Health Services Research & Development

Veterans Crisis Line Badge
Go to the ORD website
Go to the QUERI website

IAC 09-040 – HSR&D Study

New | Current | Completed | DRA | DRE | Portfolios/Projects | Centers | Career Development Projects

IAC 09-040
Prolonged Exposure (PE) for PTSD: Telemedicine vs. In Person
Ron E. Acierno PhD MS BA
Ralph H. Johnson VA Medical Center, Charleston, SC
Charleston, SC
Funding Period: July 2010 - June 2015

BACKGROUND/RATIONALE:
BACKGROUND/RATIONALE:
Approximately 15 to 17% of current Iraq war veterans meet full diagnostic criteria for MH problems such as post-traumatic stress disorder (PTSD) (Hoge et al., 2004). Prolonged Exposure (PE) is an empirically supported treatment for PTSD (Foa 1997; Schnurr et al., 2007), and has been adopted by the VAMC as one of the treatments of choice for the disorder, as evident by the VAMC-sponsored national training of clinicians to use PE. It is therefore important to employ treatment delivery methods that maximize the likelihood that all veterans in need, including veterans residing in rural settings, and veterans who avoid VAMC settings due to the stigma of receiving mental health treatment, will receive interventions such as PE. The May, 2005 Committee on Veterans Affairs, Subcommittee on Health has identified Telemedicine as a VA priority area to address this need. The present study was conducted to determine whether PE delivered via Telemedicine is as effective as PE delivered In Person. Home-based Telemedicine has been chosen for its ability to overcome what appear to be two major barriers to mental health care (Frueh et al., 2000): the difficulty that rural-residing veterans face in reaching VAMC facilities, and the stigma veterans perceive related to receiving mental health treatment. Indeed, if effective, PE delivered via telemedicine may address the problem inherent in the finding that 42% of those screening positive for PTSD indicate that they are interested in receiving help, but only 25% actually receive services (Hoge, et al., 2006).

OBJECTIVE(S):
OBJECTIVE(S):
Although effective treatments for PTSD exist and have been adopted by the VAMC, barriers to care of a social (e.g., stigma) and geographic (e.g., rural) nature prevent many veterans in need from receiving care. Telemedicine might address this need. The major objective of this study was to determine if PE delivered via Telemedicine is as effective as In Person PE.

METHODS:
We used a randomized between groups repeated measures (baseline, post-treatment, 3 & 6-month followups) design with 153 Veterans diagnosed with PTSD to assess the relative effectiveness of PE delivered via Home BasedTelemedicine vs. In Person formats. We hypothesize that no differences (i.e., non-inferiority) between the two formats will be evident in terms treatment gains, patient satisfaction, treatment attrition, patient satisfaction and direct healthcare costs.

FINDINGS/RESULTS:
-Data were available from 154 Veterans
-96.1% were male, average age 42 years, 55% were married, 36% were Black, 41% had at least 50% service connection. There were no differences on any of these variables across conditions.
-Average # of sessions completed (about 8 of 12) was not significantly different for in person ( N = 77) vs. telemedicine (N = 76) delivered PE (F(1,131) = 3.6, p = .06).
-Both groups demonstrated significant pre-post reductions on PTSD scores from a mean PCL of 59 at Baseline to 43 at post, to 47 at 9 months (F(3,453) = 112.1, p<.001). There were no significant differences between groups on the PCL at any time point.
-Both groups demonstrated significant pre-post reductions on Depression scores from a mean BDI of 29 at Baseline to 20 at post, to 20 at 9 months (F(3,453) = 57.1, p<.001)
-There were no significant differences between groups on PTSD Scores at any time point
-There were no significant differences between groups on Depression Scores at any time point)

IMPACT:
This study indicates that PE delivered via home-based Telemedicine equipment is no less effective than traditional In Person delivery of PE for post-traumatic stress disorder. As such, this study opens the path to justify delivery of mental health PTSD care directly into Veterans' homes, without the need for long commutes, experienced stigma, high travel cost, or significantly missed work. In fact, this study indicates that they can receive best practices, gold standard evidence based treatments for PTSD in the form of Prolonged Exposure safely, effectively, and at greatly reduced effort, and that this treatment can be delivered to rural areas, underserved areas, and to those with PTSD who may specifically avoid traditional VA mental health care settings (eg, MST victims).

