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VA Boston Healthcare System and Boston University. Kathleen M. Chard ... Results support the general feasibility and safety of using VT. Both groups showed ...
C 2011) Journal of Traumatic Stress, Vol. 24, No. 4, August 2011, pp. 465–469 (

BRIEF REPORT

Group Cognitive Processing Therapy Delivered to Veterans via Telehealth: A Pilot Cohort Leslie A. Morland, Anna K. Hynes, and Margaret-Anne Mackintosh Department of Veterans Affairs Pacific Islands Healthcare System

Patricia A. Resick VA Boston Healthcare System and Boston University

Kathleen M. Chard Cincinnati VA Medical Center and University of Cincinnati The authors report clinical findings from the pilot cohort of the first prospective, noninferiority-designed randomized clinical trial evaluating the clinical outcomes of delivering a cognitive–behavioral group intervention for posttraumatic stress disorder (PTSD), cognitive processing therapy (CPT), via video teleconferencing (VT) compared to the in-person modality. The treatment was delivered to 13 veterans with PTSD residing on the Hawaiian Islands. Results support the general feasibility and safety of using VT. Both groups showed clinically meaningful reductions in PTSD symptoms and no significant between-group differences on clinical or process outcome variables. In keeping with treatment manual recommendations, a few changes were made to the CPT protocol to accommodate this population. Novel aspects of this trial and lessons learned are discussed. A prevalent mental health problem among returning United States (U.S.) military personnel and veteran populations is posttraumatic stress disorder (PTSD). High levels of combat-related PTSD (2–17%; Richardson, Frueh, & Acierno, 2010) have been found in active duty military and veterans across the major U.S. war eras. Research has identified several effective cognitive–behavioral treatments (CBTs) for PTSD (Follette & Ruzek, 2006). As a result, the Department of Veterans Affairs (VA) has mandated that all veterans and active duty returning troops with PTSD be offered evidence-based CBT for PTSD. Veterans and military personnel returning from deployment often live in remote or rural areas, resulting in disparities in access to mental health care (Field, 1996). Clinicians have begun to utilize

telemental health (TMH) services, such as video teleconferencing (VT), as a mode to deliver specialized psychological treatments to rural populations (e.g., Morland, Frueh, & Pierce, 2003). However, despite the applicability of VT for increasing access to care, there are several marked limitations in the current TMH research. The most prominent limitation is the lack of randomized clinical trials (RCTs) of VT applications (e.g., Monnier, Knapp, & Frueh, 2003). Thus far, trials of VT conducted with veterans with PTSD have focused on the delivery of CBT for social skill training (Frueh et al., 2007) and anger management (Greene et al., 2010; Morland et al., 2010), rather than trauma-focused interventions. A small number of studies demonstrating the effectiveness of CBT for PTSD using a VT modality have been conducted with both veterans (Gros, Yoder, Tuerk, Lozano, & Acierno, 2011) and civilians (Germain, Marchand, Bouchard, Drouin, & Guay, 2009). Similarly, results of a recent pilot study with rural veterans supported the safety and feasibility of providing CBT via the VT modality (Tuerk, Yoder, Ruggiero, Gros, & Acierno, 2010). However, none of these studies involved the random assignment of participants to treatment delivery modality; thus, there is a continuing need to conduct RCTs with evidence-based treatments for PTSD to better understand the feasibility of providing these protocols via VT. In addition, a better understanding of the unique challenges or required modifications when providing CBT for PTSD over a VT modality is needed. Frequently reported challenges of conducting VT treatment sessions have included limited access to space and high-speed internet, managing logistics (i.e., escorting veterans to

Leslie A. Morland, Anna K. Hynes, and Margaret-Anne Mackintosh, National Center for PTSD-Pacific Islands Division, Department of Veterans Affairs Pacific Islands Healthcare System; Patricia A. Resick, National Center for PTSD-Women’s Health Science Division, VA Boston Healthcare System and Boston University; Kathleen M. Chard, PTSD and Anxiety Disorders Division, Cincinnati VA Medical Center and University of Cincinnati. This work is partially supported by Grant PT074516 from the Department of Defense and Office of Research and Development, Medical Research Service, Department of Veterans Affairs. All views and opinions expressed herein are those of the authors and do not necessarily reflect those of our respective institutions or the Department of Veterans Affairs. Correspondence concerning this article should be addressed to Leslie A. Morland, National Center for PTSD-Pacific Islands Division, Department of Veterans Affairs Pacific Islands Healthcare System, 3375 Koapaka St., Honolulu, HI 96819. E-mail address: [email protected] Published 2011. This article is a US Government work and is in the public domain in the USA. View this article online at wileyonlinelibrary.com DOI: 10.1002/jts.20661

