Abstract
Introduction
Whether they return from war, survive a rape, witness a killing, or live through another terrifying ordeal, patients with post-traumatic stress disorder (PTSD) require treatment by a skilled mental-health professional experienced in PTSD therapies to help them overcome the persistent frightening thoughts and memories that are hallmarks of this mental-health condition. However, more than 50 million Americans live in rural areas 1 and may not have access to specialists experienced in treating PTSD. Clinicians from the military, the Department of Veterans Affairs, and the lay community are reaching out to those patients and offering them telemental health services, bringing cognitive behavioral and virtual-reality therapies into their homes or community clinics.
“The research that is out there shows it is a very reliable way of doing assessments and seems to be, in the limited number of trials, an effective way of providing treatment, compared to face-to-face care,” says Bartley C. Frueh, Ph.D., a senior professor at the University of Hawaii in Hilo and director of Clinical Research at the Menninger Clinic in Houston (Fig. 1). “It certainly is better than no care at all, if that's the alternative.”
Bartley C. Frueh, Ph.D., a senior professor at the University of Hawaii in Hilo, reports research shows telemental health services are effective. Photo credit Bartley Frueh.
Frueh has found patients receptive to remote treatment. It provides an option for patients with transportation issues or worries about the stigma of going to a mental-health professional's office.
“The benefits of providing psychiatric services via telemedicine are that it makes psychiatrists more available in different locations,” says R. Andrew Harper, M.D., associate professor in the Department of Psychiatry and Behavioral Sciences and assistant dean of educational programs at the University of Texas Medical School at Houston, part of The University of Texas Health Science Center at Houston. He has provided telepsychiatry at primary care and multispecialty clinics in the Houston metropolitan area to patients who have experienced physical or sexual violence. “Typically, it appears you get a good result from telepsychiatry.”
More research is under way about what techniques work best and are safe when conducted in remote settings.
“There is not a lot of literature out there about which patients are right for in-home and which should come to a facility,” says Brian Grady, M.D., assistant professor and the director of TeleMental Health at the School of Medicine at the University of Maryland in Baltimore and the telemental health lead for the Veterans Integrated Services Network 5. Grady emphasizes that remote services can improve access to specialty care for people in rural areas.
“PTSD folks, wartime or whatever, could be more isolative,” Grady says. On the other hand, telemental health services “might be important for someone who will not leave to go get care.”
Treating Returning Soldiers Close to Home
Many soldiers fighting in Iraq and Afghanistan return with traumatic brain injuries and PTSD. They have often served with reserve units, and go back to their communities, perhaps far from a major military medical center.
“Telemedicine is being used to reach out to these soldiers who are geographically displaced,” says Col. Ronald C. Poropatich, M.D., deputy director of the U.S. Army's Medical Research and Materiel Command Telemedicine and Advanced Technology Research Center (TATRC) at Fort Detrick, MD.
TATRC has developed the mCare mobile-telephone application for communication and for monitoring patients. Clinicians may send them tips for dealing with pain or concentration issues, Poropatich says. It has sent more than 14,000 secure text messages, which are compliant with the Health Insurance Portability and Accountability Act. About 280 soldiers use mCare.
Several Veterans Administration facilities have pioneered the use of teleconferencing to deliver PTSD mental-health counseling to veterans who do not live near expert specialty services. The veterans attend sessions at a community clinic.
“The VA is spending a lot of resources trying to train clinicians in evidence-based treatments for PTSD, but it will be difficult to staff all of the clinics in rural areas across the country with trained providers,” says Peter Tuerk, Ph.D., director of research training for the Psychology Internship Program at the Medical University of South Carolina and associate director of the PTSD clinical team at the Ralph H. Johnson VA Medical Center in Charleston, SC (Fig. 2). “We need new ways to reach people. There are too many people coming back with mental health disorders to cling to our old models of service delivery.”
