Article

Telemedicine for Anger Management Therapy in a Rural Population of Combat Veterans With Posttraumatic Stress Disorder: A Randomized Noninferiority Trial

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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.

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... Mental health services provided remotely, known as telemental health, have been the focus of considerable interest in recent years. Studies have examined the feasibility of medical management via video teleconferencing,(e.g., ( Himle et al., 2006 ;Nieves et al., 2009 )) and several noninferiority studies on PTSD-related telemental health have demonstrated comparable outcomes compared to in-person treatment ( Greene et al., 2008 ;Morland et al., 2009Morland et al., , 2010. Few studies, however, have addressed the telemedicine delivery of an intervention targeted to chronic insomnia. ...
... The difference between groups, in addition to being statistically non-inferior, is also of a magnitude that is not clinically meaningful. These results are partially consistent with a growing body of evidence that clinical services can be delivered using video telehealth technology without a loss of effectiveness for patients with insomnia ( Holmqvist et al., 2014 ;Lichstein et al., 2013 ) and other disorders ( Greene et al., 2008 ;Morland et al., 2010 ). Telehealth delivery of CBT-I is a means of increasing access to evidence-based treatment for insomnia by reducing barriers such as a lack of trained providers in many locations. ...
Article
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Background Insomnia is prevalent in veterans with PTSD but often goes untreated. Cognitive behavioral therapy for insomnia (CBT-I) is an efficacious treatment but many patients do not have access to this intervention. Clinical video telehealth provides a means of increasing access to care but there is a need to understand the effectiveness of care delivered using this modality. Methods Randomized non-inferiority trial comparing group CBT-I delivered between VA clinics over video telehealth to in-person treatment. 116 Veterans with PTSD received CBT-I over six weeks in a group format at a VA healthcare facility. The Insomnia Severity Index (ISI) was the primary outcome measure. Secondary outcomes included measures of sleep, PTSD severity and quality of life. The non-inferiority margin was defined as a difference in ISI change scores between groups ≥1.67 points. Results The mean(SD) improvement in the ISI was 6.48 (0.90) points for in-person treatment and 4.45 (0.98) points for telehealth treatment in intent-to-treat analyses. In both intent-to-treat and per-protocol analyses, the difference between these change scores of 2.03 had a confidence interval that included the non-inferiority margin of 1.67, supporting the hypothesis of non-inferiority. On secondary outcomes, there were significant improvements after treatment only in sleep quality and no between-group differences. Limitations The eligibility criteria were intentionally broad, so there were several potential confounding factors. Drop-out was also considerable, with only 54.3% of subjects in the in-person group and 46.9% in the telehealth group completing treatment. Conclusions Delivery of group CBT-I by clinical video telehealth to veterans with PTSD is non-inferior to in-person treatment, although overall efficacy of treatment was modest. Telehealth technology can increase access to care without sacrificing clinical gains.
... During CBT, providers introduce and practice therapeutic exercises with patients in session and assign patients to practice those exercises between sessions (i.e., homework). Some common in-session CBT exercises delivered via TMH that have been examined in prior literature include self-monitoring (Morland et al., 2010;Lichstein et al., 2013;Hobbs et al., 2018), exposure therapy (Choi et al., 2014;Acierno et al., 2016;Hobbs et al., 2018), coping and emotion regulation (Morland et al., 2010;Choi et al., 2014), problem solving (Choi et al., 2014;Hobbs et al., 2018), and motivational strategies (Ruskin et al., 2004;Liebmann et al., 2019) that support behavioral activation (Lichstein et al., 2013;Acierno et al., 2016), mindfulness (Lichstein et al., 2013), interpersonal skills (Owen, 2019), relaxation (Lichstein et al., 2013), and selfmanagement (Ruskin et al., 2004) therapies. Currently, there is little understanding of the use of these CBT exercises within realworld, TMH sessions (Mehrotra et al., 2016;Mehrotra et al., 2017;Shi et al., 2019). ...
... During CBT, providers introduce and practice therapeutic exercises with patients in session and assign patients to practice those exercises between sessions (i.e., homework). Some common in-session CBT exercises delivered via TMH that have been examined in prior literature include self-monitoring (Morland et al., 2010;Lichstein et al., 2013;Hobbs et al., 2018), exposure therapy (Choi et al., 2014;Acierno et al., 2016;Hobbs et al., 2018), coping and emotion regulation (Morland et al., 2010;Choi et al., 2014), problem solving (Choi et al., 2014;Hobbs et al., 2018), and motivational strategies (Ruskin et al., 2004;Liebmann et al., 2019) that support behavioral activation (Lichstein et al., 2013;Acierno et al., 2016), mindfulness (Lichstein et al., 2013), interpersonal skills (Owen, 2019), relaxation (Lichstein et al., 2013), and selfmanagement (Ruskin et al., 2004) therapies. Currently, there is little understanding of the use of these CBT exercises within realworld, TMH sessions (Mehrotra et al., 2016;Mehrotra et al., 2017;Shi et al., 2019). ...
Article
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Despite its effectiveness, limited research has examined the provision of telemental health (TMH) and how practices may vary according to treatment paradigm. We surveyed 276 community mental health providers registered with a commercial telemedicine platform. Most providers reported primarily offering TMH services to adults with anxiety, depression, and trauma-and stressor-related disorders in individual therapy formats. Approximately 82% of TMH providers reported endorsing the use of Cognitive Behavioral Therapy (CBT) in their remote practice. The most commonly used in-session and between-session (i.e., homework) exercises included coping and emotion regulation, problem solving, mindfulness, interpersonal skills, relaxation, and modifying and addressing core beliefs. CBT TMH providers had a higher odds of using in-session and homework exercises and assigning them through postal mail, email or fax methods, as compared to non-CBT TMH providers. TMH providers, regardless of treatment paradigm, felt that assigning homework was neither easy nor difficult and they believed their patients were somewhat-to-moderately compliant to their assigned exercises. CBT TMH providers also collected clinical information from their patients more often than non-CBT TMH providers. They reported being less satisfied with their method, which was identified most often as paper-based surveys and forms. Overall, TMH providers employ evidence-based treatments to their patients remotely, with CBT TMH providers most likely to do so. Findings highlight the need for innovative solutions to improve how TMH providers that endorse following the CBT treatment paradigm remotely assign homework and collect clinical data to increase their satisfaction via telemedicine.
