CREW: Department of Defense: Department of The Army: Regarding PTSD Diagnosis: 6/30/2011 - Release Pgs 1-241 On 24 May 2011

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DEPARTMENT OF THE ARMY

HEADQUARTERS, UNITED STATES ARMY MEDICAL COMMAND
2050 WORTH ROAD
FORT SAM HOUSTON, TX 78234 8000
REPLY TO
ATTENTION OF
OTSG/MEDCOM Policy Memo 08-018
1 9 MAY 2008
MCCG
Expires 19 MAY 2010
MEMORANDUM FOR Commanders, MEDCOM Regional Medical Commands

SUBJECT: Screening for Post-Traumatic Stress Disorder (PTSD) and mild Traumatic Brain
Injury (mTBI) Prior to Administrative Separations
1. References.
a. Army Regulation (AR) 635-200, Active Duty Enlisted Administrative Separations,
6 June 2005.
b. Army Medical Action Plan, Phase Ill task, consider mTBI and PTSD Separations'',
July 2007.
c. Sigford, B.. M.D., Veterans Affairs, National Director, Physical Medicine and
Rehabilitation, December 2007. Screening and Evaluation of Possible TBI in OEF/OIF
Veterans, Brief.
d. Post Traumatic Stress Disorder Checklist (PCL) for DSM-IV, 1 November 1994,
Weathers, Litz, Huska, & Keane, National Center for PTSD - Behavioral Science Division.
2. Purpose. To outline procedures for PTSD and mTBI screening of Soldiers considered
for administrative separations, including but not limited to Chapter 9, Alcohol or other Drug
Abuse Rehabilitation Failure: Chapter 13, Unsatisfactory Performance; Chapter 5-13,
Personality Disorder; Chapter 5-17, Other Mental Health Condition; and Chapter 14-12,
Patterns of Misconduct, reference 1.a.
3. Proponent. The proponent for this policy is HQ, MEDCOM, Office of the Assistant
Chief of Staff for Health Policy and Services, ATTN: MCHO-CL-H.
4. Responsibilities.
a. The Surgeon General has overall responsibility for policy guidance in defining
and implementing the Army Medical Department's behavioral healthcare screening
requirements.
b.. -rhe Directorate of Health Policy and Services, through the Proponency Chiefs of the
Offices for Behavioral Health and Rehabilitation and Integration are responsible for the
distribution of behavioral health evaluation and mrsl requirements and reviewing, revising,
updating, and deleting existing policies conflicting with these requirements.
FOIA Release Page 1
MCCG
SUBJECT: Screening for Post-Traumatic Stress Disorder (PTSD) and mild Traumatic Brain
Injury (mTBI) Prior to Administrative Separations
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., above.
5. Discussion.
a. There has been concern that Soldiers with undiagnosed or untreated PTSD or mTBI
are being administratively discharged from the Army. rherefore, it is paramount that the
Army adequately assesses every one of these Soldiers for PTSD or mTBI.
b. rhis guidance refers to Soldiers who receive mental health evaluations from behavioral
health clinicians for administrative separations.
6. Policy.
a. Behavioral Health Departments within each MTF will ensure that Soldiers receiving
mental health evaluations related to the Chapters identified in paragraph 2., above are
conducted by a behavioral health clinician lAW AR 635-200. Evidence of documentation of a
screen for both PTSD and mrsl must be part of DA Form 3822-R, Report of Mental Status
Evaruation and documented in the progress note located in the Soldiers' Armed Forces
Health Longitudinal Technology Application (AHLTA) record.
b. There are screening tools (enclosures 1 and 2) for both PTSD and mTBI that can
assist the clinician during the assessment. These tools are also located at
nn mi
. The consensus of the subject matter experts is
h
that the VA screening questions and the PCL found at the website above are the best tools
for screening in this population. It should be noted that the mTBI screening tools are not
diagnostic. Any positive mTBI screen will require a further evaluation to establish the
correct diagnosis with referral and other testing if necessary. Other assessment tools may
be added at the discretion of the clinician.
7. Point of contact is (b )(
(b )(6)
2 Encls
1. PCL
2. VHA TBI Clinical Reminder
and Screening Tool
ERIC B. SCHOOMAKER
Lieutenant General
Commanding
FOIA Release Page 2
CHRONOLOGICAL RECORD OF MEDICAL CARE

SYMPTOMS. DIAGNOSIS. TREATMENT. TREAriNG ORGANIZA"riON ''
Date: _ _ __
&ach e,,;fY.
PTSD Checklist- Military Version (PCL-M)

Instructions: Below is a list of problems and complaints that veterans sometimes have in response
to stressful military experiences. Pl~ase read each one carefully~ put an ~x .. in the box to indicate
hO\\' much you have been bothered by that problem in the lasl month.
Response:
So.
1.
2.
3.
4.
Not at
A little
aU
bit
Repeated, disturbing memo1iu, thoughts, or images

of a stressful mili' ex :aicn :?
Repeated. disturbing J;itu of a stressful military
eXJ;~ ..... "':1
Suddenly acting or ~.:ling as if a stressful military
e>-."Periencewe,.e happeniJJg again (as if you were
~1oderately
Quite a
bit '4
(3'
.l
Extreme)"
"S
.
.
I
I
relivin it~ ?
Feellng~voy-u-~~-,-,-~~h-~n-s_o_m_e~th~m-~-,-e-m~m-~~e~d-y-ou-o~f~-----T-----------+------~~----~
a stressful milltary ~A ~erience~
Havipgphysical reactions :e.g., heart pounding,

trouble breathing, or sweating) when 1ometlaing
remiiJdedyvu
stressfUl miliwy~---~----t-----r-----jr-------+-----t---~
6.
Avoid rhinlcing abo111 or talking ab'!ut a stressfuJ
military experience or a\'Oid IJmringfeelir.gs related
to it?
7.
Avoid aaivitlu or situatio1u because they ,.emind
...,__...,.~=u of a sa cssful "' litary_ex )eri~ 1cc'
8.
T "h ~c remen:., .,_ important parts of a stressful
military )Cr .~:.~ceJ
9.
Loss of interest in lhi,, tluul!!;.~-...!us~t::!d~r~o~er11_~ri~tN?.~-~-~~--~---.......J~--~----J
l 0. F4 ~ling distant or crll nl1from other people'~ _
11. Feeling ~motionally numb or being unable to have
I
'
I
......_~.,_J_~o__."J: fl 9! for those close to yuu?
12. F:- i".&. as if your__-.futJue will somehow be ctll short?
I
!
13. Trouble :;!!l or st,gJ!I~as..;;..l;..;;.r~.;;,l;~;....;....-.----:"---"t---t----r-----r---...__----~
14. . F '-: ~u irritublB or l!!:::!!!&. ...~~~~;...;o;.;;u;.;.;tb;.;;u.;.;,.r.,;;.;;.'SIS_1___--t----+----+---------t----~
15.. Having ,:;,";i~/ty concentrali~
16. BeJg '"IIIIJ- al-'!' or watchful on .e

........~a_-"1_ _ _--t---t---~-----t----+---~
17.
F:ti~D'I/ or eas:[JI&...s.;;;...tan....;;....;;.le,;;;.,;;d;;..;;.?_ _ _ _ _ _........__ _.....__ _~---...._--....._--~
S.
or'
~cathcrs. F.W . Huska, J.A. K~anc, T.M.
PCL-.\Ifor flS,\1-JY. Boston: ~alional Center for prso -lJcb~vimal Science Dnisicn, 1991..
This is a Ooveanmenl document in the public domain
Score:
PATIEN'rS ;Imprint)
'TtON (Use
tl~:s SI'ICII for Mechanical
RECORDS
MAINTAINED AT:
"'PAiiENTS M ,~'E""i[iit .
REL
I~
iiiPTi )"SPCi
rst. iiiiidii lt~j ~af)

)R
rA' .,
Date Arrived AOR: - - - - - - - -
Date Departing AOR: - - - - - - - -
SSNI1"6ENTi'F
c:A"Ti''ii NO.
AFSC: ___________
CfiRONOLOGICAL RECORD OF MEDICAL CARE
No. of Previous Deployments to AOR: _ __
STANDARD FORM 100 (qEV

Praseftbld by G5.L li,d ICMR
5~)
FlrUR r4 1 CFRl Z01..s5.!C5
FOIA Release Page 3

'
VHA TBI Clinical Reminder and Screening Tool

Section 1:
During any of your OIF/OEF deployment(s) did you experience any of the
follo\ving events?
(Check all that app~l-~
D
D
D
0
Blast or Explosion
Vehicular accident/crash (any vehicle, including aircraft)
Fragment \vound or bullet \\'ound above the shoulders
Fall
Section 2:
Did you have any of these 1M MEDIATELY aftenvards?
(Check all that app~v)
0
0
D
0
D
Losing consciousness/'.knocked out""

Being dazed, confused or seeing stars'
Not remetnbering the event
Concussion
Head injury
Section 3:
Did any of the follo\ving proble111s begin or get \vorse aftenvards?
(Check all that appJ.vJ
D
D
0
D
D
D
Memory problems or lapses

Balance problems or Dizziness
Sensiti\'ity to bright light
Irritability
Headache
Sleep problems
Section 4:
In the past \Veek, have you had any of the symptoms from Section 3?
(Check all that opp(v)
D
0
0
D
D
Sensitivity to bright 1ight
Sleep problen1s
Memory problen1s or lapses

Balance problems or dizziness
Irritability
Headaches
FOIA Release Page 4
The Association Between Number of Deployments to Iraq and Mental Health

Screening Outcomes in U.S. Army Soldiers
(b )(6)
Ph.D. a,b (b )(6)

(b )(6)
c______ _ _ _ _ _ _ _ _ J
Ph.D. a*' (b )(6)
M.A., M.P.H. a
(b )(6)
Funding Source: This study was unfunded
*Corresnondence:
COL (b)(6 )
Chief, DeDa.rtment ofPsycholo~y
c _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ J
(b )(6)
FOIA Release Page 5
2
~bstract
1
2
Context: High rates of mental health concerns have been documented in Army Soldiers
deployed in support of Operation Iraqi Freedom (OIF). To our knowledge, there are no peer-
reviewed studies that have examined the impact of multiple OIF deployments on mental health
functioning.
Objective: To compare the post-deployment mental health screening results of Soldiers with one
or two deployments to Iraq.
Design & Setting: Cross sectional study of routine mental health screening data collected in the
Soldier Wellness ~ssessment Program at Fort Lewis, Washington.

~total
10
Participants:
11
deployment to Iraq, and 671 Soldiers evaluated after their second deployment to Iraq).
12
Main Outcome Measure(s): Standardized measures screened for Major Depression, Other
13
Depression, Post-traumatic stress disorder (PTSD), Panic, Other Anxiety, and hazardous alcohol
14
consumption 90 to 180 days after returning from Iraq.
15
Results: There was a significant association between number of deployments and mental health
16
screening results such that Soldiers with two deployments showed greater odds of screening
17
positive for Other Depressive Syndrome [Odds Ratio (OR)=l.46, p=.045] and Other Anxiety
18
Syndrome (OR=1.32, p=.047).
19
most recent deployment, Soldiers with two Iraq deployments showed significantly greater odds
20
of screening positive for Major Depression (OR= 1. 70, p=.02), Other Depressive Syndrome
21
(OR=1.73, p=.007), PTSD (OR=1.90, p<.001), Panic (0R=l.85, p=.04}, and Other Anxiety
22
Syndrome (OR=1.71, p<.OOl). There was no significant difference in odds of screening positive
23
for hazardous alcohol consutnption.
of 3548 Regular U.S. Army Soldiers (2,877 returning from their first
~fter
adjusting for demographic factors and combat exposure on
FOIA Release Page 6
Conclusions: These results provide preliminary evidence that multiple deployments to Iraq may
be a risk factor for mental health concerns.
FOIA Release Page 7
INTRODUCTION
High rates of mental health concerns have been docun1ented in Army Soldiers deployed
1
in support of Operation Iraqi Freedom (OIF). In an early study by Hoge and colleagues,
Soldiers assessed three to four months after a deployment to Iraq screened positive for post-
traumatic stress disorder (PTSD) in 13% of cases; depression and generalized anxiety were each
observed in about 8% of cases, and alcohol misuse was observed in over 20% of cases. With the
exception of generalized anxiety, these rates were significantly higher than pre-deployment
screening rates observed in a comparable U.S. Army unit. In a separate study, routine post-
deployment screening data collected within two weeks of returning from Iraq revealed that
10
Soldiers and Marines screened positive for a mental health problem in 19% of cases, compared
11
to 8 . 5% returr1ing from non-OIF/Operation Enduring Freedom {OEF) operationallocations .
12
Similar results have been reported in veteran populations. Examining over 103,000
13
OIF/OEF veterans, Seal and colleagues reported that 25% of a clinical Veteran Affairs (VA)
14
sample had been diagnosed with a mental health disorder, including 13% with PTSD. The rate
15
ofPTSD diagnoses in a similar VA sample was reportedly 3.7 times higher antong Soldiers or
16
Marines who served in ground units in Iraq or Afghanistan compared to Navy or Air Force
17
18
veterans of OIF/OEF.
The importance of these results is underscored by the association between anxiety or
19
mood disorders, and functional impairments. The National Survey of the Vietnam Generation
20
revealed that veterans with lifetime diagnoses ofPTSD and major depression showed
21
significantly lower employment rates and hourly wages compared to veterans without these
5
22
disorders. PTSD has been associated with increased marital distress and parental adjustment
23
6 7
problems. '
In addition, OIF/OEF veterans with PTSD or hazardous alcohol consumption
FOIA Release Page 8
5
I
reported a lower quality oflife. Furthermore, Soldiers studied one year after deployment to OIF
9
showed strong associations between PTSD and physical health problems. These impairments in
job performance, intimate and family relationships, quality of life, and physical health suggests
that OIF veterans with mental disorders may face significant functional challenges.
There is currently speculation as to whether multiple deployments to Iraq may exacerbate
the frequency and severity of mental health problems described above. Multiple deployments
may increase the cumulative stress an individual experiences, and it increases the probability that
Soldiers will be exposed to combat. Deployment stressors can include a sense of isolation,
relationship stress, homefront problems, challenges associated with adjusting to a new
10
environment, a threatened sense of safety, traumatic stress, long work hours, and stressors
11
associated with a variety of other operational demands. Concomitant reductions in usual coping
12
resources may also impact mental health functioning. In contrast, potential protective factors
13
such as unit cohesion, effective leadership, mentoring, training, and access to other resources in
14
theater may mediate the impact of deployment stress.
15
To our knowledge, there are no peer-reviewed studies that have examined the impact of
16
multiple OIF deployments on mental health functioning. Army reports from the Office of the
17
Surgeon Multinational Force-Iraq and the Office of the Surgeon General, U.S. Army Medical
.
10 11
results. '
18
Command have reported mixed
19
may increase the risk for mental health problems. For example, a Swedish study of 1824
20
randomly selected individuals from the general population revealed that trauma frequency was
21
22
There is evidence that exposure to multiple traumas
significantly associated with an increased risk ofPTSD.

patients hospitalized at trauma centers.
13
12
Similar results have been noted in
In addition, among Service Members who worked in a
FOIA Release Page 9
6
1
2
3
mortuary during the Persian Gulf War, greater changes in PTSD symptoms were observed in
groups with the greatest exposure to huntan remains.
14
The purpose of this study was to determine if there is a relationship between multiple
deployments and mental health problems as identified by mental health screening outcomes for
Soldiers with one or two deployments to Iraq.
METHODS
Study Population
Data were retrospectively analyzed from the Soldier W ellness Assessment Pilot Program
(SWAPP) database at Fort Lewis. The SWAPP is an extension of the standard Post-Deployment
) program mandated by the Assistant Secretary of Defense for
10
Health Reasssessment (PD . . .
11
Health Affairs since 2005. The PDHRA provides a global health assessment, including mental
12
health screening, for all Service Members 90 to 180 days after returning from an operational
13
deployment. In the standard Army process, Soldiers complete the three page PDHRA fonn
14
electronically, and a qualified healthcare professional (nurse practitioner, physician assistant, or
15
physician) reviews the information, conducts a brief interview, and recommends further
16
17
.&.
evaluation or referrals as indicated.
15
During the SWAPP process, Soldiers first complete on a computer an expanded set of
and additional items for demographics
18
screening measures that includes the standard PD ......
19
and military infomtation, psychosocial history, mental health screening (see Measures section
20
below), deployment exposures and stressors, and resiliency factors. Soldiers are seen by medical
21
personnel for injury prevention, smoking cessation, or other reported physical concerns as
22
needed, and a credentialed behavioral health provider meets individually with each Soldier. A
FOIA Release Page 10
7
1
nurse practitioner reviews all aspects of the Soldier's SWAPP encounters, and administrative
support staff meet with each Soldier to schedule follow-up appointments.
The SWAPP's post-deployment screening data from September 7, 2005 to April27, 2007
were analyzed. All Service Members in the database were Regular, active duty Soldiers. Cases
were included in the analysis when they met two criteria: (1) Iraq was reported as the
deployment's operational location; (2) the total historical number of deployments reported in
support of Operation Iraqi Freedom was one or two. There were not enough Soldiers with three
deployments in the database to expand the analysis to include this group. Cases were included
when they were screened within at least 60-days of the target PD
.&...&.
timeframe. Soldiers with
10
reported histories of deployment in support of Operation Enduring Freedom were excluded from
11
the analysis. The final sample included 2,877 Soldiers returning from their first deployment to
12
Iraq, and 671 Soldiers evaluated after their second deployment to Iraq. Two subjects were
13
observed in both groups. The study was approved by the Department of Clinical Investigations
14
at Madigan Army Medical Center.
15
Measures
16
SWAPP mental health screening measures included the depression and anxiety modules
17
16 18
(PHQ) - ,
18
19
20
21
from the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire
the Primary Care Posttraumatic Stress Disorder Screen
Disorder Detection Test (AUDIT).
20
19
(PC-PTSD) ,
and the Alcohol Use
In addition, 4 combat exposure items were adapted from
the Deployment Risk and Resilience Inventory.
21
PHQ. The PHQ is a self-report measure that can be entirely self-administered by

16
16 22 23
algorithms ' '
22
patients.
23
to specific DSM-IV criteria, and subthreshold disorders that require fewer symptoms than a
Standardized
screen patients for threshold disorders that correspond
8
1
DSM-IV diagnosis. The Depression and Anxiety modules administered in the SWAPP provide
screening results for threshold disorders, including Major Depression, Panic Disorder, and Other
Anxiety Disorder; the subthreshold disorder of Other Depressive Disorder is also screened. The
4
5
PHQ is widely used and has established reliability and
16 17 24 25
validity. ' ' '
PC-PTSD. The PC-PTSD is a brief, four-item (Yes-No) self-report screening instrument
for PTSD that is a standard part of the PDHRA. The PC-PTSD demonstrated sound
psychometric properties for cutoff scores of2 (sensitivity= .91, specificity= .72) and 3
(sensitivity= .78, specificity= .87) compared to diagnoses based on the Clinician Administered
10
11
Scale for PTSD (CAPS).
19
Since cutoff scores of either 2 or 3 may be appropriate, depending on
19
the clinical setting, we analyzed results for both cut-points (PTSD-2, PTSD-3).
AUDIT. The AUDIT is a 10-item self-report measure that screens for hazardous or
20
12
harmful alcohol consumption.
13
Daily) with total scores ranging from 0 to 40. The standard cutoff score of 8 for hazardous or
14
harmful consumption has consistently demonstrated favorable sensitivity and specificity in
15
16
17
numerous
26 29
studies. -
reliability.
31
Item responses range from 0 (Never) to 4 (Daily or Almost
30
The AUDIT is internally consistent, and has shown good test-retest
Combat exposure. The SWAPP screening included four Yes-No questions about combat
21
18
experienced during the most recent deployment, adapted from the DRRI.
Items asked the
19
following: During combat operations did you (1) become wounded or injured; (2) personally
20
witness a unit member, ally, enemy, or civilian being killed; (3) see the bodies of dead soldiers or
21
civilians; (4) kill others in combat (or have reason to believe others were killed as result of your
22
actions).
23
1
2
Statistical Analyses
Chi-square tests of association and t-tests were used to compare demographic and combat
exposure variables between groups with one or two Iraq deployments. Logistic regression was
used to examine associations between the number of Iraq deployments and mental health
screening outcomes (positive, negative). Multivariate logistic regression models were used to
examine the associations irrespective of age, sex, race/ethnic background, rank, education,
marital status, and combat exposure.
9
10
RESULTS
Subject Characteristics
Subject demographics are presented in Table 1. Soldiers with two Iraq deployments
11
differed from those with one deployment in terms of age, rank, education, and marital status.
12
There was no difference between the groups in raciaVethnic background or sex.
13
There was no difference between Soldiers with one or two deployments in terms of the
14
number of days between departure from theater and screening date (Mean SD = 105.51
15
37.62; 108.14 35.94, respectively). Soldiers were deployed for an average of 11.33 months
16
(SD = 2.19) in the group with one deployment and 11.03 months (SD = 2.41) in the group with
17
two deployments. For Soldiers with two deployments, the median arrival date in theater (Oct.
18
31, 2005) was about a year later than the median arrival date for Soldiers with one deployment to
19
Iraq (October 13, 2004). Subjects reported significantly lower frequencies of combat exposure
20
during their second deployment compared to Soldiers who recently returned from their first Iraq
21
deployment (Table 2).
22
23
10
Mental Health Screening Results
There was a significant association between number of deployments and mental health
screening results in the univariate analyses for Other Depressive Syndrome (OR= 1.46, p =
.045) and Other Anxiety Syndrome (OR= 1.32, p = .047; Table 3). After adjusting for
demographic factors and combat exposure, Soldiers with two Iraq deployments showed
significantly increased odds of screening positive for Major Depression (OR= 1. 70, p = .02),
Other Depressive Syndrome (OR= 1.73, p = .007), PTSD-2 (OR= 1.64, p <.001), PTSD-3 (OR
.001). There was no difference between the groups in the odds of screening positive for
10
1.90, p < .001), Panic (OR= 1.85, p = .04), and Other Anxiety Syndrome (OR= 1.71, p <
hazardous alcohol use.
11
These analyses were repeated after adding the number of days between screening and
12
departure from theater to the model. The results were unchanged with the exception of Panic
13
which no longer showed a significant association with number of Iraq deployments (OR= 1.78,
14
p = .055).
15
DISCUSSION
16
The results of this study provide preliminary evidence that multiple deployments to Iraq
17
may be a risk factor for some mental health concerns. The odds of screening positive for Other
18
Depression and Other Anxiety Syndrome was higher for Soldiers on their second deployment to
19
Iraq compared to those screened after a first deployment to Iraq.
20
These findings differ from results of the Mental Health Advisory Team (MHAT)-III
10
21
Report which found that Soldiers with multiple deployments to Iraq showed higher rates of
22
acute stress, but not depression or anxiety, compared to Soldiers on their first deployment to Iraq.
23
11
Our results are more consistent with the recent MHAT-N Report which found that Soldiers
11
1
deployed to Iraq more than once were more likely to screen positive for depression, anxiety, or
acute stress. However, different recruitment procedures, participant characteristics, and outcome
measures limit comparability. In addition, it is important to note that the MHAT Reports are
based on data collected from Soldiers during deployment, while our results were collected from
Soldiers about 3 to 6 months after returning from deployment. Some research suggests that
results obtained immediately following a deployment may differ substantially from assessments
conducted several months later.
32
After adjusting for demographic factors and combat exposure on the most recent
deployment, the odds of screening positive for Major Depression, Other Depressive Syndrome,
10
PTSD, Panic, and Other Anxiety Syndrome was 64 to 90% higher for Soldiers with two
11
deployments. These findings suggest that the odds of developing a mental health problem are
12
higher for Soldiers after a second deployment, irrespective of the combat they are exposed to
13
during their second tour. The factors contributing to these findings are unknown. Information
14
about combat exposure during first deployments (among Soldiers with two deployments) was not
15
available. Thus, the impact of additive combat exposures across multiple deployments remains
16
unknown. In addition, the impact of cumulative deployment stress, such as homefront stressors
17
and difficulties associated with working in an operational theater may contribute to these
18
findings. Additional research is needed to determine how the etiology of mental health disorders
19
following a second deployment may differ from Soldiers deployed to Iraq only once.
20
Interpretation of our findings would benefit from more information on how Soldiers with
21
one or two deployments may differ. While we were able to examine basic demographic features
22
and recent combat exposure, we do not know how the group with two deployments adjusted after
23
their first deployment compared to their entire cohort. Soldiers identified with a post-
12
deployment mental health condition that renders them unfit for duty are not deployed again until
treatment proves successful. In addition, Service Members who screen positive for mental health
2
concerns are more likely to leave military service in the year following a deployment.
Therefore, it is possible that the group with two deployments represented a healthier, more
resilient group. However, it is also possible that a number of Soldiers were successfully treated
for mental health concerns before deploying a second time. The impact of prior treatment
history on mental health functioning after a second deployment is
study of the effects of multiple deployments on mental health would be helpful to clarify these
10
~. . . . . . . .own.
A longitudinal
ISSUeS.
Analyses of demographic features revealed group differences on a number of variables.
11
These group effects were expected, as Soldiers with two deployments likely had longer military
12
careers. Therefore, differences in age, rank, education, and marital status are intuitive. The
13
difference between groups on combat exposure is less intuitive. Soldiers reported significantly
14
lower levels of combat exposure during their second deployment compared to the group with
15
only one deployment. This finding may be due, in part, to the fact that Soldiers' second
16
deployment occurred, on average, about a year later in the history of the conflict when combat
17
operations may have differed. It is also possible that Soldiers deployed to Iraq for a second time
18
may differ from Soldiers on a first deployment in some way that makes them less likely to see
19
combat. Possibilities include rank, Anny selection criteria for a second deployment, duty
20
assigmnents for Soldiers with prior theater experience, or differences in attrition from the Anny
21
by occupational duty.
22
23
Rates of positive screens for mental health disorders were generally lower than those
1
reported by Hoge and colleagues. For example, while Hoge et al. reported that 15% of their
13
1
Army sample screened positive for major depression on the PHQ after deployment to Iraq, we
observed a rate of 4o/o for our total sample using the same measure. However, significant
differences between study methods may account for these differences. Hoge et al.'s study
utilized an anonymous survey with a specific infantry division, three to four months after an 8-
month deployment to Iraq in December 2003. Our results were obtained from non-anonymous,
standard post-deployment screening efforts at Fort Lewis for Soldiers from a variety of units,
three to six months after deployments (of varying lengths) to Iraq, from September 2005 to April
2007. Many of these factors likely contributed to the differences in the results. For example,
since our sample included non-combat units, combat exposure may have been reduced in our
10
sample compared to Hoge et al.'s study. In support of this hypothesis, 62% ofHoge et al.'s
11
sample endorsed responsibility for the death of others (combatants and noncombatants)
12
compared to 33% of our total sample.
13
14
In contrast, the rates we observed were higher than those reported in a recent study that
examined population-based results of Army Soldiers and Marines screened within two weeks of
2
15
returning from a deployment to Iraq. Utilizing the 2-point cutoff score for the PC-PTSD, the
16
investigators reported a PTSD-positive screen rate of9.8% in their Iraq sample; this compares to
17
a rate of about 21% in our total sample using the same measure. Both studies included similar
18
questions about whether the Service Members saw dead bodies; the rate in our san1ple was
2
19
higher with 67% positive, compared to 49.5% in the Hoge et al. study. Thus, some of the
20
differences between the two studies could be due to higher levels of combat exposure in our local
21
sample. Unfortunately, other combat exposure items were not appropriate for comparison.
22
However, another important difference between the studies was the timing of the screening. The
23
Hoge et a1. study was conducted within two weeks of retuttling from deployment, while our data
14
was gathered about three to six months after deployment. As noted above, some data suggests
that Service Members are much more likely to report mental health problems three to four
3
4
months after deployment compared to shortly after returtling.
32
The results of the current research should be confirmed in future studies, as the cross-
sectional design limits conclusions. In addition, all study subjects were drawn from one Army
installation in Tacoma, W A with a large active duty population, including several Stryker
brigades. These Soldiers may differ from the broader Army in a number of ways, and the results
may not generalize to the rest of the Army. Generalizability is further reduced by the fact that
the current study included only Regular active duty Soldiers. Furthennore, it is important to
I0
emphasize that these results were obtained with self-administered screening instruments; these
11
results do not reflect diagnostic rates. In addition, the time-frame of the study period may prove
12
important for studying mental health outcomes of multiple deployments. As the theater matures
13
and the mission requirements of Operation Iraqi Freedom evolve, the nature of the stressors that
14
Soldiers experience may change. Therefore, rates examined during one time frame of the
15
Conflict may not generalize to other periods.
16
The importance of understanding the mental health effects of multiple deployments is
17
likely to grow as the number of Service Members with two or more deployments increases. The
18
results of this study provide preliminary evidence that the risk of mental health problems may
19
increase following a second deployment to Iraq. As the number of Service Members deployed
20
for second tours increases, these findings may have significant implications for the demand on
21
mental health treatment resources.
22
23
15
Disclosures & Acknowledgements: All authors report no competing interests. This was an
unfunded study. The opinions or assertions contained herein are the private views of the authors
and are not to be construed as official or reflecting the views of the Department of the Army or
the Department of Defense. The authors thank (b)(
c _ _ _ __ _ _ _ _ _ _ _ _ _ J
PhD, ABPP, (b)(
c _ _ _ __ _ _ _ _ _ _ _ _ J
c _ _ _ __ _ _ _ _ _ _ _ J
contributions.
16
References
1.
Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in
Iraq and Afghanistan, mental health problems, and barriers to care. N Eng/ J Med. Jul 1
2004;351(1): 13-22.
2.
Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health
services, and attrition from military service after returning from deployment to Iraq or
'
Afghanistan. Jama. Mar 1 2006;295(9): 1023-1032.
3.
Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C. Bringing the war back home:
mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan
seen at Department of Veterans Affairs facilities. Arch Intern Med. Mar 12
2007; 167(5):476-482.
4.
Kang HK, Hyatns KC. Mental health care needs a1nong recent war veterans. N Eng/ J
Med. Mar 31 2005;352(13):1289.
5.
Savoca E, Rosenheck R. The civilian labor market experiences of Vietnam-era veterans:

the influence of psychiatric disorders. J Ment Health Policy Econ. Dec 1 2000;3(4):199-
207.
6.
Jordan BK, Marmar CR, Fairbank JA, et al. Problems in fa1nilies of male Vietna1n
veterans with posttraumatic stress disorder. J Consult Clin Psycho/. Dec 1992;60(6):916-
926.
7.
Riggs DS, Byrne CA, Weathers FW, Litz BT. The quality of the intimate relationships of
male Vietnam veterans: problems associated with posttraumatic stress disorder. J Trauma
Stress. Jan 1998; 11(1 ):87-1 01.
17
8.
Erbes C, Westenneyer J, Engdahl B, Johnsen E. Post-trawnatic stress disorder and

service utilization in a sample of service members from Iraq and Afghanistan. Mil Med.
Apr 2007;172(4):359-363.
9.
Hoge CW, Terhakopian A, Castro CA, Messer SC, Engel CC. Association of
posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism
among Iraq war veterans. Am J Psychiatry. Jan 2007;164(1):150-153.
10.
Office of the Surgeon Multinational Force-Iraq and Office of the Surgeon General United
States Army Medical Conunand: Mental Health Advisory Team (MHAT-111) Report.
May 29, 2006.
11.
Office of the Surgeon Multinational Force-Iraq and Office of the Surgeon General United
States Army Medical Conunand: Mental Health Advisory Team (MHAT-IV) Report.
November 17, 2006.
12.
Frans 0, Rinuno P A, Aberg L, Fredrikson M. Trauma exposure and post-traumatic stress

disorder in the general population. Acta Psychiatr Scand. Apr 2005;111(4):291-299.
13.
Zatzick D, Jurkovich G, Russo J, et al. Posttraumatic distress, alcohol disorders, and

recurrent trauma across Ievell trauma centers. J Trauma. Aug 2004;57(2):360-366.
14.
McCarroll JE, Ursano RT, Fullerton CS, Liu X, Lundy A. Effects of exposure to death in
a war mortuary on posttraumatic stress disorder symptoms of intrusion and avoidance. J
Nerv Ment Dis. Jan 2001;189(1):44-48.

15.
Department of the Army: OTSG/MEDCOM Implementation Plan for Active Component

Post-Deployment Health Reassessment Program (PD
). OTSG/MEDCOM Policy
Memo 06-005. March 7, 2006.
18
16.
Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of
PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders.
Patient Health Questionnaire. Jama. Nov 10 1999;282(18):1737-1744.
17.
Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity measure .
Psychiatr Ann. 2002;32:509-521.
18.
Lowe B, Grafe K, Zipfel S, et al. Detecting panic disorder in medical and psychosomatic
outpatients: comparative validation of the Hospital Anxiety and Depression Scale, the
Patient Health Questionnaire, a screening question, and physicians' diagnosis. J
Psychosom Res. Dec 2003;55(6):515-519.
19.
Prins A, Ouimette P, Kimerling R, et al. The primary care PTSD screen (PC-PTSD):
development and operating characteristics. Primary Care Psychiatry. 2003 ;9(1 ):9-14.
20.
Saunders JB, Aasland OG, Babor TF, de Ia Fuente JR, Grant M. Development of the
Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on
Early Detection of Persons with Ha.rmful Alcohol Consuntption--11. Addiction. Jun
1993;88(6):791-804.
21.
King DW, King LA, Vogt DS. Manual for the Deployment Risk and Resilience Inventory
(DRRI): A Collection of Measures for Studying Deployment-Related Experiences of
Military Veterans 2003, Boston.
22.
Spitzer RL, Williams JB, Kroenke K, et al. Utility of a new procedure for diagnosing
mental disorders in primary care. The PRIME-MD 1000 study. Jama. Dec 14
1994;272(22):1749-1756.
23.
Spitzer RL, Williams JB, Kroenke K, Hornyak R, McMurray J. Validity and utility of the
PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic
19
patients: the PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study. Am
J Obstet Gynecol. Sep 2000;183(3):759-769.

24.
Fann JR, Bombardier CH, Dikmen S, et al. Validity of the Patient Health Questionnaire-9
in assessing depression following traumatic brain injury. J Head Trauma Rehabil. NovDec 2005;20(6):501-511.
25.
Means-Christensen AJ, Amau RC, Tonidandel AM, Bramson R, Meagher MW . An

efficient method of identifying major depression and panic disorder in primary care. J
Behav Med. Dec 2005;28(6):565-572.
26.
Maisto SA, Carey MP, Carey KB, Gordon CM, Gleason JR. Use of the ALTDIT and the
DAST-10 to identify alcohol and drug use disorders a:rnong adults with a severe and
'
persistent mental illness. Psychol Assess. Jun 2000;12(2):186-192.

27.
Bradley KA, Bush KR, McDonell MB, Malone T, Fihn SD. Screening for problem
drinking: comparison of CAGE and AUDIT. Ambulatory Care Quality Improvement
Project (ACQUIP). Alcohol Use Disorders Identification Test. J Gen Intern Med. Jun
1998;13(6):379-388.
28.
Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol
consumption questions (AUDIT-C): an effective brief screening test for problem
drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use
Disorders Identification Test.ArchlnternMed. Sep 141998;158(16):1789-1795.
29.
Cherpitel CJ. Comparison of screening instruments for alcohol problems between black
and white emergency room patients from two regions of the country. Alcohol Clin Exp
Res. Nov 1997;21(8):1391-1397.
20
30.
Reinert DF, Allen JP. The Alcohol Use Disorders Identification Test (AUDIT): a review
of recent research. Alcohol Clin Exp Res. Feb 2002;26(2):272-279~
31.
Daeppen JB, Yersin B, Landry U, Pecoud A, Decrey H. Reliability and validity of the
Alcohol Use Disorders Identification Test (AUDIT) imbedded within a general health
risk screening questionnaire: results of a survey in 332 primary care patients. Alcohol
Clin Exp Res. May 2000;24(5):659-665.

