Thank you Dr. Tushmit for that nice introduction.
We have just a few minutes today to cover a lot.
So right now I like to ask everybody to picture someone in your mind that you love the most
in the world.
It could be your father your mother your wife your husband and imagine that they just came
back from Iraq or Afghanistan and they have post traumatic stress disorder.
And they're not connecting with you like they used to.
They are in a shell, you can't get them to go out, can't get them to leave their room.
They are sad, mood, depressed and angry and not the person that you used to know and you
know that there's this great treatment they can help a lot.
But it's not offered in your area and the nearest place to get it is three hours away
and you can't even get them to go get a couple coffee so you know they're not going to go
three hours away So I think that when we ground ourselves and
how important delivering these treatments are through examples of this we get to see
how important Telehealth is.
And I'm really excited to be here and I really want to thank Dr. Tushmit and Mrs. Montavo
for posting us today to talk about transformation in Telehealth because it's very important
when we think about Telehealth a very large issue and we all necessarily in the system
come at it from different perspectives.
I like to share some of the questions that dominate my prospective.
First is what VA mental health services are effective enough to merit using this resource?
It is a limited resource right now we want to be wise and how we use it.
In this sense our technology platforms gives us an opportunity to self assess and okay
what treatments do we want to bring in digital era?
how we want to update the content we do?
and that's a very exciting thing to be part.
Half way through the presentation I'm going to switch away from presenting how Telehealth
improves access services, because we really wanted to improve access to effective services
that's really the key.
And we really want to talk about how technology can take our best treatments and make it even
better So with regards to the first question in PTSD,
the answer is relatively simple.
A number of expert consensus guidelines tell us that exposure therapy for PTSD is the gold
standard treatment.
The Institute of Medicine in 2007, at the request of the VA, that a large literature
search and they concluded even stronger, that exposure therapy is the only effective treatment
for combat related PTSD.
And we just have more recent evidence of a thorough literature review indicated prolonged
exposure therapy which is the name brand that we teach in the VA, is even more effective
in regular VA medical centers than when it was in the randomized controlled trials that
supported the treatment in the first place So this is very good news for our Veterans
and for our providers.
So I want to explain what exposure therapy is.
It is very easy when we're talking about Telehealth to get caught up in technology but as all
the speakers did a wonderful job talking up before; this is really about relationships
and providing care.
If we understand little bit about the care, really colors in the picture about how important
these technology platforms can be for us.
So prolonged therapy is a weekly therapy protocol.
It involves education, it involves self-assessment of distress and anxiety, in vivo exposure
which is exposing yourself to safe situations that you've been avoiding and repeated prolonged
imaginal exposure to distressing memories.
In a nutshell this treatment helps folks face their fears so they can get over them not
cope with them, not deal with them and that's the goal of the treatment we know it's effective
not because outside experts us but because VA folks have done their homework.
There's a lot of studies been done in VA settings, and this slide provides just for your reference
for later on the take-home message is that this treatment is extremely effective in many
people going through it lose the diagnosis altogether.
We know that this treatment works because we asked Veterans and you can see here PTSD
patients on the left and depression on the right and you can see that they drop over
the course of the treatment.
And this is a very typical graph because we see this over and over again in our different
treatments.
We know that statistically speaking that people that end treatment and with a lower diagnosis
for PTSD and lower self-reported symptoms and we knew this without a shadow of a doubt.
More personally what is this mean, it means that folks coming back from Iraq and Afghanistan
and want to go to college can because they can focus on their schoolwork without being
paranoid in large auditoriums.
It means that fathers, mothers and grandfathers can connect with their families in ways that
maybe they haven't been able to do in years.
And interestingly this treatment works just as well for Veterans of Vietnam era as it
does of OEF OEFND Veterans.
It means that people can go back to sleep without having to worry about being haunted
by nightmares every night.
It's just a very wonderful thing to be part of.
Administratively, what does this mean?
When we push this treatment out to folks and make it available we are actually reducing
the overall need for mental health services by as much as 50% for the people that complete
treatment.
In fact 25% of people that complete this treatment used mental-health services at the VA once
or not at all in the entire year after finishing.
This is a marked departure from how this population typically uses this service in the VA
It's tempting to think that this might save us money but really myself and most other
PTSD administrators want our clinics to be operating at full capacity, at all times.
So what this really translates into is we get to provide access to more specialty care,
to more Veterans, because now we are more efficient.
So this is definitely one of those treatments we want to push out, we want a prolonged exposure
to be available at every nook and cranny of this country, anywhere there's a Veteran who
has PTSD, we want this treatment to be available so of course we necessarily need clinical
video teleconferencing to reach that goal But how is a treatment that's designed to
make people anxious on purpose how does that work over teleconference servicing?
About six years ago we start piloting it in Charleston to our community outreach clinics
in Buford and Savannah and Myrtle Beach.
And what we found was similar graphs you can see here once again, PTSD symptoms on the
left, depression on the right and the dotted line represents folks that got the treatment
over telehealth technologies and there's no real difference is there.
Interestingly even though its not a treatment for depression, depression typically lifts
when PTSD symptoms lift.
If we think about that it's got to make sense.
We've done this study 4 or 5 different ways and so are other groups are always finding
similar results that it's relatively easy to deliver this treatment over clinical teleconferencing.
The harder nut to crack is all the relationships, interpersonally to go on between facilities.