... APA's Center for Workforce Studies has documented telehealth's growth. From 2000 to 2008, practicing psychologist's email use with clients for service delivery more than tripled and their use of videoconferencing with clients rose from 2% to 10% (Morland et al., 2010). ...
... A meta-analysis of 148 peer-reviewed publications examining the use of videoconferencing to deliver patient interventions showed high patient satisfaction, moderate-to-high clinician satisfaction, and positive clinical outcomes (Richardson et al., 2009). Moreover, several studies, including meta-analysis, have found comparable outcomes between internet-based therapy and faceto-face therapy with a range of clients and presenting issues (Barak et al., 2008;Frueh et al., 2007;Morland et al., 2010;Rees & Maclaine, 2015). Although many of these studies used videoconferencing, similar results have also been demonstrated comparing asynchronous messaging therapy such as text messaging plus Web or in-person intervention modalities, with stand-alone faceto-face therapy (e.g., Bergström et al., 2010;Spohr et al., 2015). ...
... 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. ...
Article
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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.
... Most research on telehealth treatment has either focused on individual therapy or general group therapy as a supportive healthcare service. In a 2012 systematic review on the feasibility, satisfaction, and outcomes of telehealth treatment using videoconferencing platforms, only 7 of the 42 empirical articles focused on a group therapy format (Backhaus et al., 2012), despite studies demonstrating group therapy effectiveness for a range of conditions, including depression and anxiety (Khatri et al., 2014), PTSD (Frueh et al., 2007;Morland et al., 2004), and comorbid anger and PTSD (Morland et al., 2010). In fact, the aforementioned 2012 review (Backhaus et al., 2012) suggested that telehealth psychotherapy treatment is comparable to inperson psychotherapy, while a subsequent 2019 systematic review confirmed that currently there is no evidence suggesting that either telehealth group-based treatment or in-person group-based treatment is superior to the other in terms of outcomes (Gentry et al., 2019). ...
Article
The rapid spread of COVID-19 and subsequent social distancing measures posed unprecedented challenges in providing mental health care and a swift transition of services to telehealth platforms. Social distancing measures create unique concerns for young people with social anxiety disorder who already struggle with social connection and isolation; therefore, the continuation of care via telehealth platforms is especially important for this population. To date, there is little literature regarding use of telehealth groups for this population and the current commentary aims to fill in this gap in the literature while also providing general guidelines for telehealth groups. The commentary discusses the delivery of an exposure-based cognitive behavioral therapy group for adolescents and young adults via telehealth and provides considerations, challenges, and benefits of conducting a group through a telehealth platform. In conjunction with clinically relevant examples and in-depth exposure discussions, we aim to provide guidance for youth-focused practitioners who are considering conducting groups in a telehealth format for a range of presentations.
... Studies of outpatient samples have found telehealth treatment to be both feasible and acceptable (see Bashshur et al., 2016;Hubley et al., 2016 for reviews). However, few studies directly compared patient satisfaction based on in-person and telehealth formats and the results have been mixed (Morland et al., 2010;Holden and Dew, 2008;Urness et al., 2006). ...
Article
Most research evaluating telehealth psychiatric treatment has been conducted in outpatient settings. There is a lack of research assessing the efficacy of telehealth treatment in more acute, intensive treatment settings such as a partial hospital. In the face of the COVID-19 pandemic, much of ambulatory behavioral health treatment has transitioned to a telehealth, or virtual, format. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared patient satisfaction of partial hospital services delivered via telehealth to in-person treatment provided to patients treated prior to the COVID-19 outbreak. The sample included 240 patients who were treated virtually from May, 2020 to October, 2020, and a comparison group of 240 patients who were treated in the in-person partial program a year earlier. Patients completed self-administered measures of patient satisfaction after the initial evaluation and at the end of treatment. For both the in-person and telehealth methods of delivering partial hospital level of care, patients were highly satisfied with the initial diagnostic evaluation and were optimistic at admission that treatment would be helpful. At the completion of treatment, both groups were highly satisfied with all components of the treatment program and almost all would recommend treatment to a friend or family member. Thus, patient satisfaction was as high with telehealth partial hospital treatment as with in-person treatment.
... The findings suggest that although PTSD treatments can significantly reduce anger symptoms (Cahill et al., 2003;Ford et al., 2018;Miles et al., 2020), individuals are likely to experience residual anger following PTSD treatment, and effect sizes tend to be smaller for reductions in anger than they are for PTSD symptoms (Ford et al., 2018;Miles et al., 2020;Schnurr & Lunney, 2019). There is evidence that angerspecific treatments, such as cognitive behavioral anger management interventions, are helpful in reducing problematic anger (Morland et al., 2010). Cognitive behavioral anger management interventions may also be effective in reducing hostility. ...
