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Screening for PTSD in a Primary Care Setting
Why should primary health care providers be knowledgeable about traumatic stress? The primary care practitioner is likely to see an increase in traumatized individuals after a disaster or national terroristic event. Many of these patients will present with physical rather than mental or emotional symptoms. It is recommended that primary care providers educate themselves about the effects of trauma and routinely screen individuals for trauma after major disasters.
Having knowledge about traumatic stress is important because:
In addition to disasters and other traumatic life events, life-threatening medical conditions such as myocardial infarction, severe burns, severe injuries, and cancer can cause or exacerbate PTSD.
Trauma often leads to PTSD and other impairment
Patients with PTSD experience a significant degree of functional impairment similar to that observed in patients suffering from major depression.
Patients with untreated anxiety report levels of functioning within the range expected for patients with chronic physical diseases such as diabetes and congestive heart failure.
PTSD is associated with significant problems in living, including alcohol abuse, marital problems, unemployment, and suicidal ideation. PTSD is also associated with high levels of use of medical services.
Traumatic experiences and traumatic stress bring about hormonal, neurochemical, immune functioning, and autonomic nervous system changes which can affect physical health.
PTSD often presents to primary care providers, but goes unrecognized
In the private sector, nearly half of all visits instigated by a mental-health disorder are to a medical clinic or provider. Of those visits, 90% are to primary care providers.
Despite its prevalence, PTSD is likely to remain unrecognized and untreated in primary care patients. Few medical clinics systematically identify trauma survivors who have related mental-health problems.
Failure to identify and treat PTSD has adverse effects on the patient's physical and mental health
Traumatic stress is associated with increased health complaints, health services utilization, morbidity, and mortality.
Untreated PTSD can impair recovery from medical conditions.
In failing to address the impact of traumatic stress on health, patients and doctors become less likely to achieve desired outcomes.
Screening and Referral Procedure Overview
- A. Screen administration. A practitioner can distribute a traumatic stress self-report screening instrument prior to a medical appointment. Completed screens are collected and reviewed by the physician, nurse, physician's assistant, or a mental-health consultant to identify patients who are likely to be experiencing distressing posttrauma reactions. Screening items can also be added to the standard medical history forms that patients complete at first visits.
- B. Discussion and 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 specialized mental-health evaluations. Patients with positive screens may be referred, depending on availability, to specialized PTSD treatment, behavioral medicine, or more general mental-health services for further evaluation and possible treatment.
- It is important to understand the reason for screening instruments. Some patients who screen "positive" will not actually be diagnosed with PTSD after a detailed clinical evaluation by a mental-health professional. However, screening instruments increase a primary care provider's ability to detect PTSD and to initiate appropriate referral. Patients who screen positive for PTSD should be explicitly screened for suicidal ideation as well.
- C. Educational materials. Patients who screen positive for PTSD (and their families) may also benefit from educational materials about trauma and PTSD, such as those in the National Center for PTSD website Fact Sheets section.
- D. Follow-up. At the patient's next visit, it is important to ask whether he or she followed through with the referral for mental-health evaluation or care. If the patient did follow through, the practitioner 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, the provider can try to learn what the obstacles to obtaining care were.
If the Patient Refuses Referral to Mental-Health Care
Many patients are reluctant to participate in mental-health treatment. Common reasons include discomfort with the idea of seeing a psychologist or psychiatrist, a perceived stigma associated with treatment, previous negative experiences with mental-health providers, negative attitudes towards healthcare agencies, a lack of confidence in the helpfulness of counseling, or a reluctance to open up old emotional wounds.
Faced with this situation, the primary practitioner can do several things to raise the likelihood of acceptance of a referral:
- Suggest an evaluation rather than treatment. Sometimes, it is useful to suggest that the patient meet with a mental-health professional so that he or she can learn more about posttraumatic stress, ask questions, and consider with the mental-health provider whether more contacts will be useful.
- Normalize the idea of treatment. Explain that treatment involves common sense activities that include learning more about PTSD, finding and practicing ways of coping with trauma-related symptoms and problems, taking steps to improve relationships with family and friends, and making contact with other patients who experience similar problems.
- Give the patient educational materials that describe PTSD and its common co-morbid conditions (depression, substance abuse), treatment for PTSD, and coping with PTSD. Sometimes he or she will read the materials at a later time and begin to think more carefully about participation in treatment.
- Give information about different ways the patient can seek assistance. Avenues for assistance include local mental-health services; online resources; and local community, spiritual, and mental-health resources.
- Consider involving the patient's spouse or partner in the discussion if it seems appropriate and the patient gives his or her permission. This may help clarify for the patient the impact of PTSD on others in his or her life and increase his or her motivation to seek help.
- Make sure to follow up on the issue in the next appointment and keep track of the patient's progress with respect to PTSD.
The Use of a Primary Care Screen
- The table below shows the Primary Care PTSD Screen (PC-PTSD) that has been designed for use in primary care and other medical settings. The PC-PTSD is brief and problem-focused.
- The screen does not include a list of potentially traumatic events. There are two reasons for this:
- Studies on trauma and health in both male and female patients suggest that the active mechanism linking trauma and physical health is the diagnosis of PTSD. In other words, the relationship between trauma and health appears to be mediated through a current PTSD diagnosis.
- A symptom-driven screen, rather than a trauma-focused screen, is attractive to primary care staff who may not be able to address a patient's entire trauma history during their visit with the patient. Such a trauma inquiry might be especially problematic with a VA population where the average number of traumatic events meeting criterion A for PTSD is over 4.
