wilson, Pontius, Dietrick, & Spiro, 1993;Pierce, 1997; Proctor et al., 1998; Stretch et al.,1996; The Iowa Persian Gulf Study Group,1997; Toomey et al., 2007; Unwin et al., 1999;Wolfe, Erickson, Sharkansky, King, & King,1999), and OEF/OIF (Duma, Reger, Canning,McNeil, & Gahm, 2010; Fear et al., 2010;Haskell et al., 2010; Hoge & Castro, 2006;Hoge et al., 2004; Hoge et al., 2007; Hotopf etal., 2006; Milliken et al., 2007; Seal, Bertenthal,Miner, Sen, & Marmar, 2007; Seal et al., 2009;Smith et al., 2008; Tanielian & Jaycox, 2008;Vasterling et al., 2006; Vasterling et al., 2010).Although the prevalence estimates vary widelyacross studies, overall the data in Figure 1 sug-gest that a large proportion of military personneland veterans are affected by PTSD. Severalfactors may contribute to differences in theprevalence estimates across studies, includingthe study design and methods, the diagnosticcriteria used, and characteristics of the studypopulation, such as the intensity of combat ex-posure or number of deployments (Ramchand etal., 2010). Two recent review articles summa-rized the data on the prevalence of combat-related PTSD (Richardson, Frueh, & Acierno,2010; Sundin et al., 2010); we therefore brieflysummarize the most recent prevalence data be-low and refer readers to specific publications fordetails of older studies.

Prevalence of military-related PTSD in theUnited States. The most recent prevalenceestimates of deployment-related PTSD comefrom the ongoing military operations in Iraq andAfghanistan. In a review of the prevalence lit-erature on combat-related PTSD, Richardson etal. reported estimates for current PTSD in U.S.OEF/OIF veterans ranging from 4% to 17%(Richardson et al., 2010). In a recent study notincluded in the reviews noted above, 21.8% of289,328 OEF/OIF veterans who first receivedcare at a VA facility between 2002 and 2008were diagnosed with PTSD during the 6-yearstudy period, based on International Classifica-tion of Diseases, Ninth Revision, Clinical Mod-ification (ICD-9-CM) codes from inpatient andoutpatient visits (Seal et al., 2009). However,this study population sought health care at VA

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facilities and therefore may not be representa-tive of the larger population of OEF/OIF veter-ans. In addition, PTSD diagnoses were based onelectronic medical records and were not con-firmed by other methods, likely resulting infalse positive as well as false negative diagno-ses. In contrast to the study by Seal et al., astudy published by the RAND Corporation in2008 reported that 14% of a representative sam-ple of 1,965 OEF/OIF veterans interviewed bytelephone met diagnostic criteria for PTSD (Ta-nielian & Jaycox, 2008). Extrapolating from

these results, the authors estimated that 226,000individuals who served in OEF/OIF throughOctober 31, 2007 currently have PTSD.

Prevalence of military-related PTSD inter-nationally. Studies of non-U.S. veteran pop-ulations generally report similar or lower prev-alence estimates than studies of U.S. veterans(Richardson et al., 2010; Sundin et al., 2010).For example, prevalence estimates for U.K. vet-erans who served in Iraq and Afghanistan rangefrom 3.4% to 6%, based on studies using self-administered questionnaires (Browne et al.,

Figure 1. Current/lifetime prevalence of posttraumatic stress disorder in military and vet-eran populations.

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2007; Fear et al., 2010; Hotopf et al., 2006;Iversen et al., 2008; Mulligan et al., 2010) or astructured telephone interview (Iversen et al.,2009); the lower prevalence of PTSD in thesestudies, compared with studies of U.S. OEF/OIF veterans, may be attributable in part tolower levels of combat exposure among U.K.soldiers (Hoge & Castro, 2006) or methodolog-ical differences in the studies.

Prevalence of military-related PTSD inwomen and racial/ethnic minorities. Someevidence suggests that the prevalence of PTSDmay differ among female and minority servicemembers and veterans, when compared withwhite, non-Hispanic males. Women generallyhave lower levels of combat exposure than menbut significantly higher rates of military sexualtrauma, which is strongly associated with devel-opment of PTSD (Kang, Dalager, Mahan, &Ishii, 2005). In a large study of male and femaleOEF/OIF veterans seen at VA facilities, theprevalence of PTSD was similar, although sta-tistically more prevalent, in men versus women(13% vs. 11%) (Seal et al., 2007). In this studythe prevalence of PTSD also was similar byrace/ethnicity, although black veterans wereslightly more likely to be diagnosed with PTSD(14%) than white or Hispanic veterans (13%)(Seal et al., 2007). However, several older stud-ies that examined prevalence differences byrace/ethnicity reported marked differences inthe prevalence of PTSD by minority status. Forexample, in the NVVRS the prevalence ofPTSD was 20.6% among black veteransand 27.9% among Hispanic veterans, comparedwith 13.7% among white veterans (Frueh,Brady, & de Arellano, 1998). Additional anal-yses of the NVVRS data also reported a higherprevalence of PTSD among American-Indianveterans, compared with white veterans (Fruehet al., 1998), and high levels of race-relatedstress and subsequent PTSD among Asian-American veterans (Loo, Fairbank, & Chemtob,2005). Although other individual-level or trau-ma-related characteristics may have contributedto these differences, as discussed in greater de-tail below, disparities by gender or race/ethnicity are important to consider in studies ofPTSD.

