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6 Screening and Diagnosis T his chapter begins with the rationale for screening in general and then looks at screening for posttraumatic stress disorder (PTSD) specifically. After a discussion of the goals of screening for PTSD, especially in the military and veteran populations, key considerations in screening for PTSD are examined, such as when, how, and by whom screen- ing should be conducted and the potential effect of stigma on screening. That is followed by descriptions of screening and barriers to screening in the Department of Defense (DoD), the Department of Veterans Affairs (VA), and nonmilitary settings and the different types of screening instru- ments that are used or are being developed. The screening section ends with a consideration of what should be done with screening results. The second part of the chapter discusses clinical assessment for and diagnosis of PTSD, including the current guidelines for diagnostic interviews and the use of various scales for diagnosing PTSD in military and veteran populations. SCREENING Screening has been defined as the examination of a generally healthy population to identify people as likely or unlikely to have a particular con- dition (Morrison, 1992). In light of the fact that screening is not without cost or potential damage, six criteria have been proposed for determining the acceptability of any given screening procedure (Rona et al., 2005): •  The identified condition should be an important health problem. •  The test should be clinically, socially, and ethically acceptable. 195

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196 PTSD IN MILITARY AND VETERAN POPULATIONS •  The test should be simple, precise, and valid. •  The test should lead to reduced morbidity. •  Staffing and facilities for all aspects of the screening program must  be adequate. •  Benefits of screening should outweigh potential harms. It is inherent in those criteria that the test used should detect the condition at an early stage and that treatment at an early stage is of more benefit than treatment at a later stage (Wilson and Jungner, 1968). It is generally accepted that screening for PTSD, depression, and other mental health problems is ineffective unless it is integrated into a total management program with adequate follow-up to confirm or refute a positive screening result and adequate capability to provide appropriate treatment. An illus- trative example is depression, in which screening alone without follow-up care and treatment is unlikely to improve management and is believed to be associated with an unacceptable ratio of cost to benefit (Gilbody et al., 2006; Lang and Stein, 2005; U.S. Preventive Services Task Force, 2002). Similar considerations are likely to apply to PTSD screening. Screening is not meant to replace assessment or diagnosis, but it can serve as a decision support tool. A person who has a positive screening result should undergo a clinical assessment that can be used by a trained clinician to make appropriate diagnoses—including diagnoses of comorbid conditions, such as depression or traumatic brain injury (TBI)—and to acquire additional information that is required to plan treatment. Such an assessment should take into account the symptoms that the person is expe- riencing and the severity of and functional impairment associated with the symptoms. Although it is widely believed that screening for PTSD among current and former service members is important for identifying affected people and directing them to treatment as early as possible to prevent chronic suffering and maladjustment, there is no strong evidence to sup- port this belief. Traumas associated with military service, such as combat and sexual assault, have been associated with a high prevalence of PTSD in this popu- lation, and several factors should be considered in implementing broad screening directives in this group (Kessler et al., 1995; Skinner et al., 2000). For a screening program to be effective, adequate resources need to be in place to support it, such as appropriate personnel and time (VA and DoD, 2010). The choice of instrument, method of delivery (such as self-report vs. clinician-administered), place of delivery (such as in the theater of war vs. on the home front), and intended use of the results of the screen are all important in designing a screening program. Many PTSD screening instruments are available. The VA/DoD guide- line notes there is insufficient evidence to recommend one PTSD screening

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197 SCREENING AND DIAGNOSIS tool over another, but several screening tools have been validated and should be considered for use: the Primary Care PTSD screen (PC-PTSD) (Prins et al., 2003), the PTSD Brief Screen (Leskin and Westrup, 1999), the Short Screening Scale for the Diagnostic and Statistical Manual-IV PTSD (Breslau et al., 1999), and the PTSD Checklist (PCL) (Blanchard et al., 1996, civilian version; Weathers et al., 1991, military version). The four- item PC-PTSD is the most widely used of those (see Box 6-1). In the DoD, the PC-PTSD screening questions are incorporated into longer surveys— the post-deployment health assessment (PDHA) and the post-deployment health reassessment (PDHRA). In DoD clinic settings, the PCL is commonly used. Before deployment, in addition to screening for PTSD itself, deter- mination of the presence of factors that might increase a service member’s risk of PTSD may be an associated undertaking. For those who screen positive for PTSD or when evidence suggests the presence of other disorders or comorbidities, the screening program should ensure rapid diagnostic evaluation by a trained provider that includes the assessment of other possible causes of the symptoms and issues that are important for treatment planning. The use of a structured interview may improve the validity and reliability of such an evaluation. Evaluation should address comorbidities—such as TBI, depression, other anxiety disorders, BOX 6-1 Primary Care PTSD Screen 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 SOURCE: VA (2012a).

