Posttraumatic Stress Disorder Screening Practices: A 2010 Internet Assessment of Customary Care

Posttraumatic Stress Disorder Screening Practices: A 2010 Internet Assessment of Customary Care

Jennifer J. Brown, PhD, and Richard H. Weisler, MD

Objective: Posttraumatic stress disorder (PTSD) is a signature injury of war among returning soldiers and US National Guard and Reserve members, with symptoms even more likely on rescreening. Studies that examine health care provider screening and referral practices outside the military for these patients are needed. The objective of this study was to assess health care provider PTSD practices and barriers to care.

Method: A 25-item, anonymous Internet questionnaire was developed as an educational needs assessment survey based on the US Department of Veterans Affairs and Department of Defense PTSD guideline and the companion, primary care-directed PTSD Screening and Referral for Health Care Providers of the National Center for PTSD. The assessment design included patient vignettes followed by multiple-choice questions and was distributed on the Internet to health care providers free of charge and without compensation. Of 1,338 participant health care providers, mainly from primary care and mental health specialties, 507 responded to the questions. Participant privacy was maintained for the self-assessment survey, and all responses were deidentified and analyzed in aggregate. Overall participant responses and subgroups of primary care and mental health questionnaire responses were scored against guidelines. Participant data responses to survey questions were collected from August 20, 2010, to October 3, 2010.

Results: Gaps in screening skills compared with guidelines were shown, as PTSD diagnosis questions were correctly answered by 51% of primary care and 56% of mental health providers. Real-world screening and referral differed from guidelines, as only 24% of primary care and 48% of mental health providers have a system in place to routinely screen for mental health in their patients who are returning service members. Only 25% of primary care providers had access to referral to mental health services, showing large gaps in care. Stigma associated with mental disorders was the practice barrier most frequently cited by health care providers.

Conclusions: The study identified gaps in PTSD screening and linkage to care among health care providers. Further training efforts and resources are needed to screen patients and to reduce barriers to care.

Prim Care Companion CNS Disord 2011;13(5): doi:10.4088/PCC.11m01171

© Copyright 2011 Physicians Postgraduate Press, Inc.

Submitted: February 18, 2011; accepted May 9, 2011.

Published online: September 22, 2011.

Corresponding author: Jennifer J. Brown, PhD, 825 Eighth Ave, 11th Floor, New York, NY ([email protected]).

The prevalence of posttraumatic stress disorder (PTSD) in the United States is approximately 8%,1 with higher rates among returning service members.2-4 Recent surveys of soldiers and US National Guard and Reserve members who returned from active duty found a PTSD prevalence of 12% to 25%, with symptoms even more likely on rescreening,3 along with persistent, significant functional impairment.5 Since over 2 million men and women have served in Afghanistan and/or Iraq, improved screening for PTSD and other mental health disorders of returning veterans has become a renewed focus in community and primary care settings, as well as a national priority.6,7 However, surveys show that less than half of patients who need care actually seek it.2,8,9 We are not aware of any studies that examine PTSD screening and referral practices outside the military for patients who return from active duty. While studies have documented patients’ barriers to care,10 we are not aware of any studies of the barriers that health care providers experience.

Survival of environmental disasters also causes high rates of PTSD and increased need for mental health screening. For example, 11% of workers screened after the World Trade Center attacks had probable PTSD.11 Increased PTSD symptoms of up to 19%12 were reported after hurricanes Katrina and Rita.13 Delivery of care was widely disrupted, and mental health care use declined for veterans.14

The goal of this descriptive study was to assess customary PTSD screening and referral practices of US health care providers using an anonymous, self-administered Internet questionnaire. The study assessed gaps and barriers in current PTSD screening and referral practices compared with the established guideline from the US Department of Veterans Affairs and Department of Defense and the companion, primary care-directed PTSD Screening and Referral for Health Care Providers of the National Center for PTSD.15,16

Method

Design

A 25-item, anonymous Internet assessment questionnaire in multiple-choice question format was developed on the basis of an evidence-based Department of Veterans Affairs and Department of Defense PTSD guideline written by the department working group and intended for all health care providers in the Veterans Affairs setting. In addition, recommendations from the National Center for PTSD directed toward health care providers in the primary care setting were considered (Table 1).15-17 The main points of these guidelines are awareness of the knowledge gap and problem of underrecognition, improvement of routine primary care screening, collaborative decision making using effective communication, diagnosis of symptoms and comorbidities, and appropriate referrals for coordinated and sustained follow-up of patients.

