Patient Engagement

Educating patients about depression and treatment options often has already started patients
becoming partners in their care process. The next step is provision of more specific engagement
around agreed treatment.
Provide Key Educational Messages
For patients starting antidepressant medication (available as a patient education handout):
Table 7: Advice to Patients Commencing Antidepressant Therapy
• Antidepressants only work if taken every day.
• Antidepressants are not addictive.
• Benefits from medication appear slowly.
• Continue antidepressants even after you feel better.
• Mild side effects are common, and usually improve with time.
• If you are thinking about stopping the medication, call me first.
• The goal of treatment is complete remission; sometimes it takes a few tries.

For patients starting psychological counseling:

• Counseling takes a little longer before you will feel any improvements.
• Keep your appointments with the therapist.
• Be honest and open, and ask questions.
• Work cooperatively with the therapist (e.g. complete tasks assigned to you as part of the
therapy).
• If you have problems or are not satisfied with your therapist, call us and we'll help you.
Tell all patients:
• If you are feeling worse, don't wait until your next appointment.
• Call my office right away!
Encourage a Self-Management Plan
Encourage the patient to select a small, achievable goal to work on each week for the next several
weeks. Selecting a self-management plan is an activity to reinforce positive coping and help alleviate
some symptoms while waiting for the effects of medication. In addition, self-management can
promote the patient's confidence and activation both of which are associated with improved mental
health outcomes Goals should be simple with small increments to begin with and can include
physical activity, pleasurable activities, spending time with supportive people, or relaxing activities.
The following form can be used as a helpful reminder and reinforcement.
 Figure 6: Self-Management Worksheet

SELF-MANAGEMENT WORKSHEET
There are a number of things you can do to help yourself feel better when you're not at your best. We suggest you select
one activity here that you can staft on. Remember to take it slowly at fint and add new things as you begin to feel

1. Remain physicaDy active. 4. Practice relaxing.

Make sure you make time to address YOUt basic
physieal needs, for example, walking for a
certain amount oftime each day.
Everyday next week, I will spend at least minutes (make
it easy, reasonable) doing:
2. Make time fOrpleuorable activitie..
Even though you rrYRf not feel as motivated, Q[ get the same
amount of pleasure as you used to, commit to scheduling some
fun activity each day rrYRfbe a fsvorite hobby.
F Q[ many people, the changes that
come with depression can lead to
anxiety. Since physical telaxaOon can
lead to mental relaxation, ptactidng
relazing is another way to help
yoocselE Try deep bteathing, or take
a Watm bath, or just find a guiet,
comfortable, peaceful place and say
comforting things to yoocself(like "It's okay.").
Everyday next week, I will practice physical relaxation at least
_ _ times, for at least minutes each time (make it easy,
reasonable).
5. Simple goal. and .maD .rep••
It's easy to feel overwhelmed when yoo'te

I
depressed, Some pmblems and decisions can be
delayed, but others cannot. It can be hard to deal
with them when you're feeling sad, have little
energy and are not thinking as clearly as usual.
Try breaking things down into small steps. Give
yoorself credit for each step you accomplish.

The pmblem is: _

My goal is: _
Everyday next week, I will spend at least minutes (make Step 1: _
it easy, reasonable) doing: Step 2: _
Step 3:
J. Speod time with people who can .opport
yoo. 6. Eat ftOtritiODO, balanced meat.
It's easy to avoid contact with people when you'te aod avoid alcohol
down Q[ not at YOOt best, but you need the support Alcohol is a depressant and can add to feeling
of friends and family. Explain to them what you down and alone. It can also interfere with the
ate experiencing, if you can, If you can't talk about help yoo may receive from antidepressant
it, that's okay. Just asking them to be with yoo, medication.
maybe duting one of YOUt activities, is a good 6rst
step.

During the next week, I will make contact for at least _ During the next week, I will improve my diet by:
minutes (make it easy, reasonable) with (name) doing! talking
about: (example, drinking watet at soda instead of alcohol).
Explain and Recommend Care Management
• Explain role of the care manager as a systematic extension of the clinician's ability to
monitor treatment response and side effects as well as to assist the patient in maintaining or
adjusting self-management goals.
• The care manager calls in one week to be sure treatment has started or to help solve problems
if it has not.
• The care manager generally calls at subsequent 4-week intervals to re-administer the PHQ-9
to assess effects of treatment.
• Verifying the best available phone number for the patient will facilitate an easy initial contact
by the care manager.
• Letting the patient know typical care manager contact intervals and follow-up office visit
appointments will help in treatment.
Then complete and transmit a Referral to the care manager via CHCS II / AHLTA including relevant
details as demonstrated in Figure 7.
Figure 7: Referral to Care Management
(CHCS II / AHLTA)

View Referral

Patient: Jones, John FMP/SSN:xxxxxxxx

Pat SSN: xxxxxxxx Sex/DOB/Age: 22 y

Reason for Referral:

RESPECT ID # 0001

22 yo male screened positive for depression withPHQ9 results of 6 symptoms and score of
16.

Pt. elected to start a tluoxetine 20 mg and will be returning to clinic in I month.

Pt. selects swimming as a self management goal and will start at 1x per week.

Pt. agrees to care management/requests call.

Home phone # preferred and verified.

