Posttraumatic Stress Disorder Treatment for Operation Enduring Freedom/Operation Iraqi Freedom Combat Veterans Through a Civilian Community-Based Telemedicine Network
Steven J. Ziemba, PhD, MBA, CCRC, CRCP, CIP, FACHE,1 Nicola S. Bradley, MFT, LMFT,1 Lori-Ann P. Landry, MSW, LCSW,1 Claire H. Roth, MSW, LMSW,1 Linda S. Porter, MEd, MS, EdS, LPC,1 and Robert N. Cuyler, PhD 2 1
Phoebe Putney Memorial Hospital, Albany, Georgia. 2 Clinical Psychology Consultants, Ltd., LLP, Houston, Texas. All views and opinions expressed herein are those of the authors and do not necessarily reflect those of our respective affiliations or the Department of Defense.
Abstract Background: Telemedicine holds great potential to improve access to care and to reduce barriers to treatment for military populations with posttraumatic stress disorder (PTSD). This study sought to integrate the use of telemedicine mental health treatment services by a community healthcare provider to military populations residing in a rural location and to compare the equivalency of cognitive behavioral therapy (CBT) administered via telemedicine and traditional face-toface therapy. Subjects and Methods: Study subjects were men or women 18 years of age or older who had served in Operation Enduring Freedom (OEF) and/or Operation Iraqi Freedom (OIF) and were diagnosed with PTSD. The 18 study subjects were randomized and provided 10 weekly therapy sessions of CBT. Pre- and postintervention assessments were conducted using the Clinician Administered PTSD Scale (CAPS), Hamilton Anxiety Rating Scale (HAM-A), Montgomery-Asberg Depression Rating Scale (MADRS), Life Events Checklist, and SF-36v2 (QualityMetric, Lincoln, RI) Health Survey. Results: The CAPS, HAM-A, and MADRS each demonstrated lower scores, signifying improvement, and 69% of subjects experienced a clinically significant change in the CAPS. Patient satisfaction results indicated greater satisfaction for telemedicine as opposed to traditional face-to-face treatment. Conclusions: Findings reveal a trend expressing the equivalence of telemedicine and face-to-face therapy when treating OEF/OIF veterans with PTSD among rural populations by a community provider. It further demonstrates the successful collaboration between a community healthcare provider and the military healthcare system. Key words: behavioral health, military medicine, telemedicine, telepsychiatry
446 TELEMEDICINE and e-HEALTH M A Y 2 0 1 4
Introduction
A
pproximately 2.2 million troops have been deployed to combat missions in Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]) as of December 2012.1 The increased exposure to combat stress from OIF/OEF has been marked by the prevalence of posttraumatic stress disorder (PTSD),2 with estimates ranging from 5% to 20% among Veterans.1,3 The incidence and prevalence of PTSD have been linked to various factors, including greater survivability following physical injury,4 number of deployments,5 ground combat,2 and the availability of instruments to assist with diagnosing.6 In turn, the debilitating effects of PTSD have been reported by many service members and have impacted employability,1,7 family relationships,8 and community reintegration.9 The incidence rate of PTSD among service members has placed considerable amounts of stress on the available treatment infrastructure. Significant barriers to accessing and receiving appropriate care have been noted in the literature for service members with PTSD. One well-known barrier to seeking behavioral health treatment includes accessibility to care, whether due to the availability of providers10,11 or geographic isolation.1 Efforts have been initiated to counter this barrier, such as the hiring of 1,900 mental health providers by the Veterans Administration (VA)12 or reliance upon civilian providers.4,13 However, provider availability is still limited, particularly among civilian providers.14 It has been estimated that 91% of active-duty service members live within 20 miles of a military treatment facility, but fewer than 50% of National Guard and Reserve members live within those described areas.1,13 Veterans from geographically rural areas make up a disproportionate share of service members and make up about 41% of VA-enrolled OEF/OIF Veterans.15 The combination of lack of providers and rural isolation presents substantial barriers to care for military service members diagnosed with PTSD residing in rural locations. A solution that continues to be explored for the treatment of PTSD among this population is telemedicine.16–18 Much of the work that has focused on telemedicine as an option for military patient populations has focused on VA providers. An aspect that has not been fully explored is the integration of telemedicine mental health treatment services provided by community healthcare providers to a military population residing in a rural location. This study addressed this need by means of a randomized clinical trial investigating the use of telemedicine to deliver cognitive
DOI: 10.1089/tmj.2013.0312
TREATMENT OF A MILITARY POPULATION WITH PTSD
behavioral therapy (CBT) compared with face-to-face CBT. PTSD is treated through a variety of means, including psychological or pharmacologic treatment, or a combination of the two. CBT is one of several empirically validated treatment modalities used to treat PTSD. Eligible study subjects included those who were either activeduty or Veteran military and served in OEF and/or OIF who had a diagnosis of PTSD.
