Treating Post-traumatic Stress Disorder with a Prolonged Exposure Protocol Within Primary Care Behavioral Health: A Case Example

Abstract

Posttraumatic stress disorder (PTSD) is a debilitating condition that impacts anywhere from 2 to 39% of primary care patients. Research suggests overall health, instances of hospitalizations, emergency room visits, and utilization of primary care services are impacted by a diagnosis of PTSD. Evidenced based treatments such as cognitive process therapy and prolonged exposure (PE) are available in specialty mental health but pose many barriers to treatment and implementation into primary care. This case study serves as the first known case example with an ethnic minority civilian, examining the treatment of PTSD within the Primary Care Behavioral Health Model using the brief (5 visits), PE protocol for primary care (PE-PC). PTSD was assessed using the PCL-5. Additional variables were assessed and tracked with the following tools: PHQ-9 (depressive symptoms), GAD-7 (anxiety symptoms), QLES-SF (quality of life), and the AAQ-2 (psychological flexibility) pre/post treatment, 6 months post-treatment and 9 months post-treatment. The patient reported clinically significant decreases in symptoms of PTSD, depression, and anxiety symptoms. Additionally, the patient’s scores on quality of life and psychological flexibility improved. Brief, exposure-based treatment for PTSD can be delivered within the PCBH model. This treatment may result in improved quality of life and has the potential to reduce health care costs. This case encourages the treatment of PTSD within primary care, increasing access to care for patients. Future research is needed to further investigate this protocol in primary care with underserved, civilian populations and to explore patient attitudes toward brief treatment for PTSD in a primary care setting.

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References

  1. American Psychological Association. (APA; 2017). Clinical Practice Guideline for the Treatment of PTSD. https://www.apa.org/ptsd-guideline/ptsd.pdf

  2. Andersen, J., Wade, M., Possemato, K., & Ouimette, P. (2010). Association between posttraumatic stress disorder and primary care provider-diagnosed disease among Iraq and Afghanistan veterans. Psychosomatic Medicine, 72, 498–504. https://doi.org/10.1097/PSY.0b013e3181d969a1.

    Article  PubMed  Google Scholar 

  3. Bauman, D. E., Beachy, B. R., & Ogbeide, S. A. (2018). Diabetes Management. In A. Maragakis & W. O’Donohue (Eds.), Principle-based stepped care and brief psychotherapy for integrated care settings. Cham, Switzerland: Springer.

    Google Scholar 

  4. Blevins, C. A., Weathers, F. W., Davis, M. T., Witte, T. K., & Domino, J. L. (2015). The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and initial psychometric evaluation. Journal of Traumatic Stress, 28, 489–498. https://doi.org/10.1002/jts.22059.

    Article  PubMed  Google Scholar 

  5. Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., … Zettle, R. D. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire: II: A revised measure of psychological inflexibility and experiential avoidance. Behaviour Therapy, 42, 676–688. https://doi.org/10.1016/j.beth.2011.03.007.

    Article  Google Scholar 

  6. Boscarino, J. A., Forsberg, C. W., & Goldberg, J. (2010). A twin study of the association between PTSD symptoms and rheumatoid arthritis. Psychosomatic Medicine, 72(5), 481–486. https://doi.org/10.1097/psy.0b013e3181d9a80c.

    Article  PubMed  Google Scholar 

  7. Bridges, A. J., Gregus, S. J., Rodriguez, J. H., Andrews, A. R., III, Villalobos, B. T., Pastrana, F. A., & Cavell, T. A. (2015). Diagnoses, intervention strategies, and rates of functional improvement in integrated behavioral health care patients. Journal of Consulting and Clinical Psychology, 83, 590.

    Article  Google Scholar 

  8. Cahill, S. P., & Foa, E. B. (2007). Psychological theories of PTSD (pp. 55–77). Handbook of PTSD: Science and practice.

    Google Scholar 

  9. Cigrang, J. A., Rauch, S. A., Avila, L. L., Bryan, C. J., Goodie, J. L., Hryshko-Mullen, …, STRONG STAR Consortium. (2011). Treatment of active-duty military with PTSD in primary care: Early Findings. Psychological Services, 8(2), 104–113. https://doi.org/10.1037/a0022740.

