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Pacific UniversityCommonKnowledge
School of Physician Assistant Studies Theses, Dissertations and Capstone Projects
Summer 8-2014
A Comparison of the Efficacy of Psychotherapy viaTelemedicine to Traditional In-Person Therapy forRural Veterans with PTSDMelissa WalshPacific University
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Recommended CitationWalsh, Melissa, "A Comparison of the Efficacy of Psychotherapy via Telemedicine to Traditional In-Person Therapy for Rural Veteranswith PTSD" (2014). School of Physician Assistant Studies. Paper 501.
A Comparison of the Efficacy of Psychotherapy via Telemedicine toTraditional In-Person Therapy for Rural Veterans with PTSD
AbstractBackground: The shortage of medical providers in rural areas is one of the greatest barriers to accessinghealthcare in the United States. Mental healthcare providers are especially limited in numbers and availabilityin rural areas. Although all individuals living rurally have challenges with receiving care, one group thatdemonstrates an exceptional deficiency with access to care is veterans. The numbers of veterans living rurallyare significantly higher than vets living close to urban or suburban centers of care. Considering the shortagesof mental health providers, alternatives to traditional in-person therapy are needed in order to adequatelyaddress the needs of rurally located veterans. Recently, psychotherapy via video teleconferencing has beensuggested as a way of reaching a greater number of veterans. But is this approach equivalent to in-persontherapy in the treatment of PTSD?
Methods: An exhaustive search was conducted using Medline-OVID, CINAHL, and Google Scholar usingthe keywords: mental health, veterans, rural, and telemedicine. Relevant articles were assessed for qualityusing GRADE.
Results: Three studies met the search criteria and were included in this systematic review. The first study,Frueh et al, is a randomized controlled study (RCT) to compare the efficacy of psychotherapy delivered viavideo teleconferencing or in-person therapy for combat-related PTSD. This study showed a comparabletreatment effect and patient satisfaction between the two different methods. The second study, Morland et al,is a non-inferiority-designed RCT comparing anger management therapy delivered either by videoteleconferencing or same-room therapy to veterans with PTSD. This study demonstrated similar satisfactionin both groups and an improvement in both anger and PTSD symptoms in the video teleconferencing group.The third study, Ziemba et al, is a two-arm RCT with either active-duty or veterans of Operation EnduringFreedom or Operation Iraqi Freedom comparing psychotherapy administered via video teleconferencing orin-person. This study indicated equivalence between the two types of therapies.
Conclusion: Psychotherapy administered to veterans with PTSD living in rural areas via videoteleconferencing has been shown to be equivalent to traditional in-person therapy. Multiple studies showpromise for a broader application of psychotherapy via video teleconferencing to help with the shortage ofmental health providers in rural areas; however, further studies are needed to investigate the extent to whichtelemedicine can be used effectively.
Keywords: Mental health, telemedicine, video teleconferencing, veterans.
Degree TypeCapstone Project
Degree NameMaster of Science in Physician Assistant Studies
KeywordsMental health, telemedicine, video teleconferencing, veterans
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NOTICE TO READERS This work is not a peer-reviewed publication. The Master’s Candidate author of this work has made every effort to provide accurate information and to rely on authoritative sources in the completion of this work. However, neither the author nor the faculty advisor(s) warrants the completeness, accuracy or usefulness of the information provided in this work. This work should not be considered authoritative or comprehensive in and of itself and the author and advisor(s) disclaim all responsibility for the results obtained from use of the information contained in this work. Knowledge and practice change constantly, and readers are advised to confirm the information found in this work with other more current and/or comprehensive sources. The student author attests that this work is completely his/her original authorship and that no material in this work has been plagiarized, fabricated or incorrectly attributed.
