By Sandra Basu
WASHINGTON — Limitations on travel and the lack of protected time might prevent MHS healthcare providers from receiving additional training in evidence-based therapies for post-traumatic stress disorder (PTSD) and major depressive disorder (MDD), a recent study suggested.
That finding was included in a recent RAND report entitled “Delivering Clinical Practice Guideline-Concordant Care for PTSD and Major Depression in Military Treatment Facilities,” which was sponsored by DoD’s Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.
The report examined the extent to which care for PTSD and MDD delivered in MTFs is consistent with VA/DoD clinical practice guidelines (CPG) and identified “facilitators and barriers to providing this care.” The data included a survey of 520 psychological health (PH) MTF providers, and semi-structured discussions with a small number of key individuals.
The survey focused on psychiatrists, psychiatric nurse practitioners (PNPs), doctoral-level psychologists, and master’s-level clinicians. To participate in the survey, providers had to have seen a patient with PTSD or MDD at an MTF within the previous 30 days. Providers were invited to participate and could complete a survey online or by telephone.
Limitations to the research, according to the study, was that it was “limited to a selected group of PH provider types delivering care at MTFs.”
“Primary care providers (e.g., physicians, nurses) play an important role in treating PH conditions, but we did not examine the capacity of these providers to deliver guideline-concordant PH care,” the report explained.
The report determined that master’s-level clinicians make up the largest proportion of the PH workforce across service branches, with most psychological health providers being active-duty servicemembers or civilian government employees. Contractors made up less than 20%, the researchers noted.
Of the 520 respondents, 186 said they had provided medication management for PTSD in the previous 30 days. Of those, 177 respondents indicated that their patient’s current prescriptions included psychopharmacologic medication.
While nearly 90% of these providers reported that their most recent PTSD patient was currently prescribed a guideline-concordant psychopharmacologic medication, the survey also found that “a clinically significant minority (11%) reported currently prescribing a medication that CPG guidelines recommend against—specifically, medications with the potential to cause harm or worsen PTSD outcomes.”
“For PTSD medication management, there is room for improvement in terms of prescriptions identified as harmful by the VA/DoD CPG for post-traumatic stress,” the report stated.
The survey also indicated that most providers used validated instruments to screen patients for PTSD and MDD, but fewer said they used similar evaluation to monitor treatment progress.
The majority of providers reported using guideline-concordant psychotherapies, but psychologists were more likely to do so for PTSD and psychologists and master’s-level clinicians were more likely to do that for MDD, according to the report.
Some providers reported difficulty accessing additional training, though confidence in delivering a particular psychotherapy was positively associated with at least minimal training in that therapy.
At the same time, most psychotherapy providers said they had received at least minimal training and supervision in at least one guideline-concordant psychotherapy for PTSD and MDD.
When it came to MDD, 71% of the nearly 386 providers who delivered psychotherapy felt very confident in their ability to deliver cognitive behavioral therapy for MDD, but providers were less confident in their ability to deliver interpersonal therapy and problem-solving therapy.
For the study, 503 providers were also asked to respond to a series of 26 survey items that examined potential barriers to delivering guideline-concordant care for PTSD and MDD. Providers could choose to respond to each statement by selecting “strongly disagree,” “disagree,” “neither disagree nor agree,” “agree,” or “strongly agree.”
About 30% of providers strongly agreed with the statement that limitations on travel prevented them from obtaining additional clinical training.
“A similar proportion of providers strongly agreed that their schedule lacked the protected time necessary to attend workshops or seminars to improve their clinical skills,” the report explained. “Although many providers have received minimally adequate training in evidence-based therapies, barriers to receiving training may make it difficult for those without training in specific modalities to catch up and for those with limited training to reach competence.”
The burden of travel restrictions for PH providers across the MHS may be even larger than suggested by the survey results since it did not include contracted providers, who are typically not allowed to travel for training, the authors suggested.
Also among the findings was that a quarter of providers strongly agreed they did not have the time in their schedule to see their patients as often as they would like.
“While it is not clear that these results reflect lower-quality care, it highlights the importance of understanding these patterns to ensure access and availability to psychotherapy appointments,” the report stated.
Among the recommendations was that MHS and service branch leadership should reduce barriers to receiving training in PTSD and MDDD and should consider one or more of the following policy changes:
- Lift or reduce travel restrictions for training;
- Increase delivery of onsite training that do not require travel;
- Increase the use of web-based training; and
- Provide protected time for attending training.
RAND also recommended that MHS adopt “a systematic, broad-based approach to training and certification in guideline-concordant therapies.
“Certification in a particular type of psychotherapy indicates that a provider has received training and clinical supervision, and ultimately demonstrated competence in delivering that psychotherapy,” the report explained.
Routine monitoring of the frequency and duration of psychotherapy treatment also was advised.
“This is consistent with recommendations from a recent RAND report (Hepner et al., 2016) that the MHS can improve at providing an adequate amount of treatment for service members beginning a new treatment episode for PTSD or depression,” the report noted.
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.
When Terrence O’Neil, MD, retired as chief of nephrology at the James H. Quillen VAMC in Johnson City in December 2016, he left in his wake decades of work treating kidney disease—nearly 35 years in the Air Force and DoD, plus 11 more at VA.