Evidence-Based Psychotherapies for Managing PTSD in the Primary Care

SettingKyle Possemato, Ph.D.

Clinical Research Psychologist

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session # F4October 29, 201110:30 AM

Faculty Disclosure

I have not had any relevant financial relationships during the past 12 months.

Need/Practice Gap & Supporting Resources

• PTSD is common among primary care patients – Associated with significant functional impairment, physical health

concerns, more health care utilization and mental health comorbidities.

• Significant barriers to receiving adequate treatment exist for primary care patients with PTSD.

• Mental health professionals operating as part of the primary care team have the potential to provide effective brief intervention services.

• There are no evidence-based guidelines on how to treat PTSD outside the specialty mental healthcare setting.

Objectives

• This presentation will review early research on the development and testing of primary care-based PTSD treatments and other brief PTSD interventions (i.e., telehealth and early intervention) that could be adapted to the primary care setting.

Possemato, K. (2011) The Current State of Intervention Research for Posttraumatic Stress Disorder within the Primary Care Setting. Journal of Clinical Psychology in Medical Settings, 18, 268-280.

Expected Outcome

Participants will learn:• How to incorporate evidence-based psychotherapy strategies

for treating PTSD into brief primary care encounters. • How to utilize telehealth programs to enhance and

supplement their in-person interventions. • Risks and benefits of using in-vivo and written exposure

techniques in primary care. • Next steps for clinicians and researchers in establishing

empirically supported PTSD treatment for the primary care setting.

Screening Every patient should be routinely screened

and follow-up should be conducted in a private setting (Resnick et al., 2000)

4 item PC-PTSD (Prins et al., 2003)

Positive screens should be further evaluated Assessment

17 item PTSD Checklist (PCL; Yeager et al., 2007) Lower cut offs in Primary care (30-44) Also assess:

Trauma exposure, dangerousness, physical and mental functioning and co-morbid psychiatric conditions

Motivation for treatment

Confronting Uncomfortable Memories (Cigrang et al., 2011)

Prolonged Exposure in 4, 30-minute sessions Corso et al., 2009

TAU approach delivering CBT in 5, 30-min sessions CALM (Roy-Burne et al., 2010)

Computer assisted CBT and/ or med. management CBT-PC (Prins et al., 2009)

6, 1-hour sessions focused on Cognitive Restructuring

Care Management RESPECT-P/ RESPECT-MIL (Engel et al., 2008)

TIDES/PTSD

DE-STRESS (Litz et al., 2007)

Therapist-assisted, self-management trauma focused narratives

Interapy (Knaevelsrud et al., 2010)

Trauma writing via email correspondence with therapist

PTSD Online (Klein et al., 2010)

10 online therapist assisted CBT sessions Self Help for Trauma Consequences (Hirai & Clum, 2005)

Self-guided trauma writing Afterdeployment.org

Adjusting to War Memories workshop PTSD Coach and T2 Mood Tracker

http://www.t2health.org

Adapted Prolonged Exposure (Cigrang et al., 2005)

PE vs. PE+CBT vs. supportive therapy (Bryant et al., 1999)

2 sessions + phone call (Hickling et al., 2005)

Collaborative Stepped Care (Zatzick et al., 2004)

Behavioral Activation (Wagner et al., 2007)

Brief PTSD treatment can effectively reduce PTSD symptoms

Telehealth can augment in-person PC treatment

The most evidence exists for cognitive and behavioral interventions. In addition to psychoeducation, relaxation,

cognitive restructuring and exposure are mostly commonly delivered

Can be safely and effectively delivered in primary care and via telehealth In-vivo larger effects than imaginal

Common Concerns Less monitoring Less pre-exposure skill building?

Exposure therapy in PC may not be necessary Primary care treatment can prepare patients

for full length exposure treatments.

Exposure Therapies

Dismantling studies are needed.• What CBT interventions are necessary to

reduce PTSD symptoms in primary care patients?

Lack of self-guided treatment for PTSD in PC These are effective for depression and anxiety

(Cuijpers et al., 2010)

Do treatments developed for combat trauma work for civilian trauma?

A variety of treatments need to be developed to match patients' needs and preferences

Describe "treatment as usual" approaches well and gather pre- and post symptom data.

Interventions tested with case studies and pilots need RCTs.

Telehealth and early interventions still need to be tested with primary care patients.

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!

Kyle.Possemato@va.gov