K. Referral To Mental Health Specialty

OBJECTIVE

Provide guidance for primary care providers on optimal referral for PTSD patients.

BACKGROUND

Patients with PTSD have a complex and often challenging presentation. Evidence regarding the effectiveness of treatment modalities at this point is severely limited, but there is good evidence that cognitive behavioral therapy (CBT) is an effective intervention for ASD and PTSD. (See Module C for details of mental health treatment.)

RECOMMENDATIONS

1. Primary care providers should consult with a mental health provider and/or a PTSD Specialty Team for all patients with acute or chronic stress disorders.
2. Primary care providers should continue to be involved in the treatment of patients with acute or chronic stress disorders.
3. Treatment for patients with acute stress disorder or acute or chronic PTSD should involve a multi-disciplinary team approach to include OT, Spiritual Counseling, Recreation Therapy, Social Work, Psychology and/or Psychiatry.
4. Patients with clinically significant symptoms or co-morbidities to PTSD, including chronic pain, insomnia, anxiety, and depression, should receive treatment for those complicating problem
5. Case Management should be provided, as indicated, to address high utilization of medical resources.
6. Consider referral for alternative care modalities as indicated for patient symptoms, consistent with available resources, and resonant with patient belief systems.

DISCUSSION

Because it is difficult for PCPs to be able to provide psychotherapy the Working Group recommends that primary care providers who identify patients with possible PTSD consider referral to a mental health or PTSD specialist early in the treatment algorithm. This referral should be made in consultation with the patient and with consideration of the patient’s preferences.

In addition, because there are many other therapy modalities which can be initiated and monitored in the primary care setting (e.g., Pharmacotherapy and Supportive Counseling), the Working Group recommends that the primary care practitioner consider initiating therapy pending referral or if the patient is reluctant or unable to obtain mental health services. The primary care practitioner also has a vital role to play in the health of patients with PTSD by evaluating and treating comorbid somatic illnesses, by mobilizing community resources (e.g., OT, Family Support, Command and Unit supports, Family Members, and Chaplains), and by educating and validating the patient regarding his/her illness. It is vital that the primary care provider and the primary care team (including the Health Care Integrator) stay actively involved, in coordination with the mental health specialist, in the care of patients with PTSD.

Additional Points:

• Don’t push patients, but encourage referral to mental health.
• Primary care providers should follow-up issues related to trauma after the initial visit.
• Primary care providers should ask questions about trauma related symptoms, but not delve into details of the trauma unless there is the time and skill to support the patient without causing retraumatization.