Peter Tuerk, Ph.D., director of research training for the APA-accredited Psychology Internship Program at the Medical University of South Carolina and associate director of the PTSD clinical team at the Ralph H. Johnson VA Medical Center in Charleston, SC, reports that the mental-health community must investigate new delivery methods, such as telepsychiatry, to reach more people in need of care. Photo credit Summer 2009 edition of Focus VS published by Ralph H. Johnson VA Medical Center.
Types of Therapy Provided
Tuerk et al. investigated the use of prolonged exposure therapy for PTSD in a small trial with 37 combat veterans, comparing telehealth and in-person treatment. The therapy entails education and repeated exposure to safe memories and situations avoided due to distress and unrealistic fears. They found large reductions in PTSD symptoms in both groups. 2 However, they also determined in-session avoidance behavior was more difficult to manage during telemental health sessions than in-person care.
“Our study of prolonged exposure therapy delivered via telehealth technology indicates it can be a safe and effective treatment,” Tuerk says. “There are a lot of reasons to carefully research the safety of new modalities. The people who are at higher risk of harming themselves or others, are those not coming in for weekly treatments. We hope telehealth technology will help us to increase the number of veterans we can reach. Typically, people engaged with a mental health provider and making steps toward getting better are in a lower-risk category than those without such support.”
Leslie A. Morland, Psy.D., a psychologist with the VA National Center for PTSD at the VA Pacific Islands Health Care System in Honolulu, HI, has investigated providing different treatment modalities through teleconferencing with veterans at community clinics in Hawaii (Fig. 3).
Leslie A. Morland, Psy.D., a psychologist with the VA National Center for PTSD at the VA Pacific Islands Health Care System in Honolulu, HI, has investigated providing different treatment modalities through teleconferencing with veterans at community clinics in Hawaii.
“We are focusing on the quality of care piece—is the service we are providing comparable or as good as face-to-face care,” Morland says.
Morland recently completed a clinical trial using anger-management therapy with 125 veterans with PTSD and anger. Half received in-person sessions and the other half took part in the same program through teleconferencing. 3
“The symptom reduction between the two groups was comparable,” Morland says. “The videoconferencing group had the same if not more symptom reduction, speaking to the effectiveness of the intervention.”
The team, which included Frueh, found no difference between the cohorts' group cohesion, but there was slightly less therapeutic alliance with the therapist in the videoconferencing cohort. Previous studies Frueh conducted at the VA Medical Center in Charleston, SC, suggest that patients seemed to bond well with their remote therapist.
Morland has completed the first 2 years of a 4-year clinical trial involving 126 Operation Iraqi Freedom/Operation Enduring Freedom veterans suffering from combat-related PTSD. The team provided group cognitive processing therapy either in person or at a remote clinic. The veterans attended twelve 90-minute sessions that included educating participants about processing theory, skill building to restructure thoughts, and exploring problematic beliefs.
Telehealth for PTSD in the Community
Clinicians in the civilian community also are using telehealth to treat patients with PTSD and conducting research into its effectiveness.
Vanessa Germain, Ph.D., at the Department of Psychology, University of Quebec–Montreal in Canada, published research findings earlier this year in the journal CyberPsychology, Behavior, and Social Networking. That special PTSD issue covered a variety of topics related to the use of technology in the treatment of PTSD.
