DEPARTMENT OF TilE ARMY

HEADQUARTERS. UNITED STATE5 AR:\IY :\IEDICAL COMMAND

1050 WORTH ROAD

•
FORT 5A:\1 HOUSTON. TX 78134-6000

~'REPLYTO ATTENTION OF

OTSG/MEDCOM Policy Memo 09-056

MCCS
22 JUl2009
Expires 22 July 2011

MEMORANDUM FOR Commanders, MEDCOM Regional Medical Commands

SUBJECT: Guidance for Administrative Separation for Personality Disorder (PD) or Other
Behavioral Conditions

1. References:

a. Memorandum, HO, USAMEDCOM, MCCG, 6 Aug 07, subject: Review of PD

(Chapter 5-13) Administrative Separations.

b. Memorandum, HO, USAMEDCOM, MCCG, 19 May 08, OTSG/MEDCOM Policy

Memo 08-018, subject: Screening for Post-Traumatic Stress Disorder (PTSD) and mild
Traumatic Brain Injury (mTBI) Prior to Administrative Separations.

c. DoDI 1332.14, Enlisted Administrative Separations, 28 Aug 08.

d. Memorandum, ASA(M&RA), 10 Feb 09, subject: Enlisted Separations on the Basis of

PD Policy Memorandum.

e. AR 635-200, Active Duty Enlisted Administrative Separations, 6 Jun 05.

f. AR 40-400, Patient Administration, 6 Feb 08.

g. AR 635-40, Physical Evaluation for Retention, Retirement, or Separation, 8 Feb 06.

h. ALARACT 115/2009, The Army Campaign Plan for Health Promotion, Risk
Reduction, and Suicide Prevention (ACPHP), 27 Apr 09.

i. DACS, 16 Apr 09, SUbject: Army Campaign Plan for Health Promotion, Risk Reduction
and Suicide Prevention (ACPHP).

2. In 2006 and 2007, the public raised concems that some Soldiers returning from combat
tours had been discharged from the military for PO, but were SUbsequently suffering from
PTSD or TBI related to their combat experiences. The OTSG issued policies in Aug 07 and

• This policy supersedes OTSG/MEDCOM Policy Memo 09-012.13 Mar 09, subject: MEDCOM Procedures for
Chapter 5. paragraph 5-13 and 5-17 Personality Disorder (PO) Separations.
MCCS
SUBJECT: Guidance for Administrative Separation for Personality Disorder (PD) or Other
Behavioral Conditions

May 08 to address these concerns and implement the requirement for a higher level review
of recommendations for administrative separations for PD (reference a), and screening for
PTSD and TBI for these and other administrative separations (reference b). In Aug 08,
Department of Defense Instruction (DoDI) 1332.14 mandated similar requirements across
the DoD, including the requirement that the Military Department's Surgeon General endorse
a diagnosis of PD for service members who have served or are serving in imminent danger
pay areas.

3. Army policy changes issued in a supplemental to AR 635-200 (reference d) implemented

the requirements of DoDI1332.14. The changes limit separation under Chapter 5-13 to
Soldiers with less than 2 years time in-service, but added PD to Chapter 5-17 for Soldiers
with more than 2 years time in-service. Separation for other diagnoses under 5-17 does not
require higher level review unless there is local policy to do so (e.g., the Chief of Behavioral
Health may require staff to submit for his or her review prior to release, but this is not a G-1
or OTSG/MEDCOM requirement). The requirement for endorsement by The Surgeon
General is only for the diagnosis of PD and only for Soldiers who served or are serving in an
imminent danger pay area. This modification is to prevent delays in future cases.

4. DoDI 1332.14, enclosure 3, paragraph 3.a.(8) provides additional guidance for

separation for PD:

a. The onset of PD frequently manifests in the early adult years and may reflect an
inability to adapt to the military environment as opposed to an inability to perform the
requirements of specific jobs or tasks or both. As such, observed behavior of specific
deficiencies will be documented In appropriate counseling or personnel records and include
history from sources such as supervisors, peers, and others, as necessary to establish that
the behavior is persistent, interferes with assignment to or performance of duty, and
continues after the service member was counseled and afforded an opportunity to
overcome the deficiencies.

b. Separation for PD is not appropriate nor will it be pursued when the basis is
unsatisfactory performance or misconduct. In such circumstances, the member will not be
separated under this paragraph regardless of the existence of a PD. Unless found fit for
duty by the disability evaluation system, a separation for PD is not authorized if service-
related PTSD is also diagnosed.

5. Requests for OTSG endorsement of the diagnosis of PD must address or include the
below requirements:

a. Signature of the recommendation by the evaluating Psychiatrist or doctoral level

Psychologist.

b. Review and signature of the recommendation by the MTF Chief of Behavioral Health
or equivalent official.

2
MCCS
SUB~IECT: Guidance for Administrative Separation for Personality Disorder (PD) or Other
Behavioral Conditions

c. A specific statement that the disorder is of sufficient severity to interfere with the
Soldier's ability to function in the military.

d. Documentation of the behaviors and symptoms of concern in clinical records,

counseling statements, or other personnel records; and the specific DSM-IV-TR diagnostic
criteria met (if PO not otherwise specified for mixed PO, the specific traits of each type).

e. Clinical documentation that the symptoms or behavioral problems existed prior to

enlistment, and do not simply represent maladjustment to the military. Otherwise consider
Chapter 5-17 for adjustment disorder and further review is not required.

f. Documentation of clinical treatment and/or supervisory rehabilitation efforts (e.g.,

counseling statements or Memoranda For Record).

g. Clinical documentation that PTSD and TBI were addressed with appropriate
screening instruments, and other co-morbid mental illness was ruled out or did not
contribute significantly to the diagnosis. If PTSD or other mental illness is significant. initiate
a Medical Evaluation Board (MEB) in accordance with AR 40-400, Chapter 7, and if found
to meet retention standards, a copy submitted with the clinical documentation (the MEB is
composed of two or more physician members including a Psychiatrist: it is part of the
Physical Disability Evaluation System and does not require referral to the Physical
Evaluation Board (PEB) if found to meet retention standards). If retention standards are not
met, do not submit the recommendation for administrative separation to OTSG unless and
until the PEB finds the Soldier fit for duty.

h. The requirement for endorsement by OTSG is only for the diagnosis of PO and only
for Soldiers who served or are serving in an imminent danger pay area.

FOR THE COMMANDER:

~CCkE~
Chief of Staff

3
 DElARTl\IENT OF THE AR.\,ry
HEADQUARTERS. UNITED STATES AR.MY l'tIEDICAL COM;\IANU
2050 WORTH ROAD
FORT SA..\I HOUSTON, TX 78234-6000

REPLYTO
ATTENTION OF

OTSG/MEDCOM Policy Memo lO-O~{)

MCCG
Expires 9 June 2012 09 JUN 2010
MEMORANDUM FOR Commanders, MEDCOM Regional Medical Commands

SUBJECT: Screening Requirements for Post-Traumatic Stress Disorder (PTSD) and

mild Traumatic Brain Injury (mTBI) for Administrative Separations of Soldiers

1. References:

a. Department of Defense Instruction 1332.14, Enlisted Administrative Separations,

28 August 2008.

b. Army Regulation (AR) 635-200, Active Duty Enlisted Administrative Separations,

Rapid Action Revision Issue Date: 17 December 2009.

c. National Defense Authorization Act (NOAA), H.R.2647, Health Care Provisions,

Fiscal Year 2010.

d. Medical Command (MEDCOM) Regulation 40-38, Command-Directed Mental

Health Evaluations, 1 June 1999.

