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Telemedicine for Anger Management Therapy in a Rural Population of Combat Veterans With Posttraumatic Stress Disorder: A Randomized Noninferiority Trial
Abstract
To demonstrate the noninferiority of a telemedicine modality, videoteleconferencing, compared to traditional in-person service delivery of a group psychotherapy intervention for rural combat veterans with posttraumatic stress disorder (PTSD).
A randomized controlled noninferiority trial of 125 male veterans with PTSD (according to DSM criteria on the Clinician-Administered PTSD Scale) and anger difficulties was conducted at 3 Veterans Affairs outpatient clinics. Participants were randomly assigned to receive anger management therapy delivered in a group setting with the therapist either in-person (n = 64) or via videoteleconferencing (n = 61). Participants were assessed at baseline, midtreatment (3 weeks), posttreatment (6 weeks), and 3 and 6 months posttreatment. The primary clinical outcome was reduction of anger difficulties, as measured by the anger expression and trait anger subscales of the State-Trait Anger Expression Inventory-2 (STAXI-2) and by the Novaco Anger Scale total score (NAS-T). Data were collected from August 2005 to October 2008.
Participants in both groups showed significant and clinically meaningful reductions in anger symptoms, with posttreatment and 3 and 6 months posttreatment effect sizes ranging from .12 to .63. Using a noninferiority margin of 2 points for STAXI-2 subscales anger expression and trait anger and 4 points for NAS-T outcomes, participants in the videoteleconferencing condition demonstrated a reduction in anger symptoms similar ("non-inferior") to symptom reductions in the in-person groups. Additionally, no significant between-group differences were found on process variables, including attrition, adherence, satisfaction, and treatment expectancy. Participants in the in-person condition reported significantly higher group therapy alliance.
Clinical and process outcomes indicate delivering cognitive-behavioral group treatment for PTSD-related anger problems via videoteleconferencing is an effective and feasible way to increase access to evidence-based care for veterans residing in rural or remote locations.
... Sample sizes ranged from 17 [25][26][27] to 325 [28] participants and interventions ranged from 2 weeks [29,30] to 6 months [31]. Neuropsychologists provided intervention in one trial [26], occupational therapists in six trials [25,30,[32][33][34][35], physiotherapists in twenty-six trials (30 reports) [27,29,30,32,34,, psychologists in seventeen trials (19 reports) [28,31,[61][62][63][64][65][66][67][68][69][70][71][72][73][74][75][76][77], and speech pathologists in five trials (7 reports) [78][79][80][81][82][83][84]. We did not identify trials comparing the delivery of podiatry interventions by telehealth with a face-to-face intervention. ...
... Interventions delivered by psychologists using telehealth compared with face-to-face were investigated in seventeen trials (19 reports); [28,31,[61][62][63][64][65][66][67][68][69][70][71][72][73][74][75][76][77]. Most trials evaluated Cognitive Behavioral Therapy (CBT) or components of CBT [28,31,[62][63][64][65]69,[71][72][73]75,77], or Cognitive Processing Therapy (CPT) [61,67,70,76]. ...
... Interventions delivered by psychologists using telehealth compared with face-to-face were investigated in seventeen trials (19 reports); [28,31,[61][62][63][64][65][66][67][68][69][70][71][72][73][74][75][76][77]. Most trials evaluated Cognitive Behavioral Therapy (CBT) or components of CBT [28,31,[62][63][64][65]69,[71][72][73]75,77], or Cognitive Processing Therapy (CPT) [61,67,70,76]. Five trials delivered telehealth via telephone [28,31,62,65,77] and the remainder were via VC. ...
Objectives: To determine whether allied health interventions delivered using telehealth provide similar or better outcomes for patients compared with traditional face-to-face delivery modes. Study design: A rapid systematic review using the Cochrane methodology to extract eligible randomized trials. Eligible trials: Trials were eligible for inclusion if they compared a comparable dose of face-to-face to telehealth interventions delivered by a neuropsychologist, occupational therapist, physiotherapist, podiatrist, psychologist, and/or speech pathologist; reported patient-level outcomes; and included adult participants. Data sources: MEDLINE, CENTRAL, CINAHL, and EMBASE databases were first searched from inception for systematic reviews and eligible trials were extracted from these systematic reviews. These databases were then searched for randomized clinical trials published after the date of the most recent systematic review search in each discipline (2017). The reference lists of included trials were also hand-searched to identify potentially missed trials. The risk of bias was assessed using the Cochrane Risk of Bias Tool Version 1. Data Synthesis: Fifty-two trials (62 reports, n = 4470) met the inclusion criteria. Populations included adults with musculoskeletal conditions, stroke, post-traumatic stress disorder, depression, and/or pain. Synchronous and asynchronous telehealth approaches were used with varied modalities that included telephone, videoconferencing, apps, web portals, and remote monitoring, Overall, telehealth delivered similar improvements to face-to-face interventions for knee range, Health-Related Quality of Life, pain, language function, depression, anxiety, and Post-Traumatic Stress Disorder. This meta-analysis was limited for some outcomes and disciplines such as occupational therapy and speech pathology. Telehealth was safe and similar levels of satisfaction and adherence were found across modes of delivery and disciplines compared to face-to-face interventions. Conclusions: Many allied health interventions are equally as effective as face-to-face when delivered via telehealth. Incorporating telehealth into models of care may afford greater access to allied health professionals, however further comparative research is still required. In particular, significant gaps exist in our understanding of the efficacy of telehealth from podiatrists, occupational therapists, speech pathologists, and neuropsychologists. Protocol Registration Number: PROSPERO (CRD42020203128)
... From this group, Zerwas et al. (2017) was chosen because it provided complete data to analyze the outcomes. Similarly, when considering between Greene et al. (2010) and Morland et al. (2010), the latter was deemed the appropriate choice for closer review as it included more detailed data. ...
... Over twothirds of the sample (n = 10) did not report data on race or ethnicity. The studies that reported race (n = 6) were all conducted in the US , Hall et al., 2017Morland et al., 2010. ...
... The length of both F2F and online sessions were mostly 90 min, while one study (Mayor-Silva et al., 2021) was a full day event, and another reported 50 −75-min sessions and two studies were 90-120 minutes in length (Hall et al., 2017;Lleras de Frutos et al., 2020). Two studies (Aspvall et al., 2021;Morland et al., 2010) did not report on their session length. ...
Purpose: Online group-based interventions are widely adopted, but their efficacy, when compared with similar face-to-face (F2F) psychosocial group interventions, has not been sufficiently examined. Methods: This systematic review included randomly controlled trials (RCTs) that compared an intervention/model delivered in both F2F and online formats. The review adhered to PRISMA guidelines and was registered with PROSPERO. Results: The search yielded 15 RCTs. Effect sizes ranged from small to exceptionally large. Between-condition effect sizes yielded nonsignificant differences in effectiveness except for three studies that reported superior effectiveness in outcomes for F2F interventions. High heterogeneity was found where only two studies integrated rigorous designs, thus limiting opportunity for a meta-analysis evaluation. Conclusions: Most studies showed comparable outcomes in both F2F and online modalities. However, given the heterogeneity of samples and outcomes, it is premature to conclude that online treatment is as effective as F2F for all challenges and populations.
... A total of five studies have been conducted with VTC being the main intervention evaluated (Frueh et al., 2007;Morland et al., 2010Morland et al., , 2011Morland et al., , 2014Nauphal et al., 2021). All studies by Morland et al. involved independent samples (personal communication). ...
... All studies by Morland et al. involved independent samples (personal communication). Some studies specified that the participants were physically present in the same room, while the therapist or clinician was the only one attending through VTC (Morland et al., 2010(Morland et al., , 2011(Morland et al., , 2014. In contrast, other study conducted during the COVID-19 pandemic involved all participants and the therapist being distant from each other through zoom VTC (Nauphal et al., 2021). ...
... Most of the studies were categorized as fair quality (Frueh et al., 2007;Titov et al., 2008aTitov et al., ,b, 2009Morland et al., 2010Morland et al., , 2011Morland et al., , 2014. Two studies received a poor quality rating (Nauphal et al., 2021;Reese et al., 2021), while one study was rated as good quality (Schulz et al., 2016). ...
Background
This systematic review examined the existing literature to determine the evidence supporting the efficacy of online group treatments for anxiety-, obsessive-compulsive- and trauma-related disorders (AOTDs).
Methods
A systematic review using the PUBMED, PsycInfo, Web of Science, and ClinicalTrials databases with no language, date, or study design filters was performed. The inclusion criteria comprised studies that examined individuals who had received a formal diagnosis of AOTDs, were aged 18 years or older, and had baseline and endpoint assessments of symptom severity using formal tools.
Results
Five studies on social anxiety disorder (SAD), four on post-traumatic stress disorder (PTSD) and one on tic disorders (TDs) were found. The studies were open-label (n = 2) and randomized controlled trials (RCTs) (n = 8), with five of the RCTs being non-inferiority trials. Most studies were conducted in the US and investigated psychological CBT based interventions via internet-based therapies (IBT: n = 4), video teleconferencing (VTC: n = 5) or a combination of both (n = 1). In SAD, IBT studies associated with a clinician assisted web-based forum (here termed “forum-enhanced” studies) were superior to waiting lists and not inferior to similar versions that were also “forum enhanced” but self-guided, “telephone enhanced” by a contact with a non-specialist, and “email enhanced” by a contact with a clinician individually. Studies involving VTC have shown comparable effectiveness to in-person interventions across some online group CBT based treatments for PTSD. Two open trials also demonstrated symptoms reductions of social anxiety and tics through VTC.
Conclusion
There is evidence supporting the effectiveness of online group treatments for SAD and PTSD. Further studies from different research groups may be needed to replicate the use of these and other forms of online treatments in individuals with SAD, PTSD, and other clinical populations, such as OCD, panic disorder, agoraphobia and specific phobias.
Systematic review registration
https://www.crd.york.ac.uk/prospero/, identifier CRD42023408491.
... Cognitive Behavioral Therapy (Table 2) includes Cognitive Processing Therapy (CPT) [25][26][27][28][29][30], such as Group-CPT [26,27] and CPT combined with Transcranial Magnetic Stimulation (TMS) intervention [29]. Furthermore, there are also the Cognitive Therapy [17,31,32], Trauma Management Therapy (TMT) [33], Selfmanagement Therapy (SMT) [34,35], and Angry Management Therapy (AMT) [36,37]. ...
... Two randomized controlled trials investigated interventions with male veterans using Anger Management Treatment (AMT) vs. tele-AMT [36,37], highlighting the effectiveness and feasibility of remotely delivered cognitivebehavioral group therapy for PTSD-related anger issues. Teletherapy demonstrated increased accessibility, reduced therapist workload, decreased treatment costs, and shortened practice time. ...
The objective of this systematic review is to examine the effectiveness of psychotherapy in treating Post-Traumatic Stress Disorder (PTSD) in military personnel. PubMed, Web of Science, The Cochrane Library, EBSCO and CNKI databases were searched from 1 January, 2000 to November 2022 for Randomized Controlled Trials (RCTs) on psychotherapeutic interventions for military PTSD. The physical Therapy Evidence Database (PEDro) scale was used to evaluate the quality of the literature. Two researchers conducted literature screening, data extraction, and risk bias assessment in accordance with inclusion and exclusion criteria. Ultimately, 49 RCTs were included, involving a total of 5073 veterans, retired and active military from four countries. The average score on the PEDro scale was 7.60. The primary psychotherapeutic modalities for military PTSD intervention include Cognitive-Behavioral Therapy, Exposure Therapy, Mindfulness interventions, psychotherapy based on new technological tools, and other emerging psychotherapeutic tools. The review highlights that Cognitive Processing Therapy (CPT) and Prolonged Exposure Therapy (PET) stand out as the primary psychotherapeutic modalities for treating PTSD in military personnel. In cases where CPT and PET yield limited benefits, Mindfulness interventions emerge as effective alternatives. Moreover, considering the diverse needs and high dropout rates in the military, population, the review suggests using web-based, computer, and virtual reality technology tools as supplements to first-line treatments (CPT/PET) to enhance overall intervention effectiveness. For the advancement of future psychotherapeutic initiatives, there is a pronounced emphasis on prioritizing proven first-line interventions, CPT and PET while also recognizing the potential of mindfulness-based interventions as credible alternatives. In tandem with this, the active integration of technological tools is advocated to amplify the therapeutic impact of conventional psychological treatment modalities.