32.
Bliese P, Wright K, Adler A, Thomas J. Validation of the 90 to 120 day short form
psychological screen (Research Report 2004-002). Heidelberg, Germany: US Army

Medical Research Unit Europe; 2004.
21
Table 1. Demographics Characteristics by Nuntber of Deployments
N~mber
Agea
Sex
of Deploytnents
2
n
(Mean)
%
(SD)
(27.42)
2627
207
(5.84)
92.7
7.3
n
(Mean)
(29.08)
600
61
%
(SD)
Male
Female
Race/Ethnicity American Indian
or Alaskan
2.6
22
73
Native
4.3
28
Asian
122
Pacific Islander
92
3.2
28
Black
324
11.4
85
11.9
Hispanic
337
66
1925
434
White
67.9
Other
3.0
25
86
1243
43.9
Rank
El-E4
164
1228
424
E5-E9
43.3
329
11.6
57
Officer
34
1.2
16
Warrant Officer
Some High
Education
3.5
18
100
School
High School
218
982
34.7
Graduate
Some College
1141
40.3
305
but No Degree
Associates
162
5.7
41
Degree
College Graduate
(Bachelor's
12.7
64
360
Degree)
Postgraduate or
3.1
15
Professional
89
Degree
979
34.5
155
Marital Status
Never married
1594
56.2
403
Married
4.4
Separated
125
35
135
4.8
68
Divorced
<1
0
Widowed
1
Note: For Race/Ethnic Status, Soldiers were asked to select all that applied
a Means and SDs are presented
(5.91)
90.8
9.2
p
<.001
.09
3.3
.28
4.2
4.2
12.9
10.0
65.7
3.8
24.8
64.1
8.6
2.4
.94
2.7
.21
.30
.17
.26
.32
<.001
.041
33.0
46.1
6.2
9.7
2.3
23.4
<.001
61.0
5.3
10.3
0
22
Table 2. Combat Exposure During First and Second OIF Deployments
NuJ!lber of Deployments
n
416
%
14.7
69
10.4
.005
Witnessed
Killing
1441
50.8
183
27.7
<.001
Saw Dead
Bodies
2028
71.6
338
51.1
<.001
Killed
Others
1064
37.5
101
15.3
<.001
Wounded
or Injured
23
Table 3. Mental Health Screening Results by Number of Iraq Deployments
Number of Deployments
1
2
No. Pos./n
No. Pos.ln
Crude OR (95% Cl) At!Justed ORa (95% C/)
Major
Depression
114/2772
4.1
30/651
%
4.6
Other
Depression
119/2772
4.3
40/651
6.1
1.46* (1.01, 2.11)
1.73* (1.17, 2.57)
PTSD-2
580/2803
20.7
137/653
21.0
1.02 (.83, 1.26)
1.64** (1.30, 2.08)
PTSD-3
322/2803
11.5
85/653
13.0
1.15 (.89, 1.49)
1.90** (1.43, 2.52)
Panic
56/2817
2.0
17/660
2.6
1.30 (.75, 2.26)
1.85* (1.03, 3.33)
Other
Anxiety
250/2823
8.9
75/660
11.4
1. 32 * ( 1. 004' 1. 73)
1. 71 ** ( 1.27' 2. 30)
ETOH
408/2808
14.5
85/657
12.9
.87(_68, 1.12)
1.27(.97, 1.68)
1.13 (.75, 1.70)
. 1.70* (1.09, 2.65)
* p<.05, **p<.OOl
Note: OR= Odds Ratio; No. Pos. =Number that Screened Positive; PTSD-2 = Results from the
PC-PTSD using a cutoff score of 2; PTSD-3 =Results from the PC-PTSD using a cutoff score of
3. Denominators differ because subjects did not answer every question. Subjects with missing
data did not differ from the rest of the sample in terms of Age, Sex, Race/Ethnicity, Rank,
Education, Marital Status, percent who had Combat Injuries, percent who Saw Dead Bodies, or
percent who reported Killing Others. A higher proportion of subjects with missing data reported
Seeing Dead Bodies.
a Adjusted for Age, Sex, Education, Racial/Ethnic Background, Rank, Marital Status, Combat
Exposure
DEPART~JE~T
II 1::~\DQt;,\RTF.RS.
01--- THE .-\R~I\'
STA"f[S .\R,I\~ )lf:DJC..\1.. COlll\l.r\ND

20~0 \\.ORTII R0,\0
FORT SAll HOt ~sTO~. TX 78234~000
REPLY TO
.-\11 ~-sno~
l:~ITED
o.-
13 MAR 2009
MCHO-CL
Expires 13 March 2011
MEMORANDUM FOR Commanders, MEDCOM Regional Medical Commands

SUBJECT: MEDCOM Procedures for Chapter 5. paragraph 5-13 and 5-17 Personality
Disorder (PD) Separations
1. References.
a. Department of Defense Instruction (DoDI) 1332.14, ~Enlisted Administrative
Separations''. Aug 08.
b. Anny Regulation (AR) 635-200, Active Duty Enlisted Administrative Separations,
6 Jun 05.
c. OTSG/MEDCOM Policy 08-018~ Screening for Post-Traumatic Stress Disorder
(PTSD) and mild Traumatic Brain Injury (mTBI) Prior to Administrative Separations! 19 May
08.
d. MEDCOM memorandum MCCG, Review of Personality Disorder (Chapter 5,
paragraph 5-13) Administrative Separations! 6 Aug 07.
2. Purpose. To outline new PD procedures under reference 1b., Chapter 5, paragraph 513 and 5-17.
3. Proponent. The proponent for this policy is the Director, Behavioral Health Proponency!
Office of The Surgeon General (OTSG). ATTN: DASG-HSZ.
4. Responsibilities.
and implementing the Army Medical Department's behavioral healthcare screening
requirements.
b. rhe Directorate of Health Policy and Services. Proponency Office for Behaviors'
Health. is responsible for the distribution of behavioral health policies and reviewing,
revising, updating, and deleting existing policies conflicting with these requirements.
MCHO-CL
SUBJECT: MEDCOM Procedures for Chapter 5, paragraph 5-13 and 5-17 Personality
Disorder (PO) Separations
c. MedicaJ treatment facility (MTF) Commanders will ensure that all Soldiers who are
referred for PO separations follow the procedures outlined below.
5. Discussion.
a. There has been concern that Soldiers with undiagnosed or untreated PTSO or mTBI
are administratively discharged from the Army. MEDCOM has previously issued two
policies addressing PO and screening for PTSO and mTBI (references 1c. and 1d.).
b. Reference 1a. outlines updated requirements. These requirements are similar but not
identical to the policy changes that the Army issued. This policy memorandum consolidates
the different requirements.
c. This guidance refers to Soldiers who receive mental health evaluations from behaviora'
health clinicians for Chapter 5, paragraph 5-13 and 5-17 PO administrative separations.
6. Policy.
a. DoDI1332.14, enclosure 3. paragraph 3a(8), Enristed Administrative Separations,
prescribes the following requirements for separations on the basis of enlisted Soldiers who
have served or are currently serving in imminent danger pay areas:
(1) A Psychiatrist or Ph0-1evel Psychologist must diagnose the PD.

(2) A peer or higher-level mental health professional must corroborate the diagnosis.
(3) The Army Surgeon General must endorse the diagnosis.
(4) The diagnosis must address PTSO or other co-morbid mental illness, if present.
b. For Chapter 5, paragraph 5-13, PO evaluations:
(1) In the case of Soldiers who have served or are currently serving in an imminent
danger pay area and are within the first 24 months of active duty service, the MTF Chief of
Behavioral Health (or an equivalent official) must first corroborate the diagnosis of PO for
separation under AR 635-200, Chapter 5, paragraph 5-13.
(2) The corroborated diagnosis will be forwarded for final review and confirmation by
the Director. Proponency of Behavioral Health. OTSG (OASG-HSZ).
(3) Medical review of the PO diagnosis will consider whether PTSD and/or mTBI
may be significant contributing factors to the diagnosis.
2
MCHO-CL
SUBJECT: MEDCOM Procedures for Chapter 5, paragraph 5-13 and 5-17 Personality
Disorder (PO) Separations
(4) A Soldier will not be processed for administrative separation under

AR 635-200, Chapter 5. paragraph 5-13~ if PTSD~ mTBI~ or other co-morbid mental illness
are significant contributing factors to a diagnosis of PD. but will be evaluated under the
physical disability system in accordance with AR 635-40.
c. For Chapter 5, paragraph 5-17 PO evaluations:
(1) In the case of Soldiers who have served or are currently serving in an imminent
danger pay area and have 24 months or more of active duty service, the MTF Chief of
Behavioral Health (or an equivalent official) must corroborate the diagnosis of PO for
separation under AR 635-200. Chapter 5, paragraph 5-17.
(2) The corroborated diagnosis will be forwarded for final review and confirmation by
the Director, Proponency of Behavioral Health.
(3) Medical review of the PO diagnosis will consider whether PTSD and/or mTBI. or
other co-morbid mental illness diagnosis may be significant contributing factors to the
diagnosis.
(4) A Soldier will not be processed for administrative separation under AR 635-200,
Chapter 5t paragraph 5-17, if PTSD or mTBI are significant contributing factors to a
diagnosis of PD~ but will be evaluated under the physical disability system in accordance with
AR 635-40.
7. Our point of contact is (b)(
Director. Proponency of Behavioral Health,
OTSG. The corroborated diagnosis. with aH supporting medical documentation, will be

forwarded for final review and endorsement to the OTSG (DASG-HSZ), 5109 Leesburg Pike,
Suite 693. Falls Church! Virginia 22041-3258.
FOR THE COMMANDER:
'
...... ERBERT A. COLEY
Chief of Staff
3
DEPARTl\IE~"T OF
TilE ARI\IY
HEADQUARTERS. UNITED STATES AR:\IY :\IEDJCAL COI\-11\IAND

1050 \\.ORTH ROAD
FORT SA:\I HOUSTON. TX 78134-6000
REPLY TO
ATTENTION OF

MCCS
22 JUL2009
Expires 22 July 2011
MEMORANDUM FOR Commanders. MEDCOM Regional Medical Commands

SUBJECT: Guidance for Administrative Separation for Personality Disorder (PO) or Other
Behavioral Conditions
1. References:
a. Memorandum. HQ. USAMEDCOM, MCCG, 6 Aug 07, subject: Review of PO
(Chapter 5-13) Administrative Separations.
b. Memorandum, HQ, 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
PO 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 Suiclde 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 concerns 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 517 Personality Disorder (PO) Separations.
MCCS
SUBJECT: Guidance for Administrative Separation for Personality Disorder (PO) 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 PO (reference a), and screening for
PTSD and rsr 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 PO 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 DoDI 1332.14. The changes limit separation under Chapter 5-13 to
Soldiers with less than 2 years time in-service, but added PO 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 PO 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 additionaJ guidance for
separation for PO:
a. The onset of PO 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 PO 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 PO is not authorized if servicerelated PTSD is also diagnosed.
5. Requests for OTSG endorsement of the diagnosis of PO 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 (PO) 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 w'ith 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:
'~
RBERT A. CO EY
Chief of Staff
3
DEPARTl\IEl\"T OF THE Alt\'IY

HEADQUARTERS, UNITED STATES ~\IY ftIEDICAL COl\f;\IANU
2050 \\'ORTH ROAD
FORT S~'\1 HOUSTON, TX 78134-6000
REPLY TO
AITENTION OF
OTSG/MEDCOM Policy Memo 10-04-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 Adrrrinistrative 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 mTBI screening of all So,diers
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 whUe 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:
and implementing the MEDCOM's behavioral healthcare and mTBI screening
requirements.
This policy memo supersedes OTSG/MEDCOM Policy Memo 08-018, 19 May 08, subject: Screening for PostTraumatic Stress Disorder (PTSD) and mild Traumatic Brain Injury (mTBI) Prior to Administrative Separations.
MCCG
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
w'ith 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 mTBI, in accordance with
Army Regulation 635-200. the 2010 National Defense Authorjzatjon 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. rhe Primary Care-PostTraumatic 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
pttps://www.us.ar,ny.rnil/suite/oage/222.
c. These screening tools are not diagnostic. A positive screen will require a
comprehensive evaiuation 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
mild Traumatic Brain Injury (mTBI) for Administrative Separations of Soldiers
may be performed by a physician. clinical psychologist, psychiatrist, or other healthcare
professions'. 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 PTSD or
mTBI, 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 djagnosed 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 wUI be provided to the commander for inclusion in
the separation documentation and personnel files before separation proceedings can
occur.
ERIC B. SCHOOMAKER
Lieutenant General
The Surgeon General and
Commanding General, USAMEDCOM
3 Encls
1. Primary Care - PTSD
2. TBI Screening Questions
from PDHA, 002796
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.t Sheikh. J. I. (2004). The primary care PTSD screen (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.)
(2) Vehicular accidenVcrash (any vehicle, including aircraft)
(3) Fragment wound or bullet wound above your shoulders
(4) Fall
(5) Other event (for example, a sports injury to your head).
Yes I No
Yes I No
Yes I No
Yes I No
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 1?
Lost consciousness or got "knocked out..

Felt dazed. confused, or "saw stars"
Didn't remerr1ber the event
Had a concussion
(5) Had a head injury
(1)
(2)
(3)
(4)
Yes I No
Yes I No
Yes I No
Yes I No
Yes I No
REPORT OF BEHAVIORAL HEALTH EVALUATION

For use of this form. see )0000(: The proponent asency '' MEDCOM. Release of t"ls InformatiOn to commanders or their deslanees s authorized tAW DoD 6025.1S.R and DoD Directive
6490.1 when In respons~ to a Command-Directed Mental Heahh Evaluation request or
a
of safety or fitness for duty exlsu.
NAME:
SSN:
REASON FOR EVALUATION
0 Self-Referral
D Command-Directed Mental Health Evaluation
D Hospital Discharge
D Other:
0
0
Advanced Training Application (Drill Instructor, Recruiter, etc)

Clearance for Admin Sep under AR 635-200, Chapter
0MMRB/MEB
FITNESS FOR DUTY

FROM A BEHAVIORAL HEALTH STANDPOINT, THE ABOVE SERVICE MEMBER IS DEEMED:
0 Fit for full duty, including deployment
Possibly non-deployable due to prescribed medications. Command surgeon waiver
is I
is not recommended
Requires temporary duty limitations and may benefit from behavioral health treatment
0 Unfit for duty due to a personality disorder or other mental condition that does not amount to a medical disability
Unfit for duty due to a serious mental condition that is not likely to resolve within 1 year
Further assessment is needed to determine fitness for duty
D
D
D
D
PERTINENT FINDINGS ON MENTAL STATUS EXAMINATION
0 No obvious impairments 0 Mildly impaired 0 Moderately impaired 0 Severely impaired

D Cooperative 0 Uncooperative 0 Manipulative 0 Hostile 0 Suspicious 0 Bizarre
PERCEPTI
: 0 Normal 0 Hallucinations 0 Delusions 0 Obsessions
IMPULSIVITY: 0 Unlikely to be impulsive 0 Occasionally impulsive 0 Frequently impulsive
SN
0 None 0 Suicidal Thoughts 0 Homicidal Thoughts 0 Suicidal Intent D Homicidal Intent
COGNITION:
---.....,,;;;,o,; .,...:
IMPRESSIONS
IN MY OPINION, THIS SERVICE MEMBER:
Can understand and participate in administrative proceedings
Can appreciate the difference between right and wrong
Meets medical retention requirements (i.e. does not qualify for a Medical Evaluation Board)
Requires further examination or testing to finalize diagnosis and recommendations
0 Other: _
D
0
D
0
DIAGNOSES (ONLY THOSE REQUIRED FOR ADMINISTRATIVE PROCESSING)

AXIS I (psychiatric conditions):
AXIS IJ (personality & intelligence disorders):
AXIS Ill (medical conditions):
PROPOSED TREATMENTS
0None
Follow-up appointments:
Clinic:
Phone No:
Clinic:
Phone No:
Clinic:
Phone No:
Recommend command referral
0
0
Location:
Date:
Location:
Date:
Location:
Date:
to:
Unit Chaplain
Time:
Time:
Time:
ASAP
FAP
JAG
ACS
Other:
Date
ErLc,/
RECOMMENDED PRECAUTIONS
(to be followed until no ronser deemed necessary by a behavioral health provider)
0None
Ensure the service member attends all follow-up appointments
0 Assigned duties should be relatively low-stress and 0 should not involve leadership responsibilities
per day and the service member should have
day(s) off per week.
0 Work hours should not exceed
Inspect the service member's quarters and secure all hazardous items (e.g. pills, knives, razors, weapons, etc.)
Prohibit the use of alcohol, as alcohol is a depressant and may decrease inhibitions.
Restrict access to or disarm all weapons and ammunition (including those that are privately owned)
Move the service member into the barracks
0 Secure all medications and dispense no more than
days' worth at a time
Prohibit contact between the service member and
to prevent harm to self or other individual.
0 Provide increased supervision (i.e. have someone check in with service member at least daily) or....
0 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...
0 Provide continuous 24/7 monitoring (e.g. to prevent self-injurious behavior, harm to others, substance use, etc.)
0 Other:
D
0
D
0
0
ADDITIONAL COMMENTS
A Temporary Profile with an "S'' rating of
0
0
The service member is psychiatrically cleared for any administrative action deemed appropriate by command.
The service member meets psychiatric criteria for expeditious administrative separation lAW
Chapter 5-13 or
Chapter 5-17 of AR 635-200 (or equivalent regulation from his/her branch of service).
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.
The service member has a condition that is likely to impair his/her judgment or reliability as related to access to
classified materials.
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.
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).
The service member has been screened for Post Traumatic Stress Disorder and Traumatic Brain rnjury. 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.
If the service member shows signs of further deterioration, command should call
hours, they should escort the service member to the nearest Emergency Department.
Other:
is hereby activated, to expire
The service member may participate in PT as allowed by physical profile, as exercise often improves mood.
during duty hours. After
Date
CLINI
ForP
EDUCATION
ECOMPO NT MODEL
AGEME
of DEP SSION and PTSD
(Military Version)
.
.
....
...
.,.
Copyright C May 2006 3CMTN, LLC- Version 3.0

By Thomas E. Oxman MD, Dartmouth Medical School
With contributions from, Allen J. Dietrich MD, Jolm. W. Williams, Jr. MD; Cbarles C. Engel. MD, MPH, Mathew Frledsnan, MD, PbD,
Paula Schnurr, PhD, Stanley Rosenberg. PhD
Project Director: Sheila L. Barry
This manual is intended to provide helpfol 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 climcal advice for or about specific patients. Before applying any ofthis ir(o1mation
or drawing any inferences from it, care managers should verify accuracy and applicability of the in/ol'lnation and the appropriateness of
protocol strategies within their particular clinical settings. Any management steps token with patients should include a discussion of risks and
benefits as well as patient preferences. By accessing the information in this manual, you agree that 3CMfM, ILC; Dartmouth College; Duke
University; Duke University Health System, Inc.; Private Diagnostic Clime, PUC; the John D. and Catherine T. MacArthur Foundation; any
participant in the Initiative on Depression and Primary Care; and the contributors of irifonnation to this manual shall not be liable to you for
any damages, losses or irgury caused by the use of any infolmation in this manual.
I. ltltJroclll<;tioll ....................................................................................................................................... ~
II. Co11ceptu.al Framework for RESPECT-MIL.................................................................................... . 4
Departme11t of Defe11se Clinical Practice G11icleli11es ........................................................................ 4
Systematic Approaches to Improving Care ...................................................................................... . 4
RESPECT-MIL.---The Three Compone11ts ...................................................................................... . 4
The RESPECT-MIL Process of Care ................................................................................................ ~
The RESPECT-MIL Process of Chat1ge ........................................................................................... 7
III. RESPECT-MIL Protocol for Depressio11 ............................................................................... 9
STEP 1: ~eco~ition flllcl Dia~osis ................................................................................................ 9
P1tl~-9 ........................................................................................................................................... 9
Assess S11icicle ~isk .................................................................................................................... I2
Collcl11ct a S11icicle Assessment ............................................................................................... I~
Compo11e11ts of an Eval11ation for S11iciclal Risk..................................................................... 1~
S11icicle Screeni11g Tools for Primary Care Clinicia11s ............................................................ 14
STEP 2: Treatment Selectio11......................................................................................................... 1~
<=>l>taill Aclclitio11al ~istory .......................................................................................................... I~
Use PH~-9 ~es11lts to Help Detern1i11e Treatment Selection ..................................................... 1~
Present Treatment <=>ptions ......................................................................................................... 16
Elicit Patie11t Prefere11ce for Treatme11t ...................................................................................... 16
Choosi11g Psychological Co1IDseli11g ...................................................................................... 16
Choosing Meclicatio11 ............................................................................................................. . 17
.
.
.
T
STEP~: I11tttcttt11g reatme11t ........................................................................................................ . 20
Patie11t Engageme11t ................................................................................................................... . 20
Provicle ~ey Ecl11cational Messages ........................................................................................... . 20
Enco\llrage a Self-Manageme11t Pla11 .......................................................................................... . 20
E)(}llaill Clllcl ~ecomme11<l Care Mat1ageme11t ............................................................................. 22
STEP 4: Care Ma11ageme11t Calls for Adhere11ce an<I Treatme11t ~espo11se ................................... 2~
Adherence Call at I ~eek .......................................................................................................... 2~
<=>ptional Telephone Co11tacts l>etween 1 an<l4 ~eeks: A<l<litio11al Adherence Call(s) ............. 2~
Treatme11t ~espo11se Calls Every 4 ~eeks .................................................................................. 2~
Care Ma11ageme11t Stlpei1fision ................................................................................................... 2~
Commllflication with ~m(l[){ Care Cli11ici<lll ........................................................................ 2~
Usi11g the P~~-9 to Assess Patient ~espo11se to Treatme11t. .................................................. 26
A11ti<lepressallt Si<le Effects .................................................................................................... 27
STEP ~: Ac11te Phase Follow-Up .................................................................................................. 29
Cli11iciat1 <=>ffice Visits Coor<linate<l with Care Manageme11t Co11tacts ...................................... 29
Eval11ate Patient ~espo11se to Treattne11t ................................................................................ 29
Mo<lify Treatme11t with S11b-<:>ptimal ~espo11se ..................................................................... 29
StJrive for ~emission ............................................................................................................... 29
STEP 6: Colltin11atio11 a11<l Mai11tenance Phase Treatme11t ............................................................ ~ 1
Co11tin11e Treatment ~espo11se Mo11itoring After ~emissio11 ..................................................... 3I
Contin11e S11ccessful Treatme11t for Ni11e to Twelve Mo11ths .................................................... ~ 1
1\l.leclicCLti()ns ............................................................................................................................. ~1
Psychological Co1IDseli11g ...................................................................................................... ~I
Assess ~isk Fact()rs for Nee<l for Lo11g-Tenn Prophylactic Treatment ..................................... ~~
Co11tin11e Lo11g-Term Prophylactic Treatment an<l Mo11itoring of At-~isk Patie11ts .................. ~~
IV. RESPECT-MIL Protocol for Post-Traumatic Stress Disorder o 33

STEP 1: Recognition an.d Diagnosis ..............
33
Four Components for PTSD Diagnosis ...................................................................................... 33
35
PTSD Checklist (PCL) ..........................
Assess Suicide Risk ..
37
38
Assess Suicide Risk ....................................................
Conduct a Suicide Assessment .................. o ................
39
STEP 2: Treatment Selection.......................................................................................................... 40
Present Trea1Jr.rlent <=>J>tions ......................................................................................................... 40
Elicit Patient Preference for Trea1Jr.rlent ..................................................................................... 40
Choosing Psychological Counseling ............
40
Choosing 1\l.ledication .............................................................................................................. 41
Trea1Jr.rlent Selection for Patients with Comorbid Depression ................................................ 41
STEP 3 Initiating Trea1Jr.rlent ........................................................................................................... 42
Est(tblishing RaJ>J>Ort ........
42
Provide Key EducationalJ\I.lessages............................................................................................ 42
Encourage a SelfJ\I.lan.agement Pl~o 42
EJ(J>lain an.d JRlecommend Care 1\l.lan.agement ............................................................................. 42
STEP 4: Care 1\l.lanagement Calls for Adherence and Trea1Jr.rlent Response ................................... 42
Using the PCL to Assess Patient ResJ>onse to Trea1Jr.rlent. .......................................................... 42
STEP 5: Acute Phase Follow-UJ> .................................................................................................. 46
Clinician. <:>ffice Visits Coordinated with Care Management Cont(tcts ...................................... 46
46
Evaluate Patient Response to Trea1Jr.rlent .
Modify Trea1Jr.rlent with Sub-OJ>timal ResJ>onse ..................................................................... 46
Strive Jtor Remission ............................................................................................................... 46
STEP 6: Continuation an.d 1\l.laintenan.ce Phase Trea1Jr.rlent ............................................................ 48
Continue Trea1Jr.rlent ResJ>onse 1\l.lonitoring After Remission ..................................................... 48
Continue Successful Trea1Jr.rlent for Nine to Twelve 1\l.lonths ..........................
49
Medicati<>ns............................................................................................................................. 49
0 0 0 0 0 0
0 0 0
0 ...........................................................................................
0 0
Assess Risk Factors for Need for Long-Tenn ProJ>hylactic Trea1Jr.rlent ..................................... 49
Continue Long-Tern1 Prophylactic Trea1Jr.rlent and Monitoring of At-Risk Patients .................. 49
References ................................................................................................................................... 50
References ................................................................................................................................... 50
PJr.l~-9 ............................................................................................................................................. 50
PTSD <=Juidelines ................................................................................................................................. 50
PCL oooo 50
RESPECT-DeJ>ression and the Three ComJ>onent Model .............................................................. 50
PTSD Background .................................
51
PTSD Four ~uestion Screen ..........................
51
0 . . . . . . . . . . . . . . . . . . . . . . . . . 0 0 0
0 0 0
This manual is intended to provide helpful and informative materia/for 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 of this information
or drawing any inference from it, clinicians should verify accuracy and applicability ofthe Information. Any management steps token with patients should include a discussion
ofrisks and benefits, as well as patient preferences. DARTMOUJ'H COLLEGE, DUKE UNIVERSITY; DUKE UN/JIERSITY HEALTH SYSTEM, INC; 3CAfrM UC, 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 11S SU/TABIUTY 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 ofVA/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 confirn1s 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 conununicated 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 traun1atic 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 (3CM) 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-MilA 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 inforrnal 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

Com
~onents
Primary care clinician and

prepared practice
Care manager
Psychiatrist
Res aons:ibilities
Recognition
Diagnosis
Mana_gement
Support
Monitoring
Communication
Infomtal 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 I 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 fourquestion 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
7
~
Monitoring
Response
Modify to
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 counseling, 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

Ste~s
Screen
Diagnostic
Evaluation
Engagement
Management
PTSD
MDD
2 ~;Juestions
Interview
PHQ-9
Suicide/violence assessment
Discuss diagnosis and
treatment o 'tions
Medications/counseling/both
Self management
Care management
Behavioral health clinician
advice/su J JOrt
4 C:uestions
Interview
PCL
Suicide/violence assessment
Discuss diagnosis and treatment
options
Medications/counseling/both
Self management
Care management
Behavioral health clinician
advice/su J Jort
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

Develop New Resources
Mental
Health
Consultant
Care Managers
Communication
Methods
~--------~--------~
Prepare Practices
.....---.. ..a::::-----.
Clinician
CME
Staff
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 N, 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 of the PHQ-9 is attached)
PHQ-9
The PHQ-9 is administered to all Soldiers who answer ''yes" to either of the 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-N).
The next few pages will explain how to score and use the PHQ-9.
Figure 4: Patient Health Questionnaire (PHQ-9)

PA'fiENT BF.AL1B QUESTIONNAIRE (PHQ-9)
Over the
how otten have you been
by any or the following prol>lems?
(use u../ to indicate your answer)
1
Uttfe interest or pleasure in doing things
Feeling down,
3 Trouble falfing or staying asleep, or sleeping too much
or hopeless
Feeling tired or having little energy
5 Poor appetite or overeating

6
have let
as
Moving or speaking so slowly that other people could have

8 noticed. Or the opposite - being so fidgety or restless that you
have been
around a
3
3
0
or
lot more than usual
n some
add columnet
TOTAL:[~--~-~-~~-~~-~------~~
Not difficult at all
If you checked off any problem.s. how difficult have these
10 problems made It tor you to do your w011<, take care or
things at home, or get along with other people?
Somewhat difficult
Very difficult
Extremely difficult
"'
First, tl1e number-of 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 l\'IDD Diagnosis Example 1

PATIENT UEALl'H
. .
f1
- J . .1..
:~.
..
UESTIONNAIRE (PHQ-9)
. ..
..
. .
..
. ....
. ...
. . . ...
N.eBd one .or both. (Jfthe firSt two Qllf18lions ... . .

Over the
endorsed as "2"ar.~3"PMorethiJIJ.htJJfthedays"
by any of the orHNea.dyeveryday;
.
..
(use ".j'" to

.
..
..
. .
...
. ...
. .
:.
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Poor appetite or overeating
Feeling
have let
Trouble
.L----J.!-~~~
...
. .
...
..
. ..
....
..
..
..
. .
.. ... ..
. . . . .
torm
...
Moving
noticed.
have
Thoughts that you would be better off dead. or of hurting

yourself in some way
.
.
r-----r----
If you
1o problems . ..
things at
...
..
TOTAL:
....
.. ,...._ _
~~,~or~~~~~~ ~~~~~~.
----~-----
add columns:
. .
S,TEP3:
. .
Functionallmpainnent
is
endorsed
as
at.
.
. .
.
. .
. .
.
.
~somewhat difficult" or greater.
.
Need a total Of five or more boxes. el1dorsed

Within th9 shaded
area
of
th!J
to
arriVe.
at
.
.
.
.... .
. ------1---the total.sYitfptom Count for MctidtD&pte.ssion.
(tn this examplf1 six swptCHIJs) . . ... .
0
.
~.- - 1:~---------4[
----------------~
Very difficult
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 half the 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 sununing 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 Bf:AI4m QUESTIONNAIRE (PHQ-9)
...
..
Over the
how often have you been
by any of the following problems?
(use "tl''~~ to indicate your
..
. .
0
0
Feeling tired or haVing little energy
Feeling bad about yourself.- or that you are a failure or

have let
. or
down
Trouble concentrating on things, such as reading the
television
MoVing or speaking so sloWly that other people could have

noUced. Or the opposite - being so fidgety or restless that you
have been
around a lot more than usual
Thought~ that you would be better off dead, or of hurting
1n some
.
.
..
. . ..
.
. .
. ..
. .
... .. .
. .
. . .
.
.. .
3
3
Sum:tiJB :values tram the . three ..

COlumns to obt'llin a Total seventy .
.. ..
. .. .
add coturr.ns:
..
Feeling down. depressed. or hopetess
or
. .. . :,1..-.; . . . .. ... ... . .... .. . . .. .