2. Purpose: To outline procedures for PTSD and mTSI screening of all Soldiers
considered for administrative separations who require a mental status evaluation, or
who have been deployed overseas in support of a contingency operation, and who are
diagnosed by a physician, clinical psychologist. or psychiatrist as experiencing PTSD or
mTBI or who otherwise reasonably allege, based on their service while deployed, the
influence of such a condition.

3. Proponent: The proponent for this policy is the Behavioral Health Proponency,
Assistant Chief of Staff for Health Policy and Services.

4. Responsibilities:

a. The Surgeon General has overall responsibility for policy guidance in defining
and implementing the MEDCOM's behavioral healthcare and mTSI screening
requirements.

• This policy memosupersedes OTSG/MEDCOM Policy Memo 08-018.19 May 08. subject; Screening for Post-
TraumaticStress Disorder(PTSD) and mild Traumatic Brain Injury(mTBI)Prior to Administrative Separallons.
MCCG
SUBJECT: Screening Requirements for Post-Traumatic Stress Disorder (PTSD) and
mild Traumatic Brain Injury (mTBI) for Administrative Separations of Soldiers

b. The Directorate of Health Policy and Services, through the Proponency Offices
for Behavioral Health and Rehabilitation and Reintegration, are responsible for the
distribution of behavioral health (BH) evaluation and mTBI requirements and reviewing,
revising, updating, and deleting existing policies conflicting with these requirements.

c. Medical Treatment Facility (MTF) Commanders will ensure that all Soldiers are
screened for PTSD and mTBI during routine mental health evaluations for
administrative separations related to the Chapters identified in paragraph 2., below, or
for any case involving Soldiers diagnosed with or reasonably asserting PTSD or mTBI.

5. Discussion:

a. This guidance refers to Soldiers who require mental health evaluations from
behavioral health clinicians for administrative separations, or for Soldiers diagnosed
with or reasonably asserting PTSD or mTBI.

b. This guidance refers to Soldiers who receive mental health evaluations from
behavioral health clinicians for administrative separations.

6. Policy:

a. BH Departments within each MTF will ensure that mental health evaluations
related to administrative separations are conducted by a BH clinician as required for all
Soldiers diagnosed with or reasonably asserting PTSD or mTBl, in accordance with
Army Regulation 635-200, the 2010 National Defense Authorization Act (Section 512)
and MEDCOM Regulation 40-38.

b. Enclosures 1 and 2 contain screening tools for both PTSD and mTBI that can
assist the clinician during the assessment. These tools will be administered by BH
clinicians to every Soldier requiring mental health evaluations prior to administrative
separations, and to all Soldiers reasonably asserting PTSD or mTBI who have been
deployed overseas in support of a contingency operation. The Primary Care-Post-
Traumatic Stress Disorder (PC-PTSD) measure enclosed is currently being utilized by
the Department of Veterans Affairs as a screening tool. These tools are also located at
https:/lwww.us.army.mil/suite/page/222.

c. These screening tools are not diagnostic. A positive screen will require a
comprehensive evaluation to establish the correct diagnosis, with referral and other
testing, if necessary. A "yes" response to any three items in the PC -PTSD tool, or any
one item in the mTBI screening, will be considered a positive screen indicating the need
for further evaluation and possible treatment of PTSD or mTBI, respectively.

d. PTSD screening and/or full comprehensive evaluation shall be performed by a

clinical psychologist or psychiatrist; mTBI screening and/or full comprehensive evaluation

2
MCCG
SUBJECT: Screening Requirements for Post-Traumatic Stress Disorder (PTSD) and
mild Traumatic Brain Injury (mTBI) for Administrative Separations of Soldiers

may be performed by a physician, clinical psychologist, psychiatrist, or other healthcare

professional, as appropriate.

e. Soldiers who screen positive for PTSD or mTBI, or who have already been
diagnosed by a physician, clinical psychologist, or psychiatrist as experiencing PTSO or
mTBl, will receive a full comprehensive examination to assess whether the effects of the
PTSD or mTBI are contributing or related to the reason for separation.

f. Screenings, as well as full comprehensive evaluations for positive and existing

cases of Soldiers diagnosed with PTSD or mTBI, will be documented in the "Additional
Comments" section of the Mental Status Evaluation Form MEDCOM 699 (Enclosure 3);
and in the progress note located in the Soldiers' AHLTA record. Compliance will be
monitored in accordance with AR 635-200.

g. The result of the evaluation, with a medical opinion as to the effects of mTBI
and/or PTSD on the separation action will be provided to the commander for inclusion in
the separation documentation and personnel files before separation proceedings can
occur.

3 Encls ERIC B. SCHOOMAKER

1. Primary Care - PTSD Lieutenant General
2. TBI Screening Questions The Surgeon General and
from PDHA, 002796 Commanding General, USAMEDCOM
3. Mental Status Evaluation
Form MEDCOM 699

3
 Primary Care Posttraumatic Stress Disorder (PC-PTSD) Screen

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 I No

2. Tried hard not to think about it or went out of your way to avoid situations that
reminded you of it?
Yes I No

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

Yes I No

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

Yes I No

Prins, A.• Ouimette. P., Kimerling. R.. Cameron, R. P.. Hugelshofer, D. S., Shaw-Hegwer, J., Thrailkill, A.,
Gusman. F. D., Sheikh, J. I. (2004). The primarycare PTSDscreen (PC-PTSD): development and
operating characteristics. Primary Care Psychiatry, 9, 9-14.
Mild TBI Screening Questions from Post-Deployment Health Assessment (PDHA),
002796

1. During this deployment. did you experience any of the following events?

(1) Blast or explosion (lED, RPG. land mine. grenade. etc.) Yes I No
(2) Vehicular accidenVcrash (any vehicle, including aircraft) Yes I No
(3) Fragment wound or bullet wound above your shoulders Yes I No
(4) Fall Yes I No
(5) Other event (for example. a sports injury to your head). Yes I No

Describe:

2. Did any of the following happen to you. or were you told happened to you,
IMMEDIATELY after any of the event(s) you just noted in question 17

(1) Lost consciousness or got "knocked out" Yes I No

(2) Felt dazed, confused. or "saw stars" Yes I No
(3) Didn't remember the event Yes I No
(4) Had a concussion Yes I No
(5) Had a head injury Yes I No
 REPORT OF BEHAVIORAL HEALTH EVALUATION
Foruse 01this lorm.see lOOOO(; Theproponent alenq Is MEDCOM. Releaseof this Informatlon to commandersor theIr des1lnees Isauthorlted lAW 000 6025.18-R and 000 Directive
6490.1when Inresponse10a Command-Directed Mental Hullh Evaluatlon request or wilena questIOn of safMyor fitnessfor duty e.ISU.

