BACKGROUND/RATIONALE:
Research with military troops returning from Iraq and Afghanistan suggests that there is a new generation of Veterans with high levels of combat-related posttraumatic stress disorder (PTSD). Further, research suggests that many of these troops are returning to rural and remote areas where access to care can be limited. Thus, it is critical that we identify effective ways to increase access to efficacious PTSD treatments for returning troops who live in rural or remote areas. Further, due to the influx of telemental health programs across the nation, it is crucial that research addresses the effectiveness of this mode of service delivery for high priority specialty services such as the treatment of PTSD. Rigorously designed telemental health research studies that include prospective, randomized evaluations of clinical, process, and cost-effectiveness outcomes for specialized PTSD interventions are especially needed.

OBJECTIVE(S):
The immediate objective of this project was to evaluate the clinical effectiveness of a telemental health modality (video-teleconferencing; VTC) for providing an evidence-based group intervention (Cognitive Processing Therapy; CPT-C) to rural Reservists, National Guardsmen, and Veterans suffering with PTSD. The long-term objective of this project was to develop an empirically sound telemental health protocol that would facilitate the extension of a manual-guided evidence-based PTSD treatment intervention to remote Veterans Affairs (VA) and Department of Defense (DOD) sites through VTC. It was hypothesized that using VTC is as effective as the traditional mode of service delivery (in-person; IP) for providing CPT-C. Outcome domains included: 1) clinical outcomes (symptom severity, social functioning); and 2) process outcomes (perception of treatment, satisfaction, group therapy climate and alliance, treatment compliance and credibility, and attrition). We also examined the potential influence of personal characteristics such as ethnicity, education, military branch, etc. In addition, we examined cost effectiveness of this modality. This study included 13 group cohorts plus 1 pilot group cohort. Not counting the cohort 1 pilot, approximately 246 combat Reservists, National Guardsmen, or Veterans were assessed for eligibility, and 125 were subsequently randomized from multiple VA PIHCS clinical sites.

METHODS:
The project was a 5-year prospective randomized clinical trial, which conducted a direct comparison of the VTC and in-person modalities using rigorous methodology and a sophisticated analysis of equivalency between clinical and process outcome domains. In addition, cost effectiveness of this modality was addressed. Not counting the cohort 1 pilot group, approximately 246 combat Reservists, National Guardsmen, or Veterans received a comprehensive assessment at baseline to determine eligibility. The exclusion criteria selected were consistent with large PTSD randomized clinical trials as well as research using the CPT-C protocol with military populations with PTSD. Inclusion criteria were a diagnosis of current PTSD, determined by the Clinician Administered PTSD Scale (CAPS), and a stable psychotropic medication regimen for a minimum of 45 days prior to study entry. Exclusion criteria were active psychotic symptoms/disorder, active homicidal or suicidal ideation, significant cognitive impairment or history of organic mental disorder, current substance dependence, and unwillingness to refrain from substance abuse during treatment. Female Veterans were not included due to their limited number in the study clinical sites.125 eligible participants were block randomized with 61 who were assigned to the experimental (VTC) condition and 64 to the control (in-person) condition. The group CPT-C treatment was delivered twice a week over 6 weeks by doctoral level psychologists with an overall completion rate of 77% (n=96). 96 participants attended at least 10 treatment sessions and were included in the completer sample. Quality control procedures were incorporated into the study's design to ensure integrity, fidelity and standard administration of the CPT-C intervention across both conditions. Participants received additional assessments at mid-treatment, immediately post-treatment, and at 3 and 6 months post-treatment. Outcome domains included: 1) clinical outcomes (symptom severity, social functioning); 2) process outcomes (perception of treatment, satisfaction, group therapy alliance, treatment compliance, and attrition and treatment credibility); and (3) cost-effectiveness outcomes.

