RESPECT-Mil

1. RESPECT-Mil Recognition and Management of Depression & Post-Traumatic Stress Disorder(Introduction & Depression) V. September 2007

2. Post-Deployment Background Mental Health Conditions Are Common Depression......15% Anxiety............18% PTSD...............18% Any of these....28%

3. Post-DeploymentGap Between Need and Service • Of those 20% of Soldiers screening positive for a moderate to severe MH disorder:

4. Barriers to Mental Health Help • Stigma • Concern about effects on career • Concern about ability to re-deploy • Mistrust of mental health professionals

5. Post-Deployment Health Consequences Hoge et al, 2007 Twice as many PCP visits 2,863 Iraq War Veterans one-year post-deployment

6. Challenges of Primary Care Treatment • Patients not recognized / diagnosed • Patients do not continue treatment • Management contact too infrequent • Primary care providers do not adjust treatment to achieve remission

7. Important Primary Care Mental Health Facts • Prescriptions & deployment are compatible • Primary care providers can address diagnosis and treatment despite time constraints • There are new primary care resources and tools to help

8. What is RESPECT-Mil? • Re-Engineering Systems of Primary Care Treatment - Military • An OTSG program to implement screening, assessment, and treatment of active duty Soldiers for depression and post traumatic stress disorder (PTSD) • Based on RESPECT-Depression system shown to be effective in primary care

9. PREPARED PRACTICE PATIENT PSYCHIATRIST Three Component Model (3CM) CARE FACILITATOR

10. Call at routine intervals & review symptom checklists Monitor adherence Patient education Assist setting self-management goals Review progress with psychiatrist Communicate with you Gather extensive information Discuss the patient with or meet with family members Provide therapy Schedule appointments Make out reach visits Expectations of Care Facilitator YES NO

11. 3CM Care Process in RESPECT-Mil • Screening as a routine • On arrival at sick call medic/nurse provides form to pt. as part of measuring vital signs • Assessing screen positives • Screen positives complete diagnostic tool • Primary care providers score and complete diagnosis • Treat those with a potential diagnosis • Assess suicide risk • Relevant history • Share diagnosis offer treatment & RMF with Soldier • Follow-up • Primary Care continues to manage • Care facilitation • Communication & advice to Primary Care

12. Today’s Learning Objectives • Understand concept of Depression • Use of Symptom Checklist (PHQ-9) • Diagnostic process including suicide assessment • Understand new resources for primary care • RESPECT-Mil Care Facilitator (RCF) • RCF Supervision Process • Informal Behavioral Health Consultations

13. That’s the Big Picture Questions so far, before we get into details

14. DEPRESSION

15. Handout #1 RESPECT-MilRoutine Office Visit Screening Form

16. 2. ... how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat Difficult Very Difficult Extremely Difficult Handout #2 PHQ-9 Symptom Checklist More than NearlyNot Several half the every at all days days day 0 1 2 3 1. Over the last two weeks have youbeen bothered by the following problems? a. Little interest or pleasure in doing things b. Feeling down, depressed, or hopeless c. Trouble falling or staying asleep, or sleeping too much d. Feeling tired or having little energy e. Poor appetite or overeating f. Feeling bad about yourself, or that you are a failure . . . g. Trouble concentrating on things, such as reading . . . h. Moving or speaking so slowly . . . i. Thoughts that you would be better off dead . . . Subtotals: TOTAL:

17. Case Example – CPL Jones part 1 • CPL Jones attends sick call for knee pain and screens positive on the two question screen then completes the PHQ-9 • Score PHQ-9 • Diagnostic evaluation • Illustrate efficient suicide evaluation

18. CPL Jones’ Screening Form

19. Handout #3 PHQ-9 (Baseline) More than NearlyNot Several half the every at all days days day 0 1 2 3 1. Over the last two weeks have youbeen bothered by the following problems? a. Little interest or pleasure in doing things b. Feeling down, depressed, or hopeless c. Trouble falling or staying asleep, or sleeping too much d. Feeling tired or having little energy e. Poor appetite or overeating f. Feeling bad about yourself, or that you are a failure . . . g. Trouble concentrating on things, such as reading . . . h. Moving or speaking so slowly . . . i. Thoughts that you would be better off dead . . . 2. ... how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Subtotals: TOTAL: Not difficult at all Somewhat Difficult Very Difficult Extremely Difficult

20. PHQ-9 Symptom Count More than NearlyNot Several half the every at all days days day 0 1 2 3 1. Over the last two weeks have youbeen bothered by the following problems? a. Little interest or pleasure in doing things b. Feeling down, depressed, or hopeless c. Trouble falling or staying asleep, or sleeping too much d. Feeling tired or having little energy e. Poor appetite or overeating f. Feeling bad about yourself, or that you are a failure . . . g. Trouble concentrating on things, such as reading . . . h. Moving or speaking so slowly . . . i. Thoughts that you would be better off dead . . . 2. ... how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat Difficult Very Difficult Extremely Difficult

