by Michael D. Anestis, M.S.
I came across an interesting study today examining the effectiveness of exposure therapy for post-traumatic stress disorder (PTSD) via telehealth. Telehealth technology uses television screens that enable therapists and clients to see and interact with one another from a great distance. At first glance, you might read something like that and wonder why such technology needs to enter the equation in what is typically viewed as a highly personal interaction, but its potential value is actually very high. Over the past year, as I have completed my residency in Mississippi, I have come to appreciate a point that I was beginning to understand as a graduate student in the panhandle of Florida: for some individuals, evidence-based mental health care is located too far away to be accessible. Here in Jackson, it is not at all uncommon for a patient to have to drive several hours each way in order to attend a therapy session. They might be able to find non-evidence-based care closer to home, but treatments supported by scientific evidence require an absurdly long commute. Now, imagine if you are suffering from a debilitating mental illness like PTSD and you are short on cash: would long drives with high fuel costs seem appealing to you? Given that the average patient attends only one session of psychotherapy before dropping out, adding these types of obstacles seems certain to diminish the likelihood that those in need will receive proper care. All this being said, the potential value of a service does not always line up with reality and, rather than simply assuming something like telehealth is capable of filling - or partially filling - this important gap, we need to test its performance, both in general and relative to in-person treatments so as to fully understand its true benefits.
In the study I will detail today, which is in press at Behavior Therapy, Daniel Gros, Matthew Yoder, Peter Tuerk, Brian Lozano, and Ron Acierno of the Ralph H Johnson Veterans Administration Medical Center and the Medical University of South Carolina took these important steps to offer an initial glimpse at the actual value of telehealth administered exposure therapy for PTSD. Before describing the study, however, it should be noted that there is preliminary supportive evidence for the use of telehealth in the administration of cognitive behavioral therapy for a range of anxiety disoders, including panic disorder and agoraphobia (Bouchard et al., 2004), obsessive compulsive disorder (Himle et al., 2006), social anxiety disorder (Pelletier, 2003) and PTSD (Germain, Marchand, Bouchard, Drouin, & Guay, 2009). Gros et al (in press) describe this evidence in greater detail in their paper and I encourage you to read their descriptions.
The current study included participants selected from a VA medical center in the southeastern United States. The telehealth condition included 62 veterans. The comparison group in this study included 27 veterans receiving in-person exposure therapy for PTSD. See below for demographic information:
Telehealth:
Average age = 45.1
Sex distribution = 93.5% male
Racial distribution = 50.0% Caucasian, 45.2% African American
Deployment history = 45.2% OIF/OEF, 40.3% Vietnam
In-person:
Average age = 45.2
Sex distribution = 88.9% male
Racial distribution = 51.9% Caucasian, 48.1% African American
Deployment history = 48.1% OIF/OEF, 51.9% Vietnam
Although the phrase "prolonged exposure" was not utilized in this manuscript, the authors indicated that treatment in both conditions was most consistent with the model described by Foa, Hembree, and Rothbaum (2007), the developers of PE. That being said, to be consistent with the terminology used by the authors, we will continue to simpy use the phrase "exposure therapy."
The analyses were set up to examine outcomes after 12 sessions and included not only participants who completed treatment within that timeframe, but also those who were not yet finished with treatment. Additionally, in the telehealth condition, treatment non-completers (e.g., drop-outs) and completers (n = 38) were included so as to enable analyses predicting whether or not an individual completed treatment.
Results:
Individuals in the telehealth condition completed measures of total PTSD symptoms, depression, anxiety, stress, and illness intrusiveness. Individuals with the in-person condition only completed measures of PTSD severity and depression. Importantly, in both conditions, statistically significant reductions in symptoms from baseline to post-treatment. Now, without a control condition not receiving therapy, we can not determine the degree to which those reductions were due to the treatment rather than something else (e.g., the simple passage of time); however, there is a litany of research out there demonstrating that exposure therapy for PTSD produces symptom reductions that far exceed that of waitlist control groups. Given that the in-person condition only completed measures of PTSD severity and depression, the two conditions could only be compared on those two variables. The results indicated that individuals who received in-person exposure treatment demonstrated greater improvement on both variables than did individuals who received telehealth exposure therapy. So, telehealth had a significant impact on these symptoms, but not as significant as the impact of in-person treatment.
The authors were also interested in determining whether particular individuals were more likely than others to complete telehealth treatment rather than dropping out. They found that OIF/OEF veterans were more likely to drop out than were Vietnam war veterans and that younger veterans were more likely to drop out than were older veterans (this second finding likely explains the first). Interestingly, severity of illness did not predict drop-out status, meaning that telehealth is just as viable for severely impaired individuals as it is for mildly impaired individuals.
The final set of analyses the authors ran examined predictors of treatment outcome in telehealth patients. They examined demographic variables (e.g., sex, age), combat theater (e.g., Vietnam vs OIF/OEF), and disability status but none of these variables were significantly related to treatment outcome. As such, they were unable to identify any reliable predictors of who is most likely to benefit from telehealth delivered exposure therapy for PTSD.
Thoughts:
This kind of study really intrigues me because it takes a tangible step towards developing methods of reaching people in need who might struggle to connect with evidence-based care. Obviously equipment like this can be expensive, but when efficacy and effectiveness data are accumulated demonstrating that these methods work, funding agencies become more likely to provide grants that will make it possible to acquired what is needed and get it set up.
Part of the quest to advance the availability and prominence of evidence-based mental health care involves education, and we're certainly trying to do that here, but there are many other fronts on which this battle must be waged. Clinicians in the community must be trained (and the University of Mississippi Medical Center is doing an impressive job with that as well) and potential patients must be connected with services. This study addresses that last point very well. Yes, in-person treatment produced better results than did telehealth and we need more data comparing telehealth to treatment as usual to ensure that it is incrementally valuable, but if people are not going to be able to obtain in-person evidence-based care, the pragmatic thing to do is to give them the next best thing. This might be it.
It will be interesting to see how technology enters the equation in the field of mental health care in the coming years. It seems to be a potentially remarkable opportunity to expand the reach of effective treatments, but only time will tell.
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Mike Anestis is a psychology resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology department at Florida State University.
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