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DHI 07-054 – HSR&D Study

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DHI 07-054
Veterans Telemedicine Outreach for PTSD Services
Zia Agha MD MS
VA San Diego Healthcare System, San Diego, CA
San Diego, CA
Funding Period: May 2008 - April 2012

BACKGROUND/RATIONALE:
Post-Traumatic Stress Disorder (PTSD) is considered a major public health problem in the US due to its prevalence and high rates of disability associated with the disorder. Barriers to PTSD care include poor access, mistrust, and lack of benefit from traditional treatments.

Recently developed evidenced-based treatments such as cognitive processing therapy (CPT) are very effective. Unfortunately, these treatments are not widely available to veterans, as many live in rural communities and have poor access to specialized mental health care. The VA hospital system currently supports sophisticated telemedicine technology that can provide CPT to veterans in their home communities. The project assessed the quality of CPT provided via TM and its impact on outcomes.


OBJECTIVE(S):
Primary objective was to compare PTSD outcomes (symptom improvement and quality of life) for veterans receiving CPT via telemedicine (TM) versus in-person (IP) care. Secondary objectives included comparing provider-patient communication and satisfaction during consultations.

METHODS:
We conducted a noninferiority randomized clinical trial (RCT) of 207 patients to receive CPT via TM or IP care. TM and IP visits occurred at La Jolla VA or Mission Valley VA clinic in San Diego. Providers (n=18) with specialized training in CPT provided therapy over 12 60-minute weekly sessions. PTSD symptom severity (Clinician-Administered PTSD Scale, CAPS) and health related quality of life (SF-36) were measured at baseline, completion of therapy, and 6-month follow-up. Provider-patient communication and alliance were measured at 6th treatment session and completion of therapy. Patient and provider satisfaction were measured post therapy. Descriptive statistics were used to summarize baseline demographics and outcomes. A linear mixed effects model was used to assess the difference in the change of scores between TM and IP care groups, and a linear regression model was used to study patient's WAI-SR ratings of bonds and agreement on Goals and Tasks. Two-sided 95% confidence intervals and a modified t-test were used for assessing noninferiority. The p<0.025 indicates a significance of noninferiority. We performed analysis for all randomized patients (ITT) and completers (subjects completed baseline and post assessment).

FINDINGS/RESULTS:
Of 207 enrolled, randomized patients, 104 received TM and 103 received IP visits. Study patients included 160 (77%) men and 47 (23%) women. The racial/ethnic distribution was 129 (62%) Caucasian, 34 (16%) African American, 16 (8%) others (Asian American, American Native, or Native Hawaiian), and 28 (14%) declined to answer/unknown. At baseline, both groups had comparable PTSD severity (CAPS score TM=71.3 and IP = 72.7). Both TM (pre=71.3, post=62.3) and IP (pre=72.7, post 53.3) groups showed significant improvements in PTSD symptoms on CAPS measure. At post treatment, TM was not shown to be noninferior to IP [p=0.19, 95% CI=(0.14, 0.87), NI margin=0.67] per CAPS score. However, at 6-month follow-up, IP and TM groups had similar symptom improvements (CAPS scores TM = 56.1 and IP=57.2), and TM was not shown to be inferior to IP care from baseline to 6 month [p=0.004, 95% CI=(-0.10, 0.29), NI margin=0.35].

Quality of life change, measured by SF-36 (baseline to post treatment), was similar for TM and IP for 7 out of 8 SF36 subscales. The seven subscales are (1) physical functioning [p=0.004, 95% CI=(-0.41, 0.20), NI margin=-0.52], (2) role limitation due to emotional problem [p=0.02, 95% CI=(-1.19, 0.19), NI margin=-1.20], (3) energy/fatigue [p=0.001, 95% CI=(-0.29, 0.26), NI margin=-0.47], (4) emotional well-being [p=0.01, 95% CI=(-0.47, 0.14), NI margin=-0.52], (5) social functioning [p<0.001, 95% CI=(-0.44, 0.45), NI margin=-0.76], (6) pain [p=0.01, 95% CI=(-0.51, 0.19), NI margin=-0.60] and (7) general health [p<0.001, 95% CI=(-0.17, 0.34), NI margin=-0.43]. Quality of life change, measured by SF-36 (baseline to 6 month follow-up), was similar for TM and IP for all 8 SF36 subscales, and TM was noninferior to IP care (all p's <=0.004).

