More than 20 years ago, Sheila Rauch, PhD, director of Mental Health Research at the Atlanta VA, began her career as an intern at the University of Florida Health Science Center. As an embedded primary care mental health provider, she met many people who’d experienced or witnessed traumatic events but who weren’t able, for a number of reasons, to connect with a mental health care provider and receive a full course of treatment.
Post-traumatic stress disorder (PTSD) can be a debilitating condition, afflicting survivors with unwanted thoughts, nightmares, depression, feelings of hopelessness, and hypervigilance. Fortunately, several interventions have proven effective at treating these symptoms, including cognitive processing therapy (CPT), developed by VA clinical psychologist Patti Resick, and prolonged exposure therapy (PE), pioneered by Edna Foa at the University of Pennsylvania. Each of these is recommended as a gold-standard treatment for PTSD.
These treatments are challenging for patients psychologically and emotionally, but also pose logistical hurdles for people trying to live normal lives: The PE therapy developed by Foa, for example, is typically provided in 8 to 15 weekly sessions over a period of about three months, working with a mental health care provider.
Rauch’s experience in Florida, she said, “really solidified in me the need to find ways to get effective psychotherapy specifically into primary care settings, and to find brief versions that are still as effective as full versions.”
In the early 2000s, as a faculty member at the Center for the Treatment and Study of Anxiety at the University of Pennsylvania, Rauch collaborated with Foa and David Riggs, who now chairs the Department of Medical and Clinical Psychology at the Uniformed Services University of the Health Sciences, to develop manuals for the delivery of bibliotherapy – the use of books as a means of exposure therapy – to patients in primary care who were receiving anxiety medication. She focused more specifically on PTSD in collaboration with Jeff Cigrang, a psychologist and professor at Wright State University who, as a lieutenant colonel in the U.S. Army, had treated activeduty service members with PTSD using PE and other interventions. “He was seeing the same problem I was seeing,” said Rauch, “that people needed access to good PTSD treatment.” With funding from the Department of Defense, they pioneered and tested, in a randomized clinical trial, an adaptation of PE for primary care settings: prolonged exposure for primary care, or PE-Primary Care.
“For pretty much my whole career, in different forms,” said Rauch, who is also a professor in psychiatry at the Emory University School of Medicine and Mark and Barbara Klein Distinguished Chair in Mind Body Medicine, “I’ve been working on getting exposure interventions into primary care.”
PRIMARY CARE-MENTAL HEALTH INTEGRATION (PC-MHI)
Rauch is in the right place. The Veterans Health Administration, the nation’s largest integrated health care system, devotes considerable resources to studying, developing, implementing, and refining mental health care interventions for delivery in primary care settings. Much of the VA’s mental health research is conducted at its 17 Centers of Excellence, which include 10 Mental Illness Research, Education and Clinical Centers (MIRECCs). Each of these centers has a different area of focus and is overseen by the VA’s Office of Mental Health and Suicide Prevention, but the centers also collaborate on projects administered by the Office of Research and Development (ORD).
At the Corporal Michael J. Crescenz VA Medical Center in Philadelphia, David Oslin, MD, directs the MIRECC for VISN (Veterans Integrated Service Network) 4, which focuses on the study of pharmacogenetics and precision mental health care. He’s also chief of behavioral health at the medical center and a professor of psychiatry at the University of Pennsylvania’s School of Medicine. Over the past few decades, Oslin and his colleagues at the VISN 4 MIRECC have been intimately involved with the design, implementation, and evaluation of PC-MHI. This work supports the center’s mission to incorporate patient preference in treatment decisionmaking and develop treatment algorithms and decision aids for clinicians practicing in integrated and specialty care settings.
In the 1990s, when Oslin began his career, it was clear that for whatever reason, patients were seeking mental health care from primary care providers. “In the mid- to late nineties,” he said, “the evidence really started to emerge that primary care was our front-line mental health program in the U.S., and pretty much worldwide. There was lots of data showing that primary care providers prescribed more antidepressants and more psychotropics than all of mental health combined, and that it would be rare for somebody to come to a specialist, a psychiatrist, without having some level of treatment in a primary care setting. Despite that, primary care was really not set up or designed to treat chronic illnesses like depression or anxiety disorders or alcoholism … So those early studies in the nineties really started to assess the quality of the mental health care we were providing in primary care.”
Oslin was an investigator for a pair of these early studies comparing the clinical outcomes of traditional methods of mental health care and methods that integrated specialized care into primary care settings. One study, PRISM-E (Primary Care Research in Substance Abuse and Mental Health for the Elderly), compared access, costs, and clinical outcomes between the two models of care and found that remission rates and symptom reduction were similar at the three- and six-month follow-ups.
The VA health system acted on these findings. In 2007, it began nationwide implementation of PC-MHI to both expand access and promote the treatment of common mental health conditions for patients in primary care settings.
“The main principles for PC-MHI are behavioral health staff working alongside primary care staff, so that they’re really part of the PACT [Patient-Aligned Care Team] and that they’re seeing patients together,” Oslin said. “They know each other. The clinician, the mental health provider, is an integral part of the PACT, and not just somebody the primary care provider is referring a patient to.”