... Research demonstrates that TFTs significantly reduce anger, but generally with modest effect sizes (e.g., Cahill et al., 2003;Forbes et al., 2012;Resick et al., 2008;Stapleton et al., 2006). This can be compared to anger-focused interventions, which have yielded large effect sizes on anger (Morland et al., 2010). Anger is also a common residual symptom following PTSD treatment (e.g., Miles et al., 2023). ...
... In addition to current PTSD treatment models, it is also possible that some patients may benefit or even require adjunctive anger interventions, such as anger management, which a prior study found a large effect size among individuals with PTSD (Morland et al., 2010). Future research is needed to determine whether anger management adds value beyond TFTs, and, if so, the ideal timing to deliver this intervention (e.g., concurrent with TFT, after TFT to address residual anger). ...
Objective: Anger is one of the most prevalent concerns among individuals with posttraumatic stress disorder (PTSD) and is often a residual symptom following PTSD treatment. The purpose of this systematic review and meta-analysis was to determine how effective trauma-focused PTSD psychotherapies are in reducing anger. Method: The study was reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This study conducted a systematic review of studies that reported the effect of trauma-focused treatments on anger outcomes. Additionally, a meta-analysis was conducted with a subset of studies that used randomized controlled trials (RCTs) methodologies to compare trauma-focused PTSD treatments to nontrauma-focused and control conditions. Results: The systematic review included 16 studies with a total of 1,846 participants. In 11 of the studies, there was a significant decrease in an anger dimension following treatment. Eight studies with 417 total participants met inclusion criteria for the meta-analysis. The meta-analysis yielded a pooled effect size of PTSD treatment on anger of Hedges’s g = 0.33. Conclusion: Overall, trauma-focused treatments for PTSD significantly improve anger, but the magnitude of change is small-to-medium. Additional research is needed to determine how best to maximize anger outcomes following trauma-focused treatment or determine if and when targeted anger treatment is needed.
... Previous studies have shown that various psychosocial issues have been successfully treated with videoconferencing. These included anxiety and depression [25][26][27][28], post-traumatic stress disorder [29][30][31], obsessive-compulsive disorder and affective disorders [21,32], bipolar disorder [33,34], eating disorders [35], substance use [36][37][38], anger [39,40], and pain management [41][42][43]. ...
... As for specific therapeutic approaches or activities, those mentioned as unsuitable with the highest frequency included families and pairs (46), divorce and post-divorce disputes (7), group activities (7), first-contact clients or those not sufficiently involved in the treatment process as yet (42), low-income and socially excluded individuals (including the homeless) (33), clients who cannot create a private and safe setting for an online session (26), people without technical skills or equipment (18), those who strictly reject distant care as inadequate (14), where an official or legal document must be signed (7), and where interpreting needs to be provided (i.e. with foreigners) (5). In general, the impossibility of conducting any psychodiagnostic procedures (particularly concerning the psychological and special education-related assessment of children) and the impossibility of practicing any therapeutic methods involving body therapy, touch, and non-verbal therapeutic techniques or training (such as relaxation, art therapy, and hypnotherapy) (21) were mentioned very often (39). ...
Introduction: According to the WHO, the COVID-19 pandemic has disrupted or halted critical mental health services in 93% of countries worldwide while the demand for these services continued to increase. Studies have investigated significant psychological consequences of social isolation and economic insecurity on the population's mental health. The research evidence points to elevated scores of negative mental health indicators (anxiety, depression, and distress) over time during the pandemic. At the same time, many research findings indicate that substitution in the form of online care delivery is adequate for many client groups. This study aimed to investigate the extent to which the provision of psychosocial services in clinical psychology, school counseling, and social services has changed because of the restrictive measures of the COVID-19 pandemic in Czechia. We were also interested in what barriers to online service provision existed and which clients were considered unsuitable for this form of care from the care providers' perspective.
Methods: We applied an online survey featuring a 30-item questionnaire with both closed and open questions to the sample of 441 participants selected using purposive sampling through institutions.
Results: A comparison of the pre-COVID-19 and COVID-19 operations in the first wave shows significant declines in all services provided across all main areas of psychosocial care. The overall average percentage decline across all outcomes combined was -34%. Given the need for the care shown on the part of the clients, we interpret it as a failure to ensure the availability of care as needed. The most common obstacles of online care mentioned were feeling of the impersonality of the online meeting, lack of a comprehensive visual overview of clients, concerns about maintaining quality standards, the impossibility of physical contact and application of diagnostic methods, internet connection problems, lack of privacy and disturbance by others, absence or poor quality of technical resources, communication misunderstandings due to technology, lack of time to work caused by the pandemic, and inappropriate employer attitudes and regulations.
Discussion and Conclusion: Despite research findings, providers identified most groups of clients or diagnoses unsuitable for online care.
... Dillon et al. randomized to receive either anger-focused CBT in person or via telemedicine (Morland et al., 2010). Both groups reduced significantly in anger symptoms. ...
... Addressing such perceptions through considering the "pros and cons" of anger embedded in a trauma and military context may be particularly important in treatments for those with anger and PTSD. Moreover, the studies used a variety of approaches, including telemedicine-delivered treatment (Morland et al., 2010), and mobile phone applications Morland et al., 2016). This indicates the significant potential of CBT-based anger treatments that use highly flexible approaches to reduce both anger and PTSD. ...
... TGP, particularly telehealth group cognitive behavioral therapy, can be delivered with the same fidelity as in-person group psychotherapy (Khatri et al., 2014). There is also evidence that TGP is efficacious for multiple mental health conditions such as depression, anxiety, anger, post-traumatic stress disorder, borderline personality disorder, and chronic and acute health conditions (Khatri et al., 2014;Melton et al., 2017;Moreland et al., 2010;Zalewski et al., 2021). ...
There is inadequate availability and access to behavioral health services to meet demand, and this issue amplified during the pandemic, creating a mental health crisis. Group therapy is an effective way to meet this need. The rapid implementation of telehealth group psychotherapy as part of a Primary Care Behavioral Health Integration program in a U.S. safety-net health care setting is described. Implementation lessons are summarized as barriers or facilitators, using thematic analysis of qualitative data from meeting notes. Major facilitators identified include having key staff serve as technology champions, dedicated administrative leadership to operationalize workflows, and communication and collaboration across teams and layers of infrastructure. Major barriers include uncertainty about operational workflows and technological challenges. While group visit volume initially waned, it began to rebound and quantitative analysis of demographic data shows that important underserved populations were reached. Frequent communication, collaboration, and adaptation among teams are critical elements for improving the likelihood of successful telehealth group therapy. It is feasible to expeditiously implement telehealth group psychotherapy in safety-net health care systems with limited resources.
... For example, the Substance Abuse and Mental Health Services Administration (SAMHSA) recommends a 12-session group CBT protocol emphasizing skills development for coping with problematic anger and aggression (Reilly et al., 2019). This intervention has shown preliminary evidence among Veterans with PTSD (Kalkstein et al., 2018;Mackintosh et al., 2017;Morland et al., 2010). However, CBT for problematic anger is underutilized in healthcare settings due to barriers such as a lack of clinician availability, financial costs, and stigma . ...
Problematic anger as a symptom of posttraumatic stress disorder (PTSD) is prevalent in military populations, including Veterans. Existing anger management programs may be underutilized due to barriers to accessing standard care. Mobile applications (apps) for anger management could increase access to care while using minimal resources. The current mixed-methods pilot study evaluated the satisfaction and helpfulness of the Anger and Irritability Management Skills (AIMS) app, a self-manageable mobile app developed by the VA’s National Center for PTSD for individuals struggling with anger. Veterans (N = 23) were recruited from the women’s (n = 6) and men’s (n = 15) residential Trauma Recovery Program at the VA Palo Alto Health Care System. Participants completed the Anger Expression Index (AEI) before and after using AIMS in a self-directed manner for 3 weeks. After 3 weeks, they also completed a satisfaction survey and participated in a qualitative focus group to share experiences and opinions about the app to inform future app updates. Paired samples t-tests were used to examine changes in AEI scores. Descriptive statistics were used to examine the perceived helpfulness of AIMS. Qualitative data were examined using Rapid Qualitative Analysis and themes were identified using matrix analysis. Perceived helpfulness of the AIMS app was rated, on average, between moderately to very helpful, and app satisfaction was rated between moderately to very satisfied. AEI scores significantly reduced from pre- to post-app use. Qualitative results revealed four themes: (1) symptom monitoring, (2) tailoring app use to fit users’ needs, (3) potential as a self-management resource, and (4) potential as a supplement to care. Participants generally perceived AIMS to be helpful for managing their anger and they were satisfied with the app, indicating preliminary acceptability and helpfulness of the app. Future studies with a larger sample size to explore novel ways to increase app dissemination efforts and explore using AIMS in other healthcare settings are warranted.
... Whereas other health care facilities began to ramp up their use of TMH-V during the COVID-19 pandemic, the U.S. Department of Veterans Affairs (VA) has been using TMH-V widely for more than two decades. 3,9,15,16 For bipolar disorder specifically, the VA's National Bipolar Disorders TeleHealth (BDTH) Program started providing care in 2011. 17,18 The VA designed this program to make clinical expertise in bipolar disorder available to Veterans across the country using a hub and spokes model. ...
... The current study represents secondary analyses of baseline data from a noninferiority designed RCT that compared the clinical effectiveness of cognitive-behavioral group anger management therapy (Reilly & Shopshire, 2002) delivered via videoteleconferencing (VTC) relative to traditional face-to-face treatment delivery (Morland et al., 2010). Noninferiority studies use a rigorous methodology to determine whether the novel intervention, such as therapy delivered via VTC, is noninferior to, or as good as, a well-established standard intervention, such as traditional inperson delivery (Greene, Morland, Durkalski, & Frueh, 2008). ...
Posttraumatic stress disorder (PTSD) is a significant health problem that affects people from all ethnoracial groups. In the United States, investigators have found that minority groups, particularly Asian Americans, are more likely to withdraw from treatment and to display poor health treatment outcomes compared with Caucasians. Despite the extant research regarding ethnicity and treatment, limited research exists focusing on the relationship between ethnicity and the assessment of mental health symptoms. Previous literature has found that Asian Americans may underreport mental health symptoms. Relatively less empirical work has been conducted with indigenous populations, especially those of the Pacific Islands, such as Native Hawaiians, Samoans, and Tahitians. Questions remain as to whether the method of assessment may influence symptom reporting. For example, researchers have not studied whether or not clinician-assessed ratings of mental health symptoms differ from self-report measures. The current study examined the concordance between clinician-assessed and self-reported ratings of PTSD severity in male veterans with PTSD who identified themselves as Asian American, Native Hawaiian/Pacific Islander, or Caucasian. Results suggest moderate concordance between clinician-administered and self-report PTSD assessments. Findings from this study can be used to develop more accurate methods of capturing PTSD symptoms among Asian Americans, Native Hawaiians/Pacific Islanders, and other minority groups.
... Treatment accessibility was mentioned as a potential outcome in 29% (n=14) of studies and as a future direction or hypothesis in 63% (n=30) of studies. These studies discussed access to psychotherapy in various populations, including rural veterans [54][55][56], psychiatric outpatients living in remote areas [30], and ethnically diverse women living in underserved rural and urban areas [31]. Treatment appropriateness and efficiency were mentioned as potential outcomes of interest in 4% (n=2) of studies. ...
... Its efficacy in treating depression and anxiety is evident from the literature Bouchard et al., 2022;Giovanetti et al., 2022;Matsumoto et al., 2021). Some studies have shown promising results in cases of panic disorder, agoraphobia, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder and substance use, and, not least, in improving general well-being (Biolcati et al., 2023;Bouchard et al., 2020;Lin et al., 2019;Matsumoto et al., 2021;Morland et al., 2010;Yurayat & Seechaliao, 2021). However, the literature also suggests some limits of VCP (APA, 2013(APA, , 2023Connolly et al., 2020;Tomaino et al., 2022). ...
Introduction
The spread of online platform services offering psychological psychotherapy and counselling has been observed globally. In Italy, these services were aimed at young people and offered job opportunities to early-career clinical psychologists.
Aim
The current study aimed to explore the professional experiences of early-career psychologists (age range: 29–35 years) in working on online platform services that deliver psychotherapy and counselling in Italy.
Method
A total of 13 psychologists practising psychological interventions on online platform services were interviewed. Participants had a mean of 3 years' clinical experience. A thematic analysis, following the qualitative approach of interpretative phenomenological analysis (IPA), was performed.
Results
From the analysis, four superordinate themes emerged: (1) a smart intervention; (2) professional identity; (3) a different and wide contact; and (4) grateful to the platform, loyal to the ‘company’.