~ urr'f!i8
""''tJmn
..
th. ~-
: \~~-.
. , 6>0fi~Jv.i,.
... ::.:: .:J(~ nnhf:
~-~:.: :.
..
~
IJ!ti,..,
,.;~,j,i,.if4n~j
~~m
~~~
m.~ch
>of
~ ~~ ~~
~~
~-
1 Utue interest or pleasure in doing things
-----
16
. . . ..
....
.
If you checked off any problems, how difficult have these

1o problems made it for you to do your work, take care of
things at home. or get along with other people?

Somewhat diffiCUlt
Very difficult
Extremely dlflicutt
The severity score is extremely useful for helping to detertnine 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 of an 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, conunand 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 cormnit 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 MAOis). 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. llave the$e aymptoms/feelings we'Ve been talld1w about led you to dUnk. you might be better oft deacl?
[] Yes
C No
2 This ppslWt;cL have you had any thoughts that life. is not worth liVing- Or that you~d be better off dead?
C Yes
D No
3. What about thoughts about hurting or even killing younelf.'1

C Yes -+ 00 to Que&tion 4
[JNo
4~
What-baveyqu ~bt ab.otlt? l,Iavey.ou 8Gtua)Jy ~n a.qydl~ tQ.b.~- yo1Mie1ft

C Yes
.
'IJ. No
Table 4: Assessment of Suicide Risk

DESCRIPTION OF
PATIENT SYMPTOMS
No current thoughts.
No major risk factors.
Current thoughts, but no plans.
With or without risk factors.
LEVEL OF RISK
ACTION
Low Risk
Continue follow-up visits and monitoring
Intermediate Risk
Assess suicide risk carefully at each

visit and contract with patient to call
you if suicide thoughts become more
prominent.
Consult with Mental Health

S oecialist 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
PH0-9 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

. . . . . .
. . .
. . . ....
5-9
Minimal symptoms *
Support, educate to call if worse;

retunt in 1 month
Minor depression++
Support, watchful waiting
10-14
Dysthymia*
Antidepressant or psychotherapy
Major depression, mild
15-19
Major depression, moderately

severe
>20
-
Major depression, severe
Antidepressant and psychotherapy
* Ifsymptoms present ~ two years, then probable chronic depression which wa"ants antidepressants or psychotherapy (ask,
uln 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 reconunended 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 any one 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
Tbtt"apeutic
.An~
Dose Ranee
depressant
. .
.:
. .
... .
...... . .
:
lnid1l Suggested Dost
:.
.. .
.:
. .
. :
......... mginmosning with

food (10 mg In el~ or
those with
. disorder).
Escitalopram
(Lexapto)
1\Uintain
mg for 4 '\\-eeb before dose
. .
. . . ... :
1-faintain 20 mg for U weeks and 30 mg for 2-4

weeks ~fore dose mcrease$. Inaease i.a. 10 mg
ina:enxnts at i.llten!3ls of 7 da'\--s.
., If significant
.
side ef&cn occur within 7 davs..
lo\\w dose or
~
change
so
20 mg ODC:e daily"!' usually

ia moming v.ith food
(lOmg meldedy and those
\\"ith cOGXDbid panic
<tisonler)
~{aiataiu 10 mg for
mc~ase.
before do~.
IOCftue In 10 q
at itnavals of
approximately 1 days up to a maximum of 50
mgiday_
. . ..
.
'
. .
. . . . ..
8'\"'li1,.ble. Less frequent

discOllliJmatioa. Sy.mplMlS.
cytoc:brome P450
interactions.
ofPTSD
FDAa~-.
...__
_,_,
. .
.
..
.
..
.
..~
:
.
OccasiOMily tDOte
. . .
hducesall~~pOGpSofPTSD
. . . . . . .
.
.
...... . .
. . . . . . . .
.
..
..
~ldMiy and lhose "'ith
SO mg once daily, nsuaUy

ia morning ~'ith foo4
2S- 200
(2Smgfor
..... . . .
. . : .:. . . .
R.ec1uces a three
ofPTSD
----------~------------------------~
Helpful for au:Uety
Slower to rracb $teady
Loag balf-life good for poor Mba~,
sta~, Sonxtimes too
missed doses.
$bmnlatiog. Possibly m.ore
..
.. .
. .. .
... .. .. .
2.5 mgdily (12.Smg in
(SO
in~dedy)
(Zoloft)
..: ..::...:.: ..
Increase to 20m.g it pauial respoase after 4
Redueft aU thrH
10- (40 iD
elderly)
62~5
. ..
s-e:nantioma snore pottnt thMl

10mg ~ 11SU811y efftcti\~ for most
weeb
2.S -
. ..
lOmg
inct-anents 4!\"en.
"' 7 da'\'S as tolerated.
~
20 mg iA mosning l'rlth
food (10 mg In elckdy ud
those '"itb c.UU1bid panic
disorder)
Probably
amaety disorders.
Possibly fe\\-er cytoc:luatDe P4 SO
mteractions. Generic soon.
~- Ifnotesponse~ iocreaseia
10 mg for escitalopmn
10-20
10-80
(Puil)
Disa~~ntages
.
Citalopram
(Celexa)
Paro~
Titration ScheclaJe
. ..
muease.
'
. ..
.
. .. . .
..
... .
.
....
. .
.:
...
.
. .
. . . ..
. ..: . .
...
.:
Few drug.
d}-~tioo
tS mg at hedOme (7.S mg
for 1hose in need of
sedation I hypaotic)
15 -4S
Increase in 1.5 mg
(7.5 mg i.a. elderly)
as tolftated. ),f.ainiain 30 mg: for 4 -a'ft'b. befme
further dose incftase
I eM !edatiaa a1 dote
~lay stimulate
Sedation at low dose ooly.

May ;.oiriaUy stimolate
appetite.
mcna\ed.
~lay reduce aD three syqxom groups of
PfSD
...
.. ..
.
.
. .. .
Bupropiont
(Wellbutrin
~
Wellbubitl
XL)
300-400
1SO mg in moming
.
.... .
... ..
. ..
.
. ..
Increase to lSO mg b.i.d.

7
Tnctease
to 200mg bid if insuflic:.ieot teSpODse after 4
weeks. 8 hours bet\\--eea doses aod in.itiaUy not at
beda. Witb hepati~. ~ 0111y 100 mgtotal
pefday.
. .. . .
...
. .
.
StmmJabna. Less or d.O sexual dvt.ibactioa

.
At
cbe, may indur,e:
sftz.ures io pt'BOllt wi1h
:May redoce aD three symptom groups of
seizure disorder.
Srinm1ating.
Uwally b.i.4. dosUJ&
ualess me
XL.
PISD
. .
.. ..
VenJaf.,Me
(Effexor~
75-375
Effe1mc XR)
~nut
Dose should be dh'ided b.i.d. or t.i.d. ualess XR..

For exteoded release (Xll) give 3 7.5 in a m thea
ioctease to 75 mg mam. after 1 wee~ 150 mg in
tbe am. li\er 2 w~. lfp;utial response after
font \\>-eeks iw.t-ease tc 225111! in tbe motning.
effect
OCC'U11i abo\~ 1
75 mg \\'irh food; if
anxious debilitated
37.5mg
.: . .
.
luau~ by 25 to
50 mg in the IDOioing
25-150
.
.
(Desyrl)
.. .
..
.
2 -10
..
.... ..
. :
.
. .
.. .. .
..
:
..
.. . .
. .
:. .
. .
..
. :'l,e::
as
:- :-:. w
:-: ...
. . .
... ...
... . .
.....
..
. . .
..
.. . . .
....
... . . . .. .
. dum
OJl
I jtr all TCAs'l'

aatidlolin~- Caution
witb BPH. Can ~xacerbate
~atdiae c;ondudian
problems or CHF.
ofPTSD
Availabilitv of
'\..tid blood
J.\!'@ls. I..o\\w Odhostatic bypoteasion
than otiB 1ricvd1~s.
Gft,.uie M~ilable.
,.,
I ikr all TCA.s.,.
aaticbo1iuftgic. Caution
witbBPH.
Probably reduees a\!oidancefmunbiag
ofPTSD
..
. . .. . . .. . .. ...
.
. . ..
25-600
. .....
.. ... .. .
....
. . . . .. .
. . . . .. . . . .. . .. . . .. .
... . . .
. ...
. .. .
.. .
..
. .. .
..
. ....
Pat1iallafl}" btlpfat for Digh1r..res
25 - SO mg at bedtinx
.
. .
. .
...
..
...
. ...
. .
..
IncreaR by 25 to SO mg e\"el)" S to 7 days.
. ..
. ..
. .
~ avoida""elaumbin! S)~tosn
IJK:tease by 1 to 2 mg q 4 to 7 days up to 6oag> as

tolented by blood Fesaue: tbrn add 4 mg in
lmgat
.A:~
Expemil~.
May reduce aU thret symptom groups of

PTSD
. . . . . . ....
e\"e!V S davs
,.,
"
-:...
A.llrM. .p:
Mav.. itoaeaw blocd

pressure at higher doses;.
Bid dosmg 11Diess use XR.
at\a:aoon
.. .. . .
..
. ...
. . ..
...
Truodcoe
XR ve:r$lon can be. lakea qd

Helpful. for anxiety disorders. Possibly
fewer
P450 islteractiou.
m;ailable.
tolerated to 7.Smg. Dosing too high may be

l.oef&cti\~. Obtain serum drug~~$ after 4 weeks
ifnot eft"ectilc"e".
25 mg (lOmg in bit
in the e\~ntog
. . ...
Plazosin
{MUiipress)
50 mg ~-elY 3 to 7 clays to
Jnae.ase in 10-25 mg :
. .
5ef'Oto--bn. less sedating.
initially target of 150mg fot 4 weeks.
Nortriptyline
(Al>'ellt)~
fdbitor
. . .
... .
More
..
100-JOO
(15-100 inel<llv)
'--: Ut"'IDA
...
.
.
rmpta.~W . n. .,,, ... ..... . . .
. SQ .. . .
. . .. .
. ... . .
..
. ...
..
..
. .. . . .:
. .
. ..
. . ....
.. . ...: .
. . . . .. . .
may cause
odhostatie hypotenci011
..
.
..
....
. ...
. . ... . ...
.
..
. .
... . .
.
...
.
. .
.
.. . .
Seclatmg, oo dependence risk
l.tay
At higiM:r dosa of ISO - 600 mg may lso

~ symptoms uorn aD dltee PI"SD
daytiDJesedaiion.,
patticulady at higher dost!l.
caute esceu
Rare
*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) ar~ not associated with congenital
malfonnations 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.
tGenerally 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. TCAs 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 impainnent.
19
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 conunon, 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
1
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 younelf feel better when you,re not rat your best. We s
1 you select
one activity here that you can staft oo. Remember to take it slowly at tint and add new dlilip as you begin to feel
1. Remaia physicaly active.
Make sure you make time to address your basic
physical needs. for aample, walking for a
certain amount of time each day.
Everyday next week, I will spend at least

it easy, reasonable) doing:
minutes .(make
l.Make time for pleuarable ac1ivitieL

Even though yoo ~ not feel as motNated, or get the same
amoont of pleasure as you used to, commit to scheduling some
fun activity each day maybe a favorite hobby.
4. Practice relaxing.
For many people, the changes that
come with depression can lead to
anxiety. Since physical relaxation can
lead to mental relaatiof\ practidng
relaxing is another way to help
yoorsel Try deep breathing, or take
a warm bath, or just f.nd a quiet,
cotnfottable, peaceful place and say
comforting things to yoorself(like c'lt'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 malteP

It's easy to feel overwhelmed when yoo"re
depressed. S01ne problems and decisions can be
delayed,.but others cannot. It can be hard to deal
with them when you,te feeling sad~ have little
energy and are not thinking as deady as usual.
Try breaking things down into small steps. Give
yoo rsel f credit for each step you accomplish.
The problern i s : - - - - - - - - - - - - - - - - ~ygoalis:
E1Jeryday next week, I will spend at least _ _ _ minutes (make

it easy, reasonable) doing:
___________________________________
Step 1: --------------------------------Step2:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Step 3:
3. Spead time 'With people who cao upport

you.
It's easy to avoid contact with people when yoo~re
down or not at yoor best, but you need the suppott
of friends and family. Explain to them what you
are experiencing, ifyou can. If you can't talk about
it, that's ok~. Just asking thern to be with yoo,
maybe during one of yoor activities, is a good 6rst
step.
During the next week, I will make con tact for at least _ __
.minutes (make it easy, reasonable) with (name) doing/ talking
about
6. Eat aub'itio~UJ, balaaced meals

aad avoid alcohol
Alcohol. is a depressant and can add to feeling
down and alone. It can also intetfd:e with the
help yoo may receive fi:om antidepressant.
medication.
During the next week. I will impro1Je my diet by:

(example, drinking water or 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 I AHLTA including relevant
details as demonstrated in Figure 7.
Figure 7: Referral to Care Management

(CHCS II I AHLTA)
View Referral
Patient: Jones, John
FMP/SSN:xxxxxxxx
Pat SSN: xxxxxxxx
Sex/DOB/Age: 22 y
--------------------------~-----------,_
____ _._~----
Reason for Referral:

R.ES.P.ECT J.D # 0001.
22 yo male screened positive for depression with PH:Q9 results of 6 symptonts a.nd score of
16.
Pt. elected to start a tluoxetine 20 1ng and will be returning to clinic in 1 month.
Pt. selects swimming as a self management goal and will start at lx per week
Pt. agrees to care managenent/requests call.
Honte pho.ne # 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 confitms that
appointment was made and kept or there is an intention to keep.
If medication 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 I AHLTA 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

P~fiENT
OVer the
how often
by
of the following
(use ".'" to indicate your
HEALTH QUESTIONNAIRE (PBQ-9)

you been
1 Little Interest or pleasure ln doing things

2.
Feeling down, depressed9 or hOpeless
3 Trouble falling or staying asleep. or sleeping too much

4
Poor appetite or overeaUng
Feeling bad about yourself- or that you are a -railure or

have let
or
down
Trouble concentrating on things, such as reading the
orwatchi teleVision

noticed. Or the opposite - being so fidgety or restless that you
have been
Thoughts that you would be better otr dead. or of hurting
in some
add columns:
TOTAL:
10
rt you checked off any problems, how difficult have these

problems made it for you to do your wort. take care of
things at home. or get along with other people?
l~o--:_:::---~--~_ ______.!
Not difficult at an
somewhat difficult
Very difticun
Extremely dimcult
Figure 9: Care Manager Report to Clinician

(CHCS II I AHLTA)
MailM.an rnessage .for: GRIFFIN, CH:R.ISTOPHER

Subj: JONES, JOHN
-XIX-
-Telephone Consult
From: POSTMASTER (Sender: R.ESP.ECT CARE J\IANAGE.R)

____
____ .. __ _
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 swinuning lx per week and has
completed his goal each week. He has increased goal for next month to 2x per week.
P"HQ-9 re-adrninistered over phone this date (week 4 of Tx). Score is no\v 14 (0 on suicide
question). Minirnal decrease in score or syrnptorns. Pt reports nausea but willing to
continue .Rx. Advised to take Rx \Vith food.
Dr. Gould suggests increasing dose to 40 mg at this time and monitorittg nausea.
Cl\1 \Viii call agai.n in one week to ntonitor.
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

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

PHf)-9
Score
J----------
Treatment Res ~onse
Treatment Plan
------~------------~~--~--------~
Drop of~ 5 points from baseline
Adecuate
Dro J of 2-4 Joints from baseline
Probably Inadec uate
.Drop of 1 point or no change or
Increase
Inadequate
No treatment change needed. Follow-up in

four weeks.
Often warrants an increase in
antidepressant dose.
Increase dose;
Augmentation;
Switch;
Informal or fonnal psychiatric
consultation;
Add psychological counseling (especially
if not imlroved with monotherapy'
..
..
Initial Response to PsychologicalCotlnselirtg After Three Sessions overFo11.rto;SiX .Weeks

......
..
.. ..
Treatment Res ~onse

Drop of~ 5 points frotn baseline
Drop of 2-4 points from baseline
Drop of 1 point or no change or
Increase
Adecuate
Probably Inadequate
Inadequate
. . .. ..
..
..
. . ....
. .
....
..
. . . .. .
. ..
. ...
.
..
.
. . ..
.. ..
. ...
... .
. ..
Treatment Plan
No treatment change needed. Follow-up in
four weeks.
Possibly no treatment change needed.
Share PHQ-9 with psychological
counselor.
If depression- specific psychological
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 lreferences.
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

. .. .
.
. : ..: .::.:::.... . . ~ ~-.
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.
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. . .
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,...:: .:. :.
...: ::_:_;:.:::~......
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:. :.:. .......:.:<~...... . :::. . : ;._. :_ :.: -.: : .:..~.:~~l.;_~;..l.
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i. ... .. :: . . ... : ..~ ... .: ~.
.
.
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:.
. .
Sedation
+i-
~vemedieation
at. bedtime.
. .
.
Anticholinergic
+f..
I~ase bydnllioo.
*Jocrease mirtazapme dose~

*Try caffeine.
*S~garl.ess
like symptoms
"untJcandy
otetary t'i~.
$.An~ tkial teel$..

*Consid switdling ntedication.
Dry lltQUl,laleytffl,
Cotmtpntion,
Llrinfll}' retention~
frachvL"ardili
....
OJ distress~
++
Restles..4U'less,
++
.>
Jittersrrremors
Headache
. :,
..
.:.
...
.. .
::: .
..
. ..
. : .
.. .
. . ";
Jnsouuua
'
.
-~~.
*Ofte.Dimprovd5 in 1-2wee.ks~
Tuke'with me-c~ls.
*Consider antacids or H2
blockers.
Start with sma1 1doses, cspeciaU y

with anxiety disorder.
*Reduce dose temponrily.
Add beta blocker (propranolol
10~20 mg tid/tid,
consider sbort trial of
benzodiazepine.
*Lower dose.
*Acetaminophen.
"
..
-Trazodone 25..100 ntg po qbs
(can cause orthostatic
hypotension and priapism)

.,~ake tnewcation in A.M.
SexuaJ
++
Dvsft111cti
on
v
..
*May be part of dep1 ession or
...
meclicAI di~nnters
Decrease dose.
*Try adding bupropion 100 mg
qbs or bid.
Try adrung buspronc 10~20 mg
bidldd
*Try addi~ cyproheptadine 4 mg
Seizures
\Vei ght. gain
+fN
Agranulocytosis
,..
,.,_
..
+I~
+f.
++
1-2 hrs ore sex.

consider a 1ria1 of V
Discontinue
Exercise
*Diet
consider changing
medications
Monitor for signs of infection,

ftu. -like sym.ptoms
s
KEY:
- Very Mlike1y
+I Uncommon
+ Mild
checkWBC
++ 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

(CHCS II I AHLTA)
MailMan message for R.ESP.ECT C.A.RE MA.NAGER

Subj: JONES, JOHN XXIXXX-XIX-XXXX- Telephone Consult

From: .POST.M.i\STE.R (Sender: GRlFFI..N, CH. RIS)

~---~--~-------~---~-~------------------~-------~~--
l"e.Jephone Consultation
--------------------~--
.Provider's .Note:
S: 22 year old Soldier with depression. Initial treatment with tluoxetine 20mg resulting in minimal
improvement per .P.H.Q9 readntinistered by Care 1\'lanager. Spoke today with patient.
ll\'lP/.PLAN: Inadequate treatment response. \Viii increase tluoxetine to 40 mg.
.Request Ca.re 1\rlanager ca.ll in 1 \Veek, verify pt increased .Rx..RTC 4 weeks.
Provider: GRIFFIN, CHRIS
Figure 10: Typical Frequency of Patient Contacts

"fii\JINC OF
PArrl:Nr CON1.AC1"S FllR. A "rYPICAI, CAs: OF DI~PR~:SSION

(I:NITI.AL EPISODE)
Clialebab Office Vitiils
C.are Manager
teutadl
..
A~ute
Phase
-~~---..---------~Treatmenr
i'IIHilb~
incr-~
A.
2.
....
---~~-~----~------------
..
#l
H:ee.k.s:... 0
-~~--.-.--
CoutiJtuation Phte
Treatmenr
iiJ
4
J
12
16
-'
24
6
32
8
36
9
l,IME.
'
Note. NCOA...f/EDIS Stenderds of Care lndude
clinician vlslta during lhe Acute Phllse 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
AcutePbase
Continuation Phase
Remission
Only20%
Have~ 3 Visits*
c
-
...
~
~
r.l)
e
.sc..
e
.S)mpiOIIIS
Sy11drome
Response
> 40%
...
..
'
''
Relllpse
Maiu~aance Phase
RecoJ.ery
'
''
''
\
'
''
Relapse
''
+
Stop Rx*
60% to70%
Stop Rx*
r.rJ
*JIEDLS 2002
Time
Adapted jro1n Kupfer, DJ. Long-tenn treatment of depression. J Clit1 Psyclaiarry, 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, PCL 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 recutTing 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 recu1rence of depression (i.e., diagnosis of chronic depressiondysthymia 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 phannacotherapy.
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 Ill, 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% oftrauttlatized men and 20% of
traumatized women go on to develop the disorder, PTSD, and roughly 30% of those who develop
PTSD develop a chronic fottn 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.
0
Soldier's response involved intense fear, helplessness or horror.
2. Symptoms in each of the following categories.
Re-experiencin& of event (at least one):
o Images, thoughts, perceptions

o Nightmares
o Flashbacks
o Reminders cause psychological distress
o Reminders cause physiological reaction
Avoidance of stimuli associated with the trauma and numbin& of general responsiveness (at
least three):
o
o
o
o
Avoid thoughts, feelings, conversations of trauma

Avoid activities, places, people that arouse recollections of trauma
Inability to recall aspects oftrautna
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
o
o
o
o
Insomnia
l11ritallilit){
Difficult){ concentrating
Hyper-vigilance
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 lle suffering from depression, may lle irritallle and angry, and concerned allout stigma llecause
of their reaction to trauma and the possillilizy of a psychiatric diagnosis. To aid with identification of
PTSD, a four-question screen is administered lly 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, horrillle, or upsetting
that, in the past month, you ...

1. Have had nightmares allout it or thought allout it when you did not want to?
YES
NO
2. Tried hard not to think allout it or went out of your way to avoid situations that reminded you
of it?
YES
NO
YES
NO
4. Felt numll 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 of the PCL 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)
Below is a list of
and can.ints that persons
have in
to
stressful life experiences .. Please
d each one carefully, put an -x in the box to indicate how nuch you
.....
Not at
bit Moderately Quite bit lxtrernetr

3
4
No"'
.1 Repeated, disturbing tner1ories,

thoughts, or iuages of a stt"essful
e fromthe
dr-ean of a
stnessful
e from the
?
~----~-------3 Suddenly acting or feelil"g as if a
stn!ssful
e were happening
........,......__
in
were
?
Feeling very upset when
hing
re.rrinded you of a st11!ssful experience
____
fmmthe
5 Having
reactioons e.g.. r
pounding, trouble b.-eathing .. or

sweating) when
hing t-errinded
of a stressful
f1"0m the
6
Avoid thinking about or talking about a

stR!'ssful experience from the past or
Avoid activities or situations because
they r-enind you of a str-essful
.,.
N
8 Tmuble
~rtant parts of
a stressful
ft-om the
?
9 Loss of interest in things that. you used
to
10 Feeling distant or cut
11
12
X
X
or
emot
to have loving
to
for those cfose
as
cut short?
sonehow
vour
X
alert" or watchful on
17
IF
you checked off any of the above
how
18
do
'VIork.. take care of
at
or
~n-~--~~"Not difficult
difficult
diff"~eult
have these probfens

it for you to
with other
~.~.;~~~~~~~-om>~~~~;-~,._~~=~~~"'"""""""-~~~~~-~m~~"'''""""""""
X
Very dfficult
Extrern!ly diff1eult
19 During the last 2 weeks have you had thoughts that you would be better off dead, or of hutting
yourself iin son1e way'?
Yes
X
No
....,_..... f - ..w>''"'l
lF Yes, how oft.en?
.Sevetal days
More than half the days
ADt rost everyday
Figure 14: PCL Example 1
: .. . .
: :. '.
. . : ..
. . . . . :. ... ::: . .
... .
.
:: : .
. .
. .. .
. . .
.
. . :.
..
....
... .. .. . ... . ..
COfY1Jietints that persons

have in response to
, put an "X" in the box to indicate how rnJCh you
.
. .. . . . .. .
... :
..
. . .
.
..
. .. . ...
.: .
.
.. . . . . ... .
.
. ..
.
....
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. .
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.
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.
.
.
.
. .
.
.
....
.
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. .
. .
. . .....
.. i
. : .: .
.. .
....
..
Quite a
at
4
. .
.
.
.
. .
houghts, or irt ages of a stressful
a
hom the
4
1---
were
very upset when
remnded you of a stressful e:qJerience
. ..
from the
reactioons e .. g:,,
pounding, trouble breathing, or
sweating) when sorething rerrinded you
of a st:res.sful
e from the
?
.... .
Having
____________
thinking about or talking about a
~~~~----------._
.. .
~--~------~--------~----~
.. --~---~~--~------~
.: .
.
stres.sful experience from the past or

avoid
t<elated to it?
_
_..
_ _ _ _---f ..
Avoid activities or situations. bec:ause .....~. .-. -...-.~---
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. .. .
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....
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remnd you of a stressfuJ
..
At
41110
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.
......,.___-..~
.
..
. ....
.
.
.: .
....
..
:
..
....
...
in'pott:ant parts
~--~~st:;..-.,;re;;.;s~sf-uiiiiiPI-~~~~-fro;.,;;.-m~.
::........li;,~~~~--------t . .
Loss. of intell!st in things. that you used
..
~--~-----~~~-
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:.
.... .
.;
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.
. .
.
.. . . . . .
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/ -_ _.................
iillillli
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..
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10
.
. ..
..
.
.. .
.. . . . . :
11
X
12
CIS
....
. .
.. .. . .
.. .
ut short?
. .
. ..
..
..
.
..
.
. .
.
. .
... . .
.
. .
. .
. .
.
. ..... . .
.
. .
.: .. ::::..
angry
...
...: . .. .
. ..
.
. : .. . .
..
.
: . . .. .
...
.......' . . .:: . . . .
.
. ::.
...... .
.
..
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. ..
. .
..
.
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..
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.
. ....
. .
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..... .
.
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:: .
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14
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.:
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.
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.
'
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.
.
...
...
..
.
. .:
on
17
startled?
any of t:he above problena,. how
\-.,ay?
n= Yes,
nade it for you to
have these
have you had thoughts that you would be better off