FINDINGS/RESULTS:
Clinical and process outcomes for CPT-C treatment administered via VTC were found to be non-inferior to the in-person group, thus demonstrating "as good as" outcomes across modalities. Significant reductions in PTSD symptoms, as measured by the Clinician-Administered PTSD Scale, were identified at post-treatment and maintained during follow-up. High levels of therapeutic alliance, treatment compliance, and satisfaction and moderate levels of confidence in treatment credibility and expectancies were reported across treatment groups. Providing psychological treatment to rural residents with PTSD via VTC produced outcomes that were "as good as" in-person treatment. Participants in both conditions demonstrated significant reductions in PTSD symptoms post-treatment and at 6-month follow-up. Results indicate that VTC can offer increased access to specialty mental health care for residents of rural or remote areas.

IMPACT:
This project represents the first prospective, randomized clinical trial (RCT) designed to evaluate the clinical effectiveness of delivering an evidence-based cognitive behavioral intervention specifically treating PTSD (CPT-C) via a video-teleconferencing modality. The project has accelerated an ongoing line of research designed to improve the quality and access of PTSD specialty services delivered to rural military populations returning from Iraq and Afghanistan. The goal of this study was to develop an empirically sound telemental health protocol for the treatment of PTSD that will facilitate the extension of manual-guided, clinically proven PTSD services to remote sites through the use of VTC technology. Current findings demonstrate that VTC is a viable and effective means of delivering evidence-based group psychotherapy for PTSD. This study provides evidence that delivering a psychological intervention for PTSD via VTC may be a viable solution to the longstanding access to care disparity that exists for rural and ethnically diverse populations.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Morland LA, Mackintosh MA, Greene CJ, Rosen CS, Chard KM, Resick P, Frueh BC. Cognitive processing therapy for posttraumatic stress disorder delivered to rural veterans via telemental health: a randomized noninferiority clinical trial. The Journal of clinical psychiatry. 2014 May 1; 75(5):470-6. [view]
2. Morland LA, Hynes AK, Mackintosh MA, Resick PA, Chard KM. Group cognitive processing therapy delivered to veterans via telehealth: a pilot cohort. Journal of traumatic stress. 2011 Aug 1; 24(4):465-9. [view]
3. Morland LA, Greene CJ, Rosen C, Mauldin PD, Frueh BC. Issues in the design of a randomized noninferiority clinical trial of telemental health psychotherapy for rural combat veterans with PTSD. Contemporary clinical trials. 2009 Nov 1; 30(6):513-22. [view]

VA Cyberseminars

1. Morland LA. Telemedicine and evidence based interventions for rural veterans with PTSD. [Cyberseminar]. 2010 Jan 1. [view]