Article
Veterans with posttraumatic stress disorder (PTSD) often experience high levels of hostility. Although studies have found that PTSD is associated with poorer quality of life (QoL), increased functional impairment, lower levels of social support, and increased suicidal ideation, it is unclear if hostility impacts these domains in veterans with PTSD above and beyond the impact from PTSD and depressive symptoms. The present study aimed to examine whether hostility is related to several indices of poorer QoL and functioning after controlling for demographic characteristics, PTSD symptoms, and depressive symptoms. Participants (N = 641) were male U.S. veterans seeking PTSD treatment through a specialty clinic in the Veterans Affairs Healthcare System. Veterans completed the Davidson Trauma Scale for DSM‐IV (DTS), Personality Assessment Inventory (PAI), Quality of Life Inventory, and the Sheehan Disability Scale. Hierarchical regressions were conducted to examine the impact of PAI measures of hostility on QoL, functioning, social support, and suicidal ideation beyond DTS, depression, race, and age. After covarying for DTS total score, depression symptoms, age, and race, higher levels of hostility were significantly associated with higher degrees of functional impairment and lower degrees of social support, ΔR2 = .01 and ΔR2 = .02, respectively. Higher levels of hostility were significantly related to diminished functioning and lower social support beyond PTSD and depressive symptoms in veterans seeking treatment for PTSD. These findings highlight the importance of assessing and treating hostility in veterans with PTSD.
... 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). ...
Article
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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.
... With the COVID-19 pandemic, many behavioral health providers have gained experience in providing care by telehealth and healthcare systems have updated procedures and policies to support and streamline this model of care. Although research on groups delivered via telehealth is still limited, studies suggest that telehealth groups have similar outcomes to inperson groups (Gentry et al., 2019), and they have been used to reach patients living in rural areas (Morland et al., 2010). Participants in our sample tended to be well-educated and with higher household income levels, which helps in accessing care. ...
Article
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Spontaneous coronary artery dissection (SCAD) can occur as an atypical cause of myocardial infarction. Preliminary evidence suggests that SCAD patients experience high rates of post-event psychological distress. It is unknown whether psychosocial interventions may reduce the distress burden. Seven SCAD patients (mean age = 53.3 years) completed a CBT-based support group. All seven participants completed measures for anxiety, depression, and cardiac-related quality of life at baseline and post-intervention, and five participants completed measures at 3-month follow-up. Six of 7 participants scored above the clinical threshold on a measure of anxiety at baseline and posttreatment. At follow-up, 3 of 5 participants scored below the clinical threshold. For depression, 3 of 7 reported elevated depressive symptoms at baseline. By follow-up, 1 of 5 endorsed elevated depressive symptoms. This is the first known psychosocial intervention study of patients with SCAD. Anxiety symptoms improved for most patients by follow-up with some patients having improved depressive symptoms. Although the sample size is limited, this pilot study suggests a potential benefit of group psychosocial interventions for SCAD survivors.
... Similar to telehealth services provided for other medical domains, those focused on mental health (telemental health, TMH) can alleviate barriers that impact access to care while producing positive outcomes (Hilty et al., 2013;Jacobs et al., 2019). In addition to providing services to patients who may not have access to due location, finances or stigma associated with seeking treatment, TMH has demonstrated effectiveness for a variety of mental health concerns including anxiety, depression, PTSD and anger management (Lamb et al., 2019;Morland et al., 2010;Possemato et al., 2013;Salisbury et al., 2016;Zhou et al., 2020). ...
Article
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The benefits of telehealth for both patients and clinicians are well established, but little is known about patient therapeutic alliance with telehealth for mental health (TMH) services. In the present study, 50 paediatric patients participated in rating therapeutic alliance after receiving psychological services via videoconferencing or in person. Results indicated paediatric patients rated a high level of therapeutic alliance following psychological services provided through either modality. TMH resulted in higher show rates and allowed access to care for paediatric patients who may have otherwise gone unserved due to a variety of factors. Overall, results support that TMH was well received by paediatric patients and suggest it is an effective modality for providing mental health services to paediatric patients who would otherwise not have access to care due to barriers.
... This sample size was based on primary outcome timepoint of 6-months follow-up. Following previous PTSD noninferiority trials (Morland et al., 2010), we calculated that noninferiority between CBT-L and CBT-B would be defined as an end-point difference of less than 10 points on CAPS scores (Bryant et al., 2019). It was calculated that the noninferiority hypotheses would be supported if the 95% CI for the difference between conditions was less than the predefined noninferiority margin (Sealed Envelope Power Calculator). ...
Article
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Background Emergency service personnel experience elevated rates of posttraumatic stress disorder (PTSD). There are few controlled trials for PTSD in this population, and none report longer term effects of treatment. This study evaluated the benefits of cognitive behavior therapy (CBT) for PTSD in emergency service personnel who received either brief exposure (CBT-B) to trauma memories or prolonged exposure (CBT-L) 2 years following treatment. Methods One hundred emergency service personnel with PTSD were randomized to CBT-L, CBT-B, or Wait-List (WL). Following posttreatment assessment, WL participants were randomized to an active treatment. Participants randomized to CBT-L or CBT-B were assessed at baseline, posttreatment, 6-month, and 2-year follow-up. Both CBT conditions involved 12 weekly individual sessions comprising education, CBT skills building, imaginal exposure, in vivo exposure, cognitive restructuring, and relapse prevention. Reliving trauma memories occurred for 40 min per session in CBT-L and for 10 min in CBT-B. Results At the 2-year follow-up, there were no differences in PTSD severity (Clinician Administered PTSD Scale) between CBT-L and CBT-B. There were very large effect sizes for CBT-L (1.28, 95% confidence interval [CI] = 0.90–1.64) and CBT-B (1.28, 95% CI = 0.05–1.63) from baseline to 2-year follow-up. Conclusions This study highlights that CBT can be an effective treatment of PTSD in emergency service personnel using either prolonged or brief periods of reliving the trauma memory, and that these benefits can last for at least 2 years after treatment.
... 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. ...
Article
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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
... 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). ...
Article
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.
... Rural telemedicine has been shown to improve health care access and quality in various areas, ranging from trauma and critical care [15][16][17], family medicine [18], pediatrics [19], and cancer care [20]. In fact, several randomized controlled trials have reported that telemedicine-based care can lead to similar and potentially better outcomes compared to in-person care among rural patients [21,22]. ...
