PERSPECTIVE: Health Economic Interests at NIMH and NIDA to Improve Delivery of Behavioral Health Services

BACKGROUND

Effective financing mechanisms are essential to ensuring that people can access and utilize effective treatments and services. Financing mechanisms are needed not only to pay for the delivery of those treatments and services, but also ancillary costs, while also keeping care affordable.

AIMS

This article highlights key areas of the interest of the National Institute of Mental Health (NIMH) and the National Institute on Drug Abuse (NIDA) in supporting applied health economics and health care financing research. Specifically, this article discusses the long-range impact of NIH's earlier investments in applied health economics research, and NIH's ongoing efforts to communicate its interests in health economics research. We discuss the 2023 NIMH-NIDA-sponsored health economics conference, and the ideas presented there for developing and assessing innovative behavioral health care financing models; three of the presented papers were recently published in the Journal of Mental Health Policy and Economics.

METHODS

We describe the history and impact of NIMH- and NIDA-sponsored economic research and identify current research interests as identified in the NIMH and NIDA Strategic Plans and recent funding announcements. We examine themes presented at the NIMH-NIDA Health Economics conference. The conference included over 300 participants from 20 countries, from six continents.

RESULTS

The topics highlighted at the conference highlight the ways in which NIH-funded research has promoted the development of innovative health care financing methods, both from the supply side (e.g., providers and payers) and demand side (e.g., service users and families). Invited speakers discussed the findings from NIH-supported research in the topic areas of payment and financing, behavioral economics and social determinants of health. Keynote speakers highlighted emerging topics in the field, including the economics of health equity, biases in mental health models in health care, and value-based insurance design.

DISCUSSION

We demonstrate a resurgence of and explicit interest in health economics and policy research at NIMH and NIDA. However, more work is needed in order to design funding mechanisms that fully provide access to and facilitate use of effective evidence-based practices to improve mental health outcomes. For example, it is important that policy and health economic research projects include decision makers who will be the end users of data and study results, to ensure that results can be meaningfully put into practice.

IMPLICATIONS FOR HEALTH CARE

Designing effective and efficient funding mechanisms can help ensure that service users have access to effective treatments and that clinicians and provider organizations are adequately compensated for their work.

IMPLICATIONS FOR HEALTH POLICIES

Federal, state, and local policies, as well as policies of payers and health care organizations, can influence the type of care that is supported and incentivized.

IMPLICATIONS FOR FURTHER RESEARCH

As demonstrated by the research interests as outlined in their respective Strategic Plans and funding announcements, NIMH and NIDA continue to fund health economic and policy research that aims to improve health care access, quality and outcomes for people with or at risk of developing behavioral health conditions in the US and around the world.

PERSPECTIVE: A Path to Value-Based Insurance Design for Mental Health Services

BACKGROUND

Aligning cost of mental health care with expected clinical and functional benefits of that care would incentivize the delivery of high value treatments and services. In turn, ineffective or untested care could still be offered but at costs high enough to offset the delivery of high value care.

AIMS

The authors comment on Benson and Fendrick's paper on Value-Based Insurance Design (VBID) for mental health in the September 2023 special issue of this journal. The authors also present a preliminary framework of key ingredients needed to consider VBID for mental health treatments and services.

METHODS

The authors briefly review current and past efforts to contain costs and improve quality of mental health care, which include (for example) use of carve-out and carve-in programs, evaluation of cost sharing models, impact of accountable care organizations, and studying other benefit designs and impact of federal and state policies.

RESULTS

Using PTSD as an example, key ingredients of VBID for mental health services were identified and include the following: tools for case identification and monitoring progress over time at the population level; specific treatments and services with evidence of clinical effectiveness, cost-effectiveness, and health equity; and an approach to document the specific treatment or service was delivered (versus another treatment or service that may lack evidence).

