Army's RESPECT-MIL Program Aims to Reduce Stigma by Screening All Care-Seeking Soldiers for PTSD

From Army News Service:

According to Army medical officials, the new Re-Engineering Systems for the Primary Care and Treatment of Depression and PTSD in the Military program is designed to help providers recognize warning signs and treat those disorders early while eliminating Soldiers' fears about the stigma of psychological illnesses and their treatment.

Program officials say RESPECT-MIL takes advantage of any visit Soldiers make to their assigned primary care physicians for any reason, turning those visits into opportunities to detect symptoms that could indicate that the Soldier is struggling with PTSD.

"The Army is doing a lot more as far as trying to reach out and find Soldiers who are having issues but are reluctant to seek mental health care due to the historical mental health stigma within the military," said Dr. (Maj.) David Johnson, a Schweinfurt Health Clinic psychiatrist.

In educational interest, article(s) quoted from extensively.

Continuing:

According to Col. Angela Pereira, director of Soldier and Family Support Services for the Europe Regional Medical Command, [s]oldiers usually visit their primary health providers 3.4 times a year on average, and each of those visits is a chance for doctors to detect any behavioral health problems and get Soldiers the treatment they need.

"RESPECT-MIL tears down the walls concerning PTSD by making questions concerning PTSD and depression a routine activity any time someone visits their local primary health provider, which offers Soldiers and their Family members extra chances to spot a problem early on," said Lt. Col. Raymond L. Gundry, ERMC's deputy commander of outlying clinics.

"We also try to make it clear to Soldiers that seeking help is not going to adversely affect their careers or make anyone think any less of them," he continued. "A major part of the process for 'tearing down the walls' is screening everybody that comes through, demonstrating that it is OK if someone suffering from PTSD seeks help."

By asking just a handful of questions, Gundry said, trained physicians can determine if a patient is suffering from depression or PTSD, and either help the patient -- if the physician is qualified -- or refer the patient to a mental health specialist.

A little history on the program and the training of its facilitators via a February Psychiatric News article by Aaron Levin:

The staged rollout of the program, known as RESPECT-Mil, began one year ago at the direction of the Army surgeon general and will spread to 43 clinics on 15 military bases in the U.S., Germany, and Italy over 24 months. Program leaders from 13 of the 15 bases have been trained in its function so far, and about 10 clinics have it in operation. Congress recently increased funding to expand the program further. ...

RESPECT-Mil is the military version of the "Re-Engineering Systems for Primary Care Treatment of Depression," a model developed over the last decade by researchers from Dart mouth Medical School, Duke University Medical Center, and others, backed by the John D. and Catherine T. MacArthur Foundation's Initiative on Depression and Primary Care. The model uses three types of providers: care managers, primary care providers, and psychiatrists.

The original MacArthur program began in 1995 at the behest of primary care providers led by Allen Dietrich, M.D., a family medicine specialist at Dartmouth, now a consultant to the Army.

"The MacArthur initiative was intentionally designed not to be a research trial," said Thomas Oxman, M.D., professor emeritus of psychiatry at Dartmouth and also a consultant to the Army's project, in an interview with Psychiatric News. "We were interested in dissemination and permanence from the start, and we wanted users to incur minimal costs."

To cut costs in the MacArthur initiative, for instance, telephone monitoring was used instead of face-to-face sessions with patients, and the care managers were not required to have medical or mental health backgrounds, just good interpersonal skills. ...

Preparation for RESPECT-Mil begins by training the three sets of professionals involved. The Army decided to use only nurses as care managers and calls them facilitators. The facilitators get four to eight hours of specialized training, while primary care providers (physicians, physician assistants, or nurse practitioners) get two hours, and psychiatrists get one hour. Manuals delineate procedures for everyone. [Pdf copy of the Army's Respect-Mil Care Facilitator (RCF) Reference Manual, Version 10.4, Sep 07.]

Oxman has helped train Army personnel in the program. Once trained, they go back to their bases and train more staff. The program includes provisions for "booster" training sessions, drawing on the clinical experience of the participants or case presentations. The biggest difference between civilian and military versions of the program are the current shortage of health care providers in the Army and the constant need to train new providers when the original ones get assigned to Iraq or Afghanistan, said Oxman.