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the group treatment room, sending and receiving treatment and homework materials via fax, distributing outcome measures), and difficulties audiotaping sessions. Our purpose here is to report preliminary clinical and feasibility data from a large, ongoing 4-year RCT evaluating the efficacy of group CBT for PTSD delivered via VT compared to in-person (NP) delivery in a sample of male veterans with combat-related PTSD living in rural areas. Although the full trial includes an extensive assessment battery for a broad array of clinically relevant outcomes, here we will only report pilot data on outcomes for clinical PTSD symptoms and the process variables of therapeutic alliance, treatment expectancy, session attendance, and study attrition. Lessons learned, successes, and challenges related to delivering trauma-focused mental health services to this population via VT are also presented.

METHOD Participants Study methodology and procedures used in the larger RCT are described in detail elsewhere (Morland, Greene, Rosen, Mauldin, & Frueh, 2009). This study was open to all male active duty reserves, guard, and veterans who were being treated at VA clinics on participating Hawaiian Islands. Participants were eligible if they had current combat-related PTSD and were excluded for active psychotic symptoms/disorder, active homicidal or suicidal ideation, significant cognitive impairment or history of organic mental disorder, current substance dependence, or unwillingness to refrain from substance use during treatment. In this pilot study, 18 veterans were assessed for inclusion, 13 (72%) were enrolled and 11 completed therapy, yielding a 15% attrition rate. The mean age was 48.6 years (SD = 14.2; range = 29–61) for the NP and 53.0 years (SD = 19.6; range = 28–77) for the VT conditions. Additional participant characteristics across the two conditions are provided in Table 1. Veterans in the two treatment conditions did not significantly differ on any demographic factor.

Measures Assessments were conducted in-person at baseline, immediate posttreatment, and 6- months posttreatment by a trained doctorallevel assessor who was blind to the participant’s treatment condition at all time points. The baseline evaluation included a general structured clinical interview and several self-report measures. The primary clinical outcome measure was the Clinician-Administered PTSD Scale (CAPS; Blake et al., 1995). Measures of process outcomes, including therapeutic alliance (Pinsof & Catherall, 1986), treatment expectancy (Borkovec & Nau, 1972), session attendance, and study attrition were also collected and difficulties using the CVT technology were tracked systematically.

Table 1. Sample Demographics and Characteristics by Treatment Condition

Unemployed / retired Married / cohabitating Race / ethnicity Caucasian Native Hawaiian / Pacific Islander African American Asian Branch of Service Army Marines War era Vietnam OEF / OIF Service connection status 0% 1–25% 26–50% 51–75% 76–100%

NP % (n = 7)

VT % (n = 6)

85.7 42.9

66.6 50.0

14.3 57.1 14.3 14.3

50.0 33.3 16.7 0

83.3 16.7

66.7 33.3

57.1 42.9

66.7 33.3

42.8 14.3 14.3 0 28.6

33.3 0 16.7 16.7 33.3

Note. NP = in-person condition; VT = video teleconferencing condition; Service connection status = rating of functional impairment related to service-connected disabilities; OEF/OIF = Operation Enduring Freedom/Operation Iraqi Freedom.

Procedure After the assessment clinician completed the informed consent procedure and screening interviews, participants were randomly assigned to either group cognitive processing therapy (CPT) delivered via VT or NP. Treatment groups followed the same protocol and were delivered in parallel; therefore, groups occurred in the same clinic conference room at the same time of day, but on different days of the week. The VT services were delivered via a Tandberg 880 Model Health Care System (Tandberg, New York, NY) video teleconferencing system. Per our local institutional review board requirement, a project member trained in the CPT protocol and VT technology served as the onsite observer in the event of any undue emotional escalation in the VT condition, but did not participate in the group session unless there were technological or clinical difficulties. This onsite observer was also responsible for collecting participant homework and faxing these sheets to the treatment clinicians for review during the group session. The study period for the pilot cohort was October 2008 to June 2009. CPT (Resick, Monson, & Chard, 2007) is a CBT for PTSD that primarily focuses on targeting cognitive symptoms of PTSD. It

