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Efficacy of Synchronous Telepsychology Interventions for People With Anxiety, Depression, Posttraumatic Stress Disorder, and Adjustment Disorder: A Rapid Evidence Assessment

Authors:

Abstract

Telepsychology holds promise as a treatment delivery method that may increase access to services as well as reduce barriers to treatment accessibility. The aim of this rapid evidence assessment was to assess the evidence for synchronous telepsychology interventions for 4 common mental health conditions (depression, anxiety, posttraumatic stress disorder, and adjustment disorder). Randomized controlled trials published between 2005 and 2016 that investigated synchronous telepsychology (i.e., telephone delivered, video teleconference delivered, or Internet delivered text based) were identified through literature searches. From an initial yield of 2,266 studies, 24 were included in the review. Ten studies investigated the effectiveness of telephone-delivered interventions, 11 investigated the effectiveness of video teleconference (VTC) interventions, 2 investigated Internet-delivered text-based interventions, and 2 were reviews of multiple telepsychology modalities. There was sufficient evidence to support VTC and telephone-delivered interventions for mental health conditions. The evidence for synchronous Internet-delivered text-based interventions was ranked as “unknown.” Telephone-delivered and VTC-delivered psychological interventions provide a mode of treatment delivery that can potentially overcome barriers and increase access to psychological interventions.
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TELEMEDICINE-DELIVERED PSYCHOLOGICAL INTERVENTIONS
©American Psychological Association, 2018. This
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at: http://dx.doi.org/10.1037/ser0000239
Abstract: 165
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Title: Efficacy of synchronous telepsychology interventions for people with anxiety,
depression, posttraumatic stress disorder and adjustment disorder: A rapid evidence
assessment
Short Title: Synchronous telepsychology interventions for anxiety, depression, PTSD and
adjustment disorder
Tracey Varker1, Rachel M Brand1, Janine Ward1, Sonia Terhaag1 & Andrea Phelps1
______________________________________________________________________
1Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry,
University of Melbourne
Author note
The authors would like to thank Dr Olivia Metcalf for comments that greatly improved the
manuscript.
Corresponding author:
Dr Tracey Varker, Phoenix Australia, Level 3, Alan Gilbert Building, 161 Barry St, Carlton,
VIC, 3053, Australia.
Email: tvarker@unimelb.edu.au
Phone: +61 03 9035 7526
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Abstract
Telepsychology holds promise as a treatment delivery method that may increase
access to services as well as reduce barriers to treatment accessibility. The aim of this rapid
evidence assessment was to assess the evidence for synchronous telepsychology interventions
for four common mental health conditions (depression, anxiety, posttraumatic stress disorder,
and adjustment disorder). Randomised controlled trials published between 2005 and 2016
that investigated synchronous telepsychology (i.e., telephone-delivered, video-teleconference
delivered, or internet-delivered text-based) were identified through literature searches. From
an initial yield of 2266 studies, 24 were included in the review. Ten studies investigated the
effectiveness of telephone-delivered interventions, 11 investigated the effectiveness of video-
teleconference (VTC) interventions, two investigated internet-delivered text-based
interventions; and two were reviews of multiple telepsychology modalities. There was
sufficient evidence to support VTC and telephone-delivered interventions for mental health
conditions. The evidence for synchronous internet-delivered text-based interventions was
ranked as ‘Unknown’. Telephone-delivered and VTC-delivered psychological interventions
provide a mode of treatment delivery that can potentially overcome barriers and increase
access to psychological interventions.
Keywords: telepsychology, internet-delivered text-based, telephone-delivered, video-
teleconference, synchronous
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Efficacy of synchronous telepsychology interventions for people with anxiety,
depression, posttraumatic stress disorder and adjustment disorder: A rapid evidence
assessment
The use of information and communication technologies has emerged as the next big
frontier in the efficient and effective delivery of healthcare. The term ‘telemedicinehas been
adopted to describe health care delivery via technology (Wilson & Maeder, 2015), including
in mental health treatment delivery, where it is typically known as telepsychology.
Telepsychology, the delivery of psychological services via technology, is a broad field and
encompasses various delivery modalities and formats (Nelson, Bui, & Velasquez, 2011). It
needs to be distinguished from other forms of telemedicine, such as telepsychiatry, which
further includes the delivery of psychopharmacological interventions via technology. The
various delivery modalities and formats include the use of mobile phone technology (e.g.,
short message service (SMS) or application-based (app) interventions), telephone-delivered
therapy, video teleconferencing, internet-delivered text-based therapy or treatment programs,
and other formats such as using social media, or video games as adjuncts to therapy. While
these delivery formats vary in their specifics, such as being self-directed, guided self-help, or
real-time interaction with a specialist, all are accessible to individuals with internet and/or
phone service and suitable equipment.
An important distinction in telepsychology is between ‘synchronous’ and
‘asynchronous’ delivery methods (Wilson & Maeder, 2015). Synchronous telepsychology
refers to visual and/or auditory interactions between the client and provider that are in real-
time and is therefore the most similar delivery format to traditional in-person treatment
(Osenbach, O'Brien, Mishkind, & Smolenski, 2013). Synchronous interventions include
telephone or video-teleconference delivered treatments and internet delivered text-based
treatments that involve real-time text interactions (often referred to as ‘webchat’).
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Asynchronous telepsychology involves client-provider interactions which are not in real-time
and thus includes interventions such as automated internet or computer based interventions or
email interactions with providers (Substance Abuse and Mental Health Services
Administration, 2015).
Telepsychology is of particular relevance in countries that face geographical
challenges in delivering healthcare (Mehrotra et al., 2016). Research shows that increasing
location remoteness was consistently associated with lower service use, and this relationship
was particularly strong for specialist mental health interventions (Meadows, Enticott, Inder,
Russell, & Gurr, 2015). There is even further restriction on the availability of providers who
specialise in the treatment of particularly complex mental health conditions, such as
posttraumatic stress disorder (PTSD), in regional and remote areas (Frueh, 2015; Riding-
Malon & Werth Jr, 2014). Research suggests that common barriers to seeking or receiving
mental health treatment in rural or remote areas include concerns about stigma (Wrigley,
Jackson, Judd, & Komiti, 2005), geographical isolation, difficulty accessing appropriate
transport, concerns about the cost of treatment, and perceived time commitment (Handley et
al., 2014). Certain populations of treatment-seekers may be particularly vulnerable to
perceptions of stigma relating to mental health, as well as being rurally located, such as
veterans (Frueh, 2015). Accessing treatment via telepsychology may reduce concerns about
stigma, with treatment available in the privacy of one’s own home which provides flexibility
and allows optimum use of client and therapist time (Rees & Haythornthwaite, 2004).
Evidence for the effectiveness of telepsychology has been emerging over the past
decade. Systematic reviews that have combined both types of telepsychology, i.e.
synchronous and non-synchronous, indicate that telepsychology is generally effective
(Backhaus et al., 2012). However, previous reviews have included several different
telepsychology modalities, with internet-based, computer-based, telephone-based, and video-
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based included together without examining or commenting on the difference between
synchronous and non-synchronous treatments. Synchronous treatment is the most similar
treatment to traditional psychological treatments and therefore seems to be the logical place
to start, to further our understanding of telepsychology. Common types of synchronous
treatment include telephone delivered, video-teleconferencing delivered, and internet-
delivered text-based modalities. It has been noted in the literature that these heterogeneous
modalities are commonly grouped together (Osenbach et al., 2013), however it is important
to distinguish explore whether there is differential evidence supporting each of these
modalities. There has only been one previous systematic literature review which has focused
specifically on synchronous telepsychology for the treatment of depression (Osenbach et al.,
2013), and it concluded that it was as effective as non-telehealth means in reducing
depression symptoms. In comparison, there are no literature reviews which have assessed the
evidence in relation to synchronous telepsychology for other common mental health
conditions such as anxiety, PTSD and adjustment disorder. It is important to develop an
understanding of how effective synchronous telepsychology is likely to be for these
disorders, as people experiencing these disorders are often geographically isolated,
experiencing stigma, or experiencing physical injury. Another common mental health
problem, substance abuse, has been the subject of several telepsychology reviews over the
past few years (e.g. Benavides-Vaello, Strode, & Sheeran, 2013; Young, 2012), and as such
will not be examined in the current review.
