Many Have No Access to Psychotherapy Otherwise
By Annette M. Boyle
SEATTLE – For rural veterans, the distance to a VAMC often creates a major barrier to care, particularly for treatments that require multiple trips. Telemedicine might break down those barriers, offering expanded treatment options for veterans and more hope to those suffering from post-traumatic stress disorder (PTSD).
More than 502,000 veterans receiving care through the VA have a diagnosis of PTSD, yet relatively few rural veterans are treated for the condition.
“Barriers to care such as travel distance and stigma often prevent many veterans from initiating psychotherapy or contribute to the high dropout rate” for these treatments, which require multiple sessions, said John Fortney, PhD, research health science specialist at the VA Puget Sound Health Care System and associate director for research at the AIMS Center at the University of Washington in Seattle.
Fortney and his colleagues studied a telemedicine-based collaborative care model for PTSD compared to usual care in 265 veterans being treated at 11 community-based outpatient clinics from Nov. 23, 2009, to Sept. 28, 2011. Nearly all the patients in both groups previously had been treated for PTSD using psychotropic medications, counseling or both. The patients had severe PTSD, with mean Clinician-Administered PTSD Scale scores of 75, and significant comorbidities. Nearly 80% had a diagnosis of major depressive disorder, 44% had panic disorder, and 67% experienced generalized anxiety disorder.
In results published recently in JAMA Psychiatry, the researchers found that more patients in the telemedicine group received cognitive processing therapy and had significantly larger drops in Post-Traumatic Diagnostic Scale scores after six and 12 months. 1
That is important because 41% of veterans live in a rural area and nearly two-thirds are closer to one of the VA’s 825 community-based outpatient centers than to a medical center, Fortney noted. “We hoped that we could better engage veterans in psychotherapy if we delivered it to them via interactive video closer to their homes in community-based outpatient clinics and provided telephone support from a nurse care manager,” he told U.S. Medicine.
Three collaborative teams — based in Little Rock, AR, Shreveport, LA, and Loma Linda, CA — participated in the study. Each team included nurse care managers, pharmacists, psychologists and psychiatrists who supported PTSD services at the local clinics affiliated with their medical centers via interactive video and telephone calls. The teams provided and encouraged participation in cognitive processing therapy (CPT), a trauma-based psychotherapy shown to effectively reduce symptoms of PTSD.
In 12 months of follow-up, 54.9% of the 133 patients in the telemedicine arm received cognitive processing therapy compared to only 12.1% of the 132 receiving usual care. At six months, patients randomized to the telemedicine group experienced significantly larger decreases in Post-Traumatic Diagnostic Scale scores (35.0 to 29.1) than those receiving usual care (33.5 to 32.1). The difference persisted at 12 months, with the scores of those in the telemedicine group decreasing from 35.0 to 30.1 and those in the usual-care group declining from 33.5 to 31.7.
The patients in the telemedicine arm had 18 times higher odds of initiating CPT and eight times higher odds of completing the minimal therapeutic dose of eight sessions. Attending at least eight sessions completely mediated the effect of the intervention, noted the study’s authors.
No On-Site Psychiatrists
The community based outpatient clinics participating in the study did not have on-site psychiatrists or psychologists and relied on a social worker to provide counseling. Few of the social workers had received training in CPT. The veterans randomized to the usual-care group had the option of driving to the closest VAMC, about 58 miles away on average, to receive CPT in the specialty mental health clinic.
Veterans randomized to the telemedicine group could receive 12 sessions of CPT with psychologist via interactive video in their nearby and familiar community based outpatient clinic. They also received follow-up calls from their nurse care manager every two weeks to educate them about the benefits of CPT, encourage them to try the program or continue with it and help them manage and adhere to medication regimens and self-management goals. On average, nurse care managers had 14.4 calls with each patient.
The team psychiatrists and pharmacists recommended specific medications and dosages to local providers. The researchers found no difference between the arms in the number of medications and the adherence to them by patients, but psychiatrists in the telemedicine group were more likely to prescribe prazosin than those receiving care from local providers.
Most of the veterans randomized to the usual-care group had medication management encounters with their prescriber about every three months. More than half of the veterans in the usual-care arm also had at least one psychotherapy encounter, with most receiving psychotherapy having sessions about every six weeks.
The vast majority of psychotherapy encounters for veterans in the usual-care group were not trauma- focused, either because the social workers in the community based outpatient clinics lacked training in trauma-focused psychotherapy or because the veterans declined trauma-focused psychotherapy, Fortney noted.
The VA has actively integrated mental health treatments into the primary care setting during the past few years with good results for depression and anxiety disorders, which often respond well to brief counseling and care management, according to Fortney.
“Our study suggests that, for PTSD, it may be necessary to deliver longer trauma-focused psychotherapies in the primary care setting. Importantly for rural veterans, our results indicate that it is not necessary to physically co-locate the CPT therapist in the community-based outpatient clinic,” he said.
CPT is not the only trauma-focused psychotherapy that can be effectively delivered via telemedicine. Other researchers have shown that CPT and Prolonged Exposure therapy can be delivered over interactive video with equivalent effectiveness as face to face. Eye Movement Desensitization and Reprocessing therapy, however, does not appear to be as well suited to this method.
1 Fortney JC, Pyne JM, Kimbrell TA, Hudson TJ, Robinson DE, Schneider R, Moore WM, Custer PJ, Grubbs KM, Schnurr PP. Telemedicine-based collaborative care for post-traumatic stress disorder: a randomized clinical trial. JAMA Psychiatry. 2015 Jan;72(1):58-67.