Discussion
The online platforms represented a ‘medium’ with a ‘third’ function on a double level. At one level, they mediated between the request of the client and the psychologist, using the suggestions of AI algorithms. At another level, they offered employability and a guide to online interventions to early-career psychologists. Some critical issues related to ethics emerged considering the difficulty in maintaining the psychologists' autonomy before the affiliation to the business model promoted by the company, which may not match the client's interests.
Conclusion
The study highlights that online platforms promote a new culture of psychological health services, changing the representations and meanings attributed to the online intervention, the clinical profession and the psychologist–client relationship.
... Treatment accessibility was mentioned as a potential outcome in 29% (n=14) of studies and as a future direction or hypothesis in 63% (n=30) of studies. These studies discussed access to psychotherapy in various populations, including rural veterans [54][55][56], psychiatric outpatients living in remote areas [30], and ethnically diverse women living in underserved rural and urban areas [31]. Treatment appropriateness and efficiency were mentioned as potential outcomes of interest in 4% (n=2) of studies. ...
Background
The COVID-19 pandemic necessitated rapid changes to health care delivery, including a shift from in-person to digitally delivered psychotherapy. While these changes helped ensure timely psychotherapy provision, many concerns exist, including clinical, cultural, practical, privacy, and security issues.
Objective
This scoping review systematically mapped existing peer-reviewed research on synchronous, therapist-delivered web-based psychotherapy for individuals with a diagnosed mental illness. Data were analyzed through the lens of the Alberta Quality Matrix for Health (AQMH) to assess to what degree this literature addresses key indicators of health care quality. This analysis aided in the identification and organization of knowledge gaps with regard to web-based psychotherapies, highlighting potential disparities between previously prioritized dimensions of care and those requiring further attention.
Methods
This review adhered to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines. We included peer-reviewed primary research studies in the English language investigating synchronous, therapist-delivered remote psychotherapy delivered to adults (aged 18 years and older) with a Diagnostic and Statistical Manual of Mental Disorders or International Statistical Classification of Diseases diagnosed mental illness. All other citations were excluded. Relevant studies were identified through MEDLINE, APA PsycINFO, Embase (OVID), Web of Science: Core Collection (Clarivate), Cochrane Library (Wiley), and Scopus (Elsevier) databases. Databases were searched on March 18, 2021. For every publication that was taken into consideration, the data were charted independently by 2 reviewers, and in the event of a discrepancy, the principal investigator validated the choice of either extractor. Results were thematically described according to the 6 AQMH dimensions: acceptability, accessibility, appropriateness, effectiveness, efficiency, and safety.
Results
From 13,209 publications, 48 articles were included, largely from North American studies. Most studies measured treatment effectiveness (n=48, 100%) and acceptability (n=29, 60%) health quality dimensions. Over 80% (40/48) of studies investigated either a cognitive or exposure intervention for either posttraumatic stress disorder or a mood or anxiety disorder, generally indicating comparable results to in-person therapy. Safety (n=5, 10%) was measured in fewer studies, while treatment accessibility, appropriateness, and efficiency were not explicitly measured in any study, although these dimensions were mentioned as a future direction, hypothesis, or potential outcome.
Conclusions
In relation to web-based therapist-delivered psychotherapies for those with a diagnosed mental illness, important aspects of health care quality (accessibility, appropriateness, efficiency, and safety) have received little scientific examination, underscoring a need to address these gaps. There are also significant issues related to the generalizability of this literature, including the underrepresentation of many geographic regions, cultures, populations, clinical contexts, and psychotherapy modalities. Qualitative research in underrepresented populations and settings may uncover important patient and contextual factors important for the future implementation of quality web-based psychotherapy.
... The Anger Management for Substance Abuse and Mental Health Clients treatment protocol has been found to be effective for the reduction of problematic anger in several individual treatment trials [41], including trials with veterans receiving care in the VA system [42]. Meta-analyses have found that CBT therapies overall are effective for the treatment of problematic anger [43,44]. ...
Background
Unguided digital mental health interventions (UDMHIs) have the potential to provide low-cost and effective mental health care at scale. Controlled trials have demonstrated the efficacy of UDMHIs to address mental health symptoms and conditions. However, few previous publications have described the demographics of real-world users of UDMHIs that are freely available to the public. The US Department of Veterans Affairs has created and hosts several UDMHIs on its Veteran Training Portal website. These web-based, free-to-use, and publicly available UDMHIs include Path to Better Sleep, Anger and Irritability Management Skills, and Moving Forward, which focus on insomnia, problematic anger, and depression symptoms, respectively.
Objective
This study aimed to examine the user demographics of these 3 UDMHIs in the year 2021. In addition, it aimed to compare the age and gender distribution of the users of those 3 UDMHIs with one another and with the age and gender distribution of the total US veteran population.
Methods
Google Analytics was used to collect user data for each of the 3 UDMHIs. The age and gender distribution of the users of each UDMHI was compared with that of the other UDMHIs as well as with that of the overall US veteran population using chi-square tests. Information on the total number of users, the country they were in, and the devices they used to access the UDMHIs was also collected and reported.
Results
In 2021, the 3 UDMHIs together recorded 29,306 unique users. The estimated age range and gender were available for 24.12% (7068/29,306) of those users. Each UDMHI’s age and gender distribution significantly differed from that of the other UDMHIs and from that of the overall US veteran population (P<.001 on all chi-square tests). Women and younger age groups were overrepresented among UDMHI users compared with the overall US veteran population. The majority of devices used to access the UDMHIs were desktop or laptop devices, although a substantial proportion of devices used were mobile devices (10,199/29,752, 34.28%). Most users (27,789/29,748, 93.41%) were located in the United States, with users from Canada, the United Kingdom, and Australia accounting for another 2.61% (775/29,748) of total users.
Conclusions
Our use of Google Analytics data provided useful information about the users of 3 free and publicly available UDMHIs provided by the US Department of Veterans Affairs. Although our findings should be considered in light of the limitations of autonomously collected web analytics data, they still offer useful information for health care policy makers, administrators, and UDMHI developers.
... A significant noninferiority test allows for the conclusion that the teletherapy condition is noninferior to in-person treatment. There are no commonly accepted standard margins for the variables in question, but nearly all prior research on the current constructs has utilized Cohen's d = 0.5 (Morland, 2010;Norwood et al., 2018). Noninferiority analyses were performed using the package TOSTER (Lakens, 2017). ...
Objective:
The current study aimed to inform the varied and limited research on clinical variables in the context of teletherapy. Questions remain about the comparative quality of therapeutic alliance and clinical outcome in the context of teletherapy compared to in-person treatment.
Methods:
We utilized a cohort design and a noninferiority statistical approach to study a large, matched sample of clients who reported therapeutic alliance as well as psychological distress before every session as part of routine clinical practice at a university counseling center. A cohort of 479 clients undergoing teletherapy after the emergence of the COVID-19 pandemic was compared to a cohort of 479 clients receiving in-person treatment before the onset of the pandemic. Tests of noninferiority were conducted to investigate the absence of meaningful differences between the two modalities of service delivery. Client characteristics were also examined as moderators of the association between modality and alliance or outcome.
Results:
Clients receiving teletherapy showed noninferior alliance and clinical outcome when compared to clients receiving in-person psychotherapy. A significant main effect on alliance was found with regard to race and ethnicity. A significant main effect on outcome was found with regard to international student status. Significant interactions on alliance were found between cohort and current financial stress.
Conclusions:
Study findings support the continued use of teletherapy by demonstrating commensurate clinical process and outcome. Yet, it will be important for providers to be aware of existing mental health disparities that continue to accompany psychotherapy - in person and via teletherapy. Results and findings are discussed in terms of research and clinical implications. Future directions for researching teletherapy as a viable treatment delivery method are also discussed.
... Many of the evidence-based treatments for anger are based on cognitive-behavior therapy (CBT), and meta-analytic reviews of these interventions have found medium to large effect sizes for their effects on anger (Lee & DiGiuseppe, 2018). Trials of CBT for anger among veterans with PTSD have also found medium to large effect sizes (Morland et al., 2010;Shea et al., 2022;Van Voorhees et al., 2021). However, attrition rates for the CBT conditions have been as high as 50% (Shea et al., 2022) and 44% (Van Voorhees et al., 2021). ...
Objective: Problematic anger is commonly reported among veterans with posttraumatic stress disorder (PTSD) and is associated with numerous psychosocial impairments. There is a clear need to develop innovative and effective anger interventions. One of the cognitive mechanisms associated with anger is the hostile interpretation bias, which is the tendency to interpret ambiguous interpersonal situations as hostile. The current study presents a successive cohort design methodology to develop and refine a mobile treatment application, entitled Mobile Anger Reduction Intervention (MARI), which uses interpretation bias modification techniques to modify hostile interpretation bias. Method: Two cohorts (total N = 13) of veterans with PTSD and problematic anger used the MARI application for 4 weeks. After each cohort, qualitative and quantitative data were used to modify the MARI application. The intervention is described, as well as the qualitative and quantitative findings and subsequent changes made to the mobile application based on participant feedback. Results: Treatment adherence was high (90% of participants completed all sessions). Participants reported that they found the treatment helpful and easy to use and experienced improvements in hostile interpretation bias and problematic anger. Conclusions: This study demonstrates the utility of a successive cohort treatment design for the development of mobile interventions.
... The remote treatment helped the patients to distance themselves from the events; furthermore, the setting was experienced as less fraught with feelings of shame. Previous study results already indicated the effectiveness of treating post-traumatic stress disorder (PTSD) in a distance setting [54,55] and described it as a viable alternative compared to the face-to-face setting [56]. By contrast, other respon-dents in our study considered the remote treatment of traumatized patients to be more difficult, as it did not enable patients to be supported as well, e.g., in the case of dissociative disorders. ...
The outbreak of the COVID-19 pandemic and associated measures to contain the SARS-CoV-2 coronavirus required a change in treatment format from face-to-face to remote psychotherapy. This study investigated the changes experienced by Austrian therapists when switching to psychotherapy at a distance. A total of 217 therapists participated in an online survey on changes experienced when switching settings. The survey was open from 26 June until 3 September 2020. Several open questions were evaluated using qualitative content analysis. The results show that the setting at a distance was appreciated by the therapists as a possibility to continue therapy even during an exceptional situation. Moreover, remote therapy offered the respondents more flexibility in terms of space and time. Nevertheless, the therapists also reported challenges of remote therapy, such as limited sensory perceptions, technical problems and signs of fatigue. They also described differences in terms of the therapeutic interventions used. There was a great deal of ambivalence in the data regarding the intensity of sessions and the establishment and/or maintenance of a psychotherapeutic relationship. Overall, the study shows that remote psychotherapy seems to have been well accepted by Austrian psychotherapists in many settings and can offer benefits. Clinical studies are also necessary to investigate in which contexts and for which patient groups the remote setting is suitable and where it is potentially contraindicated.
... However, most of these service members continued to report aggression after treatment, suggesting that treatments that more directly focus on hostility may be needed. Cognitive-behavioral anger management treatments in which hostile attributions are typically a target have shown efficacy for reducing anger among individuals with PTSD (Miles, Kent et al., 2020;Morland et al., 2010;see, Taft et al., 2012see, Taft et al., for a review, 2016 although few of these studies directly measured aggression; one pilot study that addressed these limitations showed marginally significant effects of CBT for anger and aggression among veterans (Shea et al., 2013). Lastly, the Strength at Home intervention that directly targets IPV was less effective for veterans with AUD (Hocking et al., 2021), suggesting that integrated treatments for co-occurring PTSD, AUD, and aggression may be more effective at reducing aggression than interventions that treat any condition alone. ...
History of childhood maltreatment is common among military veterans, particularly those with posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD). Childhood maltreatment is associated with negative psychosocial outcomes, including use of aggression during adulthood. Prior research has identified maladaptive cognitions as a key mediating variable in the association between early life trauma and aggression. Given the high rates of comorbid PTSD and AUD among veterans and the increased risk of aggression when these conditions co-occur, it is critical to examine malleable intervention targets, such as maladaptive cognitions, for this population. The current secondary analyses examined the mediating role of hostile cognitions on the associations between childhood maltreatment and adulthood aggression in a sample of dually diagnosed veterans. Participants were veterans with co-occurring PTSD and AUD (N = 73) who were enrolled in a larger randomized controlled laboratory trial. Participants completed self-report measures of childhood maltreatment, hostile cognitions, and aggressive behavior. Three models were tested to examine the mediating effect of hostility on the associations between childhood maltreatment, abuse, and neglect on aggression. Results indicated that hostility fully mediated the effect of maltreatment on aggression and partially mediated the effect of childhood abuse on aggression. The effect of childhood neglect on aggression was nonsignificant. Hostile cognitions may be a critical intervention target for veterans with co-occurring PTSD and AUD and history of childhood maltreatment, particularly for those who have experienced higher levels of childhood abuse.
