PERSPECTIVE: A Path to Value-Based Insurance Design for Mental Health Services.

BACKGROUND: Aligning cost of mental health care with expected clinical and functional benefits of that care would incentivize the delivery of high value treatments and services. In turn, ineffective or untested care could still be offered but at costs high enough to offset the delivery of high value care. AIMS: The authors comment on Benson and Fendrick's paper on Value-Based Insurance Design (VBID) for mental health in the September 2023 special issue of this journal. The authors also present a preliminary framework of key ingredients needed to consider VBID for mental health treatments and services. METHODS: The authors briefly review current and past efforts to contain costs and improve quality of mental health care, which include (for example) use of carve-out and carve-in programs, evaluation of cost sharing models, impact of accountable care organizations, and studying other benefit designs and impact of federal and state policies. RESULTS: Using PTSD as an example, key ingredients of VBID for mental health services were identified and include the following: tools for case identification and monitoring progress over time at the population level; specific treatments and services with evidence of clinical effectiveness, cost-effectiveness, and health equity; and an approach to document the specific treatment or service was delivered (versus another treatment or service that may lack evidence). DISCUSSION: The inability to afford mental health care is a top barrier to treatment seeking. People who do elect to spend time and money on mental health care are further disadvantaged by accessing care that is not well regulated and the quality at best is questionable. VBID could be an important lever for increasing access to and use of high value mental health care. Partnerships among the research, practice, and policy communities can help ensure research solutions meet needs of these two communities. IMPLICATIONS FOR HEALTH CARE: VBID holds promise to make high value mental health care more affordable while discouraging low value treatments and services. IMPLICATIONS FOR HEALTH POLICIES: While evidence gaps remain, these gaps can be filled concurrently with pursuit of VBID for mental health services. IMPLICATIONS FOR FUTURE RESEARCH: This paper identifies important research opportunities to help make VBID a reality for mental health care.

PERSPECTIVE: Health Economic Interests at NIMH and NIDA to Improve Delivery of Behavioral Health Services.

BACKGROUND: Effective financing mechanisms are essential to ensuring that people can access and utilize effective treatments and services. Financing mechanisms are needed not only to pay for the delivery of those treatments and services, but also ancillary costs, while also keeping care affordable. AIMS: This article highlights key areas of the interest of the National Institute of Mental Health (NIMH) and the National Institute on Drug Abuse (NIDA) in supporting applied health economics and health care financing research. Specifically, this article discusses the long-range impact of NIH's earlier investments in applied health economics research, and NIH's ongoing efforts to communicate its interests in health economics research. We discuss the 2023 NIMH-NIDA-sponsored health economics conference, and the ideas presented there for developing and assessing innovative behavioral health care financing models; three of the presented papers were recently published in the Journal of Mental Health Policy and Economics. METHODS: We describe the history and impact of NIMH- and NIDA-sponsored economic research and identify current research interests as identified in the NIMH and NIDA Strategic Plans and recent funding announcements. We examine themes presented at the NIMH-NIDA Health Economics conference. The conference included over 300 participants from 20 countries, from six continents. RESULTS: The topics highlighted at the conference highlight the ways in which NIH-funded research has promoted the development of innovative health care financing methods, both from the supply side (e.g., providers and payers) and demand side (e.g., service users and families). Invited speakers discussed the findings from NIH-supported research in the topic areas of payment and financing, behavioral economics and social determinants of health. Keynote speakers highlighted emerging topics in the field, including the economics of health equity, biases in mental health models in health care, and value-based insurance design. DISCUSSION: We demonstrate a resurgence of and explicit interest in health economics and policy research at NIMH and NIDA. However, more work is needed in order to design funding mechanisms that fully provide access to and facilitate use of effective evidence-based practices to improve mental health outcomes. For example, it is important that policy and health economic research projects include decision makers who will be the end users of data and study results, to ensure that results can be meaningfully put into practice. IMPLICATIONS FOR HEALTH CARE: Designing effective and efficient funding mechanisms can help ensure that service users have access to effective treatments and that clinicians and provider organizations are adequately compensated for their work. IMPLICATIONS FOR HEALTH POLICIES: Federal, state, and local policies, as well as policies of payers and health care organizations, can influence the type of care that is supported and incentivized. IMPLICATIONS FOR FURTHER RESEARCH: As demonstrated by the research interests as outlined in their respective Strategic Plans and funding announcements, NIMH and NIDA continue to fund health economic and policy research that aims to improve health care access, quality and outcomes for people with or at risk of developing behavioral health conditions in the US and around the world.