Adherence Call at 1 Week
• Care Manager calls one week after initial visit.
• If prescribed antidepressants, confirms that patient has filled prescription and started
medication.
• Care manager inquires about side effects and problem solves with patient.
• If the patient was referred to psychological counseling, care manager confirms that
appointment was made and kept or there is an intention to keep.
• Ifmedication not started or psychological counseling appointment has not occurred, further
adherence calls planned.
• Care manager discusses benefits of self-management and assists Soldier in selection an initial
goal focusing on small and simple steps to begin with.
• Care manager will mail educational materials if they were not obtained at the time of the
office visit.
Optional Telephone Contacts between 1 and 4 Weeks: Additional Adherence Call(s)
• If medication is being titrated upward, asks if dose has been increased, and if any side
effects.
• If mental health referral, has first visit been completed.
• Inquires about and encourages self-management activity.
• Helps Soldier problem solve regarding these areas noted above.
Treatment Response Calls Every 4 Weeks
• Care manager contacts are intended to occur at least every 4 week interval to re-administer
the PHQ-9 in order to assess response to treatment and to assess for remission.
• PHQ-9 score is reported to patient, clinician, and supervising psychiatrist.
• Assessments are reviewed by psychiatrist and information/concerns conveyed to the clinician
by the care manager.
Care Management Supervision
Care manager has weekly supervision with psychiatrist to review adherence problems, side effects,
and sub-optimal responses.
Communication with Primary Care Clinician
• Care manager and clinician communicate via e-mail and/or CHCS II / AHL TA after care
manager contacts and office visits.
• Supervising psychiatrist and clinician communicate by phone, email, and/or in person on
selected cases.
Below is an example of a follow-up PHQ-9 obtained by a care manager after four weeks of
antidepressant treatment at an initial adequate dose. At this point, the severity score and functional
impairment are the primary pieces of information needed to assess treatment response. Normally the
care manager will have scored the PHQ-9 and provided you with the score and the difference in
severity score from baseline. To be sure you understand how to score the PHQ-9, score the following
PHQ-9 for severity.
 Figure 8: PHQ-9 Follow-Up for Depression Scoring Exercise
PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

~U.~2 _ _ ' - _ _ ~_ /
by any of the following problems? •
/
~
fi;~ ~
(use ''''''' to indicate your -wet") ~ rle ,.&-:t~ ,+.'4l?~
1 Little Interestor pleasure In doing tt1lngs 0 1 (1) 3
2. Feeling down, depressed. Of hopeless 0 1 CD 3
3 Trouble falling Of stayingasleep, Of sleeping too much 0 1 2 <D
4 Feeling tired or having little energy 0 1 2 CD
5 Poor appetiteOf overeating
Feelingbad about yourself- or that you are arailure or
® 1 2 3
6
havelet vourself or vourfamilV down
Trouble concentrating on things, suchas reading the
0 1 <D 3
7
newspaper or watchil1Q television 0 1 0 3

8 Moving or speaking so slowly mat otherpeople could have

noticed. Or the opposite - beingso fidgetyor restless that you ® 1 2 3
havebeen movil1Q arounda lot more tt1an usual
Thoughts that you wouldbe betteroff dead. Of of hurting
9
IvourselfIn some Way ® 1 2 3

add columns:! + + -----<

TOTAL:! ------'

Not diffiCUlt at all

If you checked off any problems, how difficult havethese Somewhatdifficult
10 problems made it for you to do your wor1<, take care of
thingsat horne, or get alongwith other people?
Very difficult
Extremely difficult '"
 Figure 9: Care Manager Report to Clinician
(CHCS II / AHLTA)

MailMan message for: GRIFFIN, CHRISTOPHER

Subj: JONES, JOHN XXIXXX-X/X-XXXX - Telephone Consult

From: POSTMASTER (Sender: RESPECT CARE MANAGER)

Telephone Consultation

Provider's Note:

S: This 22 year old Soldier seen and referred on 29 March 2005 with a PHQ-9 score of 16 and
started on fluoxetine 20 mg same date. Pt. set a goal of swimming Ix per week and has
completed his goal each week. He has increased goal for next month to 2x per week.

PHQ-9 re-administered over phone this date (week 4 of Tx), Score is now 14 (0 on suicide
question). Minimal decrease in score or symptoms. Pt reports nausea but willing to
continue Rx, Advised to take Rx with food.

Dr. Gould suggests increasing dose to 40 mg at this time and monitoring nausea.

CM will call again in one week to monitor.

Provider: RESPECT CARE MANAGER

Using the PHQ-9 to Assess Patient Response to Treatment
The goal of acute phase treatment is remission of symptoms as indicated by a PHQ-9 score of < 5
points. Patients who achieve this goal enter into the continuation phase of treatment. Patients who do
not achieve this goal remain in the acute phase of treatment and require some alteration in treatment
(dose increase, medication change, augmentation, combined antidepressant/psychological
counseling). Patients who do not achieve remission after two adequate trials of antidepressants
and/or psychological counseling for 20 to 30 weeks would benefit from a formal or informal
psychiatric consultation for diagnostic and management suggestions.
Table 8: Assessment of Patient Response to Treatment

InitiaJResponse after Four - Six weeks of anAdequate Dose of an Antidepressant

PHQ-9 Score Treatment Response Treatment Plan

No treatment change needed. Follow-up in
Drop of 2 5 points from baseline
Adequate four weeks.
Often warrants an increase in
Drop of 2-4 points from baseline Probably Inadequate antidepressant dose.
Increase dose;
Drop of 1 point or no change or Inadequate Augmentation;
increase Switch;
Informal or formal psychiatric
consultation;
Add psychological counseling (especially
if not improved with monotherapy)

Initial Response to PsychologicalCounseling After Three Sessions over Four to Six Weeks

PHQ-9 Score Treatment Response Treatment Plan

Drop of'> 5 points from baseline
Drop of 2-4 points from baseline
Drop of I point or no change or
increase
No treatment change needed. Follow-up in
Adequate four weeks.
Possibly no treatment change needed.
Share PHQ-9 with psychological
Probably Inadequate
counselor.
If depression- specific psychological
Inadequate counseling (CBT, PST, IPT*) discuss with
therapist, consider adding antidepressant.

For patients satisfied in other type of

psychological counseling, consider starting
antidepressant.

For patients dissatisfied in other

psychological counseling, review treatment
options and preferences.
Antidepressant Side Effects
Side effects account for as many as two-thirds of all premature discontinuations of antidepressants.
Most side effects are early onset and time limited (e.g. SSRI decreased appetite, nausea, diarrhea,
agitation, anxiety, and headache). These can be managed by temporary aids to tolerance. Some side
effects are early-onset and persistent or late onset (e.g. SSRI apathy, fatigue, weight gain, sexual
dysfunction) and may require additional medications or a switch to another antidepressant.
Strategies for managing antidepressant side effects:
1. Allow patient to verbalize his/her complaints about side effects.
2. Wait and support. Some side effects (i.e. GI distress) will subside over 1-2 weeks.
3. Lower the dose temporarily.
4. Treat the side effects (see below).
5. Change to a different antidepressant.
6. Discontinue medications and start psychological counseling.
 Table 9: Common Side Effects of Antidepressants

8cclation +1- "Give meditationat bedtime.

