Telehealth Offers Effective Way to Treat Veterans for PTSD

Telehealth has the potential to let the Veterans Administration reach many more patients with post-traumatic stress disorder (PTSD), allowing the agency to overcome cost and geographic barriers without diminishing the quality of care, according to a pair of presenters who appeared Friday at the US Psychiatric and Mental Health Congress in San Diego, California.

Mark B. Hamner, MD, and Ron Acierno, PhD, both professors at the Medical University of South Carolina, shared how they brought telehealth to veterans with PTSD through the Veterans Affairs (VA) Medical Center in Charleston, South Carolina, which serves a broad geographic area that includes many rural communities. Telehealth has great potential but is still relatively new, Hamner said, which gives researchers what he called a “cornucopia” of research opportunities.

Younger patients, including veterans of recent conflicts in Iraq and Afghanistan, may embrace telehealth because of their comfort with technology and social media, Hamner said. “There is some degree of a natural boundary created by doing telemedicine” that may help some overcome an aversion to therapy.

Older veterans, meanwhile, deal with depression. “In my experience, they are quite willing to try telemedicine,” Hamner said.

The need for telehealth is obvious: large numbers of veterans need treatment for PTSD, yet there are shortages of psychiatrists, especially in rural areas. More than 70% of counties in the United States report they lack enough mental health professionals to serve local needs, he said. For the VA in particular, this presents a challenge because if veterans must travel for PTSD treatment, they must be compensated. Thus, both Hamner and Acierno said, it makes sense to find an in-home solution as long as care equals that in a clinic. Some veterans feel the clinic carries a stigma, so telehealth could be a way to reach more of them and keep them from dropping treatment.

Treatment for PTSD is unique. Hamner reviewed findings about the particular method, known as prolonged exposure therapy, which is used in combination with medication to gradually allow the patient to handle stimuli that trigger sensations of trauma. The therapy is very intense and involves having the patient describe the combat experience in detail; the session is recorded so the patient can review it later; Acierno likened the process to “recalibrating oneself.”

First, Hamner and Acierno had to be convinced that this treatment method could be delivered safely through telehealth. The question, Acierno said, is, “Can you gauge the anxiety?”

“We don’t want to give people second-best treatment just because it’s cheaper or easier,” he said.

Second, they had to deal with a host of practical issues, such as HIPAA compliance, security, privacy, and ensuring that veterans had computer access. They wanted to be sure each veteran understood that telehealth was choice, not a requirement, so patients came to the VA for consultations and to sign consent forms. Patients without computer access were given iPads (which were later returned). Acierno explained that just as a patient would drive himself to a doctor’s office, each one would elect to call in for a telehealth visit.

Acierno said that the program has developed protocols based on what clinicians have learned from experience. The VA recognized that a home-based program might feed into some patients’ tendencies to stay isolated, so treatment includes tasks that require them to go outside. Evaluations are done with screen shots and other visual tests so that physicians can see patients. Doctors are required to tell the patient if an intern is sitting in on the session; at the same time, patients advised to take sessions without family members nearby. Physicians are ready for emergencies: they have phone numbers for the local police dispatcher in case a patient becomes distressed. And physicians have seen it all—patients take appointments in various stages of dress and one ordered lunch at a drive-through during his appointment.

But is telehealth working? Research on Charleston area patients shows 70% reported a good relationship with their provider, 79.2% would recommend telehealth to a fellow patient, and 45.8% reported missing fewer appointments. Savings were $622 per telehealth patient, but researchers noted that all because the patients were all local, real-world savings would be larger, since avoided travel costs would increase. Telehealth also promises to allow more rural patients to participate in randomized clinical trials.

Hamner and Acierno have some concerns. Acierno notes that the dropout rate did not go down, although the number of visits increased from 3 to 7 before patients stopped attending therapy. Hamner hopes for research on whether telehealth affects medication patterns. If doctors cannot “see” a patient’s side effects, he said, “My guess is that there may be a slight shift in what physicians may be comfortable prescribing.”