Primary Care and Integrated Behavioural Health

Journal Article Annotations
2021, 1st Quarter

Primary Care and Integrated Behavioural Health

Annotations by Jai Gandhi, MD
March, 2021

  1. Stepped Collaborative Care Targeting Posttraumatic Stress Disorder Symptoms and Comorbidity for US Trauma Care Systems: A Randomized Clinical Trial

PUBLICATION #1 — Primary Care and Integrated Behavioural Health

Stepped Collaborative Care Targeting Posttraumatic Stress Disorder Symptoms and Comorbidity for US Trauma Care Systems: A Randomized Clinical Trial
Douglas Zatzick, Gregory Jurkovich, Patrick Heagerty, Joan Russo, Doyanne Darnell, Lea Parker, Michelle K Roberts, Rddhi Moodliar, Allison Engstrom, Jin Wang, Eileen Bulger, Lauren Whiteside, Deepika Nehra, Lawrence A Palinkas, Kathleen Moloney, Ronald Maier


The finding:
This important and unique study demonstrates an intervention for patients with PTSD symptoms after an acute injury and a PTSD Checklist – Civilian Version (PCL-C) score above 35. The intervention fosters collaboration between mental health services and acute surgical services by deploying stepped collaborative treatments to improve upon “treatment as usual.” The primary outcome was the PCL-C score at 3 months, 6 months, and 12 months after the injury event. The secondary outcomes included an assessment of depressive symptoms (via the Patient Health Questionnaire [PHQ-9]), alcohol use problems (via the Alcohol Use Disorder Identification Test – 3 Item Version [AUDIT-C]), and physical function (via the Medical Outcomes Study Short Form Physical Components Summary Score [MOS SF PCS – SF-12 at baseline, and the Short Form (36) Health Survey [SF-36] at 3, 6, and 12 months). PCL-C scores were significantly lower in the intervention group at 6 months but did not demonstrate statistical significance at 3 months or 12 months. The study did not have any statistically significant findings for the secondary outcomes.

Strength and weaknesses:
This study was implemented across 25 Level 1 trauma centers across the United States and encompasses a wide range of different hospital systems and heterogeneous patient populations. The study provides great detail on the methods of implementation, information on the supervision and orientation to the intervention, and a formal evaluation of implementation status for the different hospital sites across four different core domains. This also allowed for the study to reflect “real” conditions where interventions may not be faithfully implemented and captures variance in the ways the intervention was applied. These features allowed for secondary analyses to provide additional insight into the populations that can benefit the most from a stepped collaborative care intervention. Unfortunately, the study’s conclusions may be overly optimistic about the meaning of the findings. The study authors note the lack of significance may be due to higher baseline PCL-C scores in the intervention population without acknowledging the higher baseline PCL-C scores were not statistically significantly higher. Additionally, given that collaborative care interventions require buy in and extensive understanding of the underlying goals of improvement, which can include but is not limited to the core principles of the Collaborative Care Model developed at the University of Washington, one intervention workshop seems inadequate to ensure best-practice implementation. While study teams across sites had access to supervision, the study authors noted that sites with later implementation were less likely to utilize supervision which could also affect the “on-the-ground” effects of the intervention. Additionally, the average additional time spent in the intervention arm was about 122 minutes per patient over the course of the year after injury, which would amount to a little less than two and a half sessions of therapy. While the workshop reviewed psychopharmacology, it is unclear exactly how the stepped collaborative care arm advocated or implemented change in medication practice, let alone for additional therapy. These factors limit the generalizability of the current study, while still making it an important contribution to the growing collaborative care field.

This study is relevant to consultation-liaison psychiatrists as we imagine methods through which we impact populations and lead to improved outcomes with interventions that do not require a psychiatrist to deliver each intervention through face-to-face patient care. This paper is an important contribution as we seek to improve coordination between inpatient and outpatient care settings and improve outcomes for patients who struggle with detrimental effects of PTSD. The study shines a guiding light for the direction we should be looking to achieve these goals.

Type of study:
Randomized Controlled Trial