Prolonged Exposure (PE) for Post Traumatic Stress Disorder (PTSD): Telemedicine Versus In Person

• Clinician Administered PTSD Scale (CAPS): PTSD diagnosis [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• PTSD Checklist-Military (PCL-M): The PCL is a 17 item self report measure of PTSD symptoms based on the DSM-IV criteria [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• Deployment Risk and Resiliency Inventory (DRRI): Self report measure assessing 14 key deployment-related risk and resilience factors with demonstrated implications for Veterans' long term health [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• Beck Depression Inventory-II (BDI-II): 21 item self report scales to measure depression [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• Health Related Functioning: Medical Outcome Study Short Study Forms-36 Health Survey (SF 36): self report scale measures health status and functioning over the past four weeks [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• Charleston Psychiatric Outpatient Satisfaction Scale (CPOSS-VA): 16 item self report scale, general measure of patient satisfaction of treatment [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• Treatment Credibility: to assess for differences in outcome expectancy, treatment credibility scales [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• Service Delivery Perceptions Questionnaire: assess subjects' perceptions about variables specifically related to the mode of service delivery (quality of communication, ease of use, willingness to use treatment) [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• Structured Clinical Interview for DSM-IV: Interview to diagnosis Depression, Panic Disorder, and Substance Abuse [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• Prior Experience with Computer and Audiovisual Technology: short measure to learn more about participants' prior experience and comfort level with computers and audiovisual technology [ Time Frame: 1 year ] [ Designated as safety issue: No ]

• Clinician Administered PTSD Scale (CAPS) [ Time Frame: pre, post treatment and at 3 and 6 month follow-up ] [ Designated as safety issue: No ]
• PTSD Checklist-Military (PCL-M) [ Time Frame: pre, post treatment and at 3 and 6 month follow-up ] [ Designated as safety issue: No ]
• Deployment Risk and Resiliency Inventory (DRRI) [ Time Frame: pre, post treatment and at 3 and 6 month follow-up ] [ Designated as safety issue: No ]
• Beck Depression Inventory-II (BDI-II) [ Time Frame: pre, post treatment and at 3 and 6 month follow-up ] [ Designated as safety issue: No ]
• Health Related Functioning: Medical Outcome Study Short Study Forms-36 Health Survey (SF 36) [ Time Frame: pre, post treatment and at 3 and 6 month follow-up ] [ Designated as safety issue: No ]
• Charleston Pscyhiatric Outpatient Satisfaction Scale (CPOSS-VA) [ Time Frame: post treatment and at 3 and 6 month follow-up ] [ Designated as safety issue: No ]
• Treatment Credibility [ Time Frame: post treatment and at 3 and 6 month follow-up ] [ Designated as safety issue: No ]
• Service Delievery Perceptions Questionnaire [ Time Frame: post treatment and at 3 and 6 month follow-up ] [ Designated as safety issue: No ]
• Treatment Adherence [ Time Frame: post treatment and at 3 and 6 month follow-up ] [ Designated as safety issue: No ]
• Prior Experiecne with Computer and Audiovisual Technology [ Time Frame: post treatment and at 3 and 6 month follow-up ] [ Designated as safety issue: No ]

The present proposal is to study whether Prolonged Exposure (PE) delivered via Telemedicine is as effective as PE delivered In Person for Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF) Veterans and Veterans of all theatres, particularly Vietnam era with Post-Traumatic Stress Disorder (PTSD). ).

Project Background/Rationale: Approximately 15 to 17% of current Iraq war veterans meet full diagnostic criteria for MH problems such as post-traumatic stress disorder (PTSD) (Hoge et al., 2004). Prolonged Exposure (PE) is an empirically supported treatment for PTSD (Foa 1997; Schnurr et al., 2007), and has been adopted by the Department of Veterans Affairs (DOVA) as one of the treatments of choice for the disorder, as evident by the DOVA-sponsored national training of clinicians to use PE. It is therefore important to employ treatment delivery methods that maximize the likelihood that all veterans in need, including veterans residing in rural settings, and veterans who avoid DOVA settings due to the stigma of receiving mental health treatment, will receive interventions such as PE. The May, 2005 Committee on Veterans Affairs, Subcommittee on Health has identified Telemedicine as a DOVA priority area to address this need. The present proposal is to study whether PE delivered via Telemedicine is as effective as PE delivered In Person. Telemedicine has been chosen for its ability to overcome what appear to be two major barriers to mental health care (Frueh et al., 2000): the difficulty that rural-residing veterans face in reaching VAMC facilities, and the stigma veterans perceive related to receiving mental health treatment. Indeed, if effective, PE delivered via telemedicine may address the problem inherent in the finding that 42% of those screening positive for PTSD indicate that they are interested in receiving help, but only 25% actually receive services (Hoge, et al., 2006).

Project Objectives: Although effective treatments for PTSD exist and have been adopted by the Veterans Affairs Medical Centers (VAMC), barriers to care of a social (e.g., stigma) and geographic (e.g., rural) nature prevent many veterans in need from receiving care. Telemedicine might address this need. The major objective of this study is to determine if PE delivered via Telemedicine is as effective as In Person PE in terms of (1) clinical; (2) process; and (3) economic outcomes.

Project Methods: We propose to use a randomized between groups repeated measures (baseline, post-treatment, 3& 6-month followups) design with 226 OIF-OEF veterans diagnosed with PTSD to assess the relative effectiveness, measured in terms of symptoms, patient satisfaction, and costs, of PE delivered via Telemedicine vs. In Person formats. We hypothesize that no differences (i.e., non-inferiority) between the two formats will be evident in terms treatment gains, patient satisfaction, treatment attrition, patient satisfaction and direct health care costs.

Anticipated Impacts on Veterans Health care: This study will provide important information regarding whether PE delivered via home-based Telemedicine equipment is as effective as traditional In Person delivery of PE for post-traumatic stress disorder. If shown to be as effective as In Person treatment, a new, innovative, and cost effective intervention delivery system for PTSD will have initial empirical support.

• Behavioral: Telemedicine
  Prolonged Exposure (PE) therapy provided at patients house via telemedicine
• Behavioral: In Person
  PE therapy delivered in person at the VAMC

• Experimental: Arm 1
  PE via telemedicine
  Intervention: Behavioral: Telemedicine
• Active Comparator: Arm 2
  PE in person
  Intervention: Behavioral: In Person

• Strachan M, Gros DF, Yuen E, Ruggiero KJ, Foa EB, Acierno R. Home-based telehealth to deliver evidence-based psychotherapy in veterans with PTSD. Contemp Clin Trials. 2012 Mar;33(2):402-9. Epub 2011 Nov 11.
• Gros DF, Price M, Strachan M, Yuen EK, Milanak ME, Acierno R. Behavioral activation and therapeutic exposure: an investigation of relative symptom changes in PTSD and depression during the course of integrated behavioral activation, situational exposure, and imaginal exposure techniques. Behav Modif. 2012 Jul;36(4):580-99. doi: 10.1177/0145445512448097. Epub 2012 Jun 7.

Inclusion Criteria:

Participants will be 226 male and female:

• Operation Iraqi Freedom, Operation Enduring Freedom (OIF OEF) Veterans, and Veterans of all theatres, particularly Vietnam era Veterans.
• age 21 and above, and
• diagnosed via structured clinical interview with PTSD

Exclusion Criteria:

• Actively psychotic or demented persons,
• individuals with both suicidal ideation and clear intent, and
• individuals meeting full criteria for substance dependence will be excluded from participation

• University of Pennsylvania
• University of Hawaii