Telephone Therapy Technique Brings More Iraq and Afghanistan Veterans into Mental Health Treatment

A brief therapeutic intervention called motivational interviewing, administered over the telephone, was significantly more effective than a simple "check-in" call in getting Iraq and Afghanistan war veterans with mental health diagnoses to begin treatment for their conditions, in a study led by a physician at the San Francisco VA Medical Center (SFVAMC) and UCSF.

Participants receiving telephone motivational interviewing also were significantly more likely to stay in therapy, and reported reductions in marijuana use and a decreased sense of stigma associated with mental health treatment.

The study was published electronically recently in General Hospital Psychiatry (May 25, 2012).

Lead author Karen Seal, MD, MPH, director of the Integrated Care Clinic at SFVAMC and an associate professor of medicine and psychiatry at UCSF, noted that 52 percent of the approximately half-million Iraq and Afghanistan veterans currently being seen by the VA have one or more mental health diagnoses, including post-traumatic stress disorder, depression, anxiety or other related conditions.

"The VA has gone to extraordinary lengths to provide these veterans with state-of-the-art, evidence-based mental health treatment," she said. "The irony is that they are not necessarily engaging in this treatment. This study was positioned to try to connect our veterans with the treatments that are available to them."

Motivational interviewing, in which counselors encourage clients to explore and articulate discrepancies between their core values and their actual behaviors, has been used successfully as a psychotherapeutic intervention in other settings, said Seal.

"Articulating to the counselor how they want to change can motivate someone to make actual behavioral changes, such as engaging in treatment," said Seal. "The counselor then supports the client's perception that they can actually make these changes."

For the study, 73 veterans of the Iraq and Afghanistan wars who screened positive for one or more mental health diagnoses, and were not currently in treatment, were randomly assigned either to a group that received four motivational interviewing sessions or a control group that received four neutral check-in sessions over a period of eight weeks.

"We thought that using the telephone to conduct this intervention would be a really good idea because these veterans are young, they're busy, they're in school, they have families and they all carry cell phones," Seal said.

By the end of the study, 62 percent of the motivational interviewing group had begun treatment, versus 26 percent of the control group. The motivational interviewing group was significantly more likely to stay in treatment, and also reported significantly decreased marijuana use and significantly less sense of stigma associated with mental health treatment than the control group.

The counselors who conducted the study intervention were not licensed clinicians, but "qualified people with masters' degrees who were trained for about eight hours," said Seal. "This means that the expense for personnel will not need to be huge if this becomes a routine procedure."

Seal emphasized that the study was a first-time pilot trial designed to assess the potential efficacy of telephone motivational interviewing, and that more research is needed to test the technique among larger groups of veterans. To that end, Seal plans a follow-up implementation study involving veterans at VA outpatient clinics in rural communities.

Co-authors of the study are Linda Abadjian, PhD, Nicole McCamish, MA, Ying Shi, PhD and Gary Tarasovsky, BA, of SFVAMC, and Kenneth Weingardt, PhD, of Palo Alto VA Health Care System and Stanford University School of Medicine. The authors had no conflicts of interest.

The study was supported by funds from the Department of Veterans Affairs.

SFVAMC has the largest medical research program in the national VA system, with more than 200 research scientists, all of whom are faculty members at UCSF.