1123 — A Pragmatic Randomized Trial of Telemedicine Based Collaborative Care for Posttraumatic Stress Disorder
Fortney JC, Seattle HSR&D; Pyne JM, Little Rock HSR&D; Hudson TJ, Little Rock HSR&D; Grubbs KM, Little Rock HSR&D; Schnurr PP, National Center for PTSD;
PTSD is prevalent, persistent, and disabling. Although psychotherapy and pharmacotherapy have proven efficacious in controlled trials, geographic barriers impede rural veterans from engaging in these evidence-based treatments. The objective of the study was to test a telepsychiatry collaborative care model designed to improve engagement in evidence-based PTSD treatments.
The Telemedicine Outreach for PTSD (TOP) study used a pragmatic randomized effectiveness trial design with intent-to-treat analyses. Outpatients were recruited from 11 VA CBOCs lacking onsite psychiatrists and psychologists. Rural veterans were enrolled from 2009-2011 and followed for 12 months. Inclusion required meeting diagnostic criteria for current PTSD according to the Clinician-Administered PTSD Scale. Exclusion criteria included receiving PTSD treatment at the VAMC, or current diagnosis of schizophrenia, bipolar disorder, or substance dependence. 265 veterans were enrolled and randomized to usual care (UC) or the TOP intervention. The TOP intervention involved off-site PTSD care teams located at affiliated VAMCs supporting on-site CBOC providers. Off-site PTSD care teams included telephone nurse care managers, telephone pharmacists, tele-psychologists, and tele-psychiatrists. Nurses conducted care management activities. Pharmacists reviewed medication histories. Psychologists delivered Cognitive Processing Therapy (CPT) via interactive video. Psychiatrists supervised the team, and conducted interactive video psychiatric consultations. The primary outcome was PTSD severity as measured by the Posttraumatic Diagnostic Scale (PDS). Process of care outcomes included psychotropic prescribing and adherence, as well as initiation and adherence to CPT.
During the 12-month period, 54.9% of patients randomized to TOP received CPT compared to 12.1% in UC (OR = 18.08; p < 0.0001). Group differences in number of psychotropic medications and medication adherence were not significant. TOP patients had significantly larger decreases in PDS scores compared to UC at 6 (beta = ?3.81; p = 0.0018) and 12 months (beta = ?2.49; p = 0.043). Attendance at ?8 CPT sessions significantly predicted improvement in PDS scores (beta = ?3.86; p = 0.024) and fully mediated the intervention effect at 12 months.
Findings suggest that telepsychiatry collaborative care can successfully engage rural veterans in evidence-based psychotherapy to improve PTSD outcomes.
Telepsychiatry collaborative care represents a promising model for smaller CBOCs serving rural areas and could be incorporated into the Primary Care Mental Health Integration initiative.