... However, reviews of the literature indicate it is a safe and effective option for increasing access to mental health care (Fletcher et al., 2018). Looking to the extant literature on groupbased telehealth treatments, the emphasis on participation is wellfounded as difficulties developing a connection to the facilitator and other group members have been reported (Batastini and Morgan, 2016;Morland et al., 2010;Zhou et al., 2016). Similarly, in relation to the learning theme, education research has previously highlighted some challenges with using web-based video conferencing systems including technical glitches, students often unintentionally interrupting each other and teaching techniques requiring constant modification (Al-Samarraie, 2019). ...
Background
Video-telehealth delivery of trauma-based care is promising and may help address structural and perceptual barriers to receiving support. However, existing evidence relies heavily on samples from adult populations. There is potential to transfer existing child and adolescent trauma interventions to a video-telehealth delivery format; but, this requires careful consideration. The aim of this project was to adapt a group-based intervention called Teaching Recovery Techniques for online delivery and investigate the usability of the new intervention format.
Methods
A qualitative needs assessment was performed (n = 3 intervention leaders, 4 youth), followed by participatory workshops and advisory panel consultation to generate adaptation recommendations. Usability testing was performed in two cycles; the first tested the adapted manual with intervention leaders (n = 5), and the second tested newly developed digital resources with youth (n = 5).
Results
The needs assessment uncovered a number of issues that, when generating recommendations, were distilled into three topics: safety, participation and learning. Recommendations included safety rules, an emergency response protocol, communication strategies, and guidance on group composition and intervention delivery. Usability testing indicated acceptability but highlighted the need for more detailed and explicit guidance, particularly on safety processes.
Discussion
The present study demonstrates the potential for delivery format to affect intervention feasibility and acceptability, and provides recommendations that can be used to guide the transfer of other group-based mental health interventions to an online format. The young people, parents and professionals involved in the project provided rich and varied perspectives, which illustrated the value of broad stakeholder engagement.
... One of these is that of Brouzos (2021c), in which the therapeutic alliance had the smallest increase. This is consistent with previous research on the online group mode, where a lower level of therapeutic alliance was observed in the online than in the in-person intervention (Morland et al., 2010). More research is needed on this point, as it was previously stated by Weinberg et al. (2020), considering how the therapeutic factors are the transversal aspects which represent the core focus to evaluate the quality of the intervention. ...
Considering the emerging need to face the negative impact of the pandemic on mental health, social support, and access to health services, it became a critical issue to adapt to online group settings, and create new group interventions to face the developing distress during this time. The aim of the current study is to investigate the main findings on OPGI conducted during the COVID-19 pandemic from March 2020 until March 2022, with a particular focus on: a) the therapeutic group factors; b) what kind of OPGI works and for whom; c) settings and emerging dimensions. In accordance with PRISMA guidelines, we performed a systematic review on scientific databases (PsychINFO, PubMed, Web of Science and EBSCO) searching for studies published between March 2020 and March 2022. “Group intervention” or “group therapy” or “group treatment” crossed with “COVID-19” and synonymous, were used as keywords. Internet based intervention was used as an eligibility criteria during the full-text screening. A total of 1326 articles were identified, of which 24 met the inclusion criteria. Among all studies, with different participants and different orientations, data extracted supported psychological online group interventions as an effective approach to reducing psychological distress and increasing psychological resources in the interpersonal field. Our findings also showed that COVID-19 has led to new needs and issues, that require the investigation of new dimensions for online psychological interventions. Methodological and clinical implications will be discussed through a descriptive table related to setting characteristics. Recommendations are made for future research.
... 4,18,19 Randomized controlled trials have also found telehealth to be as effective as in-person behavioral health care for the treatment of PTSD, 20 bulimia, 21 and even anger management. 22 Additional concerns that have potentially hindered the uptake of telehealth for behavioral health treatment are beliefs that telehealth negatively impacts the therapeutic alliance or the degree to which clinicians can effectively build rapport with their patients, and that patients would not want to engage in this type of treatment. Concerns have been cited that detecting nonverbal cues such as fidgeting, crying, poor hygiene, or signs of intoxication may be more challenging through telehealth and that maintaining eye contact and experiencing disruptions to conversation flow due to technology would be detrimental to care. ...
The COVID-19 pandemic has highlighted the urgent need for behavioral health care services. A substantial portion of mental health care transitioned to virtual care during the COVID-19 pandemic, remains virtual today, and will continue that way in the future. Mental health needs continue to grow, and there has been growing evidence showing the efficacy of virtual health for behavioral health conditions at the system, provider, and patient level. There is also a growing understanding of the barriers and challenges to virtual behavioral health care.
... Indeed, an increasing number of studies have documented the efficacy and effectiveness of videoconferencing psychotherapy (VCP) for mental health disorders [26,29,30,32,33]. Moreover, a handful of studies have documented the non-inferiority of VCP when compared to gold-standard treatments [34][35][36][37][38]. All reviews have highlighted the need for more randomized controlled trials for mental health disorders that have not yet been studied [26,29,38], such as GAD. ...
Delivering psychotherapy by videoconference has been studied in a number of clinical trials, but no large controlled trial has involved generalized anxiety disorder (GAD). This multicenter randomized controlled non-inferiority trial was conducted to test if cognitive-behavior psychotherapy delivered by videoconference (VCP) is as effective as cognitive-behavior psychotherapy delivered face-to-face, using a strict margin of tolerance for non-inferiority. A total of 148 adults received a 15-session weekly manualized program. The treatment was based on the intolerance of uncertainty model of GAD. The impact of treatment was assessed using primary (GAD severity), secondary (worry, anxiety, and intolerance of uncertainty) and tertiary (general functioning) variables measured before and after treatment and at 6-month and 12-month follow-ups. Results showed that: (a) the treatment was effective; (b) VCP for GAD was statistically non-inferior to face-to-face psychotherapy on primary, secondary and tertiary measures at all assessment points; (c) change in intolerance of uncertainty significantly predicted change in the primary outcome measure over and above important clinical factors common to all psychotherapies (motivation, working alliance, perceived therapist competence, and client satisfaction). These findings support the use of VCP as a promising treatment option for adults with GAD. Clinical trial registry: ISRCTN#12662027.
... For example, treatments that focus on reducing irritability/aggression or insomnia may be needed. Cognitive-behavioral therapy for anger is commonly offered to service members and veterans with aggression and produces small to moderate effect-size reductions in aggression (Morland et al., 2010). More recent research suggests that Strength at Home, a trauma-informed group treatment for veterans who have engaged in interpersonal violence based on the social information processing model (Taft et al., 2016), and emotion regulation treatments (Miles, Kent, et al., 2020) may also be useful in reducing irritability/aggression as both found moderate reductions in aggressive behaviors. ...
Objective: Evidence-based psychotherapies are efficacious at reducing posttraumatic stress disorder (PTSD) symptoms, but military and veteran samples improve less than civilians. The objective of this secondary analysis of two clinical trials of cognitive processing therapy (CPT) was to determine if hyperarousal symptoms were more resistant to change compared with other PTSD symptom clusters in active duty service members. Method: Service members completed the PTSD Checklist for the DSM–5 (PCL-5) pre- and post-CPT. Symptoms were coded present if rated 2 (moderate) or higher on a 0–4 scale. Cutoffs for reliable and clinically significant change classified 21%, 18%, and 61% of participants as recovered, improved, and suboptimal responders, respectively. Data analyses focused on the posttreatment status of symptoms that were present at baseline to determine their persistence as a function of treatment outcome. Generalized linear mixed effects models with items treated as a repeated measure estimated the proportions who continued to endorse each symptom and compared hyperarousal symptoms with symptoms in other clusters. Results: Among improved participants, the average hyperarousal symptom was present in 69% compared with 49% for symptoms in other clusters (p < .0001). Among recovered patients, hyperarousal symptoms were present for 26%, while symptoms in the reexperiencing (2%), avoidance (3%), and negative alterations (4%) clusters were almost nonexistent (p < .0001). Conclusions: Even among service members who recovered from PTSD after CPT, a significant minority continue to report hyperarousal symptoms while other symptoms remit. Hyperarousal symptoms may require additional treatment.
... The use of videoconferencing for delivering mental health treatment presents some challenges and opens new possibilities for creating a strong alliance. Some clinicians report difficulty judging non-verbal behavior (Thomas et al., 2021) and hold a belief that technological disruptions may be a barrier to developing rapport (Cowan et al., 2019;Morland et al., 2010). Collaboratively deciding on the client's goals and the tasks to be accomplished may be more difficult because providers feel they cannot adequately "reach" clients or gather information via videoconferencing needed to agree, align, and form a consensus (Cataldo et al., 2021). ...
Digital mental health services leverage technology to increase access to care, yet less is known about the quality of therapeutic relationships in a virtual setting. This study examined components of therapeutic alliance (a mechanism underlying successful treatment) and its association with beneficial treatment outcomes in a real-world, virtual setting. The objective is to examine (1) participant ratings of components of therapeutic alliance with providers in a virtual setting, (2) changes in subjective well-being and depressive symptoms among participants who began care with elevated depressive symptoms, and (3) the association between components of alliance and changes in participants’ well-being. Adults ( N = 3,087, M age = 36 ± 9 years, 54% female) across the world with access to digital mental health benefits who engaged in videoconference sessions with a licensed therapist (18%, 555/3,087), certified coach (65%, 2,003/3,087), or both (17%, 529/3,087) between Sept. 29, 2020 and Oct. 12, 21. Participants completed 2 adapted items from the Working Alliance Inventory (goals and bonds subscales) after each session, and ratings were averaged across visits (Cronbach’s ɑ = .72). Participants’ World Health Organization-Five (WHO-5) Well-Being Index scores at the start and end of the study period were used to measure changes in subjective well-being. Descriptive and inferential statistics were conducted to examine average alliance ratings across demographics and utilization types and the association between alliance and well-being. The median adapted therapeutic alliance score was 4.8 (range: 1–5) and did not differ by age, country, or baseline well-being ( P s > .07). Females reported higher components of alliance than males (4.88 vs. 4.67, P = .01). Participants utilizing telecoaching reported higher components of alliance than those utilizing teletherapy or both telecoaching and teletherapy (4.83 v. 4.75, P = .004), though effect sizes were negligible. Among those with elevated baseline depressive symptoms ( n = 835), participants reported an average WHO-5 increase of 15.42 points (95% CI 14.19–16.65, P < .001, Cohen d = 1.06) with 58% (485/835) reporting clinical recovery and 57% (481/835) reporting clinical improvement in depressive symptoms. Higher components of therapeutic alliance scores predicted greater well-being at follow-up ( b = 2.04, 95% CI 0.09–3.99, P = .04) after controlling for age, sex, baseline WHO-5, and number of days in care ( R 2 = .06, P < .001). Exploratory analyses indicated this association did not differ by utilization type, baseline well-being, or session utilization ( P s > .34). People with access to one-on-one videoconferencing care via a digital mental health benefit formed a strong bond and sense of alignment on goals with both coaches and therapists. Higher components of alliance scores were associated with improvements in subjective well-being among participants who began care with elevated depressive symptoms, providing evidence that a positive bond and goal alignment with a provider are two of many factors influencing virtual care outcomes. Continued focus on the quality of therapeutic relationships will ensure digital mental health services are patient-tailored as these platforms expand equitable access to evidence-based care.
... In addition, anger is a problem area that may be associated with less perceived stigma than PTSD, anxiety or depression and hence assessing for anger in military contexts may be more likely to generate accurate self-reporting. The translation and implementation implications of these findings indicate the need to ensure that anger assessment is routinely included in clinical assessment and measurement approaches and that clinicians are cognisant of, and trained in treatment approaches with the existing evidence base now being used and tested with active and ex-serving veteran populations (Cash et al., 2018;Deffenbacher, 2011;Morland et al., 2010). Note. ...
Background
Problem Problem anger is increasingly identified as an important issue, and may be associated with suicidality and violence. This study investigates the relationship between problem anger, suicidality, and violence amongst veterans and military personnel.
Methods
Cross-sectional survey data from n = 12,806 military personnel and veterans were subject to analyses. These considered the weighted prevalence of Problem Problem anger, while further analyses of veterans (n = 4326) considered risk factors and co-occurrence with other psychiatric conditions. Path analyses examined inter-relationships involving anger, violence and suicidality.