Subjects and Methods STUDY DESIGN AND ELIGIBLITY The study followed a two-arm, randomized design with the purpose of comparing effectiveness between telemedicine-administered CBT and face-to-face–administered CBT. The approach was to demonstrate equivalence of the two arms, in order to demonstrate telemedicine as a viable option for this patient population and environment. The study design incorporated a licensed clinical therapist to deliver therapy to subjects in a controlled manner and a research rater to administer pre- and post-intervention assessments of subjects. The rater was blinded to the arm the subject was assigned to, as described below. The CBT model was based on the Beck model and was monitored for fidelity. This involved the use of a fidelity consultant to review and rate therapy sessions for compliance to the model. Fidelity was measured using the 12-item Cognitive Therapy Scale-Revised (CTS-R). The CTS-R is a widely used fidelity measurement for research involving CBT. Unlike prior versions or other fidelity measurements, the CTS-R focuses on measurement of therapist adherence to CBT in addition to therapist competence with the CBT model. According to the CTS-R scale, the scoring profile should approximate a normal distribution of at least a 3.19 Fidelity scores overall demonstrated a mean of 4.6 with an standard deviation of 0.6. Those for face-to-face sessions had a mean score of 4.7 and standard deviation of 0.6, whereas telemedicine exhibited a mean fidelity score of 4.6 and standard deviation of 0.7. A network of telemedicine units was established in a hub-andspoke design in the southwest Georgia region. A central location and six satellite clinics were used, with the range of the network extending 40 miles. The equipment used was constructed of Polycom (San Jose, CA) components through a third-party vendor and was linked within an enclosed network to maintain quality and security. Subjects were male or female 18 years of age or older who had served in OEF and/or OIF. They could have either had an existing diagnosis of PTSD or a suspicion of such a diagnosis. The study contracted with a psychiatrist, who provided a clinical evaluation and confirmation of a diagnosis of PTSD on all subjects as part of the screening process. Subjects who were prescribed medication by the study psychiatrist were placed on a delayed enrollment for 30 days to ensure medication stability. All subjects provided consent to participate and, following eligibility determination and enrollment, were randomized in a 1:1 manner through a computer algorithm. Enrolled subjects were allowed their choice of clinic within the study network that was convenient, as all clinic locations were capable of both modes of CBT
delivery. Pretherapy assessments were conducted by the research rater using telemedicine for all subjects. Assessments consisted of the Clinician Administered PTSD Scale (CAPS),20 Hamilton Anxiety Rating Scale (HAM-A),21 the Montgomery-Asberg Depression Rating Scale (MADRS),22 the Life Events Checklist,23 and the SF-36v2 (QualityMetric, Lincoln, RI) Health Survey.24 This extensive approach was used not only to measure the extent of PTSD among subjects, but also to measure anxiety and depression as components of PTSD. These instruments were scored, with the CAPS following the strict F1/ I2/TSEV65 rule.25 Subjects were then provided 10 weekly therapy sessions, although a 15-week time frame was allotted to complete the sessions. Following the final session, the rating assessments were repeated, along with a measure of the subject’s satisfaction with a patient satisfaction survey. The effectiveness of treatment was ascertained by any change in the scores of the CAPS, HAM-A, and MADRS. Extensive marketing within the region was used in the recruitment process, including electronic and print media, community presentations, and outreach to community and Veteran groups. Despite these efforts, the total enrollment within the time period of the grant was 18, with 13 subjects completing treatment and all assessments. The sample size obtained is sufficient to make determinations of trends in effectiveness and clinical significance, but statistical significance was not determined. Approval for the study was obtained from the local community hospital’s Institutional Review Board and the Human Research Protection Office, Office of Human Research Protections, U.S. Army Medical Research and Materiel Command.