Yes
X
No
!._ _Several days
2....._.....;More than half the days
.. or of hurting
J_____..Ainnst everyday
Figure 15: PCL Example 2
Below is a list of
that persons
have in response to
Please read each one carefualy, put an 'X" in the box to indic,ate how utch you
Not at all A little
1
Repeated, distu1bing re1 t raries.,
thoughts, or inages of a stressful
from t.he
?
2 Re~ated, disturbing drearrE. of a
stressful
e from the
?

~~~~~~~~~~~--~~~~--3 Sudden~ acting or feefing as if a
stressful
\"lere ha
Quite a
4
. . ..
as if
fromthe
.
. .
.
.
.
.
.. .
were
.
. .
Feeling very
when son~ething
rerrinded you of a sb-essful experience
..
.
.
..
..
.
"
.. .
"
x.
.
5 Haviing
e.g.,
pounding, t:r.ouble breathing, or
S'weating) when
reminded you
of a sb-essful
e from the
?
G Avoid thinldng about or talking about a.

stre-ssful expet'ience from the. past or
7
Avoid activities or situations

they remnd you of a stressful
..
X
.
. .
..
."
ause
X
",
rouble renenbering it t'f)Ottant pa1ts of

a stressful
lrom the
Loss of interest in things that you1 used
. . x..
"
...
x..
. . > .
.. . . .
.,.
t0
10 F'eeling dist;ant or cut off from other
11
or being
for those close
enbt
to ha:ve loving
to
. .
..
. . .:
. ..
.
..
. .
vou
12
as
..
your
..
cut short?
13
....
14
. . ..
. x .
..
. .
.
.
. . .. .
. . ..
........
....
hfut on
SEVERITY SCORE = 52
then total all the CQiumns for the
s.coreJ . .
t------
... .
. .
.
. ..
. . . .
...
.
a......
{M-..Itiply the number of bOxes .
checked
in
each
column by the
.
.
.
.number at the> top at the coluittf't.
. .
... .
..
. ..
(5 J[ ~ ) + (.J<X 2. )
..
..
+ {Q ~ :IHl + (
4 J.; 4 )
..
+ ( ~ ~ 5)
l==:.::::=:..::==::::::::=::::======::::::========:::::..J
..
you had thoughts that you would be better off dead, o.- of hurting
Yes
way
IF Yes, how often?
l_
_.Several days
X
. .
No
2.....__More than half the days
3_--:AJrrost evel'yday
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-tertn risk is highly correlated with the following risk factors:
Comorbid depressive disorder

Previous traumatic events
Hopelessness
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 PCL Results to Help Determine Treatment Selection

PCL
PCL
Provisional
Treatment
SymJJtoms & Im rJairment
Severity
Diagnosis
Recommendations
--------~------~--~------~~------~--------~----------~
< 6 symptoms at moderate or
- Reassurance and/or
<
Subthreshold or no
supportive counseling
greater severity, but
28
functional impairment
PTSD
-Education
- Self-management activity
2: 6 symptoms at moderate or
- SSRI
- Self-management activity
PTSD,
greater severity
>28
- If no improvement after
(?:1 intrusion symptom,
Mild
2: 3 avoidance symptoms,
12 weeks, refer for
2: 2 hyperarousal symptoms;
Cognitive Behavioral
PTSD,
plus functional impairment)
Therapy
>50
Moderate to Severe
- S Decial ~~ referral*
*Refer for co-management with mental health specialty clinician 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 if not 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.
Choosing Psychological Counseling
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 ternts 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 if not 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 (reexperiencing, 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 I OOmg)
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. If psychological 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)].
Explain and Recommend Care Management

. .
.:
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 PCL Scoring Exercise
PCL RESULTS AFTER 8 WEEKS

OF TREATMENT
that persons sonetines have in response to

refully, put an x.. in the box to indicate how nuch you
h.
Not at
1
Repeated, distwbing rneu ories,

thoughts, or in ages of a
X
a
Suddenly acting or
as if a
stn!ssful expet'ience Wen! happening
as if
wet-e
it ?
~~----~------~------~--------~---------
Feeling very upset when sornething

nurinded you of a
e)CJ)erience
from the
5 Having
e.g ...
pounding, trouble bJathing, or
sweating) when sonething rerrinded you
of a stressful
from the
?
6 Avoid thinking about o talking about a
stressful expetience fnlm the past or
avoid
fee
related to it?
7
~--~--~~--~------~~------+---------
A.void activities or situations because
they e-emnd you of a stressful

8
IllQ:
;t
if11lortant patts
.,.
e from the
9 loss of interest in things that you used
a stressful
.f..;
10
or cut
nu 01~ being unable

11 feeling
to have !loving feelings for those close
')
to
as your
12.
cut short?
13
14
X
X
angy
outbursts?
16
17
IF
vou
chec.ked
off
any
of
the
above
problens,
how difficult have these pr-.Jbleit& made it for you to
18
.,
~
Not difficult
Souewhat difficult
Very ctafficult
Extnmely. difficult
19 D.lring the fast 2 weeks have you had thoughts that you would be better off dead, o,,~ of hutting
yoUfS.ef in sot rR way?
Yes
)(
No
:
IF Yes, ho\~ ofte.nJ
'i-i"
Several days
Alu ost everyday
Table 11: Using the PCL to Assess Patient Response to Treatment

Initial Response after Six - Eight .weeks of an Adequate Dose of an Antidepressant
Treatment
PCL
Res~onse
Treatment 0 Jtions
Drop of~ 5 points from

baseline
Adequate
Drop of3-4 points from

baseline.
Probably
Inadequate
Warrants an increase in dose
Drop of l-2 points or no

change or increase.
Inadequate
Increase dose; Switch drugs; Augmentation; Infonnal or fonnal

psychiatric consultation; Add psychological counseling
No treatment change needed. Care manager follow-up in four weeks.
.. . .
Initial Response to Psychological Counseling After Four Sessio.ns over Six Weeks *
Treatment
PCL
Treatment 0
Res~onse
~tions
Drop of~ 5 points from

baseline
Adequate
Drop of3-4 points from

baseline
Probably
Inadequate
Probably no treatment change needed. Share PCL with

psychotherapist.
Inadequate
If PTSD-specific psychological counseling discuss with supervising

psychiatrist, consider adding pharrnacotherapy.
Drop of l -2 points or no
change or increase
No treatment change needed. Care manager follow-up in four weeks.
'
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 PCL 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 initiall2 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 I 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

(CHCS II I AHLTA)
MailMan message for: GRIFFIN, CHRIS
..... , .........
Su}Dj : B~ p . - -.. . .X){_/X.XX~Xl7X~XX ~ ...g1.-l-pl\<;)ll:e . - O<:>i~$J.t,:~t: . . . . -.

. . . . . . . - > .. - - - .- . . _ . . . . . . . _-_. _ _. _ >- ...-_. -_ . - - .. --. - . . -_ . .-.. . . .- > . -.-_.
<
r- <i
<-
<
.... - -.. - . -.. ... -__ ......... -. . _ -
..
- ..._........_ _. >
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
1x 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 f/u 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
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 pharrnacologic 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 treatment for 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 TreatmentCBT- with cognitive restructuring and /or exposure therapy). If already in CBT and not
on an antidepressant, add antidepressant.
5. Request inforrnal 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 perforn1ing 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
..
..
.. .
...
. ..
..
. .
ManagementTools
.
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 forrnal
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 Ph~
Continuation Phase
Renrission
Only 20o/o
Have~ 3 Visits*
' '
'
Symptoms
SyndrtJtne
Response
>40%
StopRx*
\
\
Recovery
''
'
\
\
Relapse
Relapse
60% to70%
Stop Rx*
''
\
\
'+
Maintenance
Phase
....
Recurrence
*]:I
r;-DI.1.T-..)'" ,..? 00.Iii,,
. :IL~.
Time
Adaptedjron1 Kupfer. DJ. Long-ternt treat111ent oftkpressioll. J Clin Psychiatry, 1991:52 (suppl. 5) :28-34
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 PCL
response periodically after remission to assess for continued symptom improvement or relapse. The
care manager also assesses risk factors for recurtence.
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 depressiondysthymia 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-tertn, 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.
:References
PHQ-9
Spitzer R, Kroenke K, Williams J. Validation and utility of a self-report version of PRIME-MD: the
PHQ Primary Care Study. Journal of the American Medical Association 1999; 282: 17371744.
Kroenke K, Spitzer R L, Williams J B. The PHQ-9: validity of a brief depression severity measure.
Journal of General Internal Medicine 2001; 16(9): 606-613
Rost K, Smith J. Retooling multiple levels to improve primary care depression treatment. Journal of
General Internal Medicine 16: 644-645,2001
Kroenke K, Spitzer RL. The PHQ-9: A new depression and diagnostic severity measure. Psychiatric
Annals 2002; 32: 509-521.
Williams JW, Noel PH, Cordes J A, Ramirez G,Pignone M. Is this patient clinically depressed?_
Journal of the American Medical Association 2002; 287: 1160-1.170.
Lowe B, Unutzer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment
outcomes with the patient health questionnaire-9. Medical Care, 2004. 42(12): 1194-201.
Pinto-Meza A, Serrano-Blanco A, Penarrubia MT, Blanco E, Haro JM. Assessing depression in
primary care with the PHQ-9: can it be carried out over the telephone? Journal of General
Internal Medicine, 2005. 20(8): 738-42.
PTSD Guidelines
Ballenger JC, Davidson JRT, Lecrubier Y, Nutt DJ, Foa EB, Kessler RC, McFarlane AC, Shalev
A Y: Consensus statement on posttraumatic stress disorder from the International Consensus
Group on Depression and Anxiety. J Clin Psychiat 2000 61 (suppl5)60-66
Management of Post-Traumatic Stress Working Group. VA/DoD Clinical Practice Guideline for the
Management of Post-Traun1atic Stress, Version 1.0. West Virginia Medical Institute and
AXCS Federal Health Care. 2004
Pizarro J, Silver RC, Prause J. Physical and mental health costs of traumatic war experiences among
Civil War veterans. Archives of General Psychiatty. Feb 2006;63(2):193-200.
Schoenfeld, FB, Mannar CR, Neylan TC, C11rrent concepts in pharmacotherapy for posttraumatic
stress disorder. Psychiatric Services, 2004. 55(5): p. 519-31.
PCL
Blanchard EH, Jones-Alexander JJ, Buckley TC, Fomeris CA: Psychometric properties of the PTSD
Checklists (PCL). Behav Res Ther 1996;34:669-673
Walker, EA, Newman E, Dobie DJ, Ciechanowski P, Katon W, Validation of the PTSD checklist in
an HMO sample of women. General Hospital Psychiatry., 2002. 24: 375-80.
RESPECT-Depression and the Three Component Model

Dietrich AJ, Oxman TE, Williams JW Jr, Schulberg HC, Bruce ML, Lee PW, Barry S, Raue PJ,
LeFever JJ, Moonseong H, Rost K, Kroenke K, Gerrity M, Nutting PA: Re-engineering
systems for the primary care treatment of depression: A cluster randomized controlled trial.
British Medical Journal 2004; 329:602-605.
Oxman TE, Dietrich AJ, Williams JW Jr, Kroenke K: A three component model for re-engineering
systems for primary care treatment of depression. Psychosomati~s 2002; 43:441-450.
PTSD Background
Hoge CW, Castro CA, Messer SC, McGurk D, Catting DI, Koffman RL: Combat duty in Iraq and
Afghanistan, mental health problems, and barriers to care. New Engl J Med 2004; 351: 13-22
Friedman MJ: Posttraumatic Stress Disorder Among Military Returnees From Afghanistan and Iraq
American Journal of Psychiatry 2006 163: 586-593
Lecrubier Y: Posttraumatic stress disorder in primary care: A hidden diagnosis. J Clin Psychiatry
2004;65 (suppll): 49-54.
PTSD Four Question Screen

Prins A, Ouimette P, Kimerling R, Cameron RP, Hugelshofer DS, Shaw-Hegwer J, Thrailkill A,
Gusman FD, Sheikh n: The primary care PTSD screen (PC-PTSD): development and
operating characteristics. Priwa;ry Care PsychiatJY 2004; 9:9-14
Zlotnick C, Rodriguez BF, Weisberg RB, Bruce SE, Spencer MA, Culpepper L, Keller MB:
Chronicity in posttraumatic stress disorder and predictors of the course of posttraumatic
stress disorder among primary care patients. J Nerv Ment Dis 2004; 192:153-159
CARE
AGER
FE
ECOMPO
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NCE
NT MODEL
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ForP
AGEME
ofDEP
(Military Version)
SSION and PTSD
Copyright C May 2006 3CMTM, LLC- Version 3.0

By Thomas E. Oxman MD, Dartlnouth Medical School
With contributions from, Allen J. Dietrich MD, John W. Williams, Jr. MD; Charles C. Engel, MD, MPH, Mathew Frledumn, MD, PhD,
Paula Schnurr, PhD, Stanley Rosenberg, PhD
Project Director: Sheila L. Barry
This manual is intended to provide helpful and informative material for care managers working with patients with depression antUor PTSD. The
information provided here is general~ and is not intended as clinical advice for or about specific patients. Before applying any ofthis infotmation
or drawing any iriferencea from it, care managers should verify accuracy and applicability of the irifonnation and the appropriateness oj
protocol strategies within their particular clinical settings. Any management steps taken with patients should include a discussion of risks and
benefits as well as patient preferences. By accessing the information in this manual, you agree that 3CMfM, UC; Dartmouth College; Duke
University; Duke University Health System~ Inc.; Private Diagnostic Clinic, PUC; the John D. and Catherine T. MacArthur Foundation; any
participant in the Initiative on Depression and Primary Care; and the contributors of infonnation to this manual shall not be liable to you for
any damages, losses or if1jury caused by the use ofany Uifotmation in this manual.
Preface
This manual is intended for use as a resource and guide for care managers providing support to Soldiers
being treated for depression and/or posttraumatic stress disorder (PTSD) through a military primary care
practice. This manual is specific to the support function of care managers. A separate manual and training
has been developed for primary care providers. Care managers should access both the primary care provider
manual and training session prior to and in conjunction with this manual and direct care management
specific training by RESPECT-MIL program staff.
Background
A variety of epidemiological studies have demonstrated over half of all depression cases are treated in
primary care practices. While primary care providers place a high priority on recognizing and treating their
patients who are suffering from depression, the obstacles to optimal care are formidable. Excellent care for
chronic diseases such as depression is more achievable when there is a well-developed system for care.
Rigorous scientific studies have recently identified several innovations that form the basis of a system to help
primary care providers overcome many of these obstacles and enhance the care they provide.
Additionally, a recent survey of U.S. combat units retu111ing from the war in Iraq (Hoge et al2004) found
that based on broad criteria, over 18% of Soldiers and Marines screened positive on a psychometric
instrument measuring symptoms of posttraumatic stress disorder (PTSD). Even with stricter severity criteria,
over 12% would have screened positive. There was a direct relationship between the number of combat
exposures (e.g., being shot at, handling dead bodies, knowing someone who was killed, or killing enemy
combatants) and those screening positive on this questionnaire. Participation in combat activities is not the
exclusive source of danger and stress in a war-zone. There is some evidence that the stress of war is
associated with an increase in rates of sexual assault and sexual harassment. Both male and female Soldiers
are at risk for sexual victimization, a traumatic experience often associated with symptoms ofPTSD.
Of particular importance now is that among those Soldiers whose survey responses met strict criteria for a
mental disorder, few sought help. Even though approximately 80% recognized that they had a problem, less
than 45% were interested in receiving help. Less than one third had received any help from any professional
- including help from primary care providers.
Primary care providers are the health professionals with the greatest opportunity to detect and start treatment
for these behavioral health disorders. Because there is a significant overlap of co-occurring depression and
PTSD, and because of successful primary care depression systems of care such as the Three Component
Model (3CM) (Oxman et al; Dietrich et al2004), a logical and effective approach to addressing depression
and PTSD in the military is to incorporate aspects of these care systems into the military's general primary
care environment. This effort is known as RESPECT-MIL- standing for theRe-Engineering Systems for
the Primary Care Treatment of depression and PTSD -Military model.
Primary care providers participating in the program's training and implementation have found RESEPCTMIL to empower them to provide enhanced depression and PTSD care. These routines (structured
diagnostic and follow-up care process steps with a timeline) and division of responsibility including a
telephone care manager role and a consulting psychiatrist in civilian primary care settings, resulted in better
outcomes than usual care (Dietrich et al2004). RESPECT-MIL was first initiated at the Roscoe Robinson
Health Clinic, Fort Bragg, NC in June 2005.
This manual explains the process of care that was successfully tested at Fort Bragg. The manual is part of an
overall education process for care mangers that includes participating in a provider education workshop(s) or
watching a training video of the workshop and establishing a relationship with the behavioral health
professional who serves as the third component of 3CM.
Page 2 of62
I~~~c:)][)llT~~Ic:~ ............................................................................................................................................ ~
SE~~IO~
1:
~HE ~HREE ~OMPO~E~~
MO][)EL & RESPE~~-MIL ................................................ 6
The Prepared Practice: Creating an Office System for Primary Care Management ofDEPRESSION
~
PTSD .......................................................................................................................................................... t
The Care Manager: Providing Soldiers and PCP Support............................ tJ

The Mental Health Interface: Access to Psychiatry Consultation ............................................................. tJ
Ove~ieli' ofthe RESPECT-MI~ Ctzre Process ............................................................... ?'
SE~~IO~
II:
~HE ~OLE
OF ~HE
~ARE MA~AGE~ I~ RESPE~~-MIL ......................................... 8
The CJroal of Treatment ................................................ ~

Setting the Care Management Process in Motion (Referral) ................................ ~
Care Manager Role in Assessing Adherence to Tretztment ....................................... 9
~arriers to Treatment ............................................ 9
~arrier ProlJlem Sol11ing .......................................................... Jrt)
Pro11iding Positi11e Reinforcement and Encouragement.................... Jr 0
Monitoring Progress ............................... Error! Boolcmark not defined.
Supporting Adherence..................... JrJr
Pro11iding Education Regarding Medication Treatment........................................................................ Jr Jr
Assessing Response to Treatment ...................................... Jr Jr
Monitoring Response to Treatment Using the PHQ-9 and/or PC~ .......................................................... Jr2
Coordinating tlle Communication ofInformation ............. Jr2
Remission Criterion .............................................. Jr?'
SE~~IO~
III: llTSE OF ~BE PHQ-9 I~ ][)EPRESSIO~
AGEME~~ ........................................... 18
GUIDE FOR COUNTING SYMPTOMS IN THE PHQ-9... 20

GUIDE FOR SCORING THE PHQ-9 (SEVERITY SCORE) .................................................................. 2Jr
Treatment Recommendations and Options .................................................... Error! Boolcmark not defined
Assessment ofPatient Response to Treatment ................. 23
SE~~IO~
IV: llTSE OF ~BE P~L I~ P~S][)
AGEME~~ ............................................................... 24
Four Components for PTSD Diagnosis.......................... 2~

PTSD ChecJilist (PC~).................................................................................... ErrtJr! BtJtJicmllrk ntJt defined
COUNTING SYMPTOMSAND EVA~UATING MINIMUM CRITERIA ............................................... 2?'
CA~CU~ATING A SEVERITY SCORE FROM THE PC~ Using PC~ Results to Help Determine
Treatment Selection ....................................... 2~
IS'sing PC~ Results to Help Determine Treatment Selection .............. 29
SE~~Ic:~ ~: SllTI~I][)ALI~~ ...................................................................................................................... ~()
~e11els
ofSuicide RisJi 30
Emergent RisJi ~e11el: ....................... 3 0
Urgent ~isJC ~e11el: ................................... 30
~olt' R~JC ~evel: .......................... 30
Components of an E11aluation for Suicidal RisJC:................................................................................... 30
Assessing Suicitie RisJC 3Jr
Guidance Notes Regarding Response to RisJC ~evels .. 32
Guidance Notes Regarding Response to ~isJC ~evels ................................................................................. 33
SE~~IO~
VI: ~O~~INllTA~IO~ AN][) MAI~~E~AN~E ....................................................................... ~4
R~JC
ofRela~se- DEPRESSION........................... 3~
Continuation ............................ 3~
Medictztions ........................................ 3~
Psychologictzl Counseling .................................. 3~
Care Mtznager Role ............................... 3~
Chronic Depression (Dy~thymia) ... 3~
What is Chronic Depression?................................... 3~
Page 3 of62
"Why is a Chronic Depression Diagnosis Important? 35

"What Questions Can Help Elicit a Diagnosis of Chronic Depression? ................................................ 35
"When should the Maintenance Questionnaire be administered?.......................................................... 36
Mtrintenance 36
Dysthymi~. 3i'
SECTION VII: IMPLEMENTING THE CARE MANAGEMENT PROCESS ............. 38
Care Management ~trtient Ctrlls 3~

~eli' ~eferral ~cti11ities 3~
~ecord ~eeJ7i11g ~et-lJrp . 3~
~rogress ~otes cit Communication 3~
11
~ractice Tasks for the InitiaVDiagnostic Office Visit ( index" 11isit) ............ Error! Bookmark not defined.
Care Manager Tasks Err()r/ 15rookmark not defined.
SECTION VIII: PLANNING CARE MANAGEMENT CONTACTS & CONDUCTING CALLS ..... 40
the Call .... ~3

~lacing the Call ... ~3
~ey Care Manager Discussion ~oints ........................................................................................................ ~3
Ending the Call ~5
Typical ~easons for Initiating ~~ Calls ~5
Communication and Coordination li'ith the ~C~ ~5
Expectations of a Care Manager: ~ Guide for ~C~s . ~i'
~reparation for
SECTION IX: CARE
AGEMENT SUPERVISION AND DATA MANAGEMENT .......... 48
Care Management ~uper11ision Calls 55

Care Management ~uper11ision ~genda . 55
~eporting and Discussion during ~upe,-,ision. 55
Enrollment ~tatus 55
~e11ie,., of Cases 55
~genda ~preadsheet .. 55
R~1f~~r~11~~s ....................................................................................................................................................... ~~
jFJjf.jfQ-~ 6Jr
jFJT~D Guidelines .. 6Jr
jFJC~ 6Jr
RE~PECT-Depression and the Three Component Model ......................................................................... 6Jr
PT~D ~ackgrounli.. 6Jr
PT~D ~our Question ~creen . 6~
Page4 of62
INTRO
Care managers (CM) attend/participate in training along with primary care providers (PCPs)- MDs, NPs,
and PAs - specific to primary care management of depression and PTSD. Further CM specific training is
provided through PowerPoint presentation (with accompanying handouts) by a program leader. This manual
serves as an adjunct to such training activities and is well used as a reference manual during initial phases of
care management responsibilities.
After training sessions as noted above, the CM will be able to:
1. Describe the role of the CM in assisting patients to adhere to prescribed primary care treatment plans
for depression and/or PTSD.
2. Understand the CM supervision process which provides follow up support for patients and PCPs.
3. Understand the depression measure of the Patient Health Questionnaire (PHQ-9) and how it is used
as a treatment response measure.
4. Understand the posttraumatic stress disorder (PTSD) measure of the PTSD Checklist (PCL) and how
it is used as a treatment response measure.
5. List the seven key medication educational messages known to improve patient outcomes that should
be delivered initially and reinforced in subsequent care manager contacts.
6. List six areas of self-management used to assist patients in actively participating in treatment of
depression and/or PTSD.
Further, the CM will have acquired basic skills to:
1. Score the PHQ-9 to monitor symptoms and severity of depression both initially and in follow up
contacts.
2. Score the PCL to monitor symptoms and severity ofPTSD both initially and in follow up contacts.
3. Use focused questions to evaluate suicidal risk.
4. Use patient education materials to promote adherence to the prescribed treatment plan including selfmanagement goals.
5. Conduct initial one week, four-week, eight-week, PRN and all subsequent care management calls
using the CM Call Log (forn1) to guide calls.
6. Complete CM Reports to effectively communicate call outcomes and patient status to PCPs.
7. Prepare the Weekly Supervision Agenda forn1 for efficient care management supervision with the
supervising psychiatrist.
8. Present patient cases and inforn1ation in a clear, concise and organized manner for care management
supervision calls.
9. Follow through with reconunendations resulting from the care management supervision.
PageS of62
SEC
-MIL
The elements of the Three Component Model for management of major depressive disorder and PTSD
treatment are not unique, but rather the product of a wide range of recent research and dissemination
activity. The essential components of this model, known as 3CM, include prepared PCPs and
practices; the CM and mental health specialists (ideally, a psychiatrist) all working in partnership with
the patient. 3CM includes a model for the Re-engineering of Systems for Primary Care Treatment in
the military (RESPECT-MIL) of common behavioral health concerns of depression and PTSD.
Recently the investigators involved in the creation of 3CM have collaborated with the Department of
Defense's Deployment Health Clinical Center (DHCC) and the Henry M. Jackson Foundation (HMJF) to
bring this model of care for behavioral health issues to the primary care sector of the Army. Specifically,
work began in early 2005 to initiate the pilot phase of this work at the Roscoe Robinson Health Clinic
(RRHC) of Womack Army Medical Center at Fort Bragg, North Carolina. The focus of this work at the
RRHC has resulted in enhanced primary care services for members of the 82nd Airborne Division. The
project is known as RESPECT-MIL.
The
an
&PTSD
Every practice or clinic has its own established routines; division of responsibilities; systems for
recordkeeping; and, lines of connnunication among practice members, patients, and specialty services.
Practices vary in the degree to which these elements are internally developed or externally mandated.
While the military has an electronic record keeping system for medical records (CHCS II or AHLTA),
there are internal variations within the primary care system that will need to be addressed clinic by clinic
as this program is implemented locally. RESPECT-MIL will help practices implement routines, divide
responsibilities, and establish systems to enhance primary care treatment of depression and PTSD.
Th
are
r:
rs a
The CM supports Soldiers and PCPs by delivering patient education; supporting patient preferences for
treatment; monitoring both patient treatment adherence and response; and providing feedback to the PCP
about patient progress so that changes in treatment/care plans are made in a timely manner.
,...... Inter ace: A ess to
Co
A psychiatrist is an essential part of the mental health interface within RESPECT-MIL. CMs routinely
and systematically consult with the supervising psychiatrist through weekly care management
supervision calls/meetings. CMs may contact the supervising psychiatrist more frequently when patient
adherence and/or response to treatment warrants. CMs play an integral role in coordinating
communication between the patient, the supervising psychiatrist and the PCP. Additionally,
psychologists will assist in the supervision process especially for issues of counseling, counseling
alternatives and/or patient self-management activities.
Note: Patients who are under the primary care ofa psychiatrist for their behavioral health needs are
generally not followed by CMs in this model. This will prevent two doctors prescribing/adjusting
medications. Usually more complex patients with inadequate response to treatment by primary care are
referred and managed by a psychiatrist.
Page 6 of62
{Jverview ofthe RESPECT-MIL Care Process

The process of care for detecting and managing depression and PTSD in primary care can be divided into
distinct steps. These steps are listed below and described in more detail in the following pages.
Steps involving the care manager are in BOLD and marked with a *
1. Reco. 'nition and Diagnosis
. . . . . . . ..:ll.rli:~sstfln . .
. ......
..
,... . . . . .
..
..
"Flags" for de pression
Two c uestion screen
PHQ-9 for de pression dial:!nosis/severity

Suicide Risk Assessment
Other ;>ertinent diagnostic assessments
. .. '
''< ...... .. >.. . . . . . . . . . .. .. .... .. . . ... HH:H. . .

. . .......... : . . .
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:::.
t.t:S.IJ. . . . .. ...... .. . . . .. '
. .. . . ...;:::::::
::::::::, :
. ... . . .. : ::. :.
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:.:.:
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..: . .
..
. .. .
Four component elements ofPTSD

Four< uestion screen (the PC-PTSD\
PCL for PTSD diagnosis/severity
Other pertinent dia~ostic assessments
2. Treatment Selection
Additional history including previous treatment, co-morbidity
Explain treatment options - medication, counseling or combination
Elicit patient treatment preferences

3. Initial Acute Phase Treatment
Patient engagement
Provide key educational messages when medication is prescribed
Establish importance of self-management and set goals
Explain and recommend care management

4. Care Management Process
*
*
*
*
*
Initial call(s) to monitor treatment initiation I adherence

Mail written educational materials (unless provided by the PCP or within the clinic)
Follow-up calls using PHQ-9 and/or PCL to assess treatment response
Care management supervision with psychiatrist
Coordinate communication between patient, psychiatrist and PCP
5. Acute Phase Follow-Up

* Care management contacts coordinated with PCP office visits
* Evaluate patient response to treatment with a goal ofremission
Modifying treatment when sub-optimal response
Strive for remission

6.
Continuation & Maintenance Phase Care

* Continue treatment response monitoring after remission
* Administer maintenance (dysthymia) questionnaire (depression only)
* Discuss risk
factors I needfor long-term prophylactic treatment during care management
supervzszon
Continue counseling and/or antidepressant treatment for 4-9 months to prevent relapse
Continue long-term prophylactic treatment and monitoring for at risk patients
Page 7 of62
MAN
RES ECTCMs are trained to help patients follow through with the depression!PTSD treatment plans prescribed by
their PCP. The various care management functions are outlined below. Implementation of these
functions is discussed in Section VII.
The
Treatm
The goal of the "acute phase of treatment" is remission. After starting and maintaining adequate
treatment for a typical interval (i.e., a therapeutic dose of antidepressant and/or specific psychological
counseling) many patients will have achieved remission.
Remission for depression is often achieved at about 12 weeks and will result in a corresponding
reduction in the measure of severity to a score of< 5 on the PHQ-9.
Remission for PTSD is often achieved after 12 weeks and will result in a corresponding reduction in
the measure of severity to a score of< 24 on the PCL for PTSD .
Those who do not achieve remission continue in acute phase treatment and likely require treatment
modifications and adjustments. Some patients will be referred to specialty behavioral health care when
an adequate response is not readily achieved and/or when remission is not achieved after 6 months of
management through the primary care setting.
With the goal of remission in mind, the role of the CM is to:
1. Assess the patient's level of adherence to the treatment plan.
2. Support adherence to the treatment plan and assist in problem solving to overcome barriers to
adherence.
3. Monitor treatment response through administration of the severity instruntents (PHQ-9 and PCL).
4. Routinely communicate information regarding patient progress and adherence to the PCP and
supervising psychiatrist.
5. Remind patients of risks for relapse including signs and recommendations if symptoms recur.
Se
e!
Pro ss in
Several key initial care management activities are initiated by the PCP and his/her practice at the time of
the initial visit when depression and/or PTSD are diagnosed. These initial activities are:
Introducing the patient to the role and purpose of care management in their treatment plan
When medication is prescribed at the initial visit, explaining the nature of the medication's
effects, it's efficacy, potential side effects and their pattern over time (e.g., tend to dissipate over
time), the importance of adherence and the care manager's role in monitoring adherence.
Initiating a discussion of the importance and benefits of self-management in overcoming

depression and/or PTSD (patient education) and the care manager's role in monitoring
adherence to such
Helping the patient set initial self-management goals as part of their treatment plan
Ensuring the connection (referral) to the CM is complete and the patient is expecting contact by
a CM within 7 to 10 days
A referral to care management is generally completed through CHCS II I AHLTA by the PCP and should
outline details of initial treatment. Treatment should include at least one of the following:
Medication
Counseling
Specific self-management goals set by the PCP with the patient

Page 8 of62
Some patients may be introduced directly to the CM at the time of the visit when co-location within
primary care exists. Co-location is highly desirable for both patient contact and coordination of
communication with PCPs in the clinic. Although co-location is the ideal and is definitely preferred by
both PCPs and patients, it should be clear, however, that CMs located remote from the clinic and/or
mental health can be equally effective in their roles.
Care Ma
Role in Ass Adhe
to
nt
CMs primarily assess the patients' adherence to recommended treatment plans throughout the course of
treatment of depression and/or PTSD. Routine contacts are made principally by phone, however, face-toface in clinic contacts are acceptable if more convenient to the patient. CMs do not provide home visits.
Each contact is intended to focus on levels of adherence to current treatment including filling/using
prescribed medications appropriately/as clinically directed; scheduling /keeping counseling
appointments; and setting/following through on self-management goals and activities.
Barriers to Treatment
Barriers to treatment are to be assessed by CMs during each patient contact. Patient's experiences/
perceptions of barriers to treatment are important and should be the primary focus ofCM contact with
each patient. CMs contacts offer an opportunity for patients to speak openly about concerns regarding
treatment. CMs also offer the patient the opportunity to "think through" (problem solve) how to get
beyond that barrier(s). CMs must focus on the patient's own problem solving rather than directing or
deciding on solutions for the patient themselves. This may be time consuming, but patient initiated
decisions are the goal and more likely to be put into practice. Barriers often include, but are not limited
to, the items listed below.
General barriers:
Fear of military consequence for diagnosis of depression and/or PTSD
Ambivalence about the diagnosis of depression and/or PTSD
Concerns about medications and deployment; also fear of addiction or stigma related to Rx
Lack of support or opposition by family members
Mood and fatigue
Financial issues relative to military career

Medication Barriers:
Has not filled prescription
Has not begun taking medicine
Not comfortable with depression/PTSD diagnosis
Not comfortable taking medicine
Worried about the stigma ofbeing on "depression" medicine
Unclear about what medication does
Concerned about addiction
Worries about drug dependence
Side effects
Psychological Counseling/Behavioral Health Treatment Barriers:
Has not scheduled an appointment with behavioral health
Does not have ready access to behavioral health counseling (non-urgent)
Does not have access to support group options

Page 9 of62
Had a previous negative experience with behavioral health service

Fear of initial experience in entering counseling/behavioral health
Worried about stigma
Family/friends have negative bias
Believes peers/military will have negative bias if any contact with behavioral health
supports
Barriers to Continued Treatment:

Considering stopping or has stopped taking medication(s)
Concerned about side effect(s)
Feeling better and wants to stop treatment
Lack of improvement
Lack of family support for and/or acknowledgement of illness and treatment
Perceived lack of command support
Wanting to stop counseling because it does not seem to be helping
In many ways, depression and PTSD themselves may well be a barrier to initiating treatment and/or
adhering to the treatment plan. For example, the depressed/PTSD patient may find it difficult to mobilize
the energy to even get to the pharmacy, to take small steps to make a behavioral health appointment or to
engage socially with a friend if just on the phone (completing a self-management goal). A hallmark
feature of PTSD is avoidance. That is, PTSD patients are inclined to avoid thinking about or confronting
their problems.
Problem Solving
Once a barrier has been identified, the CM will help the patient to set a reasonable goal to overcome that
barrier which will then lead to adherence to the treatment plan.
For example, week one ... patient was prescribed a medication but has not filled the prescription. This is a
primary barrier to treatment and would likely be the full focus on the first contact. The goal for this
particular patient would be to get the prescription filled in the next few days and begin taking it as
prescribed. If the patient indicates a willingness to follow through on filling the prescription then the CM
would also attempt to ensure the patient's agreement to actually start taking the medication. At this point
the CM would agree on a follow up contact date/time with the patient so check on the patient's follow
through on both filling and taking the medication as prescribed.
CMs frequently must brainstorm with patients about the various ways to achieve goals and facilitate
adherence to the treatment plan. The CM should encourage the patient to think of ways to achieve
treatment goals that might be different from their usual ways of coping or interacting. Patients may need
to think through exact detailed steps necessary to take a prescription that will not interfere with their
work detaiVassignment- what time of day, how to take the medication with food, how to take
medication when in the field, etc.
What may seem like a small barrier may indeed seem insurmountable to the patient with depression or
PTSD. Breaking a barrier down into smaller steps reduces the size of the barrier.
Providing Positive Reinforcement and Encouragement

Patients often require a lot of positive feedback for even the smallest of steps taken toward reaching their
goals. The process of improving is an iterative one with the first small step providing the foundation for
the next.
Page 10 of62
Supporting Adherence
The most significant role for CMs is reinforcing and supporting the patient's adherence to treatment.
Patients may not initially recognize the importance of all the parts of the treatment plan and may even
view it as a problem to military activity. This is a particularly important time for the CM to reinforce the
point that the patient's ability to fully and ably fulfill his/her work/military commitment is highly
important. If they adhere to the treatment plan, then they are far more likely to fulfill their commitments.
Some patients may decide to ignore portions of their PCP's recommendations. For example, a patient
who would benefit from counseling may be highly resistant to showing up at a behavioral health
appointment- even when there is no financial barrier. However, this may be the same patient who will
readily speak at great length to the CM by phone about the events in their lives. It is important that CMs
set limits with the patient at this point; clarifying that issues from the past or lengthy discussions of
current psychosocial stressors, etc. are the types of issues that behavioral health specialists are prepared
to help with. The CM may, in this way, be able to ease the patient into acceptance of counseling with a
behavioral health specialist.
Providing Education Regarding Medication Treatment

The PCP should have communicated key medication/educational messages during the initial
appointment. The CM should both verify the PCP provided these messages during the visit and then
routinely repeat/reinforce these key messages at appropriate times during calls. These messages include:
I.
2.
3.
4.
5.
6.
7.
8.
Antidepressants only work if taken every day.

Antidepressants are not addictive.
Benefits from medication appear slowly over time.
Antidepressants should be continued even after the patient is feeling better.
Mild side effects are common and usually improve with time.
If the patient is thinking about stopping the medication, slhe must call their PCP first.
The goal of treatment is complete remission! Sometimes it takes a few tries- do not give up.
Once symptoms subside, continued medication or counseling will likely be needed.
CMs should remind all patients that if they are feeling worse they should not wait until a scheduled office
visit- contact their PCP right away!
.._........... to
nt
Treatment for depression and/or PTSD usually takes several weeks to several months (for PTSD) before
the patient notices a response to treatment. Medications take some time to bring about changes in brain
cell structure and function that result in a noticeable difference in symptoms. Counseling may take
weeks before the patient experiences a desired affect. Self-management goals may have immediate, yet
short-term effective impact on mood. It is important to sustain the practice of setting and adhering to
self-management goals over time.
As patients are frequently eager to see a quick response, it is a responsibility of the CM to help the
patient "hang in there" until the more lasting effects of the treatment begin to be evidenced. There may
be initial short-term responses/gains that the patient may not recognize or recall over the long term. CMs
should be certain to recount these gains for the patient during routine contacts and encourage further
adherence to treatment toward the long term goal of remission.
Medication Therapy: For patients on antidepressants, a measurable initial response to adequate
treatment for depression usually occurs in 4 to 8 weeks.
Page 11 of62
Antidepressant side effects account for as much as two-thirds of all premature discontinuations of
antidepressants. Most side effects are early onset and time limited (e.g., SSRis produce decreased
appetite, nausea, diarrhea, agitation, anxiety, headache, etc.) and most can be managed by temporary
aids to tolerance - food, time of day for administration of medication, etc. Some side effects are
early onset and persistent or late onset (e.g., SSRis producing apathy, fatigue, weight gain, sexual
dysfunction, etc.) and may require additional medications or a switch in antidepressant. (See Fig II-A
for more details on side effects for a variety of medications.)
Psychological Counseling: With psychological counseling alone, an adequate initial response may
take somewhat longer and remission may depend on the severity and resolution of the psychosocial
stressors.
Monito .
Res
T.
!
us
PB
and/or
While the PHQ-9 and/or PCL may be administered at any point during treatment, they should always be
administered, scored and documented during the initial office visit with the PCP and then again at 4 week
intervals by the CM (during phone contacts) or PCP (during office visits)-throughout the acute phase of
treatment. In a brief time, the key elements of the patient's status may be captured and the CM will be
able to communicate information to the PCP regarding progress toward remission.
An adequate initial response to medication and/or counseling is a drop in PHQ-9 or PCL score of 5 or
more points from baseline once adequate treatment levels have been established.
Remission for depression occurs when there is a reduction in the measure of depression severity
to a score of< 5 on the PHQ-9
Remission for PTSD occurs when there is a reduction in the measure of depression severity to a
score of< 24 on the PCL
Sub-optimal responses occur, when the patient does not experience any drop or a sufficient drop in PHQ9 and/or PCL scores over time.
CMs are NOT expected to assess adequacy ofresponse to treatment and so detail regarding guidelines
for treatment changes are not included here. The PCP is responsible for assessment ofadequacy of
response which may occur in conjunction with consultation by the supervising psychiatrist.
Progress is monitored for both depression and PTSD through CM contacts intended to first occur a week
from diagnosis/referral when the CM confirtns the patient has initiated treatments prescribed. All
subsequent routine contacts occur at approximately 4 week intetvals and involve discussion of the
treatment plan prescribed andre-administration of the PHQ-9 and/or PCL questionnaires.
More frequent calls may be necessary for patients who have not been able to self-initiate and/or follow
through on their treatment goals or for those who present concerns to the PCP and/or CM relative to
safety. The CM generally decides on his/her own that PRN calls are needed. In addition, the PCP and/or
the supetvising psychiatrist may request more frequent contacts for patients who are particularly in need.
Coordin
the Co"!"!
tio
L ormation
The CM has frequent and sustained contacts with the patient, providing the opportunity to relay
infortnation from the patient to the PCP. The CM also has frequent contact with the supetvising
psychiatrist. Thus the care management which setves as a unique link between primary care and
behavioral health specialists which benefit the patient in the model of care.
Page 12 of62
Weekly CM supervision calls/meetings with the supervising psychiatrist provide on-going treatment
management advice regarding all patients in the program relative to depression and/or PTSD
treatment/management. In some cases, the supervising psychiatrist will offer recommendations for
treatment changes, which either the CM or the supervising psychiatrist will communicate to the PCP. A
determination is made during that supervision call itself regarding who will contact the PCP and in what
format (e.g., telephone, e-mail, face to face, etc.).
Page 13 of62
. :: .
SIDEEF'FECT
TRlfTCIJCs
1':rr"~
~~'tiNE
(
:u:!P~~
me,
I"~"~
......
ISSR]s &
:..
. . :: :: .. : : ..
:. . . . .
..:. .,: : .: .:.

. .:: ' : .:. ....
..
....
... : . . :. . .
. . ..
.
.
..
.
. .
.. .
..
. .
.. . ..
BUPROPION IMIR'I'.UAP LNJ~ ~o\GDIENTSTR.~TEG1~
;!l
.. ..
11mpr
Sedation
-+ I t
Gl distress.
+ t.
Restlessness,.
Nausea
+f.
*Give JDfl.dication a bedtime.
Increa~ mirtazapine dose.

*Tty eaffeme..
.r
+1-
*Often impm\-es in l-.2 weeks.

*Take with meals.
at1tids or H2
blockf'.rs.
+.
..
*Start with small doses,. especially

with iu:iety disorder.
*R~ dose temporarily.
*.Add bea blocker (propranolol
10-20 mg bidftid.
sbort trial of
k-,.-..a
.
Jiufrstnemors
vr>~u.:uuJazepute.
Headacbe
'In
~
. sonuua
..
*Ttamdone 25-lOOm,g poqbs
(eau ~ause ortbostati~

hypotemion and priapism)
*Tab medication in AJ\1.
*May be part of
medical disorders.
*Decrease dose.
ny adding bupropion. 100 mg
qbsorbid
(cTIT:t
-.d~iinft hn-mU!I'ft
""Q mg
~~., ~'6
v~t'UvDe }Q t:.
bid/tid
Try adding cyproheptadine 41111
1-2 bJ:s before sex.
..r-.
""- I ....,..,.,
..
\.AAiSw.g.
'UJ.Gli.
Seizures
..
\\~ight gain
+l-
+1-
+1-
+1-
'
or
of 'l.r.:
v.l.agi'a.
an;;..,_
..;...., !tnritl~a-.n~c:llnt
u~unw,ue= = c = =
Exercise
*Diet
*Consider changing
rnedJcations
_1\gnnul.ocymsis
..
*Monitor for signs of infec~tion,

~like S)~lODlS
*Stop dmg. ~check VJBC

KE'~l:
.. Very urtJikely
+i- ~-. .
+ lfild
t Moderate
...
Page 14 of62
INFORMATION GUIDE TO ANTIDEPRESSANTS

R~nsfti.Jl.INE 2116
Thera,peut:i<:
.Anudepres$\llt
Dose R.attge
,,,
"
1m 8~ .
. ose
"a.va
...
Advantages
. n ....
I~~;;.) ...... ,.
...
...
... .
20-40
Citalopram
(Celexa)
l.niti~l Suggested
..
...
..
. . ..
..
..
. . .
. . . . :
...
. : : . . : ; . ..
Msintain 20 mg fox 4 weeks before dose increase. If

no response> mer ease in. 10 mg increments every 7
days as tolerated
20 mg in morning with
food (10 mg in elderly or
disorder).
10-20
Fluoxetine
\"Prozac)
10-80
Paroxetine
(Paxil)
Se.ctraline
(Zoloft)
. ..
... . . .
-~.
..
10 mg for escitalopram
Increase to 20mg if partial response afti!r 4 -weeks

Maintain 20 mg for 4-6 weeks and 30 mg for 2-4
weeks before dose increases. Increase in 10 mg
increments at intervals of 7 days. If significant side
effects occur within 7 days, lower dose OI dt3rtge
medication.
20 mg in moming with
food (10 mg in elderly
and those with comorbid
panic disorder)
10-50 (40in
elderly)
25-62.5 (SO
in elderly)
25 mg daily (12.5mg in
elderly and those with
panic disoider)
Increase by 12.5 mg at weekly intervals, maintain 25

mg fox 4 weeks before dose increase
. ::: :: .
..... : . . ....... '
15 mg at bedtime (1.5 mg
fo:r those in need of
sedation I hypnotic)
Bup:ropiont
~ellbutrin SR,
Wellbutrin XL)
300-400
150 mg in motning
Reduces all thxee symptom groups of

PTSD.
May cause less nausea and GI distress
FDA approved for anxiety disorders

includmg PTSD. Safety shown post W.
.~h.)nJJJ. ad.iVikl!jJiaephfine. a:niJ,gD,ikt

.. .....
. .
. .: : ...
..
. . ..
...
Increase in 15 mg increments (1.5 mg in eldedy) as

tolerated Maintain 30 mg for 4 weeks before
fw:ther dose in crease
.... .
Sometimes sedating.
Occasionally more
anticholinergic -like .effects;
Possibly more cytodu:ome
P450 in.tet actions. May have
more frequent discontinuation
syntptoms.
..
.. .
. ..
. . ..
Generic.
.. . . .. : . . . . ..
...
. : . ..
Slower to reach steady state.

SometiJ:nes too stimulating.
Possibly .more cytochrome
P450 interactions.
FDA approved for most anxiety

disorders.
Maintain 50 mg for 4 weeks. Increase in 25~50 mg

increments at intervals of 7 days as tolerated
Maintain 100 mg for 4 weeks before next dcse
maease.
..
15-45
Helpful tot anxiety disorders.

Long half-life good for poot adherence>
missed doses. Less frequent
discontinuation sytnptoms.
Reduces all :3 PTSD symptom groups.
Genericfo, Poxii. Get:4ric .roonfor PaxiJ CR
SOrngonce daily, usually

in morning with food
(25mg fot elderly)
:.. .
MUtaozapine
(Rimeron)
.more potent than racemic,

10mg dose often effective; Reduces all
three symptom groups ofP'I'SD. Generic.
Maintgjn 20 mg for 4 weeks before dose increase.

Increase in 10 mg increments at intetvals of
approximately 7 days up ro a maximum of 50
mg/day.
..
Probably helpful for anxiety disorders.

Possibly fewer cytodu:ome P450
interactions. Glllieric.
s~n~tiomer
20 mg once daily, usually

in morrtin.g with food
(1<Xng in elderly & those
with como:rbid panic
disorder)
25-200
...
.~~ m H r, ... ~,._ r. i.11Ji. H ,cdiJ..:~)

q.1 ~.. 'llln aeupnpi.e,:':IRIZ# .. Mn 1~~5;
those With panic
Escitalopram
(Lexapro)
Disadvan.tages
.:
..
. .. .
..
. . ... . ....
.. .
. .
. . . .. . .
..
..
... ..
..
. .
.. .
. .
..
.. ..
Few drug interactions. Less or no sexual

dysfunction.
Less sedation as dose increased
May stimulate appetite. May reduce an
thiee sy ...HHtomgrou_ps
ofP'I'SD.
Gen~
..
....
..
. ..
N:i:Jre.
iii~~~~
dcf~
~
.t:iJm,;inJJJb.
~tor
,
.
p
.y.y~~~. . -.nJ
' ......
... 'P.
'
......
'
'
'l.
..
.
.
..
.....
..
.
.
.
..
.
.
.
...
.....
.. . .
..
..
. ..
.. . .. ..
~
: :
::::
'.
Increase to 150 mg b.i.d after 7 days. Increase to

200mg bid if insufficient response after 4 weeks. 8
hours between doses and .initially not at bedtime.
Wlth hepatic disease only 100 mg total per ds:y.
::
Stimulating. Less or no sexual

dysfunction.
May reduce sll three symptom groups of
PTSD. GenetiC..
Sedation at low dose only.

May initially stimulate appetite.
..
. . .
. ..
..
. .. :
. . ... .
At .higher dose, may induce

seizures in persorts with sei2ure
disorder. Stimulating. Usually
b.i.d. dosing, urlless more
e_ ensiveXL
..
..
1"'beapeutic
.A:ntideptess;).nt
._Dose Range
...
'
~~/da~;.,
....
. .
. .
..
loitittl Suggested
Dose
..
(Effexor,
75-375
Bffexot XR.)
'
..
40 to 60 mg per day in
single or b.id dose as
75 mg with food; if
anxious or debilitall!d,
37.5mg
. .
'
'
'
. .. . . ...:.. . .
..
'
..
...
..
Desipraminet
lOU-300
~orprmlin;
(25-100 in
elderly)
Pettofrane)
...
. . . .. ' .....
SO mg in the morn1ng
.. .
Norepi:neprhine effect ocCUs at 60mg and rugher.

60mg a~quate target dose. Up to 120mg has been
used butno clinical .advantage demonstrated.
Dose should be divided b.i<i. or t.i.d. unless XR
For extended release (Y...R) give 37.5 in a.m. then
increase to 75 mg in a.m. after 1 week, 150 mg in,
the am. after 2 weeks. If partial response after four
weeks inaease to 225 mg in the morning.
No:r_~r:..leprhine effect
occurs above ~
uy
... .
J'J'111
aDiv>M~tilep:
.. 'hii
...
tr
.
--
- :
. . .
.,
.. . '' .
..
. . _,..
'
25150
25 mg (lOmg in frail
elderly) in the evening
..
Also approved for diabetic peripheral

neutopathic pain. Used for sttess urinary
mconbrtence.
1-{a.y increase blood pressure.

b.i.d dosing. Nausea. Avoid in
any hepatic impairment or
severe renal failure
XR version can be taken qd

Helpful for anxiety disorders. Possibly
fewec cytochrome P4~ intetactions.
May r-educe all three symptom groups of
1-{a.y increase blood pressure at

higher doses, B.i.d dosing
unless use XR Expensive.
PTSD.
..- tslh
. fU. .INtDr
.
i.
reuP ... JJ. ..
. 'L '
,. . .
..
Increase by 25 to 50 mg evet.y .3 to 7 days to initially

target of 15Cmg for 4 weeks.
.. '
Increase in 10-25 mg incren1ents every 5 days as

tolerated to 75mg. Dosing too high may be
ineffective. Obtain serutn drug levas a fret 4 weeks
ifnot effectiv:e.
..
. ......
More effect on norepinephr1ne than

serotonin, less sedating..
Reduces avoidance/numbing symptom
LlLutln
Nortriptyline!
(Ave.nty~ Pamelor)
'
Sero.t(JI,Iin aiJ(I 1V~n.f!J'btin~ retiptWfe mblblltJr.-
tolerated
Venlafmne
..
..
...
40- 120
Disadvantages
..
.:\dvan:tage.s
.. .
'
Duloxetine
(Cymbalta)
Titration Schedule**
...
_.
ofPTSD. Generrr.
Availability of .rebble, valid blood level

Lower orthostatic hypote11sion than
other tncyclics.
Probably reduces 4Voidance/numbing
....
of PTSD Generic
s~
L!.L 0"
..
Like all T ._.A"', antichollnergic.

Caution with BPH Can
exacerbate cardiac condY&tion
~-
uke all TCAs, mticholinetgic.
Caution with BPH Can

gacerbate ~ardiac conduction
ptoblerns. or CHE.
"..['
*'There are more antidepx~ssants than those listed in this table; however, this list p.rovides a reasonable variety of d.rug& that have different s.ide effects and act by different neu:totransnutter
rnech~sms. Treat::tnent of Parkinson's disease may include selegiline (Bldeptyl), '(Vmch is a selectiv:e monoamine oxid~ inhibitor at low doses only. Because the use of many antidepxessants is
contiaindicated in conjunction with a nonselective MAO I, cautiOll with or discontirt1ation of Eldeptyl rn:a.y be in order. For pregnancy, TC.As and SSR!s (particularly fluoxetine, because ofmore
data collected} are not associated with congenital malfotiuations or developmenb.U delay. SSRis in the third,..tiim.estet ate associated 'With a $light decrease in gestational age and conespondingly lCN~er
weight, and occasionelly with neonatal wi.thd~awal symptoms. Dialrhea, drowsiness, and irritability are occasionally seen in breast fed infants of mothers blking ..antidepressants. The risks of
maternal depression on child development should be balanced agamst 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 o.r those sensitive to medications, start lower. Fot all
antidepressants, all~ foU! 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 dtugs.
tGenerally avoid bupropion in patie.nts with .a histocy ofsenures, significant cenual ne~vous system lesions, or: rec,nt bead trauma.
iTricyclic antidepressants (TCAs) have lower costs but somewhat rugher discontinuation rates compared to SSRis due to side ~ects and S.re mote lethal in ovetdose. TCAs may be contra.indicated
in patients with certain physical comorbidities such as recent myecatdia.l infarction, cardis.c conduction defects, urinuy retention, narrow angle gla\Jcoma, orthostatic hypotension, and cognitive
impaittnent
Remission Criterion
Remission from depression is a score of <5 points on the PHQ-9 that is maintained consistently
over 8 consecutive weeks or more. Begin looking for remission from DEPRESSION at week 8
and beyond.
If remission has continued for 8 weeks, administer the Maintenance Questionnaire
which evaluates for risk factors for dysthymia.
Advise the patient that the questions will help his/her PCP decide upon next steps
in treatment.
Emphasize to patient that medications, counseling and self-management activities
should not be discontinued even if in remission. Discuss risks and signs of
relapse.
Discuss Questionnaire during supervision for determination of dysthymia and
report results/recommendations to PCP for consideration/discussion with patient.
Remission from PTSD is a score of< 24 points on the PCL that is maintained consistently over 8
consecutive weeks or more. Remission for PTSD will likely occur more slowly. Begin looking
for PTSD remission at week 12 and beyond.
Page 17 of62
SECTION III: USE OF THE
DE
The nine depression symptom questions from the PHQ-9 are derived directly from the DSM-IV
diagnostic criteria for major depression. A tenth question also follows the DSM-IV criteria for
depression and asks about functional impairment from these symptoms (Question #10).
The PHQ-9, can be used as a patient self-administered questionnaire in the office or read to the patient
over the telephone to help confirm a depression diagnosis and determine severity. Over time as the
PHQ-9 is re-administered on 4 week intervals, it serves as a treatment response monitoring mechanism to
assess patient progress. Based on the outcomes of these 4 week assessments, treatment decisions may be
made to modify medication dosages and/or to switch medications in an effort to reach remission, add
counseling, and/or adjust self-management goals and activities.
A sample of a completed PHQ-9 is presented on the following page. Immediate subsequent pages
provide guides to counting symptoms as reported by the patient as well as a guide for scoring the
questionnaire for severity. It is important to take time to study how to both count symptoms and calculate
the severity score. CMs should always verify and, occasionally correct scores on PHQ-9s sent by PCP s
when referring patients to care management. If an error is noted, the PCP should be advised of the
corrected symptom count and/or score so that the accurate information may be recorded in the patient's
medical record (CHCS II I AHLTA).
CMs re-administer PHQ-9s to the patient during the 4, 8, 12 and 16-week calls in order to calculate a
new depression severity score for the patient. This will take some additional time with older and/or
disabled patients so call duration should be planned accordingly. It is important to remind patients to
focus on the prior two week interval and not months or years when completing the questionnaire. Such
reminders will aide the patient in completing the questions more easily. The updated scores are
communicated to the PCP through a Care Manager Report or electronically through CHCS II I AHLTA
in the form of a Telephone Consult (T-Con).
Page 18 of62
PATIENT H:EAI.1'H QUESTIONNAIRE (PHQ-9)

Over the
by any of the
how
have you been bothered
problems?
iuse ""' to indicate your answer)

1 LitUe interest or pleasure in doing things
2
Feeling down, depressed. or hopeless
3 Trouble falting or staying asleep, or sleeping too much
Feeling tired or having fittfe energy
you
7
8
or
on
or
as
television

noticed. Or the opposite - being so fidgety or
that you
have
Thoug~ that you would be better off dead, or of hurting
1n some
3
3
add columns:
TOTAL:
~------------------------~

tf you checked off any problems. how difficult have these
10 problems made it for you to do your work. take care of

things at home~ or get along with other people?
Somewhat difficult
Very difficult
Extremely difficuH
Page 19 of62
A total depression severity score is obtained from the PHQ-9 by summing the values of the endorsed
(circled or checked) responses. This is most easily done by first adding the values in each endorsed box
in each of the three columns and then summing the totals from each of the three columns.
A PHQ-9 severity score can range from 0 to a maximum of27 points.
The severity score is extremely useful in detel'mining if/how to treat depression and then to monitor the
progress of treatment.
PAfiENT BEALlB QUESTIONNAIRE (PBQ-9)

.
. .up.the Circlet} nurnbersin each of

the three COlumns on the. right
1 Little interest or pleasure in doing things
Feeling down, depressed. or hopeless
5 Poor appetite or overeating

6
7
Movfng
or
speaking
so
slowly
that
other
people
could
have
8
noticed. Or the opposite - being so ftdgety or rest1ess that you
have been
Thought~ that you would be better off dead, or of hurting
9
1n some ......
2:. ..
Sum the values from the three
.
COlumns toobtain a Total. severity .
.
. .
...
. ...
3
3
Feeling bad
yourself - or that you are a failUre or
have let
or
down
Trouble concentrating on things. such as reading the
news
televisiOn
or
add columns:
16
If you checked off any problems, how difficult have these

problems made it for you to do your work, take care of
things at home, or get along with other people?
SomeWhat difficult
Very difticult
Extremely dl1ncuR
Page 21 of62
an
The following table provides a guide for provisional diagnosis of depression which may be used by
PCPs. This table is presented for reference only and should never be used by CMs to advise patients of
severity of depression.
..
,...
.
..
..
:
. . .
........
.. .
.i:L;;;;:.. ..::::::.::: . /
I :)
... .
. .
Minimal symptoms *
Support, educate to call if worse;

return in 1 month
Minor depression++
Support, watchful waiting
10-14
Dysthymia*
15-19
Major depression, moderately

severe
Major depression, severe
Antidepressant and psychotherapy (especially if not

improved on monotherapy)
5-9
>20
-
*Ifsymptoms present 2: 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? ,)
++Ifsymptoms present~ one month or severe functional impairment, consider active treatment.
Page 22 of62
Assessment ofPatient Response to Treatment

The following table is intended for reference only and is not intended for CM decision making or as a
source for advice to patients. PCPs will use the information here as they plan treatment with/for their
patients.
. .
...
. .
. .
InitialResponse after Four- Six weeksofan.AdequateDoseofan .Antidepressant

.. . . . .
PHQ-9 Score
Drop of~ 5 points from baseline
Drop of 2 - 4 points from
baseline
Drop of .1 point or no change or
Increase
.:
. .....
..
Treatment Response
Adequate
Probably Inadequate
Inadequate
Treatment Plan
No treatment change needed. Follow-up
in four weeks.
Often warrants an increase in
antide oressant dose.
Increase dose; Augmentation; Switch;
Informal or formal psychiatric
consultation; Add psychological
counseling.
Initial Response to Psychological Counseling After Three Sessions over Four to Six Weeks
PHQ-9 Score
Drop of~ 5 points frotn baseline
Drop of 2 - 4 points from
baseline
Drop of 1 point or no change or
Increase
Treatment Response
Adequate
Probably Inadequate
Inadequate
Treatment Plan
No treatment change needed. Follow-up
in four weeks.
Possibly no treatment change needed.
Share PHQ-9 with psychological
counselor.
If depression- specific psychological
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.
Page 23 of62
SEC
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 and care management and psychiatrist supervision are the same .
-....-..-.........-....-...... ~~~..12,).or~ ~~~~ -..........

Traumatic experience.
Soldier experienced or witnessed an event that involved actual or threatened death or serious
lDJUry.
Soldier's response involved intense fear, helplessness or horror.
2. Symptoms in each of the following categories.
Re-experiencing of event (at least one):
Images, thoughts, perceptions

Nightmares
Flashbacks
Reminders cause psychological distress
Reminders cause physiological reaction
Avoidance of stimuli associated with the trauma and numbing of general responsiveness (at least
three):
Avoid thoughts, feelings, conversations of trauma

Avoid activities, places, people that arouse recollections of trauma
Inability to recall aspects of trauma
Diminished interest or participation in activities
Feeling detached or estranged from others
Restricted range of affect
Sense of foreshortened career, marriage, or life
Arousal (at least two):
Insomnia
Irritability
Difficulty concentrating
Hyper-vigilance
Exaggerated startle response
3. Functioning 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. Many 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 of a psychiatric diagnosis. To aid with identification ofPTSD,
a four question screen (PC-PTSD) is administered by the clinic along with the 2 question screen for
depression.
Page 24 of62
PTSD 4 Question Screen (PRINS)

In the past month, have you had any experience that was so frightening, horrible, or upsetting that 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?
NO
YES

YES
NO
4. Felt numb or detached from others, activities, or your surroundings?

NO
YES
If you circled YES to two or more of the four questions, please continue and complete the attached
form. (A copy ofthe PCL is attached)
ThePCL
If the patient answers "yes" to three or more of the four questions, the PCL is then used to assist with
diagnostic assessment.
Similar to the PHQ-9 for depression, the PTSD Checklist (PCL) incorporates the DSM-IV criteria for
PTSD into a self-administered questionnaire that helps confirm a PTSD diagnosis and determine
severity. The PCP discusses the reasons for completing the PCL with the patient and explains how to fill
it out.
Based on the number of symptoms present at least at a moderate level (~ 3) in each of the three
categories - intrusion, avoidance and arousal- in the past month, a total severity score > 30, plus the
presence of functional impairment, the PCP can formulate a working PTSD diagnosis.
Within each symptom category there are a minimum number of symptoms with a score of at least 3
(moderately bothered) is required to substantiate a diagnosis. These are outlined below and illustrated in
the next few pages on a sample completed PCL form.
. .
. .
CATEGORY
Intrusion
Avoidance
Arousal
TOTAL SYMPTOMS
.
. .
..
..
MN
M~ M
ENDORSEMENT
1 out of 5 c uestions in category

3 out of 7 c uestions in category
2 out of 5 cuestions in category
6 out of 17 questions by categories
noted above
Page 25 of62
SAMPLE OF COMPLETED PCL
have in
to
in the box to indicate how nIC h you
and conl)laints that persons

each one caA!fully, put an
-x"
5
Repeated, disturbing 11 enories,
thoughts, o ittages of a stt-essful
from the
2 Repeated, disturbing drean 15 of a
stressful e
e from the
~...,.,
~----~~-----3 Suddenly acting or feeling as if a
1
stressful expRrience were h

as if
4
X
X
it ?
~------~-------
Feeling very upset when sorrething
you of a stressful experience
from the
5
Having
reac
e~g.. ,
pounding, trouble br.athing, or

5\f'leating) when something remnded
of a stressful
from the
1
Avoid thinking about or talking about a
stressful expel'ie:nce from the past or
AvoLd activities or situations

they remind you of a st1-es.sfuf
.,
8
g
invortant parts of
Trouble re
a
e from
?
los.s of interest in things that you used
to
10 Feeling distant or cut off from other

11
or
una
for those close
er1ot
to have loving
to
12
as
cut short?
your
13
14
angry
akut" or watchful on
18
lF you checked
do
off any of the above problens, how difficult have these problens rrade it fo1 you to
take ca~ of
Not difficult
. at:
01
difficult
with ather
X
Very difficult
~w~,~..--~-,~~~---~-"'""''"""'"""''"~"N>~~'"""''''"'"'""""'"''"""''"""""'',,~~"''-'
difficult
19 Curing the last 2 weeks have you had thoughts that you wourd be better o.ff dead, or of hutting
yow"Self...in
sone
Yes
X
No
. . . . . . , '' ' ~~--~-='=~==~:
:.:.,:.::.:
:.::..way?
:.~:.,::. !, ~ ,,,,,,._,<:==~=.:.==..,..,,.,,::==::~~~;.,:,=,...,,,,...,,___ ,,,,.. .'m""'"-"""""'M -'""'"<mm-.. _.,_.,,.,,.,,.,,..~,,-.,,.,,,,_,__.,.,. ., . , ..,..,.,,.,,.._. -~""'"'""'"""-. .............,., . ._.,
lF Yes, how often?
Several days
2.
3____AJnost evetyday
Page 26 of62
UNTIN SYMPTOMS AND

A symptom is counted when the question is endorsed as "moderately", "quite a bit", or "extremely".
The maximum possible number of symptoms is 17.
:: .
. :.
. .
.
: .
. .
..
'
.
.
.
. .
:. ..
.. . :
: .
..
.. : ..
..
.
..
.
. .. . . .
. .. .... .. .
...
. c0f'1'1)1aints that pef50ns

have in t-esponse to
,. put an
in the box to indicate how rruch you
-x"
.. .
.....
.
.. ... .
. .
.
a
from the
acting or feeling as if a
?---~--------
..
..
_._______.__
.
.
~----
..
....
X
experience we-e happening
we~
~~~?--~=t======~
very upset when sort ething
asf
4
..
. .
. . .
remnded you of a stressful