    Article  Google Scholar 

  10. Cigrang, J. A., Rauch, S. A., Mintz, J., Brundige, A. R., Mitchell, J. A., Najera, E., …, Goodie, J. L. (2017). Moving effective treatment for posttraumatic stress disorder to primary care: A randomized controlled trial with active duty military. Families, Systems, & Health, 35(4), 450–462. https://doi.org/10.1037/fsh0000315.

    Article  Google Scholar 

  11. Cohen, B. E., Gima, K., Bertenthal, D., Kim, S., Marmar, C. R., & Seal, K. H. (2010). Mental health diagnoses and utilization of VA non-mental health medical services among returning Iraq and Afghanistan veterans. Journal of General Internal Medicine, 25, 18–24. https://doi.org/10.1007/s11606-009-1117-3.

    Article  PubMed  Google Scholar 

  12. Davis, R. G., Ressler, K. J., Schwartz, A. C., Stephens, K. J., & Bradley, R. G. (2008). Treatment barriers for low-income, urban African Americans with undiagnosed posttraumatic stress disorder. Journal of Traumatic Stress: Official Publication of The International Society for Traumatic Stress Studies, 21, 218–222. https://doi.org/10.1002/jts.20313.

    Article  Google Scholar 

  13. Deykin, E. Y., Keane, T. M., Kaloupek, D., Fincke, G., Rothendler, J., Siegfried, M., & Creamer, K. (2001). Posttraumatic stress disorder and the use of health services. Psychosomatic Medicine63(5), 835–841. https://journals.lww.com/psychosomaticmedicine/Abstract/2001/09000/Posttraumatic_Stress_Disorder_and_the_Use_of.18.aspx

  14. Doherty, A. M., & Gaughran, F. (2014). The interface of physical and mental health. Social Psychiatry and Psychiatric Epidemiology, 49, 673–682. https://doi.org/10.1007/s00127-014-0847-7.

    Article  PubMed  Google Scholar 

  15. Ede, V., Okafor, M., Kinuthia, R., Belay, Z., Tewolde, T., Alema-Mensah, E., & Satcher, D. (2015). An examination of perceptions in integrated care practice. Community Mental Health Journal, 51, 949–961. https://doi.org/10.1007/s10597-015-9837-9.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Edmondson, D., Kronish, I. M., Shaffer, J. A., Falzon, L., & Burg, M. M. (2013). Posttraumatic stress disorder and risk for coronary heart disease: A meta-analytic review. American Heart Journal, 166, 806–814. https://doi.org/10.1016/j.ahj.2013.07.031.

    Article  PubMed  Google Scholar 

  17. Engel, C. C. (2005). Improving primary care for military personnel and veterans with posttraumatic stress disorder: The road ahead. General Hospital Psychiatry, 27, 158–160. https://doi.org/10.1016/j.genhosppsych.2005.01.001.

    Article  PubMed  Google Scholar 

  18. Fagan, J., Galea, S., Ahern, J., Bonner, S., & Vlahov, D. (2003). Relationship of self-reported asthma severity and urgent health care utilization to psychological sequelae of the September 11 terrorist attacks on the world trade center among New York City area residents. Psychosomatic Medicine, 65, 993–996. https://doi.org/10.1097/01.PSY.0000097334.48556.5F.

    Article  PubMed  Google Scholar 

  19. Finley, E. P., Noël, P. H., Lee, S., Haro, E., Garcia, H., Rosen, C., …, Pugh, J. A. (2018). Psychotherapy practices for veterans with PTSD among community-based providers in Texas. Psychological Services, 15(4), 442–452. https://doi.org/10.1037/ser0000143.

    Article  PubMed  Google Scholar 

  20. Foa, E. B., Dancu, C. V., Hembree, E. A., Jaycox, L. H., Meadows, E. A., & Street, G. P. (1999). A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. Journal of Consulting and Clinical Psychology, 67, 194–200. https://doi.org/10.1037/0022-006X.67.2.194.

    CAS  Article  PubMed  Google Scholar 

  21. Gillock, K. L., Zayfert, C., Hegel, M. T., & Ferguson, R. J. (2005). Posttraumatic stress disorder in primary care: prevalence and relationships with physical symptoms and medical utilization. General Hospital Psychiatry, 27, 392–399. https://doi.org/10.1016/j.genhosppsych.2005.06.004.