*'I/Crease mirtazapinedose.
~Tty caffeino.

Anticholinergic +/- +1· "I~ue hydnlliOO.

lik.1: symptoms ·Sugarll:SS 8\l1lliClIudy
Dry lllPlllhleye:;, * Dietary fiber.
Constipation. *AnUiciaitelltS.
Urinary retentlon, "Consider switching medication.
'rachyL'aTdia

GI distress. ++ ·ofren improves in 1-2 weeks;

Nllll$rJ ·Tllkewith meals,
*Consider antacids or H2
blockers.

Restlessness, + +/ ++ "Start with small doses. especially

Jitters/l'remors with anxiety disorder.
"Reducedosetemporarily,
"Add beta blocker (propnmolol
10·20 mg tid/tid.
*Consider short trial of
benzodiazepine.

Headache + + "Lower dose.

*Acetaminophen.

Insomnia *Trazodone 25·100 mg po qhs

(cancause orthostatic
hypotension and priapism)
"'ake medication in A.M.

Sexual *May be part of depression or

Dysfunction medical disomers
"Decrease dose.
"Try adding bupropion 100 mg
qhs or bid.
*Try adding buspironc 10-20 J11g
bid/tid
"Try addingcyproheptadine 4 mg
1-2 hrs be!ore sex.
"Considera trial of Via
Seizures .Discontinuellnti ant.
Weighl.gain +/- +1 ++ ·Exercise
·Diet
*Consider changing
medications

Agranulocytosis *Monitor for signsof infection.

nulike symptoms
"SI. dru, check wee

KEY: . Very unlikely +-1· Uncommon + Mild ++ Moderate

Clinician Office Visits Coordinated with Care Management Contacts
Clinician visits should typically occur after PHQ-9 assessments. The care manager and clinician
should establish preferred routine intervals if recommended intervals are not appropriate.
Evaluate Patient Response to Treatment
For antidepressants, a measurable, partial response to adequate dose usually occurs by four weeks. A
remission of symptoms usually occurs by 8 to 12 weeks.
For psychological counseling, initial response may take somewhat longer and remission depends on
severity of psychosocial stressors.
• Review symptoms, PHQ-9 score, and functional assessment provided by care manager from
earlier phone call.
Modify Treatment with Sub-Optimal Response
Decisions to continue or modify treatment (typically at four week intervals) are made on the basis of
PHQ-9 assessments.
Input from supervising psychiatrist can be requested at any time or may be offered when indicated
after review with care manager.
Strive for Remission
The goal of acute phase treatment is to achieve remission. Reassess treatment response and modify
periodically so that patients will have:
A reduction ofthe PHQ-9 to a score <5 and no functional impairment.
When patients achieve this goal they enter into the continuation phase of treatment. Patients who do
not achieve this goal remain in acute phase treatment and require some alteration in treatment (dose
increase, augmentation, combination treatment). Patients continue with care management follow-up
periodically with clinician follow-up as needed.
 Figure 9: Clinician Reassessment
CCRCS II / ARLTA)

MailMan message for RESPECT CARE MANAGER

Subj: JONES, JOHN XXlXXX-XlX-XXXX - Telephone Consult

From: POSTMASTER (Sender: GRIFFIN, CHRIS)

Telephone Consultation

Provider's Note:
S: 22 year old Soldier with depression. Initial treatment with fluoxetlne 20mg resulting in minimal
improvement perPHQ9 readministered by Care Manager. Spoke today with patient.

IlVIP/PLAN: Inadequate treatment response. Will increase fluoxetine to 40 mg.

Request Care Manager call in 1 week, verify pt increased Rx, RTC 4 weeks.
Provider: GRIFFIN, CHRIS

Figure 10: Typical Frequency of Patient Contacts

-nl\lING OF PA'fIt:NT CON1'ACl'S foUM. A TYPICAl. CAS.: OF D.:PM.~:SSION

(INITIAL EPISODE)

o Clinician Office Vi8its

_ Care Manager CODtadS

_____ ~~~!.h.!5!. --. ~ S~!..D!!D..!!a~~ .!I!!'~ _
Treatment Treatment

#1 #2

1ttd;[: 0 2 4 6 8 12 16 24 32 36
~. J 2 3 4 6 8 9
.. TIME ..
Note: NCQA.HEDIS S/8IId8rds 01 Care indude three clinician vis/til during (he Awl£! PhttIl8 of treatment.
Continue Treatment Response Monitoring After Remission
Patients who achieve a remission from Depression enter the continuation phase. In this disorder
there is a substantial risk of relapse during the initial period. Many patients may no longer meet the
formal criteria for depression but still have continuing symptoms with or without functional
impairment. Persons with additional psychiatric disorders or psychosocial stressors are more likely
to have continued symptoms and/or relapse.
Figure 11: Long-Term Maintenance Strategy

Acute Phase ) k i - o n Phase ) ( Mainunance Phase

( )
Remission Recovery

e.. ,
... " , .0:-."-----.
\
\ \ \
\
, , \
, \

Syndrume •,- - '• -'+

Relapse Relupse Recurrence

60% to 70%
Stop Rx* *IlEDLS 2002

Time

Adaptedfrom Kupfer; DJ. Long-term treatment ofdepression. J eli" Psychiatry.1991: 52 (suppl. 5) :28·34