Results The study enrollment of 18 subjects was 90% male and 79% black. All had served in either OEF or OIF, with an average of 11 years served and two tours. Most had existing symptoms of PTSD that were subsequently diagnosed as PTSD during screening. It should be noted that several individuals were screened who did not meet the DSM-IVTR requirements for PTSD and were not enrolled. The primary measure of treatment effectiveness was the CAPS. Table 1 summarizes the results for this instrument for pretherapy and posttherapy assessments in each treatment group. Scores are normalized to the general population. Of the 18 total subjects in our sample size, pre- and post-intervention assessments were completed by 13. A clinically significant decrease in PTSD symptoms as evidenced by a ‡15 point change26 in the total CAPS score at post-
Table 1. Average Pre- and Posttherapy Clinician Administered Posttraumatic Stress Disorder Scale Scores by Modality (n = 13) MODALITY
PRETHERAPY
POSTTHERAPY
% CHANGE
Face-to-face
90
68
- 24.4%
Telemedicine
95
72
- 24.2%
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Table 2. Mean SF-36v2 Scores for Pre- and Posttherapy by Treatment Modality (n = 13) MODALITY
PRETHERAPY
POSTTHERAPY
% CHANGE
Face-to-face
44
46
+ 4.5%
Telemedicine
45
47
+ 4.4%
Face-to-face
29
40
+ 37.9%
Telemedicine
24
35
+ 45.8%
Physical health
Mental health
intervention assessment was experienced by 69% of subjects. For subjects completing both assessments, 38.4% fell below threshold criteria for diagnosis of PTSD based on CAPS post-intervention assessments. The HAM-A and MADRS demonstrated a similar reduction in symptoms for both arms following therapy. The HAM-A demonstrated average scores of 34 and 35 for the pretherapy assessments of the telemedicine and face-to-face groups, respectively. In turn, postintervention assessment scores for the HAM-A presented a score of 27 each for both groups. The MADRS demonstrated similar pretherapy scores of 32 and 31 for the telemedicine and face-to-face groups and respective post-therapy scores of 26 and 23.
Table 3. Select Patient Satisfaction Scores for Treatment Groups ALL (N = 13)
FACE-TOFACE (N = 6)
TELEMEDICINE (N = 7)
Individual counseling sessions
98.1
95.8
100.0
Time therapist spent with you
94.2
95.8
98.6
Therapist concern for your question
98.1
95.8
100.0
Therapist understood you
98.1
95.8
100.0
Information regarding your treatment
98.1
95.8
100.0
Ability of psychiatric tester
98.1
95.8
100.0
Courtesy of psychiatric tester
98.1
95.8
100.0
Explanation of psychiatric tests
98.1
95.8
100.0
Overall satisfactiona
95.3
92.1
98.1
MODALITY
a
Overall satisfaction includes measures in addition to those listed here.
448 TELEMEDICINE and e-HEALTH M A Y 2 0 1 4
The results of the CAPS, HAM-A, and MADRS provide direct measures of PTSD and its components. As PTSD can negatively impact an individual’s quality of life, the SF-36v2 was used as a metric. The SF-36v2 provides a view of the physical and mental health of an individual at a point in time. Table 2 summarizes the physical health and mental health measures from this instrument for study subjects. Patient satisfaction has become an increasingly important component of healthcare,27 and telemedicine is no exception. A patient satisfaction survey, developed for the study by Press Ganey (South Bend, IN), was used to collect measures following completion of the final therapy session. This metric incorporates several factors, including staff courtesy and facility cleanliness. For the purpose of this study, Table 3 presents the mean scores, based on a range of 0–100, for the face-to-face and telemedicine groups pertaining to therapy sessions.
Discussion The present study demonstrates the implementation of a telemedicine network to provide care for military service members in rural communities using a non-military community healthcare provider. In addition, it compares the delivery of care by means of a telemedicine modality with the traditional face-to-face model. A striking aspect is the similarity of effects between the face-to-face and telemedicine groups, which supports our hypothesis and existing research28 that telemedicine is as effective as traditional face-to-face therapy in the treatment of PTSD. Larger studies among VA populations have demonstrated the same impact in telemedicine.28 This study greatly increased convenience and accessibility to care, which fills a void documented in research.1,11 The CAPS, HAM-A, and MADRS each demonstrated lower scores, signifying improvement. In particular, the scores for the HAM-A and MADRS were essentially identical between the two treatment arms. Scores from the SF-36v2, representing the quality of life, as noted above, also followed the same pattern of equal change for each group. Although physical health was essentially unchanged for both groups, mental health demonstrated a noticeable improvement for both arms, with telemedicine demonstrating a greater change. Patient satisfaction is a documented concern in telemedicine.29,30 The results reported herein appear to indicate greater satisfaction for telemedicine subjects as opposed to those receiving traditional faceto-face treatment. That being said, the method of therapeutic treatment delivery discussed does not appear to impact the quality of the patient–provider relationship. This study had several limitations. The greatest limitation was the sample size obtained, despite the efforts to recruit. This factor prevented the ability to demonstrate statistical significance of the results. However, encouraging trends and clinical significance were observed for individual subjects and among the face-to-face and telemedicine groups. Other limitations were identified throughout the study. A small number of enrolled subjects was unable to complete the 10 sessions within the 15-week time frame. However, these subjects did complete treatment and assessments, but it is possible
TREATMENT OF A MILITARY POPULATION WITH PTSD
that the greater time period had an impact on results. Additionally, subjects were able to select at which clinic they could receive therapy, regardless of the delivery modality. This was an attempt to eliminate the impact of having face-to-face subjects being forced to travel to a specific clinic, whereas telemedicine subjects would be able to choose. In other words, it sought to reduce or eliminate convenience as a variable. However, several subjects actually traveled a substantial distance from outside the region to participate. This travel time may have had an unknown influence on the results.
