Unique Primary Care Model Effective for Comorbid Depression, PTSD

A unique primary care program successfully manages patients with depression and comorbid posttraumatic stress disorder (PTSD) and, if widely implemented may result in more rapid treatment and help alleviate wait times for specialty psychiatric care.



Zachary Zuschlag, MD

“We know there are strains on the mental healthcare system, and sometimes something as simple as getting to see a psychiatrist can be incredibly challenging,” co-investigator Zachary Zuschlag, MD, staff psychiatrist at the James A. Haley Veterans’ Hospital and assistant professor at the University of South Florida, Tampa, told Medscape Medical News.

“So, a model that encourages primary care doctors, together with consultation from us [psychiatrists] to effectively treat these patients in a more proactive way, is very beneficial,” Zuschlag said.

The findings were presented at the American Society of Clinical Psychopharmacology (ASCP) 2022 Annual Meeting.

Common Bedfellows

Zuschlag noted that comorbid PTSD and depression is common, but it is often considered too complex to be managed in a primary care setting.

Although treating these patients can be challenging, Zuschlag, who also heads his Veterans Administration (VA) facility’s antidepressant monitoring program (ADM), said that when he started the program for this patient population, he used “a much more inclusive model and welcomed these patients even if they had co-occurring issues.”

“Anecdotally, we had seen that our patients with [depression and] co-occurring PTSD appeared to be doing as well as their peers without PTSD, and we just wanted to look at it more systematically,” he added.

The ADM program is specifically designed for psychopharmacologic management of depression and anxiety in the primary care setting. It involves an interdisciplinary team of RN care managers, consulting psychiatrists, psychologists, and primary care physicians. Patients in primary care clinics likely to benefit from psychiatric medications can be enrolled and followed in the program.

The program consists of structured, protocol-based telephone contacts from the RN care managers at scheduled intervals, usually every 3-4 weeks, said Zuschlag.

During calls, information is collected via evidence-based mental health symptomatic assessment scales. The consulting psychiatrists use this and other information to help guide treatment and coordinate with patients’ primary care physicians to adjust the treatment plan, including medication changes and additional psychotherapy.

To determine the program’s efficacy the controversy retrospectively reviewed all patients enrolled in the ADM program during its first 10 months. Of the 433 program participants, 112 (26%) were identified with active PTSD symptoms at baseline. Another 43 patients had a prior diagnosis of PTSD.

Program completion rates for the cohort with PTSD did not differ from that of the cohort without PTSD.

Overall, mean improvements in depression and anxiety symptoms, as evidenced by changes in Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder Assessment-7 (GAD-7) scores of 44% and 43%, respectively.

No differences in mean reduction in symptoms of depression were observed when comparing those with no history of PTSD vs those with any history of PTSD (-6.16 vs -5.42; P = .3244) or vs those with active PTSD symptoms (-6.16 vs -5.54; P = .4543).

Similarly, for anxiety, a mean reduction of -5.61 on the GAD-7 score was observed for the cohort without PTSD vs -4.99 in the cohort with any history of PTSD and -5.35 in the cohort with active PTSD symptoms. Again, these differences were nonsignificant.

Zuschlag noted that the VA setting is unique, with a lot of resources available to conduct such a program as ADM.

“Care management programs that are multidisciplinary are very effective and, in our experience, those who have completed the program do exceptionally well. The patients love it because there is a lot of contact between them and their various care providers,” he said.

A Model for Other Settings?

Commenting on the study for Medscape Medical News, Nagy A. Youssef, MD, PhD, professor of psychiatry and director of clinical research at The Ohio State University College of Medicine, Columbus, called the results “interesting.”



Nagy A. Youssef, MD, PhD

“Treating patients with comorbid mild to moderate depression and current or past PTSD within the primary care setting using a care management program could be a model for other VA hospitals as well as in non-VA settings,” said Youssef, who was not part of the study.

Youssef noted not only was there no difference in symptomatic improvement between the depression plus PTSD vs depression-only groups, but program completion rates did not differ.

This further emphasizes “the potential utility of this approach in initial patient treatment, especially with limited mental health resources and the need to help more patients,” he said.

Zuschlag and Youssef report no relevant financial relationships.

American Society of Clinical Psychopharmacology (ASCP) 2022. Abstract 3003546. Presented June 2, 2022.

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