Therapist-patient alliance (ie, patient ratings of bonds and agreement on goals and tasks on WAI-SR) was similar for TM and IP groups, and TM was shown to be noninferior to IP group [p=0.001, 95% CI=(-0.32, 0.39), NI margin=0.57].

Patient satisfaction across four previously defined and validated subscales was similar for TM and IP care. The four subscales are (1) patient-centered communication [p=0.005, 95% CI=(-0.016,0.007), NI margin=-0.019], (2) physician's competence and skills [p=0.001, 95% CI=(-0.015, 0.01), NI margin=-0.022], (3) physician's interpersonal skills [p=0.008, 95% CI=(-0.017, 0.005), NI margin=-0.019], and (4) convenience of visit [p<0.001, 95% CI=(-0.01, 0.03), NI margin=-0.03].

Therapist satisfaction with treatment sessions, across three previously defined and validated subscales, were similar and TM was shown to be noninferior to IP group. The three subscales are (1) quality of provider-patient relation [p<0.001, 95% CI=(-0.01, 0.03), NI margin=-0.03], (2) patient's cooperative nature [p<0.001, 95% CI=(-0.01, 0.02), NI margin=- .03], and (3) use of time [p<0.001, 95% CI=(-0.01, 0.03), NI margin=-0.03]. But for adequacy of data collection process [p=0.03, 95% CI=(-0.03, 0.01), NI margin=-0.03], TM does not show noninferiority to IP care.

All analyses were performed for both intention to treat and completers, and were found to be similar.

IMPACT:
This study has advanced our understanding of the role of telemedicine for delivery of evidence-based psychotherapy and related outcomes. Both TM and IP treatment groups showed significant improvements in PTSD symptoms, as measured by the gold standard CAPS measure. While the IP group had larger initial improvement in symptoms, at 6-month follow-up, both TM and IP groups had similar symptom improvements. Telemedicine was also found to be acceptable by clinicians and by patients. Based on the success of this study, the VA San Diego Healthcare System received funding from VHA to develop a Regional Telemental Health Center. This center was launched in April 2012 and will leverage telemedicine technology, expertise, and knowledge gained from our study. At its full capacity, the center will treat up to 85 patients per week from areas as far away as Alaska and Guam. This will save time for patients who normally would travel long distances to their regional VA medical center for care. Providing state-of-the-art psychotherapies to rural patients using the Telemental Health program will also allow staff to offer more appointments and allow more time to treat a greater number of serious mental health cases.


PUBLICATIONS:

Journal Articles

  1. Backhaus A, Agha Z, Maglione ML, Repp A, Ross B, Zuest D, Rice-Thorp NM, Lohr J, Thorp SR. Videoconferencing psychotherapy: a systematic review. Psychological Services. 2012 May 1; 9(2):111-31.
  2. Thorp SR, Fidler J, Moreno L, Floto E, Agha Z. Lessons learned from studies of psychotherapy for posttraumatic stress disorder via video teleconferencing. Psychological Services. 2012 May 1; 9(2):197-9.
Conference Presentations