DISCUSSION

The inability to afford mental health care is a top barrier to treatment seeking. People who do elect to spend time and money on mental health care are further disadvantaged by accessing care that is not well regulated and the quality at best is questionable. VBID could be an important lever for increasing access to and use of high value mental health care. Partnerships among the research, practice, and policy communities can help ensure research solutions meet needs of these two communities.

IMPLICATIONS FOR HEALTH CARE

VBID holds promise to make high value mental health care more affordable while discouraging low value treatments and services.

IMPLICATIONS FOR HEALTH POLICIES

While evidence gaps remain, these gaps can be filled concurrently with pursuit of VBID for mental health services.

IMPLICATIONS FOR FUTURE RESEARCH

This paper identifies important research opportunities to help make VBID a reality for mental health care.

PERSPECTIVE: Economic and Policy Research Interests Highlighted in the 25th NIMH-Sponsored Mental Health Services Research Conference

BACKGROUND

The National Institute of Mental Health (NIMH) remains committed to addressing real-world challenges with delivering high quality mental health care to people in need by advancing a services research agenda to improve access, continuity, quality, equity, and value of mental healthcare nationwide, and to improve outcomes for people with serious mental illnesses (SMI). The NIMH-Sponsored Mental Health Services Research Conference (MHSR) is a highly productive venue for discussing topics of interest to NIMH audiences and disseminating NIMH's latest research findings directly to mental health clinicians, policy makers, administrators, advocates, consumers, and scientists who attend.

AIMS

This Perspective summarizes and provides highlights from the 25th MHSR. It also reviews three papers presented at the 25th MSHR and subsequently published in the June 2023 special issue of The Journal of Mental Health Policy and Economics (JMHPE).

METHODS

The authors review three papers published in the June 2023 special issue of JMHPE, identifying common themes across the papers and illustrating how the papers' findings promote key areas of NIMH research interests.

RESULTS

Three important areas are highlighted in this review: (i) service user engagement in the research enterprise, (ii) financing the implementation of the 988 Suicide and Crisis Lifeline, and (iii) methods to predict mental health workforce turnover.

DISCUSSION

These three papers illustrate key areas in which policy research can help to promote quality mental health care. One notable common theme across the papers is that of the role that end users play in the research enterprise. The papers focus on (i) service users and the value they bring to informing the practice of research, (ii) policy makers and the information they need to make evidence-informed decisions, and (iii) provider organization leadership, by using an innovative machine learning process to help organizations predict and address staff turnover.

IMPLICATIONS FOR HEALTH CARE

NIMH encourages and often requires strong research practice partnerships to help ensure findings will be of value to end users and make their way into the practice setting. The three papers reviewed in this perspective are exemplars of how necessary stakeholder partnerships are to improve care for those with mental illness.

IMPLICATIONS FOR HEALTH POLICIES

The highlighted papers (i) provide recommendations for structural changes to research institutions to increase service user engagement in all aspects of the research enterprise, (ii) identify policy solutions to improve fiscal readiness to address increased demand of 988, and (iii) pilot a novel data-driven approach to predict mental health workforce turnover, a significant problem in community mental health clinics, offering health system leaders and policy makers an opportunity to proactively intervene to help maintain continuity of staffing.

IMPLICATIONS FOR FURTHER RESEARCH

Consistent with NIMH's Strategic Plan for Research and current funding announcements, there remains an urgent need to (i) develop strategies to better implement, scale, and sustain existing evidence-supported treatments and services, particularly in historically underserved communities, and (ii) develop, test, and evaluate new solutions to improve access, continuity, quality, equity, and value of care.ing and clinical outcomes remains uncertain.

PERSPECTIVE: A Mental Health Services Research Agenda in the Era of COVID-19: Steadfast Commitment to Addressing Evolving Challenges

BACKGROUND

Decades of research that predate the COVID-19 pandemic demonstrate that most people with mental health needs are not receiving adequate care. The inequities between those who need care and those who receive adequate care are larger for racial and ethnic minority groups and people living in underserved communities. The pandemic is associated with an exacerbation of these inequities, resulting in increased morbidity and mortality for the most vulnerable populations.