The Canadian team enrolled 46 people with PTSD in the trial, and provided them with cognitive behavioral therapy either by videoconference or in person. They found therapeutic alliances developed similarly, and concluded that videoconferencing is a viable and attractive method of providing such services. 4
One of the authors of that study, University of Montreal associate research professor Stéphane Guay, Ph.D., director of the Trauma Studies Centre at the Louis-H. Lafontaine Hospital's Fernand-Seguin Research Centre, conducted a small study comparing outcomes of teleconference and face-to-face therapy sessions among PTSD patients, and found that the two groups benefited equally from the therapy. None of the teletherapy patients, who went to a hospital equipped with teleconferencing devices, expressed discomfort with the technological aspects of their care. 5
Alfred Lange, Ph.D., a professor in the Department of Clinical Psychology at the University of Amsterdam in the Netherlands, and colleagues, investigated using Internet-based therapy for patients with mild to relatively severe PTSD. More than half of the participants receiving the online education, screening, and treatment demonstrated a clinically significant improvement, particularly in PTSD symptoms and depression. 6
Setting Ground Rules
Brenda K. Wiederhold, Ph.D., M.B.A., B.C.I.A., serves as executive director of the Virtual Reality Medical Center and a professor in the Department of Psychiatry at the University of California, San Diego in San Diego, CA. She is conducting a trial in Europe providing virtual-reality services on mobile phones, so patients can access treatment for stress-related conditions at any time. She recommends initially meeting in the office with patients to assess thoughts of suicide or for co-morbid conditions.
“You want to make sure the person is stable, and you are not exposing them to things they cannot deal with,” Wiederhold says.
Dawn-Elise Snipes, Ph.D., L.M.H.C., C.R.C., N.C.C, E.I.P., president and director of education for CDS Ventures in Gainesville, FL, works with rape victims and law-enforcement officers involved in violent incidents. She agrees, saying that she wants to make sure the person is in a safe place mentally before using telemedicine for desensitization of trauma victims. Any person who might become suicidal is not a candidate. She also will not consider telemedicine without first meeting with the patient in person and finding that he or she can verbalize when they are decompensating and their safety plan—what they will do and who they will call if they experience a flashback or feelings of terror or a desire to hurt oneself.
Snipes considers teletherapy an adjunct tool for patients who have developed reasonable coping skills but are still dealing with flashbacks and hypervigilance. She employs it for short, 20-minute sessions, twice a week for 6 to 12 weeks.
“Helping survivors become comfortable in their own skin and own home again is crucial,” Snipes says. “One of the ways teletherapies help is by taking the person in their home environment, and when they are hitting things that are triggering flashbacks or making them nervous, walk them through it with cognitive behavioral approaches to help them try to focus on the present situation and differentiate it from the past. It seems helpful for encouraging people to take back their lives and establish a sense of normalcy.”
Care at Home or in a Clinic
While private practitioners have been treating patients in their homes, the VA has continued to use its community clinics for teletherapy. A room is set up in the clinic and a telepresenter must stay available.
Ron Acierno, Ph.D., director of the PTSD Clinical Team at the VA Medical Center in Charleston, SC, and colleagues are researching home-based exposure-based telepsychiatry sessions for the Department of Defense. He asks patients to come to the office one or two times to get to know each other and begin treatment, but he has not studied if that hybrid approach is best.
Acierno has found patients like telesessions, because they do not have to spend time traveling to the appointment. It also meshes better with work schedules. A camera allows the clinician to observe facial expressions during exposure therapy, while the patient conjures memories and learns to deal with them. Treatment typically lasts from 12 to 16 weeks.
“We think it's a little safer,” says Acierno, explaining that when someone goes to the clinic, gets overwhelmed, and leaves, he does not know where they went. “When we are doing home-based telemed, we can send the police right to them. It has more security and safety, not less. And they are not getting into a lethal weapon, meaning their car.”
Additionally, he could send a family member to them. In a recent incident, the veteran's son went immediately to the home. He calmed the patient down and waited for the ambulance to arrive and take the patient to the hospital.
Another consideration about home teletherapy relates to the disease itself. PTSD patients often isolate themselves as a nonadaptive coping mechanism, says Wiederhold, adding that she would want to get those patients to a clinic. The VA programs in which veterans attend group sessions at community clinics eases that concern.
“If they are isolated in a rural community, this is better,” Frueh says. “We work in therapy to get them out of the house.”
Snipes says she makes home visits to those patients or will meet them in a neutral, safe place but would not use teletherapy as their predominant method of care.
