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J Gen Intern Med. 2016 May; 31(5): 536.
Published online 2016 March 8. doi:  10.1007/s11606-016-3646-x
PMCID: PMC4835385

Capsule Commentary on Meredith et al., Impact of Collaborative Care for Underserved Patients with PTSD in Primary Care: A Randomized Controlled Trial

The randomized clinical trial by Meredith et al. showed that collaborative care and minimally enhanced usual care were equally effective for post-traumatic stress disorder (PTSD).1 The improvement rates in both groups were remarkably high, with effect sizes for PTSD severity reduction exceeding 1.5 SD and nearly 60 % of participants no longer meeting diagnostic criteria for PTSD at 1 year. Reasons for a negative trial might include enrollment of patients with less severe PTSD and a more favorable natural history, a stronger than expected effect of training in the enhanced usual care group, or a weaker than expected collaborative care intervention.

The CALM trial for anxiety disorders in 1004 primary care patients showed a moderate but nonsignificant effect size of 0.48 for PTSD; however, only 6 % of participants had a principal diagnosis of PTSD.2 In two primary care trials involving Veterans, one showed a minimal effect on PTSD severity,3 whereas the second showed a modest effect size of 0.31 to 0.45.4 However, the first trial3 was conducted in VA Medical Centers where patients had ready access to mental health, resulting in an average of 4.2 psychotherapy visits in both collaborative care and usual care groups. In contrast, the second trial4 enrolled from community-based clinics often located in rural areas, leading to far more psychotherapy sessions in the telecare group compared to usual care group (4.2 vs. 0.8). Notably, both this latter trial and the CALM trial assured more uniform delivery of evidence-based psychotherapy than either of the two negative trials.

In contrast to this small number of collaborative care trials with mixed results for PTSD, there have been more than 70 trials establishing the benefits of collaborative care for depression.5 Whereas medications and psychotherapy are equally effective for depression, psychotherapy may be especially important for optimal outcomes in PTSD. It is also possible that the type of trauma (e.g., combat, interpersonal violence or abuse, accidents or natural disasters) and severity of symptoms may lead to differential treatment responses. The movement towards integrating medical and behavioral health services may be most critical for disorders where pharmacotherapy alone is insufficient.

Compliance with Ethical Standards

Compliance with Ethical Standards

Conflicts of Interest

The author has no conflicts of interest with the material in this article.

REFERENCES

1. Meredith LS, Eisenman DP, Han B, Green GL, Kaltman S, Wong EC, et al. Impact of collaborative care for underserved patients with PTSD in primary care: a randomized controlled trial. J Gen Intern Med. 2016 [PMC free article] [PubMed]
2. Craske MG, Stein MB, Sullivan G, Sherbourne C, Bystritsky A, Rose RD, et al. Disorder-specific impact of Coordinated Anxiety Learning and Management Treatment for anxiety disorders in primary care. Arch Gen Psychiatry. 2011;68:378–388. doi: 10.1001/archgenpsychiatry.2011.25. [PMC free article] [PubMed] [Cross Ref]
3. Schnurr PP, Friedman MJ, Oxman TE, Dietrich AJ, Smith MW, Shiner B, et al. RESPECT-PTSD: re-engineering systems for the primary care treatment of PTSD, a randomized controlled trial. J Gen Intern Med. 2013;28:32–40. doi: 10.1007/s11606-012-2166-6. [PMC free article] [PubMed] [Cross Ref]
4. Fortney JC, Pyne JM, Kimbrell TA, Hudson TJ, Robinson DE, Schneider R, et al. Telemedicine-based collaborative care for posttraumatic stress disorder: a randomized clinical trial. JAMA Psychiatry. 2015;72:58–67. doi: 10.1001/jamapsychiatry.2014.1575. [PubMed] [Cross Ref]
5. Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst 2012, Rev 10: CD006525. doi: 10.1002/14651858.cd006525.pub2 [PubMed]

Articles from Journal of General Internal Medicine are provided here courtesy of Society of General Internal Medicine