RAND Corporation, Boston, Massachusetts2Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
RAND Corporation, Boston, Massachusetts.
JAMA Intern Med. 2016 Jul 1;176(7):948-56. doi: 10.1001/jamainternmed.2016.2402.
It is often difficult for members of the US military to access high-quality care for posttraumatic stress disorder (PTSD) and depression.
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.
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.
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.
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.
Central assistance for collaborative telecare with stepped psychosocial management modestly improved outcomes of PTSD and depression among military personnel attending primary care.
clinicaltrials.gov Identifier: NCT01492348.
美国军人往往难以获得高质量的创伤后应激障碍（PTSD）和抑郁症治疗。
确定集中辅助协同远程护理（CACT）干预对军事初级保健 PTSD 和抑郁症的疗效。
设计、地点和参与者：STEPS-UP 研究（使用初级保健逐步增强 PTSD 服务）是一项随机试验，比较 CACT 与 PTSD 或抑郁症的常规综合心理健康护理。患者主要是 20 多岁的男性，于 2012 年 2 月至 2013 年 8 月从 6 个军事设施的 18 个初级保健诊所招募，2014 年 10 月完成了 12 个月的随访。
随机分为 CACT（n=332）或常规护理（n=334）。CACT 患者接受了 12 个月的分级心理社会和药物治疗，护士通过远程护理管理病例量、症状和治疗。
主要结果是 PTSD 诊断量表（PDS；评分 0-51）和症状清单抑郁项目（SCL-20；评分 0-4）的严重程度评分。次要结果是躯体症状、疼痛严重程度、健康相关功能和精神卫生服务使用。
在 666 名患者中，81%为男性，平均（SD）年龄为 31.1（7.7）岁。CACT 和常规护理患者的基线 PDS PTSD（29.4[9.4]与 28.9[8.9]）和 SCL-20 抑郁（2.1[0.6]与 2.0[0.7]）评分相似。与常规护理相比，CACT 患者报告的 PDS PTSD 评分（-6.07[0.68]与-3.54[0.72]）和 SCL-20 抑郁评分（-0.56[0.05]与-0.31[0.05]）在 12 个月时显著下降。在 CACT 组中，与常规护理相比，12 个月时 PTSD（分别为 73[25%]与 49[17%]；相对风险，1.6[95%CI，1.1-2.4]）和抑郁症（分别为 86[30%]与 59[21%]；相对风险，1.7[95%CI，1.1-2.4]）的患者中有 50%的改善，分别需要治疗 12.5（95%CI，6.9-71.9）和 11.1（95%CI，6.2-50.5）。CACT 患者的躯体症状（12 个月患者健康问卷 15 项变化的平均值差异，-1.37[95%CI，-2.26 至-0.47]）和心理健康相关功能（12 个月短型 12 项心理健康成分摘要变化的平均值差异，3.17[95%CI，0.91 至 5.42]）有显著改善，以及电话健康咨询和适当药物使用增加。
初级保健中协作远程护理的集中辅助和分级心理社会管理适度改善了军人 PTSD 和抑郁症的预后。
clinicaltrials.gov 标识符：NCT01492348。
