Innovative service delivery for secondary prevention of PTSD in at-risk OIF–OEF service men and women

Abstract

Service personnel involved in Operation Enduring Freedom/Operation Iraqi Freedom are at high risk for trauma-related physical injury and emotional problems, including posttraumatic stress disorder (PTSD) and major depression. Although evidence-based psychotherapies are increasingly available and effective in treating symptoms of PTSD, a large number of service personnel are reluctant to seek mental health treatments due to both perceived stigma associated with these treatments and geographically-based barriers to care at specialized treatment facilities. The present investigation evaluates an innovation in service delivery designed to address these concerns. Specifically, we are comparing exposure-based therapy for PTSD delivered via traditional, in-person settings to the same exposure-based treatment delivered via telehealth technology. The proposed project is a prospective, randomized repeated measures design with two treatment groups (telehealth and in-person) assessed at pre-treatment, mid-treatment, post-treatment and 3- and 12-month follow-up points. Outcome measures ascertain longer-term effects of the treatments on three domains: clinical, process, and economic. Non-inferiority and superiority analyses will be conducted to determine symptom changes between pre-treatment, post-treatment, and follow-up time points between the two treatment conditions. The study will determine whether an exposure therapy for PTSD delivered via telehealth is at least as successful as the same exposure-based therapy delivered in-person in treating the symptoms of PTSD in both subthreshold and fully diagnosed cases.

Introduction

Service men and women involved in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) are at high risk for exposure to combat-related trauma [1], [2]. In addition to the initial physical injury and/or emotional distress associated with exposure to these events, a broad range of long-term negative outcomes, impairments, psychiatric disorders, and physical health problems also appear prevalent. One particularly impairing sequela of trauma is posttraumatic stress disorder (PTSD) and its subthreshold, albeit functionally impairing, presentations [3], [4], [5]. For example, in the National Vietnam Veterans Readjustment Study, PTSD prevalence was 9–15% of Veterans with an additional 8–11% reporting significant subthreshold symptomatology [6], [7]. Similar rates of PTSD and subthreshold PTSD have been reported in OEF/OIF Veterans [4], [8], [9], in addition to high rates of comorbid major depressive disorder, generalized anxiety disorder, and substance use disorder [4], [8], [10], [11]. Both PTSD and subthreshold PTSD contribute to significant functional impairment including relationship, legal, and employment problems as well as disproportionally high rates of health care utilization [12], [13].

Numerous evidence-based psychotherapies exist to address symptoms of PTSD [14], [15]. In particular, research has supported using exposure-based interventions that are derived from models of learning theory and involve altering patients' problematic patterns of behavioral and cognitive avoidance that appear to maintain symptoms [16], [17]. Although these interventions are available, service personnel are often reluctant to seek mental health treatment, both while in service and after leaving the military [18]. A recent study of OEF/OIF Veterans found that 42% indicated that they were interested in receiving help for their symptoms of PTSD, but only 25% actually receive services [8]. Several potential barriers to treatment have been identified in the literature, including person-based barriers (e.g., perceived stigma associated with mental health treatments), documentation concerns (e.g., fears that certain diagnoses will have adverse effects on advancement in the military), and geographically-based barriers (e.g., disparities of access associated with physical and personal environmental constraints) [4].

In order to address these barriers to obtaining effective mental health treatments, the application of non-conventional models of service delivery to military and Veteran populations has been advocated [19], [20]. In particular, new modalities for evidence-based treatments need to be broadened to make them sensitive and responsive to changes in severity and symptom presentation over the course of service delivery. One method proposed was using telehealth to overcome barriers to treatment delivery. Telehealth has several advantages for patients over traditional treatment approaches, including lower cost of transportation, travel time, and missed work [21], [22], [23]. In addition, telehealth may be useful in overcoming several of the other barriers to treatment outlined above by providing services directly Veteran in their home. Preliminary findings for PTSD treatments delivered via telehealth are promising [24]; however, additional research is needed to understand the comparable efficacy of telehealth and in-person treatment modalities [25].

The proposed project aims to compare in-person and telehealth delivery of exposure therapy in post-deployed, active duty OEF/OIF personnel presenting with significant functionally impairing symptoms of PTSD and, typically depression, to determine whether the relatively less stigmatizing telehealth medium is equally effective in terms of symptom reduction to more expensive, traditional in-person treatment medium. Such a finding would provide support for a treatment that could, potentially, reduce attrition from the military due to mental health causes and reduce eventual mental health costs for the Veteran Administration Medical Center (VAMC) system, thereby benefiting service men and women, the Department of Defense (DoD) and the Veteran Affairs (VA).

There are several hypotheses related to the research aims described above. First, exposure therapy delivered via telehealth will be as effective as in-person exposure therapy in reducing PTSD symptoms and related psychopathology at post-treatment and these findings will be maintained at the 12 month follow-up points. Second, participants in the telehealth treatment condition will report greater satisfaction with treatment, greater rates of treatment attendance, and reduced attrition compared to participants in the traditional in-person treatment condition at the end of treatment. Third, the telehealth treatment condition will be relatively more cost effective than treatment delivered in-person.