By Brenda L. Mooney
SANTA MONICA, CA – Can enhanced primary care treatment help alleviate the stigma some military servicemembers fear when told to seek mental healthcare?
A new study suggests it can. Military members who visited a primary care clinic while suffering from post-traumatic stress disorder (PTSD) and depression reported fewer symptoms and better mental health functioning a year after enrolling in a treatment program. Although in a primary care setting, the program included specially-trained care managers and telephone therapy options.
The article, published in JAMA Internal Medicine, assigned patients to nurse care managers with special training to help with their care and follow-up with treatment recommendations, as well as connect them with telephone-based therapy. The RAND Corp.-led researchers found that the approach resulted in significant improvements in recovery after one year, as compared to patients with similar issues who were assigned to care managers without the added training and tele-therapy options.1
“Although the improvements were modest, the reach of the program can be large and has the potential to bring more people under a high-quality treatment umbrella sooner,” said the lead author, retired Army Col. Charles Engel, MD, MPH, now a senior natural scientist at RAND. “These findings suggest that the military health system might use this strategy to extend the reach of mental health care and reduce time to first treatment for PTSD and depression.”
An estimated 13% to 18% percent of military servicemembers suffer from PTSD, anxiety or depression after deployment, according to background information in the report, which added that fewer than half of those affected receive military mental health services and, even when services are received, they often are not timely or adequate.
Other research has suggested that clinical outcomes are improved with collaborative care models that provide mental health treatment in primary care settings with the support of nurse managers and options to see mental health professionals. Few studies have examined whether the approach is helpful for PTSD, however, and no previous trials have examined whether the concept can work in the military healthcare system, study authors note.
For the study, researchers examined the experiences of 666 military members treated in 18 primary care clinics at six large Army bases during 2012 and 2013. Participants were mostly men in their 20s and were randomly assigned to one of two different programs that provided care for mental health problems in a primary care setting.
Used for comparison was the existing Army model, where staff is trained at primary clinics to screen for PTSD and depression. Patients are contacted by nurses monthly to check on symptoms, coordinate care with primary care providers and increase access to mental health professionals.
The new model preserved the existing Army model but added some key features, including centrally assisted collaborative telecare. Unlike the old paradigm, nurses were specially trained in behavioral activation, problem solving and motivational interviewing to help patients remain in follow-up and adhere to treatment recommendations.
The test model also used psychologists to deliver telephone-based cognitive-behavioral therapy, while offering face-to-face psychotherapy in a primary care or specialty setting. The nurse care managers also helped patients access and complete online cognitive-behavioral self-management programs.
At the same time, a centrally-located psychiatrist, psychologist and nurse care manager remotely assisted the clinic sites, using a central database of symptoms to review caseloads weekly and suggest changes in treatments as needed.
After a year, a fourth of the military servicemembers with PTSD who were treated in the centrally-assisted collaborative telecare model showed a 50% improvement in their symptoms, compared to 17% percent for those treated under the older system. For depression, meanwhile, 30% of patients treated under the newer model showed a 50% improvement in symptoms after a year, compared to 20% for the first model.
Study authors point out that military personnel treated in the centrally-assisted collaborative telecare model also had fewer suicidal thoughts and physical symptoms. A possible reason, they posited, is that the patients had more telephone contact with care managers and more months on appropriate medication for PTSD and depression.
While the extra improvement seen among those treated in the centrally assisted collaborative telecare model was not large, Engel suggested it was significant because the original Army approach already is an improvement over usual approaches to treating PTSD in primary care.
“Our findings are consistent with what has been observed in nonmilitary health care settings,” he explained. “This approach results in better outcomes and improves access to high-quality care. This is particularly important for a population that has a demonstrated need for mental health services.”
The medical clinics involved with the study were at Joint Base Lewis-McCord in Washington, Fort Bliss in Texas, Fort Bragg in North Carolina, Fort Stewart in Georgia, Fort Campbell in Kentucky and Fort Carson in Colorado. Funding was provided by the DoD’s Deployment Related Medical Research Program.
“The results support the idea that high-quality mental health care can be provided in primary care settings,” Engel said. “While many military members are reluctant to seek out mental health specialists, they are more willing to receive primary medical care. So this is a good way to encourage more people to receive mental healthcare, while also improving the quality of mental health services for military members.”
- 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. doi: 10.1001/jamainternmed.2016.2402. PubMed PMID: 27294447.