1
A Comparison of the Efficacy of Psychotherapy via Telemedicine to Traditional In-Person Therapy for Rural
Veterans with PTSD
Melissa N. Walsh
A Clinical Graduate Project Submitted to the Faculty of the
School of Physician Assistant Studies
Pacific University
Hillsboro, OR
For the Masters of Science Degree, August 2014
Faculty Advisor: Dr. Pedemonte
Clinical Graduate Project Coordinator: Annjanette Sommers, PA-C, MS
2
BIOGRAPHY
Melissa Walsh is a native of California. She received a Bachelor of Science degree in
Medical Technology from University of the Sciences in Philadelphia. Following
graduation she worked as a Transfusion Medicine Specialist. Additionally, she spent time
working at a biotech company in the Clinical Operations and Regulatory Affairs
Departments helping with an IND submission to the FDA. She decided to pursue a career
as a Physician Assistant in order work more closely with patients. She has strong interests
in family medicine in rural, underserved areas.
3
ABSTRACT
Background: The shortage of medical providers in rural areas is one of the greatest
barriers to accessing healthcare in the United States. Mental healthcare providers are
especially limited in numbers and availability in rural areas. Although all individuals
living rurally have challenges with receiving care, one group that demonstrates an
exceptional deficiency with access to care is veterans. The numbers of veterans living
rurally are significantly higher than vets living close to urban or suburban centers of care.
Considering the shortages of mental health providers, alternatives to traditional in-person
therapy are needed in order to adequately address the needs of rurally located veterans.
Recently, psychotherapy via video teleconferencing has been suggested as a way of
reaching a greater number of veterans. But is this approach equivalent to in-person
therapy in the treatment of PTSD?
Methods: An exhaustive search was conducted using Medline-OVID, CINAHL, and
Google Scholar using the keywords: mental health, veterans, rural, and telemedicine.
Relevant articles were assessed for quality using GRADE.
Results: Three studies met the search criteria and were included in this systematic
review. The first study, Frueh et al, is a randomized controlled study (RCT) to compare
the efficacy of psychotherapy delivered via video teleconferencing or in-person therapy
for combat-related PTSD. This study showed a comparable treatment effect and patient
satisfaction between the two different methods. The second study, Morland et al, is a
non-inferiority-designed RCT comparing anger management therapy delivered either by
video teleconferencing or same-room therapy to veterans with PTSD. This study
demonstrated similar satisfaction in both groups and an improvement in both anger and
PTSD symptoms in the video teleconferencing group. The third study, Ziemba et al, is a
two-arm RCT with either active-duty or veterans of Operation Enduring Freedom or
Operation Iraqi Freedom comparing psychotherapy administered via video
teleconferencing or in-person. This study indicated equivalence between the two types of
therapies.
Conclusion: Psychotherapy administered to veterans with PTSD living in rural areas via
video teleconferencing has been shown to be equivalent to traditional in-person therapy.
Multiple studies show promise for a broader application of psychotherapy via video
teleconferencing to help with the shortage of mental health providers in rural areas;
however, further studies are needed to investigate the extent to which telemedicine can be
used effectively.
Keywords: Mental health, telemedicine, video teleconferencing, veterans.
4
Acknowledgements For my loving husband who’s meditation for me through my journey has been “You were
born for this”. It has served as both an inspiration and a kick in the rear end. To my mom
for instilling in me a love of science and exemplifying what it means to be a successful,
powerful woman. Thank you dad for teaching me that speaking softly is often the best
way to help others hear your voice. Your lessons of integrity and compassion have helped
me to always find and maintain my priorities.
.
