Documente Academic
Documente Profesional
Documente Cultură
'
'
1 9 MAY 2008
MCCG
Expires 19 MAY 2010
1. References.
a. Army Regulation (AR) 635-200, Active Duty Enlisted Administrative Separations,
6 June 2005.
b. Army Medical Action Plan, Phase Ill task, consider mTBI and PTSD Separations'',
July 2007.
c. Sigford, B.. M.D., Veterans Affairs, National Director, Physical Medicine and
Rehabilitation, December 2007. Screening and Evaluation of Possible TBI in OEF/OIF
Veterans, Brief.
d. Post Traumatic Stress Disorder Checklist (PCL) for DSM-IV, 1 November 1994,
Weathers, Litz, Huska, & Keane, National Center for PTSD - Behavioral Science Division.
2. Purpose. To outline procedures for PTSD and mTBI screening of Soldiers considered
for administrative separations, including but not limited to Chapter 9, Alcohol or other Drug
Abuse Rehabilitation Failure: Chapter 13, Unsatisfactory Performance; Chapter 5-13,
Personality Disorder; Chapter 5-17, Other Mental Health Condition; and Chapter 14-12,
Patterns of Misconduct, reference 1.a.
3. Proponent. The proponent for this policy is HQ, MEDCOM, Office of the Assistant
Chief of Staff for Health Policy and Services, ATTN: MCHO-CL-H.
4. Responsibilities.
a. The Surgeon General has overall responsibility for policy guidance in defining
and implementing the Army Medical Department's behavioral healthcare screening
requirements.
b.. -rhe Directorate of Health Policy and Services, through the Proponency Chiefs of the
Offices for Behavioral Health and Rehabilitation and Integration are responsible for the
distribution of behavioral health evaluation and mrsl requirements and reviewing, revising,
MCCG
SUBJECT: Screening for Post-Traumatic Stress Disorder (PTSD) and mild Traumatic Brain
Injury (mTBI) Prior to Administrative Separations
c. Medical Treatment Facility (MTF) Commanders will ensure that all Soldiers are
screened for PTSD and mTBI during routine mental health evaluations for administrative
separations related to the Chapters identified in paragraph 2., above.
5. Discussion.
a. There has been concern that Soldiers with undiagnosed or untreated PTSD or mTBI
are being administratively discharged from the Army. rherefore, it is paramount that the
Army adequately assesses every one of these Soldiers for PTSD or mTBI.
b. rhis guidance refers to Soldiers who receive mental health evaluations from behavioral
health clinicians for administrative separations.
6. Policy.
a. Behavioral Health Departments within each MTF will ensure that Soldiers receiving
mental health evaluations related to the Chapters identified in paragraph 2., above are
conducted by a behavioral health clinician lAW AR 635-200. Evidence of documentation of a
screen for both PTSD and mrsl must be part of DA Form 3822-R, Report of Mental Status
Evaruation and documented in the progress note located in the Soldiers' Armed Forces
Health Longitudinal Technology Application (AHLTA) record.
b. There are screening tools (enclosures 1 and 2) for both PTSD and mTBI that can
assist the clinician during the assessment. These tools are also located at
nn mi
. The consensus of the subject matter experts is
h
that the VA screening questions and the PCL found at the website above are the best tools
for screening in this population. It should be noted that the mTBI screening tools are not
diagnostic. Any positive mTBI screen will require a further evaluation to establish the
correct diagnosis with referral and other testing if necessary. Other assessment tools may
be added at the discretion of the clinician.
7. Point of contact is (b )(
(b )(6)
2 Encls
1. PCL
2. VHA TBI Clinical Reminder
and Screening Tool
ERIC B. SCHOOMAKER
Lieutenant General
Commanding
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AFSC: ___________
CfiRONOLOGICAL RECORD OF MEDICAL CARE
No. of Previous Deployments to AOR: _ __
5~)
During any of your OIF/OEF deployment(s) did you experience any of the
follo\ving events?
D
D
D
0
Blast or Explosion
Vehicular accident/crash (any vehicle, including aircraft)
Fragment \vound or bullet \\'ound above the shoulders
Fall
Section 2:
Did you have any of these 1M MEDIATELY aftenvards?
(Check all that app~v)
0
0
D
0
D
Section 3:
Did any of the follo\ving proble111s begin or get \vorse aftenvards?
(Check all that appJ.vJ
D
D
0
D
D
D
Sleep problems
Section 4:
In the past \Veek, have you had any of the symptoms from Section 3?
(Check all that opp(v)
D
0
0
D
D
Sleep problen1s
Irritability
Headaches
(b )(6)
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*Corresnondence:
COL (b)(6 )
Chief, DeDa.rtment ofPsycholo~y
c _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ J
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2
~bstract
1
2
Context: High rates of mental health concerns have been documented in Army Soldiers
deployed in support of Operation Iraqi Freedom (OIF). To our knowledge, there are no peer-
reviewed studies that have examined the impact of multiple OIF deployments on mental health
functioning.
Objective: To compare the post-deployment mental health screening results of Soldiers with one
Design & Setting: Cross sectional study of routine mental health screening data collected in the
10
Participants:
11
deployment to Iraq, and 671 Soldiers evaluated after their second deployment to Iraq).
12
Main Outcome Measure(s): Standardized measures screened for Major Depression, Other
13
Depression, Post-traumatic stress disorder (PTSD), Panic, Other Anxiety, and hazardous alcohol
14
15
Results: There was a significant association between number of deployments and mental health
16
screening results such that Soldiers with two deployments showed greater odds of screening
17
positive for Other Depressive Syndrome [Odds Ratio (OR)=l.46, p=.045] and Other Anxiety
18
19
most recent deployment, Soldiers with two Iraq deployments showed significantly greater odds
20
of screening positive for Major Depression (OR= 1. 70, p=.02), Other Depressive Syndrome
21
(OR=1.73, p=.007), PTSD (OR=1.90, p<.001), Panic (0R=l.85, p=.04}, and Other Anxiety
22
Syndrome (OR=1.71, p<.OOl). There was no significant difference in odds of screening positive
23
of 3548 Regular U.S. Army Soldiers (2,877 returning from their first
~fter
Conclusions: These results provide preliminary evidence that multiple deployments to Iraq may
INTRODUCTION
High rates of mental health concerns have been docun1ented in Army Soldiers deployed
1
in support of Operation Iraqi Freedom (OIF). In an early study by Hoge and colleagues,
Soldiers assessed three to four months after a deployment to Iraq screened positive for post-
traumatic stress disorder (PTSD) in 13% of cases; depression and generalized anxiety were each
observed in about 8% of cases, and alcohol misuse was observed in over 20% of cases. With the
exception of generalized anxiety, these rates were significantly higher than pre-deployment
screening rates observed in a comparable U.S. Army unit. In a separate study, routine post-
deployment screening data collected within two weeks of returning from Iraq revealed that
10
Soldiers and Marines screened positive for a mental health problem in 19% of cases, compared
11
12
Similar results have been reported in veteran populations. Examining over 103,000
13
OIF/OEF veterans, Seal and colleagues reported that 25% of a clinical Veteran Affairs (VA)
14
sample had been diagnosed with a mental health disorder, including 13% with PTSD. The rate
15
ofPTSD diagnoses in a similar VA sample was reportedly 3.7 times higher antong Soldiers or
16
Marines who served in ground units in Iraq or Afghanistan compared to Navy or Air Force
17
18
veterans of OIF/OEF.
19
mood disorders, and functional impairments. The National Survey of the Vietnam Generation
20
revealed that veterans with lifetime diagnoses ofPTSD and major depression showed
21
significantly lower employment rates and hourly wages compared to veterans without these
5
22
disorders. PTSD has been associated with increased marital distress and parental adjustment
23
6 7
problems. '
5
I
reported a lower quality oflife. Furthermore, Soldiers studied one year after deployment to OIF
9
showed strong associations between PTSD and physical health problems. These impairments in
job performance, intimate and family relationships, quality of life, and physical health suggests
that OIF veterans with mental disorders may face significant functional challenges.
the frequency and severity of mental health problems described above. Multiple deployments
may increase the cumulative stress an individual experiences, and it increases the probability that
Soldiers will be exposed to combat. Deployment stressors can include a sense of isolation,
10
environment, a threatened sense of safety, traumatic stress, long work hours, and stressors
11
associated with a variety of other operational demands. Concomitant reductions in usual coping
12
resources may also impact mental health functioning. In contrast, potential protective factors
13
such as unit cohesion, effective leadership, mentoring, training, and access to other resources in
14
15
To our knowledge, there are no peer-reviewed studies that have examined the impact of
16
multiple OIF deployments on mental health functioning. Army reports from the Office of the
17
Surgeon Multinational Force-Iraq and the Office of the Surgeon General, U.S. Army Medical
.
10 11
results. '
18
19
may increase the risk for mental health problems. For example, a Swedish study of 1824
20
randomly selected individuals from the general population revealed that trauma frequency was
21
22
13
12
6
1
2
3
mortuary during the Persian Gulf War, greater changes in PTSD symptoms were observed in
groups with the greatest exposure to huntan remains.
14
The purpose of this study was to determine if there is a relationship between multiple
deployments and mental health problems as identified by mental health screening outcomes for
METHODS
Study Population
Data were retrospectively analyzed from the Soldier W ellness Assessment Pilot Program
(SWAPP) database at Fort Lewis. The SWAPP is an extension of the standard Post-Deployment
) program mandated by the Assistant Secretary of Defense for
10
11
Health Affairs since 2005. The PDHRA provides a global health assessment, including mental
12
health screening, for all Service Members 90 to 180 days after returning from an operational
13
deployment. In the standard Army process, Soldiers complete the three page PDHRA fonn
14
15
physician) reviews the information, conducts a brief interview, and recommends further
16
17
.&.
15
During the SWAPP process, Soldiers first complete on a computer an expanded set of
and additional items for demographics
18
19
and military infomtation, psychosocial history, mental health screening (see Measures section
20
below), deployment exposures and stressors, and resiliency factors. Soldiers are seen by medical
21
personnel for injury prevention, smoking cessation, or other reported physical concerns as
22
needed, and a credentialed behavioral health provider meets individually with each Soldier. A
7
1
nurse practitioner reviews all aspects of the Soldier's SWAPP encounters, and administrative
The SWAPP's post-deployment screening data from September 7, 2005 to April27, 2007
were analyzed. All Service Members in the database were Regular, active duty Soldiers. Cases
were included in the analysis when they met two criteria: (1) Iraq was reported as the
deployment's operational location; (2) the total historical number of deployments reported in
support of Operation Iraqi Freedom was one or two. There were not enough Soldiers with three
deployments in the database to expand the analysis to include this group. Cases were included
.&...&.
10
reported histories of deployment in support of Operation Enduring Freedom were excluded from
11
the analysis. The final sample included 2,877 Soldiers returning from their first deployment to
12
Iraq, and 671 Soldiers evaluated after their second deployment to Iraq. Two subjects were
13
observed in both groups. The study was approved by the Department of Clinical Investigations
14
15
Measures
16
SWAPP mental health screening measures included the depression and anxiety modules
17
16 18
(PHQ) - ,
18
19
20
21
from the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire
the Primary Care Posttraumatic Stress Disorder Screen
Disorder Detection Test (AUDIT).
20
19
(PC-PTSD) ,
21
16 22 23
algorithms ' '
22
patients.
23
to specific DSM-IV criteria, and subthreshold disorders that require fewer symptoms than a
Standardized
8
1
DSM-IV diagnosis. The Depression and Anxiety modules administered in the SWAPP provide
screening results for threshold disorders, including Major Depression, Panic Disorder, and Other
Anxiety Disorder; the subthreshold disorder of Other Depressive Disorder is also screened. The
4
5
16 17 24 25
validity. ' ' '
for PTSD that is a standard part of the PDHRA. The PC-PTSD demonstrated sound
psychometric properties for cutoff scores of2 (sensitivity= .91, specificity= .72) and 3
(sensitivity= .78, specificity= .87) compared to diagnoses based on the Clinician Administered
10
11
19
19
the clinical setting, we analyzed results for both cut-points (PTSD-2, PTSD-3).
AUDIT. The AUDIT is a 10-item self-report measure that screens for hazardous or
20
12
13
Daily) with total scores ranging from 0 to 40. The standard cutoff score of 8 for hazardous or
14
15
16
17
numerous
26 29
studies. -
reliability.
31
30
Combat exposure. The SWAPP screening included four Yes-No questions about combat
21
18
experienced during the most recent deployment, adapted from the DRRI.
19
following: During combat operations did you (1) become wounded or injured; (2) personally
20
witness a unit member, ally, enemy, or civilian being killed; (3) see the bodies of dead soldiers or
21
civilians; (4) kill others in combat (or have reason to believe others were killed as result of your
22
actions).
23
1
2
Statistical Analyses
Chi-square tests of association and t-tests were used to compare demographic and combat
exposure variables between groups with one or two Iraq deployments. Logistic regression was
used to examine associations between the number of Iraq deployments and mental health
screening outcomes (positive, negative). Multivariate logistic regression models were used to
examine the associations irrespective of age, sex, race/ethnic background, rank, education,
9
10
RESULTS
Subject Characteristics
Subject demographics are presented in Table 1. Soldiers with two Iraq deployments
11
differed from those with one deployment in terms of age, rank, education, and marital status.
12
13
There was no difference between Soldiers with one or two deployments in terms of the
14
number of days between departure from theater and screening date (Mean SD = 105.51
15
37.62; 108.14 35.94, respectively). Soldiers were deployed for an average of 11.33 months
16
(SD = 2.19) in the group with one deployment and 11.03 months (SD = 2.41) in the group with
17
two deployments. For Soldiers with two deployments, the median arrival date in theater (Oct.
18
31, 2005) was about a year later than the median arrival date for Soldiers with one deployment to
19
Iraq (October 13, 2004). Subjects reported significantly lower frequencies of combat exposure
20
during their second deployment compared to Soldiers who recently returned from their first Iraq
21
22
23
10
There was a significant association between number of deployments and mental health
screening results in the univariate analyses for Other Depressive Syndrome (OR= 1.46, p =
.045) and Other Anxiety Syndrome (OR= 1.32, p = .047; Table 3). After adjusting for
demographic factors and combat exposure, Soldiers with two Iraq deployments showed
significantly increased odds of screening positive for Major Depression (OR= 1. 70, p = .02),
Other Depressive Syndrome (OR= 1.73, p = .007), PTSD-2 (OR= 1.64, p <.001), PTSD-3 (OR
.001). There was no difference between the groups in the odds of screening positive for
10
1.90, p < .001), Panic (OR= 1.85, p = .04), and Other Anxiety Syndrome (OR= 1.71, p <
11
These analyses were repeated after adding the number of days between screening and
12
departure from theater to the model. The results were unchanged with the exception of Panic
13
which no longer showed a significant association with number of Iraq deployments (OR= 1.78,
14
p = .055).
15
DISCUSSION
16
The results of this study provide preliminary evidence that multiple deployments to Iraq
17
may be a risk factor for some mental health concerns. The odds of screening positive for Other
18
Depression and Other Anxiety Syndrome was higher for Soldiers on their second deployment to
19
20
These findings differ from results of the Mental Health Advisory Team (MHAT)-III
10
21
Report which found that Soldiers with multiple deployments to Iraq showed higher rates of
22
acute stress, but not depression or anxiety, compared to Soldiers on their first deployment to Iraq.
23
11
Our results are more consistent with the recent MHAT-N Report which found that Soldiers
11
1
deployed to Iraq more than once were more likely to screen positive for depression, anxiety, or
acute stress. However, different recruitment procedures, participant characteristics, and outcome
measures limit comparability. In addition, it is important to note that the MHAT Reports are
based on data collected from Soldiers during deployment, while our results were collected from
Soldiers about 3 to 6 months after returning from deployment. Some research suggests that
results obtained immediately following a deployment may differ substantially from assessments
32
After adjusting for demographic factors and combat exposure on the most recent
deployment, the odds of screening positive for Major Depression, Other Depressive Syndrome,
10
PTSD, Panic, and Other Anxiety Syndrome was 64 to 90% higher for Soldiers with two
11
deployments. These findings suggest that the odds of developing a mental health problem are
12
higher for Soldiers after a second deployment, irrespective of the combat they are exposed to
13
during their second tour. The factors contributing to these findings are unknown. Information
14
about combat exposure during first deployments (among Soldiers with two deployments) was not
15
available. Thus, the impact of additive combat exposures across multiple deployments remains
16
unknown. In addition, the impact of cumulative deployment stress, such as homefront stressors
17
and difficulties associated with working in an operational theater may contribute to these
18
findings. Additional research is needed to determine how the etiology of mental health disorders
19
following a second deployment may differ from Soldiers deployed to Iraq only once.
20
Interpretation of our findings would benefit from more information on how Soldiers with
21
one or two deployments may differ. While we were able to examine basic demographic features
22
and recent combat exposure, we do not know how the group with two deployments adjusted after
23
their first deployment compared to their entire cohort. Soldiers identified with a post-
12
deployment mental health condition that renders them unfit for duty are not deployed again until
treatment proves successful. In addition, Service Members who screen positive for mental health
2
concerns are more likely to leave military service in the year following a deployment.
Therefore, it is possible that the group with two deployments represented a healthier, more
resilient group. However, it is also possible that a number of Soldiers were successfully treated
for mental health concerns before deploying a second time. The impact of prior treatment
study of the effects of multiple deployments on mental health would be helpful to clarify these
10
~. . . . . . . .own.
A longitudinal
ISSUeS.
11
These group effects were expected, as Soldiers with two deployments likely had longer military
12
careers. Therefore, differences in age, rank, education, and marital status are intuitive. The
13
difference between groups on combat exposure is less intuitive. Soldiers reported significantly
14
lower levels of combat exposure during their second deployment compared to the group with
15
only one deployment. This finding may be due, in part, to the fact that Soldiers' second
16
deployment occurred, on average, about a year later in the history of the conflict when combat
17
operations may have differed. It is also possible that Soldiers deployed to Iraq for a second time
18
may differ from Soldiers on a first deployment in some way that makes them less likely to see
19
combat. Possibilities include rank, Anny selection criteria for a second deployment, duty
20
assigmnents for Soldiers with prior theater experience, or differences in attrition from the Anny
21
by occupational duty.
22
23
Rates of positive screens for mental health disorders were generally lower than those
1
reported by Hoge and colleagues. For example, while Hoge et al. reported that 15% of their
13
1
Army sample screened positive for major depression on the PHQ after deployment to Iraq, we
observed a rate of 4o/o for our total sample using the same measure. However, significant
differences between study methods may account for these differences. Hoge et al.'s study
utilized an anonymous survey with a specific infantry division, three to four months after an 8-
month deployment to Iraq in December 2003. Our results were obtained from non-anonymous,
standard post-deployment screening efforts at Fort Lewis for Soldiers from a variety of units,
three to six months after deployments (of varying lengths) to Iraq, from September 2005 to April
2007. Many of these factors likely contributed to the differences in the results. For example,
since our sample included non-combat units, combat exposure may have been reduced in our
10
sample compared to Hoge et al.'s study. In support of this hypothesis, 62% ofHoge et al.'s
11
sample endorsed responsibility for the death of others (combatants and noncombatants)
12
13
14
In contrast, the rates we observed were higher than those reported in a recent study that
examined population-based results of Army Soldiers and Marines screened within two weeks of
2
15
returning from a deployment to Iraq. Utilizing the 2-point cutoff score for the PC-PTSD, the
16
investigators reported a PTSD-positive screen rate of9.8% in their Iraq sample; this compares to
17
a rate of about 21% in our total sample using the same measure. Both studies included similar
18
questions about whether the Service Members saw dead bodies; the rate in our san1ple was
2
19
higher with 67% positive, compared to 49.5% in the Hoge et al. study. Thus, some of the
20
differences between the two studies could be due to higher levels of combat exposure in our local
21
sample. Unfortunately, other combat exposure items were not appropriate for comparison.
22
However, another important difference between the studies was the timing of the screening. The
23
Hoge et a1. study was conducted within two weeks of retuttling from deployment, while our data
14
was gathered about three to six months after deployment. As noted above, some data suggests
that Service Members are much more likely to report mental health problems three to four
3
4
32
The results of the current research should be confirmed in future studies, as the cross-
sectional design limits conclusions. In addition, all study subjects were drawn from one Army
installation in Tacoma, W A with a large active duty population, including several Stryker
brigades. These Soldiers may differ from the broader Army in a number of ways, and the results
may not generalize to the rest of the Army. Generalizability is further reduced by the fact that
the current study included only Regular active duty Soldiers. Furthennore, it is important to
I0
emphasize that these results were obtained with self-administered screening instruments; these
11
results do not reflect diagnostic rates. In addition, the time-frame of the study period may prove
12
important for studying mental health outcomes of multiple deployments. As the theater matures
13
and the mission requirements of Operation Iraqi Freedom evolve, the nature of the stressors that
14
Soldiers experience may change. Therefore, rates examined during one time frame of the
15
16
17
likely to grow as the number of Service Members with two or more deployments increases. The
18
results of this study provide preliminary evidence that the risk of mental health problems may
19
increase following a second deployment to Iraq. As the number of Service Members deployed
20
for second tours increases, these findings may have significant implications for the demand on
21
22
23
15
Disclosures & Acknowledgements: All authors report no competing interests. This was an
unfunded study. The opinions or assertions contained herein are the private views of the authors
and are not to be construed as official or reflecting the views of the Department of the Army or
c _ _ _ __ _ _ _ _ _ _ _ _ _ J
c _ _ _ __ _ _ _ _ _ _ _ _ J
c _ _ _ __ _ _ _ _ _ _ _ J
contributions.
16
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2.
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'
3.
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1993;88(6):791-804.
21.
King DW, King LA, Vogt DS. Manual for the Deployment Risk and Resilience Inventory
(DRRI): A Collection of Measures for Studying Deployment-Related Experiences of
Military Veterans 2003, Boston.
22.
Spitzer RL, Williams JB, Kroenke K, et al. Utility of a new procedure for diagnosing
mental disorders in primary care. The PRIME-MD 1000 study. Jama. Dec 14
1994;272(22):1749-1756.
23.
Spitzer RL, Williams JB, Kroenke K, Hornyak R, McMurray J. Validity and utility of the
PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic
19
patients: the PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study. Am
Fann JR, Bombardier CH, Dikmen S, et al. Validity of the Patient Health Questionnaire-9
in assessing depression following traumatic brain injury. J Head Trauma Rehabil. NovDec 2005;20(6):501-511.
25.
26.
Maisto SA, Carey MP, Carey KB, Gordon CM, Gleason JR. Use of the ALTDIT and the
DAST-10 to identify alcohol and drug use disorders a:rnong adults with a severe and
'
Bradley KA, Bush KR, McDonell MB, Malone T, Fihn SD. Screening for problem
drinking: comparison of CAGE and AUDIT. Ambulatory Care Quality Improvement
Project (ACQUIP). Alcohol Use Disorders Identification Test. J Gen Intern Med. Jun
1998;13(6):379-388.
28.
Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol
consumption questions (AUDIT-C): an effective brief screening test for problem
drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use
Disorders Identification Test.ArchlnternMed. Sep 141998;158(16):1789-1795.
29.
Cherpitel CJ. Comparison of screening instruments for alcohol problems between black
and white emergency room patients from two regions of the country. Alcohol Clin Exp
Res. Nov 1997;21(8):1391-1397.
20
30.
Reinert DF, Allen JP. The Alcohol Use Disorders Identification Test (AUDIT): a review
of recent research. Alcohol Clin Exp Res. Feb 2002;26(2):272-279~
31.
Daeppen JB, Yersin B, Landry U, Pecoud A, Decrey H. Reliability and validity of the
Alcohol Use Disorders Identification Test (AUDIT) imbedded within a general health
risk screening questionnaire: results of a survey in 332 primary care patients. Alcohol
Bliese P, Wright K, Adler A, Thomas J. Validation of the 90 to 120 day short form
21
Table 1. Demographics Characteristics by Nuntber of Deployments
N~mber
Agea
Sex
of Deploytnents
2
n
(Mean)
%
(SD)
(27.42)
2627
207
(5.84)
92.7
7.3
n
(Mean)
(29.08)
600
61
%
(SD)
Male
Female
Race/Ethnicity American Indian
or Alaskan
2.6
22
73
Native
4.3
28
Asian
122
Pacific Islander
92
3.2
28
Black
324
11.4
85
11.9
Hispanic
337
66
1925
434
White
67.9
Other
3.0
25
86
1243
43.9
Rank
El-E4
164
1228
424
E5-E9
43.3
329
11.6
57
Officer
34
1.2
16
Warrant Officer
Some High
Education
3.5
18
100
School
High School
218
982
34.7
Graduate
Some College
1141
40.3
305
but No Degree
Associates
162
5.7
41
Degree
College Graduate
(Bachelor's
12.7
64
360
Degree)
Postgraduate or
3.1
15
Professional
89
Degree
979
34.5
155
Marital Status
Never married
1594
56.2
403
Married
4.4
Separated
125
35
135
4.8
68
Divorced
<1
0
Widowed
1
Note: For Race/Ethnic Status, Soldiers were asked to select all that applied
a Means and SDs are presented
(5.91)
90.8
9.2
p
<.001
.09
3.3
.28
4.2
4.2
12.9
10.0
65.7
3.8
24.8
64.1
8.6
2.4
.94
2.7
.21
.30
.17
.26
.32
<.001
.041
33.0
46.1
6.2
9.7
2.3
23.4
<.001
61.0
5.3
10.3
0
22
Table 2. Combat Exposure During First and Second OIF Deployments
NuJ!lber of Deployments
n
416
%
14.7
69
10.4
.005
Witnessed
Killing
1441
50.8
183
27.7
<.001
Saw Dead
Bodies
2028
71.6
338
51.1
<.001
Killed
Others
1064
37.5
101
15.3
<.001
Wounded
or Injured
23
Table 3. Mental Health Screening Results by Number of Iraq Deployments
Number of Deployments
1
2
No. Pos./n
No. Pos.ln
Major
Depression
114/2772
4.1
30/651
%
4.6
Other
Depression
119/2772
4.3
40/651
6.1
PTSD-2
580/2803
20.7
137/653
21.0
PTSD-3
322/2803
11.5
85/653
13.0
Panic
56/2817
2.0
17/660
2.6
Other
Anxiety
250/2823
8.9
75/660
11.4
1. 32 * ( 1. 004' 1. 73)
1. 71 ** ( 1.27' 2. 30)
ETOH
408/2808
14.5
85/657
12.9
.87(_68, 1.12)
1.27(.97, 1.68)
* p<.05, **p<.OOl
Note: OR= Odds Ratio; No. Pos. =Number that Screened Positive; PTSD-2 = Results from the
PC-PTSD using a cutoff score of 2; PTSD-3 =Results from the PC-PTSD using a cutoff score of
3. Denominators differ because subjects did not answer every question. Subjects with missing
data did not differ from the rest of the sample in terms of Age, Sex, Race/Ethnicity, Rank,
Education, Marital Status, percent who had Combat Injuries, percent who Saw Dead Bodies, or
percent who reported Killing Others. A higher proportion of subjects with missing data reported
Seeing Dead Bodies.
a Adjusted for Age, Sex, Education, Racial/Ethnic Background, Rank, Marital Status, Combat
Exposure
DEPART~JE~T
II 1::~\DQt;,\RTF.RS.
