American Soldiers are reaping the rewards of an innovative Army program designed to identify and treat Soldiers at risk of post-traumatic stress disorder (PTSD) or depression earlier by conducting behavioral health screening at all primary care visits. During the American Psychiatric Association's annual meeting last month, Col. Charles Engel, M.D., M.P.H., described the RESPECT-Mil program and its results to date in his presentation, "Effective Integrated Mental Health & Primary Care Services in the U.S. Military." Col. Engel is the RESPECT-Mil program director, director of the Department of Defense Deployment Health Clinical Center at Walter Reed National Military Medical Center, and senior scientist at the Center for the Study of Traumatic Stress. He is also associate chair (Research) of the Department of Psychiatry at the Uniformed Services University School of Medicine in Bethesda, Md.
"Making behavioral health screening as standard as a blood pressure check helps defuse any perceived stigma around seeking help for symptoms of PTSD or depression," said Col. Engel. "Early intervention ensures Soldiers get effective help sooner while reducing the use of clinical services for related symptoms like back pain or accidents and emergency room visits from hazardous drinking."
Since 2007, about 63,000 Soldiers accounting for 3 percent of all primary care visits have been diagnosed with a previously unrecognized behavioral health need and received treatment. So far, results have been positive. Program data between August 2009 and December 2010 shows PTSD remissions overall have doubled over time, meaning that twice as many patients (starting at less than 10 percent and rising to more than 20 percent) experienced a clinically significant reduction in self-assessed PTSD symptom severity scores to below 27 on the PTSD checklist (PCL) over eight weeks or more. Likewise, RESPECT-Mil data shows that as the number of contacts a care coordinator has with a patient rises, the PTSD and depression severity scores trend downwards in a clinically significant way regardless of treatment method.
RESPECT-Mil has been rolled out in 88 of the Army's 96 targeted primary care clinics worldwide, with the remainder expected to be online by July. Approximately 100,000 behavioral health screenings now take place in these clinics each month a rate expected to continue rising as clinics and providers gain experience. Participating clinics follow a three-component model*, with a care coordination manager ensuring continuity of care for the patient and ongoing communication between the primary care provider and a behavioral health specialist. The care coordinator follows up with patients at regular intervals, raising any patient concerns with their providers and ensuring patients follow their treatment plans.
A core aspect of the RESPECT-Mil program is the care coordinators' use of a secure, web-based care management platform for following patients called FIRST-STEPS. Care coordinators enter assessments and schedule appointments, while behavioral health providers use it to review case loads. The most acute cases receive immediate attention. The system also automatically flags patient records that don't show clinically significant improvement after eight weeks for review so providers may adjust treatment plans in a timely way, consistent with treatment guidelines. RESPECT-Mil also offers primary care providers web-based training on how to diagnose and treat PTSD and depression.
"RESPECT-Mil has improved our clinic's efficiency in diagnosing and treating Soldiers with behavioral health concerns," said Melissa Molina, M.D., a family practice physician at Fort Bliss in El Paso, Texas. "We've had a significant reduction in the severity of symptoms of PTSD and depression in our patients. Because most Soldiers screen negative, 90 percent of clinic visits require no added provider time. But in cases where a Soldier does need attention, RESPECT-Mil gives us a proven, effective process to follow."
The Army continues to refine the RESPECT-Mil program to drive even better patient outcomes. Planned enhancements include a stepped approach of psychosocial modalities and telephone-based cognitive-behavioral therapy. Also under development is a five-year, randomized controlled trial in 18 clinics comparing the current approach to a modified approach that Col. Engel's RESPECT-Mil team hopes will offer even greater benefits for patients in need. The Army also expects to expand availability of the program to all military health system beneficiaries (not only Soldiers, but also their families) over the next year as part of the move to Patient Centered Medical Homes.