from
..
pounding, trouble bneathing, or

sweating) when
rerrinded you
a stressful
e from th.e
?
void thinking about ot talking about a
from the past Of"
s-elated to it?
activities or situations because
rerrind you of a stressful
.. .
. .
.
. : .. .
.:.
. . '.. ....
.
...
..
. . .
. ..
. ...
.
:
...
.
Loss of' inte~est in things that you used
..
.
. .
.'
::
. . .
. ... .. ... . . . ..:.

. . ..
..
.
. . ..
.
....
.
.
: .
.
.. .
:..
....
. . : .
.
.. .
,.
..
.
. ..
. . . .
..
. .
. . . . .. ...
.. .
..
x
. .
..
.
...:. ..
. .
~--~~
.. . .
..
.
. .... . ... :
. ..
. : .
.. .. . . .
.
. . :. : .
. ....
. . . .. .
. . ... .
...
.....
.. .
..
.
'
.::: :
. . ..
. . . . . ...
...
..
. . . . .
...
. ..
. .
....
.
..
.
:.
..
..
~-~~""""'
:
. ..
.. .
. .
stressful
7
..
reactioons e .. g.,
.. .
. .
. ::... .
...
...X
.. . . . . .
..... : .
: . . .. .
..
. .
'
:.
. ... :.
. .
. .
. .
.... . ..... ..
' .
:. ...
...
. .
..
..
.:
. ..
. .
.. .
..
.
11
..
nul'l"il or being unable
enot
ta have loving feelings for those close
12
as
... . .
.. . .
.
. . . .
. . ..
.. :
.
..
.. .. . ...
. .
. .
.
..
. . . . .. . .
. :. . . .
. . ..
.
. ..
.
.
.
.
.
.
.
. . . ..
. ::
.
.
:.
.
.
. ... . .. . .....:
:;. : . .. . .. . . .
: . .. : ;::..
.
.
.
. . .. .. .
. .
. ..
.
.
. . . : .
.: .
.
..
. .. .
... .
.
: .
.:. . ::
.
..
..
. .
..
. . .: .
.
. .
.
.
. .
.. :
.
: .. . ...
.
..
....
. . .. ...
:: ... . . . :::....:.:: . . :: .
.
. . ..
. ..
.. .
your
..
cut short?
..
..
__........_..._.
...:.
. .
. ... ..
. . .
..
..
.
angry
" Of'
watchful on
17
sta1tled?
any of the above
way?
Yes..
how
have these
fl'"ilde
it for you to
have you had thoughts that you would be better off dead, or of hurting
Yes
X
No
l._ _Severa.l days
2._...,.More than half the days
~.;....._.Ahrost
everyday
Page 27 of62
Us
The following table provides a guide for provisional diagnosis of PTSD which may be used by PCPs.
This table is presented for reference only and should never be used by CMs to advise patients of severity
ofPTSD.
PCL
Sy~ptoms & Impairment
< 6 symptoms at moderate or

greater severity, but
functional impairment
2:: 6 symptoms at moderate or
greater severity
~I intrusion symptom
~ 3 avoidance symptoms
~ 2 arousal symptom
plus functional impairment
PCL
Severi~v
<28
Provisional
Diaxnosis
Sub-threshold or no
PTSD
->28
PTSD,
Mild
>50
PTSD,
Moderate to Severe
*Refer for co-management with mental health specialty clinician
High suicide risk
Has substance abuse
Has complex psychosocial needs and/or
Other active mental disorders (except depression)
Treatment
Recommendations
-Reassurance and/or
supportive counseling
-Education
- SSRI
- If no improvement after
12 weeks, refer for
Cognitive Behavioral
Therapy
- Specialty referral*
ifpatient is:
Page 29 of62
Suicidal thoughts are one of the symptoms of depression and may also be present in those with PTSD.
Approximately 10% of people with major depression eventually commit suicide. Suicidality may not be
an emergent (crisis) or urgent symptom, but it is always serious.
There is no good way to predict in the short term who will commit suicide, although long-term risk is
correlated with the following risk factors:
Hopelessness
Living alone
Psychotic symptoms
Substance abuse
Male gender
Caucasian race
General medical illnesses
Family history of substance abuse
Levels o(Suicide Risk

Emergent Risk Level:
If the patient has an active desire to commit suicide and has no selfcontrol or external supports (e.g.,
family and friends) for safety, then a safe means ;!Or transport to the nearest emergency room setting
should be found.
Urgent Risk Level:

If a patient has suicidal plans but is without an active desire to commit suicide. This is an urgent
situation and could become an emergent one. The patient should receive a behavioral health
assessment within 48 hours from a behavioral health specialist and/or their PCP. Take steps to ensure
that an assessment will occur. Do NOT leave it up to the patient to arrange this!
Low Risk Level:

If the patient has no suicidal plans and no active desire to commit suicide, s!he would be considered a
low risk. Further assessment is not necessary at the time. The CM should continue to monitor any
changes in this status with every contact and report any changes that indicate increased risk to the
PCP or emergency staff according to steps above.
or
~~~~~o~~
Presence of suicidal ideation including intent and/or plan

Access to means for suicide and the lethality of those means
History and seriousness of previous attempts
Lack of social support
CMs must be prepared to respond to a suicidal patient on the other end of a phone line at any time. CMs
should discuss (talk through) options for emergent events in advance with supervisors and/or clinic
administration to develop a response plan if the CM is faced with an emergent and/or urgent patient
suicidal risk situation.
As a care manager, NEVER be unprepared!

o
en
1
con
~~~~
(Use an extra phone line or cell phone and/or access other staffin immediate area to ca/1911.)
IU
w ur
as
u can -
them to
in
Do NOT wait until vou are on the line with a patient in distress.
Page 30 of62
Need to add and discuss means of contracting for safety here.

Asses Suicid
The PHQ-9 and a modified version of the PCL in use in our program can be used as a tool to begin to
evaluate suicidal ideation. Specifically, Question 9 on the PHQ-9 and Question 19 on the PCL, asks
patients ... uln the last two weeks, how often have you had thoughts you would be better offdead or of
hurting yourself in some way. ,,
Any positive response to Question 9 or 19 - anything more than "not at all"- warrants a deterntination as
to whether there are "passive suicidal thoughts" (i.e., " ... thoughts you would be better offdead ... ")
OR
whether there are any "active suicidal thoughts" (i.e., "thoughts ofhurting yourself in some way").
There is no way to tell the difference between active and passive suicidal thinking without further
questioning the patient.
The following section provides an easy-to-use strategy to distinguish between passive and active
thoughts of death. Of course, this is only necessary to use for that small percentage of patients who
indicate a positive response to the questions indicated italics above. CMs must know that some patients
who do not originally reveal any active suicidal thoughts may "convert" to the demonstration of active
suicidal thinking. CMs may need to conduct more than one suicide risk assessment on any given patient.
ALL RISK ASSESSMENTS MUST BE DISCUSSED WITH THE SYPERVISING

PSYCHIATRIST- AT THE LATEST DURING THE NEXT SUPERVISION CALL.
(Make contact earlier when in doubt.)
Page 31 of62
Patient Name: ----~----------~Oinician: -----------.J&Pt. IDl: _ _ __

Date and Time of Call:
C..are Manager Narne: - - - - - - - - - - - - - 1. i1n ih1 . ast month;J ha,'e )'OU made any plans o,r considued a msthod that j.V1U might use to harm
)~ours lf? "' (circle one) ..
..
YES
NO
NO
.
3.
'~There l
a big dijflrf81tce bemreen having a though,t and a_cting on .a th~ght. Do you .think}'OU m.ight actualiJ~
make an attempt ttl hurl J,'OJUse.lf~n the ,nearfuture.?" (arc:Ie one)
NO
(If yes~ ask., u Can you be specific about how you might do this?']
4. ;;'In t~J~~~ month JJm'e you told anyone thatJOU 14'1.1'8 going to conJmit s.vicid~ o.r threatened that )~'II might
do 1t:- (c.rr.cle one)
I~S
NO
5. ~vo }'OU. think the:rt is mtJ~ risk that J'OU might hU11 yourselfbefore. .vou see J-our doctor the next time-?"
'i"ES
(If yes, ask,
~'JJ?Jat do you
NO
think )'OU m~~ght do?~~)
.4.ction Taken to ContDct Clinician. (Indicate ('None,. ifpt. determined at .. 'Lo'K~ Rtsk')_ _ _ _ _ _ _ __
Li*3.t~P~~
~A:M AUHMMtt P.,tlf'llt'..,.,.dp~:;::.::,.of~jjvfrttt~Mdt
~ ,_
Of ~fo.r~Cl
Page 32 of62
G
These guidance notes are intended to facilitate the gathering of appropriate inforntation/detail during the
conversation and assessment with the patient. That inforrnation/detail would then be shared with the PCP
and/or supervising psychiatrist. This should not be considered a basis for decision making by the CM;
however, they would guide the action plan to be taken as outlined in the various scenarios below.
2.
3.
4.
5.
6.
'YE"
to
"on5: HActive ic
A ...........
If patient's response is "YES" to question 5, the patient will be considered
"EMERGENT /HIGH SUICIDE RISK".
The CM must contact the patient's PCP (or the covering/on-call PCP) inunediately to expedite a
clinical evaluation. (If there is on-site mental health, this will serve as a primary alternative to
PCP assessment. The PCP must still be contacted)
If the patient presents an obvious acute risk, stay on the phone with the patient, call 911, and/or
initiate best actions to ensure that the patient goes immediately to an emergency room.
If there is another adult with the patient, then attempt to speak with that person and get assurances
that s/he will accompany the patient to an emergency room OR that s/he will dial911 if they do
not have ability or means to transport.
Inform the patient's PCP (or on-call PCP) innnediately by telephone or direct contact.
If the PCP or on-call PCP is not readily available, then the CM should next attempt to reach the
supervising psychiatrist (or the covering/on-call psychiatrist/mental health specialist).
Positive ("YES") Response to Questions 1-4: t~ctive suicidal thoughts: MODERATE TO HIGH RISK"
1. If the patient has any positive answer ("YES") to questions 1-4, the patient will be considered
''URGENT I MODERATE TO HIGH RISK".
2. This inforrnation must be communicated to the patient's PCP (or the covering/on-call PCP)
innnediately via telephone or direct contact.
3. Patients at this level of risk should be assessed by a qualified mental health specialist within 48
hours.
4. If the PCP or on-call PCP is not readily available, then the CM should next attempt to reach the
supervising psychiatrist (or the covering/on-call psychiatrist/mental health specialist).
Negative ("NO") resp9nses to Questions 1-4: t~ctive suicidal (houghts: LOW RISK"
1. If the patient answers "NO'' to questions 1-5, the patient will be considered a
"LOW SUICIDE RISK". This inforrnation should be communicated to the PCP via usual CM
reporting mechanisms.
Adaptedfrom ColeS, 'Care Manager Suicide Assessment Form~ developedfor the Collaborative on Depression in Primary
Care, Bureau of Primary Healthcare, unpublished document.
(DO WE NEED TO INCLUDE HERE?)
Page 33 of62
SE
TION
Risk ofRelapse- DEPRESSION
Figure V-A above identifies the definition of treatment outcomes during the long-term treatment of
depression. The goal of the acute phase of treatment is to achieve full symptom remission defmed as a
PHQ-9 score of< 5 points. The outcomes are similar for PTSD with remission defined as a PCL score of
< 24 points.
The risk of relapse during the first six months after achieving remission from depression is as high as
50%. Over a person's life time the risk of recurrent episodes of depression is even higher, averaging 6075%. The goal of continuation phase treatment is to keep patients in remission. Continuation of
antidepressants for 4 to 9 months after achieving remission considerably reduces risk for relapse.
Some patients with recurrent episodes of depression are at significantly higher risk for future episodes of
depression. The goal of maintenance phase treatment is to identify these patients and keep such patients
on active treatment. Many depressed patients decide on their own to discontinue to take prescribed
antidepressants after remission begins. Even fewer patients with a high risk of recurrent episodes receive
maintenance treatment. These characteristics of depression treatment make it similar to other chronic
diseases like asthma or diabetes which require a chronic disease approach, not just an acute disease
approach.
Continuation
All patients with depression and/or PTSD who enter remission should receive education to recognize
signs of relapse early on and to request an appointment with their PCP or behavioral health clinician as
soon as possible.
Medications
Patients who successfully achieve remission on medication during the acute phase should take the
same dose of that medication for 4 to 9 months once remission occurs and then taper off the medication
over several weeks under the direction of their PCP. Many patients do not refill antidepressant
prescriptions during the continuation and maintenance phases. The absence of symptoms often will give
the patient a sense that the disorder is "cured" so there is no need for further treatment. As with many
illnesses, the new absence of symptoms does not mean the problem is completely resolved. Therefore,
the CM plays an important role in ongoing monitoring and promoting adherence to long term treatment
plans.
~~~l~o
ic I Counselin
A decision to use psychological counseling during continuation depends on the symptoms,
psychosocial problems, and recommendation of the behavioral health specialist.
Care
er
e
Regardless of the selection of continuation drug therapy or psychological counseling or
discontinuation of treatment, the CM plays a pivotal role by monitoring remission by assessing PHQ9 and/or PCL response at a minimum of at least one call during the continuation phase.
During the continuation phase, the CM also assesses risk factors (see Table V-1 below and the
Maintenance Questionnaire on page 36) for recurrence to assist the supervising psychiatrist and PCP
in recommending whether or not to continue treatment into a maintenance phase. At the end of the
continuation phase, patients who sustain their remission are considered to have achieved recovery
Page 34 of62
(see Figure V-A). Those without risk factors should generally discontinue antidepressants, again with
the advice of their PCP.
Table V- 1
FACTORS FOR RISK OF HIGH RECURRENT DEPRESSIVE EPISODE
1. Dysthymia (chronic depression)
2. History of two or more previous episodes of depression
3 . History of recurrence of depressive episode within one year
4. History of one other episode within three years and that the current episode was sudden and life
threatening
Chronic Depression (])vsthvmia)

What is Chronic Depression?
The essential feature of dysthymia (or dysthymic disorder in DSM-IV) is a chronically depressed mood
that occurs for most of the day more days than not for at least two years. The mood may be one of
irritability rather than depression. In addition, a minimum of two other symptoms must be present such as
poor appetite, overeating, insomnia, hypersomnia, low energy, fatigue, low self-esteem, poor
concentration, and/or difficulty making decisions.
Chronic depression can present in several different ways. In one mode, it begins in adolescence or young
adulthood and is frequently more likely a long-term personality style than an affective disorder. A
second type is associated with major depression. Dysthymia can follow an episode of major depression
and subsequently co-occur with recurrent episodes of major depression. A third mode occurs following
chronic medical disease and/or bereavement, particularly in older persons. In each case, the duration of
the pattern is a minimum of two years.
Major depression consists of one or more discrete episodes distinct from usual mood and function. In
contrast, dysthymia is chronic, less severe, present for many years, and hard to distinguish from one's
usual function and mood.
Why is a Chronic Depression Diagnosis Important?

Evidence based reviews of antidepressant treatment for dysthymia suggest antidepressants are effective.
Short-term studies suggest some patients with dysthymia respond to placebo, but in the long term this
response is not well maintained. Thus, all patients with dysthymia should generally be advised to have at
least one twelve-month trial of adequate doses of an antidepressant. This is often difficult because of
poor adherence for this length of time.
What Questions Can Help Elicit a Diagnosis of Chronic Depression?
See page 36 for a brief interview guide for DSM-IV dysthymia in the maintenance phase. Interpretation
of the answers can be helped by additional questions. A standard question is, "In the past two years have
you felt depressed or sad most days, even if you felt okay sometimes?" Another alternative is, "Have
you been bothered by feeling depressed or low much of the time for the past two years? How much of the
time have you felt this way?" In addition, asking when the patient last remembers being really happy is a
useful question that gets more at the concept and is more open ended. Someone with dysthymia since
young adulthood will have difficulty remembering period(s) of being really happy of more than a couple
of months. Such persons often see everything in shades of gray and can convey such an outlook
whenever you are with them.
Page 35 of62
Asking about any episodes of past, more severe, depression (or other psychiatric disorders requiring
treatment) and the relationship of these episodes to the onset of a chronic period of low mood or
anhedonia is helpful. Sometimes another chronic psychiatric disorder is associated with the onset.
Some persons can clearly remember and convey lengthy periods of feeling happy and do not have any
past history of major depression. Instead they experience one or more difficult or challenging life events
in adulthood that result in a persistent change in confidence and mood.
Each of these three types can have a positive response to antidepressants and warrant at least one
adequate trial, for a year or longer.
When should the Maintenance Questionnaire be administered?

Care Managers should plan to administer the questionnaire AFTER the patient has maintained remission
(score of <5 on the PHQ-9) for at least 2 months. For example, a patient achieves remission at 8 weeks
with a score of 4, but regresses at 12 weeks to a score of7. At the 16 week contact, the score has
improved to 3. The measure of maintained remission would begin again at 16 weeks. PHQ-9 measures
would then be taken at 20 and 24 weeks with the Maintenance Questionnaire completed at 24 weeks
assuming remission was continuously maintained since the 16 week measure.
Maintenance
After assessing risk factors for recurrent depression, a decision is made whether or not to continue
prophylactic maintenance treatment for at risk patients.
For those continuing in maintenance with prophylactic treatment, education of the patient regarding early
signs of recurrent depression should be completed. It is important to help them try to remember how their
depression first appeared so they can identify recurrence as early as possible. Periodic PHQ- assessments
should also be completed by the care manager or PCP (i.e., once or twice annually). Figure V-B displays
typical timing for integration of care manager and PCP visits. If at any time depression recurs, the acute
phase schedule of contacts is resumed.
Figure V-B
Page 36 of62
MAIN1::ENANCE QU:ES'fiONNAIRij;
FORM TO BE COMPLETED WITH THE PATIENT WHEN
REMISSION HAS BEEN MAINTAINED FOR TWO MONTHS
RESULTS TO BE DISCUSSED DURING SUPERVISION.
Pt. Name:
Date Administered:
-------------
------------------------------------~
'
D~eRemissionAchieved=~----------~--~---------C~ntPHQ-9: _______________
How many times have you had depressive episodes like this current one in your life? _ __
When was the last episode prior to this current one?
Dysthymia
(FOUR ANSWERS IN BOLD* MUST ALL BE CIRCLED TO MA~ A DIAGNOSIS OF DYSTHYMIA:)
I
1.
Have you felt sad, low or depressed most of the time for the last two years?
NO IfNo, done
YES*- continue
NO*
YES
a. Did your appetite change significantly?
NO
YES
b. Did you have trouble sleeping or sleep excessively?
NO
YES
c. Did you feel tired or without energy?
NO
YES
d. Did you lose your self-confidence?
NO
YES
e. Did you have trouble concentrating or making decisions?
NO
YES
f. Did you feel hopeless?
NO
YES
ARE TWO OR MORE 3A TO 3F ANSWERS CODED YES?
NO
YES*
Did the symptoms of depression cause you significant distress or impair

your ability to function at work, socially, or in some other important way?
NO
YES*
2.
Was this period interrupted by your feeling OK for two months or more?
3.
During this period of feeling depressed most of the time:
4.
NO
*ARE ALL FOUR ANSWERS IN BOLD CIRCLED?
IF SO, THEN CIRCLE YES. OTHERWISE, CIRCLE NO.
YES
DYSTHYMIA
CURRENT
DATE REVIEWED IN SUPERVISION:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

NOTES & RECOMMENDATIONS:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Page 37 of62
VII: IMPLEMENTIN -...-T--H...

E..._.C.......................,............ l.iiiiiiiiiiii~
M
ement Patient Calls
...........
~~~
Calls to patients are typically initiated 7 to 10 days following the initial office visit where the patient was
diagnosed ( index visit") and referred to care management. Subsequent calls then occur every 4 weeks
until the patient is in remission and less frequently thereafter based on supervision decisions and
individual patient needs. Other calls at more frequent intervals may be warranted and are referred to here
as PRN calls.
11
New Referral Activities

