Delivery of self training and education for stressful situations (DESTRESS-PC): a randomized trial of nurse assisted online self-management for PTSD in primary care

doi:10.1016/j.genhosppsych.2015.04.007

Randomized Controlled Trial

. 2015 Jul-Aug;37(4):323-8.

doi: 10.1016/j.genhosppsych.2015.04.007. Epub 2015 Apr 13.

Delivery of self training and education for stressful situations (DESTRESS-PC): a randomized trial of nurse assisted online self-management for PTSD in primary care

Charles C Engel¹, Brett Litz², Kathryn M Magruder³, Elizabeth Harper⁴, Kristie Gore⁴, Nathan Stein², Derik Yeager³, Xian Liu⁵, T Ray Coe⁶

Affiliations

¹ Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA. Electronic address: cengel@rand.org.
² Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, 150 S. Huntington Ave, Jamaica Plain, MA, USA; Department of Psychiatry, Boston University, 715 Albany St., M-8th Floor, Boston, MA, USA.
³ Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC, USA; Department of Psychiatry, Medical University of South Carolina, 67 President Street, Charleston, SC, USA.
⁴ Deployment Health Clinical Center, Walter Reed National Military Medical Center, Building 8, 2nd Floor, Room 2220, 8901 Wisconsin Avenue, Bethesda, MD, USA.
⁵ Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA; Deployment Health Clinical Center, Walter Reed National Military Medical Center, Building 8, 2nd Floor, Room 2220, 8901 Wisconsin Avenue, Bethesda, MD, USA; Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Department of Psychiatry, 4301 Jones Bridge Road, Bethesda, MD, USA.
⁶ Womack Army Medical Center, 2817 Reilly Rd, Fort Bragg, NC, USA.

PMID: 25929985
PMCID: PMC4762212
DOI: 10.1016/j.genhosppsych.2015.04.007

Randomized Controlled Trial

Delivery of self training and education for stressful situations (DESTRESS-PC): a randomized trial of nurse assisted online self-management for PTSD in primary care

Charles C Engel et al. Gen Hosp Psychiatry. 2015 Jul-Aug.

. 2015 Jul-Aug;37(4):323-8.

doi: 10.1016/j.genhosppsych.2015.04.007. Epub 2015 Apr 13.

Authors

Charles C Engel¹, Brett Litz², Kathryn M Magruder³, Elizabeth Harper⁴, Kristie Gore⁴, Nathan Stein², Derik Yeager³, Xian Liu⁵, T Ray Coe⁶

Affiliations

¹ Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA. Electronic address: cengel@rand.org.
² Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, 150 S. Huntington Ave, Jamaica Plain, MA, USA; Department of Psychiatry, Boston University, 715 Albany St., M-8th Floor, Boston, MA, USA.
³ Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC, USA; Department of Psychiatry, Medical University of South Carolina, 67 President Street, Charleston, SC, USA.
⁴ Deployment Health Clinical Center, Walter Reed National Military Medical Center, Building 8, 2nd Floor, Room 2220, 8901 Wisconsin Avenue, Bethesda, MD, USA.
⁵ Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA; Deployment Health Clinical Center, Walter Reed National Military Medical Center, Building 8, 2nd Floor, Room 2220, 8901 Wisconsin Avenue, Bethesda, MD, USA; Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Department of Psychiatry, 4301 Jones Bridge Road, Bethesda, MD, USA.
⁶ Womack Army Medical Center, 2817 Reilly Rd, Fort Bragg, NC, USA.

PMID: 25929985
PMCID: PMC4762212
DOI: 10.1016/j.genhosppsych.2015.04.007

Abstract

Objective: This randomized controlled trial examined the effectiveness of a nurse assisted online cognitive-behavioral self-management intervention for war-related posttraumatic stress disorder (PTSD), compared to optimized usual primary care PTSD Treatment (OUC) to reduce PTSD symptoms.

Method: Participants were 80 veterans of recent military conflicts with PTSD as assessed by the PTSD Checklist (PCL) seeking primary care treatment at one of three Veterans Affairs (VA) and four Army clinics. DESTRESS-PC consisted of logins to a secure website three times per week for 6 weeks with monitoring by a study nurse. All participants received nurse care management in the form of phone check-ins every two weeks and feedback to their primary care providers. Blinded raters assessed outcomes 6, 12, and 18 weeks post-randomization.

Results: DESTRESS-PC was associated with a significantly greater decrease in PTSD symptoms compared to OUC (F(3, 186)=3.72, p=.012). The effect was largest at the 12-week assessment (∆PCL=12.6±16.6 versus 5.7±12.5, p<0.05) with the treatment effect disappearing by the 18-week follow-up. Notably, there was a dose effect; number of logins correlated significantly with PTSD outcomes, with more logins associated with greater PTSD symptom improvement. None of the secondary outcomes (depression, anxiety, somatic symptoms, and functional status) showed statistically significant improvement; however, the treatment effect on depression approached significance (F(3, 186)=2.17, p=.093).

Conclusions: DESTRESS-PC shows promise as a means of delivering effective, early PTSD treatment in primary care. Larger trials are needed.

Keywords: Depression; Military mental health; Posttraumatic Stress Disorder; Primary care; Telehealth.

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Figures

**Fig. 1**
CONSORT diagram showing participant flow through screening, enrollment, randomization, treatment, and follow-up. S=Savannah VA; C=Charleston VA; FB=Fort Bragg.

**Fig. 2**
PCL PTSD symptoms (treatment × time interaction).

See this image and copyright information in PMC

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References

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1. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617–27. - PMC - PubMed
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[1] Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52(12):1048–60. - PubMed

[2] Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52(12):1048–60. - PubMed

[3] Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617–27. - PMC - PubMed

[4] Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617–27. - PMC - PubMed

[5] Wang PS, Berglund P, Olfson M, Pincus HA, Wells KB, Kessler RC. Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):603–13. - PubMed

[6] Wang PS, Berglund P, Olfson M, Pincus HA, Wells KB, Kessler RC. Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):603–13. - PubMed

[7] Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004;351(1):13–22. - PubMed

[8] Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004;351(1):13–22. - PubMed

[9] Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA. 2006;295(9):1023–32. - PubMed

[10] Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA. 2006;295(9):1023–32. - PubMed

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Delivery of self training and education for stressful situations (DESTRESS-PC): a randomized trial of nurse assisted online self-management for PTSD in primary care

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Delivery of self training and education for stressful situations (DESTRESS-PC): a randomized trial of nurse assisted online self-management for PTSD in primary care

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