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Old Traumas, New Traumas, and New Approaches to Treating Trauma May 14-15, 2007 Houston, TX

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4 Year Clinical Trial Telemedicine & Anger Management Groups with PTSD Veterans in the Hawaiian Islands Principal Investigator: Leslie A. Morland, ... – PowerPoint PPT presentation

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Title: Old Traumas, New Traumas, and New Approaches to Treating Trauma May 14-15, 2007 Houston, TX


1
Old Traumas, New Traumas, and New Approaches to
Treating TraumaMay 14-15, 2007Houston, TX
2
Utilizing Tele-Mental Health to Access Remote,
Rural Veterans with PTSD
Carolyn Greene, Ph.D. Leslie Morland, Psy.D.
National Center for PTSD, Department of Veterans
Affairs, Pacific Islands Health Care System,
Spark M. Matsunaga Medical Center, Honolulu,
Hawaii
3
Acknowledgements This material is based upon
work supported in part by the Office of Research
and Development, Health Services RD Service,
Department of Veterans Affairs, VA Pacific
Islands Health Care System, Spark M. Matsunaga
Medical Center.  Support was also provided by VA
National Center for PTSD. 
4
Why Use Tele-Mental Health in the Pacific Islands
  • Geographic Dispersion of VA Health Care System
  • Reduce Travel- Increase Access to Care
  • Mental Health Needs
  • Access to specialty care
  • Clinical Coverage
  • Consultation
  • CP Exams
  • Education Training

5
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6
Objectives
  • Tele-Mental Health Overview
  • Tele-Mental Health PTSD
  • Pilot Study 1
  • Pilot Study 2
  • Current Clinical Trial
  • Clinical Application Implications
  • Future Directions

7
Tele-Mental Health Overview
  • Available technologies
  • Current TMH services in VHA
  • Current TMH services in Military and other
    sectors
  • Literature Review

8
Pilot Study 1
  • Remote PTSD Assessments, Evaluations,
  • and Treatment Consultation
  • Funded by a research grant from the VA/DOD
  • Pacific Telehealth Hui
  • Research Goal Evaluate feasibility of
    conducting comprehensive PTSD assessments
    consultation using VTC technology with remote
    veterans

9
Pilot Study 1
  • Conducted PTSD assessments which included on-line
    self-report measures, structured interviews via
    VTC, and feedback consultation via VTC. 60 VTC
    sessions were conducted.
  • 80 of veterans reported feeling comfortable with
    modality and 90 were willing to use VTC for
    future services.
  • Clinicians reported being able to establish
    rapport and perform accurate diagnostic
    evaluations.

10
Pilot Study 2
  • Telemedicine and PTSD Coping Skills Groups
  • for Pacific Island Veterans A Pilot Study
  • Principal Investigator Leslie A. Morland, Psy.D.
  • Funded by the Office of RD VISN 21 VA Young
    Investigator Award by the VA NC-PTSD
  • Research Goal Evaluate feasibility of using VTC
    technology to provide coping skills groups to
    remote veterans with chronic PTSD

11
Pilot Study 2
  • 20 PTSD veterans randomly assigned to either the
    VTC group or the traditional in-person group
    condition.
  • Provided an 8-week manual driven PTSD Coping
    Skills group which included modules on PTSD
    psychoeducation, anger management,
    conflict-resolution, and relapse prevention.
  • Both conditions had comparable outcomes of
    information retention and treatment adherence.
    Veterans, clinic staff, and the therapist rated
    the intervention favorably.

12
4 Year Clinical Trial
  • Telemedicine Anger Management Groups with PTSD
    Veterans in the Hawaiian Islands
  • Principal Investigator Leslie A. Morland, Psy.D.
  • Funded June 2005 by VA HSRD

13
Contributors/Collaborators
  • Carolyn Greene, Ph.D.- Co-I Project Manager
  • Patrick Reilly, Ph.D - Co-Investigator
  • Craig Rosen, Ph.D. - Co-Investigator
  • B. Christopher Frueh, Ph.D.- Co-Investigator
  • Jay Shore, MD, MPH - Co-investigator
  • David Foy, Ph.D. Ed Kubany, Ph.D. - Consultants
  • Dan King, Ph.D. Ian Pagano - Statisticians

14
Research Goal
  • Evaluate the effectiveness/efficacy of using VTC
    modality as compared to the traditional in-person
    modality for providing a cognitive-behavioral
    group anger management intervention with remote
    veterans with PTSD.

