PTSD, Depression Patients Benefit from Collaborative Care Model
By Beth Schwinn, DCoE Public Affairs on June 14, 2016
U.S. Air Force photo by Airman 1st Class Samantha Saulsbury
When it comes to depression and posttraumatic stress disorder (PTSD) treatment, patients do better when their primary care is augmented by nurse care managers, effective use of data registries and additional offsite support, according to a new study published this week in “JAMA Internal Medicine.” The enhanced care model can increase the uptake of mental health care, more efficiently match care based on patient symptom severity, and improve PTSD and depression outcomes.
The study is the first large-scale randomized effectiveness trial to evaluate an integrated health care model for PTSD and depression in the Military Health System. Known as the Stepped Enhancement of PTSD Services Using Primary Care (STEPS-UP), it was conducted by the Deployment Health Clinical Center (DHCC) in collaboration with Rand Corp. and RTI International.
Researchers followed more than 650 service members treated in 18 primary care clinics on six Army installations in 2012 and 2013. Patients with symptoms of PTSD or depression were randomly assigned to either the STEPS-UP model or to the standard integrated primary care treatment.
In the enhanced collaborative care model, nurses were trained to help engage patients in care throughout the year, providing psychosocial support and promoting evidence-based treatment decisions. A centralized team provided regular support to on-the-ground nurses, monitoring patients’ symptom trajectories using a data registry and providing individualized treatment recommendations.
After 12 months, patients randomized to the enhanced care experienced significant improvements in PTSD and depression symptoms, compared to peers who did not receive the extra support. In addition, patients treated under the enhanced-care model received significantly more mental health services, with patterns of care indicating that patients receiving enhanced collaborative care were better triaged to specialty care based on their symptoms.
“The enhanced care intervention is designed to manage and offer care to all identified patients over the course of their care even if they do not initially engage in care,” said Bradley E. Belsher, DHCC chief of research translation and integration, and a principal investigator on the study.
Because the intervention aims to reach and follow a large population of patients, even modest improvements in outcomes can have a major impact on the health care system, he said.
While some patients may be reluctant to seek psychological health care, there are other reasons a patient may not follow through with care, said Daniel P. Evatt, DHCC chief of research production., said Daniel P. Evatt, DHCC chief of research production.
“People drop out of care for all kinds of practical reasons. They’re too busy, or they forget to refill a medication,” Evatt said. Follow-through made a difference for these patients and helped them stay engaged with the health care system, he said.
“A key feature of the trial was its use of software that enabled the research team to crunch data from a health care support tool for those patients who participated in the trial,” Belsher said. The result was that the team could triage patients more effectively based on information such as whether their symptoms were worsening and whether they had stopped taking medication. Because the triage was managed by a psychiatrist and psychologists from a central site, there was less burden placed on primary care providers, he explained.
The clinics in the study were at Fort Bliss in Texas, Fort Bragg in North Carolina, Fort Campbell in Kentucky, Fort Carson in Colorado, Fort Stewart in Georgia, and Joint Base Lewis-McCord in Washington. Support for the study was provided by the Defense Department Deployment Related Medical Research Program.
The lead researcher for the study is Dr. Charles Engel, former director of DHCC (now at Rand Corp.). Other authors of the study are Michael C. Freed of DHCC and the Uniformed University of the Health Sciences (now at the National Institute of Mental Health); Lisa H. Jaycox, Terri Taneilian and Tara Lavelle of Rand Corp.; Robert M. Bray, Donald Brambilla Marian E. Lane, Kristine L. Rae Olmsted and Russ Vandermaas-Peeler of RTI International; Laura Novak of DHCC; Douglas Zatzick, Wayne Katon, and Jurgen Unutzer from University of Washington; and Brett Litz of the Department of Veterans Affairs Boston Healthcare System.
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