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A Comparison of the Efficacy of Psychotherapy viaTelemedicine to Traditional In-Person Therapy forRural Veterans with PTSDMelissa WalshPacific University

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Recommended CitationWalsh, Melissa, "A Comparison of the Efficacy of Psychotherapy via Telemedicine to Traditional In-Person Therapy for Rural Veteranswith PTSD" (2014). School of Physician Assistant Studies. Paper 501.

A Comparison of the Efficacy of Psychotherapy via Telemedicine toTraditional In-Person Therapy for Rural Veterans with PTSD

AbstractBackground: The shortage of medical providers in rural areas is one of the greatest barriers to accessinghealthcare in the United States. Mental healthcare providers are especially limited in numbers and availabilityin rural areas. Although all individuals living rurally have challenges with receiving care, one group thatdemonstrates an exceptional deficiency with access to care is veterans. The numbers of veterans living rurallyare significantly higher than vets living close to urban or suburban centers of care. Considering the shortagesof mental health providers, alternatives to traditional in-person therapy are needed in order to adequatelyaddress the needs of rurally located veterans. Recently, psychotherapy via video teleconferencing has beensuggested as a way of reaching a greater number of veterans. But is this approach equivalent to in-persontherapy in the treatment of PTSD?

Methods: An exhaustive search was conducted using Medline-OVID, CINAHL, and Google Scholar usingthe keywords: mental health, veterans, rural, and telemedicine. Relevant articles were assessed for qualityusing GRADE.

Results: Three studies met the search criteria and were included in this systematic review. The first study,Frueh et al, is a randomized controlled study (RCT) to compare the efficacy of psychotherapy delivered viavideo teleconferencing or in-person therapy for combat-related PTSD. This study showed a comparabletreatment effect and patient satisfaction between the two different methods. The second study, Morland et al,is a non-inferiority-designed RCT comparing anger management therapy delivered either by videoteleconferencing or same-room therapy to veterans with PTSD. This study demonstrated similar satisfactionin both groups and an improvement in both anger and PTSD symptoms in the video teleconferencing group.The third study, Ziemba et al, is a two-arm RCT with either active-duty or veterans of Operation EnduringFreedom or Operation Iraqi Freedom comparing psychotherapy administered via video teleconferencing orin-person. This study indicated equivalence between the two types of therapies.

Conclusion: Psychotherapy administered to veterans with PTSD living in rural areas via videoteleconferencing has been shown to be equivalent to traditional in-person therapy. Multiple studies showpromise for a broader application of psychotherapy via video teleconferencing to help with the shortage ofmental health providers in rural areas; however, further studies are needed to investigate the extent to whichtelemedicine can be used effectively.

Keywords: Mental health, telemedicine, video teleconferencing, veterans.

Degree TypeCapstone Project

Degree NameMaster of Science in Physician Assistant Studies

KeywordsMental health, telemedicine, video teleconferencing, veterans

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NOTICE TO READERS This work is not a peer-reviewed publication. The Master’s Candidate author of this work has made every effort to provide accurate information and to rely on authoritative sources in the completion of this work. However, neither the author nor the faculty advisor(s) warrants the completeness, accuracy or usefulness of the information provided in this work. This work should not be considered authoritative or comprehensive in and of itself and the author and advisor(s) disclaim all responsibility for the results obtained from use of the information contained in this work. Knowledge and practice change constantly, and readers are advised to confirm the information found in this work with other more current and/or comprehensive sources. The student author attests that this work is completely his/her original authorship and that no material in this work has been plagiarized, fabricated or incorrectly attributed.

1

A Comparison of the Efficacy of Psychotherapy via Telemedicine to Traditional In-Person Therapy for Rural

Veterans with PTSD

Melissa N. Walsh

A Clinical Graduate Project Submitted to the Faculty of the

School of Physician Assistant Studies

Pacific University

Hillsboro, OR

For the Masters of Science Degree, August 2014

Faculty Advisor: Dr. Pedemonte

Clinical Graduate Project Coordinator: Annjanette Sommers, PA-C, MS

2

BIOGRAPHY

Melissa Walsh is a native of California. She received a Bachelor of Science degree in

Medical Technology from University of the Sciences in Philadelphia. Following

graduation she worked as a Transfusion Medicine Specialist. Additionally, she spent time

working at a biotech company in the Clinical Operations and Regulatory Affairs

Departments helping with an IND submission to the FDA. She decided to pursue a career

as a Physician Assistant in order work more closely with patients. She has strong interests

in family medicine in rural, underserved areas.