15
Research Objectives
  • Test the hypothesis that a novel mode of mental
    health service delivery (VTC) will be equally
    effective as a traditional mode of mental health
    service delivery (in-person) for providing
    specialized mental health intervention (AMT) to
    veterans with PTSD.
  • The study will allow for a direct comparison of
    each mode of service delivery provided to
    veterans through several Veterans Affairs (VA)
    outpatient clinics on clinical and process
    categories of outcome variables.

16
Outcomes
  • (1)    The primary clinical outcome expected is
    equivalence between the two modalities on
    clinically significant reduction of anger
    expression, anger disposition, assaultive
    behavior and an increase on anger control at
    mid-treatment, post-treatment and at follow-up.
  • (2)    Process outcomes include expected
    equivalence between the two modalities on patient
    satisfaction, patients perception of services,
    therapeutic group alliance, treatment adherence,
    attendance, attrition and treatment credibility
    at mid-treatment and post-treatment.

17
Why Anger PTSD?
  • Combat veterans with PTSD report more anger,
    hostility, interpersonal violence, and
    anger-related problems than non-PTSD combat
    veterans.
  • This association between anger and combat-related
    PTSD has significant social and clinical
    implications for the veteran population including
    an impact on families, work settings, and
    society.
  • The treatment of the anger component of PTSD is
    considered essential in the trauma recovery
    process.

18
Methods
  • Design Randomized Control Trial
  • Participants 180 veterans with PTSD from 4 VA
    sites 9 cohorts (6-9 veterans per group)
  • Intervention 12 sessions of CBT Anger Management
  • Assessments At baseline, mid, post, follow-up
  • Clinical Outcomes
  • Process Outcomes
  • Primary Analyses Equivalency Analyses of VTC vs.
    in-person mental health service delivery

19
Referrals VA Vet Center
Personal or Demographic Variables Age, Ethnicity,
Educ, Service Era, SC Status, Military Branch,
Employment, Marital Status, Distance to VA
Combat Trauma PTSD - Anger
VTC Anger Group
In Person Anger Group
Process Outcomes Therapeutic Alliance Satisfaction
Trust/Comfort Convenience Compliance Attrition
Clinical Outcomes Anger Reduction
Disposition Anger Control Aggression Violence
20
Clinical Sites
21
Site Requirements
  • Access to Group room
  • Access to VTC unit (Tandberg or Polycom)
  • Back-up personnel on-site
  • Adequate Referrals

22
Recruitment Assessment
CBOC Site Recruitment
Clinician Referral
Phone Screen (CAGE, STAXI, PTSD)
Interview (SCID, CAPS, STAXI, NAS, ABS)
Randomize (war era)
VTC Condition
In-Person Condition
23
Participants
  • Inclusion criteria
  • ? PTSD diagnosis (CAPS-1) and confirmed by the
    PCL.
  • ? Significant level of anger on the 10-item
    State-Trait Anger Expression Inventory
  • ? Stable medications regimen for at least 2
    months prior to study entry
  • Exclusion criteria
  • ? active psychotic symptoms/disorder as
    determined by the SCID for DSM-IV
  • ? active homicidal or suicidal ideation as
    determined by the structured clinical interview
  • ? any significant cognitive impairment or history
    of Organic Mental Disorder
  • ? active (current) substance dependence as
    determined by the SCID
  • ? unwillingness to refrain from substance abuse
    during treatment
  • ? female veterans

24
Recruitment Retention
  • Recruitment
  • Selection of sites with limited services
  • Site visits and site liaisons
  • Flyers
  • Back-up clinical sites
  • Retention
  • Initial group meeting with PI
  • Weekly phone calls
  • Travel reimbursement per session (10)

25
Measures
  • Clinical Outcome
  • Anger (STAXI NAS)
  • Violence (ABS)
  • PTSD (CAPS PCL)
  • Quality of Life (Frisch)
  • Process Outcome
  • Attrition (Attendance)
  • Treatment Compliance (Homework)
  • Treatment Expectancy (Borkovec)
  • Group Therapy Alliance (GTAS)
  • Satisfaction (Frueh)