NAME: GRADE/SERVICE: I SSN:

REASON FOR EVALUATION

o Self-Referral o Advanced Training Application {Drillinstruetor, Recruiter, etc}
D Command-Directed Mental Health Evaluation o Clearance for Admin Sep under AR 635-200, Chapter
o Hospital Discharge DMMRB/MEB
o Other:

FITNESS FOR DUTY

FROM A BEHAVIORAL HEALTH STANDPOINT, THE ABOVE SERVICE MEMBER IS DEEMED:
o Fit for full duty, including deployment
o Possibly non-deployable due to prescribed medications. Command surgeon waiver is / is not recommended 0 0
o Requires temporary duty limitations and may benefit from behavioral health treatment
o Unfit for duty due to a personality disorder or other mental condition that does not amount to a medical disability
o Unfit for duty due to a serious mental condition that is not likely to resolve within 1 year
o Further assessment is needed to determine fitness for duty

PERTINENT FINDINGS ON MENTALSTATUS EXAMINATION

COGNITION: 0
No obvious impairments Mildly impaired 0 Moderately impaired 0Severely impaired 0
BEHAVIOR: 0
Cooperative 0
Uncooperative Manipulative 0
Hostile Suspicious 0
Bizarre 0 0
PERCEPTIONS: 0
Normal 0
Hallucinations Delusions 0
Obsessions 0
IMPULSIVITY: 0
Unlikely to be impulsive 0
Occasionally impulsive Frequently impulsive 0
DANGEROUSNESS: None 0 0
Suicidal Thoughts Homicidal Thoughts 0Suicidal Intent 0
Homicidal Intent D
OTHER:

IMPRESSIONS
IN MY OPINION, THIS SERVICE MEMBER:
D Can understand and participate in administrative proceedings
o Can appreciate the difference between right and wrong
o Meets medical retention requirements (i.e. does not qualify for a Medical Evaluation Board)
o Requires further examination or testing to finalize diagnosis and recommendations
o Other:

DIAGNOSES (ONLYTHOSE REQUIRED FOR ADMINISTRATIVE PROCESSING)

AXIS I (psychiatric conditions):

AXIS" (personality & intelligence disorders):
AXIS III (medical conditions):

PROPOSED TREATMENTS
o None
o Follow-up appointments:
Clinic: Phone No: Location: Date: TIme:
Clinic: Phone No: Location: Date: TIme:
Clinic: Phone No: Location: Date: TIme:
o Recommend command referral to: 0 Unit Chaplain 0 ASAP 0
FAP 0 JAG 0 ACS 0 Other:

Date

Ene'! .3
 RECOMMENDED PRECAUTIONS
(to be followed until no lonler deemed necessaryby a behavioral health provider)
o None
D Ensure the service member attends all follow-up appointments
o Assigned duties should be relatively low-stress and 0 should not involve leadership responsibilities
o Work hours should not exceed per day and the service member should have day(s) off per week.
D Inspect the service member's quarters and secure all hazardous items (e.g. pills, knives, razors, weapons, etc.)
o Prohibit the use of alcohol, as alcohol is a depressant and may decrease Inhibitions.
D Restrict access to or disarm all weapons and ammunition (including those that are privately owned)
o Move the service member into the barracks
o Secure all medications and dispense no more than days' worth at a time
o Prohibit contact between the service member and to prevent harm to self or other individual.
o Provide increased supervision (Le. have someone check in with service member at least daily) or...
o Assign someone to monitor the service member every hours from first formation until lights out, and
ensure he/she does not sleep in a room alone or...
o Provide continuous 24/7 monitoring (e.g. to prevent self-injurious behavior, harm to others, substance use, etc.)
o Other:

ADDITIONAL COMMENTS
o A Temporary Profile with an "S" rating of is hereby activated, to expire
o The service member is psychiatrically cleared for any administrative action deemed appropriate by command.
o The service member may participate in PTas allowed by physical profile, as exercise often improves mood.
o The service member meets psychiatric criteria for expeditious administrative separation lAW
o Chapter 5-13 or 0Chapter 5-17 of AR 635-200 (or equivalent regulation from his/her branch of service).
o The service member does not have a severe mental disorder and is not considered mentally disordered. However,
he/she has a long-standing disorder of character, behavior and adaptability (i.e. personality disorder) that is
of sufficient severity to interfere with his/her ability to function in the military. Although not currently at significant
risk for suicide or homicide, he/she has the potential to become dangerous to self or others in the future.
o The service member has a condition that is likely to impair his/her judgment or reliability as related to access to
classified materials.
o It is the professional opinion of the undersigned that this service member will not respond to command efforts at
rehabilitation (such as transfer, disciplinary action or reclassification), or to any behavioral health treatment
methods currently available in the military.

o The service member shows no evidence of a disorder that would limit his/her potential to succeed in the military.
He/she is cleared to participate in advanced military training (e.g. recruiting, drill instructor, sniper school, etc).
o The service member has been screened for Post Traumatic Stress Disorder and Traumatic Brain Injury. These
conditions are either not present or, if present, do not meet AR 40-501 criteria for a medical evaluation board.
Command is advised to consider the influence of these conditions, if present, when determining final disposition.
o If the service member shows signs of further deterioration, command should call during duty hours. After
hours, they should escort the service member to the nearest Emergency Department.
o Other:

Date
 RESPECT-MIL
CLINICIAN EDUCATION MANUAL

THREE COMPONENT MODEL

For PRIMARY CARE MANAGEMENT of DEPRESSION and PTSD
(Military Version)

Copyright0 May 2006 3CM'fI\(, LLC - Version 3.0

By Thomas E. OxmanMD, Dartmouth MedicalSchool
With contributions from, Allen 1. DietrichMD, John W. Williams, Jr. MD; CharlesC. Engel,MD, MPH, MathewFriedman, MD, PbD,
Paula Schnurr, PhD, StanleyRosenberg, PhD
ProjectDirector: SheilaL. Barry

