Post-traumatic stress disorder (PTSD) is common in the general population (9-17% lifetime prevalence;Bruce et al., 2001;Fifer et al., 1994;Gillock et al., 2005;Neria et al., 2006;Stein et al., 2000) and among primary care patients (up to 35%;Gillock et al., 2005). Most people with common mental health disorders do not seek treatment from mental health specialists (Kessler et al., 1994;1995) but from primary care clinicians (PCCs). Despite the availability of treatments for PTSD, patient, clinician, and system barriers prevent most from receiving adequate care (Lecrubier, 2004;Samson et al, 1999;Stein et al., 2000;Stein 2003;Kessler, 2000;Jaycox et al., 2004). Therefore, approaches are needed to eliminate barriers and increase treatment opportunities for those suffering from PTSD. We address this gap by drawing upon the abundant work on improving primary care for depression (Wells et al., 2000, 2004;Rost et al., 2002;Dietrich et al., 2004;Rubenstein et al., 2006;Meredith et al., 2000, 2006) and from our exploratory/developmental work (R34MH070683) that used a community-based participatory research (CBPR) approach to identify viable strategies for overcoming barriers to providing and receiving care for PTSD. We propose a 5-year follow-on randomized trial to test the impact of a PTSD Care Management (PCM) program for patients seeking primary care from community health centers (CHCs). Our proposal addresses NIMH priorities for """"""""understanding effective means of organizing, implementing, financing, and delivering mental health services in primary care"""""""" outlined in PA-07-312 """"""""Mental Health Consequences of Violence and Trauma (R01)"""""""". We will randomize 400 patients from six CHCs to either the PCM intervention (N=200) or to a control condition (N=200). The intervention includes components and strategies implemented through a Care Manager (CM): 1) patient education, 2) patient screening and feedback to PCCs, 3) clinician education and use of guidelines, 4) structured feedback between primary care and mental health clinicians, 5) continuity of patient care, and 6) a resource guide detailing available community services. The control condition includes only the clinician education and patient screening without feedback. Specifically, we aim to: 1. Evaluate the effectiveness of the PCM program compared to control in reducing PTSD and other mental health symptoms and improving health-related quality-of-life;and examine the mediating and moderating effects for use of, perceived barriers to, and satisfaction with health care (at 6 and 12 months). 2. Assess the success of the PCM program implementation through descriptive analysis of monthly reports and patient registry data maintained by CMs e.g., level of implementation for each intervention component and percent of patients assessed, treated, and referred over 12 month's time. 3. Examine the direct cost of the PCM program compared to control using exploratory analysis of staffing time, salaries, and resources data obtained from participating CHC staff.
This proposed research project is relevant to public health because its goal is to improve the health of underserved populations seen in community health centers. We propose to implement and evaluate a primary care program that addresses multiple patient-, clinician-, and system- level barriers to services for those who suffer from post-traumatic stress disorder (PTSD), a common disorder in these settings.
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