Conclusions This work recognizes the lack of available resources to provide care in rural locations. It also confirms the efficacy of telemedicine in the treatment of PTSD among returning military personnel from OIF and OEF. The study further demonstrates the successful collaboration between a community healthcare provider and the military healthcare system. The findings reveal a trend expressing the equivalence of telemedicine and face-to-face when treating OEF/OIF veterans with PTSD among rural populations by a community provider. The findings support the research on the effectiveness and ease of use when using telemedicine in psychotherapy assessment and treatment with Veterans.31
Acknowledgments This work was supported by award W81XWH-09-2-0112 from the Human Research Protection Office, Office of Human Research Protections, U.S. Army Medical Research and Materiel Command.
Disclosure Statement R.N.C. is a partner in Clinical Psychology Consultants, Ltd. S.J.Z., N.S.B., L.A.P.L., C.H.R., and L.S.P. declare no competing financial interests exist.
REFERENCES 1. National Research Council. Returning home from Iraq and Afghanistan: Assessment of readjustment needs of veterans, service members, and their families. Washington, DC: The National Academies Press, 2013. 2. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351:13–22. 3. Ramchand R, Schell TL, Karney BR, Osilla KC, Burns RM, Caldarone LB. Disparate prevalence estimates of PTSD among service members who served in Iraq and Afghanistan: Possible explanations. J Trauma Stress 2010;23:59–68. 4. Tanielian T, Jaycox LH, Adamson DH, Metscher KN. Signature wounds. In: Tanielian T, Jaycox LH, eds. Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Corp., 2008:3–17. 5. Armed Forces Health Surveillance Center. Associations between repeated deployments to OEF/OIF/OND, October 2001–December 2010, and postdeployment illnesses and injuries, active component, U.S. Armed Forces. MSMR 2011;18:2–11. 6. National Center for PTSD. Assessment. 2009 update. Available at www.ptsd.va.gov/professional/pages/assessments/assessment.asp (last accessed August 23, 2013).
7. Kleykamp M. A great place to start?: The effect of prior military service on hiring. Armed Forces Soc 2009;35:266–285. 8. Monson CM, Taft CT, Fredman SJ. Military-related PTSD and intimate relationships: From description to theory-driven research and intervention development. Clin Psychol 2009;29:707–714. 9. Sayer NA, Frazier P, Orazem RJ, Murdoch M, Gravely A, Carlson KF, Hintz S, Noorbaloochi S. Military to civilian questionnaire: A measure of post deployment community reintegration difficulty among veterans using Department of Veterans Affairs medical care. J Trauma Stress 2011;24:660–670. 10. Schaffer M, Crabtree M, Bennett E, McNally M, Okel A. Identifying barriers to treatment for PTSD among reserve component veterans in rural Pennsylvania: An analysis of five focus groups. J Rural Community Psychol 2011;E14(1). 11. VA Office of Inspector General. Veterans Health Administration: Review of veterans’ access to mental healthcare. Washington, DC: VA Office of Inspector General, 2013. 12. Freemark S. The VA is on a mental health hiring spree—But will it be enough? Available at www.publicinsightnetwork.org/2012/12/19/the-va-is-on-a-mentalhealth-hiring-spree-but-will-it-be-enough/ (last accessed August 21, 2013). 13. Department of Defense. MHS stakeholders report 2011 update. Available at www.health.mil/Libraries/Documents_Word_PDF_PPT_etc/ 2011_MHS_StakeholdersReport.pdf (last accessed August 21, 2013). 14. Ruzek JI, Rosen RC. Disseminating evidence-based treatments for PTSD in organizational settings: A high priority focus area. Behav Res Ther 2009;47:980–989. 