PERSPECTIVE: Economic and Policy Research Interests Highlighted in the 25th NIMH-Sponsored Mental Health Services Research Conference.

BACKGROUND: The National Institute of Mental Health (NIMH) remains committed to addressing real-world challenges with delivering high quality mental health care to people in need by advancing a services research agenda to improve access, continuity, quality, equity, and value of mental healthcare nationwide, and to improve outcomes for people with serious mental illnesses (SMI). The NIMH-Sponsored Mental Health Services Research Conference (MHSR) is a highly productive venue for discussing topics of interest to NIMH audiences and disseminating NIMH's latest research findings directly to mental health clinicians, policy makers, administrators, advocates, consumers, and scientists who attend. AIMS: This Perspective summarizes and provides highlights from the 25th MHSR. It also reviews three papers presented at the 25th MSHR and subsequently published in the June 2023 special issue of The Journal of Mental Health Policy and Economics (JMHPE). METHODS: The authors review three papers published in the June 2023 special issue of JMHPE, identifying common themes across the papers and illustrating how the papers' findings promote key areas of NIMH research interests. RESULTS: Three important areas are highlighted in this review: (i) service user engagement in the research enterprise, (ii) financing the implementation of the 988 Suicide and Crisis Lifeline, and (iii) methods to predict mental health workforce turnover. DISCUSSION: These three papers illustrate key areas in which policy research can help to promote quality mental health care. One notable common theme across the papers is that of the role that end users play in the research enterprise. The papers focus on (i) service users and the value they bring to informing the practice of research, (ii) policy makers and the information they need to make evidence-informed decisions, and (iii) provider organization leadership, by using an innovative machine learning process to help organizations predict and address staff turnover. IMPLICATIONS FOR HEALTH CARE: NIMH encourages and often requires strong research practice partnerships to help ensure findings will be of value to end users and make their way into the practice setting. The three papers reviewed in this perspective are exemplars of how necessary stakeholder partnerships are to improve care for those with mental illness. IMPLICATIONS FOR HEALTH POLICIES: The highlighted papers (i) provide recommendations for structural changes to research institutions to increase service user engagement in all aspects of the research enterprise, (ii) identify policy solutions to improve fiscal readiness to address increased demand of 988, and (iii) pilot a novel data-driven approach to predict mental health workforce turnover, a significant problem in community mental health clinics, offering health system leaders and policy makers an opportunity to proactively intervene to help maintain continuity of staffing. IMPLICATIONS FOR FURTHER RESEARCH: Consistent with NIMH's Strategic Plan for Research and current funding announcements, there remains an urgent need to (i) develop strategies to better implement, scale, and sustain existing evidence-supported treatments and services, particularly in historically underserved communities, and (ii) develop, test, and evaluate new solutions to improve access, continuity, quality, equity, and value of care.ing and clinical outcomes remains uncertain.

PERSPECTIVE: A Mental Health Services Research Agenda in the Era of COVID-19: Steadfast Commitment to Addressing Evolving Challenges.

