Military service members and Veterans (hereafter simply referred to as “Veterans”) are at increased risk for psychopathology following deployment. As many as 43% of post-9/11 Veterans meet criteria for a newly diagnosed mental illness (Seal et al., 2010), with elevated rates of posttraumatic stress disorder (PTSD), depression, and substance use (Elbogen et al., 2013). Effective, evidence-based psychotherapy approaches exist for these mental health conditions, yet there are barriers to treatment access and challenges inherent to the maintenance of treatment (Harpaz-Rotem, Rosenheck, Pietrzak, & Southwick, 2014; Valenstein et al., 2014).
Among Veterans, barriers to care have been well documented (Elnitsky et al., 2013) and include negative beliefs about treatment (DeViva et al., 2016; Fox, Meyer, & Vogt, 2015), competing demands of reintegration into civilian life (Gorman, Blow, Ames, & Reed, 2011), stigma and fear of disclosure (Blais, 2014; Ouimette et al., 2011), lack of unit cohesion (Pietrzak, Johnson, Goldstein, Malley, & Southwick, 2009), and frustration navigating the Veterans Administration Health Care System settings (Holland, Rabelo, & Cortina, 2016). For Veterans living in rural areas, geographic distance from providers is another significant barrier to mental health care (Schooley, Horan, Lee, & West, 2010). One study of 310 combat Veterans found that increased barriers to mental health treatment predicted increased PTSD and depression at later time points, whereas the opposite relationship was not true (Wright, Britt, & Moore, 2014). As barriers can prevent utilization of mental health treatment and predict increased symptoms in Veterans, barrier reduction strategies are essential for addressing mental health problems in Veterans.
Telepsychiatry, a subset of telehealth, is the process of providing mental health services (e.g., psychiatric evaluations, therapy, patient education, and medication management) from a distance through technology (American Psychiatric Association, 2017). Telepsychiatry has been proposed as a potential solution to facilitate treatment accessibility and engagement (Tuerk, Yoder, Ruggiero, Grose, & Acierno, 2010). These applications provide added convenience, allow easier access to providers who are geographically distant, and may even circumvent the stigma associated with physically presenting to a mental health clinic (Obisike, 2018) or asking for extended time off from work for appointments (Mistry, Heazell, Vincent, & Roberts, 2013).
Telepsychiatry appears to be comparatively effective to in-person treatments. In a randomized study of 125 male rural combat Veterans with PTSD, Morland et al. (2010) found no significant difference between a telepsychiatry delivery of a cognitive-behavioral therapy intervention for anger management and an in-person delivery format. Another study of 204 older Veterans with depression who were randomized to either telepsychiatry or in-person therapy found telepsychiatry was not inferior to in-person treatment (Egede et al., 2015).
Psychotherapy treatments for PTSD delivered via telepsychiatry also have shown promise. In one study of 24 male combat Veterans with PTSD, a mindfulness-based stress reduction program delivered via telepsychiatry was helpful in reducing PTSD symptoms (Niles et al., 2012). In their pilot study of 12 Veterans with combat-related PTSD, Tuerk et al. (2010) found that telepsychiatry-administered prolonged exposure (PE) therapy was efficacious. When compared with a sample of 35 Veterans who underwent in-person PE in the same clinic, with patients completing the same number of sessions, the authors reported no significant differences in overall symptom improvement.
In a nonrandomized study of 89 Veterans with PTSD, Gros, Yoder, Tuerk, Lozano, and Acierno (2010) found that although PE delivered through telepsychiatry was effective in reducing PTSD symptoms, anxiety, depression, stress, and general impairment, it was not as effective as in-person PE. However, the study was not randomized, which raises the possibility that other patient factors (e.g., varying levels of motivation for treatment) may explain differences in outcome. A later randomized controlled trial of 52 Veterans with combat-related PTSD found that telepsychiatry-mediated PE was not significantly different from same-room delivery and that patient satisfaction did not differ between the two groups (Yuen et al., 2015). Altogether, these studies suggest evidence-based treatments for PTSD and related problems administered via telepsychiatry may be appropriate interventions when in-person psychotherapy is unavailable or not preferred.