Results
There were 30.7% of veterans and 16.4% of military personnel that reported past month Problem Problem anger, while 14.9% of veterans and 7.4% of military personnel reported physical violence. There were higher levels of suicidality among veterans (30.3%), than military personnel (14.3%). Logistic regression models indicated that PTSD was the strongest risk factor for problem anger (PCL-5, OR = 21.68), while there were small but substantial increases in anger rates associated with depression (OR = 15.62) and alcohol dependence (OR = 6.55). Path models indicated that problem anger had an influence on suicide attempts, occurring primarily through suicidal ideation, and an influence on violence. Influences of problem anger on suicidal ideation and violence remained significant when controlling for co-occurring mental health problems.
Conclusions
Problem Problem anger, violence, and suicidality are common and inter-related issues among military personnel and veterans. Problem anger is a unique correlate of suicidality, supporting the need for anger to be included as part of violence and suicide risk assessment, and clinician training.
... It usually refers to video-calls, which enable interactive, live, and colorful two-way communication (7). Randomized controlled trials comparing video-based interventions with face-to-face (FTF) interventions have shown that in most of the disorders examined-depression (8) anxiety (9), post-trauma (10), eating disorders (11), substance abuse (12), and suicide prevention (13)-the outcomes are comparable. Moreover, other studies have suggested that mental health care provided via video calls is equivalent to FTF interventions for creating and maintaining a solid rapport, and a satisfying therapeutic relationship between physicians and patients (14,15). ...
Background
Although telemedicine care has grown in recent years, telepsychiatry is growing at a slower pace than expected, because service providers often hamper the assimilation and expansion of telepsychiatry due their attitudes and perceptions. The unified theory of acceptance and use of technology (UTAUT) is a model that was developed to assess the factors influencing the assimilation of a new technology. We used the UTAUT model to examine the associations between the attitudes and perceptions of psychiatrists in Israel toward telepsychiatry and their intention to use it.
Methods
An online, close-ended questionnaire based on a modified UTAUT model was distributed among psychiatrists in Israel. Seventy-six questionnaires were completed and statistically analyzed.
Results
The behavioral intention of Israeli psychiatrists to use telepsychiatry was relatively low, despite their perceptions of themselves as capable of high performance with low effort. Nonetheless, they were interested in using telepsychiatry voluntarily. Experience in telepsychiatry, and to a lesser extent, facilitating conditions, were found to be positively correlated with the intention to use telepsychiatry. Psychiatrists have a positive attitude toward treating patients by telepsychiatry and perceive its risk as moderate.
Discussion
Despite high performance expectancy, low effort expectancy, low perceived risk, largely positive attitudes, high voluntariness, and the expectancy for facilitating conditions, the intention to use telepsychiatry was rather low. This result is explained by the low level of experience, which plays a pivotal role. We recommend promoting the facilitating conditions that affect the continued use of telepsychiatry when initiating its implementation, and conclude that it is critical to create a sense of success during the initial stages of experience.
... There are surprisingly few controlled studies of such treatments in veterans. Further, existing studies are limited by small samples (Chemtob et al., 1997;Donahue et al., 2017;Elgoben et al., 2021;Shea et al., 2013), or no control group (Donahue et al., 2017;Gerlock, 1994;Kalkstein et al., 2018;Linkh & Sonnek, 2003;Morland et al., 2010). In a prior study (Shea et al., 2013) we piloted a cognitivebehavioral treatment (Novaco, 2001) that we adapted for OEF/OIF veterans (cognitive behavioral intervention-CBI) and found that CBI showed significantly more improvement than an active supportive therapy control group. ...
Background
Problems with anger and aggression affect many veterans who have deployed to a warzone, resulting in serious impairment in multiple aspects of functioning. Controlled studies are needed to improve treatment options for these veterans. This randomized controlled trial compared an individually delivered cognitive behavioral therapy adapted from Novaco's Anger Control Therapy to a manualized supportive therapy to control for common therapeutic factors.
Methods
Ninety-two post-911 veterans deployed during Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), or Operation New Dawn (OND) with moderate to severe anger problems were randomized to receive the cognitive behavioral intervention (CBI) or the supportive intervention (SI). Anger, aggression, multiple areas of functioning and quality of life were assessed at multiple time points inclu\ding 3- and 6-month follow-up.
Results
Hierarchical linear modeling (HLM) analyses showed significant treatment effects favoring CBI for anger severity, social and interpersonal functioning, and quality of life. The presence of a PTSD diagnosis did not affect outcomes.
Conclusions
CBI is an effective treatment for OEF/OIF/OND veterans with anger problems following deployment, regardless of PTSD diagnosis.
... In some cases, clinicians use telehealth to supplement in-person treatment. Previous research has shown that telehealth reduces patient-incurred costs and time associated with travel (Rabinowitz et al., 2010) and improves accessibility of mental healthcare for those living in rural areas (Manfredi et al., 2005;Morland et al., 2010;Weiner et al., 2011). Some even argue that remote treatment is superior to in-person consultations for some patients (Pakyurek et al., 2010;Storch et al., 2011). ...
The heightened acuity in anxiety and depressive symptoms catalyzed by the COVID-19 pandemic presents an urgent need for effective, feasible alternatives to in-person mental health treatment. While tele-mental healthcare has been investigated for practicability and accessibility, its efficacy as a successful mode for delivering high-quality, high-intensity treatment remains unclear. This study compares the clinical outcomes of a matched sample of patients in a private, nation-wide behavioral health treatment system who received in-person, intensive psychological treatment prior to the COVID-19 pandemic (N = 1,192) to the outcomes of a distinctive group of patients who received telehealth treatment during the pandemic (N = 1,192). Outcomes are measured with respect to depressive symptoms (Quick Inventory of Depressive Symptomatology-Self-Report; QIDS-SR) and quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire; Q-LES-Q). There were no significant differences in admission score on either assessment comparing in-person and telehealth groups. Patients in the partial hospitalization level of care stayed longer when treatment was remote. Results suggest telehealth as a viable care alternative with no significant differences between in-person and telehealth groups in depressive symptom reduction, and significant increases in self-reported quality of life across both groups. Future research is needed to replicate these findings in other healthcare organizations in other geographical locations and diverse patient populations.
... Notably, participants in telehealth groups experienced similar treatment outcomes relative to in-person service provision. In terms of group process factors, a number of the identified studies examined the impact of teleconference delivery on therapeutic alliance (Batastini & Morgan, 2016;Frueh et al., 2007;Morland et al., 2010). In each of these studies, participants who experienced teleconference interventions reported small decreases in therapeutic alliance, compared to in-person groups. ...
Shortly following the temporary nationwide school dismissal amid COVID-19, the current exploratory case-study evaluated the feasibility of two engagement strategies delivered during group teletherapy: Class Dojo and opportunities to respond (OTR). Three elementary students with emotional and behavioral difficulties participated. An A-B-A design was used to evaluate the effects of Class Dojo on student engagement with therapist-delivered OTRs. Due to one student’s poor response to the contingency, an A-B-C design was used to evaluate the additive effect of student-delivered OTRs on his engagement. Results indicated moderate to high rates of student attendance, and consistently high rates of engagement for two students. When students delivered OTRs, the student who initially struggled to engage demonstrated an increase in engagement. Practical issues are discussed and recommendations are considered for future research on increasing student engagement during online settings
Most healthcare systems are striving to improve access to timely, evidence-based, and cost-friendly healthcare, particularly for mental disorders. Telemental health video improves access to care regardless of the point-of-service or barriers involved, and it is effective across age, diagnosis, and populations. Asynchronous technologies like mobile health are also effective modes of service delivery to a variety of settings and populations. Early evidence-based intervention is easier to distribute via telehealth and is particularly helpful for very young children and their families, diverse populations, and others with medical disadvantages. Research is needed on how to implement and evaluate synchronous and asynchronous technologies for clinical care and training, as well as across cultures and across users’ health, lifestyle, and clinical care experiences.
Background
The COVID-19 pandemic catalyzed an uptake in virtual care. However, the rapid shift left unanswered questions about the impact of virtual care on the quality of primary care and its appropriateness and effectiveness. Moving forward, health care providers require guidance on how best to use virtual care to support high-quality primary care.
Objective
This study aims to identify and summarize clinical studies and systematic reviews comparing virtual care and in-person care in primary care, with a focus on how virtual care can support key clinical functions such as triage, medical assessment and treatment, counseling, and rehabilitation in addition to the management of particular conditions.
Methods
We conducted a scoping review following an established framework. Comprehensive searches were performed across the following databases: Embase, MEDLINE, PsycInfo, Emcare, and Cochrane Database of Systematic Reviews. Other well-known websites were also searched. PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines were followed. Articles were selected by considering article type, language, care provided, intervention, mode of care delivery, and sample size.
Results
A total of 13,667 articles were screened, and 219 (1.6%) articles representing 170 studies were included in the review. Of the 170 studies included, 142 (83.5%) were primary studies, and 28 (16.5%) were systematic reviews. The studies were grouped by functions of primary care, including triage (16/170, 9.4%), medical assessment and treatment of particular conditions (63/170, 37.1%), rehabilitation (17/170, 10%), and counseling (74/170, 43.5%). The studies suggested that many primary care functions could appropriately be conducted virtually. Virtual rehabilitation was comparable to in-person care and virtual counseling was found to be equally effective as in-person counseling in several contexts. Some of the studies indicated that many general primary care issues could be resolved virtually without the need for any additional follow-up, but data on diagnostic accuracy were limited. Virtual triage is clinically appropriate and led to fewer in-person visits, but overall impact on efficiency was unclear. Many studies found that virtual care was more convenient for many patients and provided care equivalent to in-person care for a range of conditions. Studies comparing appropriate antibiotic prescription between virtual and in-person care found variable impact by clinical condition. Studies on virtual chronic disease management observed variability in impact on overall disease control and clinical outcomes.
Conclusions
Virtual care can be safe and appropriate for triage and seems equivalent to in-person care for counseling and some rehabilitation services; however, further studies are needed to determine specific contexts or medical conditions where virtual care is appropriate for diagnosis, management outcomes, and other functions of primary care. Virtual care needs to be adapted to fit a new set of patient and provider workflows to demonstrate positive impacts on experience, outcomes, and costs of care.
Objectives: Telemental health via videoconferencing (TMH-V) can overcome many of the barriers to accessing quality mental health care. Toward this end, in 2011, the U.S. Department of Veterans Affairs (VA) established the National Bipolar Disorders TeleHealth (BDTH) Program to provide expert mental health consultation and treatment to Veterans with bipolar spectrum disorders. Methods: Initial analyses of BDTH services suggested that participants had positive changes in quality-of-care indices and clinical outcomes; however, that evaluation was based on a limited sample of both participants and VA medical centers. We were able to confirm and expand upon those early results by using nearly eight times the number of participants and more than twice as many medical centers. Results: For the 2,456 Veterans who completed the intake to our program, there were significant improvements in some of the quality metrics (e.g., lithium use) and a 54% reduction in positive suicide screens (p < 0.05). The Veterans who completed the initial and postprogram assessments (n = 815) reported a 16.6% reduction in manic symptoms (p < 0.001), a 29.3% reduction in depressive symptoms (p < 0.001), and a 21.2% reduction in mood episodes (p < 0.001). Additionally, these Veterans demonstrated significant improvements (p < 0.001) in mental health-related quality of life between the two assessments. Conclusions: These analyses provide further support for the general effectiveness and safety of telemental health via videoconferencing. Future research should examine the generalizability of these findings across various subgroups (e.g., minority patients, patients in rural areas), populations, and health care systems.
Posttraumatic stress Disorder (PTSD) is seen in a substantial proportion of
individuals experiencing trauma. The last few decades have been significant in terms of PTSD-related research. However, a quantitative charting of the evolution in evidence-based treatment modalities for PTSD is lacking. Our research seeks to address this gap.
Introduction
Difficulty controlling anger is a common postdeployment problem in military personnel. Chronic and unregulated anger can lead to inappropriate aggression and is associated with behavioral health, legal, employment, and relationship problems for military service members. Military-related betrayal (e.g., military sexual assault, insider attacks) is experienced by over a quarter of combat service members and is associated with chronic anger and aggression. The high level of physical risk involved in military deployments make interconnectedness and trust in the military organization of utmost importance for survival during missions. While this has many protective functions, it also creates a vulnerability to experiencing military-related betrayal. Betrayal is related to chronic anger and aggression. Individuals with betrayal-related injuries express overgeneralized anger, irritability, blaming others, expectations of injustice, inability to forgive others, and ruminations of revenge. Current approaches to treating anger and aggression in military populations are inadequate. Standard anger treatment is not trauma-informed and does not consider the unique cultural context of anger and aggression in military populations, therefore is not well suited for anger stemming from military-related betrayal. While trauma-informed interventions targeting anger for military personnel exist, anger outcomes are mixed, and aggression and interpersonal functioning outcomes are poor. Also, these anger interventions are designed for patients with posttraumatic stress disorder. However, not all military-related betrayal meets the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-5 definition of trauma, though it may still lead to chronic anger and aggression. As a result, these patients lack access to treatment that appropriately targets the function of their anger and aggression.