Trends in the prevalence of PTSD. Dis-parities in estimates of the prevalence of PTSDfor different wars could be a function of differ-ences in the study measures or methods (e.g.,

the diagnostic criteria and the methods of sam-pling and assessment) or characteristics of theconflict. In addition, differences in populationcharacteristics, such as the duration or intensityof combat exposure or the number of deploy-ments also may contribute to the differing prev-alence estimates across studies (Ramchand etal., 2010). However, despite these methodolog-ical challenges, it is clear that PTSD affects alarge number of current and former service menand women at some point during their lifetime.The high prevalence of PTSD in military andveteran populations highlights the importanceof screening these populations for PTSD andidentifying factors that influence risk and recov-ery from PTSD.

Risk Factors for PTSD in Veterans andMilitary Personnel

The majority of individuals exposed totrauma do not develop clinical PTSD, suggest-ing that other factors strongly influence the on-set and course of this disorder (Keane, Marx, &Sloan, 2009). Risk factors for PTSD are com-monly divided into three categories: individual-level (pretrauma) factors, characteristics of thetrauma, and posttrauma factors (Keane, Mar-shall, & Taft, 2006). Knowledge of pretraumafactors and trauma characteristics that influencerisk may help to identify populations at higherrisk of developing PTSD and who are thereforemore likely to benefit from screening, whereasposttrauma factors may help to inform preven-tion and treatment programs among men andwomen with trauma exposure.

Table 1 summarizes the epidemiologic fac-tors shown in multiple studies to influence riskof PTSD in veterans and military personnel.Characteristics of the trauma (e.g., trauma se-verity, perceived life threat, and combat-relatedinjury) and posttrauma factors (e.g., lack ofsocial support and exposure to additional lifestressors) have been strongly associated withrisk of PTSD in multiple studies. In contrast,weak to moderate associations generally havebeen reported for pretrauma factors, such asyounger age at trauma and prior psychiatrichistory.

Gender, race/ethnicity, and risk of PTSD.In addition to the risk factors included in Ta-ble 1, some studies have suggested that genderand race/ethnicity may be important in the de-

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velopment of military-related PTSD (Brewin,Andrews, & Valentine, 2000; Gahm, Lucenko,Retzlaff, & Fukuda, 2007; Koenen, Stellman,Stellman, & Sommer, 2003). In a meta-analysisof 25 studies, Brewin et al. (2000) observed asignificantly higher risk of PTSD amongwomen compared with men in civilian but notmilitary populations, although only two militarystudies of gender and PTSD were included.More recent studies are mixed, with some re-porting a higher risk among women and othersreporting no association (Street, Vogt, & Dutra,2009). Similarly, minority race/ethnicity wasassociated with an increased risk of PTSD inmilitary populations in the meta-analysis byBrewin et al. (2000), but other studies do notsupport an association (Baker et al., 2009; Fruehet al., 1998). Several factors may contribute todifferences in the associations with gender and

race observed across studies, including premili-tary trauma exposure or confounding by traumacharacteristics, social support during deploy-ment, or other stressors (Dohrenwend, Turner,Turse, Lewis-Fernandez, & Yager, 2008; Ki-merling, Gima, Smith, Street, & Frayne, 2007;Loo et al., 2005; Street et al., 2009; Vogt, Pless,King, & King, 2005). For example, premilitary/military sexual trauma is an important cause ofPTSD that disproportionately affects women(Himmelfarb, Yaeger, & Mintz, 2006; Ki-merling et al., 2007); however, studies of mili-tary and veteran populations that focus onPTSD resulting from combat, rather than allmilitary-related trauma, may fail to report casesof PTSD that are primarily attributable to mili-tary sexual trauma.

Complexity of PTSD etiology. Multivar-iate and meta-analytic studies (Brewin et al.,

Table 1Epidemiologic Factors Associated With Increased Risk of Posttraumatic Stress Disorder in Veterans andMilitary Personnel

Risk factorStrength ofassociation� References

Pre-trauma factorsYounger age at trauma � (Brewin et al., 2000; Nasky, Hines, & Simmer, 2009)Lower education �� (Brewin et al., 2000; Iversen et al., 2008; Schnurr et al.,

2004; Zohar et al., 2009)Lower intelligence �� (Brewin et al., 2000; Gale et al., 2008; Zohar et al., 2009)Lower military rank �� (Iversen et al., 2008; Nasky et al., 2009; Zohar et al., 2009)Lower socioeconomic status �� (Brewin et al., 2000; Schnurr et al., 2004)Prior trauma �� (Brewin et al., 2000; Ozer et al., 2003)Prior psychiatric history/symptoms �� (Brewin et al., 2000; Rona et al., 2009)Family psychiatric history �� (Brewin et al., 2000; Ozer et al., 2003)Behavioral problems in childhood �� (Helzer, Robins, & McEvoy, 1987; King, King, Foy, &

Gudanowski, 1996; Koenen et al., 2005)Childhood abuse or adversity �� (Brewin et al., 2000; Cabrera, Hoge, Bliese, Castro, &

Messer, 2007; Gahm et al., 2007; Iversen et al., 2008)Trauma characteristics

Trauma/combat exposure severity ��� (Brewin et al., 2000; Cabrera et al., 2007; Gahm et al.,2007; Koenen et al., 2003; O’Toole et al., 1996; Rona etal., 2009; Schnurr et al., 2004)

Perceived life threat ��� (King et al., 1998; Schnurr et al., 2004)Combat-related injury ��� (Koren, Norman, Cohen, Berman, & Klein, 2005;

MacGregor et al., 2009)Exposure to death, killing, or

abusive violence�� (Gahm et al., 2007; Iversen et al., 2008; Maguen et al.,

2010; Marx et al., 2010; McCarroll, Ursano, Fullerton,Liu, & Lundy, 2001)

Peritraumatic distress or dissociation ��� (Ozer et al., 2003; Schnurr et al., 2004)Post-trauma factors

Lack of social support ��� (Brewin et al., 2000; Ozer et al., 2003)Negative homecoming experience ��� (Johnson et al., 1997; Koenen et al., 2003)Exposure to additional life stressors ��� (Brewin et al., 2000)

� Weak effect (�), intermediate effect (��), or strong effect (���).