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198 PTSD IN MILITARY AND VETERAN POPULATIONS alcohol or substance abuse—and the presence of risky behaviors (discussed in more detail in Chapter 8). In addition, determining the severity of symp- toms, the degree and nature of functional impairments, and suicide risk are important in selecting treatment. During the evaluation, the people being evaluated should be educated regarding PTSD and other relevant diagnoses, have their treatment options explained, and participate and be in agreement with treatment decisions. The latter is key to later engagement with and adherence to treatment. Identifying those who have established PTSD and offering them treat- ment is a DoD and VA priority (VA, 2002; VA and DoD, 2010). In planning a program involving screening of active-duty service members or veterans, it is important to be clear about the goals of the activity. As will be discussed below, screening in this environment is not benign. It carries financial costs, and more important, it can lead to anxiety, further testing, and in some cases change in the course of a military career, which leads to pressure for underreporting. The costs and benefits of screening and assessment must be weighed. However, there are costs of not screening and assessing; allow- ing a physically or mentally impaired service member to continue to serve when not battle ready may jeopardize the service member’s or the unit’s safety. Allowing problems to go undetected may compound them and lead to comorbid disorders and increased disability; it then becomes even more complicated and expensive to treat than if the initial problem had been detected and treated earlier. The major psychologic conditions currently screened for in popula- tions of active-duty military personnel and veterans are PTSD, depression, alcohol use disorders, sexual trauma, suicidality, and mild TBI. All those are addressed in the DoD-administered PDHA and PDHRA, discussed in detail in Chapter 4. Here, the committee focuses on PTSD, acknowledg- ing that partial or subthreshold PTSD should not be overlooked inasmuch as it is associated with substantial functional disability (Stein et al., 1997; Walker et al., 2002). In active-duty service members, screening can identify those who have impaired operational readiness and ideally can lead to the care necessary to restore their previous levels of functioning. In veteran populations, screening and assessment can identify diagnosable disorders and functional impairments and thereby guide treatment and lead to fulfilling lives out of the military. As covered in Chapter 5, to implement an effective early intervention and potentially eradicate a developing problem or mitigate its effect, a candidate for intervention must first be identified. Therefore, wide-scale screening of all those at risk must be implemented. It is easier to define “at risk” for some other conditions than for PTSD. For example, all persons within 35 meters of a blast are considered “at risk” for TBI, but “at risk” is much harder to determine for PTSD. There are a few screen-

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199 SCREENING AND DIAGNOSIS ing tools that capture PTSD and other health issues. Although the General Health Questionnaire (Goldberg, 1972) and the 10-item and 6-item Kessler scales (Kessler et al, 2002) have been used extensively worldwide for the detection of mental health disorders, those instruments do not target spe- cific disorders. In conducting assessments of the effects of trauma exposure in the theater of war, it is important to attempt to discriminate between a norma- tive stress response and a pathologic condition that requires diagnosis and intervention. War by its nature is an extreme stressor and a life-threatening situation, and humans should be expected to react accordingly. A detailed discussion of adaptive and maladaptive responses to stress is presented in Chapter 3. The intention is not to treat a normal or adaptive stress re- sponse, which is imperative to survival, but instead to detect when it has become maladaptive and interferes with functioning. A primary purpose of the evaluation is to lead to maintaining individual service member and unit functioning and readiness. CONSIDERATIONS REGARDING SCREENING IN THE DEPARTMENT OF DEFENSE AND THE DEPARTMENT OF VETERANS AFFAIRS The VA/DoD Clinical Practice Guideline for Management of Post- Traumatic Stress (2010) considers that the evidence supporting screening with the PC-PTSD or three other scales is II-2—based on well-designed co- hort or case–control studies rather than randomized controlled trials—and that the quality of the evidence is fair and the strength of recommendation is B, that is, the recommendation can be made on the basis of fair evidence that screening improves health outcomes and that the benefits outweigh the costs. In their review of seven PTSD guidelines, Forbes et al. (2010) note that there is a range of support for screening: the American Psychiatric As- sociation concludes that level 1 evidence (defined as strong expert consen- sus) supports screening, and others, such as the British National Institute for Health and Clinical Excellence (NICE) and the Australian Guidelines, regard the evidence as weak, at the level of “good practice points” as dis- tinct from good evidence. A key weakness in the literature is the paucity of evidence regarding the effect of screening on PTSD outcomes. Delivery In the DoD and the VA, screening for PTSD is usually not the sole focus of a clinical assessment but is combined with screening and assess- ment of other conditions. The VA/DoD clinical practice guideline (2010) supports assessment of patients for psychiatric and medical conditions,

