1. Evidence-Based Psychotherapies for Managing PTSD in the Primary Care Setting Kyle Possemato, Ph.D. Clinical Research Psychologist Collaborative Family Healthcare Association 13 th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A. Session # F4 October 29, 2011 10:30 AM

2. Faculty Disclosure I have not had any relevant financial relationships during the past 12 months.

3. Need/Practice Gap & Supporting Resources PTSD is common among primary care patients – Associated with significant functional impairment, physical health concerns, more health care utilization and mental health comorbidities. Significant barriers to receiving adequate treatment exist for primary care patients with PTSD. Mental health professionals operating as part of the primary care team have the potential to provide effective brief intervention services. There are no evidence-based guidelines on how to treat PTSD outside the specialty mental healthcare setting.

4. Objectives This presentation will review early research on the development and testing of primary care-based PTSD treatments and other brief PTSD interventions (i.e., telehealth and early intervention) that could be adapted to the primary care setting. Possemato, K. (2011) The Current State of Intervention Research for Posttraumatic Stress Disorder within the Primary Care Setting. Journal of Clinical Psychology in Medical Settings, 18, 268-280.

5. Expected Outcome Participants will learn: How to incorporate evidence-based psychotherapy strategies for treating PTSD into brief primary care encounters. How to utilize telehealth programs to enhance and supplement their in-person interventions. Risks and benefits of using in-vivo and written exposure techniques in primary care. Next steps for clinicians and researchers in establishing empirically supported PTSD treatment for the primary care setting.

6.  Screening  Every patient should be routinely screened and follow-up should be conducted in a private setting (Resnick et al., 2000)  4 item PC-PTSD (Prins et al., 2003)  Positive screens should be further evaluated  Assessment  17 item PTSD Checklist (PCL; Yeager et al., 2007 )  Lower cut offs in Primary care (30-44)  Also assess:  Trauma exposure, dangerousness, physical and mental functioning and co-morbid psychiatric conditions  Motivation for treatment

7.  Confronting Uncomfortable Memories (Cigrang et al., 2011)  Prolonged Exposure in 4, 30-minute sessions  Corso et al., 2009  TAU approach delivering CBT in 5, 30-min sessions  CALM (Roy-Burne et al., 2010)  Computer assisted CBT and/ or med. management  CBT-PC (Prins et al., 2009)  6, 1-hour sessions focused on Cognitive Restructuring  Care Management  RESPECT-P/ RESPECT-MIL (Engel et al., 2008)  TIDES/PTSD

8.  DE-STRESS (Litz et al., 2007)  Therapist-assisted, self-management trauma focused narratives  Interapy (Knaevelsrud et al., 2010)  Trauma writing via email correspondence with therapist  PTSD Online (Klein et al., 2010)  10 online therapist assisted CBT sessions  Self Help for Trauma Consequences (Hirai & Clum, 2005)  Self-guided trauma writing  Afterdeployment.org  Adjusting to War Memories workshop  PTSD Coach and T2 Mood Tracker http://www.t2health.org http://www.t2health.org

9.  Adapted Prolonged Exposure (Cigrang et al., 2005)  PE vs. PE+CBT vs. supportive therapy (Bryant et al., 1999)  2 sessions + phone call (Hickling et al., 2005)  Collaborative Stepped Care (Zatzick et al., 2004)  Behavioral Activation (Wagner et al., 2007)

10.  Brief PTSD treatment can effectively reduce PTSD symptoms  Telehealth can augment in-person PC treatment  The most evidence exists for cognitive and behavioral interventions.  In addition to psychoeducation, relaxation, cognitive restructuring and exposure are mostly commonly delivered

11.  Can be safely and effectively delivered in primary care and via telehealth  In-vivo larger effects than imaginal  Common Concerns  Less monitoring  Less pre-exposure skill building?  Exposure therapy in PC may not be necessary  Primary care treatment can prepare patients for full length exposure treatments. Exposure Therapies

12.  Dismantling studies are needed. What CBT interventions are necessary to reduce PTSD symptoms in primary care patients?  Lack of self-guided treatment for PTSD in PC  These are effective for depression and anxiety (Cuijpers et al., 2010)  Do treatments developed for combat trauma work for civilian trauma?

13.  A variety of treatments need to be developed to match patients' needs and preferences  Describe "treatment as usual" approaches well and gather pre- and post symptom data.  Interventions tested with case studies and pilots need RCTs.  Telehealth and early interventions still need to be tested with primary care patients.

14. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you! Kyle.Possemato@va.gov