Preprint
BACKGROUND The COVID-19 pandemic has led to a notable increase in telemedicine adoption. Its impact on telemedicine utilization at a population level in rural and remote settings remains unclear. OBJECTIVE We aim to evaluate changes in the rate of telemedicine use among rural populations and identify patient characteristics associated with telemedicine use, prior to and during the pandemic. METHODS We conducted a repeated cross-sectional study on all rural telemedicine visits monthly and quarterly from January 2012 to June 2020 using administrative data from Ontario, Canada. We compared changes in utilization for residents of rural and urban regions of the province prior to and during the pandemic. RESULTS The rate of telemedicine visits among rural patients significantly increased from 11 visits per 1000 in December 2019 to 147 visits per 1000 in June 2020. A similar but steeper increase was seen among urban patients (7 visits per 1000 to 220 visits per 1000). CONCLUSIONS Telemedicine adoption grew in rural and remote areas during the COVID-19 pandemic and this increase was prevalent across various levels of rurality, age groups, and chronic conditions. Sharper increases in telemedicine visit rates were seen among patients residing in comparatively less rural regions.
... Health outcomes Literature reviews that CHBRP conducted for its previous reports on SB 289, AB 2507, and AB 744 identified a large number of studies that compared the effects of live video and in-person care on health outcomes (Ferrer-Roca et al., 2010;Fortney et al., 2015;Garcia-Lizana and Munoz-Mayorga, 2010;Harrison et al., 1999;Kairy et al., 2009;Morland et al., 2010Morland et al., , 2014Myers et al., 2015;Shukla et al., 2017;Wallace et al., 2004). These studies report that quality of life, clinical outcomes, and functional status, such as severity of depression symptoms, are similar between people who participate in live video and people who receive in-person care. ...
Technical Report
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The version of California Assembly Bill (AB) 32 analyzed by CHBRP would require coverage and reimbursement at parity with the equivalent in-person service for synchronous telehealth, including live video and telephone (audio-only) visits.
... Despite the consistently reported comparable benefits of telemental health across the literature in comparison to in-person service delivery, a common consensus regarding what constitutes effectiveness and how that is measured is still not well established. That said, many of the studies examined in this review used multiple approaches that were not consistent with each other to assess the diverse domains of the clinical and non-clinical outcomes of telemental health (Radloff 1977;Mair and Whitten 2000;Nelson et al. 2003;Ruskin et al. 2004;Norman 2006;O'Reilly et al. 2007;Morland et al. 2010;Spielberger 2010;Van Bastelaar et al. 2011;Deslich et al. 2013;Xie et al. 2013;Choi et al. 2014;King et al. 2014;Shore et al. 2014;Wang and Alexander 2014;Hubley et al. 2016;Hungerbuehler et al. 2016;Tarp et al. 2017;Zheng et al. 2017). There clearly is a lack of a standardised framework for evaluating telemental health programs, which limits consistent measurements and comparisons across initiatives, and may reduce the quality and generalizability of evaluations. ...
Article
Purpose: Although studies have examined the effectiveness of telemental health programs, optimal approaches for their evaluation remain unclear. We sought to review the outcomes used to evaluate telemental health programs. Methods: We conducted a literature search in PubMed and Google Scholar for peer-reviewed studies published between January 2010 until October 2019, and we excluded review articles, opinion papers, presentations, abstracts, and program report without data. Results: 1310 articles were identified, 34 of which were reviewed. Studies used a combination of non-clinical and clinical outcomes, most commonly engagement and impact rates, and standardised clinical measures. Very few studies examined technological feasibility, cost-effectiveness, and qualitative satisfaction reports. Conclusions: This review is the first to summarise approaches to evaluate telemental health programs. Strengths and weaknesses of the evaluation outcomes are discussed in this review, highlighting essential factors that should be taken into consideration when developing a standardised framework for the evaluation of future telemental health programs.
... Indeed, client ratings indicated a consistent preference for videoconferencing over in-person therapy. Only two studies reported higher alliance ratings in the in-person condition: one investigated group anger management for veterans with posttraumatic stress disorder, Morland et al., 2010) and the other was with teenagers diagnosed with seizure disorders and their parents (Glueckauf et al., 2002). Similarly, a recent study found no significant differences in the quality of empathy and therapeutic alliance across three modalities: in-person, telephone and videoconferencing (Reese et al., 2016). ...
Article
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The arrival of the coronavirus (COVID-19) pandemic has confronted us with a global and unprecedented challenge of community-wide psychological distress alongside reduced access to therapeutic services in the traditional face-to-face format, due to the need to self-isolate. This previously unimagineable set of circumstances provides a unique opportunity, and indeed an imperative, for videotherapy to fulfil its potential in addressing mental health and well-being needs from a distance. Historically, the uptake of videotherapy has been hindered by psychotherapist expectations of inferior therapeutic alliance and outcomes, in spite of considerable research evidence to the contrary. Research suggests that videotherapy provides a powerful pathway for clients to experience enhanced opportunities for self-expression, connection and intimacy. This more neutral therapeutic 'space' provides clients with multifarious opportunities for self-awareness, creative experience and collaboration, with potentially a greater sense of agency over their own experience. This paper explores ways in which videotherapy can lead to a revitalisation of the concept of the therapeutic relationship, in order to meet the challenges associated with COVID-19. A number of specific considerations for videotherapy adaptations and etiquette in the midst of COVID-19 are described.
... 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. ...
Article
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. ...
Article
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. ...
Article
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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.
... 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). ...
Article
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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.
... Yet, little is known about effective treatments in this population, and treatments targeting anger specifically are early in development. The few controlled studies targeting anger specifically have small sample sizes (12,13) or no comparison group (14)(15)(16). ...
