Comparing Mindfulness and Psychoeducation Treatments for Combat-Related PTSD Using a Telehealth Approach

Comparing Mindfulness and Psychoeducation Treatments for Combat-Related PTSD Using a Telehealth Approach

Comparing Mindfulness and Psychoeducation Treatments for Combat-Related PTSD Using a Telehealth Approach

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This pilot study examined two telehealth interventions to address symptoms of combat-related posttrau- matic stress disorder (PTSD) in veterans. Thirty-three male combat veterans were randomly assigned to one of two telehealth treatment conditions: mindfulness or psychoeducation. In both conditions, partic- ipants completed 8 weeks of telehealth treatment (two sessions in person followed by six sessions over the telephone) and three assessments (pretreatment, posttreatment, and 6-week follow-up). The mind- fulness treatment was based on the tenets of mindfulness-based stress reduction and the psychoeducation manual was based on commonly used psychoeducation materials for PTSD. Results for the 24 partici- pants who completed all assessments indicate that: (1) Telehealth appears to be a feasible mode for delivery of PTSD treatment for veterans; (2) Veterans with PTSD are able to tolerate and report high satisfaction with a brief mindfulness intervention; (3) Participation in the mindfulness intervention is associated with a temporary reduction in PTSD symptoms; and (4) A brief mindfulness treatment may not be of adequate intensity to sustain effects on PTSD symptoms.

Keywords: PTSD, mindfulness, Telehealth

The ongoing wars in Iraq and Afghanistan have intensified the need for effective psychological interventions to assist veterans returning from war. In addition to the nearly half million veterans

from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) estimated to have posttraumatic stress disorder (PTSD), a substantial portion of the five million other Veterans Health Administration (VHA) patients also suffer from PTSD related to military experiences (VHA Office of Public Health, 2009). Military-related PTSD is associated with psychosocial and health ailments that severely impact veterans and tax the VHA system and society at large. Veterans with chronic PTSD manifest myriad impairments in functioning, such as problems in family relationships (Riggs, Byrne, Weathers, & Litz, 1998), unemploy- ment and income disparities (Sanderson & Andrews, 2006; Savoca & Rosenheck, 2000), and increased morbidity (O’Toole, Catts, Outram, Pierse, & Cockburn, 2009) and mortality (Boscarino, 2006).

Although evidence-based treatments for PTSD offer relief for many sufferers (Foa, Keane, Friedman, & Cohen, 2009), many service members with PTSD diagnoses do not seek mental health treatment (Hoge et al., 2004). A proportion of individuals who do seek treatment for PTSD either drop out or are not substantially helped by it (Chard, Schumm, Owens, & Cottingham, 2010; Gar- cia, Kelley, Rentz, & Lee, 2011; Schottenbauer, Glass, Arnkoff, Tendick, & Gray, 2008). Emerging evidence suggests that OEF/ OIF veterans may be difficult to engage and likely to drop out

This article was published Online First November 14, 2011. Barbara L. Niles, National Center for PTSD–Behavioral Science Division,

and VA Boston Healthcare System and Boston University School of Medicine, Boston, Massachusetts; Julie Klunk-Gillis and Donna J. Ryngala, National Center for PTSD–Behavioral Science Division, and VA Boston Healthcare System, Boston, Massachusetts; Amy K. Silberbogen, VA Boston Healthcare System and Boston University School of Medicine, Boston, Massachusetts; Amy Paysnick, National Center for PTSD–Behavioral Science Division, and VA Boston Healthcare System, Boston, Massachusetts; Erika J. Wolf, Na- tional Center for PTSD–Behavioral Science Division, and VA Boston Health- care System and Boston University School of Medicine, Boston, Massachusetts.

This research was supported by grant 1 EA-0000043 from the Samueli Institute for Information Biology and by funding from the National Center for PTSD, Behavioral Sciences Division, VA Boston Healthcare System.

Correspondence concerning this article should be addressed to Barbara L. Niles, PhD, National Center for PTSD–Behavioral Science Division, VA Boston Health Care System, 150 South Huntington Avenue (116-B-2), Bos- ton, MA 02130. E-mail: barbara.niles@va.gov

Psychological Trauma: Theory, Research, Practice, and Policy In the public domain 2012, Vol. 4, No. 5, 538–547 DOI: 10.1037/a0026161

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(Erbes, Curry, & Leskela, 2009). It is critical to find innovative ways to address barriers to treatment and new ways to reduce symptoms. The current study examines a novel mode of treatment delivery—telehealth—and evaluates the efficacy of two treat- ments—mindfulness and psychoeducation—that have the potential to address the symptoms of PTSD.