Telepsychiatry applications may be an effective solution to the underutilization of mental health treatments among Veterans. However, a preference for in-person visits has been documented (Price & Gros, 2014). Furthermore, in one study, rural Veterans endorsed unfamiliarity with technology as a barrier to utilization (Schooley et al., 2010). Although telepsychiatry can facilitate accessibility and cost efficiency, a major barrier to adoption of applications for Veterans with PTSD is negative patient perception of telepsychiatry (Kruse et al., 2018).
Given that telepsychiatry may assist in treatment utilization for Veterans and understanding patient preferences may be an important factor in optimizing treatment engagement (Roy-Byrne, 2013), it is necessary to examine Veterans' prospective attitudes surrounding telepsychiatry prior to its implementation. The current study sought to examine Veterans' attitudes about potential use of telepsychiatry in a routine, clinical setting and to identify demographic and symptom correlates to determine whether certain patient factors were associated with telepsychiatry preference.
Participants were treatment-seeking Iraq and Afghanistan Veterans who were evaluated at a community-based outpatient clinic offering mental health services to Veterans, service members, and their families. The clinic is affiliated with the psychiatry department of an urban academic medical setting. Patients attending this clinic have a variety of presenting problems, including PTSD, depressive disorders, anxiety disorders, substance use disorders, interpersonal problems (e.g., marital strain, parenting difficulties), and adjustment-related concerns. De-identified clinical data were maintained in an institutional review board–approved database repository.
Veterans were eligible to participate if they presented for an in-person, initial evaluation at the clinic following a standard phone intake conducted by a Veteran peer outreach worker. Participants with active psychosis, mania, suicidality, or severe substance use disorder requiring detoxification or referral to a higher level of care would not have been eligible for outpatient care; thus, this subpopulation of Veterans is not represented in the current study.
Demographic Questionnaire and Diagnostic Information. Individuals provided basic demographic information (e.g, age, sex) as part of routine clinical care. In addition, zip code information was collected, and individuals were classified as living in rural areas (i.e., population <2,500), urban clusters (i.e., population between 2,500 and 50,000), or metropolitan (i.e., population >50,000) areas according to U.S. Census definitions. Information about diagnoses was gathered based on clinician diagnosis using an unstructured, clinical interview as part of routine clinical care. Individuals could have multiple diagnoses.
Telehealth Attitudes. All individuals were administered the five-item Telehealth Attitudes Questionnaire (TAQ), an investigator-designed measure developed to assess attitudes and level of comfort with receiving mental health treatment through telehealth. This measure assessed comfort with telehealth use in a clinic, comfort with telehealth use from home, preference for in-person visits versus telehealth, and preference for telehealth if it would save time (e.g., 1 or 2 hours) driving to the clinic. Individuals indicated agreement with items using a 5-point Likert scale, with a score of 1 corresponding to not at all and a score of 5 corresponding to extremely. Total scores on the measure ranged from 5 to 25. This measure was designed for the purposes of this study; therefore, no psychometric data currently exist for the TAQ. Internal reliability for the full measure in this sample was good (α = 0.82).
To further investigate the structure and constructs of this measure, an exploratory factor analysis using a principal-axis factor extraction was conducted. Initially, the factorability of the five TAQ items was examined. All items correlated at least 0.30 with at least one other item, and four of the five items correlated at least 0.50 with at least one other item, suggesting reasonable factorability. An exploratory factor analysis revealed a one-factor solution that accounted for 97% of the variance. Two items were ultimately eliminated. Item 3 was eliminated because it did not have a primary factor loading >0.40, whereas all other items had a primary factor loading between 0.67 and 0.85. To reduce redundancy, Item 5 also was eliminated because it was highly correlated with Item 4 (r = 0.81). Internal reliability for the reduced, 3-item measure in the sample was identical to the full 5-item measure (α = 0.82).
PTSD. PTSD symptom severity was assessed using the 17-item self-report PTSD Checklist-Civilian Version (PCL-C) (Weathers, Litz, Herman, Huska, & Keane, 1994), which is based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.). The PCL has demonstrated good validity and reliability in Veteran samples (Dobie et al., 2002; Searle et al., 2015). Total scores range from 17 to 85, with higher scores indicating greater PTSD symptom severity. Internal reliability for the measure in the current sample was excellent (α = 0.94).