The assessment used 2 patient vignettes. Patient vignettes are valid assessments of clinical practices, which studies have shown are comparable to chart reviews.18,19 Cases and questions were designed to assess gaps by addressing clinical points in the guideline regarding screening and referral.15

The first case described a soldier who had recently returned from combat duty to assess practices in combat-related stress. The second case described a police officer after Hurricane Katrina to assess environmental disaster-related stress. Stress disorder can result from other common traumas such as illness, abuse, and violence as noted in the guidelines; however, these traumas were not included in the 2 case descriptions used. Questions tested PTSD knowledge (6 questions) and screening practices (7 questions) in multiple-choice, single-best-answer format. Additional questions assessed use of screening tools, perceptions of self-efficacy, and barriers to care (7 questions) in multiple-choice format. Demographic questions identified practice setting, patient load, proportion of service members in the practice, and linkage to referral (5 questions).

Polling results were displayed giving immediate feedback to each participant after every question. This feedback showed bar graph averages of aggregate responses from all participants. The features of interactivity and comparison to peers are effective Internet teaching methods for health care professionals.20 The program is freely available online at http://www.medscape.com/viewarticle/727096.

Participants

Participants were actively recruited through newsletters emailed to registered members of the health care information Web site (http://www.medscape.com) and through online placement with integrated search terms. Participants were informed that the self-assessment tested knowledge and practices and that data would identify clinical practice gaps. Registration at the Internet site as a US health care provider, which is free of charge, was an inclusion criterion, and no compensation was offered for survey participation. No clinical specialties were excluded because any provider is highly likely to care for patients with prior trauma. The most relevant participant subgroups for analysis were defined as psychiatry/mental health and primary care providers (family medicine and internal medicine) because these providers care for the majority of patients with PTSD.16 Although veterans also may seek professional help from a member of the clergy, this group was not available in the study population.

Measurements

Participant data responses to survey questions were collected from August 20, 2010, to October 3, 2010. All data were deidentified and aggregated to maintain confidentiality of participants’ information and sorted based on profession or specialty. In planning the design, a response of 100 providers was considered sufficient to identify existing gaps in care and to extrapolate to similar health care provider practices. A response of 507 eligible participants was achieved within the study period, and all responses were used in the analysis and reporting. Responses were scored by concordance with the guideline for hypothesis testing.15 Overall mean scores and primary care and mental health provider subgroups were reported to identify any gaps.

RESULTS

Participant Characteristics

During the 6-week study period, 1,338 health care providers accessed the Internet PTSD assessment online. Of these, approximately 22% (n = 289) to 38% (n = 507) of participants responded to 1 or more of the multiple-choice questions, and the rate of response varied by question. Participation was highest for physicians; the next largest professional groups represented were health business administration professionals, nurses and nurse practitioners, and psychologists (Table 2). The top clinical specialties represented were mental health and primary care providers.

Clinical practice settings included community mental health centers (33%), Veterans Affairs hospitals (19%), private practice (14%), group practice (12%), academic hospitals (13%), and community hospitals (9%). These settings are representative of those that returning service members and disaster survivors utilize. Inclusion of providers outside the military was important, as most patients with symptoms of PTSD present initially to primary care providers, and many may not have easy access to military facilities for care.20

Gaps in Knowledge and Confidence

Gaps in knowledge of PTSD epidemiology, symptom presentation, and diagnostic criteria were identified by comparison with the US Department of Veterans Affairs and Department of Defense guideline (Table 3).15 Appropriate responses were selected by 67% of primary care providers, 75% of respondents in mental health specialties, and 67% of respondents overall, demonstrating gaps of 25% to 33% compared with the guideline. Appropriate responses on individual questions ranged from 39% to 94%. Intraquestion variability between primary care providers and mental health groups was small (12% or less).

