Depression and comorbid PTSD in veterans: evaluation of collaborative care programs and impact on utilization and costs
Depressed patients with comorbid posttraumatic stress disorder (PTSD) are often more functionally impaired and more severely mentally ill than patients with depression alone. However, few studies have examined depression and comorbid PTSD in primary care settings. This dissertation describes three studies of depressed Veterans in primary cam clinics across the U.S. Data were drawn from two group-randomized trials of collaborative care depression treatment: a multi-site trial in nine Veterans Affairs (VA) primary care clinics, and a second trial based in the Seattle VA General Internal Medicine clinic. The first, cross-sectional study, found that PTSD screen positive (PTSD+) depressed patients had more frequent mental health, primary care depression, and outpatient visits, and a higher proportion were prescribed antidepressants than PTSD screen negative (PTSD-) patients. PTSD+ patients had correspondingly higher mental health, primary care depression, outpatient, and antidepressant costs. The second study evaluated the effectiveness and cost-effectiveness of collaborative care depression treatment compared to usual care over 9 months. Under collaborative care, a mental health team developed an individualized treatment plan for primary care providers, a social worker telephoned patients to enhance adherence, and suggested treatment modifications. In PTSD+ depressed veterans, there was a trend toward collaborative care improving depression symptoms and functioning but findings were not statistically significant. Collaborative care was associated with more depression-free days and moderately increased treatment costs. The third, pre-post comparison study, assessed whether depression care manager assessment, a crucial component of collaborative care, changed patients' knowledge and attitudes regarding mental health treatment among PTSD+ depressed veterans. The depression care manager assessment was a 45-minute phone intervention monitoring patient symptoms and problem-solving around treatment barriers. We found that this one-time assessment did not lead to greater knowledge, more positive attitudes towards depression treatment or less stigma in PTSD+ depressed veterans. As service members return from war, providers will see more patients with PTSD and depression and can expect increased outpatient and mental health services use and costs. There were some indications from these studies that collaborative care may be an effective treatment approach for depressed patients with PTSD, but more research is needed to confirm these trends.
- Health services