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

Telemental Health for Rural Combat Veterans has been found to be efficacious in both civilian and VA treatment settings and is listed as a recommended treatment by the U.S. Department of Veterans Affairs/Department of Defense in the Clinical Practice Guidelines for the Management of Post-Traumatic Stress (2010). Cognitive processing therapy with cognitive therapy only (CPT-C) is a variant of CPT that excludes the component of producing a written trauma narrative and has been found to be as effective as original CPT (Resick et al., 2008). Participants received the manualized group CPT-C protocol as twelve 90-minute sessions that took place twice a week over a 6-week period.

Data Analysis Results focus on qualitative descriptions of implementation issues and modifications made to the CPT-C protocol to better accommodate the study population. Preliminary clinical outcome and treatment process data are also presented. Due to the small sample size and high variability among scores, robust rank-order tests were used to assess differences between treatment conditions (see Siegel & Castellan, 1988 for procedures) and Wilcoxon signed rank tests to assess for significant changes in scores across time using SPSS Version 19.0.

RESULTS Lessons learned are divided into two main areas. First, issues related to providing specialized PTSD treatment via VT were identified and implemented solutions are presented. Second, issues related to the participants’ lack of familiarity with the language and concepts underlying CPT-C arose. Modifications made to the protocol to help the veterans discuss mental health diagnoses and trauma symptoms are presented. Quantitative data support the safety and tolerability of providing CPT-C via VT. One participant (15%) dropped out of the VT group during the active treatment phase, but there was no significant difference between NP and VT conditions on treatment dropout, χ2 (1) = 1.26, p = .26. No significant differences were found in medians (NP = 9 and VT = 8) between conditions in the number of sessions attended (U = .04, p > .05), or medians (NP = 11 and VT = 10.5) of total number of completed homework assignments (U = .03, p > .05). The use of VT also did not appear to negatively impact veterans’ confidence in treatment outcomes or satisfaction with received services. Five veterans in the VT group completed the Telemedicine Satisfaction and Acceptance Scale (developed by Frueh, Monnier, & Knapp; Telepsychiatry Service Delivery to Trauma Victims, R01-HS11642, funded by the Agency for Healthcare Research and Quality) posttreatment and scored a median of 51.0 (range = 37–54 out of 55 possible), indicating high levels of acceptance and satisfaction with therapy provided

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using VT. There was no significant difference on median scores between treatment conditions (U = 0.19, p > .05) on a treatment expectancy measure (Borkovec & Nau, 1972), with medians of 28 and 30 for the NP and VT groups, respectively. Inspection of individual item medians indicated that the majority of veterans reported at least moderate or high levels of confidence in the treatment. Veterans in the VT group did not appear to be negatively impacted by logistical challenges reported by the therapist, as there was no significant difference in medians for the total Group Therapy Alliance Scale (Pinsof & Catherall, 1986) scores, with an overall median of 123 out of 150 (U = .64, p > .05). Although the group CPT protocol recommends having two treatment therapists to co-lead each group, we attempted to provide the intervention using a single therapist. This approximated the realistic limitations that many rural locations face in not having access to multiple therapists trained to provide specialty mental health services. However, this resulted in the therapist encountering a number of logistical challenges that occurred in both conditions, but were more pronounced in the VT condition. Specifically, the therapist found it difficult to be fully attentive to the needs of all the participants while also collecting and reviewing homework sheets, answering questions, and moving briskly through the ambitious content agenda. To allow the primary therapist to focus on the content, we returned to the clinical recommendation provided in the group CPT protocol of having two therapists. In addition, a few technical issues were encountered, including difficulties with the fax machine during two sessions, which limited the therapist’s ability to review homework, and a slight echo that was heard throughout two sessions that did not impact session progression. No adverse events or technical problems resulted in a cancellation or delay of sessions. The onsite observer was instrumental in executing solutions to the aforementioned logistical challenges. The presence of the observer was initially required by our local institutional review board in case of clinical or technical emergencies; however, because there was no occurrence of these events, this person was not used in that capacity. The CPT manual provides suggestions for modifications in certain circumstances; thus, a few minor changes were made to the CPT protocol in response to our experiences with the pilot cohort. First, the manual states pretreatment orientation sessions are helpful for explaining basic concepts, improving buyin, and increasing client motivation. We found that the remote participants varied drastically in their baseline understanding of PTSD and basic cognitive–behavioral concepts. To address this variability and increase each participant’s ability to benefit from treatment, we added an individual 2-hour pretreatment orientation session to our protocol to review general psychoeducation and CBT concepts. Second, many veterans reported that the terminology and structure of the CPT-C homework assignments were somewhat confusing and unfamiliar; therefore, we modified the CPT-C worksheets to make them easier to follow for some veterans. For example, the Challenging Beliefs Worksheet was