    Article  PubMed  Google Scholar 

  22. Greene, T., Neria, Y., & Gross, R. (2016). Prevalence, detection and correlates of PTSD in the primary care setting: A systematic review. Journal of Clinical Psychology in Medical Settings, 23(2), 160–180. https://doi.org/10.1007/s10880-016-9449-8.

    Article  PubMed  Google Scholar 

  23. Haagsma, J. A., Polinder, S., Olff, M., Toet, H., Bonsel, G. J., & van Beeck, E. F. (2012). Posttraumatic stress symptoms and health-related quality of life: A two year follow up study of injury treated at the emergency department. BMC Psychiatry, 12(1), 1–8.

    Article  Google Scholar 

  24. Hunter, C., Goodie, J., Oordt, M., & Dobmeyer, D. (2017). Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention (2nd ed.). Washington, DC: American Psychological Association.

    Google Scholar 

  25. Johnson, J., Lee, A., Vinson, D., & Seale, P. (2013). Use of AUDIT-based measures to identify unhealthy alcohol use and alcohol dependence in primary care: A validation study. Alcoholism: Clinical and Experimental Research, 37, 253–259.

    Article  Google Scholar 

  26. Kartha, A., Brower, V., Saitz, R., Samet, J. H., Keane, T. M., & Liebschutz, J. (2008). The impact of trauma exposure and post-traumatic stress disorder on healthcare utilization among primary care patients. Medical Care, 46, 388–393. https://doi.org/10.1097/MLR.0b013e31815dc5d2.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Kroenke, K., Spitzer, R., & Williams, J. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of Internal Medicine, 16, 606–613.

    CAS  Google Scholar 

  28. Kubzansky, L. D., Koenen, K. C., Spiro, A., Vokonas, P. S., & Sparrow, D. (2007). Prospective study of posttraumatic stress disorder symptoms and Coronary Heart Disease in the Normative Aging Study. Archives of General Psychiatry, 64, 109–116. https://doi.org/10.1001/archpsyc.64.1.109.

    Article  PubMed  Google Scholar 

  29. Lamoureux-Lamarche, C., Vasiliadis, H. M., Préville, M., & Berbiche, D. (2016). Healthcare use and costs associated with post-traumatic stress syndrome in a community sample of older adults: Results from the ESA-Services study. International Psychogeriatrics, 28, 903–911. https://doi.org/10.1017/S1041610215001775.

    Article  PubMed  Google Scholar 

  30. Libby, P. (2006). Inflammation and cardiovascular disease mechanisms. The American Journal of Clinical Nutrition, 83, 456S–460S. https://doi.org/10.1093/ajcn/83.2.456S.

    CAS  Article  PubMed  Google Scholar 

  31. Liebschutz, J., Saitz, R., Brower, V., Keane, T., Lloyd-Travaglini, C., Averbuch, T., & Samet, J. (2007). PTSD in urban primary care: High prevalence and low physician recognition. Journal of General Internal Medicine, 22, 719–726. https://doi.org/10.1007/s11606-007-0161-0.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Löwe, B., Kroenke, K., Spitzer, R., Williams, J., Mussell, M., Rose, M., …, Spitzer, C. (2011). Trauma exposure and posttraumatic stress disorder in primary care patients: Cross-sectional criterion standard study. The Journal of Clinical Psychiatry, 72(3), 304–312. https://doi.org/10.4088/JCP.09m05290blu.

    Article  PubMed  Google Scholar 

  33. McEwen, B. S. (2003). Mood disorders and allostatic load. Biological Psychiatry, 54, 200–207. https://doi.org/10.1016/S0006-3223(03)00177-X.

    Article  PubMed  Google Scholar 

  34. Meredith, L., Eisenman, D., Han, B., Green, B., Kaltman, S., Wong, E., …, Tobin, J. (2016). Impact of Collaborative Care for underserved patients with PTSD in primary care: A randomized controlled trial. Journal of General Internal Medicine, 31(5), 509–517. https://doi.org/10.1007/s11606-016-3588-3.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Meredith, L. S., Eisenman, D. P., Green, B. L., Basurto-Dávila, R., Cassells, A., & Tobin, J. (2009). System factors affect the recognition and management of post-traumatic stress disorder by primary care clinicians. Medical Care, 47(6), 686–694. https://doi.org/10.1097/mlr.0b013e318190db5d.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Miller, S. (2009). Cultural humility is the first step to becoming global care providers. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 38, 92–93.