The aim of this review is to determine the efficacy of synchronous telepsychology for
the treatment of three common mental health disorders (anxiety, PTSD, and adjustment
disorder) that have not yet been investigated through systematic review, in addition to
updating the literature on synchronous telepsychology for the treatment of depression beyond
the findings from Osenbach and colleagues (Osenbach et al., 2013). Given that the study
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focus is heterogeneous in respect to modality (all forms of synchronous telepsychology) and
disorder (anxiety, PTSD, adjustment disorder, and depression), and given that telepsychology
is a rapidly developing field, it is well-suited to a rapid evidence assessment (REA) approach
as opposed to a systematic review.
Methods
This study utilised a REA methodology, which is a rigorous process that avoids a
number of the challenges that face a systematic review, such as the time and resource cost
(Crawford, Boyd, Jain, Khorsan, & Jonas, 2015; Varker et al., 2015). The key limitations of
an REA methodology come from the restricted search period, and the exclusion of
unpublished, difficult-to-obtain, and/or foreign language studies (Varker et al., 2015). The
steps of an REA methodology are outlined below.
Defining the question
The first stage of the REA is defining the population, intervention, comparison and
outcome (PICO), in the same manner as a systematic review (Crawford et al., 2015). The
population of interest was defined as adults with a diagnosis of depression, anxiety, PTSD, or
adjustment disorder (ascertained by diagnosis or cut off score on a validated measure). The
intervention was defined as any psychological intervention delivered using synchronous
telepsychology. The comparison included studies with treatment as usual, in-person
treatments, or alternative telepsychology intervention comparisons. The outcome was defined
as change in mental health symptom severity.
Search strategy
Medline, PsycINFO and the Cochrane library were searched for peer-reviewed
literature published from January 2005 to July 2016. Each database was single searched using
the title/s, abstract/s, MeSH terms, and Keywords lists with search terms specific to
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telepsychology, common mental health conditions (i.e. depression, PTSD, adjustment
disorder and anxiety) and study type. The interventions that were searched for were those that
are typically used in the treatment of depression, PTSD, adjustment disorder and anxiety. The
following search terms were used: “major depressive disorder” OR depression OR PTSD OR
“posttraumatic stress” OR “post-traumatic stress” OR “traumatic stress” OR “stress disorder”
OR anxiety OR “GAD” OR “generali*ed anxiety disorder” OR “anxiety disorder” OR phobia
OR panic OR “adjustment disorder” AND “cognitive behavioural therapy” OR “cognitive
behavioral therapy” OR CBT OR “cognitive processing therapy” OR “cognitive therapy” OR
“dialectical behaviour therapy” OR “dialectical behavior therapy” OR “behaviour therapy”
OR “behavior therapy” OR exposure OR “imaginal exposure” OR “in vivo exposure” OR
“motivational interviewing” OR “acceptance and commitment therapy” OR “mindfulness”
OR “schema therapy” OR “interpersonal therapy” OR EMDR OR “eye movement
desensiti*ation and reprocessing” OR “narrative therapy” OR “solution focused therapy” OR
“solution focussed therapy” OR “psychiatric consultation” OR therapy OR treatment OR
counselling OR intervention AND telepsychology, OR telemedicine, OR e-health, OR
telehealth, OR telephone, OR “mobile phone” OR video, OR videoconferencing, OR skype,
OR face-time, OR internet, OR online, OR web, OR web-based, OR internet-based OR
internet-delivered OR telephone-based OR telephone-delivered OR web-delivered AND
“systematic review” OR “meta-analysis” OR RCT OR “randomi*ed controlled trial” OR
“control trial” OR “effectiveness trial” OR “control study” OR “clinical trial”.
Study selection
Studies were included if they were published in English, were peer-reviewed meta-
analyses, systematic reviews or randomised controlled trials (RCTs), involved adults (≥ 18
years of age), used psychological interventions delivered by synchronous telepsychology,
included participants with a diagnosis or cut-off score indicating an anxiety disorder, major
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depressive disorder, PTSD, or adjustment disorder, and where trial outcomes included mental
health symptom severity. Studies were excluded where asynchronous telepsychology
modalities were used. One author (RB) initially screened the studies based on title and
abstract and obtained the full-text papers that satisfied the inclusion criteria. The full-text
papers were then screened for inclusion, with 10% of these randomly selected and checked
by a second author (TV) for agreement. This meant that these papers were reviewed by the
second author for eligibility as per the inclusion/exclusion criteria. Of this 10% checked by
both reviewers, there was 100% inter-rater agreement. Any disagreements between reviewers
would have been resolved by discussion, or through adjudication by a third author (AP). If a
meta-analysis selected for inclusion in the REA included a study that was also found as an
independent article, then the individual study was not included or counted for the purposes of
the current review, and was only reported on as part of the meta-analysis.
Quality assessment
The quality of included research studies was appraised using the criteria from the
Australian National Health and Medical Research Council (NHMRC) checklist (NHMRC,
1999), which considers the following four study features: the method of treatment assignment
(i.e., correct blinding and randomization); control of selection bias (i.e. intention to treat and
drop-out rate); blinding of outcome assessor; and whether standardized assessment was used.
The quality of systematic reviews and meta-analyses were assessed using National Health
and Medical Research Council quality criteria (NHMRC, 2000), which considers the
adequacy of the search strategy; appropriateness of the inclusion criteria; presence of quality
assessment for individual studies; summary of the results of individual studies; and
quantitative synthesis of results (where relevant). An overall rating of the quality of each
study is provided in Table 2. The results of these quality assessments were then used to
inform the overall strength of the evidence.
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Ranking the overall evidence
The evidence was evaluated using five criteria (Merlin, Weston, & Tooher, 2009): the
strength of the evidence, in terms of the quality, quantity, and design of the included
studies; the direction of the findings; the consistency of the findings across the included
studies (including across a range of study populations and study designs); and the
generalizability (of the body of evidence to the target population) and applicability of the
findings to the population of interest, as defined by the PICO. Three independent raters (RB,
TV and JW) made ratings about the strength of the evidence, direction of the findings,
consistency of the findings, generalizability and applicability. Strength of the evidence was
based on the following categories: high strength, where there is one or more systematic
review or meta-analysis of RCTs with a low risk of bias (i.e. risk of there being a systematic
error in the results, which can lead to underestimation or overestimation of the true
intervention effect) or three or more RCTs with a low risk of bias; moderate strength, where
there is one or two RCTs with a low risk of bias; and low strength, where there is one or more
RCT with a high risk of bias. The direction of the findings were judged in terms of whether
the weight of the evidence showed positive results, unclear results (i.e. no significant effects
or mixed results), or negative results. Further details on the methods for making each of these
judgments for each of the five criteria are detailed in Varker et al (2015).
