NEW YORK — A systems-level collaborative care model for the screening, referral, and treatment of depression and posttraumatic stress disorder in U.S. soldiers has led to an increase in the number of soldiers receiving mental health care, Col. Charles C. Engel, MC, USA, said at the American Psychiatric Association's Institute on Psychiatric Services.
A feasibility study of the Re-Engineering Systems for the Primary Care Treatment of Depression and PTSD in the Military (RESPECT-Mil) model shows that the intervention often leads to clinical improvements, Dr. Engel reported.
Since its 2007 rollout, the model has been implemented in 35 of a planned 43 primary care clinics on 15 military bases in the United States, Germany, and Italy. Preliminary data from the participating clinics indicate that screening for depression and PTSD has occurred in two-thirds of primary care visits, with a positive screen rate of 14%, said Dr. Engel, director of the Department of Defense Deployment Health Clinical Center at Walter Reed Army Medical Center, Washington, and associate professor in the department of psychiatry at the Uniformed Services University of the Health Sciences.
Of the 14% who screened positive, 60% received a diagnosis of depression or PTSD and started treatment, noted Dr. Engel, a psychiatric epidemiologist who has been instrumental in helping the departments of Veterans Affairs and Defense develop guidelines for depression, PTSD, and medically unexplained symptoms.
The RESPECT-Mil program, based on a three-component model that has been used extensively in civilian populations, addresses some of the challenges that have kept soldiers from receiving needed mental health services, including reluctance to seek behavioral health services, insufficient mental health workforce, lack of competency in evidence-based mental health practice, and inadequate access to care, Dr. Engel said.
It achieves those goals by integrating the efforts of primary care physicians, nurse care facilitators, and psychiatrists, starting with a mandate for universal screening for depression and PTSD for soldiers during routine primary care visits, he said.
Patients who screen positive on the two-question depression screen (PHQ-2) or the four-item PTSD screen undergo a diagnosis and severity assessment using the Patient Health Questionnaire-9 (PHQ-9) and the 17-item PTSD Check List, as well as a suicide and violence risk assessment, Dr. Engel said. “We've modified the assessment tools so that it's easy for clinicians to look at and determine whether patients are high or low probability for suffering from a trauma reaction or suicidal ideation.”
When there is a presumptive diagnosis of depression or PTSD, the primary care clinician will initiate treatment and offer follow-up monitoring with a psychiatrist-supervised care facilitator and, when necessary, a behavioral health specialist.
“The care facilitators are the single most important ingredient in the [RESPECT-Mil] model,” Dr. Engel said. After the initial primary care visit, the care facilitators serve as the liaisons between the primary care providers and the consulting psychiatrists. The care facilitators provide follow-up via telephone and consult weekly with the supervising psychiatrist to evaluate patient progress. Patients with significant mental health issues may be referred from primary care to specialty care. Patients' initial treatment response is evaluated at 6-8 weeks for those on antidepressants and 4-6 weeks for those undergoing psychological counseling, and the treatment plan is adjusted if necessary, he said.
The early data are promising, but “the real challenge is going to come during the course of [2010], because we're going to be doubling the size of the program by getting it into almost all of the Army's approximately 100 primary care clinics,” Dr. Engel said. As this happens, “it's going to be a great platform for studying systems solutions approaches.
Disclosures: Dr. Engel has no relevant conflicts of interest.