New referrals are initiated by PCPs through CHCS II I AHLTA to the CM. There is referral
documention of the PHQ-9 and/or PCL symptom/scores, the treatment plan selected, and when the PCP
would like the patient to return for a follow up visit. Effective practice also entails the PCP forwarding
the actual completed PHQ-9 and/or PCL to the CM for detailed references for patient contact. If the CM
is contracted and. located off post, then there may be a need for a consent form which will be developed
specific to the clinic/post. That consent along with the PHQ-9 and/or PCL should be delivered to the CM
(often occurring through FAX).
As noted earlier a review by the CM of PHQ-9 and PCL forms is important to verify accuracy of
symptom count and scoring. If the forms are incorrectly scored, the CM should provide appropriate
feedback to the PCP (phone call, face-to-face, or electronic CM report in CHCS II I AHLTA). The
method of feedback will be determined by the CM based on working relationship status with the PCP.
Record Keeping Set-Up

An identifying code number should be assigned for each new patient referred. Files should be created for
each patient and labeled with the code number. These individual files will be used to store CM specific
anecdotal notes and documents relating to that patient. The code numbering system is important for
referencing patients during supervision calls when specific patient identity is not used in order to protect
confidentiality. All files and patient records will be maintained in a secure manner in accordance with
the clinic/post requirements/guidelines for PHI and that complies with all local, state and federal
regulations regarding patient health care and treatment.
Pro res Notes Communicatio
Generally two types of documentation and/or forms support the RESPECT-MIL process; namely, the
Care Manager Log and the Care Manager Report. Most Care Manager Reports will be T-Cons, however
a hardcopy form is available for any sites that do not have CHCS II I AHLTA access. Care Manager
Logs are used to both guide the call during early phases of treatment and to record anecdotal notes during
each patient contact. The logs also serve as a source of data which specific sites may decide to monitor,
for example, time length of calls or number of failed call attempts. The Care Manager Report serves to
provide routine and summary information communication to the PCP following each routine contact,
PRN calls with significant information obtained, and/or after weekly supervision where there is
information to communicate from the supervising psychiatrist.
Page 38 of62
Soldier completes reports for primary care visit and

RESPECT-MIL screening forms
PCC reviews screening and evaluates Soldier
Soldier have a
diagnosis of depression
and/or PTSD?
>----------NO---------
Soldier declines
PCC discusses diagnosis and treatments options (including ~care management
care management) with Soldier and elicits preferences
option
DONE
PCC handles all

monitoring
Soldier wants
care management
PCC makes referral to CM via CHCS II/ AHLTA

regarding diagnosis and treatment plan
PCC forwards copies of PHQ-9 and/or PCL to CM
Page 39 of62
CM receives referral and completed PHQ-9 and/or

PCL forms
t
Are forms ~r-ed
accurately?
--...:>----NO--
Advise PCC of corrected

scores for medical record
CM makes Initial CM call 7 to 10 days from referral

(diagnosis).
CM introduces self, relationship to PCC and

describes process of care management
(what s/he can expect from the CM ).
CM reviews exact details of treatment pjan

(as thev apply to each case};
-what was prescribed for Rx (if any)
- has Rx been filled and begun
any side effects
-has Soldier gone for counseling
- did Solder receive educational
information
- has Soldier reviewed educational
information
-did PCC help Soldier set selfmanagement goal(s)
-is Soldier acting on self-management
goal(s)
CM encourages adherence to treatment

plan by supporting actions taken and
assisting with problem solving barriers
CM schedules next call4 weeks from date

'
of referral/diagnosis and reminds Soldier

that the PCC will receive a brief update
regarding progress
Care Management Report (T-Con) sent to

PCC briefly stating progress/treatment plan
adherence level
Page 40 of62
CM makes call at week 4, 8, 12, 16, etc.
CM reviews exact details of treatment Wan

{as they apply to each case):
-confirm what prescribed Rx is being taken
(if any)
- review for any side effects
... has Soldier gone for counseling
... has Soldier reviewed educational
information
... how is Soldier doing with self-management
goal(s)
... assist with adjusting self...management
goals if set too high or no progress
CM encourages adherence to treatment

plan by supporting actions taken and
assisting with problem solving barriers
CM re-administers PHQ-9 and/or PCL as

appropriate to diagnosis; calculates
score(s); and offers general feedback on
progress.
t
Are scores lower
than last set of scores?
>-----NO or INCREASE-_____,
CM inquires if there are events/
circumstances that could be
influencing scores.
YES
j'_
CM schedules next call4 weeks later and

reminds Soldier that the PCC will receive a
brief update regarding progress
NO
Is a PRN call
needed~ ,
YES
~-
Care Management Report (T-Con) sent to

PCC briefly stating progress/treatment plan
adherence level
CM sets time to call in next 12 weeks for PRN

~-------------~
Page 41 of62
SECTION VIII: PLANNIN
CARE
GEMENT
CT
There are a number of useful principles for CMs who are engaged in telephonic management of
chronically ill patients. The principles listed here will help with efficiency and workload over time.
Maintain a balance between efficiency (staying on task with completion of the CM Log) and
focusing on the needs of the patient.
Acknowledge the patient's issues and concerns, yet focus on the patient driving solutions rather
than extensive discussion of the details and giving direct instruction.
Encourage that the patient define his/her own clear and attainable self-management goals.
Offer appropriate assistance with scheduling appointments; connecting with mental health
specialists; setting self-management goals; and problem solving to overcome barriers to
treatment.
CMs are not the patient's mental health specialist or counselor and must be on guard not to slip into that
role during the course of calls. Calls should take approximately 20 minutes unless there are unique
circumstances during the call. If calls are running well over 20 minutes and the patient is not in crisis,
then there a need to better define boundaries for future calls/discussions. This is often a sign that the
patient would benefit from mental health counseling and a referral should be initiated (may require PCP
involvement). CMs that engage routinely in calls of30 minutes or more are likely providing "therapy",
counseling, etc. and should evaluate how to focus calls on inunediate issues of adhering to the treatment
plan only.
Nonresponsive/Elusive Patients
CMs should have an understanding with the organizationlpractice/PCPs and the supervising psychiatrist
regarding the maximun1 number of failed call attempts they will make before referring the patient back to
the PCP for follow-up. CMs should attempt contacting the patient at varying days and hours (including
early evening) through the week. There should also be a very clear limit on number of messages left
with individuals for the patient or via voicemail. Too many messages can easily be viewed as harassing.
It is better to set a limit and then attempt to make contact in writing to determine if the patient is
passively attempting to withdraw from care management.
Notations should be made on the Care Manager Log for each failed attempt to reach the patient.
Information to be included is the date, time, and outcome of the call (i.e., left message, talked to spouse,
etc.). A typical protocol is to make four attempts to reach the.patient, leaving messages at each call unless
the patient has requested otherwise, and then advising the PCP through a Care Manager Report (T-Con)
of inability to reach the patient. There should also be advice to the PCP regarding the CM's plan to
either continue attempting contact (e.g., sending a letter to patient requesting s/he call CM directly) or to
suspend efforts pending PCP action (e.g., scheduling an office visit). It is then the responsibility of the
PCP to contact the patient and notify the CM if and when to attempt to reach the patient again.
A friendly inquiry letter (see Appendix A- need to redraft) to the patient is appropriate prior to
''disenrolling" the patient in care management. The letter should offer the patient the option to continue
with care management and to verify the best phone number and times of day/week when they can be
reached. The letter should also offer the patient the option to decline further contact. CMs should
include a prepaid self-addressed return envelope so the patient will have less to do in order to respond.
If the patient does not return the letter in the time allowed (again agree on this with the clinic and key
parties - 2 weeks is usually a reasonable interval) or indicates they no longer wish to be contacted, then
the CM should notify the PCP inunediately so that they are aware their patient no longer has CM support.
Page 42 of62
CMs should forward copies to PCPs of all letters from patients that have clear responses indicating their
desire to withdraw from care management.
Preparation (or the Call

The CM's file on the patient should be carefully reviewed prior to each call to ensure familiarity with
accurate patient information (i.e., medications currently prescribed; schedule of office and/or counseling
visits; established self-management goals; and any questions requiring follow-up). Where appropriate,
the CM should transfer information from the file onto a Care Manager Log prior to the call.
The more familiar the CM is with the patient's particular information is beforehand, the less likely it will
appear a checklist is being filled out and the CM's interest in the patient's status is being reflected
throughout the call. A hardcopy Care Manager Face Sheet for patient files is available for organization
of overall CM information for each individual patient. The form offers "at-a-glance" access to key
information regarding progress, contact history and treatment change history. This form may not be
useful when the CM is very familiar with and has ready access to CHCS II I AHLTA. See Appendix A
for form samples.
R
e
l
CMs should initially introduce themselves by indicating that slhe is working with Dr, NP or PA "X" and
inquire if patient recalls being informed of the care management service. An introduction might go
something like this;
uHello, this is (your name) and I work with Dr. Smith. Is this (patient's name)? Did I catch you at good
time when you have a few minutes and some privacy? As you may remember, Dr. Smith told you that I
would be calling to follow up after your visit with him/her. Do you recall this? ..... ,
CMs must be prepared to field questions about such topics as medication side effects, what depression
and/or PTSD treatments have been prescribed (per the referral), and setting or modifying selfmanagement goals. Inevitably, a patient will ask a question the CM is not prepared to answer or would
more appropriately be answered by their PCP. When and if this occurs and the issue cannot wait,
patients should be advised to call their PCP or to schedule an office visit. If the question is appropriate
for the CM to respond to but the CM needs to obtain more information, s/he should advise the patient
when to expect a call back with the requested infonnation. The CM should note patient
concerns/questions on the CM Log along with the plan of action.
It is recommended CMs use the data sections on the CM Logs as a guide to forming questions while
talking with the patient. If barriers are identified, prompts are outlined in Section VIII, which may be
used to offer assistance or help the patient.
It is important to systematically review the details of the patient's treatment plan as prescribed by their
PCP during each call. The initial CHCS II I AHLTA referral should provide a great deal of information
needed to assess adherence during the initial one week call.
rD
Ca
Medications:
Verify medication has been obtained (a good tip is to have the patient bring the Rx containers
to the phone and read the information on the label)
Confirm level of dosage/time of day being taken
Confirm the date when medication was started
Inquire about any side effects
Page 43 of62
Identify any barriers to taking medication as prescribed

Offer suggestions about how to counteract side effects (see page 13)
In some cases, the PCP will ask the patient to start with a half dose for a week then increase to the
full dose. If this is the case, be sure the patient is complying with this plan. In the cases when this
gradual approach is used, a repeat call one week after the initial call is reconnnended to be certain the
patient has increased the medicine appropriately and no new side effects have occurred.
When the side effects are difficult for the patient, this information will often be communicated
readily. When the side effects are more subtle, the patient may need prompting/questioning. Patients
may not understand that what they are experiencing is a side effect and/or that it will subside or go
away over time. This is an opportunity for the CM to educate the patient about side effects or to
guide the patient to contact their PCP or pharmacist (they are often able to provide specific
information regarding less connnon side effects). Side effects that appear abnormal or extreme
should be brought to the PCP's attention by the CM as well as advising the patient to contact the
clinic promptly.
Psychological Counseling:
Verify name and type of mental health specialist (MD, PhD, MSW, clergy, etc.)
Inquire whether appointment(s) was been scheduled and/or completed
Verify the recormnended frequency of visits
Identify any barriers to participating in psychological counseling
Patients may also be involved with support groups (PTSD groups are comntonly offered).
Verify that the patient has been referred, knows the location and schedule of the group, and
that the patient is attending accordingly.
Patient Education:
Verify what written materials the patient has received
Verify whether patient has reviewed written materials and set goals if not
Send/mail appropriate materials or resource listings (books, etc.)
Discuss key points within the materials
Provide information in response to patient questions or concerns
Self-management goals:
Determine if self-management goals were established with PCP
Assist patient in setting goals if none were set with the PCP and/or different goals are needed
that can more easily be attained
Assess what progress has been made
Assess appropriateness of current goals and likelihood of success and/or assist patient to
modify goals if set too high (simple, small steps to begin with will lead to a stronger sense of
accomplishment and self-management)
Re-adn1inistering the PH0-9 and/or PCL:
Remind the patient of the form(s) s/he completed at the PCP's office
Administer the PHQ-9 first (skip to PCL if there is no depression diagnosis)
As a timesaver, run through each questions asking for only a yes or no to whether s/he has
been bother my the symptom noted. THEN return to the ''yes" items and provide the rating
scale (e.g., not at all, some of the days, most of the days, nearly everyday).
Page44 of62
Quickly calculate the score and give the patient feedback and general infonnation about a
decrease in the score and offer encouragement that slhe is on the right track.
If there is no change, be supportive and encourage the patient to "hang-in" with the treatment.
This may be a patient that should be called again sooner than 4 weeks to check on progress.
If there is an increase in score, provide general feedback and ask if there has been anything
different going on since the last scores were obtained that might indicate why they are feeling
worse. This will be very helpful during supervision in making decision whether to bump up
an Rx dose or to stay the course when the increase may be situational.
If there is any positive endorsement of the suicide question, then complete a risk assessment
inunediately as outlined in Section V.
Next Office Appointment:

Confirtn schedule of all follow-up PCP appointments for depression and/or PTSD
Communicate importance of attending all follow-up visits
Identify any barriers to attending follow-up visits with PCP
Patients should always be given a final opportunity to verbalize any concerns regarding their treatment
by asking, "Before we hang up, is there anything at all that you are concerned about regarding your
treatment that you haven 't already mentioned? ,,
By asking this question directly, the patient is encouraged to voice things that may not have surfaced
earlier in the call. Also, patients should be reminded that a brief summary of the conversation and the
results of the PHQ-9 and/or PCL (ifre-administered during the call) will be sent to their PCP. The next
CM call should be scheduled before hanging up in hopes of decreasing failed contacts for subsequent
calls.
-i
PRN calls may be required for a number of reasons and are generally initiated based on the CM's own
decision. There are also times, however, when the PCP and/or supervising psychiatrist will request more
frequent calls based on patient status. These calls are often shorter than routine calls as outlined earlier
but are often of great importance for those struggling with treatment. CMs often give one or more of the
following as reasons for a PRN call:
Patient has not begun the full dose of medication; has had a change in dosage; medication has
been changed; or additional medication was added.
Concern the patient will not continue (or start) their medication due to ambivalence regarding
diagnosis; presence of side effects; concern about addictiveness of medication; etc.
Patient is having difficulty with or wants to discontinue counseling; needs help getting an
appointment; and/or is seeking alternatives to counseling (clergy, support groups, etc.).
Lack of privacy for the patient or chaotic situation during scheduled call (e.g., children present).
If a suicide screen was conducted during a CM contact and there is a need to follow up.
or~
Communication and Coordination with the PCP

A sununary of each patient contact should be prepared using a Care Manager Report form (T-Con). Only
essential specific details regarding the patient's adherence to the treatment plan should be noted as well
as any specific critical barriers identified. These reports should be sent to the PCP at least by the end of
the working day and prior to known scheduled follow-up office visits for depression.
Page 45 of62
Matters that appear urgent I emergent should also be conveyed by phone as soon as possible. Electronic
or Faxed reports should still be initiated but should not be considered the sole or primary means of
communication under such circumstances.
'
Page46 of62
o a Care M
~:~A~~~~o:!:.rLP~C~~~s
What Should a PCP Expect from a CM?

The CM will call the patient at routine intervals (at 1, 4, 8, 12, 16, etc. weeks) and administer the
PHQ-9 and/or PCL approximately at monthly intervals.
At the request of the PCP, the supervising psychiatrist, or at the discretion of the CM him/herself,
more frequent calls may be made.
A written Care Manager Report will be sent through CHCS II I AHLTA (or Faxed when
electronic connection is not possible) to the PCP after each routine call and after PRN calls as
appropriate (some will not watTant a note).
The CM will review newly referred patients, patients who are not responding, and problem cases
with the consulting psychiatrist during weekly supervision.
The CM will communicate those recommendations for treatment made by the supervising
psychiatrist via T-Con, e-mail and/or phone call to the PCP and/or patient as directed by the
supervising psychiatrist (e.g., take an Rx in the AM rather than before bed). The supervising
psychiatrist may call the PCP directly to discuss treatment options.
The PCP (or his/her covering PCP) will receive a telephone call if there is an emergency
situation, e.g., when a patient is at risk for suicide.
The CM will provide basic patient education about depression, PTSD, medications, counseling
options, and self-management goal setting.
The CM will facilitate adherence to all aspects of the prescribed treatment plan and report patient
inability or resistance to implementation to the PCP.
The CM will identify barriers to implementing the treatment plan and help the patient problem
solve and identify solutions.
The CM will make at least 4 attempts to locate the patient for initial calls. If, after this "good
faith" effort, the patient cannot be located by phone, a letter will be sent to the patient (copy to
PCP) indicating that if s/he wants to continue care management s/he should contact the CM.
The CM will provide notification to PCPs of patients who are disenrolled from care management,
along with the reasons for disenrollment. Reasons may include patient withdrawal from the care
management process, failure to respond to calls for extended intervals (not due to work
assigrunent), ETS, etc. Patients relocating within the military to another CONUS post may
continue to be followed by the CM.
The CM will assist as appropriate getting follow-up or specialty visits scheduled with PCPs,
Division Mental Health, etc. The CM will advise the PCP when s/he is unable to assist.
What Should a Clinician NOT Expect from a Care Manager?
The CM will NOT review extensive historical, medical or psychosocial information about the
patient in CHCS III AHLTA. If the CM would benefit from some specific information contained
in a medical history, PCP should advise such a review.
The CM will NOT provide counseling or therapy. If PCP believes the patient would benefit from
psychological counseling, and the patient has chosen not to accept this recommendation, the CM
will attempt to gain agreement from the patient and then facilitate a referral.
The CM will NOT have in-depth discussions of family difficulties, loss and grief, or other
psychosocial issues. The CM may suggest options for social support services for families.
The CM will NOT make home visits.
The CM will NOT speak separately with family members outside the presence of the patient and
only at the patient's request if it is appropriate..
Page 47 of62
Sample Scripts
Initial Week One Call- Ba11iers to Treatment

Patient Has Not Begun Taking Medication for the Following Reaon(s):
PATIENT MIGHT SAY:

"I dm1 't re.nlly feel t/#pri!S:sed "
~J don 't think that .I am that depressed ''
"I am rett~tJ jU6t strested OUI. ''
EXPLORE BY ASKING:
~~ Jlt1Jat do yo.11 think is goiiB 911P 1'
INTERVENE BY:
Explaining to the patient that their prinacy. care clinician believed they are depressed
and that treatment would be helpfUl.
EX,plore wJ.lat is uncomfortable abc;nn the di~gnosis (40 tlJey leuow $ottteone who- is
depressed or seriously mol1tally il.I and pt.rhaps tllis is f[i ._, . . eng to them.)~
Explore what they belitave having ~.,~pression!-t meat\$ ano dispel some ofthe n1yths.
If a pmient conti11ues to -be adamant that. tbey do~~ have ~pression, acknowledge
ibeit stance and focus mote on what symptomsH tb.ey have.
FQr e.xcuJ. Hte~ ~uggest.1hatthe otedi~ation tlrey ha:ve been pres.c.ribed \vill help relieve
their d oult}' sleepmg.
If after ~lkin~ ~~ wi~ th~ pat,ent,: you-~tink tM,tbe..orshe i~: ~~~UliJ more a~ut
the ud1agnos1S ~ - you mtght me.nti0n tbat tdcprcss1on~' ts a oombmatlou ofthe vanous
symp.t~ that. thtty ate "-.Jt.periencing... difficulty sleepin.~ feeling hopeless, etc, .(areas,
they checked otfQn 1lie PHQ-9).
PATIENT MIGilT SAY:

J am jtut not o ,.dk111ion- kh.'d ofp~''-." "
EXl,LORE BY ASKING;
~ lf-'11111 ~perhmce l1qveyo.u lt.\atll:Wih ,_,icatwn in th~p.pt?"
lN.TltRVENE BY:
tb
.
..
ti
I
.
di. ...:
h
.b
.
'
1
H
. c;.p1.ns e. p4ttent c~ll,ore: sJtua oh& 'v.ten me .calion u o;- . . as cen Jtccewsary~
lielp dtetn to see. that medication for d~ion is no different Jhan a. medicati,on for .high
blood pressure or diabetes tor otbor conditio._ that thoY may. m.en.tiQnJ
Someti.tnes givins tbe "bU$ analogy"-ittbo.Jp.ful. Expl'ainingto fl_po.ie.nttha.i tbey may
be able to g~t beUer wilbo.U\ ttu1dicine however, 11 \vill be a ~eat deal 1nore di:fficult.
Much like-.a petson who has.a.$ptaine.d legHaod,bas totrav~lfrom.pointA.to -~oint

B.. that person could walk-but taking the bus would be a. lot easier.nnd faster~ Itt tho
bus analogy, one~ the persons leg -has heal_,d- slhe will o()t,need tit~ bus btlt.fur the
sborr~tcrrn. tbe ptt'$()tl is,taJdng-.t
__ .. _eof.thc h-.Jpfh41isvaill\bl~! This i.k1rucfor

going 011 medication. Medication can be a_ temporary lt~Jp. f.ot. a pAtient during difficult
tin1~H. Eventually, people.,de-v~l<)l> the skills to not need the, ntedicati(ln anymQre.
Page 48 of62
Also; it is helpful to me.ntion here that some patients even find that they teel so ntuch
better on the medicine that they choose to Hremain on. it indefinitely.
Gently rentind them that their problems and concerns have not gone away on their own
and usual.ly do not go away spontaneou~ly for m.ost pcop1e.
,
PATIENT MIGHT SAY:
''I don't want to be on .a depression medicatio11. ~,
-1 wouliln 't "HYIIJt an.vone to knDH thllt I was on a medicotionfor depression. ''
EXPLORE BY.A.SKJNG:.
"JVhat-isyOJWconc~n tlboutbeinB
on ttmedietliiDilfor tl(!pta~:ifln (thtzy m11J1 kntJW
6011feOHe w/10 htttl blltfri* tdf/JCII) ?"

Or tbey may be con<:.Qmed abotat the g011eral stig.tna or bou1gjudged by se.mconc i.tt.
particularT
u:w.Jro do.you;thinft willjudge.ybll hanhfyfor .
. 011 metliclllioll?lt
INTERVENE' BY:
franting tho iss\1e: oftaking ~ncdlcatio.n as
care of1hentselves and ssk tbem to
think about bow olbel'$ triigktj ud.ge them ifthy we.m perceived as not taking care of
themselves.
EA-pla.itt that d:epress1otl is a ;mediclll condition that happetlS. wh~ someQne is lacking
certajfl neurottansmmer,clt~icals in .the brain,
It is not a cbataclct O~w or matter Qf wi Upower or a need .for. a pc.~n, to just +~ull
1hentselvea up by thcr=ir boo.t41;1taps,.. .
Ask:iftbey have ever bad pt k:110W someone who bas l1acl'diabetcs or pneUmonia lltld
.has to 1uke m_,dication. \Vould we expect tbe.n1 tojUst 'pull thenl.Selves up by their
,
bo<>~lra,ps''?
Rehearse \vhat the. _patient can telltheil: fiupjly abaut the med.ication thatthey -~
taking atld the COttdition tbat they have~ Offer t~ send dJe.mthe tnedieatiott edueatiotlaJ
pa~kcl.
PATIENT MIC7HT S/\Y:

,,,1 don't lllltlerRtlllillvhy rhe prillttrrJ' ctll'e c/inicitln presa.i/Md till$ medicillio.n. ..
J'fdon ., even k:ntm ttthllt thimedicfllitllfliof!:f; t
EXPLORE BY ASKING:
..
INT-ERVENE BY:
Taking the 9ppo.rtunity t.o educate tbepaticnl:onHhow. their J.Dcdlc.ation worb {oJl'crlo JQid .
dtoJrted.icatio.n cdacational fufonnat:ion.
ifdy luw.e ~cived it-. cfter,'to J'O'IiGW :it \titll
tbot.n),
.
Recommend that they ahao talk tp th;ir pri111ary cateclinician at tlleir ncxtvisit.aboutlhe
medication and why the.y were prcecnocd' it.
.
..
Page 49 of62
PA-fi.ENT MIGHT SAY:

'J don ;t want to be on the medicine forever, "
"1 don 't want to become at/dieted to it "
EXPLORE BY ASKING:
'iHtWe yo letUYI or lm.own about
''
EXPLORE BY ASKING:
.~ Have you numti.OiJedtliif.,ttJ)'tJU.r_prU,UU,r etare clbJicllw ?'
.. If they ba.ve insuranee but ~ un~re abriut their q1enW bc~ltb cove~e, Nk:
Haveyotl, cQ/k,4the B(IIJ 11o11-tle b.tlck ofym.lr inllltce ctrdtot~tkaboutyour
~M~~tnl heolth et~vu~~ge?"
INTERVENE BY!
~
Suggestingthattll.ey dist,USstbia-withtbe.irprimaty care.~inieian becalJ.SeJhcre are generic

dru~, <dm.g ampl~ Qr v.ouebe.r pro8f3JU$ .f().J; pooplo wilhourprt$eriptioninsur.noe coverage
or mmb\ll'tenient.
llelp than to fuid the= mental healthlsubsl111 -abuse 800# on their insl.lflllcecar~t
OJrer to call their insurance oompany for lhell\ if you so111o, ~hal ~Y are.~t too
overwhwme<t
Page 50 of62
Initial Week ()ne Call- Barriers to Treatment

Patient HilS Not Scheduled Their
ftJr the FtJiloK'ing Rea,on(s):
With
11 Menta.l Health
Specialist li't
PATIENT .MIGIIT SAY:

''//rave b~en befor~ a11d/ound that it wasn't very helpfuL'~
EXPLORE BY ASKING:
"flow long ago was it that you -e11t to co11nseling?"
uDidyou like the mental healtla specialist you smv?
'JJow lo11g lJ'B"e you i11 counseling?"
''Do you k1rmt specijieaUy wlrat il was tlrtll you ditln t like about the experie11ce?"
INTERVE.NE BY:
EncourJ.ging the patient to ex-plore the rea.~ons why the counseling wac; not helpful.
By helping a. patient to understand more about wbat they didn~t like in their previous
counseling e~11erience, a patient can beoorne clearer on what tb.ey do want and you
tnay be able to belp thetn find the right situation.
P.:-'\TIENT l\11GHT SAY:

'(Jh, !/raven 't lrad a cha11ce to Cllll someo11e yet, I've been bl1sy. '
"1 just am 110t sure ab011t Mlrether I want to go rigl1t noM'. ''
EXPLORE BY ASKING:
..Do .~ou l1ave IIIJJ' que.ftio11s about vl1at ~.ow1seliltg is like?"
Jfbllld)ou like help ~chedulingm1 appointment?"
INTERV"E.N'E
"
~. -~ .8\'
Educating the patient about wbat to expect front counseling.
Certai.nly validate the. persons feeling ofbein~ busy (this ~ay be. very true), however,
often tt t.c; the wderlytng nervousness or amb1valence that ts behtnd the person
procrastinating scheduling an appointnte11t
PATIENT 1\11GltT SAY:

'J am not lhat bad off.''
".1 haven 'tgone tl1111 ~-r,qv Jel. ''
J4:XPLC>RF.: BY i\SKlN(;:
..:Do you Jcnow lln)wne ,.,o ha 1on~ 1/J counselin1? ~'
If yes~ aslc 'JJ71at did tllllipeno~t ttl/ you?'.
lNTER\tENE BY:
ASsuring them that the truly "crazy~, or mentally ill people do not go to counseling..
Rather" it is the llealtby pet)p)o \llho seekbelp by going to 4. mental healdl $pecialist.
Page 51 of62
PKfiEN'f MIGHT SAY:

'~1 htne left Jtu1.ltiple messages 111 the mmtaliJI!Illth. center and no one hm gonen
lxlck to me. ''
'No one seems to answer the pho11e when I CtlU. ,.
EXPLORE BY ASKING:
'' WouldJ~ou like help schedulins the appointmBtJtt''
INTERVENE BY:
Ot.re.ring, to help them set ~p,the firSt appl)intrn~ht You q~ay run into difficulty a~
well but oRen ca.lling .fr.o.m a prin1ory care ,clinician~s otlie can obtain u quicker
re~ponse.
Page 52 of62
Week 4, 8, .12, 16 CalL~ .. Barriers To Treatment

Patient is Con~fidering or HilS Stopped Ttddng Medicine for the FA .
!
Re.ason(s):
fl
PATIENT MlGIIT SA\':

'i/ htne t~feeling ofdrynes1 in-.119' mouth.''
EXPLORE BY ASKING:
''How long has tl1is been goi.trg on?"
now bothersoms is the t#rJ' mouth for you?''
INTERV.ENEBV:
Ex-plaining that m.~1 side effcctA will subside .or gl1 aw~y within a few weeks and if
the side etl'el-1. i~ not very butbe.n;otne; ~hey should be patient
Give_ tips on h~. ~ otctnage; tbeit symptoms,i ~or example. sucldna on bard: sugarless
candtes 81ld dttnking water ofte.n can help with dry motrth.
taking the JnediciJ1e with food can bdlp: with stoou&cb upset.
If the side effect i; very bQthers(lrn.e, e~'})lain thalfindiog the right rnedio{tJ'e can tak().
son1e trial-and error.
A patient rnay t1eed -to tty sevetal dim.reot D1edtines before ftnding tlte. ,right one for
.
tbetn.
Acknowledge that this process can be .ftustrtttln& as people want to just.feet better, not
ex~Jimerit with Pl')d:ications~
fmlp.ha'\tze, the irnportence of talking to tl1~irprim_, ca.te clinician about.tbeir side
effects.
Ce~inly~ if1he. patic!nt: has .stopped -~akin.$ !the.it ntedici!W. q,r f<!U settse tbey are
gotn .to, en.coutage tbe: patienl 10 call thtr pr.unary cate ~IJt.uctan~s office \Ybtm you
cone ude your call. (See.Antidepressant,SideEffeet)
PATIENT MIGHT SAY:

4
' 1 amftellng ""'eli bettllr so, I dt1n 'tndlo ke.llJJ taking the
,,
EXPLORE BYAS~KING:
!
First say thttt :it is great tha.ttbe tned:icine 1tas helped them.
E~])lain tlutt often ;when people feel better tncy want to ,top the medicine but. for these
medicines~ it is best to remwtl on fc,r period oftin1e evota wbe.n feeling ~-tter~
1ne decision when to stop medicine Jbould be made with 01eir, prinnuy care clinician.
Page 53 of62
'
PATIENT MIGHT SAY:

n1 don't feel a11y diJferent than I tiUl before taking the ltUldkatitJn. n
"I don't undsttmd why dlingsn.'e not getting btltl~,
EXPLORE BY ASKING-:
''When did you expect that .vou. wouldfeel better?"
''What did your primary ct1re c/inida1J t81l yo about when you slaould begin to feel
better?''
INTERVENE BY:
E~11lainiJtg tbat it can. take up to 6 weeks before patients; feel the pQJitive efte.ct of a
mcdic-afion~
lf after this th1le the patient s.tiltfcc\8 n.o po.sit.ivc e,tfect. thcsl they $ltQ~ld taU~. to tbcir
primacy eve c]inici~n ahp~t trying a diffCit.nt .n1cdic:irl.e (see medication sccliJJtlfor
suggestions .Qn how tQ.educate patiettt about m.edie.ation tte,ttnent
tilneline),
.
EXPJ~RE
..
..
..
BY ASKING;
'' W11at were .v.o"' expecllltio11a 11bout CIJruueling wl1e1l you beB.llll ,,.,
'(j)itlyorfeel thillyou wnnecte4 with y.our~ntlll heo.llb,,pllQi.llilt1'
uHQ\'f! ytJU e)eJ' bun. in CQIIIJ1elin8 i,n the pllll'! ''
ff. ,.TVQC!
vp"Io ~e what th..4ft+
""or enl
...
.. wa~ l':Le
1.1\i t
. '
. ..
'i!'i 'a' ft.
... '
.. .
. .
uq .
t.J l .
INTERVENE BY:
lie lping the patient understand wlty they want tQ $\Qp Q();llf\SCiiJlg.
Sometitnes it is more a matter Q.f:a patient being With d1e V\'rong mental health
spoc:ialist "tbas1. co\Utteliag itself being not helpib.l tbr the patimrt.
Ltse this opportunity to ~"cate. the patient 011 what to cX])ect from com1selillg a~d tile
time frame to expect ehan~s.
Page 54 of62
SEC
ON
ATAMANAGEME ......
Care Man ement S

rvision Calls
CM supervision calls/meetings are generally scheduled weekly. Participants typically include the CM(s),
the supervising psychiatrist and CM supervisor. The CM and the psychiatrist, based on a standardized
supervision agenda created for this care process, establish the format for the call. In some cases, the
clinic or organization's primary care physician leader may also be a regular participant.
An Excel spreadsheet (see sample on following page) has been developed and serves as the supervision
agenda and helps to structure the call. This CM Agenda should be forwarded via encrypted e-mail to all
call participants in advance of each call.
In some cases where several CMs participate in the supervision call, data may be compiled separately
then consolidated into a single supervision agenda for the meeting. It is recommended the agenda be
completed and forwarded 24 hours in advance of the supervision meeting to ensure access. Participants
will also benefit by familiarizing themselves with the information in advance. Use of a CM specific
patient ID system will provide confidentiality when more than one CM is involved in the call, etc.
R
and
io d
io
The following sections will serve as a guideline for the type and level of detail to be summarized for
review with the supervision psychiatrist. Other info may be needed to provide clarification of a patient's
status and the "Note" section for each entry offers a good mechanism for that.
Enrollment Status
Total number of patients in "registry" (total number of the patients that are being actively
monitored)
Total new patients referred since last supervision call
Review of Cases
For an initial period (3 to 6 months), all new patients referred should be discussed to allow the
supervising psychiatrist and CM to gauge what level of detail is required for effective review of
cases. This will also allow the participants to gain a sense of whether information is being presented
appropriately, at the right frequency and with an efficient amount of detail.
In addition, this provides an opportunity to look for trends in PCP treatments that might benefit from
a general communication by the supervising psychiatrist or the CM to the PCP (e.g., need for
information to
PCPs about benefits of sleep aids for those with PTSD; best SSRis for PTSD; when to
Rx dose, etc.). After this initial interval, the CM should bring up only those new
bump up the
referrals/cases that
raise red flags.
Agenda Spreadsheet
The following page displays the categories of information that are reviewed each week for individual
patients. Cases are brought up by CM specific ID code rather then by patient name. These ID codes
do not reflect ID numbers within CHCS II I AHLTA. Clinics with in-house behavioral health and
care management may, however, choose to discuss individual patients by name as long as
confidentiality is maintained. The agenda fortn for patients with recent PHQ-9 and/or PCL scores are
presented at each meeting as well as for those patients who may be having difficulty with treatment
adherence, side effects, or other events that may interfere with treatment.
Page 55 of62
SAMPLE SUPERVISION AGENDA PAGE FOR AN INDIVIDUAL PATIENT
,Gender
'
Ref.. Date
Ox
2DWks
Wks
RxTi
P.tedication Name
startJ [
Date
.!!!&.
Refused
Barriers I Side Effects I Tx Issues
Page 56 of62
APPENDIX A
SAMPLE FO
S FOR THE C
AGEMENT PROCESS
Page 57 of62
Patimt Name:
M F
.DOB: ~-- 10#:_ _~---:------:--Altentate Phone II (
) __ _ _ _ (Type_._ _ )
Primary Phone# < ) -~

.(fwe_ _ _ )
Allowed? No
Yes- details:
----~~~--~----~
..
/JmDArs & TIMBS TO CdJJ.; Mon. Tues. Weds. Thurs. Fri.
liME;
Address:
-----------------------------------Momins Noon Afternoon Evening
Ctim~------------~cwm~
~-~~~m~',~T~d~.----------~F~AX~:--------------------------------------,~.
"*I
... .
"""""'"- .. -
-- .- ........
SCHEDULE OF VISITS Wll'HPCC
Nat.omce
IMel omce
Nett'omc:e
VIsit
Visit
Vtalt
o _ _ _,,.............._,._
-~----_....
~'~
--'
-~-~......
Nttomce
VIsit
>,__:~~~o-.::IBH
...___
. . . li
W(
Nl-)')')o)Wt_ _. . .
- .......
Nest om~
VWt
NeltODlet
''
Vl51t
'
...
Nt.Uomce
VI$It
Ntltomae
'
'
)-- -
---"' -'
..
~'-
coNTACT
-~'"~
Ill a
'
'
'
'
VIsit
....-........
owu-ow
"
Natomce
Next.OIIlce
VIsit
Vl11t
>
&RECORD
'
'
'
,'
T~
l"'iil.... ~-~ ~ ..
: :::: ::: :
) ;
' ' '
1' tt()r~;, 1~ .t. or.~.

