Psychological Services 2014, Vol. 11, No. 3, 295–299
In the public domain DOI: 10.1037/a0035846
Preliminary Findings for a Brief Posttraumatic Stress Intervention in Primary Mental Health Care A. Lisa Harmon, Elizabeth S. R. Goldstein, Brian Shiner, and Bradley V. Watts White River Junction Veterans Affairs Medical Center, White River Junction, Vermont and Geisel School of Medicine at Dartmouth A team of clinicians at a small rural Veterans’ Health Administration (VHA) medical center piloted a brief psychological intervention for posttraumatic stress in a primary mental health care setting. Symptom measures were completed by veterans before and after receiving the brief trauma treatment (BTT), and were then analyzed using paired t tests. In our uncontrolled study, we found a statistically insignificant improvement in symptoms of posttraumatic stress disorder, though there were statistically significant, but not clinically significant, improvements in depression and general anxiety. The intervention may enhance subsequent specialty mental health engagement. Fifty-one veterans (62.20%) went on to receive psychotherapy in a specialty mental health setting, which represents a substantial increase in specialty psychotherapy engagement compared to reports elsewhere in the literature. Lack of controlled comparison precludes definitive conclusions, but the current preliminary results support future studies of brief psychological interventions in primary care settings, including randomized controlled comparisons. Keywords: posttraumatic stress disorder, brief psychological intervention, integrated care
within the Veterans Health Administration between 2002 and 2008, fewer than 10% of Iraq and Afghanistan veterans received nine or more sessions of recommended PTSD treatment in a VA PTSD clinic within the first year of PTSD diagnosis. HarpazRotem and Rosenheck (2011) examined a similar dataset and found that Iraq and Afghanistan veterans were less likely to stay in treatment than Vietnam veterans. Variables likely to affect mental health service utilization include access to care, stigma, and readiness to engage (Hoge et al., 2004; Murphy & Rosen, 2006). Studies indicate that veterans with PTSD are likely to present to primary care clinics (e.g., Magruder, Frueh, Knapp, Davis, & Hammer, 2005), which carry less stigma than mental health settings (Hoge et al., 2004). Due to the issues listed above, many of the individuals seen in primary care will never make their way to specialized mental health care (Hoge et al., 2006). Thus, in an effort to meet veterans where they first present for health care and increase appropriate mental health service utilization, an open access walk-in primary mental health clinic (PMHC) has become a commonly used model for integrated mental health and primary care (Pomerantz & Sayers, 2010). The PMHC model offers outpatient mental health care colocated in a primary care setting. The goal of the clinic is to allow the majority of referred veterans to receive initial care within primary care, and to conserve specialty mental health services for veterans who complex clinical conditions who are ready to engage in treatment when given a referral. However, a previous study (Shiner et al., 2012) showed low engagement in mental health services for patients with PTSD after initial evaluation in the PMHC, with low receipt of psychotherapy and a relatively greater focus on medication management. A growing body of literature demonstrates the effectiveness of psychological interventions delivered in primary care settings for a variety of clinical problems, including PTSD, with most incorporating cognitive– behavioral elements (e.g., Cigrang, Rauch, Avila, Bryan, & Goodie, 2011; Hamblen, Mueser, Rosenberg, & Rosen-
With reported posttraumatic stress disorder (PTSD) prevalence rates of 5%–15% (Ramchand, Karney, Osilla, Burns, & Caldarone, 2008), many military service members returning from recent conflicts will need treatment to recover from the psychological trauma they experienced. There is a strong body of evidence supporting the use of efficacious specialized psychological interventions for PTSD (see Foa, Keane, Friedman, & Cohen, 2009 for review). These treatments are delivered to veterans and military service members in specialty mental health clinics across the United States Department of Defense (DoD) and the Department of Veterans Affairs (VA; Karlin et al., 2010; McHugh & Barlow, 2010). Although rates of mental health services utilization among veterans and military service members have increased in the recent past (Hermes, Rosenheck, Desai, & Fontana, 2012; Rosenheck & Fontana, 2007; Shiner, Drake, Watts, Desai, & Schnurr, 2012; Tsan, Zeber, Stock, Sun & Copeland, 2012), sustained engagement in treatment remains less than ideal (Erbes et al., 2009; HarpazRotem & Rosenheck, 2011; Hoge et al., 2006; Seal et al., 2010; Spoont et al., 2010). For example, Seal et al. (2010) found that
This article was published Online First March 3, 2014. A. Lisa Harmon, Elizabeth S. R. Goldstein, Brian Shiner, and Bradley V. Watts, White River Junction Veterans Affairs Medical Center (VAMC), White River Junction, Vermont and Geisel School of Medicine at Dartmouth. This project was inspired by Andrew Pomerantz’s dedication to integrated care. We would like to acknowledge the support of Barbara Street and Mary Kline. In addition, we thank colleagues for feedback on this article at various stages, including Jessica Hamblen, Anya Moon, Laurie Sloane, Ann Kraybill, Richard Wren, Nancy Bernardy, and Matthew Friedman. Correspondence concerning this article should be addressed to Lisa Harmon, White River Junction VAMC, 215 N. Main St., White River Junction, VT 05009. E-mail: [email protected] 295
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berg, 2008; Possemato, Ouimette, & Knowlton, 2011; Roy-Byrne et al., 2010). We piloted a three-session brief trauma treatment (BTT; Goldstein et al., 2009). It was developed for a range of trauma sequelae (e.g., PTSD, depression) and symptom severity levels. BTT is theoretically consistent with well-established evidence-based treatments for PTSD and usable within a primary care model (Strosahl, 1996). For example, a unique feature of the BTT is a 20-min session duration, which is an important distinction between primary care settings and specialty mental health settings, in which sessions are typically 50 –90 min in duration. The present study used an uncontrolled treatment outcome design to gather preliminary information about the use of a brief psychological intervention for posttraumatic stress in a VA primary mental health clinic, in which clinicians care for a variety of mental health concerns and face many competing demands in the context of a large health care system. We used paired t tests to statistically analyze data collected before and after veterans received the BTT. We sought to better understand how this intervention was impacting veterans’ subsequent mental health service engagement and utilization rates. Given how brief the intervention, it was unclear what prediction to make regarding the outcome on symptom severity. The BTT has not been the focus of outcome research, thus, our goal was to determine through a pilot study whether an outcome study might be warranted in the future.
Method Participants Participants were 82 veterans with trauma-related concerns who presented for routine care in a walk-in (open access) primary mental health clinic colocated in a primary care clinic. Veterans were included in the study if they were offered the BTT and agreed to attend. They were excluded if they were actively psychotic, actively suicidal, or otherwise in need of inpatient stabilization or detoxification. The average distance traveled by veterans to the VA was 50 miles (SD ⫽ 27), with most driving more than 30 miles. All participants were men (see Table 1). Their mean age was 45.30 (SD ⫽ 14.69). Most served in the Iraq and Afghanistan Wars (n ⫽ 37; 45.12%; mean age ⫽ 32.30) or the Vietnam War (n ⫽ 26; 31.70%, mean age ⫽ 61.31), and 71 (87%) were combat veterans. Most had a VA-compensated disability related to their military services including 23% receiving VA disability because of PTSD. The most common diagnosis was PTSD. Forty-seven individuals who accepted a referral to the BTT reported previous psychotherapy experience (57.32%).
