Telemedicine and Anger Management Groups With PTSD Veterans in the Hawaiian Islands

• 1. Anger symptom severity/reduction assessed using standardized scales including the State-Trait Anger Inventory (STAXI) , Novaco Anger Scale (NAS), and the Assault Behavior Scale (ABS) at baseline, mid-treatment and 3 and 6 months follow-up [ Time Frame: Our primary outcome of anger is assessed at baseline, mid-treatment, post-treatment and at 3 and 6 months follow-up treatment. ] [ Designated as safety issue: No ]
  

• Satisfaction, Therapeutic Alliance, Treatment Credibility, and Service Delivery Perception Credibility assessed using standardized scales at mid and post-treatment. [ Time Frame: Our secondary outcomes are assessed at baseline, mid-treatment, post-treatment and at 3 and 6 months follow-up treatment. ] [ Designated as safety issue: No ]
  

Background: Posttraumatic stress disorder (PTSD) is a prevalent problem among military troops. Recovery from combat-related PTSD is often complicated by problems with anger. Veterans with difficulties managing PTSD-related anger may be particularly likely to live in remote geographical regions where access to specialized mental health care is often limited. Telemental health (TMH) has been touted as a potential means of increasing access to care in rural or remote areas. Objectives: This study compared the effectiveness of group Anger Management Therapy (AMT) delivered via videoteleconferencing (VTC) and in-person delivery in a sample of rural combat veterans with PTSD. The long-range objective of this project was to develop an empirically sound TMH protocol that will facilitate the extension of manual guided clinical services to remote sites via VTC. We hypothesized that providing a manualized group therapy intervention via VTC would result in similar reductions in anger symptoms as obtained from traditional in-person care. Further, we hypothesized that key process indicators (i.e., attrition, adherence, satisfaction, and therapeutic alliance) would not be significantly different between the VTC and in-person conditions. The specific objectives of this project were to: a) determine if group AMT delivered via VTC is as effective as the same intervention delivered in-person on clinical outcomes measuring reductions in anger symptoms and b) determine if group AMT delivered via VTC is as effective as the same intervention delivered in-person on group process outcomes. Methods: A randomized controlled non-inferiority trial of 125 male veterans with PTSD and anger difficulties was conducted at three Department of Veterans Affairs' outpatient clinics. Participants were randomly assigned to receive AMT delivered in a group setting with the therapist either in-person (N= 64) or via VTC (N= 61). Participants were assessed at baseline, mid-treatment, post-treatment, and 3 and 6-months post-treatment. The primary clinical outcome was reduction of anger difficulties, as measured by the Anger Expression and Trait Anger subscales of the State-Trait Anger Expression Inventory and the Novaco Anger Total Scale. Process variables were measured to assess the feasibility of AMT delivered via VTC. SAS MEANS procedure was used to calculate means and standard deviations for change from baseline at subsequent assessment points for both intent-to-treat and per-protocol analysis. Results: Participants in both groups showed significant and clinically meaningful reductions in anger symptoms, with pre-post effect sizes ranging from .12 to .63. Participants in the VTC condition demonstrated a reduction in anger symptoms similar ("non-inferior") to symptom reductions in the in-person groups. Additionally, no significant between-group differences were found on the process variables of attrition, adherence, patient satisfaction, and treatment expectancy. Participants in the in-person condition reported significantly higher group therapy alliance. Impact: Telemental health may offer potential solutions for large health care systems that provide comprehensive services to patients in rural and remote areas. By demonstrating the effectiveness and feasibility of a cognitive-behavioral group treatment for PTSD-related anger problems delivered via VTC, this study provided support for the use of a VTC modality as a way to increase access to evidence-based care for veterans residing in rural or remote locations.