title: Telemedicine-based collaborative care for posttraumatic stress disorder: a randomized clinical trial.
abstract: OBJECTIVE
  Posttraumatic stress disorder (PTSD) is prevalent, persistent, and disabling. Although psychotherapy and pharmacotherapy have proven efficacious in randomized clinical trials, geographic barriers impede rural veterans from engaging in these evidence-based treatments.
  
  
  OBJECTIVE
  To test a telemedicine-based collaborative care model designed to improve engagement in evidence-based treatment of PTSD.
  
  
  METHODS
  The Telemedicine Outreach for PTSD (TOP) study used a pragmatic randomized effectiveness trial design with intention-to-treat analyses. Outpatients were recruited from 11 Department of Veterans Affairs (VA) community-based outpatient clinics serving predominantly rural veterans. Inclusion required meeting diagnostic criteria for current PTSD according to the Clinician-Administered PTSD Scale. Exclusion criteria included receiving PTSD treatment at a VA medical center or a current diagnosis of schizophrenia, bipolar disorder, or substance dependence. Two hundred sixty-five veterans were enrolled from November 23, 2009, through September 28, 2011, randomized to usual care (UC) or the TOP intervention, and followed up for 12 months.
  
  
  METHODS
  Off-site PTSD care teams located at VA medical centers supported on-site community-based outpatient clinic providers. Off-site PTSD care teams included telephone nurse care managers, telephone pharmacists, telepsychologists, and telepsychiatrists. Nurses conducted care management activities. Pharmacists reviewed medication histories. Psychologists delivered cognitive processing therapy via interactive video. Psychiatrists supervised the team and conducted interactive video psychiatric consultations.
  
  
  METHODS
  The primary outcome was PTSD severity as measured by the Posttraumatic Diagnostic Scale. Process-of-care outcomes included medication prescribing and regimen adherence and initiation of and adherence to cognitive processing therapy.
  
  
  RESULTS
  During the 12-month follow-up period, 73 of the 133 patients randomized to TOP (54.9%) received cognitive processing therapy compared with 16 of 132 randomized to UC (12.1%) (odds ratio, 18.08 [95% CI, 7.96-41.06]; P < .001). Patients in the TOP arm had significantly larger decreases in Posttraumatic Diagnostic Scale scores (from 35.0 to 29.1) compared with those in the UC arm (from 33.5 to 32.1) at 6 months (β = -3.81; P = .002). Patients in the TOP arm also had significantly larger decreases in Posttraumatic Diagnostic Scale scores (from 35.0 to 30.1) compared with those in the UC arm (from 33.5 to 31.7) at 12 months (β = -2.49; P=.04). There were no significant group differences in the number of PTSD medications prescribed and adherence to medication regimens were not significant. Attendance at 8 or more sessions of cognitive processing therapy significantly predicted improvement in Posttraumatic Diagnostic Scale scores (β = -3.86 [95% CI, -7.19 to -0.54]; P = .02) and fully mediated the intervention effect at 12 months.
  
  
  CONCLUSIONS
  Telemedicine-based collaborative care can successfully engage rural veterans in evidence-based psychotherapy to improve PTSD outcomes.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT00821678.
authors.affiliation: Health Services Research and Development, Central Arkansas Veterans Healthcare System, North Little Rock2South Central Mental Illness Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock3Division of Health Services.
authors.forename: John C
authors.initials: JC
authors.lastname: Fortney
authors.affiliation: Health Services Research and Development, Central Arkansas Veterans Healthcare System, North Little Rock2South Central Mental Illness Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock3Division of Health Services.
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Pyne
authors.affiliation: Health Services Research and Development, Central Arkansas Veterans Healthcare System, North Little Rock2South Central Mental Illness Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock3Division of Health Services.
authors.forename: Timothy A
authors.initials: TA
authors.lastname: Kimbrell
authors.affiliation: Health Services Research and Development, Central Arkansas Veterans Healthcare System, North Little Rock2South Central Mental Illness Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock3Division of Health Services.
authors.forename: Teresa J
authors.initials: TJ
authors.lastname: Hudson
authors.affiliation: Mental Health Service, Southeast Louisiana Veterans Health Care System, New Orleans.
authors.forename: Dean E
authors.initials: DE
authors.lastname: Robinson
authors.affiliation: Mental Health Service, Overton Brooks Veterans Affairs Medical Center, Shreveport, Louisiana7Department of Psychiatry, Louisiana State University Health Sciences Center, Shreveport.
authors.forename: Ronald
authors.initials: R
authors.lastname: Schneider
authors.affiliation: Health Services Research and Development, Central Arkansas Veterans Healthcare System, North Little Rock2South Central Mental Illness Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock.
authors.forename: William M
authors.initials: WM
authors.lastname: Moore
authors.affiliation: Mental Health Service, Veterans Affairs Loma Linda Health Care System, Loma Linda, California.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Custer
authors.affiliation: Health Services Research and Development, Central Arkansas Veterans Healthcare System, North Little Rock2South Central Mental Illness Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock3Division of Health Services.
authors.forename: Kathleen M
authors.initials: KM
authors.lastname: Grubbs
authors.affiliation: National Center for PTSD, Veterans Affairs Medical Center, White River Junction, Vermont10Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
authors.forename: Paula P
authors.initials: PP
authors.lastname: Schnurr
mesh_terms: D000328:Adult; D000554:Ambulatory Care Facilities / Q000706:statistics & numerical data; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D003151:Community Health Centers / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D033183:Interdisciplinary Communication; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team; D011569:Psychiatric Status Rating Scales; D011619:Psychotropic Drugs / Q000627:therapeutic use; D012424:Rural Population; D013313:Stress Disorders, Post-Traumatic / Q000175:diagnosis / Q000523:psychology / Q000628:therapy; D017216:Telemedicine / Q000379:methods / Q000458:organization & administration; D016896:Treatment Outcome; D014728:Veterans / Q000523:psychology*; D049269:Videoconferencing
chemical_list: D011619:Psychotropic Drugs