1. Old Traumas, New Traumas, and New Approaches to Treating Trauma May 14-15, 2007 Houston, TX

2. Utilizing Tele-Mental Health to Access Remote, Rural Veterans with PTSD Carolyn Greene, Ph.D. & Leslie Morland, Psy.D. National Center for PTSD, Department of Veterans Affairs, Pacific Islands Health Care System, Spark M. Matsunaga Medical Center, Honolulu, Hawaii

3. Acknowledgements: This material is based upon work supported in part by the Office of Research and Development, Health Services R&D Service, Department of Veterans Affairs, VA Pacific Islands Health Care System, Spark M. Matsunaga Medical Center. Support was also provided by VA National Center for PTSD. Acknowledgements: This material is based upon work supported in part by the Office of Research and Development, Health Services R&D Service, Department of Veterans Affairs, VA Pacific Islands Health Care System, Spark M. Matsunaga Medical Center. Support was also provided by VA National Center for PTSD.

4. Why Use Tele-Mental Health in the Pacific Islands Geographic Dispersion of VA Health Care System Geographic Dispersion of VA Health Care System Reduce Travel- Increase Access to Care Reduce Travel- Increase Access to Care Mental Health Needs Mental Health Needs Access to specialty care Access to specialty care Clinical Coverage Clinical Coverage Consultation Consultation C&P Exams C&P Exams Education & Training Education & Training

6. Objectives Tele-Mental Health Overview Tele-Mental Health Overview Tele-Mental Health & PTSD Tele-Mental Health & PTSD Pilot Study 1 Pilot Study 1 Pilot Study 2 Pilot Study 2 Current Clinical Trial Current Clinical Trial Clinical Application & Implications Clinical Application & Implications Future Directions Future Directions

7. Tele-Mental Health Overview Available technologies Available technologies Current TMH services in VHA Current TMH services in VHA Current TMH services in Military and other sectors Current TMH services in Military and other sectors Literature Review Literature Review

8. Pilot Study 1 Remote PTSD Assessments, Evaluations, and Treatment Consultation Funded by a research grant from the VA/DOD Pacific Telehealth Hui Research Goal: Evaluate feasibility of conducting comprehensive PTSD assessments & consultation using VTC technology with remote veterans

9. Pilot Study 1 Conducted PTSD assessments which included on-line self-report measures, structured interviews via VTC, and feedback consultation via VTC. 60 VTC sessions were conducted. Conducted PTSD assessments which included on-line self-report measures, structured interviews via VTC, and feedback consultation via VTC. 60 VTC sessions were conducted. 80% of veterans reported feeling comfortable with modality and 90% were willing to use VTC for future services. 80% of veterans reported feeling comfortable with modality and 90% were willing to use VTC for future services. Clinicians reported being able to establish rapport and perform accurate diagnostic evaluations. Clinicians reported being able to establish rapport and perform accurate diagnostic evaluations.

10. Pilot Study 2 Telemedicine and PTSD Coping Skills Groups for Pacific Island Veterans: A Pilot Study Principal Investigator: Leslie A. Morland, Psy.D. Funded by the Office of R&D VISN 21 VA Young Investigator Award by the VA & NC-PTSD Research Goal: Evaluate feasibility of using VTC technology to provide coping skills groups to remote veterans with chronic PTSD

11. 20 PTSD veterans randomly assigned to either the VTC group or the traditional in-person group condition. 20 PTSD veterans randomly assigned to either the VTC group or the traditional in-person group condition. Provided an 8-week manual driven PTSD Coping Skills group which included modules on PTSD psychoeducation, anger management, conflict- resolution, and relapse prevention. Provided an 8-week manual driven PTSD Coping Skills group which included modules on PTSD psychoeducation, anger management, conflict- resolution, and relapse prevention. Both conditions had comparable outcomes of information retention and treatment adherence. Veterans, clinic staff, and the therapist rated the intervention favorably. Both conditions had comparable outcomes of information retention and treatment adherence. Veterans, clinic staff, and the therapist rated the intervention favorably. Pilot Study 2

12. 4 Year Clinical Trial Telemedicine & Anger Management Groups with PTSD Veterans in the Hawaiian Islands Principal Investigator: Leslie A. Morland, Psy.D. Funded June 2005 by VA HSR&D

