PTSD: National Center for PTSD

PTSD Screening and Referral: For Health Care Providers

Health care providers are often the first point of contact for individuals with trauma-related experiences and PTSD symptoms. We review reasons for screening and introduce the Primary Care PTSD Screen for DSM-5 (PC-PTSD-5). We also provide suggestions for how to respond to patients after screening, including how to provide a referral for those who screen positive for PTSD.

Why Is It Important to Be Aware of Trauma and PTSD in Health Care Settings?

There are several reasons why it is valuable for health care providers to assess patients for a history of trauma exposure and PTSD. Some of the most important reasons are:

• Traumatic experiences and PTSD are common. Seventy percent of adults in the U.S. will experience at least one trauma in their lifetime and the lifetime PTSD prevalence is 6.1% (1).
• PTSD is highly comorbid with other disorders. In civilian, military and Veteran samples, comorbidity, such as with depression, appears to be the rule rather than the exception (2-4).
• PTSD affects health and health care utilization. PTSD is associated with a range of poor health outcomes such as arterial, musculoskeletal, gastrointestinal, dermatologic, autoimmune, and cerebrovascular conditions (5). Individuals with PTSD are also more likely to utilize health care services (6,7).
• PTSD is underrecognized by health care providers. Most patients with PTSD are not properly identified and are not offered education, counseling or referrals for mental health evaluation (8). Additionally, many patients avoid talking about their trauma, making it even less likely that patients will spontaneously report their trauma experiences or related symptoms.

What Can Health Care Providers Do?

Health care providers can increase the chances of improved health outcomes for their patients by following these steps:

• Screen for PTSD
• Discuss the results
• Provide a referral
• Provide educational materials
• Follow up with the patient

Screen for PTSD

Providers can use a screening questionnaire to ask about trauma-related symptoms. You can ask the patient to complete the screening questionnaire prior to their appointment. Completed screens can be collected and reviewed by the primary care provider.

The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) is a 5-item screen designed to identify individuals with probable PTSD in primary care settings (9,10). If a respondent endorses a trauma exposure, they can score 0-5 on the screen, which reflects a count of "yes" responses to 5 questions about how the trauma has affected them in the past month. Research in a large sample of VA primary care patients found that a cut-point of 4 ideally balanced false negatives and false positives for the overall sample and for men (10). However, a cut-point of 3 may be better for women Veterans and for settings where additional evaluation resources are available (10).

You can read more detailed information and download the PC-PTSD-5 to help inform your decisions. Or refer patients to our online, interactive version.

Discuss the results

Here are a few general tips:

• Screening results should always be communicated to the patient. Remember to provide an appropriate context for the discussion. Ensure privacy by closing the door and keeping family members out of the room.
• Show interest and concern and tell the patient that you are glad that they told you about their symptoms. Offer empathic support.
• Normalize screening and let the patient know that trauma-related experiences can impact their physical and mental health. For example, "I ask all my patients these screening questions because we know that trauma can impact health and health care. For example, it's helpful to know if sleep is disrupted because of trauma-related nightmares, or if certain medical procedures are difficult because of trauma-related experiences."
• Unless you have appropriate mental health training and will be the person to evaluate or treat the patient, it is not advisable to elicit a detailed account of the trauma or to challenge the patient's report in any way.

When a patient screens positive, the following suggestions may facilitate further discussion:

• Extend appreciation for the patient's willingness to share their trauma-related distress with you. "Thank you for letting me know that you are struggling with some trauma-related symptoms."
• Give the result: "The results of your screen suggest you may have PTSD."
• Acknowledge any reported distress: "I'm sorry you have had such terrible nightmares."
• Make no assumptions about the meaning or impact of traumatic events for an individual; your assumptions may be inconsistent with the patient's feelings and experience.
• Determine if the reported symptoms are disruptive to the patient's life: "How have these thoughts, memories, or feelings affected your life? Have they interfered with your relationships? Your work? How about with recreation or your enjoyment of activities?"
• Ascertain whether traumatic events are ongoing in a patient's life. If so, it is critical that you determine whether the patient needs an immediate referral for social work or mental health services. You might ask: "Are any of these dangerous or life-threatening experiences still continuing in your life now?" If ongoing family violence or safety concerns are suspected, it is imperative that the patient be told the limits of confidentiality for medical professionals, who are mandated to report suspected abuse of children and dependent adults. Discussion of possible abuse should take place in the absence of the suspected perpetrator. The goal is to develop a safety plan that increases rather than decreases the safety of the patient and their loved ones.