5
Table of Contents
Biography……………………………………………………………………………….....2
Abstract……………………………………………………………………………………3
Acknowledgments…………………………………………………………………………4
Table of Contents………………………………………………………………………….5
List of Tables……………………………………………………………………………...6
List of Abbreviations……………………………………………………………………...6
Background………………………………………………………………………………..7
Methods……………………………………………………………………………………8
Results……………………………………………………………………………………..9
Discussion………………………………………………………………………………..14
Conclusion……………………………………………………………………………….16
References………………………………………………………………………………..17
Table I. Characteristics of Reviewed Studies……………………………………………21
Table II. Clinical Outcomes, Frueh et al…………………………………………………22
6
LIST OF TABLES
Table I Characteristics of Reviewed Studies
Table II Clinical Outcomes, Frueh et al
LIST OF ABBREVIATIONS
BDI Beck Depression Inventory
CAPS Clinician-Administered PTSD Scale
CI Confidence Interval
CPOSS-VA Charleston Psychiatric Outpatient Satisfaction Scale-VA PSTD
Version
CPT-C Cognitive Processing Therapy with cognitive therapy
DOD Department of Defense
FDA Food and Drug Administration
FTF Face to Face
GRADE Grading of Recommendations, Assessment, Development and
Evaluations IND Investigational New Drug
NAS-T Novaco Anger Scale total score
OEF Operation Enduring Freedom
OIF Operation Iraqi Freedom
PTSD Post Traumatic Stress Disorder
PCL-M PTSD Checklist-Military Version
RCT Randomized Controlled Trial
SCL-90-R Symptom Checklist-90-Revised
SD Standard Deviation
SF-36v2 Short Form 36 Health Survey
STAXI-2 State Trait Anger Expression Inventory-2
T-ANG 10-item Trait Anger
TM Telemedicine
VA Department of Veterans Affairs
VAMC Veterans Administration Medical Center
7
A Comparison of the Efficacy of Psychotherapy via Telemedicine to Traditional Face-to-Face Therapy for Rural Veterans with PTSD
BACKGROUND
The shortage of medical providers in rural communities presents one of the
greatest challenges in delivering healthcare.1 This is particularly true of mental
healthcare.1,2
One population greatly affected by lack of care in rural areas is veterans.
According to the Veterans Health Administration Office of Rural Health (VA ORH),
“veterans from geographically rural areas make up a disproportionate share of service
members”.3 Veterans also have higher rates of mental health issues than the general
population, specifically Post Traumatic Stress Disorder (PTSD). PTSD has been linked
to combat stressors including, increased exposure,4 survivability following combat
sustained injury, 5
and the number of deployments.6
Cognitive behavioral therapies such as exposure therapy are considered to be first
line treatments of PTSD by the Department of Veterans Affairs (VA) and Department of
Defense (DOD).7 Veterans living rurally however, are less likely to seek behavioral
health treatment because of the limited availability of providers.8 The VA ORH continues
to seek ways of addressing this disparity.3 One possible solution is the use of
telemedicine. Past research has demonstrated that psychiatric interviewing performed via
telemedicine is reliable. High levels of patients and provider satisfaction with care have
also been observed.9,10
However, until recently there was little evidence to support the
efficacy of using telemedicine to treat mental illness. Although telemedicine can employ
different modalities, this review will focus on studies that specifically used video
teleconferencing for treatment. Since in-person psychotherapy is the gold standard for
8
treating many types of mental illness, including PTSD, one way to determine the efficacy
of telemedicine is to compare treatment groups receiving either therapy in-person or via
telemedicine.
As healthcare has expanded to include more people, finding a way to provide care
to individuals in geographically isolated areas is increasingly important. As it is now,
veterans living in these rural areas often fall through the cracks. Since they commonly
have lingering ill effects on their health after providing service to our country,
determining a way to address their needs is arguably one of the most important current
healthcare issues. Programs such as telemedicine could be a way to provide greater
outreach to our service men and women. Thus, it is important to determine if
psychotherapy delivered via telemedicine is as effective as traditional face-to-face
therapy.
METHODS
An exhaustive search was conducted using Medline-OVID, CINAHL, and Google
Scholar using the keywords: mental health, veterans, rural, and telemedicine. The
references of relevant studies were also screened for potential articles. After the initial
search only articles written in the English language were considered. Articles discussing
telemedicine techniques other than video teleconferencing were excluded. Grading of
Recommendations, Assessment, Development and Evaluation (GRADE)11
was employed
to evaluate the quality of the relevant articles.
9
RESULTS
The initial database search returned 76 studies. After the articles were screened
for eligibility, two articles12,13
met the inclusion criteria. A search of references revealed
one additional article.14
See Table I.