... CrJmplete
Silicide
A#I!UIIIiltt;lfQaudon
-'-i''
,.
(
19
..
..
&ct~tddem;led/l'(ltes:iJJ& pt. "YHitltet log& CM RtpOrt.

:
:1
::
Dale:
::
I I
::
I~
. . . . ... ... . ..
. ... .
'
::
::
I I I I I
Date:
I I I I
.
. . ... .
. .....
.
.. .
. .. . . .. . . . . .....
Page 58 of62
CARE MANAGER CONTACT LOG- DEPRESSION & PTSD

Patient Name:
AddteSt>:
Practice:
M F
DOB:
ID#:
Date oflnQex Offiee Visit:
-----------------I
I
-
Clinician:
--~----------------------------Primary Phone # ( ...... ) .--..,... - - ,............. ---~~. . (Type--~--~-,,._) Alternate Phone # ( _)
.- _,-.. .*-- (Type-~..... ..M~,- )
Call Interval ~~-lit~ qf!bltilfJ: l Wk 4 Wks 8 Wks 12 \\'ks 16 \Vb (_jWb
Call Type:
Initial PRN Routine
Phase:
Ac\ie Continuation Maintenance
Completed CaD- Date;
I
I
Start time . :
End time
:
Total Time:
minutes
M
Home
AvaiL
I
' 1
I ;;
I I
Jl
#3
;Pfescri.pti.QPS tilled, .but nQt bc.gUll

Prescriptions .sto.ppo4 by:
(tllcek wttl
Patient
PCC
Other(
)
AdUitional pte$Ct1paoiis 'fit1e. but nOt 6egwi"" ~~PP!$CriptiOIJS bcaun and/or cattinued .dlrecteci
II I
.activity
Pleasum&Ie.aotivities
Support from. pe~J)le
~tier; rdaxation
Simple.
. steps
Improved nutrition
()tber
...
..
~' '~.
~
..
b..nl Ptofe$$iont~l DiBclplihe; Pl)-cbietrist ~ogist

s~~ Workar
N~ a~ Ot11et f __
Next ApptdAte~ - ./~../~-
1-requency ofAppts~_- - - : - - - - - - - - - - - 11 Appf&lsessions CODiplcfecl:::...- . # Appts/sessioJUl IWssed:... ,.._............. Reason;;______... .. . ~..~.,..
oOX""' . . . . . _ )
H ...
Page 59 of62
111CDdS
ily,~
No accessible oounselor
Insimanaged care problems
Counseling costs
MissedlfCI"got -.ppt
No transportation
Excessive wait for appt.
uncenainty about counseling effectiveness
Other-
Score
Symptoms
Question "I"
Funettonlng
* C.i1l!!R111.1fL~!JJ.lt:Jil.t.ti~R!N.flll. . I..Qwm~. .~c_8t;.g:~.,..ti.,J~1.,1,..,l1t:fatMmml..0tntQI!ie~
Passivctb.ouibts ~tdiOli. rcqUirtd

.
..
A21)ve
,tmfl dttion8 IDbn fooltJdina cfialr.IRUSR'IJlf.ljt
..
..
= ; .
'
.:
CRmPlttfuiiii!Nma.f!1 i!Qw.tli91J. tt.lJil ,ICOl\! ,, },, 1 AC 1

.:llawnmtClutcant~
PassNo:tltqbU Clilytno action recpred
~~D tboUJbaa ~
'
''
..
CMCal
DateofNesr
.....
eli
..
'd
~JJ&;h
.........
. CJosr Notes"'
c---..t tnvl GlrioiU tulrb.-im:l1iilln8 timtti.!!tJl~t
; ;
. I
:1:1 I
il I
I I I
:;
I I I I H
I I I
:;
; I I I I I
Date;
1/N() IPJ!L.
I
' .
:I
Routme ca1l
PRN;.. Issue.:
Batt:
(~reiJ
.,.
:I
:.
I
I
' '
' .is
..
-----J. . _ '
!lw$
....~.......
....,;.
. . . lilt(Y ~
.
. $r
. .~,;,.l.l;;ihM'''j;
u-.:wnr_,llf', (IUif,Q!JIIIaWt
... ,~
Page 60 of62
References
PHo-9
Spitzer R, Kroenke K, Williams J. Validation and utility of a self-report version of PRIME-MD: the
PHQ Primary Care Study. Journal of the American Medical Association 1999; 282: 1737-1744
Kroenke K, Spitzer R L, Williams J B. The PHQ-9: validity of a brief depression severity measure.
Journal of General Internal Medicine 2001; 16(9): 606-613
Rost K, Smith J. Retooling multiple levels to improve primary care depression treatment. Journal of
General Internal Medicine 16: 644-645, 2001
Kroenke K, Spitzer RL. The PHQ-9: A new depression and diagnostic severity measure. Psychiatric
Annals 2002; 32: 509-521
Williams JW, Noel PH, Cordes J A, .Ramirez G,Pignone M. Is this patient clinically depressed?
Journal of the American Medical Association 2002; 287: 1160-1170
Lowe B, Unutzer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment
outcomes with the patient health questionnaire-9. Medical Care, 2004. 42(12): 1194-201
Pinto-Meza A, Serrano-Blanco A, Penarrubia MT, Blanco E, Haro JM. Assessing depression in
primary care with the PHQ-9: can it be carried out over the telephone? Journal of General Internal
Medicine, 2005. 20(8): 738-42
PTSD Guidelines
Ballenger JC, Davidson JRT, Lecrubier Y, Nutt DJ, Foa EB, Kessler RC, McFarlane AC, Shalev AY:
Consensus statement on posttraumatic stress disorder from the International Consensus Group on
Depression and Anxiety. J Clin Psychiat 2000 61 (suppl 5)60-66
Management of Post-Traumatic Stress Working Group. VA/DoD Clinical Practice Guideline for the
Management of Post-Traumatic Stress, Version 1.0. West Virginia Medical Institute and AXCS
Federal Health Care. 2004
Pizarro J, Silver RC, Prause J. Physical and mental health costs of traumatic war experiences among
Civil War veterans. Archives of General Psychiatry. Feb 2006;63(2): 193-200
Schoenfeld, FB, Martnar CR, Neylan TC, Current concepts in pharmacotherapy for posttraumatic
stress disorder. Psychiatric Services, 2004. 55(5): p. 519-31
PCL
Blanchard EH, Jones-Alexander JJ, Buckley TC, Fomeris CA: Psychometric properties of the PTSD
Checklists (PCL). Behav Res Ther 1996;34:669-673
Walker, EA, Newman E, Dobie DJ, Ciechanowski P, Katon W, Validation of the PTSD checklist in
an HMO sample of women. General Hospital Psychiatry., 2002. 24: 375-80
RESPECT-Depression and the Three Component Model

Dietrich AJ, Oxman TE, Williams JW Jr, Schulberg HC, Bruce ML, Lee PW, Barty S, Raue PJ,
LeFever JJ, Moonseong H, Rost K, Kroenke K, Gerrity M, Nutting PA: Re-engineering systems for
the primary care treatment of depression: A cluster randomized controlled trial. British Medical
Journal 2004; 329:602-605
Oxman TE, Dietrich AJ, Williams JW Jr, Kroenke K: A three component model for re-engineering
systems for primary care treatment of depression. Psychosomati~s 2002; 43:441-450
PTSD Ba round
Hoge CW, Castro CA, Messer SC, McGurk D, Catting DI, Koffman RL: Combat duty in Iraq and
Afghanistan, mental health problems, and barriers to care. New Engl J Med 2004; 351: 13-22
Page 61 of62
Friedman MJ: Posttraumatic Stress Disorder Among Military Returnees From Afghanistan and Iraq
American Journal ofPsychiatty 2006 163: 586-593
Lecrubier Y: Posttraumatic stress disorder in primary care: A hidden diagnosis. J Clin Psychiaqy
2004;65 (suppl1 ): 49-54
PTSD Four Question Screen

Prins A, Ouimette P, Kimerling R, Cameron RP, Hugelshofer OS, Shaw-Hegwer J, Thrailkill A,
Gusman FD, Sheikh ll:The primary care PTSD screen (PC-PTSD): development and operating
characteristics. Primary Care Psychiatry 2004; 9:9-14
1
Zlotnick C, Rodriguez BF, Weisberg RB, Bruce SE, Spencer MA, Culpepper L, Keller MB:
Chronicity in posttraumatic stress disorder and predictors of the course of posttraumatic stress
disorder among primary care patients. J Nerv
Page 62 of62
(b )(6)
CO~------------~
(b )(6)
and
PT, OPT, OCS
(b )(6)
PURPOSE: To provide basic information on PTSD, TBI and behavioral health

issues and programs in the Army.
(b )(6)
Slide 2 of 15
orl
ar 1--"shell shock", over evacuation le to chronic s chiatric
con itions
or
ar 11--ine ective re-screen in , " attle ati ue", lessons
re earne , hots an a cot
The Korean ar--- 1rst hi h rates o s chiatric casualties, then ramatic
ecrease
Vietnam
Dru an alcohol use, miscon uct
Post Traumatic tress Disor er
Desert torm hiel
"Persian u illnesses", me icall unex Iaine
h sica I s m toms
uestions a out ex osures to toxins
erations ther Than

ar
om at an
erational tress antral, routine rant line mental
health treatment
9 11
"Thera
walkin aroun "
(b )(6)
Slide 3 of 15
at, etc.
etainees
(b )(6)
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era e
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e av1ors
o era e o severe
e ress1on
co o
(b )(6)
e en ence
Slide 6 of 15
rea o
ea
n ense ear,
ser1ous 1n u
e
essness or
orror
a1n
avo1 a nee soc1a 1so a 1on

,,
IC
WI
(b )(6)
Slide 7 of 15
rauma 1c
ra1n n u
rom a
ow or o
1s a
e ca e onze
as m1
m1
1s
1s 1nc
1 eren
e uca 1on an
(b )(6)
s m
rov1 e
reassurance
oma 1c rom
1n u
ene ra 1n
re erre
ecause
a
e
1n
are m1
s rea e
o re uce
ea
, mo era e, severe, or
s occurr1n
IS 1m o an
1
ene ra 1n
ro nos1s 1s exce en
a resu s
rom mo era e, severe an
e rna or1
>
concussions; ,.,
'
ra1n unc 1on
e erm concuss1on 1s
oncuss1on -
1on o
or a
1sru
ea
can
oo
w1
1ers rece1ve
recover
o a no
er concuss1on w
1e
e 1rs one
Slide 8 of 15
Ro ust surveillance in theater an

ental
ea th A visa
Post Deplo ment
'
upon return
T earns
ealth Assessment and Re-Assessment
Di iculties with access to care
ti rna a out mental ealth care espite:

hain teach on PT D and
81 with
00, 0
oldiers in 2 07
Be on the Front an
haul er to haul er in 200
lncreasin surveillance o PT D an
Bl
Risin suici e rate multiple reasons: racture
a use.
ervices to elp ani

Numerous hel in
(b )(6)
artial
relationshi s, alcohol
inte rate
a encies, includin
medica , ehavioral heath,
Slide 9 of 15
Evolvin
omprehensive Behavioral ealth trate
Comprehensive Soldier Fitness
Army's Campaign Plan for Health Promotion, Risk Reduction & Suicide
Prevention ACPHP
Child and Adolescent Center of Excellence Madigan

ovenant
Arm Famil
Arm PH s end plan
The Army has implemented over 45 initiatives under the categories of
access to care, resiliency, quality of care, and surveillance
(b )(6)
FYO , P
fun s FY10-15
Improve access to care
48% increase in behavioral health providers since 2007
Number of visits has more than doubled since 2003
ti rna reduction
Battlemind lifecycle products fielded toT DOC Basic Battlemind
New policies to screen or P
D and B
Extensive unit and population- ase research
Returned focus on
eration Endurin Freedom
EF
Slide 10 of 15
on tnue o 1m rove access o care

lnte rate
ehavioral heath and rima
care
Revise orce structure with increased ehavioral health
e uce s 1 rna
De ense enter o Excellence D oE lead in anti-sti rna
cam a1 n: ea
arr1ors
ew rea men s, researc , an
an
atn mana emen
(b )(6)
c 1n1ca
u1 e 1nes or
'
Slide 11 of 15
.... ra1n n u
u
ose:
o es a
1s
a s an ar 1ze , com re ens1ve
rov1 es a con 1nuum o 1n e ra e
an
a 1en s w1
--- o
1ers,
rom
s, accor 1n
o
ene 1C1ar1es, an
e1r
o1n -o -1n u
serv1ces or
o re urn o
e1r
care an
am11es WI
1ers
or
1n
rm
eve , 1n or er o
re urn o
ve
care con ruen w1

en necessa
(b )(6)
w1
ro
1m1ze unc 1ona ou comes an
ro ram
me 1ca
e eve o
Slide 12 of 15
un s
1n
'
un e
c 1on
a
s a
1n
on
an
o su
care
0
resse
rm
(b )(6)
an:
1 a e
ro ram om onen s
Earl i entification, evaluation, mana ement, treatment,
ocumentation, an co in of ol iers an
atients with TBI
Neuroco nitive testin
ele-health assets
E ucation an trainin for ol iers, lea ers, atients,
rovi ers, communit heath care rovi ers, Fami mem ers, an
others
trate ic communications an mar etin
Research
81 Pro ram Vali ation-1
ull vali ate , 21 initiall vali ate
Slide 13 of 15
on 1nue em
as1s on
o1n o 1n u
1 en 1 1ca 1on an
1n erven 1on or concuss1on
on 1nue
rna or1
ro
r1ma
a ten s WI
e erne 1c1ne 1m
(b )(6)
care mana emen ca a 11 1es or
concusston
emen e
ew rea men s an
na 1ona
an
1n erna 1ona
researc
Slide 14 of 15
1ssues
(b )(6)
Slide 15 of 15
INFORMATION PAPER
DASG-HSZ
15 Sep 2008
SUBJECT: Post Traumatic Stress Disorder
1. Purpose. To provide information on the incidence and prevalence of Post Traumatic
Stress Disorder (PTSD) and to understand the impact of PTSD on the force.
2. Facts.
a. We can safely estimate that between 5 and 10 percent of Soldiers who are
deployed have symptoms of PTSD. Over the past 4 years, there were approximately
32,022 diagnosed cases of PTSD broken down by calendar year as follows: CY03 1,020; CY04 - 3,845; CY05 - 6,554; CY06 - 6,845; and CY07 - 10,523. We estimate
that the nurr1ber of newly identified PTSD cases for CY08 will be around 12,000. PTSD
is usually treated as an outpatient diagnosis, and seldom requires a medical board. The
vast majority of Soldiers diagnosed witt1 PTSD will remain on active duty.
b. Military research shows that approximately 15% of Soldiers deployed during OIF
have PTSD symptoms and another 10 to 15/o percent will experience other behavioral
health problems that could benefit from treatment. The MHATs have shown that longer
deployments, multiple deployments, greater time away from base camps, and combat
intensity all contribute to higher rates of PTSD, depression, and marital problems. The
MHAT V also showed that Soldiers in BCTs deployed to Afghanistan are now
experiencing levels of combat exposure and mental health rates equivalent to Iraq.
c. Comparable surveys in the post-deployment period have shown that rates of
mental health problems, particularly PTSD, remain elevated and even increase during
the first 12 months after return home, indicating that 12 months is insufficient time to
reset the mental health of Soldiers after a year-plus combat tour.
d. Five to 6% of Soldiers are generally referred to behavioral health based on their
Post Deployment Health Assessment. Approximately 12k of Soldiers are referred to
behavioral health based on the Post Deployment Health Reassessment.
e. All Soldiers (AD, USAR, and ARNG) were mandated to participate in training on
mild TBI and PTSD. The "Chain Teach" product was designed to provide an overview
and understanding of concussion injuries and Post Combat Stress Reactions that may
result in PTSD. rhere are a number of other training programs for Soldiers and
Families available at www.battlemind.army.ll)il or www.behavioralhealth.armv.mil.
f. Using $125M in supplemental funds, the Army has implemented over 45 initiatives
under the categories of access to care, resiliency, quality of care, and surveillance.
Significant among these is the hiring of over 200 behavioral health providers to augment
behavioral health services worldwide across Army installations.
(b )(6)
rov1n
7 August 2008
Evidence-Based Treatment of PTSD
PURPOSE: To provide information on current evidence-based treatments of

PTSD and their use in Army MTFs.
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(b )(6)
Slide 2 of 10
7 Aug 08
stematic esensitization,
'
inoculation trainin ,
thera
o nitive thera
tress
o nitive
rocessin
PT
Pharmacot era
-
Anti e ressants
Anticonvulsants
Anti s chotics
ar amaze 1ne
uetia ine, Ris eri one
nOS IS
(b )(6)
Slide 3 of 10
7 Aug 08

Good evidence, effective
CBT, Exposure therapy, CPT, EMDR eye movements probably add
nothing
SSRis
Limited evidence, maybe effective
Prazosin specific symptoms
Psychodynamic therapy
Acupuncture
Hypnosis
Ineffective or no benefit
Biofeedback, CISD maybe even harmful , BZDs
Insufficient evidence to evaluate
Marital and family therapy, Combination therapy, Length of therapy,
other CAM
(b )(6)
Slide 4 of 10
7 Aug 08
IC
era
'
ase
os a
era
a so use
'
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(b )(6)
'
, an
Slide 5 of 10
7 Aug 08
_ac
ou co
1n ras rue ure o rou tne
easure
rocesses or
es
e ne
(b )(6)
Slide 7 of 10
7 Aug 08
ra1n1n
'
(b )(6)
Slide 8 of 10
7 Aug 08
acumen a 1on o 1n 1v1 ua
a 1en 1m rovemen
linical assessment vs. stan ar ize scales
a ture in
HL
to evaluate oth process an
re ate or
ro ram e ectiveness
(b )(6)
Slide 9 of 10
7 Aug 08
unc 1ona ou comes re evan
e m1 1 a
RTD rates
MEB ratin s
esearc
1mum en
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~.,.",~' ?~~~//4::--//.':0!"~-.: *..:t >~%.........,~'?'"~-:..:evva~~' r;'-~<-! ''"' ":- ' ! ''

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Slide 10 of 10
7 Aug 08
rou
ISSUe
(b )(6)
Slide 11 of 10
7 Aug 08
(b )(6)
Slide 12 of 10
7 Aug 08
o 1ona
. . .- ee
(b )(6)
r1e
rove
or
en
Slide 13 of 10
7 Aug 08
tncor ora 1n
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cases severe enou

rae o
(b )(6)
Slide 14 of 10
7 Aug 08

0
Distr1~
~itQJ~
are
~fif~r)~ving
Measure Advocate: (b)( )

DCoE
Monitoring: Monthly
Data Source: MDR(SADR, SIDR,
TEDI, TEDNI), DMDC CTS roster
Other Reporting: None currently
Assessment Criteria
c______ _ _ _ _ _ _ _ _ J
Diagnosis of PTSD over period 2002-2008
14,000
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11-25
26-50
>50
Number of Visits with Dx of PTSD
What are we measuring?: This measures the total number of visits recorded for a service member who received a diagnosis of PTSD
after being deployed. If a person received their care in the VA or if the provider did not record that the visit was for PTSD, or if an initial
diagnosis of PTSD changed to another diagnosis. the visits would not be captured, so this may be an underestimate of the amount of care
provided.
Why is it important?: We want to be sure that everyone with PTSD receives adequate treatment. The best available evidence suggests
that a person with appropriately diagnosed PTSD should receive 10 psychotherapy visits. If we are identifying PTSD but patients are not
getting appropriate treatment, then patients could fail to recover and we would not be accomplishing our mission of rehabilitation and
reintegration to the force for people with mental disorders.
What does our performance tell us?: There have been a total of approximately 44,000 service members who have been diagnosed with
PTSD following a deployment of >30 days since 2002. Of these, less than half have documentation of more than 6 visits for PTSD. We will
need more data to determine if this is a true reflection of the care that is actually being providedw The Armed Forces Health Surveillance
Center is now conducting such a study of available data.
Reference: Institute of Medicine. l,reatn1ent of P1"Sll: An
Assessanent of the Evidence,. Wash DC, Nat
~~cad l,r-c.~ss,
2007.
(b )(6)
Slide 15 of 1 0
7 Aug 08
'
ear
ecta
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r------------------------------ --- - - - 0 Soldiers with 002796 Referred for Clinic Care ***
. D Referred Soldiers Receiving Care in Clinic within 30d of 002796
1
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-~--
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RMC
RMC
Western RMC
Pacific RMC
Europe RMC
Notes:
Percentages are based off of total referral rate per RMC
Reflects most recent 002796 per service member; each form may have multiple referrals
Referral Pattern from Post Deployment Health Assessment

(b )(6)
Source: Defense Medical Surveillance Systern (DMSS)
Slide 16 of 10
7 Aug 08
ec1a
o Total Active Duty Referred
Referred to Mental Health Specialty
a Encounters at Mental Health Specialty
---------------------------------------------------
- - - - ---------
68,682
Army
Active Duty
'
SM with
completed
002900**
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Notes:
Reflects most recent 002900 per service member: each form may have multiple referrals
Referral Pattern from Post Deployment Health Reassessment
PDHRA I 002900 , from
ram start of10-Mar-2005
(b )(6)
33/o of Solders completing DO 2900 forms

were referred for follow up.
12/o of all SM's Referred were to Mental
Health Specialty care
65o/o of soldiers Referred to Mental Health
Specialty Care have been seen for
treatment
Additional 9,245 Soldiers coded for
Behavioral Health in a Primary Care with no
encounter data.
Source: Defense Medical Surveillance System (DMSS)
Slide 17 of 10
7 Aug 08
PTSD Checklist- Civilian Version (PCLC)

Patient's Name:
I
I
------------------------------------------
Instruction to patient:
Below is a list of problems and complaints that veterans sometimes have in response to stressful life experiences. Please read
: each one carefully, put an "X" in the box to indicate how much you have been bothered by that problem in the last month.
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Weathers, F.W., Huska, J.A., Keane, T.M. PCL-C for DSM-IV. Boston: National Center for PTSD- Behavioral
Science Division, 1991.
PTSD Checklist -Military Version (PCL-M)

NAME:_ _ _ _ _ _ _ _ __
SS#______________
Instruction to patient: Below is a list of problems and complaints that veterans sometimes have in response to stressful life experiences.
Please read each one carefully, put an "X" in the box to indicate how much you have been bothered by that problem in the last month.
r----~------------------------------~------~----~~--------~--------~------~------~
j
, No.. I
Response
Not at all . A Iittle bit Moderately Quite a bit

(1)
(2)
(3)
(4)
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: 3.
.
i.
Repeated, disturbing memories, thoughts, or images of a

stressful military experience from the past?
Repeated, disturbing dreams of a stressful military
experience from the past?
.Suddenly acting or feeling as if a stressful military
.experience were happening again (as if you were reliving
it)?
.
"::'"""''-
-',;,
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4
stressful military experience from the past?
Having physical reactions (e.g., heart pounding, trouble
1 5. breathing, or sweating) when something reminded you of a
1
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thinking
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about
a
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~
6. .experience from the past or avoid having feelings related to
it?
~-'~----~------------~----------~~------~-,-M--'o*-MM-'---"-~~------~-------+------~
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7
. .
' stressful military experi~,~~ from th~ past?
l
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8
! ,experience from the past?
.
<
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110.
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...
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11
..
~eelings for tho.se ~lose to you?
. . . . ....
....
12. Feeling as if your future will somehow be cut short?
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PCL-M for DSM-IV (11/1/94) Weathers, l_itz, Huska, & Keane National Center for PTSD- Behavioral
Science Division
INFORMATION PAPER
DASG-HSZ
10 March 2008
SUBJECT: Deployability of Soldiers diagnosed with PTSD
1. Purpose. To provide information on deployability of Soldiers diagnosed with PTSD.

2. Talking Points
Post Traumatic Stress Disorder and other psychiatric conditions controlled by

medication do not automatically lead to nondeployment. Soldiers with a
controlled psychiatric illness can still deploy.
The recommendation of deployability should rest with the clinical judgment of the
treating physician or other privileged provider, in consultation with the unit
commander.
Medications that may be used safely in theater include selective serotonin reuptake inhibitors and sleep medications, which are often used to treat PTSD.
3. Facts.
a. Army identifies Soldiers at risk through a pre-deployment screening process. Soldiers
get a face-to-face assessment with a provider. Providers make recommendations to
Commanders about deployability of Soldiers; Commanders use their best judgment
based on mission requirements and make the final decisions, taking into consideration
medical recornmendations.
b. Soldiers who are diagnosed with PTSD or identified during the Pre-Deployment
Health Assessment as having behavioral/mental health issues that rr1ight be
exacerbated by deployment are assessed further by a provider with behavioral health
expertise. If the Soldier is determined to be non-deployable, they should be given a
profile stating their limitations. If their psychiatric situation is stable, they may be
deployed and followed-up by a behavioral health provider in theater.
c. Few medications are inherently disqualifying for deployment to all potential
operational locations and at all times during the conduct of operations. Clinical
proximity, tempo and demand of operations, and length of the deployment rotation must
be considered when determining use of psychotropic medications in the operational
environment. Soldiers with conditions determined to be at significant risk for performing
poorly in the operational environment, or whose conditions do not significantly improve
within two weeks of treatment initiation, will be clinically recommended for return to
home station, in consultation with the Commander.
Approved by:
(b)( )
c _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ J
INFORMATION PAPER
DASG-HSZ
6 July 2008
SUBJECT: PTSD Screening and Soldiers
1. Purpose: To provide information on policy screening updates for PTSD for
Soldiers
2. Facts:
a. This information paper is being written to inform the public on screening for
PTSD, specifically 'What are you doing to ensure that Soldier's identified with a
pre-existing personality disorder aren't wrongfully discharged when the real
problem is something else such as PTSD or TBI? "
b. A new policy was implemented in August 2007, where all recommendations
for a 5-13 personality disorder discharge need to be reviewed by the Chief of
Behavioral Health at the installation (enclosed).
c. All Soldiers discharged for selected administrative reasons are required to
receive a mental status evaluation as per Army Regulation 635-200. A new
policy was implemented in May 2008 where Soldiers who are being discharged
for any reason related to misconduct need to be specifically screened for PTSD
and TBI (enclosed).
d. Since approximately 1998, all Soldiers redeploying from the theater of
operations have been required to complete the Post Deployment Health
Assessment (DD Form 2796) either before leaving theater or shortly after
redeployment. The DD Form 2796 screens for PTSD, Major Depression,
concerns about Family issues, and concerns about drug and alcohol abuse. The
primary care provider reviews the form, interviews the Soldier as required, and
refers the Soldier to a behavioral health care provider as required. The primary
care provider may make referrals to on-site counselors or to military treatment
facilities. Approximately 5 to 6/o of Soldiers are referred to behavioral health.
e. Since 2005, completing the Post-Deployment Health Reassessment
(PDHRA) screening program has been required of all redeployed Soldiers 90 to
180 after they have redeployed. Specific questions about TBI have been
recently added. If following the re-assessment there are identified healthcare
needs, Soldiers are offered care through military medical treatment facilities, VA
medical centers or VET centers, or by private healthcare providers through
TRICARE. Approximately 12 % of Soldiers are referred to behavioral health.
f. All Soldiers (AD, USAR, and ARNG) were mandated to participate in

training on Mild Traumatic Brain Injury (mTBI) and Post Traumatic Stress
Disorder (PTSD) by 18 OCT 2007. This chain teaching program was intended to
provide leaders and Soldiers information and resources on concussions and Post
Combat and Operational Stress. The "Chain Teach" product was designed to
provide an overview and understanding of concussion injuries such as mTBI and
Post Combat Stress Reactions that may result in PTSD. Approximately 900,000
Soldiers received this trair,ing by the end of 2007. There are a number of other
trainings available for Soldiers and their Families, available at
www.battlemind.org or www.behavioralhealth.army.mil.
g. All Army deploying behavioral health providers now attend the Combat and
Operational Stress Control Course. Emphasizing the policies above is part of the
curriculum. rhis information is also reinforced at the annual Force Health
Protection conference.
3. The Way Ahead
a. Continue to ensure that Soldiers are carefully evaluated and treated for
PTSD, TBI, and other psychiatric illnesses.
(b )(6)
Approved
6
by ...__(b-)(_)_ _ _ _____,
INFORMATION PAPER
DASG-HSZ
7 March, 2008
SUB.JECT: Deployability of Soldiers diagnosed with PTSD
1. Purpose. To provide information on deployability of Soldiers diagnosed with PTSD.