15. Department of Veterans Affairs. Veterans Health Administration Office of Rural Health strategic plan refresh fiscal years 2012–2014. Available at www.ruralhealth.va.gov/docs/ORH_StrategicPlanRefresh_FY2012-2014.pdf (last accessed August 21, 2013). 16. Frueh BC, Deitsch SH, Santos AB, Gold PB, Johnson MR, Meisler N, et al. Procedural and methodological issues in telepsychiatry research and program development. Psychiatr Serv 2000;15:1522–1527. 17. Hilty DM, Marks SL, Urness D, Yellowlees PM, Nesbitt TS. Clinical and educational telepsychiatry applications: A review. Can J Psychiatry 2004;49:12–23. 18. Morland LA, Greene CJ, Rosen C, Foy D, Reilly P, Shore J, He Q, Frueh BC. Telemedicine for anger management therapy in a rural population of combat veterans with posttraumatic stress disorder: A randomized noninferiority trial. J Clin Psychiatry 2010;71:855–863. 19. Blackburn IM, James IA, Milne DL, Reichelt FK. Cognitive Therapy Scale-Revised (CTS-R). Newcastle-upon-Tyne, United Kingdom: Newcastle Cognitive and Behavioural Therapies Centre, 2001. 20. Blake DD, Weathers FW, Nagy LM, Kaloupek DG, Gusman FD, Charney DS, Keane TM. The development of a clinician-administered PTSD scale. J Trauma Stress 1995;8:75–90. 21. Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol 1959;32:50–55. 22. Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry 1979;134:382–389. 23. Gray MJ, Litz BT, Hsu JL, Lombardo TW. The psychometric properties of the Life Events Checklist. Assessment 2004;11:330–341. 24. QualityMetric. SF-36v2 Health Survey. Available at www.qualitymetric.com/ WhatWeDo/GenericHealthSurveys/SF36v2HealthSurvey/tabid/185/Default.aspx (last accessed March 19, 2009). 25. Weathers FW, Ruscio AM, Keane TM. Psychometric properties of nine scoring rules for the Clinician-Administered Posttraumatic Stress Disorder Scale. Psychol Assess 1999;11:124–133. 26. Weathers FW, Keane TM, Davidson JRT. Clinician-Administered PTSD Scale: A review of the first ten years of research. Depress Anxiety 2001;13:132–156. 27. Agha Z, Schapira RM, Laud PW, McNutt G, Roter DL. Patient satisfaction with physician-patient communication during telemedicine. Telemed J E Health 2009;15:830–839.
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28. Frueh BC, Monnier J, Yim E, Grubaugh AL, Hamner MB, Knapp RG. A randomized trial of telepsychiatry for post-traumatic stress disorder. J Telemed Telecare 2007;13:142–147. 29. Hsueh MT, Eastman K, McFarland LV, Raugi GJ, Reiver GE. Teledermatology patient satisfaction in the Pacific Northwest. Telemed J E Health 2012;18:377–381. 30. John S, Sengupta S, Reddy SJ, Prabhu P, Kirubanandan K, Badrinath SS. The Sankara Nethralaya mobile teleophthalmology model for comprehensive eye care delivery in rural India. Telemed J E Health 2012;18:382–388. 31. American Telemedicine Association. Evidence-based practice for telemental health. July 2009 update. Available at www.americantelemed.org/docs/defaultsource/standards/evidence-based-practice-for-telemental-health.pdf?sfvrsn=4 (last accessed September 9, 2013).
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Address correspondence to: Lori-Ann P. Landry, MSW, LCSW 6541 Specker Rd. Bldg. 1830 Ft. Carson, CO 80913 E-mail: [email protected] Received: September 10, 2013 Accepted: September 12, 2013
Steven J. Ziemba, PhD, MBA, CCRC, CRCP, CIP, FACHE,1 Nicola S. Bradley, MFT, LMFT,1 Lori-Ann P. Landry, MSW, LCSW,1 Claire H. Roth, MSW, LMSW,1 Linda S. Porter, MEd, MS, EdS, LPC,1 and Robert N. Cuyler, PhD 2 1
Phoebe Putney Memorial Hospital, Albany, Georgia. 2 Clinical Psychology Consultants, Ltd., LLP, Houston, Texas. All views and opinions expressed herein are those of the authors and do not necessarily reflect those of our respective affiliations or the Department of Defense.