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200 PTSD IN MILITARY AND VETERAN POPULATIONS which includes “past and current psychiatric and substance use problems and treatment, prior trauma exposure, pre-injury psychological stressors, and existing social support.” The number of deployments that a person has had should also be considered. PTSD screening can be divided into premilitary trauma, peritrauma, and posttrauma screening, each having specific considerations, which are addressed below. The Role of the Screener As previously discussed, the results of screening tests are usually in- tegrated into a more comprehensive assessment, and positive or negative results require interpretation by qualified professionals. Service members must give informed consent before completing the pre-deployment health assessment, PDHA, or PDHRA, and this consent states that responses on the form “may result in a referral for additional healthcare that may include medical, dental or behavioral healthcare or diverse community support services” (10 U.S.C. 136, 1074f, 3013, 5013, 8013, and Executive Order 9397). A credentialed health care provider is required to review and discuss the service member’s responses during the face-to-face part of the assess- ment. Physicians, physician’s assistants, nurse practitioners, and others who are medically trained to administer the PDHA and PDHRA, such as independent corpsmen and technicians, are examples of such providers. A health care provider interviews the subject and completes the second part of the assessment, documents any concerns, and makes recommendations for further treatment or referral. The provider then signs off on the PDHA or PDHRA, documenting the nature of the service provided and of the refer- ral given and whether the service member accepted the recommendations. PDHA and PDHRA assessments are filed in the service member’s medical record and in the Defense Medical Surveillance System. A credentialed health care practitioner at the service member’s home base is expected to review the findings and ensure that follow-up occurs and that necessary appointments are scheduled (GAO, 2008). The Effect of Stigma Regardless of the reliability and validity of a screening instrument in ideal testing environments, as long as there is the belief that being labeled with a given condition may affect one’s future adversely, especially in the U.S. military, there will be an underreporting bias. It is only touched on here, but a more complete discussion of stigma can be found in Chapter 9. In one study that used a brigade of Army soldiers as the population of interest, service members first completed the PDHA, and then a subsample were invited to complete an anonymous survey that consisted of the same

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201 SCREENING AND DIAGNOSIS mental health questions found on the PDHA. A comparison of the PDHA and the anonymous survey (which would not be a part of the soldiers’ records) found that the numbers of positive responses to the mental health questions overall and to the PTSD-specific questions more than doubled and in some cases quadrupled. On the PDHA, 3.3% of soldiers screened positive for PTSD, whereas on the anonymous survey, 7.7% screened positive. Of the service members that screened positive for either PTSD or depression on the anonymous survey (12.1%), 20.3% reported that they were not comfortable in reporting their answers honestly on the PDHA. The positive-screen group also indicated they were less likely to seek treat- ment for these issues (one-third indicated that they thought it would harm their careers) than the group that screened negative for PTSD or depression (Warner et al., 2011). Those results indicate a high level of underreporting of mental health symptoms, which may have adverse implications for the health and readiness of the armed forces. As discussed in the next section, additional specific stigma-related concerns are involved in screening before and after deployment. Timing of Screening One of the many considerations in screening for PTSD is when to screen. In the active-duty (and National Guard and reserve) force, screen- ing can occur before deployment to a combat zone, during deployment in the theater of war, or after deployment. Because PTSD symptoms may not show for a number of months or years or may not be present when a service member transitions from active duty to the civilian population, screening for PTSD is also an important consideration in the VA. Predeployment Screening There are several approaches to predeployment screening of service members, including screening before accession, basic training and boot camp, and screening prior to the actual deployment. Service members undergo a rigorous selection process to ensure physical and mental fitness. Each of the different services has its own criteria for acceptance, including minimum scores on the Armed Forces Qualification Test, minimum level of education, and policies for waivers. Basic training also serves to test physi- cal and mental strength and abilities, and this can lead to discharges of unqualified people. Because the resulting force consists of people who have high levels of physical and mental health, the value of additional screening for PTSD symptoms in this cohort before deployment is uncertain (Hyams, 2006). Screening just before deployment has been proposed as an additional