The strength of the evidence, the direction of the findings, and the consistency of the
findings reflect the internal validity of the findings in support of efficacy for an intervention.
The last two components considered the external factors that may influence effectiveness. On
the basis of these five factors, the total body of the evidence was then ranked into one of four
categories: ‘Supported’, ‘Promising’, ‘Unknown’ and ‘Not Supported’.A ranking of
‘Supported’ means that there is clear, consistent evidence of a beneficial effect with no
evidence suggesting a negative or harmful effect, ‘Promising’ means that the evidence is
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suggestive of beneficial effect but further information is required. An ‘Unknown’ ranking
means that there is insufficient evidence of beneficial effect and further research is required,
and ‘not supported’ means there is clear, consistent evidence of no effect or negative/harmful
effect (Varker et al., 2015). Agreement on ranking was sought between three independent
raters (TV, RB, JW), with 100% inter-rater agreement found. Discrepancies between the
raters would have been resolved through discussion.
Results
Figure 1 shows the yield at all stages of the review. After removing duplicate articles
from an initial yield of 2266 articles, 2196 articles were screened on title and abstract and 206
were deemed eligible for full text review. After the full text review stage, 24 articles were
deemed eligible for inclusion. Given the relatively small number of articles identified in the
REA, the studies were grouped by telepsychology modality to provide the most meaningful
results possible, regardless of the mental health disorder addressed in the study.
Of the 24 articles included in the review: eight studies (Brenes, Danhauer, Lyles,
Hogan, & Miller, 2015; Dwight-Johnson et al., 2011; Gellis, Kenaley, & Have, 2014; Lovell
et al., 2006; Ludman, Simon, Tutty, & Von Korff, 2007; Mohr, Carmody, Erickson, Jin, &
Leader, 2011; Mohr et al., 2005; Mohr et al., 2012) and one meta-analysis (Mohr, Vella,
Hart, Heckman, & Simon, 2008) investigated the effectiveness of telephone-delivered
interventions for depression; 10 studies (Acierno et al., 2016; Choi et al., 2014; Egede et al.,
2015; Fortney et al., 2015; Morland et al., 2014; Morland et al., 2015; Stubbings, Rees,
Roberts, & Kane, 2013; Vogel et al., 2014; Yuen et al., 2015; Ziemba et al., 2014) and one
systematic review which included 20 studies (Rees & Maclaine, 2015), investigated the
effectiveness of video-teleconference delivered interventions for anxiety disorders; two
further studies investigated internet-delivered text-based interventions; and one meta-analysis
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(Osenbach et al., 2013) investigated the effectiveness of multiple telepsychology modalities
in the treatment of depression, while another meta-analysis investigated the effectiveness of
multiple telepsychology modalities in the treatment of mood or functional mental health
problems (Bee et al., 2008). The majority of the studies were conducted in the USA (n = 15),
with studies also conducted in Europe (n = 4) and Australia (n = 1). A summary of the key
characteristics of the included studies are described below and are presented in Table 1. The
overall findings for each intervention type are presented below and in Table 2.
Telephone-delivered interventions: Overall, 11 studies investigated the effectiveness
of telephone-delivered psychological interventions. Two meta-analyses looked at a range of
telepsychology modalities including telephone-delivered therapy (Bee et al., 2008; Osenbach
et al., 2013) while a third meta-analysis looked specifically at telephone-delivered
psychotherapy for depression (Mohr et al., 2008). Eight individual RCTs assessed telephone-
delivered therapy for a range of disorders (i.e. generalized anxiety disorder, depression, and
obsessive compulsive disorder), with treatment as usual comparisons (Dwight-Johnson et al.,
2011; Gellis et al., 2014; Ludman et al., 2007; Mohr et al., 2011) in-person therapy
comparisons (Lovell et al., 2006; Mohr et al., 2012), and telepsychology comparisons
(Brenes et al., 2015; Mohr et al., 2005).
Overall, the strength of the evidence for telephone-delivered therapy was rated as
high, given that there were three meta-analyses, one of which had low risk of bias (Bee et al.,
2008) and two of which had moderate risk of bias (Mohr et al., 2008; Osenbach et al., 2013)
which had results supporting the use of telephone-delivered therapy. In addition to this there
were several other high quality individual RCTs (Brenes et al., 2015; Dwight-Johnson et al.,
2011; Gellis et al., 2014; Lovell et al., 2006; Ludman et al., 2007; Mohr et al., 2011; Mohr et
al., 2012). The direction of the evidence was judged to be positive, since all studies except for
one, reported that telephone-delivered therapy was as effective as standard in-person
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treatment or was better than TAU on a range of outcomes. One study did not find a
significant difference in improvement between T-CBT and TAU groups (Mohr et al., 2011),
but given the strong positive weight of the rest of the evidence, this finding was judged not to
be significant enough to lower the direction rating to ‘Unclear’. The consistency of the
findings was judged to be moderate to high, as the majority of studies reported similar trends
in the findings, with telephone-delivered therapy being as effective as TAU or standard in-
person treatments. Specifically, T-CBT was found to be as effective as in-person treatments
in non-inferiority trials (i.e. trials comparing a novel treatment to an existing standard
treatment), but was found to be superior to TAU. Given that the majority of studies were
consistent in their findings, it was determined that these results are highly likely to be
replicable. The generalizability of these studies was rated as moderate to high, as the studies
included a range of disorders and samples. The applicability of these findings was judged to
be high, as the treatments and delivery formats are highly relevant and applicable to a western
health system. Thus, given the high strength, positive direction, moderate to high consistency,
moderate to high generalizability and high applicability, the use of telephone-delivered
telepsychology for clients with mental health conditions was ranked as ‘Supported’.
Video-teleconference delivered interventions: Twelve studies were identified that
investigated the effectiveness of VTC-delivered interventions. One meta-analytic review
looked at a range of telepsychology modalities, including VTC (Osenbach et al., 2013) one
systematic review of VTC was identified (Rees & Maclaine, 2015) and ten individual RCTs
were also found, all of which used in-person intervention comparisons (Acierno et al., 2016;
Choi et al., 2014; Egede et al., 2015; Fortney et al., 2015; Morland et al., 2014; Morland et
al., 2015; Stubbings et al., 2013; Vogel et al., 2014; Yuen et al., 2015; Ziemba et al., 2014),
other than one study which used a self-help book on evidence-based exposure and response
prevention or waitlist comparison (Vogel et al., 2014).
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Overall, the strength of the evidence base for VTC-delivered telepsychology
interventions was rated as high. This rating was primarily based on the presence of five high
quality RCTs with low risk of bias (Acierno et al., 2016; Egede et al., 2015; Fortney et al.,
2015; Morland et al., 2014; Yuen et al., 2015). The remaining RCTs in the VTC literature
yield were rated as being at moderate or high risk of bias due to methodological issues such
as small sample sizes, high drop-outs (i.e. >25%) or lack of blinding of assessors (i.e. the
assessors were aware of the treatment condition) (Choi et al., 2014; Morland et al., 2015;
Stubbings et al., 2013; Vogel et al., 2014; Ziemba et al., 2014). The direction of the evidence
was rated as positive, with all studies finding that VTC-delivered therapy had results showing
it was as effective as in-person therapy and one study finding that VTC-delivered therapy
was superior to using a self-help book on evidence-based exposure and response prevention,
and a waitlist control (Vogel et al., 2014). The consistency was rated as high, as all studies
were consistent in their findings. The generalizability of the evidence base was rated as
moderate to high, with the samples in the studies representative of adults with mental health
conditions. Of note however, six of the included studies focussed solely on US veteran
populations. The applicability was also judged to be high as all treatments offered in the
studies were considered to be available in a western health system. Taken together, the high
strength, positive direction, high consistency, moderate to high generalizability, and high
applicability of the VTC studies, led to the use of VTC-delivered telepsychology for clients
with mental health conditions being ranked as ‘Supported’.