This manual is intended to provide helpfUl and informative material for care managers working with patients with depression and/or PTSD. The
information provided here is general, and is not intended as clinical advice for or about specific patients. Before applying any ofthis i!iformation
or drawing any inferences from it, care managers should verify accuracy and applicability of the i!iformation and the appropriateness of
protocol strategies Within their particular clinical settings. Any management steps taken with patients should include a discussion ofrisks and
benefits as well as patient preferences. By accessing the information in this manual, you agree that 3CMCM, ILC; Dartmouth College; Duke
University; Duke University Health System, !J'Ic.; Private Diagnostic Clinic, PILC; the John D. and Catherine T. MacArthur Foundation; any
participant in the Initiative on Depression and Primary Care; and the contributors of iriformation to this manual shall not be liable to you for
any damages, losses or injury caused by the use ofany information in thismanual.
I. Introduction 3
II. Conceptual Framework for RESPECT-MIL 4
Department of Defense Clinical Practice Guidelines 4
Systematic Approaches to Improving Care 4
RESPECT-MIL-The Three Components 4
The RESPECT-MIL Process of Care 5
The RESPECT-MIL Process of Change 7
III. RESPECT-MIL Protocol for Depression 9
STEP 1: Recognition and Diagnosis 9
PHQ-9 9
Assess Suicide Risk 12
Conduct a Suicide Assessment 13
Components of an Evaluation for Suicidal Risk 13
Suicide Screening Tools for Primary Care Clinicians 14
STEP 2: Treatment Selection 15
Obtain Additional History 15
Use PHQ-9 Results to Help Determine Treatment Selection 15
Present Treatment Options 16
Elicit Patient Preference for Treatment 16
Choosing Psychological Counseling 16
Choosing Medication 17
STEP 3: Initiating Treatment 20
Patient Engagement 20
Provide Key Educational Messages 20
Encourage a Self-Management Plan 20
Explain and Recommend Care Management 22
STEP 4: Care Management Calls for Adherence and Treatment Response 23
Adherence Call at 1 Week 23
Optional Telephone Contacts between 1 and 4 Weeks: Additional Adherence Call(s) 23
Treatment Response Calls Every 4 Weeks 23
Care Management Supervision 23
Communication with Primary Care Clinician 23
Using the PHQ-9 to Assess Patient Response to Treatment.. 26
Antidepressant Side Effects 27
STEP 5: Acute Phase Follow-Up 29
Clinician Office Visits Coordinated with Care Management Contacts 29
Evaluate Patient Response to Treatment 29
Modify Treatment with Sub-Optimal Response 29
Strive for Remission 29
STEP 6: Continuation and Maintenance Phase Treatment 31
Continue Treatment Response Monitoring After Remission 31
Continue Successful Treatment for Nine to Twelve Months 31
Medications 31
Psychological Counseling 31
Assess Risk Factors for Need for Long-Term Prophylactic Treatment 33
Continue Long-Term Prophylactic Treatment and Monitoring of At-Risk Patients 33
IV. RESPECT-MIL Protocol for Post-Traumatic Stress Disorder 33
STEP 1: Recognition and Diagnosis 33
Four Components for PTSD Diagnosis 33
PTSD Checklist (PCL) 35
Assess Suicide Risk 37
Assess Suicide Risk 38
Conduct a Suicide Assessment 39
STEP 2: Treatment Selection 40
Present Treatment Options 40
Elicit Patient Preference for Treatment 40
Choosing Psychological Counseling 40
Choosing Medication 41
Treatment Selection for Patients with Comorbid Depression 41
STEP 3 Initiating Treatment 42
Establishing Rapport 42
Provide Key Educational Messages 42
Encourage a Self Management Plan 42
Explain and Recommend Care Management 42
STEP 4: Care Management Calls for Adherence and Treatment Response 42
Using the PCL to Assess Patient Response to Treatment.. 42
STEP 5: Acute Phase Follow-Up 46
Clinician Office Visits Coordinated with Care Management Contacts 46
Evaluate Patient Response to Treatment 46
Modify Treatment with Sub-Optimal Response 46
Strive for Remission 46
STEP 6: Continuation and Maintenance Phase Treatment.. 48
Continue Treatment Response Monitoring After Remission 48
Continue Successful Treatment for Nine to Twelve Months 49
Medications 49
Psychological Counseling 49
Assess Risk Factors for Need for Long-Term Prophylactic Treatment 49
Continue Long-Term Prophylactic Treatment and Monitoring of At-Risk Patients 49
References 50
References 50
PHQ-9 50
PTSD Guidelines 50
PCL 50
RESPECT-Depression and the Three Component Model.. 50
PTSD Background 51
PTSD Four Question Screen 51
This manual is intended to provide helpful and informative materialfor clinicians on the subject ofpost traumatic stress disorder. This manual is not intended to provide
medical advice to patients. The information provided here is general and is not intended as clinical advice for or about specific patients. Before applying any ofthis information
or drawing any inferencefrom it, clinicians should verify accuracy and applicability ofthe Information. Any management steps taken with patients should include a discussion
ofrisks and benefits, as well as patient preferences. DARTMOUTH COUEGE; DUKE UNIVERSITY; DUKE UNIVERSITY HEALTH SYSTEM, INC; 3CMDlUC; THE JOHN
D. AND CATHERINE T. MACARTHUR FOUNDATION; ANY PARTICIPANT IN THE INITIATIVE ON DEPRESSION AND PRIMARY CARE; AND CONTRIBUTORS OF
INFORMATION MAKE NO WARRANTY, EITHER EXPRESSED OR IMPUED. REGARDING THE COMPLETENESS, ACCURACY, OR CURRENCY OF THIS
INFORMATION, NOR ITS SUITABIUTY FOR ANY PARTICULAR PURPOSE.
By accessing the information in this manual, you agree that the above parties shall not be liable for any damages, losses or injury caused by the use ofany information on this
manual or its references/citations.
I. Introduction
Mental health disorders are common among troops that have returned from war zones. This
observation is not new. A report based on health records of Civil War veterans showed life-long health
consequences of combat even among those who escaped traumatic injury. Surveys of U.S. combat
units returning from the war in Iraq (Hoge, et al, 2004 and 2006) found that as many as one in four
soldiers met criteria for a mental health disorder.
Among this group, fewer than one in three had received help from a mental health or primary
care professional. The stigma of having a mental health disorder looms large. While 80% of these
soldiers recognized that they had a problem, fewer than half were interested in receiving help.
The gap between need for treatment and receiving it deserves urgent attention. This manual
provides one step towards closing this gap by providing background needed for primary care clinicians
to provide high quality mental health care that has a solid evidence base for its effectiveness.
Recommendations are consistent with and support application of VA/DoD Clinical Practice Guidelines
for PTSD and for Depression.
The manual describes the RESPECT-Mil program and how to apply the Three Component
Model, a systematic primary care approach to the management of depression. The Three Component
Model has been extensively and successfully used in civilian populations (Oxman, et al; Dietrich, et al
2004). A recent project with the 82nd Airborne Division at Fort Bragg expanded TCM to address post
traumatic stress disorder (PTSD) in addition to depression. The project demonstrated that this approach
can guide management of depression and PTSD primary care settings that provide care for troops post
deployment.

Here's how the Three Component Model works:

• Soldiers attending primary care for sick call and other reasons are routinely screened for
depression (two questions) and PTSD (four questions);

• Those with positive screens complete appropriate diagnostic and severity instruments before
seeing the clinician;

• If the instruments suggest that mental health issues require exploration and the clinician's
diagnostic interview confirms the diagnosis of depression or PTSD, treatment is initiated by the
primary care clinician who will continue to follow the patient closely;

• In addition to primary care follow up visits, soldiers in treatment are provided with telephone
support from a specially trained care manager who promotes adherence to the management
plan and monitors response to treatment using validated quantitative instruments. The care
manager is supervised by a mental health professionals (including a psychiatrist via telephone
for shortage facilities) who may provide management suggestions communicated in reports
from the care manager to the primary care clinician. The mental health professional also assists
in linking a soldier to a mental health professional when indicated or requested;

• Thus, a partnership with the patient is shared among the primary care clinician, a care manager,
and mental health specialists.
 In the following pages, this manual describes the RESPECT-Mil conceptual framework and its
application first to depression, then to post traumatic stress disorder. For both conditions use of
validated instruments for screening and for symptom assessment are central as are the services of a
care manager, frequent primary care contact, promotion of self management, and modification of the
management plan if needed to achieve improvement in symptoms.

II. Conceptual Framework for RESPECT-MIL

This section provides an overview of the concepts upon which the RESPECT-MIL program is based.

Department of Defense Clinical Practice Guidelines

The Department of Defense (DoD), in collaboration with the Veterans Administration, has developed
evidence-based clinical practice guidelines (CPGs) for the care for service members. This manual
focuses on the application of two of these DoD CPGs-those for major depressive disorder and PTSD.
While the DoD CPGs provide a comprehensive overview with a scientific basis for each guideline, this
manual focuses on practical application, including a description of new resources available to you as
you apply this program with your active duty patients.
Systematic Approaches to Improving Care
We have all been exposed to algorithms that break down a complex task using a series of steps. Such
systematic approaches have strong research support for their effectiveness in many fields. One
example is the promotion of preventive services. When a medic or other medical assistant checks a
patient in and the flow sheet at the front of the chart indicates the patient is not up to date for a certain
service, such as an immunization, that service would be provided through standing orders.
Use of systematic approaches has been extended to depression care with demonstrated improved
outcomes. These approaches including tools, routines, and clear responsibilities assure that key
questions about family and personal history are asked, suicide ideation is explored, evidence-based
patient education is provided, and response to treatment is monitored closely. At least five randomized
controlled trials have shown substantial improvements in depression using systematic approaches. This
manual is based on the Three Component Model (3CMTM) of depression care, which has been widely
applied in civilian populations. This model has now been pilot-tested and shown to be feasible in
selected Womack Army Medical Center clinics serving the 82nd Airborne Division at Fort Bragg,
North Carolina. The model for the Army is referred to as RESPECT-MIL.
RESPECT -MIL-The Three Components
The three components of the model are clinical roles that consist of the prepared primary care clinician
and the practice; a trained care manager; and a supervising psychiatrist. In the RESPECT-MIL model,
the primary care clinician (PCC) is equipped to recognize Soldiers who potentially suffer from
depression or PTSD, completes a diagnostic assessment including a suicide evaluation, engages the
patients in getting help, and provides appropriate management. To aid in this process, new tools and
other resources have been developed and are described in Sections III and IV.
Two new resources intended to aid the prepared primary care practice and its PCCs deserve special
note. The first new resource is the addition of a trained care manager. Care managers receive extensive
training to help Soldiers suffering from depression and/or PTSD. The care manager provides frequent
contact with the Soldier to answer any questions; encourages the Soldier to stick with the treatment
plan; and monitors the Soldier's response to treatment. Care managers work closely with the PCC,
communicating in person, by telephone, e-mail, and through the electronic medical record. Care
managers typically make the first contact with the Soldier within a week of beginning primary care
management for depression or PTSD and then follow up monthly and as needed until remission is
reached.
The second new resource, the supervising psychiatrist, participates in the model in several important
ways. First, he or she meets weekly with the care manager (in person or by telephone) to discuss
specific cases and progress. This supervision provides guidance to the care manager and presents a
mechanism for the psychiatrist to monitor progress on a large number of cases that are being followed
in primary care. The psychiatrist is also available to the PCC to provide informal advice about
diagnosis and about management. In some cases, the PCC, working with the care manager, will
facilitate a direct contact between the patient and the psychiatrist. Table 1 provides an overview of how
responsibilities are shared.
Table 1: RESPECT-Mil: A Team Working Together to Support the Force