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202 PTSD IN MILITARY AND VETERAN POPULATIONS method of identifying persons who have disqualifying conditions and are not otherwise eliminated. However, the preponderance of evidence does not support that approach (Hyams, 2006). The pre-deployment health as- sessment has one mental health question: “During the past year, have you sought counseling or care for your mental health?” This question is of lim- ited usefulness for the assessment of predeployment mental health concerns, particularly given the stigma associated with seeking mental health care or the assumption that a service member may not recognize that he or she has a mental health problem. An affirmative response to the question results in referral for an interview by a trained medical provider who may then sign a form indicating medical readiness for deployment. One British study demonstrated that in a sample of soldiers deployed to Iraq, screening for common mental disorders, including PTSD, before deployment would not reduce morbidity or predicted PTSD (Rona et al., 2006). A prospective study of 22,630 service members enrolled in the Mil- lennium Cohort Study found that those who reported one or more mental health disorders on a predeployment questionnaire were significantly more likely to screen positive for postdeployment PTSD symptoms (odds ratio 2.52, 95% confidence interval 2.01–3.16) (Sandweiss et al., 2011). How- ever, this study did not assess morbidity and did not categorize service members’ fitness for duty. Categorizing service members as unfit to deploy or unfit for military duty on the basis of such an unfounded approach may have unjustified adverse implications for their lives and careers. A large nonrandomized controlled cohort study that compared screened and unscreened combat brigades deployed to Iraq showed that the com- bination of predeployment screening and subsequent contact with mental health services in the theater of war reduced the rate of combat stress reac- tions, behavioral health disorders, suicidal ideation, and occupational-duty restrictions (Warner et al., 2011). The purpose of the screening was not to keep service members from deploying but to link them to needed services in the theater of war. Predeployment screening opens the possibility of under- reporting that is perhaps driven by service members’ desire not to compro- mise their chance of deploying. Evidence supporting that argument comes in part from a retrospective cohort study of service members deployed in support of Operation Enduring Freedom (OEF) that found that fewer than half those who received a diagnosis of a mental health disorder during the predeployment period gave an affirmative response to the pre-deployment health assessment question “During the past year, have you sought counsel- ing or care for your mental health?” That demonstrates the low validity of this instrument for identifying service members who have diagnosed mental health disorders before deployment (Nevin, 2009).

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203 SCREENING AND DIAGNOSIS Postdeployment Screening Evidence that screening for PTSD immediately after deployment may result in underreporting compared with screening later can be seen in re- sults of a matched study of 509 soldiers returning from Iraq. Statistically significant increases in mental health symptoms of PTSD, depression, gen- eral psychologic distress, anger, and relationship problems were found 120 days after deployment compared with the immediate integration period (Bliese et al., 2007). Because the PDHA and the PDHRA are not anony- mous, such underreporting may be due to fear of delaying family reunion and interference with an allocated extended period of leave after returning from deployment (Bliese et al., 2007; DoD, 2007; McClure, 2007). Another possible explanation for lower rates of symptom reporting in the immediate reintegration period is that some symptom clusters may not be present or may not have a recognized adverse effect on functioning during this time (Bliese et al., 2007). A third possibility may be that service members’ relief at being home overshadows any mental health issues. In a longitudinal follow-up of more than 88,000 soldiers returning from Iraq, Milliken et al. (2007) found that the rates of positive PTSD screening results were more than 50% higher in the PDHRA than in the initial PDHA. The increases were greatest in the National Guard and re- serve components, in which the prevalence increased from 9% to 14%. In active-duty soldiers, the prevalence increased from 6% to 9%. However, the investigators observed a reduction in the rate of positive PTSD screen- ing results in the PDHA sample on rescreening several months later. The implications are that PTSD symptoms in the early posttraumatic phase often resolve and that educational programs in the military promote re- covery. One other important finding from the Milliken et al. study is that the rates of self-reported interpersonal problems increased substantially in the PDHRA. Inasmuch as those issues often involve spouses, there may be a case for greater involvement of spouses, partners, or close family mem- bers in some part of the screening process or for facilitating access of such people to the health care system (Milliken et al., 2007). Screening, assessment, and diagnosis are different. Whereas screening instruments and tools are used to identify persons who are likely to have the condition of interest, in the case of PTSD, assessment and diagnosis are necessary to confirm diagnosis and plan treatment. A positive PTSD screening result on the PDHA and PDHRA is indicated by an affirmative response to two or more of the four PTSD-specific questions. From August 2010 through July 2011, a total of 231,822 active-duty service members in all services and 75,219 reserve-component members (National Guard and reserves) completed the PDHA. During the same period, 223,582 active- duty and 86,421 reserve-component members completed the PDHRA. In