Prevalence of PTSD among soldiers was identified by 39% of primary care providers, 43% of mental health providers, and 45% of respondents overall, demonstrating a large gap. Approximately half of respondents knew that the Primary Care PTSD Screen (PC-PTSD) takes 2 minutes or less, as noted in the guideline,15,21 and half overestimated the time required for this multiple-choice question. The largest group estimated 5 minutes, and 18% estimated 6-10 minutes. Sixty-two percent of primary care providers, 54% of mental health providers, and 59% of respondents overall recognized a positive screen (presence of 3 of 4 symptoms on the 4-item PC-PTSD). In contrast, nearly all respondents knew that patients present with somatic symptoms and experience functional impairment similar to that of major depression.

The majority of respondents reported low levels of confidence in their own PTSD diagnoses on a scale from “not at all confident” to “very confident” (n = 300). Overall, 59% selected “somewhat confident” or “not at all confident” in screening, while 61% were “somewhat confident” or “not at all confident” in diagnosis. Only 25% were “confident,” and 15% to 17% were “very confident” in screening and diagnosis.

Gaps in Screening Skills

Posttraumatic stress disorder screening practice questions were correctly answered by 51% of primary care providers, 56% of mental health providers, and 53% of respondents overall, showing a large gap compared with the guideline (Table 4).15 The range of appropriate response rates between questions was wide, from 13% to 89%. Intraquestion variability between primary care providers and mental health specialties was small (less than 14%).

In the first case of a soldier who had recently returned from active duty, 78% of primary care practitioners, 88% of mental health practitioners, and 81% of respondents overall would screen for PTSD, indicating agreement with the guideline. After the polling responses of peers were displayed and answer explanations were shown, a second case was presented of a police officer in New Orleans, Louisiana, during Hurricane Katrina. In this case, 87% of primary care practitioners, 89% of mental health practitioners, and 88% of respondents overall would screen for PTSD. Nearly all respondents chose to screen for depression: 95% of primary care practitioners, 100% of mental health practitioners, and 99% of respondents overall. The patient described was using opioid medication for headache pain, a potential risk for medication misuse, abuse, or diversion.22,23 Approximately one-third of respondents chose to mitigate the potential for misuse, abuse, or overdose of opioid: 39% of primary care practitioners, 36% of mental health practitioners, and 32% of respondents overall (Table 4).

Relatively few participants selected steps that the guideline recommends following the positive PTSD screen.15 Twenty-seven percent of primary care providers, 41% of mental health providers, and 31% of respondents overall used the structured interview for diagnosis. Even fewer respondents chose to review positive screens with the patient privately: 16% of primary care providers, 20% of mental health providers, and 18% of respondents overall. When the patient refuses mental health referral, few identified an effective method of communication (19% overall).

Real-World Screening and Referral

Of respondents, only 24% of primary care providers, 48% of mental health providers, and 35% of respondents overall (n = 563) have a system in place to routinely screen for mental health in their patients who are returning service members. This finding identifies a large gap in systems of health care. Approximately half of the respondents use PTSD screening tools in their practices: 43% of primary care providers and 55% of respondents overall (n = 467). Among those who do use screening tools, the PC-PTSD was the most often used among the 9 listed, followed by the short form of the PTSD Checklist24 and the Short Screening Scale for PTSD.25 Only 25% of primary care respondents, 32% of mental health respondents, and 28% of respondents overall (n = 302) had access to referral to mental health services, showing large gaps in care.

Approximately 33% of respondents indicated that 6% to 10% of their patients served in the military, and 28% reported that over 10% served. Providers may have patients who served in the military yet be unaware of this aspect of their history. Overall, respondents reported screening relatively few patients for PTSD; only 23% of providers screened 6 to 10 patients per week. Similarly, 15% of respondents diagnosed PTSD in more than 5 patients per month.