Internet-delivered text-based treatments: Three studies were identified that
investigated the effectiveness of psychotherapy delivered via the internet, in which therapists
and clients communicated in real time through type-written responses (webchats). A meta-
analysis by Bee and colleagues (2008) looked at psychotherapy delivered via a range of
telepsychology modalities including the internet; and two individual RCTs assessed internet-
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delivered text-based therapy for depression with treatment as usual comparison groups
(Kessler et al., 2009; Kramer, Conijn, Oijevaar, & Riper, 2014).
The evidence base for internet-delivered text-based therapy was judged to be of low
strength, as it primarily consisted of two RCTs which were judged to be of low quality and
have high risk of selection bias (Kessler et al., 2009; Kramer et al., 2014). Although there
was one meta-analysis, this study did not provide enough information to assess the individual
merits of internet-delivered text-based therapy and did not contribute to improving the
strength of the evidence (Bee et al., 2008). The findings from the two RCTs were in the same
positive direction, and the consistency was judged to be low to moderate as only two studies
were included. The generalizability was judged to be moderate as one study used adults while
the other used young people (i.e. where the mean age of the sample was 19.5 years). The
applicability was rated as high, as the treatments were considered to be applicable and
relevant to the western health system, given the treatments are available in western settings.
Given the positive direction, low to moderate consistency, moderate generalizability, high
applicability but low strength of the evidence, the effectiveness of internet-delivered text-
based interventions for the treatment of mental health conditions including depression,
anxiety, PTSD and adjustment disorder was considered to be ‘Unknown’.
Discussion
The aim of this REA was to assess the effectiveness of telepsychology for clients with
depression, anxiety, PTSD, or adjustment disorders. The reviewed literature suggests that
there is a fast growing evidence base in this area. The REA found that the evidence base is
currently strongest and of the highest quality in the area of telephone-delivered and VTC-
delivered interventions. Both telephone-delivered and VTC interventions met the criteria for
a ‘Supported’ treatment for mental health conditions, meaning that there is clear, consistent
evidence of beneficial effect.
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The ‘Supported’ rating for telephone-delivered interventions was informed by three
meta-analyses (two of good quality with few risk of bias issues, and one with moderate
quality and bias issues) and several high quality RCTs, all of which indicated that telephone-
delivered interventions are significantly more effective than TAU and, in non-inferiority
trials, are as effective as standard in-person treatments. Of note, there was one high quality
RCT with US veterans that did not find a significant difference in outcomes for telephone-
delivered CBT for depression in comparison to a TAU group (Mohr et al., 2011). The authors
suggest that this may be evidence that more treatment resistant groups, such as veterans, may
need more intensive approaches to treatment than telephone-delivered therapy. The authors
also question whether there may be a publication bias in the literature for telephone-delivered
interventions, in which null results are not being routinely published. Alternatively, it may be
the case that there is generally very little research being conducted on telephone-delivered
interventions. This needs to be noted in an appraisal of the evidence base for telephone-
delivered interventions for mental health conditions, but given the specific population in the
study (veterans) and the strong weight of evidence in contrary to the findings of this study, it
was not considered to be enough to lower the overall “Supported” ranking for telephone-
delivered interventions for mental health conditions.
In the case of VTC-delivered interventions, the ‘Supported’ rating was informed
primarily by five high quality RCTs with low risk of bias. Notably, these five RCTs were all
conducted in the US with veteran populations (Acierno et al., 2016; Egede et al., 2015;
Fortney et al., 2015; Morland et al., 2014; Yuen et al., 2015). Veterans are a specific
population who may benefit from VTC interventions, given that they are a group with
particularly high rates of mental health conditions (Ikin et al., 2004; Searle, Lawrence-Wood,
Saccone, & McFarlane, 2013) and with documented barriers to accessing appropriate
evidence-based treatments (Brooks et al., 2012). This is likely to be the reason for a
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proliferation of recent research into telepsychology-delivered interventions in veteran
populations particularly.
The evidence for internet-delivered text-based synchronous interventions for mental
health conditions was limited and primarily consisted of two RCTs judged to be of only
moderate quality due to a lack of control of selection bias (Kessler et al., 2009; Kramer et al.,
2014). These RCTs suggested that internet-delivered text-based synchronous interventions
(by webchat) were superior to waitlist control, specifically in treating depression. Given the
lack of high quality evidence in this area, the use of internet-delivered text-based
synchronous interventions for mental health conditions was ranked as ‘Unknown’, indicating
that there is insufficient evidence of beneficial effect and further methodologically rigorous
research across different populations and mental health conditions is needed.
The technology involved in telepsychology interventions is relatively new,
particularly in the case of VTC-delivered interventions. This is reflected in the fact that all of
the VTC studies were conducted after 2013, with the more than half having been published in
the last year. It is therefore likely that the evidence base for VTC interventions in particular
will continue to grow at a rapid rate in the coming years.
Limitations and future directions
The findings must considered alongside the limitations of an REA. The omission of
potentially important papers, including those that were unpublished, non-English, published
prior to 2005 limit the comprehensiveness of an REA (Varker et al., 2015). The evaluations
of the evidence were not as exhaustive as in a systematic review or meta-analysis
methodology, and the study results were not synthesised in a statistical way. The REA
focused specifically on adults, meaning the relevance of these findings to children and
adolescents is unknown. The majority of the included studies were conducted in western
17
SYNCHRONOUS TELEPSYCHOLOGY INTERVENTIONS FOR ANXIETY,
DEPRESSION, PTSD AND ADJUSTMENT DISORDER
settings, which limits the generalizability to non-western countries. In addition, the scope of
this review was guided by the funders of the research, and therefore limited to anxiety,
depression, PTSD and adjustment disorder. As such, several other important psychiatric
disorders were not investigated. Finally, due to the fact that this was an REA, data from the
studies included in this review was not meta-analysed. This is a limitation of the REA
methodology, in comparison to systematic reviews which often include meta-analysis.
An important direction for future research is to repeat and extend the current
research, with the inclusion of meta-analysis. It will be important to identify which
populations benefit most from telepsychology, and to also identify whether adverse effects
are observed in any populations. In addition, the current review revealed that relatively few
RCTs have been conducted on internet-delivered text-based interventions, and those that have
been done have had methodological limitations. Therefore, there is a need for further well-
designed RCTs to examine the efficacy of internet-delivered text-based interventions.
Conclusions
Based on the findings of this REA, both telephone and VTC-delivered interventions
for mental health conditions are ‘Supported’ by the current available evidence. Synchronous
internet-delivered text-based interventions require further methodologically rigorous RCTs
and reviews in order to provide more robust data on their effectiveness. The potential for
telepsychology to overcome common barriers to treatment access and its apparent efficacy
and equivalence to in-person treatments therefore suggests that it is a promising delivery
method for increasing the reach of evidence based psychological interventions. This may be
of particular use in rural and remote communities who have significant issues with access to
evidence based psychological therapies. Given that these are relatively new technologies,
18
SYNCHRONOUS TELEPSYCHOLOGY INTERVENTIONS FOR ANXIETY,
DEPRESSION, PTSD AND ADJUSTMENT DISORDER
which are increasing in their mass availability, it will also be important to watch the evidence
in this area over the next five to ten years.