Article
Introduction: Anger is an important clinical feature of posttraumatic stress disorder (PTSD) that can hamper recovery. We recently reported that intermittent theta burst stimulation (iTBS) demonstrated preliminary efficacy to reduce symptoms of posttraumatic stress disorder and major depression; here, we performed a secondary analysis testing whether iTBS reduced symptoms of anger over the course of iTBS treatment and compared to sham stimulation. Materials and methods: Fifty veterans with chronic PTSD received ten daily sessions of sham-controlled, double-blind iTBS (1800 pulses/session, once per weekday) targeting the right dorsolateral prefrontal cortex (intent-to-treat = 25 per group). Participants who completed the double-blind phase were offered another ten sessions of unblinded iTBS. Participants completed the Dimensions of Anger Reactions scale at pre-iTBS baseline, treatment midpoints, and endpoints of the blinded and unblinded phases, and at one-month after the last stimulation session. Correlations between anger, PTSD, depression, and sleep were also explored. Results: After the first week, during the double-blind phase, participants randomized to active stimulation reported significantly reduced anger compared to sham stimulation (p = 0.04). Participants initially randomized to sham appeared to catch-up to the point they no longer differed from those initially randomized to active iTBS when they received iTBS during the unblinded phase (p = 0.14). Anger reduction was maintained at one-month after iTBS in participants initially randomized to active stimulation (i.e., total of four weeks of iTBS). Conclusions: This secondary analysis suggests that iTBS might reduce anger in veterans with PTSD. Future studies focused on more granular level anger outcomes and effects of number of stimulation sessions are needed.
... The evidence-base for OVT in veteran populations continues to grow with results from randomised controlled trials (RCTs) demonstrating promising results, suggesting that veterans receiving treatment via OVT tend to experience a significant decrease in symptomology for a range of mental health problems, including depression [13,14], anxiety [14] and PTSD [15,16]. These improvements are not significantly different to those achieved by clients receiving treatment in-person. ...
Article
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Background Whilst treatment for mental health issues has traditionally been conducted in-person, advances in technology has seen a recent growth in the use of online video therapy services to help overcome access-to-care barriers faced by those living in rural locations and those unable to travel. These barriers are particularly apparent in the case of veteran populations, which is the focus of this review. Whilst the research investigating the efficacy of online video therapy to treat mental health issues among veterans is promising, widespread adoption and utilisation of this modality remains low with efforts often failing to progress past the pilot phase to implementation. This review focuses on the implementation of online video therapy in veteran mental health care settings and aims to identify the potential barriers and facilitators relevant to implementing the modality in military organisations. Methods A systematic search of three databases (PsycInfo, PubMed, and Web of Science) was conducted. To be eligible for inclusion, studies had to investigate the challenges, lessons learnt, or factors operating as barriers and/or facilitators to the implementation of online video therapy in veteran health care systems. Results The initial search revealed a total of 202 articles. This was reduced to 133 when duplicates were removed. After screening the titles and abstracts a further 70 articles were excluded leaving 63 to be retrieved for full review. A total of 10 studies were included in this review. The most commonly reported barriers were related to clinician concerns, logistical problems, and technology. Other barriers included access to resources as well as challenges posed by collaborations, policy and recruitment. Facilitators included experience using the modality and having dedicated staff responsible for promoting and managing the new service (e.g., on-site champions and telehealth technicians). Conclusions This review suggests that numerous barriers must be identified and addressed before attempting to implement an online video therapy service in veteran organisations. Further research is needed to establish best practice for implementation, particularly across geographically dispersed sites. It is hoped that the findings of this review will be used to help inform future implementation efforts and research initiatives in this space.
... 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. ...
Article
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). ...
Article
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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.
Article
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Background: Veterans have higher rates of PTSD and depression compared to the general population and experience substantial functional impairment. Impairment in social functioning has been a significant concern among Veterans, particularly rural Veterans, who have limited access to mental health care and are at risk for social isolation. Objective: A mixed-method study was implemented to evaluate the feasibility and effectiveness of webSTAIR, a web-based skills training programmeme, paired with home-based telehealth sessions. It was hypothesized that the programme would lead not only to reductions in PTSD and depression but also to improvements in social functioning. Method: Participants were 80 trauma-exposed Veterans enrolled in rural-serving VHA facilities with clinically elevated symptoms of either PTSD or depression. The study directed substantial outreach efforts to rural women Veterans and those who have experienced military sexual trauma (MST). Results: Significant improvements were obtained with PTSD and depression symptoms as well as in social functioning, emotion regulation, and interpersonal problems at post-treatment and 3-month follow-up. Ratings of therapeutic alliance were high as were reports of overall satisfaction in the programme. There were no differences by gender or MST status in symptom outcomes or satisfaction. Conclusions: The results support the feasibility and effectiveness of this integrated telehealth web-based skills training programme for both male and female Veterans as well as for those with and without MST. The focus on resource building and improved functioning make this programme of particular interest. Further testing is warranted.
Preprint
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Introduzione: Visto il periodo storico che tutto il mondo sta attraversando, ovvero quello della pandemia da COVD-19, questo lavoro si è incentrato sulla ricerca relativa alla telepsichiatria. Viene illustrato il metodo, l’efficacia, gli ambiti di applicazione, il setting e i vantaggi del metodo di applicazione relativamente ai disturbi psichiatrici, in ambito internazionale. Obiettivo: comprendere se la telepsichiatria fosse un metodo di cura del paziente con problemi psichiatrici adeguato e/o paragonabile alla terapia faccia a faccia. Comprendere come il setting potesse influenzare o meno le cure e capire come il metodo telepsichiatrico influisse sulle cure dei pazienti. Metodo: revisione della letteratura scientifica di pertinenza dal 2010 al 2020. Gli articoli sono stati selezionati mediante keywords coincidenti con “telepsychiatry”, “mental health”, “depression”, “anxiety”, “PTSD” e “mental disorder” su Google schoolar e PubMed. Le ricerche includono una vasta gamma di campioni, di età diverse e appartenenti sia alla popolazione femminile, sia alla popolazione maschile. Risultati: la revisione sistematica ha condotto a risultati soddisfacenti in tutti gli ambiti analizzati. Conclusioni: le ipotesi di ricerca, sono state avvalorate dagli studi analizzati in questo lavoro. In tal senso la telepsichiatria si è rivelata essere una metodologia valida ed efficace, al pari della terapia faccia a faccia e in taluni casi, anche migliore.