Abstract Background: Telemedicine holds great potential to improve access to care and to reduce barriers to treatment for military populations with posttraumatic stress disorder (PTSD). This study sought to integrate the use of telemedicine mental health treatment services by a community healthcare provider to military populations residing in a rural location and to compare the equivalency of cognitive behavioral therapy (CBT) administered via telemedicine and traditional face-toface therapy. Subjects and Methods: Study subjects were men or women 18 years of age or older who had served in Operation Enduring Freedom (OEF) and/or Operation Iraqi Freedom (OIF) and were diagnosed with PTSD. The 18 study subjects were randomized and provided 10 weekly therapy sessions of CBT. Pre- and postintervention assessments were conducted using the Clinician Administered PTSD Scale (CAPS), Hamilton Anxiety Rating Scale (HAM-A), Montgomery-Asberg Depression Rating Scale (MADRS), Life Events Checklist, and SF-36v2 (QualityMetric, Lincoln, RI) Health Survey. Results: The CAPS, HAM-A, and MADRS each demonstrated lower scores, signifying improvement, and 69% of subjects experienced a clinically significant change in the CAPS. Patient satisfaction results indicated greater satisfaction for telemedicine as opposed to traditional face-to-face treatment. Conclusions: Findings reveal a trend expressing the equivalence of telemedicine and face-to-face therapy when treating OEF/OIF veterans with PTSD among rural populations by a community provider. It further demonstrates the successful collaboration between a community healthcare provider and the military healthcare system. Key words: behavioral health, military medicine, telemedicine, telepsychiatry
446 TELEMEDICINE and e-HEALTH M A Y 2 0 1 4
Introduction
A
pproximately 2.2 million troops have been deployed to combat missions in Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]) as of December 2012.1 The increased exposure to combat stress from OIF/OEF has been marked by the prevalence of posttraumatic stress disorder (PTSD),2 with estimates ranging from 5% to 20% among Veterans.1,3 The incidence and prevalence of PTSD have been linked to various factors, including greater survivability following physical injury,4 number of deployments,5 ground combat,2 and the availability of instruments to assist with diagnosing.6 In turn, the debilitating effects of PTSD have been reported by many service members and have impacted employability,1,7 family relationships,8 and community reintegration.9 The incidence rate of PTSD among service members has placed considerable amounts of stress on the available treatment infrastructure. Significant barriers to accessing and receiving appropriate care have been noted in the literature for service members with PTSD. One well-known barrier to seeking behavioral health treatment includes accessibility to care, whether due to the availability of providers10,11 or geographic isolation.1 Efforts have been initiated to counter this barrier, such as the hiring of 1,900 mental health providers by the Veterans Administration (VA)12 or reliance upon civilian providers.4,13 However, provider availability is still limited, particularly among civilian providers.14 It has been estimated that 91% of active-duty service members live within 20 miles of a military treatment facility, but fewer than 50% of National Guard and Reserve members live within those described areas.1,13 Veterans from geographically rural areas make up a disproportionate share of service members and make up about 41% of VA-enrolled OEF/OIF Veterans.15 The combination of lack of providers and rural isolation presents substantial barriers to care for military service members diagnosed with PTSD residing in rural locations. A solution that continues to be explored for the treatment of PTSD among this population is telemedicine.16–18 Much of the work that has focused on telemedicine as an option for military patient populations has focused on VA providers. An aspect that has not been fully explored is the integration of telemedicine mental health treatment services provided by community healthcare providers to a military population residing in a rural location. This study addressed this need by means of a randomized clinical trial investigating the use of telemedicine to deliver cognitive
DOI: 10.1089/tmj.2013.0312
TREATMENT OF A MILITARY POPULATION WITH PTSD
behavioral therapy (CBT) compared with face-to-face CBT. PTSD is treated through a variety of means, including psychological or pharmacologic treatment, or a combination of the two. CBT is one of several empirically validated treatment modalities used to treat PTSD. Eligible study subjects included those who were either activeduty or Veteran military and served in OEF and/or OIF who had a diagnosis of PTSD.
