Primary Care For Trauma-related Mental Health Problems

描述(申请人提供)：创伤后应激障碍(PTSD)和阈值以下创伤后应激障碍(PTSD)患者向初级保健临床医生(PCCs)提出的比率类似于抑郁症。据估计，创伤后应激障碍的终生患病率在一般人群中为7.8%，在服务不足的人群中更高，这些人群因人际、政治和社区暴力而患上创伤后应激障碍的风险更大。此外，创伤后应激障碍的发现很差，治疗不足，并且使人虚弱。但是，与初级保健中成熟的抑郁症领域不同，在这种情况下，人们对有效治疗创伤后应激障碍知之甚少。我们将采用一个基于理论的多层次框架来指导研究计划的第一步，该计划旨在为创伤后应激障碍发展基于初级保健的干预措施。我们计划在这项拟议工作的结果基础上进行全面的有效性研究应用。我们提出了一项探索性研究(R34)，以更好地理解初级保健创伤处理，并确定有前景的战略，以改善患有创伤后应激障碍和阈值以下创伤后应激障碍的成年拉丁裔移民患者的护理。我们将与临床主任网络公司(CDN)合作进行这项研究，CDN是一个以社区为导向、以实践为基础的研究网络，为贫困和服务不足的少数族裔和移民人口提供初级和预防性卫生保健服务。具体地说，我们的目标是：1.从多个利益相关者(医务主任、PCC和患者)的角度描述在结构特征不同且拉美裔移民患者比例较高的社区/移民卫生中心(C/MHC)样本中对创伤后应激障碍和阈值以下创伤后应激障碍的初级保健。2.确定PCC倾向的结构性和个体PCC预测因子，以筛选、评估、参考和管理创伤后应激障碍和阈值下创伤后应激障碍。3.根据AIMS 1和AIMS 2的数据，阐明可能的干预策略，为可行的策略制定建议，这些策略可以在后续研究中测试，以改善创伤后应激障碍和阈值以下创伤后应激障碍的初级保健。对于目标1，我们将从一个CDN地区为拉丁裔移民和难民提供服务的57家C/MHC中有目的地抽取5家，代表可能影响创伤后应激障碍护理的一系列临床结构(5名医务主任、15名初级保健中心和4名目前患有创伤后应激障碍的患者，N=60)，对三类主要信息提供人进行实地考察和访谈。对于目标2，我们将正式测试关于创伤后应激障碍治疗变异预测因素的假设，方法是对所有57名C/MHC主任进行代表性调查，并随机抽样285名PC(每C/MHC 5名)。AIM 3将使用AIM 1和2数据以及利益相关者会议来确定最有可能改善创伤后应激障碍管理的潜在干预措施，并将以后续R01应用程序为最终结果，实施和评估一项有前景的干预计划，用于成人、拉丁裔移民的基于初级保健的创伤后应激障碍和阈值以下创伤后应激障碍的治疗。

DESCRIPTION (provided by applicant): Patients with posttraumatic stress disorder (PTSD) and sub threshold PTSD present to primary care clinicians (PCCs) at rates similar to depression. The estimated lifetime prevalence of PTSD is 7.8% in the general population and is higher for underserved populations that are at greater risk for PTSD resulting from interpersonal, political, and community violence. Moreover, PTSD is poorly detected, under-treated, and debilitating. But, unlike the maturing field of depression in primary care with successful quality improvement interventions, little is known about effectively treating PTSD in this setting. We will employ a theory-based multi-level framework for guiding the first step in a program of research geared toward the development of primary care-based interventions for PTSD. We plan to follow with a full-scale effectiveness study application based on the results of this proposed work. We propose an exploratory study (R34) to better understand primary care trauma management and to identify promising strategies for improving the care of adult Latino immigrant patients suffering from PTSD and sub threshold PTSD. We will conduct this research in collaboration with the Clinical Directors Network, Inc. (CDN), a community-oriented practice-based research network that provides primary and preventive health care services for poor and underserved minority and immigrant populations. Specifically, we aim to:1. Describe primary care for PTSD and sub threshold PTSD from multiple stakeholder perspectives (medical directors, PCCs, and patients) among a sample of community/migrant health centers (C/MHCs) ranging in structural characteristics, and with a high proportion of Latino immigrant patients. 2. Identify structural and individual PCC predictors of PCC tendency to screen for, assess, refer, and manage PTSD and sub threshold PTSD. 3. Elucidate potential intervention strategies, based on data from Aims 1 and 2, to develop recommendations for viable strategies that could be tested in a follow-on study to improve primary care for PTSD and sub threshold PTSD. For Aim 1, we will conduct site visits and interviews with three types of key informants from a purposeful sample of five of the 57 C/MHCs that serve Latino immigrants and refugees in one CDN region that represent a range of clinical structures that might affect PTSD care (5 medical directors, 15 PCCs, and 4 patients with current PTSD matched to each of the 15 PCCs, N=60). For Aim 2, we will formally test hypotheses about predictors of variation in treatment for PTSD with a representative survey of a census of all 57 C/MHC directors and a random sample of 285 PCCs (5 per C/MHC). Aim 3 will use Aim 1 and 2 data and stakeholder meetings to identify potential interventions most likely to improve PTSD management and will culminate with a follow-on R01 application to implement and evaluate a promising intervention program for primary care-based treatment of PTSD and sub threshold PTSD in adult, Latino immigrants.