Telehealth

The use of telecommunications technologies to provide or en- hance health care has become increasingly popular. Therapy ad- ministered over the telephone has gained attention as mobile telephones have become commonplace, are easy to use, and pri- vate (Mohr, Vella, Hart, Heckman, & Simon, 2008). Telephone therapy addresses two important barriers to treatment: inconve- nience and privacy. Telephone calls can be easily scheduled at convenient times to accommodate busy schedules. Because ses- sions are not held in a clinic, they bypass the perceived stigma associated with mental health care. Furthermore, telephone inter- ventions are less costly than face-to-face visits, as the financial and time costs of travel are eliminated.

Challenges associated with telephone mental health treatment have also been identified. Building rapport may be more difficult, and there is the potential for both therapist and client to be distracted by their environments (Haas, Benedict, & Kobos, 1996). It is important that safety and ethical issues (e.g., assisting a suicidal client) may be more challenging when the therapist is geographically distant from the client (Haas et al., 1996). None- theless, studies investigating efficacy and client satisfaction of telehealth interventions have been quite promising. A recent meta- analysis of telephone-delivered psychotherapy for depression in- dicates that it significantly reduces symptoms, with dropout rates below 10% (Mohr et al., 2008).

Studies evaluating telehealth treatments to address PTSD are scant, but findings suggest that telehealth treatments for PTSD can be as effective as those delivered in person. No differences in efficacy, dropout rates, or attendance were detected between cognitive–behavioral therapy (CBT) delivered over the phone and CBT delivered in person for veterans with combat-related PTSD (Frueh et al., 2007). In a trial comparing videoteleconferencing versus in-person modalities of anger-management group therapy for veterans with PTSD, no significant differences were found on measures of attrition, adherence, satisfaction, treatment expec- tancy, or measures of anger difficulties (Morland et al., 2010). A study of prolonged exposure therapy delivered via one-to-one videoconference demonstrated feasibility and high acceptability for this modality and resulted in significant decreases in self- reported PTSD and depression (Tuerk, Yoder, Ruggiero, Gros, & Acierno, 2010). Thus, there is great potential for the use of telehealth technologies in the treatment of PTSD.

Mindfulness

Mindfulness, frequently defined as a focused attention on pres- ent experiences without judgment (Kabat–Zinn, 1994), has re- ceived increasing attention in the clinical treatment literature. One of the most popular and well-researched mindfulness interventions is mindfulness-based stress reduction (MBSR; Kabat–Zinn, 1990), an 8-week group treatment that introduces a meditative practice

and cultivates present awareness of mental processes and physical states. MBSR has demonstrated efficacy in ameliorating a wide range of medical and mental health diagnoses (see Baer, 2003; Grossman, Niemann, Schmidt, & Walach, 2004).

The use of MBSR as a stand-alone treatment for PTSD has not been thoroughly investigated, though Santorelli and Kabat–Zinn (2009) do not recommend the MBSR program as a first-step treatment, due to concerns that clients may lack skills to tolerate difficult emotions. However, one recent pilot study evaluated the impact of MBSR on symptoms of PTSD and depression among adult survivors of childhood trauma in concurrent psychotherapy (Kimbrough, Magyari, Langenberg, Chesney, & Berman, 2010). Although this trial lacked a control or comparison condition, results showed significant reductions in depression and PTSD symptoms at posttreatment that were largely sustained at the follow-up assessment 4 months later.

Mindfulness skills are key components of some empirically validated treatments for conditions that frequently co-occur with PTSD, such as depression (Segal, Williams, & Teasdale, 2002), borderline personality disorder (Linehan, 1993), and generalized anxiety disorder (Roemer & Orsillo, 2007), suggesting that mind- fulness may augment other therapies. A recent meta-analysis also demonstrated robust effects of mindfulness-based therapy on de- pression and anxiety symptoms in clinical samples (Hoffman, Sawyer, Witt, & Oh, 2010).

Despite the encouraging research on mindfulness for psycho- logical disorders, the extant research suffers from methodological flaws, such as a lack of control groups, small sample sizes, inadequate adherence monitoring, failure to determine clinical significance, and absence of follow-up assessment. Recent com- mentaries (e.g., Davidson, 2010) have called for empirically sound research to address these methodological issues in order to deter- mine whether mindfulness interventions can be efficacious in treating psychological problems, such as PTSD.

