Expanding the Reach of Effective PTSD Treatment Into Primary Care: Prolonged Exposure for Primary Care

In a comprehensive study of mental health costs related to deployment for the conflicts in Afghanistan and Iraq, the RAND Corporation (RAND) reported an estimated two-year cost of $4.0 to $6.2 billion (in U.S. dollars). Furthermore, RAND estimated that providing evidence-based therapies (EBTs) for PTSD and depression could save an estimated $86.2 million (1). Impact on work function and employment is significant, with research estimating annual employer costs of $651 per veteran with PTSD (2) and modest reductions in PTSD severity related to significant increases in probability of employment (3). While untreated PTSD inflicts a high cost on society, two independent studies from the Department of Veterans Affairs (VA) have demonstrated that PTSD treatment—specifically, therapy—is associated with a 50% annual cost reduction due to the decreased need for long-term mental health service utilization (4, 5). In addition, treating PTSD symptoms with an EBT is an effective way to reduce suicidal ideation, a primary risk factor for suicide (6), further reducing a specific cost associated with PTSD. Despite the need for provision of effective psychotherapy for PTSD, in a review of Veterans Health Administration (VHA) patients who were recently diagnosed as having PTSD, only 33% received minimally adequate PTSD care, either medication management or therapy (7, 8). Efforts to disseminate effective psychotherapy in VHA have been underway since 2006, with mixed results (9). Alternate strategies need to be considered to meet the demands for care.

Significant research clinical practice guidelines and meta-analysis support prolonged exposure (PE) therapy (10–12) as an effective, first-line treatment for PTSD related to large reduction in PTSD, depression, and related symptoms (13, 14). In addition to data supporting symptom reduction with PE therapy, Tuerk and colleagues (4) showed an average savings of $11,644 in the year after completion of PE therapy for veterans who completed treatment, compared with those who started, but did not complete, PE therapy. Finally, use of PE with patient populations with complex and comorbid conditions has shown efficacy (15). As such, PE therapy has demonstrated efficacy in symptom reduction, cost savings, and robust outcome, even with comorbidity. Given these strengths, PE therapy may be especially positioned as an efficacious PTSD treatment.

Typically, PE therapy is provided in specialty mental health settings in eight to 15 weekly, 90-minute individual sessions. Many people with PTSD are unwilling to follow through on a referral to specialty mental health services and, as such, do not get an opportunity to receive this treatment option. Furthermore, this significant commitment of time in long sessions, as well as across many weeks, can be an obstacle for patients with PTSD who are often struggling with severe symptoms, including anger and other life stressors. Providing brief interventions in the setting where most patients first present for primary care (PC) may be helpful for these patients.

Possemato and colleagues reported that 67% of patients who were referred to specialty mental health services by a VHA PC provider (PCP) either refused or expressed ambivalence (16). Subsequently, many are serviced solely in PC settings (16). Veterans seeking care are also balancing multiple issues after their return from deployment (e.g., finding work, returning to school, and family difficulties) that make time constraints for care especially difficult. Indeed, in a survey of service members after their return from Iraq and Afghanistan, concern regarding the stigma of seeking help from mental health services was greatest among those most in need of help (17). Indeed, only 23% to 40% of those who screened positive for a mental health issue had received any professional assistance, with only 13% to 27% receiving assistance from a mental health professional in the past year. These issues are not restricted to veterans of the current conflicts; Lu et al. (18) reported that veterans older than age 30 were less likely to attend specialty mental health visits after receiving a positive screen for PTSD. These patients may be especially suited for a brief intervention provided in a PC setting.

In a study examining the prevalence of PTSD therapy initiation within one year of a positive PTSD screen by location of services for a 30% random sample of all VHA PC patients (N=21,427), 53% of those in PC, 85% of those in PCMH integration (PCMHI, or PCMH), and 84% of those in specialty mental health services started therapy. While provision of same-day mental health services shows a positive impact on the initiation of treatment, there remain 15% in the same-day group and 47% of those who receive standard PC services who have not sought PTSD treatment (19). The interventions received in PC were most likely limited to medication and supportive contacts and did not typically include any psychotherapy options (20). Although engagement was improved, we do not know whether outcomes were also improved for these patients.

