June 13, 2016
Military members who visited a primary care clinic while suffering from post-traumatic stress disorder and depression reported fewer symptoms and better mental health functioning a year after enrolling in a treatment program that included specially trained care managers and telephone therapy options, according to a new study.
The study focused on primary care as a way of combating the stigma many service members feel about going directly to a mental health specialist.
The intervention assigns patients to nurse care managers with special training to help patients remain in care and follow treatment recommendations, coordinate patients' status with the health care team, and help patients to access telephone-based therapy. Researchers found that the approach resulted in significant improvements in recovery after one year, as compared to peers assigned to care managers without the added training and teletherapy options.
The findings are published online by the journal JAMA Internal Medicine.
"Although the improvements were modest, the reach of the program can be large and has the potential to bring more people under a high-quality treatment umbrella sooner," said Dr. Charles Engel, the study's lead author and a senior natural scientist at RAND, a nonprofit research organization. "These findings suggest that the military health system might use this strategy to extend the reach of mental health care and reduce time to first treatment for PTSD and depression."
The prevalence of mental health issues is relatively high in the U.S. military, with an estimated 13 percent to 18 percent of members suffering from PTSD, anxiety or depression after deployment. Fewer than half of the affected personnel receive military mental health services and when services are received they often are not timely or adequate.
Collaborative care models that provide mental health treatment in primary care settings with the support of nurse managers and options to see mental health professionals have been widely shown to provide high-quality care and improve clinical outcomes. However, few studies have examined whether the approach is helpful for PTSD and no previous studies have examined whether the concept can work in the military health care system.
The study, conducted by researchers from RAND, RTI International and the Department of Defense Deployment Health Clinical Center, examined the experiences of 666 military members treated in 18 primary care clinics at six large Army bases during 2012 and 2013. Participants, who were mostly men in their 20s, were randomly assigned to one of two different programs that provided care for mental health problems in a primary care setting.
The existing Army model, used for test comparison, trained staff at primary clinics to screen for PTSD and depression. Nurses contacted patients monthly to check on symptoms, coordinate care with primary care providers and increase access to mental health professionals.
The test model, centrally assisted collaborative telecare, preserved existing Army model and added some key features. The nurses were specially trained in behavioral activation, problem solving and motivational interviewing to help patients remain in follow-up and stick to treatment recommendations.
In addition, the test model used psychologists to deliver telephone-based cognitive-behavioral therapy and offered face-to-face psychotherapy in a primary care or specialty setting. The nurse care managers also helped patients access and complete online cognitive-behavioral self-management programs. A centrally located psychiatrist, psychologist and nurse care manager remotely assisted the clinic sites, using a central database of symptoms to review caseloads weekly and suggest changes in treatments as needed.
Engel said that while the extra improvement seen among those treated in the centrally assisted collaborative telecare model was not large, it is important given that the original Army approach already is an improvement over usual approaches to treating PTSD in primary care.
"Our findings are consistent with what has been observed in nonmilitary health care settings," Engel said. "This approach results in better outcomes and improves access to high-quality care. This is particularly important for a population that has a demonstrated need for mental health services."
After 12 months of care, 25 percent of military members with PTSD who were treated in the centrally assisted collaborative telecare model showed a 50 percent improvement in their symptoms, compared to 17 percent for those treated under the first model. Similarly, among patients with depression, 30 percent treated under the second model showed a 50 percent improvement in symptoms after a year, compared to 20 percent for the first model.
People treated in the centrally assisted collaborative telecare model also had fewer suicidal thoughts and physical symptoms. In addition, patients treated under the model had more telephone contact with care managers and more months on appropriate medication for PTSD and depression.
"The results support the idea that high-quality mental health care can be provided in primary care settings," Engel said. "While many military members are reluctant to seek out mental health specialists, they are more willing to receive primary medical care. So this is a good way to encourage more people to receive mental health care, while also improving the quality of mental health services for military members."
The medical clinics involved with the study were at Joint Base Lewis-McCord in Washington, Fort Bliss in Texas, Fort Bragg in North Carolina, Fort Stewart in Georgia, Fort Campbell in Kentucky and Fort Carson in Colorado.
Support for the study was provided by the U.S. Department of Defense Deployment Related Medical Research Program.
Other authors of the study are Lisa H. Jaycox and Terri Tanielian of RAND; Michael C. Freed of the Uniformed Services University of the Health Sciences and the Deployment Health Clinical Center (now at the National Institute of Mental Health); Robert M. Bray, Donald Brambilla, Marian E. Lane, Kristine L. Rae Olmsted and Russ Vandermaas-Peeler of RTI International; Dr. Douglas Zatzick, Dr. Jürgen Unützer and Dr. Wayne J. Katon the University of Washington School of Medicine; Brett Litz of the VA Boston Healthcare System and Boston University School of Medicine; and Laura A. Novak, Bradley E. Belsher and Daniel P. Evatt of the Deployment Health Clinical Center.
RAND Health is the nation's largest independent health policy research program, with a broad research portfolio that focuses on health care costs, quality and public health preparedness, among other topics.