Barriers in identifying PTSD in clinical practice averaged 2 to 3 barriers per participant and included both patient-related and systems-related barriers (n = 289). One of the multiple-choice response options, stigma associated with a mental disorder, was reported 3 times as often as any of the other barriers (n = 303). Causes of perceived stigma are an important area of further study. Additional barriers in order of frequency were need for patient educational resources (n = 104), insufficient time with patients for effective screening (n = 93), lack of availability of referral (n = 88), and lack of access to Veterans Affairs care (n = 75).

DISCUSSION

Results of the Internet assessment of customary care in PTSD screening among US health care providers show gaps in practices compared with guideline recommendations.15 Large gaps exist in use of mental health screening tools developed for primary care, systematic screening, and linkage to care. Each of these items is an area of focus in the current PTSD screening guidelines for both military-associated and primary care settings. Confidence in screening and diagnosis was low. While many trauma types are causes of stress disorder, this assessment focused on those screening practice choices relevant to combat and environmental disaster stress: a soldier recently returned from combat duty and a police officer working in New Orleans, Louisiana, during Hurricane Katrina. In the assessment, PTSD screening, diagnosis, and referral practices failed to meet expectations based on the guideline.15 As PTSD is one of the signature injuries of war, providers need to improve PTSD screening and referral to help heal psychological wounds of returning service people.10,26

Strengths and Limitations of the Study

Strengths of the study include the use of patient vignettes, a valid and reliable measure of practice choices18 that eliminates interpatient variability of practice-based assessments. The cross-section of settings sampled is one strength of the study, as many soldiers returning from combat utilize general medical care outside the military.9 A limitation of the study is selection bias in self-directed learning, as those interested in PTSD would participate. Self-report of practices may be a limitation to the reliability of data; however, large gaps in care indicated that providers did not select strictly socially desirable responses. Further, the study did not assess screening for other causes of trauma, for example, illness, sexual abuse, or domestic violence.

Customary Care Gaps in Screening for PTSD

Because more soldiers report mental health concerns at later screening times, identification of PTSD in the community setting and in primary care has taken on heightened importance.3,5 This assessment’s results reveal that most providers lack systems for routine PTSD screening of returning soldiers. Low rates of screening may relate to the overwhelming task of screening for multiple items in the primary care setting; over 100 items are recommended by the US Preventative Services Task Force, for example. Use of the Patient Centered Medical Home principles may help improve screening, with single or multistage approaches. Mental health screening can be simplified by use of clinical tools in practice; however, results show limited use of existing tools. The Electronic Preventive Services Selector application from the US Preventive Services Task Force includes screening for depression, suicidality, and illicit drug use, but at the time of this study, omitted PTSD screening.

Many providers did not use the short PC-PTSD screen recommended by the guideline; they overestimated the time required and failed to identify a positive screen. The PC-PTSD is best suited for screening and is validated for use in primary care with soldiers returning from combat.27 Therefore, the results indicate that training on its use is needed. The 12-item Short Posttraumatic Stress Disorder Rating Interview (SPRINT-E) was specifically created to measure postdisaster distress, including symptoms such as depression, suicidality, stress vulnerability, and functional disability; however, results show that this tool is unfortunately rarely used in practice.28 The SPRINT-E is also useful for determining the need for referral or treatment, and increased practice skills are needed in this area.

Most providers understood that patients with PTSD are highly likely to present with somatic symptoms.15 These symptoms are often treated with pain medication, yet surprisingly few providers mitigated potential for misuse, abuse, or overdose of opioid pain medication. Misuse can increase impulsivity, increasing risks for accident, injury, or suicide, which is a particular concern in returning soldiers.23,29 Approximately 14% of active-duty military members are reported to be receiving opiate medications, and high rates of opiate use are common after discharge. Concomitant use of alcohol and benzodiazepines increases adverse drug events risk, including suicide and accidental drug poisoning deaths, and both are particular concerns for returning soldiers. Therefore, mitigating the risk for opioid misuse as well as alcohol and other types of drug abuse is an important area in which health care providers need additional training. At the same time, clinicians need to be sensitive to pain relief needs for soldiers who may have also suffered physical injuries that cause pain.