Acknowledgements
This research was funded by the Transport Accident Commission (TAC) via the
Institute for Safety, Compensation and Recovery Research (ISCRR).
Declaration of Conflicting Interests
The authors declare that there is no conflict of interest.
19
SYNCHRONOUS TELEPSYCHOLOGY INTERVENTIONS FOR ANXIETY,
DEPRESSION, PTSD AND ADJUSTMENT DISORDER
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1
Figure 1: Flowchart of search for studies
Duplicates excluded
(n = 70)
Total records retrieved through
database search
(N = 2266)
Identification
Records screened on title and abstract
(n = 2196)
Screening
Title and abstract records
excluded
(n = 1984)
Full text unavailable
(n = 6)
Full-text articles assessed for eligibility
(n = 206)
Eligibility
Full text articles excluded
due to ineligibility
(n = 182)
Primary reasons for
exclusion: asynchronous
telepsychology, no therapist
involvement, no quantitative
outcomes for anxiety
disorder, major depressive
disorder, PTSD, or
adjustment disorder,
population was adolescents,
and non-systematic review
(n = 24)
(2- several modalities; 2- internet
delivered text-based; 9-telephone; 11-
video-teleconference)
Included
1
Table 1
Characteristics of the studies investigating synchronous telepsychology interventions
Intervention Type
Study
Design
Comparison
condition
Total sample size,
Sample description
Mean age
(SD)^
Gender
Dosage of
Intervention
Several Modalities
Psychotherapy for
depression or anxiety
related disorders,
delivered by telephone
or video teleconference
Bee et al., 2008
MA of 13
controlled trials
TAU/ WL = 8
Face to face = 2
Telemedicine
delivered
alternative therapy
= 3
Total sample = 1567;
people with depression or
anxiety disorders.
Included samples from US
(n = 8), Netherlands (n =
2), UK (n = 2) & Canada
(n = 1)
NR
NR
Range: 8 16 sessions
Psychotherapy for
depression, delivered by
telephone or video
teleconference
Osenbach et al.,
2013
MA of 14
RCTs
TAU = 8
Face to face = 6
Total sample = 1725;
people with depression.
Details of countries where
samples drawn from were
not provided.
NR
NR
Range: 6-20 sessions
Internet delivered text-based treatments
CBT for depression,
delivered by webchat
Kessler et al., 2009
RCT with 4
and 8 month
follow-up
TAU
297; UK primary care
patients with confirmed
primary diagnosis of
depression
34.9 (11.6)
32%
male
10 sessions within 16
weeks
2
Solution-focussed
therapy, delivered by
webchat
Kramer et al., 2014
RCT with 9
and 18 week
follow-up
WL
263; Netherlands young
people with depressive
symptoms (CESD>20)
19.5 (1.7)
22.3%
male
Mean number of 1.4
sessions with an
average of 4.3 weeks
between first and last
session
Telephone-delivered treatments
CBT for GAD
Brenes et al., 2015
RCT with 4
month follow-
up
Telephone
delivered NST
141 US rural older adults
with a diagnosis of GAD
NR
18.4%
male
9-11 weekly sessions
of 50 minutes
CBT for depression
Dwight-Johnson et
al., 2011
RCT with 6
month follow-
up
Enhanced TAU
101; US Latino primary
care patients in rural
settings
39.8 (10.6)
22%
male
8 weekly sessions of
45-50 minutes
PST for depression
Gellis et al., 2014
RCT with 12
month follow-
up
TAU
115; US medically frail,
older, homebound adults
79.2 (7.4)
34.3%
male
8 weekly sessions
with daily monitoring
Exposure and response
prevention for OCD
Lovell et al, 2006
RCT with 6
month follow-
up
Face to face
72; UK people with a
diagnosis of OCD
31.9 (9.5)
40.3%
male
10 weekly sessions of
60 minutes
CBT for depression
Ludman, 2007
RCT with 18
month follow-
up
TAU
393; US patients with
depression commencing
anti-depressant treatment
44.4 (15.8)
24%
male
8 sessions of 30-40
minutes, followed by
2-4 booster sessions
over the course of a
year
3
CBT for depression
Mohr et al., 2011
RCT with 6
month follow-
up
TAU
85; US veterans with
major depressive disorder
55.9 (10.59)
90.6%
male
16 sessions of 45-50
minutes provided over
20 weeks
CBT for depression
Mohr et al., 2012
RCT with 6
month follow-
up
Face to face CBT
325; US primary care
patients with major
depressive disorder
47.7 (13.1)
22.5%
male
18 sessions of 45
minutes: 2 sessions
weekly for first 2
weeks, then 12 weekly
sessions, and 2 final
booster sessions over
4 weeks
Psychotherapy for
depression
Mohr et al., 2008
MA of 10
RCTs, 1 CT, 1
single-arm
study
TAU
Total sample: 1312;
People with current or
previous depressive
disorder. Details of
countries where samples
drawn from were not
provided.
NR
NR
Range: 4-16 sessions
CBT for depression
Mohr et al., 2005
RCT with 12
month follow-
up
Supportive,
emotion-focussed
therapy, delivered
by telephone
127; US adults with
multiple sclerosis
48.6 (9.6)
27.1%
male
16 weekly sessions of
50 minutes
Video-teleconference delivered treatments
BA-TE
Acierno et al.,
2016
RCT with 12
month follow-
up
Face to face BA-
TE
232; US veterans with
threshold or subthreshold
PTSD
45.6 (14.9)
94.4%
male
8 weekly sessions of
90 minutes
4
PST for depression
Choi et al., 2014
RCT with 9
month follow-
up
Face to face PST
158; US low-income,
homebound older adults
with depression
64.8 (9.2)
21.5%
male
6 weekly sessions
Collaborative care,
including; monitoring,
education, goal setting,
pharmacist, psychiatrist,
CPT
Fortney et al., 2015
RCT with 12
month follow-
up
Face to face
collaborative care
265; US rural veterans
with PTSD
52.2 (13.8)
89.8%
male
Varying numbers of
sessions and services
received.
BA
Egede et al., 2015
RCT with 12
month follow-
up
Face to face BA
141; US older veterans
63.9 (5.1)
98%
male
8 weekly sessions
CPT-C
Morland et al.,
2014
RCT with 6
month follow-
up
Face to face CPT-
C
125; US veterans with
PTSD
55.3 (12.5)
100%
male
12 twice weekly
sessions of 90 minutes
CPT
Morland et al.,
2015
RCT with 6
month follow-
up
Face to face CPT
126; US female veterans
and civilians with PTSD
46.4 (11.9)
0% male
12 once or twice
weekly sessions of 90
minutes
Psychological treatments
for anxiety disorders
Rees & Maclaine,
2015
SR
50% uncontrolled.
50% with face to
face control
Total sample = 613;
Adults with PTSD, OCD,
mixed anxiety and
depression, panic disorder
and social phobia. Details
of countries where
samples drawn from were
not provided.