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204 PTSD IN MILITARY AND VETERAN POPULATIONS all the completed surveys, 8.3% of active-duty service members screened positive for PTSD on the PDHA and 9.5% on the PDHRA, and 9.2% of reserve members screened positive on the PDHA and 16.6% on the PDHRA. When stratified by service, both active-duty and reserve Army and Marine Corps personnel had the highest rates of positive PTSD screens on the PDHA and the PDHRA. Of all active-duty service members, 5.9% were referred for additional mental health assessment by a provider (for any mental health concern indicated, not specifically PTSD) after the PDHA, but 10.9% after the PDHRA. Of all reserve-component members, 4.9% were referred for additional mental health assessment after the PDHA and 16.2% after the PDHRA. Because the percentage of referrals for any mental health concern was reported, it is impossible to know how many service members who had affirmative responses to the PTSD questions were referred. Among both active-duty and reserve-component members, the percentage of mental health referrals increased between the PDHA and the PDHRA. Furthermore, 95.9% of all active-duty service members and 94.6% of reserve-component service members who were given referrals after the PDHA had a medical visit (according to records of outpatient or inpatient visits for either mental health or physical health concerns) within 6 months of the referrals (Armed Forces Health Surveillance Center, 2011). Screening of Veterans In the VA, positive screenings for PTSD, depression, suicidality, or military sexual trauma (sexual assault or extreme harassment that oc- curred during service in the military) result in referral of the veteran to a mental health professional for evaluation. Patients referred are to receive an initial evaluation within 24 hours and a full evaluation within 14 days after referral. However, no data are available to track what happens after referral—for example, what proportion engage and complete evaluations, enter and complete treatment, continue or return to active duty, or are discharged. A recent analysis of 125,729 Operation Iraqi Freedom (OIF) and OEF veterans screened for military sexual trauma in VA primary care and mental health clinics found that 15.1% of women and 0.7% of men reported military sexual trauma and that such trauma was associated with increased odds of PTSD, depression, and other mental health disorders (Kimerling et al., 2010). SCREENING IN PRIMARY CARE Given that an estimated 90% of patients who have received mental health diagnoses are seen in primary care (Gebhart and Neeley, 1996) and that persons who receive diagnoses of PTSD are more likely to seek

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205 SCREENING AND DIAGNOSIS medical care than mental health care (VA, 2002), screening for PTSD in primary care settings is paramount. A variety of primary care venues are available through the DoD, the VA, and private practices, each of which is discussed below. This section concludes with a brief overview of some of the challenges to implementing PTSD screening in primary care settings and how they might be overcome by using lessons learned from implementing screening for depression in primary care settings. The Department of Defense The DoD provides primary care through the individual services and through contracted TRICARE providers. Service members who received care in an integrated behavioral health and primary care setting had signifi- cantly reduced psychologic distress and significant improvement in clinical outcomes (Cigrang et al., 2006). One example of a successful implemented screening program that is Army-specific is the Re-Engineering Systems for Primary Care Treatment of Depression and PTSD in the Military (RESPECT-Mil) program, discussed in Chapter 4. Primary care providers are trained to screen and treat soldiers for PTSD and depression at every visit. It is an approach to establish collaboration between primary care and behavioral health professionals to overcome many of the barriers to effective management of PTSD in primary care settings in the DoD. Key elements of the program include universal primary care screening for PTSD and depression, including use of the single-item PTSD screener, developed for military primary care settings (Gore et al., 2008); brief standardized primary care diagnostic assessment for those who screen positive; and use of a nurse–care facilitator to ensure continuity of care for those who have unmet depression and PTSD treatment needs. The care facilitator assists primary care clinicians with follow-up, symptom monitoring, and treatment adjustment and enhances the primary care interface with specialty mental health services (Engel et al., 2008). Separate manuals that integrate care for PTSD with care for major depression guide the primary care clinician, behavioral health specialist, and care facilitator in their roles. As of Fall 2011, RESPECT-Mil had been implemented in 32 of 37 Army sites and in 84 primary care clinics. Since its inception, more than 1.1 million primary care visits have included screening for PTSD and depression, and approxi- mately 13% of the screenings have been positive (DoD, 2011). According to the official RESPECT-Mil website (DoD, 2011), “The US Army Medical Command has directed wide implementation of RESPECT- Mil in Army primary care facilities. Tri-service implementation is in the planning stages.” During FY 2012–2016, as the DoD phases in its primary care model of the patient-centered medical home—that is, a health care setting model with goals of providing comprehensive primary care for all