AIMS

This Perspective summarizes longstanding and evolving challenges to the provision of high quality care for people with mental illness, describes the National Institute of Mental Health's (NIMH) commitment to addressing those challenges, and embeds salient research priorities most germane to the health policy readership of this journal.

METHODS

Example funding announcements and extant funding priorities are highlighted to demonstrate NIMH's commitment to health services research during the pandemic. The collaborative care model is presented as an evidence-supported service delivery model that could be delivered via telehealth. Recent studies that compare the utilization of routine telehealth services during the pandemic, when compared to in-person services pre-pandemic, are summarized.

RESULTS

In FY2020, NIMH invested $171,194,275 in health services research. Over the past two years, NIMH led or participated on dozens of funding announcements that call for mental health services research to help improve the provision of care for people with mental illness. Service delivery models like collaborative care can offer effective intervention via telehealth. The practice community can deliver routine services via telehealth at volumes similar to pre-pandemic in-person levels. However, wide variation in telehealth utilization exists, with inequities associated with racial and ethnic groups and underserved rural locations. A limitation is that clinical outcomes are not routinely available from administrative datasets.

DISCUSSION

There continues to be an urgent need for health policy research and collaboration with the health policy community as part of the research enterprise.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE

NIMH encourages and often requires strong research practice partnerships to help ensure findings will be of value to end users and make their way into the practice setting. There is a need to study pandemic related changes in financing, delivery, receipt, and outcomes of mental health care.

IMPLICATIONS FOR HEALTH POLICIES

Despite robust evidence, clinical practice guideline recommendations, and established financing mechanisms, uptake of service delivery models that can be delivered in part or in full via telehealth (e.g., the collaborative care model) is poor.

IMPLICATIONS FOR FURTHER RESEARCH

In the era of COVID-19, the charge to the mental health services research community is urgent: (i) develop strategies to better implement, scale, and sustain existing evidence-supported treatments and services and (ii) develop, test, and evaluate new solutions to improve access, continuity, quality, equity, and value of care.

PERSPECTIVES: Insurance markets, labor markets, and the mental health services delivery system

INTRODUCTION

The authors are health scientist administrators at the National Institute of Mental Health (NIMH). The mission of NIMH is "to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure." As part of its portfolio, NIMH supports research on mental health economics, and mental health services research.

METHOD

In this perspective article, the authors comment on two papers presented at the NIMH-sponsored Mental Health Services Research Conference in 2018 and subsequently published in the September 2019 issue of the Journal of Mental Health Policy and Economics. Two important areas are highlighted in this review: (i) the impact of insurance and labor markets on the delivery of high-quality mental health services, and (ii) the need for advancements in method development and design in future studies.

DISCUSSION

The complexity of health insurance markets created some unintended consequence of the mental health insurance parity legislation. Mental health provider shortages in local labor markets are a barrier to successful implementation and sustainment of innovative and evidence-based mental health service-delivery models for people with serious mental illness.

IMPLICATIONS FOR RESEARCH

Data-capture techniques that seamlessly integrate insurance claims with clinical outcomes (e.g., from electronic health records) will better equip health economists and other end-users with rigorous research findings to inform public health policy and practice recommendations. Despite early signals of success, larger sample sizes and more rigorous research designs are needed to refine predictive models of functional outcomes of evidence-based service-delivery models (e.g., coordinated specialty care model including supported education, and supported employment) for people with first-episode psychosis.

