Delivery of Services for Ptsd

Conventional research on the roots of psychopa­ thology and on the efficacy of treatment in controlled trials are only the first steps toward the ultimate goal of health care systems: improving the health of the public at large. Health services research picks up the baton from basic and clinical research to examine how services are delivered, their costs, and above all, their effectiveness in “real world” settings. Research on the delivery of health care services can be thought of as addressing three goals. First, service use, along with epidemiological data on disease prevalence, is an indicator of the burden of disease on the general population and its economic consequences. Second, studies of service use provide information on the accessibility of services, i.e., the success or failure of the health care system to address the needs of its target population. Finally, studies of service use are important in simultaneously evaluating the effec­ tiveness and cost of services, i.e., their ultimate value to the public. Severity/Burden of Disease. In an important paper from the National Co-Morbidity Survey, Kessler et al. (1999) present information on the both the likeli­ hood and intensity of service use among Americans with various mental illnesses. This study shows that PTSD is associated with nearly the highest rate of service use, and by implication, the highest percapita cost of any mental illness. This study illus­ trates the central importance of PTSD to the public’s mental health. In a more focused study of severe PTSD, Ford (1999) demonstrated exceptionally high levels of service use among combat veterans meeting criteria for DESNOS. Switzer et al. (1999), studying service use among clients with PTSD at an urban mental health center, found 94% with a history of trauma and 42% with PTSD, and documented espe­ cially high levels of service use among those with PTSD, as compared to others. Moving from mental health service use to general medical service use, both Leserman et al. (1998) and Friedman and Schnurr (1995) showed that PTSD is also associated with high levels of use of non-mental health services. An im­ portant HMO-based study (Walker et al., 1999) reported substantially increased health care costs among patients who reported childhood trauma. Access to Care. While some studies have focused on the high levels of service use among people with PTSD, others have demonstrated considerable underuse of services. Although best known for its documentation of the high prevalence of PTSD in Vietnam Veterans, the National Vietnam Veterans Readjustment Study (Kulka et al., 1990) also docu­ mented dramatically low rates of service use among veterans and helped stimulate the development of a national network of specialized VA services for PTSD. Schwarz and Kowalski (1992) demonstrated that survivors of a man-made disaster were reluctant to use mental health services because of the fear that painful memories would be aroused, and they advo­ cate special efforts to reach out to such people. Solomon and Davidson (1997) also suggest that while people with PTSD are high users of health care services, they are often reluctant to use mental health services. Hankin et al. (1996) showed that 30% of a sample of non-psychiatric patients in the VA system met crite­ ria for PTSD and that the PTSD group reported more severe medical symptoms than other veterans. There has been considerable concern that the low rates of service use among Vietnam veterans with PTSD reported by Kulka et al. (1990) might reflect a special reluctance of these veterans, and especially minority veterans, to use VA services because of their distrust of the government that sent them to war. Rosenheck and Fontana (1995), however, found that, after controlling for other factors, Vietnam veterans with PTSD were 1.8 times more likely than other veterans to use VA mental health services. Further­ more, minorities with PTSD were more likely to use VA services than other veterans, even after adjusting for income and other relevant factors (Rosenheck & Fontana, 1994), although they had similar outcomes (Rosenheck & Fontana, 1996). Access can be thought of as having several com­ ponents: having any contact with the health care system; obtaining adequate intensity of service; and receiving appropriate quality of service. While there are no well-established guidelines for the treatment of PTSD, program monitoring can allow continuous assessment of the characteristics of treatment. In a study of clinician-client racial pairing, Rosenheck, Fontana, and Cottrol (1995) demonstrated the use of such a quality monitoring system and showed that African-American veterans treated for PTSD had lower participation ratings than whites but no differ­ ences in clinician-reported outcomes. These findings