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220 PTSD IN MILITARY AND VETERAN POPULATIONS TABLE 6-4 Symptom-Severity Instruments for PTSD Scale Name Reference PTSD Checklist—civilian and military versions Blanchard et al., 1996 (civilian); Weathers et al., 1991 (military) Mississippi Scale—civilian and combat versions Keane et al., 1988, McFall et al., 1990 Impact of Event Scale updated for DSM-IV Horowitz et al., 1979; Weiss and Marmar, 1997 MMPI-Keane PTSD Scale Keane et al., 1984 Hovens Self Rating Inventory for PTSD Hovens et al., 2002 PTSD Diagnostic Scale Foa et al., 1997 Davidson Trauma Scale Davidson et al., 1997b War Zone Related PTSD subscale from the Symptom Derogatis and Cleary, 1977 Checklist 90—Revised Los Angeles Symptom Checklist King et al., 1995 26-item Penn Inventory Hammarberg, 1992 22-item Self-Rating Scale for PTSD Carlier et al., 1998, from the SIP (Davidson et al., 1997a) Reactions to Stressful Experiences Scale Johnson et al., 2011 PTSD Symptom Scale—Self Report Version Foa et al., 1993 scales is intended to replace a clinical assessment, but they can constitute a useful supplement to information obtained in the face-to-face encounter. QUALITY OF LIFE, DISABILITY, AND RESILIENCE MEASURES Several instruments have been developed that measure quality of life, functioning and disability, and resilience and are shown in Table 6-5. Among the main quality of life scales that may be used in assessing people who have PTSD are the Quality of Life Experiences Scale (Endicott et al., 1993), the EURO-QOL (EuroQol, 1990), the 100-question World Health Organization Quality of Life Assessment and an abbreviated form (WHOQOL-BREF) (Harper et al., 1998), the Quality of Life Inventory (Frisch et al., 1992), and the Manchester Short Assessment of Quality of Life (Priebe et al., 1999). Functioning can be assessed with the Medical Outcomes Study Short Form 36-item and shorter versions (such as SF-12) (McHorney et al., 1994),

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221 SCREENING AND DIAGNOSIS TABLE 6-5 Quality of Life, Disability, and Resilience Measures Instrument Reference Medical Outcomes Study Short Form 36 Ware and Sherbourne, 1992 Medical Outcomes Study Short Form 12 Ware et al., 1996 Quality of Life Experiences Scale Endicott et al., 1993 Sheehan Disability Scale Sheehan et al., 1996 World Health Organization Quality of Life Assessment WHO, 1998 Manchester Short Assessment of Quality of Life Priebe et al., 1999 Resilience Scale Wagnild and Young, 1993 Resilience Scale for Adults Friborg et al., 2003 Connor Davidson Resilience Scale, 25-, 10-, and 2-item Connor and Davidson, 2003 versions (25 item); Campbell-Sills and Stein, 2007 (10 item); Vaishnavi et al., 2007 (2 item) Quality of Life Inventory Frisch et al., 1992 Dispositional Resilience Scale, 45-, 30-, and 15-item forms Bartone et al., 2008 EURO-QOL EuroQoL, 1990 the Global Assessment of Function (APA, 1994), and the Sheehan Disability Scale (Sheehan, 1983). Resilience has become the focus of greater attention in recent years, and there are a number of psychometrically valid scales that measure this construct. They include the brief five-item scale of Smith et al. (2008), the 2-, 10-, and 25-item versions of the Connor-Davidson Resilience Scale (Campbell-Sills and Stein, 2007; Connor and Davidson, 2003; Vaishnavi et al., 2007), the 25- and 14-item versions of the Resilience Scale (Wagnild and Young, 1993), the Resilience Scale for Adults (Friborg et al., 2003), and the 45-, 30-, and 15-item forms of the Dispositional Resilience Scale (Bartone et al., 2008). As is the case with the PTSD symptom scales and measures of quality of life and disability, studies have shown that resilience can improve as the result of treatment (Lavretsky et al., 2010). SUMMARY Screening for PTSD is essential for identifying those who need treat- ment. Issues including stigma and timing of screening should be considered, in addition to the venue of screening (DoD, VA, and nonmilitary settings). Many types of screening instruments exist, but only a few are used by