Impact of financial reimbursement on retention rates in military clinical trial research: A natural experiment within a multi-site randomized effectiveness trial with active duty service members

Introduction

Achieving adequate retention rates in clinical trials is essential to ensuring meaningful results. Although financial reimbursement is an effective strategy to increase participant retention, current policies restrict the use of federal funds to reimburse U.S. active duty Service members for research participation. It is unknown whether permitting financial reimbursement among this population would improve trial retention rates. A recent randomized effectiveness trial received approval to provide reimbursement to Service member participants several months after recruitment began, creating a natural experiment to study the effects of financial reimbursement on retention.

Materials and methods

Active duty Service members recruited from six U.S. military treatment facilities (N = 666) were enrolled in a collaborative care study and completed assessments at baseline, three-, six-, and 12-months. Data on study assessment completion rates at three- and six-months were analyzed using the mixed-effects binary logit model to determine the probabilities of completing assessments based on reimbursement status.

Results

Participants who received reimbursement were significantly more likely to complete study assessments at both time-points than participants who did not receive reimbursement (p < 0.01). Survey completion was 5% and 4% greater among participants offered reimbursement at three- and six-month time-points, respectively.

Conclusion

Results suggest that providing Service members with reimbursement for research participation is associated with modest increases in retention rates in clinical trials. Findings provide useful insight for researchers, funding agencies, and policy-makers in considering retention strategies to maximize the value and impact of military research.

Collaborative Care for Depression and Posttraumatic Stress Disorder: Evaluation of Collaborative Care Fidelity on Symptom Trajectories and Outcomes

BACKGROUND

Despite the growing consensus that collaborative care is effective, limited research has focused on the importance of collaborative care fidelity as it relates to mental health clinical outcomes.

OBJECTIVE

To assess the relationship of collaborative care fidelity on symptom trajectories and clinical outcomes among military service members enrolled in a multi-site randomized controlled trial for the treatment of depression and posttraumatic stress disorder (PTSD).

DESIGN

Study data for our analyses came from a two-parallel arm randomized trial that evaluated the effectiveness of a centralized collaborative care model compared to the existing collaborative care model for the treatment of PTSD and depression. All patients were included in the analyses to evaluate how longitudinal trajectories of PTSD and depression scores differed across various collaborative care fidelity groupings.

PARTICIPANTS

A total of 666 US Military Service members screening positive for probable PTSD or depression through primary care.

MAIN MEASURES

Disease registry data from a web-based clinical management support tool was used to measure collaborative care fidelity for patients enrolled in the trial. Participant depression and PTSD symptoms were collected independently from research survey assessments at four time points across the 1-year trial period. Treatment utilization records were acquired from the Military Health System administrative records to determine mental health service use.

KEY RESULTS

Consistent and late fidelity to the collaborative care model predicted an improving symptom trajectory over the course of treatment. This effect was more pronounced for patients with depression than for patients with PTSD.

CONCLUSIONS

Long-term fidelity to key collaborative care elements throughout care episodes may improve depression outcomes, particularly for patients with elevated symptoms. More controlled research is needed to further understand the influence of collaborative care fidelity on clinical outcomes.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier NCT01492348.

Cost-effectiveness of collaborative care for depression and PTSD in military personnel

OBJECTIVES

Collaborative care is an effective approach for treating posttraumatic stress disorder (PTSD) and depression within the US Military Health System (MHS), but its cost-effectiveness remains unstudied. Our objective was to evaluate the costs and cost-effectiveness of centrally assisted collaborative telecare (CACT) versus optimized usual care (OUC) for PTSD and depression in the MHS.

STUDY DESIGN

A randomized trial compared CACT with OUC. Routine primary care screening identified active-duty service members with PTSD or depression. Eligible participants (N = 666) were randomized to CACT or OUC and assessed at 3, 6, and 12 months. OUC patients could receive care management and increased behavioral health support. CACT patients could receive these services plus stepped psychosocial treatment and routine centralized team monitoring.

METHODS

Quality-adjusted life-years (QALYs) were derived from the 12-Item Short Form Health Survey. Claims and case management data were used to estimate costs. Cost-effectiveness analyses were conducted from a societal perspective.