13. Contributors/Collaborators Carolyn Greene, Ph.D.- Co-I & Project Manager Carolyn Greene, Ph.D.- Co-I & Project Manager Patrick Reilly, Ph.D - Co-Investigator Patrick Reilly, Ph.D - Co-Investigator Craig Rosen, Ph.D. - Co-Investigator Craig Rosen, Ph.D. - Co-Investigator B. Christopher Frueh, Ph.D.- Co-Investigator B. Christopher Frueh, Ph.D.- Co-Investigator Jay Shore, MD, MPH - Co-investigator Jay Shore, MD, MPH - Co-investigator David Foy, Ph.D. & Ed Kubany, Ph.D. - Consultants David Foy, Ph.D. & Ed Kubany, Ph.D. - Consultants Dan King, Ph.D. & Ian Pagano - Statisticians Dan King, Ph.D. & Ian Pagano - Statisticians

14. Research Goal Evaluate the effectiveness/efficacy of using VTC modality as compared to the traditional in- person modality for providing a cognitive- behavioral group anger management intervention with remote veterans with PTSD. Evaluate the effectiveness/efficacy of using VTC modality as compared to the traditional in- person modality for providing a cognitive- behavioral group anger management intervention with remote veterans with PTSD.

15. Research Objectives: Test the hypothesis that a novel mode of mental health service delivery (VTC) will be equally effective as a traditional mode of mental health service delivery (in- person) for providing specialized mental health intervention (AMT) to veterans with PTSD. Test the hypothesis that a novel mode of mental health service delivery (VTC) will be equally effective as a traditional mode of mental health service delivery (in- person) for providing specialized mental health intervention (AMT) to veterans with PTSD. The study will allow for a direct comparison of each mode of service delivery provided to veterans through several Veterans Affairs (VA) outpatient clinics on clinical and process categories of outcome variables. The study will allow for a direct comparison of each mode of service delivery provided to veterans through several Veterans Affairs (VA) outpatient clinics on clinical and process categories of outcome variables.

16. Outcomes (1) The primary clinical outcome expected is equivalence between the two modalities on clinically significant reduction of anger expression, anger disposition, assaultive behavior and an increase on anger control at mid-treatment, post-treatment and at follow-up. (1) The primary clinical outcome expected is equivalence between the two modalities on clinically significant reduction of anger expression, anger disposition, assaultive behavior and an increase on anger control at mid-treatment, post-treatment and at follow-up. (2) Process outcomes include expected equivalence between the two modalities on patient satisfaction, patients’ perception of services, therapeutic group alliance, treatment adherence, attendance, attrition and treatment credibility at mid-treatment and post-treatment. (2) Process outcomes include expected equivalence between the two modalities on patient satisfaction, patients’ perception of services, therapeutic group alliance, treatment adherence, attendance, attrition and treatment credibility at mid-treatment and post-treatment.

17. Why Anger & PTSD? Combat veterans with PTSD report more anger, hostility, interpersonal violence, and anger-related problems than non-PTSD combat veterans. Combat veterans with PTSD report more anger, hostility, interpersonal violence, and anger-related problems than non-PTSD combat veterans. This association between anger and combat-related PTSD has significant social and clinical implications for the veteran population including an impact on families, work settings, and society. This association between anger and combat-related PTSD has significant social and clinical implications for the veteran population including an impact on families, work settings, and society. The treatment of the anger component of PTSD is considered essential in the trauma recovery process. The treatment of the anger component of PTSD is considered essential in the trauma recovery process.

18. Methods Design: Randomized Control Trial Design: Randomized Control Trial Participants: 180 veterans with PTSD from 4 VA sites; 9 cohorts (6-9 veterans per group) Participants: 180 veterans with PTSD from 4 VA sites; 9 cohorts (6-9 veterans per group) Intervention: 12 sessions of CBT Anger Management Intervention: 12 sessions of CBT Anger Management Assessments: At baseline, mid, post, follow-up Assessments: At baseline, mid, post, follow-up Clinical Outcomes Clinical Outcomes Process Outcomes Process Outcomes Primary Analyses: Equivalency Analyses of VTC vs. in-person mental health service delivery Primary Analyses: Equivalency Analyses of VTC vs. in-person mental health service delivery

19. Process Outcomes Therapeutic Alliance Satisfaction Trust/Comfort Convenience Compliance Attrition Clinical Outcomes Anger Reduction Disposition Anger Control Aggression Violence Referrals VA & Vet Center Personal or Demographic Variables Age, Ethnicity, Educ, Service Era, SC Status, Military Branch, Employment, Marital Status, Distance to VA Combat – Trauma PTSD - Anger VTC Anger Group In Person Anger Group

