Overview of DHCC Military Health System Research

Overview of DHCC Military Health System Research
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In 2012, DHCC became the psychological health operational arm for DCoE, and began to develop an integrated portfolio of research to improve the psychological health system of care. Through congressional mandate, DCoE is responsible for psychological health and traumatic brain injury in the DoD, and is allocated funds by the DoD to conduct relevant research. Research at DHCC is conducted by a multi-disciplinary team of scientists, providers, subject matter experts and support staff. The team brings together a wide variety of experience and expertise to effectively carry out DHCC’s research mission. The center’s major research activities include:

  • Conduct novel research in order to develop and test strategies to better recognize, manage and treat psychological health related problems as well as improve access to and continuity of services
  • Manage research portfolio conducted off-site, including serving in an oversight capacity of Federally Funded Research and Development Centers (FFRDC) studies
  • Translate research studies, including dissemination of scholarly findings to stakeholders, policy makers, providers and other researchers; influencing decisions related to clinical practice
  • Set priorities for new research, including leading and assisting with gap analyses to influence psychological health research priorities within the DoD
  • Provide subject matter expert support to working groups, internal progress reviews (IPRs), program reviews and responses to outside stakeholders

DHCC’s research team collaborates with organizations and subject matter experts within and outside of the government.  Past and current collaborators include government agencies, independent research organizations and academic institutions.

DHCC Research Mission

The DHCC research mission is to initiate, conduct and manage a portfolio of innovative programmatic and externally-funded psychological health research while leading and assisting with research priority setting and knowledge dissemination, translation and integration efforts to close the science-to-service delivery gap.

Research Overview

DHCC conducts military health services research on a wide range of topics, including treatment for PTSD and depression, primary care PTSD screening, collaborative care/primary care-based treatments for mental health disorders, telehealth treatment for mental health disorders, and screening and brief intervention for alcohol abuse. Recent projects have focused on the following areas:

  • Survey/epidemiological studies and literature reviews to broaden the research in this field
  • Studies to improve the screening and identification of those who need treatment
  • Efficacy studies to test new treatments for mental health problems that are common among post-deployed service members
  • Large-scale effectiveness studies that aim to improve the system of care for military service members and evaluate the relative cost-effectiveness of various interventions
  • Studies that examine how to bring better screening and interventions to primary care and how to integrate specialty mental health care into the primary care setting where most service members receive their health care

Research Spotlight

STEPS UP: A Randomized Effectiveness Trial for PTSD and Depression in Primary Care

The Stepped Enhancement of PTSD Services Using Primary Care (STEPS UP) trial tests whether a system of collaborative care within military primary care improves the quality and outcomes for service members with PTSD and depression as compared to those service members who receive standard care. The [JRH1] Primary Care Behavioral Health Program (formally, RESPECT-Mil), a collaborative care management program for PTSD and depression, already exists as the standard of care. However, the STEPS UP intervention offers the following significant enhancements to the optimized usual care:

  1. The option for centralized, telephone-based care management to improve fidelity of intervention delivery, continuity of care, and access to care during off-hours.
  2. A centralized care team to provide staffing to care managers, support medication management, track patients over time, and provide treatment recommendations.
  3. Care manager training in motivational enhancement, problem solving, and behavioral activation strategies to improve patient engagement.
  4. The option for psychosocial interventions —stepped in intensity and based on patient preference and symptom severity—to supplement pharmacotherapy.

The effectiveness of the STEPS UP package was compared to optimized usual care at six Army posts over four time points. The study team hypothesized that STEPS UP would improve (1) PTSD and depression symptom severity (primary hypothesis); (2) other anxiety and somatic symptom severity, alcohol use, mental health functioning and work functioning; (3) STEPS UP will be deemed a cost-effective management package for PTSD and depression; and (4) patients, their family members, and providers will find the approach an acceptable, effective and satisfying way to deliver and receive care.

Study recruitment, data collection and analysis are complete. A manuscript with full study findings has been submitted with expected publication in winter/spring 2016. Several other study-related manuscripts are in press, under review, or in progress.

SIPS: Refining a Single Item PTSD Screener for Primary Care

In a previous research study, DHCC developed and evaluated the Single Item PTSD Screener (SIPS) to facilitate screening among primary care providers in a DoD primary care population. DHCC has been awarded additional grant funding to complete phase two of the study, in which the SIPS will be further refined and evaluated. The goal of this project is to improve the SIPS’ sensitivity and specificity with the desired outcome that the item will perform as well as or better than the widely used four-item screen, the Primary Care-PTSD Screen (PC-PTSD). The original SIPS and two alternate versions are being tested against a gold standard PTSD structured diagnostic interview and a self-report questionnaire with a representative sample of up to 600 DoD health care beneficiaries recruited from a DoD primary care clinic waiting area. Data collection is complete, and data analysis is underway.