When a patient screens negative on the PC-PTSD-5, it's important to normalize their results and to determine if additional assessment is needed.

• Normalize a negative screen: "Despite traumatic events in your past, the results of your screen suggest that you are not experiencing posttraumatic stress disorder. This is often the case--most people do not develop PTSD after a traumatic event."
• If additional assessment is needed, try to facilitate a warm handoff to a mental health provider. Make sure the patient has the name and number of the mental health provider.

Provide a referral

After a review of the screen results and a discussion with the patient, the provider can decide whether the patient may benefit from further evaluation or treatment. Referrals can be made to mental health or behavioral specialists in primary care, or to general mental health or PTSD specialty clinics.

• Explain why the screen results lead you to recommend further evaluation and/or treatment. For example: "Screening positive does not mean that you have PTSD, it means that you might have PTSD and that it would be a good idea to meet with a mental health professional for follow up."
• Encourage the patient to ask any questions they might have about assessment or treatment.
• Let the patient know that there are effective treatments for PTSD and that they have options. For example: "Although additional assessment is needed to determine if you have PTSD, I want you to know there are a number of PTSD treatments that have been shown to reduce symptoms and other trauma-related problems like difficulties with functioning or relationships. The most effective treatments are trauma-focused talk therapies but there are other talk therapies and medications that have also been shown to work."
• Provide the patient with a written referral to a mental health professional.
• If the patient does not want a referral, you can still provide educational resources. Additionally, with the patient's permission, you could involve the patient's spouse or partner in the discussion.

When possible, provide the mental health professional to whom you refer the patient:

• A copy of the PC-PTSD-5 results
• Any relevant information about health events or injuries that might have been traumatic
• Information about any suspected negative impact of the patient's posttraumatic symptoms on health or medical compliance (e.g., avoidance of medical procedures or treatments)

Provide educational materials

Educational materials can be provided to all patients who are experiencing trauma-related difficulties. Many print materials are available for you to download or order to have on-hand, including our Understanding PTSD booklet series. Here are a few suggestions for web-based educational products:

• For patients who are unsure if they want to engage with PTSD care, recommend AboutFace, a website featuring real stories of Veterans with PTSD and their experiences with PTSD symptoms and treatment.
• For patients considering treatments for PTSD, recommend the PTSD Treatment Decision Aid, a user-friendly web tool to learn about options and identify treatment preferences.
• For patients wanting self-management strategies, recommend the PTSD Coach mobile app. There is also a desktop (web-based) version, PTSD Coach Online.
• For partners/families wanting to encourage participation in PTSD treatment, recommend the web-based training CRAFT-PTSD.

Follow up with the patient

At the patient's next visit, it is important to ask whether they followed through with the referral for mental health evaluation or care. If the patient did follow through, you can ask if the referral was perceived as helpful. If the patient did not follow through with the referral and is still in need of care, try to learn what the obstacles were to obtaining care.

Consider scheduling frequent brief office visits or telephone follow-ups. Regular check-ins with patients about their current functioning as well as follow-ups on referrals are important for keeping patients involved in their own recovery process.

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Identify A PTSD Consultant

It may be helpful for you, the health care provider, to identify a mental health professional trained in PTSD. This mental health provider can offer additional assessment and treatment information as well as support for referrals and patient education. Working with a PTSD consultant can also help you detect and manage PTSD in your health care setting. For providers treating Veterans, you can contact the PTSD Consultation Program for advice at any time.