Measures Veterans completed self-report measures that included the PTSD Checklist-Military version (PCL-M; Weathers, Litz, Herman, Huska, & Keane, 1993), the Patient Health Questionnaire-9 (PHQ-9; Kroenke, Spitzer, & Williams, 2001), and the Generalized Anxiety Disorder-7 (GAD-7; Spitzer, Kroenke, Williams, & Lowe, 2006). The PCL-M assesses DSM–IV criteria for PTSD and assigns a severity score. We used established thresholds for clinically meaningful change on these scales. Previous work with this population found that a 5-point change on the PCL-M was both
Table 1 Demographic Characteristics
Men Age Lower than 30 30 to 44 45 to 59 Greater than 60 Marital status Never married Married Separated Divorced Widowed Conflict Iraq and Afghanistan Persian Gulf Vietnam All other VA disability Any Any psychiatric PTSD Clinician’s primary diagnosis PTSD Depression Other anxiety disorder Adjustment disorders Alcohol dependence Dyssomnia Note.
f
%
82
100.00
18 24 19 21
21.95 29.27 23.17 25.61
12 51 1 17 1
14.63 62.20 1.22 20.73 1.22
37 8 26 11
45.12 9.76 31.70 14.47
53 36 29
64.63 43.90 23.17
67 6 4 3 1 1
81.71 7.32 4.88 3.66 1.22 1.22
PTSD ⫽ posttraumatic stress disorder.
reliable and associated with clinically meaningful changes in functioning (Shiner et al., 2011). The minimal clinically important difference on the PHQ-9 has been determined to be 5 points (Lowe, Unutzer, Callahan, Perkins, & Kroenke, 2004). No established categorical value available to judge whether improvement on the GAD-7 is clinically meaningful. However, data are available regarding symptom severity level cut points, with 5, 10 and 15 representing mild, moderate, and severe levels, respectively (Kroenke, Spitzer, Williams, & Lowe, 2010).
Procedure Veterans first met with a clerk who clarified their reason for coming to the clinic, verified they were not receiving specialized mental health services, and assessed basic level of distress for triage purposes. The clerk then had the patient complete the PCL, PHQ-9, and GAD-7, routinely, at each visit. The results were computed and printed on a handout for clinicians to review prior to meeting with the patient. The veteran then met with a therapist and a medication prescriber with complementary services offered as needed, such as care management and health psychology (for more detailed information on the clinical processes of the White River Junction VAMC PMHC see Pomerantz et al., 2010). After being initially assessed by PMHC clinical staff, veterans reporting concerns related to a traumatic event were offered the option of being referred BTT in primary care as one of their treatment options as long as they did not meet the exclusion criteria detailed above. No data was kept on individuals who were offered the BTT and did not accept a referral.
POSTTRAUMATIC STRESS RECOVERY IN PRIMARY CARE
BTT was implemented as part of ongoing process improvement efforts in the integrated primary care-mental health setting at White River Junction (e.g., Kim et al., 2013). All patients in this clinic complete standardized symptomatic assessments regardless of whether they receive BTT (e.g., Zubkoff et al., 2012). As such, this was a retrospective analysis to evaluate a change in routine practice. Therefore, a waiver of informed consent was granted by the Dartmouth Center for the Protection of Human Subjects (CPHS#21631). One clinician treated 85% of the veterans and the remaining 15% were treated by psychology interns and postdoctoral fellows. The BTT was piloted between June 2009 and October 2010. A chart review was conducted to obtain information on previous psychotherapy, although limited information was available regarding that care beyond a simple “yes” or “no.” More information was available regarding post-BTT follow-up psychotherapy care given that most individuals received care through the VA for the subsequent period ending September 2011. All statistical analyses were performed using STATA software (version 10.0; StataCorp, 2007). Paired t tests were used to examine relationships between pre- and post-BTT measures of PTSD, depression, and general anxiety. Counts and percentages were used to describe additional mental health treatments received after BTT.
Intervention Brief Trauma Treatment (BTT; Goldstein et al., 2009) is a three-session intervention designed for the heterogeneous population presenting to primary care settings with reactions to psychological trauma. The primary goal of BTT is to enhance the natural recovery process using a patient-centered approach, and to enhance motivation to engage in additional care as needed, including specialized trauma-focused treatment, which usually involves weekly sessions over many weeks. Conceptually similar to recovery-based interventions for PTSD, there are four components of BTT: (a) psychoeducation regarding common reactions to trauma, focusing on the role of avoidance of both trauma-related cues and pleasurable activities in delaying recovery; (b) behavioral activation of valued activities as well as gradual exposure to some avoided trauma-related stimuli (e.g., unpacking a bag from a deployment, cooking dinner for the family, going to the park with a child, putting on their uniform, and sending an e-mail to a fellow service member who had been redeployed); (c) collaborative veteran-centered treatment planning incorporating the veteran’s lifestyle, personal goals, comorbidities, and/or other injuries; and (d) motivational enhancement strategies that are threaded throughout each session. Of note, substance misuse can be targeted by this brief intervention if a veteran identifies the overuse or misuse of substances to avoid feelings, intrusions, and/or use as a sleep aid. Consistent with primary care scheduling, all sessions were delivered in approximately 20 –30 minutes. A two-page handout was used to guide each brief therapy session, and was then used by the veteran to guide and record between-session practice. The tasks for practice assignments were chosen by the patient and then a collaborative assessment of motivation and confidence was conducted to ensure a small, but successful first step. For example, a veteran might list practice assignments that would be very challenging, triggering a strong desire to avoid, so the therapist would ask the veteran to not choose their most challenging activity, but rather
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one which is a little challenging and they feel confident in completing. Duration between sessions was determined by veteran preference. If a veteran chose a time that the therapist felt was too far in the future, the therapist would negotiate for a closer date, although ultimately the decision was based on the veteran’s preference. Anecdotally, some veterans chose lengthy gaps between sessions for a variety of reasons: travel plans, school, work conflicts, or tolerance of the intervention. In some cases, a fourth session was added to assist veterans in deciding among next steps, including additional therapy. The veteran was offered the additional session if expressing uncertainty regarding next steps, or requesting additional information regarding next steps.
Results Of the 82 individuals who accepted a referral to BTT, 56 (68.29%) completed three or more sessions of the BTT (21 completed a fourth session). Nineteen veterans (23%) completed two sessions and seven (9%) completed only one session. The mean time to complete three sessions of the BTT was 31 days. Paired t tests were used to compare pre-BTT and post-BTT scores of depression, anxiety, and PTSD measures in the intent to treat sample (n ⫽ 82). As seen in Table 2, as a group, the veterans who received the BTT did not experience a statistically significant or clinically meaningful improvement in PTSD symptoms as measured by the PCL. Improvements in depressive symptoms as measured by the PHQ-9 and in general anxiety symptoms as measured by the GAD-7 were statistically significant, but small in magnitude, with improvements of approximately 1 point on each scale. This falls below the threshold for clinically meaningful change on the PHQ-9 (a 5-point change), and is unlikely to be clinically meaningful on the GAD-7, which is scaled similarly. After the BTT, 43 individuals (52.44%) were referred to the specialty mental health clinic for psychotherapy. Of those 43, one (2%) did not show to the specialty mental health clinic or engage in any treatment. Four veterans (9%) did not attend an initial appointment, but did engage in subsequent specialty mental health therapy appointments. Further, eight veterans who were not initially referred for specialty mental health care eventually sought out a referral to specialty mental health during the study period. Thus, a total of 51 (62.20%) of veterans who accepted a referral to the BTT went on to receive some specialty individual (n ⫽ 44), group (n ⫽ 15), or family (n ⫽ 4) psychotherapy. Several individuals received more than one type of psychotherapy, with most receiving a combination of individual and group psychotherapy (n ⫽ 11). Most of the individuals who engaged in psychotherapy after the BTT reported receiving at least
Table 2 Symptomatic Outcomes of Brief Trauma Treatment Initial
PCL PHQ-9 GAD-7
Final
Mean
SD
Mean
SD
p
58.93 13.57 12.68
11.90 5.48 5.12
57.27 12.34 11.45
13.20 6.10 5.51
0.18 0.02 0.02
Note. PCL ⫽ PTSD Checklist; PHQ-9 ⫽ Patient Health Questionnaire-9; GAD-7 ⫽ Generalized Anxiety Disorder-7; p refers to paired t-test comparing scores between the first and final session.
