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Article Excerpt
Active-duty military personnel face deterrents to seeking outpatient mental health treatment despite the high prevalence of posttraumatic stress disorder (PTSD) in this population. The Behavioral Health Consultation (BHC) model moo, be the answer for those presenting subthreshold PTSD symptoms, at high risk for PTSD due to their occupation, not interested in outpatient mental health treatment, or unable to seek such treatment due to occupational limitations. Three empirically based interventions that have been effective in managing symptoms of PTSD are summarized and then integrated into the established BHC model as suggested treatments for managing PTSD symptoms in an integrated primary care setting. Pilot data and recommendations for future research and practice are provided.
WHY PRIMARY CARE SETTINGS?
Symptoms of posttraumatic stress disorder (PTSD) among U.S. military veterans deployed during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) have been detected at rates as high as 17%. PTSD prevalence rates were determined to be as high as 52% in veterans who were seen in primary care and diagnosed with at least one mental health disorder (Seal, Bertenthal, Miner, Sen, & Marmar, 2007). Unfortunately, only 10% of male and 26% of female active-duty personnel reporting mental health symptoms will pursue treatment (Visco, 2008). The wide-ranging reasons for their low help-seeking behaviors include such factors as avoidant coping strategies associated with PTSD, frequent redeployments that destabilize living arrangements, and fears that seeking treatment will negatively impact their careers (e.g., security clearance, weapons-bearing status, time away from the duty section when staffing is scarce). Clearly, these obstacles decrease the likelihood that active-duty members will seek treatment for mental health symptoms like those of PTSD.
Assuming that the obstacles can be surmounted, effective treatment protocols are rigorous and time-consuming--as much as 12 weeks of weekly 60-90 minute sessions (Foa et al., 1999; Foa et al., 2005; Foa, Rothbaum, Riggs, & Murdock, 1991; Resick, Nishith, Weaver, Astin, & Feurer, 2002; Rothbaum, Astin, Millie, & Marsteller, 2005; Rothbaum et al., 2006; Schnurr et al., 2007). It is vital to better manage disorders like PTSD and to formulate innovative approaches to manage them and subthreshold levels of PTSD (presenting symptoms that do not meet full diagnostic criteria).
The primary care setting is where military members' PTSD symptoms are most likely to be identified, due to the population-based approach the military uses to detect health problems resulting from deployments. Like civilians, those in the military have more frequent and feasible contact with medical providers in primary care clinics than in mental health clinics, so it makes sense to address PTSD symptoms in primary care. To do so, assessment and intervention must be tailored to meet that delivery model.
Randomized clinical trials (RCTs) have previously targeted PTSD in civilians or in discharged military veterans treated long after their combat exposure. It appears that a large proportion of patients with non-combat-related PTSD can be brought to remission with early cognitive-behavioral interventions (Bryant, Sackville, Dang, Moulds, & Guthrie, 1999; Litz, Gray, Bryant, & Adler, 2002).
A few studies have evaluated the efficacy of PTSD screening and the adaptation of interventions for primary care (Clum, Chrestman, & Resick, 2004; Samson, Bensen, Beck, Price, & Nimmer, 1999; U.S. Dept. of Veteran Affairs/Department of Defense [VA/DOD], 2004). One model for integrating mental health into primary care, Behavioral Health Consultation (BHC), may be an effective way to address PTSD for those who are (1) unable or unwilling to participate in specialized mental health treatment; (2) at chronic risk for PTSD due to frequent deployment; or (3) experiencing subthreshold levels of PTSD.
THE BEHAVIORAL HEALTH CONSULTATION MODEL
Various models of collaboration between mental health and medical providers--often termed integrated primary care--have been implemented to address the finding that 70% of mental health problems are treated by primary care providers (PCPs; Blount, 1998; Gatchel & Oordt, 2003; Packard, 2007; Strosahl, 2001). They vary in terms of how the mental health provider interacts with patients and, more importantly, who retains primary responsibility for treatment decisions.
The BHC model is marked by collaborative decision-making. It has been the premier model used at United States Air Force (USAF) hospitals and internship/externship training programs worldwide. In this model PCPs refer patients to specially trained mental health professionals (behavioral health consultants [BHCs]) who conduct brief evaluations and interventions with patients, then provide recommendations related to mental and behavioral health concerns to the PCP. The PCP retains full responsibility for patient care decisions. This contrasts markedly to specialty mental health settings in which the mental health professional exercises autonomy. The BHC acts as an embedded consultant within the primary care clinic, allowing for true integration of health care through immediate access to a mental health provider. Patient contact with a BHC is brief and problem-focused. The typical course of care spans one to four appointments, each lasting 15 to 30 minutes.
Training for military BHCs involves one month of practice with intensive supervision within a social work or clinical psychology internship program. Civilian psychology internships also offer training in integrated primary care (Association of Psychology Postdoctoral Internship Programs Online Directory, http://www.appic.org/directory/4_1_directory_online.asp). For more information about integrated primary care see Gatchel and Oordt, 2003, and Strosahl, 2001.
Consistent with the primary care model of medicine, BHC appointments do not comprehensively evaluate the patient's mental health history. Nor is therapy or counseling consistent with BHC, which employs a consultation model. However, all patients are screened for suicidality, alcohol use, and other health behaviors (e.g., tobacco use). Those who are assessed as needing specialty mental health treatment are referred to a clinic. Because the assessment is brief and patients with PTSD often present with comorbid symptoms, strategies for managing the risk of, e.g., depression or suicide within the BHC model have been explored (Bryan, Corso, Neal-Walden, & Rudd, in press; Bryan, Rudd, Corso & Cordero, 2008).
Numerous studies have demonstrated the efficacy of the integrated primary care model. Collectively, they found that symptoms of depression and anxiety were reduced and functioning and quality of life increased in adolescents, adults, and older adults (Asarnow et al., 2005; Katon, Roy-Byrne, Russo, & Cowley, 2002; Roy-Byrne, Katon, Cowley, & Russo, 2001; Simon et al., 2001; Unutzer et al., 2002). More recent studies of the BHC model within military primary care clinics found it to be effective for a wide range of presenting conditions, with clinical recovery typically occurring in as few as two or three appointments (Bryan, Morrow, & Appolonio, in press; Cigrang, Dobmeyer, Becknell, Roa-Navarrete, & Yerian, 2007).
We first summarize three empirically based interventions that have proved effective in treating PTSD in mental health settings and then explain how they can be adapted to the primary care...
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