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2000; King, King, Foy, Keane, & Fairbank,1999; Ozer, Best, Lipsey, & Weiss, 2003;Wolfe et al., 1999) highlight the complexity ofpredicting who will and will not developchronic PTSD. Risk and resilience factors, in-cluding the quality of the family environmentduring childhood, age at trauma exposure, his-tory of prior adversity, severity of trauma expo-sure, breadth and strength of the social supportnetwork, exposure to additional life stressors,and individual-level characteristics such as har-diness and neurobiology have consistently beenfound to influence the development of PTSD(King et al., 1999; King, King, Fairbank, Keane,& Adams, 1998; Pietrzak et al., 2010; Pietrzak,Johnson, Goldstein, Malley, & Southwick,2009). This research suggests that vulnerabilityto PTSD is not simply a function of traumaexposure but a function of the interaction be-tween trauma exposure, preexisting psycholog-ical and biological vulnerabilities, and the post-trauma environment. Other research indicatesthat the factors influencing development andmaintenance of PTSD may differ (Schnurr,Lunney, & Sengupta, 2004).

Genetics of PTSD. Finally, although fa-milial studies support a heritable component ofPTSD, limited data are available on geneticpolymorphisms that may influence risk in mili-tary and veteran populations (Afifi, Asmundson,Taylor, & Jang, 2010; Koenen, 2007). In a studyof male twin pairs who served during the Viet-nam era, True et al. observed that approximately30% of the variability in PTSD symptoms wasattributable to genetic factors, whereas sharedfamily environment did not appear to influencethe development of PTSD (True et al., 1993).Studies of specific genetic variants have focusedon the dopaminergic, serotonergic, and otherneurobiochemical pathways (Nugent, Amstad-ter, & Koenen, 2008). Polymorphisms in thedopamine receptor D2 (DRD2) gene have beenassociated with risk of PTSD in some but not allstudies of combat-exposed populations (Nugentet al., 2008; Voisey et al., 2009), and one studyreported lower dopamine beta-hydroxylase(DBH) activity among veterans with PTSDcompared with those without PTSD, suggesting apossible role of the DBH gene in the developmentof PTSD (Mustapic et al., 2007). However, studiesof genes in other pathways generally have beennull in military and veteran populations, althoughthe number of available studies is small (re-

viewed in Koenen, 2007; Nugent et al., 2008).Large, genome-wide association studies wouldbe helpful in identifying other chromosomalregions that may be important in PTSD. Al-though future genetic studies may help to elu-cidate the mechanisms involved in the develop-ment of PTSD and may be informative for riskprediction and screening or prevention, cur-rently the evidence is too limited for widespreaduse of genetic data for screening purposes inmilitary and veteran populations.

Screening Programs for PTSD in Veteransand Military Personnel

The high prevalence of PTSD in military andveteran populations and the potential serious-ness of the symptoms and associated emotional/physical health consequences highlight the im-portance of effective screening and early inter-vention efforts for these groups. The goal ofscreening in this population is to identify trauma-exposed individuals with undiagnosed or sub-syndromal PTSD, or those at risk for develop-ing the disorder, to intervene earlier in thecourse of disease than would occur in the ab-sence of screening. Although screening forPTSD differs from screening for chronic dis-eases, such as cancer, in that symptoms oftenare present at the time of screening, the goal ofreducing morbidity or mortality from disease issimilar, as early intervention may result in ashorter course of disease and fewer negativeoutcomes related to PTSD (Bryant et al., 2008;Kessler, Sonnega, Bromet, Hughes, & Nelson,1995; O’Donnell, Bryant, Creamer, & Carty,2008). Screening may also be of value in iden-tifying subgroups of individuals or specific co-horts at increased risk for developing PTSD,tracking changes in prevalence over time, andassessing the degree of unmet need for services.

In 2003, the DoD instituted a military-widescreening program—the Post-DeploymentHealth Assessment (PDHA)—that assesses ser-vice members’ physical and mental health sta-tus after deployment. Specific mental healthareas addressed include depression, suicidalideation, aggression, and PTSD (Hoge et al.,2006). Screening occurs within 1–2 weeks ofreturn from deployment and consists of a three-page self-report questionnaire followed by abrief interview with a health care professional,who documents any concerns, determines

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whether additional evaluation is needed, andprovides information on available resources fordealing with postdeployment issues (U.S. De-partment of Defense Deployment Health Clini-cal Center). Results of this large-scale screeningprogram suggest that a substantial percentage ofservice members who served in Iraq and Af-ghanistan screen positive for probable PTSD;during the first year after implementation of thePHDA, 9.8% of Army soldiers and Marinesreturning from Iraq and 4.7% returning fromAfghanistan screened positive for probablePTSD (Hoge et al., 2006). Although it is possi-ble that these estimates overstate the prevalenceof PTSD because of patients seeking secondarygain, it is also possible that these studies under-estimate the prevalence of PTSD among activeduty military personnel who may not report thepresence of PTSD symptoms because of con-cerns that public knowledge of their symptomsmay damage their personal or professional rep-utations. As part of this ongoing screening pro-gram, the DoD mandated in 2005 that servicemembers be assessed again 3–6 months afterreturn from deployment (Milliken et al., 2007).Screening at two time points yielded evenhigher positive screening rates for probablePTSD and other mental health concerns; at thereassessment, 16.7% of active soldiersand 24.5% of National Guard and Reserve sol-diers screened positive for PTSD (Milliken etal., 2007). A second study found that the pro-portion of individuals screening positive forPTSD and other mental health conditions washigher when screening was delayed until severalmonths postdeployment, indicating that screen-ing soon after return from deployment may missa large number of cases as a result of delayedonset or false negative screens (Bliese, Wright,Adler, Thomas, & Hoge, 2007).