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

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simplified to include concepts that were more easily understood and assisted with flexible thinking. Veterans who continued to struggle with this worksheet after repeated attempts began to challenge problematic cognitions using the simpler ABC Sheet in place of the more complex Challenging Beliefs Worksheet. Despite some of these therapeutic challenges, analysis of the PTSD clinical outcome data provides initial support for the effectiveness of CPT-C with this population. Wilcoxon signed rank tests indicated significant differences between CAPS scores at pretreatment compared to posttreatment (Z = −2.90, p = .004), and 6-month follow-up (Z = −2.81, p = .005). There were no significant differences between treatment conditions at posttreatment (U = .33, p > .05), with medians for the NP and VT groups of 62 and 69, respectively; or at 6-month follow-up (U = −1.70, p > .05), with medians for the NP and VT groups of 66 and 59, respectively. Median changes in CAPS symptoms from pretreatment to posttreatment were −15.0 (range = −36 to +4 points) for NP and −13.5 (range = −17 to −1 points) for VT.

DISCUSSION This study is the first investigation we know of to demonstrate the feasibility of providing group CBT for PTSD via VT. Our experience with this pilot cohort resulted in minor modifications to the study procedures. Overall results suggest that CPT is robust to changes in diversity of treatment populations and offer preliminary support for the clinical effectiveness of group CPT-C delivered via VT. Participants in both conditions tolerated and benefited from CPT-C, making this one of the few published studies to show meaningful treatment benefits for reducing PTSD problems in veterans using a VT modality. Findings are enhanced by the fact that our population primarily consisted of both rural veterans as well as racial minorities, including Pacific Islanders (33%), for whom there is a dearth of empirical data regarding PTSD impairment and treatment outcomes (Pole, Gone, & Kulkarni, 2008). Our process outcomes support the acceptability and safety of implementing VT for group psychotherapy. There were no adverse events or necessary clinical or technical interventions by the inroom observer in the VT condition. Based on our experience with this pilot cohort and past research and clinical experience (Morland et al., 2010) it is not necessary to have an in-room observer when conducting groups over VT; however, an onsite person who can escort the group members to the treatment room and manage logistics (i.e., collecting homework, distributing outcome measures) is required. Participants in both conditions reported high levels of treatment credibility, satisfaction with care, and homework adherence. Treatment dropout (15%) was lower than the 20–35% often reported in clinical trials with veterans or PTSD patients (Pole et al., 2008). The VT modality evidenced very few disruptions caused

by technical difficulties and no treatment sessions were impacted by technological difficulties. Together, these data indicate that VT can be a valuable service delivery strategy for reducing geographic disparities in access to psychological treament. There are several important and novel aspects of this study. First, it is one of only a handful of published studies examining the utility of VT interventions for group psychotherapy with a PTSD population. Second, process outcomes clearly demonstrate the acceptability and feasibility of using VT to improve access to psychiatric care for rural veterans with severe mental illnesses. Third, the treatment, with minor protocol modifications, appears to be successful when working with a highly rural and ethnically diverse population. This study has several limitations. This is a small pilot sample of ethnically diverse rural veterans residing in Hawaii; therefore, our ability to generalize findings from this single cohort to rural veterans and civilians residing in other geographical regions is limited. Future research should investigate the effects of VT with rural veterans in other areas of the U.S. In addition, the small sample size of this pilot cohort only allows for limited statistical power so lack of differences between conditions needs to be interpreted cautiously and replicated with larger samples; however, a full RCT is underway that will allow for a more rigorous evaluation of the clinical effectiveness of CPT-C delivered via VT.

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Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

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Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.