Frueh et al
The Frueh et al study14
is a randomized controlled trial (RCT) comparing the
efficacy of psychotherapy delivered via video teleconferencing or in-person therapy for
combat-related PTSD. The patients were recruited from a Veterans Administration
Medical Center (VAMC) either through physician or self-referral. Inclusion criteria
mandated that the patients met diagnostic criteria for PTSD as defined by the DSM IV,
were non-psychotic, and were not presently abusing any substances. After recruitment,
patients were randomized to their group using an urn randomization procedure.15
The
study ran for 14 weeks with weekly sessions and clinical interviews were conducted prior
to treatment and three months following study completion. Additionally, patients reported
psychiatric symptoms through several self-reported surveys prior to treatment, after
treatment, and at a 3-month follow up. Satisfaction with treatment was also self-reported
via the Charleston Psychiatric Outpatient Satisfaction Scale-VA PSTD Version (CPOSS-
VA) at week 4 and following treatment.14
A total of 38 patients were randomized after screening for eligibility and consent.
Treatment groups were balanced with regards to baseline characteristics including:
demographics, psychiatric diagnosis, trauma exposure, and baseline mental health
assessment scores. Of the patients in the telemedicine (TM) group (n=17), eight
participants did not complete the 90 minute weekly sessions. Comparatively, nine
10
patients in the same-room group (n=21) did not complete the therapy. A total of five
patients, two from the TM group and three from the same-room group, were lost to
follow up during the 3-month follow up phase of the study.14
Clinical outcomes were measured by self-reported surveys. The 17-item PTSD
Checklist-M (PCL-M)16
was used to evaluate PTSD symptom severity. The Symptom
Checklist-90-Revised (SCL-90-R)17
measured overall psychiatric functioning. The Beck
Depression Inventory (BDI)18
evaluated symptoms of depression. Patients were also
asked to rate their social activities inside the home, social activities outside the home, and
the quality of their social relationships as further evidence of their psychiatric
functioning.14
Of note was the change in the PCL scores from baseline to 3-month
follow-up. At 3-month follow up, the change from baseline in the TM group was -2.67.
In the same-room group the change from baseline at the 3-month follow up was 0.22. The
p-value was 0.67, which indicates there is no statistical significance between the two
groups. In other words, both groups showed little change in the severity of their PTS
symptoms. See Table II.
The authors cited several limitations to this study. High levels of pathology and
psychiatric comorbidity were hypothesized to be responsible for low rates of clinical
change (improvement) in both groups.19
Small sample size may have also resulted in low
power for detecting treatment differences. Finally, they noted, “high drop-out rate post
randomization may have resulted in bias comparison between samples.” Based on the
results with the noted limitations of the study, the authors cautiously suggest that
telemedicine may be effectively used in the treatment of PTSD.14
11
Morland et al
Morland et al12,20
is a non-inferiority-designed RCT comparing anger
management therapy delivered either by video teleconferencing or same-room therapy to
veterans with PTSD in a group setting. Patients were recruited from three VA clinical
sites and three vet Centers on the islands of Hawaii, Maui, and Oahu. To be included in
the study the veterans had to have a current or lifetime diagnosis of PTSD as determined
by Clinician-Administered PTSD Scale (CAPS)21
and a stable medication regimen for a
minimum of two months prior to beginning the study. Additionally, a score of ≥ 20 on the
10-item Trait Anger (T-ANG) subscale of the State-Trait Anger Expression Inventory-2
(STAXI-2) were needed in order to demonstrate a moderate to severe anger problem.22
Patients were excluded if they had active psychosis, suicidal or homicidal ideation, or
substance dependence. “Females veterans were excluded due to their small numbers at
participating clinics and the resulting inability to establish a therapeutic gender mix
within the groups.” 9
Significant history of other mental illnesses was also
disqualifying.12,20
After eligibility and consent, an off-site statistician randomly assigned patients to
a treatment group. The goal was to form nine groups of 14 patients (7=TM, 7=FTF) at
four different clinical sites. Of the 61 patients assigned to the TM group 11 were lost to
follow up over the course of the study. The FTF group began with 64 patients and 20
were lost to follow up. There were no statistically significant differences of baseline
characteristics between the groups.