Despite the apparent success of these screen-ing efforts by the DoD, some researchers havevoiced concerns, citing limited evidence of theeffectiveness of screening in military popula-tions (Rona, Hyams, & Wessely, 2005). Ronaand colleagues argued that the number of posi-tive screens requiring prompt psychological at-tention is small relative to the total number ofindividuals screening positive and that severalfactors may influence over- or underreporting ofsymptoms in military populations (Rona et al.,2005). However, in a study of 1,578 militarypersonnel returning from a year-long deploy-

ment to Iraq, Bliese et al. reported a sensitivityof 0.73 and specificity of 0.88 for the four-itemPrimary Care PTSD Screen (PC-PTSD) used inthe PDHA compared with a structured inter-view, indicating that the PDHA has reasonablygood validity (Bliese, Wright, Thomas, Adler,& Hoge, 2004, December).

In 2004, the VA implemented the Afghan andIraq Post-Deployment Screen, a 10–15 minuteassessment for PTSD, depression, and high-riskalcohol use (Seal et al., 2008). Veterans seekingcare at Veterans Health Administration (VHA)primary care and specialty clinics are routinelyscreened by their clinician, who is prompted tocomplete the assessment by an automatic re-minder in the VHA’s computerized medical re-cord system (Seal et al., 2008; Veterans HealthAdministration, 2004). PTSD symptoms are as-sessed using the four-item PC-PTSD, and clini-cians are encouraged to refer veterans with apositive screen to a specialty mental healthclinic (Seal et al., 2008). In a study by Seal andcolleagues (2008), 45% of OEF/OIF veteransseen at a VHA Medical Center or associatedclinic were screened, and 50% of those screenedmet the criteria for probable PTSD. This isconsistent with a study of active duty militarypersonnel seen at outpatient mental health clin-ics in which 44% screened positive for probablePTSD (Gahm & Lucenko, 2008). Although theprevalence of PTSD likely is elevated amongactive duty military personnel and veteransseen at VHA facilities, as this populationincludes individuals seeking care for symp-toms of PTSD or related conditions, thesestudies highlight the importance of screeningfor PTSD in this setting. Beginning in 2010,the VA required that all OEF/OIF veteransbeing actively treated for PTSD at a VHAfacility be evaluated for PTSD symptoms ev-ery 90 days using the PTSD Checklist (PCL),to monitor changes in PTSD symptoms andassess whether individuals previously diag-nosed with PTSD continue to meet diagnosticcriteria (Department of Veterans Affairs,2009).

Ongoing evaluation of the efforts to screenactive duty military personnel and veterans isneeded to maximize the effectiveness of thesescreening programs. For example, studies of theoptimal timing of the PDHA and the optimalfrequency of the VA screen would help to en-sure that cases are detected and treatment is

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initiated early but that the number of casesmissed because of delayed onset is minimized.In addition, validation studies should be con-ducted where none are available, to evaluate theeffectiveness of the screening programs as wellas to assess the psychometric properties anddiagnostic accuracy of new screening measuresin these populations.

Overview of Screening Instruments forIdentifying PTSD in Military and VeteranPopulations

Various methods have been used to assess thesigns and symptoms of PTSD in military andveteran populations; however, the most com-mon approach involves the use of self-reportquestionnaires. In a review of screening instru-ments for assessing symptoms of PTSD in thegeneral population, Brewin noted that screeningtools designed to assess Diagnostic and Statis-tical Manual of Mental Disorders, 4th Edition(DSM–IV) symptoms were superior to other in-struments, and that measures with fewer items,simpler response scales, and simpler methods ofscoring usually were superior (Brewin, 2005).

Some screening instruments, including thosereviewed by Brewin (2005), more generally as-sess the presence of PTSD that may or may notbe combat related. In contrast, other screeningmeasures are specifically designed to assesscombat-related PTSD. Combat-specific PTSDscreening instruments may have higher sensi-tivity and specificity in military and veteranpopulations than screening tools designed foruse in the general population. However, morefocused screening tools may fail to identifyPTSD cases that are unrelated to combat, suchas PTSD resulting from military sexual trauma(Suris & Lind, 2008); screening measuresshould therefore be broad enough to effectivelyscreen for both combat-related PTSD and PTSDrelated to other trauma in military settings.

Screening instruments for PTSD assess someor all of the characteristic symptoms of PTSDand are typically validated against a “gold stan-dard” of clinical diagnosis by a qualified clini-cian. Additional validation tests include dis-criminant or known groups validity (“does thetest distinguish between individuals with andwithout the disorder?”), predictive validity(“does the test predict who will develop thedisorder?”), and convergent validity (“do the

test results correlate with other similar mea-sures?”). Reliability assessment (test-retest, in-ternal consistency) is also necessary. Ideally,PTSD screening tools should have a high degreeof sensitivity and at least modest specificity,when compared with expert diagnosis. Al-though the negative consequences of a falsepositive screen for PTSD may be acceptable,because a positive screen should always be fol-lowed by in-depth diagnostic assessment by aqualified mental health professional, the numberof false positives should not be so large as tooverwhelm the available resources for diagnosingand treating PTSD. In contrast, false negativescreens have potentially serious consequences andshould be minimized, as individuals with PTSDwho are not identified may not receive furtherassessment and could potentially be symptomaticfor several years without receiving diagnosis ortreatment.