Gaps in Patient Communication

Patients may fear that mental health problems will damage their military future or delay return to their family.9 The guideline stresses the importance of providing privacy to discuss positive results of a PTSD screen.15 A positive screen result means that the patient may have the disorder, not that he or she definitely has it; therefore, diagnosis with a structured interview for PTSD and other mental disorders is needed. Yet, few providers used the structured interview or ensured patient privacy when discussing the screen results. Furthermore, few participants identified effective communication to increase acceptance of a referral by focusing on evaluation rather than on treatment. Skill improvement in these areas may help overcome patient-related barriers to care.

Real-World Barriers to PTSD Screening

Several studies show that survivors of trauma and returning soldiers are reluctant to seek care and often experience barriers to care.9,10,30 In the study reported here, health care providers reported stigma associated with a mental disorder as the greatest barrier to care, similar to the previous reports of patient barriers. This finding emphasizes the importance of working to understand and reduce stigma associated with mental health care, an important area of future study.9 A need for patient education including languages that patients understand highlights a need to improve available resources. The overwhelming burden of screening needs in the primary care setting argues for adopting systems of screening to save time and increase efficiencies in health care delivery. Systems barriers encountered were interrelated; for example, providers are unlikely to screen if they overestimate the time required to use screening tools and when linkage to care is not available for accurate diagnosis and follow-up treatment.

CONCLUSIONS

This practice assessment identified gaps in PTSD knowledge, screening, diagnosis, and linkage to care among US health care providers compared with the guideline.15 Recently, primary care providers have been encouraged to screen returning service members for stress disorders in addition to substance abuse, suicidality, and depression.7 Clinicians need to be aware that suicide rates are increasing in the US Army including the Reserve component, with 239 suicides in 2009 alone and 1,713 attempted suicides.29 Posttraumatic stress disorder, comorbid mood and substance abuse disorders, and traumatic brain injury all further increase the risk of suicide, unintentional drug poisoning deaths, or motor vehicle accident deaths. Additional educational training resources are needed in the health care community to evaluate patients for PTSD following combat experience and disaster exposure in order to implement guideline recommendations.

Author affiliations: Medscape, LLC, New York, New York (Dr Brown); and Duke University School of Medicine, Durham, and University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (Dr Weisler).

Potential conflicts of interest: Dr Weisler receives or has received research support from Abbott, AstraZeneca, Biovail, Bristol-Myers Squibb, Burroughs Wellcome, CeNeRx, Cephalon, Ciba-Geigy, CoMentis, Dainippon-Sumitomo, Eisai, Eli Lilly, Forest, GlaxoSmithKline, Janssen, Johnson & Johnson, Lundbeck, McNeil, MediciNova, Merck, National Institute of Mental Health, Neurochem, New River, Novartis, Organon, Parke Davis, Pfizer, Pharmacia, Repligen, Saegis, Sandoz, Sanofi, Sanofi-Synthelabo, Schwabe/Ingenix, Sepracor, Shire, Synaptic Pharmaceutical, Sunovion, Takeda, TAP, Transcept Pharma, TransTech, UCB, Upjohn, Vela, and Wyeth; is or has been a speaker for Abbott, AstraZeneca, Biovail, Bristol-Myers Squibb, Burroughs Wellcome, Cephalon, Ciba-Geigy, Eli Lilly, Forest, GlaxoSmithKline, Janssen, Johnson & Johnson, Novartis, Organon, Pfizer, Sanofi, Sanofi-Synthelabo, Shire, Solvay, Sunovion, Validus, and Wyeth Ayerst; is or has been a consultant for Abbott, AstraZeneca, Biovail, Bristol-Myers Squibb, Cephalon, Corcept, Eli Lilly, Forest, GlaxoSmithKline, Johnson & Johnson, Medscape Advisory Board, Organon, Otsuka, Pfizer, Pharmacia, Sanofi, Sanofi-Synthelabo, Shire, Solvay, Sunovion, Transcept Pharma, TransTech, Validus, and Wyeth; and is or has been a financial stockholder of Bristol-Myers Squibb, Cortex, Merck, and Pfizer. Dr Brown reports no conflicts of interest related to the subject of this article.

Funding/support: None reported.

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