3

ABSTRACT

Background: The shortage of medical providers in rural areas is one of the greatest

barriers to accessing healthcare in the United States. Mental healthcare providers are

especially limited in numbers and availability in rural areas. Although all individuals

living rurally have challenges with receiving care, one group that demonstrates an

exceptional deficiency with access to care is veterans. The numbers of veterans living

rurally are significantly higher than vets living close to urban or suburban centers of care.

Considering the shortages of mental health providers, alternatives to traditional in-person

therapy are needed in order to adequately address the needs of rurally located veterans.

Recently, psychotherapy via video teleconferencing has been suggested as a way of

reaching a greater number of veterans. But is this approach equivalent to in-person

therapy in the treatment of PTSD?

Methods: An exhaustive search was conducted using Medline-OVID, CINAHL, and

Google Scholar using the keywords: mental health, veterans, rural, and telemedicine.

Relevant articles were assessed for quality using GRADE.

Results: Three studies met the search criteria and were included in this systematic

review. The first study, Frueh et al, is a randomized controlled study (RCT) to compare

the efficacy of psychotherapy delivered via video teleconferencing or in-person therapy

for combat-related PTSD. This study showed a comparable treatment effect and patient

satisfaction between the two different methods. The second study, Morland et al, is a

non-inferiority-designed RCT comparing anger management therapy delivered either by

video teleconferencing or same-room therapy to veterans with PTSD. This study

demonstrated similar satisfaction in both groups and an improvement in both anger and

PTSD symptoms in the video teleconferencing group. The third study, Ziemba et al, is a

two-arm RCT with either active-duty or veterans of Operation Enduring Freedom or

Operation Iraqi Freedom comparing psychotherapy administered via video

teleconferencing or in-person. This study indicated equivalence between the two types of

therapies.

Conclusion: Psychotherapy administered to veterans with PTSD living in rural areas via

video teleconferencing has been shown to be equivalent to traditional in-person therapy.

Multiple studies show promise for a broader application of psychotherapy via video

teleconferencing to help with the shortage of mental health providers in rural areas;

however, further studies are needed to investigate the extent to which telemedicine can be

used effectively.

Keywords: Mental health, telemedicine, video teleconferencing, veterans.

4

Acknowledgements For my loving husband who’s meditation for me through my journey has been “You were

born for this”. It has served as both an inspiration and a kick in the rear end. To my mom

for instilling in me a love of science and exemplifying what it means to be a successful,

powerful woman. Thank you dad for teaching me that speaking softly is often the best

way to help others hear your voice. Your lessons of integrity and compassion have helped

me to always find and maintain my priorities.

.

5

Table of Contents

Biography……………………………………………………………………………….....2

Abstract……………………………………………………………………………………3

Acknowledgments…………………………………………………………………………4

Table of Contents………………………………………………………………………….5

List of Tables……………………………………………………………………………...6

List of Abbreviations……………………………………………………………………...6

Background………………………………………………………………………………..7

Methods……………………………………………………………………………………8

Results……………………………………………………………………………………..9

Discussion………………………………………………………………………………..14

Conclusion……………………………………………………………………………….16

References………………………………………………………………………………..17

Table I. Characteristics of Reviewed Studies……………………………………………21

Table II. Clinical Outcomes, Frueh et al…………………………………………………22

6

LIST OF TABLES

Table I Characteristics of Reviewed Studies

Table II Clinical Outcomes, Frueh et al

LIST OF ABBREVIATIONS

BDI Beck Depression Inventory

CAPS Clinician-Administered PTSD Scale

CI Confidence Interval

CPOSS-VA Charleston Psychiatric Outpatient Satisfaction Scale-VA PSTD

Version

CPT-C Cognitive Processing Therapy with cognitive therapy

DOD Department of Defense

FDA Food and Drug Administration

FTF Face to Face

GRADE Grading of Recommendations, Assessment, Development and

Evaluations IND Investigational New Drug

NAS-T Novaco Anger Scale total score

OEF Operation Enduring Freedom

OIF Operation Iraqi Freedom

PTSD Post Traumatic Stress Disorder

PCL-M PTSD Checklist-Military Version

RCT Randomized Controlled Trial

SCL-90-R Symptom Checklist-90-Revised

SD Standard Deviation

SF-36v2 Short Form 36 Health Survey

STAXI-2 State Trait Anger Expression Inventory-2

T-ANG 10-item Trait Anger

TM Telemedicine

VA Department of Veterans Affairs

VAMC Veterans Administration Medical Center

7

A Comparison of the Efficacy of Psychotherapy via Telemedicine to Traditional Face-to-Face Therapy for Rural Veterans with PTSD

BACKGROUND

The shortage of medical providers in rural communities presents one of the

greatest challenges in delivering healthcare.1 This is particularly true of mental

healthcare.1,2

One population greatly affected by lack of care in rural areas is veterans.

