Psychotherapy Treatment of Deployment-Related Post-Traumatic Stress Disorder (PTSD) in Primary Care Settings

The study investigators have developed a 4-session PTSD treatment protocol including a
behavioral health consultants (BHC) manual and a patient guide for use in primary care (See
Appendix A) The treatment incorporates key elements of effective treatments for PTSD used
in specialty settings and has been developed based on the investigators' clinical experience
in primary care and a review and editing input from nationally-recognized experts on PTSD
treatment Therapists will be psychologists who are functioning as behavioral health
consultants (BHC) in an integrated primary care clinic. Study participants will receive four
30-minute treatment sessions over six weeks, and up to two additional sessions if the
therapist and participant agree that additional sessions would be beneficial.

At WHMC and BAMC: Potential participants will be active duty, separated, and retired OIF/OEF
veterans with PTSD symptoms who are referred by their primary care manager to the behavioral
health consultant. Current standard of care for these patients is to provide assessment,
psycho-education, and referral to specialty mental health care for a trial of CBT for PTSD.
However, many veterans are reluctant to be seen in specialty care and will not accept a
referral. The behavioral health consultants (BHC) routinely sees these patients now in
primary care for a time-limited consultation (typically two to three 30-minute appointments
over 5-6 week period) while the primary care manager retains overall responsibility for
their care. Consultation in these cases has consisted of abbreviated elements of effective
specialty care treatments. The abbreviated treatments, while usually shown helpful for
individual patients, have not been systematically evaluated and the content has varied
across provider and time. The purpose of the present research proposal is to develop and
evaluate a standardized version of behavioral health consultation for PTSD in primary care.

At the STVHCS: Potential participants will be active duty, separated, or retired OIF/OEF
veterans with PTSD symptoms who are referred by their primary care manager to the behavioral
health consultant. Current standard of care for these patients is to provide assessment,
psycho-education, and referral to specialty mental health care in the PTSD clinic for
prolonged exposure, cognitive processing therapy, and/or psychoeducational interventions
However, many veterans are reluctant to be seen in specialty care and will not accept a
referral. The behavioral health consultants (BHC) routinely sees these patients now in
primary care for a time-limited consultation (typically three to four 30-minute individual
appointments on a monthly basis or weekly group psychotherapy using CBT and psycho-education
on a weekly basis for 4 weeks) while the primary care manager retains overall responsibility
for their care. Consultation in these cases has consisted of abbreviated elements of
effective specialty care treatments. The abbreviated treatments, while usually shown
helpful for individual patients, have not been systematically evaluated and the content has
varied across provider and time. The purpose of the present research proposal is to develop
and evaluate a standardized version of behavioral health consultation for PTSD in primary
care.

The study will employ a quasi-experimental design in which we will measure within subject
changes in a series of clinical cases. This design is sometimes referred to as a clinical
replication series (Morin, Stone, McDonald, & Jones, 1994). This design will be used
because it will allow us to evaluate the general effectiveness of this treatment approach
when used in clinical practice in military primary care settings. It will also provide the
valuable pilot data that may lead to a larger randomized clinical trial in the future.

Effectiveness of behavioral health consultation in primary care will be assessed based on
degree of reduction in PTSD symptoms at post-treatment and at 6 and 12 month follow-up
periods. The effect of consultation on symptoms of depression will be examined as
depressive symptoms often co-exist with PTSD symptoms and are responsive to CBT treatments
for PTSD. A general measure of global mental health functioning will also be included in
the outcome measures.