REPLY TO
.-\11 ~-sno~
l:~ITED
o.-
13 MAR 2009
MCHO-CL
Expires 13 March 2011
1. References.
a. Department of Defense Instruction (DoDI) 1332.14, ~Enlisted Administrative
Separations''. Aug 08.
b. Anny Regulation (AR) 635-200, Active Duty Enlisted Administrative Separations,
6 Jun 05.
c. OTSG/MEDCOM Policy 08-018~ Screening for Post-Traumatic Stress Disorder
(PTSD) and mild Traumatic Brain Injury (mTBI) Prior to Administrative Separations! 19 May
08.
d. MEDCOM memorandum MCCG, Review of Personality Disorder (Chapter 5,
paragraph 5-13) Administrative Separations! 6 Aug 07.
2. Purpose. To outline new PD procedures under reference 1b., Chapter 5, paragraph 513 and 5-17.
3. Proponent. The proponent for this policy is the Director, Behavioral Health Proponency!
Office of The Surgeon General (OTSG). ATTN: DASG-HSZ.
4. Responsibilities.
a. The Surgeon General has overall responsibility for policy guidance in defining
and implementing the Army Medical Department's behavioral healthcare screening
requirements.
b. rhe Directorate of Health Policy and Services. Proponency Office for Behaviors'
Health. is responsible for the distribution of behavioral health policies and reviewing,
revising, updating, and deleting existing policies conflicting with these requirements.
MCHO-CL
SUBJECT: MEDCOM Procedures for Chapter 5, paragraph 5-13 and 5-17 Personality
Disorder (PO) Separations
c. MedicaJ treatment facility (MTF) Commanders will ensure that all Soldiers who are
referred for PO separations follow the procedures outlined below.
5. Discussion.
a. There has been concern that Soldiers with undiagnosed or untreated PTSO or mTBI
are administratively discharged from the Army. MEDCOM has previously issued two
policies addressing PO and screening for PTSO and mTBI (references 1c. and 1d.).
b. Reference 1a. outlines updated requirements. These requirements are similar but not
identical to the policy changes that the Army issued. This policy memorandum consolidates
the different requirements.
c. This guidance refers to Soldiers who receive mental health evaluations from behaviora'
health clinicians for Chapter 5, paragraph 5-13 and 5-17 PO administrative separations.
6. Policy.
a. DoDI1332.14, enclosure 3. paragraph 3a(8), Enristed Administrative Separations,
prescribes the following requirements for separations on the basis of enlisted Soldiers who
have served or are currently serving in imminent danger pay areas:
2
FOIA Release Page 29
MCHO-CL
SUBJECT: MEDCOM Procedures for Chapter 5, paragraph 5-13 and 5-17 Personality
Disorder (PO) Separations
(1) In the case of Soldiers who have served or are currently serving in an imminent
danger pay area and have 24 months or more of active duty service, the MTF Chief of
Behavioral Health (or an equivalent official) must corroborate the diagnosis of PO for
separation under AR 635-200. Chapter 5, paragraph 5-17.
(2) The corroborated diagnosis will be forwarded for final review and confirmation by
the Director, Proponency of Behavioral Health.
(3) Medical review of the PO diagnosis will consider whether PTSD and/or mTBI. or
other co-morbid mental illness diagnosis may be significant contributing factors to the
diagnosis.
(4) A Soldier will not be processed for administrative separation under AR 635-200,
Chapter 5t paragraph 5-17, if PTSD or mTBI are significant contributing factors to a
diagnosis of PD~ but will be evaluated under the physical disability system in accordance with
AR 635-40.
'
...... ERBERT A. COLEY
Chief of Staff
3
FOIA Release Page 30
DEPARTl\IE~"T OF
TilE ARI\IY
REPLY TO
ATTENTION OF
22 JUL2009
Expires 22 July 2011
2. In 2006 and 2007, the public raised concerns that some Soldiers returning from combat
tours had been discharged from the military for PO, but were subsequently suffering from
PTSD or TBI related to their combat experiences. The OTSG issued policies in Aug 07 and
This policy supersedes OTSG/MEDCOM Policy Memo 09-012. 13 Mar 09, subject: MEDCOM Procedures for
Chapter 5. paragraph 5-13 and 517 Personality Disorder (PO) Separations.
MCCS
SUBJECT: Guidance for Administrative Separation for Personality Disorder (PO) or Other
Behavioral Conditions
May 08 to address these concerns and implement the requirement for a higher level review
of recommendations for administrative separations for PO (reference a), and screening for
PTSD and rsr for these and other administrative separations (reference b). In Aug 08,
Department of Defense Instruction (DoDI) 1332.14 mandated similar requirements across
the DoD, including the requirement that the Military Department's Surgeon General endorse
a diagnosis of PO for service members who have served or are serving in imminent danger
pay areas .
2
FOIA Release Page 32
MCCS
SUB'"IECT: Guidance for Administrative Separation for Personality Disorder (PO) or Other
Behavioral Conditions .
c. A specific statement that the disorder is of sufficient severity to interfere with the
Soldier's ability to function in the military.
d. Documentation of the behaviors and symptoms of concern in clinical records,
counseling statements, or other personnel records; and the specific DSM-IV-TR diagnostic
criteria met (if PO not otherwise specified for mixed PO, the specific traits of each type).
e. Clinical documentation that the symptoms or behavioral problems existed prior to
enlistment, and do not simply represent maladjustment to the military. Otherwise consider
Chapter 5-17 for adjustment disorder and further review is not required.
f. Documentation of clinical treatment and/or supervisory rehabilitation efforts (e.g.,
counseling statements or Memoranda For Record).
g. Clinical documentation that PTSD and TBI were addressed w'ith appropriate
screening instruments. and other co-morbid mental illness was ruled out or did not
contribute significantly to the diagnosis. If PTSD or other mental 'illness is significant. initiate
a Medical Evaluation Board (MEB) in accordance with AR 40-400, Chapter 7, and if found
to meet retention standards. a copy submitted with the clinical documentation (the MEB is
composed of two or more physician members including a Psychiatrist: it is part of the
Physical Disability Evaluation System and does not require referral to the Physical
Evaluation Board (PEB) if found to meet retention standards). If retention standards are not
met, do not submit the recommendation for administrative separation to OTSG unless and
until the PEB finds the Soldier fit for duty.
h. The requirement for endorsement by OTSG is only for the diagnosis of PO and only
for Soldiers who served or are serving in an imminent danger pay area.
FOR THE COMMANDER:
'~
RBERT A. CO EY
Chief of Staff
3
FOIA Release Page 33
REPLY TO
AITENTION OF
MCCG
Expires
9 June 2012
09 JUN 2010
This policy memo supersedes OTSG/MEDCOM Policy Memo 08-018, 19 May 08, subject: Screening for PostTraumatic Stress Disorder (PTSD) and mild Traumatic Brain Injury (mTBI) Prior to Administrative Separations.
MCCG
SUBJECT: Screening Requirements for Post-Traumatic Stress Disorder (PTSD) and
mild Traumatic Brain Injury (mTBI) for Administrative Separations of Soldiers
b. The Directorate of Health Policy and Services, through the Proponency Offices
for Behavioral Health and Rehabilitation and Reintegration. are responsible for the
distribution of behavioral health (BH) evaluation and mTBI requirements and reviewing,
revising, updating, and deleting existing policies conflicting with these requirements.
c. Medical Treatment Facility (MTF) Commanders will ensure that all Soldiers are
screened for PTSD and mTBI during routine mental health evaluations for
administrative separations related to the Chapters identified in paragraph 2 . below, or
for any case involving Soldiers diagnosed with or reasonably asserting PTSD or mTBI.
5. Discussion:
a. This guidance refers to Soldiers who require mental health evaluations from
behavioral health clinicians for administrative separations. or for Soldiers diagnosed
w'ith or reasonably asserting PTSD or mTBI.
b. This guidance refers to Soldiers who receive mental health evaluations from
behavioral health clinicians for administrative separations.
6. Policy:
a. BH Departments within each MTF will ensure that mental health evaluations
related to administrative separations are conducted by a BH clinician as required for all
Soldiers diagnosed with or reasonably asserting PTSD or mTBI, in accordance with
Army Regulation 635-200. the 2010 National Defense Authorjzatjon Act (Section 512)
and MEDCOM Regulation 40-38.
b. Enclosures 1 and 2 contain screening tools for both PTSD and mTBI that can
assist the clinician during the assessment. These tools will be administered by BH
clinicians to every Soldier requiring mental health evaluations prior to administrative
separations. and to all Soldiers reasonably asserting PTSD or mTBI who have been
deployed overseas in support of a contingency operation. rhe Primary Care-PostTraumatic Stress Disorder (PC-PTSD) measure enclosed is currently being utilized by
the Department of Veterans Affairs as a screening tool. These tools are also located at
pttps://www.us.ar,ny.rnil/suite/oage/222.
c. These screening tools are not diagnostic. A positive screen will require a
comprehensive evaiuation to establish the correct diagnosis, with referral and other
testing, if necessary. A "yes.. response to any three items in the PC -PTSD tool. or any
one item in the mTBI screening, will be considered a positive screen indicating the need
for further evaluation and possible treatment of PTSD or mTBI, respectively.
d. PTSD screening and/or full comprehensive evaluation shall be performed by a
clinical psychologist or psychiatrist; mTBI screening and/or full comprehensive evaluation
2
FOIA Release Page 35
MCCG
SUBJECT: Screening Requirements for Post-Traumatic Stress Disorder (PTSD) and
mild Traumatic Brain Injury (mTBI) for Administrative Separations of Soldiers
may be performed by a physician. clinical psychologist, psychiatrist, or other healthcare
professions'. as appropriate.
e. Soldiers who screen positive for PTSD or mTBI. or who have already been
diagnosed by a physician, clinical psychologist, or psychiatrist as experiencing PTSD or
mTBI, will receive a full comprehensive examination to assess whether the effects of the
PTSD or mTBI are contributing or related to the reason for separation.
f. Screenings, as well as full comprehensive evaluations for positive and existing
cases of Soldiers djagnosed with PTSD or mTBI, will be documented in the "Additional
Comments" section of the Mental Status Evaluation Form MEDCOM 699 (Enclosure 3);
and in the progress note located in the Soldiers' AHLTA record. Compliance will be
monitored in accordance with AR 635-200.
g. The result of the evaluation, with a medical opinion as to the effects of mTBI
and/or PTSD on the separation action wUI be provided to the commander for inclusion in
the separation documentation and personnel files before separation proceedings can
occur.
ERIC B. SCHOOMAKER
Lieutenant General
The Surgeon General and
Commanding General, USAMEDCOM
3 Encls
1. Primary Care - PTSD
2. TBI Screening Questions
from PDHA, 002796
3. Mental Status Evaluation
Form MEDCOM 699
3
FOIA Release Page 36
In your life, have you ever had any experience that was so frightening, horrible, or
upsetting that, in the past month, you:
1. Have had nightmares about it or thought about it when you did not want to?
Yes I No
2. Tried hard not to think about it or went out of your way to avoid situations that
reminded you of it?
Yes I No
Prins, A. Ouimette, P., Kimerling. R. Cameron, R. P.. Hugelshofer. D. s.. Shaw-Hegwer, J. Thrailkill, A.
Gusman, F. D.t Sheikh. J. I. (2004). The primary care PTSD screen (PC-PTSD): development and
operating characteristics. Primary Care Psychiatry, 9, 9-14.
002796
1. During this deployment, did you experience any of the following events?
(1) Blast or explosion (lED, RPG, land mine, grenade. etc.)
(2) Vehicular accidenVcrash (any vehicle, including aircraft)
(3) Fragment wound or bullet wound above your shoulders
(4) Fall
(5) Other event (for example, a sports injury to your head).
Yes I No
Yes I No
Yes I No
Yes I No
Yes I No
Describe:
2. Did any of the following happen to you, or were you told happened to you,
IMMEDIATELY after any of the event(s) you just noted in question 1?
(1)
(2)
(3)
(4)
Yes I No
Yes I No
Yes I No
Yes I No
Yes I No
NAME:
SSN:
0 Self-Referral
D Command-Directed Mental Health Evaluation
D Hospital Discharge
D Other:
0
0
D
D
D
D
IMPRESSIONS
IN MY OPINION, THIS SERVICE MEMBER:
Can understand and participate in administrative proceedings
Can appreciate the difference between right and wrong
Meets medical retention requirements (i.e. does not qualify for a Medical Evaluation Board)
Requires further examination or testing to finalize diagnosis and recommendations
0 Other: _
D
0
D
0
PROPOSED TREATMENTS
0None
Follow-up appointments:
Clinic:
Phone No:
Clinic:
Phone No:
Clinic:
Phone No:
Recommend command referral
0
0
Location:
Date:
Location:
Date:
Location:
Date:
to:
Unit Chaplain
Time:
Time:
Time:
ASAP
FAP
JAG
ACS
Other:
Date
ErLc,/
RECOMMENDED PRECAUTIONS
(to be followed until no ronser deemed necessary by a behavioral health provider)
0None
Ensure the service member attends all follow-up appointments
0 Assigned duties should be relatively low-stress and 0 should not involve leadership responsibilities
per day and the service member should have
day(s) off per week.
0 Work hours should not exceed
Inspect the service member's quarters and secure all hazardous items (e.g. pills, knives, razors, weapons, etc.)
Prohibit the use of alcohol, as alcohol is a depressant and may decrease inhibitions.
Restrict access to or disarm all weapons and ammunition (including those that are privately owned)
Move the service member into the barracks
0 Secure all medications and dispense no more than
days' worth at a time
Prohibit contact between the service member and
to prevent harm to self or other individual.
0 Provide increased supervision (i.e. have someone check in with service member at least daily) or....
0 Assign someone to monitor the service member every
hours from first formation until lights out, and
ensure he/she does not sleep in a room alone or...
0 Provide continuous 24/7 monitoring (e.g. to prevent self-injurious behavior, harm to others, substance use, etc.)
0 Other:
D
0
D
0
0
ADDITIONAL COMMENTS
0
0
The service member is psychiatrically cleared for any administrative action deemed appropriate by command.
The service member meets psychiatric criteria for expeditious administrative separation lAW
Chapter 5-13 or
Chapter 5-17 of AR 635-200 (or equivalent regulation from his/her branch of service).
The service member does not have a severe mental disorder and is not considered mentally disordered. However,
he/she has a long-standing disorder of character, behavior and adaptability (i.e. personality disorder) that is
of sufficient severity to interfere with his/her ability to function in the military. Although not currently at significant
risk for suicide or homicide, he/she has the potential to become dangerous to self or others in the future.
The service member has a condition that is likely to impair his/her judgment or reliability as related to access to
classified materials.
It is the professional opinion of the undersigned that this service member will not respond to command efforts at
rehabilitation (such as transfer, disciplinary action or reclassification), or to any behavioral health treatment
methods currently available in the military.
The service member shows no evidence of a disorder that would limit his/her potential to succeed in the military.
He/she is cleared to participate in advanced military training (e.g. recruiting, drill instructor, sniper school, etc).
The service member has been screened for Post Traumatic Stress Disorder and Traumatic Brain rnjury. These
conditions are either not present or, if present, do not meet AR 40..501 criteria for a medical evaluation board.
Command is advised to consider the influence of these conditions, if present, when determining final disposition.
If the service member shows signs of further deterioration, command should call
hours, they should escort the service member to the nearest Emergency Department.
Other:
The service member may participate in PT as allowed by physical profile, as exercise often improves mood.
Date
CLINI
ForP
EDUCATION
ECOMPO NT MODEL
AGEME
of DEP SSION and PTSD
(Military Version)
.
.
....
...
.,.
I. ltltJroclll<;tioll ....................................................................................................................................... ~
II. Co11ceptu.al Framework for RESPECT-MIL.................................................................................... . 4
Departme11t of Defe11se Clinical Practice G11icleli11es ........................................................................ 4
Systematic Approaches to Improving Care ...................................................................................... . 4
RESPECT-MIL.---The Three Compone11ts ...................................................................................... . 4
The RESPECT-MIL Process of Care ................................................................................................ ~
The RESPECT-MIL Process of Chat1ge ........................................................................................... 7
III. RESPECT-MIL Protocol for Depressio11 ............................................................................... 9
STEP 1: ~eco~ition flllcl Dia~osis ................................................................................................ 9
P1tl~-9 ........................................................................................................................................... 9
Assess S11icicle ~isk .................................................................................................................... I2
Collcl11ct a S11icicle Assessment ............................................................................................... I~
Compo11e11ts of an Eval11ation for S11iciclal Risk..................................................................... 1~
S11icicle Screeni11g Tools for Primary Care Clinicia11s ............................................................ 14
STEP 2: Treatment Selectio11......................................................................................................... 1~
<=>l>taill Aclclitio11al ~istory .......................................................................................................... I~
Use PH~-9 ~es11lts to Help Detern1i11e Treatment Selection ..................................................... 1~
Present Treatment <=>ptions ......................................................................................................... 16
Elicit Patie11t Prefere11ce for Treatme11t ...................................................................................... 16
Choosi11g Psychological Co1IDseli11g ...................................................................................... 16
Choosing Meclicatio11 ............................................................................................................. . 17
.
.
.
T
STEP~: I11tttcttt11g reatme11t ........................................................................................................ . 20
Patie11t Engageme11t ................................................................................................................... . 20
Provicle ~ey Ecl11cational Messages ........................................................................................... . 20
Enco\llrage a Self-Manageme11t Pla11 .......................................................................................... . 20
E)(}llaill Clllcl ~ecomme11<l Care Mat1ageme11t ............................................................................. 22
STEP 4: Care Ma11ageme11t Calls for Adhere11ce an<I Treatme11t ~espo11se ................................... 2~
Adherence Call at I ~eek .......................................................................................................... 2~
<=>ptional Telephone Co11tacts l>etween 1 an<l4 ~eeks: A<l<litio11al Adherence Call(s) ............. 2~
Treatme11t ~espo11se Calls Every 4 ~eeks .................................................................................. 2~
Care Ma11ageme11t Stlpei1fision ................................................................................................... 2~
Commllflication with ~m(l[){ Care Cli11ici<lll ........................................................................ 2~
Usi11g the P~~-9 to Assess Patient ~espo11se to Treatme11t. .................................................. 26
A11ti<lepressallt Si<le Effects .................................................................................................... 27
STEP ~: Ac11te Phase Follow-Up .................................................................................................. 29
Cli11iciat1 <=>ffice Visits Coor<linate<l with Care Manageme11t Co11tacts ...................................... 29
Eval11ate Patient ~espo11se to Treattne11t ................................................................................ 29
Mo<lify Treatme11t with S11b-<:>ptimal ~espo11se ..................................................................... 29
StJrive for ~emission ............................................................................................................... 29
STEP 6: Colltin11atio11 a11<l Mai11tenance Phase Treatme11t ............................................................ ~ 1
Co11tin11e Treatment ~espo11se Mo11itoring After ~emissio11 ..................................................... 3I
Contin11e S11ccessful Treatme11t for Ni11e to Twelve Mo11ths .................................................... ~ 1
1\l.leclicCLti()ns ............................................................................................................................. ~1
Psychological Co1IDseli11g ...................................................................................................... ~I
Assess ~isk Fact()rs for Nee<l for Lo11g-Tenn Prophylactic Treatment ..................................... ~~
Co11tin11e Lo11g-Term Prophylactic Treatment an<l Mo11itoring of At-~isk Patie11ts .................. ~~
0 0 0
0 ...........................................................................................
0 0
Assess Risk Factors for Need for Long-Tenn ProJ>hylactic Trea1Jr.rlent ..................................... 49
Continue Long-Tern1 Prophylactic Trea1Jr.rlent and Monitoring of At-Risk Patients .................. 49
References ................................................................................................................................... 50
References ................................................................................................................................... 50
PJr.l~-9 ............................................................................................................................................. 50
PTSD <=Juidelines ................................................................................................................................. 50
PCL oooo 50
RESPECT-DeJ>ression and the Three ComJ>onent Model .............................................................. 50
PTSD Background .................................
51
PTSD Four ~uestion Screen ..........................
51
0 . . . . . . . . . . . . . . . . . . . . . . . . . 0 0 0
0 0 0
This manual is intended to provide helpful and informative materia/for clinicians on the subject ofpost traumatic stress disorder. This manual is not intended to provide
medical advice to patients. The information provided here is general and is not intended as clinical advice for or about specific patients. Before applying any of this information
or drawing any inference from it, clinicians should verify accuracy and applicability ofthe Information. Any management steps token with patients should include a discussion
ofrisks and benefits, as well as patient preferences. DARTMOUJ'H COLLEGE, DUKE UNIVERSITY; DUKE UN/JIERSITY HEALTH SYSTEM, INC; 3CAfrM UC, THE JOHN
D. AND CATHERINE T. MACARTHUR FOUNDATION; ANY PARTICIPANT IN THE INITIATIVE ON DEPRESSION AND PRIMARY CARE; AND CONTRIBUTORS OF
INFORMATION MAKE NO WARRANTY, EITHER EXPRESSED OR IMPUED, REGARDING THE COMPLETENESS, ACCURACY, OR CURRENCY OF THIS
INFORMATION, NOR 11S SU/TABIUTY FOR ANY PARTICULAR PURPOSE.
By accessing the information in this manual, you agree that the above parties shall not be liable for any damages, losses or injury caused by the use ofany information on this
manual or its references/citations.
I. Introduction
Mental health disorders are common among troops that have returned from war zones. This
observation is not new. A report based on health records of Civil War veterans showed life-long health
consequences of combat even among those who escaped traumatic injury. Surveys of U.S. combat
units returning from the war in Iraq (Hoge, et al, 2004 and 2006) found that as many as one in four
soldiers met criteria for a mental health disorder.
Among this group, fewer than one in three had received help from a mental health or primary
care professional. The stigma of having a mental health disorder looms large. While 80% of these
soldiers recognized that they had a problem, fewer than half were interested in receiving help.
The gap between need for treatment and receiving it deserves urgent attention. This manual
provides one step towards closing this gap by providing background needed for primary care clinicians
to provide high quality mental health care that has a solid evidence base for its effectiveness.
Recommendations are consistent with and support application ofVA/DoD Clinical Practice Guidelines
for PTSD and for Depression.
The manual describes the RESPECT-Mil program and how to apply the Three Component
Model, a systematic primary care approach to the management of depression. The Three Component
Model has been extensively and successfully used in civilian populations (Oxman, et al; Dietrich, et al
2004). A recent project with the 82nd Airborne Division at Fort Bragg expanded TCM to address post
traumatic stress disorder (PTSD) in addition to depression. The project demonstrated that this approach
can guide management of depression and PTSD primary care settings that provide care for troops post
deployment.
Here's how the Three Component Model works:
Soldiers attending primary care for sick call and other reasons are routinely screened for
depression (two questions) and PTSD (four questions);
Those with positive screens complete appropriate diagnostic and severity instruments before
seeing the clinician;
If the instruments suggest that mental health issues require exploration and the clinician's
diagnostic interview confirn1s the diagnosis of depression or PTSD, treatment is initiated by the
primary care clinician who will continue to follow the patient closely;
In addition to primary care follow up visits, soldiers in treatment are provided with telephone
support from a specially trained care manager who promotes adherence to the management
plan and monitors response to treatment using validated quantitative instruments. The care
manager is supervised by a mental health professionals (including a psychiatrist via telephone
for shortage facilities) who may provide management suggestions conununicated in reports
from the care manager to the primary care clinician. The mental health professional also assists
in linking a soldier to a mental health professional when indicated or requested;
Thus, a partnership with the patient is shared among the primary care clinician, a care manager,
and mental health specialists.
In the following pages, this manual describes the RESPECT-Mil conceptual framework and its
application first to depression, then to post traun1atic stress disorder. For both conditions use of
validated instruments for screening and for symptom assessment are central as are the services of a
care manager, frequent primary care contact, promotion of self management, and modification of the
management plan if needed to achieve improvement in symptoms.
training to help Soldiers suffering from depression and/or PTSD. The care manager provides frequent
contact with the Soldier to answer any questions; encourages the Soldier to stick with the treatment
plan; and monitors the Soldier's response to treatment. Care managers work closely with the PCC,
communicating in person, by telephone, e-mail, and through the electronic medical record. Care
managers typically make the first contact with the Soldier within a week of beginning primary care
management for depression or PTSD and then follow up monthly and as needed until remission is
reached.
The second new resource, the supervising psychiatrist, participates in the model in several important
ways. First, he or she meets weekly with the care manager (in person or by telephone) to discuss
specific cases and progress. This supervision provides guidance to the care manager and presents a
mechanism for the psychiatrist to monitor progress on a large number of cases that are being followed
in primary care. The psychiatrist is also available to the PCC to provide inforrnal advice about
diagnosis and about management. In some cases, the PCC, working with the care manager, will
facilitate a direct contact between the patient and the psychiatrist. Table 1 provides an overview of how
responsibilities are shared.
~onents
Psychiatrist
Res aons:ibilities
Recognition
Diagnosis
Mana_gement
Support
Monitoring
Communication
Infomtal advice to clinician
Supervision of care manager
Consultations
Diagnostic Evaluation
Engage
Management
7
~
Monitoring
Response
Modify to
Achieve
Remission
Informed by screening and diagnostic instrument results, the PCC will then respond to the Soldier's
chief complaint as well as to any information suggesting a diagnosis of depression or PTSD. That is, if
either diagnosis is suggested, the PCC will make a reference to positive screening and diagnostic
information as appropriate and complete an appropriate diagnostic interview. In all cases, this
diagnostic interview should include a suicide assessment.
If the patient fits the diagnosis of either PTSD or depression, the clinician will engage the Soldier in an
initial course of therapy. This usually begins with determining the appropriate framework for
managing the condition counseling, medication, or a combination of both. At the conclusion of the
appointment, the clinician will offer the Soldier suffering from major depressive disorder or PTSD the
services of a care manager who will be able to assist the Soldier over time. These care management
contacts do not substitute for clinical follow-up visits, but rather provide additional contacts to help
Soldiers stay the course and achieve a high level of satisfaction and response to treatment. In addition,
the care manager performs a valuable and unique role in coordinating communication between the
patient, primary care, and the supervising psychiatrist.
The RESPECT-MIL approach to MDD and PTSD follows a similar structure as illustrated in Table 2.
Screen
Diagnostic
Evaluation
Engagement
Management
PTSD
MDD
2 ~;Juestions
Interview
PHQ-9
Suicide/violence assessment
Discuss diagnosis and
treatment o 'tions
Medications/counseling/both
Self management
Care management
Behavioral health clinician
advice/su J JOrt
4 C:uestions
Interview
PCL
Suicide/violence assessment
Discuss diagnosis and treatment
options
Medications/counseling/both
Self management
Care management
Behavioral health clinician
advice/su J Jort
Mental
Health
Consultant
Care Managers
Communication
Methods
~--------~--------~
Prepare Practices
.....---.. ..a::::-----.