Materials and Methods
This manuscript describes rationale, design, and methodology of a pilot clinical trial examining Countering Chronic Anger and Aggression Related to Trauma and Transgressions (CART). CART is a transdiagnostic, transgression-focused intervention for military personnel who have experienced military-related betrayal, targeting chronic anger and aggression, and improving interpersonal relationships. The pilot study will use an interrupted timeseries design, where participants are randomized to a 2-, 3-, or 4-week minimal contact waitlist before starting treatment. This design maximizes the sample size so that all participants receive the treatment and act as their own control, while maintaining a robust design via stepped randomization. This trial aims to (1) test the acceptability and feasibility of CART, (2) test whether CART reduces anger and aggression in military personnel with a history of military-related betrayal, and (3) test whether CART improves interpersonal functioning.
Results
The primary feasibility outcome will be the successful recruitment, enrollment, and initiation of 40 participants. Primary outcome measures include the Client Satisfaction Survey-8, the State Trait Anger Expression Inventory-2, Overt Aggression Scale-Modified, and the Inventory of Interpersonal Problems-Short Version.
Conclusion
If outcomes show feasibility, acceptability, and initial effectiveness, CART will demonstrate a culturally relevant treatment for chronic anger, the most frequent postdeployment problem, in a sample of active duty service members who have suffered a military betrayal. The DoD will also have an evidence-based treatment option focusing on interpersonal functioning, including relationships within the military and within families.
Objective
This naturalistic, nonblinded, nonrandomized study examined the efficacy of multimodal treatment including intensive cognitive-behavioral therapy (CBT) for pediatric obsessive-compulsive disorder (OCD) delivered via telehealth (TH) compared with a matched sample of youth treated in person (IP).
Method
Patients included 1,286 youth ages 7 to 17 inclusive (643 TH, 643 IP) who received TH or IP in either partial hospitalization (n = 818) or intensive outpatient (n = 468) programs. Changes in patient-rated OCD symptoms and quality of life from pretreatment to posttreatment were examined.
Results
TH patients were discharged with a statistically higher Children’s Yale-Brown Obsessive-Compulsive Scale Self-Report score than IP patients, although this group difference (1.4) was not clinically significant. Quality-of-life scores at discharge did not significantly differ between TH patients and IP patients. Treatment response was robust attesting to the broad applicability of the treatment model.
Conclusion
Youth receiving CBT via TH responded both well and comparably to youth treated IP, offering a viable access path forward. These findings extend the reach of CBT for pediatric OCD. Concerted efforts must now be made to improve CBT availability for families for whom financial, insurance, geographical, and other barriers preclude access at present.
Diversity & Inclusion Statement
We worked to ensure that the study questionnaires were prepared in an inclusive way. We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. We actively worked to promote sex and gender balance in our author group. While citing references scientifically relevant for this work, we also actively worked to promote sex and gender balance in our reference list. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list.
Skype is often used for psychotherapy, especially where face-to-face alternatives are unavailable. Some suggest that Skype is not suitable, because of concerns about confidentiality. We believe it is at least as secure as many other ways psychotherapists communicate with clients .
The COVID-19 international crisis has challenged us all in health care systems around the world. But, in military and veteran health care system, it may appear that the challenges are far greater. For example, military health care providers and soldiers have additional responsibility of deploying to defend the nation. Even, when soldiers are not at war, the day-to-day routine involves long hours, coupled with stressful field training exercise. In addition, military personnel typically relocate or move very three to four years from one duty assignment to another. In this chapter, suggestions are made for future research and clinical applications as part of a response to the COVID-19 challenges in the unique military and veteran health clinics. The need to improve treatment engagement and support for health care workers in military and veteran hospitals are provided.KeywordsVeteransMilitaryCOVID-19Health psychology
Anger Management Education (AME) is a growing genre of Family Life Education and Extension that shows promise in helping individuals manage the frequency and intensity of their anger. The majority of research using AME, however, has primarily examined outcomes from high-risk populations such as incarcerated populations, delinquent youth, and couples in relationship duress. This study examines the perceived benefits and experiences of 36 Latino adult participants in the RELAX: Alternatives to Anger family life education program. Five themes emerged using data from five focus group interviews depicting positive evaluative findings among participants, including (1) anger management strategies, (2) understanding anger, (3) improved relationships, (4) social support, and (5) cultural influence of anger. Implications for developing and implementing AME programming for Latino audiences are described.
Research on post-traumatic stress disorder (PTSD) has burgeoned since its introduction in DSM-III in 1980. PTSD is conceptualised as a disorder of recovery and has been regarded as intrusion-driven, disordered, anxiety. However, recently there has been a call for explanatory theories of PTSD that better capture the complexity of the condition. Problematic anger is now recognised as an important aspect of PTSD in most sufferers. It is a key predictor of the development, maintenance and severity of PTSD and may be the principal impediment to successful treatment. Nevertheless, the psychological mechanisms underlying the relationship between PTSD and anger are not well understood. This chapter reviews evidence that imagery is an important mechanism within this relationship and is fundamental to the experience of traumatic stress reactions. Imagery is directly related to the prevalence of intrusions in PTSD and is highly correlated with posttraumatic anger. Further, visual imagery with angry content has profound psycho-physiological effects, magnifies the intensity of experienced anger and, ultimately, mediates the experience of PTSD itself. This review elucidates the linkages between angry imagery and PTSD symptomatology and offers propositions for adapting imagery-based PTSD interventions to the treatment of anger-affected PTSD.
Group treatment of trauma-related problems was popularized with the introduction of “rap groups” for combat veterans in the 1960s. Since this era, substantial advances have been made in individual psychosocial treatment approaches for trauma-related disorders, including the development and testing of several empirically supported treatments. Unfortunately, group treatments for trauma-related disorders have lagged behind these efforts, owing to considerable methodological issues that are intrinsic to the study of group therapy. This gap in our knowledge is problematic as the group approach is frequently used in clinical settings. In this chapter, we will briefly review what is known about group treatment for trauma-related psychological disorders and describe the advantages of group treatment relative to individual-format therapies. Also, clinical aspects of group treatment for trauma survivors will be discussed, including various facets of clinical lore about treating trauma-related symptoms in a group setting. Finally, we will summarize key directions for clinical applications of group treatments for trauma-related disorders, as well as needed research directions.
Military occupational exposures are varied and the health effects from these exposures may accumulate over time, causing health concerns in Veterans. However, there are currently no comprehensive exposure assessment tools to assess these military exposures. In this report, we present findings from an ongoing study conducted remotely using telehealth technologies to assess the associations between military exposures and health measures. Veterans were recruited for the study and following enrollment, study participants completed remote data collection by (1) completing web surveys, (2) undergoing remote cognitive performance assessment and (3) wearing a wrist actigraphy device for seven days to examine sleep measures. Past military exposures were assessed using the Veteran-Military Occupational Assessment Tool (V-MOAT) which is a detailed survey that assesses military occupational exposures across well-defined occupational and environmental medicine domains of chemical, physical, biological, ergonomic/injury, and psychosocial hazards. Preliminary findings reveal that while longer military service duration and exposure duration were associated with better self-reported health measures and cognitive performance, military exposure frequency was more associated with poor self-reported health measures. Additionally, the exposure duration and service duration were negatively associated with the sleep efficiency and total sleep time respectively. These findings suggest that longer periods of military occupational exposures may not be as detrimental to health as higher exposure frequency.KeywordsEnvironmental exposureMilitary exposure assessmentRemote assessmentTelehealthVeteran healthMilitary healthSleep quality
Introdução: Dentre as inúmeras possibilidades que um indivíduo possui de experienciar e expressar a raiva ou a ira, não é raro que o sentimento fuja do controle e termine em hostilidade e agressões, podendo gerar consequências importantes na vida de uma pessoa e de outros ao seu redor. Diante disso, torna-se fundamental a aplicação de técnicas comprovadamente eficazes, objetivando uma maior qualidade de vida ao indivíduo e às pessoas que com ele convivem. Objetivos: Identificar as principais técnicas no manejo da raiva em adultos. Método: Revisão sistemática de artigos científicos de estudos clínicos. Resultados: Nove estudos clínicos randomizados com utilização de técnicas psicológicas para o manejo da ira foram utilizados na análise. A Terapia Cognitivo-Comportamental mostrou-se predominante nas intervenções analisadas e provou-se eficaz para o controle da ira. Conclusão: Técnicas cognitivo-comportamentais, em especial a psicoeducação e a reestruturação cognitiva, são as ferramentas mais frequentemente usadas para o manejo da raiva em distintos grupos clínicos de pacientes, com resultados positivos na regulação emocional.
The progressive escalation in military suicides, along with a substantial increase in post-traumatic stress diagnosis among active military personnel and veterans, has become a significant humanitarian, societal, and cultural concern. Such a defining moment illuminates the need for timely and innovative treatment approaches for combat-related post-traumatic stress. This research explored depth psychological practices within short-term, group-based treatment programs. Using a phenomenological research method, interviews were conducted with six former combat veteran alumni of these programs to gather new insights and understanding into their lived experience. Informants described meaningful reductions in post-traumatic stress, moral injury, and treatment-resistance, while treatment completion rates increased significantly. Research findings suggest depth psychological practices do exhibit compelling potential as valuable, or formidable treatment approaches, alongside current evidence-based treatments. Based on the findings of this preliminary exploration future research is warranted on depth psychological treatments and group-based programs for combat-related post-traumatic stress.
This systematic review synthesizes the evidence on pretreatment patient characteristics and program features associated with treatment retention, response, and remission in military populations with posttraumatic stress disorder (PTSD).
Telemental health (TMH) conducted via videoconferencing allows for the real-time delivery of mental health care when patients and providers are at a distance. TMH can be provided from larger hospitals to smaller clinics lacking mental health services, as well as to nonclinical locations such as prisons, schools, community centers, and increasingly, directly to patients’ homes. Patients and providers can connect via a variety of video-enabled devices, including smartphones, tablets, and desktop or laptop computers. A full spectrum of mental health services has been successfully provided via TMH, ranging from individual and group psychotherapy, to psychiatric medication management, diagnostic consultation, and neuropsychological assessment. Over its 60-year history, TMH has evolved from a relative novelty to a common mode of care delivery that is becoming increasingly integrated into health-care systems worldwide. This chapter will provide an overview of TMH, including factors related to effectiveness, safety, and uptake on a global scale.
The coronavirus pandemic expanded the adoption of virtual financial planning, or tele-financial planning practices, as it's referred to in this paper. Unfortunately, limited empirical research on telefinancial planning exists to guide planners through this transition. However, there are similarities between financial planning and counseling; therefore, a systematic literature review on tele-mental health interventions was conducted to provide guidance for financial planning practices and future research. Research suggests the efficacy of tele-mental health is comparable to face-to-face delivery while creating greater efficiency for the therapist and the patient. The breadth and severity of conditions treated suggest that this delivery method is a viable channel, not a convenient stopgap for extraordinary circumstances or lower-value engagements. These findings suggest financial planners might leverage a virtual delivery channel to provide effective recommendations while expanding their reach and providing an experience that is less stressful and more convenient. The operational efficiencies experienced in tele-mental health suggest that financial planners could also improve the efficiency of their practices. Planners should proactively ensure that all clients have the resources and knowledge to engage in a virtual capacity and review their data security measures. For the financial planning profession to advance, practitioners cannot solely rely on research and best practices from related disciplines. Thus, this paper serves as a call for further study on telefinancial planning.
FOREWORD Substance use and abuse often coexist with anger and violence. Data from the Substance Abuse and Mental Health Services Administration's National Household Survey on Drug Abuse, for example, indicated that 40 percent of frequent cocaine users reported engaging in some form of violent behavior. Anger and violence often can have a causal role in the initiation of drug and alcohol use and can also be a consequence associated with substance abuse. Individuals who experience traumatic events, for example, often experience anger and act violently, as well as abuse drugs or alcohol. Clinicians often see how anger and violence and substance use are linked. Many substance abuse and mental health clients are victims of traumatic life events, which, in turn, lead to substance use, anger, and violence. Despite the connection of anger and violence to substance abuse, few treatments have been developed to address anger and violence problems among people who abuse substances. Clinicians have found the dearth of treatment approaches for this important issue disheartening. To provide clinicians with tools to help deal with this important issue, the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration is pleased to present Anger Management for Substance Abuse and Mental Health Clients: A Cognitive Behavioral Therapy Manual.
