PTSD is prevalent, persistent, and frequently disabling. The prevalence of current PTSD in Department of Veterans Affairs (VA) primary care clinics is 11.5%. Although psychotherapy and pharmacotherapy treatments for PTSD have been proven to be efficacious in controlled trials, geographic barriers often prevent rural Veterans from accessing and adhering to these evidence-based treatments. While most parent VAMCs offer specialized PTSD programs, Community-Based Outpatient Clinics (CBOCs) often find it infeasible to hire on-site psychiatrists or other mental health specialists with PTSD expertise.
Specific Aim #1: To compare process of care delivered to CBOC patients with PTSD randomized to the TOP intervention group with usual care.
Specific Aim #2: To compare outcomes of care delivered to CBOC patients with PTSD randomized to the TOP intervention with usual care.
Three concurrent recruitment strategies were used: provider referral, self-referral and opt-out letters. Informed consent was obtained via interactive video. A total of 265 eligible Veterans who met diagnostic criteria for PTSD according to the CAPS were enrolled from 11 CBOCs and randomized to the TOP intervention or usual care (UC). Patients were the unit of randomization. During baseline and follow-up telephone interviews blinded research assistants collected information about PTSD severity using the Posttraumatic Diagnostic Scale (PDS) and depression severity using the SCL20. Medications prescribed for PTSD were identified by chart review and adherence was measured form self-report. Receipt of Cognitive Processing Therapy (CPT) during the 12 month study period was determined by chart review. Patients with 8 or more CPT sessions were classified as having a therapeutic dosage of CPT.
The Telemedicine Outreach for PTSD (TOP) intervention is a telemedicine-based collaborative care program designed to improve access and adherence to evidence-based pharmacotherapy and psychotherapy for Veterans treated in CBOCs. The TOP intervention uses telemedicine technologies (e.g., telephone, interactive video, electronic medical records, and web-based clinical information system) to communicate with patients and on-site CBOC providers. Three off-site PTSD care teams were located at the three parent VAMCs and support on-site CBOC providers. Each off-site PTSD care team included a: 1) telephone nurse care manager (RN); 2) telephone clinical pharmacist (PharmD); 3) tele-psychologist (PhD); and 4) tele-psychiatrist (MD). The off-site telephone nurse care managers conducted care management activities. The off-site telephone clinical pharmacists reviewed the patient's PTSD treatment history and made treatment recommendations to the CBOC providers. The off-site tele-psychologists delivered evidence-based Cognitive Processing Therapy (CPT) via interactive video. The off-site tele-psychiatrists supervised the TOP care team, and conducted interactive video psychiatric consultations as necessary.
Almost a third (29.1%) of the patients were OEF/OIF Veterans. About half were service connected for PTSD. About half of the patients reported that their worst trauma was combat related. Mental health comorbidity was highly prevalent, with 79% meeting diagnostic criteria for major depressive disorder. SF12V Mental Health Component Summary (MCS) scores SF12V Physical Health Component Summary (PCS) scores were about one and a half standard deviations below the national mean. On average, patients had 4 chronic physical health conditions.
There were significant group differences in the proportion of patients being prescribed medications for PTSD during the first six months (OR=2.98, p=0.045), but not the second six months (OR=2.32, p=0.114). There were significant group differences the proportion being prescribed Prazosin during the first six months (OR=2.43, p=0.022) and second six months (OR=3.58, p=0.0008). Group differences in medication adherence were not significant during the first six months (OR=0.86, p=0.64) or the second six months (OR=0.91, p=0.792). During the 12 month study period, 54.89% of patients randomized to the TOP intervention received some CPT compared to 12.12% in the usual care group and group differences were highly significant (OR=18.08, p<0.0001). Group differences in the proportion attending eight or more CPT sessions were significant (OR=7.86, p<0.0001). Among those patients attending any CPT sessions in the intervention group, the mean number of sessions attended was 7.6. Among those patients attending any CPT sessions in the intervention group, 98.25% (505/514) of the sessions were conducted via interactive video.
At the six month follow-up, patients randomized to the TOP intervention experienced a 5.31 decrease in PTSD symptom severity compared to 1.07 decrease for patients randomized to UC (t=3.42, p=0.0007, Cohen's D=0.45). At the twelve month follow-up, patients randomized to the TOP intervention experienced a 4.17 decrease in PTSD symptom severity compared to 1.32 decrease for patients randomized to UC (t=2.30, p=0.022, Cohen's D=0.31). Controlling for casemix, group differences were statistically significant at both the six month follow-up ( =-3.81 p=0.0018) and the twelve month follow-up ( =-2.49 p=0.043). In a post hoc mediation analysis, attendance at 8 or more CPT sessions significantly predicted improvement in PTSD symptom severity ( =-3.86 p=0.024) and fully mediated the intervention effect. Group differences in depression severity improvement were statistically significant at the six month follow-up ( =-0.25 p=0.0011) and the twelve month follow-up ( =-0.228 p=0.010).