Clinician
CME
Staff
In-service
A care manager for your unit has been trained and stands ready to receive referrals. The referral
process will proceed electronically and you will receive updates after each telephone or face-to-face
contact the care manager has with your patients.
In addition, advice from the psychiatrist resulting from routine care manager supervision meetings will
be passed along to you. If you do not know the psychiatrist for your unit already, an introduction will
be arranged shortly.
In implementing the model, taking the first steps may require overcoming some inertia. As described
in the next sections, you will become familiar with the screening questions and the follow-up severity
and diagnostic tools. You will be trained in how to share the results of these instruments with patients
and engage them in the decision of whether and how to obtain treatment for their condition. We urge
you to not miss the chance to try the model at your first opportunity, working with the leadership of
your unit to have the process go smoothly and using the program to further the health and healthcare
for the Soldiers who serve .
..
Recognizing that a patient is depressed can be challenging, as often patients are concerned about social
stigma or career issues when told their symptoms suggest a depression diagnosis. To aid with
identification of depression clinicians look for "red flags" (e.g. multiple unexplained somatic
symptoms, recent major stress or loss, chronic pain, chief complain of insomnia, fatigue or appetite
change) and selectively use a two question-screen. In addition, RESPECT-MIL routines establish a
mechanism for more systematic screening for all patients post-deployment presenting with a new chief
complaint. Whichever mechanism is used, recognition begins with a two-question screen completed by
the Soldier. If you suspect a Soldier is depressed, despite responding "no" to the two items on the
screen, trust your intuition and offer the Soldier the PHQ-9 or use your usual clinical interview.
NO
NO
If you circled YES to EITHER of the questions in this box, please continue and complete the attached
form. (A copy of the PHQ-9 is attached)
PHQ-9
The PHQ-9 is administered to all Soldiers who answer ''yes" to either of the two screening questions.
The PHQ-9 is a patient self-administered questionnaire that helps make a depression diagnosis and
determine severity of depression. The clinician and or medic/office staff discusses the reasons for
completing the questionnaire and explains how to fill it out.
After the patient has completed the PHQ-9 questionnaire, it is scored by the clinician or office staff.
There are two components to be tallied:
Assessing the number of symptoms and functional impairment to make a tentative depression
diagnosis.
Deriving a severity score to help select and monitor treatment.
The PHQ-9 is based directly on the diagnostic criteria for major depressive disorder in the American
Psychiatric Association Diagnostic and Statistical Manual Fourth Edition (DSM-N).
The next few pages will explain how to score and use the PHQ-9.
Feeling down,
or hopeless
have let
as
around a
3
3
0
or
n some
add columnet
TOTAL:[~--~-~-~~-~~-~------~~
Not difficult at all
If you checked off any problem.s. how difficult have these
10 problems made It tor you to do your w011<, take care or
things at home, or get along with other people?
Somewhat difficult
Very difficult
Extremely difficult
"'
First, tl1e number-of symptoms and functional impairment endorsed on the PHQ-9 are examined to
make a tentative diagnosis of major depressive disorder by looking for three criteria.
..
UESTIONNAIRE (PHQ-9)
. ..
..
. .
..
. ....
. ...
. . . ...
.
..
(use ".j'" to
.
..
..
. .
...
. ...
. .
:.
Feeling
have let
Trouble
.L----J.!-~~~
...
. .
...
..
. ..
....
..
..
..
. .
.. ... ..
. . . . .
torm
...
Moving
noticed.
have
.
.
r-----r----
If you
1o problems . ..
things at
...
..
TOTAL:
....
.. ,...._ _
~~,~or~~~~~~ ~~~~~~.
----~-----
add columns:
. .
S,TEP3:
. .
Functionallmpainnent
is
endorsed
as
at.
.
. .
.
. .
. .
.
.
~somewhat difficult" or greater.
.
~.- - 1:~---------4[
----------------~
Not difficult at all
Very difficult
Extremely difficult
In this example, the criteria for major depressive disorder are met. The second question ("Feeling
down, depressed, or hopeless") is endorsed more than half the days, a total of six of the nine symptoms
are within the shaded area, and there is functional impairment from the symptoms. Note that for
symptoms 1 through 8, endorsement more than half the days is required. Symptom 9, suicidal thoughts
is significant even if endorsed only several days. A positive answer to question 9 needs follow-up and
will be discussed after computing the PHQ-9 severity score.
Second, a total depression severity score is obtained from the PHQ-9 by sununing the values of the
endorsed (circled or checked) symptoms. This is most easily done by first adding the values in each of
the three columns and then summing the three values. A PHQ-9 severity score can range from 0 to 27.
Over the
how often have you been
by any of the following problems?
(use "tl''~~ to indicate your
..
. .
0
0
television
..
. . ..
.
. .
. ..
. .
... .. .
. .
. . .
.
.. .
3
3
. .. .
add coturr.ns:
..
or
..
~
IJ!ti,..,
,.;~,j,i,.if4n~j
~~m
~~~
m.~ch
>of
~ ~~ ~~
~~
~-
-----
16
. . . ..
....
.
The severity score is extremely useful for helping to detertnine if and how to treat depression and then
to monitor the progress of treatment. First, however, the positively endorsed suicide symptom must be
further assessed.
Hopelessness
Prior suicide attempts
Living alone
Psychotic symptoms
Substance abuse
Male gender (completed suicides)
Caucasian race
General medical illnesses
Twenty-five percent of suicide attempts are not premeditated. Suicidality may be an emergent (crisis)
or an urgent symptom, but it is always serious.
Emergent
If the patient has an active desire to cormnit suicide and has no self control or external supports
(e.g. family and friends) for safety, then a safe means for transport to the nearest mental health
clinic or emergency room setting should be found.
Urgent
If a patient has suicidal thoughts without an active plan to commit suicide, it is an urgent situation
and could become an emergent one. He/she should get a mental health assessment within 48 hours.
Patients should know who to get a hold of in a crisis and where to go for emergency help.
Treatment of major depression should begin as soon as it is identified, even if a mental health
referral has been made, as urgent symptoms may degrade to crisis proportions without it. Prescribe
medications that are not deadly in overdose (avoid tricyclics and MAOis). If anxiety is treated with
a benzodiazepine while a patient is suicidal, have a fellow Soldier or family member dispense it, or
prescribe it in weekly amounts until the acute risk subsides.
The following tools can be used to help in the evaluation of suicide risk.
If question 1 is negative and suspicion is low, the subsequent questions can be skipped
1. llave the$e aymptoms/feelings we'Ve been talld1w about led you to dUnk. you might be better oft deacl?
[] Yes
C No
2 This ppslWt;cL have you had any thoughts that life. is not worth liVing- Or that you~d be better off dead?
C Yes
D No
4~
'IJ. No
LEVEL OF RISK
ACTION
Low Risk
Intermediate Risk
High Risk
Emergency MH Referral
5-9
Minimal symptoms *
Minor depression++
Support, watchful waiting
10-14
Dysthymia*
Antidepressant or psychotherapy
Major depression, mild
15-19
Antidepressant or psychotherapy
>20
-
* Ifsymptoms present ~ two years, then probable chronic depression which wa"ants antidepressants or psychotherapy (ask,
uln the
past 2 years have you felt depressed or sad most days, even ifyou felt okay sometimes?')
+ + If symptoms present ~ one month or severe functional impairment, consider active treatment.
For patients who are taking antidepressants, other types of psychological counseling may also be
helpful and should be recommended for patients who:
Choosing Medication
Antidepressants are effective for depression treatment. Many antidepressants are available and there is
no evidence that any one is better than another. The major differences are the side effects and
cost/availability. The following table lists the dosing, advantages and disadvantages of the various
antidepressants available.
17
FOIA Release Page 58
.An~
Dose Ranee
depressant
. .
.:
. .
... .
...... . .
:
:.
.. .
.:
. .
. :
Escitalopram
(Lexapto)
1\Uintain
. .
. . . ... :
change
so
~{aiataiu 10 mg for
mc~ase.
before do~.
IOCftue In 10 q
at itnavals of
approximately 1 days up to a maximum of 50
mgiday_
. . ..
.
'
. .
. . . . ..
cytoc:brome P450
interactions.
ofPTSD
FDAa~-.
...__
_,_,
. .
.
..
.
..
.
..~
:
.
OccasiOMily tDOte
. . .
hducesall~~pOGpSofPTSD
. . . . . . .
.
.
...... . .
. . . . . . . .
.
..
..
2S- 200
(2Smgfor
..... . . .
. . : .:. . . .
R.ec1uces a three
ofPTSD
----------~------------------------~
Helpful for au:Uety
Slower to rracb $teady
Loag balf-life good for poor Mba~,
sta~, Sonxtimes too
missed doses.
$bmnlatiog. Possibly m.ore
..
.. .
. .. .
... .. .. .
(SO
in~dedy)
(Zoloft)
..: ..::...:.: ..
Redueft aU thrH
10- (40 iD
elderly)
62~5
. ..
weeb
2.S -
. ..
lOmg
inct-anents 4!\"en.
"' 7 da'\'S as tolerated.
~
20 mg iA mosning l'rlth
food (10 mg In elckdy ud
those '"itb c.UU1bid panic
disorder)
Probably
amaety disorders.
Possibly fe\\-er cytoc:luatDe P4 SO
mteractions. Generic soon.
~- Ifnotesponse~ iocreaseia
10 mg for escitalopmn
10-20
10-80
(Puil)
Disa~~ntages
.
Citalopram
(Celexa)
Paro~
Titration ScheclaJe
. ..
muease.
'
. ..
.
. .. . .
..
... .
.
....
. .
.:
...
.
. .
. . . ..
. ..: . .
...
.:
Few drug.
d}-~tioo
tS mg at hedOme (7.S mg
for 1hose in need of
sedation I hypaotic)
15 -4S
Increase in 1.5 mg
(7.5 mg i.a. elderly)
as tolftated. ),f.ainiain 30 mg: for 4 -a'ft'b. befme
further dose incftase
I eM !edatiaa a1 dote
~lay stimulate
mcna\ed.
PfSD
...
.. ..
.
.
. .. .
Bupropiont
(Wellbutrin
~
Wellbubitl
XL)
300-400
1SO mg in moming
.
.... .
... ..
. ..
.
. ..
. .. . .
...
. .
.
At
cbe, may indur,e:
sftz.ures io pt'BOllt wi1h
seizure disorder.
Srinm1ating.
Uwally b.i.4. dosUJ&
ualess me
XL.
PISD
. .
.. ..
VenJaf.,Me
(Effexor~
75-375
Effe1mc XR)
~nut
effect
OCC'U11i abo\~ 1
75 mg \\'irh food; if
anxious debilitated
37.5mg
.: . .
.
luau~ by 25 to
50 mg in the IDOioing
25-150
.
.
(Desyrl)
.. .
..
.
2 -10
..
.... ..
. :
.
. .
.. .. .
..
:
..
.. . .
. .
:. .
. .
..
. :'l,e::
as
:- :-:. w
:-: ...
. . .
... ...
... . .
.....
..
. . .
..
.. . . .
....
... . . . .. .
. dum
OJl
problems or CHF.
ofPTSD
Availabilitv of
'\..tid blood
J.\!'@ls. I..o\\w Odhostatic bypoteasion
than otiB 1ricvd1~s.
Gft,.uie M~ilable.
,.,
aaticbo1iuftgic. Caution
witbBPH.
ofPTSD
..
. . .. . . .. . .. ...
.
. . ..
25-600
. .....
.. ... .. .
....
. . . . .. .
. . . . .. . . . .. . .. . . .. .
... . . .
. ...
. .. .
.. .
..
. .. .
..
. ....
25 - SO mg at bedtinx
.
. .
. .
...
..
...
. ...
. .
..
. ..
. ..
. .
~ avoida""elaumbin! S)~tosn
lmgat
.A:~
Expemil~.
e\"e!V S davs
,.,
"
-:...
A.llrM. .p:
at\a:aoon
.. .. . .
..
. ...
. . ..
...
Truodcoe
m;ailable.
25 mg (lOmg in bit
in the e\~ntog
. . ...
Plazosin
{MUiipress)
50 mg ~-elY 3 to 7 clays to
Jnae.ase in 10-25 mg :
. .
Nortriptyline
(Al>'ellt)~
fdbitor
. . .
... .
More
..
100-JOO
(15-100 inel<llv)
'--: Ut"'IDA
...
.
.
rmpta.~W . n. .,,, ... ..... . . .
. SQ .. . .
. . .. .
. ... . .
..
. ...
..
..
. .. . . .:
. .
. ..
. . ....
.. . ...: .
. . . . .. . .
may cause
odhostatie hypotenci011
..
.
..
....
. ...
. . ... . ...
.
..
. .
... . .
.
...
.
. .
.
.. . .
l.tay
daytiDJesedaiion.,
patticulady at higher dost!l.
caute esceu
Rare
*There are more antidepressants than those listed in this table; however, this list provides a reasonable variety of drugs that have different side effects and act by
different neurotransmitter mechanisms. Treatment of Parkinson's disease may include selegiline (Eldepryl), which is a selective monoamine oxidase inhibitor
at low doses only. Because the use of many antidepressants is contraindicated in conjunction with a nonselective MAOI, caution with or discontinuation of
Eldepryl may be in order. For pregnancy, TCAs and SSRis (particularly fluoxetine, because of more data collected) ar~ not associated with congenital
malfonnations or developmental delay. SSRis in the third-trimester are associated with a slight decrease in gestational age and correspondingly lower weight,
and occasionally with neonatal withdrawal symptoms. Diarrhea, drowsiness, and irritability are occasionally seen in breast fed infants of mothers taking
antidepressants. The risks of maternal depression on child development should be balanced against the effects of antidepressants on an individual basis.
*For SSRis, generally start at beginning of therapeutic range. If side effects are bothersome, reduce doses and increase slower. In debilitated or those
sensitive to medications, start lower. For all
antidepressants, allow four weeks at a therapeutic dose, assess for a response. If a partial or slight
response then increase the dose. If no response or worse symptoms then consider switching drugs.
tGenerally avoid bupropion in patients with a history of seizures, significant central nervous system lesions, or recent head trauma.
tTricyclic antidepressants (TCAs) have lower costs but somewhat higher discontinuation rates compared to SSRis due to side effects and are more lethal in
overdose. TCAs may be contraindicated in patients with certain physical comorbidities such as recent myocardial infarction, cardiac conduction defects, urinary
retention, narrow angle glaucoma, orthostatic hypotension, and cognitive impainnent.
19
FOIA Release Page 60
Patient Engagement
Educating patients about depression and treatment options often has already started patients
becoming partners in their care process . The next step is provision of more specific engagement
around agreed treatment
Counseling takes a little longer before you will feel any improvements.
Keep your appointments with the therapist
Be honest and open, and ask questions.
Work cooperatively with the therapist (e.g. complete tasks assigned to you as part of the
therapy).
If you have problems or are not satisfied with your therapist, call us and we'll help you.
If you are feeling worse, don't wait until your next appointment
Call my office right away!
minutes .(make
4. Practice relaxing.
For many people, the changes that
come with depression can lead to
anxiety. Since physical relaxation can
lead to mental relaatiof\ practidng
relaxing is another way to help
yoorsel Try deep breathing, or take
a warm bath, or just f.nd a quiet,
cotnfottable, peaceful place and say
comforting things to yoorself(like c'lt's okay.").
Everyday next week, I will practice. physical relaxation at least
_ _ times, for at least
.minutes each time (make .it easy,
reasonable).
___________________________________
Step 1: --------------------------------Step2:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Step 3:
Explain role of the care manager as a systematic extension of the clinician's ability to
monitor treatment response and side effects as well as to assist the patient in maintaining or
adjusting self-management goals.
The care manager calls in one week to be sure treatment has started or to help solve problems
if it has not.
The care manager generally calls at subsequent 4-week intervals to re-administer the PHQ-9
to assess effects of treatment.
Verifying the best available phone number for the patient will facilitate an easy initial contact
by the care manager.
Letting the patient know typical care manager contact intervals and follow-up office visit
appointments will help in treatment.
Then complete and transmit a Referral to the care manager via CHCS II I AHLTA including relevant
details as demonstrated in Figure 7.
FMP/SSN:xxxxxxxx
Sex/DOB/Age: 22 y
--------------------------~-----------,_
____ _._~----
Pt. elected to start a tluoxetine 20 1ng and will be returning to clinic in 1 month.
Pt. selects swimming as a self management goal and will start at lx per week
Pt. agrees to care managenent/requests call.
Honte pho.ne # preferred and verified,
If medication is being titrated upward, asks if dose has been increased, and if any side
effects.
If mental health referral, has first visit been completed.
Inquires about and encourages self-management activity.
Helps Soldier problem solve regarding these areas noted above.
Care manager contacts are intended to occur at least every 4 week interval to re-administer
the PHQ-9 in order to assess response to treatment and to assess for remission.
PHQ-9 score is reported to patient, clinician, and supervising psychiatrist.
Assessments are reviewed by psychiatrist and information/concerns conveyed to the clinician
by the care manager.
Care manager has weekly supervision with psychiatrist to review adherence problems, side effects,
and sub-optimal responses.
Communication with Primary Care Clinician
Care manager and clinician communicate via e-mail and/or CHCS II I AHLTA after care
manager contacts and office visits.
Supervising psychiatrist and clinician communicate by phone, email, and/or in person on
selected cases.
Below is an example of a follow-up PHQ-9 obtained by a care manager after four weeks of
antidepressant treatment at an initial adequate dose. At this point, the severity score and functional
impairment are the primary pieces of information needed to assess treatment response. Normally the
care manager will have scored the PHQ-9 and provided you with the score and the difference in
severity score from baseline. To be sure you understand how to score the PHQ-9, score the following
PHQ-9 for severity.
OVer the
how often
by
of the following
(use ".'" to indicate your
10
l~o--:_:::---~--~_ ______.!
Not difficult at an
somewhat difficult
Very difticun
Extremely dimcult
-XIX-
-Telephone Consult
--------------------Provider's Note:
S: This 22 year old Soldier seen and referred on 29 March 2005 with a PHQ-9 score of 16 and
started on fluoxetine 20 mg same date. Pt. set a goal of swinuning lx per week and has
completed his goal each week. He has increased goal for next month to 2x per week.
P"HQ-9 re-adrninistered over phone this date (week 4 of Tx). Score is no\v 14 (0 on suicide
question). Minirnal decrease in score or syrnptorns. Pt reports nausea but willing to
continue .Rx. Advised to take Rx \Vith food.
Dr. Gould suggests increasing dose to 40 mg at this time and monitorittg nausea.
Cl\1 \Viii call agai.n in one week to ntonitor.
Provider: RESPECT CARE MANAGER
..
. . .. . . . .
. .. .. .
Treatment Plan
------~------------~~--~--------~
Adecuate
Increase
Inadequate
..
..
..
.. ..
Adecuate
Probably Inadequate
Inadequate
. . .. ..
..
..
. . ....
. .
....
..
. . . .. .
. ..
. ...
.
..
.
. . ..
.. ..
. ...
... .
. ..
Treatment Plan
No treatment change needed. Follow-up in
four weeks.
Possibly no treatment change needed.
Share PHQ-9 with psychological
counselor.
If depression- specific psychological
counseling (CBT, PST, IPT*) discuss with
therapist, consider adding antidepressant.
For patients satisfied in other type of
psychological counseling, consider starting
antidepressant.
For patients dissatisfied in other
psychological counseling, review treatment
options and lreferences.
.
.
. .. . .:~;.
: .
. . .
. . . ...
.
.
.
.
.
.
. .
. ..
:.
,...:: .:. :.
...: ::_:_;:.:::~......
.. :
.:
.
. ..
: . ::
... :
:.
.. ..
.. . .....
: . ... .:
... :..:;;. . . .
. . .
~.:~: .:
. .
. .
. .
..
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.
.
: .
..
:.
. .
Sedation
+i-
~vemedieation
at. bedtime.
. .
.
Anticholinergic
+f..
I~ase bydnllioo.
like symptoms
"untJcandy
otetary t'i~.
Dry lltQUl,laleytffl,
Cotmtpntion,
Llrinfll}' retention~
frachvL"ardili
....
OJ distress~
++
Restles..4U'less,
++
.>
Jittersrrremors
Headache
. :,
..
.:.
...
.. .
::: .
..
. ..
. : .
.. .
. . ";
Jnsouuua
'
.
-~~.
*Ofte.Dimprovd5 in 1-2wee.ks~
Tuke'with me-c~ls.
*Consider antacids or H2
blockers.
*Lower dose.
*Acetaminophen.
"
..
SexuaJ
++
Dvsft111cti
on
v
..
...
meclicAI di~nnters
Decrease dose.
*Try adding bupropion 100 mg
qbs or bid.
Try adrung buspronc 10~20 mg
bidldd
Seizures
\Vei ght. gain
+fN
Agranulocytosis
,..
,.,_
..
+I~
+f.
++
s
KEY:
- Very Mlike1y
+I Uncommon
+ Mild
checkWBC
++ Moderate
Review symptoms, PHQ-9 score, and functional assessment provided by care manager from
earlier phone call.
l"e.Jephone Consultation
--------------------~--
.Provider's .Note:
S: 22 year old Soldier with depression. Initial treatment with tluoxetine 20mg resulting in minimal
improvement per .P.H.Q9 readntinistered by Care 1\'lanager. Spoke today with patient.
ll\'lP/.PLAN: Inadequate treatment response. \Viii increase tluoxetine to 40 mg.
.Request Ca.re 1\rlanager ca.ll in 1 \Veek, verify pt increased .Rx..RTC 4 weeks.
Provider: GRIFFIN, CHRIS
A~ute
Phase
-~~---..---------~Treatmenr
i'IIHilb~
incr-~
A.
2.
....
---~~-~----~------------
..
#l
H:ee.k.s:... 0
-~~--.-.--
CoutiJtuation Phte
Treatmenr
iiJ
4
J
12
16
-'
24
6
32
8
36
9
l,IME.
'
AcutePbase
Continuation Phase
Remission
Only20%
Have~ 3 Visits*
c
-
...
~
~
r.l)
e
.sc..
e
.S)mpiOIIIS
Sy11drome
Response
> 40%
...
..
'
''
Relllpse
Maiu~aance Phase
RecoJ.ery
'
''
''
\
'
''
Relapse
''
+
Stop Rx*
60% to70%
Stop Rx*
r.rJ
*JIEDLS 2002
Time
Adapted jro1n Kupfer, DJ. Long-tenn treatment of depression. J Clit1 Psyclaiarry, 1991: 52 (suppl. 5) :28-34
All patients who no longer meet criteria for depression will receive education from the care manager
to recognize relapse early and request an appointment with their primary care or mental health
clinician. This education should be reinforced by the primary care clinician. Patients who still have
some symptoms should continue on pharmacotherapy because continued symptom relief is likely to
occur.
The care manager plays a pivotal role by monitoring remission and assessing PHQ-9 response (and
for PTSD, PCL response) periodically after remission to assess for continued symptom improvement
or relapse . The care manager also assesses risk factors for recurrence.
At the end of the continuation phase, patients who sustain their remission are considered to have
achieved recovery.
Psychological Counseling
A decision to use continuation counseling depends on the symptoms, psychosocial problems, and
recommendation of the counselor.
Post-Traumatic Stress Disorder (PTSD) is a psychiatric disorder that can occur following the
experience or witnessing of life-threatening events such as military combat, natural disasters,
terrorist incidents, serious accidents, or violent personal assaults like rape. Events such as rape,
torture, genocide, and severe war zone stress (including the killing of civilians or enemy combatants)
are experienced as traumatic events by nearly everyone. Most people who are exposed to a
traumatic, stressful event transiently experience some of the symptoms of PTSD in the days and
weeks following exposure. Available data suggest that about 8% oftrauttlatized men and 20% of
traumatized women go on to develop the disorder, PTSD, and roughly 30% of those who develop
PTSD develop a chronic fottn that persists throughout their lifetimes. People who suffer from PTSD
often relive the experience through nightmares and flashbacks, have difficulty sleeping, and feel
detached or estranged, and these symptoms can be severe enough and last long enough to
significantly impair the person's daily life.
The process of care for PTSD is nearly identical to that for depression. Just as with depression there
is a brief screening form and a longer diagnostic and severity assessment form. Initial treatment and
patient engagement are similar as are care management and psychiatric supervision. The following
description highlights content that is different, but for similar process steps, the reader is referred
back to the appropriate steps of Section III.
Four Components for PTSD Diagnosis
1. Traumatic experience.
Soldier experienced or witnessed an event that involved actual or threatened death or serious
InJury.
0
o Flashbacks
o Reminders cause psychological distress
o Reminders cause physiological reaction
Avoidance of stimuli associated with the trauma and numbin& of general responsiveness (at
least three):
o
o
o
o
o
o
o
o
o
Insomnia
l11ritallilit){
Difficult){ concentrating
Hyper-vigilance
Exaggerated startle response
As with depression, recognizing that a patient is suffering from PTSD is challenging. Patients may
also lle suffering from depression, may lle irritallle and angry, and concerned allout stigma llecause
of their reaction to trauma and the possillilizy of a psychiatric diagnosis. To aid with identification of
PTSD, a four-question screen is administered lly the clinic along with the two-question screen for
depression.
YES
NO
2. Tried hard not to think allout it or went out of your way to avoid situations that reminded you
of it?
YES
NO
YES
NO
YES
NO
If you circled YES to two or more of the four questions, please continue and complete the
attached form. (A copy of the PCL is attached)
Below is a list of
and can.ints that persons
have in
to
stressful life experiences .. Please
d each one carefully, put an -x in the box to indicate how nuch you
.....
Not at
No"'
stn!ssful
e were happening
........,......__
in
were
?
Feeling very upset when
hing
re.rrinded you of a st11!ssful experience
____
fmmthe
5 Having
reactioons e.g.. r
.,.
N
8 Tmuble
~rtant parts of
a stressful
ft-om the
?
9 Loss of interest in things that. you used
to
10 Feeling distant or cut
11
12
X
X
or
emot
to have loving
to
as
cut short?
sonehow
vour
X
alert" or watchful on
17
IF
you checked off any of the above
how
18
do
'VIork.. take care of
at
or
~n-~--~~"Not difficult
difficult
diff"~eult
19 During the last 2 weeks have you had thoughts that you would be better off dead, or of hutting
yourself iin son1e way'?
Yes
X
No
....,_..... f - ..w>''"'l
.Sevetal days
: .. . .
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....
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Quite a
at
4
. .
.
.
.
. .
a
hom the
4
1---
were
very upset when
remnded you of a stressful e:qJerience
. ..
from the
reactioons e .. g:,,
pounding, trouble breathing, or
sweating) when sorething rerrinded you
of a st:res.sful
e from the
?
.... .
Having
____________
thinking about or talking about a
~~~~----------._
.. .
~--~------~--------~----~
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in'pott:ant parts
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10
.