Previous attempts to address PTSD in PC settings have focused on care management and patient-directed therapy programs, with a magnitude of impact on PTSD symptoms that has not been ideal (21). Focus on a patient- and provider-directed PTSD-focused therapy option may increase the magnitude of impact by capitalizing on patient motivation. Furthermore, since the model is not dependent on the PC provider to give the intervention but, rather, just to identify patients who want to work on PTSD, the PC provider can maintain focus on the many other health issues required in PC. With immediate access to a mental health service provider who also provides intervention in PC, the patient and PC provider benefit as the intervention fits the brief visits and hectic atmosphere of PC.

In addition to the issues of veterans accepting referrals to specialty mental health services, obstacles in availability of PE therapy and other EBTs in specialty mental health treatment continue. Hermes et al. (22) reviewed VHA administrative data to examine the specialty mental health care workload in 1997–2005 and 2005–2010. They found both an increase in veterans seeking care (117%) and an increase in the intensity of care across veteran eras (i.e., more visits per veteran) (22). How to address this increased patient demand over time in a sustainable way is not yet clear.

As previously mentioned, the availability of PE remains restricted. The PE training program has trained over 1,700 VHA providers in PE therapy. Although many clinicians report finding the training and treatment to be highly effective and report high intent to use them after the training period, many are not treating a high volume of patients six months after completing consultation (23). The most commonly cited reason for seeing few patients include logistical barriers (e.g., no clinic grid time to implement PE therapy in eight to 15 weekly sessions). Given the efficacy of PE therapy, it is imperative to find alternate solutions to overcome logistical barriers. For those patients who present in PC, provision of a brief version of PE therapy to determine who remits with this lower “dose” can save resources. If this PE-PC treatment is provided within the context of a facilitated referral to specialty mental health services to continue those who need a larger “dose” in the full PE model, then an efficient model that provides the right care in the right location at the right dose is apparent. This model maximizes the specialty-trained provider’s time efficiency and the patient’s chance to respond. Thus, providing a briefer yet effective therapeutic option in PCMHI may help ease the workload required to meet the increased VHA demand and expand the reach of EBT for PTSD into the PC setting.

VHA initiated systemwide integration of mental health providers in PC (i.e., care managers, therapists, and medication prescribers) in 2007 (24). An estimated one million visits to PCMHI providers were completed in fiscal year 2014 by nearly 8% of the PC patient population. The initial focus of PCMHI has been to improve the quality of PC-based treatment of depression, anxiety, and problem drinking by increasing same-day access to services and use of evidence-based collaborative care protocols. There has been no national mandate to treat PTSD in PCMHI, given the lack of empirical effectiveness data for treating PTSD in PC settings. This remains true, despite the fact that PTSD is routinely screened for in PCMHI.

PE-PC therapy could address this gap, fill the identified need for services, and increase the reach of evidence-based PTSD care. Of note, the intention of PE-PC therapy is not to replace specialty mental health evidence-based interventions for PTSD but to increase the reach of PE therapy and provide access to effective first-line intervention for a much larger population of veterans with PTSD. For some veterans, this brief dose will produce symptom improvement or even remission. For others, it may increase the acceptability of referral to a higher level of care. Ideally, PE-PC treatment would be implemented in a model in which veterans who require an increasing intensity of intervention will receive a facilitated referral, transferring the veteran from PE-PC therapy into a full-PE or cognitive-processing therapy (CPT) specialty treatment.

To enhance implementation and fit the intervention fully into the PCMH settings, PE-PC therapy was developed as a brief version of PE therapy. Following a study examining enhanced case management for PTSD that found no difference in outcomes, Schnurr et al. (21) advocated for the development of effective brief therapy interventions for PTSD that can be delivered in the PC environment. While some PCMH teams do allow for use of full PE protocol on occasion, the current staffing models in place for these teams would not allow for the full PE protocol within the PC setting to meet the access needs for the veterans presenting with PTSD. Furthermore, quick access to brief treatment (typically, 30-minute sessions and six or fewer sessions) is the hallmark of PCMH treatment, and interventions that are more provider and patient intensive would not fit the model and would result in delays and system issues. To this end, we have developed the PE-PC protocol (25, 26).

The four-session PE-PC treatment protocol includes a PCMHI manual and a patient guide (see Table 1). The protocol was developed on the basis of both clinical and research experience in PC and specialty mental health services, with review and editing input from nationally recognized experts on PTSD treatment. The protocol comprises those elements of PE that coincide with therapeutic efficacy through mechanistic studies conducted in Dr. Rauch’s laboratory and elsewhere. The protocol is intended for PCMH providers (psychologists, social workers, or psychiatric nurses) with a training model in place for those who already have PE or CPT provider status. A pilot study supports its feasibility and initial effectiveness in military treatment facilities with reduction in PTSD and depression and maintenance for one year (25, 26). A majority of patients preferred PE-PC treatment to no treatment, medication only, and referral to specialty mental health services. Indeed, in the pilot study in which they were offered PE-PC treatment or referral to specialty mental health services, none of the service members chose the referral.