Article
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Veterans face a variety of stressors due to their military service and are more likely to develop psychological problems as a result. Research suggests that as many as half of veterans with mental health conditions go untreated due to barriers including lack of accessibility to services and stigma. The present study builds on previous research by using meta-analytic techniques to determine the effectiveness of telepsychology-delivered therapy with veterans. Empirical studies were included if they reported veteran-related outcome data on a psychological intervention used to treat a mental health condition remotely using either videoconferencing or telephone. Twenty-seven studies including 2,648 total participants (1,667 in treatment conditions and 981 in control conditions) met our inclusion criteria and were incorporated into our analysis. Twenty-five studies provided pre-post data to evaluate various therapy outcomes, and 18 studies used a randomized clinical trials (RCTs) design that allowed a comparison between telehealth and traditional in-person therapy. Publication bias was evaluated using correlations between sample and effect sizes for posttraumatic stress disorder (PTSD) and depression for pretest-posttest and RCT designs; risk was determined to be minimal. Weighted average pre-post effect sizes were moderate-to-strong for depression and trauma, and videoconferencing was more effective than telephone for depression (d = 0.86 and 0.46, respectively) and trauma (d = 1.00 and 0.51, respectively). Weighted average effect sizes computed from RCT studies suggest telepsychology is similarly effective as services provided face-to-face. More research is needed for telepsychology-delivered treatments for other mental health conditions faced by veterans. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Article
With the rapid shift to telemedicine brought on by the COVID-19 pandemic, physiatrists must get accustomed to the new technology and learn how to optimize their evaluations. For those practitioners managing patients with acquired brain injuries, which include stroke and traumatic brain injury, this can seem a daunting task given potential physical and cognitive barriers. However, as the authors discuss techniques to optimize visits, the aim is to illustrate how telehealth appointments can not only be comparable to in-person examinations but also may help increase outreach, compliance, and even satisfaction among this unique population.
Article
Background: People with a history of complex traumatic events typically experience trauma and stressor disorders and additional mental comorbidities. It is not known if existing evidence-based treatments are effective and acceptable for this group of people. Objective: To identify candidate psychological and non-pharmacological treatments for future research. Design: Mixed-methods systematic review. Participants: Adults aged ≥ 18 years with a history of complex traumatic events. Interventions: Psychological interventions versus control or active control; pharmacological interventions versus placebo. Main outcome measures: Post-traumatic stress disorder symptoms, common mental health problems and attrition. Data sources: Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 onwards); Cochrane Central Register of Controlled Trials (CENTRAL) (from inception); EMBASE (1974 to 2017 week 16); International Pharmaceutical Abstracts (1970 onwards); MEDLINE and MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (1946 to present); Published International Literature on Traumatic Stress (PILOTS) (1987 onwards); PsycINFO (1806 to April week 2 2017); and Science Citation Index (1900 onwards). Searches were conducted between April and August 2017. Review methods: Eligible studies were singly screened and disagreements were resolved at consensus meetings. The risk of bias was assessed using the Cochrane risk-of-bias tool and a bespoke version of a quality appraisal checklist used by the National Institute for Health and Care Excellence. A meta-analysis was conducted across all populations for each intervention category and for population subgroups. Moderators of effectiveness were assessed using metaregression and a component network meta-analysis. A qualitative synthesis was undertaken to summarise the acceptability of interventions with the relevance of findings assessed by the GRADE-CERQual checklist. Results: One hundred and four randomised controlled trials and nine non-randomised controlled trials were included. For the qualitative acceptability review, 4324 records were identified and nine studies were included. The population subgroups were veterans, childhood sexual abuse victims, war affected, refugees and domestic violence victims. Psychological interventions were superior to the control post treatment for reducing post-traumatic stress disorder symptoms (standardised mean difference -0.90, 95% confidence interval -1.14 to -0.66; number of trials = 39) and also for associated symptoms of depression, but not anxiety. Trauma-focused therapies were the most effective interventions across all populations for post-traumatic stress disorder and depression. Multicomponent and trauma-focused interventions were effective for negative self-concept. Phase-based approaches were also superior to the control for post-traumatic stress disorder and depression and showed the most benefit for managing emotional dysregulation and interpersonal problems. Only antipsychotic medication was effective for reducing post-traumatic stress disorder symptoms; medications were not effective for mental comorbidities. Eight qualitative studies were included. Interventions were more acceptable if service users could identify benefits and if they were delivered in ways that accommodated their personal and social needs. Limitations: Assessments about long-term effectiveness of interventions were not possible. Studies that included outcomes related to comorbid psychiatric states, such as borderline personality disorder, and populations from prisons and humanitarian crises were under-represented. Conclusions: Evidence-based psychological interventions are effective and acceptable post treatment for reducing post-traumatic stress disorder symptoms and depression and anxiety in people with complex trauma. These interventions were less effective in veterans and had less of an impact on symptoms associated with complex post-traumatic stress disorder. Future work: Definitive trials of phase-based versus non-phase-based interventions with long-term follow-up for post-traumatic stress disorder and associated mental comorbidities. Study registration: This study is registered as PROSPERO CRD42017055523. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 43. See the NIHR Journals Library website for further project information.