All patients who no longer meet criteria for depression will receive education from the care manager
to recognize relapse early and request an appointment with their primary care or mental health
clinician. This education should be reinforced by the primary care clinician. Patients who still have
some symptoms should continue on pharmacotherapy because continued symptom relief is likely to
occur.
The care manager plays a pivotal role by monitoring remission and assessing PHQ-9 response (and
for PTSD, peL response) periodically after remission to assess for continued symptom improvement
or relapse. The care manager also assesses risk factors for recurrence.
At the end of the continuation phase, patients who sustain their remission are considered to have
achieved recovery.
Continue Successful Treatment for Nine to Twelve Months
Medications
Patients who successfully achieve remission on medication should take the same dose for nine to
twelve months following remission. Many patients do not refill their prescriptions during this phase,
therefore the care manager also assesses adherence during contacts to administer the PHQ-9 and/or
PCL.
Psychological Counseling
A decision to use continuation counseling depends on the symptoms, psychosocial problems, and
recommendation of the counselor.
Assess Risk Factors for Need for Long-Term Prophylactic Treatment
PTSD is often a chronic or recurring disorder. All patients who maintain remission for six to twelve
months should receive education to recognize recurrence early and request an appointment with their
primary care or mental health clinician.
Patients at risk for chronicity or recurrence of depression (i.e., diagnosis of chronic depression-
dysthymia-or a history of two or more previous episodes of major depression) or PTSD (i.e.,
history of previous trauma exposure, active psychiatric comorbidity) should be advised of the
possible advantages for long-term, maintenance pharmacotherapy.
Continue Long-Term Prophylactic Treatment and Monitoring of At-Risk Patients
Periodic PHQ-9 and/or PCL assessments should be considered in all patients at risk.
IV. RESPECT-MIL Protocol for Post-Traumatic Stress Disorder
This section provides a step-by-step view of RESPECT-MIL applied to the diagnosis and
management ofPSTD. As we have seen in Section III, the framework is quite similar to that for
depression.

Post-Traumatic Stress Disorder (PTSD) is a psychiatric disorder that can occur following the
experience or witnessing of life-threatening events such as military combat, natural disasters,
terrorist incidents, serious accidents, or violent personal assaults like rape. Events such as rape,
torture, genocide, and severe war zone stress (including the killing of civilians or enemy combatants)
are experienced as traumatic events by nearly everyone. Most people who are exposed to a
traumatic, stressful event transiently experience some of the symptoms of PTSD in the days and
weeks following exposure. Available data suggest that about 8% of traumatized men and 20% of
traumatized women go on to develop the disorder, PTSD, and roughly 30% of those who develop
PTSD develop a chronic form that persists throughout their lifetimes. People who suffer from PTSD
often relive the experience through nightmares and flashbacks, have difficulty sleeping, and feel
detached or estranged, and these symptoms can be severe enough and last long enough to
significantly impair the person's daily life.
The process of care for PTSD is nearly identical to that for depression. Just as with depression there
is a brief screening form and a longer diagnostic and severity assessment form. Initial treatment and
patient engagement are similar as are care management and psychiatric supervision. The following
description highlights content that is different, but for similar process steps, the reader is referred
back to the appropriate steps of Section III.
Four Components for PTSD Diagnosis
1. Traumatic experience.
• Soldier experienced or witnessed an event that involved actual or threatened death or serious
injury.
• Soldier's response involved intense fear, helplessness or horror.
2. Symptoms in each of the following categories.
• Re-experiencing of event (at least one):
o Images, thoughts, perceptions
o Nightmares
o Flashbacks
o Reminders cause psychological distress
o Reminders cause physiological reaction
• A voidance of stimuli associated with the trauma and numbing of general responsiveness (at
least three):
o Avoid thoughts, feelings, conversations of trauma
o Avoid activities, places, people that arouse recollections of trauma
o Inability to recall aspects of trauma
o Diminished interest or participation in activities
 o Feeling detached or estranged from others
o Restricted range of affect
o Sense of foreshortened career, marriage, or life
• Arousal (at least two):
o Insomnia
o Irritability
o Difficulty concentrating
o Hyper-vigilance
o Exaggerated startle response
3. Function at work, home, or socially is impaired.
4. Condition is persistent over at least one month.
As with depression, recognizing that a patient is suffering from PTSD is challenging. Patients may
also be suffering from depression, may be irritable and angry, and concerned about stigma because
of their reaction to trauma and the possibility ofa psychiatric diagnosis. To aid with identification of
PTSD, a four-question screen is administered by the clinic along with the two-question screen for
depression.
Figure 12: PTSD Screening Form

In your life, have you ever had any experience that was so frightening, horrible, or upsetting
that, in the past month, you ...

1. Have had nightmares about it or thought about it when you did not want to?

YES NO

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you
of it?

YES NO

3. Were constantly on guard, watchful, or easily startled?

YES NO

4. Felt numb or detached from others, activities, or your surroundings?

YES NO

If you circled YES to two or more of the four questions, please continue and complete the
attached form. (A copy ofthe peL is attached)
PTSD Checklist (PCL)
If the patient answers ''yes'' to two or more of the four questions, use the PCL to assist with
diagnostic assessment.
Similar to the PHQ-9 for depression, the PTSD Checklist (PCL) incorporates the previous DSM-IV
criteria (see previous page) into a self-administered questionnaire that helps make a PTSD diagnosis
and determine severity. The clinician and/or office staff discusses with the patient the reasons for
completing the checklist and explains how to fill it out.
Similar to the PHQ-9, based on the number of symptoms rated as at least at a moderately severe
level (~3) in each of the three categories (intrusion ~ I symptom endorsed, avoidance ~ 3 symptoms
endorsed, hyperarousal ~ 2 symptoms endorsed) in the past month, a total severity score> 30 [cut of
30 is appropriate - 28 is too low - most would even say 30 is too low, but we've not had a problem
with too many PTSD positives, so 30 works for me], and the presence of functional impairment, the
clinician can formulate a working PTSD diagnosis.
 Figure 13: PTSD Checklist (PCL)

peL
Instruction to patient: Below is a list of problems ancl carJ1)laints that persons 50rnttimes have in response to
stressful life experiences. Please read each one carefully, put an "X. in the box to inclicate how rnJCh you
have been botl-nod Iw that oroblem in the last month.
Not iIIt i1111 A little bit Moderatelv Quite ill bit Extremely
No. Response: (1) (2) (3) (4) (5)
1 Repeated, dist:urbing IT'emories,
thoughts, or images of a stressful X
experience from the past?
;1 Repeated, disturbing dreams of a
stressful exoerience from the oast? X
3 suddenly acting or feelil'l9 as if a
stressful experience wefe happenil'l9 X
~
Q
aoain (as if YOU were relivino it}?
4 Feeling very upset when sorrething
rerrinded you of a stl1i!ssful experience X
from the oast?
5 Having physical t'tiICtioons (e.g., heart
pouncIil'l9, tt'OUble bt'eathing, or
sweatil'l9) when something ''errinded you X
of a stressful experience fr'Om the past?
6 Avoid thinking about or tallocil'lg about a
stressful experience from the past or X
avoid havino feelinQs related to it?
7 Avoid activities or situations because
theyr'errind you of a stl'essful X
eXDlllience from the oast?
S Trouble relT1!rrbering important parts of
X
~ a stt'l!Ssful emerience from the oast?
9 loss of interest in things that you used
~ to eniov? X
10 Feeling distant or cut off from other
I....."""'? X
11 Feelil'l9 emotionally num, or being unable
to have loVing f_lings for those close X
to YOu?
12 Feeling as if your futuI"I! will somehow be
cut short? X
13 Trouble fall' ..... or ctavinn aslee",? X
14 Feeling in'!table or having angry
Q
outbursts? X
! 1'" Havin<l difficultvconcentratina?
16 Beina "suDer alert" or watchful on a~rd?
y