21. PHQ-9Scoring More than NearlyNot Several half the every at all days days day 0 1 2 3 1. Over the last two weeks have youbeen bothered by the following problems? a. Little interest or pleasure in doing things b. Feeling down, depressed, or hopeless c. Trouble falling or staying asleep, or sleeping too much d. Feeling tired or having little energy e. Poor appetite or overeating f. Feeling bad about yourself, or that you are a failure . . . g. Trouble concentrating on things, such as reading . . . h. Moving or speaking so slowly . . . i. Thoughts that you would be better off dead . . . Subtotals: TOTAL:

22. PHQ-9Scoring More than NearlyNot Several half the every at all days days day 0 1 2 3 1. Over the last two weeks have youbeen bothered by the following problems? a. Little interest or pleasure in doing things b. Feeling down, depressed, or hopeless c. Trouble falling or staying asleep, or sleeping too much d. Feeling tired or having little energy e. Poor appetite or overeating f. Feeling bad about yourself, or that you are a failure . . . g. Trouble concentrating on things, such as reading . . . h. Moving or speaking so slowly . . . i. Thoughts that you would be better off dead . . . Subtotals: 4 6 6 TOTAL: 16

23. Handout #4 Diagnosis and Initial Treatment

24. Handout #4 Diagnosis and Initial Treatment *With functional impairment

25. Handout #3 PHQ-9 (Baseline) More than NearlyNot Several half the every at all days days day 0 1 2 3 1. Over the last two weeks have youbeen bothered by the following problems? a. Little interest or pleasure in doing things b. Feeling down, depressed, or hopeless c. Trouble falling or staying asleep, or sleeping too much d. Feeling tired or having little energy e. Poor appetite or overeating f. Feeling bad about yourself, or that you are a failure . . . g. Trouble concentrating on things, such as reading . . . h. Moving or speaking so slowly . . . i. Thoughts that you would be better off dead . . . 2. ... how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Subtotals: TOTAL: Not difficult at all Somewhat Difficult Very Difficult Extremely Difficult

26. Handout #5 Evaluation of Suicide Risk 1. Have these symptoms/feelings we’ve been talking about led you to believe that you would be better off dead? NO YES 2. This past week, have you had any thoughts that life is not worth living or that you would be better off dead? NO YES 3. What about thoughts of hurting or even killing yourself? NO YES 4. What have you thought about? Do you have a plan or have you actually tried to hurt your self? NO YES 5. RISK FACTORS: • History of suicide attempt • Substance abuse • Significant comorbid anxiety • Social isolation • Hopelessness

27. Handout #5 Evaluation of Suicide Risk

28. IMPORTANT RESPECT-Mil does not and must not in any way replace, substitute for, or compete with established protocols that are in place to deal with Soldiers at high risk to harm themselves or others.

29. Diagnostic Evaluation • Explore PHQ-9 responses and other relevant symptoms • Evaluate function • Explore substance use, bipolar, prior mental health treatment • Ascertain relevant family history

30. Case Example – CPL Jones part 2 CPL Jones attends sick call for knee pain and screens positive on the two question screen then completes the PHQ-9 Role play to demonstrate: • Score PHQ-9 • Diagnostic evaluation • Illustrate efficient suicide evaluation

31. Confirm and Present Diagnosis • Explain: PHQ-9, Context (seen often in similar experiences, biological basis) • Barriers: Acknowledge concerns about stigma, career • Document: For continuity of care/handoff

32. Fitness / Deployability • Mental health diagnosis & treatment does not automatically preclude deployment • Medications can be & are used during deployment • Untreated Depression likely to get worse and lead to fitness problem • Fitness/deployability should be determined by MH specialist (RCF will facilitate) • Participation in RESPECT-Mil program does not start the Chapter Discharge or Medical Board process

33. Red Flags • Consider mental health referral if: • concern about harm to self or others • concurrent substance abuse • potential bipolar disorder • occupational problems • probable depression and deploying soon • your gut tells you to

34. A Word about Confidentiality • All medical/mental health treatment is documented but protected from routine disclosure to anyone, with two exceptions • If soldier discloses threat to self or others • If disorder is severe & refractory, requiring fitness evaluation • In the majority of mental health treatment (>90%), treatment remains confidential and private

35. Next, Depression Treatment:Explain the Options & Patient Choice Psychological Counseling and/or Medication Treatment

36. Handout #6 Key Educational Messages • Antidepressants only work if taken every day. • Antidepressants are not addictive. • Benefits from medication appear slowly. • Continue antidepressants even after you feel better. • Mild side effects are common, and usually improve with time. • If you’re thinking about stopping the medication, call clinic first. • The goal of treatment is complete remission; sometimes it takes a few tries.

