BACKGROUND/RATIONALE:
Posttraumatic stress disorder (PTSD) is a prevalent problem among military troops. Recovery from combat-related PTSD is often complicated by problems with anger. Veterans with difficulties managing PTSD-related anger may be particularly likely to live in remote geographical regions where access to specialized mental health care is often limited. Telemental health (TMH) has been touted as a potential means of increasing access to care in rural or remote areas.

OBJECTIVE(S):
This study compared the effectiveness of group Anger Management Therapy (AMT) delivered via videoteleconferencing (VTC) and in-person delivery in a sample of rural combat veterans with PTSD. The long-range objective of this project was to develop an empirically sound TMH protocol that will facilitate the extension of manual guided clinical services to remote sites via VTC. We hypothesized that providing a manualized group therapy intervention via VTC would result in similar reductions in anger symptoms as obtained from traditional in-person care. Further, we hypothesized that key process indicators (i.e., attrition, adherence, satisfaction, and therapeutic alliance) would not be significantly different between the VTC and in-person conditions. The specific objectives of this project were to: a) determine if group AMT delivered via VTC is as effective as the same intervention delivered in-person on clinical outcomes measuring reductions in anger symptoms and b) determine if group AMT delivered via VTC is as effective as the same intervention delivered in-person on group process outcomes.

METHODS:
A randomized controlled non-inferiority trial of 125 male veterans with PTSD and anger difficulties was conducted at three Department of Veterans Affairs outpatient clinics. Participants were randomly assigned to receive AMT delivered in a group setting with the therapist either in-person (N= 64) or via VTC (N= 61). Participants were assessed at baseline, mid-treatment, post-treatment, and 3 and 6-months post-treatment. The primary clinical outcome was reduction of anger difficulties, as measured by the Anger Expression and Trait Anger subscales of the State-Trait Anger Expression Inventory and the Novaco Anger Total Scale. Process variables were measured to assess the feasibility of AMT delivered via VTC. SAS MEANS procedure was used to calculate means and standard deviations for change from baseline at subsequent assessment points for both intent-to-treat and per-protocol analysis.

FINDINGS/RESULTS:
Participants in both groups showed significant and clinically meaningful reductions in anger symptoms, with pre-post effect sizes ranging from .12 to .63. Participants in the VTC condition demonstrated a reduction in anger symptoms similar ("non-inferior") to symptom reductions in the in-person groups. Additionally, no significant between-group differences were found on the process variables of attrition, adherence, patient satisfaction, and treatment expectancy. Participants in the in-person condition reported significantly higher group therapy alliance.


IMPACT:
Telemental health may offer potential solutions for large health care systems that provide comprehensive services to patients in rural and remote areas. By demonstrating the effectiveness and feasibility of a cognitive-behavioral group treatment for PTSD-related anger problems delivered via VTC, this study provided support for the use of a VTC modality as a way to increase access to evidence-based care for veterans residing in rural or remote locations.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Macdonald A, Greene CJ, Torres JG, Frueh BC, Morland LA. Concordance between clinician-assessed and self-report ratings of posttraumatic stress disorder across three ethnoracial groups. Psychological trauma : theory, research, practice and policy. 2012 Jan 1; 24:doi: 10.1037/a0027313. [view]
2. Greene CJ, Morland LA, Macdonald A, Frueh BC, Grubbs KM, Rosen CS. How does tele-mental health affect group therapy process? Secondary analysis of a noninferiority trial. Journal of consulting and clinical psychology. 2010 Oct 1; 78(5):746-50. [view]
3. Greene CJ, Morland LA, Durkalski VL, Frueh BC. Noninferiority and equivalence designs: issues and implications for mental health research. Journal of traumatic stress. 2008 Oct 1; 21(5):433-9. [view]
4. Mackintosh MA, Morland LA, Kloezeman K, Greene CJ, Rosen CS, Elhai JD, Frueh BC. Predictors of anger treatment outcomes. Journal of Clinical Psychology. 2014 Oct 1; 70(10):905-13. [view]
5. Gros DF, Gros K, Acierno R, Frueh BC, Moreland L. Relation between treatment satisfaction and treatment outcome in veterans with posttraumatic stress disorder. Journal of psychopathology and behavioral assessment. 2013 Jun 28; 35(4):522-30. [view]
6. Morland LA, Greene CJ, Rosen CS, 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. The Journal of clinical psychiatry. 2010 Jul 1; 71(7):855-63. [view]
7. Morland LA, Raab M, Mackintosh MA, Rosen CS, Dismuke CE, Greene CJ, Frueh BC. Telemedicine: a cost-reducing means of delivering psychotherapy to rural combat veterans with PTSD. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2013 Oct 1; 19(10):754-9. [view]
8. Morland LA, Greene CJ, Grubbs K, Kloezeman K, Mackintosh MA, Rosen C, Frueh BC. Therapist adherence to manualized cognitive-behavioral therapy for anger management delivered to veterans with PTSD via videoconferencing. Journal of Clinical Psychology. 2011 Jun 1; 67(6):629-38. [view]

