Primary care role key in postwar mental illness.

TUCSON, ARIZ. -- Primary care physicians have a key role to play in screening soldiers and veterans of the Iraq and Afghanistan wars for posttraumatic stress disorder and depression, Col. Charles C. Engel, MC, USA, said at the annual meeting of the Academy of Psychosomatic Medicine.

Unlike civilians in motor vehicle accidents, many soldiers who develop posttraumatic stress disorder (PTSD) do not present with symptoms immediately after trauma, according to Dr. Engel, director of the Department of Defense Deployment Health Clinical Center at the Walter Reed Army Medical Center, Washington.

Severity of physical injuries is the only known predictor of which soldiers might go on to develop PTSD or depression, he said. And when they do become symptomatic, soldiers often are reluctant to seek mental health care because of the stigma.

"That's one of the reasons we like to reach into primary care," Dr. Engel said. 'A lot of these folks don't seek specialty mental health care, and we obviously would like to reach them, monitor them for symptoms, and, if they develop them, to intervene early." It's estimated that between 90% and 95% of military troops receive at least one primary care visit each year. By comparison, only 5%-10% seek care from a mental health professional.

Recognizing the need to reach out to soldiers via the primary care system, the Army Surgeon General has backed an initiative rooted in primary care to improve depression and PTSD services, said Dr. Engel. The program, called Reengineering Systems of Primary Care Treatment of Mental Illness in the Military, or RESPeCT-MIL, charges primary care providers with screening for, diagnosing, and treating PTSD and depression. Care managers are then responsible for program adherence, self-management, and monitoring. Mental health practitioners give supervision, informal advice, and referral care.

The vast majority of miliary personnel with postwar mental illness have relatively mild manifestations that can be managed with "lower intensity psychosocial interventions offered within the existing primary care system," Dr. Engel noted in a July 2005 statement on the program before the Committee on Veterans' Affairs.

Coordinated at Fort Bragg in North Carolina, the RESPeCT-MIL program is currently being rolled out at 15 deployment sites, including two bases in Germany and one in Italy. Primary care physicians in Veterans Affairs medical centers also are screening veterans who have returned from the Mideast war zones, according to Dr. Engel.

For primary care physicians outside of the VA system, Dr. Engel emphasized the need to monitor former service members for symptoms of PTSD and depression.

"No single wave of screening is going to do the trick for all groups.... We're creating what I would describe as a redundant safety net," he said.

Dr. Engel coauthored a recent study that followed 613 seriously wounded soldiers at Walter Reed for PTSD and depression (Am. J. Psychiatry 2006;163:1777). At 1 month, 4.2% met criteria for PTSD and 4.4% for depression. At 7 months, 12% of 243 soldiers still in the study had PTSD and 9.3% were depressed.

What was most surprising, Dr. Engel said, was that 79% (26/33) of soldiers with PTSD or depression at 7 months were not symptomatic 1 month after receiving their injuries. Meanwhile, many of the soldiers diagnosed at 1 month had improved and no longer met diagnostic criteria.

"With motor vehicle accidents, you see a high level of distress that goes down over time," Dr. Engel said. "In our population it seems to be rising. That is what is different in our setting. And I think we are still trying to understand what is happening there ... why it is rising."

Capt. Thomas A. Grieger, MC, USN, lead author of the study, described PTSD as "a waxing and waning condition" in a telephone interview. He suggested that some soldiers who were diagnosed early probably still had symptoms at 7 months, even though they no longer met diagnostic criteria.

"What our study showed is that severity of physical complaints is clearly a marker for someone who needs to be more carefully assessed," said Dr. Grieger, an associate professor and senior scientist at the Center for the Study of Traumatic Stress in the department of psychiatry at the Uniformed Services University in Bethesda, Md., where Dr. Engel is also a faculty member. "In many soldiers, this is not identified early on and will develop with the passage of time," Dr. Grieger said.

"Screening is a relatively easy thing to do in a primary care setting and would clearly warrant a referral for mental health treatment in anyone [with a] high level of symptoms regardless of the passage of time since deployment."

BY JANE SALODOF MACNEIL

Southwest Bureau

RELATED ARTICLE: Resources for Treating Veterans

The PHQ-9 and Posttraumatic Stress Disorder Checklist are screening tools for depression and PTSD, respectively, that patients can fill out in a primary care office. Both can be found at www.pdhealth.mil, a Web site designed to assist clinicians in the delivery of postdeployment health care.

In addition, "The Iraq War Clinician Guide," 2nd edition, has chapters on treatment of returning veterans and the implications of PTSD for primary care. It can be downloaded at www.ncptsd.va.gov/war/guide/index.html.