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one session of psychotherapy prior to participating in the BTT (n ⫽ 33; 64.71%). Our medical records review showed that the 44 veterans who subsequently engaged in individual psychotherapy in the specialty mental health clinic received a variety of protocols (see Table 3). Most individuals received one type of individual psychotherapy (n ⫽ 31), and some received two or three types (n ⫽ 13). The mean number of individual psychotherapy sessions was 20.02 (SD ⫽ 19.11; range ⫽ 1–99). The most common individual psychotherapy received was Cognitive Processing Therapy (n ⫽ 22; mean number sessions ⫽ 11.64). For those who received two or three types of individual psychotherapy, most received a supportive or interpersonal psychotherapy and then a cognitive– behavioral therapy, usually with the same provider.
Discussion Although a three-session brief trauma treatment delivered in primary mental health care did not result in an immediate reduction in symptoms of PTSD, it may have a small positive effect on symptoms of depression and general anxiety. Further, it did appear to enhance engagement in subsequent specialty psychotherapy. The extremely low “no show” rate to specialty mental health care was not expected, but appears to be attributed to features of BTT. Previously published work suggests treatment engagement in psychotherapy for PTSD from 1% to 13% (Shiner et al., 2012; Watts et al., in press). In this study more than 60% of those who accepted the BTT later engaged in specialized psychotherapy. Most individuals who chose an episode of specialty care received individual psychotherapy with cognitive processing therapy occurring most frequently. Overall, the specialty mental health findings are an attempt to be consistent with VA/DoD clinical practice standards for PTSD (Friedman, Lowry, & Rusek, 2010; Kussman, 2008). It is difficult to know what to make of the limited immediate effect of BTT on PTSD symptoms. It is possible that the elements of the Table 3 Individual Psychotherapy Engagement for Veterans Receiving Brief Trauma Treatment Therapy type
Total
%
Mean # sessions
Individual therapy None CPT Supportive CBT other than PTSD Integrative ACT PE Interpersonal/relationship Phase-oriented EMDR Behavior therapy Health psychology
32 22 10 9 7 5 2 2 1 1 1 1
39.02 26.83 12.20 10.98 8.54 6.10 2.44 2.44 1.22 1.22 1.22 1.22
11.64 20.40 16.89 15.71 5.40 9.00 29.00 42.00 3.00 1.00 10.00
SD
Range
7.31 25.19 11.03 9.62 4.16 9.90 36.77
2–29 2–88 2–29 5–30 2–12 2–16 3–55
Note. N ⫽ 82; CPT ⫽ Cognitive Processing Therapy; PE ⫽ Prolonged Exposure Therapy; EMDR ⫽ Eye Movement Desensitization Reprocessing; CBT for PTSD ⫽ Cognitive Behavior Therapy not directly focused on trauma processing; ACT ⫽ Acceptance and Commitment Therapy. Thirtyone individuals (37.80%) received one type of specialized psychotherapy, and 13 (15.85%) received two or three types of individual psychotherapy. CPT, PE, and EMDR are mutually exclusive.
intervention may be insufficient to lead to substantial positive gain. Using a similar intervention, Cigrang, Rauch, Avila, Bryan, and Goodie (2011) found that 33% of their sample did not meet criteria for PTSD at a 1-month follow up assessment. In that study, participants received four to six 30-min sessions, whereas in the current intent to treatment sample, many participants only received one or two sessions, thus number of sessions might be a factor in the current study. Further, Cigrang et al. (2011) used an active duty sample, whereas we used a sample of veterans, some of whom had PTSD from combat during the Vietnam War. Thus, it is possible that targeting individuals in primary care with more recent PTSD would lead to greater improvement in PTSD symptoms. In addition to the absence of a control group, there are other limitations to this study. First, the intervention was primarily delivered by one clinician, thus therapist effects are confounding. Second, we only have information on the group of male veterans who were offered the BTT and accepted. We do not have data on the veterans who were not offered BTT or those who declined. Third, it is possible that the lack of statistically significant positive results calls into question the validity of the BTT, although it is also possible that the BTT could have prevented symptoms from worsening. Overall, the lack of a control group precludes us from making any definitive statements about the relationship between BTT and symptom reduction, engaging in additional therapy, or remaining in therapy for longer periods of time. Obviously, conclusive statements should await randomized controlled studies of BTT. Future studies examining outcomes by number of sessions received could shed light on the optimal number of sessions for brief PTSD interventions for primary care. Our overall conclusion is that the BTT is a recovery-focused intervention deserving additional study. Primary mental health integration has many strong points, and adapting evidence-based psychotherapy within a system of care is an important area for future attention.