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11
X
12
CIS
....
. .
.. .. . .
.. .
ut short?
. .
. ..
..
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.
..
.
. .
.
. .
... . .
.
. .
. .
. .
.
. ..... . .
.
. .
.: .. ::::..
angry
...
...: . .. .
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.
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..
.
: . . .. .
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.......' . . .:: . . . .
.
. ::.
...... .
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. . . . ..
. ..
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.
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.
. ....
. .
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.
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:: .
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14
. . . .
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.
. .:
on
17
startled?
any of t:he above problena,. how
\-.,ay?
n= Yes,
have these
.. or of hurting
J_____..Ainnst everyday
Below is a list of
that persons
have in response to
Please read each one carefualy, put an 'X" in the box to indic,ate how utch you
Not at all A little
1
Repeated, distu1bing re1 t raries.,
thoughts, or inages of a stressful
from t.he
?
2 Re~ated, disturbing drearrE. of a
stressful
e from the
?
~~~~~~~~~~~--~~~~--3 Sudden~ acting or feefing as if a
stressful
\"lere ha
Quite a
4
. . ..
as if
fromthe
.
. .
.
.
.
.
.. .
were
.
. .
Feeling very
when son~ething
rerrinded you of a sb-essful experience
..
.
.
..
..
.
"
.. .
"
x.
.
5 Haviing
e.g.,
pounding, t:r.ouble breathing, or
S'weating) when
reminded you
of a sb-essful
e from the
?
..
X
.
. .
..
."
ause
X
",
. . x..
"
...
x..
. . > .
.. . . .
.,.
t0
10 F'eeling dist;ant or cut off from other
11
or being
for those close
enbt
to ha:ve loving
to
. .
..
. . .:
. ..
.
..
. .
vou
12
as
..
your
..
cut short?
13
....
14
. . ..
. x .
..
. .
.
.
. . .. .
. . ..
........
....
hfut on
SEVERITY SCORE = 52
s.coreJ . .
t------
... .
. .
.
. ..
. . . .
...
.
a......
checked
in
each
column by the
.
.
.
.number at the> top at the coluittf't.
. .
... .
..
. ..
(5 J[ ~ ) + (.J<X 2. )
..
..
+ {Q ~ :IHl + (
4 J.; 4 )
..
+ ( ~ ~ 5)
l==:.::::=:..::==::::::::=::::======::::::========:::::..J
..
you had thoughts that you would be better off dead, o.- of hurting
Yes
way
l_
_.Several days
X
. .
No
3_--:AJrrost evel'yday
Many if not most patients with PTSD will achieve some symptom relief with an SSRI. The clinician
should present the benefits and side effects of this class of medications. Remission from PTSD often
requires psychological counseling and patients should be informed of this and offered the option of
an early referral. Selection of treatments should be patient-centered, encouraging and supporting
patient preference.
Elicit Patient Preference for Treatment
Some patients want the clinician to make the decision, but the clinician should ask the patient for
their treatment preference explaining the broad choice of medications (usually SSRis) or
psychological counseling.
Choosing Psychological Counseling
Cognitive-behavioral strategies have been the most frequently studied and most effective form of
psychotherapy treatment for PTSD. The essential feature in all cognitive therapies is an
understanding of PTSD in ternts of the workings of the mind. Implicit in this approach is the idea
that PTSD is, in part, caused by the way we think. Cognitive Behavioral Therapy (CBT) helps
people understand the connection between their thoughts and feelings. CBT can help change the way
we think ("cognitive restructuring") by exploring alternative explanations, and assessing the
accuracy of our thoughts. Even if we are not able to change the situation, we can change the way we
think about a situation.
CBT is based on the understanding that many of our emotional and behavioral reactions to situations
are learned. The goal of therapy is to unlearn the unhelpful reactions to certain events and situations
and learn new ways of responding. CBT relies on evaluating thoughts to see whether they are based
on fact or on assumptions. Often we get upset because we think something is occurring when it is
not. CBT encourages us to look at our thoughts as hypotheses to be questioned and tested. CBT for
trauma includes strategies for processing thoughts about the event and challenging negative or
unhelpful thinking patterns.
Exposure therapy is one form ofCBT. Exposure therapy uses careful, repeated, detailed imagining
of the trauma (exposure) in a safe, controlled context to help the survivor face and gain control of the
fear and distress that were overwhelming during the trauma. In some cases, trauma memories or
reminders can be confronted all at once ("flooding"). For other individuals or traumas, it is
preferable to work up to the most severe trauma gradually by using relaxation techniques and by
starting with less upsetting life stresses or by taking the trauma one piece at a time
("desensitization"). Clinicians with the necessary training and skill to implement CBT are available
at many if not most Army mental health clinics.
Choosing Medication
Antidepressants are the most frequently studied and prescribed agents for the treatment ofPTSD.
Double-blind trials of sertraline (Zoloft), paroxetine (Paxil), fluoxetine (e.g. Prozac), fluvoxamine
(Luvox), and citalopram (Celexa, Lexapro) have established SSRis as the pharmacologic treatment
of choice for PTSD. Sertraline and paroxetine are FDA approved for the treatment ofPTSD.
Fluoxetine and paroxetine have been shown to reduce symptoms in all three clusters (reexperiencing, avoidance, hyperarousal). Citalopram and fluvoxamine have been less studied but
show promise. Among the older tricyclic antidepressants, amitriptyline and imipramine have been
effective in randomized controlled trials, although not for avoidance symptoms. Monoamine oxidase
inhibitors (MAOis) may be more effective than tricyclics; however, they must be used cautiously
because of drug and food interactions that may cause a hypertensive crisis.
It should be noted that Vietnam veterans have not been shown to benefit from SSRis.
In general the initial pharmacologic treatment of choice is to start with sertraline or paroxetine.
If a patient on an SSRI is having sleep difficulties it is reasonable to use low dose (25 to I OOmg)
trazodone (e.g. Desyrel) at bedtime.
Refer to Table 6 on pages 16 and 17 which lists the dosing, advantage, and disadvantages ofthe
various antidepressants available.
Treatment Selection for Patients with Comorbid Depression
When a Soldier is suffering from both PTSD and depression, if medication management is the
patient's preference, then management of depression can guide the initial selection and modification
of medications. If psychological counseling is the patient's preference, then cognitive behavior
therapy that is specific to trauma should be offered to the patient as the initial treatment.
Establishing Rapport
Persons with PTSD usually do not want to talk about their traumatic experiences. It is very upsetting
for them to do so. Detailed information about the traumatic experience(s) may cause additional
distress and is not recommended. Focus instead on current symptoms and circumstances. Survivors
of sexual trauma, in particular, often struggle with feelings of self-blame and may be reluctant to
reveal the details of a sexual assault.
Many people with PTSD find that their relationships with others have changed as a result of
exposure to trauma. They often report that they have difficulty trusting others and are suspicious of
authority.
It is better to let the patient know that you recognize how difficult it may be for them to answer
questions such as those on the PCL and that if they begin to get upset they should let you know. If
this happens, do not resume trauma-related questions until the patient is comfortable enough to do
so, even if it means delaying such questioning until another appointment.
Assist Patient in Establishing a Self-Management Plan [if we are talking about the care
manager here, then 'assist' is the right wording. if we are talking about the primary care doc,
then 'encourage' is the right wording (hard enough to get them to engage at all)].
See page 18 in the Depression section.
.:
h.
Not at
1
X
a
Suddenly acting or
as if a
stn!ssful expet'ience Wen! happening
as if
wet-e
it ?
~~----~------~------~--------~---------
from the
5 Having
e.g ...
pounding, trouble bJathing, or
sweating) when sonething rerrinded you
of a stressful
from the
?
6 Avoid thinking about o talking about a
stressful expetience fnlm the past or
avoid
fee
related to it?
7
~--~--~~--~------~~------+---------
IllQ:
;t
if11lortant patts
.,.
e from the
9 loss of interest in things that you used
a stressful
.f..;
10
or cut
as your
12.
cut short?
13
14
X
X
angy
outbursts?
16
17
IF
vou
chec.ked
off
any
of
the
above
problens,
how difficult have these pr-.Jbleit& made it for you to
18
.,
~
Not difficult
Souewhat difficult
Very ctafficult
Extnmely. difficult
19 D.lring the fast 2 weeks have you had thoughts that you would be better off dead, o,,~ of hutting
yoUfS.ef in sot rR way?
Yes
)(
No
:
'i-i"
Several days
Res~onse
Treatment 0 Jtions
Adequate
Probably
Inadequate
Inadequate
.. . .
Initial Response to Psychological Counseling After Four Sessio.ns over Six Weeks *
Treatment
PCL
Treatment 0
Res~onse
~tions
Adequate
Probably
Inadequate
Inadequate
Drop of l -2 points or no
change or increase
'
Patients who achieve this goal enter into the continuation phase of treatment. Patients who do not
achieve this goal remain in acute phase treatment and require some alteration in treatment (dose
increase, referral to psychological counseling or addition of medication depending on initial
treatment augmentation, or combination treatment).
As with depression, beneficial effects may be seen in four to six weeks. Perhaps unlike depression,
patients with PTSD taking an SSRI like sertraline or paroxetine, who have had an initial response,
experience improvement that may not be measurable until after twelve weeks (as opposed to an
additional four weeks as is often the case in depression). As many as 60% of patients who are not in
remission after the initiall2 weeks may still become remitters during the next 12-24 weeks. Some
patients will feel uncomfortable waiting and the practical question is, how long can you encourage
the patient to stay the course? The supervising I consulting psychiatrist can be helpful in this
situation.
Patients who do not achieve remission after two adequate trials of pharmacotherapy and/or
psychological counseling by 24 weeks should have a psychiatric consultation for diagnostic and
management suggestions (evaluation for childhood trauma, personality disorder, and/or substance
use disorder).
<
r- <i
<-
<
..
- ..._........_ _. >
.. ...
. ._ . .
. .
- .
- --
-------.-.-----------.--------------------------------------Telephone Consultation
--------- .... -----------.-Provider's Note:
S: This 25 year old Soldier referred for PTSD on 16 June 2005 with a
PCL score of 52 was started on fluoxetine 20mg increasing to 40
mg.
PCL readministered over phone this date. At 4 weeks score
markedly reduced to 38. At 8 weeks only down to 34. No suicide
risk (=0). More reactive, but still with disturbing nightmares
and says can't discuss trauma. Trouble with follow through on
self-mgmt goal of swimming 2x week due to fatigue. Will reduce to
1x per week for a shorter interval of time - target now 15
minutes.
Dr. Gould recommends you increase fluoxetine to 60mg
CM will call again in 1 week to f/u your recommendation and pt.
choice. Dr. Gould will contact you if no improvement on next PCL
in 4 weeks.
Provider: RESPECT CARE MANAGER
16 August 2005
Review symptoms, PCL score, and functional assessment provided by care manager from
most recent call.
Decisions to continue or modify treatment are made on the basis of PCL and function
assessments.
Input from the supervising psychiatrist can be requested at any time or may be offered when
indicated after review with care manager.
6. Refer for formal psychiatric consultation to review diagnosis and treatment plan.
Especially refer those who:
Have a suicidal plan
Comorbid substance abuse
Suggestion of hallucinations or delusional thinking
Failure to respond to two trials of adequate dose and duration
Serious or prolonged difficulty in perforn1ing military duties
Table 12: Parallel Diagnostic and Management Tools for PTSD and Depression
PTSD
DEPRESSION
. .
..
..
.. . .
. .
..
Diagnostic Tools
. .. .
..
. .. . .
.. .
... .
PHQ-9
Suicide assessment
Suicide assessment
..
..
.. .
...
. ..
..
. .
ManagementTools
.
Care Management
Care Management
. .. . .
......
..
..
'
.
. ..
.....
. . . .. . ..
.
. .. . .::....
.. . . .
..
.
.
.....
........
.... ' ......
Acute Ph~
Continuation Phase
Renrission
Only 20o/o
Have~ 3 Visits*
' '
'
Symptoms
SyndrtJtne
Response
>40%
StopRx*
\
\
Recovery
''
'
\
\
Relapse
Relapse
60% to70%
Stop Rx*
''
\
\
'+
Maintenance
Phase
....
Recurrence
*]:I
r;-DI.1.T-..)'" ,..? 00.Iii,,
. :IL~.
Time
Adaptedjron1 Kupfer. DJ. Long-ternt treat111ent oftkpressioll. J Clin Psychiatry, 1991:52 (suppl. 5) :28-34
All patients who no longer meet criteria for PTSD will receive education from the care manager to
recognize relapse early and request an appointment with their primary care or mental health
clinician. This education should be reinforced by the primary care clinician. Patients who still have
some symptoms should continue on pharmacotherapy because continued symptom relief is likely to
occur.
The care manager plays a pivotal role by monitoring remission and assessing PHQ-9 and/or PCL
response periodically after remission to assess for continued symptom improvement or relapse. The
care manager also assesses risk factors for recurtence.
At the end of the continuation phase, patients who sustain their remission are considered to have
achieved recovery. As many as one-third of patients with PTSD may continue with some symptoms
indefinitely particularly if there is a history of earlier trauma exposure or chronic coping problems.
Medications
Patients who successfully achieve remission on medication should take the same dose for nine to
twelve months following remission. Many patients do not refill their prescriptions during this phase,
therefore the care manager also assesses adherence during contacts to administer the PHQ-9 and/or
PCL.
Psychological Counseling
A decision to use continuation counseling depends on the symptoms, psychosocial problems, and
recommendation of the counselor.
:References
PHQ-9
Spitzer R, Kroenke K, Williams J. Validation and utility of a self-report version of PRIME-MD: the
PHQ Primary Care Study. Journal of the American Medical Association 1999; 282: 17371744.
Kroenke K, Spitzer R L, Williams J B. The PHQ-9: validity of a brief depression severity measure.
Journal of General Internal Medicine 2001; 16(9): 606-613
Rost K, Smith J. Retooling multiple levels to improve primary care depression treatment. Journal of
General Internal Medicine 16: 644-645,2001
Kroenke K, Spitzer RL. The PHQ-9: A new depression and diagnostic severity measure. Psychiatric
Annals 2002; 32: 509-521.
Williams JW, Noel PH, Cordes J A, Ramirez G,Pignone M. Is this patient clinically depressed?_
Journal of the American Medical Association 2002; 287: 1160-1.170.
Lowe B, Unutzer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment
outcomes with the patient health questionnaire-9. Medical Care, 2004. 42(12): 1194-201.
Pinto-Meza A, Serrano-Blanco A, Penarrubia MT, Blanco E, Haro JM. Assessing depression in
primary care with the PHQ-9: can it be carried out over the telephone? Journal of General
Internal Medicine, 2005. 20(8): 738-42.
PTSD Guidelines
Ballenger JC, Davidson JRT, Lecrubier Y, Nutt DJ, Foa EB, Kessler RC, McFarlane AC, Shalev
A Y: Consensus statement on posttraumatic stress disorder from the International Consensus
Group on Depression and Anxiety. J Clin Psychiat 2000 61 (suppl5)60-66
Management of Post-Traumatic Stress Working Group. VA/DoD Clinical Practice Guideline for the
Management of Post-Traun1atic Stress, Version 1.0. West Virginia Medical Institute and
AXCS Federal Health Care. 2004
Pizarro J, Silver RC, Prause J. Physical and mental health costs of traumatic war experiences among
Civil War veterans. Archives of General Psychiatty. Feb 2006;63(2):193-200.
Schoenfeld, FB, Mannar CR, Neylan TC, C11rrent concepts in pharmacotherapy for posttraumatic
stress disorder. Psychiatric Services, 2004. 55(5): p. 519-31.
PCL
Blanchard EH, Jones-Alexander JJ, Buckley TC, Fomeris CA: Psychometric properties of the PTSD
Checklists (PCL). Behav Res Ther 1996;34:669-673
Walker, EA, Newman E, Dobie DJ, Ciechanowski P, Katon W, Validation of the PTSD checklist in
an HMO sample of women. General Hospital Psychiatry., 2002. 24: 375-80.
systems for the primary care treatment of depression: A cluster randomized controlled trial.
British Medical Journal 2004; 329:602-605.
Oxman TE, Dietrich AJ, Williams JW Jr, Kroenke K: A three component model for re-engineering
systems for primary care treatment of depression. Psychosomati~s 2002; 43:441-450.
PTSD Background
Hoge CW, Castro CA, Messer SC, McGurk D, Catting DI, Koffman RL: Combat duty in Iraq and
Afghanistan, mental health problems, and barriers to care. New Engl J Med 2004; 351: 13-22
Friedman MJ: Posttraumatic Stress Disorder Among Military Returnees From Afghanistan and Iraq
American Journal of Psychiatry 2006 163: 586-593
Lecrubier Y: Posttraumatic stress disorder in primary care: A hidden diagnosis. J Clin Psychiatry
2004;65 (suppll): 49-54.
CARE
AGER
FE
ECOMPO
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(Military Version)
This manual is intended to provide helpful and informative material for care managers working with patients with depression antUor PTSD. The
information provided here is general~ and is not intended as clinical advice for or about specific patients. Before applying any ofthis infotmation
or drawing any iriferencea from it, care managers should verify accuracy and applicability of the irifonnation and the appropriateness oj
protocol strategies within their particular clinical settings. Any management steps taken with patients should include a discussion of risks and
benefits as well as patient preferences. By accessing the information in this manual, you agree that 3CMfM, UC; Dartmouth College; Duke
University; Duke University Health System~ Inc.; Private Diagnostic Clinic, PUC; the John D. and Catherine T. MacArthur Foundation; any
participant in the Initiative on Depression and Primary Care; and the contributors of infonnation to this manual shall not be liable to you for
any damages, losses or if1jury caused by the use ofany Uifotmation in this manual.
Preface
This manual is intended for use as a resource and guide for care managers providing support to Soldiers
being treated for depression and/or posttraumatic stress disorder (PTSD) through a military primary care
practice. This manual is specific to the support function of care managers. A separate manual and training
has been developed for primary care providers. Care managers should access both the primary care provider
manual and training session prior to and in conjunction with this manual and direct care management
specific training by RESPECT-MIL program staff.
Background
A variety of epidemiological studies have demonstrated over half of all depression cases are treated in
primary care practices. While primary care providers place a high priority on recognizing and treating their
patients who are suffering from depression, the obstacles to optimal care are formidable. Excellent care for
chronic diseases such as depression is more achievable when there is a well-developed system for care.
Rigorous scientific studies have recently identified several innovations that form the basis of a system to help
primary care providers overcome many of these obstacles and enhance the care they provide.
Additionally, a recent survey of U.S. combat units retu111ing from the war in Iraq (Hoge et al2004) found
that based on broad criteria, over 18% of Soldiers and Marines screened positive on a psychometric
instrument measuring symptoms of posttraumatic stress disorder (PTSD). Even with stricter severity criteria,
over 12% would have screened positive. There was a direct relationship between the number of combat
exposures (e.g., being shot at, handling dead bodies, knowing someone who was killed, or killing enemy
combatants) and those screening positive on this questionnaire. Participation in combat activities is not the
exclusive source of danger and stress in a war-zone. There is some evidence that the stress of war is
associated with an increase in rates of sexual assault and sexual harassment. Both male and female Soldiers
are at risk for sexual victimization, a traumatic experience often associated with symptoms ofPTSD.
Of particular importance now is that among those Soldiers whose survey responses met strict criteria for a
mental disorder, few sought help. Even though approximately 80% recognized that they had a problem, less
than 45% were interested in receiving help. Less than one third had received any help from any professional
- including help from primary care providers.
Primary care providers are the health professionals with the greatest opportunity to detect and start treatment
for these behavioral health disorders. Because there is a significant overlap of co-occurring depression and
PTSD, and because of successful primary care depression systems of care such as the Three Component
Model (3CM) (Oxman et al; Dietrich et al2004), a logical and effective approach to addressing depression
and PTSD in the military is to incorporate aspects of these care systems into the military's general primary
care environment. This effort is known as RESPECT-MIL- standing for theRe-Engineering Systems for
the Primary Care Treatment of depression and PTSD -Military model.
Primary care providers participating in the program's training and implementation have found RESEPCTMIL to empower them to provide enhanced depression and PTSD care. These routines (structured
diagnostic and follow-up care process steps with a timeline) and division of responsibility including a
telephone care manager role and a consulting psychiatrist in civilian primary care settings, resulted in better
outcomes than usual care (Dietrich et al2004). RESPECT-MIL was first initiated at the Roscoe Robinson
Health Clinic, Fort Bragg, NC in June 2005.
This manual explains the process of care that was successfully tested at Fort Bragg. The manual is part of an
overall education process for care mangers that includes participating in a provider education workshop(s) or
watching a training video of the workshop and establishing a relationship with the behavioral health
professional who serves as the third component of 3CM.
Page 2 of62
I~~~c:)][)llT~~Ic:~ ............................................................................................................................................ ~
SE~~IO~
1:
The Prepared Practice: Creating an Office System for Primary Care Management ofDEPRESSION
~
PTSD .......................................................................................................................................................... t
II:
~HE ~OLE
OF ~HE
AGEME~~ ........................................... 18
AGEME~~ ............................................................... 24
ofSuicide RisJi 30
Emergent RisJi ~e11el: ....................... 3 0
Urgent ~isJC ~e11el: ................................... 30
~olt' R~JC ~evel: .......................... 30
Components of an E11aluation for Suicidal RisJC:................................................................................... 30
Assessing Suicitie RisJC 3Jr
Guidance Notes Regarding Response to RisJC ~evels .. 32
Guidance Notes Regarding Response to ~isJC ~evels ................................................................................. 33
SE~~IO~
R~JC
ofRela~se- DEPRESSION........................... 3~
Continuation ............................ 3~
Medictztions ........................................ 3~
Psychologictzl Counseling .................................. 3~
Care Mtznager Role ............................... 3~
Chronic Depression (Dy~thymia) ... 3~
What is Chronic Depression?................................... 3~
Page 3 of62
Page4 of62
INTRO
Care managers (CM) attend/participate in training along with primary care providers (PCPs)- MDs, NPs,
and PAs - specific to primary care management of depression and PTSD. Further CM specific training is
provided through PowerPoint presentation (with accompanying handouts) by a program leader. This manual
serves as an adjunct to such training activities and is well used as a reference manual during initial phases of
care management responsibilities.
After training sessions as noted above, the CM will be able to:
1. Describe the role of the CM in assisting patients to adhere to prescribed primary care treatment plans
for depression and/or PTSD.
2. Understand the CM supervision process which provides follow up support for patients and PCPs.
3. Understand the depression measure of the Patient Health Questionnaire (PHQ-9) and how it is used
as a treatment response measure.
4. Understand the posttraumatic stress disorder (PTSD) measure of the PTSD Checklist (PCL) and how
it is used as a treatment response measure.
5. List the seven key medication educational messages known to improve patient outcomes that should
be delivered initially and reinforced in subsequent care manager contacts.
6. List six areas of self-management used to assist patients in actively participating in treatment of
depression and/or PTSD.
Further, the CM will have acquired basic skills to:
1. Score the PHQ-9 to monitor symptoms and severity of depression both initially and in follow up
contacts.
2. Score the PCL to monitor symptoms and severity ofPTSD both initially and in follow up contacts.
3. Use focused questions to evaluate suicidal risk.
4. Use patient education materials to promote adherence to the prescribed treatment plan including selfmanagement goals.
5. Conduct initial one week, four-week, eight-week, PRN and all subsequent care management calls
using the CM Call Log (forn1) to guide calls.
6. Complete CM Reports to effectively communicate call outcomes and patient status to PCPs.
7. Prepare the Weekly Supervision Agenda forn1 for efficient care management supervision with the
supervising psychiatrist.
8. Present patient cases and inforn1ation in a clear, concise and organized manner for care management
supervision calls.
9. Follow through with reconunendations resulting from the care management supervision.
PageS of62
SEC
-MIL
The elements of the Three Component Model for management of major depressive disorder and PTSD
treatment are not unique, but rather the product of a wide range of recent research and dissemination
activity. The essential components of this model, known as 3CM, include prepared PCPs and
practices; the CM and mental health specialists (ideally, a psychiatrist) all working in partnership with
the patient. 3CM includes a model for the Re-engineering of Systems for Primary Care Treatment in
the military (RESPECT-MIL) of common behavioral health concerns of depression and PTSD.
Recently the investigators involved in the creation of 3CM have collaborated with the Department of
Defense's Deployment Health Clinical Center (DHCC) and the Henry M. Jackson Foundation (HMJF) to
bring this model of care for behavioral health issues to the primary care sector of the Army. Specifically,
work began in early 2005 to initiate the pilot phase of this work at the Roscoe Robinson Health Clinic
(RRHC) of Womack Army Medical Center at Fort Bragg, North Carolina. The focus of this work at the
RRHC has resulted in enhanced primary care services for members of the 82nd Airborne Division. The
project is known as RESPECT-MIL.
The
an
&PTSD
Every practice or clinic has its own established routines; division of responsibilities; systems for
recordkeeping; and, lines of connnunication among practice members, patients, and specialty services.
Practices vary in the degree to which these elements are internally developed or externally mandated.
While the military has an electronic record keeping system for medical records (CHCS II or AHLTA),
there are internal variations within the primary care system that will need to be addressed clinic by clinic
as this program is implemented locally. RESPECT-MIL will help practices implement routines, divide
responsibilities, and establish systems to enhance primary care treatment of depression and PTSD.
Th
are
r:
rs a
The CM supports Soldiers and PCPs by delivering patient education; supporting patient preferences for
treatment; monitoring both patient treatment adherence and response; and providing feedback to the PCP
about patient progress so that changes in treatment/care plans are made in a timely manner.
Co
A psychiatrist is an essential part of the mental health interface within RESPECT-MIL. CMs routinely
and systematically consult with the supervising psychiatrist through weekly care management
supervision calls/meetings. CMs may contact the supervising psychiatrist more frequently when patient
adherence and/or response to treatment warrants. CMs play an integral role in coordinating
communication between the patient, the supervising psychiatrist and the PCP. Additionally,
psychologists will assist in the supervision process especially for issues of counseling, counseling
alternatives and/or patient self-management activities.
Note: Patients who are under the primary care ofa psychiatrist for their behavioral health needs are
generally not followed by CMs in this model. This will prevent two doctors prescribing/adjusting
medications. Usually more complex patients with inadequate response to treatment by primary care are
referred and managed by a psychiatrist.
Page 6 of62
Steps involving the care manager are in BOLD and marked with a *
1. Reco. 'nition and Diagnosis
. . . . . . . ..:ll.rli:~sstfln . .
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2. Treatment Selection
Patient engagement
*
*
*
*
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supervzszon
Continue counseling and/or antidepressant treatment for 4-9 months to prevent relapse
Page 7 of62
MAN
RES ECTCMs are trained to help patients follow through with the depression!PTSD treatment plans prescribed by
their PCP. The various care management functions are outlined below. Implementation of these
functions is discussed in Section VII.
The
Treatm
The goal of the "acute phase of treatment" is remission. After starting and maintaining adequate
treatment for a typical interval (i.e., a therapeutic dose of antidepressant and/or specific psychological
counseling) many patients will have achieved remission.
