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