Conference Presentations

1. Mackintosh M, Thorpe S, Hynes A, J’Anthony C, Sones H, Morland LA. Cross-Cultural Psychometric Properties of the Clinician Administered PTSD Scale (CAPS) among Mainland and Pacific Island Combat Veterans. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2010 Nov 1; Montréal, Canada. [view]
2. Morland LA. New areas of focus in combat-related Post Traumatic Stress Disorder (PTSD) treatment. Paper presented at: Institute on Violence, Abuse and Trauma International Conference; 2011 Mar 1; Honolulu, HI. [view]
3. Morland LA. Post-deployment adjustment mental health treatment: Pacific perspective and overview. Paper presented at: American Telemedicine Association / Telemedicine and Advanced Technology Research Center Symposium; 2011 Sep 1; Anchorage, AK. [view]
4. Acierno R, Chard K, Darkins A, Frankenfield L, Godleski L, Greene CJ, Karlin B, Morland LA, Shore P, Smith T, Thorp S, Tuerk P, Yoder M. Providing evidence-based practices for PTSD via telemental health (TMH). Paper presented at: VA Mental Health Annual Conference; 2011 Aug 1; Baltimore, MD. [view]
5. Morland LA, Greene C, Hynes AK, Morgan TG, Grubbs KM, Kloezeman K, Morita K, Chard K, Rosen C, Frueh BC. Telehealth and Cognitive Processing Therapy for Rural Combat Veterans. Poster session presented at: Department of Defense / Congressionally Directed Medical Research Programs Military Health Research Forum; 2009 Sep 1; Kansas City, MO. [view]
6. Morland LA. Telemental health and cognitive processing therapy for rural combat veterans with PTSD. Paper presented at: Department of Defense / Congressionally Directed Medical Research Programs Mental Health Research Forum; 2011 Feb 1; Frederick, MD. [view]
7. Hynes A, Slade K, Morgan T, Chard K, Grubbs K, Morland LA. Telemental Health and Cognitive Processing Therapy Groups for Rural Combat Veterans with PTSD: Preliminary Findings. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2009 Nov 1; Atlanta, GA. [view]
8. Morland LA. Telemental Health and PTSD Services for Rural Combat Veterans with PTSD: Findings Updates from Two Non-inferiority Trials. Paper presented at: American Telemedicine Association Annual Meeting; 2010 May 1; San Antonio, TX. [view]
9. Morland LA, Greene C, Rosen C, Frueh C. Telemental health technology: Two randomized clinical trials for PTSD care. Paper presented at: VA Mental Health Annual Conference; 2009 Jul 1; Baltimore, MD. [view]
10. Hynes A, Morland LA, Menez U. Telemental Health Technology: Updates and Future Directions for PTSD Services. Paper presented at: Institute on Violence, Abuse and Trauma Hawaii Conference on Preventing, Assessing & Treating Annual Child, Adolescent and Adult; 2011 Mar 1; Honolulu, HI. [view]
11. Morland LA. Updates and advances in telemental health effectiveness. Paper presented at: VA Telehealth 2010 and Beyond Conference on Expanding Patient-Centric Care; 2010 May 1; St. Louis, MO. [view]
12. Morland LA. Updates and advances in telemental health effectiveness. Paper presented at: VA HSR&D Rural Health / VA Office of Rural Health Field-Based Meeting; 2010 May 1; Portland, ME. [view]
13. Mackintosh M, Hynes A, Earleywine M, Love A, Aosved A, Raab D, Morland LA. Use of the PTSD Symptom Scale-Interview (PSS-I) among Pacific Island Combat Veterans: Early Results of a Psychometric Evaluation. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2010 Nov 1; Montréal, Canada. [view]
14. Morland LA, Greene CJ, Hynes AK, Mackintosh M. Using teleconferencing to deliver cognitive behavior therapy groups to veterans with PTSD: Research advances and implications. Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2010 Nov 1; San Francisco, CA. [view]
15. Morland LA, Greene CJ, Hynes AK, Mackintosh M. Using teleconferencing to deliver cognitive behavior therapy groups to veterans with PTSD: Research advances and implications. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2010 Nov 1; Montréal, Canada. [view]
16. Morland LA, Greene C, Hynes A, Mackintosh M. Using video teleconferencing to deliver cognitive behavioral therapy groups to veterans with PTSD: Research advances and implications. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2010 Nov 1; Montréal, Canada. [view]
17. Morland LA, Greene C. Using Videoteleconferencing to Provide PTSD Group Psychotherapy to Rural Veterans. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2009 Nov 1; Atlanta, GA. [view]
18. Morland LA. Utilizing telemental Health Technology to Increase Access to Evidence-based PTSD Care for Rural Populations. Paper presented at: VA VISN 21 Rural Health Meeting; 2010 Jan 1; San Francisco, CA. [view]
19. Morland LA, Hynes A. Utilizing Telemental Health Technology to Increase Access to Evidence-based PTSD Care for Rural Populations. Paper presented at: Institute on Violence, Abuse and Trauma Hawaii Conference on Preventing, Assessing & Treating Annual Child, Adolescent and Adult; 2010 Mar 1; Honolulu, HI. [view]
20. Morland LA, Hynes AK. Utilizing telemental health technology to increase access to evidence-based PTSD care for rural populations. Paper presented at: Institute on Violence, Abuse and Trauma International Conference; 2010 Sep 11; San Diego, CA. [view]

DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Treatment - Observational, Prevention, Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: Deployment Related, PTSD, Telemedicine
MeSH Terms: none