Remission for depression is often achieved at about 12 weeks and will result in a corresponding
reduction in the measure of severity to a score of< 5 on the PHQ-9.
Remission for PTSD is often achieved after 12 weeks and will result in a corresponding reduction in
the measure of severity to a score of< 24 on the PCL for PTSD .
Those who do not achieve remission continue in acute phase treatment and likely require treatment
modifications and adjustments. Some patients will be referred to specialty behavioral health care when
an adequate response is not readily achieved and/or when remission is not achieved after 6 months of
management through the primary care setting.
With the goal of remission in mind, the role of the CM is to:
1. Assess the patient's level of adherence to the treatment plan.
2. Support adherence to the treatment plan and assist in problem solving to overcome barriers to
adherence.
3. Monitor treatment response through administration of the severity instruntents (PHQ-9 and PCL).
4. Routinely communicate information regarding patient progress and adherence to the PCP and
supervising psychiatrist.
5. Remind patients of risks for relapse including signs and recommendations if symptoms recur.
Se
e!
Pro ss in
Several key initial care management activities are initiated by the PCP and his/her practice at the time of
the initial visit when depression and/or PTSD are diagnosed. These initial activities are:
Introducing the patient to the role and purpose of care management in their treatment plan
When medication is prescribed at the initial visit, explaining the nature of the medication's
effects, it's efficacy, potential side effects and their pattern over time (e.g., tend to dissipate over
time), the importance of adherence and the care manager's role in monitoring adherence.
Helping the patient set initial self-management goals as part of their treatment plan
Ensuring the connection (referral) to the CM is complete and the patient is expecting contact by
a CM within 7 to 10 days
A referral to care management is generally completed through CHCS II I AHLTA by the PCP and should
outline details of initial treatment. Treatment should include at least one of the following:
Medication
Counseling
Some patients may be introduced directly to the CM at the time of the visit when co-location within
primary care exists. Co-location is highly desirable for both patient contact and coordination of
communication with PCPs in the clinic. Although co-location is the ideal and is definitely preferred by
both PCPs and patients, it should be clear, however, that CMs located remote from the clinic and/or
mental health can be equally effective in their roles.
Care Ma
Role in Ass Adhe
to
nt
CMs primarily assess the patients' adherence to recommended treatment plans throughout the course of
treatment of depression and/or PTSD. Routine contacts are made principally by phone, however, face-toface in clinic contacts are acceptable if more convenient to the patient. CMs do not provide home visits.
Each contact is intended to focus on levels of adherence to current treatment including filling/using
prescribed medications appropriately/as clinically directed; scheduling /keeping counseling
appointments; and setting/following through on self-management goals and activities.
Barriers to Treatment
Barriers to treatment are to be assessed by CMs during each patient contact. Patient's experiences/
perceptions of barriers to treatment are important and should be the primary focus ofCM contact with
each patient. CMs contacts offer an opportunity for patients to speak openly about concerns regarding
treatment. CMs also offer the patient the opportunity to "think through" (problem solve) how to get
beyond that barrier(s). CMs must focus on the patient's own problem solving rather than directing or
deciding on solutions for the patient themselves. This may be time consuming, but patient initiated
decisions are the goal and more likely to be put into practice. Barriers often include, but are not limited
to, the items listed below.
General barriers:
Concerns about medications and deployment; also fear of addiction or stigma related to Rx
Side effects
Psychological Counseling/Behavioral Health Treatment Barriers:
Problem Solving
Once a barrier has been identified, the CM will help the patient to set a reasonable goal to overcome that
barrier which will then lead to adherence to the treatment plan.
For example, week one ... patient was prescribed a medication but has not filled the prescription. This is a
primary barrier to treatment and would likely be the full focus on the first contact. The goal for this
particular patient would be to get the prescription filled in the next few days and begin taking it as
prescribed. If the patient indicates a willingness to follow through on filling the prescription then the CM
would also attempt to ensure the patient's agreement to actually start taking the medication. At this point
the CM would agree on a follow up contact date/time with the patient so check on the patient's follow
through on both filling and taking the medication as prescribed.
CMs frequently must brainstorm with patients about the various ways to achieve goals and facilitate
adherence to the treatment plan. The CM should encourage the patient to think of ways to achieve
treatment goals that might be different from their usual ways of coping or interacting. Patients may need
to think through exact detailed steps necessary to take a prescription that will not interfere with their
work detaiVassignment- what time of day, how to take the medication with food, how to take
medication when in the field, etc.
What may seem like a small barrier may indeed seem insurmountable to the patient with depression or
PTSD. Breaking a barrier down into smaller steps reduces the size of the barrier.
Supporting Adherence
The most significant role for CMs is reinforcing and supporting the patient's adherence to treatment.
Patients may not initially recognize the importance of all the parts of the treatment plan and may even
view it as a problem to military activity. This is a particularly important time for the CM to reinforce the
point that the patient's ability to fully and ably fulfill his/her work/military commitment is highly
important. If they adhere to the treatment plan, then they are far more likely to fulfill their commitments.
Some patients may decide to ignore portions of their PCP's recommendations. For example, a patient
who would benefit from counseling may be highly resistant to showing up at a behavioral health
appointment- even when there is no financial barrier. However, this may be the same patient who will
readily speak at great length to the CM by phone about the events in their lives. It is important that CMs
set limits with the patient at this point; clarifying that issues from the past or lengthy discussions of
current psychosocial stressors, etc. are the types of issues that behavioral health specialists are prepared
to help with. The CM may, in this way, be able to ease the patient into acceptance of counseling with a
behavioral health specialist.
CMs should remind all patients that if they are feeling worse they should not wait until a scheduled office
visit- contact their PCP right away!
.._........... to
nt
Treatment for depression and/or PTSD usually takes several weeks to several months (for PTSD) before
the patient notices a response to treatment. Medications take some time to bring about changes in brain
cell structure and function that result in a noticeable difference in symptoms. Counseling may take
weeks before the patient experiences a desired affect. Self-management goals may have immediate, yet
short-term effective impact on mood. It is important to sustain the practice of setting and adhering to
self-management goals over time.
As patients are frequently eager to see a quick response, it is a responsibility of the CM to help the
patient "hang in there" until the more lasting effects of the treatment begin to be evidenced. There may
be initial short-term responses/gains that the patient may not recognize or recall over the long term. CMs
should be certain to recount these gains for the patient during routine contacts and encourage further
adherence to treatment toward the long term goal of remission.
Medication Therapy: For patients on antidepressants, a measurable initial response to adequate
treatment for depression usually occurs in 4 to 8 weeks.
Page 11 of62
Antidepressant side effects account for as much as two-thirds of all premature discontinuations of
antidepressants. Most side effects are early onset and time limited (e.g., SSRis produce decreased
appetite, nausea, diarrhea, agitation, anxiety, headache, etc.) and most can be managed by temporary
aids to tolerance - food, time of day for administration of medication, etc. Some side effects are
early onset and persistent or late onset (e.g., SSRis producing apathy, fatigue, weight gain, sexual
dysfunction, etc.) and may require additional medications or a switch in antidepressant. (See Fig II-A
for more details on side effects for a variety of medications.)
Psychological Counseling: With psychological counseling alone, an adequate initial response may
take somewhat longer and remission may depend on the severity and resolution of the psychosocial
stressors.
Monito .
Res
T.
!
us
PB
and/or
While the PHQ-9 and/or PCL may be administered at any point during treatment, they should always be
administered, scored and documented during the initial office visit with the PCP and then again at 4 week
intervals by the CM (during phone contacts) or PCP (during office visits)-throughout the acute phase of
treatment. In a brief time, the key elements of the patient's status may be captured and the CM will be
able to communicate information to the PCP regarding progress toward remission.
An adequate initial response to medication and/or counseling is a drop in PHQ-9 or PCL score of 5 or
more points from baseline once adequate treatment levels have been established.
Remission for depression occurs when there is a reduction in the measure of depression severity
to a score of< 5 on the PHQ-9
Remission for PTSD occurs when there is a reduction in the measure of depression severity to a
score of< 24 on the PCL
Sub-optimal responses occur, when the patient does not experience any drop or a sufficient drop in PHQ9 and/or PCL scores over time.
CMs are NOT expected to assess adequacy ofresponse to treatment and so detail regarding guidelines
for treatment changes are not included here. The PCP is responsible for assessment ofadequacy of
response which may occur in conjunction with consultation by the supervising psychiatrist.
Progress is monitored for both depression and PTSD through CM contacts intended to first occur a week
from diagnosis/referral when the CM confirtns the patient has initiated treatments prescribed. All
subsequent routine contacts occur at approximately 4 week intetvals and involve discussion of the
treatment plan prescribed andre-administration of the PHQ-9 and/or PCL questionnaires.
More frequent calls may be necessary for patients who have not been able to self-initiate and/or follow
through on their treatment goals or for those who present concerns to the PCP and/or CM relative to
safety. The CM generally decides on his/her own that PRN calls are needed. In addition, the PCP and/or
the supetvising psychiatrist may request more frequent contacts for patients who are particularly in need.
Coordin
the Co"!"!
tio
L ormation
The CM has frequent and sustained contacts with the patient, providing the opportunity to relay
infortnation from the patient to the PCP. The CM also has frequent contact with the supetvising
psychiatrist. Thus the care management which setves as a unique link between primary care and
behavioral health specialists which benefit the patient in the model of care.
Page 12 of62
Weekly CM supervision calls/meetings with the supervising psychiatrist provide on-going treatment
management advice regarding all patients in the program relative to depression and/or PTSD
treatment/management. In some cases, the supervising psychiatrist will offer recommendations for
treatment changes, which either the CM or the supervising psychiatrist will communicate to the PCP. A
determination is made during that supervision call itself regarding who will contact the PCP and in what
format (e.g., telephone, e-mail, face to face, etc.).
Page 13 of62
. :: .
SIDEEF'FECT
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Page 14 of62
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anxious or debilitall!d,
37.5mg
. .
'
'
'
. .. . . ...:.. . .
..
'
..
...
..
Desipraminet
lOU-300
~orprmlin;
(25-100 in
elderly)
Pettofrane)
...
. . . .. ' .....
SO mg in the morn1ng
.. .
uy
... .
J'J'111
aDiv>M~tilep:
.. 'hii
...
tr
.
--
- :
. . .
.,
.. . '' .
..
. . _,..
'
25150
25 mg (lOmg in frail
elderly) in the evening
..
mconbrtence.
PTSD.
..- tslh
. fU. .INtDr
.
i.
reuP ... JJ. ..
. 'L '
,. . .
..
.. '
..
. ......
Nortriptyline!
(Ave.nty~ Pamelor)
'
tolerated
Venlafmne
..
..
...
40- 120
Disadvantages
..
.:\dvan:tage.s
.. .
'
Duloxetine
(Cymbalta)
Titration Schedule**
...
_.
ofPTSD. Generrr.
..
~-
"..['
*'There are more antidepx~ssants than those listed in this table; however, this list p.rovides a reasonable variety of d.rug& that have different s.ide effects and act by different neu:totransnutter
rnech~sms. Treat::tnent of Parkinson's disease may include selegiline (Bldeptyl), '(Vmch is a selectiv:e monoamine oxid~ inhibitor at low doses only. Because the use of many antidepxessants is
contiaindicated in conjunction with a nonselective MAO I, cautiOll with or discontirt1ation of Eldeptyl rn:a.y be in order. For pregnancy, TC.As and SSR!s (particularly fluoxetine, because ofmore
data collected} are not associated with congenital malfotiuations or developmenb.U delay. SSRis in the third,..tiim.estet ate associated 'With a $light decrease in gestational age and conespondingly lCN~er
weight, and occasionelly with neonatal wi.thd~awal symptoms. Dialrhea, drowsiness, and irritability are occasionally seen in breast fed infants of mothers blking ..antidepressants. The risks of
maternal depression on child development should be balanced agamst the effects of antidepressants on an indiVidual basis.
*For SSRis, generally start at beginning of therapeutic range. If side effects are bothersome, reduce doses and increase slower. In debilitated o.r those sensitive to medications, start lower. Fot all
antidepressants, all~ foU! weeks at a therapeutic dose, assess for a response. If a partial or slight response then increase the dose~ If no response or: worse symptoms then consider switching dtugs.
tGenerally avoid bupropion in patie.nts with .a histocy ofsenures, significant cenual ne~vous system lesions, or: rec,nt bead trauma.
iTricyclic antidepressants (TCAs) have lower costs but somewhat rugher discontinuation rates compared to SSRis due to side ~ects and S.re mote lethal in ovetdose. TCAs may be contra.indicated
in patients with certain physical comorbidities such as recent myecatdia.l infarction, cardis.c conduction defects, urinuy retention, narrow angle gla\Jcoma, orthostatic hypotension, and cognitive
impaittnent
Remission Criterion
Remission from depression is a score of <5 points on the PHQ-9 that is maintained consistently
over 8 consecutive weeks or more. Begin looking for remission from DEPRESSION at week 8
and beyond.
If remission has continued for 8 weeks, administer the Maintenance Questionnaire
which evaluates for risk factors for dysthymia.
Advise the patient that the questions will help his/her PCP decide upon next steps
in treatment.
Emphasize to patient that medications, counseling and self-management activities
should not be discontinued even if in remission. Discuss risks and signs of
relapse.
Discuss Questionnaire during supervision for determination of dysthymia and
report results/recommendations to PCP for consideration/discussion with patient.
Remission from PTSD is a score of< 24 points on the PCL that is maintained consistently over 8
consecutive weeks or more. Remission for PTSD will likely occur more slowly. Begin looking
for PTSD remission at week 12 and beyond.
Page 17 of62
DE
The nine depression symptom questions from the PHQ-9 are derived directly from the DSM-IV
diagnostic criteria for major depression. A tenth question also follows the DSM-IV criteria for
depression and asks about functional impairment from these symptoms (Question #10).
The PHQ-9, can be used as a patient self-administered questionnaire in the office or read to the patient
over the telephone to help confirm a depression diagnosis and determine severity. Over time as the
PHQ-9 is re-administered on 4 week intervals, it serves as a treatment response monitoring mechanism to
assess patient progress. Based on the outcomes of these 4 week assessments, treatment decisions may be
made to modify medication dosages and/or to switch medications in an effort to reach remission, add
counseling, and/or adjust self-management goals and activities.
A sample of a completed PHQ-9 is presented on the following page. Immediate subsequent pages
provide guides to counting symptoms as reported by the patient as well as a guide for scoring the
questionnaire for severity. It is important to take time to study how to both count symptoms and calculate
the severity score. CMs should always verify and, occasionally correct scores on PHQ-9s sent by PCP s
when referring patients to care management. If an error is noted, the PCP should be advised of the
corrected symptom count and/or score so that the accurate information may be recorded in the patient's
medical record (CHCS II I AHLTA).
CMs re-administer PHQ-9s to the patient during the 4, 8, 12 and 16-week calls in order to calculate a
new depression severity score for the patient. This will take some additional time with older and/or
disabled patients so call duration should be planned accordingly. It is important to remind patients to
focus on the prior two week interval and not months or years when completing the questionnaire. Such
reminders will aide the patient in completing the questions more easily. The updated scores are
communicated to the PCP through a Care Manager Report or electronically through CHCS II I AHLTA
in the form of a Telephone Consult (T-Con).
Page 18 of62
how
have you been bothered
problems?
you
7
8
or
on
or
as
television
3
3
add columns:
TOTAL:
~------------------------~
Somewhat difficult
Very difficult
Extremely difficuH
Page 19 of62
A total depression severity score is obtained from the PHQ-9 by summing the values of the endorsed
(circled or checked) responses. This is most easily done by first adding the values in each endorsed box
in each of the three columns and then summing the totals from each of the three columns.
A PHQ-9 severity score can range from 0 to a maximum of27 points.
The severity score is extremely useful in detel'mining if/how to treat depression and then to monitor the
progress of treatment.
Movfng
or
speaking
so
slowly
that
other
people
could
have
8
noticed. Or the opposite - being so ftdgety or rest1ess that you
have been
around a lot more than usual
Thought~ that you would be better off dead, or of hurting
9
1n some ......
2:. ..
Sum the values from the three
.
COlumns toobtain a Total. severity .
.
. .
...
. ...
3
3
Feeling bad
yourself - or that you are a failUre or
have let
or
down
Trouble concentrating on things. such as reading the
news
televisiOn
or
add columns:
16
SomeWhat difficult
Very difticult
Extremely dl1ncuR
Page 21 of62
an
The following table provides a guide for provisional diagnosis of depression which may be used by
PCPs. This table is presented for reference only and should never be used by CMs to advise patients of
severity of depression.
..
,...
.
..
..
:
. . .
........
.. .
.i:L;;;;:.. ..::::::.::: . /
I :)
... .
. .
Minimal symptoms *
Minor depression++
10-14
Dysthymia*
Antidepressant or psychotherapy
15-19
Antidepressant or psychotherapy
5-9
>20
-
*Ifsymptoms present 2: two years, then probable chronic depression which warrants antidepressants or
psychotherapy (ask, ~~In the past 2 years have you felt depressed or sad most days, even ifyou felt okay
sometimes? ,)
++Ifsymptoms present~ one month or severe functional impairment, consider active treatment.
Page 22 of62
. .
...
. .
. .
PHQ-9 Score
Drop of~ 5 points from baseline
Drop of 2 - 4 points from
baseline
Drop of .1 point or no change or
Increase
.:
. .....
..
Treatment Response
Adequate
Probably Inadequate
Inadequate
Treatment Plan
No treatment change needed. Follow-up
in four weeks.
Often warrants an increase in
antide oressant dose.
Increase dose; Augmentation; Switch;
Informal or formal psychiatric
consultation; Add psychological
counseling.
Initial Response to Psychological Counseling After Three Sessions over Four to Six Weeks
PHQ-9 Score
Drop of~ 5 points frotn baseline
Drop of 2 - 4 points from
baseline
Drop of 1 point or no change or
Increase
Treatment Response
Adequate
Probably Inadequate
Inadequate
Treatment Plan
No treatment change needed. Follow-up
in four weeks.
Possibly no treatment change needed.
Share PHQ-9 with psychological
counselor.
If depression- specific psychological
counseling (CBT, PST, IPT*) discuss
with therapist, consider adding
antidepressant.
For patients satisfied in other type of
psychological counseling, consider
starting antidepressant.
For patients dissatisfied in other
psychological counseling, review
treatment options and preferences.
Page 23 of62
SEC
The process of care for PTSD is nearly identical to that for depression. Just as with depression there is a
brief screening form and a longer diagnostic and severity assessment form. Initial treatment and patient
engagement are similar and care management and psychiatrist supervision are the same .
Soldier experienced or witnessed an event that involved actual or threatened death or serious
lDJUry.
Soldier's response involved intense fear, helplessness or horror.
Avoidance of stimuli associated with the trauma and numbing of general responsiveness (at least
three):
Insomnia
Irritability
Difficulty concentrating
Hyper-vigilance
Exaggerated startle response
Page 24 of62
1. Have had nightmares about it or thought about it when you did not want to?
YES
NO
2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
NO
YES
NO
YES
If you circled YES to two or more of the four questions, please continue and complete the attached
form. (A copy ofthe PCL is attached)
ThePCL
If the patient answers "yes" to three or more of the four questions, the PCL is then used to assist with
diagnostic assessment.
Similar to the PHQ-9 for depression, the PTSD Checklist (PCL) incorporates the DSM-IV criteria for
PTSD into a self-administered questionnaire that helps confirm a PTSD diagnosis and determine
severity. The PCP discusses the reasons for completing the PCL with the patient and explains how to fill
it out.
Based on the number of symptoms present at least at a moderate level (~ 3) in each of the three
categories - intrusion, avoidance and arousal- in the past month, a total severity score > 30, plus the
presence of functional impairment, the PCP can formulate a working PTSD diagnosis.
Within each symptom category there are a minimum number of symptoms with a score of at least 3
(moderately bothered) is required to substantiate a diagnosis. These are outlined below and illustrated in
the next few pages on a sample completed PCL form.
. .
. .
CATEGORY
Intrusion
Avoidance
Arousal
TOTAL SYMPTOMS
.
. .
..
..
MN
M~ M
ENDORSEMENT
Page 25 of62
have in
to
in the box to indicate how nIC h you
-x"
5
Repeated, disturbing 11 enories,
thoughts, o ittages of a stt-essful
from the
2 Repeated, disturbing drean 15 of a
stressful e
e from the
~...,.,
~----~~-----3 Suddenly acting or feeling as if a
1
X
X
it ?
~------~-------
from the
5
Having
reac
e~g.. ,
.,
8
g
invortant parts of
Trouble re
a
e from
?
los.s of interest in things that you used
to
or
una
for those close
er1ot
to have loving
to
12
as
cut short?
your
13
14
angry
akut" or watchful on
18
lF you checked
do
off any of the above problens, how difficult have these problens rrade it fo1 you to
take ca~ of
Not difficult
. at:
01
difficult
with ather
X
Very difficult
~w~,~..--~-,~~~---~-"'""''"""'"""''"~"N>~~'"""''''"'"'""""'"''"""''"""""'',,~~"''-'
difficult
19 Curing the last 2 weeks have you had thoughts that you wourd be better o.ff dead, or of hutting
yow"Self...in
sone
Yes
X
No
. . . . . . , '' ' ~~--~-='=~==~:
:.:.,:.::.:
:.::..way?
:.~:.,::. !, ~ ,,,,,,._,<:==~=.:.==..,..,,.,,::==::~~~;.,:,=,...,,,,...,,___ ,,,,.. .'m""'"-"""""'M -'""'"<mm-.. _.,_.,,.,,.,,.,,..~,,-.,,.,,,,_,__.,.,. ., . , ..,..,.,,.,,.._. -~""'"'""'"""-. .............,., . ._.,
lF Yes, how often?
Several days
2.
3____AJnost evetyday
Page 26 of62
:: .
. :.
. .
.
: .
. .
..
'
.
.
.
. .
:. ..
.. . :
: .
..
.. : ..
..
.
..
.
. .. . . .
. .. .... .. .
...
-x"
.. .
.....
.
.. ... .
. .
.
a
from the
acting or feeling as if a
?---~--------
..
..
_._______.__
.
.
~----
..
....
X
we~
~~~?--~=t======~
very upset when sort ething
asf
4
..
. .
. . .
..
rerrinded you
a stressful
e from th.e
?
void thinking about ot talking about a
from the past Of"
s-elated to it?
activities or situations because
rerrind you of a stressful
.. .
. .
.
. : .. .
.:.
. . '.. ....
.
...
..
. . .
. ..
. ...
.
:
...
.
..
.
. .
.'
::
. . .
.
.
: .
.
.. .
:..
....
. . : .
.
.. .
,.
..
.
. ..
. . . .
..
. .
. . . . .. ...
.. .
..
x
. .
..
.
...:. ..
. .
~--~~
.. . .
..
.
. .... . ... :
. ..
. : .
.. .. . . .
.
. . :. : .
. ....
. . . .. .
. . ... .
...
.....
.. .
..
.
'
.::: :
. . ..
. . . . . ...
...
..
. . . . .
...
. ..
. .
....
.
..
.
:.
..
..
~-~~""""'
:
. ..
.. .
. .
stressful
7
..
reactioons e .. g.,
.. .
. .
. ::... .
...
...X
.. . . . . .
..... : .
: . . .. .
..
. .
'
:.
. ... :.
. .
. .
. .
.... . ..... ..
' .
:. ...
...
. .
..
..
.:
. ..
. .
.. .
..
.
11
..
enot
12
as
... . .
.. . .
.
. . . .
. . ..
.. :
.
..
.. .. . ...
. .
. .
.
..
. . . . .. . .
. :. . . .
. . ..
.
. ..
.
.
.
.
.
.
.
. . . ..
. ::
.
.
:.
.
.
. ... . .. . .....:
:;. : . .. . .. . . .
: . .. : ;::..
.
.
.
. . .. .. .
. .
. ..
.
.
. . . : .
.: .
.
..
. .. .
... .
.
: .
.:. . ::
.
..
..
. .
..
. . .: .
.
. .
.
.
. .
.. :
.
: .. . ...
.
..
....
. . .. ...
:: ... . . . :::....:.:: . . :: .
.
. . ..
. ..
.. .
your
..
cut short?
..
..
__........_..._.
...:.
. .
. ... ..
. . .
..
..
.
angry
" Of'
watchful on
17
sta1tled?
any of the above
way?
Yes..
how
have these
fl'"ilde
it for you to
have you had thoughts that you would be better off dead, or of hurting
Yes
X
No
~.;....._.Ahrost
everyday
Page 27 of62
Us
The following table provides a guide for provisional diagnosis of PTSD which may be used by PCPs.
This table is presented for reference only and should never be used by CMs to advise patients of severity
ofPTSD.
PCL
Sy~ptoms & Impairment
PCL
Severi~v
<28
Provisional
Diaxnosis
Sub-threshold or no
PTSD
->28
PTSD,
Mild
>50
PTSD,
Moderate to Severe
Treatment
Recommendations
-Reassurance and/or
supportive counseling
-Education
- SSRI
- If no improvement after
12 weeks, refer for
Cognitive Behavioral
Therapy
- Specialty referral*
ifpatient is:
Page 29 of62
Suicidal thoughts are one of the symptoms of depression and may also be present in those with PTSD.
Approximately 10% of people with major depression eventually commit suicide. Suicidality may not be
an emergent (crisis) or urgent symptom, but it is always serious.
There is no good way to predict in the short term who will commit suicide, although long-term risk is
correlated with the following risk factors:
Hopelessness
Prior suicide attempts
Living alone
Psychotic symptoms
Substance abuse
Male gender
Caucasian race
General medical illnesses
Family history of substance abuse
or
~~~~~o~~
CMs must be prepared to respond to a suicidal patient on the other end of a phone line at any time. CMs
should discuss (talk through) options for emergent events in advance with supervisors and/or clinic
administration to develop a response plan if the CM is faced with an emergent and/or urgent patient
suicidal risk situation.
w ur
as
u can -
them to
in
Do NOT wait until vou are on the line with a patient in distress.
Page 30 of62
OR
whether there are any "active suicidal thoughts" (i.e., "thoughts ofhurting yourself in some way").
There is no way to tell the difference between active and passive suicidal thinking without further
questioning the patient.
The following section provides an easy-to-use strategy to distinguish between passive and active
thoughts of death. Of course, this is only necessary to use for that small percentage of patients who
indicate a positive response to the questions indicated italics above. CMs must know that some patients
who do not originally reveal any active suicidal thoughts may "convert" to the demonstration of active
suicidal thinking. CMs may need to conduct more than one suicide risk assessment on any given patient.
Page 31 of62
YES
NO
NO
.
3.
'~There l
a big dijflrf81tce bemreen having a though,t and a_cting on .a th~ght. Do you .think}'OU m.ight actualiJ~
make an attempt ttl hurl J,'OJUse.lf~n the ,nearfuture.?" (arc:Ie one)
NO
(If yes~ ask., u Can you be specific about how you might do this?']