Components Responsibilities
Primary care clinician and • Recognition
prepared practice • Diagnosis
• Management
Care manager • Support
• Monitoring
• Communication
Psychiatrist • Informal advice to clinician
• Supervision of care manager
• Consultations

The RESPECT-MIL Process of Care

An overview of the RESPECT-MIL process is provided in Figure 1 below. The RESPECT-MIL
process begins with routine screening for PTSD and major depressive disorder when Soldiers come in
for sick call and other clinical visits. A two-question screen for major depressive disorder and a four-
question screen for PTSD are completed when the Soldier registers for a visit. Those who screen
positive are asked to complete more extensive diagnostic instruments prior to seeing the PCC. These
instruments, described in the next sections, do not substitute for the diagnostic interview. Instead, they
assure assessment of key diagnostic factors and provide a quantitative assessment of severity of
symptoms.
 Figure 1: RESPECT-MIL Process of Care for Depression and PTSD
Screen/Recognize

Diagnostic Evaluation

Engage

Management

Monitoring Modify to
Response Achieve
Remission

Informed by screening and diagnostic instrument results, the PCC will then respond to the Soldier's
chief complaint as well as to any information suggesting a diagnosis of depression or PTSD. That is, if
either diagnosis is suggested, the PCC will make a reference to positive screening and diagnostic
information as appropriate and complete an appropriate diagnostic interview. In all cases, this
diagnostic interview should include a suicide assessment.
If the patient fits the diagnosis of either PTSD or depression, the clinician will engage the Soldier in an
initial course of therapy. This usually begins with determining the appropriate framework for
managing the condition--eounseling, medication, or a combination of both. At the conclusion of the
appointment, the clinician will offer the Soldier suffering from major depressive disorder or PTSD the
services of a care manager who will be able to assist the Soldier over time. These care management
contacts do not substitute for clinical follow-up visits, but rather provide additional contacts to help
Soldiers stay the course and achieve a high level of satisfaction and response to treatment. In addition,
the care manager performs a valuable and unique role in coordinating communication between the
patient, primary care, and the supervising psychiatrist.
The RESPECT-MIL approach to MDD and PTSD follows a similar structure as illustrated in Table 2.
 Table 2: RESPECT-MIL Approach to MDD and PTSD
Steps MDD PTSD
Screen 2 Questions 4 Questions
Diagnostic Interview Interview
Evaluation PHQ-9 PCL
Suicide/violence assessment Suicide/violence assessment
Engagement Discuss diagnosis and Discuss diagnosis and treatment
treatment options options
Management Medications/counseling/both Medications/counseling/both
Self management Self management
Care management Care management
Behavioral health clinician Behavioral health clinician
advice/support advice/support

The RESPECT-MIL Process of Change

Preparing your practice to provide enhanced primary care of depression and PTSD is the central
element to RESPECT-MIL. In addition to the continuing medical education instruction you will
receive about depression and PTSD in the next sections, resources as illustrated in Figure 2 are already
in place to help you provide the best possible care to your active duty patients.

Figure 2: Implementing RESPECT-MIL

Care Managers Mental Communication

Health Methods
Consultant

Prepare Practices

Clinician Staff
CME In-service
A care manager for your unit has been trained and stands ready to receive referrals. The referral
process will proceed electronically and you will receive updates after each telephone or face-to-face
contact the care manager has with your patients.
In addition, advice from the psychiatrist resulting from routine care manager supervision meetings will
be passed along to you. If you do not know the psychiatrist for your unit already, an introduction will
be arranged shortly.
In implementing the model, taking the first steps may require overcoming some inertia. As described
in the next sections, you will become familiar with the screening questions and the follow-up severity
and diagnostic tools. You will be trained in how to share the results of these instruments with patients
and engage them in the decision of whether and how to obtain treatment for their condition. We urge
you to not miss the chance to try the model at your first opportunity, working with the leadership of
your unit to have the process go smoothly and using the program to further the health and healthcare
for the Soldiers who serve.
III. RESPECT-MIL Protocol for Depression
This section provides a step-by-step view of RESPECT-MIL applied to the diagnosis and management
of depression. As you will see in Section IV, the framework is quite similar for PTSD.

Recognizing that a patient is depressed can be challenging, as often patients are concerned about social
stigma or career issues when told their symptoms suggest a depression diagnosis. To aid with
identification of depression clinicians look for "red flags" (e.g. multiple unexplained somatic
symptoms, recent major stress or loss, chronic pain, chief complain of insomnia, fatigue or appetite
change) and selectively use a two question-screen. In addition, RESPECT-MIL routines establish a
mechanism for more systematic screening for all patients post-deployment presenting with a new chief
complaint. Whichever mechanism is used, recognition begins with a two-question screen completed by
the Soldier. If you suspect a Soldier is depressed, despite responding "no" to the two items on the
screen, trust your intuition and offer the Soldier the PHQ-9 or use your usual clinical interview.

Figure 3: Depression Screening Form

Over the Last 2 WEEKS, have you been bothered by

Feeling down, depressed, or hopeless YES NO

Little interest or pleasure in doing things YES NO

If you circled YES to EITHER of the questions in this box, please continue and complete the attached
form. (A copy ofthe PHQ-9 is attached)
PHQ-9
The PHQ-9 is administered to all Soldiers who answer ''yes'' to either ofthe two screening questions.
The PHQ-9 is a patient self-administered questionnaire that helps make a depression diagnosis and
determine severity of depression. The clinician and or medic/office staff discusses the reasons for
completing the questionnaire and explains how to fill it out.
After the patient has completed the PHQ-9 questionnaire, it is scored by the clinician or office staff.
There are two components to be tallied:
• Assessing the number of symptoms and functional impairment to make a tentative depression
diagnosis.
• Deriving a severity score to help select and monitor treatment.
The PHQ-9 is based directly on the diagnostic criteria for major depressive disorder in the American
Psychiatric Association Diagnostic and Statistical Manual Fourth Edition (DSM-IV).
The next few pages will explain how to score and use the PHQ-9.
 Figure 4: Patient Health Questionnaire (PHQ-9)