Article
Background The COVID-19 pandemic has led to a notable increase in telemedicine adoption. However, the impact of the pandemic on telemedicine use at a population level in rural and remote settings remains unclear. Objective This study aimed to evaluate changes in the rate of telemedicine use among rural populations and identify patient characteristics associated with telemedicine use prior to and during the pandemic. Methods We conducted a repeated cross-sectional study on all monthly and quarterly rural telemedicine visits from January 2012 to June 2020, using administrative data from Ontario, Canada. We compared the changes in telemedicine use among residents of rural and urban regions of Ontario prior to and during the pandemic. ResultsBefore the pandemic, telemedicine use was steadily low in 2012-2019 for both rural and urban populations but slightly higher overall for rural patients (11 visits per 1000 patients vs 7 visits per 1000 patients in December 2019, P
Article
The use of videoconferencing technologies (VCT) is on the rise given its potential to close the gap between mental health care need and availability. Yet, little is known about the effectiveness of these services compared to those delivered in-person. A series of meta-analyses were conducted using 57 empirical studies (43 examining intervention outcomes; 14 examining assessment reliability) published over the past two decades that included a variety of populations and clinical settings. Using conventional and HLM3 meta-analytical approaches, VCT consistently produced treatment effects that were largely equivalent to in-person delivered interventions across 281 individual outcomes and 4336 clients, with female clients and those treated in medical facilities tending to respond more favorably to VCT than in-person. Results of an HLM3 model suggested assessments conducted using VCT did not appear to lead to differential decisions compared to those conducted in-person across 83 individual outcomes and 332 clients/examinees. Although aggregate findings support the use of VCT as a viable alternative to in-person service delivery of mental healthcare, several limitations in the current literature base were revealed. Most concerning was the relatively limited number of randomized controlled trials and the inconsistent (and often incomplete) reporting of methodological features and results. Recommendations for reporting the findings of telemental health research are provided.
Article
In‐person psychotherapy (IPP) has a long and storied past but technology advances have ushered in a new era of video‐delivered psychotherapy (VDP). In this meta‐analysis, pre‐post changes within VDP were evaluated as were outcome differences between VDP vs IPP or other comparison groups. A literature search identified k=56 within‐group studies (N= 1681 participants) and 47 between‐group studies (N=3564). The pre‐post effect size of VDP was large and highly significant, g=+0.99 95% CI [0.67; 0.31]. VDP was significantly better in outcome than wait list controls (g=0.77) but negligible in difference from IPP. Within‐groups heterogeneity of effect sizes was reduced after subgrouping studies by treatment target, of which anxiety, depression, and PTSD (each with k> 5) had effect sizes nearing 1.00. Disaggregating within‐groups studies by therapy type, the effect size was 1.34 for CBT, and 0.66 for non‐CBT. Adjusted for possible publication bias, the overall effect size of VDP within groups was g=0.54. In conclusion, substantial and significant improvement occurs from pre‐ to post‐phases of VDP, this in turn differing negligibly from IPP treatment outcome. The VDP improvement is most pronounced when CBT is used, and when anxiety, depression, or PTSD are targeted, and it remains strong though attenuated by publication bias. Clinically, therapy is no less efficacious when delivered via videoconferencing than in‐person, with efficacy most pronounced in CBT for affective disorders. Live psychotherapy by video emerges not only as a popular and convenient choice but also one that is now upheld by meta‐analytic evidence.
Chapter
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
Thesis
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Introduzione: Visto il periodo storico che tutto il mondo sta attraversando, ovvero quello della pandemia da COVD-19, questo lavoro si è incentrato sulla ricerca relativa alla telepsichiatria. Viene illustrato il metodo, l’efficacia, gli ambiti di applicazione, il setting e i vantaggi del metodo di applicazione relativamente ai disturbi psichiatrici, in ambito internazionale. Obiettivo: comprendere se la telepsichiatria fosse un metodo di cura del paziente con problemi psichiatrici adeguato e/o paragonabile alla terapia faccia a faccia. Comprendere come il setting potesse influenzare o meno le cure e capire come il metodo telepsichiatrico influisse sulle cure dei pazienti. Metodo: revisione della letteratura scientifica di pertinenza dal 2010 al 2020. Gli articoli sono stati selezionati mediante keywords coincidenti con “telepsychiatry”, “mental health”, “depression”, “anxiety”, “PTSD” e “mental disorder” su Google schoolar e PubMed. Le ricerche includono una vasta gamma di campioni, di età diverse e appartenenti sia alla popolazione femminile, sia alla popolazione maschile. Risultati: la revisione sistematica ha condotto a risultati soddisfacenti in tutti gli ambiti analizzati. Conclusioni: le ipotesi di ricerca, sono state avvalorate dagli studi analizzati in questo lavoro. In tal senso la telepsichiatria si è rivelata essere una metodologia valida ed efficace, al pari della terapia faccia a faccia e in taluni casi, anche migliore.
Thesis
Introduzione: Visto il periodo storico che tutto il mondo sta attraversando, ovvero quello della pandemia da COVD-19, questo lavoro si è incentrato sulla ricerca relativa alla telepsichiatria. Viene illustrato il metodo, l’efficacia, gli ambiti di applicazione, il setting e i vantaggi del metodo di applicazione relativamente ai disturbi psichiatrici, in ambito internazionale. Obiettivo: comprendere se la telepsichiatria fosse un metodo di cura del paziente con problemi psichiatrici adeguato e/o paragonabile alla terapia faccia a faccia. Comprendere come il setting potesse influenzare o meno le cure e capire come il metodo telepsichiatrico influisse sulle cure dei pazienti. Metodo: revisione della letteratura scientifica di pertinenza dal 2010 al 2020. Gli articoli sono stati selezionati mediante keywords coincidenti con “telepsychiatry”, “mental health”, “depression”, “anxiety”, “PTSD” e “mental disorder” su Google schoolar e PubMed. Le ricerche includono una vasta gamma di campioni, di età diverse e appartenenti sia alla popolazione femminile, sia alla popolazione maschile. Risultati: la revisione sistematica ha condotto a risultati soddisfacenti in tutti gli ambiti analizzati. Conclusioni: le ipotesi di ricerca, sono state avvalorate dagli studi analizzati in questo lavoro. In tal senso la telepsichiatria si è rivelata essere una metodologia valida ed efficace, al pari della terapia faccia a faccia e in taluni casi, anche migliore.