Drawbacks to Remote Care
“[Telepsychiatry] is an exciting, emerging technology that has a lot of potential, and we are on the cusp of making it work,” Harper says. “The big issue is making it cost effective, and that will get better as it becomes more acceptable.”
Limitations of private payer reimbursement for telemedical services may put telemental health services out of reach for many patients who are not veterans.
“Reimbursement is huge; it's the fly in the ointment right now,” says Harper. Equipment purchases and personnel costs at the distant sites also deter some clinicians from providing videoconferencing services, he adds.
Treating PTSD
The peer-reviewed journal CyberPsychology, Behavior, and Social Networking published a special issue in February about new technology-based approaches, such as virtual reality, for treating PTSD. The number of cases is increasing, threatening to overload established healthcare and social-support systems. Technology may assist in reaching more clients.
Virtual reality provides an environment that helps patients relive the traumatic experience in a controlled manner. At the same time, the therapist can help the patient learn new methods for coping with the emotions elicited. Journal articles discuss using the treatment with combat veterans, earthquake survivors, and motor-vehicle accident victims.
“Preliminary results show that VR-enhanced, physiologically facilitated, prolonged exposure therapy is more effective than traditional therapy,” says journal Editor-in-Chief Brenda K. Wiederhold, Ph.D., M.B.A., B.C.I.A., in an accompanying editorial. “As these data become available, therapists will clamor for training on VR handheld systems, which will lend therapists a competitive edge and allow their clients to destress anytime, anywhere.”
The issue is available at
Medicare will reimburse for telehealth services, including individual psychotherapy, presented from an originating site located in either a rural Health Professional Shortage Area or a county outside of a Metropolitan Statistical Area. Medicaid coverage varies among the states.
Equipment costs can prove problematic for some patients if they seek home telemedical sessions. Wiederhold says a head-mounted virtual-reality display costs about $500. In addition, it requires a computer with special software and video cards. However, she adds, costs have come down.
Acierno's Department of Defense trial provides teletherapy patients, who do not have a computer, with a $600 videophone. He is investigating cheaper alternatives.
Another concern, according to Frueh, is that equipment may break down or malfunction. For instance, Germain reported technical problems due to power outages and surges during the Canadian study. Tuerk also reported that, during high-traffic times, video images did not always come through clearly.
Frueh has found some resistance among practitioners. Some of the people he has trained voiced concerns that telemental health services could put them out of a job, since more care could be rendered remotely.
Monitoring Clinicians' Care
The U.S. Air Force is using Behavior Imaging® technology to educate and supervise clinicians treating PTSD with virtual-reality systems to augment prolonged exposure therapy.
The therapist records the session, tags various parts of it, and burns a DVD to send to experts at Cornell and Emory universities for review. Via secure messaging, supervisors can log in, review the sessions, and make annotations and recommendations about things that could be done differently.
“We think the future of this is for storing telepsychiatry,” says U.S. Air Force Lt. Col. Tim Lacy, M.D., outgoing chief of Telehealth and Cybermedicine for the USAF. Home caregivers will be able to capture behaviors in the home to show the mental-health professional during the next visit.
“When you sell this to a clinician, they feel something is lost not having a clinician in the room,” Morland adds.
Patients, especially younger ones, may be more apt to embrace convenient telemental health services. Snipes says younger people who have grown up with technology tend to communicate more effectively online. Soldiers returning from the war in Afghanistan may have prompted Acierno's home-based telepsychiatry clinical trial, but once the team showed participants the equipment, they were all receptive.
“We have a new generation of veterans coming down the road from Iraq and Afghanistan, and a lot of them are young and tech savvy,” Morland says. “The model of care is shifting to what works with the new generation of troops. Our goal is to keep them integrated in their lives and functioning, and technology allows us to do that. But we need to be careful and make sure it is good care, quality care, and safe care.”