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

Over the last 2 weeks. how otten have you been bothered
by any of the following problems?
(use u./_ to indicate your answer) ~. /~
~(Ji
-f
..IfJ •
/,':I~'~~
/
1 Littleinterestor pleasurein doingthings 0 CD 2 3
2 Feeling down,depressed, or hopeless 0 1 <V 3
3 Trouble falfingor staying asleep, or sleeping too much 0 1 2 G>
4 Feeling tired or having tittleenergy 0 1 2 G)
5 Poor appetiteor overeating 0 G) 2 3
Feeling bad about yourself- or that you are a failureor
6
have let vourselfor vour familv down 0 1 G) 3
Trouble concenlrating on things, such as reading the
7
neWSPaper or watchingtelevision 0 1 (i) 3
Movingor speaking so slowlythat other peoplecould have
8 0 2 3
noticed. Or the opposite - being so fidgetyor restlessthat you
have been movinq arounda lot more than usual
C)
Thoughtsthat you wouldbe better off dead, or of hurting
9
I vourselfin some way
0 CD 2 3

~
addcolumna:le- + + ~
TOTAd _

Not difficultat all

If you checkedoff any problems, how difficulthave these Somewhat difficult
10 problemsmade It for you to do your wOl1<, take care of Very difficult ./
things at home,or get along with other people? Extremely difficult
First, the numberof symptoms and functional impairment endorsed on the PHQ-9 are examined to
make a tentative diagnosis of major depressive disorder by looking for three criteria.
Figure 5: PHQ-9 lVIDD Diagnosis Example 1

PATIENT BEALm QUESTIONNAIRE (PHQ-9)

STEP 1;

(use ..v» to I
NeiKJ="'.... ~"':""'tvm~
Over the 1Ht. endorsed as "2Ror "3 R("More than haff the .days R
by any of the or "Neatlyeverydayj
I
.
/
6( ..,
~J"
~
~# ~
/+0.J'
. , ti'
~•..,,.
1 Little interest or pleasure in doing things 0 ~ 2 3
2 Feeling down. depressed, or hopeless 0 1
- G) 3
3 Trouble falling or staying asleep, or sleeping too much 0 1 2 G>
4 Feeling tired or having little energy 0 1 2 G)
5 Poor appetite or overeating 0 CD 2 3
Feeling b
6
havelety STEP 2;
0 1 G) 3
7
Trouble c Nood a.totalOffive
newsoaps
or more boxes endorsed
Within the shaded area of the form to arrive at
Moving or the.total·.symptom count.forMajorD&pressiM.
u 1 rr cv 3

8 noticed. ( (Inthisaxample six symptoms) 0 2 3

have bee , ..v .... a,vu ..u a 'v' ..V"" u ,a"
~ u~ua,
C)
Thoughts that you would be better off dead, or of hurting
9 yourself in some way 0 CD 2 3

add coIumns:I'-- + + _

TOTAL:
STEP 3:
Functional Impairment isandorsed as at least
If you che "somewhat difficult" or greater.
- Not difficult at all
,"".
-
10 problems Very difficult ~"'.J
things at lome. or gel along wnn omer people'! Extremely difficult

In this example, the criteria for major depressive disorder are met. The second question ("Feeling
down, depressed, or hopeless") is endorsed more than half the days, a total of six of the nine symptoms
are within the shaded area, and there is functional impairment from the symptoms. Note that for
symptoms 1 through 8, endorsement more than halfthe days is required. Symptom 9, suicidal thoughts
is significant even if endorsed only several days. A positive answer to question 9 needs follow-up and
will be discussed after computing the PHQ-9 severity score.
Second, a total depression severity score is obtained from the PHQ-9 by summing the values of the
endorsed (circled or checked) symptoms. This is most easily done by first adding the values in each of
the three columns and then summing the three values. A PHQ-9 severity score can range from 0 to 27.
 Figure 6: PHQ-9 MDD Diagnosis Example 2
PATIENT BEALm QUESTIONNAIRE (PHQ-9)

Over the last 2 ~. how often have you been bothered /~1;
AddlJPthecifJiednumbersUl eschof
by any of the followJng problems? • the thrffe columns on the right.
(use ".,n to indicate your answer)
/":1' /lfi" '(0" / O'

1 Ultle interestor pleasure in doing things 0 CD 2 3

2 Feelingdown, depressed, or hopeless 0 1 CD 3
I 3 Trouble failing or staying asleep,or sleepingtoo much 0 1 2 ())
I 4 Feelingtired or having little energy 0 1 2 (])
I 5 Poor appetite or overeating 0 CD 2 3
Feelingbad about yourself- or that you are a failureor
6
have let vourselfor vour familv down 0 1 CD 3
Trouble concentrating on things,such as reading the
I
7
newsoaoer or watchioo television 0 1 CV 3
I
8Moving or speaking so sloWly that other people couldhave
noticed. Or the opposite- being so fidgetyor restlessthat you
0 CD 2 3
have been movingaround a lot more than usual

., ,.Q)
; Thoughts that you would be better off dead, or Of hurting
9
Ivourselfin some way
0 2 3
I
'lII r ... ...
STEP 2:
add columns: 4 + 6 + 6
Sum.the·valuesfrotn the three
columns to obtain a Total severity 16
SCOl9.
Not di1Ticurt at all
If you checked off any problems, how difficulthavethese Somewhat di1TiCU1t
10 problems made it for you to do your won<, take careof Verydiflicult .,
thingsat home, or get along with other people? Extremely dlflicUlt

The severity score is extremely useful for helping to determine if and how to treat depression and then
to monitor the progress of treatment. First, however, the positively endorsed suicide symptom must be
further assessed.
Assess Suicide Risk
The Army takes quite seriously the potential for suicide risk in Soldiers. RESPECT-MIL helps to
address the risk of suicide post-deployment. Suicidal thoughts are often the symptoms of major
depression. Four to six percent of persons with this illness eventually commit suicide. 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:
• Hopelessness
• Prior suicide attempts
• Living alone
• Psychotic symptoms
 • Substance abuse
• Male gender (completed suicides)
• Caucasian race
• General medical illnesses
Twenty-five percent of suicide attempts are not premeditated. Suicidality may be an emergent (crisis)
or an urgent symptom, but it is always serious.
Conduct a Suicide Assessment
Always ask patients with depression if they have suicidal thoughts and/or suicidal plans. If they do,
find 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").
Components ofan Evaluation for Suicidal Risk
1. Presence of suicidal or homicidal ideation, intent, or plans.
2. Access to means for suicide and the lethality of those means.
3. Presence of psychotic symptoms, command hallucinations, or severe anxiety.
4. History and seriousness of previous attempts.
5. Family history of or recent exposure to suicide.
Emergent
If the patient has an active desire to commit suicide and has no self control or external supports
(e.g. family and friends) for safety, then a safe means for transport to the nearest mental health
clinic or emergency room setting should be found.
Urgent
If a patient has suicidal thoughts without an active plan to commit suicide, it is an urgent situation
and could become an emergent one. He/she should get a mental health assessment within 48 hours.
Patients should know who to get a hold of in a crisis and where to go for emergency help.
Treatment of major depression should begin as soon as it is identified, even if a mental health
referral has been made, as urgent symptoms may degrade to crisis proportions without it. Prescribe
medications that are not deadly in overdose (avoid tricyclics and MAGIs). If anxiety is treated with
a benzodiazepine while a patient is suicidal, have a fellow Soldier or family member dispense it, or
prescribe it in weekly amounts until the acute risk subsides.
The following tools can be used to help in the evaluation of suicide risk.
Suicide Screening Tools for Primary Care Clinicians
When you make a diagnosis of depression, suicide risk requires assessment. Ask the following,
progressive questions.
Table 3: Suicide Screening Questions
If question 1 is negative and suspicion is low, the subsequent questions can be skipped.
1. Havethe$esymptomslfeelings we'Ve beentalkingaboutled you to thinkyou mightbe better oft dead?
o Yes
o No