DESTRESS-PC: A Brief Online Self-Management Tool for PTSD

Delivery of Self Training and Education for Stressful Situations—Primary Care (DESTRESS-PC) is a brief internet-based online self-management tool for PTSD based on empirically valid cognitive behavioral therapy strategies. This randomized controlled trial assessed the feasibility and efficacy of DESTRESS-PC for reducing the symptoms of PTSD of Iraq and Afghanistan war-zone exposed soldiers and veterans. The goal of this study was to improve primary care mental health services for combat-deployed military personnel and veterans with PTSD by providing early, high-quality access to low-stigma mental health care. Recruitment ended in 2011 at the three study sites. Primary data analysis is complete, and a manuscript was published in General Hospital Psychiatry in 2015.

DHCC Selected Presentations

  • Evatt, D. P., & Freed, M. (2015). Improving PTSD and Depression Care in the U.S. Military: Evidence for System Change. Talk presented at the American Psychological Association Annual Convention, Toronto, Canada. September, 2015.
  • Freed, M.C. (May 2015). Randomized Effectiveness Trial of Collaborative Care in the U.S. Military: Effects on PTSD, Depression, Functioning, and Service Use. In C.C. Engel (Chair), Implementation and Evidence: Collaborative Primary Care for PTSD and Depression in the U.S. Military. Symposium conducted at the 168th Annual Meeting of the American Psychiatric Association, Toronto, ON.
  • Freed, M.C. (August 2014). Collaborative Primary Care for Depression and PTSD in the U.S. Military Health System: Design and Early Findings from STEPS-UP, a Multisite Randomized Effectiveness Trial. Presented at the Military Health System Research Symposium (MHSRS), Ft. Lauderdale, FL.
  • Freed, M.C., Engel, C.C., Belsher, B., Evatt, D., Wortmann, J., Novak, L., Jaycox, L.H., & Bray, R.M. (November 2014). Suicide Risk and Correlates to PTSD, Depression, and Alcohol Misuse in Military Primary Care Populations. Presented at the 30th annual meeting of the International Society for Traumatic Stress Studies, Miami, FL.
  • Freed, M.C., Novak, L.A., Killgore, W.D.S., Koehlmoos, T.P., Ginsberg, J.P., Krupnick, J., Rauch, S., Rizzo, A., & Engel C.C. (August 2014). DoD IRB Delays: Do They Really Matter? And If So, Why and for Whom? Poster presented at the Military Health System Research Symposium (MHSRS), Ft. Lauderdale, FL.
  • Khusid, M. (May 2014). Self-Care Meditation Approaches Used Adjunctively in PTSD Management. Workshop given at the 167th American Psychiatric Association Annual Meeting, New York, NY.

DHCC Selected Publications

  • Belsher, B.E., Curry, J., McCutchan, P., Oxman, T., Corso, K.A., Williams, K., & Engel, C.C. (2014). Implementation of a Collaborative Care Initiative for PTSD and Depression in the Army Primary Care System. Social Work in Mental Health, 12(5-6), 500-522.
  • Engel, C.C., Bray, R.M., Jaycox, L., Freed, M.C., Zatzick, D., Lane, M.E., Brambilla, D., Olmstead, K.R., Vandermaas-Peeler, R., Litz, B., Tanielian, T., Belsher, B.E., Evatt, D.P., Novak, L.A., Unutzer, J., & Katon, W.J. (2014). Implementing collaborative primary care for depression and posttraumatic stress disorder: Design and sample for a randomized trial in the U.S. military health system. Contemp Clin Trials, 39(2), 310-319.
  • Engel, C.C., Cordova, E.H., Benedek, D.M., Liu, X., Gore, K.L., Goertz, C., Freed, M.C., Crawford, C., Jonas, W.B., & Ursano, R.J. (2014). Randomized Effectiveness Trial of a Brief Course of Acupuncture for Posttraumatic Stress Disorder. Med Care, 52(12 Suppl  5), s57-s64.
  • Engel, C.C., Litz, B., Magruder, K., Harper Cordova, E., Gore, K., Stein, N., Yeager, D., Liu, X., & Coe, T. (2015). Delivery of Self Training and Education for Stressful Situations (DESTRESS-PC): A Randomized Trial of Nurse Assisted Online Self-Management for PTSD in Primary Care. Gen Hosp Psychiatry, X(X).
  • Gore, K.L., Engel, C.C., Freed, M.C., Liu, X., & Armstrong, D.W. (2008). Test of a Single-Item Posttraumatic Stress Disorder Screener in a Military Primary Care Setting. Gen Hosp Psychiatry, 30(5), 391.
  • Khusid, M, Vythilingam, M. The emerging role of mindfulness meditation as effective self-management strategy: parts 1, 2: clinical implications for depression, PTSD, anxiety, chronic pain, substance misuse, and insomnia. Military Medicine, in press.
  • Liu, X. (2014). Survival Models on Unobserved Heterogeneity and their Applications in Analyzing Large-scale Survey Data. J Biomet Biostat, 5(191), 2-12.