BACKGROUND: Decades of research that predate the COVID-19 pandemic demonstrate that most people with mental health needs are not receiving adequate care. The inequities between those who need care and those who receive adequate care are larger for racial and ethnic minority groups and people living in underserved communities. The pandemic is associated with an exacerbation of these inequities, resulting in increased morbidity and mortality for the most vulnerable populations. AIMS: This Perspective summarizes longstanding and evolving challenges to the provision of high quality care for people with mental illness, describes the National Institute of Mental Health's (NIMH) commitment to addressing those challenges, and embeds salient research priorities most germane to the health policy readership of this journal. METHODS: Example funding announcements and extant funding priorities are highlighted to demonstrate NIMH's commitment to health services research during the pandemic. The collaborative care model is presented as an evidence-supported service delivery model that could be delivered via telehealth. Recent studies that compare the utilization of routine telehealth services during the pandemic, when compared to in-person services pre-pandemic, are summarized. RESULTS: In FY2020, NIMH invested $171,194,275 in health services research. Over the past two years, NIMH led or participated on dozens of funding announcements that call for mental health services research to help improve the provision of care for people with mental illness. Service delivery models like collaborative care can offer effective intervention via telehealth. The practice community can deliver routine services via telehealth at volumes similar to pre-pandemic in-person levels. However, wide variation in telehealth utilization exists, with inequities associated with racial and ethnic groups and underserved rural locations. A limitation is that clinical outcomes are not routinely available from administrative datasets. DISCUSSION: There continues to be an urgent need for health policy research and collaboration with the health policy community as part of the research enterprise. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: NIMH encourages and often requires strong research practice partnerships to help ensure findings will be of value to end users and make their way into the practice setting. There is a need to study pandemic related changes in financing, delivery, receipt, and outcomes of mental health care. IMPLICATIONS FOR HEALTH POLICIES: Despite robust evidence, clinical practice guideline recommendations, and established financing mechanisms, uptake of service delivery models that can be delivered in part or in full via telehealth (e.g., the collaborative care model) is poor. IMPLICATIONS FOR FURTHER RESEARCH: In the era of COVID-19, the charge to the mental health services research community is urgent: (i) develop strategies to better implement, scale, and sustain existing evidence-supported treatments and services and (ii) develop, test, and evaluate new solutions to improve access, continuity, quality, equity, and value of care.

Guest editorial: Psychologists aim to HEAL the opioid and pain crises.

The opioid and pain crises affect every domain of family and community life with two million Americans living with opioid addiction, and 46,802 people dying from opioid overdoses in 2018 alone (National Center for Health Statistics, 2019). In addition, over 50 million Americans experience chronic pain, and half of those people suffer from chronic pain daily. Opioids are widely used to treat acute and chronic pain, and the lack of widespread access to nonpharmacological strategies to manage pain has contributed to the misuse of opioids. In fiscal year 2018, Congress added $500 million to the NIH's base appropriation to generate scientific solutions to the opioid and pain crises in America. The result was the Helping to End Addiction Long-Term Initiative, or NIH HEAL Initiative, a bold transagency effort. The authors of this editorial-psychologists in leadership roles in three NIH institutes- highlight several investments of the NIH HEAL Initiative, note the role of psychologists involved in HEAL, and describe the unprecedented steps the NIH is taking to harmonize data and rapidly and widely disseminate HEAL findings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Impact of financial reimbursement on retention rates in military clinical trial research: A natural experiment within a multi-site randomized effectiveness trial with active duty service members.

INTRODUCTION: Achieving adequate retention rates in clinical trials is essential to ensuring meaningful results. Although financial reimbursement is an effective strategy to increase participant retention, current policies restrict the use of federal funds to reimburse U.S. active duty Service members for research participation. It is unknown whether permitting financial reimbursement among this population would improve trial retention rates. A recent randomized effectiveness trial received approval to provide reimbursement to Service member participants several months after recruitment began, creating a natural experiment to study the effects of financial reimbursement on retention. MATERIALS AND METHODS: Active duty Service members recruited from six U.S. military treatment facilities (N = 666) were enrolled in a collaborative care study and completed assessments at baseline, three-, six-, and 12-months. Data on study assessment completion rates at three- and six-months were analyzed using the mixed-effects binary logit model to determine the probabilities of completing assessments based on reimbursement status. RESULTS: Participants who received reimbursement were significantly more likely to complete study assessments at both time-points than participants who did not receive reimbursement (p < 0.01). Survey completion was 5% and 4% greater among participants offered reimbursement at three- and six-month time-points, respectively. CONCLUSION: Results suggest that providing Service members with reimbursement for research participation is associated with modest increases in retention rates in clinical trials. Findings provide useful insight for researchers, funding agencies, and policy-makers in considering retention strategies to maximize the value and impact of military research.

PERSPECTIVES: Insurance markets, labor markets, and the mental health services delivery system.

