This report identifies factors associated with changes in outcomes for soldiers who received Army behavioral health specialty care and provides recommendations to improve care and outcomes for posttraumatic stress disorder, depression, and anxiety. Analyses of 141 patient and treatment variables indicated that two treatment factors—therapeutic alliance and receipt of benzodiazepines—were associated with outcomes.

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Improving Behavioral Health Care for U.S. Army Personnel

Identifying Predictors of Treatment Outcomes

by Kimberly A. Hepner, Carol P. Roth, Eric R. Pedersen, Sujeong Park, Claude Messan Setodji

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Research Question

  1. What factors are associated with changes in outcomes for soldiers who receive Army BH specialty care?

This report identifies factors associated with changes in outcomes for soldiers who received Army behavioral health (BH) specialty care and provides recommendations to improve BH care and outcomes. RAND researchers identified three samples of soldiers who received Army BH care with diagnoses of posttraumatic stress disorder (PTSD), depression, or anxiety and whose symptoms were assessed during their care. Multivariate analyses included 141 patient and treatment variables to identify factors associated with symptom improvement. Analyses also examined patterns in how the symptoms changed over time.

Analyses suggest that the Behavioral Health Data Portal, an online system that allows for collection of multiple patient- and clinician-reported measures, is widely used to track symptoms of PTSD, depression, and anxiety, but there are opportunities to expand symptom tracking. Two treatment factors—therapeutic alliance and receipt of benzodiazepines—were associated with treatment outcomes. Specifically, a stronger therapeutic relationship or alliance with providers, as reported by soldiers, was associated with improved PTSD, depression, and anxiety outcomes. Further, receipt of more than a 30-day supply of benzodiazepines was associated with poorer PTSD, depression, and anxiety outcomes. Many soldiers' trajectories of symptom change did not demonstrate improvement.

Recommendations include providing feedback and guidance to providers on how to strengthen alliance with their patients, expanding tracking and feedback on benzodiazepine prescribing, and increasing provider use of measurement-based BH care.

Key Findings

The Behavioral Health Data Portal (BHDP) is widely used to track PTSD, depression, and anxiety symptoms within Army BH care, but there are opportunities to expand symptom tracking

  • Soldiers had more symptom scores the longer they were in treatment, suggesting that BHDP has been widely implemented and that soldiers routinely received scores during BH visits.
  • Some soldiers had BH visits after their last symptom measure score. Thus, a soldier's last score was not necessarily a measure of symptoms at the last visit.

Stronger patient-reported therapeutic alliance was associated with improved PTSD, depression, and anxiety outcomes

  • Even when controlling for other treatment factors, a perceived strong working relationship between soldiers and their providers was associated with decreased PTSD, depression, and anxiety symptoms.
  • No pretreatment variables, such as demographic or risk variables, were consistently associated with outcomes.

Increased supply of benzodiazepines was associated with worse PTSD, depression, and anxiety outcomes

  • Soldiers with more than a 30-day supply of benzodiazepines experienced poorer outcomes.

Many soldiers' trajectories of symptom change did not demonstrate improvement

  • Rates of achieving either response to treatment (i.e., symptom improvement) or remission within one to six months were 35 percent for PTSD, 45 percent for depression, and 41 percent for anxiety.
  • The authors identified trajectories of symptom change for each sample. The majority of soldiers with PTSD (83 percent) were included in a trajectory that did not demonstrate improvement in their symptoms.
  • Among patients with depression, 34 percent were included in a trajectory that showed no improvement, and 45 percent showed a small improvement.
  • Forty-five percent of the anxiety sample were in a trajectory that showed no improvement.

Recommendations

  • Provide feedback and guidance to providers to help strengthen therapeutic alliance. Knowledge of how soldiers perceive their "working relationship" with providers may help improve therapeutic alliance with patients and address patients' concerns about treatment. The Army can encourage providers to routinely assess therapeutic alliance early in treatment and deliver provider training to help minimize treatment dropout and improve outcomes.
  • Expand tracking and feedback on benzodiazepine prescribing. The clinical practice guideline for PTSD cautions against using benzodiazepines as monotherapy or augmentation therapy, and these medications have been identified as potentially harmful in this population. RAND results support the Army and the Defense Health Agency continuing their efforts in benzodiazepine monitoring and feedback.
  • Increase provider use of measurement-based BH care. The Army continues to expand and monitor outcomes for patients who receive BH care. The Behavioral Health Data Portal, an online system that allows for collection of multiple patient and clinician-reported measures, is widely used to track PTSD, depression, and anxiety symptoms, but there are opportunities to expand symptom tracking. The Army can support providers in frequently collecting patient-reported symptom measures during their BH care. Training on how to routinely use the information from symptom measures to guide treatment decisions and discussions with patients would support increased use of measurement-based care.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Methods

  • Chapter Three

    Implementation of Treatment Outcome Monitoring and the Army's Outcome Measures

  • Chapter Four

    Characteristics and Representativeness of Soldiers in the Multivariate Analysis Samples

  • Chapter Five

    Identifying Pretreatment and Treatment Predictors of PTSD, Depression, and Anxiety Outcomes

  • Chapter Six

    Trajectories of PTSD, Depression, and Anxiety Symptom Change

  • Chapter Seven

    Summary and Recommendations

  • Appendix A

    Variables Used in the Multivariate Models

  • Appendix B

    PTSD, Depression, and Anxiety Outcome Models: Full Model Results

Research conducted by

The research described in this report was sponsored by the United States Army and conducted by the Personnel, Training, and Health Program within the RAND Arroyo Center.

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