by Craig J. Bryan, Psy.D.The problem
Symptoms of 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%. Not unlike the civilian world, as the “first stop” for the majority of one’s health care needs, patients in the military have more frequent and feasible contact with medical providers in primary care clinics versus specialty mental health settings. Recent reports of psychiatric prevalence rates (i.e., meeting criteria for at least one mental health disorder) for OIF/OEF veterans seen in primary care were determined to be as high as 25% (Seal, Bertenthal, Miner, Sen, & Marmar, 2007). PTSD symptoms are a significant health problem, contributing to poorer general health and somatic symptoms including headaches, chest pain, dizziness, fainting, and digestive problems (Hoge, Terhakopian, Castro, Messer, & Engel, 2007). It should not be surprising that veterans with PTSD, therefore, visit primary care medical providers more frequently, and miss twice as many days of work, than veterans without PTSD (Hoge et al., 2007). These health problems and functional impairment increase with comorbid depression (Campbell et al., 2007), as does the risk for suicide (Oquendo et al., 2003).
The convergence of these data, in combination with anecdotal reports and clinical experience, point to the primary care clinic as the most likely health care setting where military members’ PTSD symptoms will first be identified. Unfortunately, only 10% of male and 26% of female active duty personnel reporting mental health symptoms will pursue specialty mental health treatment (Visco, 2008). The reasons for low help-seeking behaviors among active duty personnel are wide-ranging and include such factors as avoidant coping strategies associated with PTSD, frequent re-deployments that contribute to instability in living arrangements, and mental health stigma stemming from fears that seeking mental health treatment will negatively impact the service member’s career.
When I first started working in an integrated family medicine clinic, I found there was a sizable percentage of active duty veterans who returned to the primary care clinic again and again for sleep disturbances, low energy, diffuse pain, and other somatic symptoms that would not improve with traditional medical treatments. Often times these members would be referred to numerous medical specialties and undergo a wide range of tests and procedures that ultimately would result in negative findings. The impact of these veterans on the medical system was considerable, both in terms of financial expenditures and increased utilization of limited resources. As time passed, these service members continued to suffer and became increasingly discouraged and hopeless as specialist after specialist was unable to pinpoint the disease process underlying their health issues. It seemed very clear to me at the time that the problem with this subgroup of veterans was unrecognized PTSD (and oftentimes comorbid depression). Through consultation with the primary care providers (PCPs) in my clinic, we improved screening and identification of deployment-related health problems, and PCPs increased their referrals to me for behavioral health consultation.
In the beginning of this process, when I met with veterans whom I believed met criteria for PTSD, I would routinely encourage them to access specialty mental health treatment at the local outpatient clinic to initiate one of two empirically-supported treatments (ESTs) for PTSD: prolonged exposure (PE) or cognitive processing therapy (CPT). It did not take me long to recognize a significant problem with this approach: the overwhelming majority of service members outright refused to access specialty mental health services, preferring to “just deal with it on my own.” By and large, these individuals continued to experience functional impairment and continued to access medical services at a high rate. One variable that stood out was the persistence of re-experiencing symptoms (i.e., nightmares, memories, flashbacks), and, critically, the veteran’s continued employment of avoidance strategies in response to these experiences. It quickly became evident that, if any improvements were to occur with this group of veterans, targeting of re-experiencing and avoidance symptoms would be necessary, which would necessitate a re-engineering of how PTSD symptomatology was approached within primary care.
The parameters
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 medical visits in primary care are due to psychosocial factors. The models vary in terms of how the mental health provider interacts with patients and, more importantly, who maintains primary responsibility for treatment decisions. One model of integrated primary care is the behavioral health consultant (BHC) model, which is marked by collaborative decision-making between PCPs and mental health professionals, who serve as consultants to the PCP. The BHC model of integrated primary care has been implemented by the United States Air Force (USAF) at hospitals and medical clinics world-wide. A thorough discussion and explanation of the BHC model is not practical for the purposes of this article, but readers are directed to Robinson and Reiter (2007) and Gatchel and Oordt (2003) for further information about the BHC model.