    Article  Google Scholar 

  37. Ogbeide, S. A., Landoll, R. R., Nielsen, M. K., & Kanzler, K. E. (2018). To go or not go: Patient preference in seeking specialty mental health versus behavioral consultation within the primary care behavioral health consultation model. Families, Systems, & Health, 36, 513–517. https://doi.org/10.1037/fsh0000374.

    Article  Google Scholar 

  38. Polusny, M. A., Ries, B. J., Schultz, J. R., Calhoun, P., Clemensen, L., & Johnsen, I. R. (2008). PTSD symptom clusters associated with physical health and health care utilization in rural primary care patients exposed to natural disaster. Journal of Traumatic Stress, 21, 75–82. https://doi.org/10.1002/jts.20281.

    Article  PubMed  Google Scholar 

  39. Prins, A., Bovin, M. J., Kimerling, R., Kaloupek, D. G., Marx, B. P., Pless Kaiser, A., & Schnurr, P. P. (2015). The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5). [Measurement instrument].

  40. PTSD Assessment Instruments. (2018, September 26). https://www.apa.org/ptsd-guideline/assessment/

  41. Rajaram, S., & Bockrath, S. (2014). Cultural competence: New conceptual insights into its limits and potential for addressing health disparities. Journal of Health Disparities Research and Practice, 7, 82–89.

    Google Scholar 

  42. Raven, M. C., Tieu, L., Lee, C. T., Ponath, C., Guzman, D., & Kushel, M. (2017). Emergency department use in a cohort of older homeless adults: Results from the HOPE HOME study. Academic Emergency Medicine, 24, 63–74. https://doi.org/10.1111/acem.13070.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Reiter, J. T., Dobmeyer, A. C., & Hunter, C. L. (2018). The primary care behavioral health (PCBH) model: An overview and operational definition. Journal of Clinical Psychology in Medical Settings, 25, 109–126. https://doi.org/10.1007/s10880-017-9531-x.

    Article  PubMed  Google Scholar 

  44. Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault victims. Journal of Consulting and Clinical Psychology, 60, 748–756. https://doi.org/10.1037/0022-006X.60.5.748.

    CAS  Article  PubMed  Google Scholar 

  45. Roberts, A. L., Gilman, S. E., Breslau, J., Breslau, N., & Koenen, K. C. (2011). Race/ethnic differences in exposure to traumatic events, development of Posttraumatic Stress Disorder, and treatment-seeking for Posttraumatic Stress Disorder in the United States. Psychological Medicine, 41, 71–83. https://doi.org/10.1017/S0033291710000401.

    CAS  Article  PubMed  Google Scholar 

  46. Robinson, P., Gould, D., & Strosahl, K. (2011). Real behavior change in primary care: Improving patient outcomes and increasing job satisfaction. Oakland, CA: New Harbinger Publications.

    Google Scholar 

  47. Robinson, P. J., & Reiter, J. T. (2016). Behavioral consultation and primary care: A guide to integrating services (2nd ed.). Geneva, Switzerland: Springer.

    Google Scholar 

  48. Rosen, C. S., Eftekhari, A., Crowley, J. J., Smith, B. N., Kuhn, E., Trent, L., …, Ruzek, J. I. (2017). Maintenance and reach of exposure psychotherapy for posttraumatic stress disorder 18 months after training. Journal of Traumatic Stress, 30(1), 63–70. https://doi.org/10.1002/jts.22153.

    Article  PubMed  Google Scholar 

  49. Rotar, A. M., Van Den Berg, M. J., Schäfer, W., Kringos, D. S., & Klazinga, N. S. (2018). Shared decision making between patient and GP about referrals from primary care: Does gatekeeping make a difference. PLoS ONE, 13, 1–9. https://doi.org/10.1371/journal.pone.0198729.

    CAS  Article  Google Scholar 

  50. Sayer, N. A., Friedemann-Sanchez, G., Spoont, M., Murdoch, M., Parker, L. E., Chiros, C., & Rosenheck, R. (2009). A qualitative study of determinants of PTSD treatment initiation in veterans. Psychiatry Interpersonal and Biological Processes, 72(3), 238–255. https://doi.org/10.1521/psyc.2009.72.3.238.