20. Clinical Sites Clinical Site Unique Veterans % receiving Mental Health svcs. % w/ PTSD Dx Expected # of Referrals Honolulu, Oahu 14,298 2,394 (17%) 689 (30%) 120 (approx.) Kona CBOC, Hawaii 1,114 278 (24%) 252 (53%) Not known Hilo CBOC, Hawaii 1,627 475 (29%) 225 (68%) Not known Maui CBOC, Maui 1,362 330 (24%) 141 (43%) Not known Kauai CBOC, Kauai 1,067 234 (22%) 94 (40%) Not known

21. Site Requirements Access to Group room Access to Group room Access to VTC unit (Tandberg or Polycom) Access to VTC unit (Tandberg or Polycom) Back-up personnel on-site Back-up personnel on-site Adequate Referrals Adequate Referrals

22. Recruitment & Assessment CBOC Site Recruitment Randomize (war era) Clinician Referral Phone Screen (CAGE, STAXI, PTSD) Interview (SCID, CAPS, STAXI, NAS, ABS) VTC Condition In-Person Condition

23. Participants Inclusion criteria:  PTSD diagnosis (CAPS-1) and confirmed by the PCL.  Significant level of anger on the 10-item State-Trait Anger Expression Inventory  Stable medications regimen for at least 2 months prior to study entry Exclusion criteria:  active psychotic symptoms/disorder as determined by the SCID for DSM-IV  active homicidal or suicidal ideation as determined by the structured clinical interview  any significant cognitive impairment or history of Organic Mental Disorder  active (current) substance dependence as determined by the SCID  unwillingness to refrain from substance abuse during treatment  female veterans

24. Recruitment & Retention Recruitment Recruitment Selection of sites with limited services Selection of sites with limited services Site visits and site liaisons Site visits and site liaisons Flyers Flyers Back-up clinical sites Back-up clinical sites Retention Retention Initial group meeting with PI Initial group meeting with PI Weekly phone calls Weekly phone calls Travel reimbursement per session ($10) Travel reimbursement per session ($10)

25. Measures Clinical Outcome Clinical Outcome Anger (STAXI & NAS) Anger (STAXI & NAS) Violence (ABS) Violence (ABS) PTSD (CAPS & PCL) PTSD (CAPS & PCL) Quality of Life (Frisch) Quality of Life (Frisch) Process Outcome Process Outcome Attrition (Attendance) Attrition (Attendance) Treatment Compliance (Homework) Treatment Compliance (Homework) Treatment Expectancy (Borkovec) Treatment Expectancy (Borkovec) Group Therapy Alliance (GTAS) Group Therapy Alliance (GTAS) Satisfaction (Frueh) Satisfaction (Frueh)

27. Sessions Week 1 Introduction to Conceptual Framework Week 2Cues to Anger Week 3Anger Control Plan, Relaxation Week 4Aggression Cycle, Relaxation Week 5Cognitive-Restructuring Week 6Review Session #1 Weeks 7 & 8 Assertiveness Training/Conflict Resolution Weeks 9 & 10Anger in the Family Week 11Review Session #2 Week 12Closing and Graduation

28. Each 90-minute group session consists of two components: A didactic presentation of the cognitive- A didactic presentation of the cognitive- behavioral material behavioral material A check-in procedure involving group A check-in procedure involving group interaction and discussion interaction and discussion

29. Cognitive-Behavioral (CBT) Intervention Types Relaxation Interventions (target emotional and physiological components of anger) Relaxation Interventions (target emotional and physiological components of anger) Cognitive Interventions (target hostile appraisals and attributions, and irrational beliefs) Cognitive Interventions (target hostile appraisals and attributions, and irrational beliefs) Social/Communication Skills Interventions - (target conflict resolution and communication skills) Social/Communication Skills Interventions - (target conflict resolution and communication skills) Combined Interventions - (target multiple response domains by integrating two or more intervention components) Combined Interventions - (target multiple response domains by integrating two or more intervention components)

30. Analyses Univariate descriptive statistics and frequency distributions will be derived as appropriate for all variables. Univariate descriptive statistics and frequency distributions will be derived as appropriate for all variables. Equivalency Analyses - non-traditional approach - it is hypothesized that the two treatment modalities under examination (VTC vs. IP) are equivalent. Equivalency Analyses - non-traditional approach - it is hypothesized that the two treatment modalities under examination (VTC vs. IP) are equivalent.

