Telephone Pep Talk Gets More Vets Into Therapy

Megan Brooks

August 03, 2012

August 3, 2012 — A brief motivational telephone interview is much more effective than a standard "check-in" call in getting veterans of the Iraq and Afghanistan wars who have mental health diagnoses to start treatment, new research shows.

The pilot randomized study also showed that veterans receiving telephone motivational interviewing also were significantly more likely to stay in therapy. There was also a reduction in the reported rates of marijuana use, and there was less feeling of stigma surrounding mental health treatment.

The authors note that more than one half (52%) of the roughly half million Iraq and Afghanistan veterans currently receiving healthcare through the Veterans Administration (VA) have 1 or more mental health diagnoses, including posttraumatic stress disorder (PTSD), depression, anxiety, or other related conditions.

"The VA has gone to extraordinary lengths to provide these veterans with state-of-the-art, evidence-based mental health treatment," lead author Karen Seal, MD, MPH, director of the Integrated Care Clinic at the San Francisco VA Medical Center, in California, said in a statement.

Dr. Karen Seal

"The irony is that they are not necessarily engaging in this treatment. This study was positioned to try to connect our veterans with the treatments that are available to them," said Dr. Seal, who is also associate professor of medicine and psychiatry at the University of California, San Francisco.

The study was published online May 28 in General Hospital Psychiatry.

Large Effect Size

Participants included 73 veterans of the Iraq and Afghanistan wars (36% women, 48% younger than 30 years) who screened positive for at least 1 mental health disorder (ie, PTSD, depression, anxiety, high-risk drinking and/or illicit substance use) and who were referred for mental health treatment but were not currently in treatment.

They were randomly assigned to receive either 4 telephone motivational interviewing sessions or 4 "neutral" telephone check-in sessions (control) conducted at baseline and at 2, 4, and 8 weeks.

The motivational interviewers had at least a Master's degree in psychology or a related field and were trained in motivational interviewing techniques. Motivational interviewing, in which counselors express empathy and encourage people to explore and articulate discrepancies between their core values and their actual behaviors, has been used successfully as a psychotherapeutic intervention in other settings, the researchers note.

A total of 17 participants did not complete the study (7 in the intervention arm and 10 in the control arm). In intent-to-treat analyses, 21 of 34 (62%) veterans assigned to telephone motivational interviewing engaged in mental health treatment compared with only 10 of 39 (26%) of control participants (relative risk [RR], 2.41; 95% confidence interval [CI] 1.33 - 4.37; P = .004). This represents a large effect size (Cohen's h = 0.74), the authors say. The authors note that the effect was stronger for treatment-naïve veterans than for treatment-experienced ones.

Veterans in the motivational interviewing group were also significantly more likely to stay in mental health treatment (mean number of visits, 1.68 vs 0.38 visits for the control group). The incidence rate ratio was 4.36 (95% CI, 1.96 - 9.68; P < .001). The authors note, however, that the motivational interviewing intervention "was not intended to increase retention in mental health treatment, nor powered to detect differences in retention."

The motivational group also reported significant reductions in mental health treatment stigma and marijuana use at 8 weeks (P < .05).

For some veterans, "failing to engage in mental health treatment can be lethal; suicide rates may be higher in this generation of war veterans than in prior eras. For others, failing to engage in mental health treatment may result in chronic mental illness and social and occupational dysfunction with high costs to individuals, families, and society."

"Collectively, these outcomes may reduce long-term morbidity and costs to individuals, society, the VA and other healthcare systems," the authors say.

Novel Approach

Suzette Glasner-Edwards, PhD, of the David Geffen School of Medicine at UCLA, Los Angeles, California, said "one of the most novel aspects of this particular study is that phone-based motivational interviewing has not been well studied, to date, to target mental health treatment engagement; thus far, the literature on this particular evidence-based therapeutic technique has been more focused on its utility in primary care (for example, to facilitate management of chronic conditions such as diabetes, cancer, cardiovascular disease)."

"There have also been some studies on this approach for populations with drug and alcohol use disorders; however, this study focused primarily on the impact of the intervention on mental health treatment engagement, which appears promising," added Dr. Glasner-Edwards. She was not involved in the study.

She also told Medscape Medical News that although the generalizability of the study is limited owing to the fact that the population consisted of veterans only, this is also a strength of the study, "since there is and will continue to be a great need for this particular population to become engaged in mental health treatment."

"This is a great first step towards thinking outside of the box about how to get this population 'in the door' so that they can start to work on their psychiatric and substance abuse–related difficulties," Dr. Glasner-Edwards said.

Dr. Seal and colleagues are planning a follow-up study involving veterans at VA outpatient clinics in rural communities. As reported recently by Medscape Medical News, research has shown that providing telemental health services to patients living in rural and remote areas can dramatically reduce psychiatric hospitalization rates.

The study was supported by funds from the Department of Veterans Affairs. The authors and Dr. Glasner-Edwards have disclosed no relevant financial relationships.

Gen Hosp Psychiatry. Published online May 28, 2012. Abstract

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