Psychoeducation

Education about PTSD has been recommended as a treatment or component of treatment for persistent PTSD (Foa et al., 1999). The goals of psychoeducation are to increase one’s understanding of stress reactions, readjustment difficulties, and recovery, as well as to normalize experiences, and assist in the early identification of symptoms that may reflect the development or exacerbation of a mental disorder. Even though most empirically validated treat- ments for PTSD begin with psychoeducation (e.g., Foa & Roth- baum, 1998; Resick & Schnicke, 1993), there has been little evaluation of its efficacy.

Current Study

In this pilot study, we examined two telehealth interventions— mindfulness and psychoeducation—to address symptoms of combat-related PTSD in veterans using a randomized experimental design. A combination of two face-to-face sessions, followed by six telephone sessions was used in both treatments provided. Primary variables of interest were feasibility and client satisfaction with the telehealth approach and the content of the two therapies. We hypothesized that both treatments would be associated with reduced symptoms of PTSD at posttreatment and 6-week follow-

539COMPARING MINDFULNESS AND PSYCHOEDUCATION

up, with greater and more clinically significant reductions ex- pected for the mindfulness condition.

Method

Participants

Participants were 33 male veterans recruited through: (1) flyers posted throughout Veterans Administration (VA) Boston Health care System; (2) clinician referrals; and (3) an electronic partici- pant recruitment database. Inclusion criteria were: documented military service in a war zone or peace-keeping theater, a current diagnosis of PTSD (as determined by structured interview), and access to a telephone. Exclusion criteria were: severe organicity or active psychosis, an unstable regimen of psychiatric medication over the last 2 months, psychiatric hospitalization in the last 2 months, or symptoms consistent with a diagnosis of alcohol or drug dependence within the past 3 months. The Addiction Severity Index (McLellan, Luborsky, Woody, & O’Brien, 1980) and the substance abuse module of the Structured Clinical Interview for the Diagnostic and Statistical Manual for Mental Disorders 4th

edition (DSM–IV) Axis I Disorders (SCID-SA; First, Spitzer, Gibbon, & Williams, 2002) were used to assess current substance use problems as part of the study screen to determine participant eligibility (see below). Substance abuse was not an exclusion criterion.

Sixty-eight veterans completed a telephone screening, 41 com- pleted an initial assessment, and 33 met eligibility criteria and enrolled in the study. See Figure 1 for the study flowchart.

All participants were male, between the ages of 23 and 66 (mean [M]age � 52.0; standard deviation [SD] � 13.0), were exposed to trauma in either warzone or peacekeeping theaters, and met full criteria for PTSD as measured by the Clinician-Administered PTSD Scale (CAPS; Blake et al., 1990, see below). Regarding era of military service, 30% (n � 10) were veterans of Operation Iraqi Freedom (OIF), 64% (n � 21) had served in Vietnam, and 6% (n � 2) had served during peace-keeping missions (e.g., Bosnia). Additionally, 76% of the sample (n � 25) identified as White, not Hispanic, 15% (n � 5) Black, not Hispanic, 6% (n � 2) White, Hispanic, and 3% (n � 1) as “other.”

Participants were not required to discontinue ongoing treatment with other mental health providers during the study. Use of and changes in psychiatric medication were assessed through review of VA medical records (for participants receiving mental health care through the VA, n � 27) or by self report (for participants receiving psychiatric care from other providers, n � 6). Most participants (67%, n � 21) were taking prescribed psychiatric medication when they entered the study.

Involvement in ongoing psychotherapy was also assessed by review of medical records. Most of the participants who completed treatment (66%, n � 15 of 27) had one or more individual sessions with a mental health provider in addition to the treatment provided

Figure 1. Flowchart for participant completion rates.

540 NILES ET AL.

by the study, and PTSD was the focus of at least one session for 33% (n � 9 of 27). Per medical record notes, 8 participants (30%) completed 4 or more individual sessions during the 8 weeks in which the study treatment was ongoing, and the average number of sessions for those in individual treatment was 5.5 (range � 1 to 12).

Measures

The Clinician Administered PTSD Scale (CAPS; Blake et al., 1990). Considered the “gold-standard” for PTSD assess- ment, the CAPS is a 30-item structured interview that assesses all DSM–IV diagnostic criteria for PTSD. The scale yields a dichot- omous diagnosis and a continuous score of clinician—rated fre- quency and intensity for each symptom rated on 5-point scales. Symptom severity is determined by summing frequency and in- tensity scores. We employed the commonly used “Frequency �1/Intensity �2” scoring rule to determine thresholds for each symptom. The CAPS has repeatedly demonstrated strong and robust psychometric properties with excellent test–retest reliability (r � .89–1.00; Weathers, Ruscio, & Keane, 1999), interrater reliability (r � .92 for total severity; Weathers et al., 1999), and concurrent validity (r � .91 with the Mississippi Scale for Combat-Related PTSD; Weathers et al., 1999). The internal con- sistency for this measure in the current study was high: Time 1 � � .90, Time 2 � � .93.