4. ;;'In t~J~~~ month JJm'e you told anyone thatJOU 14'1.1'8 going to conJmit s.vicid~ o.r threatened that )~'II might
do 1t:- (c.rr.cle one)
I~S
NO
5. ~vo }'OU. think the:rt is mtJ~ risk that J'OU might hU11 yourselfbefore. .vou see J-our doctor the next time-?"
'i"ES
(If yes, ask,
~'JJ?Jat do you
NO
.4.ction Taken to ContDct Clinician. (Indicate ('None,. ifpt. determined at .. 'Lo'K~ Rtsk')_ _ _ _ _ _ _ __
Li*3.t~P~~
~ ,_
Of ~fo.r~Cl
Page 32 of62
G
These guidance notes are intended to facilitate the gathering of appropriate inforntation/detail during the
conversation and assessment with the patient. That inforrnation/detail would then be shared with the PCP
and/or supervising psychiatrist. This should not be considered a basis for decision making by the CM;
however, they would guide the action plan to be taken as outlined in the various scenarios below.
2.
3.
4.
5.
6.
'YE"
to
"on5: HActive ic
A ...........
If patient's response is "YES" to question 5, the patient will be considered
"EMERGENT /HIGH SUICIDE RISK".
The CM must contact the patient's PCP (or the covering/on-call PCP) inunediately to expedite a
clinical evaluation. (If there is on-site mental health, this will serve as a primary alternative to
PCP assessment. The PCP must still be contacted)
If the patient presents an obvious acute risk, stay on the phone with the patient, call 911, and/or
initiate best actions to ensure that the patient goes immediately to an emergency room.
If there is another adult with the patient, then attempt to speak with that person and get assurances
that s/he will accompany the patient to an emergency room OR that s/he will dial911 if they do
not have ability or means to transport.
Inform the patient's PCP (or on-call PCP) innnediately by telephone or direct contact.
If the PCP or on-call PCP is not readily available, then the CM should next attempt to reach the
supervising psychiatrist (or the covering/on-call psychiatrist/mental health specialist).
Positive ("YES") Response to Questions 1-4: t~ctive suicidal thoughts: MODERATE TO HIGH RISK"
1. If the patient has any positive answer ("YES") to questions 1-4, the patient will be considered
''URGENT I MODERATE TO HIGH RISK".
2. This inforrnation must be communicated to the patient's PCP (or the covering/on-call PCP)
innnediately via telephone or direct contact.
3. Patients at this level of risk should be assessed by a qualified mental health specialist within 48
hours.
4. If the PCP or on-call PCP is not readily available, then the CM should next attempt to reach the
supervising psychiatrist (or the covering/on-call psychiatrist/mental health specialist).
Negative ("NO") resp9nses to Questions 1-4: t~ctive suicidal (houghts: LOW RISK"
1. If the patient answers "NO'' to questions 1-5, the patient will be considered a
"LOW SUICIDE RISK". This inforrnation should be communicated to the PCP via usual CM
reporting mechanisms.
Adaptedfrom ColeS, 'Care Manager Suicide Assessment Form~ developedfor the Collaborative on Depression in Primary
Care, Bureau of Primary Healthcare, unpublished document.
(DO WE NEED TO INCLUDE HERE?)
Page 33 of62
SE
TION
Risk ofRelapse- DEPRESSION
Figure V-A above identifies the definition of treatment outcomes during the long-term treatment of
depression. The goal of the acute phase of treatment is to achieve full symptom remission defmed as a
PHQ-9 score of< 5 points. The outcomes are similar for PTSD with remission defined as a PCL score of
< 24 points.
The risk of relapse during the first six months after achieving remission from depression is as high as
50%. Over a person's life time the risk of recurrent episodes of depression is even higher, averaging 6075%. The goal of continuation phase treatment is to keep patients in remission. Continuation of
antidepressants for 4 to 9 months after achieving remission considerably reduces risk for relapse.
Some patients with recurrent episodes of depression are at significantly higher risk for future episodes of
depression. The goal of maintenance phase treatment is to identify these patients and keep such patients
on active treatment. Many depressed patients decide on their own to discontinue to take prescribed
antidepressants after remission begins. Even fewer patients with a high risk of recurrent episodes receive
maintenance treatment. These characteristics of depression treatment make it similar to other chronic
diseases like asthma or diabetes which require a chronic disease approach, not just an acute disease
approach.
Continuation
All patients with depression and/or PTSD who enter remission should receive education to recognize
signs of relapse early on and to request an appointment with their PCP or behavioral health clinician as
soon as possible.
Medications
Patients who successfully achieve remission on medication during the acute phase should take the
same dose of that medication for 4 to 9 months once remission occurs and then taper off the medication
over several weeks under the direction of their PCP. Many patients do not refill antidepressant
prescriptions during the continuation and maintenance phases. The absence of symptoms often will give
the patient a sense that the disorder is "cured" so there is no need for further treatment. As with many
illnesses, the new absence of symptoms does not mean the problem is completely resolved. Therefore,
the CM plays an important role in ongoing monitoring and promoting adherence to long term treatment
plans.
~~~l~o
ic I Counselin
A decision to use psychological counseling during continuation depends on the symptoms,
psychosocial problems, and recommendation of the behavioral health specialist.
Care
er
e
Regardless of the selection of continuation drug therapy or psychological counseling or
discontinuation of treatment, the CM plays a pivotal role by monitoring remission by assessing PHQ9 and/or PCL response at a minimum of at least one call during the continuation phase.
During the continuation phase, the CM also assesses risk factors (see Table V-1 below and the
Maintenance Questionnaire on page 36) for recurrence to assist the supervising psychiatrist and PCP
in recommending whether or not to continue treatment into a maintenance phase. At the end of the
continuation phase, patients who sustain their remission are considered to have achieved recovery
Page 34 of62
(see Figure V-A). Those without risk factors should generally discontinue antidepressants, again with
the advice of their PCP.
Table V- 1
FACTORS FOR RISK OF HIGH RECURRENT DEPRESSIVE EPISODE
1. Dysthymia (chronic depression)
2. History of two or more previous episodes of depression
3 . History of recurrence of depressive episode within one year
4. History of one other episode within three years and that the current episode was sudden and life
threatening
Page 35 of62
Asking about any episodes of past, more severe, depression (or other psychiatric disorders requiring
treatment) and the relationship of these episodes to the onset of a chronic period of low mood or
anhedonia is helpful. Sometimes another chronic psychiatric disorder is associated with the onset.
Some persons can clearly remember and convey lengthy periods of feeling happy and do not have any
past history of major depression. Instead they experience one or more difficult or challenging life events
in adulthood that result in a persistent change in confidence and mood.
Each of these three types can have a positive response to antidepressants and warrant at least one
adequate trial, for a year or longer.
Maintenance
After assessing risk factors for recurrent depression, a decision is made whether or not to continue
prophylactic maintenance treatment for at risk patients.
For those continuing in maintenance with prophylactic treatment, education of the patient regarding early
signs of recurrent depression should be completed. It is important to help them try to remember how their
depression first appeared so they can identify recurrence as early as possible. Periodic PHQ- assessments
should also be completed by the care manager or PCP (i.e., once or twice annually). Figure V-B displays
typical timing for integration of care manager and PCP visits. If at any time depression recurs, the acute
phase schedule of contacts is resumed.
Figure V-B
Page 36 of62
MAIN1::ENANCE QU:ES'fiONNAIRij;
FORM TO BE COMPLETED WITH THE PATIENT WHEN
REMISSION HAS BEEN MAINTAINED FOR TWO MONTHS
RESULTS TO BE DISCUSSED DURING SUPERVISION.
Pt. Name:
Date Administered:
-------------
------------------------------------~
'
D~eRemissionAchieved=~----------~--~---------C~ntPHQ-9: _______________
How many times have you had depressive episodes like this current one in your life? _ __
When was the last episode prior to this current one?
Dysthymia
(FOUR ANSWERS IN BOLD* MUST ALL BE CIRCLED TO MA~ A DIAGNOSIS OF DYSTHYMIA:)
I
1.
Have you felt sad, low or depressed most of the time for the last two years?
NO IfNo, done
YES*- continue
NO*
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES*
NO
YES*
2.
Was this period interrupted by your feeling OK for two months or more?
3.
4.
NO
*ARE ALL FOUR ANSWERS IN BOLD CIRCLED?
IF SO, THEN CIRCLE YES. OTHERWISE, CIRCLE NO.
YES
DYSTHYMIA
CURRENT
Page 37 of62
...........
~~~
Calls to patients are typically initiated 7 to 10 days following the initial office visit where the patient was
diagnosed ( index visit") and referred to care management. Subsequent calls then occur every 4 weeks
until the patient is in remission and less frequently thereafter based on supervision decisions and
individual patient needs. Other calls at more frequent intervals may be warranted and are referred to here
as PRN calls.
11
Page 38 of62
Soldier have a
diagnosis of depression
and/or PTSD?
>----------NO---------
Soldier declines
PCC discusses diagnosis and treatments options (including ~care management
care management) with Soldier and elicits preferences
option
DONE
Soldier wants
care management
Page 39 of62
t
Are forms ~r-ed
accurately?
--...:>----NO--
Page 40 of62
t
Are scores lower
than last set of scores?
>-----NO or INCREASE-_____,
CM inquires if there are events/
circumstances that could be
influencing scores.
YES
j'_
NO
Is a PRN call
needed~ ,
YES
~-
Page 41 of62
CARE
GEMENT
CT
There are a number of useful principles for CMs who are engaged in telephonic management of
chronically ill patients. The principles listed here will help with efficiency and workload over time.
Maintain a balance between efficiency (staying on task with completion of the CM Log) and
focusing on the needs of the patient.
Acknowledge the patient's issues and concerns, yet focus on the patient driving solutions rather
than extensive discussion of the details and giving direct instruction.
Encourage that the patient define his/her own clear and attainable self-management goals.
Offer appropriate assistance with scheduling appointments; connecting with mental health
specialists; setting self-management goals; and problem solving to overcome barriers to
treatment.
CMs are not the patient's mental health specialist or counselor and must be on guard not to slip into that
role during the course of calls. Calls should take approximately 20 minutes unless there are unique
circumstances during the call. If calls are running well over 20 minutes and the patient is not in crisis,
then there a need to better define boundaries for future calls/discussions. This is often a sign that the
patient would benefit from mental health counseling and a referral should be initiated (may require PCP
involvement). CMs that engage routinely in calls of30 minutes or more are likely providing "therapy",
counseling, etc. and should evaluate how to focus calls on inunediate issues of adhering to the treatment
plan only.
Nonresponsive/Elusive Patients
CMs should have an understanding with the organizationlpractice/PCPs and the supervising psychiatrist
regarding the maximun1 number of failed call attempts they will make before referring the patient back to
the PCP for follow-up. CMs should attempt contacting the patient at varying days and hours (including
early evening) through the week. There should also be a very clear limit on number of messages left
with individuals for the patient or via voicemail. Too many messages can easily be viewed as harassing.
It is better to set a limit and then attempt to make contact in writing to determine if the patient is
passively attempting to withdraw from care management.
Notations should be made on the Care Manager Log for each failed attempt to reach the patient.
Information to be included is the date, time, and outcome of the call (i.e., left message, talked to spouse,
etc.). A typical protocol is to make four attempts to reach the.patient, leaving messages at each call unless
the patient has requested otherwise, and then advising the PCP through a Care Manager Report (T-Con)
of inability to reach the patient. There should also be advice to the PCP regarding the CM's plan to
either continue attempting contact (e.g., sending a letter to patient requesting s/he call CM directly) or to
suspend efforts pending PCP action (e.g., scheduling an office visit). It is then the responsibility of the
PCP to contact the patient and notify the CM if and when to attempt to reach the patient again.
A friendly inquiry letter (see Appendix A- need to redraft) to the patient is appropriate prior to
''disenrolling" the patient in care management. The letter should offer the patient the option to continue
with care management and to verify the best phone number and times of day/week when they can be
reached. The letter should also offer the patient the option to decline further contact. CMs should
include a prepaid self-addressed return envelope so the patient will have less to do in order to respond.
If the patient does not return the letter in the time allowed (again agree on this with the clinic and key
parties - 2 weeks is usually a reasonable interval) or indicates they no longer wish to be contacted, then
the CM should notify the PCP inunediately so that they are aware their patient no longer has CM support.
Page 42 of62
CMs should forward copies to PCPs of all letters from patients that have clear responses indicating their
desire to withdraw from care management.
R
e
l
CMs should initially introduce themselves by indicating that slhe is working with Dr, NP or PA "X" and
inquire if patient recalls being informed of the care management service. An introduction might go
something like this;
uHello, this is (your name) and I work with Dr. Smith. Is this (patient's name)? Did I catch you at good
time when you have a few minutes and some privacy? As you may remember, Dr. Smith told you that I
would be calling to follow up after your visit with him/her. Do you recall this? ..... ,
CMs must be prepared to field questions about such topics as medication side effects, what depression
and/or PTSD treatments have been prescribed (per the referral), and setting or modifying selfmanagement goals. Inevitably, a patient will ask a question the CM is not prepared to answer or would
more appropriately be answered by their PCP. When and if this occurs and the issue cannot wait,
patients should be advised to call their PCP or to schedule an office visit. If the question is appropriate
for the CM to respond to but the CM needs to obtain more information, s/he should advise the patient
when to expect a call back with the requested infonnation. The CM should note patient
concerns/questions on the CM Log along with the plan of action.
It is recommended CMs use the data sections on the CM Logs as a guide to forming questions while
talking with the patient. If barriers are identified, prompts are outlined in Section VIII, which may be
used to offer assistance or help the patient.
It is important to systematically review the details of the patient's treatment plan as prescribed by their
PCP during each call. The initial CHCS II I AHLTA referral should provide a great deal of information
needed to assess adherence during the initial one week call.
rD
Ca
Medications:
Verify medication has been obtained (a good tip is to have the patient bring the Rx containers
to the phone and read the information on the label)
Confirm level of dosage/time of day being taken
Confirm the date when medication was started
Inquire about any side effects
Page 43 of62
In some cases, the PCP will ask the patient to start with a half dose for a week then increase to the
full dose. If this is the case, be sure the patient is complying with this plan. In the cases when this
gradual approach is used, a repeat call one week after the initial call is reconnnended to be certain the
patient has increased the medicine appropriately and no new side effects have occurred.
When the side effects are difficult for the patient, this information will often be communicated
readily. When the side effects are more subtle, the patient may need prompting/questioning. Patients
may not understand that what they are experiencing is a side effect and/or that it will subside or go
away over time. This is an opportunity for the CM to educate the patient about side effects or to
guide the patient to contact their PCP or pharmacist (they are often able to provide specific
information regarding less connnon side effects). Side effects that appear abnormal or extreme
should be brought to the PCP's attention by the CM as well as advising the patient to contact the
clinic promptly.
Psychological Counseling:
Verify name and type of mental health specialist (MD, PhD, MSW, clergy, etc.)
Inquire whether appointment(s) was been scheduled and/or completed
Verify the recormnended frequency of visits
Identify any barriers to participating in psychological counseling
Patients may also be involved with support groups (PTSD groups are comntonly offered).
Verify that the patient has been referred, knows the location and schedule of the group, and
that the patient is attending accordingly.
Patient Education:
Verify what written materials the patient has received
Verify whether patient has reviewed written materials and set goals if not
Send/mail appropriate materials or resource listings (books, etc.)
Discuss key points within the materials
Provide information in response to patient questions or concerns
Self-management goals:
Determine if self-management goals were established with PCP
Assist patient in setting goals if none were set with the PCP and/or different goals are needed
that can more easily be attained
Assess what progress has been made
Assess appropriateness of current goals and likelihood of success and/or assist patient to
modify goals if set too high (simple, small steps to begin with will lead to a stronger sense of
accomplishment and self-management)
Re-adn1inistering the PH0-9 and/or PCL:
Remind the patient of the form(s) s/he completed at the PCP's office
Administer the PHQ-9 first (skip to PCL if there is no depression diagnosis)
As a timesaver, run through each questions asking for only a yes or no to whether s/he has
been bother my the symptom noted. THEN return to the ''yes" items and provide the rating
scale (e.g., not at all, some of the days, most of the days, nearly everyday).
Page44 of62
Quickly calculate the score and give the patient feedback and general infonnation about a
decrease in the score and offer encouragement that slhe is on the right track.
If there is no change, be supportive and encourage the patient to "hang-in" with the treatment.
This may be a patient that should be called again sooner than 4 weeks to check on progress.
If there is an increase in score, provide general feedback and ask if there has been anything
different going on since the last scores were obtained that might indicate why they are feeling
worse. This will be very helpful during supervision in making decision whether to bump up
an Rx dose or to stay the course when the increase may be situational.
If there is any positive endorsement of the suicide question, then complete a risk assessment
inunediately as outlined in Section V.
Patients should always be given a final opportunity to verbalize any concerns regarding their treatment
by asking, "Before we hang up, is there anything at all that you are concerned about regarding your
treatment that you haven 't already mentioned? ,,
By asking this question directly, the patient is encouraged to voice things that may not have surfaced
earlier in the call. Also, patients should be reminded that a brief summary of the conversation and the
results of the PHQ-9 and/or PCL (ifre-administered during the call) will be sent to their PCP. The next
CM call should be scheduled before hanging up in hopes of decreasing failed contacts for subsequent
calls.
-i
PRN calls may be required for a number of reasons and are generally initiated based on the CM's own
decision. There are also times, however, when the PCP and/or supervising psychiatrist will request more
frequent calls based on patient status. These calls are often shorter than routine calls as outlined earlier
but are often of great importance for those struggling with treatment. CMs often give one or more of the
following as reasons for a PRN call:
Patient has not begun the full dose of medication; has had a change in dosage; medication has
been changed; or additional medication was added.
Concern the patient will not continue (or start) their medication due to ambivalence regarding
diagnosis; presence of side effects; concern about addictiveness of medication; etc.
Patient is having difficulty with or wants to discontinue counseling; needs help getting an
appointment; and/or is seeking alternatives to counseling (clergy, support groups, etc.).
Lack of privacy for the patient or chaotic situation during scheduled call (e.g., children present).
If a suicide screen was conducted during a CM contact and there is a need to follow up.
or~
Page 45 of62
Matters that appear urgent I emergent should also be conveyed by phone as soon as possible. Electronic
or Faxed reports should still be initiated but should not be considered the sole or primary means of
communication under such circumstances.
'
Page46 of62
o a Care M
~:~A~~~~o:!:.rLP~C~~~s
Page 47 of62
Sample Scripts
INTERVENE BY:
Explaining to the patient that their prinacy. care clinician believed they are depressed
and that treatment would be helpfUl.
EX,plore wJ.lat is uncomfortable abc;nn the di~gnosis (40 tlJey leuow $ottteone who- is
depressed or seriously mol1tally il.I and pt.rhaps tllis is f[i ._, . . eng to them.)~
Explore what they belitave having ~.,~pression!-t meat\$ ano dispel some ofthe n1yths.
If a pmient conti11ues to -be adamant that. tbey do~~ have ~pression, acknowledge
ibeit stance and focus mote on what symptomsH tb.ey have.
FQr e.xcuJ. Hte~ ~uggest.1hatthe otedi~ation tlrey ha:ve been pres.c.ribed \vill help relieve
their d oult}' sleepmg.
If after ~lkin~ ~~ wi~ th~ pat,ent,: you-~tink tM,tbe..orshe i~: ~~~UliJ more a~ut
the ud1agnos1S ~ - you mtght me.nti0n tbat tdcprcss1on~' ts a oombmatlou ofthe vanous
symp.t~ that. thtty ate "-.Jt.periencing... difficulty sleepin.~ feeling hopeless, etc, .(areas,
they checked otfQn 1lie PHQ-9).
lN.TltRVENE BY:
tb
.
..
ti
I
.
di. ...:
h
.b
.
'
1
H
. c;.p1.ns e. p4ttent c~ll,ore: sJtua oh& 'v.ten me .calion u o;- . . as cen Jtccewsary~
lielp dtetn to see. that medication for d~ion is no different Jhan a. medicati,on for .high
blood pressure or diabetes tor otbor conditio._ that thoY may. m.en.tiQnJ
Someti.tnes givins tbe "bU$ analogy"-ittbo.Jp.ful. Expl'ainingto fl_po.ie.nttha.i tbey may
be able to g~t beUer wilbo.U\ ttu1dicine however, 11 \vill be a ~eat deal 1nore di:fficult.
Page 48 of62
Also; it is helpful to me.ntion here that some patients even find that they teel so ntuch
better on the medicine that they choose to Hremain on. it indefinitely.
Gently rentind them that their problems and concerns have not gone away on their own
and usual.ly do not go away spontaneou~ly for m.ost pcop1e.
,
PATIENT MIGHT SAY:
''I don't want to be on .a depression medicatio11. ~,
-1 wouliln 't "HYIIJt an.vone to knDH thllt I was on a medicotionfor depression. ''
EXPLORE BY.A.SKJNG:.
"JVhat-isyOJWconc~n tlboutbeinB
particularT
u:w.Jro do.you;thinft willjudge.ybll hanhfyfor .
. 011 metliclllioll?lt
INTERVENE' BY:
franting tho iss\1e: oftaking ~ncdlcatio.n as
care of1hentselves and ssk tbem to
think about bow olbel'$ triigktj ud.ge them ifthy we.m perceived as not taking care of
themselves.
EA-pla.itt that d:epress1otl is a ;mediclll condition that happetlS. wh~ someQne is lacking
certajfl neurottansmmer,clt~icals in .the brain,
It is not a cbataclct O~w or matter Qf wi Upower or a need .for. a pc.~n, to just +~ull
1hentselvea up by thcr=ir boo.t41;1taps,.. .
Ask:iftbey have ever bad pt k:110W someone who bas l1acl'diabetcs or pneUmonia lltld
.has to 1uke m_,dication. \Vould we expect tbe.n1 tojUst 'pull thenl.Selves up by their
,
bo<>~lra,ps''?
Rehearse \vhat the. _patient can telltheil: fiupjly abaut the med.ication thatthey -~
taking atld the COttdition tbat they have~ Offer t~ send dJe.mthe tnedieatiott edueatiotlaJ
pa~kcl.
EXPLORE BY ASKING:
..
INT-ERVENE BY:
Taking the 9ppo.rtunity t.o educate tbepaticnl:onHhow. their J.Dcdlc.ation worb {oJl'crlo JQid .
dtoJrted.icatio.n cdacational fufonnat:ion.
ifdy luw.e ~cived it-. cfter,'to J'O'IiGW :it \titll
tbot.n),
.
Recommend that they ahao talk tp th;ir pri111ary cateclinician at tlleir ncxtvisit.aboutlhe
medication and why the.y were prcecnocd' it.
.
..
Page 49 of62
''
EXPLORE BY ASKING:
.~ Have you numti.OiJedtliif.,ttJ)'tJU.r_prU,UU,r etare clbJicllw ?'
.. If they ba.ve insuranee but ~ un~re abriut their q1enW bc~ltb cove~e, Nk:
Haveyotl, cQ/k,4the B(IIJ 11o11-tle b.tlck ofym.lr inllltce ctrdtot~tkaboutyour
~M~~tnl heolth et~vu~~ge?"
INTERVENE BY!
~
overwhwme<t
Page 50 of62
With
11 Menta.l Health
Specialist li't
EXPLORE BY ASKING:
"flow long ago was it that you -e11t to co11nseling?"
uDidyou like the mental healtla specialist you smv?
'JJow lo11g lJ'B"e you i11 counseling?"
''Do you k1rmt specijieaUy wlrat il was tlrtll you ditln t like about the experie11ce?"
INTERVE.NE BY:
EncourJ.ging the patient to ex-plore the rea.~ons why the counseling wac; not helpful.
By helping a. patient to understand more about wbat they didn~t like in their previous
counseling e~11erience, a patient can beoorne clearer on what tb.ey do want and you
tnay be able to belp thetn find the right situation.
EXPLORE BY ASKING:
..Do .~ou l1ave IIIJJ' que.ftio11s about vl1at ~.ow1seliltg is like?"
INTERV"E.N'E
"
~. -~ .8\'
Educating the patient about wbat to expect front counseling.
Certai.nly validate the. persons feeling ofbein~ busy (this ~ay be. very true), however,
often tt t.c; the wderlytng nervousness or amb1valence that ts behtnd the person
procrastinating scheduling an appointnte11t
Page 51 of62
Ot.re.ring, to help them set ~p,the firSt appl)intrn~ht You q~ay run into difficulty a~
well but oRen ca.lling .fr.o.m a prin1ory care ,clinician~s otlie can obtain u quicker
re~ponse.
Page 52 of62
Re.ason(s):
fl
EXPLORE BY ASKING:
''How long has tl1is been goi.trg on?"
now bothersoms is the t#rJ' mouth for you?''
INTERV.ENEBV:
Ex-plaining that m.~1 side effcctA will subside .or gl1 aw~y within a few weeks and if
the side etl'el-1. i~ not very butbe.n;otne; ~hey should be patient
Give_ tips on h~. ~ otctnage; tbeit symptoms,i ~or example. sucldna on bard: sugarless
candtes 81ld dttnking water ofte.n can help with dry motrth.
taking the JnediciJ1e with food can bdlp: with stoou&cb upset.
If the side effect i; very bQthers(lrn.e, e~'})lain thalfindiog the right rnedio{tJ'e can tak().
son1e trial-and error.
A patient rnay t1eed -to tty sevetal dim.reot D1edtines before ftnding tlte. ,right one for
.
tbetn.
Acknowledge that this process can be .ftustrtttln& as people want to just.feet better, not
ex~Jimerit with Pl')d:ications~
fmlp.ha'\tze, the irnportence of talking to tl1~irprim_, ca.te clinician about.tbeir side
effects.
Ce~inly~ if1he. patic!nt: has .stopped -~akin.$ !the.it ntedici!W. q,r f<!U settse tbey are
gotn .to, en.coutage tbe: patienl 10 call thtr pr.unary cate ~IJt.uctan~s office \Ybtm you
cone ude your call. (See.Antidepressant,SideEffeet)
,,
EXPLORE BYAS~KING:
!
First say thttt :it is great tha.ttbe tned:icine 1tas helped them.
E~])lain tlutt often ;when people feel better tncy want to ,top the medicine but. for these
medicines~ it is best to remwtl on fc,r period oftin1e evota wbe.n feeling ~-tter~
1ne decision when to stop medicine Jbould be made with 01eir, prinnuy care clinician.
Page 53 of62
'
EXPLORE BY ASKING-:
''When did you expect that .vou. wouldfeel better?"
''What did your primary ct1re c/inida1J t81l yo about when you slaould begin to feel
better?''
INTERVENE BY:
E~11lainiJtg tbat it can. take up to 6 weeks before patients; feel the pQJitive efte.ct of a
mcdic-afion~
lf after this th1le the patient s.tiltfcc\8 n.o po.sit.ivc e,tfect. thcsl they $ltQ~ld taU~. to tbcir
primacy eve c]inici~n ahp~t trying a diffCit.nt .n1cdic:irl.e (see medication sccliJJtlfor
suggestions .Qn how tQ.educate patiettt about m.edie.ation tte,ttnent
tilneline),
.