Clinicians talking to administrators, referral streams, things like that a lot.
A lot of these issues have been unsolved and I was actually very humbled yesterday when
I had the opportunity to come here and listen to all the presentations because a lot of
the problems that we've experience in the past of pushing Telehealth out are being solved
by people in this room and you're going to get a chance to hear about exciting innovations
that help us not only engage with our patients better but with each other in our different
facilities, so it's really a wonderful time Going I would like to switch gears now and
in addition to increasing access to effective care how can technology help us improve this
treatment?
Well we look at the problems with this treatment, we see like all behavioral treatments there's
a dropout rate.
It's not any higher for this treatment than other treatments but folks that drop out are
about 30-35% don't get any benefit from the treatment at all
Folks that drop out from treatment continue to use VA mental health services at the same
or higher levels the long-term.
So in a sense we've got the right diagnosis, with the right disorder ,with the right treatment,
the right therapist ,the right patient, the right technology in the recognition platform
all come together at the same time It's really what I call a holy inner crossroads,
we don't want to blow it by dropout so again to figure out how technology might be helping
us I think it's important to ground ourselves and what this treatment is what it does so
exposure therapy helps patients identify with their most distressing memories and sit with
him long enough for them to get over them.
For this Veteran here he had an intrusive memory, nightmare of a child dying in Iraq
by accident and after a couple sessions where we got to know him and explain how the treatment
works we invited him to do an imaginal exposure which is he comes in and closes his eyes and
he recount the child's death in vivid detail over and over again.
And every five minutes were asking him "How distressed are you?" and its really every
five minute.
We train folks to have their stopwatches to do it every five minutes.
It's really an antiquated way to get at anxiety.
How anxious are you from zero to hundred scale but it's how we do things.
It's been how've been treating anxiety in 40 years.
It seems to work okay you can see the first exposure he rated pretty , second exposure
he peaked up a little bit higher which is very common pattern and its 2 3 4 5 exposures
for this Veteran to really start understanding hey this is working for me, this treatment
is going to help me feel better The problem with this is that when we see
dropout, it usually happens early on the treatment process in between sessions wanted to 1 or
2 and 3 and before the Veterans get a chance to see the treatment working for them.
So we thought about this and we thought how could technology help us with this we got
this great treatment that works really well but there's this dropout rate and we got this
really antiquated way of testing anxiety and we know that when people's anxiety levels
come down and they say that out loud it really helps them engaged with treatment and gives
them hope.
So we decided to measure physiological responses and add that to the subjective ratings of
distress.
Maybe that'll help patients engage more.
One of the problems with that is traditionally measuring psychophysiological responses in
the context of PTSD takes a lot of provider expertise.
There's a lot of wires, there's complicated programming and all these kinds of stuff.
But nowadays with new technology we can take something like this and pop it on a wristband
and it measures is physiological arousal.
It's wireless and has a battery life 72 hours.
It only has one button so you can folks like me can use it.
In fact I was wearing this before I came on the day I can share the results via email
with folks.
You'll be able to see me getting more anxious as my time to speak came up.
And if I continue to wear you'll be able to come down as well.
So this next slide is the same, the same exposures but now instead of looking at subjective ratings
we're looking at objective physiological responses and we can see that his second session is
much lower than the first and the difference between third and second is bigger than it
was on the subjective ratings.
We are very aggressively piloting this, we are very excited about these results and so
far we've been surprised on how easy it is to document these declines between first second
third and fourth exposures and when we show this to Veterans when they're done with their
exposure wonderful things happen.
"It showed me my reactions are not just mental and I'm actually having a physical response
that can go away.
I spend most my time trying to distract myself from memories in Iraq so was counterintuitive
almost crazy to me to think about them on purpose.
Being able to see that the exposures were helping my body relaxed, helped me to trust
the process and what my doc was saying" This is exactly what we're trying to get at.
We're trying to get that trust because we know then treatment works.
So in clinical tests so far this application of showing people their physiological responses
has led to a 60% drop in dropout.
Now it's just a pilot trial and we need to make sure that we replicate it in scientific
ways and we got to roll up our sleeves and do the work work but if we can actually replicate
just a 5% drop in dropout we're cooking with gas.
So we're really excited about these results what else can we do this?
Well instead of sending somebody else to the local mall to do their exposures and say go
to the food court and see how you feel, now it's in about this thing and via Bluetooth
we can be watching their physiological responses back at the VAMC and if they have a Smartphone
, we can be zapping them their responses as they go throughout the day.
That really connects us with our patient.
So whenever we increase connectivity between a patient getting exposure therapy and a therapist
that's a good thing.
It also gives the Veteran valuable information that they can use to carry out their mission
and they can know that they are doing it the right way.
My therapist said I'm not supposed to leave here till I've calmed down to 50%.
So now they've got an objective measure we can use anything.
If they have to sit there for four hours ago they have to sit there for four hours what
the next time they go to that that mall they will feel a lot better.
So when we're thinking about how technology can help us, I want to talk about the underlying
principle that you've heard every speaker talk about and that's about relationships
really.
When we engage in our relationships in a way that helps us communicate with people that
they don't have to be stuck with this disorder, that there's actually hope out there, it's
really wonderful thing and as you'll be hearing from the folks that will be coming after me
today, there's just great things in the pipeline.
I thank you all for your time and your attention.