NEW YORK — A systems-level collaborative care model for the screening, referral, and treatment of depression and posttraumatic stress disorder in U.S. soldiers has led to an increase in the number of soldiers receiving mental health care, Col. Charles C. Engel, MC, USA, said at the American Psychiatric Association's Institute on Psychiatric Services.
A feasibility study of the Re-Engineering Systems for the Primary Care Treatment of Depression and PTSD in the Military model, or RESPECT-Mil, shows that the intervention often leads to clinical improvements, Dr. Engel reported.
So far, the model has been implemented in 35 of a planned 43 primary care clinics on 15 military bases in the United States, Germany, and Italy. The rollout began in 2007.
Preliminary data from the participating clinics indicate that screening for depression and PTSD has occurred in two-thirds of primary care visits, with a positive screen rate of 14%, said Dr. Engel, director of the Department of Defense Deployment Health Clinical Center at Walter Reed Army Medical Center, Washington, and associate professor in the department of psychiatry at the Uniformed Services University of the Health Sciences.
Of the 14% who screened positive, 60% received a diagnosis of depression or PTSD and started treatment, noted Dr. Engel, a psychiatric epidemiologist who has been instrumental in helping the departments of Veterans Affairs and Defense develop guidelines for depression, PTSD, and medically unexplained symptoms.
The need for addressing mental health issues in the U.S. military has never been greater. For example, earlier this year, Sen. Ben Nelson (D-Neb.), chairman of the Senate Armed Services Committee's Personnel Subcommittee, testified that suicides per 100,000 personnel between 2007 and 2008 increased in every branch: from 17 to 20 in the Army; from 11 to 12 in the Navy; from 17 to 19 in the Marine Corps; and from 10 to 12 in the Air Force.
“These numbers indicate that, despite the services' best efforts, there's still much work to be done to prevent military suicides,” he said.
The RESPECT-Mil program, based on a three-component model that has been used extensively in civilian populations, addresses some of the challenges that historically have kept soldiers from receiving needed mental health services—including reluctance to seek behavioral health services, insufficient mental health workforce capacity, lack of competency in evidence-based mental health practice, and inadequate systems support for improving access to care, Dr. Engel said. It achieves those goals by integrating, through a manualized approach, the efforts of primary care physicians, nurse care facilitators, and psychiatrists, beginning with a mandate for universal screening for depression and PTSD for soldiers during routine primary care visits, he said.
Patients who screen positive on the two-question depression screen (PHQ-2) or the four-item PTSD screen undergo a diagnosis and severity assessment using the Patient Health Questionnaire-9 (PHQ-9) and the 17-item PTSD Check List, as well as a suicide and violence risk assessment, Dr. Engel said. “We've modified the assessment tools so that it's easy for clinicians to look at and determine whether patients are high or low probability for suffering from a trauma reaction or suicidal ideation.”
When there is a presumptive diagnosis of either depression or PTSD, the primary care clinician will engage the patient in an initial course of therapy to determine the appropriate management framework based on the patient's symptoms and preferences and will offer follow-up monitoring with a psychiatrist-supervised care facilitator and, when necessary, a behavioral health specialist, Dr. Engel said.
After the initial primary care visit, the care of patients identified as needing mental health services is managed by the care facilitators, who serve as the liaisons between the primary care providers and the consulting psychiatrists, Dr. Engel said. The care facilitators provide continuous follow-up via regular telephone consultations during which they monitor patients' progress, assess compliance with drug and other therapies, and offer support and suggestions, he said, noting that they also consult weekly with the supervising psychiatrist to evaluate patient progress and discuss changes to treatment plans.
Patients with significant mental health issues might be referred out of the primary care caseload to specialty care, he said.
“The care facilitators are the single most important ingredient in the [RESPECT-Mil] model,” Dr. Engel said. In fact, consistent with much of the services literature, it doesn't matter what treatment you tried first, what matters in terms of helping patients get better is that you followed up with the patient continuously and changed treatment plans within a reasonable amount of time if they were not working.”
Patients' initial treatment response is evaluated at 6-8 weeks for those on antidepressants and 4-6 weeks for those undergoing psychological counseling, and adjustments are made in the treatment plan at that time, if necessary, Dr. Engel said.
“We give the clinicians cheat sheets describing how to alter treatments when they're not achieving the desired outcome.” The cheat sheets delineate when to increase antidepressant dose, or switch medications, how and when to combine medication and counseling approaches, and when to request a behavioral health consultation.”
To improve the fidelity of the program, much of the backbone is automated, and the protocol is codified in separate guides for the primary care doctor, the case facilitator, and the behavioral health specialist, Dr. Engel said. Additionally, supporting patient education materials are available to patients at the point of care or through the care facilitators.
Because of the integrated nature of the system, the added accessibility to mental health screening and services has not resulted in a drain on behavioral health resources, Dr. Engel stressed. Participating psychiatrists initially were leery about resource limitations but are finding that this is a feasible, acceptable approach to patient management. “The supervision needs are reasonable and typically don't add up to more than 5 minutes per patient, depending on the severity of their symptoms and their past trauma history, and most patients don't have major risk factors or need treatment plan changes,” he said.
While the early data are promising, “the real challenge is going to come during the course of next year, because we're going to be doubling the size of the program by getting it into almost all of the Army's approximately 100 primary care clinics,” Dr. Engel said. As this happens, “it's going to be a great platform for studying systems solutions approaches.”
Dr. Engel reported no conflicts of interest related to his presentation.
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