Treatment of Depression and PTSD by Collaborative Care Within the Military

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Much has been written and discussed about the increase in post-traumatic stress disorder (PTSD), depression, alcohol abuse, sexual violence, suicide and other mental health problems among soldiers in Iraq and Afghanistan after 13 years of armed conflict. These problems are considered among the most serious in military healthcare, for which scientific solutions are needed.

All solutions face problems in the healthcare system, such as stigmatization, barriers to care, and quality of care for soldiers and their families. The military health care system (MHS) serves a wide range of families and patients: from the rich to the poor, from young children to the elderly, and from men to women in equal measure. It covers almost all medical specialties, professions and levels of training.

The healthcare system costs $52 billion a year and covers some 9.6 million beneficiaries, including 1.4 million military personnel. Collaborative care has played an important role in the Army's efforts to help soldiers with PTSD and depression. I have had the privilege of leading these innovations for several years, since the program's inception in 2003.

It was then that I came into contact with the researchers of the MacArthur Foundation's Depression in Primary Care initiative, namely Alan Dietrich, Tom Oxman, John Williams, and Kurt Kroenke. The MacArthur Initiative Task Force called its approach a three-component model:

1) primary care readiness, which means equipping clinics with treatment tools, such as screening instruments and diagnostic aids, and improving information technology; 2) adding a care manager, usually a nurse, to each participating primary care clinic; and 3) a reinforced specialty care liaison, usually a psychiatrist, who meets weekly with the care manager to review the patient's condition and jointly make specific recommendations to the primary care physician.

With the generous help of MacArthur Initiative experts and funding from the Department of Defense, we adapted the MacArthur Initiative model for depression, added a module specifically for PTSD, and successfully implemented the program in 2004-2005 at a large military primary care clinic at Fort Bragg, North Carolina.

Lt. Gen. Kevin Kiley, then the Army's surgeon general, heard about our efforts. Before we could say “be careful what you ask for,” we received funding, personnel and an OPORD (Operation Orders of Responsibility) from the Army Health System, which directed us to implement the program at 15 large, widely deployed installations (42 primary care clinics) around the world.

We called our modified MacArthur approach RESPECT-MIL (Re-Engineering Systems of Primary Care for PTSD and Depression in the Military) and began implementing it in January 2007. As the military health system struggled to sustain two wars, military health system leaders and physicians were not unanimous in their belief that collaborative care was a step in the right direction. We had to be credible and persuasive advocates.

We went to each implementation site, talked to leaders and staff at all levels, visited clinics, saw firsthand what processes worked, and learned from variations in implementation where they could not be avoided. For maximum impact, we gave each facility's implementation team the space to do it themselves and take pride in the fact that their version of RESPECT-MIL is better than another.

For example, one facility boasted about its unique and streamlined selection process, and another about its business model that allows it to earn RVU credits. However, as a global implementation team, we had to stand firm and retain the conceptual pillars of collaborative care, educate and reinforce them to ensure better clinical outcomes.

By 2010, RESPECT-Mil was operational in all 42 designated clinics. A web-based care management support system was introduced, based on the system used in the IMPACT study. The IMPACT study was one of the first large-scale multicenter trials to provide collaborative care for depressed patients in primary care. We sent site-specific reports comparing each site's results with those of all other sites. We mailed facilities and equipment on a fixed schedule.

Our progress was rewarded. That same year, a new OPORD was issued expanding RESPECT-Mil to 37 sites, covering 92 primary care clinics. We had the confidence of the leadership, which allowed us to create competitive models.

For example, the Army is moving toward a patient-centered medical home. Some physicians and leaders have advocated consolidating primary care mental health activities and placing a mental health specialist in each clinic. However, this strategy is costly and does not improve outcomes: although it is easy and visible to place a specialist in every clinic, this approach unnecessarily limits the specialist's work to a single clinic.

Unless the treatment process is changed, primary care physicians often neglect patients with mental disorders and fail to connect them with a mental health specialist. Sometimes, a primary care physician may identify them and refer them to a specialist, but if there is no care manager actively seeking to engage the patient in some form of acute care, the patient may be excluded from treatment.

So we've managed to stick to our message: improving outcomes requires more than adding a mental health specialist to primary care: it requires broader, proactive changes, such as the use of a care manager to ensure full engagement of patients and their primary care teams, and the systematic use of valid measurement tools, such as the PHQ-9 and the PTSD checklist, to help clinicians identify, monitor and periodically review patients' care needs.

Just prior to the OPORD expansion, we received a major research grant to conduct a five-year randomized efficacy study of the second-generation RESPECT-Mil approach, which we call the STEPS-UP (Stepped Enhancement of PTSD Services Using Primary Care) model.

Several innovations have been added, including centralized implementation support, web-based and telephone-based stepped psychotherapies, training of care managers in intensive patient engagement strategies to increase consistency, and systematic use of automated registries to identify patients requiring medication changes.

Doug Zatzick, Jürgen Unützer, Wayne Katon, Lisa Jaycox and Terri Tanielian are the principal contributors to this exciting study, the results of which will be published next spring. When I retired from the Army last fall, RESPECT-Mil was operating in 88 Army primary care clinics and had improved care for more than 3 million patient visits.

The program has helped tens of thousands of soldiers with PTSD and depression, including thousands with positive suicide risk scores. In my new job at the RAND Corporation, I am fortunate to have the opportunity to participate in this way.

Collaborative therapy has provided a unique opportunity to offer a scientific solution to a major military problem. It has helped thousands of men and women in uniform in a way that also contributes to making our mental health system more effective for all Americans.

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