The study consisted of two sessions per week for six weeks. Both groups received
Cognitive Processing Therapy with cognitive therapy only (CPT-C). Assessments of both
12
self-reported clinical and process outcomes were measured at baseline, mid-treatment,
post-treatment, and three and six months post-treatment. Clinical outcomes included
anger expression and trait (STAXI-2), PTSD symptoms (PCL-M), and the cognitive,
arousal, and behavioral aspects of anger (NAS-T).9,14
Attrition, treatment adherence,
treatment expectancy, and group therapeutic alliance were the measured process
outcomes. Patient satisfaction, measured by the CPOSS-VA, was also considered to be a
process variable.9,14
Both groups demonstrated improvement on the anger analysis surveys, STAXI-2,
PCL-M, and Novaco Anger Scale23
total score (NAS-T) at post-treatment and the 3-
month timeframe. “The upper limit of the CI is below the minimum clinically meaningful
difference, indicating that the video teleconferencing was non-inferior to in-person.”12
Results continued to demonstrate non-inferiority at six months post-treatment on the
STAXI-2 however the large Standard Deviation (SD) of the NAS-T scores prevented
analysis. Overall, the analysis demonstrated a slightly larger improvement with video
teleconferencing with regards to the anger trait. Evaluation of PTSD symptoms revealed
improvement across both groups but the data did not statistically prove non-
inferiority.12,20
The authors state that while the study does confirm that video teleconferencing is
an acceptable and safe way of providing psychotherapy to veterans with anger or PTSD
issues there are several items the study did not address. Some of the limitations discussed
include the lack of investigation of the overall effects of anger or PTSD symptom
improvement on other domains of life and the effectiveness of using video
teleconferencing to treat mental conditions with acute safety concerns. The study also
13
failed to assess whether patients used to traditional therapy would be able to transition
effectively to using video teleconferencing. More studies are needed to address these
concerns and to understand how to incorporate telemedicine into current health care
practices.12,20
Ziemba et al
Ziemba et al13
is a two-arm RCT with either active-duty or veterans of Operation
Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) comparing video
teleconferencing and in-person psychotherapy. Male or female active-duty and veterans
of OEF and/or OIF with either a suspicion or a previously confirmed diagnosis of PTSD
were recruited for the study using a combination of presentations, electronic, and print
media. Eligible subjects had the diagnosis of PTSD confirmed by a contracted
psychiatrist as part of the screening process. Any patients started on psychiatric
medication by the study psychiatrist had enrollment delayed by 30 days to ensure
medication stability. Enrolled patients were randomized in a 1:1 manner using a
computer algorithm.
Patients were given 15 weeks to complete 10 therapy sessions. A licensed clinical
therapist was in charge of conducting therapy sessions while a research rater administered
both the pre and post assessments. The research rater was blinded to the subject’s therapy
type. A fidelity consultant was also used to review and rate therapy sessions to ensure
therapist adherence to and competence with the therapy protocol. Evaluations including
CAPS, Montgomery-Asberg Depression Rating Scale (MADRS),24
and Hamilton
Anxiety Rating Scale (HAM-A)25
which evaluated the symptoms of PTSD, depression,
and anxiety were conducted both prior to and following treatment. Physical health was
14
also evaluated by the Short Form 36 Health Survey (SF-36v2)26
as a means of evaluating
the effect of PTSD on quality of life. Finally, satisfaction with care was evaluated via a
survey developed for the study by Press Ganey (South Bend, IN) upon completion of the
trial.13
A total of 18 patients were randomized however, five were lost to follow up. Both
groups of patients demonstrated improvement with regards to mental health with the
telemedicine group improving more (TM +45.8%, FTF +37.9%). Physical health
remained relatively unchanged in both groups (TM + 4.4%, FTF + 4.5%).13
The greatest limitation of the study was its inability to demonstrate statistical
significance of results due to small sample size. Additionally, the travel distance needed
for some subjects to participate may have influenced the results. Overall, the authors
determined that the study could be used to estimate trends in the effectiveness and
clinical significance of video teleconferencing.13
DISCUSSION
Studies have had promising results in demonstrating that telemedicine,
specifically video teleconferencing, is an effective form of psychotherapy to provide care
to Veterans living in rural communities.12-14
While the primary focus of this review has
been using video teleconferencing to treat PTSD, there are other available studies which
demonstrate positive outcomes with other mental health conditions such as anger
management12
, depression,27
and anxiety.28
All three studies reviewed compare video
teleconferencing to in-person psychotherapy using a RTC model.