Based on the philosophy and practice standards of the BHC model, the following parameters were established a priori to guide treatment development within the scope of care of the BHC:
- Interventions must be able to be delivered in less than 30 minutes. Because BHC appointments mirror the pace and structure of the primary care clinic, appointments are generally only 20-30 minutes in duration. Interventions must therefore be designed to be rapidly demonstrated and learned by the patient.
- Interventions must demonstrate rapid, clinically-meaningful improvement. Because the typical course of care within the BHC model is very brief and time-limited, interventions must be highly-focused on the presenting problem and must demonstrate effectiveness in less than 5 appointments.
- Intervention approach must be based on a self-management model. Interventions must be problem-focused and geared towards the development of specific skills that can be learned, implemented, and sustained by the patient with minimal support by the clinician, since appointments with the clinician typically occur in 2-3 week intervals.
- Interventions must be supportable by the PCP. Because the PCP maintains full control of the patient’s treatment plan, any interventions developed must be acceptable and easily supported by the PCP. Similarly, the PCP must have a basic understanding of the rationale and mechanisms behind the intervention so they can explain treatment recommendations clearly to patients and effectively choose how and when to incorporate such interventions into their treatment plan.
In order to determine the effectiveness of any interventions implemented, it was first necessary to define and measure the constructs of interest in a manner that was appropriate for the clinical context. Extensive assessment with multiple measures or lengthy questionnaires is inconsistent with primary care and impractical in a fast-paced setting that emphasizes volume over intensity of services. Outcomes measurement must, therefore, balance brevity and pragmatics with reliability and validity, and should be limited to only those constructs of interest. Two self-report checklists that were both brief and psychometrically sound were chosen.
PTSD Checklist-Military Version (PCL-M). A particularly useful and practical measure for use with post-deployers seen in primary care is the PTSD Checklist-Military Version (PCL-M; Weathers, Litz, Herman, Huska, & Keane, 1993), which is a 17-item self-report inventory that assesses the severity of each DSM-IV-defined PTSD symptom. The PCL-M is widely used in the DOD and the VA, and it has excellent reliability and validity (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996; Weathers, et al., 1993). Members referred for deployment-related issues can routinely complete the PCL-M in about 2-3 minutes either before or during each BHC appointment.
Behavioral Health Measure-20 (BHM). The Behavioral Health Measure-20 (BHM) is a brief self-report questionnaire that uses a five-point Likert Scale to assess the three domains of mental health, consistent with the phase model of psychotherapy: well-being, psychological symptoms, and life functioning (Kopta & Lowry, 2002). The 20 items of the BHM aggregate to a total score that provides an index of overall mental health called Global Mental Health (GMH). The measure has considerable psychometric strength (Kopta & Lowry, 2002) and can be used to distinguish several levels of mental health functioning (Healthy, Mild Distress, Moderate Distress, Severe Distress) based on the clinical significance criteria recommended by Jacobson and Truax (1991). As such, the BHM is designed to detect clinically meaningful changes in mental health functioning.
In 2007, the Institute of Medicine’s (IOM) Committee on Treatment of Post-traumatic Stress Disorder published the most comprehensive scientific review to date of treatments for PTSD, which included results from 90 randomized clinical trials of psychotherapy and pharmacotherapy treatments for PTSD (IOM, 2007). The committee found that evidence of efficacy was sufficient only for exposure-based psychotherapies, while the scientific evidence currently available for other psychotherapy treatment modalities and pharmacotherapy were judged to be inadequate to determine efficacy. Prolonged exposure therapy (Foa, Dancu, Hembree, Jaycox, Meadows, & Street, 1999; Foa, Hembree, Cahill, Rauch, Riggs, Feeny, et al., 2005; Foa, Rothbaum, Riggs, & Murdock, 1991; Schnurr, Friedman, Engel, Foa, Shea, Chow, et al., 2007) and cognitive processing therapy (Resick, Nishith, Weaver, Astin, & Feurer, 2002; Resick, & Schnicke, 1992; Monson, Schnurr, Resick, Friedman, Young-Xu, & Stevens, 2006) have emerged from the past decade of clinical research as effective, first-line treatments for PTSD, and were therefore considered as potential candidates for modification and integration into a primary care clinic.