References Cigrang, J. A., Rauch, S. A. M., Avila, L. L., Bryan, C. J., & Goodie, J. L. (2011). Treatment of active-duty military with PTSD in primary care: Early findings. Psychological Services, 8, 104 –113. doi:10.1037/a0022740 Erbes, C. R., Curry, K. T., & Leskela, J. (2009). Treatment presentation and adherence of Iraq/Afghanistan era veterans in outpatient care for PTSD. Psychological Services, 6, 175–183. doi:10.1037/a0016662 Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. (Eds.). (2009). Effective treatments for PTSD: Practice guidelines from the international society of traumatic stress studies (2nd ed.). New York, NY: Guilford Press. Friedman, M. J., Lowry, P., & Ruzek, J. (2010). VA/DoD clinical practice guidelines for the management of post-traumatic stress. Washington, DC: The Management of Post-Traumatic Stress Working Group. Retrieved from http://www.healthquality.va.gov/PTSD-FULL-2010c.pdf Goldstein, E. S. R., Harmon, A. L., Smith, A. M., Zayed, M. H., Bernardy, N. C., & Scott, D. L. (2009). Brief posttraumatic stress recovery intervention in a VA primary care Setting. Unpublished manuscript. Hamblen, J. L., Mueser, K. T., Rosenberg, S. D., & Rosenberg, H. J. (2008). Brief cognitive behavioral treatment for PTSD: Military version. Unpublished manuscript. Harpaz-Rotem, I., & Rosenheck, R. A. (2011). Serving those who served: Retention of newly returning veterans from Iraq and Afghanistan in mental health treatment, Psychiatric Services, 62, 22–27. doi:10.1176/ appi.ps.62.1.22
POSTTRAUMATIC STRESS RECOVERY IN PRIMARY CARE Hermes, E. D., Rosenheck, R. A., Desai, R., & Fontana, A. F. (2012). Recent trends in the treatment of posttraumatic stress disorder and other mental disorders in the VHA. Psychiatric Services, 63, 471– 476. doi: 10.1176/appi.ps.201100432 Hoge, C. W., Auchterlonie, J. L., & Milliken, C. S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association, 295, 1023–1032. doi:10.1001/ jama.295.9.1023 Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The New England Journal of Medicine, 351, 13–22. doi:10.1056/NEJMoa040603 Karlin, B. E., Ruzek, J. I., Chard, K. M., Eftekhari, A., Monson, C. M., Hembree, E. A., . . . Marmar, C. R. (2010). Dissemination of evidencebased psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. Journal of Traumatic Stress, 23, 663– 673. doi:10.1002/jts.20588 Kim, B., Elstein, Y., Shiner, B., Konrad, R., Pomerantz, A. S., & Watts, B. V. (2013). Use of discrete event simulation to improve a mental health clinic. General Hospital Psychiatry. Advance online publication. doi:10.1016/j.genhosppsych.2013.06.004 Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606 – 613. doi:10.1046/j.1525-1497.2001.016009606.x Kroenke, K., Spitzer, R. L., Williams, J. B., & Lowe, B. (2010). The patient health questionnaire somatic, anxiety, and depressive symptoms scales: A systematic review. General Hospital Psychiatry, 32, 345–359. doi:10.1016/j.genhosppsych.2010.03.006 Kussman, M. J. (2008). VHA handbook 1160.01: Uniform mental health services in VA medical centers and clinics. Retrieved from http://www1 .va.gov/vhapublications/ViewPublication.asp?pub_ID⫽1762 Lowe, B., Unutzer, J., Callahan, C. M., Perkins, A. J., & Kroenke, K. (2004). Monitoring depression treatment outcomes with the patient health questionnaire-9. Medical Care, 42, 1194 –1201. doi:10.1097/ 00005650-200412000-00006 Magruder, K. M., Frueh, B. C., Knapp, R. G., Davis, L. L., & Hammer, M. B. (2005). Prevalence of PTSD in Veterans Affairs primary care clinics. General Hospital Psychiatry, 27, 169 –179. doi:10.1016/j .genhosppsych.2004.11.001 McHugh, R. K., & Barlow, D. H. (2010). Dissemination and implementation of evidence-based psychological interventions: A review of current efforts. American Psychologist, 65, 73– 84. doi:10.1037/a0018121 Murphy, R. T., & Rosen, C. S. (2006). Addressing readiness to change PTSD with a brief intervention: A description of the PTSD Motivation Enhancement Group. Journal of Aggression, Maltreatment and Trauma, 12, 7–28. Pomerantz, A. S., & Sayers, S. L. (2010). Primary care-mental health integration in healthcare in the Department of Veterans Affairs. Families, Systems, & Health, 28, 78 – 82. doi:10.1037/a0020341 Pomerantz, A. S., Shiner, B., Watts, B. V., Detzer, M. J., Kutter, C., Street, B., & Scott, D. (2010). The White River model of co-located collaborative care: A platform for mental and behavioral health care in the medical home. Families, Systems, & Health, 28, 78 – 82. doi:10.1037/a0020341 Possemato, K., Ouimette, P., & Knowlton, P. (2011). A brief self-guided telehealth intervention for post-traumatic stress disorder in combat veterans: A pilot study. Journal of Telemedicine and Telecare, 17, 245–250. Ramchand, R., Karney, B. R., Osilla, K. C., Burns, R. M., & Caldarone, L. B. (2008). Prevalence of PTSD, depression, and TBI among returning
299
service members. In T. Tanielian & L. H. Jaycox (Eds.), Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery (pp. 35– 85). Santa Monica, CA: RAND Corporation. Rosenheck, R. A., & Fontana, A. F. (2007). Recent trends in VA treatment of PTSD and other mental disorders. Health Affairs (Project Hope), 26, 1720 –1727. doi:10.1377/hlthaff.26.6.1720 Roy-Byrne, P. P., Craske, M. G., Sullivan, G., Rose, R. D., Edlund, M. J., Lang, A. J., . . . Stein, M. B. (2010). Delivery of evidence-based treatment for multiple anxiety disorders in primary care: A randomized controlled trial. Journal of the American Medical Association, 303, 1921–1928. doi:10.1001/jama.2010.608 Seal, K. H., Maguen, S., Cohen, B., Gima, K. S., Metzler, T. J., Ren, L., . . . Marmar, C. R. (2010). VA mental health services utilization in Iraq and Afghanistan veterans in the first year of receiving new mental health diagnoses. Journal of Traumatic Stress, 23, 5–16. Shiner, B., Watts, B. V., Pomerantz, A., Young-Xu, Y., & Schnurr, P. P. (2011). Sensitivity of the SF-36 to PTSD symptom change in veterans. Journal of Traumatic Stress, 24, 111–115. Shiner, B., Bateman, D., Zayed, M. H., Young-Xu, Y., Harmon, A. L., Pomerantz, A. S., & Watts, B. V. (2012). Comparing the stability of diagnosis in full vs. partial PTSD. Journal of Nervous and Mental Disease, 200, 520 –525. doi:10.1097/NMD.0b013e318257c6da Shiner, B., Drake, R. E., Watts, B. V., Desai, R. A., & Schnurr, P. P. (2012). Access to VA services for returning veterans with PTSD. Military Medicine, 177, 814 – 822. doi:10.7205/MILMED-D-12-00009 Spitzer, R. L., Kroenke, K., Williams, J. B., & Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166, 1092–1097. doi:10.1001/archinte.166.10.1092 Spoont, M. R., Murdoch, M., Hodges, J., & Nugent, S. (2010). Treatment receipt by veterans after a PTSD diagnosis in PTSD, mental health, or general medical clinics. Psychiatric Services, 61, 58 – 63. doi:10.1176/appi .ps.61.1.58 StataCorp. (2007). Stata statistical software: Release 10. College Station, TX: StataCorp. Strosahl, K. (1996). Mind and body primary mental healthcare: New model for integrated services. Behavioral Healthcare Tomorrow, 5, 93–95. Tsan, J. Y., Zeber, J. E., Stock, E. M., Sun, F., & Copeland, L. A. (2012). Primary care-mental health integration and treatment retention among Iraq and Afghanistan war veterans. Psychological Services, 9, 336 –348. doi:10.1037/a0028308 Watts, B. V., Shiner, B., Zubkoff, L., Carpenter-Song, E., Ronconi, J., & Coldwell, C. (in press). Implementation of evidence-based psychotherapies for PTSD in U.S. veterans affairs specialty clinics. Psychiatric Services. Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993, October). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the 9th annual meeting of the ISTSS, San Antonio, TX. Zubkoff, L., Young-Xu, Y., Shiner, B., Pomerantz, A. S., & Watts, B. V. (2012). Do providers find symptom feedback useful? The implementation of measurement based care in an integrated primary mental health care clinic. Psychiatric Services, 63, 91–93. doi:10.1176/appi.ps .201100323
Received December 11, 2012 Revision received September 24, 2013 Accepted December 16, 2013 䡲
In the public domain DOI: 10.1037/a0035846