VA Cyberseminars

1. Morland LA. Telemedicine and anger management groups for rural veterans with PTSD: a noninferiority trial. [Cyberseminar]. 2009 Jun 1. [view]

Conference Presentations

1. Castelda B, Strom TQ, Morland LM, Greene C, Pagano IH, MacDonald T. Acculturation, PTSD symptom severity and Anger in Pacific Island veterans. Poster session presented at: American Psychological Association Annual Convention; 2007 Aug 1; San Francisco, CA. [view]
2. Morland LA, Greene CJ, Strom TQ. Anger and Posttraumatic Stress Disorder---New Insights Into the Relationship. Paper presented at: American Psychological Association Annual Convention; 2007 Aug 1; San Francisco, CA. [view]
3. Morland LA, Greene CJ. Anger management and PTSD group intervention using VTC in the Pacific Islands. Presented at: VA Care Coordination Annual Conference; 2006 Jan 1; Denver, CO. [view]
4. Morland LA, Greene CJ, Reilly PM, MacDonald TM, Pagano IH, Foy DW. Anger Management Group Therapy for Veterans Diagnosed with PTSD in the Hawaiian Islands. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2006 Nov 1; Hollywood, CA. [view]
5. Sones H, Thorp S, Morland LA, Grubbs K. Ethnocultural differences in PTSD and anger among Hawaiian Island veterans. Paper presented at: American Psychological Association Annual Convention; 2009 Aug 1; San Diego, CA. [view]
6. Strom TQ, Morland LM, Ralston T, Pagano IH, MacDonald T. Ethnocultural identification and PTSD symptom severity in Pacific Island veterans. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2006 Nov 1; Hollywood, CA. [view]
7. Sakai KK, Greene CJ, Morland LA, Lu C, Ries RI, Andrews A. Ethnocultural Variation in Anger Expression in Veterans with PTSD in the Hawaiian Islands. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2006 Nov 1; Hollywood, CA. [view]
8. Greene CJ, Morland LA. Evaluating the effectiveness of an innovative treatment with a culturally diverse, rural, remote population: Methodological challenges and strategies. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2007 Nov 1; Baltimore, MD. [view]
9. Morland LA, Greene CJ. Providing Specialty PTSD Telemental Health to Rural Pacific Island Veterans. Paper presented at: American Psychological Association Annual Convention; 2007 Aug 1; San Francisco, CA. [view]
10. Strom TQ, Greene CJ, Pagano L, Morland LA. PTSD, Anger and Health Risk Behavior in Hawaiian Island Veterans. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2007 Nov 1; Baltimore, MD. [view]
11. Strom TQ, Morland LA, Castelda B, Frueh BC, Greene CJ. PTSD-related anger and high risk behaviors. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2007 Nov 1; Baltimore, MD. [view]
12. Morland LA, Greene C, Rosen CS, Frueh BC. Telemedicine and anger management groups for rural veterans with PTSD: a noninferiority trial. Poster session presented at: VA HSR&D National Meeting; 2009 Feb 1; Baltimore, MD. [view]
13. Morland LA, Greene C, Rosen CS, Frueh BC. Telemental health technology: results from a noninferiority trial. Paper presented at: VA MIRECC Annual Best Practices in Mental Health Conference; 2009 Jul 1; Baltimore, MD. [view]
14. Morland LA, Greene C, Rosen CS. Updates and advances in telemental health effectiveness. Paper presented at: VA / DoD Mental Health National Summit; 2009 Oct 26; Washington, DC. [view]
15. Greene CJ, Morland LA, Strom TQ. Using Telemental Health for PTSD Care in Rural Populations: Best Practices and Practical Skills. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2007 Nov 1; Baltimore, MD. [view]
16. Greene CJ, Morland LA. Utilizing Tele-Mental Health to Access Remote, Rural Veterans with PTS. Paper presented at: VA MIRECC Annual Conference; 2007 Jul 1; Houston, TX. [view]
17. Morland LA, Greene C. Utilizing telemental health to access rural veterans with PTSD. Paper presented at: VA Office of Mental Health Services Conference; 2008 Apr 1; Washington, DC. [view]

DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Treatment - Observational
Keywords: Access, Deployment, Operation Iraqi Freedom, Telemedicine
MeSH Terms: none