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222 PTSD IN MILITARY AND VETERAN POPULATIONS the DoD and the VA. Some are based on exposure to trauma and others are symptom-based. Screening instruments may be self-administered or clinician-administered. Although screening is useful for identifying potential PTSD cases, a diagnosis can be made only on the basis of a comprehensive clinical evaluation performed by a qualified professional. Several structured interviews and symptom-based rating scales may be used for diagnosis and to determine severity of symptoms. The next chapter describes the differ- ent treatments that have been found to be effective in treating persons who have a diagnosis of PTSD. REFERENCES Air Force Medical Operations Agency. 2011. Primary behavioral health care services: Practice manual. Lackland AFB, TX: Airforce Medical Operations Agency (AFMOA), Mental Health Division/SGHW. APA (American Psychiatric Association). 1994. Diagnostic and statistical manual of mental disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association. Armed Forces Health Surveillance Center (U.S.). 2011. Deployment health assessments: U.S. Armed Forces. Silver Spring, MD: Armed Forces Health Surveillance Center. Atlanta Braves, and Emory University. 2011. Braveheart: Welcome back veterans southeast initiative. http://braveheartveterans.org/ (accessed January 24, 2012). Bartone, P. T., R. R. Roland, J. J. Picano, and T. Williams. 2008. Psychological hardiness predicts success in US Army special forces candidates. International Journal of Selection and Assessment 16(1):78-81. Batres, A. R. 2011. Readjustment counseling service. Paper presented to the Committee on the Assessment of Ongoing Efforts in the Treatment of PTSD, Washington, DC, April 21. Bernstein, D. P., J. A. Stein, M. D. Newcomb, E. Walker, D. Pogge, T. Ahluvalia, J. Stokes, L. Handelsman, M. Medrano, D. Desmond, and W. Zule. 2003. Development and valida- tion of a brief screening version of the childhood trauma questionnaire. Child Abuse & Neglect 27(2):169-190. Blake, D. D., F. W. Weathers, L. M. Nagy, D. G. Kaloupek, F. D. Gusman, D. S. Charney, and T. M. Keane. 1995. The development of a clinician-administered PTSD scale. Journal of Traumatic Stress 8(1):75-90. Blanchard, E. B., J. Jones-Alexander, T. C. Buckley, and C. A. Forneris. 1996. Psychometric properties of the PTSD checklist (PCL). Behaviour Research & Therapy 34(8):669-673. Bliese, P. D., K. M. Wright, A. B. Adler, J. L. Thomas, and C. Hoge. 2007. Timing of post- combat mental health assessments. Psychological Services 4(3):141-148. Boscarino, J. A., S. Larson, I. Ladd, E. Hill, and S. J. Paolucci. 2010. Mental health experiences and needs among primary care providers treating OEF/OIF veterans: Preliminary find- ings from the Geisinger Veterans Initiative. International Journal of Emergency Mental Health 12(3):161-170. Breslau, N., E. L. Peterson, R. C. Kessler, and L. R. Schultz. 1999. Short screening scale for DSM-IV posttraumatic stress disorder. American Journal of Psychiatry 156(6):908-911. Brewin, C. R. 2005. Systematic review of screening instruments for adults at risk of PTSD. Journal of Traumatic Stress 18(1):53-62. Brewin, C. R., S. Rose, B. Andrews, J. Green, P. Tata, C. McEvedy, S. Turner, and E. B. Foa. 2002. Brief screening instrument for post-traumatic stress disorder. British Journal of Psychiatry 181:158-162.

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