2 This past week.have you had any thoughts that life is not worth livingorthat you'd be betteroff dead?
o Yes
o No

3. What about thoughts aboul hurting or even killing yourse1t'l

Cl Yes ~ Go to Question4
DNo

4, Whathwe)''qu thong1lt ab()tlt'?Haveyou llQ~b' don~.ing tq,llUtt Y<llllSe1tt

o Yes
o No

51 RISKFACTORS F0Rsuromll:
o Blslpryof suiciideat1einpt
o
SociaHsolatlbn
o Subs_e abJllc
o Hopek:II~s
o SiggffiClUlt CG-lJIorbid &Olriety

Table 4: Assessment of Suicide Risk

DESCRIPTION OF LEVEL OF RISK ACTION
PATIENT SYMPTOMS
No current thoughts. Low Risk Continue follow-up visits and monitoring
No major risk factors.
Current thoughts, but no plans. Intermediate Risk Assess suicide risk carefully at each
With or without risk factors. visit and contract with patient to call
you if suicide thoughts become more
prominent.
Consult with Mental Health
Specialist as needed.
Current thoughts with plans. High Risk Emergency MH Referral
Obtain Additional History
Before explaining the diagnosis or recommending a treatment, it may be necessary to learn more about
the patient's presenting problem and related symptoms; interviewing techniques can elicit important
information from the patient. Discussion with the patient should include:
• Previous treatment history and response (e.g. history of mania)
• History of response to medication in patient or first-degree relative
• Medications and medical problems
• Patient sensitivity to medications (e.g. anxiety, somatization)
• Psychosocial stressors
• Other psychiatric disorders
Use PHQ-9 Results to Help Determine Treatment Selection
A depression diagnosis that warrants treatment or treatment change, needs at least one of the first two
PHQ-9 questions endorsed as positive (little pleasure, feeling depressed) indicating the symptom has
been present more than half the time in the past two weeks. In addition, the tenth question about
difficulty at work or home or getting along with others should be answered at least "somewhat
difficult."

Table 5: Treatment Recommendations

Minimal symptoms • Support, educate to call if worse;

return in 1 month

Minor depression++
Support, watchful waiting
10-14 Dysthymia"
Antidepressant or psychotherapy
Major depression, mild

15-19 Major depression, moderately Antidepressant or psychotherapy

severe

~20 Major depression, severe Antidepressant and psychotherapy (@8tJ@@iaUy if B8t

• If symptoms present ~ two years, then probable chronic depression which warrants antidepressants or psychotherapy (ask, "In the
past 2 years have you felt depressed or sad most days, even ifyou felt okay sometimes? ")
++ If symptoms present ~ one month or severe functional impairment, consider active treatment.
Present Treatment Options
Clinician presents feasible options for treatment to the patient and describes the pros and cons of each
approach. Discussion with the patient should include:
• Side effect profiles for antidepressants available/being considered.
• Availability of psychological counseling.
• Description of psychological counseling.
Elicit Patient Preference for Treatment
Some patients want their clinician to make the decision, but the clinician should ask the patient for
their treatment preference.
Choosing Psychological Counseling
In psychological counseling, patients with depression work with a mental health specialist (therapist)
who listens to them, talks, and helps them correct overly negative thinking (which reinforces depressed
mood) and improve their relationships with others.
Psychological counseling for depression is NOT talking about your childhood.
Psychological counseling has been shown to be just as effective as antidepressant medication in
treating many people with depression. Psychological counseling can be done individually (only you
and a therapist), in a group (a therapist, you, and other people with similar problems), or it can be
family or marriage therapy where a therapist, you, and your spouse or family members participate.
More than half of the people with mild to moderate depression respond well to psychological
counseling. While the length of time that persons are involved in counseling differs, people with
depression can typically expect to attend a weekly 30 to 60 minute long counseling session for 4-20
weeks. If your depression is not noticeably improved after six to twelve weeks of counseling, this
usually means that you need to try a different treatment for your depression. Psychological counseling
by itself is not recommended as the only treatment for persons whose depression is more chronic or
severe. Medication is needed for those types of depression, and it can be taken in combination with
psychological counseling.
Psychological counseling is recommended for patients who:
• Prefer psychological counseling.
• Had a previous good response to psychological counseling.
• Cannot tolerate medications.
• Have a prior course of illness that is chronic or characterized by poor inter-episode recovery.
For patients who are taking antidepressants, other types of psychological counseling may also be
helpful and should be recommended for patients who:
• Have partial response to full dose of an antidepressant;
• Have personality disorders; and/or
• Have complex psychosocial problems.
Choosing Medication
Antidepressants are effective for depression treatment. Many antidepressants are available and there is
no evidence that anyone is better than another. The major differences are the side effects and
cost/availability. The following table lists the dosing, advantages and disadvantages of the various
antidepressants available.

17
 Table 6: Guide to Antidepressants for Depression & PTSD
Revised April 2006

Thfrapeutk
And-
deprnsa.nr· Dose Ran!e Initial Suggfstfd Dose Titration Schfdale H Adnntages Di'iam-antages
(me/da",)
.... . .. : r-r: . ..... ,'.;.""
.: .;. •. .. .....•
'.

i $~t;"Ut ~"'~If~ ~'). .. , ;t.';,':;" , .....

......: " . • ...,.
"
.... 'i "':;'., i.:'
Citlllopl'lItD 10 - 40 1 0 mg in DlOfDing with Mainta in 10 mg for 4 weeks before do~ Probably IWpful for anxiety diSOfden.
(eden) food (10 mg in ~lderly or increase, If DO Je\pon~. iocJ~8se in 10IDl POMibly f~\\i'eC cytochrome P450
those with panic disOfder). ina~s every 7 days as tolerated, intemctioos. Generic !>C0I1.
~tiOD1e1' more potent than racemic,
Escitalopram 10 - 20 tomg for escitaJopram Increase to 20mg if partial response aftef 4 IOmg ~ usuallyeffKti,~ formost
(Leupro) \Web
Reduces all ~ ~-mptom. groups ofPTSD
Helpful for aD."tieIy disorders.
Slower to reach steady
Maintain 20 mg for 4-6 w~ and 30 JUg for 2-4 Long hAlf.life good for poor adbe'ltl1Ce,
20 mg in DlOfDing with state. Sometimes too
\Web before dose mcrease$ . Increase in 10 mg missed dose.
F1uoxetisle food (10 JUg in elcSedy and stimnlating. Po.wbly more
10- 80 increments at inl~n..:us of7 cb)"S. If sigJ!itk&1t
(Prozac) tho~ v..i1bcomorbid panic GeDerir 8."ai1able. Less frequem eytocllromeP450
side elRcn occur within 7 daY!>.. 1o\\"'eC do5e or
disoTdef) change medica1iOQ. • . cW.c:oatinnatiOll symptoms. interactions.
Reduce aUthrH S\'DJSltom.!/,'l'01Jl)SofPTSD
Paro~ 10- 50 (40 in 20 mg oace daily, usua11y Maintain 20 1118 for 4 \fteks befOtedose FDAIppio\~fc:ii mOst imxietYdisOrderii-
(P1Xil) elderly) in DJOOIin.g v..ith food increue. GeDeric klOil. Sometim6~ .
(lOmg in elderly and those Increase an10 mg increments at imen"a1s of Occasion.aJ.ly IDOft
\\"ithcOClOfbid panic appro:rimately 7 days up to a muimmn of 50 hducesaUtine ~gttlUpS OfPTSD . mticboliDertic:-~ etYeds.
disorda) mgfday. PO&siblymoac~
P450 inte:ractioDs.
2,S -62.'s (50 25 mgdaily (l Umg in May ba\-e more ftequent
(Paxi1 CR)
in elderly) elde1"ly and !bose with Iacrease by 12.51118 at~· imen'll1s. ~y~ .~~~GIdisbm
discoatimJation symptoms.
panic disordet") maintain 25 DIg for 4 Vw-eeks before dose ~ I ,,, .....
.'" ..

