WASHINGTON, DC—Not every servicemember returning from theater with PTSD symptoms is ready to embrace treatment. TheDCoE’s Deployment Health Clinical Center (DHCC) addresses this issue with programs that it hopes will meet the needs of a wide range of patients. These patients include those who may “not be convinced of what they have or convinced about what they should do,” those not willing to take medication, or those who aren’t even sure they want to see a clinician about it, according to Army Col Charles Engel, MD, who is director of DHCC at Walter Reed Army Medical Center.

Studies indicate that about three-fourths of patients who meet the criteria for PTSD have not received treatment for it, according to Engel, who noted that this is also a problem in the civilian sector.

One program, called RESPECT-MiL, attempts to help troubled servicemembers who are hesitant about seeking help from a mental health professional. The program, designed by DHCC and modeled after a civilian program for treating depression, is a model of care that equips providers in the primary care setting to screen, assess, and treat soldiers with depression or PTSD.

Helping Patients in the Primary Care Setting

There is an opportunity to help servicemembers in the primary care setting with PTSD because, while many may not want to seek help from a behavioral health specialist, they are making primary care visits. According to Engel, the average servicemember is using about 3.5 primary care visits a year.

Through the RESPECT-MiL model of care, patients are screened in the primary care setting for PTSD and depression and given an opportunity to voice any concerns. Primary care physicians have always had the option to refer patients to behavioral healthcare but in clinics using the RESPECT-Mil program, physicians have the added option to work with a registered nurse to follow patients with symptoms with input from a behavioral health specialist. Since many patients may not be willing to see a behavioral health specialist, this allows them to receive support in the primary care setting.

The nurse, known as a care facilitator, meets with a behavioral health specialist weekly to discuss patients and to provide feedback to the primary care provider that the provider may use for treatment decisions.

Having a care facilitator follow the patient ensures that the patient does not fall through the cracks. “The nurse is always there and calls [the patient] on a regular basis, checks in about the symptoms, talks with the patient about the side effects about treatment. It may just be for some patients watchful waiting because they refuse treatment.”

Engel said that the advantage of this program is that it creates an opportunity for those who utilize medical care on a regular basis to “raise their hand” if they are experiencing issues. Secondly, it creates help for the busy primary care doctor who may not be sure what to do for the patient, especially if the patient does not want to go to a specialist. “It creates this way of following the patient very carefully over time, monitoring their symptoms to see if they are getting better or not, and getting advice from a psychiatrist, even though the psychiatrist isn’t coming face to face with the patient.”

The model is used in 40 Army clinics and the plan is to add the model to another 55 Army clinics, according to Engel. “The reality is that we know these kinds of [mental health issues] can come on at unexpected times for a long time after someone returns from deployment, so it really has to be built in to the system of care at every level, and so we have been building it into primary care.”

The Army’s recent report, Health Promotion, Risk Reduction, Suicide Prevention Report 2010, also underscored the importance of expanding primary care provider screening of patients for behavioral health issues and cited RESPECT-MiL as an example of this.

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