Impact of Collaborative Care for Underserved Patients with PTSD in Primary Care: a Randomized Controlled Trial

Abstract

BACKGROUND:The effectiveness of collaborative care of mental health problems is clear for depression and growing but mixed for anxiety disorders, including posttraumatic stress disorder (PTSD). We know little about whether collaborative care can be effective in settings that serve low-income patients such as Federally Qualified Health Centers (FQHCs). OBJECTIVE: We compared the effectiveness of minimally enhanced usual care (MEU) versus collaborative care for PTSD with a care manager (PCM). DESIGN: This was a multi-site patient randomized controlled trial of PTSD care improvement over 1 year. PARTICIPANTS: We recruited and enrolled 404 patients in six FQHCs from June 2010 to October 2012. Patients were eligible if they had a primary care appointment, no obvious physical or cognitive obstacles to participation, were age 18-65 years, planned to continue care at the study location for 1 year, and met criteria for a past month diagnosis of PTSD. MAIN MEASURES: The main outcomes were PTSD diagnosis and symptom severity (range, 0-136) based on the Clinician-Administered PTSD Scale (CAPS). Secondary outcomes were medication and counseling for mental health problems, and health-related quality of life assessed at baseline, 6 months, and 12 months. KEY RESULTS: Patients in both conditions improved similarly over the 1-year evaluation period. At 12 months, PTSD diagnoses had an absolute decrease of 56.7 % for PCM patients and 60.6 % for MEU patients. PTSD symptoms decreased by 26.8 and 24.2 points, respectively. MEU and PCM patients also did not differ in process of care outcomes or health-related quality of life. Patients who actually engaged in care management had mental health care visits that were 14 % higher (p < 0.01) and mental health medication prescription rates that were 15.2 % higher (p < 0.01) than patients with no engagement. CONCLUSIONS:A minimally enhanced usual care intervention was similarly effective as collaborative care for patients in FQHCs.

The Prevalence of Posttraumatic Stress Disorder in Primary Care: A Systematic Review

“…69, 70 There is some preliminary evidence including three randomized controlled trials indicating that collaborative care may be an effective intervention for PTSD in primary care; 10, 71-74 and some evidence that other interventions in primary care may be equally or more effective than collaborative care. 75, 76 One randomized controlled trial found that patients who attended eight cognitive processing therapy (CPT) sessions in addition to usual care by a primary care clinician had equal improvement to patients who received extensive telemedicine collaborative care interventions. 71 This finding might reflect that patients who are able to tolerate eight therapy sessions are a self-selecting population who is more able to engage in treatment, or it might indicate that therapy is the mainstay of treatment for PTSD.…”

“…Another randomized controlled trial found that patients receiving a “minimally enhanced usual care intervention” consisting of primary care clinician education about “trauma, PTSD, and evidence-based psychopharmacology” resulted in improvement greater than those receiving a more traditional and resource intensive collaborative care intervention. 76 This surprising finding may indicate that treatment with a provider whom the patient is comfortable and has an already-established relationship is more successful than more intensive treatment with a new team, and suggests that psychoeducation and medication education for primary care physicians may be a cost effective method of treating patients with PTSD. However, decreased PTSD symptoms were noted for all groups in the study, and improvements in the “minimally enhanced usual care” group were not overwhelmingly different than the collaborative care group.…”

“…However, decreased PTSD symptoms were noted for all groups in the study, and improvements in the “minimally enhanced usual care” group were not overwhelmingly different than the collaborative care group. 76 It seems that attention to this diagnosis is likely helpful, and that researchers have yet to determine the specific clinical treatment that works best. Given the high prevalence of PTSD in primary care and the lack of specialty mental health providers to adequately manage PTSD, more studies of types of collaborative care or other interventions for this condition in primary care settings are needed to better understand how to optimally meet the needs of this population.…”

“…76 Primary care providers can use a screening tool such as the PTSD symptom checklist-civilian (PCL-C, 17 questions) or the PC-PTSD (4 questions) (both showed >80% sensitivity and specificity) 31 to help identify possible PTSD in patients presenting with symptoms of anxiety or depression who have a history of trauma exposure. Following a positive PTSD screen and warranted diagnostic assessment to confirm a positive screen, primary care providers can prescribe prazosin for nightmares, serotonin reuptake inhibitors (paroxetine and sertraline are the only medications that are FDA approved for PTSD treatment) and/or venlafaxine as evidence-based options that have been shown to have efficacy for PTSD, and refer for appropriate therapy if the patient is agreeable to this intervention.…”

Capsule Commentary on Meredith et al., Impact of Collaborative Care for Underserved Patients with PTSD in Primary Care: A Randomized Controlled Trial

“…1 The improvement rates in both groups were remarkably high, with effect sizes for PTSD severity reduction exceeding 1.5 SD and nearly 60 % of participants no longer meeting diagnostic criteria for PTSD at 1 year. Reasons for a negative trial might include enrollment of patients with less severe PTSD and a more favorable natural history, a stronger than expected effect of training in the enhanced usual care group, or a weaker than expected collaborative care intervention.…”