EXPJ~RE
..
..
..
BY ASKING;
'' W11at were .v.o"' expecllltio11a 11bout CIJruueling wl1e1l you beB.llll ,,.,
'(j)itlyorfeel thillyou wnnecte4 with y.our~ntlll heo.llb,,pllQi.llilt1'
uHQ\'f! ytJU e)eJ' bun. in CQIIIJ1elin8 i,n the pllll'! ''
ff. ,.TVQC!
vp"Io ~e what th..4ft+
""or enl
...
.. wa~ l':Le
1.1\i t
. '
. ..
... '
.. .
. .
uq .
t.J l .
INTERVENE BY:
lie lping the patient understand wlty they want tQ $\Qp Q();llf\SCiiJlg.
Sometitnes it is more a matter Q.f:a patient being With d1e V\'rong mental health
spoc:ialist "tbas1. co\Utteliag itself being not helpib.l tbr the patimrt.
Ltse this opportunity to ~"cate. the patient 011 what to cX])ect from com1selillg a~d tile
time frame to expect ehan~s.
Page 54 of62
SEC
ON
ATAMANAGEME ......
An Excel spreadsheet (see sample on following page) has been developed and serves as the supervision
agenda and helps to structure the call. This CM Agenda should be forwarded via encrypted e-mail to all
call participants in advance of each call.
In some cases where several CMs participate in the supervision call, data may be compiled separately
then consolidated into a single supervision agenda for the meeting. It is recommended the agenda be
completed and forwarded 24 hours in advance of the supervision meeting to ensure access. Participants
will also benefit by familiarizing themselves with the information in advance. Use of a CM specific
patient ID system will provide confidentiality when more than one CM is involved in the call, etc.
R
and
io d
io
The following sections will serve as a guideline for the type and level of detail to be summarized for
review with the supervision psychiatrist. Other info may be needed to provide clarification of a patient's
status and the "Note" section for each entry offers a good mechanism for that.
Enrollment Status
Total number of patients in "registry" (total number of the patients that are being actively
monitored)
Total new patients referred since last supervision call
Review of Cases
For an initial period (3 to 6 months), all new patients referred should be discussed to allow the
supervising psychiatrist and CM to gauge what level of detail is required for effective review of
cases. This will also allow the participants to gain a sense of whether information is being presented
appropriately, at the right frequency and with an efficient amount of detail.
In addition, this provides an opportunity to look for trends in PCP treatments that might benefit from
a general communication by the supervising psychiatrist or the CM to the PCP (e.g., need for
information to
PCPs about benefits of sleep aids for those with PTSD; best SSRis for PTSD; when to
Rx dose, etc.). After this initial interval, the CM should bring up only those new
bump up the
referrals/cases that
raise red flags.
Agenda Spreadsheet
The following page displays the categories of information that are reviewed each week for individual
patients. Cases are brought up by CM specific ID code rather then by patient name. These ID codes
do not reflect ID numbers within CHCS II I AHLTA. Clinics with in-house behavioral health and
care management may, however, choose to discuss individual patients by name as long as
confidentiality is maintained. The agenda fortn for patients with recent PHQ-9 and/or PCL scores are
presented at each meeting as well as for those patients who may be having difficulty with treatment
adherence, side effects, or other events that may interfere with treatment.
Page 55 of62
,Gender
'
Ref.. Date
Ox
2DWks
Wks
RxTi
P.tedication Name
startJ [
Date
.!!!&.
Refused
Page 56 of62
APPENDIX A
SAMPLE FO
S FOR THE C
AGEMENT PROCESS
Page 57 of62
Patimt Name:
M F
.DOB: ~-- 10#:_ _~---:------:--Altentate Phone II (
) __ _ _ _ (Type_._ _ )
Ctim~------------~cwm~
~-~~~m~',~T~d~.----------~F~AX~:--------------------------------------,~.
"*I
... .
"""""'"- .. -
-- .- ........
SCHEDULE OF VISITS Wll'HPCC
Nat.omce
IMel omce
Nett'omc:e
VIsit
Visit
Vtalt
o _ _ _,,.............._,._
-~----_....
~'~
--'
-~-~......
Nttomce
VIsit
>,__:~~~o-.::IBH
...___
. . . li
W(
Nl-)')')o)Wt_ _. . .
- .......
Nest om~
VWt
NeltODlet
''
Vl51t
'
...
Nt.Uomce
VI$It
Ntltomae
'
'
)-- -
---"' -'
..
~'-
coNTACT
-~'"~
Ill a
'
'
'
'
VIsit
....-........
owu-ow
"
Natomce
Next.OIIlce
VIsit
Vl11t
>
&RECORD
'
'
'
,'
T~
l"'iil.... ~-~ ~ ..
: :::: ::: :
) ;
:1
::
Dale:
::
I I
::
I~
. . . . ... ... . ..
. ... .
'
::
::
I I I I I
Date:
I I I I
.
. . ... .
. .....
.
.. .
. .. . . .. . . . . .....
Page 58 of62
M F
DOB:
ID#:
Date oflnQex Offiee Visit:
-----------------I
I
-
Clinician:
--~----------------------------Primary Phone # ( ...... ) .--..,... - - ,............. ---~~. . (Type--~--~-,,._) Alternate Phone # ( _)
.- _,-.. .*-- (Type-~..... ..M~,- )
Call Interval ~~-lit~ qf!bltilfJ: l Wk 4 Wks 8 Wks 12 \\'ks 16 \Vb (_jWb
Call Type:
Initial PRN Routine
Phase:
Ac\ie Continuation Maintenance
Completed CaD- Date;
I
I
Start time . :
End time
:
Total Time:
minutes
M
Home
AvaiL
I
' 1
I ;;
I I
Jl
#3
.activity
Pleasum&Ie.aotivities
Support from. pe~J)le
~tier; rdaxation
Simple.
. steps
Improved nutrition
()tber
...
..
~' '~.
~
..
H ...
Page 59 of62
111CDdS
ily,~
No accessible oounselor
Insimanaged care problems
Counseling costs
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References
PHo-9
Spitzer R, Kroenke K, Williams J. Validation and utility of a self-report version of PRIME-MD: the
PHQ Primary Care Study. Journal of the American Medical Association 1999; 282: 1737-1744
Kroenke K, Spitzer R L, Williams J B. The PHQ-9: validity of a brief depression severity measure.
Journal of General Internal Medicine 2001; 16(9): 606-613
Rost K, Smith J. Retooling multiple levels to improve primary care depression treatment. Journal of
General Internal Medicine 16: 644-645, 2001
Kroenke K, Spitzer RL. The PHQ-9: A new depression and diagnostic severity measure. Psychiatric
Annals 2002; 32: 509-521
Williams JW, Noel PH, Cordes J A, .Ramirez G,Pignone M. Is this patient clinically depressed?
Journal of the American Medical Association 2002; 287: 1160-1170
Lowe B, Unutzer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment
outcomes with the patient health questionnaire-9. Medical Care, 2004. 42(12): 1194-201
Pinto-Meza A, Serrano-Blanco A, Penarrubia MT, Blanco E, Haro JM. Assessing depression in
primary care with the PHQ-9: can it be carried out over the telephone? Journal of General Internal
Medicine, 2005. 20(8): 738-42
PTSD Guidelines
Ballenger JC, Davidson JRT, Lecrubier Y, Nutt DJ, Foa EB, Kessler RC, McFarlane AC, Shalev AY:
Consensus statement on posttraumatic stress disorder from the International Consensus Group on
Depression and Anxiety. J Clin Psychiat 2000 61 (suppl 5)60-66
Management of Post-Traumatic Stress Working Group. VA/DoD Clinical Practice Guideline for the
Management of Post-Traumatic Stress, Version 1.0. West Virginia Medical Institute and AXCS
Federal Health Care. 2004
Pizarro J, Silver RC, Prause J. Physical and mental health costs of traumatic war experiences among
Civil War veterans. Archives of General Psychiatry. Feb 2006;63(2): 193-200
Schoenfeld, FB, Martnar CR, Neylan TC, Current concepts in pharmacotherapy for posttraumatic
stress disorder. Psychiatric Services, 2004. 55(5): p. 519-31
PCL
Blanchard EH, Jones-Alexander JJ, Buckley TC, Fomeris CA: Psychometric properties of the PTSD
Checklists (PCL). Behav Res Ther 1996;34:669-673
Walker, EA, Newman E, Dobie DJ, Ciechanowski P, Katon W, Validation of the PTSD checklist in
an HMO sample of women. General Hospital Psychiatry., 2002. 24: 375-80
PTSD Ba round
Hoge CW, Castro CA, Messer SC, McGurk D, Catting DI, Koffman RL: Combat duty in Iraq and
Afghanistan, mental health problems, and barriers to care. New Engl J Med 2004; 351: 13-22
Page 61 of62
Friedman MJ: Posttraumatic Stress Disorder Among Military Returnees From Afghanistan and Iraq
American Journal ofPsychiatty 2006 163: 586-593
Lecrubier Y: Posttraumatic stress disorder in primary care: A hidden diagnosis. J Clin Psychiaqy
2004;65 (suppl1 ): 49-54
Zlotnick C, Rodriguez BF, Weisberg RB, Bruce SE, Spencer MA, Culpepper L, Keller MB:
Chronicity in posttraumatic stress disorder and predictors of the course of posttraumatic stress
disorder among primary care patients. J Nerv
Page 62 of62
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orl
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con itions
or
ar 11--ine ective re-screen in , " attle ati ue", lessons
re earne , hots an a cot
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ecrease
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Post Traumatic tress Disor er
Desert torm hiel
"Persian u illnesses", me icall unex Iaine
h sica I s m toms
uestions a out ex osures to toxins
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Slide 3 of 15
at, etc.
etainees
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FOIA Release Page 158
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FOIA Release Page 160
rea o
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Slide 7 of 15
FOIA Release Page 161
rauma 1c
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Slide 8 of 15
FOIA Release Page 162
ea th A visa
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upon return
T earns
81 with
00, 0
oldiers in 2 07
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haul er to haul er in 200
lncreasin surveillance o PT D an
Bl
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a use.
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artial
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Slide 9 of 15
FOIA Release Page 163
Evolvin
omprehensive Behavioral ealth trate
Comprehensive Soldier Fitness
Army's Campaign Plan for Health Promotion, Risk Reduction & Suicide
Prevention ACPHP
(b )(6)
FYO , P
fun s FY10-15
Improve access to care
48% increase in behavioral health providers since 2007
Number of visits has more than doubled since 2003
ti rna reduction
Battlemind lifecycle products fielded toT DOC Basic Battlemind
New policies to screen or P
D and B
Extensive unit and population- ase research
Returned focus on
eration Endurin Freedom
EF
Slide 10 of 15
FOIA Release Page 164
care
e uce s 1 rna
De ense enter o Excellence D oE lead in anti-sti rna
cam a1 n: ea
arr1ors
ew rea men s, researc , an
an
atn mana emen
(b )(6)
c 1n1ca
u1 e 1nes or
'
Slide 11 of 15
FOIA Release Page 165
.... ra1n n u
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ose:
o es a
1s
an
a 1en s w1
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rom
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rm
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Slide 12 of 15
FOIA Release Page 166
un s
1n
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un e
c 1on
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s a
1n
on
an
o su
care
0
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rm
(b )(6)
an:
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ocumentation, an co in of ol iers an
atients with TBI
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ele-health assets
E ucation an trainin for ol iers, lea ers, atients,
rovi ers, communit heath care rovi ers, Fami mem ers, an
others
trate ic communications an mar etin
Research
81 Pro ram Vali ation-1
ull vali ate , 21 initiall vali ate
Slide 13 of 15
FOIA Release Page 167
on 1nue em
as1s on
o1n o 1n u
1 en 1 1ca 1on an
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researc
Slide 14 of 15
FOIA Release Page 168
1ssues
(b )(6)
Slide 15 of 15
FOIA Release Page 169
INFORMATION PAPER
DASG-HSZ
15 Sep 2008
SUBJECT: Post Traumatic Stress Disorder
1. Purpose. To provide information on the incidence and prevalence of Post Traumatic
Stress Disorder (PTSD) and to understand the impact of PTSD on the force.
2. Facts.
a. We can safely estimate that between 5 and 10 percent of Soldiers who are
deployed have symptoms of PTSD. Over the past 4 years, there were approximately
32,022 diagnosed cases of PTSD broken down by calendar year as follows: CY03 1,020; CY04 - 3,845; CY05 - 6,554; CY06 - 6,845; and CY07 - 10,523. We estimate
that the nurr1ber of newly identified PTSD cases for CY08 will be around 12,000. PTSD
is usually treated as an outpatient diagnosis, and seldom requires a medical board. The
vast majority of Soldiers diagnosed witt1 PTSD will remain on active duty.
b. Military research shows that approximately 15% of Soldiers deployed during OIF
have PTSD symptoms and another 10 to 15/o percent will experience other behavioral
health problems that could benefit from treatment. The MHATs have shown that longer
deployments, multiple deployments, greater time away from base camps, and combat
intensity all contribute to higher rates of PTSD, depression, and marital problems. The
MHAT V also showed that Soldiers in BCTs deployed to Afghanistan are now
experiencing levels of combat exposure and mental health rates equivalent to Iraq.
c. Comparable surveys in the post-deployment period have shown that rates of
mental health problems, particularly PTSD, remain elevated and even increase during
the first 12 months after return home, indicating that 12 months is insufficient time to
reset the mental health of Soldiers after a year-plus combat tour.
d. Five to 6% of Soldiers are generally referred to behavioral health based on their
Post Deployment Health Assessment. Approximately 12k of Soldiers are referred to
behavioral health based on the Post Deployment Health Reassessment.
e. All Soldiers (AD, USAR, and ARNG) were mandated to participate in training on
mild TBI and PTSD. The "Chain Teach" product was designed to provide an overview
and understanding of concussion injuries and Post Combat Stress Reactions that may
result in PTSD. rhere are a number of other training programs for Soldiers and
Families available at www.battlemind.army.ll)il or www.behavioralhealth.armv.mil.
f. Using $125M in supplemental funds, the Army has implemented over 45 initiatives
under the categories of access to care, resiliency, quality of care, and surveillance.
Significant among these is the hiring of over 200 behavioral health providers to augment
behavioral health services worldwide across Army installations.
(b )(6)
rov1n
7 August 2008
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Slide 2 of 10
7 Aug 08
FOIA Release Page 172
stematic esensitization,
'
inoculation trainin ,
thera
o nitive thera
tress
o nitive
rocessin
PT
Pharmacot era
-
Anti e ressants
Anticonvulsants
Anti s chotics
ar amaze 1ne
uetia ine, Ris eri one
nOS IS
(b )(6)
Slide 3 of 10
7 Aug 08
FOIA Release Page 173
(b )(6)
Slide 4 of 10
7 Aug 08
FOIA Release Page 174
IC
era
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ase
os a
era
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(b )(6)
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Slide 5 of 10
7 Aug 08
FOIA Release Page 175
_ac
ou co
easure
rocesses or
es
e ne
(b )(6)
Slide 7 of 10
7 Aug 08
FOIA Release Page 177
ra1n1n
'
(b )(6)
Slide 8 of 10
7 Aug 08
FOIA Release Page 178
a 1en 1m rovemen
a ture in
HL
re ate or
ro ram e ectiveness
(b )(6)
Slide 9 of 10
7 Aug 08
FOIA Release Page 179
e m1 1 a
RTD rates
MEB ratin s
esearc
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Slide 10 of 10
7 Aug 08
FOIA Release Page 180
rou
ISSUe
(b )(6)
Slide 11 of 10
7 Aug 08
FOIA Release Page 181
(b )(6)
Slide 12 of 10
7 Aug 08
FOIA Release Page 182
o 1ona
. . .- ee
(b )(6)
r1e
rove
or
en
Slide 13 of 10
7 Aug 08
FOIA Release Page 183
tncor ora 1n
e
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(b )(6)
Slide 14 of 10
7 Aug 08
FOIA Release Page 184
~itQJ~
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What are we measuring?: This measures the total number of visits recorded for a service member who received a diagnosis of PTSD
after being deployed. If a person received their care in the VA or if the provider did not record that the visit was for PTSD, or if an initial
diagnosis of PTSD changed to another diagnosis. the visits would not be captured, so this may be an underestimate of the amount of care
provided.
Why is it important?: We want to be sure that everyone with PTSD receives adequate treatment. The best available evidence suggests
that a person with appropriately diagnosed PTSD should receive 10 psychotherapy visits. If we are identifying PTSD but patients are not
getting appropriate treatment, then patients could fail to recover and we would not be accomplishing our mission of rehabilitation and
reintegration to the force for people with mental disorders.
What does our performance tell us?: There have been a total of approximately 44,000 service members who have been diagnosed with
PTSD following a deployment of >30 days since 2002. Of these, less than half have documentation of more than 6 visits for PTSD. We will
need more data to determine if this is a true reflection of the care that is actually being providedw The Armed Forces Health Surveillance
Center is now conducting such a study of available data.
Reference: Institute of Medicine. l,reatn1ent of P1"Sll: An
Assessanent of the Evidence,. Wash DC, Nat
~~cad l,r-c.~ss,
2007.
(b )(6)
Slide 15 of 1 0
7 Aug 08
FOIA Release Page 185
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North Atlantic
Great Plains
Southeast
RMC
RMC
RMC
Western RMC
Pacific RMC
Europe RMC
Notes:
Percentages are based off of total referral rate per RMC
Reflects most recent 002796 per service member; each form may have multiple referrals
Slide 16 of 10
7 Aug 08
FOIA Release Page 186
ec1a
o Total Active Duty Referred
---------------------------------------------------
- - - - ---------
68,682
Army
Active Duty
'
SM with
completed
002900**
'
213,517
'
'
'
'
8 066
'
>
Notes:
Reflects most recent 002900 per service member: each form may have multiple referrals
Referral Pattern from Post Deployment Health Reassessment
PDHRA I 002900 , from
ram start of10-Mar-2005
(b )(6)
treatment
Additional 9,245 Soldiers coded for
Behavioral Health in a Primary Care with no
encounter data.
Slide 17 of 10
7 Aug 08
FOIA Release Page 187
I
I
------------------------------------------
Instruction to patient:
Below is a list of problems and complaints that veterans sometimes have in response to stressful life experiences. Please read
: each one carefully, put an "X" in the box to indicate how much you have been bothered by that problem in the last month.
2.
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Weathers, F.W., Huska, J.A., Keane, T.M. PCL-C for DSM-IV. Boston: National Center for PTSD- Behavioral
SS#______________
Instruction to patient: Below is a list of problems and complaints that veterans sometimes have in response to stressful life experiences.
Please read each one carefully, put an "X" in the box to indicate how much you have been bothered by that problem in the last month.
r----~------------------------------~------~----~~--------~--------~------~------~
j
, No.. I
Response
Extremely
(S)
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~~void
thinking
about
or
talking
about
a
stressful
military
~
6. .experience from the past or avoid having feelings related to
it?
~-'~----~------------~----------~~------~-,-M--'o*-MM-'---"-~~------~-------+------~
~void activities or situations because they remind you of a
7
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8
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Feeling emotionally numb or being unable to have loving
11
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12. Feeling as if your future will somehow be cut short?
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PCL-M for DSM-IV (11/1/94) Weathers, l_itz, Huska, & Keane National Center for PTSD- Behavioral
Science Division
INFORMATION PAPER
DASG-HSZ
10 March 2008
SUBJECT: Deployability of Soldiers diagnosed with PTSD
3. Facts.
a. Army identifies Soldiers at risk through a pre-deployment screening process. Soldiers
get a face-to-face assessment with a provider. Providers make recommendations to
Commanders about deployability of Soldiers; Commanders use their best judgment
based on mission requirements and make the final decisions, taking into consideration
medical recornmendations.
b. Soldiers who are diagnosed with PTSD or identified during the Pre-Deployment
Health Assessment as having behavioral/mental health issues that rr1ight be
exacerbated by deployment are assessed further by a provider with behavioral health
expertise. If the Soldier is determined to be non-deployable, they should be given a
profile stating their limitations. If their psychiatric situation is stable, they may be
deployed and followed-up by a behavioral health provider in theater.
c. Few medications are inherently disqualifying for deployment to all potential
operational locations and at all times during the conduct of operations. Clinical
proximity, tempo and demand of operations, and length of the deployment rotation must
be considered when determining use of psychotropic medications in the operational
environment. Soldiers with conditions determined to be at significant risk for performing
poorly in the operational environment, or whose conditions do not significantly improve
within two weeks of treatment initiation, will be clinically recommended for return to
home station, in consultation with the Commander.
Approved by:
(b)( )
c _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ J
INFORMATION PAPER
DASG-HSZ
6 July 2008
SUBJECT: PTSD Screening and Soldiers
1. Purpose: To provide information on policy screening updates for PTSD for
Soldiers
2. Facts:
a. This information paper is being written to inform the public on screening for
PTSD, specifically 'What are you doing to ensure that Soldier's identified with a
pre-existing personality disorder aren't wrongfully discharged when the real
problem is something else such as PTSD or TBI? "
b. A new policy was implemented in August 2007, where all recommendations
for a 5-13 personality disorder discharge need to be reviewed by the Chief of
Behavioral Health at the installation (enclosed).
c. All Soldiers discharged for selected administrative reasons are required to
receive a mental status evaluation as per Army Regulation 635-200. A new
policy was implemented in May 2008 where Soldiers who are being discharged
for any reason related to misconduct need to be specifically screened for PTSD
and TBI (enclosed).
d. Since approximately 1998, all Soldiers redeploying from the theater of
operations have been required to complete the Post Deployment Health
Assessment (DD Form 2796) either before leaving theater or shortly after
redeployment. The DD Form 2796 screens for PTSD, Major Depression,
concerns about Family issues, and concerns about drug and alcohol abuse. The
primary care provider reviews the form, interviews the Soldier as required, and
refers the Soldier to a behavioral health care provider as required. The primary
care provider may make referrals to on-site counselors or to military treatment
facilities. Approximately 5 to 6/o of Soldiers are referred to behavioral health.
e. Since 2005, completing the Post-Deployment Health Reassessment
(PDHRA) screening program has been required of all redeployed Soldiers 90 to
180 after they have redeployed. Specific questions about TBI have been
recently added. If following the re-assessment there are identified healthcare
needs, Soldiers are offered care through military medical treatment facilities, VA
medical centers or VET centers, or by private healthcare providers through
TRICARE. Approximately 12 % of Soldiers are referred to behavioral health.
Approved
6
by ...__(b-)(_)_ _ _ _____,
INFORMATION PAPER
DASG-HSZ
7 March, 2008
a. We have pre-deployment screening process that identifies Soldiers at risk. They get a
face-to-face assessment with a provider. Providers make a recommendation to
Commanders about deployability of Soldiers; Commanders use their best judgment
based on mission requirements, etc. and make the final decision, taking into
consideration medical recommendations.
b. Soldiers who are diagnosed with PTSD or identified during the Pre-Deployn1ent
Health Assessment as having behavioral/mental health issues that might be
exacerbated by deployment are assessed further by a provider with behavioral health
expertise. Guidance on Deployment Limiting Psychiatric Conditions is delineated in the
Health Affairs Policy issued in November, 2006. If the Soldier is determined to be nondeployable, they should be given a profile stating their limitations. If their psychiatric
situation is stable, they may be deployed and followed-up by a behavioral health
provider in theater.
c. Deployment-Limiting Psychiatric Conditions Policy Memorandum, 7 November 2006,
specifies deployment considerations related to behavioral health care. The provider will
carefully assess the patient's condition, treatment regimen, and risk level. The clinical
decision to maintain or evacuate personnel diagnosed with psychiatric disorders in
Theater is based upon: the severity of symptoms and/or medication side effects; the
degree of functional impairment resulting from the disorder and/or medications; the risk
of exacerbation if the member were exposed to trauma or severe operational stress;
estimation of the member's ability and motivation to psychologically tolerate the rigors of
the deployed environment; and prognosis for recovery.
d. There are few medications that are inherently disqualifying for deployment to all
potential operational locations and at all times during the conduct of operations. Clinical
proximity, tempo and demand of operations, and time during the deployment rotation
must be considered when deterrr1ining use of psychotropic medications in the
operational environment. Service branch specific standards must also be considered
(aviators for example). Medications disqualifying for deployment include anti psychotics
used to control psychotic, bipolar, and chronic insomnia symptoms: lithium and
anticonvulsants to control bipolar symptoms. Personnel diagnosed with psychotic or
bipolar spectrum disorders will be recommended for return to their home station.
Service members with other conditions that are determined to be at signi'ficant risk for
performing poorly or decompensate in the operational environment, or whose conditions
does not significantly improve within two weeks of treatment initiation, will be clinically
recommended for return to their home station, in consultation with their Commander.
e. An Army policy was issued in April 2007, which provided implementing guidance and
the waiver process. Waivers need to be submitted to and approved by the CENTCOM
Surgeon. Since April, 70 waiver requests have been received, and sixteen have been
denied.
(b )(6)
Approved by:
(b )( )
c _ _ _ __ _ _ _ _ _ __ _ _ _ _ J
INFORMATION PAPER
DASG-HSZ
7 March 2010
SUBJECT: Post Traumatic Stress Disorder Prevention, Diagnosis and Treatment
1. Purpose: To provide an update on Post Traumatic Stress Disorder for the TSG Prep
Book.
2. Facts:
a. Post-Traumatic Stress Disorder is a psychiatric disorder that may occur after
exposure to trauma. Typical symptoms include hypervigilence, intrusive thoughts,
flashbacks, numbness, avoidance, and nightmares. PTSD diagnosis rates have steadily
increased from CY03 to CY08 for both deployed and nondeployed Solders. CY09 rates
have declined from their CY08 peaks. Deployed Soldier diagnosis rates have declined
from 10,137 in CY08 to 8,553 in CY09. Nondeployed Soldier diagnosis rates have
declined form 1,311 in CY08 to 1,059 in CY09. We expect the number of new cases to
be related to the number of exposed troops, the number of deployments and the overall
exposure to combat. We currently estimate that the number of Newly Identified PTSD
Cases for CY1 0 to be similar to CY09.
b. The Army has numerous education, identification, and treatment programs for
PTSD, including Battlemind, PDHA, PDHRA, the chain-teach program, and Respectmil. The most common forms of psychotherapy for Post Traumatic Stress Disorder are
cognitive-behavioral therapy and exposure therapy. Usually psychotherapy requires
approximately 10 to 20 sessions, if possible on a weekly basis. There are several
medications used to treat the symptoms of Post Traumatic Stress Disorder. These
usually include anti-depressants such as selective serotonin reuptake inhibitors, more
frequently referred to as SSRis. There a number of different types used for sleep
difficulties, including Am bien, Trazodone, and Seroquel for trauma-induced nightmares.
d. During pre-deployment, Resources available to Soldiers include buddy aid,
leadership support, chaplaincy services, primary care, and behavioral health services.