26
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27
Sessions
  • Week 1 Introduction to Conceptual Framework
  • Week 2 Cues to Anger
  • Week 3 Anger Control Plan, Relaxation
  • Week 4 Aggression Cycle, Relaxation
  • Week 5 Cognitive-Restructuring
  • Week 6 Review Session 1
  • Weeks 7 8 Assertiveness Training/Conflict
    Resolution
  • Weeks 9 10 Anger in the Family
  • Week 11 Review Session 2
  • Week 12 Closing and Graduation

28
  • Each 90-minute group session consists of two
    components
  • A didactic presentation of the cognitive-
  • behavioral material
  • A check-in procedure involving group
  • interaction and discussion

29
Cognitive-Behavioral (CBT) Intervention Types
  • Relaxation Interventions (target emotional and
    physiological components of anger)
  • Cognitive Interventions (target hostile
    appraisals and attributions, and irrational
    beliefs)
  • Social/Communication Skills Interventions -
    (target conflict resolution and communication
    skills)
  • Combined Interventions - (target multiple
    response domains by integrating two or more
    intervention components)

30
Analyses
  • Univariate descriptive statistics and frequency
    distributions will be derived as appropriate for
    all variables.
  • Equivalency Analyses - non-traditional approach -
    it is hypothesized that the two treatment
    modalities under examination (VTC vs. IP) are
    equivalent.

31
Analyses
  • A multilevel modeling procedure will be used for
    the analyses
  • This method will include both individuals and
    sessions (group cohorts) as units of analysis,
    with participants (Level 1) nested within
    sessions (Level 2).
  • Including baseline values for the outcome measure
    as a covariate in the model will ensure
    comparability across treatments and sessions at
    baseline.

32
Analyses
  • Primary clinical outcome is a clinically
    significant change in anger as measured by
  • STAXI, NAS, ABS
  • Additional process outcomes measured include
  • Veteran Satisfaction, GTAS, Treatment Expectancy,
    Compliance, Attrition
  • Secondary analyses will include examining the
    influence of confound variables such as
    psychiatric comorbidity, concurrent treatment,
    PTSD severity, etc.

33
Preliminary Results
  • Currently Conducting 7th Cohort
  • Total Enrolled 98
  • Drop-outs 6
  • Attrition 6
  • Groups cancelled due to technical difficulties
    0
  • Groups cancelled due to clinical difficulties 0
  • 8th cohort scheduled for July

34
Total Participants
  • N 98
  • Mean Age 55 (SD 8.7)
  • Range of Ages 22 to 80
  • Pacific Island 39.0
  • Asian 25.6
  • Caucasian 25.6
  • Hispanic 4.9
  • African-American 4.9

35
War Eras Served In
  • Vietnam 68.6
  • Desert Storm 16.3
  • World War II 3.5
  • OIF/OEF 3.5
  • Korean 3.5
  • Other 3.5

36
Clinical Outcomes
  • Anger Reduction
  • STAXI
  • Novaco (NAS)
  • Assaultive Behavior Scale (ABS)
  • PCL

37
Process Outcomes
  • Treatment Expectancy
  • Attrition (drop-outs)
  • Compliance (Attendance Homework)
  • Group Therapy Alliance Scale

38
Qualitative Data
  • Overall impressions of intervention and modality
  • How well the intervention fits with cultural
    beliefs
  • Validity of assessment measures
  • Feedback to research team

39
Lessons Learned
  • Technology
  • Staff Training Support
  • Participant Expectations
  • Managing Logistics

40
Clinical Implications
  • Feasibility of conducting anger management group
    therapy using TMH with PTSD veterans
  • Preliminary data supports the clinical
    effectiveness of Anger Management Therapy (AMT)
    for Pacific Island Veterans
  • Veterans acceptance and willingness to use
  • these services in the future
  • Satisfaction and comfort this modality

41
Clinical Application in Pacific Islands
  • PTSD Specialty Services
  • Coping Skills Groups
  • Sleep Hygiene Groups
  • Anger Management Groups
  • Assessment Consultation
  • Future Clinical Application Sites
  • Returning OIF/OEF troops
  • Continuity of Care

42
Future Research Direction
  • More Randomized Clinical Trials (RCTs)
  • Clinical, Process and Economic Outcomes
  • Differential Cost Clinical Effectiveness
    Studies
  • Application in Ethnically and Culturally Diverse
    Populations
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