NR
NR
NR
5
Note: BA = behavioural activation, BA-TE = behavioural activation and therapeutic exposure, CBT = cognitive behavioural therapy, CPT = cognitive processing therapy, CT = controlled trial, ERP =
exposure and response, GAD = generalised anxiety disorder, MA = meta-analysis, NR = not reported, NST = nondirective supportive therapy, OCD = obsessive compulsive disorder, PE =
prolonged exposure, PST = problem solving therapy, PTSD = posttraumatic stress disorder, RCT = randomised controlled trial , SR = systematic review, prevention, TAU = treatment as usual, US =
United States of America, WL = waitlist
CBT
Stubbings et al.,
2013
RCT with 6
week follow-up
Face to face CBT
26; Australian adults with
a mood or anxiety disorder
30 (11)
42.3%
male
12 weekly sessions of
60 minutes
ERP
Vogel et al., 2014
RCT with 3
month follow-
up
Self-help ERP or
waitlist
30; Norwegian adults with
OCD
33.1 (10.2)
40%
male
15 90 minute sessions
over 12 weeks
PE
Yuen et al., 2015
RCT with
Face to face PE
52; US veterans with
PTSD
44.0 (15.18)
98.1%
male
8-12 weekly sessions
CBT
Ziemba et al., 2014
RCT with no
follow-up
Face to face CBT
18; US veterans with
PTSD
NR
90%
male
10 sessions over 15
weeks
1
Table 2.
Research evaluating the effectiveness of synchronous telemedicine-delivered psychological interventions for clients with high prevalence mental health
conditions
Study
Mental health symptom
outcomes measures
Key results
Comments
Quality
assessment
rating
Several Modalities
Bee et al., 2008
MA of studies using
various standardised
mental health outcome
measures.
Compared to control conditions, remotely
delivered therapy demonstrated a large effect
size for anxiety-related disorders (1.15) and a
medium effect size for depressive disorders
(0.44).
Attrition rates varied widely depending on
population studied, nature of the intervention
and length of follow-up, suggesting different
treatment modalities may differ in their
perceived acceptability.
Only two of the 13 studies compared
remote versus face-to-face
psychotherapy. The effect sizes for
this comparison were non-significant
and the shortage of literature limits
the utility of this result.
The majority of identified studies had
small sample sizes and
methodological weaknesses
High quality
Osenbach et al.,
2013
MA of studies using
various standardised
measures of symptoms of
depression.
Telemedicine-delivered interventions were
found to be non-inferior to non-telemedicine-
delivered formats (g = 0.14, p = 0.98).
Studies that compared telemedicine
interventions with TAU showed a small effect
size (g = 0.29, p <0.001), suggesting superiority
of telemedicine interventions over TAU in
reducing depression symptoms.
Effects were moderated by TAU comparison
groups, studies primarily targeting depression
and studies using telephone-delivered
Individual study quality was not
assessed or reported on.
Results of individual studies were not
reported in the review.
Moderate
quality
2
interventions specifically, with these moderators
being related to larger effect sizes.
Internet delivered text-based treatments
Kessler et al.,
2009
BDI-II
SF-12
EQ-5D
The online CBT intervention group were
significantly more likely to recover from
depression at four and eight month follow-up
than those receiving TAU (odds ratio 2.39,
p=0.022, odds ratio 2.07, p = 0.023).
At four month follow-up the effect of the
intervention was greater for participants with
more severe baseline depression.
Attrition rates from treatment were
high (48 %).
Moderate
quality
Kramer et al.,
2014
CES-D
Participants receiving the web-based chat
intervention showed a significantly greater
reduction in depressive symptoms at nine week
(d = 0.18) and four and a half month follow-up
(d = 0.79) compared to the waitlist group.
Participants were aged 12-22.
There was high attrition (49% at 4.5
month follow-up) and limited
adherence to the intervention, with
only 42% of those who had access to
the chat intervention making use of it.
Moderate
quality
Telephone-delivered treatments
Brenes et al.,
2015
HAM-A
PSWQ-A
GAD-7
BDI-II
At 4 month follow-up the telephone-delivered
CBT group showed significantly greater
reductions in worry severity (p = 0.004), GAD
symptoms (p = 0.005) and depressive symptoms
(p = 0.02) than the telephone-delivered NST
group.
Comparison of two telephone-
delivered treatments.
High quality
3
Dwight-
Johnson et al.,
2011
HSCL
PHQ-9
Patients in the telephone-delivered CBT group
were more likely to experience improvement in
depression compared to enhanced TAU
participants (t = -2.36, p=0.18).
A greater proportion of the telephone-delivered
CBT group achieved treatment response at three
months (p=0.013).
The telephone-delivered CBT group reported
being significantly more satisfied with their
treatment.
Only 44% of participants in the
treatment group completed 6 or more
sessions.
High quality
Gellis et al.,
2014
HAM-D
PHQ-9
SF-12
SPSI-R
Satisfaction
questionnaire
Healthcare use
Participants in the I-TEAM condition
experienced significant decreases in depression
symptoms at three months, compared to the
TAU group (p=0.02) and these effects were
maintained at six month follow-up (p=0.05).
At twelve month follow-up, I-TEAM
participants had significantly fewer visits to the
ED than the TAU group (p=0.03), but no
difference was found on days spent in hospital
between the two groups (p=0.06).
Participants were all older adults.
High quality
Lovell et al,
2006
Y-BOCS
BDI-II
Telephone CBT was found to be non-inferior to
face-to-face CBT.
Patients in both conditions reported high levels
of satisfaction with the treatment.
High quality
Ludman, 2007
HSCL
PHQ-9
Patients in the telephone-delivered treatment
group had significantly lower depression scores
from 6 months to 18 month than the TAU group
(F(1,366)=11.28, p<0.001).
High quality
4
Forty-eight percent of patients in the phone
therapy group were in remission at the 12 and
18 month follow-up, compared to 38% in the
TAU group.
Mohr et al.,
2005
SCID depression
BDI-II
HDRS
PANAS-PA
GNDS
Improvements on positive affect and HDRS
depression scores were significantly greater in
the T-CBT condition compared to the T-SEFT
condition (p= 0.008, p = 0.02).
At the 12-month follow-up period, but
differences between treatments were no longer
present.
Compares two telephone-delivered
interventions.
Low quality
Mohr et al.,
2008
MA of studies using
various standardised
measures of symptoms of
depression.
Telephone-delivered psychotherapy resulted in
significant reductions in symptoms of
depression compared to control conditions (d =
0.26, p < 0.0001).
Attrition rates were reported to be significantly
lower compared to face-to-face treatments.
Treatment format, specifically group vs
individual, did not moderate treatment
effectiveness. Treatments that were delivered by
mental health professionals produced
significantly greater reductions in depressive
symptoms than other professionals.
Quality of included studies was not
assessed or reported.
Moderate
quality
Mohr et al.,
2011
MINI- Depression
HAM-D
PHQ-9
When comparing telephone-delivered CBT with
TAU, there were no significant time x treatment
effects (ps > 0.20), suggesting that telephone-
delivered CBT does not confer benefits over
TAU.
Participants were all veterans.
Authors suggest that this is a
particularly treatment refractory
group.
Moderate
quality
5
Mohr et al.,
2012
Secondary
paper:
Kalapatapu et
al, 2014
HAM-D
PHQ-9
Significantly fewer participants discontinued the
T-CBT compared to face-to-face CBT (p =
0.02)
Telephone- delivered CBT was non-inferior to
face-to-face CBT at posttreatment (d=0.14, p =
0.22).
Participants receiving face-to-face CBT were
significantly less depressed at six month follow-
up (p < 0.001).
A secondary analysis using this dataset was
done by Kalapatapu et al. (2014) also found
Telephone-delivered CBT to be non-inferior to
face-to-face CBT in treating depression in a
subgroup of participants with co-occurring
alcohol use disorders.
Sample size was relatively high in
socio-economic status.
High quality
Video-teleconference delivered treatments
Acierno et al.,
2016
BDI-II
PCL-5
PTSD and depression symptom improvement
following VTC-delivered treatment was non-
inferior to face-to-face-delivered treatment at
posttreatment and three and six month follow-
up.
Participants were all US veterans.
