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Screening Patients for Post-traumatic Stress Disorder
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Am Fam Physician. 2005 Aug 1;72(3):518-521.
Significant trauma is increasingly common in the general population, and an estimated one in four of those exposed to life-threatening situations develops post-traumatic stress disorder (PTSD). Without treatment, PTSD causes symptoms for more than five years in the majority of cases, and may bring about additional psychiatric morbidity such as depression. The highest rates of PTSD follow sexual assault, but many women are not diagnosed and treated. An estimated 73 percent of women who have been raped or assaulted seek medical care in the year following the attack, whereas only 19 percent seek psychologic help. If patients with PTSD could be identified and treated, significant morbidity could be avoided. Meltzer-Brody and colleagues developed and tested a screening instrument for PTSD, targeting women who attended a gynecology clinic.
The researchers offered screening to all 292 women who attended the clinic for routine annual examination between June 2001 and March 2002. Patients completed a comprehensive health survey that included questions about significant trauma. Those who reported a traumatic event were asked to complete a four-item screening survey known as SPAN (Startle, Physiological arousal, Anger, and emotional Numbness), named for the four major symptoms of PTSD. The screening performance of the SPAN questionnaire was compared with full psychiatric assessment, including a structured interview designed to detect PTSD.
Of the 292 participants, 46 percent were single, 49 percent were black, and 43 percent were white. The mean age was 34 (± 12) years. Significant traumatic events were reported by 88 (30 percent) of the women; of these, 32 women agreed to full psychiatric assessment, and 56 declined. There were no significant differences in variables between the two groups. The main reasons given for non-participation were lack of time and inability to return to the clinic. Interviews identified criteria for one or more psychiatric diagnoses in 31 of 32 women. Twenty-five women (78 percent) met criteria for PTSD, but only three of these were receiving any form of psychiatric treatment. Other diagnoses included major depression (62 percent), panic disorder (28 percent), social phobia (28 percent), generalized anxiety disorder (19 percent), and substance abuse (15 percent).
The authors calculate that the single question about experiencing significant trauma had a positive predictive value of 78 percent for PTSD in the study population. The SPAN instrument had a sensitivity of 72 percent and a specificity of 71 percent using a cutoff score of 5. These findings equate to a positive likelihood ratio of 2.52 and a negative likelihood ratio of 0.39.
As in other studies, one third of women reported experiencing significant trauma; however, the proportion who developed clinical PTSD was much higher than expected. This could be because of selection bias in the women who agreed to take part in the study. Nevertheless, the authors conclude that asking about trauma and following up with the SPAN questionnaire can effectively identify which women to refer for more intensive psychiatric assessment and treatment.
Meltzer-Brody S, et al. A brief screening instrument to detect posttraumatic stress disorder in outpatient gynecology. Obstet Gynecol. October 2004;104:770–6.
Copyright © 2005 by the American Academy of Family Physicians.
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