Returning to the Army News Service piece:

Maj. Joseph Dougherty, the chief of behavioral health at the Vilseck (Germany) Health Clinic, recently completed the three-day RESPECT-MIL training program. He said the course teaches different approaches to detecting and treating depression and PTSD.

"We learned about how the different processes of screening, identifying, and treatment of these disorders function under RESPECT-MIL; did some role play; and had a rundown of the entire program," Dougherty said. "We also learned how we can educate other primary care providers and psychiatrists in the RESPECT-MIL system."

Gundry said the bottom line is that "the training RESPECT-MIL provides allows primary health care providers to get help for their patients immediately."

For example, he explained, if a Soldier visits a physician trained in RESPECT-MIL methods for a physical exam, the doctor might ask if the Soldier has had difficulty sleeping or has been feeling constantly "down." Based on the answers, the doctor can determine if the Soldier may be suffering from PTSD or depression and recommend treatment.

"Screening all Soldiers and getting their doctors to talk to them about mental health" is a critical step to treating the increased number of Soldiers with mental health problems, Johnson said. "The cycle of deployments that (we are) in has generated a lot more mental health problems in Soldiers who might otherwise never have seen me.”

The Army's RESPECT-MIL initiative was developed at the Fort Bragg, N.C., RESPECT-MIL Center of Excellence, the organization leading the Army's worldwide implementation of the program. ... "The trials performed at the Fort Bragg Center of Excellence showed a significant increase in the successful diagnosing and treatment of Soldiers with PTSD and depression," said Pereira. Gundry added that during the 2006 trials, 60-90 percent of PTSD patients showed improvement.

What the program looks like in practice via Psychiatric News:

During each visit, a medic administers a two-question depression screen (PHQ-2) and a four-item PTSD screen, said Engel. Anyone screening positive gets the full PTSD Check List and the full PHQ-9 for depression, plus a 10-minute session with the primary provider. The PHQ-9 score determines the provisional diagnosis and appropriate treatment recommendations. Any diagnosis of depression or PTSD also calls for an evaluation of suicide risk assessing suicidal thoughts and risk factors. Indications of suicidality call for a longer visit (30 to 45 minutes) with the provider.

Patients and providers discuss treatment options, including the risks and benefits of antidepressants. Patients may choose to accept medication or psychotherapy or both. (In earlier tests at Fort Bragg, N.C., about 10 percent of soldiers refused any treatment.) Soldiers also learn about other options for care, such as chaplains, Army Community Services, or Military OneSource, a contract service that provides support and counseling for troops and their families.

The nurse facilitator takes over after the initial visit and follows each patient with telephone calls to monitor progress and offer support and suggestions. The psychiatrist consults weekly with the facilitator, who relays information back to the primary care provider. Psychiatrists, although first concerned about the added workload (about 30 cases), are able to confer efficiently with the facilitators.

"Supervision requires about two to five minutes per patient, depending on patient acuity, severity, and past history of problems," said [Army Lt. Col. (Dr.) Charles] Engel. "Many patients don't need any changes in treatment plan or have major risk factors, so these patients can be reviewed briefly."

Those with significant problems need more time but are also more likely to be referred to specialty care and out of the primary care caseload. Patients remaining in primary care have less acute or severe symptoms and so require less time.

Initial response to treatment is evaluated at six to eight weeks for antidepressants and four to six weeks for psychological counseling; treatment is adjusted after that evaluation.

"We encourage adherence, overcome barriers, and monitor the response with accountable, continuous follow-up until remission," said Engel, who is also director of the Deployment Health Clinical Center at Walter Reed Army Medical Center and an associate professor in the Department of Psychiatry at the Uniformed Services University of the Health Sciences.

It is too early to measure clinical outcomes of the program, but 75 percent of visits at participating sites have resulted in screens, compared with 2 percent to 5 percent at comparable sites. About 9 percent of the screens were positive for PTSD, 9 percent for depression, and 10 percent for both, said Engel. Furthermore, 91 percent of positive screens have documented referrals for follow-up visits.