Abstract
We describe the case of a US veteran from the war in Afghanistan with post-traumatic stress disorder (PTSD). The patient was undergoing treatment at home via telehealth as part of a research trial. In week six, he presented with severe suicidal ideation and required emergency hospitalization. Through a series of immediate enhanced communications (i.e. by videoconference) between the patient, patient's family, treatment team and local resources, the patient's symptoms were assessed to identify suicidality and an intervention was successfully carried out, involving the development of a safety plan and eventual transportation to an inpatient unit at the local Veterans Administration Medical Center, where he was hospitalized for three days. This demonstrates the value of telehealth in identifying and treating severe psychiatric symptoms in addition to supporting the safety of these procedures to address suicidality.
Introduction
Telepsychiatry has been employed in a number of settings, including patients in rural areas, older adults, racial/ethnic minorities, patients adjudicated by the courts and military veterans. 1 In addition, there is strong evidence for both high patient and moderately high provider satisfaction with mental health services delivered via telehealth. 2 Recent studies support the effectiveness of telehealth for delivering evidence-based psychotherapies to rural veterans with post-traumatic stress disorder (PTSD). 3–5 Similar beneficial effects of mental health care delivered via telehealth have been demonstrated for other psychiatric conditions, including panic disorder, 6 obsessive compulsive disorder 7 and social phobia. 8
Little is known regarding the safety of providing telehealth-delivered treatment to high-risk patients. Traditionally, telehealth services have been provided to patients at community-based outpatient clinics where local services are immediately available. 4,5 However, as these technologies improve, telehealth is shifting to in-home services to further improve patient outcomes and cost savings, but potentially raising additional concerns that are associated with the absence of an on-site health-care provider. The present case report concerns a US veteran of the Afghanistan war with PTSD, who developed severe suicidal ideation.
Case report
Mr B was a 45-year-old African-American male veteran living in a rural county in the south-east United States (population about 40,000 in 2005). Mr B lived in a trailer with his 21-year-old son and 20-year-old daughter, while his home was being repaired. Mr B and his wife were divorced and lived apart. Mr B served in an Army Reserve unit and completed two deployments in Afghanistan. While in Afghanistan in 2007, Mr B witnessed a suicide bombing at the rear of a convoy entering the base. The force of the explosion pushed Mr B into a wall. Afterwards, Mr B inspected the scene of the explosions and was ordered to gather the scattered body parts of the suicide bomber. After returning from his deployment, Mr B reported constant, unrelenting intrusive thoughts and images related to his service in Afghanistan and the suicide bombing, including nearly daily nightmares associated with the event (e.g. seeing dead bodies). Mr B also reported moderate situational avoidance of crowded locations (e.g. shops and restaurants), extreme hypervigilance, exaggerated startle and sleep disruption. Mr B also had several other health complaints, including chronic lower back pain and diabetes.
All study procedures described below were approved by the appropriate ethics committees. At baseline assessment, Mr B met the diagnostic criteria for PTSD on the Clinician Administered PTSD Scale and major depressive disorder (MDD) on the Structured Clinical Interview for DSM-IV. 9,10 Mr B reported mild alcohol use (2–4 times a month) on the Alcohol Use Disorders Identification Test and denied drug use in the past month on the Drug Abuse Screening Test. 11,12 Mr B's self-reported drug and alcohol use was consistent with drug tests and blood work completed as part of his hospitalization. Three months prior to beginning psychotherapy, Mr B was prescribed citalopram hydrobromide (50 mg daily) for his mood, risperidone (1 mg daily) for his sleep, and morphine sulphate SR (30 mg daily) for his back pain. However, Mr B initially reported inconsistent use of his mood and sleep medications.
Home telehealth
Mr B was participating in a large randomized controlled trial of home-based telehealth in veterans with PTSD. 13 Telehealth treatment sessions were conducted using videoconferencing to his home. An analogue videophone (Viterion 500, Viterion TeleHealthcare, NY, USA) was used that operated via a conventional telephone line. The videophone had a 10-cm LCD colour screen displaying video at 18 frames per second.
Treatment
The treatment provided was consistent with the treatment model described by Foa and colleagues. 14,15 Thus, the primary treatment components were in vivo and imaginal exposure trials. There were 10 treatment sessions, all conducted by telehealth.
