Exposure Therapy for PTSD Delivered to Veterans via Telehealth: Predictors of Treatment Completion and Outcome and Comparison to Treatment Delivered in Person

Mental Health Service 116, Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC 29401, USA.
Behavior therapy (Impact Factor: 3.69). 06/2011; 42(2):276-83. DOI: 10.1016/j.beth.2010.07.005
Source: PubMed


Recent research has focused on the effectiveness of evidence-based psychotherapy delivered via telehealth services. Unfortunately to date, the majority of studies employ very small samples and limited predictor and moderator variables. To address these concerns and further replicate and extend the literature on telehealth, the present study investigated the effectiveness of 12-session exposure therapy delivered either via telehealth (n=62) or in person (n=27) in veterans with posttraumatic stress disorder (PTSD). Findings demonstrated that although older veterans and Vietnam veterans were more likely to complete the telehealth treatment, telehealth findings were not influenced by patient age, sex, race, combat theater, or disability status. Exposure therapy delivered via telehealth was effective in reducing the symptoms of PTSD, anxiety, depression, stress, and general impairment with large effect sizes. Interestingly, exposure therapy via telehealth was less effective than exposure therapy delivered in person; however, lack of random assignment to condition limits conclusions of differential effectiveness. Overall, these findings support the utility of telehealth services to provide effective, evidence-based psychotherapies.