INTRODUCTION: The authors are health scientist administrators at the National Institute of Mental Health (NIMH). The mission of NIMH is "to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure." As part of its portfolio, NIMH supports research on mental health economics, and mental health services research. METHOD: In this perspective article, the authors comment on two papers presented at the NIMH-sponsored Mental Health Services Research Conference in 2018 and subsequently published in the September 2019 issue of the Journal of Mental Health Policy and Economics. Two important areas are highlighted in this review: (i) the impact of insurance and labor markets on the delivery of high-quality mental health services, and (ii) the need for advancements in method development and design in future studies. DISCUSSION: The complexity of health insurance markets created some unintended consequence of the mental health insurance parity legislation. Mental health provider shortages in local labor markets are a barrier to successful implementation and sustainment of innovative and evidence-based mental health service-delivery models for people with serious mental illness. IMPLICATIONS FOR RESEARCH: Data-capture techniques that seamlessly integrate insurance claims with clinical outcomes (e.g., from electronic health records) will better equip health economists and other end-users with rigorous research findings to inform public health policy and practice recommendations. Despite early signals of success, larger sample sizes and more rigorous research designs are needed to refine predictive models of functional outcomes of evidence-based service-delivery models (e.g., coordinated specialty care model including supported education, and supported employment) for people with first-episode psychosis.

Population Impact of PTSD and Depression Care for Military Service Members: Reach and Effectiveness of an Enhanced Collaborative Care Intervention.

Objective: Epidemiologic studies suggest high rates of posttraumatic stress disorder (PTSD) and depression among military members and veterans. To meet the needs of this population, evidence-based treatments are recommended as first-line interventions, based on their clinical efficacy and not the proportion of the target population that the intervention reaches. We apply a public health framework to examine the population impact of an enhanced collaborative care model on a targeted population that takes into account effectiveness and reach. METHODS: Using data collected from a 2012 - 2016 randomized trial, the effectiveness of enhanced collaborative care for PTSD and depression was evaluated using probable diagnostic status as the primary outcome. Exclusion criteria were then applied to a 2011 disease registry to examine the representativeness of the trial sample and estimate the potential reach of the intervention. Population impact was derived from the estimated effectiveness and reach of the intervention. RESULTS: Enhanced collaborative care was associated with a significantly greater probability of PTSD/depression remission by the end of the trial (conditional effect = -0.066, chisq = 51.1, p < 0.001). Based on the effectiveness and reach of the enhanced intervention, an estimated 250 (out of the 3,436) more Army soldiers with PTSD and/or depression would experience diagnostic remission during the preceding year if the enhanced model was available. CONCLUSION: The population framework permits the estimated differential impact of two collaborative care models to inform implementation considerations. These results highlight the value of applying public health models to identify front line treatments.

Collaborative Care for Depression and Posttraumatic Stress Disorder: Evaluation of Collaborative Care Fidelity on Symptom Trajectories and Outcomes.

BACKGROUND: Despite the growing consensus that collaborative care is effective, limited research has focused on the importance of collaborative care fidelity as it relates to mental health clinical outcomes. OBJECTIVE: To assess the relationship of collaborative care fidelity on symptom trajectories and clinical outcomes among military service members enrolled in a multi-site randomized controlled trial for the treatment of depression and posttraumatic stress disorder (PTSD). DESIGN: Study data for our analyses came from a two-parallel arm randomized trial that evaluated the effectiveness of a centralized collaborative care model compared to the existing collaborative care model for the treatment of PTSD and depression. All patients were included in the analyses to evaluate how longitudinal trajectories of PTSD and depression scores differed across various collaborative care fidelity groupings. PARTICIPANTS: A total of 666 US Military Service members screening positive for probable PTSD or depression through primary care. MAIN MEASURES: Disease registry data from a web-based clinical management support tool was used to measure collaborative care fidelity for patients enrolled in the trial. Participant depression and PTSD symptoms were collected independently from research survey assessments at four time points across the 1-year trial period. Treatment utilization records were acquired from the Military Health System administrative records to determine mental health service use. KEY RESULTS: Consistent and late fidelity to the collaborative care model predicted an improving symptom trajectory over the course of treatment. This effect was more pronounced for patients with depression than for patients with PTSD. CONCLUSIONS: Long-term fidelity to key collaborative care elements throughout care episodes may improve depression outcomes, particularly for patients with elevated symptoms. More controlled research is needed to further understand the influence of collaborative care fidelity on clinical outcomes. TRIAL REGISTRATION: Clinicaltrials.gov Identifier NCT01492348.

Cost-effectiveness of collaborative care for depression and PTSD in military personnel.

