Prolonged Exposure (PE) for PTSD: Telemedicine vs. In Person
Ron Acierno PhD MS BA
Ralph H. Johnson VA Medical Center, Charleston, SC
Charleston, SC
Funding Period: July 2010 - June 2014

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 VAMC as one of the treatments of choice for the disorder, as evident by the VAMC-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 VAMC 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 VA 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).

OBJECTIVE(S):
Although effective treatments for PTSD exist and have been adopted by the 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.

METHODS:
We propose to use a randomized between groups repeated measures (baseline, post-treatment, 3 & 6-month followups) design with 226 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 healthcare costs.

FINDINGS/RESULTS:
N/A. This project is in the recruitment phase; see STATUS section for recruitment information.

IMPACT:
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. The study is currently in the active recruitment phase, with 3 completed treatments of participants, hence impact statements are premature at this time .

PUBLICATIONS:

Journal Articles

1. Tuerk PW, Wangelin B, Rauch SA, Dismuke CE, Yoder M, Myrick H, Eftekhari A, Acierno R. Health Service Utilization Before and After Evidence-Based Treatment for PTSD. Psychological Services. 2012 Nov 12.
2. 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. Behavior Modification. 2012 Jul 1; 36:(4):580-99.
3. Strachan M, Gros DF, Yuen E, Ruggiero KJ, Foa EB, Acierno R. Home-based telehealth to deliver evidence-based psychotherapy in veterans with PTSD. Contemporary clinical trials. 2012 Mar 1; 33(2):402-9.

Conference Presentations

1. Dismuke CE, Gebregziabher MG. Racial/ethnic disparities in access to VA as a pathway to mortality. Poster session presented at: Medical University of South Carolina Frontiers in Neuroscience Annual Research Day; 2012 Mar 30; Charleston, SC.
2. Acierno R. Update: Secondary prevention of PTSD in at risk OIF-OEF service men and women: BA-TE via HOME based telemedicine. Paper presented at: Department of Defense / Military Operational Medicine Research Program Congressionally Directed Medical Research Programs Annual PTSD Conference; 2012 Mar 1; Bethesda, MD.
3. Acierno R, Ruggiero KJ, White S, Williamson V, McMichael O, Vladimirov V, Koenen KC, Kilpatrick DG, Galea S, Gelernter J, Amstadter AB. Association of CRHR1 and Post traumatic stress symptoms in a population-based study of hurricane exposed adults. Poster session presented at: Annual Biomedical Research Conference for Minority Students; 2011 Nov 1; St. Louis, MO.
4. Acierno RE. Emerging technologies and new applications for telemental health. Paper presented at: American Telemedicine Association Annual Meeting; 2011 Mar 1; Tampa, FL.

DRA: Health Systems, Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational, Prevention, Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: Comparative Effectiveness, Psychiatric health care delivery, PTSD, Telemedicine/Telehealth
MeSH Terms: none