This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s Terms & Conditions.

Original Research

Telemedicine for Anger Management Therapy in a Rural Population of Combat Veterans With Posttraumatic Stress Disorder: A Randomized Noninferiority Trial

Leslie A. Morland, PsyD; Carolyn J. Greene, PhD; Craig S. Rosen, PhD; David Foy, PhD; Patrick Reilly, PhD; Jay Shore, MD, MPH; Qimei He, PhD; and B. Christopher Frueh, PhD

Published: January 26, 2010

Article Abstract

Objective: To demonstrate the noninferiority of a telemedicine modality, videoteleconferencing, compared to traditional in-person service delivery of a group psychotherapy intervention for rural combat veterans with posttraumatic stress disorder (PTSD).

Method: A randomized controlled noninferiority trial of 125 male veterans with PTSD (according to DSM criteria on the Clinician-Administered PTSD Scale) and anger difficulties was conducted at 3 Veterans Affairs outpatient clinics. Participants were randomly assigned to receive anger management therapy delivered in a group setting with the therapist either in-person (n‘ ‰=‘ ‰64) or via videoteleconferencing (n‘ ‰=‘ ‰61). Participants were assessed at baseline, midtreatment (3 weeks), posttreatment (6 weeks), and 3 and 6 months posttreatment. 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-2 (STAXI-2) and by the Novaco Anger Scale total score (NAS-T). Data were collected from August 2005 to October 2008.

Results: Participants in both groups showed significant and clinically meaningful reductions in anger symptoms, with posttreatment and 3 and 6 months posttreatment effect sizes ranging from .12 to .63. Using a noninferiority margin of 2 points for STAXI-2 subscales anger expression and trait anger and 4 points for NAS-T outcomes, participants in the videoteleconferencing 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 process variables, including attrition, adherence, satisfaction, and treatment expectancy. Participants in the in-person condition reported significantly higher group therapy alliance.

Conclusions: Clinical and process outcomes indicate delivering cognitive-behavioral group treatment for PTSD-related anger problems via videoteleconferencing is an effective and feasible way to increase access to evidence-based care for veterans residing in rural or remote locations.

Trial Registration: Identifier: NCT00122109

J Clin Psychiatry 2010;71(7):855-863

Submitted: August 11, 2009; accepted September 28, 2009.

Online ahead of print: January 26, 2010 (doi:10.4088/JCP.09m05604blu).

Corresponding author: Leslie A. Morland, PsyD, National Center for PTSD-Pacific Islands Division, Department of Veterans Affairs Pacific Islands Healthcare System, 3375 Koapaka St, Suite I-560, Honolulu, HI 96819 (

Volume: 71

Quick Links:

Continue Reading…

Subscribe to read the entire article


Buy this Article as a PDF