OBJECTIVES: Collaborative care is an effective approach for treating posttraumatic stress disorder (PTSD) and depression within the US Military Health System (MHS), but its cost-effectiveness remains unstudied. Our objective was to evaluate the costs and cost-effectiveness of centrally assisted collaborative telecare (CACT) versus optimized usual care (OUC) for PTSD and depression in the MHS. STUDY DESIGN: A randomized trial compared CACT with OUC. Routine primary care screening identified active-duty service members with PTSD or depression. Eligible participants (N = 666) were randomized to CACT or OUC and assessed at 3, 6, and 12 months. OUC patients could receive care management and increased behavioral health support. CACT patients could receive these services plus stepped psychosocial treatment and routine centralized team monitoring. METHODS: Quality-adjusted life-years (QALYs) were derived from the 12-Item Short Form Health Survey. Claims and case management data were used to estimate costs. Cost-effectiveness analyses were conducted from a societal perspective. RESULTS: Data from 629 patients (320 CACT and 309 OUC) with sufficient follow-up were analyzed. CACT patients gained 0.02 QALYs (95% CI, -0.001 to 0.03) relative to OUC patients. Twelve-month costs, including productivity, were $987 (95% CI, -$3056 to $5030) higher for CACT versus OUC. CACT was estimated to cost $49,346 per QALY gained compared with OUC over 12 months. There is a 58% probability that CACT is cost-effective at a $100,000/QALY threshold. CONCLUSIONS: Despite its higher costs, CACT appears to be a cost-effective strategy relative to OUC for managing PTSD and depression in the MHS.

Rescaling the Post-Traumatic Stress Disorder Checklist for Use in Primary Care.

The Posttraumatic Stress Disorder (PTSD) Checklist (PCL) is a 17-item self-report measure of PTSD symptom severity that has demonstrated excellent psychometric properties across a variety of settings, purposes, and populations. The PCL is widely used in busy Department of Defense primary care settings as part of routine PTSD screening, requiring that it is easy for patients to complete and providers to score. The clinical utility of the PCL may be improved through use of a zero-anchored Likert-type response scale by providing intuitive anchors for respondents and fewer calculations for clinic staff; however, changes to the response scale may invalidate the known psychometric properties of the measure. The purpose of this study is to evaluate the equivalence of a zero-anchored PCL to the traditional one-anchored PCL. Differences in total scores were examined using inferential confidence intervals. Substantial overlap of the inferential confidence intervals and small Rg (maximum probable difference) value of 0.68 indicated that the zero-anchored PCL is equivalent to the one-anchored PCL on the basis of our specified delta (amount of difference considered inconsequential). These findings support the use of a zero-anchored PCL in clinical practice, and more broadly, the use of zero-anchored measures in the larger field of psychological assessment.

IRB and Research Regulatory Delays Within the Military Health System: Do They Really Matter? And If So, Why and for Whom?

Institutional review board (IRB) delays may hinder the successful completion of federally funded research in the U.S. military. When this happens, time-sensitive, mission-relevant questions go unanswered. Research participants face unnecessary burdens and risks if delays squeeze recruitment timelines, resulting in inadequate sample sizes for definitive analyses. More broadly, military members are exposed to untested or undertested interventions, implemented by well-intentioned leaders who bypass the research process altogether. To illustrate, we offer two case examples. We posit that IRB delays often appear in the service of managing institutional risk, rather than protecting research participants. Regulators may see more risk associated with moving quickly than risk related to delay, choosing to err on the side of bureaucracy. The authors of this article, all of whom are military-funded researchers, government stakeholders, and/or human subject protection experts, offer feasible recommendations to improve the IRB system and, ultimately, research within military, veteran, and civilian populations.

Centrally Assisted Collaborative Telecare for Posttraumatic Stress Disorder and Depression Among Military Personnel Attending Primary Care: A Randomized Clinical Trial.

