By Brenda L. Mooney
SANTA MONICA, CA — The MHS does an excellent job following up with patients after being discharged from mental healthcare treatment but falls short in some other areas, according to a new assessment from the RAND Corp.
The report, which looked at how the U.S. military cares for servicemembers with post-traumatic stress disorder (PTSD) and depression, found that the overwhelming majority received at least one psychotherapy visit. Among the areas of care needing improvement, however, were the number and timing of subsequent visits, which reviewers suggested could be inadequate to deliver evidence-based psychotherapy.1
In general, RAND found that military personnel with both PTSD and depression suffer a high rate of comorbid health conditions.
“Regardless of where they serve, where they live or who they are, all members of the U.S. armed forces should receive high-quality mental healthcare,” said lead author Kimberly A. Hepner, PhD, a clinical psychologist at RAND, a nonprofit research organization. “Developing transparent assessments of care that can be routinely reviewed both internally and externally are essential to ensuring excellent care for all servicemembers and their families.”
The report points out that, to meet clinical guidelines, patients newly diagnosed with either PTSD or depression should receive at least four psychotherapy or two medication-management visits within eight weeks of their diagnosis. Yet, in the MHS, only a third of patients newly diagnosed with PTSD and fewer than one-fourth of those with depression met those established thresholds.
Requested by DoD’s Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE), the RAND study is touted as the largest, most-comprehensive independent look at how military healthcare managements servicemembers with PTSD and depression.
For the study, researchers reviewed administrative data and medical records of 14,576 active-duty servicemembers diagnosed with PTSD and 30,541 who were diagnosed with depression from January 2012 to June 2012.
Also examined were variations in quality measure rates by service branch — Army, Air Force, Marine Corps and Navy — and by TRICARE region — North, South, West and Overseas.
The quality of care provided for PTSD and depression varied, according to the results, but no military branch or region consistently outperformed or underperformed, compared with the others. In addition, researchers found no consistent patterns of variation in the quality of care by patient characteristics, such as age, gender, pay grade, race-ethnicity or deployment history.
Still, rates of follow-up within seven days after a mental-health hospitalization differed across service branches by as much as 14%, and rates of adequate filled prescriptions for targeted medications varied by pay grade by as much as 29%.
It also found that medication trial rates were similar or even higher than estimates from other healthcare systems, but rates of follow-up medication management were similar but low. Similarly, despite the high rate of at least some psychotherapy treatment, the number of visits were, overall, too low.
“The Military Health System (MHS) generally performs well in the areas of initiating psychotherapy and follow-up after hospitalization, but is inconsistent or weaker in the areas of medication management and ongoing care,” the authors wrote. “The MHS largely succeeds in providing patients with an initial psychotherapy visit, but could improve rates of delivering ongoing treatment.”
On the other hand, the MHS is a leader in achieving high rates of follow-up after psychiatric hospitalization. The report suggested that high rates of follow-up after psychiatric hospitalization relative to other healthcare systems could have been the result of a 2011 MHS mandate describing follow-up procedures for missed behavioral health appointments.
The RAND report recommended that the MHS do the following:
- Improve the quality of care for psychological health conditions delivered by MHS.
- Establish an enterprisewide performance measurement, monitoring and improvement system that includes high-priority standardized metrics to assess care for psychological health (PH) conditions.
- Integrate routine outcome monitoring for servicemembers with PH conditions as structured data in the medical record as part of a measurement-based care strategy.
- Routinely report quality-measure results for PH conditions internally, enterprisewide and publicly to support and incentivize ongoing quality improvement and to facilitate transparency.
- Investigate the reasons for significant variation in quality of care for PH conditions by service branch, region and servicemember characteristics.
1 Hepner, KA, Sloss EM, Roth CP, Krull H, et al. Quality of Care for PTSD and Depression in the Military Health System: Phase I Report. Santa Monica, CA: RAND Corporation, 2016. http://www.rand.org/pubs/research_reports/RR978.html. Also available in print form.