PUBLICATIONS:

Journal Articles

  1. Acierno R, Gros DF, Ruggiero KJ, Hernandez-Tejada BM, Knapp RG, Lejuez CW, Muzzy W, Frueh CB, Egede LE, Tuerk PW. BEHAVIORAL ACTIVATION AND THERAPEUTIC EXPOSURE FOR POSTTRAUMATIC STRESS DISORDER: A NONINFERIORITY TRIAL OF TREATMENT DELIVERED IN PERSON VERSUS HOME-BASED TELEHEALTH. Depression and anxiety. 2016 May 1; 33(5):415-23.
  2. Acierno RE. Symptoms of posttraumatic stress disorder and major depressive disorder in veterans of Operations Enduring/Iraqi Freedom in comparison with those veterans of other conflicts. Military Behavioral Health. 2016 Apr 25; 4(4):383-389.
  3. Korte KJ, Allan NP, Gros DF, Acierno R. Differential treatment response trajectories in individuals with subclinical and clinical PTSD. Journal of anxiety disorders. 2016 Mar 1; 38:95-101.
  4. Price M, Kuhn E, Hoffman JE, Ruzek J, Acierno R. Comparison of the PTSD Checklist (PCL) Administered via a Mobile Device Relative to a Paper Form. Journal of traumatic stress. 2015 Oct 1; 28(5):480-3.
  5. Hershenberg R, Paulson D, Gros DF, Acierno R. Does Amount and Type of Activity Matter in Behavioral Activation? A Preliminary Investigation of the Relationship between Pleasant, Functional, and Social Activities and Outcome. Behavioural and cognitive psychotherapy. 2015 Jul 1; 43(4):396-411.
  6. Yuen EK, Gros DF, Price M, Zeigler S, Tuerk PW, Foa EB, Acierno R. Randomized Controlled Trial of Home-Based Telehealth Versus In-Person Prolonged Exposure for Combat-Related PTSD in Veterans: Preliminary Results. Journal of Clinical Psychology. 2015 Jun 1; 71(6):500-12.
  7. Pelton D, Wangelin B, Tuerk P. Utilizing Telehealth to Support Treatment of Acute Stress Disorder in a Theater of War: Prolonged Exposure via Clinical Videoconferencing. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2015 May 1; 21(5):382-7.
  8. Badour CL, Gros DF, Szafranski DD, Acierno R. Problems in sexual functioning among male OEF/OIF veterans seeking treatment for posttraumatic stress. Comprehensive psychiatry. 2015 Apr 1; 58:74-81.
  9. Zhang J, Sheerin C, Mandel H, Banducci AN, Myrick H, Acierno R, Amstadter AB, Wang Z. Variation in SLC1A1 is related to combat-related posttraumatic stress disorder. Journal of anxiety disorders. 2014 Dec 1; 28(8):902-7.
  10. Tuerk PW. Starting from something: augmenting exposure therapy and methods of inquiry. The American journal of psychiatry. 2014 Oct 1; 171(10):1034-7.
  11. Paul LA, Gros DF, Strachan M, Worsham G, Foa EB, Acierno R. Prolonged Exposure for Guilt and Shame in a Veteran of Operation Iraqi Freedom. American journal of psychotherapy. 2014 Sep 1; 68(3):277-286.
  12. Hernandez-Tejada MA, Zoller JS, Ruggiero KJ, Kazley AS, Acierno R. Early treatment withdrawal from evidence-based psychotherapy for PTSD: telemedicine and in-person parameters. International journal of psychiatry in medicine. 2014 Jan 1; 48(1):33-55.
  13. Soltis K, Acierno R, Gros DF, Yoder M, Tuerk PW. Post-traumatic stress disorder: ethical and legal relevance to the criminal justice system. The Journal of law, medicine & ethics : a journal of the American Society of Law, Medicine & Ethics. 2014 Jan 1; 42(2):147-54.
  14. Acierno R, Gros DF, Morland L, Greene C, Strachan MK, Egede LE, Tuerk PW, Frueh BC, Myrick H. Delivery of evidence-based psychotherapy via video telehealth. Journal of psychopathology and behavioral assessment. 2013 Dec 1; 35(4):506-521.
  15. Gros DF, Price M, Yuen EK, Acierno R. Predictors of completion of exposure therapy in OEF/OIF veterans with posttraumatic stress disorder. Depression and anxiety. 2013 Nov 1; 30(11):1107-13.
  16. Tuerk PW, Wangelin B, Rauch SA, Dismuke CE, Yoder M, Myrick H, Eftekhari A, Acierno R. Health service utilization before and after evidence-based treatment for PTSD. Psychological Services. 2013 Nov 1; 10(4):401-9.
  17. 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.
  18. Price M, Gros DF, Strachan M, Ruggiero KJ, Acierno R. The Role of Social Support in Exposure Therapy for Operation Iraqi Freedom/Operation Enduring Freedom Veterans: A Preliminary Investigation. Psychological trauma : theory, research, practice and policy. 2013 Jan 1; 5(1):93-100.
  19. Gros DF, Price M, Strachan M, Yuen EK, Milanak ME, Acierno R. Behavioral activation and therapeutic exposure: an investigation of relative symptom changes in PTSD and depression during the course of integrated behavioral activation, situational exposure, and imaginal exposure techniques. Behavior Modification. 2012 Jul 1; 36(4):580-99.
  20. Strachan M, Gros DF, Yuen E, Ruggiero KJ, Foa EB, Acierno R. Home-based telehealth to deliver evidence-based psychotherapy in veterans with PTSD. Contemporary clinical trials. 2012 Mar 1; 33(2):402-9.
Book Chapters

