Peter W. Tuerk

A pilot study of prolonged exposure therapy for posttraumatic stress disorder delivered via telehealth technology

The authors present a pilot study of 12 veterans diagnosed with combat-related PTSD and treated with prolonged exposure therapy (PE) via telehealth technology. A reference sample of 35 combat veterans treated with in-person PE in the same clinic is also included for a comparison. Feasibility and clinical outcomes of interest include technical performance and practicality of the telehealth equipment, patient safety, treatment completion rates, number of sessions required for termination, and clinical outcomes. Results indicated large statistically significant decreases in self-reported pathology for veterans treated with PE via telehealth technology. Preliminary results support the feasibility and safety of the modality. Suggestions for the implementation of PE via telehealth technology are discussed.

Prolonged exposure therapy for combat-related posttraumatic stress disorder: An examination of treatment effectiveness for veterans of the wars in Afghanistan and Iraq

The Veterans Health Administration (VHA) has launched a large-scale initiative to promote prolonged exposure (PE) therapy, an evidence-based treatment for PTSD. While existing randomized controlled trials (RCTs) unambiguously support the efficacy of PE in civilian and some military populations, there is a need to better understand the course of treatment for combat Veterans of the current wars receiving PE in normative mental healthcare settings. The current study investigates 65 Veterans receiving care at an urban VA medical center. All Veterans were diagnosed with PTSD via a structured interview and treated with PE. Measures of PTSD and depression were collected pre- and post-treatment and every two sessions during treatment. Dependent means t-tests were used to estimate pre- and post-treatment d-type effect sizes. Additionally, hierarchical linear models (HLM) were used to investigate treatment effects over time, relationships between patient characteristics and outcomes, and to provide estimates of R(2)-type effect sizes. Results indicate that PE in regular VA mental healthcare contexts can be as effective as when implemented in carefully conducted RCTs.

Exposure Therapy for PTSD Delivered to Veterans via Telehealth: Predictors of Treatment Completion and Outcome and Comparison to Treatment Delivered in Person

Recent research has focused on the effectiveness of evidence-based psychotherapy delivered via telehealth services. Unfortunately to date, the majority of studies employ very small samples and limited predictor and moderator variables. To address these concerns and further replicate and extend the literature on telehealth, the present study investigated the effectiveness of 12-session exposure therapy delivered either via telehealth (n=62) or in person (n=27) in veterans with posttraumatic stress disorder (PTSD). Findings demonstrated that although older veterans and Vietnam veterans were more likely to complete the telehealth treatment, telehealth findings were not influenced by patient age, sex, race, combat theater, or disability status. Exposure therapy delivered via telehealth was effective in reducing the symptoms of PTSD, anxiety, depression, stress, and general impairment with large effect sizes. Interestingly, exposure therapy via telehealth was less effective than exposure therapy delivered in person; however, lack of random assignment to condition limits conclusions of differential effectiveness. Overall, these findings support the utility of telehealth services to provide effective, evidence-based psychotherapies.

Prolonged exposure therapy for combat-related posttraumatic stress disorder: comparing outcomes for veterans of different wars

There is significant support for exposure therapy as an effective treatment for posttraumatic stress disorder (PTSD) across a variety of populations, including veterans; however, there is little empirical information regarding how veterans of different war theaters respond to exposure therapy. Accordingly, questions remain regarding therapy effectiveness for treatment of PTSD for veterans of different eras. Such questions have important implications for the dissemination of evidence based treatments, treatment development, and policy. The current study compared treatment outcomes across 112 veterans of the Vietnam War, the first Persian Gulf War, and the wars in Afghanistan and Iraq. All subjects were diagnosed with PTSD and enrolled in prolonged exposure (PE) treatment. Veterans from all three groups showed significant improvement in PTSD symptoms, with veterans from Vietnam and Afghanistan/Iraq responding similarly to treatment. Persian Gulf veterans did not respond to treatment at the same rate or to the same degree as veterans from the other two eras. Questions and issues regarding the effectiveness of evidence based treatment for veterans from different eras are discussed.

Health service utilization before and after evidence-based treatment for PTSD.

Posttraumatic stress disorder (PTSD) is associated with functional impairment, co-occurring diagnoses, and increased health care utilization. Associated high demand for health care services is an important contributor to the large public-health cost of PTSD. Treatments incorporating exposure therapy are efficacious in ameliorating or eliminating PTSD symptoms. Accordingly, the Veterans Health Administration has made significant investments toward nationwide dissemination of a manualized exposure therapy protocol, prolonged exposure (PE). PE is effective with veterans; however, the relationship between PE and mental health service utilization is unknown. The current study investigates PE as it relates to actual tracked mental health service utilization in an urban VA medical center. A sample of 60 veterans with a diagnosis of PTSD was used to examine mental health service utilization in the 12-months prior to and 12-months after being offered PE. Hierarchical Linear Models and traditional repeated-measures ANOVA were used to estimate R²- and d-type effect sizes for service utilization. Associated estimated cost saving are reported. PE was associated with large reductions in symptoms and diagnosis remission. Treatment was also associated with statistically significant, large reductions in mental health service utilization for veterans who completed treatment. Findings suggest that expanding access to PE can increase access to mental health services in general by decreasing ongoing demand for specialty care clinical services.

