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TEL 03-135 – HSR&D Study

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TEL 03-135
Telephone Case Monitoring for Veterans with PTSD
Craig S. Rosen PhD
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: April 2006 - September 2011

BACKGROUND/RATIONALE:
Poor compliance with aftercare may contribute to high rates of relapse and rehospitalization among veterans who received residential treatment for posttraumatic stress disorder (PTSD). Telephone case monitoring has been shown to improve treatment adherence and reduced relapse among patients with chronic medical and substance use disorders, but has not been tested in PTSD patients.

OBJECTIVE(S):
This multisite randomized controlled trial tested whether augmenting usual aftercare with telephone monitoring improved resulted in 1) improved clinical outcomes (less violence, substance use, and PTSD symptoms; 2) longer time to rehospitalization; 3) better compliance with aftercare in the year after discharge from residential treatment for PTSD.

METHODS:
This trial recruited 837 subjects from 6 PTSD residential treatment programs at 5 VA medical centers, 94.7% of the 884 projected. Patients who completed at least 14 days of residential PTSD treatment and discharged to VA outpatient care were eligible to participate. Subjects were randomized to usual aftercare care (n = 425) or usual aftercare plus biweekly telephone case monitoring calls during the first three months after discharge (n = 412). Several factors contributed to our not meeting our planned enrollment target. Seventy-two subjects (not counted in the 837) were excluded after initial consenting because they later met exclusion criteria by discharging within 14 days of admission or discharging directly to another inpatient unit. One site had a higher than expected proportion of active duty patients who were ineligible to participate. Recruitment at two of the study sites was suspended for several months because they both had research stand-downs (unrelated to our study), which required establishing new Institutional Review Boards and re-approving all existing study protocols.

Telephone case monitors assessed current problems, encouraged treatment adherence, provided problem-solving support, and alerted providers to emergent care needs. Patient self-report measures of psychiatric symptoms, substance use, and violence were obtained at intake to residential treatment and 4 months (69% completion rate) and 12 months (64% completion rate) after discharge. Retention was lower than our planned 70% to 75% rate due to difficulty locating some patients who moved (even their collateral informants did not know where they were) and 45 participants asking to discontinue due to lack of time (n = 10), general dissatisfaction with VA (n = 6), distress during phone calls (n = 5), dissatisfaction with compensation (n = 1), or no specified reason (n = 24). Treatment utilization data was obtained from the VA National Patient Care Database.

Intent-to-treat analyses used mixed modeling to compare clinical outcomes in the telephone monitoring and usual care groups and 4 and 12 months after discharge. Survival analysis was used to compare conditions on time to rehospitalization. Having a smaller-than-intended sample size resulted in modest reductions in statistical power, e.g., power to detect the expected d = .25 effect on PTSD outcomes was reduced from about 90% to 82%, and power to detect the anticipated W = .105 difference in rehospitalization rates was reduced from 88% to 85%. Secondary analyses assessed whether differences in outcomes between the telephone case monitoring and usual care groups were mediated by attending more outpatient visits and completing more medication refills. Exploratory analyses examined whether the effect of telephone support on the clinical outcome measures, number of treatment visits, and medication refills was moderated by number of outpatient mental health visits in the prior year, distance from clinic, treatment expectancies, therapeutic alliance, or co-occurring substance use problems.

FINDINGS/RESULTS:
Telephone case monitors reached 86% of intervention participants (n = 355), and completed 4.5 out of 6 planned telephone calls. However, there were no significant differences in any clinical outcomes or in treatment utilization (number of mental health visits and medication refills) between patients in the telephone case monitoring and usual care conditions. Observed differences for all outcomes were small effects (d = -.09 to +.06) and as likely to favor usual care as the intervention. In contrast with prior studies reporting poor continuity of care in this population, participants in both arms of this study completed a mental health visit an average of every 10 days in the year after discharge. Many participants had continuing problems despite high utilization of outpatient care.

IMPACT:
Impact: Telephone care management had little incremental value in a context where patients were already high utilizers of mental health services. Telephone case monitoring may be more useful in other settings where patients currently receive less intensive services.