X
17 Feelil'l9 jurrpy or easily startled? X
18 IF you checked off any of the above pfoblems, how diffICult have these problems made it for you to
I""" I'~'''~' "~,~,J':,2,!JL wo~.,~~~ c~~w~, thinSl~,~,!:!ome, ~~'!'2!!~L~ith ~,'!!!'!!!~.l!!!L~~.~"",~ ••• ,.,~
w ••• •••, . , .

Not difficult Somewhat difficult X Very dfficult Extrern!1y diffkult

j..
19 During the last: 2 weelcs have you had thoughts that you would be better off dead, or of hurting
I·· I"
I,Y'~,"~" in some Ve,. X No
"'-'"

IF Yes, how often? l _ _Sevetal days 2_ _Mol'1! than half the days 3_ _Almost everyday
 Figure 14: ret Example 1

PeL
cOf'f1)laints that persons sOfT2l:ir'rEs have in response to
st lIy, put an "X. in the box to indicate how J11JCh you
ha FOR DfAGN h.
NEED FOUR t at all A little bit Moderately Quite D bit Exuemelv
(1) (2) () (4) (5)

thoughts, Of" ilT'&lges of it stressful

rience from thoe ast?
x
2 Repeated, distuliJing dreams of a
stressful ex rience from theast? x
3 Suddenly acting or feeling as if a
stressful experience were happening
in as if 01.1 were relivi it?
4 Feeling very upset when something
remnded you of a stressful experience x
from the lOt?
5 Having physical reactioons (e.g., heart
pounding, trouble breathing, or
sweating) when something rerrinded you x
of a stressful experience from the past?
Avoid thinking about or talking about a
stressful experience from the past or x
avoid havin feeli related to it?
Avoid activities or situations because
they rerrindyou of a stressful x
ex erienc e from t hoe st?
Trouble remermering irrlJotb nt parts
a stressful e rience from thoest?
Loss of interest in things that you used
to en' ?
Feeling distant or cut off from other
Ie? x
Feeling erTDticnally nurmor being una~
to have loving feelings for those close
to ou?
x
Feeling as if your uture wil somehow be
cut short?
x
x

2_ _More than half the days J_._Almost everyday

 Figure 15: ret, Example 2

pel
Instruction to patient: Below is a list of problems and conplaints that persons sometifTEs have in I'1!sponse to
stressful life experiences. Please read each one caJ'1!fully, put an -X" in the box to indicate how much you
have been bothered bv that omhlem In the fast rronth.
Not at all A little bit Modenlltelv Quite a bit E.xtremely
No. Re$ponse: (1) (2) (3) (4) (5)
1 Repeated, disturbing merrories,
thoughts, or imilges of a stl'1!ssful X
experience from the past?
2 Repeated, distul'bing dn!ams of a
stressful eXPErience from the past? X
3 Suddenly acting or feeling as if a
w stressful experience \..re1'1! happening X
<t aaain (as if vou wel'e relivina it)?
Q
4 Feeling very upset when something
reminded you of a stressful experience X
from the Dast?
5 Having physical reactioans (e.g.. heart
pounding. trouble bl'eillthing, or
sweating) when something reminded you X
of a stressful experience from the past?
6 Avoid thinking about or talking about a
stressful experience from the past or X
avoid havin" feelinas related to it?
7 Avoid activities or situations because
they remnd you of a stl'1!ssful X
eXD&rience from the cast?
8 Trouble rerrerrbering ~ottant palts of
X
i... a stressful experience from the past?
9 Loss of interest in things that you used
to enjoy? X
10 Feeling distant or cut off from other
oeo.m,;? X
11 Feeling emotionally nurrb or being unable
to have loVing fee.lings for those dose X
to YOU?
12 Feeling as if your future will sofl'Ehow be
cut short? X
13 Trouble fallina or sta1.linn asleen? :x
14 Feeling inil:able or having angry
Q
outbursts? X
! .
H. HavinCI difficultv concentt-atin'"
II" 1_-
lC
" hful on guard? X
SEVERITY SCORE 52 rtled1 =
(Mliitiply the number of bous
checked in each column by the
number at the top of the column,
:.
~~boveP?rc~
then total all the columns for the ....-. mewhat
scoreJ
X

t) + u.x
2) +UIX3) + (U4) + ~5}J
ve you had thoughts that you would be better off dead, 01" of hu.ting
I I yu~,... .. In some way~ _Yes X No
IF Yes, how often? 1____Sever.a1d a vs 2____More than half the days 3____AJmost evelyday
Assess Suicide Risk
Suicidal thoughts are often symptoms ofPTSD. Persons suffering from both PTSD and depression
have a higher rate of suicidal behavior. There is no good way to predict in the short term who will
commit suicide, although long-term risk is highly correlated with the following risk factors:
• Comorbid depressive disorder
• Previous traumatic events
• Hopelessness
• Prior suicide attempts
• Substance abuse
• Panic attacks
• Generalized anxiety
Conduct a Suicide Assessment
Always ask patients with PTSD if they have suicidal thoughts and/or suicidal plans. If they do, fmd
out if they have an active intent (e.g., "I'm going to go home and shoot myself'), or passive intent, "I
wish the Lord would take me").
 Table 10: Using peL Results to Help Determine Treatment Selection

