This is the first randomized controlled trial to evaluate non-inferiority of Prolonged Exposure (PE) delivered via home-based telehealth (HBT) compared to standard in-person (IP) PE. One-hundred ...thirty two Veterans recruited from a Southeastern Veterans Affairs Medical Center and affiliated University who met criteria for posttraumatic stress disorder (PTSD) were randomized to receive PE via HBT or PE via IP. Results indicated that PE-HBT was non-inferior to PE-IP in terms of reducing PTSD scores at post-treatment, 3 and 6 month follow-up. However, non-inferiority hypotheses for depression were only supported at 6 month follow-up. HBT has great potential to reduce patient burden associated with receiving treatment in terms of travel time, travel cost, lost work, and stigma without sacrificing efficacy. These findings indicate that telehealth treatment delivered directly into patients' homes may dramatically increase the reach of this evidence-based therapy for PTSD without diminishing effectiveness.
•Prolonged Exposure (PE) decreases posttraumatic stress disorder (PTSD) symptoms.•Home-based telehealth (HBT) was compared to in person (IP) delivery of PE.•HBT-PE was non-inferior to IP-PE in terms of PTSD symptoms at post, 3 and 6 month followup points.•HBT-PE was non-inferior to IP-PE in depression symptoms at 6-month follow-up only.•HBT-PE can increase the reach of this evidence-based treatment for PTSD.
We estimated prevalence and assessed correlates of emotional, physical, sexual, and financial mistreatment and potential neglect (defined as an identified need for assistance that no one was actively ...addressing) of adults aged 60 years or older in a randomly selected national sample.
We compiled a representative sample by random digit dialing across geographic strata. We used computer-assisted telephone interviewing to standardize collection of demographic, risk factor, and mistreatment data. We subjected prevalence estimates and mistreatment correlates to logistic regression.
We analyzed data from 5777 respondents. One-year prevalence was 4.6% for emotional abuse, 1.6% for physical abuse, 0.6% for sexual abuse, 5.1% for potential neglect, and 5.2% for current financial abuse by a family member. One in 10 respondents reported emotional, physical, or sexual mistreatment or potential neglect in the past year. The most consistent correlates of mistreatment across abuse types were low social support and previous traumatic event exposure.
Our data showed that abuse of the elderly is prevalent. Addressing low social support with preventive interventions could have significant public health implications.
Objective
Combat veterans returning to society with impairing mental health conditions such as PTSD and major depression (MD) report significant barriers to care related to aspects of traditional ...psychotherapy service delivery (e.g., stigma, travel time, and cost). Hence, alternate treatment delivery methods are needed. Home‐based telehealth (HBT) is one such option; however, this delivery mode has not been compared to in person, clinic‐based care for PTSD in adequately powered trials. The present study was designed to compare relative noninferiority of evidence‐based psychotherapies for PTSD and MD, specifically Behavioral Activation and Therapeutic Exposure (BA‐TE), when delivered via HBT versus in person, in clinic delivery.
Method
A repeated measures (i.e., baseline, posttreatment, 3‐, 6‐month follow‐up) randomized controlled design powered for noninferiority analyses was used to compare PTSD and MD symptom improvement in response to BA‐TE delivered via HBT versus in person, in clinic conditions. Participants were 232 veterans diagnosed with full criteria or predefined subthreshold PTSD.
Results
PTSD and MD symptom improvement following BA‐TE delivered by HBT was comparable to that of BA‐TE delivered in person at posttreatment and at 3‐ and 12‐month follow‐up.
Conclusion
Evidence‐based psychotherapy for PTSD and depression can be safely and effectively delivered via HBT with clinical outcomes paralleling those of clinic‐based care delivered in person. HBT, thereby, addresses barriers to care related to both logistics and stigma.
With a national household probability sample of 4,023 telephone-interviewed adolescents ages 12-17, this study provides prevalence, comorbidity, and risk-factor data for posttraumatic stress disorder ...(PTSD), major depressive episode (MDE), and substance abuse/dependence (SA/D). Roughly 16% of boys and 19% of girls met criteria for at least 1 diagnosis. Six-month PTSD prevalence was 3.7% for boys and 6.3% for girls, 6-month MDE prevalence was 7.4% for boys and 13.9% for girls, and 12-month SA/D prevalence was 8.2% for boys and 6.2% for girls. PTSD was more likely to be comorbid than were MDE and SA/D. Results generally support the hypothesis that exposure to interpersonal violence (i.e., physical assault, sexual assault, or witnessed violence) increases the risk of these disorders and of diagnostic comorbidity.