PUBLICATIONS:

Journal Articles

  1. Rosen CS, Tiet QQ, Harris AH, Julian TF, McKay JR, Moore WM, Owen RR, Rogers S, Rosito O, Smith DE, Smith MW, Schnurr PP. Telephone monitoring and support after discharge from residential PTSD treatment: a randomized controlled trial. Psychiatric services (Washington, D.C.). 2013 Jan 1; 64(1):13-20.
  2. Belsher BE, Tiet QQ, Garvert DW, Rosen CS. Compensation and treatment: disability benefits and outcomes of U.S. veterans receiving residential PTSD treatment. Journal of traumatic stress. 2012 Oct 9; 25(5):494-502.
Conference Presentations

  1. Rosen CS, Katz E, Azevedo K, Hawkins N, Hernandez J, Tiet QQ. Telephone support for adherence to PTSD treatment: feasibility, acceptability, and clinical issues. Poster session presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2013 Mar 21; San Francisco, CA.
  2. Katz E, Rosen CS, Azevedo K, Tiet QQ. What Do Men and Women Want from Outpatient and Residential PTSD Treatment? Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2012 Nov 1; Los Angeles, CA.
  3. Koo K, Tiet QQ, Rosen CS. Working alliance, expectancies and ethnic minority status among Veterans with PTSD. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2012 Nov 1; Los Angeles, CA.
  4. Tiet QQ, Blau K, Turchik JA, Rosen CS. Military Sexual Assaults: Prevalence and gender differences in treatment outcomes. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2012 Nov 1; Los Angeles, CA.
  5. Belsher B, Tiet QQ, Garvert D, Rosen CS. Compensation and Treatment: The Influence of Disability Benefits on Treatment Outcomes for Veterans Engaged in Residential Trauma Programs. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2011 Nov 3; Baltimore, MD.
  6. Katz E, Rosen CS, Kalaf K, Tiet QQ. Gender and service era differences in goals of US Veterans entering residential PTSD treatment. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2011 Nov 3; Baltimore, MD.
  7. Rosito O, Blau K, Kalaf K, Tiet QQ, Rosen CS. Changes in PTSD Symptoms Over Time: The Role of Social Support. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2011 Nov 3; Baltimore, MD.
  8. Rosen CS, Tiet QQ. Telephone Case Monitoring for Veterans with PTSD. Presented at: VA National Center for PTSD Dissemination and Training Division Meeting; 2011 Oct 20; Palo Alto, CA.
  9. Blau K, Rosito O, Tiet QQ, Joyce E, Rosen CS. Call completion in a telephone monitoring study for Veterans with PTSD: Preliminary findings. Poster session presented at: American Psychological Association Annual Convention; 2011 Aug 5; Washington, DC.
  10. Joyce E, Tiet QQ, Rosito O, Bradley B, Rosen CS. Implementation procedure of a telephone case monitoring intervention for Veterans with Posttraumatic Stress Disorder. Poster session presented at: American Psychological Association Annual Convention; 2011 Aug 5; Washington, DC.
  11. Kavanaugh N, Tiet QQ, Rosito O, Rosen CS. The effect of period of service and race/ethnicity on disability compensation claims status in a sample of military Veterans with PTSD. Poster session presented at: American Psychological Association Annual Convention; 2011 Aug 5; Washington, DC.
  12. Rosito O, Tiet QQ. Call completion in a Telephone Case Monitoring Study for Veterans with Posttraumatic Stress Disorder: Comparing rural and urban participants. Poster session presented at: American Psychological Association Annual Convention; 2011 Aug 5; Washington, DC.
  13. Penner A, Tiet QQ, Sweeton J, Fitt J, Jordan F, tran T, Rosen CS. Age and quality of life among inpatient combat Veterans with PTSD. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2009 Nov 6; Atlanta, GA.
  14. Rosen CS, Tiet QQ, Greene CJ, Nguyen D, Fitt J, Sweeton J, Penner A. Telephone case monitoring of PTSD patients. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2009 Nov 6; Atlanta, GA.
  15. Sweeton J, Tiet QQ, Penner A, Greene CJ, Fitt J, Frank J, Rosen CS, Tran T. VA substance treatment may not fulfill the needs of ethnically diverse Veterans with PTSD. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2009 Nov 6; Atlanta, GA.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Substance Abuse and Addiction, Health Systems
DRE: Treatment - Observational, Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: Deployment Related, Operation Enduring Freedom, Operation Iraqi Freedom, PTSD, Telemedicine/Telehealth
MeSH Terms: none