High quality
Choi et al.,
2014
HAM-D
WHODAS
Both VTC-delivered PST and face-to-face PST
were efficacious in reducing depression and
disability.
The effects of VTC-delivered PST were larger
than those for face-to-face PST at 36 week
follow-up for depression scores (d=0.68 vs d =
Participants were all older adults.
Moderate
quality
6
0.20) and disability scores ( d = 0.47 vs d =
0.25)
Egede et al.,
2015
GDS
BDI-II
SCID
The VTC condition was non-inferior to the face-
to-face condition in treating depression.
Participants were all older US
veterans.
High quality
Fortney et al.,
2015
PDS
HSCL
SF-12
Patients in the VTC arm has significantly
greater reductions in PTSD symptoms compared
with usual care at six months (p = 0.002) and 12
months (p = 0.04).
The intervention was a collaborative
care package which differed for each
participant. 54.9% of the VTC group
received CPT vs only 12.1% of the
TAU group. CPT was a predictor of
positive outcome, therefore the
results do not necessarily show the
efficacy of VTC per se, but show that
VTC facilitates better access to care.
High quality
Morland et al.,
2014
CAPS
CPOSS-VA
TSAS
TEQ
GTAS
VTC was found to be non-inferior to face-to-
face treatment. Significant reductions in
symptoms of PTSD were reported at post-
treatment (d = 0.78, p <0.05). These reductions
were maintained at three and six month follow-
up.
Participants in both conditions reported high
therapeutic alliance, treatment compliance and
satisfaction, with no significant differences
between conditions.
High quality
Morland et al.,
2015
CAPS
TEQ
WAI-SF
CPOSS-VA
TSAS
The VTC condition was non-inferior to the face-
to-face condition in treating PTSD symptoms at
posttreatment (d=-0.06) and three (d = 0.11) and
six month follow-up (d = 0.17).
Participants were all female.
Method of randomisation was not
described, selection bias was not
adequately controlled, and outcome
assessor blinding was not described
Moderate
quality
7
Rees &
Maclaine, 2015
SR of studies using
various standardised
mental health outcome
measures
VTC significantly reduced symptoms of Panic
Disorder from pre to post-treatment, but further
research is needed with larger samples and
randomised controls.
For OCD, all studies reported reductions in
symptoms post-treatment, and those that also
had a control condition reported non-inferior or
better outcomes in the VTC condition compared
to the control.
For PTSD, all studies found significant
reductions in symptoms of PTSD after VTC-
delivered treatment. These results were limited
by many studies lacking a control condition.
In a single uncontrolled study of VTC for social
phobia, VTC resulted in significant decreases in
symptoms.
An RCT examining VTC for mixed anxiety and
depression failed to find any differences
between the two groups.
The quality of included studies was
not assessed or reported.
Characteristics, baseline
demographics and results of
individual studies were not reported.
50% of included studies were
uncontrolled studies.
Moderate
quality
Stubbings et al.,
2013
DASS
BDI-II
HAQ
ASI
PSWQ
QLES
WAI-SF
TSQ
VTC was non-inferior to face-to-face treatment
in treating depression (d= 0.37, p = 0.165),
anxiety (d = 0.22, p = 0.41), stress (d = 0.38, p =
0.15), and improving quality of life (d = 0.13, p
=0.77).
Low quality
Vogel et al.,
2014
Y-BOCS
VOCI
ADIS-IV\BDI-II
Patients in the VTC condition reported
significantly greater reductions in OCD
Low quality
8
WAI
symptoms compared to self-help and waitlist
control groups (F (2, 27) = 7.8, p = 0.002).
Yuen et al.,
2015
PCL-M
BDI-II
BAI
There were no significant differences between
the rates of PTSD diagnosis between VTC and
face-to-face conditions at posttreatment (X2 (2)
= 0.62, p = 0.73)
VTC was non-inferior to face-to-face treatment
for PSTD (g=0.13 and anxiety (g= 0.10). Non-
inferiority analyses for depression were
inconclusive (g=-0.19).
Participants were all US veterans.
Randomisation not described.
High quality
Ziemba et al.,
2014
CAPS
HAM-A
MADRS
SF-36
Both groups evidenced a comparable reduction
in symptoms for anxiety and depression.
Overall treatment satisfaction was rated very
high (95.3 out of 100), with patients in
telemedicine being slightly more satisfied than
those in face-to-face treatment (98.1 vs 92.1,
respectively).
Relatively small sample size (n=18)
and no statistical comparisons
conducted.
Low quality
Note. ADIS-IV = anxiety disorders interview schedule for DSM-IV, ASI = anxiety sensitivity index, BAI = beck anxiety inventory, BDI II = beck depression inventory II,
CAPS = clinician administered PTSD scale, CBT = cognitive behavioural therapy, CES-D = centre for epidemiological studies depression scale revised, CPOSS-VA =
Charleston Psychiatric Outpatient Satisfaction Scale, DASS = depression, anxiety and stress scale, ED = emergency department, EQ-5D = Euroqol five dimensions
questionnaire, GAD = generalised anxiety disorder, GAD 7 = generalised anxiety disorder 7 item scale, GDS = geriatric depression scale, GNDS = guys neurological
disability scale, GTAS = group therapy alliance scale, HAM-A = Hamilton anxiety rating scale, HAM-D / HDRS = Hamilton depression rating scale, HAQ = health anxiety
questionnaire, HSCL = Hopkins symptom checklist, I-TEAM = integrated telehealth education and activation of mood, MA = meta-analysis, MADRS = Montgomery-
Asberg depression rating scale, MINI = Mini Neuropsychiatric Interview, PANAS-PA = positive and negative affect scale positive affect, PCL-5 = PTSD checklist for
DSM-5, PDS = PTSD diagnostic scale, PHQ-9 = patient health questionnaire 9, PST = problem solving therapy, PSWQ-A = Penn state worry questionnaire A, QLES =
quality of life and enjoyment scale, SCID = structured clinical interview for DSM disorders, SF-12 = short form survey 12, SF-36 = short form survey 36, SPSI-R = social
problem solving inventory revised, SR = systematic review, TAU = treatment as usual, T-CBT = telephone delivered CBT, TEQ = treatment expectancy questionnaire,
TSAS = telemedicine satisfaction and acceptance scale, TSQ = telehealth satisfaction questionnaire, T-SEFT = telephone delivered supportive emotion focussed therapy,
9
VOCI = Vancouver obsessional compulsive inventory, VTC = video-teleconference, WAI-SF = working alliance inventory short form, WHODAS = world health
organisation disability assessment scale, Y-BOCS = Yale-Brown obsessive compulsive scale.
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This study describes trends in telemedicine utilization in Medicare from 2004-2013.Telemedicine may increase access and improve quality, particularly in rural areas.1 Because inadequate reimbursement may limit telemedicine use, 29 states have passed telemedicine parity laws mandating that commercial insurers reimburse telemedicine visits.2 In contrast, Medicare limits telemedicine reimbursement to select live video encounters with the patient at a clinic or facility in a rural area.3 Federal legislation has been proposed to expand Medicare telemedicine coverage. To inform the debate regarding telemedicine expansion, we describe trends in telemedicine utilization in Medicare from 2004-2013.
