Supporting Willingness

Ensuring excellent treatment of PTSD and depression in the military

Post-traumatic stress disorder (PTSD) and depression are common and treatable mental health problems. Without proper treatment, these diagnoses can have a significant impact on soldiers and their families, but little is known about the quality of care provided by the military health system (MHS).

To find answers, the RAND Corporation is conducting perhaps the largest and most comprehensive independent study of the MHS's treatment of soldiers with PTSD and depression as part of a Department of Defense-funded research initiative. The study is an important step toward improving psychological care for military personnel.

Military personnel with PTSD or depression require excellent care to meet their complex needs

Soldiers with PTSD or depression receive a lot of medical treatment. The average number of outpatient visits for PTSD patients is 41 per year and 30 per year for patients with depression. Military personnel with PTSD or depression see a wide range of providers; in the survey year, there were 14 providers for patients with PTSD and 12 providers for patients with depression.

These service users also often have other mental health problems, such as sleep disorders and anxiety. Five out of six service users received at least one psychotropic medication, and 45% of patients with PTSD and 31% of patients with depression received four or more medications. Excellent treatment is appropriate, timely, and coordinated. Given this mix of treatment use, the number of different providers, and comorbid diagnoses, it is essential to ensure coordination of care among these providers.

The strengths of the MHS are important, but the treatment of PTSD and depression needs to be improved

The RAND results suggest that the MHS is a leader in timely outpatient follow-up after psychiatric hospitalization. Of patients with PTSD or depression, 86% attended an outpatient visit within seven days of discharge. The post-discharge period can be vulnerable and these follow-up visits are vital for these patients.

In addition, the vast majority of patients with a diagnosis received at least one psychotherapy visit: approximately 91% of patients with PTSD and 82% of patients with depression. This suggests that military patients diagnosed with PTSD or depression are receiving at least one form of psychological treatment. However, there are also areas where improvement is needed.

We are fortunate to be part of a system that celebrates its successes and directly addresses areas that need more attention.

Areas of excellence

• Eighty-six percent of patients with PTSD or depression attended an outpatient visit within seven days of discharge from a psychiatric hospital.
• 91% of patients with PTSD and 82% of patients with depression received at least one psychotherapy session.

Areas for improvement

• Only 34% of newly diagnosed PTSD patients received at least adequate treatment (at least four psychotherapy sessions or two therapy sessions) within eight weeks of diagnosis. Only 24% of patients with depression reached this threshold.
• Only 45% of people with PTSD and 42% of people with depression had a follow-up visit within 30 days of starting a new medication.

Although most patients received at least one psychotherapy visit, the number and timing of visits may have been insufficient to provide evidence-based psychotherapy. For example, patients diagnosed with PTSD or depression should receive at least four psychotherapy or two pharmacotherapy visits within eight weeks of diagnosis.

However, only one-third (34%) of newly diagnosed PTSD patients and less than one-quarter (24%) of patients with depression met this threshold. In addition, only 45% of patients with PTSD and 42% of patients with depression had a follow-up visit within 30 days of starting new medication. Patients need timely medication follow-up visits to adjust their treatment, and these visits are especially important when patients are on multiple medications.

The RAND approach

The study examined administrative data from the military health system on 14,576 active-duty soldiers diagnosed with PTSD and 30,541 diagnosed with depression in the first six months of 2012. RAND tracked their care for one year after diagnosis to assess whether these soldiers received evidence-based care and whether there were differences in quality of care by branch of service, geographic region, or soldier characteristics.

Soldiers with PTSD or depression receive important medical care, so it is essential that they receive excellent care

• The median number of outpatient visits for PTSD patients is 41 visits per year.
• 30 visits per year is the average number of outpatient visits for patients with depression.
• Five out of six received psychotropic medication.
• 14 individual providers is the mean number of individual providers per PTSD patient.
• 12 individual providers is the mean number of individual providers per patient with depression.

The quality of care for PTSD and depression varies by type of service, region, and demographics of individuals served

The DoD is well positioned to be a leader in providing quality, evidence-based care for PTSD and depression.

However, no area or region outperformed or outperformed the others. Nor were there consistent differences in quality of care by patient characteristics (age, gender, education, race/ethnicity, or placement history). However, these differences suggest that it is possible to improve maternal health by providing consistently excellent care.

Recommendations

RAND recommends that the military take the following steps to implement strategies to improve the quality of mental health care provided by the military health system:

1. Implement an enterprise-wide system that includes priority quality measures to assess the management of mental health problems. A separate system for mental health is not necessary, but quality measures for mental health could be included in an enterprise-wide system for assessing the management of medical and psychiatric conditions.
2. Increase transparency-which provides important information to guide improvements in care-by reporting the results of quality measures for PTSD, depression, and mental health, both internally and publicly. The MHS has recently increased the number of public reports on quality measures (www.health.mil and www.tricare.mil), although only two measures are currently related to mental health (outpatient follow-up after psychiatric hospitalization at seven and 30 days after discharge).
3. Explore the reasons for differences in the treatment of PTSD and depression. Understanding what factors lead to better or worse outcomes can guide quality improvement initiatives. For example, it may be useful to introduce throughout the organization some policies or practices that have been adopted in one service area.