PCL PCL Provisional Treatment

Symptoms & Impairment Severity Diagnosis Recommendations
< 6 symptoms at moderate or - Reassurance and/or
greater severity, but Subthreshold or no supportive counseling
<28
functional impairment PTSD - Education
- Self-management activity
2:6 symptoms at moderate or - SSRI
greater severity PTSD, - Self-management activity
2: 28
(2:1 intrusion symptom, Mild - If no improvement after
2: 3 avoidance symptoms, 12 weeks, refer for
2: 2 hyperarousal symptoms; Cognitive Behavioral
PTSD,
plus functional impairment) > 50 Therapy
Moderate to Severe
- Specialty referral*
*Refer for co-management WIth mental health specialty climcian If patient is:
• High suicide risk
• Has substance abuse
• Has complex psychosocial needs and/or
• Other active mental disorders (except depression)
Present Treatment Options
Many ifnot most patients with PTSD will achieve some symptom relief with an SSRI. The clinician
should present the benefits and side effects of this class of medications. Remission from PTSD often
requires psychological counseling and patients should be informed of this and offered the option of
an early referral. Selection of treatments should be patient-centered, encouraging and supporting
patient preference.
Elicit Patient Preference for Treatment
Some patients want the clinician to make the decision, but the clinician should ask the patient for
their treatment preference explaining the broad choice of medications (usually SSRIs) or
psychological counseling.
ChoosingPsychologicalCounseling
Cognitive-behavioral strategies have been the most frequently studied and most effective form of
psychotherapy treatment for PTSD. The essential feature in all cognitive therapies is an
understanding of PTSD in terms of the workings of the mind. Implicit in this approach is the idea
that PTSD is, in part, caused by the way we think. Cognitive Behavioral Therapy (CBT) helps
people understand the connection between their thoughts and feelings. CBT can help change the way
we think ("cognitive restructuring") by exploring alternative explanations, and assessing the
accuracy of our thoughts. Even if we are not able to change the situation, we can change the way we
think about a situation.
CBT is based on the understanding that many of our emotional and behavioral reactions to situations
are learned. The goal of therapy is to unlearn the unhelpful reactions to certain events and situations
and learn new ways of responding. CBT relies on evaluating thoughts to see whether they are based
on fact or on assumptions. Often we get upset because we think something is occurring when it is
not. CBT encourages us to look at our thoughts as hypotheses to be questioned and tested. CBT for
trauma includes strategies for processing thoughts about the event and challenging negative or
unhelpful thinking patterns.
Exposure therapy is one form ofCBT. Exposure therapy uses careful, repeated, detailed imagining
of the trauma (exposure) in a safe, controlled context to help the survivor face and gain control of the
fear and distress that were overwhelming during the trauma. In some cases, trauma memories or
reminders can be confronted all at once ("flooding"). For other individuals or traumas, it is
preferable to work up to the most severe trauma gradually by using relaxation techniques and by
starting with less upsetting life stresses or by taking the trauma one piece at a time
("desensitization"). Clinicians with the necessary training and skill to implement CBT are available
at many ifnot most Army mental health clinics.
Choosing Medication
Antidepressants are the most frequently studied and prescribed agents for the treatment ofPTSD.
Double-blind trials of sertraline (Zoloft), paroxetine (Paxil), fluoxetine (e.g. Prozac), fluvoxamine
(Luvox), and citalopram (Celexa, Lexapro) have established SSRIs as the pharmacologic treatment
of choice for PTSD. Sertraline and paroxetine are FDA approved for the treatment ofPTSD.
Fluoxetine and paroxetine have been shown to reduce symptoms in all three clusters (re-
experiencing, avoidance, hyperarousal). Citalopram and fluvoxamine have been less studied but
show promise. Among the older tricyclic antidepressants, amitriptyline and imipramine have been
effective in randomized controlled trials, although not for avoidance symptoms. Monoamine oxidase
inhibitors (MAOIs) may be more effective than tricyclics; however, they must be used cautiously
because of drug and food interactions that may cause a hypertensive crisis.
It should be noted that Vietnam veterans have not been shown to benefit from SSRIs.
In general the initial pharmacologic treatment of choice is to start with sertraline or paroxetine.
If a patient on an SSRI is having sleep difficulties it is reasonable to use low dose (25 to IOOmg)
trazodone (e.g. Desyrel) at bedtime.
Refer to Table 6 on pages 16 and 17 which lists the dosing, advantage, and disadvantages ofthe
various antidepressants available.
Treatment Selection for Patients with Comorbid Depression
When a Soldier is suffering from both PTSD and depression, if medication management is the
patient's preference, then management of depression can guide the initial selection and modification
of medications. Ifpsychological counseling is the patient's preference, then cognitive behavior
therapy that is specific to trauma should be offered to the patient as the initial treatment.
Establishing Rapport
Persons with PTSD usually do not want to talk about their traumatic experiences. It is very upsetting
for them to do so. Detailed information about the traumatic experience(s) may cause additional
distress and is not recommended. Focus instead on current symptoms and circumstances. Survivors
of sexual trauma, in particular, often struggle with feelings of self-blame and may be reluctant to
reveal the details of a sexual assault.
Many people with PTSD find that their relationships with others have changed as a result of
exposure to trauma. They often report that they have difficulty trusting others and are suspicious of
authority.
It is better to let the patient know that you recognize how difficult it may be for them to answer
questions such as those on the PCL and that if they begin to get upset they should let you know. If
this happens, do not resume trauma-related questions until the patient is comfortable enough to do
so, even if it means delaying such questioning until another appointment.
Provide Key Educational Messages
See page 18 in the Depression section.
Assist Patient in Establishing a Self-Management Plan [if we are talking about the care
manager here, then 'assist' is the right wording. if we are talking about the primary care doc,
then 'encourage' is the right wording (hard enough to get them to engage at all)].
See page 18 in the Depression section.
Explain and Recommend Care Management
See page 20 in the Depression section.