Subjects and Methods STUDY DESIGN AND ELIGIBLITY The study followed a two-arm, randomized design with the purpose of comparing effectiveness between telemedicine-administered CBT and face-to-face–administered CBT. The approach was to demonstrate equivalence of the two arms, in order to demonstrate telemedicine as a viable option for this patient population and environment. The study design incorporated a licensed clinical therapist to deliver therapy to subjects in a controlled manner and a research rater to administer pre- and post-intervention assessments of subjects. The rater was blinded to the arm the subject was assigned to, as described below. The CBT model was based on the Beck model and was monitored for fidelity. This involved the use of a fidelity consultant to review and rate therapy sessions for compliance to the model. Fidelity was measured using the 12-item Cognitive Therapy Scale-Revised (CTS-R). The CTS-R is a widely used fidelity measurement for research involving CBT. Unlike prior versions or other fidelity measurements, the CTS-R focuses on measurement of therapist adherence to CBT in addition to therapist competence with the CBT model. According to the CTS-R scale, the scoring profile should approximate a normal distribution of at least a 3.19 Fidelity scores overall demonstrated a mean of 4.6 with an standard deviation of 0.6. Those for face-to-face sessions had a mean score of 4.7 and standard deviation of 0.6, whereas telemedicine exhibited a mean fidelity score of 4.6 and standard deviation of 0.7. A network of telemedicine units was established in a hub-andspoke design in the southwest Georgia region. A central location and six satellite clinics were used, with the range of the network extending 40 miles. The equipment used was constructed of Polycom (San Jose, CA) components through a third-party vendor and was linked within an enclosed network to maintain quality and security. Subjects were male or female 18 years of age or older who had served in OEF and/or OIF. They could have either had an existing diagnosis of PTSD or a suspicion of such a diagnosis. The study contracted with a psychiatrist, who provided a clinical evaluation and confirmation of a diagnosis of PTSD on all subjects as part of the screening process. Subjects who were prescribed medication by the study psychiatrist were placed on a delayed enrollment for 30 days to ensure medication stability. All subjects provided consent to participate and, following eligibility determination and enrollment, were randomized in a 1:1 manner through a computer algorithm. Enrolled subjects were allowed their choice of clinic within the study network that was convenient, as all clinic locations were capable of both modes of CBT
delivery. Pretherapy assessments were conducted by the research rater using telemedicine for all subjects. Assessments consisted of the Clinician Administered PTSD Scale (CAPS),20 Hamilton Anxiety Rating Scale (HAM-A),21 the Montgomery-Asberg Depression Rating Scale (MADRS),22 the Life Events Checklist,23 and the SF-36v2 (QualityMetric, Lincoln, RI) Health Survey.24 This extensive approach was used not only to measure the extent of PTSD among subjects, but also to measure anxiety and depression as components of PTSD. These instruments were scored, with the CAPS following the strict F1/ I2/TSEV65 rule.25 Subjects were then provided 10 weekly therapy sessions, although a 15-week time frame was allotted to complete the sessions. Following the final session, the rating assessments were repeated, along with a measure of the subject’s satisfaction with a patient satisfaction survey. The effectiveness of treatment was ascertained by any change in the scores of the CAPS, HAM-A, and MADRS. Extensive marketing within the region was used in the recruitment process, including electronic and print media, community presentations, and outreach to community and Veteran groups. Despite these efforts, the total enrollment within the time period of the grant was 18, with 13 subjects completing treatment and all assessments. The sample size obtained is sufficient to make determinations of trends in effectiveness and clinical significance, but statistical significance was not determined. Approval for the study was obtained from the local community hospital’s Institutional Review Board and the Human Research Protection Office, Office of Human Research Protections, U.S. Army Medical Research and Materiel Command.
Results The study enrollment of 18 subjects was 90% male and 79% black. All had served in either OEF or OIF, with an average of 11 years served and two tours. Most had existing symptoms of PTSD that were subsequently diagnosed as PTSD during screening. It should be noted that several individuals were screened who did not meet the DSM-IVTR requirements for PTSD and were not enrolled. The primary measure of treatment effectiveness was the CAPS. Table 1 summarizes the results for this instrument for pretherapy and posttherapy assessments in each treatment group. Scores are normalized to the general population. Of the 18 total subjects in our sample size, pre- and post-intervention assessments were completed by 13. A clinically significant decrease in PTSD symptoms as evidenced by a ‡15 point change26 in the total CAPS score at post-
Table 1. Average Pre- and Posttherapy Clinician Administered Posttraumatic Stress Disorder Scale Scores by Modality (n = 13) MODALITY
PRETHERAPY
POSTTHERAPY
% CHANGE
Face-to-face
90
68
- 24.4%
Telemedicine
95
72
- 24.2%
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Table 2. Mean SF-36v2 Scores for Pre- and Posttherapy by Treatment Modality (n = 13) MODALITY
PRETHERAPY
POSTTHERAPY
% CHANGE
Face-to-face
44
46
+ 4.5%
Telemedicine
45
47
+ 4.4%
Face-to-face
29
40
+ 37.9%
Telemedicine
24
35
+ 45.8%
Physical health
Mental health
intervention assessment was experienced by 69% of subjects. For subjects completing both assessments, 38.4% fell below threshold criteria for diagnosis of PTSD based on CAPS post-intervention assessments. The HAM-A and MADRS demonstrated a similar reduction in symptoms for both arms following therapy. The HAM-A demonstrated average scores of 34 and 35 for the pretherapy assessments of the telemedicine and face-to-face groups, respectively. In turn, postintervention assessment scores for the HAM-A presented a score of 27 each for both groups. The MADRS demonstrated similar pretherapy scores of 32 and 31 for the telemedicine and face-to-face groups and respective post-therapy scores of 26 and 23.