Because ethnoracial minorities are a growing part of the U.S. population yet are underrepresented in the psychopathology literature, we reviewed the evidence for differences in prevalence and treatment of posttraumatic stress disorder (PTSD) in African Americans, Latino Americans, Asian and Pacific Islander Americans, and American Indians. With respect to prevalence, Latinos were most consistently found to have higher PTSD rates than their European American counterparts. Other groups also showed differences that were mostly explained by differences in trauma exposure. Many prevalence rates were varied by subgroup within the larger ethnoracial group, thereby limiting broad generalizations about group differences. Regarding service utilization, some studies of veterans found lower utilization among some minority groups, but community-based epidemiological studies following a traumatic event found no differences. Finally, in terms of treatment, the literature contained many recommendations for culturally sensitive interventions but little empirical evidence supporting or refuting such treatments. Taken together, the literature hints at many important sources of ethnoracial variation but raises more questions than it has answered. The article ends with recommendations to advance work in this important area.
We included 50 between-group studies with control groups and 7 studies with only within-group data in a meta-analysis of adult anger treatments. Overall, we examined 92 treatment interventions that incorporated 1,841 subjects. Results showed that subjects who received treatment showed significant and moderate improvement compared to untreated subjects and a large amount of improvement when compared to pretest scores. In the group of controlled studies significant heterogeneity of variance and significant differences among effect sizes for different dependent variable categories were found. Anger interventions produced reductions in the affect of anger, reductions in aggressive behaviors, and increases in positive behaviors. An analysis of follow-up data suggested that treatment gains were maintained.
Empirical evidence of a relationship between combat-related PTSD and increased anger is lacking. In this study, 24 veterans of the Vietnam War with posttraumatic stress disorder (PTSD) scored significantly higher on an Anger factor comprising multiple measures of anger than did comparison groups of 23 well-adjusted Vietnam combat veterans and 12 noncombat Vietnam-era veterans with psychiatric diagnoses. In contrast, the 3 groups did not differ significantly on orthogonal factors, one of which comprised cognitive impulsivity measures and the other of which reflected motor impulsivity. Changes in heart rate in response to provocation loaded positively on the Anger factor and negatively on the 2 Impulsivity factors. Concurrent depression and trait anxiety did not have an effect on level of anger in individuals with PTSD. These empirical findings support and extend the clinical evidence regarding PTSD and anger.
We describe a typology of regulatory deficits associated with anger in combat-related posttraumatic stress disorder (PTSD). Cognitive, arousal, and behavioral domain deficits in anger regulation were observed clinically in PTSD patients with high levels of anger who were participating in a multi-year trial of a structured anger treatment. We also describe a category of patients whose anger type we have termed "ball of rage." These patients exhibit regulatory deficits in all three domains of anger regulation. We offer a conceptual framework to advance the understanding of anger associated with PTSD and to guide its effective treatment.
Cocaine abusers who fail to manage anger appropriately may have greater difficulty achieving and maintaining abstinence. We conducted a pilot study to examine an anger management group treatment in a sample of 59 men and 32 women with a diagnosis of cocaine dependence. Participants attended a 12-week anger management group treatment and background substance abuse treatment. Levels of anger, negative affect, and anger control were measured at baseline, weekly during treatment, and at 3-month posttreatment follow-up. Levels of anger decreased and anger control increased between baseline and the end of treatment. End-of-treatment changes were maintained at follow-up. These findings were not moderated by gender, age, or psychiatric medication use. In the absence of a randomized control group, we cannot make conclusive statements regarding the effectiveness of the anger management group treatment. However, these preliminary findings demonstrate the need for a randomized clinical trial to test the efficacy of the anger management group treatment.
The authors reviewed the literature related to telepsychiatry-applications of videoconferencing technology for mental health care-which offers hope for an affordable means of solving long-standing workforce problems, particularly in geographical areas where specialist providers are not readily available.
To conduct a comprehensive review of the telepsychiatry literature, the authors searched the MEDLINE database (1970 to February 2000), using the keywords telepsychiatry, telemedicine, and videoconferencing. Studies were selected that included the use of videoconferencing technology for the provision of any form of mental health care services.
Psychiatric interviews conducted by telepsychiatry appear to be generally reliable, and patients and clinicians generally report high levels of satisfaction with telepsychiatry. A significant limitation of the literature is the lack of empirical research on telepsychiatry, especially cost analyses and clinical outcome studies. The authors outline a research agenda addressing the procedural and methodological issues that should shape future research: study design, outcome measurement, consideration of patient characteristics, and program design.
In 1988, the National Vietnam Veterans Readjustment Study (NVVRS) of a representative sample of 1200 veterans estimated that
30.9% had developed posttraumatic stress disorder (PTSD) during their lifetimes and that 15.2% were currently suffering from
PTSD. The study also found a strong dose-response relationship: As retrospective reports of combat exposure increased, PTSD
occurrence increased. Skeptics have argued that these results are inflated by recall bias and other flaws. We used military
records to construct a new exposure measure and to cross-check exposure reports in diagnoses of 260 NVVRS veterans. We found
little evidence of falsification, an even stronger dose-response relationship, and psychological costs that were lower than
previously estimated but still substantial. According to our fully adjusted PTSD rates, 18.7% of the veterans had developed
war-related PTSD during their lifetimes and 9.1% were currently suffering from PTSD 11 to 12 years after the war; current
PTSD was typically associated with moderate impairment.
Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) have endured high combat stress and are eligible for 2 years of free military service-related health care through the Department of Veterans Affairs (VA) health care system, yet little is known about the burden and clinical circumstances of mental health diagnoses among OEF/OIF veterans seen at VA facilities.
US veterans separated from OEF/OIF military service and first seen at VA health care facilities between September 30, 2001 (US invasion of Afghanistan), and September 30, 2005, were included. Mental health diagnoses and psychosocial problems were assessed using International Classification of Diseases, Ninth Revision, Clinical Modification codes. The prevalence and clinical circumstances of and subgroups at greatest risk for mental health disorders are described herein.
Of 103 788 OEF/OIF veterans seen at VA health care facilities, 25 658 (25%) received mental health diagnosis(es); 56% of whom had 2 or more distinct mental health diagnoses. Overall, 32 010 (31%) received mental health and/or psychosocial diagnoses. Mental health diagnoses were detected soon after the first VA clinic visit (median of 13 days), and most initial mental health diagnoses (60%) were made in nonmental health clinics, mostly primary care settings. The youngest group of OEF/OIF veterans (age, 18-24 years) were at greatest risk for receiving mental health or posttraumatic stress disorder diagnoses compared with veterans 40 years or older.
Co-occurring mental health diagnoses and psychosocial problems were detected early and in primary care medical settings in a substantial proportion of OEF/OIF veterans seen at VA facilities. Targeted early detection and intervention beginning in primary care settings are needed to prevent chronic mental illness and disability.
Evidence-based practices designed for large urban clinics are not necessarily portable into smaller isolated clinics. Implementing practice-based collaborative care for depression in smaller primary care clinics presents unique challenges because it is often not feasible to employ on-site psychiatrists.
The purpose of the Telemedicine Enhanced Antidepressant Management (TEAM) study was to evaluate a telemedicine-based collaborative care model adapted for small clinics without on-site psychiatrists.
Matched sites were randomized to the intervention or usual care.
Small VA Community-based outpatient clinics with no on-site psychiatrists, but access to telepsychiatrists. In 2003-2004, 395 primary care patients with PHQ9 depression severity scores > or = 12 were enrolled, and followed for 12 months. Patients with serious mental illness and current substance dependence were excluded.
Medication adherence, treatment response, remission, health status, health-related quality of life, and treatment satisfaction.
The sample comprised mostly elderly, white, males with substantial physical and behavioral health comorbidity. At baseline, subjects had moderate depression severity (Hopkins Symptom Checklist, SCL-20 = 1.8), 3.7 prior depression episodes, and 67% had received prior depression treatment. Multivariate analyses indicated that intervention patients were more likely to be adherent at both 6 (odds ratio [OR] = 2.1, p = .04) and 12 months (OR = 2.7, p = .01). Intervention patients were more likely to respond by 6 months (OR = 2.0, p = .02), and remit by 12 months (OR = 2.4, p = .02). Intervention patients reported larger gains in mental health status and health-related quality of life, and reported higher satisfaction.
Collaborative care can be successfully adapted for primary care clinics without on-site psychiatrists using telemedicine technologies.
The use of interactive videoconferencing to provide psychiatric services to geographically remote regions, often referred to as telepsychiatry, has gained wide acceptance. However, it is not known whether clinical outcomes of telepsychiatry are as good as those achieved through face-to-face contact. This study compared a variety of clinical outcomes after psychiatric consultation and, where needed, brief follow-up for outpatients referred to a psychiatric clinic in Canada who were randomly assigned to be examined face to face or by telepsychiatry.
A total of 495 patients in Ontario, Canada, referred by their family physician for psychiatric consultation were randomly assigned to be examined face to face (N=254) or by telepsychiatry (N=241). The treating psychiatrists had the option of providing monthly follow-up appointments for up to four months. The study tested the equivalence of the two forms of service delivery on a variety of outcome measures.
Psychiatric consultation and follow-up delivered by telepsychiatry produced clinical outcomes that were equivalent to those achieved when the service was provided face to face. Patients in the two groups expressed similar levels of satisfaction with service. An analysis limited to the cost of providing the clinical service indicated that telepsychiatry was at least 10% less expensive per patient than service provided face to face.
Psychiatric consultation and short-term follow-up can be as effective when delivered by telepsychiatry as when provided face to face. These findings do not necessarily mean that other types of mental health services, for example, various types of psychotherapy, are as effective when provided by telepsychiatry.
The therapeutic alliance concept has been confined primarily to the literature on individual psychotherapy. This paper formally introduces the concept into the family and marital therapy domain and presents various clinical hypotheses about the nature of the alliance and its role in familyand marital therapy. A systemic perspective is brought to bear on the concept within individual psychotherapy. A new, integrative definition of the alliance is presented that conceptualizes individual, couple and family therapy as occurring within the same systemic framework. The implications of this integrative-alliance concept for family, couple and individual therapy research are examined. Three new system-ically oriented scales to measure the alliance in individual, couple and family therapy are presented along with some preliminary data on their methodological characteristics.
Several interviews are available for assessing PTSD. These interviews vary in merit when compared on stringent psychometric and utility standards. Of all the interviews, the Clinician-Administered PTSD Scale (CAPS-1) appears to satisfy these standards most uniformly. The CAPS-1 is a structured interview for assessing core and associated symptoms of PTSD. It assesses the frequency and intensity of each symptom using standard prompt questions and explicit, behaviorally-anchored rating scales. The CAPS-1 yields both continuous and dichotomous scores for current and lifetime PTSD symptoms. Intended for use by experienced clinicians, it also can be administered by appropriately trained paraprofessionals. Data from a large scale psychometric study of the CAPS-1 have provided impressive evidence of its reliability and validity as a PTSD interview.
Four hundred and fifty college students rated the credibility of the rationales and procedural descriptions of two therapy, three placebo, and one component-control procedure frequently used in analogue outcome research. The rating scale was designed to assess both the credibility and the expectancy for improvement generated by the rationales. The results indicated that the control conditions were, in general, less credible than the therapy conditions. Implications for outcome research are briefly discussed.
The terms noninferiority and equivalence are often used interchangeably to refer to trials in which the primary objective is to show that a novel intervention is as effective as the standard intervention. The use of these designs is becoming increasingly relevant to mental health research. Despite the fundamental importance of these designs, they are often poorly understood, improperly applied, and subsequently misinterpreted. In this article, the authors explain noninferiority and equivalence designs and key methodological and statistical considerations. Decision points in using these designs are discussed, such as choice of control condition, determination of the noninferiority margin, and calculation of sample size and power. With increasing utilization of these designs, it is critical that researchers understand the methodological issues, advantages, disadvantages, and related challenges.