Written exercises were initially utilized to target the re-experiencing symptoms (e.g., intrusive thoughts, memories, and dreams) that contribute to avoidance and emotional detachment, which are the primary mechanisms underlying the functional impairment among trauma survivors. These exercises entailed directing veterans to record any specific events from their deployment that they find particularly problematic or bothersome and were heavily influenced by the work of Pennebaker, who has demonstrated that writing about stressful events (which he termed expressive writing) can contribute to a range of improved health outcomes (Pennebaker & Chung, 2007). Referring to the intervention as “combat writing” instead of “expressive writing” seemed to increase the appeal of the exercise among veterans. Asking veterans to write and re-write an account of their traumatic deployment experience through combat writing mirrors the process of prolonged exposure (PE), which repeatedly exposes the patient to distressing memories until they habituate to the physiological and emotional arousal, which eventually contributes to the modification of beliefs and perceptions of the traumatic event and the reduction of the avoidant response patterns that fuel PTSD.
Combat writing was employed in primary care because of its time-efficiency given the context of primary care, while maintaining an emphasis on repeated exposure to the traumatic memory and avoidant responses. In this way, it dovetails with the structure of the BHC service, in which the patient actively works to reduce symptoms outside of the appointment. Combat writing was utilized with a number of patients with some evidence of effectiveness (see Corso et al, in press, for a report of findings), with patient non-adherence being a particularly troublesome barrier. Patients cited several factors that reduced their adherence to the exercise:
- Veterans would often avoid the task because the memories were uncomfortable. Because appointments with the BHC were spaced out over periods of 2-3 weeks, it was difficult for the clinician to promptly target avoidance and reinforce adherence. This contributed to delayed clinical response, which was problematic given the time limitations of BHC work.
- Some veterans did not report a specific, identifiable traumatic event in which their lives, or the lives of others, were in danger or threatened, but rather reported a more generalized dissatisfaction or disgust with some aspect of their deployed experience. These veterans seemed to be experiencing more “existential” conflicts related to the meaning of their experiences, rather than a fear or anxiety response.
In short, although this initial attempt demonstrated some effectiveness, it could not be delivered in a manner that remained within the four parameters established at the outset, and therefore was not adequate for this setting.
The research literature was again reviewed, and discussions were initiated with colleagues and peers in the field. During one such discussion, Patti Resick brought my attention to a recent dismantling study of cognitive processing therapy (CPT; Resick, Galovski, Uhlmansiek, Scher, Clum, & Young-Xu, 2008) in which she found that cognitive restructuring without a written account of the trauma was not only as effective as cognitive restructuring with a written account, but (critically) also demonstrated more rapid symptom remission. She, therefore, suggested adapting some of the interventions and procedures from CPT for use within primary care clinics. A core intervention within CPT is the impact statement (IS), which helps to identify how the traumatic event is construed and coped with by the person who is trying to regain a sense of mastery and control in his or her life (Resick, Monson, & Chard, 2007). CPT focuses on the content of thoughts and the effect that distorted, unrealistic thoughts have on emotional responses and behaviors. Adopting a more realistic perspective of the traumatic event contributes to decreased emotional activation associated with memories of it. Thus, the IS could be used as a tool to identify unrealistic beliefs and perspectives, which can then be modified through basic cognitive restructuring skills.
Use of the IS within our clinic demonstrated good preliminary effectiveness (see Corso et al, in press) and circumvented the primary barriers experienced with combat writing. Specifically, veterans seemed much more willing to complete the assignment, which resulted in clinically-meaningful improvements in very few appointments.
The outcome results of the process outlined above are reported in Corso et al. (in press). Although preliminary effectiveness for these strategies was found, further research under controlled conditions is clearly needed to truly establish the efficacy of these interventions for PTSD in primary care; currently, a randomized controlled trial is underway. The key conclusion of this clinical program, however, was the demonstration of the feasibility of brief interventions within integrated primary care clinics when they are based on sound science.
The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of Defense, the Department of the Air Force, or the U.S. Government.
Craig Bryan is a captain in the United States Air Force and a clinician at Wilford Hall Medical Center.
Subscribe in a reader