Si'F.Ep·III~·.: • !~@"¢I!.l\'I]ll.tJ.@g~m¢n~·I~ll.
See pages 22-24 in the Depression section.
Using the PCL to Assess Patient Response to Treatment
Below is an example of a follow-up PCL obtained by a care manager after eight weeks of
antidepressant treatment at an initially adequate dose. At this point, the severity score and functional
impairment are the primary pieces of information needed to assess treatment response. Normally the
care manager will have scored the PCL and provided you with the score and the difference in
severity score from baseline. To be sure you understand how to score the PCL, score the following
PCL for severity.
 Figure 16: Follow-Up peL Scoring Exercise

pel RESULTS AFTER 8 WEEKS

peL
OF TREATMENT
I~ and co~ints that persons sometimes have in response to
arefully, ptJt an "X" in the box to indicate how !TUCh you
have Deen m IiO .,'" ....., month.
Not at all A little bit Moderately Quite II bit I!xb'em ely
No. Response: (1) (2) (3) (4) (5)
1 Repeated, djstUlbing memories,
thoughts. or images of a stressful x
experience from the nast?
2 Repeated, disturoing dreams of a
stressful eXDelience from the past? X
3 Suddenly acting or feeling as if a
stressful experience were happening X
51---+==~"::::"..::....!="':':'::::":"":'::::':"::":::il....:.i..:.-_-+-----1----+----1------+------I
again (as if YOU were relivioo iiI:)?
4 Feeling vellf upset when sorrethil'g
rl!rrinded you of a stressful experience X
from the DasH
5 Having physical r~ctioons (e.g., heart
poundil'g, trouble breathil'g, or
sweating) when something rerrinded you X
of astrl!ssful experience from the past?
Avoid thinking about 01' talking about a
6
stressful expe.ience from the past or X
avom l1avina feelinas related to it?
7 Avoid activities or situations because
they rerrind you of a stll!ssful X
eXDlO,ience from the "asf?
8 Trouble rerrelTbering in'llortantpalts of
X
ltIl---F-'=:'=;="';;==;':';:;'=-=~~::'::";"".,...-f----+----+----+----f-----I
a stressful experience from the :past?
I 9 loss of interest in things that you used
X
~1-:-:~~~Z+.-:--~-~,:,:"",:,-~:----+----f----+-----lf----f-----1
to enjoy?
10 Feeling distant or cut off from other
Ill@O~? X
11 feeling emotionally numb or being unable
to have ,Iovil'g feelings fer those close X
to you?
12 feeling as if YOU1' future \'/ill somehow be
cut short? X
13 Trouble fallin<l or stav1nO asleeD? X
14 feeling init:able or havil'g ang.y X
o outbursts?
! 111 HavinQ difticultv concent:ratin(J? X
16 Beina FSugeJ' alert- 0" watchful on guaro? X
17 feeling jumpy or easily startled? X
18 IF you checked off any of the above problems, how difficult have these problems made it for you to
1""~""""~"~""do""dL2,,HL~,2~,,,,ta":!~!;,'!!'!"£!U,,t:tilJ5tU~11o~!~J!~t..aJ2!!L~.te!.!:!!.!:.e!p~L•...",~ " . . ,,_.~~ .• ~••• ,. ~ .....~
_ _Not difficult --->L-Som!what difficult Vellf <flffic:ult _ _Extremely difficult
19 OJring the last 2 weeks have you had thoughts that you would be better off dead, or of hurting
I~·I"·"··"·' ,~~~~~ in SOm! way? Yes)( No

If Yes, 110\'/ often? l _ _Sevel'ill days 2_ _More than half the days 3_ _Almost everyday
 Table 11: Using the peL to Assess Patient Response to Treatment

Initial Response after Six - Eight.weeks of an Adequate Dose of an Antidepressant

Treatment
PCL Resnonse Treatment Options

Drop of> 5 points from Adequate No treatment change needed. Care manager follow-up in four weeks.
baseline

Drop of3-4 points from Probably Warrants an increase in dose

baseline. Inadequate

Drop of 1-2 points or no Inadequate Increase dose; Switch drugs; Augmentation; Informal or formal
change or increase. psychiatric consultation; Add psychological counseling

Initial Response to Psychological Counseling After Four Sessions over Six Weeks *

Treatment
PCL Resnense Treatment Options

Drop of> 5 points from Adequate No treatment change needed. Care manager follow-up in four weeks.
baseline

Drop of3-4 points from Probably Probably no treatment change needed. Share PCL with
baseline Inadequate psychotherapist.

If PTSD-specific psychological counseling discuss with supervising

Drop of I -2 points or no Inadequate psychiatrist, consider adding pharmacotherapy.
change or increase
For patients satisfied in other psychological counseling, consider
, starting pharmacotherapy

For patients dissatisfied in other psychological counseling, review

treatment options and preferences
* CBT (Cognitive Behavioral Therapy) and/or Exposure Therapy
The goal of acute phase treatment is remission of symptoms so that patients will have:
• A reduction of the peL to a score < 24
• And item 18 is "not difficult at all"
Patients who achieve this goal enter into the continuation phase of treatment. Patients who do not
achieve this goal remain in acute phase treatment and require some alteration in treatment (dose
increase, referral to psychological counseling or addition of medication--depending on initial
treatment-augmentation, or combination treatment).
 As with depression, beneficial effects may be seen in four to six weeks. Perhaps unlike depression,
patients with PTSD taking an SSRI like sertraline or paroxetine, who have had an initial response,
experience improvement that may not be measurable until after twelve weeks (as opposed to an
additional four weeks as is often the case in depression). As many as 60% of patients who are not in
remission after the initial 12 weeks may still become remitters during the next 12-24 weeks. Some
patients will feel uncomfortable waiting and the practical question is, how long can you encourage
the patient to stay the course? The supervising / consulting psychiatrist can be helpful in this
situation.
Patients who do not achieve remission after two adequate trials of pharmacotherapy and/or
psychological counseling by 24 weeks should have a psychiatric consultation for diagnostic and
management suggestions (evaluation for childhood trauma, personality disorder, and/or substance
use disorder).
Figure 16: Care Manager Report to Clinician
CCHCS II / AHLTA)
MailMan message for: GRIFFIN, CHRIS

Subj: B.D. XX/XXX-X/X-XXXX - Telephone Consult

From: POSTMASTER (Sender: RESPECT CARE MANAGER)

