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Telemedicine collaborative care for posttraumatic stress disorder in US veterans

The JAMA Network Journals

Military veterans with posttraumatic stress disorder (PTSD) who live in rural areas successfully engaged in evidence-based psychotherapy through a telemedicine-based collaborative care model thereby improving their clinical outcomes, according to a report published online by JAMA Psychiatry.

A disabling disorder, PTSD develops in some people exposed to traumatic events. More than 500,000 military veterans enrolled in the Veterans Health Administration (VHA) health care system (about 9.2 percent of the VHA population) were diagnosed with PTSD in 2012. A large portion of these veterans live in rural areas. Although PTSD treatments have been widely disseminated by the VHA, stigma and geographic barriers can prevent rural veterans from engaging in these evidence-based treatments, according to background information detailed in the study.

John C. Fortney, Ph.D., of the University of Washington, Seattle, and co-authors tested a telemedicine based collaborative care model designed to improve engagement in evidence-based treatment of PTSD. They developed the Telemedicine Outreach for PTSD (TOP) intervention to improve PTSD outcomes for veterans treated at VHA community-based outpatient clinics (CBOCs) without on-site psychiatrists or psychologists. In the intervention, an off-site PTSD care team used telemedicine tools (telephone calls, interactive videos and shared electronic medical records) to support the PTSD treatment delivered by providers at CBOCs. Care manager and pharmacist activities were conducted by telephone to a patient's home and psychotherapy and psychiatric consultations were delivered via interactive video to the CBOC, while feedback and treatment recommendations were given to CBOC providers through electronic health records.

The study enrolled 265 veterans from 11 CBOCs from November 2009 through September 2011; 133 patients received the TOP intervention while 132 received usual care (UC). The patients were primarily rural, unemployed, middle-aged men with severe symptoms of PTSD and other mental health coexisting illnesses.

Study results indicate that during the 12-month follow-up, 73 of 133 patients (54.9 percent) in the TOP intervention received cognitive processing therapy compared with 16 of 132 patients (12.1 percent) in UC. Patients in the TOP intervention also had larger decreases in scores on a posttraumatic diagnostic scale, which measures PTSD severity, at six and 12 months compared with UC patients. There were no significant group differences in the number of PTSD medications prescribed and adherence to medication regimens was not significant. The authors found that attending eight or more sessions of cognitive processing therapy predicted improvement in posttraumatic diagnostic scale scores.

"Despite its limitations, this trial introduces a promising model for managing PTSD in a treatment-resistant population. Findings suggest that telemedicine-based collaborative care can successfully engage this population in evidence-based psychotherapy for PTSD, thereby improving clinical outcomes," the researchers conclude.

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(JAMA Psychiatry. Published online November 19, 2014. doi:10.1001/jamapsychiatry.2014.1575. Available pre-embargo to the media at http://media.jamanetwork.com.)

Editor's Note: The study was supported by a grant from the Department of Veterans Affairs, by the VA Health Services Research and Development Center for Mental Healthcare and Outcomes Research and by the VA South Central Mental Illness Research Education and Clinical Center. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Media Advisory: To contact author John C. Fortney, Ph.D., call Deborah Bach at 206-543-2580 or email bach2@uw.edu

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