  1. Agha Z, Thorp SR, Moreno L, Zamora T, Floto E, Fidler J, Ross BS, Repp AL, Shah N, Madra N, Rodgers C, Zuest DK. Cost Analysis of Delivering PTSD Psychotherapy via Telemedicine. Paper presented at: American Telemedicine Association Annual Meeting; 2011 May 16; San Antonio, CA.
  2. Zuest DK, Thorp SR, Moreno L, Floto E, Zamora T, Fidler J, Ross BS, Repp AL, Shah N, Madra N, Rodgers C, Agha Z. Telemedicine versus Face-to-Face Patient Care: A Comparison of Treatment Avoidance in Post Traumatic Stress Disorder (PTSD) Patients. Paper presented at: VA HSR&D National Meeting; 2011 Feb 1; Washington, DC.
  3. Floto E, Thorp SR, Zuest DK, Repp AL, Moreno L, Fidler J, Zamora T, Ross BS, Agha Z. Prolonged Exposure Therapy (PE) via Telemedicine for the Treatment of Post-Traumatic Stress Disorder (PTSD) in Veterans. Poster session presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2010 Nov 18; San Francisco, CA.
  4. Moreno L, Thorp SR, Floto E, Zamora T, Fidler J, Ross BS, Repp AL, Shah N, Madra N, Rodgers N, Agha Z. PTSD Telemedicine Study: The Key to Enrolling Patients in Cognitive Processing and Prolonged Exposure Therapies. Poster session presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2010 Nov 1; San Francisco, CA.
  5. Ross BS, Repp AL, Moreno L, Fidler J, Floto E, Shah N, Zamora T, Madra N, Hurst S, Liu L, Agha Z, Thorp SR. Treating Veterans with PTSD via Telemedicine: Provider Experience and Satisfaction. Paper presented at: American Psychological Association Annual Convention; 2010 May 22; New Orleans, LA.
  6. Zuest DK, Thorp SR, Moreno L, Floto E, Zamora T, Fidler J, Zamora T, Ross BS, Agha Z. Treatment Avoidance in PTSD Patients: Face-to-Face Versus Telemedicine. Poster session presented at: American Telemedicine Association Annual Meeting; 2010 May 16; San Antonio, CA.
  7. Moreno L, Thorp SR, Floto E, Zamora T, Fidler J, Ross BS, Repp AL, Shah N, Madra N, Rodgers C, Agha Z. PTSD Telemedicine study: The Key to Enrolling Patients. Poster session presented at: VA Telehealth 2010 and Beyond Conference on Expanding Patient-Centric Care; 2010 May 1; St. Louis, MO.
  8. Repp AL, Thorp SR, Floto E, Zuest DK, Ross BS, Fidler J, Madra N, Zamora T, Shah N, Agha Z. Treating Veterans with PTSD via Telemedicine: Association with Reduced Travel Distrance, Time and Costs. Poster session presented at: VA Telehealth 2010 and Beyond Conference on Expanding Patient-Centric Care; 2010 May 1; St. Louis, MO.
  9. Repp AL, Thorp SF, Floto E, Zuest DK, Ross BS, Moreno L, Fidler J, Madra N, Zamora T, Shah N, Agha Z. Cost Analysis of Cognitive Behavioral and Prolonged Exposure Therapy via Telemedicine for Treating Post Traumatic Stress Disorder. Paper presented at: VA HSR&D National Meeting; 2010 Feb 1; Washington, DC.
  10. Thorp SR. Delivering Psychotherapy for PTSD via telemedicine. Paper presented at: VA Office of Mental Health Services, Updates on PTSD: Meeting the Challenges of the Uniform Mental Health Services Handbook Annual Conference; 2009 Sep 1; Palo Alto, CA.
  11. Thorp SR. Psychotherapy via telemedicine for post-traumatic stress disorder. Poster session presented at: Military Health Research Forum; 2009 Aug 31; Kansas City, MO.
  12. Thorp SR, Raftery J, Shah NH, Campbell LB, Agha Z, Fiedler J. Increasing number of unique veterans with access to telemental health services. Paper presented at: VA San Diego VAMC Performance Improvement Fair; 2009 Jan 1; San Diego, CA.


DRA: Mental, Cognitive and Behavioral Disorders, Health Systems, Military and Environmental Exposures
DRE: Treatment - Observational, Treatment - Comparative Effectiveness
Keywords: Cognitive Therapy, PTSD, Telemedicine, Telemedicine/Telehealth
MeSH Terms: none

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