This report provides an overview of the psychological health workforce at military treatment facilities (MTFs), examines the extent to which care is consistent with clinical practice guidelines, and identifies facilitators and barriers to providing this care. This report offers a comprehensive assessment of providers' perspectives on their capacity to deliver care for PTSD and depression. Strategies to improve care in MTFs are described.

Cover: Delivering Clinical Practice Guideline–Concordant Care for PTSD and Major Depression in Military Treatment Facilities
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Delivering Clinical Practice Guideline–Concordant Care for PTSD and Major Depression in Military Treatment Facilities

by Kimberly A. Hepner, Coreen Farris, Carrie M. Farmer, Praise O. Iyiewuare, Terri Tanielian, Asa Wilks, Michael W. Robbins, Susan M. Paddock, Harold Alan Pincus

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Research Questions

  1. What is the capacity of the military treatment facilities to deliver evidence-based care for PTSD and major depressive disorder?
  2. In which areas could the MHS focus its efforts to continuously improve the quality of care provided to all service members?

Providing accessible, high-quality care for psychological health (PH) conditions, such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), is important to maintaining a healthy, mission-ready force. It is unclear whether the current system of care meets the needs of service members with PTSD or MDD, and little is known about the barriers to delivering guideline-concordant care. RAND used existing provider workforce data, a provider survey, and key informant interviews to (1) provide an overview of the PH workforce at military treatment facilities (MTFs), (2) examine the extent to which care for PTSD and MDD in military treatment facilities is consistent with Department of Veterans Affairs/Department of Defense clinical practice guidelines, and (3) identify facilitators and barriers to providing this care. This report provides a comprehensive assessment of providers' perspectives on their capacity to deliver PH care within MTFs and presents detailed results by provider type and service branch. Findings suggest that most providers report using guideline-concordant psychotherapies, but use varied by provider type. The majority of providers reported receiving at least minimal training and supervision in at least one recommended psychotherapy for PTSD and for MDD. Still, more than one-quarter of providers reported that limits on travel and lack of protected time in their schedule affected their ability to access additional professional training. Finally, most providers reported routinely screening patients for PTSD and MDD with a validated screening instrument, but fewer providers reported using a validated screening instrument to monitor treatment progress.

Key Findings

The Composition of the Psychological Health Workforce in Military Treatment Facilities Varies by Service Branch in Terms of Provider Type and Employment Status

  • Master's-level clinicians make up the largest proportion of the PH workforce across service branches.
  • Most PH providers are active-duty service members or civilian government employees, with contractors making up less than 20 percent.

Most Providers Reported Routinely Screening Patients for PTSD and Major Depressive Disorder with a Validated Screening Instrument

  • Fewer providers reported using a validated screening instrument to monitor treatment progress.

Most Providers Reported Using Guideline-Concordant Psychotherapies for Patients with PTSD or MDD, Though Use Varied by Provider Type

  • Psychologists were most likely to select a guideline-concordant psychotherapy as their primary psychotherapy approach for patients with PTSD.
  • Psychologists and master's-level clinicians were more likely to select a guideline-concordant psychotherapy as their primary psychotherapy approach for MDD.

Nearly All Psychiatrists and Psychiatric Nurse Practitioners Reported Using Guideline-Concordant Medication

  • Eleven percent reported that their most recent PTSD patient was receiving a medication identified by VA/DoD clinical practice guidelines as potentially harmful for patients with PTSD.

Most Psychotherapy Providers Reported Receiving at Least Minimal Training and Supervision in at Least One Guideline-Concordant Psychotherapy for PTSD and MDD

  • The PTSD psychotherapy with the highest provider confidence level was cognitive processing therapy; fewer than half of providers felt 'very confident' in their ability to deliver it.
  • Some providers reported difficulty accessing additional training, though confidence in delivering a particular psychotherapy was positively associated with at least minimal training in that therapy.

Recommendations

  • Maximize the effectiveness of psychotherapy training and reduce barriers: Adopt a systematic, broad-based approach to training and certification in guideline-concordant therapies, and track provider progress; and reduce barriers to receiving training in guideline-concordant therapies.
  • Monitor the frequency and duration of psychotherapy treatment.
  • Expand monitoring of treatment outcomes and use that information to improve quality of care for PH conditions.
  • Develop a systematic, MHS-wide approach to increasing the delivery of guideline-concordant PH care through a continuing quality improvement strategy.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Methods

  • Chapter Three

    Characteristics of the Psychological Health Workforce Across the MHS

  • Chapter Four

    Delivery of Guideline-Concordant Care for PTSD and MDD

  • Chapter Five

    Facilitators and Barriers to Provision of Guideline-Concordant Care for PTSD and MDD

  • Chapter Six

    Summary and Recommendations

  • Appendix A

    Survey Sampling and Weighting

  • Appendix B

    Survey Domains

  • Appendix C

    Survey of Psychological Heath Providers in the MHS

  • Appendix D

    Key Informant Interview Discussion Guide

Research conducted by

This research was sponsored by the Department of Defense's Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute, a federally funded research and development center sponsored by the Office of the Secretary of Defense, the Joint Staff, the Unified Combatant Commands, the Navy, the Marine Corps, the defense agencies, and the defense Intelligence Community.

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