title: Telemedicine for anger management therapy in a rural population of combat veterans with posttraumatic stress disorder: a randomized noninferiority trial.
abstract: OBJECTIVE
  To demonstrate the noninferiority of a telemedicine modality, videoteleconferencing, compared to traditional in-person service delivery of a group psychotherapy intervention for rural combat veterans with posttraumatic stress disorder (PTSD).
  
  
  METHODS
  A randomized controlled noninferiority trial of 125 male veterans with PTSD (according to DSM criteria on the Clinician-Administered PTSD Scale) and anger difficulties was conducted at 3 Veterans Affairs outpatient clinics. Participants were randomly assigned to receive anger management therapy delivered in a group setting with the therapist either in-person (n = 64) or via videoteleconferencing (n = 61). Participants were assessed at baseline, midtreatment (3 weeks), posttreatment (6 weeks), and 3 and 6 months posttreatment. The primary clinical outcome was reduction of anger difficulties, as measured by the anger expression and trait anger subscales of the State-Trait Anger Expression Inventory-2 (STAXI-2) and by the Novaco Anger Scale total score (NAS-T). Data were collected from August 2005 to October 2008.
  
  
  RESULTS
  Participants in both groups showed significant and clinically meaningful reductions in anger symptoms, with posttreatment and 3 and 6 months posttreatment effect sizes ranging from .12 to .63. Using a noninferiority margin of 2 points for STAXI-2 subscales anger expression and trait anger and 4 points for NAS-T outcomes, participants in the videoteleconferencing condition demonstrated a reduction in anger symptoms similar ("non-inferior") to symptom reductions in the in-person groups. Additionally, no significant between-group differences were found on process variables, including attrition, adherence, satisfaction, and treatment expectancy. Participants in the in-person condition reported significantly higher group therapy alliance.
  
  
  CONCLUSIONS
  Clinical and process outcomes indicate delivering cognitive-behavioral group treatment for PTSD-related anger problems via videoteleconferencing is an effective and feasible way to increase access to evidence-based care for veterans residing in rural or remote locations.
authors.affiliation: National Center for PTSD-Pacific Islands Division, Department of Veterans Affairs Pacific Islands Healthcare System, 3375 Koapaka St., Honolulu, HI 96819, USA. Leslie.Morland@va.gov
authors.forename: Leslie A
authors.initials: LA
authors.lastname: Morland
authors.forename: Carolyn J
authors.initials: CJ
authors.lastname: Greene
authors.forename: Craig S
authors.initials: CS
authors.lastname: Rosen
authors.forename: David
authors.initials: D
authors.lastname: Foy
authors.forename: Patrick
authors.initials: P
authors.lastname: Reilly
authors.forename: Jay
authors.initials: J
authors.lastname: Shore
authors.forename: Qimei
authors.initials: Q
authors.lastname: He
authors.forename: B Christopher
authors.initials: BC
authors.lastname: Frueh
mesh_terms: D000328:Adult; D000368:Aged; D000786:Anger; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D015331:Cohort Studies; D003130:Combat Disorders / Q000175:diagnosis / Q000523:psychology / Q000628:therapy*; D019317:Evidence-Based Medicine; D047830:Gulf War; D006801:Humans; D008297:Male; D008875:Middle Aged; D010552:Personality Assessment / Q000706:statistics & numerical data; D011594:Psychometrics; D019114:Remote Consultation / Q000379:methods*; D012424:Rural Population; D013313:Stress Disorders, Post-Traumatic / Q000175:diagnosis / Q000523:psychology / Q000628:therapy*; D014728:Veterans / Q000523:psychology*; D049269:Videoconferencing; D047829:Vietnam Conflict