Preliminary Findings for a Brief Posttraumatic Stress Intervention in Primary Mental Health Care A. Lisa Harmon, Elizabeth S. R. Goldstein, Brian Shiner, and Bradley V. Watts White River Junction Veterans Affairs Medical Center, White River Junction, Vermont and Geisel School of Medicine at Dartmouth A team of clinicians at a small rural Veterans’ Health Administration (VHA) medical center piloted a brief psychological intervention for posttraumatic stress in a primary mental health care setting. Symptom measures were completed by veterans before and after receiving the brief trauma treatment (BTT), and were then analyzed using paired t tests. In our uncontrolled study, we found a statistically insignificant improvement in symptoms of posttraumatic stress disorder, though there were statistically significant, but not clinically significant, improvements in depression and general anxiety. The intervention may enhance subsequent specialty mental health engagement. Fifty-one veterans (62.20%) went on to receive psychotherapy in a specialty mental health setting, which represents a substantial increase in specialty psychotherapy engagement compared to reports elsewhere in the literature. Lack of controlled comparison precludes definitive conclusions, but the current preliminary results support future studies of brief psychological interventions in primary care settings, including randomized controlled comparisons. Keywords: posttraumatic stress disorder, brief psychological intervention, integrated care
within the Veterans Health Administration between 2002 and 2008, fewer than 10% of Iraq and Afghanistan veterans received nine or more sessions of recommended PTSD treatment in a VA PTSD clinic within the first year of PTSD diagnosis. HarpazRotem and Rosenheck (2011) examined a similar dataset and found that Iraq and Afghanistan veterans were less likely to stay in treatment than Vietnam veterans. Variables likely to affect mental health service utilization include access to care, stigma, and readiness to engage (Hoge et al., 2004; Murphy & Rosen, 2006). Studies indicate that veterans with PTSD are likely to present to primary care clinics (e.g., Magruder, Frueh, Knapp, Davis, & Hammer, 2005), which carry less stigma than mental health settings (Hoge et al., 2004). Due to the issues listed above, many of the individuals seen in primary care will never make their way to specialized mental health care (Hoge et al., 2006). Thus, in an effort to meet veterans where they first present for health care and increase appropriate mental health service utilization, an open access walk-in primary mental health clinic (PMHC) has become a commonly used model for integrated mental health and primary care (Pomerantz & Sayers, 2010). The PMHC model offers outpatient mental health care colocated in a primary care setting. The goal of the clinic is to allow the majority of referred veterans to receive initial care within primary care, and to conserve specialty mental health services for veterans who complex clinical conditions who are ready to engage in treatment when given a referral. However, a previous study (Shiner et al., 2012) showed low engagement in mental health services for patients with PTSD after initial evaluation in the PMHC, with low receipt of psychotherapy and a relatively greater focus on medication management. A growing body of literature demonstrates the effectiveness of psychological interventions delivered in primary care settings for a variety of clinical problems, including PTSD, with most incorporating cognitive– behavioral elements (e.g., Cigrang, Rauch, Avila, Bryan, & Goodie, 2011; Hamblen, Mueser, Rosenberg, & Rosen-
With reported posttraumatic stress disorder (PTSD) prevalence rates of 5%–15% (Ramchand, Karney, Osilla, Burns, & Caldarone, 2008), many military service members returning from recent conflicts will need treatment to recover from the psychological trauma they experienced. There is a strong body of evidence supporting the use of efficacious specialized psychological interventions for PTSD (see Foa, Keane, Friedman, & Cohen, 2009 for review). These treatments are delivered to veterans and military service members in specialty mental health clinics across the United States Department of Defense (DoD) and the Department of Veterans Affairs (VA; Karlin et al., 2010; McHugh & Barlow, 2010). Although rates of mental health services utilization among veterans and military service members have increased in the recent past (Hermes, Rosenheck, Desai, & Fontana, 2012; Rosenheck & Fontana, 2007; Shiner, Drake, Watts, Desai, & Schnurr, 2012; Tsan, Zeber, Stock, Sun & Copeland, 2012), sustained engagement in treatment remains less than ideal (Erbes et al., 2009; HarpazRotem & Rosenheck, 2011; Hoge et al., 2006; Seal et al., 2010; Spoont et al., 2010). For example, Seal et al. (2010) found that
This article was published Online First March 3, 2014. A. Lisa Harmon, Elizabeth S. R. Goldstein, Brian Shiner, and Bradley V. Watts, White River Junction Veterans Affairs Medical Center (VAMC), White River Junction, Vermont and Geisel School of Medicine at Dartmouth. This project was inspired by Andrew Pomerantz’s dedication to integrated care. We would like to acknowledge the support of Barbara Street and Mary Kline. In addition, we thank colleagues for feedback on this article at various stages, including Jessica Hamblen, Anya Moon, Laurie Sloane, Ann Kraybill, Richard Wren, Nancy Bernardy, and Matthew Friedman. Correspondence concerning this article should be addressed to Lisa Harmon, White River Junction VAMC, 215 N. Main St., White River Junction, VT 05009. E-mail: [email protected] 295
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berg, 2008; Possemato, Ouimette, & Knowlton, 2011; Roy-Byrne et al., 2010). We piloted a three-session brief trauma treatment (BTT; Goldstein et al., 2009). It was developed for a range of trauma sequelae (e.g., PTSD, depression) and symptom severity levels. BTT is theoretically consistent with well-established evidence-based treatments for PTSD and usable within a primary care model (Strosahl, 1996). For example, a unique feature of the BTT is a 20-min session duration, which is an important distinction between primary care settings and specialty mental health settings, in which sessions are typically 50 –90 min in duration. The present study used an uncontrolled treatment outcome design to gather preliminary information about the use of a brief psychological intervention for posttraumatic stress in a VA primary mental health clinic, in which clinicians care for a variety of mental health concerns and face many competing demands in the context of a large health care system. We used paired t tests to statistically analyze data collected before and after veterans received the BTT. We sought to better understand how this intervention was impacting veterans’ subsequent mental health service engagement and utilization rates. Given how brief the intervention, it was unclear what prediction to make regarding the outcome on symptom severity. The BTT has not been the focus of outcome research, thus, our goal was to determine through a pilot study whether an outcome study might be warranted in the future.
Method Participants Participants were 82 veterans with trauma-related concerns who presented for routine care in a walk-in (open access) primary mental health clinic colocated in a primary care clinic. Veterans were included in the study if they were offered the BTT and agreed to attend. They were excluded if they were actively psychotic, actively suicidal, or otherwise in need of inpatient stabilization or detoxification. The average distance traveled by veterans to the VA was 50 miles (SD ⫽ 27), with most driving more than 30 miles. All participants were men (see Table 1). Their mean age was 45.30 (SD ⫽ 14.69). Most served in the Iraq and Afghanistan Wars (n ⫽ 37; 45.12%; mean age ⫽ 32.30) or the Vietnam War (n ⫽ 26; 31.70%, mean age ⫽ 61.31), and 71 (87%) were combat veterans. Most had a VA-compensated disability related to their military services including 23% receiving VA disability because of PTSD. The most common diagnosis was PTSD. Forty-seven individuals who accepted a referral to the BTT reported previous psychotherapy experience (57.32%).
