Centrally Assisted Collaborative Telecare for Posttraumatic Stress Disorder and Depression Among Military Personnel Attending Primary Care

Abstract

IMPORTANCE It is often difficult for members of the US military to access high-quality care for posttraumatic stress disorder (PTSD) and depression.OBJECTIVE To determine effectiveness of a centrally assisted collaborative telecare (CACT) intervention for PTSD and depression in military primary care. DESIGN, SETTING, AND PARTICIPANTSThe STEPS-UP study (Stepped Enhancement of PTSD Services Using Primary Care) is a randomized trial comparing CACT with usual integrated mental health care for PTSD or depression. Patients, mostly men in their 20s, were enrolled from 18 primary care clinics at 6 military installations from February 2012 to August 2013 with 12-month follow-up completed in October 2014.INTERVENTIONS Randomization was to CACT (n = 332) or usual care (n = 334). The CACT patients received 12 months of stepped psychosocial and pharmacologic treatment with nurse telecare management of caseloads, symptoms, and treatment. MAIN OUTCOMES AND MEASURESPrimary outcomes were severity scores on the PTSD Diagnostic Scale (PDS; scored 0-51) and Symptom Checklist depression items (SCL-20; scored 0-4). Secondary outcomes were somatic symptoms, pain severity, health-related function, and mental health service use. RESULTSOf 666 patients, 81% were male and the mean (SD) age was 31.1 (7.7) years. The CACT and usual care patients had similar baseline mean (SD) PDS PTSD (29.4 [9.4] vs 28.9 [8.9]) and SCL-20 depression (2.1 [0.6] vs 2.0 [0.7]) scores. Compared with usual care, CACT patients reported significantly greater mean (SE) 12-month decrease in PDS PTSD scores (−6.07 [0.68] vs −3.54 [0.72]) and SCL-20 depression scores −0.56 [0.05] vs −0.31 [0.05]). In the CACT group, significantly more participants had 50% improvement at 12 months compared with usual care for both PTSD (73 [25%] vs 49 [17%]; relative risk, 1.6 [95% CI, 1.1-2.4]) and depression (86 [30%] vs 59 [21%]; relative risk, 1, with a number needed to treat for a 50% improvement of 12.5 (95% CI, 6.9-71.9) and 11.1 (95% CI, 6.2-50.5), respectively. The CACT patients had significant improvements in somatic symptoms (difference between mean 12-month Patient Health Questionnaire 15 changes, −1.37 [95% CI, −2.26 to −0.47]) and mental health-related functioning (difference between mean 12-month Short Form-12 Mental Component Summary changes, 3.17 [95% CI, 0.91 to 5.42]), as well as increases in telephone health contacts and appropriate medication use. CONCLUSIONS AND RELEVANCECentral assistance for collaborative telecare with stepped psychosocial management modestly improved outcomes of PTSD and depression among military personnel attending primary care. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01492348

Factors influencing the adoption of telemedicine for treatment of military veterans with post-traumatic stress disorder

“…was found in 9 out of 68 occurrences (13%) (12,14,16,17,25,26,33,34,37). Studies demonstrated that telehealth served as a means to reduce costs for both patients and providers.…”

“…"General interest/acceptance by veterans" was discussed in 7 out of 66 occurrences (10%) (13,14,27,31,33,35,36).…”

“…was another facilitator observed in the literature. This facilitator was identified in 6 out of 68 (9%) occurrences (14,18,19,27,29,30). Maintaining a good relationship between the provider and patient through telemedicine may be difficult, as the in-person contact is removed; however, 3 out of 68 occurrences (4%) identified "unaffected patient-provider relationship" as a facilitator to telemedicine adoption among veterans with PTSD (22,27,33).…”

“…Maintaining a good relationship between the provider and patient through telemedicine may be difficult, as the in-person contact is removed; however, 3 out of 68 occurrences (4%) identified "unaffected patient-provider relationship" as a facilitator to telemedicine adoption among veterans with PTSD (22,27,33). "Patient independence/autonomy" was identified in 3 out of 68 occurrences (4%) (14,17,36). Telemedicine allowed patients to feel more in control and aware of their symptoms.…”

Face-to-Face Versus Video Assessment of Facial Paralysis: Implications for Telemedicine (Preprint)

“…Patients have reported similar or better quality of life compared to usual care [23]. In addition, Internet-based interventions have been found to significantly decrease pain intensity, depression, anxiety and stress, and increase quality of life compared with in-person psychotherapy in patients with medically unexplained pain [20], in youth with depression and anxiety [21], in military personnel with PTSD and depression [17,24], and in patients with neurofibromatosis [15].…”