RESULTS

Data from 629 patients (320 CACT and 309 OUC) with sufficient follow-up were analyzed. CACT patients gained 0.02 QALYs (95% CI, -0.001 to 0.03) relative to OUC patients. Twelve-month costs, including productivity, were $987 (95% CI, -$3056 to $5030) higher for CACT versus OUC. CACT was estimated to cost $49,346 per QALY gained compared with OUC over 12 months. There is a 58% probability that CACT is cost-effective at a $100,000/QALY threshold.

CONCLUSIONS

Despite its higher costs, CACT appears to be a cost-effective strategy relative to OUC for managing PTSD and depression in the MHS.

Rescaling the Post-Traumatic Stress Disorder Checklist for Use in Primary Care

The Posttraumatic Stress Disorder (PTSD) Checklist (PCL) is a 17-item self-report measure of PTSD symptom severity that has demonstrated excellent psychometric properties across a variety of settings, purposes, and populations. The PCL is widely used in busy Department of Defense primary care settings as part of routine PTSD screening, requiring that it is easy for patients to complete and providers to score. The clinical utility of the PCL may be improved through use of a zero-anchored Likert-type response scale by providing intuitive anchors for respondents and fewer calculations for clinic staff; however, changes to the response scale may invalidate the known psychometric properties of the measure. The purpose of this study is to evaluate the equivalence of a zero-anchored PCL to the traditional one-anchored PCL. Differences in total scores were examined using inferential confidence intervals. Substantial overlap of the inferential confidence intervals and small Rg (maximum probable difference) value of 0.68 indicated that the zero-anchored PCL is equivalent to the one-anchored PCL on the basis of our specified delta (amount of difference considered inconsequential). These findings support the use of a zero-anchored PCL in clinical practice, and more broadly, the use of zero-anchored measures in the larger field of psychological assessment.

Population Impact of PTSD and Depression Care for Military Service Members: Reach and Effectiveness of an Enhanced Collaborative Care Intervention

Objective: Epidemiologic studies suggest high rates of posttraumatic stress disorder (PTSD) and depression among military members and veterans. To meet the needs of this population, evidence-based treatments are recommended as first-line interventions, based on their clinical efficacy and not the proportion of the target population that the intervention reaches. We apply a public health framework to examine the population impact of an enhanced collaborative care model on a targeted population that takes into account effectiveness and reach.

METHODS

Using data collected from a 2012 - 2016 randomized trial, the effectiveness of enhanced collaborative care for PTSD and depression was evaluated using probable diagnostic status as the primary outcome. Exclusion criteria were then applied to a 2011 disease registry to examine the representativeness of the trial sample and estimate the potential reach of the intervention. Population impact was derived from the estimated effectiveness and reach of the intervention.

RESULTS

Enhanced collaborative care was associated with a significantly greater probability of PTSD/depression remission by the end of the trial (conditional effect = -0.066, chisq = 51.1, p < 0.001). Based on the effectiveness and reach of the enhanced intervention, an estimated 250 (out of the 3,436) more Army soldiers with PTSD and/or depression would experience diagnostic remission during the preceding year if the enhanced model was available.

CONCLUSION

The population framework permits the estimated differential impact of two collaborative care models to inform implementation considerations. These results highlight the value of applying public health models to identify front line treatments.

IRB and Research Regulatory Delays Within the Military Health System: Do They Really Matter? And If So, Why and for Whom?

Institutional review board (IRB) delays may hinder the successful completion of federally funded research in the U.S. military. When this happens, time-sensitive, mission-relevant questions go unanswered. Research participants face unnecessary burdens and risks if delays squeeze recruitment timelines, resulting in inadequate sample sizes for definitive analyses. More broadly, military members are exposed to untested or undertested interventions, implemented by well-intentioned leaders who bypass the research process altogether. To illustrate, we offer two case examples. We posit that IRB delays often appear in the service of managing institutional risk, rather than protecting research participants. Regulators may see more risk associated with moving quickly than risk related to delay, choosing to err on the side of bureaucracy. The authors of this article, all of whom are military-funded researchers, government stakeholders, and/or human subject protection experts, offer feasible recommendations to improve the IRB system and, ultimately, research within military, veteran, and civilian populations.