37. Handout #7 Self-Management Plan 1. Stay physically active. 2. Make time for pleasurable activities. 3. Spend time with people who can support you 4. Practice relaxing. 5. Simple goals and small steps. 6. Eat balanced meals and avoid alcohol

38. Case Example - CPL Jones Part 3 Role play to demonstrate: • Presenting treatment options • Give key messages if medication prescribed • Explain RESPECT-Mil care facilitation • Discuss primary care clinic continuity • Encourage self-management

39. Follow-up • Establish preferred mode and time of care facilitator contact • Care facilitator calls – • Initial call one week after treatment started • Minimum calls at 4 week intervals • Follow-up PHQ-9 at 4 week intervals • Care facilitator review PHQ-9 score changes with psychiatrist for possible treatment change recommendations

40. PCP PCP PCP PCP PCP PCP RCF RCF RCF RCF RCF RCF RCF 4 1 8 12 20 40 32 36 Typical Frequency of Patient Contacts Care Facilitator Phone Call Primary Care Provider Visit RCF PCP Acute Phase Continuation Phase WEEK

41. Handout #7 CPL Jones – Part 4, f/u PHQ-9 More than NearlyNot Several half the every at all days days day 0 1 2 3 1. Over the last two weeks have youbeen bothered by the following problems? a. Little interest or pleasure in doing things b. Feeling down, depressed, or hopeless c. Trouble falling or staying asleep, or sleeping too much d. Feeling tired or having little energy e. Poor appetite or overeating f. Feeling bad about yourself, or that you are a failure . . . g. Trouble concentrating on things, such as reading . . . h. Moving or speaking so slowly . . . i. Thoughts that you would be better off dead . . . Subtotals: TOTAL:

42. CPL Jones – Part 4, f/u PHQ-9 More than NearlyNot Several half the every at all days days day 0 1 2 3 1. Over the last two weeks have youbeen bothered by the following problems? a. Little interest or pleasure in doing things b. Feeling down, depressed, or hopeless c. Trouble falling or staying asleep, or sleeping too much d. Feeling tired or having little energy e. Poor appetite or overeating f. Feeling bad about yourself, or that you are a failure . . . g. Trouble concentrating on things, such as reading . . . h. Moving or speaking so slowly . . . i. Thoughts that you would be better off dead . . . Subtotals: 0 8 6 TOTAL: 14

43. Handout #8 Treatment Modification Table

44. Remission • The goal of depression treatment is remission: • a PHQ-9 score less than 5 and no functional impairment • To obtain remission, you will often be advised to do one or more of: • increase the dose of medication • switch to another medication • add a medication • recognize and treat a co-occurring disorder • consider a different diagnosis • refer for counseling or mental health evaluation • Attaining and maintaining remission • ongoing contact with primary care as well as the RCF • usually takes 8-12 weeks to achieve and may take longer • requires continuation therapy for at least 6 to 9 months

45. Logistics – Screenings, Referrals and Communications • All AD patients are being screened starting(date) • Return dark or light blue folders • Soldiers with a Dx of depression &/or PTSD offered treatment & care facilitation (RCF) • Refer to RCF via AHLTA

46. Referrals and Communications • Face-to face introductions with RCF are okay and often helpful if possible (AHLTA referral still required!) • Ask for more frequent or earlier RCF initial call (e.g. 48 hours) when you have concern about pt. follow through on treatment

47. Referrals: What to Expect • Refer to RCF through AHLTA • You will receive a T-CON note by AHLTA after each routine RCF contact (and called if there is a more urgent concern) • You will NOT routinely hear about supervision discussions unless a modification in management is suggested

48. Depression Skills Practice • Those handed a blue folder partner with someone without a folder • Twenty minutes to practice • Scoring PHQ-9 • Depression evaluation • Suicide assessment • Treatment recommendation & RMF referral • Key medication instructions & self management

49. Summary • Major Depressive Disorder is a significant health problem post-deployment • RESPECT-Mil implements a system including new resources for depression care process • The system improves outcomes by • Increasing treatment adherence • Monitoring patient response to treatment • Making treatment changes when there is a sub-optimal response with goal of remission

50. Evaluation Handouts WE WANT THIS TO WORK FOR YOU! • Please take a moment now and complete our brief evaluation form Your feedback is important to this implementation effort. Next session on PTSD Thank you!