  1. Acierno RE, Williams JL, Tuerk PW. Common Elements of the Expert Consensus Guidelines for Clinical Videoconferencing. In: Behavioral telehealth. Cham, Switzerland: Springer International Publishing; 2015. Chapter 3. 55-67 p.
  2. Tuerk PW, Shore P. Technologies and clinical videoconferencing infrastructures: a guide to selecting appropriate systems. In: Tuerk PW, Shore P, editors. Clinical Videoconferencing in Telehealth. New York, NY: Springer International Publishing; 2015. Chapter 1. 3-22 p.
Center Products

  1. Tuerk PW. New PTSD Treatments Use Apps and Video Conferences. CBS News (WLTX) interview. 2014 Nov 13.
  2. Tuerk PW. Community Mental Health: Ozark Center for PE for PTSD. 2014 Aug 27.
  3. Tuerk PW. VA Internship: Prolonged Exposure (PE) Professional Training. 2014 Aug 13.
  4. Tuerk PW. VA OMHS Prolonged Exposure (PE) 4-day Professional Training. 2014 Jun 24.
  5. Tuerk PW. DoD Integrating Technology into Mental Health Treatments. 2014 May 15.
  6. Tuerk PW. Community Mental Health: Ozark Center VR Exposure for PTSD. 2014 Jan 10.
VA Cyberseminars

  1. Tuerk PW. Home-based and Therapist Assisted Exposure Therapy. Advanced Call Series, National Center for PTSD, Education Division. [Cyberseminar]. 2014 Aug 1.
Conference Presentations