The PTSD Checklist–Military Version (PCL-M; Weathers, Litz, Herman, Huska & Keane, 1993). The PCL-M is a self-report measure consisting of 17 items that parallel the DSM–IV PTSD criteria. Respondents indicate on a 5-point scale how much they have been bothered in the last month by particular symptoms that are related to stressful military experiences. The PCL has been shown to have excellent test–retest reliability (r � .96; Weathers et al., 1993) and concurrent validity as compared with structured clinical interviews for PTSD (r � .79 to 0.93; Blanchard, Jones–Alexander, Buckley, & Forneris, 1996). The internal consistency for this measure in the current study was high: Time 1 � � .89, Time 2 � � .95, Time 3 � � .91.

The Participant Satisfaction Questionnaire (PSQ). The PSQ is a self-report questionnaire developed for the current study to gather information about participants’ levels of satisfaction with the interventions. Responses using a 5-point scale are summed and averaged to derive an overall satisfaction score. Psychometric properties of this scale have not been established.

Procedure

Clinicians. Two female clinicians with PhDs in clinical psy- chology served as therapists. Both served as therapists for both conditions, were regular practitioners of mindfulness meditation, and had received training in assessment and treatment of PTSD in veterans at the National Center for PTSD, Behavioral Science Division, VA Boston Healthcare System. Each participant was assigned to one of the two clinicians to complete the initial assessment and the treatment.

Informed consent. The institutional review board-approved informed consent form was reviewed with the participant, and the participant’s signature was obtained at the outset of the first visit.

Assessments. The CAPS and Addiction Severity Index were administered to participants at the baseline (Time 1) assessment. If

a participant screened positive on the Addiction Severity Index, the SCID-SA was administered, and those who met criteria for sub- stance dependence were screened out. Self-report measures were administered and therapy sessions were scheduled with the clini- cian who conducted the assessment. Dr. Niles then informed the therapist of the group assignment that had been determined by a random numbers generator. A stratified randomization procedure was used to balance the number of OEF/OIF veterans in each condition. Clinicians and participants were blind to treatment condition until after the first assessment had been completed.

The posttreatment (Time 2) assessment included the same mea- sures as the initial assessment with one additional measure, the PSQ. In order to reduce participant and therapist demand bias, posttreatment assessments were not completed by the participant’s therapist, but by the other study clinician or principal investigator. Participants were compensated $40 for the pre- and posttreatment assessments.

The 6-week follow-up (Time 3) assessment was identical to the posttreatment assessment, with three exceptions: the PSQ was not readministered due to redundancy, the CAPS was not readminis- tered in an effort to reduce participant burden, and participants were compensated $30.

Treatment. At the first session for both treatment conditions, participants were provided with a handbook (specific to treatment condition) comprised of two- to three-page readings for each week of treatment. The handbooks for both treatment conditions were developed to meet the needs of a veteran population (e.g., text was in a large and easy-to-read font, written at an eighth grade level). In addition to providing content, the two 45-min in-person sessions were used to establish rapport. The six weekly telephone sessions reviewed information presented in the manuals. The eighth session was used to review the previous seven sessions and address ter- mination issues. Telephone sessions were approximately 20 min in length.

Mindfulness. The Mindfulness Handbook was developed in collaboration with the codirector of Professional Training at the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School. It complemented the information covered during the sessions and provided educa- tion about these mindfulness topics: defining mindfulness, notic- ing sensations, noticing thoughts and emotions, beginner’s mind, choice, patience, continuing to practice. During the two initial in-person sessions, participants were led through two experiential exercises. Participants were given portable CD players and CDs with 5- to 15-min guided mindfulness exercises to practice the mindfulness skills outside of sessions. Participants were asked to keep track of their practice using monitoring sheets provided, and to report this each week. A few minutes of each session were spent focusing on any difficulties participants may have encountered with the practice.

Psychoeducation. The PTSD Education Handbook, based on content from an introductory psychoeducation group developed at the National Center for PTSD, complemented the information covered in the initial two sessions and provided additional educa- tion on a variety of topics: trust, safety and self-care, effects of trauma, relationships and trauma, coping and healing, change, and moving forward. The treatment was focused on educating partic- ipants about how PTSD may affect their lives (e.g., avoidance may take the form of social isolation, workaholism, substance abuse).

