View on treatment outcomes
The Army strives to provide the highest quality behavioral health care possible to ensure the psychological readiness of every Soldier. To support this effort, the Army asked RAND researchers to identify factors associated with changes in outcomes for soldiers receiving Army behavioral health care.
The Army is monitoring military behavioral health care performance
The Army will track the percentage of soldiers whose symptoms improve during mental health treatment using outcome measures. Specifically, the Army will track changes in symptoms of post-traumatic stress disorder (PTSD), depression, and anxiety.
Outcome measures include treatment response (whether symptoms have improved to some extent) and remission (whether symptoms have improved and are below a certain threshold). Identifying factors associated with improved outcomes can guide continuous quality improvement efforts in the military.
Two treatment factors – cooperation with treatment and benzodiazepine administration – were
were associated with treatment outcomes
- A stronger therapeutic relationship, or alliance, with service members is consistently associated with better treatment outcomes for PTSD, depression, and anxiety disorders. Soldiers are asked to indicate their “working relationship” with their service providers during treatment.
- Benzodiazepine use for more than 30 days was associated with worsening PTSD, depression, and anxiety disorders.
Two treatment-related factors – treatment collaboration and benzodiazepine use – were associated with treatment outcomes.
A stronger relationship or therapeutic alliance with providers was consistently associated with better treatment outcomes for PTSD, depression, and anxiety symptoms. Soldiers are asked to indicate their “working relationship” with their providers during treatment.
More than 30 days of benzodiazepine use was associated with worse treatment outcomes for PTSD, depression, and anxiety.
RAND suggests major changes to support permanent improvement in behavioral healthcare
Provide information and guidance to providers to strengthen the therapeutic alliance
Knowing how the military perceives its working relationship with providers can help improve the therapeutic relationship between providers and patients and address patient concerns about care.
The military can encourage providers to systematically assess the therapeutic alliance at the beginning of treatment and provide training to providers to reduce treatment interruptions and improve treatment outcomes.
Develop monitoring and reporting of benzodiazepine prescriptions
Veterans Health Administration and Department of Defense clinical practice guidelines on PTSD advise against the use of benzodiazepines as monotherapy or adjunctive therapy. RAND's findings support efforts by the military and the Department of Defense Office of Public Health to continue to monitor benzodiazepine use and provide information to providers.
Improve provider use of measurement-based behavioral health care
The Army will continue to develop and track outcomes for patients receiving behavioral health care. The Behavioral Health Data Portal is an online system that collects multiple measures reported by patients and clinicians. It is widely used for tracking symptoms of PTSD, depression, and anxiety, but symptom tracking can be expanded.
The Army can support more frequent collection of patient-reported symptoms during behavioral care. Training on how to systematically use information from symptom measurement to inform treatment decisions and guide discussions with patients would contribute to broader use of measurement-based treatment.
The Department of the Army and the Department of Defense will continue efforts to improve outcomes for soldiers receiving mental health care
In 2018, the DoD launched a program to track benzodiazepine prescribing among PTSD and acute stress disorder providers: the PTSD Provider Prescribing Profile. Results will be monitored and shared with military treatment facilities. The Army Mental Health Service is also monitoring the prescribing of benzodiazepines and atypical antipsychotics for the treatment of PTSD.
Approach of RAND
RAND researchers identified three samples of active-duty soldiers receiving Army behavioral health treatment who had been diagnosed with PTSD (N = 3264), depression (N = 3801), or anxiety (N = 4282).
To be included, soldiers had to 1) have received a medical specialist-prescribed behavioral health treatment for PTSD, depression, or anxiety in 2016-2017; 2) not have received a medical specialist-prescribed behavioral health treatment for that diagnosis in the previous six months, indicating the onset of a new treatment episode; 3) a first symptom score indicating significant symptom severity; and 4) a second symptom score between one and six months later.
The research team assessed 57 pretreatment variables (e.g., demographic characteristics, treatment history) and 84 treatment variables (e.g., visits, medications), examining their association with symptom outcomes through a multistep process. All models were adjusted for baseline symptom severity and soldier characteristics.
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David W. Newton is a board certified pharmacist and also has been a board member for boards of examiners for the National Association of Boards of Pharmacy since 1983. His areas of expertise are primarily pharmaceuticals as well as cannabinoids. You can read an article about his expertise in CBD on the National Library of Medicine.