    Article  Google Scholar 

  51. Serrano, C. V., Jr., Setani, K. T., Sakamoto, E., Andrei, A. M., & Fraguas, R. (2011). Association between depression and development of coronary artery disease: Pathophysiologic and diagnostic implications. Vascular Health and Risk Management, 7, 159–164. https://doi.org/10.2147/VHRM.S10783.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Simiola, V., Ellis, A., Thompson, R., Schnurr, P., & Cook, J. (2019). Provider perspectives on choosing Prolonged Exposure or Cognitive Processing Therapy for PTSD: A national investigation of VA residential treatment providers. Practice Innovations, 4(3), 194–203. https://doi.org/10.1037/pri0000091.

    Article  Google Scholar 

  53. Spitzer, R., Kroenke, K., Williams, J., & Löwe, B. (2006). A brief measure for assessing Generalized Anxiety Disorder: The GAD-7. Archives of Internal Medicine, 166, 1092–1097. https://doi.org/10.1001/archinte.166.10.1092.

    Article  PubMed  Google Scholar 

  54. Stevanovic, D. (2011). Quality of life enjoyment and satisfaction questionnaire: Short form for quality of life assessments in clinical practice: A psychometric study. Journal of Psychiatric and Mental Health Nursing, 18, 744–750. https://doi.org/10.1111/j.1365-2850.2011.01735.

    CAS  Article  PubMed  Google Scholar 

  55. Trusz, S. G., Wagner, A. W., Russo, J., Love, J., & Zatzick, D. F. (2011). Assessing barriers to care and readiness for cognitive behavioral therapy in early acute care PTSD interventions. Psychiatry Interpersonal & Biological Processes, 74(3), 207–223. https://doi.org/10.1521/psyc.2011.74.3.207.

    Article  Google Scholar 

  56. Vogt, D. (2011). Mental health-related beliefs as a barrier to service use for military personnel and veterans: A review. Psychiatric services, 62(2), 135–142.

    Article  Google Scholar 

  57. Vu, F., Daeppen, J. B., Hugli, O., Iglesias, K., Stucki, S., Paroz, S., …, Bodenmann, P. (2015). Screening of mental health and substance users in frequent users of a general Swiss emergency department. BMC Emergency Medicine, 15(1), 15–27. https://doi.org/10.1186/s12873-015-0053-2.

    CAS  Article  Google Scholar 

  58. Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013). The PTSD Checklist for DSM-5 (PCL-5)—Standard [Measurement instrument]. https://www.ptsd.va.gov/

  59. Westphal, M., Olfson, M., Gameroff, M., Wickramaratne, P., Pilowsky, D., Neugebauer, R., …, Neria, Y. (2011). Functional impairment in adults with past Posttraumatic Stress Disorder: Findings from primary care. Depression and Anxiety, 28(8), 686–695. https://doi.org/10.1002/da.20842.

    Article  PubMed  PubMed Central  Google Scholar 

  60. “Working with ACT”. (n.d.). Using mindfulness and values in the workplace to improve performance and wellbeing. https://workingwithact.com/about/about-this-site/

  61. Yudko, E., Lozhkina, O., & Fouts, A. (2007). A comprehensive review of the psychometric properties of the Drug Abuse Screening Test. Journal of Substance Abuse Treatment, 32, 189–198.

    Article  Google Scholar 

  62. Zuchowski, J. L., Rose, D. E., Hamilton, A. B., Stockdale, S. E., Meredith, L. S., Yano, E. M., …, Cordasco, K. M. (2015). Challenges in referral communication between VHA primary care and specialty care. Journal of General Internal Medicine, 30(3), 305–311. https://doi.org/10.1007/s11606-014-3146-9.

    Article  PubMed  Google Scholar 

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Ogbeide, S.A., Young, A., Houston, B. et al. Treating Post-traumatic Stress Disorder with a Prolonged Exposure Protocol Within Primary Care Behavioral Health: A Case Example. J Clin Psychol Med Settings (2020). https://doi.org/10.1007/s10880-020-09747-z

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Keywords

  • Posttraumatic stress disorder
  • Primary care
  • Prolonged exposure