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Conclusion

Trauma-related problems are common among the general population and Veterans, and such problems can affect physical and psychological functioning as well as use of health care services. However, PTSD is often underrecognized by medical practitioners, resulting in patients not being offered the effective treatments that are available. It is recommended that health care providers routinely screen individuals for trauma-related symptoms. Use of a PTSD screen increases a health care provider's ability to detect PTSD and to initiate appropriate referral.

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References

1. Goldstein, R.B., Smith, S. M., Chou, S. P., Saha, T. D., Jung, J., Zhang, H., Pickering, R. P., Ruan, W. J., Huang, B., & Grant, B. F. (2016). The epidemiology of DSM-5 posttraumatic stress disorder in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. Social Psychiatry and Psychiatric Epidemiology, 51,1137-1148. https://www.doi.org/10.1007/s00127-016-1208-5
2. Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant, B. F. (2012). Psychiatric comorbidity of full and partial posttraumatic stress disorder among older adults in the United States: Results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. The American Journal of Geriatric Psychiatry, 20(5), 380-390. https://doi-org.libaccess.sjlibrary.org/10.1097/JGP.0b013e31820d92e7
3. Walter, K. H., Levine, J. A., Highfill, M. R. M., Navarro, M., & Thomsen, C. J. (2018). Prevalence of posttraumatic stress disorder and psychological comorbidities among US active duty service members, 2006-2013. Journal of Traumatic Stress, 31(6), 837-844. https://doi-org.libaccess.sjlibrary.org/10.1002/jts.22337
4. Smith, S. M., Goldstein, R. B., & Grant, B. F. (2016). The association between post-traumatic stress disorder and lifetime DSM-5 psychiatric disorders among Veterans: Data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III). Journal of Psychiatric Research, 82, 16-22. https://doi-org.libaccess.sjlibrary.org/10.1016/j.jpsychires.2016.06.022
5. Schnurr, P. P., Wachen, J. S., Green, B. L., & Kaltman, S. (2021). Trauma exposure, PTSD, and physical health. In M. J. Friedman, P. P. Schnurr, & T. M. Keane (Eds.), Handbook of PTSD: Science and practice, 3rd ed. (pp. 462-479). The Guilford Press.
6. Klassen, B. J., Porcerelli, J. H., & Markova, T. (2013). The effects of PTSD symptoms on health care resource utilization in a low‐income, urban primary care setting. Journal of Traumatic Stress, 26(5), 636-639. https://doi-org.libaccess.sjlibrary.org/10.1002/jts.21838
7. Possemato, K., Wade, M., Andersen, J., & Ouimette, P. (2010). The impact of PTSD, depression, and substance use disorders on disease burden and health care utilization among OEF/OIF veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 2(3), 218-223. https://doi-org.libaccess.sjlibrary.org/10.1037/a0019236
8. Joneydi, R., Lack, K. A., Olsho, L., Corry, N. H., & Spera, C. (2021). Addressing Posttraumatic Stress Disorder in Primary Care: Primary Care Physicians' Knowledge, Confidence and Screening Practices Related to PTSD Among Military Populations. Medical care, 59(6), 557-564. https://doi.org/10.1097/MLR.0000000000001546
9. Prins, A., Bovin, M. J., Smolenski, D. J., Marx, B. P., Kimerling, R., Jenkins-Guarnieri, M. A., Kaloupek, D. G., Schnurr, P. P., Kaiser, A. P., Leyva, Y. E., & Tiet, Q. Q. (2016). The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5): Development and Evaluation Within a Veteran Primary Care Sample. Journal of general internal medicine, 31(10), 1206-1211. https://doi.org/10.1007/s11606-016-3703-5
10. Bovin, M. J., Kimerling, R., Weathers, F. W., Prins, A., Marx, B. P., Post, E. P., & Schnurr, P. P. (2021). Diagnostic Accuracy and Acceptability of the Primary Care Posttraumatic Stress Disorder Screen for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) Among US Veterans. JAMA network open, 4(2), e2036733. https://doi.org/10.1001/jamanetworkopen.2020.36733

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