IMPORTANCE: It is often difficult for members of the US military to access high-quality care for posttraumatic stress disorder (PTSD) and depression. OBJECTIVE: To determine effectiveness of a centrally assisted collaborative telecare (CACT) intervention for PTSD and depression in military primary care. DESIGN, SETTING, AND PARTICIPANTS: The STEPS-UP study (Stepped Enhancement of PTSD Services Using Primary Care) is a randomized trial comparing CACT with usual integrated mental health care for PTSD or depression. Patients, mostly men in their 20s, were enrolled from 18 primary care clinics at 6 military installations from February 2012 to August 2013 with 12-month follow-up completed in October 2014. INTERVENTIONS: Randomization was to CACT (n = 332) or usual care (n = 334). The CACT patients received 12 months of stepped psychosocial and pharmacologic treatment with nurse telecare management of caseloads, symptoms, and treatment. MAIN OUTCOMES AND MEASURES: Primary outcomes were severity scores on the PTSD Diagnostic Scale (PDS; scored 0-51) and Symptom Checklist depression items (SCL-20; scored 0-4). Secondary outcomes were somatic symptoms, pain severity, health-related function, and mental health service use. RESULTS: Of 666 patients, 81% were male and the mean (SD) age was 31.1 (7.7) years. The CACT and usual care patients had similar baseline mean (SD) PDS PTSD (29.4 [9.4] vs 28.9 [8.9]) and SCL-20 depression (2.1 [0.6] vs 2.0 [0.7]) scores. Compared with usual care, CACT patients reported significantly greater mean (SE) 12-month decrease in PDS PTSD scores (-6.07 [0.68] vs -3.54 [0.72]) and SCL-20 depression scores -0.56 [0.05] vs -0.31 [0.05]). In the CACT group, significantly more participants had 50% improvement at 12 months compared with usual care for both PTSD (73 [25%] vs 49 [17%]; relative risk, 1.6 [95% CI, 1.1-2.4]) and depression (86 [30%] vs 59 [21%]; relative risk, 1.7 [95% CI, 1.1-2.4]), with a number needed to treat for a 50% improvement of 12.5 (95% CI, 6.9-71.9) and 11.1 (95% CI, 6.2-50.5), respectively. The CACT patients had significant improvements in somatic symptoms (difference between mean 12-month Patient Health Questionnaire 15 changes, -1.37 [95% CI, -2.26 to -0.47]) and mental health-related functioning (difference between mean 12-month Short Form-12 Mental Component Summary changes, 3.17 [95% CI, 0.91 to 5.42]), as well as increases in telephone health contacts and appropriate medication use. CONCLUSIONS AND RELEVANCE: Central assistance for collaborative telecare with stepped psychosocial management modestly improved outcomes of PTSD and depression among military personnel attending primary care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01492348.

Mental Health Utilization Patterns During a Stepped, Collaborative Care Effectiveness Trial for PTSD and Depression in the Military Health System.

BACKGROUND: Integrated health care models aim to improve access and continuity of mental health services in general medical settings. STEPS-UP is a stepped, centrally assisted collaborative care model designed to improve posttraumatic stress disorder (PTSD) and depression care by providing the appropriate intensity and type of care based on patient characteristics and clinical complexity. STEPS-UP demonstrated improved PTSD and depression outcomes in a large effectiveness trial conducted in the Military Health System. The objective of this study was to examine differences in mental health utilization patterns between patients in the stepped, centrally assisted collaborative care model relative to patients in the collaborative care as usual-treatment arm. METHODS: Patients with probable PTSD and/or depression were recruited at 6 large military treatment facilities, and 666 patients were enrolled and randomized to STEPS-UP or usual collaborative care. Utilization data acquired from Military Health System administrative datasets were analyzed to determine mental health service use and patterns. Clinical complexity and patient characteristics were based on self-report questionnaires collected at baseline. RESULTS: Compared with the treatment as usual arm, STEPS-UP participants received significantly more mental health services and psychiatric medications across primary and specialty care settings during the year of their participation. Patterns of service use indicated that greater clinical complexity was associated with increased service use in the STEPS-UP group, but not in the usual-care group. CONCLUSIONS: Results suggest that stepped, centrally assisted collaborative care models may increase the quantity of mental health services patients receive, while efficiently matching care on the basis of the clinical complexity of patients.

Deployment, combat, and risk of multiple physical symptoms in the US military: a prospective cohort study.