Review of self-report screening instru-ments. In Table 2 we provide an overview ofthe self-report scales and screening instrumentsthat have been used to detect probable PTSD inmilitary and veteran populations (Blanchard,Jones-Alexander, Buckley, & Forneris, 1996;Brewin, 2005; Carlson, 2001; Davidson et al.,1997; Foa, Cashman, Jaycox, & Perry, 1997;Gore, Engel, Freed, Liu, & Armstrong, 2008;Hammarberg, 1992; Horowitz, Wilner, & Alva-rez, 1979; Hovens, Bramsen, & van der Ploeg,2002; Keane, Caddell, & Taylor, 1988; Marx etal., 2008; Meltzer-Brody, Churchill, & David-son, 1999; Neal et al., 1994; O’Donnell,Creamer et al., 2008; Prins et al., 2003; Weath-ers, Litz, Herman, Huska, & Keane, 1993;Weathers et al., 1996). In the interest of spacewe are unable to discuss all of the instrumentsincluded in Table 2, but additional informationregarding some of the most widely used and/orinnovative instruments is presented below.

Early studies, including the NVVRS, usedtwo self-report instruments to screen for PTSD:the 15-item Impact of Events Scale (Horowitz etal., 1979) and the 35-item Mississippi Scale(Keane et al., 1988). The Mississippi Scale wasultimately the biggest contributor to the diagnos-tic algorithm developed to establish prevalence inthe NVVRS. More recently, the PCL has emergedas the standard self-report instrument for screen-ing military and veteran populations (Weathers etal., 1993). The PCL includes 17 items whichalign with DSM–IV criteria and assess symp-

369PTSD IN VETERANS AND MILITARY PERSONNEL

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Tab

le2

Pos

ttra

umat

icSt

ress

Dis

orde

rSc

reen

ing

Inst

rum

ents

Nam

eN

o.of

item

s

Psyc

hom

etri

cs

Item

stru

ctur

ean

dde

scri

ptio

nC

utof

fsc

ore

Sens

itivi

tySp

ecifi

city

Effi

cien

cy

PTSD

Che

cklis

t(P

CL

)(B

lanc

hard

etal

.,19

96;

Wea

ther

set

al.,

1993

)17

0.78

–0.9

40.

83–0

.86

0.83

–0.9

0R

ate

how

muc

hsp

ecifi

cpr

oble

ms

have

both

ered

patie

ntin

the

past

mon

thra

ngin

gfr

om1

(not

atal

l)to

5(e

xtre

mel

y)

Var

ies

Prim

ary

Car

ePo

sttr

aum

atic

Stre

ssD

isor

der

Scre

en(P

C-P

TSD

)(P

rins

etal

.,20

03)

40.

780.

870.

85In

dica

tepr

esen

ce/a

bsen

ceof

nigh

tmar

es,

avoi

danc

e,hy

perv

igila

nce,

and

num

bnes

sin

the

past

mon

thre

sulti

ngfr

oma

trau

mat

icev

ent

3

Dav

idso

nT

raum

aSc

ale

(DT

S)(D

avid

son

etal

.,19

97)

170.

690.

950.

83R

ate

freq

uenc

y/se

veri

tyof

each

sym

ptom

inth

epa

stw

eek

from

0�

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atal

lto

4�

ever

yda

y/ex

trem

ely

dist

ress

ing.

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xper

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ing

sym

ptom

sar

etie

dto

asp

ecifi

cev

ent.

40

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tle,

Phys

iolo

gica

lar

ousa

l,A

nger

,an

dN

umbn

ess

(SPA

N)

(Mel

tzer

-Bro

dyet

al.,

1999

)

40.

840.

910.

88R

ate

freq

uenc

y/se

veri

tyof

sym

ptom

sfr

om0–

45

Scre

enfo

rPo

sttr

aum

atic

Stre

ssD

isor

der

(SPT

SS)

(Car

lson

,20

01)

170.

940.

60R

ate

freq

uenc

yof

sym

ptom

sov

erth

epa

sttw

ow

eeks

from

0(n

ever

)to

10(e

very

day)

4

Impa

ctof

Eve

ntSc

ale

(IE

S)(H

orow

itzet

al.,

1979

;N

eal

etal

.,19

94)

150.

890.

880.

88R

ate

freq

uenc

yof

sym

ptom

sin

past

wee

k(n

otat

all,

rare

ly,

som

etim

es,

and

ofte

n)in

resp

onse

toa

spec

ific

life

even

t

35

Mis

siss

ippi

PTSD

Scal

e(K

eane

etal

.,19

88)

350.

930.

890.

90It

ems

rate

don

afiv

e-po

int

scal

e(r

espo

nses

vary

byite

m),

time

peri

od“s

ince

the

even

t”

107

Sing

leIt

emPT

SDSc

reen

(SIP

S)(G

ore

etal

.,20

08)

10.

760.

79“N

otbo

ther

edat

all,”

“bot

here

da

little

,”or

“bot

here

da

lot”

bya

past

trau

mat

icex

peri

ence

“Bot

here

da

little

War

-Zon

eR

elat

edPT

SDSc

ale

(WZ

-PT

SD)

(Bre

win

,20

05;

Wea

ther

set

al.,

1996

)25

0.87

–0.9

00.