Many older adults with major depression, particularly veterans, do not have access to evidence-based psychotherapy. Telemedicine could increase access to best-practice care for older adults facing ...barriers of mobility, stigma, and geographical isolation. We aimed to establish non-inferiority of behavioural activation therapy for major depression delivered via telemedicine to same-room care in largely male, older adult veterans.
In this randomised, controlled, open-label, non-inferiority trial, we recruited veterans (aged ≥58 years) meeting DSM-IV criteria for major depressive disorder from the Ralph H Johnson Veterans Affairs Medical Center and four associated community outpatient-based clinics in the USA. We excluded actively psychotic or demented people, those with both suicidal ideation and clear intent, and those with substance dependence. The study coordinator randomly assigned participants (1:1; block size 2-6; stratified by race; computer-generated randomisation sequence by RGK) to eight sessions of behavioural activation for depression either via telemedicine or in the same room. The primary outcome was treatment response according to the Geriatric Depression Scale (GDS) and Beck Depression Inventory (BDI; defined as a 50% reduction in symptoms from baseline at 12 months), and Structured Clinical Interview for DSM-IV, clinician version (defined as no longer being diagnosed with major depressive disorder at 12 months follow-up), in the per-protocol population (those who completed at least four treatment sessions and for whom all outcome measurements were done). Those assessing outcomes were masked. The non-inferiority margin was 15%. This trial is registered with ClinicalTrials.gov, number NCT00324701.
Between April 1, 2007, and July 31, 2011, we screened 780 patients, and the study coordinator randomly assigned participants to either telemedicine (120 50%) or same-room treatment (121 50%). We included 100 (83%) patients in the per-protocol analysis in the telemedicine group and 104 (86%) in the same-room group. Treatment response according to GDS did not differ significantly between the telemedicine (22 22·45%, 90% CI 15·52-29·38 patients) and same-room (21 20·39%, 90% CI 13·86-26·92) groups, with an absolute difference of 2·06% (90% CI -7·46 to 11·58). Response according to BDI also did not differ significantly (telemedicine 19 24·05%, 90% CI 16·14-31·96 patients; same room 19 23·17%, 90% CI 15·51-30·83), with an absolute difference of 0·88% (90% CI -10·13 to 11·89). Response on the Structured Clinical Interview for DSM-IV, clinician version, also did not differ significantly (39 43·33%, 90% CI 34·74-51·93 patients in the telemedicine group and 46 48·42%, 90% CI 39·99-56·85 in the same-room group), with a difference of -5·09% (-17·13 to 6·95; p=0·487). Results from the intention-to-treat population were similar. MEM analyses showed that no significant differences existed between treatment trajectories over time for BDI and GDS. The criteria for non-inferiority were met. We did not note any adverse events.
Telemedicine-delivered psychotherapy for older adults with major depression is not inferior to same-room treatment. This finding shows that evidence-based psychotherapy can be delivered, without modification, via home-based telemedicine, and that this method can be used to overcome barriers to care associated with distance from and difficulty with attendance at in-person sessions in older adults.
US Department of Veterans Affairs.
Abstract Objective Few studies have examined sexual dysfunction among Operations Enduring/Iraqi Freedom (OEF/OIF) veterans with posttraumatic stress disorder (PTSD). The present study investigated ...predictors of erectile dysfunction ED and self-reported sexual problems among 150 male combat veterans seeking outpatient treatment for PTSD within the Veterans Affairs healthcare system. Method Participants completed clinical interviews and several questionnaires including measures of sexual arousal and sexual desire. A medical records review was also conducted to document evidence of an ED diagnosis or associated medication use. Results An ED diagnosis was present for 12% of the sample, and 10% were taking associated medications. Sexual arousal problems were reported by sixty-two percent of partnered veterans. Sexual desire problems were endorsed by 63% of the total sample, and by 72% of partnered veterans. Age was the only significant predictor of ED diagnosis or medication use. Age, race, PTSD diagnosis (versus subclinical symptoms), depression, and social support predicted self-reported sexual arousal problems; while race, combat exposure, social support, and avoidance/numbing symptoms of PTSD predicted self-reported sexual desire problems. Conclusions Sexual problems are common among male OEF/OIF combat veterans seeking treatment for PTSD. Moreover, avoidance/numbing symptoms robustly predicted sexual desire problems. These findings highlight the importance of expanding assessment of sexual dysfunction and support the need for additional research in this area.