In session 1, the therapist provided psycho-education about common reactions to traumatic events, development of PTSD and depression, and how avoidance and withdrawal operate to maintain PTSD and symptoms of depression. Mr B was instructed to monitor his activities and avoidance and corresponding mood using the daily planner provided at the start of treatment. Session 2 involved identifying patterns of behavioural avoidance and withdrawal, and defining sets of behaviours to promote recovery. Mr B was instructed to begin scheduling value-based activities in his daily planner. In session 3, both in vivo and imaginal exposure hierarchies and detailed exposure narratives (audio and/or written) of the traumatic event were developed, and both within- and between-session in vivo and imaginal exposures, as well as continued value-based activities, were scheduled in Mr B's daily planner. This was repeated for the remainder of treatment (sessions 3–8). The primary role of the therapist during these sessions was to emphasize the relation between symptom maintenance and avoidance behaviours, identify continued patterns of avoidance, and prescribe activities based on Mr B's self-reports of symptomatology. The final session emphasized relapse prevention strategies.
Mr B completed the first five weekly sessions of exposure therapy. During the sixth session, Mr B reported suicidal ideation and emergency procedures were used (see below). Mr B was hospitalized for three days at the Veterans Administration Medical Center (VAMC). During his hospitalization, Mr B's medication regiment was evaluated and altered to better address his physical and mental health concerns (e.g. diabetes medications were added). Upon symptom stabilization and subsequent discharge, Mr B completed a brief stabilization psychotherapy session via telehealth and the final three sessions of exposure therapy via telehealth per protocol. Upon completion of the telehealth treatment, Mr B was referred to the VAMC for continuation of care.
Suicide intervention via home-based telehealth
Mr B reported mild suicidal ideation during the first five sessions of exposure therapy, but denied having intent and/or plan of action. However in week six, Mr B reported a 3 (‘I would kill myself if I had the chance’) on the Beck Depression Inventory (BDI-2). 16 Mr B stated that he would hang himself on further assessment. Mr B said that he felt more and more like hurting himself and could not guarantee his own safety.
The following steps were taken to address Mr B's suicidality. First, the therapist contacted another therapist (therapist 2) to provide consultation and co-ordination with local services in Mr B's rural area. Second, the therapist developed a safety plan with Mr B via telehealth and was able to incorporate Mr B's family in the planning (e.g. his son was at home). The safety plan included identifying warning signs, coping skills, social contacts, family support and emergency contacts. The plan also created a safe environment, by removing any potentially harmful objects. Once again, Mr B could not guarantee his safety and required hospitalization, but lacked transportation to facilitate his hospitalization. Third, therapist 2 contacted Mr B's local emergency dispatcher to co-ordinate hospitalization while therapist 1 remained connected with Mr B and his family via telehealth. Mr B's information (e.g. medical history, risks, treatment programme, suicidality, and his address and telephone number) was communicated to the first responders via therapist 2. Unfortunately, the local officials in Mr B's rural area could only transport Mr B to a local hospital, rather than the VAMC located 80 km away. Fourth, after the police arrived, therapist 1 contacted the local hospital to arrange transfer to the VAMC and therapist 2 contacted the VAMC to arrange hospitalization. Each step was communicated to Mr B by therapist 1 and therapist 2 via telehealth in the home.
The home-based telehealth equipment provided several benefits to the provider and patient during this emergency. First, the telehealth equipment provided a secondary route of communication for the provider, allowing for continual communication and observation of Mr B while co-ordinating care with outside facilities and providers. Second, Mr B's behavioural information (facial cues and body language), as viewed through the telehealth equipment, presented an additional assessment of Mr B's level of distress. Third, the telehealth equipment also allowed for the behavioural observation of Mr B's actions, reducing the likelihood that Mr B would engage in any risky (e.g. leaving the home) or self-injurious (e.g. swallowing pills) behaviours while viewed on the telehealth monitor. Thus, the use of telehealth in this case probably assisted in the successful management of Mr B's suicidality.