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    • "ID Study n Setting Treatment Type Dropout rate 1 Chard et al., 2010 51 VET RC CPT I 35 2 Cigrang et al., 2011 15 AD/Reserve RES CPT + PE I 33 3a Davis et al., 2013 44 VET + mTBI RC CPT I 39 3b Davis et al., 2013 92 VET RC CPT I 38 4 DeViva, 2014 110 VET RC Varied B 78 5 Erbes et al., 2009 106 VET RC Varied B 31 6 Garcia et al., 2011 117 VET RC Varied B 68 7 Gray et al., 2012 44 AD RES Adaptive discl I 25 8 Gros et al., 2011 33 VET RC PE I 55 9a Gros et al., 2013 49 VET RES BA + EXP I 3 9b Gros et al., 2013 43 VET RES TELE + BA + EXP I 26 10 Kaysen et al., 2014 158 VET RC CPT I 36 11a Litz et al., 2012 13 VET RES IE + DCS I 31 11b Litz et al., 2012 13 VET RES IE + PBO I 15 12 McLay et al., 2012 42 AD RES PE via VR I 52 13a McLay et al., 2011 10 AD RES VR I 0 13b McLay et al., 2011 10 AD RES TAU, varied I 10 14a Miyahira et al., 2012 29 AD RES CBT + VR I 0 14b Miyahira et al., 2012 13 AD RES MA I 10 15 Norman et al., 2010 14 VET RES SS G 36 16a Possemato et al., 2011 15 VET RES Written emot discl I 0 16b Possemato et al., 2011 16 VET RES Control writing I 31 17 Reger et al., 2011 31 AD RC PE I 23 18a Roy et al., 2010 12 AD RES PE I 17 18b Roy et al., 2010 12 AD RES VR I 25 19a Tuerk et al., 2010 9 VET RC TELE PE I 33 19b Tuerk et al., 2010 25 VET RC PE I 24 20 Tuerk et al., 2011 65 VET RC PE I 34 "
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    ABSTRACT: A significant number of veterans of the conflicts in Iraq and Afghanistan have posttraumatic stress disorder (PTSD), yet underutilization of mental health treatment remains a significant problem. The purpose of this review was to summarize rates of dropout from outpatient, psychosocial PTSD interventions provided to U.S. Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) veterans with combat-related PTSD. There were 788 articles that were identified which yielded 20 studies involving 1,191 individuals eligible for the review. The dropout rates in individual studies ranged from 5.0% to 78.2%, and the overall pooled dropout rate was 36%, 95% CI [26.20, 43.90]. The dropout rate differed marginally by study type (routine clinical care settings had higher dropout rates than clinical trials) and treatment format (group treatment had higher dropout rates than individual treatment), but not by whether comorbid substance dependence was excluded, by treatment modality (telemedicine vs. in-person treatment), or treatment type (exposure therapy vs. nonexposure therapy). Dropout is a critical aspect of the problem of underutilization of care among OEF/OIF/OND veterans with combat-related PTSD. Innovative strategies to enhance treatment retention are needed.
    Journal of Traumatic Stress 09/2015; 28(5). DOI:10.1002/jts.22038 · 2.72 Impact Factor
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    • "Younger age is the only demographic variable that predicted dropout in more than one trial (Garcia et al., 2011; Gros et al., 2011; Jeffreys et al., 2014; Rizvi et al., 2009). Affective variables, such as total PTSD symptomology, PTSD symptom clusters, depression, and other comorbid conditions were also evaluated (Chard et al., 2010; Garcia et al., 2011; Gros et al., 2011; Mott, Mondragon, et al., 2014; Rizvi et al., 2009; Taylor, 2003; van Minnen & Hagenaars, 2002; van Minnen et al., 2002; Zayfert et al., 2005; Zoellner et al., 1999). The results were equivocal; some trials reported increased rates of PTSD symptomology, particularly avoidance symptoms, and elevated symptoms of depression were associated with dropout, whereas others failed to find an association. "
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    ABSTRACT: Emerging data suggest that few veterans are initiating prolonged exposure (PE) and cognitive processing therapy (CPT) and dropout levels are high among those who do start the therapies. The goal of this study was to use a large sample of veterans seen in routine clinical care to 1) report the percent of eligible and referred veterans who (a) initiated PE/CPT, (b) dropped out of PE/CPT, (c) were early PE/CPT dropouts, 2) examine predictors of PE/CPT initiation, and 3) examine predictors of early and late PE/CPT dropout. We extracted data from the medical records of 427 veterans who were offered PE/CPT following an intake at a Veterans Health Administration (VHA) PTSD Clinical Team. Eighty-two percent (n = 351) of veterans initiated treatment by attending Session 1 of PE/CPT; among those veterans, 38.5% (n = 135) dropped out of treatment. About one quarter of veterans who dropped out were categorized as early dropouts (dropout before Session 3). No significant predictors of initiation were identified. Age was a significant predictor of treatment dropout; younger veterans were more likely to drop out of treatment than older veterans. Therapy type was also a significant predictor of dropout; veterans receiving PE were more likely to drop out late than veterans receiving CPT. Findings demonstrate that dropout from PE/CPT is a serious problem and highlight the need for additional research that can guide the development of interventions to improve PE/CPT engagement and adherence. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
    Psychological Trauma Theory Research Practice and Policy 06/2015; DOI:10.1037/tra0000065 · 2.31 Impact Factor
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    • "Taken together, the current literature suggests that PE is an effective treatment for PTSD across diverse samples; however, the knowledge base regarding comparative outcomes for female and male veterans is limited. Four studies peripherally report equivocal PE results for female and male veterans in head to head statistical comparisons (Gros et al., 2011; Meyers et al., 2013; Tuerk et al., 2011, 2013) but are underpowered for true gender comparisons. One study (Schnurr et al., 2007) reports exposure therapy outcomes with an adequate sample of female veterans, but does not include male veterans as a comparison group. "
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    ABSTRACT: As the proportion of women serving in the United States military continues to increase, more female veterans are being treated for posttraumatic stress disorder (PTSD) in Department of Veterans Affairs (VA) health care settings. Prolonged Exposure (PE) therapy is an evidence-based treatment for PTSD and is often used in VA settings. However, only a few studies have investigated the effectiveness of PE specifically for female veterans with appropriate power. Results of these studies have varied, with similar effects between female and male veterans on par with civilian effects, and more recently, better outcomes for female veterans receiving PE compared with male veterans. The current study contextualizes the evidence from those studies and considers new data regarding clinical outcomes pre- and posttreatment for a large (N = 325) sample of male and female veterans treated with PE in a PTSD specialty clinic. Results indicate a large statistically significant decrease in PTSD as measured by PTSD Checklist (PCL) scores for both male and female veterans treated with PE (d = 1.33). No difference in effectiveness and no difference in treatment completion rates were found between male and female veterans. Our findings support the effectiveness of PE for the treatment of PTSD in female as well as male veterans. Results are compared and contrasted to previous findings in the literature taking into account heterogeneity in methodological and ecological factors among the studies. Emphasis is placed on context of care issues to further the empirical conversation regarding meeting the mental health needs of female veterans. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
    Psychological Services 06/2015; DOI:10.1037/ser0000040 · 1.08 Impact Factor
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