Telepsychiatry can be used in two kinds of psychiatric emergencies: one-time clinical events and public health situations associated with mass disaster. Emergency telepsychiatry delivered by videoconferencing has the potential to improve patient care in many settings. Although experience is limited, it has been found to be safe and effective, as well as satisfactory to both emergency department staff and the psychiatric patients treated. The development of comprehensive and standardized guidelines is necessary. There has been little use of acute telemedicine in disaster situations to date. However, telemedicine is becoming part of routine emergency medical response planning in many jurisdictions. Emergency telepsychiatry has the potential to reduce emergency department overcrowding, provide much needed care in rural areas and improve access to psychiatric care in the event of a natural or man-made disaster.
The extent to which the results of randomized controlled trials can be expected to generalize to clinical populations has been the subject of much debate. To examine this issue among a population of individuals diagnosed with posttraumatic stress disorder (PTSD), the clinical characteristics of Veterans Affairs (VA) patients with PTSD were compared to the eligibility criteria for clinical trials of psychosocial treatments for PTSD. Administrative data for 239,668 patients who received a diagnosis of PTSD within the VA healthcare system during the 2003 fiscal year were compared with inclusion and exclusion criteria of 31 clinical trials for PTSD. Based on available data, all patients appeared to be eligible for at least one study, and half (50%) were eligible for between 16 and 21 (50% or more) of the 31 studies examined. The studies for which the most veterans with PTSD would have been eligible targeted combat-related trauma or did not specify type of trauma in their eligibility criteria. Veterans who exhibited psychotic symptoms (3% of the sample) were ineligible for most, but not all, of the studies. However, most veterans with comorbid Axis I conditions, such as depression, anxiety disorders, and substance use disorders, were eligible for multiple studies. These findings, which indicate that the existing literature on the efficacy of psychosocial treatment may inform the treatment of the majority of veterans who present with PTSD, have applications for the design of future clinical trials and for consultation of the literature regarding appropriate treatments for veterans with PTSD.
Telemedicine--the use of information and telecommunications technologies to provide and support health care when distance separates the participants--is receiving increasing attention not only in remote areas where health care access is troublesome but also in urban and suburban locations. Yet the benefits and costs of this blend of medicine and digital technologies must be better demonstrated before today's cautious decisionmakers invest significant funds in its development. Telemedicine presents a framework for evaluating patient care applications of telemedicine. The book identifies managerial, technical, policy, legal, and human factors that must be taken into account in evaluating a telemedicine program. The committee reviews previous efforts to establish evaluation frameworks and reports on results from several completed studies of image transmission, consulting from remote locations, and other telemedicine programs. The committee also examines basic elements of an evaluation and considers relevant issues of quality, accessibility, and cost of health care. Telemedicine will be of immediate interest to anyone with interest in the clinical application of telemedicine.
The contribution to outcome of two group-process factors, group cohesion and group therapeutic alliance, was tested in the context of a randomized, controlled treatment trial for borderline personality disorder. Group members from four time-limited groups of an experimental model of group psychotherapy completed measures of group cohesion and group alliance at prespecified intervals across the 30-session therapy. Outcome was measured in terms of psychiatric symptoms, social adaptation, and indicators of behavioral dysfunction. The results showed that cohesion and alliance were correlated significantly and separately contributed to outcome on most of the dependent measures. Stepwise regression analyses showed, however, that when compared with cohesion, alliance accounted for more outcome variance on the dependent measures. The clinical implications of the findings and the limitations of the study are discussed.
This study examined the effects of combat exposure and posttraumatic stress disorder (PTSD) on dimensions of anger in Vietnam veterans. Vietnam combat veterans were compared with Vietnam era veterans without war zone duty on the Multidimensional Anger Inventory (MAI). Combat veterans were not significantly more angry than their veteran peers who did not serve in Southeast Asia. Additionally, various parameters of war zone duty were not highly associated with anger scores. However, combat veterans with PTSD scored significantly higher than veterans without PTSD on measures of anger arousal, range of anger-eliciting situations, hostile attitudinal outlook, and tendency to hold anger in. These results suggest that PTSD, rather than war zone duty, is associated with various dimensions of angry affect.
In response to new developments and interest in the area of telepsychiatry, literature on this topic has greatly increased over the past three years. Because of this increase, the authors conducted a literature review of telepsychiatry to update a previously published review that covered the years 1970 to 2000.
A search was conducted on the MEDLINE, PsycINFO, and Telemedicine Information Exchange (TIE) databases for literature published from March 2000 to March 2003 on telepsychiatry applications, using the following terms: telepsychiatry, telepsychology, telemental health, videoconferencing, and video conferencing.
Sixty-eight publications were identified over this three-year period, exceeding the 63 publications identified in the previous literature review. The authors summarize the results of findings in six areas: novel clinical demonstrations and current program descriptions; the reliability of clinical assessments; clinical outcomes; satisfaction of patients and clinicians; cost and cost-effectiveness; and legal, regulatory, and ethical issues. Studies describing existing programs and novel clinical applications support the belief that the use of telepsychiatry is expanding. Overall, studies continued to support the notion that telepsychiatry assessments can produce reliable results, telepsychiatric services can lead to improved clinical status, and patients and clinicians are satisfied with treatment delivered via telepsychiatry. Evidence supported the notion that telepsychiatry is a cost-effective means of delivering mental health services; however, this conclusion was based on limited studies of economic models of telepsychiatry programs. Also limited were papers on the topics of legal, regulatory, and ethical issues.
Despite the rapid increase in information on telepsychiatry, methodologically sound studies in the area of telepsychiatry are still infrequent.
Patients with post-traumatic stress disorder (PTSD) were randomly assigned to either an eight-week videoconferencing PTSD coping skills group or a traditional face-to-face PTSD coping skills group. Levels of attrition and compliance, patient satisfaction, clinician satisfaction and patients' retention of information were compared between the two conditions. Of the 41 referred veterans, 20 were eligible and agreed to participate in the study. Three of these participants withdrew from the study before randomization. By the end of the study, 89% of the patients remained in the videoconferencing group, whereas only 50% remained in the face-to-face group. Patients in the face-to-face group attended an average of 4.9 sessions and patients in the videoconferencing group attended 6.3 sessions (this difference was not significant). There was no difference between levels of patient satisfaction or clinician satisfaction at weeks 4 or 8. Patients' retention of information was similar in the two groups. The results show that videoconferencing can be used to provide coping skills groups for veteran patients with PTSD who reside in remote rural locations.
Despite the difficulties with successfully developing effective treatments for posttraumatic stress disorder (PTSD), very little research has been conducted on veterans' perceptions of satisfaction with the treatments they receive through the VA.
Our objective was to evaluate combat veterans' satisfaction with Veterans Affairs (VA) services and to evaluate the reliability and preliminary validity of a measure of patient satisfaction, the Charleston Psychiatric Outpatient Satisfaction Scale-VA PTSD Version, which was originally designed for general psychiatric outpatients.
Fifty-one combat veterans currently receiving specialty mental health care at a VA outpatient PTSD clinic were asked to complete two instruments designed to assess their satisfaction with services provided within the VA mental health and primary care clinics.
Data show that the reliability (alpha = 0.96 and 0.95) and validity of these two measures of patient satisfaction were good and indicate that veterans receiving specialty mental health care for PTSD rate their mental health and primary care quite positively.
These results provide preliminary support for the internal reliability and convergent validity of a novel measure of patient satisfaction for use with combat veterans suffering from PTSD and treated within a VA hospital specialty mental health clinic; the results also support the satisfaction of these patients with mental health and primary care services received through the VA.
The US military has conducted population-level screening for mental health problems among all service members returning from deployment to Afghanistan, Iraq, and other locations. To date, no systematic analysis of this program has been conducted, and studies have not assessed the impact of these deployments on mental health care utilization after deployment.
To determine the relationship between combat deployment and mental health care use during the first year after return and to assess the lessons learned from the postdeployment mental health screening effort, particularly the correlation between the screening results, actual use of mental health services, and attrition from military service.
Population-based descriptive study of all Army soldiers and Marines who completed the routine postdeployment health assessment between May 1, 2003, and April 30, 2004, on return from deployment to Operation Enduring Freedom in Afghanistan (n = 16,318), Operation Iraqi Freedom (n = 222,620), and other locations (n = 64,967). Health care utilization and occupational outcomes were measured for 1 year after deployment or until leaving the service if this occurred sooner.
Screening positive for posttraumatic stress disorder, major depression, or other mental health problems; referral for a mental health reason; use of mental health care services after returning from deployment; and attrition from military service.
The prevalence of reporting a mental health problem was 19.1% among service members returning from Iraq compared with 11.3% after returning from Afghanistan and 8.5% after returning from other locations (P<.001). Mental health problems reported on the postdeployment assessment were significantly associated with combat experiences, mental health care referral and utilization, and attrition from military service. Thirty-five percent of Iraq war veterans accessed mental health services in the year after returning home; 12% per year were diagnosed with a mental health problem. More than 50% of those referred for a mental health reason were documented to receive follow-up care although less than 10% of all service members who received mental health treatment were referred through the screening program.
Combat duty in Iraq was associated with high utilization of mental health services and attrition from military service after deployment. The deployment mental health screening program provided another indicator of the mental health impact of deployment on a population level but had limited utility in predicting the level of mental health services that were needed after deployment. The high rate of using mental health services among Operation Iraqi Freedom veterans after deployment highlights challenges in ensuring that there are adequate resources to meet the mental health needs of returning veterans.
This study examined rates, predictors, and course of probable posttraumatic stress disorder (PTSD) and depression among seriously injured soldiers during and following hospitalization.
The patients were 613 U.S. soldiers hospitalized following serious combat injury. Standardized screening instruments were administered 1, 4, and 7 months following injury; 243 soldiers completed all three assessments. Cross-sectional and longitudinal analyses of risk factors were performed. PTSD was assessed with the PTSD Checklist; depression was assessed with the Patient Health Questionnaire. Combat exposure, deployment length, and severity of physical problems were also assessed.
At 1 month, 4.2% of the soldiers had probable PTSD and 4.4% had depression; at 4 months, 12.2% had PTSD and 8.9% had depression; at 7 months, 12.0% had PTSD and 9.3% had depression. In the longitudinal cohort, 78.8% of those positive for PTSD or depression at 7 months screened negative for both conditions at 1 month. High levels of physical problems at 1 month were significantly predictive of PTSD (odds ratio=9.1) and depression at 7 months (odds ratio=5.7) when the analysis controlled for demographic variables, combat exposure, and duration of deployment. Physical problem severity at 1 month was also associated with PTSD and depression severity at 7 months after control for 1-month PTSD and depression severity, demographic variables, combat exposure, and deployment length.
Early severity of physical problems was strongly associated with later PTSD or depression. The majority of soldiers with PTSD or depression at 7 months did not meet criteria for either condition at 1 month.
Telepsychiatry, in the form of live interactive videoconferencing, is an emerging application for emergency psychiatric assessment and treatment and can improve the quality and quantity of mental health services, particularly for rural, remote and isolated populations. Despite the potential of emergency telepsychiatry, the literature has been fairly limited in this area.
Drawing on the combined clinical and administrative experiences of its authors, this article reviews the common administrative, legal/ethical and clinical issues that arise in emergency telepsychiatry.
An initial set of guidelines for emergency telepsychiatry is presented to generate further discussion to assist those who are considering establishing general telepsychiatry and/or emergency telepsychiatry services.
The practices and techniques of emergency telepsychiatry are relatively new and require further examination, modification and refinement so that they may be fully utilized within comprehensive mental health service systems.
We compared the efficacy of telepsychiatry and same-room treatment of combat-related post-traumatic stress disorder (PTSD) using cognitive behavioural therapy in 14 weekly, 90-min treatment sessions. Of 97 patients referred for study participation, 38 were randomized (17 into telepsychiatry, 21 into same-room), and approximately 25 (the number differed by instrument) had at least one post-baseline assessment. Measures of clinical and process outcomes were examined. No group differences were found on clinical outcomes at three-month follow-up. Satisfaction with treatment ratings was similar in both groups, with 'strong satisfaction' indicated by veterans in both modalities. Attendance and drop-out were similar in the two groups. The same-room group reported more comfort in talking with their therapist at post-treatment and had better treatment adherence. The results provide preliminary support for the use of telepsychiatry in the treatment of PTSD to improve access to care.
An accumulating body of empirical data suggests that current Department of Veterans Affairs (VA) psychiatric disability and rehabilitation policies for combat-related posttraumatic stress disorder (PTSD) are problematic. In combination, recent administrative trends and data from epidemiological and clinical studies suggest theses policies are countertherapeutic and hinder research efforts to advance our knowledge regarding PTSD. Current VA disability policies require fundamental reform to bring them into line with modern science and medicine, including current empirically supported concepts of resilience and psychiatric rehabilitation.
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