Measures Veterans completed self-report measures that included the PTSD Checklist-Military version (PCL-M; Weathers, Litz, Herman, Huska, & Keane, 1993), the Patient Health Questionnaire-9 (PHQ-9; Kroenke, Spitzer, & Williams, 2001), and the Generalized Anxiety Disorder-7 (GAD-7; Spitzer, Kroenke, Williams, & Lowe, 2006). The PCL-M assesses DSM–IV criteria for PTSD and assigns a severity score. We used established thresholds for clinically meaningful change on these scales. Previous work with this population found that a 5-point change on the PCL-M was both
Table 1 Demographic Characteristics
Men Age Lower than 30 30 to 44 45 to 59 Greater than 60 Marital status Never married Married Separated Divorced Widowed Conflict Iraq and Afghanistan Persian Gulf Vietnam All other VA disability Any Any psychiatric PTSD Clinician’s primary diagnosis PTSD Depression Other anxiety disorder Adjustment disorders Alcohol dependence Dyssomnia Note.
f
%
82
100.00
18 24 19 21
21.95 29.27 23.17 25.61
12 51 1 17 1
14.63 62.20 1.22 20.73 1.22
37 8 26 11
45.12 9.76 31.70 14.47
53 36 29
64.63 43.90 23.17
67 6 4 3 1 1
81.71 7.32 4.88 3.66 1.22 1.22
PTSD ⫽ posttraumatic stress disorder.
reliable and associated with clinically meaningful changes in functioning (Shiner et al., 2011). The minimal clinically important difference on the PHQ-9 has been determined to be 5 points (Lowe, Unutzer, Callahan, Perkins, & Kroenke, 2004). No established categorical value available to judge whether improvement on the GAD-7 is clinically meaningful. However, data are available regarding symptom severity level cut points, with 5, 10 and 15 representing mild, moderate, and severe levels, respectively (Kroenke, Spitzer, Williams, & Lowe, 2010).
Procedure Veterans first met with a clerk who clarified their reason for coming to the clinic, verified they were not receiving specialized mental health services, and assessed basic level of distress for triage purposes. The clerk then had the patient complete the PCL, PHQ-9, and GAD-7, routinely, at each visit. The results were computed and printed on a handout for clinicians to review prior to meeting with the patient. The veteran then met with a therapist and a medication prescriber with complementary services offered as needed, such as care management and health psychology (for more detailed information on the clinical processes of the White River Junction VAMC PMHC see Pomerantz et al., 2010). After being initially assessed by PMHC clinical staff, veterans reporting concerns related to a traumatic event were offered the option of being referred BTT in primary care as one of their treatment options as long as they did not meet the exclusion criteria detailed above. No data was kept on individuals who were offered the BTT and did not accept a referral.
POSTTRAUMATIC STRESS RECOVERY IN PRIMARY CARE
BTT was implemented as part of ongoing process improvement efforts in the integrated primary care-mental health setting at White River Junction (e.g., Kim et al., 2013). All patients in this clinic complete standardized symptomatic assessments regardless of whether they receive BTT (e.g., Zubkoff et al., 2012). As such, this was a retrospective analysis to evaluate a change in routine practice. Therefore, a waiver of informed consent was granted by the Dartmouth Center for the Protection of Human Subjects (CPHS#21631). One clinician treated 85% of the veterans and the remaining 15% were treated by psychology interns and postdoctoral fellows. The BTT was piloted between June 2009 and October 2010. A chart review was conducted to obtain information on previous psychotherapy, although limited information was available regarding that care beyond a simple “yes” or “no.” More information was available regarding post-BTT follow-up psychotherapy care given that most individuals received care through the VA for the subsequent period ending September 2011. All statistical analyses were performed using STATA software (version 10.0; StataCorp, 2007). Paired t tests were used to examine relationships between pre- and post-BTT measures of PTSD, depression, and general anxiety. Counts and percentages were used to describe additional mental health treatments received after BTT.
Intervention Brief Trauma Treatment (BTT; Goldstein et al., 2009) is a three-session intervention designed for the heterogeneous population presenting to primary care settings with reactions to psychological trauma. The primary goal of BTT is to enhance the natural recovery process using a patient-centered approach, and to enhance motivation to engage in additional care as needed, including specialized trauma-focused treatment, which usually involves weekly sessions over many weeks. Conceptually similar to recovery-based interventions for PTSD, there are four components of BTT: (a) psychoeducation regarding common reactions to trauma, focusing on the role of avoidance of both trauma-related cues and pleasurable activities in delaying recovery; (b) behavioral activation of valued activities as well as gradual exposure to some avoided trauma-related stimuli (e.g., unpacking a bag from a deployment, cooking dinner for the family, going to the park with a child, putting on their uniform, and sending an e-mail to a fellow service member who had been redeployed); (c) collaborative veteran-centered treatment planning incorporating the veteran’s lifestyle, personal goals, comorbidities, and/or other injuries; and (d) motivational enhancement strategies that are threaded throughout each session. Of note, substance misuse can be targeted by this brief intervention if a veteran identifies the overuse or misuse of substances to avoid feelings, intrusions, and/or use as a sleep aid. Consistent with primary care scheduling, all sessions were delivered in approximately 20 –30 minutes. A two-page handout was used to guide each brief therapy session, and was then used by the veteran to guide and record between-session practice. The tasks for practice assignments were chosen by the patient and then a collaborative assessment of motivation and confidence was conducted to ensure a small, but successful first step. For example, a veteran might list practice assignments that would be very challenging, triggering a strong desire to avoid, so the therapist would ask the veteran to not choose their most challenging activity, but rather
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one which is a little challenging and they feel confident in completing. Duration between sessions was determined by veteran preference. If a veteran chose a time that the therapist felt was too far in the future, the therapist would negotiate for a closer date, although ultimately the decision was based on the veteran’s preference. Anecdotally, some veterans chose lengthy gaps between sessions for a variety of reasons: travel plans, school, work conflicts, or tolerance of the intervention. In some cases, a fourth session was added to assist veterans in deciding among next steps, including additional therapy. The veteran was offered the additional session if expressing uncertainty regarding next steps, or requesting additional information regarding next steps.
Results Of the 82 individuals who accepted a referral to BTT, 56 (68.29%) completed three or more sessions of the BTT (21 completed a fourth session). Nineteen veterans (23%) completed two sessions and seven (9%) completed only one session. The mean time to complete three sessions of the BTT was 31 days. Paired t tests were used to compare pre-BTT and post-BTT scores of depression, anxiety, and PTSD measures in the intent to treat sample (n ⫽ 82). As seen in Table 2, as a group, the veterans who received the BTT did not experience a statistically significant or clinically meaningful improvement in PTSD symptoms as measured by the PCL. Improvements in depressive symptoms as measured by the PHQ-9 and in general anxiety symptoms as measured by the GAD-7 were statistically significant, but small in magnitude, with improvements of approximately 1 point on each scale. This falls below the threshold for clinically meaningful change on the PHQ-9 (a 5-point change), and is unlikely to be clinically meaningful on the GAD-7, which is scaled similarly. After the BTT, 43 individuals (52.44%) were referred to the specialty mental health clinic for psychotherapy. Of those 43, one (2%) did not show to the specialty mental health clinic or engage in any treatment. Four veterans (9%) did not attend an initial appointment, but did engage in subsequent specialty mental health therapy appointments. Further, eight veterans who were not initially referred for specialty mental health care eventually sought out a referral to specialty mental health during the study period. Thus, a total of 51 (62.20%) of veterans who accepted a referral to the BTT went on to receive some specialty individual (n ⫽ 44), group (n ⫽ 15), or family (n ⫽ 4) psychotherapy. Several individuals received more than one type of psychotherapy, with most receiving a combination of individual and group psychotherapy (n ⫽ 11). Most of the individuals who engaged in psychotherapy after the BTT reported receiving at least
Table 2 Symptomatic Outcomes of Brief Trauma Treatment Initial
PCL PHQ-9 GAD-7
Final
Mean
SD
Mean
SD
p
58.93 13.57 12.68
11.90 5.48 5.12
57.27 12.34 11.45
13.20 6.10 5.51
0.18 0.02 0.02
Note. PCL ⫽ PTSD Checklist; PHQ-9 ⫽ Patient Health Questionnaire-9; GAD-7 ⫽ Generalized Anxiety Disorder-7; p refers to paired t-test comparing scores between the first and final session.