Of the three studies, the Morland et al study12,20
was the most complete
assessment in terms of diversity and quantity of veterans, but there was an imbalance in
15
the patients lost to follow up where 11 of 61 were lost in the telemedicine group while 20
of 64 were lost in the in person group. The Frueh et al14
and Ziemba et al13
had much
smaller sample sizes and thus no statistical significance is gleaned from the data.
However, conclusions were drawn based on encouraging trends. This lack of sample size
indicates a need for further studies. See Table I.
While research from these studies is encouraging, further RCT studies are needed
to fully address efficacy as well as long-term treatment effects. In order to gain the
sample size needed to see relevant effect non-veterans may need to be included. In that
case, researchers may need to further stratify the type of trauma associated with the
PTSD to ensure that a difference between study subjects does not create inconsistency in
the results.
The majority of the results of these studies were self-reported. While the
evaluations given are designed to produce an accurate picture of a patient’s symptoms
and severity of symptoms, it is still a subjective measurement. Further investigations
may try implementing a system incorporating both patient questionnaires and a separate
evaluation by an off-site mental health professional. A correlation between these two
types of evaluations may provide proof of efficacy.
The trends in the research do support using psychotherapy via video
teleconferencing as an alternative to in-person therapy. For patients in a rural setting or
without access to a mental health provider this type of intervention is recommended.
Both patients and providers should give close attention to progress and satisfaction in
order to ensure successful treatment of the patient.
16
CONCLUSION
Psychotherapy administered to veterans with PTSD living in rural areas via video
teleconferencing has been shown to be equivalent to traditional in-person therapy. Similar
levels of satisfaction with care are also noted when comparing the two methods.
Although recruitment can be challenging in remote areas, results have been consistent
over multiple studies. PTSD symptoms were the primary interest but other psychological
pathologies (anger) also showed improvement with video teleconferencing. The
combined quality of the evidence for the reviewed studies based on the GRADE criteria
is low; however, these studies show promise for broader application psychotherapy via
video teleconferencing to help with a shortage of mental health providers in rural areas.
Further studies are needed to investigate the extent to which telemedicine can be used to
treat different types of mental illness and if its effects are broad enough to positively
influence other domains of life.
17
REFERENCES
1. Holzer III CE, Goldsmith HF, Ciarlo JA. The availability of health and mental health
providers by population density. J Wash Acad Sci. 2000;86(3):25-33.
2. Hendryx M. Mental health professional shortage areas in rural appalachia. J Rural Health.
2008;24(2):179-182.
3. ORH stratigic plan refresh fiscal years 2012-2014.
http://www.ruralhealth.va.gov/docs/ORH_StrategicPlanRefresh_FY2012-2014.pdf. Accessed
06/13, 2014.
4. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in iraq
and afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004;351(1):13-22.
5. Tanielian TL, Jaycox L. Invisible wounds of war: Psychological and cognitive injuries, their
consequences, and services to assist recovery. Vol 720. Rand Corporation; 2008.
6. Armed Forces Health Surveillance Center. Causes of medical evacuations from operations iraqi
freedom (OIF), new dawn (OND) and enduring freedom (OEF), active and reserve components,
U.S. armed forces, October 2001- september 2010. Medical Surveillance Monthly Report
(MSMR). 2011;18(2).
7. VA/DoD clinical practice guideline FOR management of post-traumatic stress .
http://www.healthquality.va.gov/guidelines/MH/ptsd/cpg_PTSD-FULL-201011612.pdf.
Accessed 06/13, 2014.