Telephone Consultation

Provider's Note:
S: This 25 year old Soldier referred for PTSD on 16 June 2005 with a
PCL score of 52 was started on fluoxetine 20mg increasing to 40
mg.
PCL readministered over phone this date. At 4 weeks score
markedly reduced to 38. At 8 weeks only down to 34. No suicide
risk (=0). More reactive, but still with disturbing nightmares
and says can't discuss trauma. Trouble with follow through on
self-mgmt goal of swimming 2x week due to fatigue. Will reduce to
Ix per week for a shorter interval of time - target now 15
minutes.
Dr. Gould recommends you increase fluoxetine to 60mg
CM will call again in 1 week to flu your recommendation and pt.
choice. Dr. Gould will contact you if no improvement on next PCL
in 4 weeks.
Provider: RESPECT CARE MANAGER 16 August 2005
STEP 5: Acute Phas
Clinician Office Visits Coordinated with Care Management Contacts
Clinician visits should typically occur after PCL assessments. Care manager and clinician should
establish preferred routine intervals if recommended intervals are not appropriate.
Evaluate Patient Response to Treatment
For pharmacologic agents (antidepressants), a measurable, partial response to an adequate dose may
be seen by four weeks, but should be seen by 12 weeks.
For psychological counseling (CBT or Exposure), the initial response should occur between 8 and 12
weeks.
• Review symptoms, PCL score, and functional assessment provided by care manager from
most recent call.
Modify Treatment with Sub-Optimal Response
• Decisions to continue or modify treatment are made on the basis of PCL and function
assessments.
• Input from the supervising psychiatrist can be requested at any time or may be offered when
indicated after review with care manager.
Strive for Remission
The goal of acute phase treatment is to achieve remission. Remission in PTSD may be more difficult
or take longer than in depression. Reassess treatment response and modify periodically so that
patients will have:
A reduction ofthe PCL-M to a score <24 and NO functional impairment.
When patients achieve this goal they enter into the continuation phase of treatment.
Patients who do not achieve this goal remain in acute phase treatment and require some alteration in
treatment (dose increase, augmentation, combination treatment). Patients continue with care
management follow-up periodically with clinician follow-up as needed.

Strategies to modify treatmentfor sub-optimal and non-response at 12 and 24 weeks:

1. Increase the dose of antidepressant to the maximal dose.
2. Switch to a different antidepressant, i.e. change to a different selective serotonin reuptake
inhibitor.
3. Switch to a different neurotransmitter mechanism antidepressant, especially if comorbid
depression present and not in remission.
4. Combine medication and psychological counseling (Cognitive Behavioral Treatment-
CBT- with cognitive restructuring and lor exposure therapy). If already in CBT and not
on an antidepressant, add antidepressant.
S. Request informal psychiatric consultation by telephone or email.
 6. Refer for formal psychiatric consultation to review diagnosis and treatment plan.
Especially refer those who:
• Have a suicidal plan
• Comorbid substance abuse
• Suggestion of hallucinations or delusional thinking
• Failure to respond to two trials of adequate dose and duration
• Serious or prolonged difficulty in performing military duties

Table 12: Parallel Diagnostic and Management Tools for PTSD and Depression

PTSD DEPRESSION
Diagnostic Tools
Four Question Screen Two Question Screen
PCL (PTSD Checklist) PHQ-9
Suicide assessment Suicide assessment
Management Tools
Key messages for drug adherence Key messages for drug adherence
Care Management Care Management
Self Management Plan Self Management Plan
Systematic informal psychiatric consultation Systematic informal psychiatric consultation
Continue Treatment Response Monitoring After Remission
Patients who achieve a remission from PTSD enter the continuation phase. In both disorders there is
a substantial risk of relapse during the initial period. Many patients may no longer meet the formal
criteria for PTSD but still have continuing symptoms with or without functional impairment. Persons
with additional psychiatric disorders or psychosocial stressors are more likely to have continued
symptoms and/or relapse.
Figure 17: Long-Term Maintenance Strategy

Acute Phase . ~. . .on ..... ) ( .....tenance ..... )

Remission Recovery
• , e'!:"",- - - - - .
e. , ", ",
\ \ \
\ \ \
Symptoms \
1- _I
\
__ -'
\

Syndr(}t1U! + + +
Relapse Relapse Recurrence

60% to 70%
StopRx* *lJEDIS 2002

Time

Adaptedfrom Kupfer. DJ. Long-term treatmentofdepression. J eli" Psychiatry, 1991: 52 tsuppi. 5) :28-]4

All patients who no longer meet criteria for PTSD will receive education from the care manager to
recognize relapse early and request an appointment with their primary care or mental health
clinician. This education should be reinforced by the primary care clinician. Patients who still have
some symptoms should continue on pharmacotherapy because continued symptom relief is likely to
occur.
The care manager plays a pivotal role by monitoring remission and assessing PHQ-9 and/or peL
response periodically after remission to assess for continued symptom improvement or relapse. The
care manager also assesses risk factors for recurrence.
At the end of the continuation phase, patients who sustain their remission are considered to have
achieved recovery. As many as one-third of patients with PTSD may continue with some symptoms
indefinitely particularly if there is a history of earlier trauma exposure or chronic coping problems.
Continue Successful Treatment for Nine to Twelve Months
Medications
Patients who successfully achieve remission on medication should take the same dose for nine to
twelve months following remission. Many patients do not refill their prescriptions during this phase,
therefore the care manager also assesses adherence during contacts to administer the PHQ-9 and/or
PCL.
Psychological Counseling
A decision to use continuation counseling depends on the symptoms, psychosocial problems, and
recommendation of the counselor.
Assess Risk Factors for Need for Long-Term Prophylactic Treatment
PTSD is often a chronic or recurring disorder. All patients who maintain remission for six to twelve
months should receive education to recognize recurrence early and request an appointment with their
primary care or mental health clinician.
Patients at risk for chronicity or recurrence of depression (i.e., diagnosis of chronic depression-
dysthymia-or a history of two or more previous episodes of major depression) or PTSD (i.e.,
history of previous trauma exposure, active psychiatric comorbidity) should be advised of the
possible advantages for long-term, maintenance pharmacotherapy.
Continue Long-Term Prophylactic Treatment and Monitoring of At-Risk Patients
Periodic PHQ-9 and/or PCL assessments should be considered in all patients at risk.