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one session of psychotherapy prior to participating in the BTT (n ⫽ 33; 64.71%). Our medical records review showed that the 44 veterans who subsequently engaged in individual psychotherapy in the specialty mental health clinic received a variety of protocols (see Table 3). Most individuals received one type of individual psychotherapy (n ⫽ 31), and some received two or three types (n ⫽ 13). The mean number of individual psychotherapy sessions was 20.02 (SD ⫽ 19.11; range ⫽ 1–99). The most common individual psychotherapy received was Cognitive Processing Therapy (n ⫽ 22; mean number sessions ⫽ 11.64). For those who received two or three types of individual psychotherapy, most received a supportive or interpersonal psychotherapy and then a cognitive– behavioral therapy, usually with the same provider.
Discussion Although a three-session brief trauma treatment delivered in primary mental health care did not result in an immediate reduction in symptoms of PTSD, it may have a small positive effect on symptoms of depression and general anxiety. Further, it did appear to enhance engagement in subsequent specialty psychotherapy. The extremely low “no show” rate to specialty mental health care was not expected, but appears to be attributed to features of BTT. Previously published work suggests treatment engagement in psychotherapy for PTSD from 1% to 13% (Shiner et al., 2012; Watts et al., in press). In this study more than 60% of those who accepted the BTT later engaged in specialized psychotherapy. Most individuals who chose an episode of specialty care received individual psychotherapy with cognitive processing therapy occurring most frequently. Overall, the specialty mental health findings are an attempt to be consistent with VA/DoD clinical practice standards for PTSD (Friedman, Lowry, & Rusek, 2010; Kussman, 2008). It is difficult to know what to make of the limited immediate effect of BTT on PTSD symptoms. It is possible that the elements of the Table 3 Individual Psychotherapy Engagement for Veterans Receiving Brief Trauma Treatment Therapy type
Total
%
Mean # sessions
Individual therapy None CPT Supportive CBT other than PTSD Integrative ACT PE Interpersonal/relationship Phase-oriented EMDR Behavior therapy Health psychology
32 22 10 9 7 5 2 2 1 1 1 1
39.02 26.83 12.20 10.98 8.54 6.10 2.44 2.44 1.22 1.22 1.22 1.22
11.64 20.40 16.89 15.71 5.40 9.00 29.00 42.00 3.00 1.00 10.00
SD
Range
7.31 25.19 11.03 9.62 4.16 9.90 36.77
2–29 2–88 2–29 5–30 2–12 2–16 3–55
Note. N ⫽ 82; CPT ⫽ Cognitive Processing Therapy; PE ⫽ Prolonged Exposure Therapy; EMDR ⫽ Eye Movement Desensitization Reprocessing; CBT for PTSD ⫽ Cognitive Behavior Therapy not directly focused on trauma processing; ACT ⫽ Acceptance and Commitment Therapy. Thirtyone individuals (37.80%) received one type of specialized psychotherapy, and 13 (15.85%) received two or three types of individual psychotherapy. CPT, PE, and EMDR are mutually exclusive.
intervention may be insufficient to lead to substantial positive gain. Using a similar intervention, Cigrang, Rauch, Avila, Bryan, and Goodie (2011) found that 33% of their sample did not meet criteria for PTSD at a 1-month follow up assessment. In that study, participants received four to six 30-min sessions, whereas in the current intent to treatment sample, many participants only received one or two sessions, thus number of sessions might be a factor in the current study. Further, Cigrang et al. (2011) used an active duty sample, whereas we used a sample of veterans, some of whom had PTSD from combat during the Vietnam War. Thus, it is possible that targeting individuals in primary care with more recent PTSD would lead to greater improvement in PTSD symptoms. In addition to the absence of a control group, there are other limitations to this study. First, the intervention was primarily delivered by one clinician, thus therapist effects are confounding. Second, we only have information on the group of male veterans who were offered the BTT and accepted. We do not have data on the veterans who were not offered BTT or those who declined. Third, it is possible that the lack of statistically significant positive results calls into question the validity of the BTT, although it is also possible that the BTT could have prevented symptoms from worsening. Overall, the lack of a control group precludes us from making any definitive statements about the relationship between BTT and symptom reduction, engaging in additional therapy, or remaining in therapy for longer periods of time. Obviously, conclusive statements should await randomized controlled studies of BTT. Future studies examining outcomes by number of sessions received could shed light on the optimal number of sessions for brief PTSD interventions for primary care. Our overall conclusion is that the BTT is a recovery-focused intervention deserving additional study. Primary mental health integration has many strong points, and adapting evidence-based psychotherapy within a system of care is an important area for future attention.