Centrally Assisted Collaborative Telecare for Posttraumatic Stress Disorder and Depression Among Military Personnel Attending Primary Care: A Randomized Clinical Trial

IMPORTANCE

It is often difficult for members of the US military to access high-quality care for posttraumatic stress disorder (PTSD) and depression.

OBJECTIVE

To determine effectiveness of a centrally assisted collaborative telecare (CACT) intervention for PTSD and depression in military primary care.

DESIGN, SETTING, AND PARTICIPANTS

The STEPS-UP study (Stepped Enhancement of PTSD Services Using Primary Care) is a randomized trial comparing CACT with usual integrated mental health care for PTSD or depression. Patients, mostly men in their 20s, were enrolled from 18 primary care clinics at 6 military installations from February 2012 to August 2013 with 12-month follow-up completed in October 2014.

INTERVENTIONS

Randomization was to CACT (n = 332) or usual care (n = 334). The CACT patients received 12 months of stepped psychosocial and pharmacologic treatment with nurse telecare management of caseloads, symptoms, and treatment.

MAIN OUTCOMES AND MEASURES

Primary outcomes were severity scores on the PTSD Diagnostic Scale (PDS; scored 0-51) and Symptom Checklist depression items (SCL-20; scored 0-4). Secondary outcomes were somatic symptoms, pain severity, health-related function, and mental health service use.

RESULTS

Of 666 patients, 81% were male and the mean (SD) age was 31.1 (7.7) years. The CACT and usual care patients had similar baseline mean (SD) PDS PTSD (29.4 [9.4] vs 28.9 [8.9]) and SCL-20 depression (2.1 [0.6] vs 2.0 [0.7]) scores. Compared with usual care, CACT patients reported significantly greater mean (SE) 12-month decrease in PDS PTSD scores (-6.07 [0.68] vs -3.54 [0.72]) and SCL-20 depression scores -0.56 [0.05] vs -0.31 [0.05]). In the CACT group, significantly more participants had 50% improvement at 12 months compared with usual care for both PTSD (73 [25%] vs 49 [17%]; relative risk, 1.6 [95% CI, 1.1-2.4]) and depression (86 [30%] vs 59 [21%]; relative risk, 1.7 [95% CI, 1.1-2.4]), with a number needed to treat for a 50% improvement of 12.5 (95% CI, 6.9-71.9) and 11.1 (95% CI, 6.2-50.5), respectively. The CACT patients had significant improvements in somatic symptoms (difference between mean 12-month Patient Health Questionnaire 15 changes, -1.37 [95% CI, -2.26 to -0.47]) and mental health-related functioning (difference between mean 12-month Short Form-12 Mental Component Summary changes, 3.17 [95% CI, 0.91 to 5.42]), as well as increases in telephone health contacts and appropriate medication use.

CONCLUSIONS AND RELEVANCE

Central assistance for collaborative telecare with stepped psychosocial management modestly improved outcomes of PTSD and depression among military personnel attending primary care.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01492348.

Implementing collaborative primary care for depression and posttraumatic stress disorder: design and sample for a randomized trial in the U.S. military health system

BACKGROUND

War-related trauma, posttraumatic stress disorder (PTSD), depression and suicide are common in US military members. Often, those affected do not seek treatment due to stigma and barriers to care. When care is sought, it often fails to meet quality standards. A randomized trial is assessing whether collaborative primary care improves quality and outcomes of PTSD and depression care in the US military health system.