65–0

.72

0.81

–0.8

2R

ate

curr

ent

PTSD

sym

ptom

s(o

ccur

ring

inth

epa

st7

days

)on

afiv

e-po

int

scal

e

1.3

370 GATES, HOLOWKA, VASTERLING, KEANE, MARX, AND ROSEN

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toms during the past month, using a scalefrom 1 (not at all) to 5 (extremely). A positivescreen for PTSD is typically determined basedon either a cutoff score (e.g., a score of 50 orhigher) or DSM criteria (i.e., the presence ofone reexperiencing symptom, three avoidancesymptoms, and two arousal symptoms), or acombination of both criteria (Hoge et al., 2007).In a sample of Vietnam veterans, the PCL dem-onstrated excellent test–retest reliability (0.96)and internal consistency (0.97), and adequatesensitivity (0.82) and specificity (0.83) using acutoff score of 50 (Weathers et al., 1993). How-ever, more recent studies in veteran populationssupport the use of a lower cutoff for the PCL(Bliese et al., 2008; Yeager, Magruder, Knapp,Nicholas, & Frueh, 2007); Yeager et al. (2007)reported a sensitivity and specificity of 0.81using a cutoff of 31, versus a sensitivity of 0.53and a specificity of 0.95 using a cutoff of 50,while a recent study by Dunn et al. (2011)reported an optimal cutoff of 44 based on areceiver operating characteristic curve, with asensitivity of 0.81 and a specificity of 0.83.Differences in the sensitivity and specificity fora given cutoff score and the optimal cutoff scoreacross studies may be attributable to populationcharacteristics such as the severity of PTSDsymptoms, the interrater reliability of thescreening instrument, or differences in the “goldstandard” diagnostic assessment to which thescreening instrument is compared (Warner,2004). Because it is a relatively brief measure,the PCL is easily implemented in survey studiesand has been widely used in military (Hoge etal., 2004; Smith et al., 2008) and veteran pop-ulations (Hoge et al., 2007; Kline et al., 2010) asa measure of probable PTSD and PTSD symp-tom severity. In addition, a brief screening in-strument has been derived from the PCL (Lang& Stein, 2005).

The Davidson Trauma Scale consists of 17items, with self-ratings of both frequency andseverity for each symptom on a five-pointscale (Davidson et al., 1997). It has beenvalidated for use in military and veteran pop-ulations (McDonald, Beckham, Morey, &Calhoun, 2009) and demonstrated adequate tes-t–retest reliability (0.86) and internal consis-tency (0.97–0.99) in a mixed trauma sample of353 individuals, including 110 male war veter-ans (Davidson et al., 1997). In a study of U.S.veterans who served after September 11, 2001,T

able

2(c

onti

nued

)

Nam

eN

o.of

item

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Psyc

hom

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dde

scri

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utof

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Sens

itivi

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ecifi

city

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cien

cy

PTSD

Stat

istic

alPr

edic

tion

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rum

ent

(PSP

I)(M

arx

etal

.,20

08)

120.

86–0

.99

0.36

–0.8

0.78

–0.8

7T

wel

veite

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that

sign

ifica

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pred

ict

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diag

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imal

lyef

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e(P

AS-

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nell,

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amer

etal

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100.

820.

84Fi

ve-i

tem

seve

rity

-bas

edL

iker

tsc

ale

rang

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from

“Not

atal

l”to

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ally

16

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-Rat

ing

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ntor

yfo

rPT

SD(S

RIP

)(H

oven

set

al.,

2002

)22

0.86

0.71

0.78

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-poi

ntL

iker

tsc

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from

“not

atal

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“ver

ym

uch”

ratin

gsy

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omin

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ity

52

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ntor

yfo

rPT

SD(H

amm

arbe

rg,

1992

)26

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94–1

.00

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–0.9

74

scal

edse

nten

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mea

suri

ngpr

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abse

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ofPT

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oms,

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trau

mat

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iagn

ostic

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e(P

TD

S)(F

oaet

al.,

1997

)49

0.89

0.75

Sym

ptom

freq

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ona

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efr

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k”

371PTSD IN VETERANS AND MILITARY PERSONNEL

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a cutoff score of 32 resulted in a sensitivityof 0.97, a specificity of 0.91, and an overallefficiency of 0.94 (McDonald et al., 2009).

A general trend in screening instrument de-velopment is the drive to create measures thatare as brief as possible but still retain excellentpsychometric properties. This, coupled with thefact that PTSD is commonly unrecognized inprimary care settings, led to the development ofthe PC-PTSD, a brief screening tool for PTSDthat is easily administered and scored by non-mental health professionals (Prins et al., 2003).The PC-PTSD consists of four items that assesssymptoms of reexperiencing, numbing, avoid-ance, and hyperarousal (Prins et al., 2003). In avalidation study conducted among 352 postde-ployment soldiers, Bliese et al. (2008) reporteda weighted sensitivity and specificity of 0.76and 0.92, respectively, using a cutoff score of 3.

The Startle, Physiological Arousal, Anger,and Numbness instrument is another four-itemself-report measure developed from the severityitems of the Davidson Trauma Scale (Meltzer-Brody et al., 1999). Among veterans seen in aVA primary care setting, the sensitivity andspecificity were 0.74 and 0.82, respectively, us-ing a cutoff score of 5 and comparing the resultsto the Clinician-Administered PTSD Scale(Yeager et al., 2007).

Gore and colleagues (2008) recently developeda single-item PTSD measure with a three-pointresponse scale ranging from “not bothered” to“bothered a lot.” However, the psychometricproperties of the single-item measure were in-ferior to the four-item PC-PTSD; the sensitivityand specificity in a military primary care settingwere 0.76 and 0.79, respectively, for those whowere “bothered a little” by a past traumaticexperience. In contrast, the PC-PTSD had asensitivity of 0.91 and a specificity of 0.84 inthis population, based on a cutoff score of 2(Gore et al., 2008).