References Cigrang, J. A., Rauch, S. A. M., Avila, L. L., Bryan, C. J., & Goodie, J. L. (2011). Treatment of active-duty military with PTSD in primary care: Early findings. Psychological Services, 8, 104 –113. doi:10.1037/a0022740 Erbes, C. R., Curry, K. T., & Leskela, J. (2009). Treatment presentation and adherence of Iraq/Afghanistan era veterans in outpatient care for PTSD. Psychological Services, 6, 175–183. doi:10.1037/a0016662 Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. (Eds.). (2009). Effective treatments for PTSD: Practice guidelines from the international society of traumatic stress studies (2nd ed.). New York, NY: Guilford Press. Friedman, M. J., Lowry, P., & Ruzek, J. (2010). VA/DoD clinical practice guidelines for the management of post-traumatic stress. Washington, DC: The Management of Post-Traumatic Stress Working Group. Retrieved from http://www.healthquality.va.gov/PTSD-FULL-2010c.pdf Goldstein, E. S. R., Harmon, A. L., Smith, A. M., Zayed, M. H., Bernardy, N. C., & Scott, D. L. (2009). Brief posttraumatic stress recovery intervention in a VA primary care Setting. Unpublished manuscript. Hamblen, J. L., Mueser, K. T., Rosenberg, S. D., & Rosenberg, H. J. (2008). Brief cognitive behavioral treatment for PTSD: Military version. Unpublished manuscript. Harpaz-Rotem, I., & Rosenheck, R. A. (2011). Serving those who served: Retention of newly returning veterans from Iraq and Afghanistan in mental health treatment, Psychiatric Services, 62, 22–27. doi:10.1176/ appi.ps.62.1.22
POSTTRAUMATIC STRESS RECOVERY IN PRIMARY CARE Hermes, E. D., Rosenheck, R. A., Desai, R., & Fontana, A. F. (2012). Recent trends in the treatment of posttraumatic stress disorder and other mental disorders in the VHA. Psychiatric Services, 63, 471– 476. doi: 10.1176/appi.ps.201100432 Hoge, C. W., Auchterlonie, J. L., & Milliken, C. S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association, 295, 1023–1032. doi:10.1001/ jama.295.9.1023 Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The New England Journal of Medicine, 351, 13–22. doi:10.1056/NEJMoa040603 Karlin, B. E., Ruzek, J. I., Chard, K. M., Eftekhari, A., Monson, C. M., Hembree, E. A., . . . Marmar, C. R. (2010). Dissemination of evidencebased psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. Journal of Traumatic Stress, 23, 663– 673. doi:10.1002/jts.20588 Kim, B., Elstein, Y., Shiner, B., Konrad, R., Pomerantz, A. S., & Watts, B. V. (2013). Use of discrete event simulation to improve a mental health clinic. General Hospital Psychiatry. Advance online publication. doi:10.1016/j.genhosppsych.2013.06.004 Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606 – 613. doi:10.1046/j.1525-1497.2001.016009606.x Kroenke, K., Spitzer, R. L., Williams, J. B., & Lowe, B. (2010). The patient health questionnaire somatic, anxiety, and depressive symptoms scales: A systematic review. General Hospital Psychiatry, 32, 345–359. doi:10.1016/j.genhosppsych.2010.03.006 Kussman, M. J. (2008). VHA handbook 1160.01: Uniform mental health services in VA medical centers and clinics. Retrieved from http://www1 .va.gov/vhapublications/ViewPublication.asp?pub_ID⫽1762 Lowe, B., Unutzer, J., Callahan, C. M., Perkins, A. J., & Kroenke, K. (2004). Monitoring depression treatment outcomes with the patient health questionnaire-9. Medical Care, 42, 1194 –1201. doi:10.1097/ 00005650-200412000-00006 Magruder, K. M., Frueh, B. C., Knapp, R. G., Davis, L. L., & Hammer, M. B. (2005). Prevalence of PTSD in Veterans Affairs primary care clinics. General Hospital Psychiatry, 27, 169 –179. doi:10.1016/j .genhosppsych.2004.11.001 McHugh, R. K., & Barlow, D. H. (2010). Dissemination and implementation of evidence-based psychological interventions: A review of current efforts. American Psychologist, 65, 73– 84. doi:10.1037/a0018121 Murphy, R. T., & Rosen, C. S. (2006). Addressing readiness to change PTSD with a brief intervention: A description of the PTSD Motivation Enhancement Group. Journal of Aggression, Maltreatment and Trauma, 12, 7–28. Pomerantz, A. S., & Sayers, S. L. (2010). Primary care-mental health integration in healthcare in the Department of Veterans Affairs. Families, Systems, & Health, 28, 78 – 82. doi:10.1037/a0020341 Pomerantz, A. S., Shiner, B., Watts, B. V., Detzer, M. J., Kutter, C., Street, B., & Scott, D. (2010). The White River model of co-located collaborative care: A platform for mental and behavioral health care in the medical home. Families, Systems, & Health, 28, 78 – 82. doi:10.1037/a0020341 Possemato, K., Ouimette, P., & Knowlton, P. (2011). A brief self-guided telehealth intervention for post-traumatic stress disorder in combat veterans: A pilot study. Journal of Telemedicine and Telecare, 17, 245–250. Ramchand, R., Karney, B. R., Osilla, K. C., Burns, R. M., & Caldarone, L. B. (2008). Prevalence of PTSD, depression, and TBI among returning
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service members. In T. Tanielian & L. H. Jaycox (Eds.), Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery (pp. 35– 85). Santa Monica, CA: RAND Corporation. Rosenheck, R. A., & Fontana, A. F. (2007). Recent trends in VA treatment of PTSD and other mental disorders. Health Affairs (Project Hope), 26, 1720 –1727. doi:10.1377/hlthaff.26.6.1720 Roy-Byrne, P. P., Craske, M. G., Sullivan, G., Rose, R. D., Edlund, M. J., Lang, A. J., . . . Stein, M. B. (2010). Delivery of evidence-based treatment for multiple anxiety disorders in primary care: A randomized controlled trial. Journal of the American Medical Association, 303, 1921–1928. doi:10.1001/jama.2010.608 Seal, K. H., Maguen, S., Cohen, B., Gima, K. S., Metzler, T. J., Ren, L., . . . Marmar, C. R. (2010). VA mental health services utilization in Iraq and Afghanistan veterans in the first year of receiving new mental health diagnoses. Journal of Traumatic Stress, 23, 5–16. Shiner, B., Watts, B. V., Pomerantz, A., Young-Xu, Y., & Schnurr, P. P. (2011). Sensitivity of the SF-36 to PTSD symptom change in veterans. Journal of Traumatic Stress, 24, 111–115. Shiner, B., Bateman, D., Zayed, M. H., Young-Xu, Y., Harmon, A. L., Pomerantz, A. S., & Watts, B. V. (2012). Comparing the stability of diagnosis in full vs. partial PTSD. Journal of Nervous and Mental Disease, 200, 520 –525. doi:10.1097/NMD.0b013e318257c6da Shiner, B., Drake, R. E., Watts, B. V., Desai, R. A., & Schnurr, P. P. (2012). Access to VA services for returning veterans with PTSD. Military Medicine, 177, 814 – 822. doi:10.7205/MILMED-D-12-00009 Spitzer, R. L., Kroenke, K., Williams, J. B., & Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166, 1092–1097. doi:10.1001/archinte.166.10.1092 Spoont, M. R., Murdoch, M., Hodges, J., & Nugent, S. (2010). Treatment receipt by veterans after a PTSD diagnosis in PTSD, mental health, or general medical clinics. Psychiatric Services, 61, 58 – 63. doi:10.1176/appi .ps.61.1.58 StataCorp. (2007). Stata statistical software: Release 10. College Station, TX: StataCorp. Strosahl, K. (1996). Mind and body primary mental healthcare: New model for integrated services. Behavioral Healthcare Tomorrow, 5, 93–95. Tsan, J. Y., Zeber, J. E., Stock, E. M., Sun, F., & Copeland, L. A. (2012). Primary care-mental health integration and treatment retention among Iraq and Afghanistan war veterans. Psychological Services, 9, 336 –348. doi:10.1037/a0028308 Watts, B. V., Shiner, B., Zubkoff, L., Carpenter-Song, E., Ronconi, J., & Coldwell, C. (in press). Implementation of evidence-based psychotherapies for PTSD in U.S. veterans affairs specialty clinics. Psychiatric Services. Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993, October). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the 9th annual meeting of the ISTSS, San Antonio, TX. Zubkoff, L., Young-Xu, Y., Shiner, B., Pomerantz, A. S., & Watts, B. V. (2012). Do providers find symptom feedback useful? The implementation of measurement based care in an integrated primary mental health care clinic. Psychiatric Services, 63, 91–93. doi:10.1176/appi.ps .201100323
Received December 11, 2012 Revision received September 24, 2013 Accepted December 16, 2013 䡲
