U.S. military veterans living in rural areas who engage in evidence-based psychotherapy and telemedicine-based collaborative care can significantly increase their chances of improving outcomes related to posttraumatic stress disorder, according to a new study.
“Although psychotherapy and pharmacotherapy treatments for PTSD have proven to be efficacious in randomized clinical trials and have been disseminated widely by the [Veterans Health Administration], stigma and geographic barriers often prevent rural veterans from engaging in these evidence-based treatments,” says the study, published in JAMA (2014 Nov. 19 [doi.101001/jamapsychiatry.2014.1575]) and led by John C. Fortney, Ph.D., of the University of Washington’s department of psychiatry and behavioral sciences in Seattle, and his associates.
In a pragmatic, randomized effectiveness trial, Dr. Fortney and his associates recruited outpatients from 11 Department of Veterans Affairs (VA) community-based outpatient clinics (CBOCs) in predominantly rural areas of the United States over the course of 22 months. A total of 265 patients completed baseline interviews and randomization after meeting eligibility criteria, which consisted of meeting diagnostic standards for PTSD; having no medical history of schizophrenia, bipolar disorder, substance dependence, or hearing impairment; having a telephone; not having a life-threatening illness; and lacking capacity to consent.
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Veterans receiving telemedicine outreach for PTSD had significantly larger decreases in posttraumatic diagnostic scale scores.
The 265 subjects were randomized into one of two groups: those receiving usual care (UC), or those receiving the Telemedicine Outreach for PTSD (TOP) treatment developed by the investigators. Patients were mostly unemployed, middle-aged men with severe PTSD symptoms and “other mental health coexisting illnesses,” according to a press release.
Subjects in the UC group received certain health care services, such as psychotropic medications for PTSD prescribed by psychiatrists, evidence-based psychotherapy for PTSD delivered by psychologists or social workers, supportive PTSD-focused therapy delivered by psychologists or social workers (individual and group), and supportive therapy delivered by social workers (individual and group), among others. Subjects in the TOP group, however, received the attention of telephone nurse care managers, including PTSD symptom monitoring and medication regimen adherence monitoring and promotion. In addition, those in the TOP group received access to a telephone pharmacist and telepsychologist.
Subjects were enrolled in a series of 12 cognitive processing therapy sessions for the duration of the study, from Nov. 23, 2009, through Sept. 28, 2011, and attendance was taken at each session. After the sessions concluded, subjects were then followed up on for 12 months.
During that follow-up period after treatments ended, patients who received TOP had significantly larger decreases in Posttraumatic Diagnostic Scale (PDS) scores (from 35.0 to 29.1), compared with those from the UC group (from 33.5 to 32.1) at 6 months (beta = −3.81; P = .002) and 12 months (beta = −2.49; P = .04). At 12 months, TOP subjects also had significantly larger decreases in PDS scores (from 35.0 to 30.1), compared with those who received UC (from 33.5 to 29.1) .
Subjects who attended at least eight cognitive processing therapy sessions were more likely to improve their PDS scores (beta = −3.86 [95% confidence interval, −7.19 to −0.54]; P = .02). However, the authors noted that there were “no significant group differences in the number of PTSD medications prescribed and adherence to medication regimens” was not significant.
“This trial introduces a promising model for managing PTSD in a treatment-resistant population,” Dr. Fortney and his associates wrote. “Findings suggest that telemedicine-based collaborative care can successfully engage this population in evidence-based psychotherapy for PTSD, thereby improving clinical outcomes.”
Among the study limitations cited by the investigators is that the PDS was administered to assess PTSD, rather than the Clinician-Administered PTSD Scale, which is the reference standard.
The authors reported no relevant financial conflicts of interest.