8. Review of veterans' access to mental health care. http://www.va.gov/oig/pubs/VAOIG-12-
00900-168.pdf. Accessed 06/13, 2014.
18
9. Frueh BC, Deitsch SE, Santos AB, et al. Procedural and methodological issues in
telepsychiatry research and program development. Psychiatric Services. 2000;51(12):1522-1527.
10. Monnier J, Knapp RG, Frueh BC. Recent advances in telepsychiatry: An updated review.
Psychiatric Services. 2003;54(12):1604-1609.
11. GRADE Working Group. GRADE website. http://gradeworkinggroup.org/. Accessed June 1,
2014.
12. Morland LA, Greene CJ, Rosen CS, et al. Telemedicine for anger management therapy in a
rural population of combat veterans with posttraumatic stress disorder: A randomized
noninferiority trial. J Clin Psychiatry. 2010;71(7):855-863.
http://dx.doi.org/10.4088/JCP.09m05604blu. Accessed 20100729.
13. Ziemba SJ, Bradley NS, Landry LA, Roth CH, Porter LS, Cuyler RN. Posttraumatic stress
disorder treatment for operation enduring freedom/operation iraqi freedom combat veterans
through a civilian community-based telemedicine network. Telemed J E Health. 2014;20(5):446-
450. doi: http://dx.doi.org/10.1089/tmj.2013.0312. Accessed 20140507.
14. Frueh BC, Monnier J, Yim E, Grubaugh AL, Hamner MB, Knapp RG. A randomized trial of
telepsychiatry for post-traumatic stress disorder. J Telemed Telecare. 2007;13(3):142-147.
15. Wei L, Lachin JM. Properties of the urn randomization in clinical trials. Control Clin Trials.
1988;9(4):345-364.
16. Weathers FW, Litz BT, Herman DS, Huska JA, Keane TM. The PTSD checklist (PCL):
Reliability, validity, and diagnostic utility. . 1993;141(7).
19
17. Derogatis LR, Unger R. Symptom Checklist‐90‐Revised. Corsini encyclopedia of psychology.
2010.
18. Beck AT, Steer RA. BDI, beck depression inventory: Manual. Psychological Corporation
New York; 1987.
19. Keane T, Wolfe J. Comorbidity in post-traumatic stress disorder an analysis of community
and clinical studies. Journal of Applied Social Psychology. 1990;20(21):1776-1788.
20. Morland LA, Greene CJ, Rosen C, Mauldin PD, Frueh BC. Issues in the design of a
randomized noninferiority clinical trial of telemental health psychotherapy for rural combat
veterans with PTSD. Contemp Clin Trials. 2009;30(6):513-522.
21. Blake DD, Weathers FW, Nagy LM, et al. The development of a clinician-administered
PTSD scale. J Trauma Stress. 1995;8(1):75-90.
22. Spielberger CD. State-trait anger expression inventory: Professional manual. Psychological
Assessment Resources Odessa, FL; 1988.
23. Novaco RW. The novaco anger scale and provocation inventory. Los Angeles, CA: Western
Psychological Services. 2003.
24. Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Br J
Psychiatry. 1979;134:382-389.
25. Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol. 1959;32(1):50-55.
26. QualityMetric.
http://www.qualitymetric.com/whatwedo/generichealthsurveys/sf36v2healthsurvey/tabid/185/def
ault.aspx. Accessed 06/13, 2014.
20
27. Deitsch SE, Frueh BC, Santos AB. Telepsychiatry for post-traumatic stress disorder. J
Telemed Telecare. 2000;6(3):184-186.
28. Yuen EK, Herbert JD, Forman EM, et al. Acceptance based behavior therapy for social
anxiety disorder through videoconferencing. J Anxiety Disord. 2013;27(4):389-397.