Depression and Anxiety. Depression symptom severity was assessed using the Depression, Anxiety, and Stress Scale-21 Items (DASS-21) (Lovibond & Lovibond, 1995). This self-report instrument is designed to measure three emotional states, with seven corresponding items per subscale: depression, anxiety, and tension/stress. Subscale scores are multiplied by two to calculate the final subscale scores, which range from 0 to 42. The short form DASS has demonstrated good validity and reliability in clinical samples (Brown, Chorpita, & Barlow, 1998; Ng et al., 2007). Internal reliability for the measure in the current sample was excellent (α = 0.95).
Procedures and Analytic Strategy
The study took place over an approximately 18-month period between 2013 and 2015. Upon arrival to the clinic for their in-person evaluation, participants completed a battery of measures as part of their intake process. These measures generally were completed on a private computer located in the waiting room. In some cases, participants completed the surveys using pencil and paper. Total time to complete the surveys generally ranged between 15 and 30 minutes.
Descriptive statistics for continuous variables are reported as means and standard deviations. Categorical variables are reported as percentages and frequencies. Pearson correlations were conducted between total score on the TAQ and variables of symptom severity and continuous demographic variables. Independent samples t tests were calculated to compare total scores on the TAQ between rural and non-rural Veterans. Similarly, differences in TAQ total score were examined by whether or not individuals endorsed barriers to treatment. All analyses were conducted using Stata 14, and the level of statistical significance was set as 0.05 (two-tailed).
Participant (N = 253) demographics and clinical diagnoses are summarized in Table 1. Mean scores on self-report measures of PTSD, depression, anxiety, and stress were as follows: PCL-C, 56.11 (SD = 15.56, n = 238); DASS-depression, 17.40 (SD = 11.81, n = 239); DASS-anxiety, 14.89 (SD = 11.38, n = 246); and DASS-stress, 21.79 (SD = 10.77, n = 243). Total scores on the reduced TAQ ranged from 3 to 15 (mean = 7.69, SD = 3.49).
Demographic and Diagnostic Characteristics
Item Level Responses. Item level responses are shown in Table 2. A minority of Veterans (13.4%) indicated they were “extremely comfortable” using telehealth from home. A similar minority (8.3%) indicated they were “extremely comfortable” using telehealth at a local clinic. Approximately one third of Veterans (32.8%) indicated they preferred telehealth to in-person mental health visits.
Telehealth Attitudes Questionnaire (TAQ) Item Level Responses (N= 253)
Clinical and Symptom Correlates. Total score on the TAQ was not associated with age (r = −0.08, p = 0.21), PTSD severity (r = 0.06, p = 0.38), stress (r = 0.06, p = 0.36), anxiety (r = 0.11, p = 0.07), or depression severity (r = 0.10, p = 0.13). Veterans from rural areas were no more likely to prefer telehealth visits than Veterans from urban areas (t = 0.72, p = 0.47). Similarly, Veterans who considered geographic distance from the clinic to be a barrier to treatment did not have higher preferences for telehealth (mean = 8.84, SD = 0.60) relative to Veterans who did not consider geographic distance to be a barrier (mean = 7.57, SD = 0.25; t = −1.71, p = 0.09). Finally, Veterans who endorsed any barriers to treatment did not have higher preferences for telehealth (mean = 7.95, SD = 0.31) compared with Veterans who reported no barriers to treatment (mean = 7.42, SD = 0.31; t = −1.21, p = 0.23).
Veterans' prospective attitudes toward telepsychiatry were varied. Approximately one third of the sample indicated they would prefer to engage in mental health treatment via telehealth rather than in-person care. Yet, only a minority of Veterans indicated they were comfortable using telepsychiatry. There were no significant differences in symptom severity of Veterans who preferred telepsychiatry to in-person treatment. Veterans from rural areas were no more likely to prefer telepsychiatry than Veterans from urban areas. Similarly, facing geographic barriers to care was not associated with preference for telepsychiatry.