- A positive response to the screen does not necessarily indicate that a patient has Post-traumatic Stress Disorder. However, a positive response does indicate that a patient may have PTSD or trauma-related problems and further investigation of trauma symptoms by a mental-health professional may be warranted.
In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you*
1. Have had nightmares about it or thought about it when you did not want to?
YES [ ] NO [ ]
2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
YES [ ] NO [ ]
3. Were constantly on guard, watchful, or easily startled?
YES [ ] NO [ ]
4. Felt numb or detached from others, activities, or your surroundings?
YES [ ] NO [ ]
Current research suggests that the results of the PC-PTSD should be considered "positive" if a patient answers "yes" to any three items.
Discussing Screening Results with Patients
Provide an appropriate context for the discussion
Ensure privacy by closing the door and keeping family members out of the room.
Inform patients that traumatic events and the distress they create can have important effects on the body and on health as well as on the patient's psychological functioning.
Explain that you are opening this discussion as part of an effort to provide more comprehensive health care and that a greater understanding and recognition of symptoms of posttraumatic stress may be of benefit, both psychologically and physically.
Ask about traumatic events
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.
As the patient is responding to your questions:
- Acknowledge any reported distress (e.g., "I'm sorry you have had such terrible nightmares").
- Show interest and concern, and tell the patient that you are glad that he or she has told you about the symptoms.
- Offer empathic support.
- 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.
- The practitioner may say: "At some point in their lives, many people have experienced extremely distressing events such as combat, physical or sexual assault, or a bad accident. Have you ever had any experiences like that?"
If the PC-PTSD screening instrument is utilized, clarify responses to determine:
- a. Whether the patient has had a traumatic experience
- "I notice from your answers to our questionnaire that you experience some symptoms of stress. At some point in their lives, many people have experienced extremely distressing events such as combat, physical or sexual assault, or a bad accident, and sometimes those events lead to the kinds of symptoms you have. Have you ever had any experiences like that?"
- b. Whether endorsed screen items are really trauma-related symptoms
- "I see that you have said you have nightmares about or have thought about an upsetting experience when you did not want to. Can you give me an example of a nightmare or thinking about an upsetting experience when you didn't want to?"
- If a patient gives an example of a symptom that does not appear to be in response to a traumatic event (e.g., a response to a divorce rather than to a traumatic event), it may be that he or she is ruminating about a negative life event rather experiencing intrusive thoughts about a traumatic stressor.
- c. Whether endorsed screen items 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?"
- Positive responses to these questions in addition to endorsement of trauma symptom items on the PC-PTSD Screen indicate an increased likelihood that the patient has PTSD and needs further evaluation.
- Discern whether traumatic events are ongoing in a patient's life
- If ongoing traumatic events are a part of the patient's life, it is critical that the primary care practitioner discern whether the patient needs an immediate referral for social work or mental-health services.
The practitioner might ask:
"Are any of these dangerous or life-threatening experiences still continuing in your life now?"
If ongoing family violence is suspected, it is imperative that the patient be told the limits of confidentiality for medical professionals, who are mandated to report suspected ongoing abuse of children and dependent adults.
Discussion of possible abuse should take place in the absence of the suspected perpetrator; if the abuser is present, victims may deny abuse for fear of retaliation.
If ongoing threats to safety are present:
Acknowledge the difficulty in seeking help when the trauma has not stopped.
Determine if reporting is legally mandated. If it is, develop a plan with the patient to file the report in a way that increases rather than decreases the safety of the patient and his or her loved ones.
If reporting is not appropriate, provide written information (or oral if written might stimulate violent behavior in the perpetrator) about local resources that might help the situation. Establish a plan that the patient will agree to in order to move toward increased safety. The National Domestic Violence Hotline is available to guide callers to local resources: 1-800-799-SAFE or TTY: 1-800-787-3224.
Make a recommendation for further evaluation and provide a referral.
If it appears that a patient does have active PTSD symptoms:
- Explain why the screen results lead you to recommend that he or she seek further evaluation and/or treatment.
- Encourage the patient to voice any reservations or concerns he or she might have about seeking treatment. You may be able to facilitate pursuit of treatment by listening to these concerns, acknowledging their validity, and addressing some of the patient's questions about what to expect during mental-health evaluation and treatment.
- Make sure the patient understands that he or she is not crazy.
- Explain to patients that although a wish to avoid reminders of the trauma is natural and common, this avoidance may actually interfere with recovery. This avoidance may prohibit helpful processes that can result from talking through the experience, receiving social support, or receiving specialized treatment.
- After discussion with the patient, if possible, invite family members to participate in a brief discussion and enlist their support for a mental-health evaluation by a specialist.
- Provide the patient with a written referral to a mental-health professional.
- Provide information to the mental-health professional
Provide the mental-health professional with:
- A copy of the PC-PTSD 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
- Schedule a follow-up
- Consider scheduling in-person or telephone follow-ups and/or relatively frequent brief office visits. Regular check-ins with patients about their current functioning and follow-ups with referrals is crucial for keeping patients involved in their own recovery process.
Prins, A., Kimerling, R., Cameron, R., Oumiette, P.C., Shaw, J., Thrailkill, A., Sheikh, J. & Gusman, F. (1999). The Primary Care PTSD Screen (PC-PTSD). Paper presented at the 15th annual meeting of the International Society for Traumatic Stress Studies, Miami, FL.
Mental Health Services
[I would offer my total support for all returning troops, no matter the MOS to take this test!] Then I get that gut reaction of where's the money to make forms, administer the test and correct them!]
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