INFORMATION PAPER 13 Mar 2009

SUBJECT: Improving Primary Care Provider Skills on Assessment and Management of Depression and PTSD and
Suicide Risk Assessment

1. PURPOSE. To provide information about an Army initiative to improve primary care prov ider skills on assessment and
management of depression and PT SD. including suicide risk assessment
2. FACTS :
A. N early 20% of ret urning soldiers screen pos itive for major men tal disorder. Of these, 78% of them ack nowledge a
need for help , yet only about one fourth of these pursue mental health specialty care . Soldiers who screen positive are
twice as likely to perceive barriers (e.g., ca reer effects , stigma, poor access, mistrust) to seeking specialty ca re help
(Hoge et ai, 200 4) .
B. Primary care-based RESPECT·Depression (Re-engineering systems for the treatment of dep ress ion, Dietrich et ai,
2004) or similar approaches are significa ntly more effective than usual PC care in multiple large, multisite randomized
control trials.
C. RESPECT-MIL incorporates the management of PTSD, depression, and deployment-related health concerns us ing
applicab le DoDNA pract ice guideli nes .
D. With 90-95% of sold iers accessing primary care annually at a rate of 3.4 primary ca re visits per year. primary care
offers opportunities for bette r mental health care access and penetration , less stig ma, and ear lier ass istance wit h a more
preventive focus.
E. Deployment of RESPECT· MIL at Fort Bragg in 2005/06 revealed significa nt provider satisfaction/e nthusiasm .
Approximately 2/3 of Soldiers screening pos itive for PTSD or depression who are then enrolled in the RESPECT-MIL care
managem ent reported clinically significa nt improvements in their symptoms (Enge l et ai, 200 8).
F. Epidemiologica l data reveal that individuals with depression and anxiety disorders have markedly higher rates of
suicides. Data also reveal that a very high percentage of individuals who have completed suicide have visited their
primary care provider within the past three mon ths. Therefore, it is reasonable to expect that equipping primary care
clinics and providers to more ade quately asse ss and manage depressive and anx iety disorders (e .g., PTSD), to include
suicidal risk assessment, will have a posi tive impact on reducing pop ulation suicide rates.
G . RESPECT- MIL. with a Center of Excellence (COE) at Fort Bragg (transferring soo n to Walter Reed ), involves:
• A structured prog ram with man uals an d rigorous Jive and web-based training for participating clinicians
• Routine screen ing for depression, PT SD, and post deployment health co ncerns with ris k assessment (suicide
and violence) as clinically appropriate .
• Follow-up brief PC diagn ostic and sym ptom severity assessments for scree n positives
• Identified and co nsenting individuals continue in PC and are also referred to men tal health supervised care-
managers for facilitated care
• Systematic Mental health spec ialty consultation or referral care as needed
H. Essen tial to program success. Care Facili tators:
• Monitor symptom seve rity/risk assessment issues and problem solve soldier difficu lties initially and during
scheduled follow up phone co ntacts
• Rev iew cases weekly w ith men tal health consultant. providing feedbac k to soldier and primary care provider
as needed

3. Army Prim ary Care Initiative.

A. Recognizing the need to im prove primary care provider training, The Surgeon General, US Army. issued' OPORD
09 -05, directing that all Army Primary Care Providers complete mandatory traini ng on the asse ssment and manag emen t
of depression and PT SD in a primary ca re environment. The OPORD stipulates bas ic training during the first yea r,
followed by extende d training during the second year . The training co ntent utilizes RESPECT-Mil training materials that
have bee n implemented at 43 clinics at 15 installations world-wide . Training co ntent focuses on the assess ment and
management of dep ression and PTSD utilizing provider- friendly clinical tools utilized in the RESPECT-Mil progr am. to
inclu de screening, diagnostic asses sment, and treatment monitoring instrum ents and the utilization of care facilitation and
specia lly care co nsultation s trategies . It also provides systematic training on how a primary care provider can assess
suicidal risk, utiliZing ev idence-based RESPECT-Mil tools and protocols.
8 . To acco mplish this, two web -based. interactive training modules were develop ed, one for Depression and for PTSD.
They are available at http://www.pdhealth.miVrespect-mil/index .asp. This training becam e ava ilab le in Dec 2008 and will
be acco mplished ove r the next yea r. AMEDD cas is in the process of enhancing the automa ted tracking of training.

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