Table 3. Select Patient Satisfaction Scores for Treatment Groups ALL (N = 13)
FACE-TOFACE (N = 6)
TELEMEDICINE (N = 7)
Individual counseling sessions
98.1
95.8
100.0
Time therapist spent with you
94.2
95.8
98.6
Therapist concern for your question
98.1
95.8
100.0
Therapist understood you
98.1
95.8
100.0
Information regarding your treatment
98.1
95.8
100.0
Ability of psychiatric tester
98.1
95.8
100.0
Courtesy of psychiatric tester
98.1
95.8
100.0
Explanation of psychiatric tests
98.1
95.8
100.0
Overall satisfactiona
95.3
92.1
98.1
MODALITY
a
Overall satisfaction includes measures in addition to those listed here.
448 TELEMEDICINE and e-HEALTH M A Y 2 0 1 4
The results of the CAPS, HAM-A, and MADRS provide direct measures of PTSD and its components. As PTSD can negatively impact an individual’s quality of life, the SF-36v2 was used as a metric. The SF-36v2 provides a view of the physical and mental health of an individual at a point in time. Table 2 summarizes the physical health and mental health measures from this instrument for study subjects. Patient satisfaction has become an increasingly important component of healthcare,27 and telemedicine is no exception. A patient satisfaction survey, developed for the study by Press Ganey (South Bend, IN), was used to collect measures following completion of the final therapy session. This metric incorporates several factors, including staff courtesy and facility cleanliness. For the purpose of this study, Table 3 presents the mean scores, based on a range of 0–100, for the face-to-face and telemedicine groups pertaining to therapy sessions.
Discussion The present study demonstrates the implementation of a telemedicine network to provide care for military service members in rural communities using a non-military community healthcare provider. In addition, it compares the delivery of care by means of a telemedicine modality with the traditional face-to-face model. A striking aspect is the similarity of effects between the face-to-face and telemedicine groups, which supports our hypothesis and existing research28 that telemedicine is as effective as traditional face-to-face therapy in the treatment of PTSD. Larger studies among VA populations have demonstrated the same impact in telemedicine.28 This study greatly increased convenience and accessibility to care, which fills a void documented in research.1,11 The CAPS, HAM-A, and MADRS each demonstrated lower scores, signifying improvement. In particular, the scores for the HAM-A and MADRS were essentially identical between the two treatment arms. Scores from the SF-36v2, representing the quality of life, as noted above, also followed the same pattern of equal change for each group. Although physical health was essentially unchanged for both groups, mental health demonstrated a noticeable improvement for both arms, with telemedicine demonstrating a greater change. Patient satisfaction is a documented concern in telemedicine.29,30 The results reported herein appear to indicate greater satisfaction for telemedicine subjects as opposed to those receiving traditional faceto-face treatment. That being said, the method of therapeutic treatment delivery discussed does not appear to impact the quality of the patient–provider relationship. This study had several limitations. The greatest limitation was the sample size obtained, despite the efforts to recruit. This factor prevented the ability to demonstrate statistical significance of the results. However, encouraging trends and clinical significance were observed for individual subjects and among the face-to-face and telemedicine groups. Other limitations were identified throughout the study. A small number of enrolled subjects was unable to complete the 10 sessions within the 15-week time frame. However, these subjects did complete treatment and assessments, but it is possible
TREATMENT OF A MILITARY POPULATION WITH PTSD
that the greater time period had an impact on results. Additionally, subjects were able to select at which clinic they could receive therapy, regardless of the delivery modality. This was an attempt to eliminate the impact of having face-to-face subjects being forced to travel to a specific clinic, whereas telemedicine subjects would be able to choose. In other words, it sought to reduce or eliminate convenience as a variable. However, several subjects actually traveled a substantial distance from outside the region to participate. This travel time may have had an unknown influence on the results.
Conclusions This work recognizes the lack of available resources to provide care in rural locations. It also confirms the efficacy of telemedicine in the treatment of PTSD among returning military personnel from OIF and OEF. The study further demonstrates the successful collaboration between a community healthcare provider and the military healthcare system. The findings reveal a trend expressing the equivalence of telemedicine and face-to-face when treating OEF/OIF veterans with PTSD among rural populations by a community provider. The findings support the research on the effectiveness and ease of use when using telemedicine in psychotherapy assessment and treatment with Veterans.31
Acknowledgments This work was supported by award W81XWH-09-2-0112 from the Human Research Protection Office, Office of Human Research Protections, U.S. Army Medical Research and Materiel Command.
Disclosure Statement R.N.C. is a partner in Clinical Psychology Consultants, Ltd. S.J.Z., N.S.B., L.A.P.L., C.H.R., and L.S.P. declare no competing financial interests exist.
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Address correspondence to: Lori-Ann P. Landry, MSW, LCSW 6541 Specker Rd. Bldg. 1830 Ft. Carson, CO 80913 E-mail: [email protected] Received: September 10, 2013 Accepted: September 12, 2013
