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IAC 06-073 – HSR&D Study

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IAC 06-073
Reengineering Systems for the Primary Care Treatment of PTSD
Paula P Schnurr PhD
White River Junction VA Medical Center, White River Junction, VT
White River Junction, VT
Funding Period: March 2007 - December 2010

BACKGROUND/RATIONALE:
Enhancing strategies for managing PTSD in primary care settings is important. It is neither feasible nor necessary to refer all cases of PTSD to mental health, and some patients may prefer to receive mental health care from their Primary Care provider. However, there have been no randomized trials of primary care-based treatment for PTSD patients. Because depression often co-occurs with PTSD, collaborative care models proven to work for treating depression offer a promising strategy for treating PTSD in primary care.

OBJECTIVE(S):
Our immediate objective was to implement collaborative care in VA primary care clinics to facilitate the management of PTSD and evaluate the effects on patient outcomes, provider behavior, and costs. We expected that collaborative care, relative to usual care, would result in better patient outcomes and greater likelihood of receiving guideline-based treatment. Our long-term objectives were to generate information to support implementation of collaborative care for PTSD in VHA.

METHODS:
RESPECT-PTSD was a two-arm, parallel randomized clinical trial of the Three Component Model of collaborative care (3CM), which consists of (1) a prepared practice, (2) telephone care management, and (3) enhanced mental health support. We recruited 195 Veterans with PTSD from 5 primary care clinics at 4 VA healthcare facilities and randomized them to receive usual care or usual care plus 3CM. On average, participants were 45 years old, 91% were male, 56% were White, 40% served in Iraq or Afghanistan, and 42% served in Vietnam. Blinded assessors collected data at baseline and 3- and 6-month follow-up. PTSD symptom severity was the primary outcome. Depression, functioning, perceived quality of care, utilization, and costs were secondary outcomes.

FINDINGS/RESULTS:
There were no differences between 3CM and usual care in symptoms or functioning. Overall improvement was modest in both groups. Participants assigned to 3CM were more likely to have a mental health visit and fill an antidepressant prescription. Participants assigned to 3CM also had more mental health visits and higher outpatient pharmacy costs.

IMPACT:
The information obtained in this study supports the increased emphasis on primary care treatment in VA and complements the increased use of telehealth strategies to optimize the delivery of VA care. The study provides information that can help VA planners and policymakers facilitate the implementation of collaborative care system-wide. Results suggest the need for careful examination of how collaborative care models for PTSD are implemented, and for additional supports to encourage primary care providers to manage PTSD.

PUBLICATIONS:

Journal Articles

  1. Schnurr PP, Friedman MJ, Oxman TE, Dietrich AJ, Smith MW, Shiner B, Forshay E, Gui J, Thurston V. RESPECT-PTSD: re-engineering systems for the primary care treatment of PTSD, a randomized controlled trial. Journal of general internal medicine. 2013 Jan 1; 28(1):32-40.
Conference Presentations

  1. Schnurr PP, Friedman MJ, Oxman TE, Dietrich AJ, Smith MW, Shiner B, Forshay E, Gui J, Thurston V. RESPECT-PTSD: Re-Engineering Systems for the Primary Care Treatment of PTSD, A Randomized Controlled Trial. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2012 Nov 1; Los Angeles, CA.
  2. Schnurr PP, Friedman MJ, Oxman TE, Dietrich A, Shiner B, Smith MW, Gui J, Chen S. RESPECT-PTSD: Re-Engineering Systems for the Primary Care Treatment of PTSD. Paper presented at: VA Mental Health Annual Conference; 2011 Aug 24; Baltimore, MD.
  3. Schnurr PP, Friedman MJ, Oxman TE, Dietrich A, Shiner B, Smith MW. RESPECT-PTSD: Re-Engineering Systems for the Primary Care Treatment of PTSD. Poster session presented at: American Psychological Association Annual Convention; 2011 Aug 6; Washington, DC.
  4. Schnurr PP, Friedman MJ, Oxman TE, Dietrich A. RESPECT-PTSD: Re-engineering systems for the primary care treatment of PTSD. Poster session presented at: VA MIRECC Annual Best Practices in Mental Health Conference; 2009 Jul 1; Baltimore, MD.
  5. Schnurr PP, Friedman MJ, Oxman TE, Dietrich A. RESPECT-PTSD: Re-engineering systems for the primary care treatment of PTSD. Poster session presented at: VA National Research Week; 2009 May 1; White River Junction, VT.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Treatment - Observational
Keywords: Deployment Related, Guideline Development and Implementation, Implementation, Organizational issues, Outpatient, PTSD
MeSH Terms: none

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