Making PTSD Screening More Likely by Identifying Abbreviated Versions of the PCL-5

Timothy J. Geier, PhD, Sadie Larsen, PhD., & Terri deRoon-Cassini, PhD

Life after a traumatic injury can be scary and stressful. Beyond the general stressful life disruptions and uncertainties, there are often numerous follow-up appointments for the patient, such as physical rehabilitation, wound care, and pain management. There are also numerous professions with different goals involved in the care for the patient during this time, including surgeons, nurses, physical and occupational therapists, social workers, as well as mental health professionals. The mental wellbeing of patients navigating this process is a crucial factor in their overall physical recovery and quality of life. In fact, the American College of Surgeons Committee on Trauma, the national organization responsible for accrediting trauma centers, has recommended PTSD assessment for trauma survivors as a part of rehabilitative care (Rotondo et al., 2014). To this end, trauma centers have started to assess and monitor common post-traumatic emotional reactions more commonly. One barrier to these efforts has been the inability to briefly, efficiently, and validly measure PTSD symptom severity in this population. Although good measures of PTSD are available, often even a short measure is too long in the context of a busy and high-pressure trauma care environment. For instance, the PCL-5 is a validated measure of DSM-5 PTSD symptom severity, but the 20-question full form is still too long for trauma surgery hospital settings.

To increase the ability of trauma center to assess PTSD, we conducted a study to determine how two abbreviated versions of the PCL-5 would function in a traumatically injured patient population approximately 6 months after injury. Shorter versions of the measure would help facilitate consistent implementation of screening, referral for treatment, and outcomes measurement in research. The abbreviated versions consist of a four-item scale (PCL4-5) as well as an eight-item scale (PCL8-5), with the items originally developed by Price and his colleagues (Price, Szafranski, van Stolk-Cooke, & Gros, 2016). The Clinician-Administered PTSD Scale was used to provide the gold standard PTSD diagnosis.

In the current study, these measures were used with people admitted to the hospital after a traumatic injury. Both abbreviated scales were highly correlated with the total scale and demonstrated robust psychometric properties, suggesting they may be useful as abbreviated screening tools within this population. An optimal cut-score of >4 was identified for the PCL4-5 to indicate risk of PTSD, whereas a cut-score of >12 was identified for the PCL8-5 to indicate PTSD risk. Because institutions vary by population characteristics and needs, this study provided a range of cut-scores for each abbreviated scale to offer institutions the ability to determine an appropriate cut-score for their specific, potentially unique needs. For instance, some settings may need to prioritize speed of administration, and all sites will need to balance the importance of identifying PTSD with the frustration and potential resource loss associated with a false positive. Further, suggestions for which abbreviated measure to utilize were provided to highlight to need to consider contextual factors. For example, the brevity of the PCL4-5 would likely be more easily incorporated into routine longer-term rehabilitative care and study of survivors, including in rehabilitation centers as well as physical therapy and primary care encounters.

Results are promising as trauma centers move toward a protocol for early PTSD identification following traumatic injury, as a brief scale is more likely to be regularly implemented into routine care. Studies in other settings have found that brief measures (like the PHQ-9) can enhance the likelihood of screening actually being adopted, and our hope is that this brief scale can help move the field in that direction.

References

Price, M., Szafranski, D. D., van Stolk-Cooke, K., & Gros, D. F. (2016). Investigation of abbreviated 4 and 8 item versions of the PTSD Checklist 5. Psychiatry research, 239, 124-130.

Rotondo, M., Cribari, C., Smith, R., & Trauma, A. C. o. S. C. o. (2014). Resources for optimal care of the injured patient. Chicago: American College of Surgeons, 6.

Reference Article

Geier, T.J., Hunt, J.C., Hanson, J.L., Heyrman, K., Larsen, S.E., Brasel, K.J. and deRoon‐Cassini, T.A. (2020), Validation of Abbreviated Four‐ and Eight‐Item Versions of the PTSD Checklist for DSM‐5 in a Traumatically Injured Sample. Journal of Traumatic Stress. doi:10.1002/jts.22478

About the Authors

Timothy J. Geier, PhD, is a Trauma and Health Psychology Postdoctoral Fellow in the Department of Surgery, Division of Trauma & Acute Care Surgery at the Medical College of Wisconsin, in Milwaukee, Wisconsin.

Sadie Larsen, PhD, is an Associate Professor in the Department of Psychiatry, Medical College of Wisconsin, Milwaukee, WI.

Terri A. deRoon-Cassini, PhD, is an Associate Professor and Director of Trauma Psychology, in the Department of Surgery, Division of Trauma & Acute Care Surgery, at the Medical College of Wisconsin, Milwaukee, WI.

Discussion Questions

1. In what settings would sensitivity matter more than sensitivity? Vice versa?
2. If trauma surgery settings more frequently screened for PTSD, what other aspects of the setting would likely need to change simultaneously?