Caroline Helwick

March 31, 2011

March 31, 2011 (New Orleans, Louisiana) — Prolonged exposure (PE) therapy for the treatment of posttraumatic stress disorder (PTSD) can be safely and effectively delivered to veterans living in rural areas via telehealth, according to results of a pilot study presented here at the Anxiety Disorders Association of America 31st Annual Conference.

Researchers at the Medical University of South Carolina and the Ralph H. Johnson Veterans Administration (VA) Medical Center, Charleston, found veterans who received PE therapy via telehealth experienced similar improvements in PTSD symptoms as their counterparts receiving in-person care. Furthermore, the safety profile of the 2 treatment delivery methods appeared to be equivalent.

According to study investigator Peter W. Tuerk, PhD, telemental health has many benefits, including lower cost without sacrificing quality of care, less lost employment time, and improved accessibility to rural veterans.

"Satisfaction with service delivery seems high among patients and providers. In terms of efficacy, the data are limited but supportive," said Dr. Tuerk.

The telehealth project at the Ralph H. Johnson VA system aims to provide evidence-based care to veterans who face barriers to completing in-person treatment. This includes rural veterans and veterans who receive care through community-based outpatient clinics (CBOCs).

"This was not a study with an experimental manipulation but rather an investigation of patient care at our clinic," he explained.

The study included 47 combat veterans diagnosed as having PTSD, 72% of whom were veterans of the wars in Afghanistan and Iraq and 28% of whom were veterans of the Vietnam War. Their average age was 32 years, 94% were male, 66% were white, and 34% were black.

PE was delivered to 35 veterans in person and to 12 via telehealth, which was an option offered to all veterans in rural areas or living near CBOCs; all who were offered this option accepted it.

For telehealth participants, rating scale measures were administered at baseline and every 2 weeks of treatment by the treating clinician. The normal PE protocol was followed with a few modifications: fax machines were used to convey homework assignments and self-report measures, and patients were mailed their session tapes, resulting in a short delay in listening to sessions as homework.

Pretreatment and posttreatment effect sizes were estimated for the PE and PE-telehealth groups. The study was not appropriately powered to prove the null hypothesis between groups. The investigators presented inferential statistics to provide a broad framework for feasibility and potential efficacy for the telehealth approach, not to investigate equivalency or inferiority, Dr. Tuerk explained.

Safe and Effective

No adverse events occurred in either treatment arm. Although Dr. Tuerk had obtained telephone numbers of CBOCs' support and safety staff, in case of emergency, no on-site staff needed to be contacted during therapy.

The treatment completion rate for the PE-telehealth group was 75%, compared with 83% for the in-person PE group. The average number of sessions to treatment termination was 10 in each arm, he reported.

The pretreatment to posttreatment change in PTSD Check List, military version (PCL-M) scores averaged 31 points in each group, which were significant. Because of the small numbers of patients, the confidence intervals are larger and the effect size smaller in the telehealth group, he explained.

In-person PE

  • Pretreatment: 60.69 (SD = 9.54)

  • Posttreatment: 27.69 (SD = 6.00)

  • t = 16.87 (P < .001; d = 4.25)

Telehealth PE

  • Pretreatment: 61.00 (SD = 10.58)

  • Posttreatment: 34.89 (SD = 7.56)

  • t = 12.29 (P < .001, d = 2.88)

Scores on the Beck Depression Inventory (BDI-II) also dropped significantly:

In-person PE

  • Pretreatment: 27.79 (SD = 9.30)

  • Posttreatment: 10.90 (SD = 6.42)

  • t = 8.66 (P < .001, d = 2.15)

Telehealth PE

  • Pretreatment: 27.33 (SD = 12.48)

  • Posttreatment: 7.56 (SD = 4.69)

  • t = 5.53 (P < .001, d = 2.30)

"PE delivery via telemental health is feasible" and can be recommended for veterans with PTSD. “The effect sizes are good, and it appears safe," said Dr. Tuerk.

"In most situations, there was no meaningful difference in the structure and process of the PE treatment. But in-session avoidance behavior can be more difficult to manage via telehealth."

When patients seek distraction, for example, they get up from their chair or keep the office door open, the therapist is somewhat helpless in preventing this.

"The telehealth condition appeared to pose additional difficulties only for severe patients. It may not be the best modality for these patients, though it is probably better than no treatment at all," he said.


Dr. Tuerk noted the study's limitations included that it was uncontrolled, lacked independent assessment, and had a small sample size. In addition, its clinicians were well trained to deliver PE and had institutional support, and this is frequently not the case in the community, he noted.

The main hurdle in implementing telehealth delivery system, said Dr. Tuerk, is "molding the healthcare system to a new way of doing things. This is an ongoing struggle at every level."

He added that efforts should be made to obtain "buy in" from staff at CBOCs, which requires occasional on-site visits. "Coordinated efforts and good professional relationships between facilities were important factors in our program."

Barbara Rothbaum, PhD, professor of psychiatry and director of the Trauma and Anxiety Recovery Program at Emory University School of Medicine, Atlanta, Georgia, has conducted seminal research on virtual reality treatment of PTSD in veterans of the wars in Afghanistan and Iraq.

She told Medscape Medical News that Dr. Tuerk and colleagues are "removing barriers to the treatment of PTSD in veterans" by developing an effective telehealth delivery model.

"It seems to work almost as well via telehealth as in person. The message is that if you can't get to us for health, we will bring the help to you," she said.

Dr. Tuerk and Dr. Barlow have disclosed no relevant financial relationships.

Anxiety Disorders Association of America (ADAA) 31st Annual Conference. Presented March 26, 2011.


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