Telehealth Research Papers - Academia.edu (original) (raw)

Objective: To compare clinical and process outcomes of cognitive processing therapy-cognitive only version (CPT-C) delivered via videoteleconferencing (VTC) to in-person in a rural, ethnically diverse sample of veterans with posttraumatic stress disorder (PTSD). Method: A randomized clinical trial with a noninferiority design was used to determine if providing CPT-C via VTC is effective and "as good as" in-person delivery. The study took place between March 2009 and June 2013. PTSD was diagnosed per DSM-IV. Participants received 12 sessions of CPT-C via VTC (n = 61) or in-person (n = 64). Assessments were administered at baseline, midtreatment, immediately posttreatment, and 3 and 6 months posttreatment. The primary clinical outcome was posttreatment PTSD severity, as measured by the Clinician-Administered PTSD Scale. Results: Clinical and process outcomes found VTC to be noninferior to in-person treatment. Significant reductions in PTSD symptoms were identified at posttreatment (Cohen d = 0.78, P < .05) and maintained at 3-and 6-month follow-up (d = 0.73, P < .05 and d = 0.76, P < .05, respectively). High levels of therapeutic alliance, treatment compliance, and satisfaction and moderate levels of treatment expectancies were reported, with no differences between groups (for all comparisons, F < 1.9, P > .17). Conclusions: Providing CPT-C to rural residents with PTSD via VTC produced outcomes that were "as good as" in-person treatment. All participants demonstrated significant reductions in PTSD symptoms posttreatment and at follow-up. Results indicate that VTC can offer increased access to specialty mental health care for residents of rural or remote areas. Trial Registration: ClinicalTrials.gov identifier: NCT00879255 J Clin Psychiatry 2014;75(5):470-476 P osttraumatic stress disorder (PTSD) is a costly and debilitating disorder that is associated with an elevated risk for a host of problems, including suicide, 1 substance use, 2 and anger problems. 3 The prevalence is estimated to be 6% in the US population, 4 with increased rates in military populations, including 9%-15% of Vietnam veterans 5 and 10%-20% of veterans of the wars in Iraq and Afghanistan. 6 Despite the urgent need for care and the availability of effective treatments, mental health services for veterans are characterized by high rates of underutilization and attrition. Among veterans in need of PTSD services, 50%-90% attend an insufficient number of visits or do not initiate them at all. 7,8 Furthermore, veterans who do initiate PTSD treatment demonstrate high rates of treatment dropout, ranging from 20% to 40% in clinical trials. 9 Factors associated with treatment nonengagement or dropout include PTSD symptomatology (avoidance), fear of stigmatization, and logistical problems (transportation, scheduling, child care). 10 These barriers are compounded for rural residents, whose access to evidence-based mental health care for PTSD is typically limited, 11,12 in part due to lack of treatment providers. 13 This disparity is particularly concerning given that 40% of US veterans live in rural areas. 11 Technological innovations, such as videoteleconferencing (VTC), can help address many of the clinical and logistical impediments to accessing care for underserved rural populations. 12 The delivery of services via VTC involves use of telecommunications equipment so that a clinician in one location can provide treatment to patients in another. VTC offers a number of advantages over traditional treatment approaches, 14,15 as VTC patients benefit in terms of decreased transportation costs, travel time, and missed work 16 and enhanced access to treatment for veterans with serious injuries or scheduling difficulties due to work, school, or childcare responsibilities. Studies of psychotherapy delivered via VTC have shown high degrees of patient and clinician satisfaction 17 and outcomes comparable to in-person delivery with regard to rates of attendance 18 and information retention. 19 VTC is an effective delivery modality for non-trauma-focused interventions for veterans with PTSD. 19-21 Preliminary evidence supports the effectiveness of VTC delivery of PTSD care with veterans. 22,23 However, questions remain about the feasibility of using VTC to deliver trauma-focused interventions, which directly assess a particular traumatic event and the subsequent thoughts or behaviors associated with that event, because patients with PTSD are often reluctant to engage in such therapies due to avoidance. Thus, the next step in assessing the feasibility and safety of VTC as a delivery modality is a rigorous evaluation of whether trauma-focused treatments delivered by VTC produce comparable outcomes to in-person delivery. One efficacious treatment for PTSD is cognitive processing therapy (CPT). 24 CPT is a trauma-focused psychotherapy that can be delivered in