Research Highlights
Reaching out to provide PTSD care
Telehealth studies span seas, mountains
January 8, 2009
When Leslie Morland, PsyD, began
work at the VA Pacific Islands
Health Care System nine years ago, much
of her time was spent flying. The scenery
was nice—looking down over white-sand
beaches and shimmering blue ocean
waters—but the mission was critical:
providing counseling to veterans with
PTSD and other issues who lived in farflung
Hawaiian or Pacific islands.
"I flew to Hilo twice a week, Kona once
a week, and Guam periodically," says
Morland, a psychologist with the Honolulu
division of VA's National Center for PTSD.
Today, Morland still flies now and then,
but more of her time is spent seeing
patients on a video screen. She is the
"telemental health" lead for her VA region.
She is also one of several VA researchers
exploring the use of videoteleconferencing
(VTC) in PTSD care.
In a typical VTC setup, a group of
veterans meets in a room at a VA
community-based outpatient clinic, along
with a facilitator. They are all visible on
camera to the person at the other end: a
psychologist or other trained therapist,
usually based at a VA medical center. The
therapist can see all the group members,
although catching the nuances of facial
expressions and body language may be a
bit more challenging.
No technology can replace face-to-face
contact, but according to studies by
Morland and others, the outcomes with
VTC are about the same as those with inperson
therapy. Researchers have seen
reductions in PTSD symptoms—usually the
main study outcome—but they've also seen
ample evidence that the technology doesn't
crimp relationships among veterans who are
in group therapy together, or between
veterans and providers.
Morland's group recently concluded a
study with 127 veterans who had PTSD and
needed help with anger management. About
half received in-person therapy, while the
others participated in video sessions at VA
outpatient clinics on Hawaii's Big Island,
Maui or other outlying sites.
VA is telehealth leader
The term "telehealth" means
providing care, education and support to
patients in remote locations through
technologies such as videoteleconferencing,
telephone, email or the
Internet. The term "telemedicine" is
usually used more narrowly,
encompassing the curative aspect of
health care but not educational or
preventive programs.
VA has been cited by the Institute of
Medicine for its pacesetting work in
telehealth, and the agency’s researchers
have contributed numerous papers to the
medical literature documenting that
telehealth can be as effective as inperson
care.
A complete overview of VA telehealth
can be found at www.carecoordination.va.gov, but here are some examples of
how the program works:
- Visiting nurses take digital photos of
homebound patients' skin wounds and
email the images from their laptops to a
secure website, where they are viewed
online or downloaded by dermatologists.
- Psychiatrists talk via video with
veterans in rural areas who have
depression, PTSD or other conditions
and make recommendations to the
patients’ primary care doctors
- Veterans with diabetes get eye
exams at local clinics that have
specialized imaging equipment. The
images are sent electronically to experts
who check for signs of retinal disease.
- VA patients log onto a secure
website where they can access key parts
of their health record and refill
prescriptions.
- Speech pathologists located at VA
medical centers use video to provide
therapy to post-stroke veterans in rural
areas.
"We found both approaches to be
clinically effective," says Morland, "and we
found no difference in process variables like
trust, satisfaction, cohesion. We had very
low attrition." The psychologist says that "a
big issue with PTSD care is making sure
people continue to come to therapy."
The anger study was a particularly good
test of VTC, notes Morland. "One of the
research questions we had was whether we
could work with a lot of 'affect' in the
room—a lot of emotion, people getting
angry before they even come into the group.
We found it wasn't a problem."
In today's era of Webcams and iPhones,
the technology of VTC may seem ho-hum.
But there's a lot of coordination required
before and during each session, says
Morland. Her group's anger study
proceeded with hardly any glitches. They
held 120 video sessions and never had to
cancel or reschedule due to technical
problems.
She acknowledges that because they
were doing a funded study, enough
resources were in place to prevent any
mishaps, both in terms of staff and
equipment. Still, she asserts that with good
coordination, VTC can be used smoothly in
routine clinical settings.
Coordination is key
One of the keys, she says, is having an
information-technology person on call to
troubleshoot technical snags. Another is
making sure there is adequate bandwidth. It
also helps to make calls between only two
points, rather than involving multiple sites.
Above all, staff at both ends have to call and
email ahead of time to make sure everything
is in place.
"When things aren't planned, that's when
things can go wrong," warns Morland.
"That's when veterans and providers say, 'I
don't want to do this.'"
It's especially important that the first few
sessions go well, she says. "You have only a
couple of opportunities to show it will
work; otherwise, veterans may start to get
frustrated."
The Honolulu group just launched a new
study of VTC for cognitive processing
therapy, one of the evidence-based PTSD
treatments used most commonly by VA
clinicians.
Morland stresses that the research
focuses not on validating the treatment
itself—it's already been shown effective in
many studies—but on showing whether
VTC can produce the same results as inperson
therapy.
She points out that not everyone is an
instant believer. "Anytime there's
something novel, there's going to be a
segment of the population that's resistant."
That's the case with patients and perhaps
even more so with the providers who have
to deliver the service, she says. Getting their
buy-in is crucial to spreading the use of
VTC and other telehealth methods in VA.
But with VA's increasing needs to serve
veterans in rural areas—and a strong
evidence base for psychotherapy for
PTSD—even skeptics are finding it hard to
deny the promise of telehealth. Further
research may win them over for good.
"We need to look at whether we're going
to achieve the same clinical effectiveness,"
says Morland. "If we are, then we can say
this isn't a second-rate service. We know
this works."
This article originally appeared in the January 2009 issue of VA Research Currents.
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