Screening for PTSD resulting from pre-military or military sexual trauma. In ad-dition to combat, PTSD symptoms among vet-erans and military personnel may originate frompremilitary or military sexual trauma. VA sur-veillance data suggest that 22% of females and1% of males experience sexual trauma while inthe military (Suris & Lind, 2008); however,estimates vary across studies and the true prev-alence may be even higher because of underre-porting (Suris & Lind, 2008; Valente & Wight,

2007). Given the scope of the problem, specificscreening measures have been developed to as-sess PTSD symptoms related to military sexualtrauma. For example, the VHA implementeduniversal screening for military sexual traumausing a two-item instrument, which has beensuccessful in identifying individuals for referralto mental health services (Kimerling et al.,2007; Kimerling, Street, Gima, & Smith, 2008).Both questions have high sensitivity (0.89–0.92) and specificity (0.89–0.90), comparedwith a clinical interview, and a positive screenhas been associated with a significantly in-creased odds of PTSD (adjusted odds ra-tio � 8.83 for women and 3.00 for men) (Ki-merling et al., 2007).

Screening for PTSD in women and racial/ethnic minorities. As noted above, militarysexual trauma is an important considerationwhen screening women for PTSD. Screeninginstruments should be designed to accuratelydiagnose PTSD regardless of the gender or race/ethnicity of the individual being screened, andthe reliability and validity of instruments shouldbe assessed in diverse populations (Frueh et al.,1998). Because several studies have reportedracial/ethnic differences and a high prevalenceof PTSD among minority veterans (Frueh et al.,1998; Loo et al., 2005; Seal et al., 2007), vali-dation studies of current and future screeninginstruments should include adequate numbersof minority participants to ensure the represen-tativeness of relevant domains and items in mi-nority respondents.

Predictive assessments for risk of develop-ing PTSD. Although symptom-based PTSDscreening instruments may help to reduce mor-bidity related to PTSD by allowing for earlierintervention, they are limited by their inabilityto prevent the onset of PTSD in individualsexposed to trauma. Recent research suggeststhat measures designed to quantify informationabout risk and resilience factors for PTSD canbe used to identify asymptomatic, trauma-exposed individuals who are more likely to de-velop PTSD. O’Donnell and colleagues devel-oped a screening tool that identifies hospitalizedadults at high risk of PTSD or major depression(O’Donnell, Creamer et al., 2008). In this study,527 civilians hospitalized with nonlethal inju-ries answered questions related to 13 risk fac-tors for PTSD. Patients were assessed 12months later for the presence of PTSD or major

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depression. Responses from half of the partici-pants were used in factor analyses to derive the10-item Posttraumatic Adjustment Scale, whichwas then validated in the remaining partici-pants. After 12 months, 8% of participants haddeveloped PTSD, and the scale had moderatesensitivity (0.82) and specificity (0.84) whenpredicting PTSD diagnoses (O’Donnell,Creamer et al., 2008).

In another recent study, Marx et al. (2008)used data from 1,081 Vietnam era veterans todevelop and test a similar screening instrumentfor combat-related PTSD. Participants com-pleted self-report measures and structured inter-views for PTSD and supplied information onrisk and resilience variables. Participants weredivided into three subsamples, two of whichwere used to identify variables that differenti-ated between individuals with and withoutPTSD. Twelve risk and resilience items wereincluded in the resulting PTSD Statistical Pre-diction Instrument, which was validated usingthe remaining subsample. This instrument dis-played adequate sensitivity (0.86) and moderatespecificity (0.77) in the validation sample, usinga cutoff score of 6, and strong internal consis-tency (0.84) (Marx et al., 2008). These resultssuggest that primary prevention of PTSD maybe possible in military and veteran populations,which would be expected to result in improvedoutcomes and decreased health care utilizationby PTSD patients.

Psychophysiological screening. In addi-tion to traditional questionnaire-based assess-ments, some research suggests that psychophys-iological testing, such as the acoustic startleresponse and heart rate variability, may havepotential applications for PTSD screening. Sev-eral studies have reported that veterans withPTSD have decreased heart rate variability(Tan, Dao, Farmer, Sutherland, & Gevirtz,2011; Tan et al., 2009) and a heightened acous-tic startle response (Butler et al., 1990; Morgan,Grillon, Southwick, Davis, & Charney, 1996;Orr, Lasko, Shalev, & Pitman, 1995), raisingthe possibility that these measures could be usedto identify individuals with undiagnosed or pre-clinical PTSD. However, the use of biologicalassays and psychophysiological methods for as-sessment and screening is still in the early de-velopmental stages and additional research onthe utility of these measures for screening pur-poses is needed.

Risks and limitations of screening instru-ments. Despite the intense effort and interestin developing methods to screen for symptomsof PTSD in military and veteran populations, allof the current methods have inherent limita-tions. For example, all self-report scales may bevulnerable to response bias from varioussources (Elhai, Frueh, Davis, Jacobs, & Ham-ner, 2003). Concerns about the potential impli-cations of positive (or negative) screening re-sults may lead to over- or underreporting ofsymptoms, depending on the individual and cir-cumstances of testing. In addition, reliance on asingle measure or assessment methodology maylead to inaccurate diagnosis in many cases anda large number of false positives and negatives.