Results from the recently completed randomized clinical trial (principal investigator, Jeffrey Cigrang; co-investigator, Sheila A. M. Rauch) of PE-PC treatment compared with minimal attention control (including continuation of any PC-initiated treatment) will be available soon. Of note, exclusions for these studies were minimal and included only risk to self for others that required intervention or alcohol or substance use at a level that required intervention to ensure that it fits with the model of PCMH. On the basis of these studies, the intervention resulted in symptom reductions that were maintained over time, and providers found the intervention easy to learn and use.

Based on VHA provider requests for training, Dr. Cigrang and Dr. Rauch have trained over 20 VHA providers and five Department of Defense providers to date. The current model is designed for mental health and behavioral health providers who are embedded in PC and who have completed training in either PE or CPT for PTSD. These providers receive the manual and patient workbook and then complete a one-on-one phone call with Dr. Rauch before joining the consultation calls. Each trainee is expected to attend the consultation calls for six months and attend at least two cases. A survey of provider graduates of the six-month PE-PC training is ongoing. Using an agreement rating scale ranging from 1, not at all, to 5, very much, training graduates indicate high ratings for PE-PC treatment in increasing access to PTSD treatment for the veterans (4.3), achieving significant improvements in PTSD over a short period of time (4.3), and being useful in their PCMH work (4.9). In addition, providers report good patient acceptance and response. Larger dissemination initiatives are in design for military and VHA settings moving to training providers who do not have PE or CPT experience.

As is typical in PCMH settings, the initial contact includes a very brief and focused assessment of the presenting issues of the patient to determine a focus for intervention. For PE-PC, if the outcome of this assessment suggests that the patient is having clinically significant PTSD symptoms that he/she would like to address in treatment, and is not expressing suicide risk or another issue that takes priority because of the risk of harm, then PE-PC treatment may be initiated. This starts in the assessment session, with a brief presentation of rationale for exposure. Session one then starts with a discussion of the narrative exposure model that is used in PE-PC treatment and an introduction to the patient workbook materials that will guide the patient though self-exposure exercises. This narrative exposure parallels how the imaginal exposure is used in the full PE protocols and includes emotional processing questions after the memory narrative. There is also discussion of a couple of people, places, and/or situations that the patient wants to “take back” from PTSD—similar to in vivo exposure in the full PE protocol. The patient then completes the narrative exposure between sessions; first, writing it out and then reading it for 30 minutes/day. Patients write a new version once per week. They also complete the in vivo exposure situation between sessions. When the patient returns, the PCMH provider reviews the patient’s completed materials and has the patient read the narrative if he or she completed the exercise (or verbally go through the narrative if he or she did not complete it). They spend most of the session on emotional processing of the exposure, and then the provider reassigns the same homework (narrative exposure and in vivo). This continues through to the last session. If the patient is not showing reductions in PTSD Checklist score, he or she is immediately referred to specialty mental health services for PE or CPT for start without delay. For patients who respond, the PCMH provider has a brief check-in by phone or in person one month after completion to ensure integration and maintenance of gains.

PE-PC treatment takes the most active ingredients of a proven effective and flexible treatment for PTSD to create a protocol that fits PCMH with the goal of reducing PTSD and depressive symptoms and increasing access to effective intervention and treatment choice in PC. Brief interventions that are based in PC may provide the necessary therapeutic dose for many veterans and may increase initiation and adherence to EBT in specialty mental health services for those veterans who do not fully remit while receiving care via PE-PC treatment. Starting with a brief version of an effective psychotherapy for PTSD in PC can assist the VHA in addressing access issues in PTSD treatment by providing treatment to a larger number of veterans and only referring on to specialty mental health services those veterans who do not respond to the brief intervention in PC. In summary, this innovative project addresses a critical gap in care for veterans and supports the mission of the VHA to provide access to effective PTSD treatment to improve function. PE-PC treatment can simultaneously improve access to PTSD-focused therapy and improve resource allocation for specialty PTSD services.

The authors acknowledge the contributions of Edna B. Foa, Ph.D., for her work on emotional processing theory, which forms the basis of the protocol.