Two Stepped Care Models for PTSD among Cambodian Refugees in Primary Care

Massachusetts General Hospital, Boston MA

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Abstract

DESCRIPTION (provided by applicant): The NIMH has identified treatment development for non-English-speaking groups, particularly for posttraumatic stress disorder (PTSD), as a major Institute priority, as stated in the Surgeon General's report, Mental Health: Culture, Race, and Ethnicity (U.S. Department of Health and Human Services [USDHHS], 2001). The recently published NIMH Strategic Plan (USDHHS, 2008) has as one of its four strategic objectives to Develop New and Better Interventions that Incorporate the Diverse Needs and Circumstances of People with Mental Illness (USDHHS, 2008), and the plan emphasizes the need to personalize care so that it is appropriate for different cultural groups, for delivery in different contexts (primary care), and the report emphasizes the need to investigate the variables that influence who will benefit from which treatments (see too, USDHHS, 2010). Investigating these issues leads toward another of the NIMH Strategic Plan's strategic objectives: Strengthen the Public Health Impact of NIMH-Supported Research. There is only one study examining an intervention for PTSD in a primary care clinic (Roy-Byrne et al., 2010), and there is no study of the treatment of PTSD among a refugee or ethnic minority group in primary care. This is a major gap in the literature. The current study is a hybrid effectiveness-efficacy study of Cambodian refugees, a group with an extremely high community rate of PTSD: a 62% community prevalence in one study (Marshall et al., 2005). The study utilizes several means to make the treatment more effective that can be utilized with other cultural groups, including the methods to increase the prescribing of adequate pharmacology by the primary care physician, the methods to increase medication adherence, the method of culturally appropriate evaluation, and the culturally sensitive CBT. The proposed grant would allow us to investigate whether effective treatment can be provided in primary care for Cambodian refugees with PTSD (with all the treatment adaptations, e.g., the hybrid culturally adapted CBT, applicable to all refugee and ethnic minority populations), and will compare two models of care. At step 1, all patients receive PTSD medication for 12 weeks. After step 1, patients who are still symptomatic will be randomized to one of two augmentation strategies. In the Pharmacology Augmentation Stepped Care Model, step 2 is pharmacologic augmentation (adding another PTSD pharmacological agent). In the CBT Augmentation Stepped Care Model, step 2 is a culturally adapted CBT (Hinton et al., 2004, 2005). We will investigate aspects of personalized care: in step 1, variables that moderate response to the initial pharmacological treatment (e.g., gender, education level, level of anger), and in step 2, variables that moderate the response to pharmacological and CBT augmentation (e.g., the moderators assessed for step 1, poor response to pharmacology in step 1, and treatment preference, viz., pharmacology or CBT).