OBJECTIVE

The aim of this study is to describe the design and sample for a randomized effectiveness trial of collaborative care for PTSD and depression in military members attending primary care.

METHODS

The STEPS-UP Trial (STepped Enhancement of PTSD Services Using Primary Care) is a 6 installation (18 clinic) randomized effectiveness trial in the US military health system. Study rationale, design, enrollment and sample characteristics are summarized.

FINDINGS

Military members attending primary care with suspected PTSD, depression or both were referred to care management and recruited for the trial (2592), and 1041 gave permission to contact for research participation. Of those, 666 (64%) met eligibility criteria, completed baseline assessments, and were randomized to 12 months of usual collaborative primary care versus STEPS-UP collaborative care. Implementation was locally managed for usual collaborative care and centrally managed for STEPS-UP. Research reassessments occurred at 3-, 6-, and 12-months. Baseline characteristics were similar across the two intervention groups.

CONCLUSIONS

STEPS-UP will be the first large scale randomized effectiveness trial completed in the US military health system, assessing how an implementation model affects collaborative care impact on mental health outcomes. It promises lessons for health system change.

A trial of prazosin for combat trauma PTSD with nightmares in active-duty soldiers returned from Iraq and Afghanistan

OBJECTIVE

The authors conducted a 15-week randomized controlled trial of the alpha-1 adrenoreceptor antagonist prazosin for combat trauma nightmares, sleep quality, global function, and overall symptoms in active-duty soldiers with posttraumatic stress disorder (PTSD) returned from combat deployments to Iraq and Afghanistan.

METHOD

Sixty-seven soldiers were randomly assigned to treatment with prazosin or placebo for 15 weeks. Drug was titrated based on nightmare response over 6 weeks to a possible maximum dose of 5 mg midmorning and 20 mg at bedtime for men and 2 mg midmorning and 10 mg at bedtime for women. Mean achieved bedtime doses were 15.6 mg of prazosin (SD=6.0) and 18.8 mg of placebo (SD=3.3) for men and 7.0 mg of prazosin (SD=3.5) and 10.0 mg of placebo (SD=0.0) for women. Mean achieved midmorning doses were 4.0 mg of prazosin (SD=1.4) and 4.8 mg of placebo (SD=0.8) for men and 1.7 mg of prazosin (SD=0.5) and 2.0 mg of placebo (SD=0.0) mg for women. Primary outcome measures were the nightmare item of the Clinician-Administered PTSD Scale (CAPS), the Pittsburgh Sleep Quality Index, and the change item of the Clinical Global Impressions Scale anchored to functioning. Secondary outcome measures were the 17-item CAPS, the Hamilton Depression Rating Scale, the Patient Health Questionnaire-9, and the Quality of Life Index. Maintenance psychotropic medications and supportive psychotherapy were held constant.

RESULTS

Prazosin was effective for trauma nightmares, sleep quality, global function, CAPS score, and the CAPS hyperarousal symptom cluster. Prazosin was well tolerated, and blood pressure changes did not differ between groups.

CONCLUSIONS

Prazosin is effective for combat-related PTSD with trauma nightmares in active-duty soldiers, and benefits are clinically meaningful. Substantial residual symptoms suggest that studies combining prazosin with effective psychotherapies might demonstrate further benefit.

Preference-weighted health status of PTSD among veterans: an outcome for cost-effectiveness analysis using clinical data

OBJECTIVE

Posttraumatic stress disorder (PTSD) is a highly prevalent, chronic, disabling but treatable condition. Preference-based measures (for example, health utilities) are recommended for and useful in cost-effectiveness analyses and for policy decisions because they reflect a population's valuation of the desirability of disease states. However, no such measures exist for PTSD. This study aimed to estimate preference-weighted health status associated with PTSD and common co-occurring mental disorders in a sample of veterans by transforming health-related quality-of-life data into preference-weighted health status scores (PWHS scores), develop a usable regression model to predict PWHS scores from other data sets, and compare preference-weighted health status of PTSD with that of another chronic disorder, chronic obstructive pulmonary disease (COPD).

