How to Screen Veterans for PTSD Risk
How should clinicians screen US military veterans for probable PTSD risk using the risk patterns identified in this study?
Veterans in current practice may have higher PTSD burden than older prevalence estimates suggest, and risk is not limited to combat trauma alone. This guide applies to clinicians evaluating veterans in VA or community settings who need a focused way to identify who warrants more intensive PTSD assessment.
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Start with broad trauma exposure screening
Ask whether the veteran has experienced at least 1 potentially traumatic event and do not limit this inquiry to combat-related experiences. In this study, 84.2% of veterans reported at least 1 potentially traumatic event, and the mean number of trauma types endorsed was 3.0, supporting routine, broad trauma inquiry.
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Ask the veteran to identify the worst trauma
Have the veteran identify the traumatic event they consider their most distressing or worst event, because PTSD symptoms in this study were anchored to the perceived worst potentially traumatic event. Be prepared for the index trauma to be noncombat, as the most commonly endorsed worst events were sudden death of a close family member or friend, life-threatening illness or injury, and witnessing someone being badly injured or killed.
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Probe specifically for high-risk assaultive and military trauma
Ask directly about forced sexual experiences in childhood and adulthood and about military-related traumatic experiences, even if these are not volunteered initially. These trauma types had the highest conditional prevalence of lifetime PTSD when identified as the worst trauma: 65.5% for forced sex during childhood, 48.9% for forced sex during adulthood, and 33.0% for military-related traumatic experiences.
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Prioritize case-finding in higher-risk veteran subgroups
Maintain a lower threshold to evaluate PTSD in younger veterans, women, racial and ethnic minority veterans, combat-exposed veterans, and veterans using the VA as their primary source of care. In this study, prevalence was especially high in veterans aged 18 to 44 years, in female veterans, in combat-exposed veterans, and in veterans relying on VA care.
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Use the PCL-5 to screen for probable PTSD
Assess the 20 DSM-5 PTSD symptoms with the PTSD Checklist for DSM-5 in relation to the identified worst trauma, and evaluate both lifetime and past-month symptoms if your goal is to mirror this study's approach. The study classified probable PTSD using a PCL-5 cut score of 38, which the authors selected for comparability with prior survey waves.
Clinical Considerations
- The study used self-report measures rather than clinician-administered interviews, so symptom and trauma reports may be subject to reporting bias.
- The PCL-5 cutoff used in the study was 38, which the authors note is more conservative than the more commonly used cutoff of 33 in clinical and research settings.
- The findings identify prevalence patterns and correlates, but the cross-sectional design does not establish causal pathways or a validated risk prediction algorithm.
Bottom Line
When screening veterans for PTSD, assess broad lifetime trauma exposure, ask about the veteran's worst trauma, directly probe for sexual and military trauma, and keep a high index of suspicion in younger, female, combat-exposed, minority, and VA-using veterans.