Veterans randomized to the UC group experienced very little improvement in PTSD or depression severity. However, compared to Veterans randomized to UC, those randomized to the TOP intervention experienced significantly greater improvements in PTSD and depression severity at six months (large effect sizes) and at twelve months (small effect sizes). These findings indicate that the TOP intervention was successful at improving PTSD symptoms compared to UC. The TOP intervention attempted to improve access and adherence to both evidence-based pharmacotherapy and evidence-based psychotherapy, and the intervention had a major impact on receipt of CPT. In a post hoc mediation analysis, completing eight or more sessions of CPT completely mediated the effect of the TOP intervention. This finding suggests that the primary mechanism of action in the TOP intervention was improving access and adherence to CPT. This interpretation is consistent with the finding that of the two previous randomized controlled trials of collaborative care for PTSD, the intervention with an evidence-based psychotherapy component had a significant effect while the intervention without an evidence-based psychotherapy component did not have a significant effect. Our findings suggest that collaborative care models that focus on optimizing pharmacotherapy will not be sufficient to improve outcomes for Veterans with PTSD.
- Painter JT, Fortney JC, Austen MA, Pyne JM. Cost-Effectiveness of Telemedicine-Based Collaborative Care for Posttraumatic Stress Disorder. Psychiatric services (Washington, D.C.). 2017 Nov 1; 68(11):1157-1163.
- Grubbs KM, Fortney JC, Kimbrell T, Pyne JM, Hudson T, Robinson D, Moore WM, Custer P, Schneider R, Schnurr PP. Usual Care for Rural Veterans With Posttraumatic Stress Disorder. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2017 Jun 1; 33(3):290-296.
- Grubbs KM, Fortney JC, Pyne JM, Hudson T, Moore WM, Custer P, Schneider R, Schnurr PP. Predictors of Initiation and Engagement of Cognitive Processing Therapy Among Veterans With PTSD Enrolled in Collaborative Care. Journal of traumatic stress. 2015 Dec 1; 28(6):580-4.
- Fortney JC, Pyne JM, Kimbrell TA, Hudson TJ, Robinson DE, Schneider R, Moore WM, Custer PJ, Grubbs KM, Schnurr PP. Telemedicine-based collaborative care for posttraumatic stress disorder: a randomized clinical trial. JAMA psychiatry (Chicago, Ill.). 2015 Jan 1; 72(1):58-67.
HSR&D or QUERI Articles
- Fortney JC, Grubbs KM. Improving Digital Access to Evidence-Based Psychotherapy. VA HSR&D FORUM: Translating research into quality health care for Veterans. 2014 May 1; 7-8.
- Painter JT, Fortney JC, Gressler J, Pyne JM. Comparing the Sensitivity of Generic and Disease-Specific Effectiveness Measures in Persons with PTSD. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 27; Boston, MA.
- Painter JT, Pyne JM, Fortney JC. Cost-Effectiveness of Telemedicine-Based Collaborative Care for PTSD. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 27; Boston, MA.
- Fortney JC, Pyne JM, Hudson TJ, Grubbs KM, Schnurr PP. A pragmatic randomized trial of telemedicine based collaborative care for posttraumatic stress disorder. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
- Koenig CJ, Cheney AM, Miller C, Wright T, Zamora K, Stanley R, Pyne JM. Comparing and contrasting Veterans’ experiences of access with the SOTA Access Model. Paper presented at: AcademyHealth Annual Research Meeting; 2015 Jun 14; Minneapolis, MN.
- Fortney JC, Pyne JM, Kimbrell TA, Hudson TJ, Robinson DE, Schneider R, Moore WM, Custer PJ, Grubbs KM, Schnurr PP. A pragmatic randomized trial of telemedicine based collaborative care for posttraumatic stress disorder. Paper presented at: AcademyHealth Annual Research Meeting; 2014 Jun 9; San Diego, CA.
- Grubbs KM, Fortney JC, Lunsford AK, Kimbrell TA, Pyne JM, Hudson TJ, Robinson D, Otero J, Moore WM, Custer P, Schneider R, Schnurr P. Influence of collaborative care on psychotherapy service utilization in VA community based outpatient clinics (CBOCs). Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2013 Nov 7; Philadelphia, PA.
- Fortney JC, Pyne JM, Kimbrell TA, Hudson TJ. Six Month Outcomes for the Telemedicine Outreach for PTSD (TOP) Study. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2012 Nov 2; Los Angeles, CA.
- Fortney JC, Pyne JM, Kimbrell T, Hudson TJ. Telemedicine Outreach for PTSD in Department of Veterans Affairs Community Based Outpatient Clinics. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2010 Nov 4; Montréal, Canada.
Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Health Systems
Treatment - Observational, Treatment - Efficacy/Effectiveness Clinical Trial
Cognitive Therapy, Organizational Structure, Outcomes - Patient, PTSD, Rural, Telemedicine, Telemedicine/Telehealth