News
Preventive Treatment for Posttraumatic Stress Disorder
Researchers identify pretrauma predictors and preventive coping skills for participants at risk for developing PTSD.
Primary Care
With the primary care setting considered the de facto mental health system, integrated approaches enhance the reach of care by incorporating uniform mental health screening and referral for patients coming through primary care. Specific evidence-based treatments can be integrated into this approach within a stepped-care framework that aims to match patients strategically to the right type of care and leverage specialty care resources as needed. Integrated care approaches for the treatment of PTSD and depression have been developed and evaluated inside and outside of the MHS. Findings indicate that integrated treatment approaches can improve care access, care continuity, patient satisfaction, quality of care,and in several trials, PTSD and depression outcomes.43-47
Recently, an integrated care approach targeting U.S. Army soldiers who screened positive for PTSD or depression in primary care was evaluated in a multisite effectiveness trial.48 Patients randomized to the treatment approach experienced significant improvements in both PTSD and depression symptoms relative to patients in usual care.43 In addition, patients treated in this care model received significantly more mental health services; the patterns of care indicated that patients with comorbid PTSD and depression were more likely to be triaged to specialty care, whereas patients with a single diagnosis were more likely to be managed in primary care.49 This trial suggests that integrated care models feasibly can be implemented in the U.S. Army care system, yielding increased uptake of mental health care, more efficiently matched care based on patient comorbidities, and improved PTSD and depression outcomes.
Treatment Research
The MHS supports a large portfolio of research in PTSD and depression through DoD/VA research consortia (eg, the Congressionally Directed Medical Research Program, the Consortium to Alleviate PTSD, the Injury and Traumatic Stress Clinical Consortium). The U.S. Army Medical Research and Materiel Command (USAMRMC) executes and manages the portfolio of research, relying on a joint program committee of DoD and non-DoD experts to make funding recommendations based on identified research priorities, policy guidance, and knowledge translation needs.
Health systems research on PTSD and MDD in federal health care settings is expanding. For example, the RAND Corporation recently evaluated a candidate set of quality measures for PTSD and MDD, using an operational definition of an episode of care.37 This work is intended to inform efforts to measure and improve the quality of care for PTSD and depression across the enterprise.
The DoD Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury is simultaneously completing an inferential assessment of adjunctive mental health care services, many focused on PTSD and depression, throughout the health care enterprise. Along with the substantial resources devoted to research on PTSD and depression, the MHS is implementing strategies to improve the system of care for service members with mental health conditions.
Army Care System Innovations
The U.S. Army is engaged in a variety of strategies to improve the identification of patients with mental health conditions, increase access to mental health services, and enhance the quality of care that soldiers receive for PTSD and depression. To improve the coordination of mental health care, the U.S. Army Medical Command implemented a wide-scale innovative transformation of its mental health care system through the establishment of the Behavioral Health Service Line program management office.
This move eliminated separate departments of psychiatry, psychology, and social work in favor of integrated behavioral health departments that are now responsible for all mental health care delivered to soldiers, including inpatient, outpatient, partial hospitalization, residential, embedded care in garrison, and primary care settings. This transformation ensured coordination of care for soldiers, eliminating potential miscommunication with patients, commands, and other clinicians while clearly defining performance indicators in process (eg, productivity, scheduling, access to care, and patient satisfaction) and outcome measures.49 In conjunction with the development of its service line, the U.S. Army created a Behavioral Health Data Portal (BHDP), an electronic and standardized means to assess clinical outcomes for common conditions.
To promote higher quality mental health care, the Office of the Surgeon General of the U.S. Army provided direct guidance on the treatment of PTSD and depression. U.S. Army policy mandates that providers treating mental health conditions adhere to the VA/DoD clinical practice guidelines (CPGs) and that soldiers with PTSD and depression be offered treatments with the highest level of scientific support and that outcome measures be routinely administered. In line with the CPGs, U.S. Army policy also recommends the use of both integrated and embedded mental health care approaches to address PTSD, depression, and other common physical and psychological health conditions.
To reduce stigma and improve mental health care access, the U.S. Army began implementing integrated care approaches in 2007 with its Re-Engineering Systems of Primary Care Treatment in the Military (RESPECT-Mil) program, an evidence-based collaborative care model.51-55 This approach included structured screening and diagnostic procedures, predictable follow-up schedules for patients, and the coordination of the divisions of responsibility among and between primary care providers, paraprofessionals, and behavioral health care providers. From 2007 to 2013, this collaborative care model was rolled out across 96 clinics worldwide and provided PTSD and depression screening to more than 1 million encounters per year.52,53
More recently, the U.S. Army led DoD in integrating behavioral health personnel in patient centered medical homes (PCMH) in compliance with DoD Instruction 6490.15.56 This hybrid integrated care model combines collaborative care elements developed in the RESPECT-Mil program with elements of the U.S. Air Force Behavioral Health Optimization project colocating behavioral health providers in primary care settings to provide brief consultative services.