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Objective: Combat veterans returning to society with impairing mental health conditions such as PTSD and major depression (MD) report significant barriers to care related to aspects of traditional psychotherapy service delivery (e.g., stigma, travel time, and cost). Hence, alternate treatment delivery methods are needed. Home-based telehealth (HBT) is one such option; however, this delivery mode has not been compared to in person, clinic-based care for PTSD in adequately powered trials. The present study was designed to compare relative noninferiority of evidence-based psychotherapies for PTSD and MD, specifically Behavioral Activation and Therapeutic Exposure (BA-TE), when delivered via HBT versus in person, in clinic delivery. Method: A repeated measures (i.e., baseline, posttreatment, 3-, 6-month follow-up) randomized controlled design powered for noninferiority analyses was used to compare PTSD and MD symptom improvement in response to BA-TE delivered via HBT versus in person, in clinic conditions. Participants were 232 veterans diagnosed with full criteria or predefined subthreshold PTSD. Results: PTSD and MD symptom improvement following BA-TE delivered by HBT was comparable to that of BA-TE delivered in person at posttreatment and at 3- and 12-month follow-up. Conclusion: Evidence-based psychotherapy for PTSD and depression can be safely and effectively delivered via HBT with clinical outcomes paralleling those of clinic-based care delivered in person. HBT, thereby, addresses barriers to care related to both logistics and stigma.
Article
Generalized anxiety disorder (GAD) is common in older adults; however, access to treatment may be limited, particularly in rural areas. To examine the effects of telephone-delivered cognitive behavioral therapy (CBT) compared with telephone-delivered nondirective supportive therapy (NST) in rural older adults with GAD. Randomized clinical trial in the participants' homes of 141 adults aged 60 years and older with a principal or coprincipal diagnosis of GAD who were recruited between January 27, 2011, and October 22, 2013. Telephone-delivered CBT consisted of as many as 11 sessions (9 were required) focused on recognition of anxiety symptoms, relaxation, cognitive restructuring, the use of coping statements, problem solving, worry control, behavioral activation, exposure therapy, and relapse prevention, with optional chapters on sleep and pain. Telephone-delivered NST consisted of 10 sessions focused on providing a supportive atmosphere in which participants could share and discuss their feelings and did not provide any direct suggestions for coping. Primary outcomes included interviewer-rated anxiety severity (Hamilton Anxiety Rating Scale) and self-reported worry severity (Penn State Worry Questionnaire-Abbreviated) measured at baseline, 2 months' follow-up, and 4 months' follow-up. Mood-specific secondary outcomes included self-reported GAD symptoms (GAD Scale 7 Item) measured at baseline and 4 months' follow-up and depressive symptoms (Beck Depression Inventory) measured at baseline, 2 months' follow-up, and 4 months' follow-up. Among the 141 participants, 70 were randomized to receive CBT and 71 to receive NST. At 4 months' follow-up, there was a significantly greater decline in worry severity among participants in the telephone-delivered CBT group (difference in improvement, -4.07; 95% CI, -6.26 to -1.87; P = .004) but no significant differences in general anxiety symptoms (difference in improvement, -1.52; 95% CI, -4.07 to 1.03; P = .24). At 4 months' follow-up, there was a significantly greater decline in GAD symptoms (difference in improvement, -2.36; 95% CI, -4.00 to -0.72; P = .005) and depressive symptoms (difference in improvement, -3.23; 95% CI, -5.97 to -0.50; P = .02) among participants in the telephone-delivered CBT group. In this trial, telephone-delivered CBT was superior to telephone-delivered NST in reducing worry, GAD symptoms, and depressive symptoms in older adults with GAD. clinicaltrials.gov Identifier: NCT01259596.
Article
Technology is the key to solving mental healthcare access problems in the twenty-first century. Perhaps the greatest challenge we face in harnessing the possibilities of information technology in healthcare today is to ensure that we do it in a manner that is clearly evidence-based. This means innovations must be evaluated in a variety of contexts, using designs to ensure they are feasible and acceptable to our patients, are effective in treating the symptoms and disorders for which they are applied, and ultimately are structured to have the best possible balance of increasing access, minimising costs, and maximising clinical outcomes. As a service delivery medium, telemedicine, or telepsychology, offers a viable means of delivering high quality, specialised mental health services to people with significant access-to-care barriers, such as those living in remote or rural areas, lacking in transportation, or experiencing ambulatory problems such as many elderly people do. Randomised controlled trials have demonstrated the clinical efficacy of telemedicine for specific populations with discrete psychiatric disorders. Going forward we must discover how to best integrate telemedicine with in-person care and other forms of communications technology, including the Internet, mobile technology and its “apps”, social media, virtual reality, “smart homes,” and wearable monitoring devices. It is also imperative that we better integrate these approaches with primary medical care so that “mental healthcare” does not continue to be viewed as independent from physical health.
Article
Objective Recently, increasing attention has been given to the issue of limited access to evidence-based psychological treatments. Factors affecting access can include geographical distance from service providers, lack of trained specialists, and prohibitive costs for treatment. Videoconferencing provides a convenient, low-cost alternative to in-person psychotherapy. Although videoconferencing treatment has been trialled for a vast array of mental health problems, surprisingly little research has been conducted exploring the efficacy of videoconferencing for the treatment of anxiety disorders. Anxiety disorders are highly prevalent and disabling conditions for which effective psychological treatment exists. The aim of the present study was to determine the state of the evidence with regard to the effectiveness of videoconference-delivered treatment for anxiety disorders.Method Using preferred reporting items for systematic reviews and meta-analyses guidelines, we conducted a systematic review of all studies that primarily recruited individuals with anxiety disorders, published between 2004 and 2014.ResultsWe identified 20 studies involving a total of 613 participants. Of the included studies, 50% were uncontrolled and 50% were controlled trials. The majority of studies conducted to date focused on post-traumatic stress disorder (PTSD; n = 10), followed by obsessive-compulsive disorder (n = 5), mixed anxiety and depression (n = 2), panic disorder (n = 2), and social phobia (n = 1). No studies were located that focused on investigating videoconference-delivered therapy exclusively for generalised anxiety disorder.Conclusions Findings are discussed in terms of the accumulating evidence for the effectiveness of videoconference-delivered therapy to treat anxiety disorders and the need for more trials overall, but particularly for generalised anxiety disorder.
Article
This study examined the effectiveness of telemedicine to provide psychotherapy to women with posttraumatic stress disorder (PTSD) who might be unable to access treatment. Objectives were to compare clinical and process outcomes of PTSD treatment delivered via videoteleconferencing (VTC) and in-person (NP) in an ethnically diverse sample of veteran and civilian women with PTSD. A randomized controlled trial of Cognitive Processing Therapy, an evidence-based intervention for PTSD, was conducted through a noninferiority design to compare delivery modalities on difference in posttreatment PTSD symptoms. Women with PTSD, including 21 veterans and 105 civilians, were assigned to receive psychotherapy delivered via VTC or NP. Primary treatment outcomes were changes in PTSD symptoms in the completer sample. Improvements in PTSD symptoms in the VTC condition (n = 63) were noninferior to outcomes in the NP condition (n = 63). Clinical outcomes obtained when both conditions were pooled together (N = 126) demonstrated that PTSD symptoms declined substantially posttreatment (mean = -20.5, 95% CI -29.6 to -11.4) and gains were maintained at 3- (mean = -20.8, 95% CI -30.1 to -11.5) and 6-month followup (mean = -22.0, 95% CI -33.1 to -10.9. Veterans demonstrated smaller symptom reductions posttreatment (mean = -9.4, 95% CI -22.5 to 3.7) than civilian women (mean = -22.7, 95% CI -29.9 to -15.5. Providing psychotherapy to women with PTSD via VTC produced outcomes comparable to NP treatment. VTC can increase access to specialty mental health care for women in rural or remote areas. © 2015 Wiley Periodicals, Inc.