21
TABLE I. Characteristics of Reviewed Studies, Grade Profile
aRisk for performance bias due to inability to blind providers and patients in the Frueh et al, Morland et al, and Ziemba et al studies. bNon-inferiority analysis used in the Frueh et al study and the Morland et al study and strong use of self-reported data in all studies. cSmall sample sizes and/or large lost to follow up in all studies
Quality Assessment
Downgrade Criteria
Quality Studies Design Limitations Indirectness Imprecision Inconsistency
Publication bias likely
PTSD Symptoms
Frueh et al
RCT No serious limitationsa
Serious indirectnessb
Serious imprecisionc
No serious inconsistencies
No bias likely
Low
Morland et al
RCT
No serious limitationsa
Serious indirectnessb
Serious imprecisionc
No serious inconsistencies
No bias likely
Low
Ziemba et al
RCT
No serious limitationsa
Serious indirectnessb
Serious imprecisionc
No serious inconsistencies
No bias likely
Low
Patient Satisfaction
Frueh et al
RCT
No serious limitations
No serious indirectness
Serious imprecisionc
No serious inconsistencies
No bias likely
Moderate
Morland et al
RCT
No serious limitations
No serious indirectness
Serious imprecision
No serious inconsistencies
No bias likely
Moderate
Ziemba et al
RCT
No serious limitations
No serious indirectness
Serious imprecisionc
No serious inconsistencies
No bias likely
Moderate
22
Baseline Post-treatment Change from baseline Lower limit of
one-sided 95% CI
3 month follow-up 3 month follow-up change-from-baseline
Lower limit of
one-sided
95% CI
Survey
Same-room mean (SD, n)
Telepsychiatry mean (SD, n)
Same-room
mean (SD, n)
Telepsychiatry mean (SD, n)
Same-room
mean (SD, n)
Telepsychiatry mean (SD, n)
P
Same-room
mean (SD, n)
Telepsychiatry mean (SD, n)
Same-room
mean (SD, n)
Telepsychiatry mean (SD, n)
P
PCL 62.38 (12.8, 21) 67.00 (9.4, 17) 56.58 (10.1,12) 68.11 (11.0, 9) -2.58 (11.3, 12) 1.78 (11.0, 9) 0.39 -12.9 60.56 (9.8, 9) 61.43 (14.6, 7) 0.22 (11.0, 9) -2.67 (11.0, 6) 0.67 -7.2
BDI 24.43 (8.6, 21) 24.41 (11.2, 17) 25.17 (7.6, 12) 27.56 (11.9, 9) 1.42 (6.1, 12) 2.89 (8.6, 9) 0.65 -7.0 27.67 (7.6, 9) 28.71 (12.7, 7) 2.78 (8.5, 9) 3.67 (7.1, 6) 0.84 -8.2
SCL-90-R 2.02 (0.8, 21) 2.21 (0.8, 17) 1.85 (0.6, 12) 2.41 (0.9, 9) -0.02 (0.5, 12) -0.01 (0.6, 9) 0.97 -0.4 1.89 (0.9, 9) 2.22 (1.0, 7) -0.08 (0.4, 9) -0.07 (0.5, 6) 0.97 -0.4
Social activities
inside home
1.85 (3.4, 20) 0.81 (1.3, 16) 1.83 (2.0, 12) 2.25 (3.4, 8) 0.55 (1.1, 11) 1.86 (4.0, 7) 0.43 -0.9 0.78 (1.0, 9) 0.86 (1.1, 7) 0.00 (1.5, 8) 0.20 (1.8, 5) 0.83 -1.4
Social activities
outside home
1.63 (1.9, 19) 1.06 (0.9, 16) 4.83 (5.5, 12) 3.50 (3.8, 8) 1.90 (3.5, 10) 1.57 (2.4, 7) 0.83 -3.0 1.11 (1.6, 9) 1.57 (1.9, 7) -0.50 (2.4, 8) 0.40 (1.8, 5) 0.49 -1.3
Quality of social
relationships
4.10 (2.6, 20) 4.00 (2.5, 17) 5.75 (2.2, 12) 3.89 (2.6, 9) 1.00 (3.6, 11) 2.22 (8.6, 9) 0.70 -3.7 4.22 (2.2, 9) 7.00 (10.2, 7) 0.75 (3.0, 8) -0.40 (1.1, 5) 0.43 -3.2
TABLE II. Clinical Outcomes, Frueh et al
top related