The Effects of Home-Based Telemental Health for Rural Veterans With PTSD

The Office of Rural Health has funded the VA Pacific Islands Healthcare System (VAPIHCS) to provide HBTMH for rural veterans diagnosed by a mental health provider as having PTSD. VAPIHCS serves an area about the size of the continental United States. Outside of Honolulu, there are few mental health specialists to serve Veterans with PTSD and common comorbid disorders, such as traumatic brain injury (TBI), pain, insomnia, and substance abuse. Moreover, many such Veterans have difficulty following-up for services at Community-Based Outpatient Clinics (CBOCs) due to psychological or physical limitations, transportation, work schedule, or stigma.

Cost is another reason to develop a HBTMH approach. Seventy percent of those who complete a course of Evidence Based Therapy (EBT) significantly improve their symptoms, with most no longer carrying the diagnosis following such treatments (Bradley, Greene, Russ, Dutra, \& Westen, 2005). However those who lack access to EBTs, especially those with polytraumas, have a low chance of recovery (Elhers \& Clark, 2008; Lyons \& Keane, 1992). The lack of specialists in these regions means that the Veterans continue to suffer with PTSD and related disorders far longer than if specialized care were available. Sending experts to these areas is costly, and inefficient. The cost and difficulty for highly rural Veterans to travel for weekly appointments to a CBOC that lacks expertise in EBT for PTSD and treating Veterans with polytrauma has minimal value. Finally, the no-show rate for such Veterans can run well above 15%, whereas research with HBTMH has no-show rates of less than 4% (http://conference.avapl.org/pubs/2012%20Conference%20Presentations/HBTMH%20SOP_Shore_11-12-11%20copy.pdf)

To improve services for Veterans, the VA provides telehealth options at its CBOC locations in the Pacific Islands. Many patients live too far from the CBOC or prefer to receive mental health treatment in the comfort of their own homes. HBTMH technology, such as televideo sessions between a home-based patient and their mental healthcare provider, has been successfully implemented in the VA (e.g. throughout VISN 20 and VISN 7) and in the Department of Defense (DOD). VAPIHCS was funded by the ORH to provide evidence-based specialty treatment via HBTMH to rural Veterans with PTSD who would not otherwise have such treatment available to them. The clinical project is funded to provide up to 100 rural patients who were referred by their CBOC providers to this specialty clinic for HBTMH PTSD treatment. This VAPIHCS clinic provides evidence-based treatment to eligible veterans in their homes via televideo by clinicians currently based at the NCPTSD. Only ORH-funded VAPIHCS clinical staff will provide treatment to the PTSD patients who choose to and are eligible to receive the home-based telemental health. Veterans are eligible for this VAPIHCS-HBTMH clinic if they have been diagnosed with PTSD by a licensed mental health provider at a CBOC, or are referred by a CBOC (via clinical consult).

In order to initially evaluate the effectiveness of HBTMH, the current research study will evaluate veterans participating in the VAPIHCS-HBTMH clinic compared to Treatment as Usual (TAU - those who were referred to the clinic, however either refused to participate in this type of clinical care or were ineligible to be part of this clinic due to structural difficulties (no 4G in their area, can't type, lack of nearby emergency services, etc). Thus, this protocol is assessment only, and is separate from the treatment provided to the rural Veterans.

Currently, there are no standardized, objective assessments available for determining impairment and improvement of PTSD. The Defense Automated Neurobehavioral Assessment (DANA) is a clinical decision support tool developed for the Department of Defense (DoD) for field and clinic-based neurobehavioral functioning. This neurobehavioral assessment system was developed on the assumption that various risk factors (PTSD, Depression, Insomnia, anger, pain, etc.) lead to significantly slower and less accurate (throughput) performance on cognitive tests. The primary goal of DANA is to assist providers in determining level of functioning and to track recovery over time. An important purpose of this study is to collect longitudinal data from patients receiving EBT (both in clinics and through HBTMH) in order to assess whether cognitive functioning improves as PTSD symptoms decrease with treatment. This information will provide support for DANA's validity as an objective measure of PTSD impairment. The study also plans to determine the sensitivity and specificity of DANA neurocognitive measures in determining changes in cognitive functioning within PTSD patients engaged in EBT over time.

The proposed project aims to examine the effectiveness of an empirically based trauma-focused treatment intervention delivered via video conferencing to the home. This project aims to:

Objective 1: Examine the feasibility of HBTMH compared to treatment as usual.

Objective 2: Compare the effectiveness of HBTMH compared to treatment as usual.

Objective 3: Determine predictors of successful treatment outcomes (including treatment completion and clinically significant reduction in PTSD and related symptoms).

Objective 4: Determine the sensitivity and specificity of Defense Automated Neurobehavioral Assessment (DANA) neurocognitive measures in determining changes in psychological functioning within subjects over time.