Research Studies

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, the first large-scale, randomized effectiveness trial of integrated mental health services conducted in the Military Health System (MHS), tested whether a system of centrally assisted collaborative telecare within military primary care improves the quality of care and outcomes for service members with PTSD and depression, as compared to those service members who receive standard care.

The effectiveness of the centrally assisted collaborative telecare package was compared to optimized usual care at six Army posts over four time points. Compared with standard care, participants in the centrally assisted collaborative telecare group reported significantly greater decreases in depression and PTSD symptoms at 12 months, as well as significantly greater improvements in somatic symptoms and mental health-related functioning. Participants in the centrally assisted collaborative telecare group were also more efficiently triaged to appropriate care based on the complexity of their presenting symptoms, compared to the standard care group.

Selected Publications

Refining a Single-Item PTSD Screener for Use in DoD Primary Care

The Single-Item PTSD Screener (SIPS) is an ultra-brief PTSD screening tool that was developed and tested by PHCoE in a previous research study to facilitate efficient and effective screening in DoD primary care. This study built upon the previous study by testing data-driven refinements to the SIPS item. The goal was to examine the performance of the refined SIPS relative to the widely used 4-item Primary Care PTSD Screen (PC-PTSD) in predicting probable PTSD diagnosis.

Two refined versions of the SIPs were tested against a “gold standard” PTSD structured diagnostic interview with a representative sample of 437 DoD health care beneficiaries. Analyses are currently underway, but preliminary findings suggest that the SIPS is a promising ultra-brief PTSD screening instrument for military primary care.

Selected Presentations

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 PTSD symptoms 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.

Eighty veterans with PTSD participated in the trial, and DESTRESS-PC was associated with significantly greater decreases in PTSD symptoms at six and 12 weeks. DESTRESS-PC shows promise as a means of delivering effective, early PTSD treatment in primary care, but larger trials are needed.

Evaluating Alternate Response Formats of the Posttraumatic Stress Disorder Checklist

The Posttraumatic Stress Disorder Checklist, Civilian Version (PCL-C) is a 17-item self-report measure developed for measuring PTSD symptom severity and estimating PTSD caseness when administration of a structured clinical interview is not feasible. The validated PCL-C uses a 1–5 Likert scale, which may result in response bias because the minimum anchor of the scale does not inherently indicate the absence of the attribute (specifically PTSD symptoms). A zero-anchored response scale may improve the clinical utility of the measure by providing more intuitive anchors for respondents and easier scoring for clinic staff. The purpose of the study was to evaluate the equivalence of a zero-anchored PCL (0–4 Likert scale) to the traditional one-anchored version.

Results indicated that the zero-anchored PCL-C was equivalent to the one-anchored PCL-C in a sample of 120 DoD primary care patients. Findings support the use of a zero-anchored PCL-C in clinical practice, as well as the use of zero-anchored scales in the larger field of psychological assessment.

Multiple Somatic Symptoms in U.S. Military Personnel

Multiple physical symptoms (MPS) have historically been observed after deployment to a combat zone and are often disabling in nature. The Multiple Somatic Symptoms in U.S. Military Personnel study supports efforts to understand MPS and their relationship to deployment over time. The study used a multinomial logistic regression model to examine the prevalence, incidence, relationship to deployment and longitudinal trends of MPS in 76,924 service members who participated in the Millennium Cohort Study, a prospective health project launched in 2001 at the DoD Center for Deployment Health Research to evaluate the long-term health effects of military service, including deployments.

After adjustment for demographic, military and health characteristics, service members who deployed with combat were significantly more likely to report MPS at each time point compared with those not deployed, and those who deployed without combat.

Selected Publications