Article
Background: Tele-mental health care has been rapidly adopted to maintain services during the COVID-19 pandemic, and there is now substantial interest in its future role. Service planning and policy making for recovery from the pandemic and beyond should draw not only on COVID-19 experiences, but also on the substantial research evidence accumulated prior to this. Objective: To conduct an umbrella review of systematic reviews of research literature and evidence-based guidance on tele-mental health, including both qualitative and quantitative literature. Methods: Three databases were searched between January 2010 and August 2020 for systematic reviews meeting pre-defined criteria. Reviews retrieved were independently screened and those meeting inclusion criteria were synthesised and assessed for risk of bias. Narrative synthesis was used to report findings. Results: Nineteen systematic reviews met the inclusion criteria. Fifteen examined clinical effectiveness, eight reported on aspects of tele-mental health implementation, ten reported on acceptability to service users and clinicians, two on cost-effectiveness and one on guidance. Most reviews were assessed as low quality. Findings suggested that video-based communication could be as effective and acceptable as face-to-face formats, at least in the short-term. Evidence was lacking on the extent of digital exclusion and how it can be overcome, and on some significant contexts such as children and young people's services and inpatient settings. Conclusions: This umbrella review suggests that tele-mental health has potential to be an effective and acceptable form of service delivery. However, we found limited evidence on impacts of large-scale implementation across catchment areas. Combining previous evidence and COVID-19 experiences may allow realistic planning for future tele-mental health implementation. Clinicaltrial:
Article
Objective: Telehealth is being increasingly incorporated into the delivery of mental health care and has received widespread attention during the COVID-19 pandemic for its ability to facilitate care during physical distancing restrictions. Videoconferencing is a common telehealth modality for delivering psychotherapy and has demonstrated similar outcomes to those of face-to-face therapy. Cognitive behavioural therapy (CBT) is the most common psychotherapy evaluated across various telehealth modalities; however, studies on CBT delivered via videoconference, particularly in a group therapy format, are lacking. Further, little research exists on videoconference group CBT for anxiety disorders. Accordingly, the present study compared the outcomes of group CBT for anxiety and related disorders delivered via videoconference versus face-to-face. Method: Using a non-randomized design, data on attendance, dropout, clinical outcomes, and functional impairment were collected from 413 adult outpatients of a tertiary care anxiety disorders clinic who attended a CBT group for panic disorder/agoraphobia, social anxiety disorder, generalized anxiety disorder (GAD), or obsessive-compulsive disorder delivered either face-to-face (pre-COVID-19 pandemic) or via videoconference (since the onset of COVID-19 pandemic). Outcomes were assessed using well-validated self-report measures. Data were collected pre-treatment, across 12 weekly sessions, and post-treatment. Intent-to-treat analyses were applied to symptom outcome measures. Results: Face-to-face CBT conferred only a slight benefit over videoconference CBT for symptom outcomes across all groups, but when assessed individually, only the GAD group showed greater symptom improvement in the face-to-face format. Effect sizes for significant differences between the delivery formats were small. Participants in videoconference groups tended to have slightly higher attendance rates in some instances, whereas functional improvement and treatment dropout were comparable across the delivery formats. Conclusions: Results provide preliminary evidence that videoconference group CBT for anxiety and related disorders may be a promising and effective alternative to face-to-face CBT. Additional research is needed to establish equivalence between these delivery formats.
Article
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BACKGROUND: Telemental health care has been rapidly adopted for maintaining services during the COVID-19 pandemic, and a substantial interest is now being devoted in its future role. Service planning and policy making for recovery from the pandemic and beyond should draw on both COVID-19 experiences and the substantial research evidence accumulated before this pandemic. OBJECTIVE: We aim to conduct an umbrella review of systematic reviews available on the literature and evidence-based guidance on telemental health, including both qualitative and quantitative literature. METHODS: Three databases were searched between January 2010 and August 2020 for systematic reviews meeting the predefined criteria. The retrieved reviews were independently screened, and those meeting the inclusion criteria were synthesized and assessed for risk of bias. Narrative synthesis was used to report these findings. RESULTS: In total, 19 systematic reviews met the inclusion criteria. A total of 15 reviews examined clinical effectiveness, 8 reported on the aspects of telemental health implementation, 10 reported on acceptability to service users and clinicians, 2 reported on cost-effectiveness, and 1 reported on guidance. Most reviews were assessed to be of low quality. The findings suggested that video-based communication could be as effective and acceptable as face-to-face formats, at least in the short term. Evidence on the extent of digital exclusion and how it can be overcome and that on some significant contexts, such as children and young people’s services and inpatient settings, was found to be lacking. CONCLUSIONS: This umbrella review suggests that telemental health has the potential to be an effective and acceptable form of service delivery. However, we found limited evidence on the impact of its large-scale implementation across catchment areas. Combining previous evidence and COVID-19 experiences may allow realistic planning for the future implementation of telemental health.
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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.
Chapter
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.
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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).
Research
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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.
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Chapter
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
Chapter
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.
Chapter
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.
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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.
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Psychiatry is one of the first medical specialties to move to the practice of telehealth. Social distancing in the time of COVID-19 has prompted many face-to-face practices, including psychotherapy, to transition to virtual formats. Patients and physicians may have reservations about the change in approach and may have concerns about privacy and the security of protected health information. By utilizing telepsychiatry, patients and psychiatrists can have increased access to one another, bringing a host of benefits and challenges along with it. Addressing these concerns is an important part of telepsychiatry in psychotherapy practice. Here, we discuss practical solutions to challenges clinicians might encounter when moving a psychotherapy practice to telehealth, such as privacy issues, health information security, and developing/maintain a therapeutic bond.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
Article
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.
Article
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.
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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.
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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.
Article
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.
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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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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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