PURPOSE: Multiple physical symptoms (MPS) have historically been observed after deployment to a combat zone and are often disabling in nature. This study examined longitudinal trends in MPS status and its relationship to deployment in U.S. military service members. METHODS: Using longitudinal data from panel 1 participants in the Millennium Cohort Study (n = 76,924), MPS status was assessed at three time points (2001-2008) using the 15-item Patient Health Questionnaire. Probability of reporting MPS was analyzed using mixed-effects multinomial logit regression, with time and deployment experience as main explanatory variables. RESULTS: After adjustment for demographic, military, and health characteristics, service members who deployed with combat were significantly more likely to report MPS at each time point compared with those not deployed (odds ratio [OR] and 95% confidence interval [CI] for wave 1 = 1.49 [1.47-1.52], wave 2 = 1.73 [1.69-1.78], wave 3 = 2.08 [2.03-2.12]), and those who deployed without combat (OR and CI for wave 1 = 2.66 [2.59-2.74], wave 2 = 1.81 [1.75-1.87]; wave 3 = 1.68 [1.63-1.74]). CONCLUSIONS: Longitudinal trends indicate that the probability of reporting MPS has increased consistently over time only for those deployed, regardless of combat experience.

Randomized effectiveness trial of a brief course of acupuncture for posttraumatic stress disorder.

BACKGROUND: Initial posttraumatic stress disorder (PTSD) care is often delayed and many with PTSD go untreated. Acupuncture appears to be a safe, potentially nonstigmatizing treatment that reduces symptoms of anxiety, depression, and chronic pain, but little is known about its effect on PTSD. METHODS: Fifty-five service members meeting research diagnostic criteria for PTSD were randomized to usual PTSD care (UPC) plus eight 60-minute sessions of acupuncture conducted twice weekly or to UPC alone. Outcomes were assessed at baseline and 4, 8, and 12 weeks postrandomization. The primary study outcomes were difference in PTSD symptom improvement on the PTSD Checklist (PCL) and the Clinician-administered PTSD Scale (CAPS) from baseline to 12-week follow-up between the 2 treatment groups. Secondary outcomes were depression, pain severity, and mental and physical health functioning. Mixed model regression and t test analyses were applied to the data. RESULTS: Mean improvement in PTSD severity was significantly greater among those receiving acupuncture than in those receiving UPC (PCLΔ=19.8±13.3 vs. 9.7±12.9, P<0.001; CAPSΔ=35.0±20.26 vs. 10.9±20.8, P<0.0001). Acupuncture was also associated with significantly greater improvements in depression, pain, and physical and mental health functioning. Pre-post effect-sizes for these outcomes were large and robust. CONCLUSIONS: Acupuncture was effective for reducing PTSD symptoms. Limitations included small sample size and inability to parse specific treatment mechanisms. Larger multisite trials with longer follow-up, comparisons to standard PTSD treatments, and assessments of treatment acceptability are needed. Acupuncture is a novel therapeutic option that may help to improve population reach of PTSD treatment.

Implementing collaborative primary care for depression and posttraumatic stress disorder: design and sample for a randomized trial in the U.S. military health system.

BACKGROUND: War-related trauma, posttraumatic stress disorder (PTSD), depression and suicide are common in US military members. Often, those affected do not seek treatment due to stigma and barriers to care. When care is sought, it often fails to meet quality standards. A randomized trial is assessing whether collaborative primary care improves quality and outcomes of PTSD and depression care in the US military health system. OBJECTIVE: The aim of this study is to describe the design and sample for a randomized effectiveness trial of collaborative care for PTSD and depression in military members attending primary care. METHODS: The STEPS-UP Trial (STepped Enhancement of PTSD Services Using Primary Care) is a 6 installation (18 clinic) randomized effectiveness trial in the US military health system. Study rationale, design, enrollment and sample characteristics are summarized. FINDINGS: Military members attending primary care with suspected PTSD, depression or both were referred to care management and recruited for the trial (2592), and 1041 gave permission to contact for research participation. Of those, 666 (64%) met eligibility criteria, completed baseline assessments, and were randomized to 12 months of usual collaborative primary care versus STEPS-UP collaborative care. Implementation was locally managed for usual collaborative care and centrally managed for STEPS-UP. Research reassessments occurred at 3-, 6-, and 12-months. Baseline characteristics were similar across the two intervention groups. CONCLUSIONS: STEPS-UP will be the first large scale randomized effectiveness trial completed in the US military health system, assessing how an implementation model affects collaborative care impact on mental health outcomes. It promises lessons for health system change.