31. Analyses A multilevel modeling procedure will be used for the analyses A multilevel modeling procedure will be used for the analyses This method will include both individuals and sessions (group cohorts) as units of analysis, with participants (Level 1) nested within sessions (Level 2). This method will include both individuals and sessions (group cohorts) as units of analysis, with participants (Level 1) nested within sessions (Level 2). Including baseline values for the outcome measure as a covariate in the model will ensure comparability across treatments and sessions at baseline. Including baseline values for the outcome measure as a covariate in the model will ensure comparability across treatments and sessions at baseline.

32. Analyses Primary clinical outcome is a clinically significant change in anger as measured by: Primary clinical outcome is a clinically significant change in anger as measured by: STAXI, NAS, ABS STAXI, NAS, ABS Additional process outcomes measured include: Additional process outcomes measured include: Veteran Satisfaction, GTAS, Treatment Expectancy, Compliance, Attrition Veteran Satisfaction, GTAS, Treatment Expectancy, Compliance, Attrition Secondary analyses will include examining the influence of confound variables such as psychiatric comorbidity, concurrent treatment, PTSD severity, etc. Secondary analyses will include examining the influence of confound variables such as psychiatric comorbidity, concurrent treatment, PTSD severity, etc.

33. Preliminary Results Currently Conducting 7 th Cohort Currently Conducting 7 th Cohort Total Enrolled = 98 Total Enrolled = 98 Drop-outs = 6 Drop-outs = 6 Attrition = 6% Attrition = 6% Groups cancelled due to technical difficulties = 0 Groups cancelled due to technical difficulties = 0 Groups cancelled due to clinical difficulties = 0 Groups cancelled due to clinical difficulties = 0 8 th cohort scheduled for July 8 th cohort scheduled for July

34. Total Participants N= 98 Mean Age = 55 (SD = 8.7) Range of Ages = 22 to 80 Pacific Island39.0% Asian25.6% Caucasian25.6% Hispanic4.9% African-American4.9%

35. War Eras Served In Vietnam68.6% Desert Storm16.3% World War II 3.5% OIF/OEF 3.5% Korean 3.5% Other 3.5%

36. Clinical Outcomes Anger Reduction Anger Reduction STAXI STAXI Novaco (NAS) Novaco (NAS) Assaultive Behavior Scale (ABS) Assaultive Behavior Scale (ABS) PCL PCL

37. Process Outcomes Treatment Expectancy Treatment Expectancy Attrition (drop-outs) Attrition (drop-outs) Compliance (Attendance & Homework) Compliance (Attendance & Homework) Group Therapy Alliance Scale Group Therapy Alliance Scale

38. Qualitative Data Overall impressions of intervention and modality Overall impressions of intervention and modality How well the intervention fits with cultural beliefs How well the intervention fits with cultural beliefs Validity of assessment measures Validity of assessment measures Feedback to research team Feedback to research team

39. Lessons Learned Technology Technology Staff Training & Support Staff Training & Support Participant Expectations Participant Expectations Managing Logistics Managing Logistics

40. Clinical Implications Feasibility of conducting anger management group therapy using TMH with PTSD veterans Feasibility of conducting anger management group therapy using TMH with PTSD veterans Preliminary data supports the clinical effectiveness of Anger Management Therapy (AMT) for Pacific Island Veterans Preliminary data supports the clinical effectiveness of Anger Management Therapy (AMT) for Pacific Island Veterans Veterans acceptance and willingness to use Veterans acceptance and willingness to use these services in the future Satisfaction and comfort this modality Satisfaction and comfort this modality

41. Clinical Application in Pacific Islands PTSD Specialty Services PTSD Specialty Services Coping Skills Groups Coping Skills Groups Sleep Hygiene Groups Sleep Hygiene Groups Anger Management Groups Anger Management Groups Assessment & Consultation Assessment & Consultation Future Clinical Application Sites Future Clinical Application Sites Returning OIF/OEF troops Returning OIF/OEF troops Continuity of Care Continuity of Care

42. Future Research Direction More Randomized Clinical Trials (RCTs) More Randomized Clinical Trials (RCTs) Clinical, Process and Economic Outcomes Clinical, Process and Economic Outcomes Differential Cost & Clinical Effectiveness Studies Differential Cost & Clinical Effectiveness Studies Application in Ethnically and Culturally Diverse Populations Application in Ethnically and Culturally Diverse Populations