PC-MHI is also designed to be timely – delivered by the primary care provider when the patient needs it – and time-limited. “You’re not seeing patients for five years, two years – or even for a year,” said Oslin. “You’re seeing them for three to six months at most, and then you’re seeing the next patient or group of patients. If they really need long-term psychiatric or mental health care, they’ll go to our specialty care program.”
The integrated clinical program Oslin developed on the heels of PRISM-E has been used not only throughout the VA, but in other health care systems, and has been recognized with an award from the American Psychological Association. “We published a training program, called Foundations for Integrated Care,” he said, “which provides sort of an overview and content training for clinicians who want to work in this space.”
A critical element of PC-MHI is the ability to measure outcomes; these measurements take the form of patient questionnaires. Oslin’s team developed the software that about three-fourths of VA facilities use to track these self-reported outcomes in mental health care.
The software – the Behavioral Health Laboratory – is about to become easier for veteran patients to use: It will soon be rolled out in a format that will allow patients to fill it out and send it back to providers using their phones or other mobiles devices.
“The texting piece will be a huge upgrade for everybody,” Oslin said. It’s a perfect example of the innovations helping to connect veteran patients with quality mental health care, at the VA health care facility easiest for them to access.
TREATING PTSD IN PRIMARY CARE
The mental health needs of service members returning from Afghanistan and Iraq created a surge in demand for VA’s mental health care services, and the development of PC-MHI has been, in part, a response to this surge. A few years ago, the VA launched a concerted push to expand its capacity to help veterans, hiring more than 1,000 additional mental health professionals around the country.
The mental health needs of veteran patients continue to challenge the VA’s more than 24,000 mental health professionals. “There aren’t enough doctors trained in what works,” said Rauch. “Whether you’re talking about medication management or psychotherapy, there just aren’t enough of us out there.”
Getting veteran patients into primary care for Rauch’s specialty, PTSD, is important for another reason: “A lot of patients never land in specialty mental health care,” she said. The process of jumping through preliminary hoops to get from primary care to a specialty mental health clinic – submitting a referral, waiting for an intake appointment, undergoing assessment, and then orientation, and in some cases a few weeks of preparatory classes – is often never completed.
“PTSD is a disorder of avoidance,” Rauch said. “If we don’t grab them the moment they say: ‘Okay, I do want to address this,’ and quickly give them the intervention we think works best, they’ll fall back into old patterns of avoidance. They’re very likely not to follow through on those referrals and never actually show up in specialty mental health.” If they do, she said, they may not be able to stick with a program that requires 8 to 15 sessions of 90-minutes duration each.
Rauch has adapted the PE-Primary Care intervention she developed with Cigrang for use in VA primary care settings. This pilot version is briefer than the traditional PE model for treating PTSD. But although it involves fewer and shorter sessions, it’s a demanding course of therapy that asks veterans to approach their worst memories and fears, in procedures known as imaginal exposure (vividly recalling a traumatic experience), in vivo exposure (directly confronting a feared situation or activity), and emotional processing (unlearning the emotional avoidance of traumatic memories).
“We wanted to develop something that was as effective as the full PTSD treatment that could be distributed to a larger population,” Rauch said. She recently completed a randomized clinical trial comparing outcomes of PE-Primary Care – four to six 30-minute sessions, delivered in primary care clinics – to traditional PTSD treatments. “We had a 40 percent remission rate for people who had PTSD,” she said – about the same rate as traditional PE or CPT. “Most of the patients showed clinically significant reductions in PTSD symptoms.”
Both Oslin and Rauch point out that integrated care is meant to complement, not replace, specialty mental health care. Years ago, a subgroup of subjects in Oslin’s PRISM-E study – those with major depression – responded better to specialty care. And some conditions, such as psychotic disorders or bipolar disorder, tend to be better served in specialty care practice.
Likewise, when a group of patients has completed Rauch’s PE-Primary Care treatment for PTSD, the care team turns its attention to the patients who still experience some symptoms. “There are two groups I would describe there,” she said. “One group, when we first start seeing them in PE-Primary Care, we know right away that they require more support to be able to approach their trauma memory than we can provide in a brief primary care setting. So they would get a facilitated quick referral to work with a specialty mental health provider in a standard PE or CPT model.”
Another group may have received some benefit from PE-Primary Care, but may need some follow-up with a specialty care provider. Rauch and her team are currently focusing a study specifically on that group of patients, to see whether, compared to those who are referred right off the bat, they are as likely to follow through on the referral after completing a course of PE-Primary Care. The ultimate point of this intervention, Rauch said, is to get veterans into active, effective PTSD treatment in whatever setting they’re willing to participate, and to make sure they stay connected to that care until they have their best chance of remission.
In this, Rauch’s aims are perfectly in tune with VA’s efforts to integrate effective mental health care into its primary care settings: “I want to find ways to get effective treatments out there to people where they are,” she said. “My goal in my career – and not just in my PE-Primary Care work – is really to help people with PTSD have access to care in whatever setting they want to receive it, and have that care be the highest quality possible.”
This article along with other articles on VA Research can be found in the following edition of Veterans Affairs & Military Medicine OUTLOOK.