  1. Acierno RE. Home- Telehealth vs. In Person Delivery of Evidence Based Psychotherapy for Combat PTSD. Paper presented at: VA Rural Health State of the Science Conference; 2016 Sep 12; Washington, DC.
  2. Acierno RE. Protection through connection: The importance of social support to mental health. Paper presented at: Medical University of South Carolina’s Community Science Café Series; 2016 Aug 18; Charleston, SC.
  3. Acierno RE. Home-telehealth vs. In-Person delivery of behavioral activation and therapeutic exposure for combat PTSD. Paper presented at: Military Health System Research Symposium; 2016 Aug 15; Orlando, FL.
  4. Meis L, Spoont M, Erbes C, Polusny M, Noorbaloochi S, Hagel EC, Bangerter A, Eftekhari A, Kattar K, Tuerk PW. The Role of Individual Beliefs and Family Involvement in Understanding Veterans’ Commitment to Evidence Based Treatments for PTSD. Paper presented at: International Society for Traumatic Stress Studies Annual Symposium; 2014 Nov 6; Miami, FL.
  5. Meis LA, Spoont MR, Erbes CR, Polusny MA, Noorbaloochi S, Hagel Campbell EM, Bangerter AK, Eftekhari A, Kattar K, Tuerk P. Can Families Help Shape Veteran's Opinions of and Response to Evidence Based Treatments for PTSD? Poster session presented at: International Society for Traumatic Stress Studies Annual Symposium; 2014 Nov 6; Miami, FL.
  6. Acierno RE. Trauma across the lifespan: a collaborative approach to trauma care: Evidence-based treatments for PTSD. Workshop presented at the US Psychiatric and Mental Health Congress, Orlando, FL. Paper presented at: U.S. Psychiatric and Mental Health Annual Congress; 2014 Sep 20; Orlando, FL.
  7. Acierno RE, Hernandez-Tejado M. Early Treatment Withdrawal from Evidence-based Psychotherapy for PTSD: Telemedicine and In-Person Parameters. Paper presented at: Sociedad Espanola para el Estudio de la Ansiedad Annual Conference; 2014 Sep 9; Valencia, Spain.
  8. Tuerk PW. Technology-Based Resources for Mental Health Providers Treating PTSD. Paper presented at: American Association of Anxiety Disorders Annual Conference; 2014 Mar 27; Chicago, IL.
  9. Tuerk PW, Wangelin B. Enhancing Exposure Therapy for PTSD with Yohimbine HCL: A Double-Blind, Randomized Controlled Study Implementing Subjective and Objective Measures of Treatment Outcome. Paper presented at: American Association of Anxiety Disorders Annual Conference; 2014 Mar 27; Chicago, IL.
  10. Tuerk PW, Mouilso E, Peterson A, Rauch SA, Kumpula M, Lamp K, Resick P, Foa E, McLean CP. Negative Cognition in PTSD across Trauma Populations. Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2013 Nov 21; Nashville, TN.
  11. Acierno RE, Price M, Ruggiero KJ, Resnick HS. Prospective comparison of PTSD and depression symptoms among victims who sought mental health treatment after sexual assault. Poster session presented at: International Society for Traumatic Stress Studies Annual Symposium; 2013 Nov 5; Philadelphia, PA.
  12. Tuerk PW, Wangelin B, Rauch SA, Yoder M, Acierno RE. Health Service Utilization Before and After Evidence-Based Treatment for PTSD. Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2013 Nov 1; Nashville, TN.
  13. Tuerk PW, Yoder M, Acierno RE. Assessment of therapist-level and patient-level factors in evidence-based therapy outcomes for PTSD in a Veterans affairs outpatient clinic. Paper presented at: International Society for Traumatic Stress Studies Annual Symposium; 2013 Nov 1; Philadelphia, PA.
  14. Ruggiero KJ, Fleeman A, Henderson T. The use of a color logo on the mailing materials of an address-based sample (ABS). Paper presented at: American Association for Public Opinion Research Annual Conference; 2013 May 16; Boston, MA.