Family members are instructed on their roles, responsibilities, ways by which they may
cope more effectively, strategies for supporting their deploying Soldier, and ways to
seek professional assistance.
e. During pre-deployment and deployment, Soldiers are introduced to Combat and
Operational Stress Control concepts and resources to prepare for combat and
operational stress. It is now mandatory that all Army deploying behavioral health
providers attend Combat and Operational Stress Control training.
DASG-HSZ
SUBJECT: Post Traumatic Stress Disorder {PTSD) Screening and Soldiers
f. Since Oct 98, all Soldiers redeploying from the rheater of operations have been
required to complete the Post Deployment Health Assessment (PDHA) (DO Form
2796), either before leaving Theater or shortly after redeployment. The DO Form 2796
screens for Post Traumatic Stress Disorder, Major Depression, family issues, and
concerns about drug and alcohol abuse. The primary care provider reviews the form,
interviews the Soldier as required, and refers the Soldier to a behavioral healthcare
provider when indicated.
g. Since Jan 06 (retroactive to Mar 05), all Soldiers have been required to complete
the Post-Deployment Health Reassessment (DD Form 2900) at 90 to 180 days after
they have redeployed. Approximately 12/o of Soldiers are referred to behavioral health
from the Post-Deployment Health Reassessment.
h. Another Army effort in the prevention and screening of Post Traumatic Stress
Disorder is the Post Traumatic Stress Disorder Training Course developed by US Army
Medical Cornmand and Army Medical Department Center and School. The PTSD
Training Course is intended to provide DOD uniformed and civilian behavioral health
counselors critical clinical education and intervention tools in the identification and
treatment of Post Traumatic Stress Disorder.
i. rhe Army has implemented behavioral health training into primary care. All
primary care providers receive two (2), one hour blocks of instruction covering a range
of behavioral health related issues focused around Post Traumatic Stress Disorder and
Depression.
(b )(6)
Approved by:
6
L__(b_)(_)_ _ _ _ _
____J
2
FOIA Release Page 196
INFORMATION PAPER
DASG-HSZ
18 March 2009
SUB'"JECT: Medical Care Available for Soldiers with Post-Traumatic Stress Disorder (PTSD)
1. Purpose: To provide information regarding what medical care is available to Soldiers with
PTSD.
2. Facts:
a. Army leadership is taking aggressive. far-reaching steps to ensure an array of behavioral
health services are available to Soldiers and their Families to help those dealing with PTSD and
other psychological effects of war. Soldiers and their Families are telling senior leaders that
their behavioral healthcare is a top concern. and Army leaders are in turn making it their number
one priority.
b. The following list of continually evolving programs and initiatives are examples of the
integrated and synchronized web of behavioral health services in place to help Soldiers and
their Families heal from the effects of multiple deployments and high operational stress:
(1 ). The Post Deployment Health Assessment, originally developed in 1998, was revised
and updated in 2003. All Soldiers receive this on re-deployment, usually in the theater of
operations.
(2). In the fall of 2003, the first Mental Health Assessment Team (MHAT) deployed into
theater. Never before had the mental health of combatants been studied in a systematic
manner during conflict. Four subsequent MHAT's in 2004, 2005, 2006, and 2007 continue to
build upon the success of the original and further influence our policies and procedures not only
in theater but before and after deployment as well. Based on MHAT recommendations, the
Army has improved the distribution of behavioral health providers and expertise throughout the
theater. Access to care and quality of care have improved as a result. An MHAT is currently in
Iraq, and will be deploying to Afghanistan this spring.
(3). In 2004, researchers at the Walter Reed Army Institute of Research (WRAIR)
published initial results of the groundbreaking "Land Combat Study" which has provided insights
related to care and treatment of Soldiers upon return from combat experiences and led to
development of the Post Deployment Health Reassessment (PDHRA).
(4). In 2005, the Army rolled out the PDHRA. The PDHRA provides Soldiers the
opportunity to identify any new physical or behavioral health concerns they may be experiencing
that may not have been present immediately after their redeployment. This assessment
includes an interview with a healthcare provider and has been a very effective new program for
identifying Soldiers who are experiencing some of the symptoms of stress-related disorders and
getting them the care they need before their symptoms manifest into more serious problems.
We continue to review the effectiveness of the PDHRA and have added and edited questions as
needed.
DASG-HSZ
SUB'"IECT: Medical Care Available for Soldiers with Post-Traumatic Stress Disorder (PTSD)
(5). In 2006,the US Army Medical Command (MEDCOM) piloted a program at Fort Bragg,
intended to reduce the stigma associated with seeking mental health care. The Respect-Mil
pilot program integrates behavioral healthcare into the primary care setting, providing education,
screening tools, and treatment guidelines to primary care providers. It has been so successful
that medical personnel have implemented this program at fifteen sites across the Army.
Another 17 sites should implement it in 2009.
(6). Also in 2006, the Army incorporated into the Deployment Cycle Support program a
new training program developed at WRAIR called "BATrLEMIND" training. Prior to this war,
there were no empirically-validated training strategies to mitigate combat-related mental health
problems. This post-deployment training is being evaluated by MEDCOM personnel using
scientifically rigorous methods, with good initial results. It is a strengths-based approach
highlighting the skills that helped Soldiers survive in combat instead of focusing on the negative
effects of corr1bat. Please visit www.battlemind.org for more information.
(7). MEDCOM's pursuit for improvement continues with BATTLEMIND training program
for Soldiers and spouses prior to deployments; a behavioral health web site
http://www.b~havioralhealth.army.mil; creation of a Behavioral Health Proponency Office in Mar
08; and a new PTSD training course started in Jun 08.
(8). Two DVD/CDs that deal with Family deployment issues are now available: an
animated video program for 6 to 11 year olds, called "Mr. Poe and Friends," and a teen
interview for 12 to 19 year olds, "Military Youth Coping with Separation: When Family Members
Deploy." Viewing the interactive video programs with children can help decrease some of the
negative outcomes of Family separation. Parents, guardians and community support providers
will learn right along with the children by viewing the video and discussing the questions and
issues provided in the facilitator's guides with the children during and/or after the program. This
reintegration Family tool kit provides a simple, direct way to help communities reduce tension
and anxiety, and use mental health resources more appropriately, and promote healthy coping
mechanisms for the entire deployment cycle that will help Families readjust more quickly on
redeployment. Go to www.behavioralhealth.army.mil and click on children.
(9). On average 200 behavioral health personnel are deployed in support of Operation
Iraqi Freedom, and about 30 in Operation Enduring Freedom (these numbers include providers
from all the Services).
(1 0). In mid-July 2007 the Army launched a PTSD and mild Traumatic Brain Injury
(mTBI) Chain Teaching Program that will reach more than 1 million Soldiers, a measure that will
ensure early intervention. The objective of the chain teaching package was to educate all
Soldiers and leaders on PTSD and TBI so they can help recognize, prevent and treat these
debilitative health issues.
(11 ). In 2008, the DoD revised Question 21, the questionnaire for national security
positions regarding mental and emotional health. rhe revised question now excludes non-court
ordered counseling related to marital, family, or grief issues, unless related to violence by
members; and counseling for adjustments from service in a military combat environment.
Seeking professional care for these mental health issues should not be perceived to jeopardize
an individual's professional career or security clearance. On the contrary, failure to seek care
2
FOIA Release Page 198
DASG-HSZ
SUBJECT: Medical Care Available for Soldiers with Post-Traumatic Stress Disorder (PTSD)
actually increases the likelihood that psychological distress could escalate to a more serious
mental condition, which could preclude an individual from performing sensitive duties.
(12). We've also instituted post-traumatic stress training for our health care providers so
that they can accurately diagnose and treat combat stress injuries; we're dedicating time and
energy toward provider resiliency training; and we have hired 250 more behavioral health care
providers and over 40 marriage and family therapists in recent months to work in military
treatment facilities in the United States. We also have numerous longer-term efforts to
enhance recruitment and retention of uniformed behavioral health providers.
(13). In 2008, the Army began piloting Warrior Adventure Quest (WAQ). WAQ combines
existing high adventure, extreme sports, and outdoor recreation activities (i.e. rock climbing,
mountain biking, paintball, scuba, ropes courses, skiing, and others) with a leader-led after
action debriefing (L-LAAD). rhe L-LAAD is a leader decompression tool that addresses the
potential impact of executing military operations and enhances cohesion and bonding among
and within small units. L-LAAD integrates WAQ and bridges operational occurrences to assist
Soldiers' transition their operational experiences into a "new normal", enhancing military
readiness, reintegration, and adjustment to garrison or "home" life.
(14). The Comprehensive Soldier Fitness Program was established on 1 Oct 08, as a
Directorate in the Army G-3/5/7. rhe mission of this program is to develop and institute a
holistic, resilience building fitness program for Soldiers, Families, and Army civilians. rhe
program will focus on optimizing five dimensions of strength: Physical, Emotional, Social,
Spiritual, and Family. rhis holistic approach to fitness will enhance the performance (capability)
and build resilience (capacity) of the Force in this era of persistent conflict and high operational
tempo.
(15). The Army put out ACE "Ask, Care, Escort." Beginning 15 Feb 09, the Army started
a "standdown" to ensure that all Soldiers learned not only the risk factors of suicidal Soldiers but
how to intervene if they are concerned about their buddies. The ''Beyond the Front" interactive
video is the core training for this effort. It will be followed by a chain teach which focuses on a
video "Shoulder to Shoulder; No Soldier Stands Alone" and vignettes drawn from real cases.
c______ _ _ _ _ ____J
Approved by
(b )( )
3
FOIA Release Page 199
INFORMAl-ION PAPER
DASG-HSZ
24 February 2009
SUB'"IECT: Post Traumatic Stress Disorder and Traumatic Brain Injury (PTSD/TBI)
1. Purpose. To provide information on the potential increase in cases of PTSD/TBI
among Service members and veterans as a result of multiple deployments.
2. Facts.
a. Since 2002, there have been a total of approximately 36,256 Operation Iraqi
Freedom and Operation Enduring Freedom (OIF/OEF) Soldiers who have been
diagnosed with PTSD following deployment of greater than 30 days. The number of
new PTSD cases has more than tripled since FY04. Cumulative deployed time is
associated with increased PTSD diagnoses; Length of most recent deployment is not. It
is projected that diagnosed cases of PTSD will continue to increase in future years.
b. As of Nov 08, there were 6,751 Army TBI cases reported to the Defense Veterans
Brain Injury Center OIF/OEF. This represents an eight fold increase of reported TBI
cases since FY03. Most rsl cases resulted from Improvised Explosive Devices I Blast
injuries, and most were categorized as mild TBI. Increases in the number of mild rsl
cases have largely been due to aggressive identification efforts both in theater and as
part of Post Deployment Screening and not as a result of multiple deployments. It is
expected that this number will increase as more cases are identified.
c. Since Oct 98, all Soldiers redeploying from the theater of operations have been
required to complete the PDHA, either before leaving theater or shortly after
redeployment. The DD Form 2796 screens for PTSD, Major Depression, concerns
about family issues, and concerns about drug and alcohol abuse. The primary care
provider reviews the form, interviews the Soldier as required, and refers the Soldier to a
behavioral healthcare provider when indicated. rhe primary care provider may make
referrals to on-site counselors, network providers or to military treatment facilities
(MTFs). Five to 6/o of Soldiers are generally referred to behavioral health at this time.
d. Since Jan 06 (retroactive to Mar 05), all Soldiers have been required to complete
the PDHRA (Form 2900) at 90 to 180 days after they have redeployed. Specific
questions about rr1ild TBI (concussion) were added in Nov 07 for the Army. rhese
questions were revised and made available for all Services in May 08. If healthcare
needs are identified through the PDHRA, Soldiers are offered care through MTFs,
Veteran Administration Medical Facilities, or by private healthcare providers through
TRICARE. Approximately 12/o of Soldiers are referred to behavioral health 'from the
PDHRA.
DASG-HSZ
SUBJECT: Post-Traumatic Stress Disorder Screening and Deployment
e. All Soldiers (AD, USAR, and ARNG) were mandated to participate in training on
mild TBI and PTSD NLT 18 Oct 07. rhe "Chain Teach" product was designed to
provide an overview and understanding of concussion injuries and Post Combat Stress
Reactions that may result in PTSD. Approximately 900,000 Soldiers received this
training by the end of 2007. There are a number of other training programs for Soldiers
and their Families available at www.battlemind.army.mil or
www.behavioralhealth.army.mil. The content of the "Chain Teach" has been
institutionalized through the Battlemind Training System Office (BMTS), AMEDDC&S
which has integrated this training into lifecycle mrsl and PTSD training modules that
will be incorporated into The US Army Training and Doctrine Command (TRADOC)
Programs) Programs of Instruction (POl). Mild TBI and PTSD training will occur in all
TRADOC OES and NCOES POls. In addition, the Post-Deployment and Spouses
Battlemind are available at the web sites indicated above. New training videos are in
development.
f. All Soldiers discharged for selected administrative reasons are required to receive
a mental status evaluation as per Army Regulation 635-200. A new policy was
published in May 08 directing that Soldiers being discharged for any reason related to
misconduct must be specifically screened for PTSD and mild TBI.
g. MEDCOM and AMEDDC&S have developed a PTSD Training Course intended to
provide DoD uniformed and civilian BH counselors critical clinical education and
intervention tools in the identification and treatment of PTSD. Specifically, this provides
the BH provider a broader understanding of the clinical characteristics and prevalence
of PTSD Acute and Chronic Features, medical and psychiatric co-morbidity of PTSD,
the theoretical underpinnings for this disorder and the ability to identify risk and
resiliency factors related to development of PTSD. Attendees also learn about a variety
of screening and assessment tools to accurately and reliably measure traumatic
stressors and PTSD, learn about TBI, most notably as a result of blast-related
concussion, and hear about strategies to diagnose co-morbid PTSD and rei. Finally,
participants hear an overview about therapeutic clinical strategies for coordinated
treatment of combat-related stress issues. This course is mandatory training for all
uniformed and civilian Social Workers, Nurse Case Managers and Basic Psychiatric
Nurses.
h. Specific to TBI, two patient education brochures and 5 patient education
handouts were developed and distributed throughout U.S. Army Medical Department
(MEDCOM), staff have conducted public relations efforts at 14 conferences and 10
professional meetings, and computer-based education tools for Soldiers, Families,
providers, leaders and patients are in development. MEDCOM established a validation
program for all MEDCOM Medical Treatment Facilities (MTFs) that provide care to
Soldiers and other beneficiaries with TBI. rhis validation program was designed to
establish standards of care and to ensure that services, physical facilities, and staffing
levels were consistent across the Army MTFs, based on the level of care provided at
the facility. Six sites have received initial validation and review of all CONUS sites is
DASG-HSZ
SUBJECT: Post-Traumatic Stress Disorder Screening and Deployment
scheduled between Feb and Jun 09 with a goal of having every site achieve initial
validation by 30 Sep 09.
(b )(6)
Approved by:
(b )(6)
c _ _ _ _ _ _ _ _ _____,
DASG-HSZ
SUBJECT: Post-Traumatic Stress Disorder Screening and Deployment
. -.
--CY06
'!'"'
CY08
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We expect the number of new cases to be related to the number of exposed troops, the number
of deployments and the overall exposure to combat. We would estimate that the number of
Newly Identified PTSD Cases for CY09 to be similar to CY08 !f deploy numbers are also similar~
Source: Office of the Sufl}eon General
2003
(_b_)(_6_)____
2004
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DASG-HSZ
SUB'-JECT: Post-Traumatic Stress Disorder Screening and Deployment
Behavioral Health and Social Epidemiology
Army Suicides and Rates of Behavioral Health Diagnoses in Army
*Future predicted. rates based on Z005~2007average annual increases
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This slide depicts TBI of varying severity based on data from the Defense Veterans Brain
Injury Center, November 2008. The Trend Indicates variation tn the number of Soldiers with
Mild TBI and a decrease In the number of Soldiers with Severe TBI over time.
Source: Office or the Sl.lf{leOn General (_b.L...;)(..__6-'--)_ ___,
L . l . . l
DASG-HSZ
SUBJECT: Post-Traumatic Stress Disorder Screening and Deployment
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This slide depicts TBI of varying severity based on data from the Defense Veterans Brain Injury
Center, November 2008. As of November 2008, there were 6,751 cases reported to DVBICmost from lED/BLAST, and most were MILD. Data reflects onty Army OIF/OEF .
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FOIA Release Page 212
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Background:
The 14 Oct 2008 Directive-Tme Memorandum (DTM) provides that the MEB will
include a Nanative Summary (NARSUM) (and Addenda) which meets the minimum
criteria outlined in the VA Worksheets. This new requirement enhances unifonnity of
disability assessments within the DoD and the VA. It also helps individuals transition
between the two systems. The suggested NARSUM fonnat is designed to help assure the
MEB psychiatrist meets these minimum criteria and other regulatory requirements.
Adherence will enhance timely processing of disability cases and ensure a reduced return
of MEBs to the MTFs.
Outline:
NARSUM: Recommended Fonnat
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
Identifying Infonnation.
Sources of Infonnation.
Synopsis of Events Leading to MEB Referral.
Premilitary History.
Military History.
Medical History.
Psychiattic History (primary focus on past 12 months} and Current Subjective
Complaints.
Current Mental Status Examination (MSE).
Symj>toms (include those relating to or caused by diagnosis (es)) and associated
impact on occupational and/or social functioning.
DSM-IV TR Diagnosis.
Psychometric Testing Results.
DSM-IV TR Mutliaxial Assessment and Discussion
Mental Competency.
N. -----~~;n ~~~
0. Additional Considerations and Conclusions.
P. Verification of Accuracy ofDA Fonn 3349 {Physical Profile).
23
se t e terms
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succinct an
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29
REPLY TO
AnENTION OF
DASG-HSZ
11 May 2009
1 . References
a. Memorandum, HQ, USAMEDCOM, MCCG, 6 Aug 2007, subject: Review of
Personality Disorder (Chapter 5-13) Administrative Separations.
b. MemorandJJm, HQ, USAMEDCOM, MCCG, 19 May 2008, OTSG/MEDCOM
Policy Memo 08-018, subject: Screening for Post-Traumatic Stress Disorder (PTSD)
and mild Traumatic Brain lrrjury (mTBI) Prior to Administrative Separations.
c. DoDI 1332.14, Enlisted Administrative Separations, 28 ArJg 2008.
d. Memorandum, ASA(M&RA), 10 Feb 2009, subject: Enlisted Separations on
the Basis of Personality Disorder POLICY MEMORANDUM.
e. AR 635-200, Active Duty Enlisted Administrative Separations, 6 Jun 2005.
f. AR 40-400, Patient Administration, 6 Feb 2008.
g. AR 635-40, Physical Evaluation for Retention, Retirement, or Separation, 8
Feb 2006.
h. Memorandum, HQ, USAMEDCOM, MCHO-CL, 13 Mar 2009,
OTSG/MEDCOM Policy Memo 09-012, subject: MEDCOM Procedures for Chapter 5.
paragraph 5-13 and 5-17 Personality Disorder (PO) Separations.
2. In 2006 and 2007 public concern was raised that some soldiers returning from
combat tours had been discharged from the military for personality disorder, but were
subsequently suffering from PTSD or TBI related to their cornbat experiences. To
address these concerns, OTSG issued policies in August 2007 and May 2008 requiring
higher level review of recommendations for administrative separations for personality
disorder (reference a), and screening for PTSD and TBI for these and other
DASG-HSZ
SUBJECT: Guidance for Administrative Separation for Personality Disorder or Other
Mental Conditions
2
FOIA Release Page 236
DASG-HSZ
SUBJECT: Guidance for Administrative Separation for Personality Disorder or Other
Mental Conditions
g. Clinical documentation that PTSD and TBI were addressed with appropriate
screening instruments, and other co-morbid mental illness was ruled out or did not
contribute significantly to the diagnosis. If PTSD is diagnosed or other mental illness is
significant, a MEB should be initiated lAW AR 40-400, chapter 7, and if found to meet
retention standards, a copy submitted with the clinical documentation (the MEB is
corr1posed of two or more physician members including a psychiatrist; it is part of the
Physical Disability Evaluation System and does not require referral to the PEB if found
to met retention standards). If retention standards are not met, the recommendation for
administrative separation should not be forwarded to OTSG unless and until the soldier
has been adjudicated fit for duty by the PEB.
h. Endorsement by OTSG is required ONLY for the diagnosis of Personality
Disorder and ONLY in soldiers who have served or are serving in an imminent danger
pay area (reference h).
-~~
~
(b )(6)
""'~
Ii~
(b )(6)
(b )(6)
COL. MC
(b )(6)
3
FOIA Release Page 237
UNCLASSIFIED
26 February 2008
(U) P LICY/PRO
SO
lA NOSED
PT
TER (U)
(DASG-HSZ) Deployment-Limiting Psychiatric Conditions Policy Memorandum, 24 ARP 2007
specifies during deployment considerations related to behavioral health care. This guidance
includes the diagnosis ofPTSD. The provider will carefully assess the patient's condition,
treatment regimen, and risk level. The clinical decision to maintain or evacuate personnel
diagnosed with psychiatric disorders in theater is based upon: the severity of symptoms and/or
medication side effects; the degree of functional impainnent resulting from the disorder and/or
medications; the risk of exacerbation if the member were exposed to trauma or severe
operational stress; estimation of the member's ability and motivation to psychologically tolerate
the rigors of the deployed environment; and prognosis for recovery. Personnel diagnosed with
psychotic or bipolar spectrum disorders will be reconnnended for return to their home station.
Service members with other conditions that are detern1ined to be at significant risk for
performing poorly or decompensate in the operational environment, or whose conditions does
not significantly improve within two weeks of treatment initiation, will be clinically
reconunended for return to their home station, in consultation with their cormnander.
PREPARE MEMO- - - - (b )(6)
Approved by:
(b)( )
c______ _ _ _ _ _ ____J
UNCLASSIFIED
INFORMAl-JON PAPER
DASG-HSZ
14 July 2008
SUBJECT: Post Traumatic Stress Disorder (PTSD) Screening and Soldiers
DASG-HSZ
SUBJECT: Post Traumatic Stress Disorder (PTSD) Screening and Soldiers
Reactions that may result in PTSD. Approximately 900,000 Soldiers received this
training by the end of 2007. There are a number of other training programs for Soldiers
and their Families available at www.battlemind.army.mil or
www.behavioralhealth.arrny.mil.
f. All Army deploying behavioral health providers now attend the Combat and
Operational Stress Control (COSC) Course. To date, 152 Army behavioral health
officers, 62 Army enlisted health specialists, 60 Air Force behavioral health officers and
63 Airmen have been trained. We have also trained 23 Chaplains. These reflect all
eight COSC Courses conducted since inception in Feb 07. Emphasizing the policies
above is part of the curriculum. This information is also reinforced to providers at the
annual Force Health Protection conference.
g. The Army is implementing behavioral health training into primary care. All primary
care providers will receive two (2), one hour blocks of instruction covering a range of
behavioral health related issues focused around PTSD and Depression. rhis will be
followed by a one hour block of instruction provided annually and additional education
provided during primary care lecture series.
3. The Way Ahead. Continue to ensure that Soldiers are carefully evaluated and
treated for PTSD, TBI, and other psychiatric illnesses.
(b )(6)
Encl
as
Approved by:
(b )( 6 )
2
FOIA Release Page 240
INFORMATION PAPER
13 Mar 2009
SUBJECT: Improving Primary Care Provider Skills on Assessment and Management of Depression and PTSD and
Suicide Risk Assessment
1. PURPOSE. To provide information about an Army initiative to improve primary care provider skills on assessment and
management of depression and PTSD, including suicide risk assessment
2. FACTS:
A. Nearly 20% of returning soldiers screen positive for major mental disorder. Of these, 78/f, of them acknowledge a
need for help, yet only about one fourth of these pursue mental health specialty care. Soldiers who screen positive are
twice as likely to perceive barriers (e.g., career effects, stigma, poor access, mistrust) to seeking specialty care help
(Hoge et al, 2004).
B. Primary care-based RESPECT-Depression (Re-engineering systems for the treatment of depression, Dietrich et al,
2004) or similar approaches are significantly more effective than usual PC care in multiple large, multisite randomized
control trials.
C. RESPECT-MIL incorporates the management of PTSD, depression, and deployment-related health concerns using
applicable DoDNA practice guidelines.
D. With 90-95/f, of soldiers accessing primary care annually at a rate of 3.4 primary care visits per year, primary care
offers opportunities for better mental health care access and penetration. less stigma, and earlier assistance with a more
preventive focus.
E. Deployment of RESPECT-MIL at Fort Bragg in 2005/06 revealed significant provider satisfaction/enthusiasm.
Approximately 2/3 of Soldiers screening positive for PTSD or depression who are then enrolled in the RESPECT-MIL care
management reported clinically significant improvements in their symptoms (Engel et al, 2008).
F. Epidemiological data reveal that individuals with depression and anxiety disorders have markedly higher rates of
suicides. Data also reveal that a very high percentage of individuals who have completed suicide have visited their
primary care provider within the past three months. rherefore, it is reasonable to expect that equipping primary care
clinics and providers to more adequately assess and manage depressive and anxiety disorders (e.g., PTSD), to include
suicidal risk assessment, will have a positive impact on reducing population suicide rates.
G. RESPECT-MIL, with a Center of Excellence (COE) at Fort Bragg (transferring soon to Walter Reed), involves:
A structured program with manuals and rigorous Jive and web-based training for participating clinicians
Routine screening for depression, PTSD, and post deployment health concerns with risk assessment (suicide
and violence) as clinically appropriate.
Follow-up brief PC diagnostic and symptom severity assessments for screen positives
Identified and consenting individuals continue in PC and are also referred to mental health supervised caremanagers for facilitated care
Monitor symptom severity/risk assessment issues and problem solve soldier difficulties initially and during
scheduled follow up phone contacts
Review cases weekly with mental health consultant, providing feedback to soldier and primary care provider
as needed
3. Army Primary Care Initiative.
A. Recognizing the need to improve primary care provider training, The Surgeon General, US Army, issued OPORD
09-05, directing that all Army Primary Care Providers complete mandatory training on the assessment and management
of depression and PTSD in a primary care environment. The OPORD stipulates basic training during the first year,
followed by extended training during the second year. The training content utilizes RESPECT-Mil training materials that
have been implemented at 43 clinics at 15 installations world-wide. Training content focuses on the assessment and
management of depression and PTSD utilizing provider-friendly clinical tools utilized in the RESPECT-Mil program, to
include screening, diagnostic assessment, and treatment monitoring instruments and the utilization of care facilitation and
specialty care consultation strategies. It also provides systematic training on how a primary care provider can assess
suicidal risk, utilizing evidence-based RESPECT-Mil tools and protocols.
B. To accomplish this, two web-based, interactive training modules were developed, one for Depression and for PTSD.
They are available at http://www.pdhealth.mil/respect-mil/index.asp. This training became available in Dec 2008 and will
be accomplished over the next year. AMEDD C&S is in the process of enhancing the automated tracking of training.
(b )(6)