As a result of these limitations, it has becomestandard practice to use multiple methods andmeasures to better inform diagnostic decisions(Weathers, Keane, & Foa, 2009). Such multim-ethod assessment of PTSD takes advantage ofeach individual measure’s relative strengths,overcoming the potential psychometric limita-tions of any single instrument and maximizingcorrect diagnostic decisions. On the other hand,the use of multiple assessment methods reducescost efficiency and increases the respondent andclinician burden in proportion to the number ofinstruments used. In determining cut points orcriteria for further evaluation, it is generallypreferable to err on the side of increased sensi-tivity, rather than specificity, in the use of suchscreeners. All other things being equal, a mod-est number of false positives may be acceptableon the initial shorter screening measure, fol-lowed by perhaps longer but increasingly accu-rate and specific measures. For instance, Felkerand colleagues (Felker, Hawkins, Dobie, Guti-errez, & McFall, 2008) used the four-itemPC-PTSD followed by the longer PCL. Otherresearchers found that using a composite mea-sure, created from various self-report symptom-based measures, led to increased diagnosticaccuracy, compared with the use of several in-dividual measures (Wright et al., 2007).

Additional resources for clinicians. Inaddition to the references noted above and thoseincluded in Table 2, several resources related toPTSD screening are available through the VA.The VA/DoD Clinical Practice Guideline forthe Management of Post-Traumatic Stress (De-partment of Veterans Affairs, 2004) includesinformation on PTSD screening and treatment,

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as well as monitoring and follow-up of patientswith potential PTSD. The VA National Centerfor PTSD website (Department of Veterans Af-fairs, 2011) includes extensive resources onPTSD for both clinicians and researchers, in-cluding an overview of PTSD screening instru-ments.

Discussion

Although numerous symptom checklists andself-administered questionnaires have been de-veloped, there is no compelling evidence thatone screening instrument outperforms the oth-ers in veteran and military populations. Severalinstruments have adequate psychometric prop-erties and have been used successfully to screenfor PTSD in active duty military personnel andveterans. In general, short measures seem to doas well as longer questionnaires and thereforeshould be used whenever possible to decreasethe time and effort required to screen for PTSD.When appropriate, short screening instrumentsmay be followed by longer measures withgreater specificity to decrease the number offalse positive screens. Continued evaluation ofnew and existing screening measures, and inparticular validation against more rigorous di-agnostic methods, is needed to ensure that thescreening measures in use are detecting cases ofprobable PTSD while minimizing the numberof missed diagnoses.

Screening programs such as those imple-mented by the DoD and VA have been success-ful in identifying individuals with presumptiveor probable PTSD. Individuals who screen pos-itive are then referred for further clinical assess-ment and diagnostic evaluation by a mentalhealth professional, who might also providetreatment of the disorder as needed. By detect-ing and treating patients as soon as possibleafter the onset of symptoms, screening maycontribute to a shorter duration of disease andmore favorable outcomes (Kessler et al., 1995).In addition, screening instruments have beenused in large-scale surveys to evaluate the prev-alence of key symptoms of PTSD before andafter deployment, and to identify subgroups ofindividuals at increased risk for PTSD and re-lated conditions, such as substance abuse anddepression. However, despite the potential ben-efits of screening, there are also several limita-tions. Current screening programs detect symp-

toms of PTSD in individuals who already showsigns of the disorder; therefore, these programsmay lead to earlier diagnosis and treatment, butmay not prevent the onset of PTSD symptoms.Although some research has evaluated the ef-fectiveness of predeployment screening, thequestion remains as to whether screeningasymptomatic individuals can result in accurateidentification of a sufficient number of militarypersonnel at risk for future PTSD, and whetherthose who screen positive are more likely toobtain and benefit from services. Rona and col-leagues found little benefit of predeploymentscreening for predicting subsequent onset ofPTSD, in part because of the low prevalence ofPTSD in the sample (Rona et al., 2006). Addi-tional limitations of screening include the factthat individuals with symptoms of PTSD maybe less likely to participate in screening pro-grams (Rona, Jones, French, Hooper, & Wes-sely, 2004) or seek treatment (Sayer et al.,2009). These findings raise serious concerns, asthe individuals with greatest need of diagnosisand treatment may be least likely to receive it.

Further, individuals exposed to military-related trauma may have multiple adverse ef-fects, and PTSD may not be the most immediateconcern after trauma exposure. For example, ina recent study of British troops deployed to Iraqor Afghanistan the prevalence of probablePTSD was only 4%, compared with 13% foralcohol abuse and 20% for symptoms of otherpsychiatric disorders (Fear et al., 2010). How-ever, several studies have reported an increasein PTSD prevalence with increasing time sincereturn from deployment (Bliese et al., 2007;Kang, Li, Mahan, Eisen, & Engel, 2009; Mil-liken et al., 2007), suggesting that continuedsurveillance and screening for PTSD areneeded.

In summary, PTSD is a potentially disablingmental disorder that is common among activeduty military personnel and veterans. Preva-lence studies and large scale screening pro-grams have helped to define the scope of theproblem in military and veteran populations,while epidemiologic studies have improved ourunderstanding of the etiology of the disorderand the characteristics of those at highest risk.Although research and interest in this field hasgrown in recent years, there is still much to belearned about the risk, detection, natural history,and treatment of PTSD. In particular, prospec-

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tive studies of military cohorts that begin beforedeployment and follow individuals for traumaexposure and its sequelae will help to improveour understanding of the epidemiology and de-tection of PTSD, while longitudinal registries ofPTSD patients will help to elucidate the mosteffective treatment regimens and other factorsinfluencing recovery. Given the debilitating na-ture of the symptoms of PTSD and the serious-ness of the associated medical conditions, addi-tional research on PTSD should be an area ofhigh priority.

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Received December 17, 2010Revision received December 7, 2011

Accepted December 29, 2011 �

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