METHODS

A secondary analysis was performed on data from a random sample of 808 veterans (79% male; 12% met criteria for PTSD) in four primary care clinics. Veterans responded to the PTSD Checklist (PCL), Clinician-Administered PTSD Scale, Mini-International Neuropsychiatric Interview, and Medical Outcomes Survey Short Form-36.

RESULTS

PWHS scores were .029 lower among veterans with PTSD compared with veterans without PTSD, all else being equal. However, scores depended on PTSD severity, when the analysis controlled for other model variables. Specifically, PWHS scores dropped by .004 with a 1-unit increase in PCL scores among veterans without PTSD. Among veterans with PTSD, the reduction was .002. PTSD was associated with lower preference-weighted health status than COPD.

CONCLUSIONS

This is the first study to estimate preference-weighted health status of persons with PTSD. These PWHS scores can be helpful in cost-effectiveness studies of PTSD treatments.

Test of a single-item posttraumatic stress disorder screener in a military primary care setting

BACKGROUND

Posttraumatic stress disorder (PTSD) is prevalent in primary care, frequently goes undetected and can be highly debilitating when untreated.

OBJECTIVE

We assessed the operating characteristics of a single-item PTSD screener (SIPS) for primary care and compared it to a commonly used four-item primary care PTSD screener (PC-PTSD). The SIPS asks: "Were you recently bothered by a past experience that caused you to believe you would be injured or killed ... not bothered, bothered a little, or bothered a lot?"

METHODS

A total of 3,234 patients from three Washington, DC, area military primary care clinics completed the SIPS. Independent, blinded assessments using a structured diagnostic PTSD interview were completed in 213 of these patients.

RESULTS

The SIPS yielded a reasonable range of likelihood ratios, suggesting capacity to discriminate between low- and high-probability PTSD patients. However, the SIPS sensitivity was only 76% for those reporting "bothered a little" and the four-item PC-PTSD yielded significantly better test characteristics on Receiver-Operator Curve analysis.

CONCLUSION

A single, user-friendly primary care PTSD screening question with three response options, while sensible and worth further investigation, failed to offer sound test characteristics for PTSD screening. Ways of improving SIPS performance are discussed.

Estimating health utilities and quality adjusted life years in seasonal affective disorder research

BACKGROUND

Seasonal affective disorder (SAD) episodes will recur annually without effective intervention. Effectiveness of such interventions is traditionally measured with depression-specific tools (e.g., Beck Depression Inventory 2nd Edition; BDI-II). In a climate of potentially scarce resources, generic outcomes, such as Quality Adjusted Life Years (QALYs), are recommended for cost-effectiveness research. For treatments to be deemed cost-effective, they must show effectiveness relative to each other and relative to interventions across other disorders. To date, QALYs have not been used to determine effectiveness of SAD treatments. Given the recurrent nature of SAD, QALYs, which weight quality of life with time, are an ideal SAD treatment outcome.

METHOD

A method to assess QALYs for SAD was developed using pilot clinical trial data. The method estimated health utilities, a measure of quality of life for a QALY, by anchoring pilot BDI-II data from the SAD clinical trial with previously derived health utilities for nonseasonal depression.

RESULTS

Relative to no treatment, median QALYs gained ranged from 0.11-0.18 over 1 year, depending on the intervention assessed.

DISCUSSION

Any treatment for SAD must compete with spontaneous spring remission, as illness severity attenuates in the spring.

LIMITATIONS

Health utilities were estimated from the depression literature, and potential side effects from SAD treatments were not included in the estimates. The clinical trial time horizon was limited to 1-year.

CONCLUSIONS

The proposed method offers researchers a tool to transform SAD efficacy data into a generic outcome for use in cost-effectiveness analysis of SAD treatments.