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| IMPLEMENTATION STORIES
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RESPECT Expands Beyond Depression
When Colonel Charles Engel of the Department of Defense, Deployment Health Clinical Center heard Dr. Allen Dietrich’s presentation about the RESPECT-Depression Project1, he wondered: Could RESPECT-Depression be expanded to serve the mental health needs of troops returning from war zones? Follow-up conversations between Dr. Dietrich and Colonel Engel resulted in a pilot project with initial support from the John D. and Catherine T. MacArthur Foundation and additional support from the Henry Jackson Foundation and the Department of Defense.
The project idea was to expand the scope of the MacArthur Foundation Initiative, Re-Engineering Systems in Primary Care Treatment of Depression (RESPECT-Depression), to include posttraumatic stress disorder (PTSD) as well. Screening was also added. The original RESPECT-Depression Project did not include screening, but rather focused on patients already recognized by their clinicians as suffering from depression. Colonel Engel felt that active duty soldiers needed to be screened both because of potential stigma about self-identifying for a mental health problem and because continuity of care may not be available, making recognition more of a challenge.
The RESPECT-Depression Project was thus transformed into RESPECT-Mil. The project included a two-question screen for depression and a four-question screen for PTSD given to soldiers at the time of the medical visit2. Those who screen positive receive more detailed assessments, the PHQ-9 for depression (see Tool Kit Page 17), and the PCL, a validated diagnostic and severity instrument for posttraumatic stress disorder3. Upon seeing the patient, the clinician is provided with either the negative screening results or, if the screening is positive, completed diagnostic instruments.
The Three Component Model has been central in the development and implementation of RESPECT-Mil. Within this model, the primary care clinician, a care manager, and mental health professional work together with affected soldiers to achieve remission and the highest level of function possible.
Army primary care clinicians come from a variety of backgrounds and include family physicians, general internists, physician assistants, and nurse practitioners. RESPECT-Mil includes training for these clinicians in diagnostic evaluation and management of both PTSD and depression.
Informed by screening, diagnostic instrument results, and their interview with the patient, primary care clinicians manage those who meet diagnostic criteria for depression and/or PTSD. Management includes the services of a trained nurse (“care facilitator”) who provides regular telephone support, reinforces the management plan, re-administers severity instruments to monitor improvement, and meets weekly with a psychiatrist (“behavioral health champion”) to review their active caseload and offer advice to primary care as needed.
The RESPECT-Mil pilot began at a clinic in Fort Bragg in 20054. With new support from the Henry Jackson Foundation, RESPECT-Mil has now been expanded to other clinics within Fort Bragg and to 15 other posts in the United States and Europe, web-based primary care training has been implemented, and a web-based care facilitation tool developed.
Most recently, the Department of Defense Deployment Related Medical Research Program was competitively awarded a five-year $15M grant (led by COL Engel and colleagues, including Drs. Dietrich, Williams, and Kroenke) to complete a six-site randomized controlled trial of a RESPECT-Mil variation using centralized care management and preference-based stepped care.
| 1 |
Dietrich AJ, Oxman TE, Williams Jr JW, Schulberg HC, Bruce ML, Lee PW, Barry S, Raue PJ, Lefever J, Heo M, Rost K, Kroenke K, Gerrity M, Nutting PA. (2004). Re-Engineering Systems in the Treatment of Depression in Primary Care: Cluster Randomised Controlled Trial. BMJ 329(7466):602-7 |
| 2 |
Prins A, Ouimette P, Kimerling R, Cameron RP, Hugelshofer DS, ShawHegwer J, Thrailkill A, Gusman FD, Sheikh JI. (2003). The primary care PTSD screen (PC-PTSD): Development and operating characteristics. Primary Care Psychiatry 9(1)9-14. |
| 3 |
Bliese PD, Wright KM, Adle AB, Cabrera O, Castro CA, Hoge CW. (2008). Validating the Primary Care Posttraumatic Stress Disorder Screen and the Posttraumatic Stress Disorder Checklist With Soldiers Returning From Combat. Journal of Consulting and Clinical Psychology 76(2)272-281. |
| 4 |
Engel CC, Oxman T, Yamamoto C, Gould D, Barry S, Stewart P, Kroenke K, Williams JW, Dietrich AJ. (2008). RESPECT-Mil: Feasibility of a Systems-Level Collaborative Care Approach to Depression and Post-Traumatic Stress Disorder in Military Primary Care. Military Medicine 173(10)935-940. |
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