Mainblin 50 1118 for 4 \\-eek.s. Inaea.se in 25-50 F'l?!L' llJlIlro\~ for~' dUonm··Sakty
50 DIg cece 4aiIy. usua1Jy mg ~ at inten'a1s of 7 days as tolenrted.. shown ~.Mt .
SenraIiPe
25 - 200 Us moming 'ilo'ith food Maintain 1()() mg for 4 weeks beftn next dose
(Zoloft)
(251118 for e1defly) ~a&e. .
.: ;
": .., .. , ... ...
..",,.,, .v.
....•.... " ;'. .'.,
i ·" ",,'
.: "
...•
., ..;:::'" ...... . Sn-Olf,nin'"". NS' #Pillqthrln# ,m~OId!l ;.; . ::.:; •.... .,.
;

....
Few drug iDt.er.tctions. Less or no sexual
dy$functioo
Sedation at low dose·ooly.
15 mg at bedtime (7.S mg Inause in 15 DIg increments (7.5 mg in elderly)
MirtazapjDe Less ~0Il. AI dose inctft~ May i1lirially..timu1ate
15 - 45 fer 1hosein need of as tolerated. Mainrain 30 mg for 4 \\-n before
(RemerQl1) May stimulate JPPdire . appetite.
$edation i h}]XKltic) fwtber dow iDcrea5e
May reducean three symptom groupsof
PTSD
.' .... .,:..,.. .. .. .. . .....
.. .
" .:
':'
:':' .... ...
'
:·./JortpiH" ,,,,,,,-:arul:. miM-nJaplrdre illJtibitDr .: ';'.:
Buptopioot Increase to 1,S0 mg b.i.d, aftu 7 days.. Increase Stimulating. Less or 110 sexual dyt.iboction. At higher dose , IDlIY~
(We1nlutrin to 200mg bid if inmffit~ teSpOO!oe afttr 4 sm.uus in penom wi1h
SR. \Web. S boors bem.-een doses aod initiallynot at MAy reduce an three symptom groups of ~ diSCllder.
300-400 150 mg in morning
Wel1butrin bedtime. With hepatic ctisease only 100 DIg total PTSO Stimulating.
XL) pet·cby. Uwally b.i.d, dosWg.
un165 more ~-e XL.
 SBrotoHin 11114NorqUtq,hrift~reupMke
. ..

-, . ifthihitw ....
Dose should be dhi.ded b.i.d. or t.i.d, unless XR.. XR ver$ionem be Ween qd
Venl.afaxine For extended release (XR) give 37.5 in a.m. then Helpful for anxiety disorder". Pombl}" May UJa-eue blood
75 mg 1.\i.lh food; if
(Effexor,
75 - 375 amtiou&or debilitated,
mcreas.e to 75 mg in am. after 1 week, 150 mg in fev."ef eytoehfOme P450interactions. pre5suce at higher doses.
Effe1tof- XR) the :un. after 2 weeks. Ifpartial responseafter Bid ~g l1Il1ess use XR.
37-5mg
four weeks ino-ease to 225 mg in the morning. May reduce all ~ symptomgroupsof Expensive.
NorepinepJbine effect onlv 0CC'UI'liabm.'e l:5o'Dut. PTSD
.. . .. .,
.. Pf'ilffJlri1j N<HipiMphrilteMlpl4lrfilrldbit(1f .. . .. .. . •• .
=

Desipramine
Moreeffect011 OOIepinepbrine !han
roerotmin,leu sedating. Geueric
Like all TCAs, --
anticholineIgi<:_Caution
t 100-300
50 mg in the morning
Increase by 25 to 50 enge\-ery3 to 7 days to M:ailab1e. with BPH. Can exacerbate
{Notprmlin, (25-100ine1derly) initially target of150mg Cot 4 weeks.
~ .....oidanl::efnumbing symptom Catdiac conduction
Pmofrane)
~ofPTSD problems or CHF.
AV3i1ability ofreliab1e, -,.1ilidbl00d l.ikr all TCAs,
Nortriptyline Increase in 10-25mg iDcreaHmts e\'eJY :5 days a5 ~,~1s. I..<m.-er- ot1host.atic hypoteosion anticholinagic. Caution
t 25-150
25 mg (1Omg in frail toleratedto 75mg. Dosingtoo high mal' be Chan otle"1ri<:vdic~ . Generic available. with BPH. Cap c.:wabate
(A \.'eI1%}i, elderly) in the e\-ening ioeffecti\>r. Obtain serum drugle\'ds after 4 wMs
Probably redutes A\'oidanceimunbiDg cardiac cQ!Jd n c1i Oll
Pame1or) if not e1fecti,,~.
SVDlDtomlO'OUPofPTSD prob1elm orCHF.
. ..
... . ..
..
.. ,
.. ...
.

•4irMn-gicAlt1lt8t11fUb • ... -:
. ..
. ..
.. .
. .. .. ~. . . ..., .,

~by 1 t02 mgq 4to7 cbysopto 6mg , as B«mse it i& an

Prazosin
2 -10 1 mg at bed!u- to~ted by blood preS!O\ft, then add 4 mg in Particn1ady helpful for nigh1DweS antihypertemive, may cause
(MUJipress)
aftenKlOl1. otIbostatie hypotmUoa
. . . ... ..
.......
..
..
. . ..
.. ..
Arerrtf l or S1lttp
. ...
..
. ... .. ... . ... . . -: .

Sedating, no ~ risk May initially Cau'ie ~

Truodooe At higherdoliC$ of 150- 600 mg may abo day time sedation.
25 -600 25 - 50 mg at bedtime Increase by 25 to 50 mg e\"el] 5 to 7 days . partic:u1ady.t hi~ do5iK.
(Des}n) ~ symptoms fJom alllhree PTSD
S\'!DOtO!D categories. Rare eases of priapism

*There are more antidepressants than those listed in this table; however, this list provides a reasonable variety of drugs that have different side effects and act by
different neurotransmitter mechanisms. Treatment of Parkinson's disease may include selegiline (Eldepryl), which is a selective monoamine oxidase inhibitor
at low doses only. Because the use of many antidepressants is contraindicated in conjunction with a nonselective MAOI, caution with or discontinuation of
Eldepryl may be in order. For pregnancy, TCAs and SSRIs (particularly fluoxetine, because of more data collected) are not associated with congenital
malformations or developmental delay. SSRIs in the third-trimester are associated with a slight decrease in gestational age and correspondingly lower weight,
and occasionally with neonatal withdrawal symptoms. Diarrhea, drowsiness, and irritability are occasionally seen in breast fed infants of mothers taking
antidepressants. The risks of maternal depression on child development should be balanced against the effects of antidepressants on an individual basis.
"For SSRIs, generally start at beginning of therapeutic range . If side effects are bothersome, reduce doses and increase slower. In debilitated or those
sensitive to medications, start lower. For all antidepressants, allow four weeks at a therapeutic dose, assess for a response. If a partial or slight
response then increase the dose. If no response or worse symptoms then consider switching drugs.
[Generally avoid bupropion in patients with a history of seizures, significant central nervous system lesions, or recent head trauma.
tTricyclic antidepressants (TCAs) have lower costs but somewhat higher discontinuation rates compared to SSRIs due to side effects and are more lethal in
overdose. TeAs may be contraindicated in patients with certain physical comorbidities such as recent myocardial infarction, cardiac conduction defects, urinary
retention, narrow angle glaucoma, orthostatic hypotension, and cognitive impairment,

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