Only approximately 20% to 25% of this sample indicated having quite a bit or extreme comfort levels with using telepsychiatry from home or another local clinic. There are two primary implications from these findings. First, other alternatives besides telepsychiatry should be examined for increasing access to mental health care for Veterans. Second, providers or clinics that want to increase use of telepsychiatry applications should ensure patients are given ample opportunities to increase comfort with such modalities. Given that treatment preference has been shown to be related to treatment outcomes (Zoellner, Roy-Byrne, Mavissakalian, & Feeny, 2018), it seems especially important that providers do not simply assume telepsychiatry options will be equally viable for all patients and present this as the only option for alternative care delivery.
In the current study, comfort with telepsychiatry was not associated with symptom severity or age. This was similar to the findings of Price and Gros (2014) who reported no relationship between telepsychiatry perceptions and symptom change in their study of 59 combat Veterans participating in exposure-based treatment of PTSD via telepsychiatry. Although providers may be hesitant to offer telepsychiatry alternatives to patients with more severe symptoms, for reasons related to clinical management, providers should not assume patient symptom severity necessarily affects patient preferences.
This is one of the first studies to examine patient attitudes about telepsychiatry in a sample of treatment-seeking Veterans. However, there are several important limitations in the current study. First, the data were cross-sectional. Along these lines, data were not available regarding the treatment type that Veterans ultimately chose, how many sessions of treatments they were able to attend, or how well they responded to or engaged in treatment. Future studies should address how prospective attitudes toward telepsychiatry impact treatment engagement and treatment outcomes for Veterans with PTSD, mood disorders, and anxiety disorders. The current sample comprised Veterans seeking treatment in a metroplitan area where access to mental health treatment may be easier for Veterans and service members than in other parts of the country. Future studies should consider exploring preferences for Veterans from a more geographically diverse or rural sample. Finally, this sample of Veterans was also a treatment-seeking population able to overcome logistical barriers to complete an initial in-person visit. Nontreatment-seeking Veterans and Veterans unable to attend an in-person evaluation may have differing attitudes toward telepsychiatry as well as differing relationships between their mental health concerns and their symptoms.
Telepsychiatry is a viable means of increasing access to mental health treatment and should be explored further. However, patient preference always should be considered when evaluating treatment options to facilitate patient engagement into care.
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Demographic and Diagnostic Characteristics
|Sex (n = 243)|
| Men||223 (91.8)|
| Women||20 (8.2)|
|Age (years) (mean, SD) (n = 243)||34.15 (8.34)|
|Geographic area (n = 253)|
| Urban cluster||222 (87.8)|
| Metropolitan||28 (11.1)|
| Rural||3 (1.2)|
|Branch (n = 249)|
| Army||159 (63.9)|
| Marine Corps||60 (24.1)|
| Navy||17 (6.8)|
| Air Force||8 (3.2)|
| Coast Guard||5 (2)|
|Discharge status (n = 197)|
| Honorable||121 (61.4)|
| Medical||30 (15.2)|
| Other than honorable||15 (7.6)|
| General||14 (7.1)|
| Active duty||14 (7.1)|
| Bad conduct||3 (1.5)|
|Diagnosisa (n = 245)|
| Posttraumatic stress disorder||203 (82.9)|
| Traumatic brain injury||79 (32.3)|
| Major depressive disorder||105 (42.9)|
Telehealth Attitudes Questionnaire (TAQ) Item Level Responses (N= 253)
|Not at All (1)||A Little Bit (2)||Moderately (3)||Quite a Bit (4)||Extremely (5)|
|1. I would feel comfortable using telepsychiatry at a local clinic||84 (33.2)||64 (25.3)||60 (23.7)||24 (9.5)||21 (8.3)|
|2. I would feel comfortable using telepsychiatry from my home||65 (25.7)||60 (23.7)||62 (24.5)||32 (12.6)||34 (13.4)|
|3. I prefer to visit a mental health professional in person (instead of using telepsychiatry)||83 (32.8)||65 (25.7)||61 (24.1)||27 (10.7)||17 (6.7)|
|4. I would use telepsychiatry if it would save me a 1-hour drive to a clinic||77 (30.4)||47 (18.6)||47 (18.5)||39 (15.4)||43 (17)|
|5. I would use telepsychiatry if it would save me a 2-hour drive to a clinic||76 (30)||32 (12.7)||43 (17)||38 (15)||64 (25.3)|