Centrally Assisted Collaborative Telecare for Posttraumatic Stress Disorder and Depression Among Military Personnel Attending Primary Care

A Randomized Clinical Trial

Published in: JAMA Internal Medicine, 2016

Posted on RAND.org on June 24, 2016

by Charles C. Engel, Lisa H. Jaycox, Michael C. Freed, Robert M. Bray, Donald Brambilla, Douglas F. Zatzick, Brett T. Litz, Terri Tanielian, Laura A. Novak, Marian E. Lane, Bradley E. Belsher, Kristine Rae Olmsted, Daniel P. Evatt, Russ Vandermaas-Peeler, Jurgen Unutzer, Wayne J. Katon

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Research Question

  1. Can central assistance of collaborative primary care for post-traumatic stress disorder (PTSD) and depression among military service members improve illness outcomes?

Importance

It is often difficult for members of the US military to access high-quality care for posttraumatic stress disorder (PTSD) and depression.

Objective

To determine effectiveness of a centrally assisted collaborative telecare (CACT) intervention for PTSD and depression in military primary care.

Design, Setting, and Participants

The STEPS-UP study (Stepped Enhancement of PTSD Services Using Primary Care) is a randomized trial comparing CACT with usual integrated mental health care for PTSD or depression. Patients, mostly men in their 20s, were enrolled from 18 primary care clinics at 6 military installations from February 2012 to August 2013 with 12-month follow-up completed in October 2014.

Interventions

Randomization was to CACT (n = 332) or usual care (n = 334). The CACT patients received 12 months of stepped psychosocial and pharmacologic treatment with nurse telecare management of caseloads, symptoms, and treatment.

Main Outcomes and Measures

Primary outcomes were severity scores on the PTSD Diagnostic Scale (PDS; scored 0-51) and Symptom Checklist depression items (SCL-20; scored 0-4). Secondary outcomes were somatic symptoms, pain severity, health-related function, and mental health service use.

Results

Of 666 patients, 81% were male and the mean (SD) age was 31.1 (7.7) years. The CACT and usual care patients had similar baseline mean (SD) PDS PTSD (29.4 [9.4] vs 28.9 [8.9]) and SCL-20 depression (2.1 [0.6] vs 2.0 [0.7]) scores. Compared with usual care, CACT patients reported significantly greater mean (SE) 12-month decrease in PDS PTSD scores (-6.07 [0.68] vs -3.54 [0.72]) and SCL-20 depression scores -0.56 [0.05] vs -0.31 [0.05]). In the CACT group, significantly more participants had 50% improvement at 12 months compared with usual care for both PTSD (73 [25%] vs 49 [17%]; relative risk, 1.6 [95% CI, 1.1-2.4]) and depression (86 [30%] vs 59 [21%]; relative risk, 1.7 [95% CI, 1.1-2.4]), with a number needed to treat for a 50% improvement of 12.5 (95% CI, 6.9-71.9) and 11.1 (95% CI, 6.2-50.5), respectively. The CACT patients had significant improvements in somatic symptoms (difference between mean 12-month Patient Health Questionnaire 15 changes, -1.37 [95% CI, -2.26 to -0.47]) and mental health–related functioning (difference between mean 12-month Short Form-12 Mental Component Summary changes, 3.17 [95% CI, 0.91 to 5.42]), as well as increases in telephone health contacts and appropriate medication use.

Conclusions and Relevance

Central assistance for collaborative telecare with stepped psychosocial management modestly improved outcomes of PTSD and depression among military personnel attending primary care.

Key Findings

  • Service members receiving centrally assisted collaborative telecare (CACT) reported significantly larger decreases in PTSD and depressive symptoms than service members receiving usual integrated care.
  • Those receiving CACT were significantly more likely than those receiving integrated care to experience clinically significant (50 percent) improvements in PTSD (25 percent versus 17 percent) and depression (30 percent versus 21 percent) at 12 months.
  • Central implementation assistance of collaborative primary care for PTSD and depression can improve illness outcomes in military personnel and may offer an effective approach for other groups of people with PTSD.

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