  15. Ruggiero KJ, Fleeman A, Henderson T, Vanderwolf P. Numbers, numbers on the dial, which is the fairest one on file? Cell or landline? Home or work? Findings from an ABS longitudinal study. Paper presented at: American Association for Public Opinion Research Annual Conference; 2013 May 16; Boston, MA.
  16. Acierno R, Rogers SM, Iannazzo AT, Zeigler SM, Muzzy WA, Muzzy SP. PTSD + Inescapable Social Stress: Team Sailing as a Community Reintegration Method. Poster session presented at: South Carolina Psychological Association Annual Conference; 2013 Apr 1; Myrtle Beach, SC.
  17. Acierno R, Yoder MS, Center KB, Lozano B, Tuerk PW, Pelusi-Abbott S. Prolonged Exposure Therapy with Older Adults. Poster session presented at: American Association for Geriatric Psychiatry Annual Meeting; 2013 Mar 14; Los Angeles, CA.
  18. Acierno R, Rogers SM, Yeun EK, Zeigler SM, Kuhlman T, Rosenlieb T, Rossi J, Veronee K, Worsham G, Tuerk PW. Treatment barriers to therapeutic exposure. Poster session presented at: Southeastern Psychological Association Annual Meeting; 2013 Mar 1; Atlanta, GA.
  19. Dismuke CE, Lopez-Raab M, Mackintosh M, Willis E, Powell A, Morland L. Direct Cost Minimization of Telemedicine for Psychotherapy Service Delivery to Rural Combat Veterans with PTSD (Preliminary Analysis). Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2012 Nov 15; Los Angeles, CA.
  20. Dismuke CE, Horner MD, Muzzy W, VanKirk KK, Turner TH. Suboptimal effort on neuropsychological evaluation is associated with increased healthcare utilization. Paper presented at: National Academy of Neuropsychology Annual Conference; 2012 Nov 7; Nashville, TN.
  21. Acierno R, Price M, Gros DF, Strachan MK, Ruggiero KJ. The interactive effect of increased combat exposure and pre-deployment training on exposure therapy outcomes in PTSD for Operation Enduring Freedom/Operation Iraqi Freedom Veterans. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2012 Nov 1; Los Angeles, CA.
  22. Acierno R. Behavioral Activation for Depression. Paper presented at: Joint Base Lewis-McChord Soldier Training Site Fall Meeting; 2012 Oct 1; Seattle, WA.
  23. Dismuke CE, Gebregziabher MG. Racial/ethnic disparities in access to VA as a pathway to mortality. Poster session presented at: Medical University of South Carolina Frontiers in Neuroscience Annual Research Day; 2012 Mar 30; Charleston, SC.
  24. Acierno R. Update: Secondary prevention of PTSD in at risk OIF-OEF service men and women: BA-TE via HOME based telemedicine. Paper presented at: Department of Defense / Military Operational Medicine Research Program Congressionally Directed Medical Research Programs Annual PTSD Conference; 2012 Mar 1; Bethesda, MD.
  25. Acierno R, Ruggiero KJ, White S, Williamson V, McMichael O, Vladimirov V, Koenen KC, Kilpatrick DG, Galea S, Gelernter J, Amstadter AB. Association of CRHR1 and Post traumatic stress symptoms in a population-based study of hurricane exposed adults. Poster session presented at: Annual Biomedical Research Conference for Minority Students; 2011 Nov 1; St. Louis, MO.
  26. Acierno RE. Emerging technologies and new applications for telemental health. Paper presented at: American Telemedicine Association Annual Meeting; 2011 Mar 1; Tampa, FL.


DRA: Health Systems, Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational, Prevention, Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: PTSD, Comparative Effectiveness, Psychiatric health care delivery, Telemedicine/Telehealth
MeSH Terms: none