Telemedicine-based Collaborative Care Intervention Improves PTSD Outcomes among Veterans Residing in Rural Settings
BACKGROUND:
A large portion (38%) of VA enrollees diagnosed with PTSD live in rural areas, and two-thirds live closer to a community-based outpatient clinic (CBOC) than a large VAMC. This randomized effectiveness trial sought to test a collaborative care model designed to improve access to and engagement in evidence-based psychotherapy and pharmacotherapy for Veterans with PTSD living in rural settings. Investigators developed the Telemedicine Outreach for PTSD (TOP) intervention, in which an off-site PTSD care team used telemedicine technologies to support the PTSD treatment delivered by CBOC providers. Off-site PTSD care teams included telephone nurse care managers, telephone pharmacists, tele-psychologists, and tele-psychiatrists. Nurses conducted care management activities, pharmacists reviewed medication histories, and psychologists delivered Cognitive Processing Therapy (CPT) via interactive video. Psychiatrists supervised the team and conducted interactive video psychiatric consultations. Veterans (n=265), who were enrolled from 2009-2011, were randomized to the TOP intervention (n=133) or usual care (n=132) and were followed for 12 months. Veterans in the usual care group were not referred to any particular treatment by the research team. The primary outcome measure was PTSD severity. Other outcome measures included medication initiation and adherence, and CPT initiation and adherence.
FINDINGS:
- Telemedicine-based collaborative care successfully engaged Veterans who lived in rural settings in evidence-based psychotherapy to improve PTSD outcomes. During the 12-month study period, 55% of the Veterans randomized to TOP received CPT compared to 12% of Veterans that were randomized to usual care.
- Veterans randomized to TOP had 18 times higher odds of initiating CPT and 8 times higher odds of completing >8 sessions (considered the minimally therapeutic dosage). In post-hoc analysis, attending >8 sessions of CPT completely mediated the effect of the TOP intervention, suggesting that the primary mechanism of action in the intervention was improved engagement in CPT.
- Veterans in the TOP group had significantly larger decreases in PTSD symptoms compared to Veterans in the usual care group – a 5.31 decrease in symptom severity on the Posttraumatic Diagnostic Scale at six months, on average, compared to 1.07 for Veterans in usual care (a 5-point decrease in the Scale represents a decrease in frequency from 2 to 4 times a week to once a week for 5 symptoms of PTSD).
- The TOP group had significantly greater reductions in depression symptom severity compared to usual care at both six and twelve months.
- Nearly all Veterans reported taking psychotropic medications previously and/or receiving counseling, and Veterans randomized to usual care experienced no improvement in symptoms. Thus, the Veterans in this study can be characterized as being highly treatment resistant.
LIMITATIONS:
- This study did not employ rigorous measures of CPT fidelity.
- Because the trial was designed to be pragmatic rather than explanatory, it was not possible to confirm the mechanism of action for the TOP intervention.
Fortney J, Pyne J, Kimbrell T, et al. Telemedicine-based Collaborative Care for Post-traumatic Stress Disorder: A Randomized Clinical Trial. JAMA Psychiatry. November 19, 2014;e-pub ahead of print.