541COMPARING MINDFULNESS AND PSYCHOEDUCATION

Participants were encouraged to reflect on how symptoms may be impacting their day-to-day lives and suggestions for positive cop- ing were offered (e.g., listening to music, physical exercise) but no specific techniques for coping, such as relaxation exercises or behavioral activation, were delivered.

Treatment adherence. At each telephone session, partici- pants in both groups were asked to report the percentage of assigned readings they completed. Participants in the mindfulness condition were also asked to keep a log of the CD track numbers and the amount of unguided practice they engaged in each day during the 8-week treatment. Time spent in mindfulness practice during the 6-week follow-up period was not assessed.

To ensure therapist compliance with treatment delivery, thera- pists completed a checklist of the major points to be covered at each session. Each therapist met weekly with the principal inves- tigator for supervision regarding the cases. In addition, the thera- pists and investigators met weekly as a team to review session progress and to problem solve difficulties with the protocols or participant responses. The consultant from the Center for Mind- fulness joined team meetings via telephone to provide guidance regarding the mindfulness treatment.

Data Analysis

Univariate analyses were performed with a t test or chi-square test. Repeated measures analyses of variance (RM-ANOVAs) were used to examine differences between the two conditions across all three time points. The type of intervention (mindfulness vs. psychoeducation) was the between-subjects factor and time was the within-subjects factor. The RM-ANOVAs were then sep- arated by group and post hoc tests were used to determine signif- icance between specific cells.

Results

Completion, Compliance, and Satisfaction

Of the 33 veterans who were randomized, 27 (82%) completed the 8-week intervention and posttreatment (Time 2) assessment and 24 (72%) completed the 6-week follow-up (Time 3) assess- ment (See Figure 1).

Treatment and posttreatment assessment completion rates did not differ significantly between conditions: 76% for the mindful- ness condition and 87% for the psychoeducation condition, �2(1, N � 33) � .674, p � .412. Reasons for dropping out were: moved away (n � 2), terminated after being frequently unavailable for telephone sessions (n � 2), experienced a manic episode and dropped out of all VA treatment (n � 1), and no reason provided (n � 1). OIF veterans had similar treatment completion rates (80.0%) as veterans from other eras, 82.6%; �2(1, N � 33) � .032, p � 1.00. Three participants who completed the Time 2 assess- ment declined the follow-up (Time 3) assessment. There was no significant difference between groups for completion of the Time 3 assessment, �2(1, N � 27) � .081, p � .776. For both groups, no adverse reactions to treatment were reported during the treat- ment or follow-up periods.

Baseline scores on most demographics (race, ethnicity, educa- tion level, employment status, meditation experience) and outcome measures did not differ between the nine dropouts and the 24

completers. Although OIF veterans did not differ from others on the completion of the Time 2 assessment, a chi-square test indi- cated a trend for OIF veterans to be more likely to drop out of the study before the follow up assessment. Half (50%) of the OIF veterans dropped out by the Time 3 assessment, as compared with 17% of the other veterans, �2(1, N � 33) � 3.74, p � .053. A follow-up t test showed that veterans who dropped out were significantly younger (Mage � 42.22, SD � 10.59) than the vet- erans who completed, Mage � 55.25, SD � 15.48, t(31) � 2.56, p � .016.

Participants who completed the interventions were very com- pliant: 89% reported that they completed an average of at least 75% of the readings, while 63% reported completing all readings in their entirety. In the mindfulness condition, compliance with mindfulness practice was surprisingly high: participants reported practicing over 2 hours per week on average (M � 137, SD � 91, range � 41 to 307 min), even though the total amount of practice time assigned in the study ranged from only 20–50 min per week. They also reported practicing an average of over 5 days per week, and 69% reported practicing both with and without the help of the guided exercises on CDs.

All participants who completed the study reported high satis- faction ratings on the PSQ. There were no differences in satisfac- tion ratings between groups, with 88% of completing participants reporting that the intervention was “convenient” and 81% report- ing they “would recommend the intervention to other individuals.” The remaining participants reported being neutral on both of these statements; none reported dissatisfaction.

Pretreatment Group Differences

No differences were found between the two intervention groups on demographic variables (age, race, ethnicity, education level, employment status, era of service, meditation experience). Despite randomization, however, PTSD symptoms for the mindfulness group were less severe at baseline. For the 24 participants who completed all three assessments, scores on the PCL-M were sig- nificantly lower, t(22) � �2.18, p � .040. The repeated-measures analyses reported below compare the two groups on their relative changes in symptoms over time; due to the small sample size, however, no additional statistical procedure was used to control for the unequal baseline scores in symptoms.