By Annette M. Boyle
SANTA MONICA, CA — In the year since the release of a RAND report critical of follow-up within the Military Health System (MHS) for patients with post-traumatic stress disorder (PTSD) and depression, the DoD has released results of several new programs to improve screening, increase the number of therapeutic visits and track mental health measures.1
The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury estimate that up to 20% of the 2.6 million servicemembers who served in the Iraq and Afghanistan conflicts have or will develop PTSD.
At the end of 2014, 2.5% of all active duty servicemembers and 4.3% of those still on active duty who had ever deployed had received a diagnosis of PTSD at some point, but the center noted that many cases of PTSD in the military go undiagnosed and untreated. Studies place the prevalence of major depressive disorder among currently deployed servicemembers at 12% and at 13% among those previously deployed.2
MHS research into improved treatment for PTSD and depression stands to not only improve care for military patients, but to change how civilians receive care as well. “There’s very little in the civilian healthcare world that looks at how patients with PTSD and depression who receive behavioral health services do over time,” explained Kimberly A. Hepner, PhD, senior behavioral scientist at RAND and lead author of the 2016 report.
The first step in improving treatment and outcomes is identifying patients who need help. The four-question Primary Care PTSD Screen (PC-PTSD) followed by a more in-depth assessment for those who screen positive has been the “gold standard” for PTSD screening. An update to a single question tool (SIPS A and SIPS B) might challenge that position, as both versions of the ultra-brief screen had greater sensitivity and comparable specificity to the PC-PTSD. SIPS A and B and PC-PTSD had similar positive and negative predictive value and diagnostic efficiency, according to a presentation made at the Annual Meeting of the International Society for Traumatic Stress Studies in November.3
“These findings suggest that the SIPS A and SIPS B are promising ultra-brief screening instruments for military primary care,” the authors said. The shorter form provides particular value for high-volume medical facilities treating a patient group with elevated risk. “Population-level screening necessitates a validated PTSD screening tool that minimizes patient and provider burden in busy primary care clinics,” said the presenters.
The 2016 RAND report praised the MHS for its consistent and quick follow-up with patients following psychiatric hospitalizations but noted that relatively few patients received a minimally adequate number of psychotherapy sessions in the immediate post-diagnosis period.
“Several factors might contribute to the lower rates of psychotherapy or evaluation and management visits,” Hepner told U.S. Medicine. “It could be inadequate staffing or too few appointments available or that the appointment times are inconvenient or that servicemembers have competing demands for their time or worry about how mental health treatment might impact their careers.”
A centrally assisted collaborative telecare program might address those issues. When compared to patients who received standard care, soldiers at six Army posts who participated in the primary care-based telecare program received significantly more mental health services during the year of treatment. Participants in the test program experienced nearly twice the reduction in PTSD and depression symptoms, on average, and about 50% more patients achieved symptom reduction of 50% or more following treatment. The program also provided superior triage, stepping up treatment for patients with more complex symptoms more effectively than standard care.4
RAND had recommended that MHS adopt a clinical support system that could simplify tracking of treatment and key measures of care as well as outcomes. Two systems currently in use can help MHS achieve this goal. The Behavioral Health Data Portal developed by the Army—and now being adopted by the other services—is a web-based application that operates outside of the Armed Forces Health Longitudinal Technology Application (AHLTA), the DoD’s electronic medical record.
BHDP helps providers track disorder severity while supporting implementation of data-driven quality improvement practices, and aggregating reporting to assist in analysis and informed decision-making at the provider, program, facility or other levels.
“Once a patient is diagnosed with PTSD or other common mental health conditions, BHDP will prompt for the patient’s symptoms to be assessed routinely. This provides important clinical information for providers and also will provide data to the MHS about the effectiveness of care,” Hepner said.
In addition, the rollout of the new GENESIS electronic health record might enable MHS to more easily introduce evidence-based programs for mental health treatment across service branches and systemwide. The first installation, Fairchild Air Force Base in Spokane, WA, deployed GENESIS in February. The system will be gradually implemented across MHS over the next several years.
During its rollout and testing, new functionality will be added to the electronic health record system, likely including improved tracking of mental health measures and automated support for clinicians treating service members with PTSD and depression.
“Mental health leaders have expressed a desire for GENESIS to support this kind of care,” Hepner pointed out. And GENESIS program executives have repeatedly noted that the system will be refined based on provider input and operational experience as it spreads across the country.
Whether clinicians use BHDP or GENESIS, increased attention to key metrics will continue to improve the care provided to military patients with PTSD and depression. Standardization across the system will help secure MHS’s leadership position in mental healthcare. Already, Hepner noted, “MHS is the leader in monitoring patient outcomes for psychotherapy.”
- Hepner KA, Sloss EM, Roth CP, Krull H, Paddock SM, Moen S, Timmer MJ, Pincus HA. Quality of Care for PTSD and Depression in the Military Health System: Phase I Report. Rand Health Q. 2016 Jun 20;6(1):14.
- Gadermann AM, Engel CC, Naifeh JA, Nock MK, Petukhova M, Santiago PN, Wu B, Zaslavsky AM, Kessler RC. Prevalence of DSM-IV major depression among U.S. military personnel: meta-analysis and simulation. Mil Med. 2012 Aug;177(8 Suppl):47-59.
- Stewart L, Evatt D, Hrper E, Belsher B, Beech E, Freed M. Operating Characteristics of the Single-Item PTSD Screener (SIPS). 32nd Annual Meeting of the International Society for Traumatic Stress Studies. November 2016.
- Engel CC, Jaycox LH, Freed MC, Bray RM, Brambilla D, Zatzick D, Litz B, Tanielian T, Novak LA, Lane ME, Belsher BE, Olmsted KL, Evatt DP, Vandermaas-Peeler R, Unützer J, Katon WJ. Centrally Assisted Collaborative Telecare for Posttraumatic Stress Disorder and Depression Among Military Personnel Attending Primary Care: A Randomized Clinical Trial. JAMA Intern Med. 2016 Jul 1;176(7):948-56.