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Original Investigation |

Centrally Assisted Collaborative Telecare for Posttraumatic Stress Disorder and Depression Among Military Personnel Attending Primary Care A Randomized Clinical Trial

Charles C. Engel, MD1,2; Lisa H. Jaycox, PhD1; Michael C. Freed, PhD2,3,4; Robert M. Bray, PhD5; Donald Brambilla, PhD5; Douglas Zatzick, MD6; Brett Litz, PhD7; Terri Tanielian, MA1; Laura A. Novak, BS3; Marian E. Lane, PhD5; Bradley E. Belsher, PhD3; Kristine L. Rae Olmsted, MSPH5; Daniel P. Evatt, PhD3; Russ Vandermaas-Peeler, MS5; Jürgen Unützer, MD6; Wayne J. Katon, MD†6
[+] Author Affiliations
1RAND Corporation, Boston, Massachusetts
2Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
3Deployment Health Clinical Center, Silver Spring, Maryland
4now with National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland
5RTI International, Research Triangle Park, North Carolina
6Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
7Veterans Affairs Boston Healthcare System, Boston, Massachusetts
JAMA Intern Med. 2016;176(7):948-956. doi:10.1001/jamainternmed.2016.2402.
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Importance  It is often difficult for members of the US military to access high-quality care for posttraumatic stress disorder (PTSD) and depression.

Objective  To determine effectiveness of a centrally assisted collaborative telecare (CACT) intervention for PTSD and depression in military primary care.

Design, Setting, and Participants  The STEPS-UP study (Stepped Enhancement of PTSD Services Using Primary Care) is a randomized trial comparing CACT with usual integrated mental health care for PTSD or depression. Patients, mostly men in their 20s, were enrolled from 18 primary care clinics at 6 military installations from February 2012 to August 2013 with 12-month follow-up completed in October 2014.

Interventions  Randomization was to CACT (n = 332) or usual care (n = 334). The CACT patients received 12 months of stepped psychosocial and pharmacologic treatment with nurse telecare management of caseloads, symptoms, and treatment.

Main Outcomes and Measures  Primary outcomes were severity scores on the PTSD Diagnostic Scale (PDS; scored 0-51) and Symptom Checklist depression items (SCL-20; scored 0-4). Secondary outcomes were somatic symptoms, pain severity, health-related function, and mental health service use.

Results  Of 666 patients, 81% were male and the mean (SD) age was 31.1 (7.7) years. The CACT and usual care patients had similar baseline mean (SD) PDS PTSD (29.4 [9.4] vs 28.9 [8.9]) and SCL-20 depression (2.1 [0.6] vs 2.0 [0.7]) scores. Compared with usual care, CACT patients reported significantly greater mean (SE) 12-month decrease in PDS PTSD scores (−6.07 [0.68] vs −3.54 [0.72]) and SCL-20 depression scores −0.56 [0.05] vs −0.31 [0.05]). In the CACT group, significantly more participants had 50% improvement at 12 months compared with usual care for both PTSD (73 [25%] vs 49 [17%]; relative risk, 1.6 [95% CI, 1.1-2.4]) and depression (86 [30%] vs 59 [21%]; relative risk, 1.7 [95% CI, 1.1-2.4]), with a number needed to treat for a 50% improvement of 12.5 (95% CI, 6.9-71.9) and 11.1 (95% CI, 6.2-50.5), respectively. The CACT patients had significant improvements in somatic symptoms (difference between mean 12-month Patient Health Questionnaire 15 changes, −1.37 [95% CI, −2.26 to −0.47]) and mental health–related functioning (difference between mean 12-month Short Form-12 Mental Component Summary changes, 3.17 [95% CI, 0.91 to 5.42]), as well as increases in telephone health contacts and appropriate medication use.

Conclusions and Relevance  Central assistance for collaborative telecare with stepped psychosocial management modestly improved outcomes of PTSD and depression among military personnel attending primary care.

Trial Registration  clinicaltrials.gov Identifier: NCT01492348

Figures in this Article


Place holder to copy figure label and caption
Posttraumatic Stress Disorder (PTSD) and Depression Study Flow Diagram

AUDIT indicates Alcohol Use Disorders Identification Test; PDS, PTSD Diagnostic Scale; SCL-20, Somatic Symptom Severity Score-20.

aA total of 273 participants had data at baseline and all follow-ups for PDS; 280 participants had data at baseline and all follow-ups for SCL-20.

bA total of 271 participants had data at baseline and all follow-ups for PDS; 279 participants had data at baseline and all follow-ups for SCL-20.

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