Response to therapy
Mr B's scores on the BDI-2, Beck Anxiety Inventory (BAI), and PTSD Checklist – Military Version (PCL-M) are shown in Figure 1. 17,18 In addition to these assessments, Mr B completed regular telephone check-ins and appointments with his new providers at the VAMC, following his final session of exposure therapy. The BDI-2 was the only measure administered during the crisis week due to Mr B's response to item 9 (suicidal thoughts and wishes). Mr B showed a steady improvement in the BDI-2, BAI, and PCL-M scores from baseline to week 10. A small elevation was observed on the BDI-2 on the crisis week. After the completion of exposure therapy, Mr B reported an increase in symptoms at the 30-day follow-up assessment, which was probably related to a hospitalization for a physical health concern on the week prior to the assessment.
Symptoms of PTSD, depression and anxiety from baseline, during treatment sessions, crisis week and at 30-day follow-up. Crisis = crisis week in which hospitalization occurred; PCL-M = PTSD Checklist; BDI-2 = Beck Depression Inventory – Version II; BAI = Beck Anxiety Inventory
Discussion
We used telehealth to treat a patient with PTSD and MDD, and co-ordinate care to address acute suicidality. These telehealth services were provided from a VAMC in an urban area directly into the home of a veteran patient living in a rural area. Through a series of immediate enhanced communications (i.e. by videoconference) between the patient, patient's family, treatment team and local resources, the patient's symptoms were assessed to identify suicidality and an intervention was successfully carried out, involving the development of a safety plan and eventual transportation to an inpatient unit at the local VAMC. This demonstrates the value of telehealth in identifying and treating severe psychiatric symptoms in addition to supporting the safety of these procedures to address suicidality.
The present case report raises several important matters for future providers of home-based telehealth for at-risk patients in rural settings. First, telehealth services rely on telecommunication lines, such as ordinary telephone lines or broadband connections. These services may tie up the only line of communication between patient and provider. Thus, providers must have a backup communication method (e.g. mobile phone or second telephone line) in case of emergencies. This includes arranging for a health-care provider to be accessible in the event of an emergency. Second, knowledge of the local services and facilities is necessary for emergency situations. This includes contact information for the local emergency services (e.g. police department), transportation services and local hospitals with emergency mental health services. Providers must be able to communicate quickly any emergency needs to local services. Providers may want to prepare local services for emergency situations (e.g. suicidality) to familiarize them with the telehealth procedures and develop a local action plan. Third, although the present case was complicated by barriers (e.g. lack of transportation) that were successfully overcome via telehealth communications, the successful management of the case hinged on the willingness of the patient to maintain communication throughout the process. Had the patient disconnected the telehealth unit, a different protocol would have been required to address his suicidality, including immediately contacting local emergency services. Note that the likelihood of patient contact with clinicians is significantly higher in telehealth, since patients who might otherwise fail to attend a clinic for treatment because they are suicidal or very depressed are more likely to participate in home-based telehealth on these particularly dangerous days. Clinicians therefore have a better opportunity to intervene and help suicidal patients. In other words, for patients such as Mr B, safety is enhanced via telehealth.
The benefits of telehealth services have been emphasized in the literature. 1,2,19 Recent studies have focused on the delivery of evidence-based psychotherapies and have reported promising results. 3–5 The present case report may represent a useful direction for future clinical interventions. Our patient lived in a rural area with severe psychiatric symptoms. He had limited transportation available and would have been unlikely to have received services without the aid of home-based telehealth, and certainly would not have made the effort to travel to the clinic on the day he was overtly suicidal. In addition to the promotion of telehealth in the treatment of psychiatric disorders, home telehealth could also be utilized to assess, track and prevent suicidality in at-risk patients. It may be both feasible and highly beneficial to provide frequent telehealth check-ins with patients identified as high risk for suicidality. Although this form of home-based telehealth may not have the same cost-saving benefits as transferring standard in-person treatments to telehealth services (as described above), the use of home-based telehealth to assess suicidality would probably improve outcomes in at-risk patients for little extra cost.
In summary, the preliminary findings in the present case support the use of telehealth in the identification and intervention of suicidality at home.
Footnotes
Acknowledgements
The work was supported by the Department of Defense (grant W81XWH-07-PTSD-IIRA) and the Ralph H Johnson VAMC Research Enhancement Award Program (REA08-261). The views expressed in this article do not necessarily reflect those of the Department of VA or the US Government.