Yohimbine enhancement of exposure therapy for social anxiety disorder: A randomized controlled trial

BACKGROUND Preclinical and clinical trials suggest that yohimbine may augment extinction learning without significant side effects. However, previous clinical trials have only examined adults with specific phobias. Yohimbine has not yet been investigated in the augmentation of exposure therapy for other anxiety disorders. METHODS Adults (n = 40) with a DSM-IV diagnosis of social anxiety disorder were randomized to placebo or yohimbine HCl (10.8 mg) 1 hour before each of four exposure sessions. Outcome measures were collected at baseline, each treatment session, posttreatment, and 1-month follow-up. RESULTS Yohimbine was well tolerated. Yohimbine augmentation, relative to placebo augmentation, resulted in faster improvement and better outcomes on self-report measures of social anxiety disorder severity (Liebowitz Social Anxiety Scale, d = .53) and depressed mood severity (Beck Depression Inventory, d = .37) but not on the clinician-rated measures (Clinical Global Impressions-Severity Scale, d = .09; Clinical Global Impressions-Improvement Scale, d = .25). Between-group differences on the Liebowitz Social Anxiety Scale were moderated by the level of fear reported at the end of an exposure exercise (end fear), such that the advantage of yohimbine over placebo was only evident among patients who reported low end fear. CONCLUSIONS The results provide moderate support for yohimbine as a therapeutic augmentation strategy for exposure therapy in social anxiety disorder, one that may be especially effective when coupled with successful exposure experiences. Beneficial effects for yohimbine were readily evident for self-report measures but not for clinician-rated outcomes of social anxiety severity and improvement.

Mild Traumatic Brain Injury and Treatment Response in Prolonged Exposure for PTSD

A proportion of U.S. veterans returning from Iraq and Afghanistan have experienced mild traumatic brain injury (mTBI), which is associated with increased risk for developing posttraumatic stress disorder (PTSD). Prolonged Exposure (PE) has proven effectiveness in the treatment of PTSD; however, some clinicians have reservations about using PE with individuals with a history of mTBI. We examined the impact of PE for veterans with PTSD and with or without a history of mTBI in a naturalistic sample of 51 veterans who received PE at a Veterans Health Administration PTSD clinic. We also analyzed previously collected data from a controlled trial of 22 veterans randomly assigned to PE or present centered therapy. For both sets of data, we found that PE reduced symptom levels and we also did not detect an effect for mTBI, suggesting that PE may be helpful for individuals with PTSD and a history of mTBI.

Estimating Physician Effects on Glycemic Control in the Treatment of Diabetes: Methods, Effects Sizes, and Implications for Treatment Policy

OBJECTIVE—Researchers have only just begun to investigate physician-related effects on medical outcomes. Such research is necessary for developing empirically informed practice guidelines and policy. The primary goal of this study was to investigate whether glucose management in type 2 diabetes varies by randomly assigned physicians over the course of a year in treatment. A second goal of the study was to investigate whether physician-related effects vary across differential patient characteristics. A tertiary goal was to investigate potential patient-level effects on glucose management. RESEARCH DESIGN AND METHODS—Hierarchical linear models were used to investigate A1C among 1,381 patients, nested within 42 randomly assigned primary care physicians at a Veterans Affairs medical center in the southeastern U.S. The primary outcome measure was change in A1C over the course of 1 year in treatment. On average, each study physician had 33 patients with diabetes. RESULTS—Overall, physician-related factors were associated with statistically significant but modest variability in A1C change (2%), whereas patient-level factors accounted for the majority of variation in A1C change (98%). Physician effects varied by patient characteristics, mattering more for black patients, patients aged 65 years, and patients whose glucose management improved over the treatment year. CONCLUSIONS—The results of this study indicate that differential physician effects have minimal impact on glycemic control. Results suggest that it is logical to support policies encouraging the development of patient-level behavioral interventions because that is the level that accounts for the majority of variance in glycemic control.

Randomized Controlled Trial of Home-Based Telehealth Versus In-Person Prolonged Exposure for Combat-Related PTSD in Veterans: Preliminary Results

OBJECTIVES Telehealth technology may reduce the effect of treatment barriers and improve participation in treatment for veterans with posttraumatic stress disorder (PTSD). The present study is an ongoing randomized controlled trial comparing the effectiveness of prolonged exposure (PE) delivered via in person or home-based video telehealth modalities. METHOD A total of 52 veterans with combat-related PTSD were randomized to receive 8-12 weeks of PE through either home-based telehealth or standard in-person office-based care. RESULTS Participants evinced significant reductions in symptoms of PTSD, depression, and anxiety from pre- to posttreatment across both conditions. Analyses conducted within a noninferiority framework suggested nonsignificant treatment outcome differences in clinician-reported PTSD and self-reported anxiety between the conditions. Results were inconclusive for self-reported PTSD and depression symptoms. Patient satisfaction ratings did not significantly differ between the two groups. CONCLUSIONS Results suggest that PE can be delivered via home-based telehealth with outcomes and satisfaction ratings comparable to in-person practices for certain symptoms, however additional research is needed. This modality has the potential to address stigma- and geographic-related barriers to treatment, such as travel time and cost.

Examining the factor structure of PTSD between male and female veterans in primary care

The present study assessed potential gender differences between the two prevailing PTSD models - the emotional numbing (King, Leskin, King, & Weathers, 1998) and dysphoria (Simms, Watson, & Doebbelling, 2002) models - in order to establish whether one model is superior with regard to its cross-gender generalizability. The sample included 188 female and 690 male trauma-exposed United States Veterans presenting to Veterans Affairs primary care medical clinics. Multigroup confirmatory factor analyses with covariates (MIMIC models) were conducted using the PTSD Checklist. The covariates included were socio-demographic variables and the type of traumatic event experienced. The emotional numbing model was statistically superior for men, but no difference between models was noted for females. After controlling for model covariates, men reported higher item-level severity and women had larger residual error variances and larger factor variances and covariances in the emotional numbing model. These results suggest partial generalizability of the emotional numbing model across gender.