title: RESPECT-Mil: feasibility of a systems-level collaborative care approach to depression and post-traumatic stress disorder in military primary care.
abstract: BACKGROUND
  U.S. military ground forces report high rates of war-related traumatic stressors, posttraumatic stress disorder (PTSD), and depression following deployment in support of recent armed conflicts in Iraq and Afghanistan. Affected service members do not receive needed mental health services in most cases, and they frequently report stigma and significant structural barriers to mental health services. Improvements in primary care may help address these issues, and evidence supports the effectiveness of a systems-level collaborative care approach.
  
  
  OBJECTIVE
  To test the feasibility of systems-level collaborative care for PTSD and depression in military primary care. We named our collaborative care model "Re-Engineering Systems of Primary Care for PTSD and Depression in the Military" (RESPECT-Mil).
  
  
  METHODS
  Key elements of RESPECT-Mil care include universal primary care screening for PTSD and depression, brief standardized primary care diagnostic assessment for those who screen positive, and use of a nurse "care facilitator" to ensure continuity of care for those with unmet depression and PTSD treatment needs. The care facilitator assists primary care providers with follow-up, symptom monitoring, and treatment adjustment and enhances the primary care interface with specialty mental health services. We report assessments of feasibility of RESPECT-Mil implementation in a busy primary care clinic supporting Army units undergoing frequent Iraq, Afghanistan, and other deployments.
  
  
  RESULTS
  Thirty primary care providers (family physicians, physician assistants, and nurse practitioners) were trained in the model and in the care of depression and PTSD. The clinic screened 4,159 primary care active duty patient visits: 404 screens (9.7%) were positive for depression, PTSD, or both. Sixty-nine patients participated in collaborative care for 6 weeks or longer, and the majority of these patients experienced clinically important improvement in PTSD and depression. Even although RESPECT-Mil participation was voluntary for providers, only one refused participation. No serious adverse events were noted.
  
  
  CONCLUSIONS
  Collaborative care is an evidence-based approach to improving the quality of primary care treatment of anxiety and depression. Our version of collaborative care for PTSD and depression, RESPECT-Mil, is feasible, safe, and acceptable to military primary care providers and patients, and participating patients frequently showed clinical improvements. Efforts to implement and evaluate collaborative care approaches for mental disorders in populations at high risk for psychiatric complications of military service are warranted.
authors.affiliation: Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.
authors.forename: Charles C
authors.initials: CC
authors.lastname: Engel
authors.forename: Thomas
authors.initials: T
authors.lastname: Oxman
authors.forename: Christopher
authors.initials: C
authors.lastname: Yamamoto
authors.forename: Darin
authors.initials: D
authors.lastname: Gould
authors.forename: Sheila
authors.initials: S
authors.lastname: Barry
authors.forename: Patrice
authors.initials: P
authors.lastname: Stewart
authors.forename: Kurt
authors.initials: K
authors.lastname: Kroenke
authors.forename: John W
authors.initials: JW
authors.lastname: Williams
authors.forename: Allen J
authors.initials: AJ
authors.lastname: Dietrich
mesh_terms: D000293:Adolescent; D000328:Adult; D003299:Cooperative Behavior; D003863:Depression / Q000175:diagnosis / Q000517:prevention & control*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007391:International Cooperation; D008297:Male; D008403:Mass Screening; D008889:Military Personnel; D008890:Military Psychiatry; D008960:Models, Psychological; D011320:Primary Health Care; D011581:Psychological Tests; D011594:Psychometrics; D011787:Quality of Health Care / Q000592:standards; D012307:Risk Factors; D013313:Stress Disorders, Post-Traumatic / Q000175:diagnosis / Q000517:prevention & control*; D011795:Surveys and Questionnaires; D014481:United States; D055815:Young Adult