Prolonged Exposure (PE) for Post Traumatic Stress Disorder (PTSD): Telemedicine Versus In Person

Project Background/Rationale: Approximately 15 to 17% of current Iraq war Veterans meet full
diagnostic criteria for MH problems such as post-traumatic stress disorder (PTSD) (Hoge et
al., 2004). Prolonged Exposure (PE) is an empirically supported treatment for PTSD (Foa 1997;
Schnurr et al., 2007), and has been adopted by the Department of Veterans Affairs (DOVA) as
one of the treatments of choice for the disorder, as evident by the DOVA-sponsored national
training of clinicians to use PE. It is therefore important to employ treatment delivery
methods that maximize the likelihood that all Veterans in need, including Veterans residing
in rural settings, and Veterans who avoid DOVA settings due to the stigma of receiving mental
health treatment, will receive interventions such as PE. The May, 2005 Committee on Veterans
Affairs, Subcommittee on Health has identified Telemedicine as a DOVA priority area to
address this need. The present proposal is to study whether PE delivered via Telemedicine is
as effective as PE delivered In Person. Telemedicine has been chosen for its ability to
overcome what appear to be two major barriers to mental health care (Frueh et al., 2000): the
difficulty that rural-residing Veterans face in reaching VAMC facilities, and the stigma
Veterans perceive related to receiving mental health treatment. Indeed, if effective, PE
delivered via telemedicine may address the problem inherent in the finding that 42% of those
screening positive for PTSD indicate that they are interested in receiving help, but only 25%
actually receive services (Hoge, et al., 2006).

Project Objectives: Although effective treatments for PTSD exist and have been adopted by the
Veterans Affairs Medical Centers (VAMC), barriers to care of a social (e.g., stigma) and
geographic (e.g., rural) nature prevent many Veterans in need from receiving care.
Telemedicine might address this need. The major objective of this study is to determine if PE
delivered via Telemedicine is as effective as In Person PE in terms of (1) clinical; (2)
process; and (3) economic outcomes.

Project Methods: The investigators propose to use a randomized between groups repeated
measures (baseline, post-treatment, 3& 6-month followups) design with 226 OIF-OEF Veterans
diagnosed with PTSD to assess the relative effectiveness, measured in terms of symptoms,
patient satisfaction, and costs, of PE delivered via Telemedicine vs. In Person formats. The
investigators hypothesize that no differences (i.e., non-inferiority) between the two formats
will be evident in terms treatment gains, patient satisfaction, treatment attrition, patient
satisfaction and direct health care costs.

Anticipated Impacts on Veterans Health care: This study will provide important information
regarding whether PE delivered via home-based Telemedicine equipment is as effective as
traditional In Person delivery of PE for post-traumatic stress disorder. If shown to be as
effective as In Person treatment, a new, innovative, and cost effective intervention delivery
system for PTSD will have initial empirical support.

Inclusion Criteria:

Participants will be 226 male and female:

- Operation Iraqi Freedom, Operation Enduring Freedom (OIF OEF) Veterans, and Veterans
of all theatres, particularly Vietnam era Veterans.

- age 21 and above, and

- diagnosed via structured clinical interview with PTSD

Exclusion Criteria:

- Actively psychotic or demented persons,

- individuals with both suicidal ideation and clear intent, and

- individuals meeting full criteria for substance dependence will be excluded from
participation