Objectives: Despite its subjective nature, self-report of health status is strongly correlated with long-term physical morbidity and mortality. Among the most reliable predictors of self-reported ...poor health is older age. In younger adult populations, the second reliable predictor of reported poor health is the experience of domestic and other interpersonal violence. However, very little research exits on the connection between elder mistreatment and self-reports of poor health. The aim of this study was to examine the level of, and correlates for, poor self-rated health in a community sample of older adults with particular emphasis on elder mistreatment history, demographics, and social dependency variables. Design: Random digit dialing telephone survey methodology. Setting: A national representative phone survey of noninstitutionalized U.S. household population. Participants: Five thousand seven hundred seventy-seven U.S. adults, aged 60 years and older. Measurements: Individuals participated in a structured interview assessing elder mistreatment history, demographics, and social dependency variables. Results: Poor self-rated health was endorsed by 22.3% of the sample. Final multivariable logistic regression models showed that poor self-rated health was associated with unemployment, marital status, low income, low social support, use of social services, needing help in activities of daily living, and being bothered by emotional problems. Secondary analyses revealed a mediational role of emotional symptoms in the association between physical maltreatment and poor health. Conclusions: Results suggest that poor health is common among older adults. This study also identified correlates of poor health that may be useful in identification of those in need of intervention.
Post-traumatic stress disorder (PTSD) is a highly prevalent and impairing condition for which there are several evidence-based psychotherapies. However, a significant proportion of patients fail to ...complete a 'sufficient dose' of psychotherapy, potentially limiting treatment gains.
The present study investigated predictors of premature treatment discontinuation during a trial of prolonged exposure (PE) therapy for PTSD.
Combat veterans with PTSD were recruited to participate in a randomized clinical trial of PE delivered in person or via telehealth technologies. Of the 150 initial participants, 61 participants discontinued the trial before the completion of eight sessions (of an 8‒12 session protocol). Treatment condition (telehealth or in person) and factors identified by prior research (age, combat theatre, social support, PTSD symptoms) were tested as predictors of treatment discontinuation.
A Cox proportional hazards model (a subtype of survival analysis) was used to evaluate predictors of treatment discontinuation. Disability status and treatment condition were identified as significant predictors of discontinuation, with a noted disability and use of telehealth demonstrating higher risk.
The present findings highlight the influence of telehealth and disability status on treatment discontinuation, while minimizing the role of the previously identified variables from studies with less sensitive analyses.
Effective treatments for posttraumatic stress disorder (PTSD) (e.g., prolonged exposure (PE); cognitive processing therapy (CPT)) exist and are widely adopted by the Departments of Veterans Affairs ...(VA) and Defense (DoD). Unfortunately, dropout from these treatments regularly exceeds 30%. However, in a recent survey of patients who dropped out of PE, approximately half indicated a greater likelihood of completion if a peer who had completed treatment were available to help with the in vivo exposure homework.
We will use a between-groups randomized controlled design with repeated assessment at baseline, post treatment, and 3- and 6-month follow-up across measures of PTSD, depression, and functioning with 150 veterans who have indicated that they intend to drop out of treatment. Participants will be randomly assigned to one of two PE + Peer Support conditions: (1) a peer will offer support directly during in vivo exposure homework for 3-4 weeks; vs (2) a peer will call weekly for 3-4 weeks to offer general support and to check in on treatment progress.
The present study was designed to test the hypothesis that dropout from exposure-based PTSD treatment may be mitigated by using peers as support agents directly during PE in vivo homework experiences. Specifically, we intend to determine: whether patients who have dropped out of PE and are offered the "in vivo peer" adjunctive component to PE therapy will (1) return and complete treatment and (2) evince reduced PTSD symptomatology, compared to the same PE treatment, but with general peer support more reflective of current VA practices.
This study protocol is approved and information is available at ClinicalTrials.gov, ID: NCT03485391. Registered on 2 April 2018.
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