2. Facts.
a. We have pre-deployment screening process that identifies Soldiers at risk. They get a
face-to-face assessment with a provider. Providers make a recommendation to
Commanders about deployability of Soldiers; Commanders use their best judgment
based on mission requirements, etc. and make the final decision, taking into
consideration medical recommendations.
b. Soldiers who are diagnosed with PTSD or identified during the Pre-Deployn1ent
Health Assessment as having behavioral/mental health issues that might be
exacerbated by deployment are assessed further by a provider with behavioral health
expertise. Guidance on Deployment Limiting Psychiatric Conditions is delineated in the
Health Affairs Policy issued in November, 2006. If the Soldier is determined to be nondeployable, they should be given a profile stating their limitations. If their psychiatric
situation is stable, they may be deployed and followed-up by a behavioral health
provider in theater.
c. Deployment-Limiting Psychiatric Conditions Policy Memorandum, 7 November 2006,
specifies deployment considerations related to behavioral health care. The provider will
carefully assess the patient's condition, treatment regimen, and risk level. The clinical
decision to maintain or evacuate personnel diagnosed with psychiatric disorders in
Theater is based upon: the severity of symptoms and/or medication side effects; the
degree of functional impairment resulting from the disorder and/or medications; the risk
of exacerbation if the member were exposed to trauma or severe operational stress;
estimation of the member's ability and motivation to psychologically tolerate the rigors of
the deployed environment; and prognosis for recovery.
d. There are few medications that are inherently disqualifying for deployment to all
potential operational locations and at all times during the conduct of operations. Clinical
proximity, tempo and demand of operations, and time during the deployment rotation
must be considered when deterrr1ining use of psychotropic medications in the
operational environment. Service branch specific standards must also be considered
(aviators for example). Medications disqualifying for deployment include anti psychotics
used to control psychotic, bipolar, and chronic insomnia symptoms: lithium and
anticonvulsants to control bipolar symptoms. Personnel diagnosed with psychotic or
bipolar spectrum disorders will be recommended for return to their home station.
Service members with other conditions that are determined to be at signi'ficant risk for
performing poorly or decompensate in the operational environment, or whose conditions
does not significantly improve within two weeks of treatment initiation, will be clinically
recommended for return to their home station, in consultation with their Commander.
e. An Army policy was issued in April 2007, which provided implementing guidance and
the waiver process. Waivers need to be submitted to and approved by the CENTCOM
Surgeon. Since April, 70 waiver requests have been received, and sixteen have been
denied.
(b )(6)
Approved by:
(b )( )
c _ _ _ __ _ _ _ _ _ __ _ _ _ _ J
INFORMATION PAPER
DASG-HSZ
7 March 2010
SUBJECT: Post Traumatic Stress Disorder Prevention, Diagnosis and Treatment
1. Purpose: To provide an update on Post Traumatic Stress Disorder for the TSG Prep
Book.
2. Facts:
a. Post-Traumatic Stress Disorder is a psychiatric disorder that may occur after
exposure to trauma. Typical symptoms include hypervigilence, intrusive thoughts,
flashbacks, numbness, avoidance, and nightmares. PTSD diagnosis rates have steadily
increased from CY03 to CY08 for both deployed and nondeployed Solders. CY09 rates
have declined from their CY08 peaks. Deployed Soldier diagnosis rates have declined
from 10,137 in CY08 to 8,553 in CY09. Nondeployed Soldier diagnosis rates have
declined form 1,311 in CY08 to 1,059 in CY09. We expect the number of new cases to
be related to the number of exposed troops, the number of deployments and the overall
exposure to combat. We currently estimate that the number of Newly Identified PTSD
Cases for CY1 0 to be similar to CY09.
b. The Army has numerous education, identification, and treatment programs for
PTSD, including Battlemind, PDHA, PDHRA, the chain-teach program, and Respectmil. The most common forms of psychotherapy for Post Traumatic Stress Disorder are
cognitive-behavioral therapy and exposure therapy. Usually psychotherapy requires
approximately 10 to 20 sessions, if possible on a weekly basis. There are several
medications used to treat the symptoms of Post Traumatic Stress Disorder. These
usually include anti-depressants such as selective serotonin reuptake inhibitors, more
frequently referred to as SSRis. There a number of different types used for sleep
difficulties, including Am bien, Trazodone, and Seroquel for trauma-induced nightmares.
d. During pre-deployment, Resources available to Soldiers include buddy aid,
leadership support, chaplaincy services, primary care, and behavioral health services.
Family members are instructed on their roles, responsibilities, ways by which they may
cope more effectively, strategies for supporting their deploying Soldier, and ways to
seek professional assistance.
e. During pre-deployment and deployment, Soldiers are introduced to Combat and
Operational Stress Control concepts and resources to prepare for combat and
operational stress. It is now mandatory that all Army deploying behavioral health
providers attend Combat and Operational Stress Control training.
DASG-HSZ
SUBJECT: Post Traumatic Stress Disorder {PTSD) Screening and Soldiers
f. Since Oct 98, all Soldiers redeploying from the rheater of operations have been
required to complete the Post Deployment Health Assessment (PDHA) (DO Form
2796), either before leaving Theater or shortly after redeployment. The DO Form 2796
screens for Post Traumatic Stress Disorder, Major Depression, family issues, and
concerns about drug and alcohol abuse. The primary care provider reviews the form,
interviews the Soldier as required, and refers the Soldier to a behavioral healthcare
provider when indicated.
g. Since Jan 06 (retroactive to Mar 05), all Soldiers have been required to complete
the Post-Deployment Health Reassessment (DD Form 2900) at 90 to 180 days after
they have redeployed. Approximately 12/o of Soldiers are referred to behavioral health
from the Post-Deployment Health Reassessment.
h. Another Army effort in the prevention and screening of Post Traumatic Stress
Disorder is the Post Traumatic Stress Disorder Training Course developed by US Army
Medical Cornmand and Army Medical Department Center and School. The PTSD
Training Course is intended to provide DOD uniformed and civilian behavioral health
counselors critical clinical education and intervention tools in the identification and
treatment of Post Traumatic Stress Disorder.
i. rhe Army has implemented behavioral health training into primary care. All
primary care providers receive two (2), one hour blocks of instruction covering a range
of behavioral health related issues focused around Post Traumatic Stress Disorder and
Depression.
(b )(6)
Approved by:
6
L__(b_)(_)_ _ _ _ _
____J
2
INFORMATION PAPER
DASG-HSZ
18 March 2009
SUB'"JECT: Medical Care Available for Soldiers with Post-Traumatic Stress Disorder (PTSD)
1. Purpose: To provide information regarding what medical care is available to Soldiers with
PTSD.
2. Facts:
a. Army leadership is taking aggressive. far-reaching steps to ensure an array of behavioral
health services are available to Soldiers and their Families to help those dealing with PTSD and
other psychological effects of war. Soldiers and their Families are telling senior leaders that
their behavioral healthcare is a top concern. and Army leaders are in turn making it their number
one priority.
b. The following list of continually evolving programs and initiatives are examples of the
integrated and synchronized web of behavioral health services in place to help Soldiers and
their Families heal from the effects of multiple deployments and high operational stress:
(1 ). The Post Deployment Health Assessment, originally developed in 1998, was revised
and updated in 2003. All Soldiers receive this on re-deployment, usually in the theater of
operations.
(2). In the fall of 2003, the first Mental Health Assessment Team (MHAT) deployed into
theater. Never before had the mental health of combatants been studied in a systematic
manner during conflict. Four subsequent MHAT's in 2004, 2005, 2006, and 2007 continue to
build upon the success of the original and further influence our policies and procedures not only
in theater but before and after deployment as well. Based on MHAT recommendations, the
Army has improved the distribution of behavioral health providers and expertise throughout the
theater. Access to care and quality of care have improved as a result. An MHAT is currently in
Iraq, and will be deploying to Afghanistan this spring.
(3). In 2004, researchers at the Walter Reed Army Institute of Research (WRAIR)
published initial results of the groundbreaking "Land Combat Study" which has provided insights
related to care and treatment of Soldiers upon return from combat experiences and led to
development of the Post Deployment Health Reassessment (PDHRA).
(4). In 2005, the Army rolled out the PDHRA. The PDHRA provides Soldiers the
opportunity to identify any new physical or behavioral health concerns they may be experiencing
that may not have been present immediately after their redeployment. This assessment
includes an interview with a healthcare provider and has been a very effective new program for
identifying Soldiers who are experiencing some of the symptoms of stress-related disorders and
getting them the care they need before their symptoms manifest into more serious problems.
We continue to review the effectiveness of the PDHRA and have added and edited questions as
needed.
DASG-HSZ
SUB'"IECT: Medical Care Available for Soldiers with Post-Traumatic Stress Disorder (PTSD)
(5). In 2006,the US Army Medical Command (MEDCOM) piloted a program at Fort Bragg,
intended to reduce the stigma associated with seeking mental health care. The Respect-Mil
pilot program integrates behavioral healthcare into the primary care setting, providing education,
screening tools, and treatment guidelines to primary care providers. It has been so successful
that medical personnel have implemented this program at fifteen sites across the Army.
Another 17 sites should implement it in 2009.
(6). Also in 2006, the Army incorporated into the Deployment Cycle Support program a
new training program developed at WRAIR called "BATrLEMIND" training. Prior to this war,
there were no empirically-validated training strategies to mitigate combat-related mental health
problems. This post-deployment training is being evaluated by MEDCOM personnel using
scientifically rigorous methods, with good initial results. It is a strengths-based approach
highlighting the skills that helped Soldiers survive in combat instead of focusing on the negative
effects of corr1bat. Please visit www.battlemind.org for more information.
(7). MEDCOM's pursuit for improvement continues with BATTLEMIND training program
for Soldiers and spouses prior to deployments; a behavioral health web site
http://www.b~havioralhealth.army.mil; creation of a Behavioral Health Proponency Office in Mar
08; and a new PTSD training course started in Jun 08.
(8). Two DVD/CDs that deal with Family deployment issues are now available: an
animated video program for 6 to 11 year olds, called "Mr. Poe and Friends," and a teen
interview for 12 to 19 year olds, "Military Youth Coping with Separation: When Family Members
Deploy." Viewing the interactive video programs with children can help decrease some of the
negative outcomes of Family separation. Parents, guardians and community support providers
will learn right along with the children by viewing the video and discussing the questions and
issues provided in the facilitator's guides with the children during and/or after the program. This
reintegration Family tool kit provides a simple, direct way to help communities reduce tension
and anxiety, and use mental health resources more appropriately, and promote healthy coping
mechanisms for the entire deployment cycle that will help Families readjust more quickly on
redeployment. Go to www.behavioralhealth.army.mil and click on children.
(9). On average 200 behavioral health personnel are deployed in support of Operation
Iraqi Freedom, and about 30 in Operation Enduring Freedom (these numbers include providers
from all the Services).
(1 0). In mid-July 2007 the Army launched a PTSD and mild Traumatic Brain Injury
(mTBI) Chain Teaching Program that will reach more than 1 million Soldiers, a measure that will
ensure early intervention. The objective of the chain teaching package was to educate all
Soldiers and leaders on PTSD and TBI so they can help recognize, prevent and treat these
debilitative health issues.
(11 ). In 2008, the DoD revised Question 21, the questionnaire for national security
positions regarding mental and emotional health. rhe revised question now excludes non-court
ordered counseling related to marital, family, or grief issues, unless related to violence by
members; and counseling for adjustments from service in a military combat environment.
Seeking professional care for these mental health issues should not be perceived to jeopardize
an individual's professional career or security clearance. On the contrary, failure to seek care
2
DASG-HSZ
SUBJECT: Medical Care Available for Soldiers with Post-Traumatic Stress Disorder (PTSD)
actually increases the likelihood that psychological distress could escalate to a more serious
mental condition, which could preclude an individual from performing sensitive duties.
(12). We've also instituted post-traumatic stress training for our health care providers so
that they can accurately diagnose and treat combat stress injuries; we're dedicating time and
energy toward provider resiliency training; and we have hired 250 more behavioral health care
providers and over 40 marriage and family therapists in recent months to work in military
treatment facilities in the United States. We also have numerous longer-term efforts to
enhance recruitment and retention of uniformed behavioral health providers.
(13). In 2008, the Army began piloting Warrior Adventure Quest (WAQ). WAQ combines
existing high adventure, extreme sports, and outdoor recreation activities (i.e. rock climbing,
mountain biking, paintball, scuba, ropes courses, skiing, and others) with a leader-led after
action debriefing (L-LAAD). rhe L-LAAD is a leader decompression tool that addresses the
potential impact of executing military operations and enhances cohesion and bonding among
and within small units. L-LAAD integrates WAQ and bridges operational occurrences to assist
Soldiers' transition their operational experiences into a "new normal", enhancing military
readiness, reintegration, and adjustment to garrison or "home" life.
(14). The Comprehensive Soldier Fitness Program was established on 1 Oct 08, as a
Directorate in the Army G-3/5/7. rhe mission of this program is to develop and institute a
holistic, resilience building fitness program for Soldiers, Families, and Army civilians. rhe
program will focus on optimizing five dimensions of strength: Physical, Emotional, Social,
Spiritual, and Family. rhis holistic approach to fitness will enhance the performance (capability)
and build resilience (capacity) of the Force in this era of persistent conflict and high operational
tempo.
(15). The Army put out ACE "Ask, Care, Escort." Beginning 15 Feb 09, the Army started
a "standdown" to ensure that all Soldiers learned not only the risk factors of suicidal Soldiers but
how to intervene if they are concerned about their buddies. The ''Beyond the Front" interactive
video is the core training for this effort. It will be followed by a chain teach which focuses on a
video "Shoulder to Shoulder; No Soldier Stands Alone" and vignettes drawn from real cases.
COL Ritchie. (b)(
c______ _ _ _ _ ____J
Approved by
(b )( )
3
INFORMAl-ION PAPER
DASG-HSZ
24 February 2009
SUB'"IECT: Post Traumatic Stress Disorder and Traumatic Brain Injury (PTSD/TBI)
1. Purpose. To provide information on the potential increase in cases of PTSD/TBI
among Service members and veterans as a result of multiple deployments.
2. Facts.
a. Since 2002, there have been a total of approximately 36,256 Operation Iraqi
Freedom and Operation Enduring Freedom (OIF/OEF) Soldiers who have been
diagnosed with PTSD following deployment of greater than 30 days. The number of
new PTSD cases has more than tripled since FY04. Cumulative deployed time is
associated with increased PTSD diagnoses; Length of most recent deployment is not. It
is projected that diagnosed cases of PTSD will continue to increase in future years.
b. As of Nov 08, there were 6,751 Army TBI cases reported to the Defense Veterans
Brain Injury Center OIF/OEF. This represents an eight fold increase of reported TBI
cases since FY03. Most rsl cases resulted from Improvised Explosive Devices I Blast
injuries, and most were categorized as mild TBI. Increases in the number of mild rsl
cases have largely been due to aggressive identification efforts both in theater and as
part of Post Deployment Screening and not as a result of multiple deployments. It is
expected that this number will increase as more cases are identified.
c. Since Oct 98, all Soldiers redeploying from the theater of operations have been
required to complete the PDHA, either before leaving theater or shortly after
redeployment. The DD Form 2796 screens for PTSD, Major Depression, concerns
about family issues, and concerns about drug and alcohol abuse. The primary care
provider reviews the form, interviews the Soldier as required, and refers the Soldier to a
behavioral healthcare provider when indicated. rhe primary care provider may make
referrals to on-site counselors, network providers or to military treatment facilities
(MTFs). Five to 6/o of Soldiers are generally referred to behavioral health at this time.
d. Since Jan 06 (retroactive to Mar 05), all Soldiers have been required to complete
the PDHRA (Form 2900) at 90 to 180 days after they have redeployed. Specific
questions about rr1ild TBI (concussion) were added in Nov 07 for the Army. rhese
questions were revised and made available for all Services in May 08. If healthcare
needs are identified through the PDHRA, Soldiers are offered care through MTFs,
Veteran Administration Medical Facilities, or by private healthcare providers through
TRICARE. Approximately 12/o of Soldiers are referred to behavioral health 'from the
PDHRA.
DASG-HSZ
SUBJECT: Post-Traumatic Stress Disorder Screening and Deployment
mild TBI and PTSD NLT 18 Oct 07. rhe "Chain Teach" product was designed to
provide an overview and understanding of concussion injuries and Post Combat Stress
Reactions that may result in PTSD. Approximately 900,000 Soldiers received this
training by the end of 2007. There are a number of other training programs for Soldiers
and their Families available at www.battlemind.army.mil or
www.behavioralhealth.army.mil. The content of the "Chain Teach" has been
institutionalized through the Battlemind Training System Office (BMTS), AMEDDC&S
which has integrated this training into lifecycle mrsl and PTSD training modules that
will be incorporated into The US Army Training and Doctrine Command (TRADOC)
Programs) Programs of Instruction (POl). Mild TBI and PTSD training will occur in all
TRADOC OES and NCOES POls. In addition, the Post-Deployment and Spouses
Battlemind are available at the web sites indicated above. New training videos are in
development.
f. All Soldiers discharged for selected administrative reasons are required to receive
a mental status evaluation as per Army Regulation 635-200. A new policy was
published in May 08 directing that Soldiers being discharged for any reason related to
misconduct must be specifically screened for PTSD and mild TBI.
g. MEDCOM and AMEDDC&S have developed a PTSD Training Course intended to
provide DoD uniformed and civilian BH counselors critical clinical education and
intervention tools in the identification and treatment of PTSD. Specifically, this provides
the BH provider a broader understanding of the clinical characteristics and prevalence
of PTSD Acute and Chronic Features, medical and psychiatric co-morbidity of PTSD,
the theoretical underpinnings for this disorder and the ability to identify risk and
resiliency factors related to development of PTSD. Attendees also learn about a variety
of screening and assessment tools to accurately and reliably measure traumatic
stressors and PTSD, learn about TBI, most notably as a result of blast-related
concussion, and hear about strategies to diagnose co-morbid PTSD and rei. Finally,
participants hear an overview about therapeutic clinical strategies for coordinated
treatment of combat-related stress issues. This course is mandatory training for all
uniformed and civilian Social Workers, Nurse Case Managers and Basic Psychiatric
Nurses.
h. Specific to TBI, two patient education brochures and 5 patient education
handouts were developed and distributed throughout U.S. Army Medical Department
(MEDCOM), staff have conducted public relations efforts at 14 conferences and 10
professional meetings, and computer-based education tools for Soldiers, Families,
providers, leaders and patients are in development. MEDCOM established a validation
program for all MEDCOM Medical Treatment Facilities (MTFs) that provide care to
Soldiers and other beneficiaries with TBI. rhis validation program was designed to
establish standards of care and to ensure that services, physical facilities, and staffing
levels were consistent across the Army MTFs, based on the level of care provided at
the facility. Six sites have received initial validation and review of all CONUS sites is
DASG-HSZ
scheduled between Feb and Jun 09 with a goal of having every site achieve initial
validation by 30 Sep 09.
i. The Army expects continued increases in PTSD/TBI cases and is monitoring

caseloads and trends closely to identify the potential impact on readiness and provide
appropriate treatment to Soldiers and the Army family.
(b )(6)
Approved by:
(b )(6)
c _ _ _ _ _ _ _ _ _____,
DASG-HSZ
. -.
s:tr.:-tnt ofnr.,., t~Hs
--CY06
'!'"'
CY08
~~.:m1 t)ftte,. cse~
1~.000 ~
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Service Members with Diagnosed

Post Traumatic Stress Disorder
after First Deployment to OEF/OIF
~.
5.18tl
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YR Cumul.aliY'f
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~
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Ptent of nf"'' cues
Number of Newly Identified Cases, Army OIF/OEF Soldiers
.-\R."iG
...&81
C'/05
POST TRAUMATIC STRESS DISORDER
AC
6,000
4,000
::>
l.
2.000
l
!
!
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CY06
..,
We expect the number of new cases to be related to the number of exposed troops, the number
of deployments and the overall exposure to combat. We would estimate that the number of
Newly Identified PTSD Cases for CY09 to be similar to CY08 !f deploy numbers are also similar~
Source: Office of the Sufl}eon General
2003
(_b_)(_6_)____
2004
.. ..c=& 7 to 12
Last updaled: 9 JAN 09
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13+
DASG-HSZ
SUB'-JECT: Post-Traumatic Stress Disorder Screening and Deployment
Behavioral Health and Social Epidemiology
Army Suicides and Rates of Behavioral Health Diagnoses in Army
*Future predicted. rates based on Z005~2007average annual increases
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DMOO. Recurrent.
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Trend for Army, OIF/OEF Soldiers
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States 0 PTSO
OlF OEF OCT 2001--NOV lOOS

...
HII.D
TRAUMATIC BRAIN INJURY
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f
i
os
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Increase in the number of mild TBI cases was largely due

to Post Deployment Screenings and aggressive
tdentification of incident and symptoms.
'
The Number of Mild TBI in Qtr4 CY07, Qtr1 CY08, Qtr2

CYOS, and Otr3 CY08 {dotted blue line) wil~ increase as
more cases are identified during Post Deployment
Screenings and Health Risk Assessments. The lag time
between date of injury and Mtld TBl identification is
expected due to the nature of this condition.
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Calendar Quarter In which Injury Occurred
This slide depicts TBI of varying severity based on data from the Defense Veterans Brain
Injury Center, November 2008. The Trend Indicates variation tn the number of Soldiers with
Mild TBI and a decrease In the number of Soldiers with Severe TBI over time.
Source: Office or the Sl.lf{leOn General (_b.L...;)(..__6-'--)_ ___,
Last updated: 09 JAN 09
L . l . . l
DASG-HSZ
T81 SEVERITY OF INJURY

ARMY. OIF/OEF
TBI PRIMARY INJURY MECHANISM

ARMY, OIF/OEF
Bultet
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This slide depicts TBI of varying severity based on data from the Defense Veterans Brain Injury
Center, November 2008. As of November 2008, there were 6,751 cases reported to DVBICmost from lED/BLAST, and most were MILD. Data reflects onty Army OIF/OEF .
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22
Initial MEB Evaluation of Posttraumatic Stress Disorder (PTSD} and

Other Psychiatric Disorders (Other than Eating Disorders)
(Endorsed by OTSG Health Policy and Services Directorate)
Version 1: 17 MAR 2009
Background:
The 14 Oct 2008 Directive-Tme Memorandum (DTM) provides that the MEB will
include a Nanative Summary (NARSUM) (and Addenda) which meets the minimum
criteria outlined in the VA Worksheets. This new requirement enhances unifonnity of
disability assessments within the DoD and the VA. It also helps individuals transition
between the two systems. The suggested NARSUM fonnat is designed to help assure the
MEB psychiatrist meets these minimum criteria and other regulatory requirements.
Adherence will enhance timely processing of disability cases and ensure a reduced return
of MEBs to the MTFs.
Outline:
NARSUM: Recommended Fonnat
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
Identifying Infonnation.
Sources of Infonnation.
Synopsis of Events Leading to MEB Referral.
Premilitary History.
Military History.
Medical History.
Psychiattic History (primary focus on past 12 months} and Current Subjective
Complaints.
Current Mental Status Examination (MSE).
Symj>toms (include those relating to or caused by diagnosis (es)) and associated
impact on occupational and/or social functioning.
DSM-IV TR Diagnosis.
Psychometric Testing Results.
DSM-IV TR Mutliaxial Assessment and Discussion
Mental Competency.
N. -----~~;n ~~~
0. Additional Considerations and Conclusions.
P. Verification of Accuracy ofDA Fonn 3349 {Physical Profile).
23
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29
DEPARTMENT OF THE ARMY

OFFICE OF THE SURGEON GENERAL
5109 LEESBURG PIKE
FALLS CHURCH, VA 22041-3258
REPLY TO
AnENTION OF
DASG-HSZ
11 May 2009
MEMORANDLIM FOR See Distribution

SLJBJECT: Guidance for Administrative Separation for Personality Disorder or Other
Mental Conditions
1 . References
a. Memorandum, HQ, USAMEDCOM, MCCG, 6 Aug 2007, subject: Review of
Personality Disorder (Chapter 5-13) Administrative Separations.
b. MemorandJJm, HQ, USAMEDCOM, MCCG, 19 May 2008, OTSG/MEDCOM
Policy Memo 08-018, subject: Screening for Post-Traumatic Stress Disorder (PTSD)
and mild Traumatic Brain lrrjury (mTBI) Prior to Administrative Separations.
c. DoDI 1332.14, Enlisted Administrative Separations, 28 ArJg 2008.
d. Memorandum, ASA(M&RA), 10 Feb 2009, subject: Enlisted Separations on
the Basis of Personality Disorder POLICY MEMORANDUM.
e. AR 635-200, Active Duty Enlisted Administrative Separations, 6 Jun 2005.
f. AR 40-400, Patient Administration, 6 Feb 2008.
g. AR 635-40, Physical Evaluation for Retention, Retirement, or Separation, 8
Feb 2006.
h. Memorandum, HQ, USAMEDCOM, MCHO-CL, 13 Mar 2009,
OTSG/MEDCOM Policy Memo 09-012, subject: MEDCOM Procedures for Chapter 5.
paragraph 5-13 and 5-17 Personality Disorder (PO) Separations.
2. In 2006 and 2007 public concern was raised that some soldiers returning from
combat tours had been discharged from the military for personality disorder, but were
subsequently suffering from PTSD or TBI related to their cornbat experiences. To
address these concerns, OTSG issued policies in August 2007 and May 2008 requiring
higher level review of recommendations for administrative separations for personality
disorder (reference a), and screening for PTSD and TBI for these and other
DASG-HSZ
SUBJECT: Guidance for Administrative Separation for Personality Disorder or Other
Mental Conditions
administrative separations (reference b). In August 2008, DoDI 1332.14 mandated

similar requirements across the DoD, including the requirement that the diagnosis of
personality disorder for servicemembers who have served or are serving in imminent
danger pay areas must be endorsed by the Military Department's Surgeon General.
3. The Army policy changes supplementing AR 635-200 until its next revision
(reference d) implementing the requirements of DoDI 1332.14 limited separation under
Chapter 5-13 to soldiers with less than 2 years time in service, but added personality
disorder 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).
Endorsement by OTSG is required ONLY for the diagnosis of Personality Disorder and
ONLY in soldiers who have served or are serving in an imminent danger pay area. rhis
clarification should prevent delays in future cases due to unnecessary requests for
endorsement that is not required.
4. DoDI 1332.14, Enclosure 3, paragraph 3.a.(8) provides additional guidance for
separation for personality disorder:
a. The onset of personality disorder is frequently manifested 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 should 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 has continued after the Service member was
counseled and afforded an opportunity to overcome the deficiencies.
b. Separation for personality disorder is not appropriate nor should it be pursued
when separation is warranted on the basis of unsatisfactory performance or misconduct.
In such circumstances, the member should not be separated under this paragraph
regardless of the existence of a personality disorder. Unless found fit for duty by the
disability evaluation system, a separation for personality disorder is not authorized if
service-related PTSD is also diagnosed.
5. Requests for OTSG endorsement of the diagnosis of personality disorder must
address these requirements and should provide the following information:
a. Signature of the recommendation by the evaluating psychiatrist or doctoral
level psychologist;
b. Review and signature of the recommendation by the Chief of Behavioral
Health or eqJJivalent official;
2
DASG-HSZ
SUBJECT: Guidance for Administrative Separation for Personality Disorder or Other
Mental Conditions
c. A specific statement that the disorder is of sufficient severity to interfere with

the soldier's ability to function in the rr1ilitary;
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 PD NOS for mixed personality disorder, 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 is diagnosed or other mental illness is
significant, a MEB should be initiated lAW AR 40-400, chapter 7, and if found to meet
retention standards, a copy submitted with the clinical documentation (the MEB is
corr1posed 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 PEB if found
to met retention standards). If retention standards are not met, the recommendation for
administrative separation should not be forwarded to OTSG unless and until the soldier
has been adjudicated fit for duty by the PEB.
h. Endorsement by OTSG is required ONLY for the diagnosis of Personality
Disorder and ONLY in soldiers who have served or are serving in an imminent danger
pay area (reference h).
-~~
~
(b )(6)
""'~
Ii~
(b )(6)
(b )(6)
COL. MC
(b )(6)
3
UNCLASSIFIED
26 February 2008
(U) P LICY/PRO
SO
lA NOSED
PT
TER (U)
(DASG-HSZ) Deployment-Limiting Psychiatric Conditions Policy Memorandum, 24 ARP 2007
specifies during deployment considerations related to behavioral health care. This guidance
includes the diagnosis ofPTSD. The provider will carefully assess the patient's condition,
treatment regimen, and risk level. The clinical decision to maintain or evacuate personnel
diagnosed with psychiatric disorders in theater is based upon: the severity of symptoms and/or
medication side effects; the degree of functional impainnent resulting from the disorder and/or
medications; the risk of exacerbation if the member were exposed to trauma or severe
operational stress; estimation of the member's ability and motivation to psychologically tolerate
the rigors of the deployed environment; and prognosis for recovery. Personnel diagnosed with
psychotic or bipolar spectrum disorders will be reconnnended for return to their home station.
Service members with other conditions that are detern1ined to be at significant risk for
performing poorly or decompensate in the operational environment, or whose conditions does
not significantly improve within two weeks of treatment initiation, will be clinically
reconunended for return to their home station, in consultation with their cormnander.
PREPARE MEMO- - - - (b )(6)
Approved by:
(b)( )
c______ _ _ _ _ _ ____J
UNCLASSIFIED
INFORMAl-JON PAPER
DASG-HSZ
14 July 2008
SUBJECT: Post Traumatic Stress Disorder (PTSD) Screening and Soldiers
1. Purpose: To provide information on screening for PTSD, specifically addressing the

question, 'What is the Army doing to ensure that Soldiers identified with a pre-existing
personality disorder aren't wrongfully discharged when the real problem is something
else such as PTSD or rBI? "
2. Facts:
a. A new policy was published in Aug 07, directing that all recommendations for a
personality disorder discharge be reviewed by the Military Treatment Facility's Chief of
Behavioral Health (Enclosure 1).
b. All Soldiers discharged for selected administrative reasons are required to receive
a mental status evaluation as per Army Regulation 635-200. A new policy was
published in May 08 directing that Soldiers being discharged for any reason related to
misconduct must be specifically screened for PTSD and mild rsl (Enclosure 2).
c. Since Oct 98, all Soldiers redeploying from the theater of operations have been
required to complete the Post Deployment Health Assessment (DO Form 2796), either
before leaving theater or shortly after redeployment. The DO Form 2796 screens for
PTSD, Major Depression, concerns about farr1ily issues, and concerns about drug and
alcohol abuse. The primary care provider reviews the form, interviews the Soldier as
required, and refers the Soldier to a behavioral healthcare provider when indicated. The
primary care provider may make referrals to on-site counselors, network providers or to
military treatment facilities (MTFs). Five to 6% of Soldiers are generally referred to
behavioral health at this time.
d. Since Jan 06 (retroactive to Mar 05), all Soldiers have been required to complete
the Post-Deployment Health Reassessment (PDHRA; DD Form 2900) at 90 to 180 days
after they have redeployed. Specific questions about mild TBI (concussion) were added
in Nov 07. If, following the PDHRA, there are identified healthcare needs, Soldiers are
offered care through MTFs, VA medical facilities, or by private healthcare providers
through TRICARE. Approximately 12k of Soldiers are referred to behavioral health
from the PDHRA.
mild rsl and PTSD NLT 18 Oct 07. rhe "Chain Teach" product was designed to
provide an overview and understanding of concussion injuries and Post Combat Stress
DASG-HSZ
SUBJECT: Post Traumatic Stress Disorder (PTSD) Screening and Soldiers
Reactions that may result in PTSD. Approximately 900,000 Soldiers received this
training by the end of 2007. There are a number of other training programs for Soldiers
and their Families available at www.battlemind.army.mil or
www.behavioralhealth.arrny.mil.
f. All Army deploying behavioral health providers now attend the Combat and
Operational Stress Control (COSC) Course. To date, 152 Army behavioral health
officers, 62 Army enlisted health specialists, 60 Air Force behavioral health officers and
63 Airmen have been trained. We have also trained 23 Chaplains. These reflect all
eight COSC Courses conducted since inception in Feb 07. Emphasizing the policies
above is part of the curriculum. This information is also reinforced to providers at the
annual Force Health Protection conference.
g. The Army is implementing behavioral health training into primary care. All primary
care providers will receive two (2), one hour blocks of instruction covering a range of
behavioral health related issues focused around PTSD and Depression. rhis will be
followed by a one hour block of instruction provided annually and additional education
provided during primary care lecture series.
3. The Way Ahead. Continue to ensure that Soldiers are carefully evaluated and
treated for PTSD, TBI, and other psychiatric illnesses.
(b )(6)
Encl
as
Approved by:
(b )( 6 )
2
INFORMATION PAPER
13 Mar 2009
SUBJECT: Improving Primary Care Provider Skills on Assessment and Management of Depression and PTSD and
1. PURPOSE. To provide information about an Army initiative to improve primary care provider skills on assessment and
management of depression and PTSD, including suicide risk assessment
2. FACTS:
A. Nearly 20% of returning soldiers screen positive for major mental disorder. Of these, 78/f, of them acknowledge a
need for help, yet only about one fourth of these pursue mental health specialty care. Soldiers who screen positive are
twice as likely to perceive barriers (e.g., career effects, stigma, poor access, mistrust) to seeking specialty care help
(Hoge et al, 2004).
B. Primary care-based RESPECT-Depression (Re-engineering systems for the treatment of depression, Dietrich et al,
2004) or similar approaches are significantly more effective than usual PC care in multiple large, multisite randomized
control trials.
C. RESPECT-MIL incorporates the management of PTSD, depression, and deployment-related health concerns using
applicable DoDNA practice guidelines.
D. With 90-95/f, of soldiers accessing primary care annually at a rate of 3.4 primary care visits per year, primary care
offers opportunities for better mental health care access and penetration. less stigma, and earlier assistance with a more
preventive focus.
E. Deployment of RESPECT-MIL at Fort Bragg in 2005/06 revealed significant provider satisfaction/enthusiasm.
Approximately 2/3 of Soldiers screening positive for PTSD or depression who are then enrolled in the RESPECT-MIL care
management reported clinically significant improvements in their symptoms (Engel et al, 2008).
F. Epidemiological data reveal that individuals with depression and anxiety disorders have markedly higher rates of
suicides. Data also reveal that a very high percentage of individuals who have completed suicide have visited their
primary care provider within the past three months. rherefore, it is reasonable to expect that equipping primary care
clinics and providers to more adequately assess and manage depressive and anxiety disorders (e.g., PTSD), to include
suicidal risk assessment, will have a positive impact on reducing population suicide rates.
G. RESPECT-MIL, with a Center of Excellence (COE) at Fort Bragg (transferring soon to Walter Reed), involves:
A structured program with manuals and rigorous Jive and web-based training for participating clinicians
Routine screening for depression, PTSD, and post deployment health concerns with risk assessment (suicide
and violence) as clinically appropriate.
Follow-up brief PC diagnostic and symptom severity assessments for screen positives
Identified and consenting individuals continue in PC and are also referred to mental health supervised caremanagers for facilitated care
Systematic Mental health specialty consultation or referral care as needed

H. Essential to program success, Care Facilitators:
Monitor symptom severity/risk assessment issues and problem solve soldier difficulties initially and during
scheduled follow up phone contacts
Review cases weekly with mental health consultant, providing feedback to soldier and primary care provider
as needed
3. Army Primary Care Initiative.
A. Recognizing the need to improve primary care provider training, The Surgeon General, US Army, issued OPORD
09-05, directing that all Army Primary Care Providers complete mandatory training on the assessment and management
of depression and PTSD in a primary care environment. The OPORD stipulates basic training during the first year,
followed by extended training during the second year. The training content utilizes RESPECT-Mil training materials that
have been implemented at 43 clinics at 15 installations world-wide. Training content focuses on the assessment and
management of depression and PTSD utilizing provider-friendly clinical tools utilized in the RESPECT-Mil program, to
include screening, diagnostic assessment, and treatment monitoring instruments and the utilization of care facilitation and
specialty care consultation strategies. It also provides systematic training on how a primary care provider can assess
suicidal risk, utilizing evidence-based RESPECT-Mil tools and protocols.
B. To accomplish this, two web-based, interactive training modules were developed, one for Depression and for PTSD.
They are available at http://www.pdhealth.mil/respect-mil/index.asp. This training became available in Dec 2008 and will
be accomplished over the next year. AMEDD C&S is in the process of enhancing the automated tracking of training.
(b )(6)

CREW: Department of Defense: Department of The Army: Regarding PTSD Diagnosis: 6/30/2011 - Release Pgs 1-241 On 24 May 2011

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DEPARTMENT OF THE ARMY

OTSG/MEDCOM Policy Memo 08-018

MEMORANDUM FOR Commanders, MEDCOM Regional Medical Commands

updating, and deleting existing policies conflicting with these requirements.

FOIA Release Page 1

FOIA Release Page 2

CHRONOLOGICAL RECORD OF MEDICAL CARE

PTSD Checklist- Military Version (PCL-M)

Repeated, disturbing memo1iu, thoughts, or images

a stressful milltary ~A ~erience~

Havipgphysical reactions :e.g., heart pounding,

16. BeJg '"IIIIJ- al-'!' or watchful on .e

~cathcrs. F.W . Huska, J.A. K~anc, T.M.

tl~:s SI'ICII for Mechanical

rst. iiiiidii lt~j ~af)

Date Arrived AOR: - - - - - - - -

Date Departing AOR: - - - - - - - -

STANDARD FORM 100 (qEV

FlrUR r4 1 CFRl Z01..s5.!C5

FOIA Release Page 3

VHA TBI Clinical Reminder and Screening Tool

(Check all that app~l-~

Losing consciousness/'.knocked out""

Memory problems or lapses

Sensitivity to bright 1ight

Memory problen1s or lapses

FOIA Release Page 4

The Association Between Number of Deployments to Iraq and Mental Health

Ph.D. a,b (b )(6)

Ph.D. a*' (b )(6)

Funding Source: This study was unfunded

FOIA Release Page 5

or two deployments to Iraq.

Soldier Wellness ~ssessment Program at Fort Lewis, Washington.

consumption 90 to 180 days after returning from Iraq.

Syndrome (OR=1.32, p=.047).

for hazardous alcohol consutnption.

adjusting for demographic factors and combat exposure on

FOIA Release Page 6

be a risk factor for mental health concerns.

FOIA Release Page 7

to 8 . 5% returr1ing from non-OIF/Operation Enduring Freedom {OEF) operationallocations .

The importance of these results is underscored by the association between anxiety or

In addition, OIF/OEF veterans with PTSD or hazardous alcohol consumption

FOIA Release Page 8

There is currently speculation as to whether multiple deployments to Iraq may exacerbate

relationship stress, homefront problems, challenges associated with adjusting to a new

theater may mediate the impact of deployment stress.

Command have reported mixed

There is evidence that exposure to multiple traumas

significantly associated with an increased risk ofPTSD.

Similar results have been noted in

In addition, among Service Members who worked in a

FOIA Release Page 9

Soldiers with one or two deployments to Iraq.

Health Reasssessment (PD . . .

electronically, and a qualified healthcare professional (nurse practitioner, physician assistant, or

evaluation or referrals as indicated.

screening measures that includes the standard PD ......

FOIA Release Page 10

support staff meet with each Soldier to schedule follow-up appointments.

when they were screened within at least 60-days of the target PD