According to the Veterans Health Administration Office of Rural Health (VA ORH),

“veterans from geographically rural areas make up a disproportionate share of service

members”.3 Veterans also have higher rates of mental health issues than the general

population, specifically Post Traumatic Stress Disorder (PTSD). PTSD has been linked

to combat stressors including, increased exposure,4 survivability following combat

sustained injury, 5

and the number of deployments.6

Cognitive behavioral therapies such as exposure therapy are considered to be first

line treatments of PTSD by the Department of Veterans Affairs (VA) and Department of

Defense (DOD).7 Veterans living rurally however, are less likely to seek behavioral

health treatment because of the limited availability of providers.8 The VA ORH continues

to seek ways of addressing this disparity.3 One possible solution is the use of

telemedicine. Past research has demonstrated that psychiatric interviewing performed via

telemedicine is reliable. High levels of patients and provider satisfaction with care have

also been observed.9,10

However, until recently there was little evidence to support the

efficacy of using telemedicine to treat mental illness. Although telemedicine can employ

different modalities, this review will focus on studies that specifically used video

teleconferencing for treatment. Since in-person psychotherapy is the gold standard for

8

treating many types of mental illness, including PTSD, one way to determine the efficacy

of telemedicine is to compare treatment groups receiving either therapy in-person or via

telemedicine.

As healthcare has expanded to include more people, finding a way to provide care

to individuals in geographically isolated areas is increasingly important. As it is now,

veterans living in these rural areas often fall through the cracks. Since they commonly

have lingering ill effects on their health after providing service to our country,

determining a way to address their needs is arguably one of the most important current

healthcare issues. Programs such as telemedicine could be a way to provide greater

outreach to our service men and women. Thus, it is important to determine if

psychotherapy delivered via telemedicine is as effective as traditional face-to-face

therapy.

METHODS

An exhaustive search was conducted using Medline-OVID, CINAHL, and Google

Scholar using the keywords: mental health, veterans, rural, and telemedicine. The

references of relevant studies were also screened for potential articles. After the initial

search only articles written in the English language were considered. Articles discussing

telemedicine techniques other than video teleconferencing were excluded. Grading of

Recommendations, Assessment, Development and Evaluation (GRADE)11

was employed

to evaluate the quality of the relevant articles.

9

RESULTS

The initial database search returned 76 studies. After the articles were screened

for eligibility, two articles12,13

met the inclusion criteria. A search of references revealed

one additional article.14

See Table I.

Frueh et al

The Frueh et al study14

is a randomized controlled trial (RCT) comparing the

efficacy of psychotherapy delivered via video teleconferencing or in-person therapy for

combat-related PTSD. The patients were recruited from a Veterans Administration

Medical Center (VAMC) either through physician or self-referral. Inclusion criteria

mandated that the patients met diagnostic criteria for PTSD as defined by the DSM IV,

were non-psychotic, and were not presently abusing any substances. After recruitment,

patients were randomized to their group using an urn randomization procedure.15

The

study ran for 14 weeks with weekly sessions and clinical interviews were conducted prior

to treatment and three months following study completion. Additionally, patients reported

psychiatric symptoms through several self-reported surveys prior to treatment, after

treatment, and at a 3-month follow up. Satisfaction with treatment was also self-reported

via the Charleston Psychiatric Outpatient Satisfaction Scale-VA PSTD Version (CPOSS-

VA) at week 4 and following treatment.14

A total of 38 patients were randomized after screening for eligibility and consent.

Treatment groups were balanced with regards to baseline characteristics including:

demographics, psychiatric diagnosis, trauma exposure, and baseline mental health

assessment scores. Of the patients in the telemedicine (TM) group (n=17), eight

participants did not complete the 90 minute weekly sessions. Comparatively, nine

10

patients in the same-room group (n=21) did not complete the therapy. A total of five

patients, two from the TM group and three from the same-room group, were lost to

follow up during the 3-month follow up phase of the study.14

Clinical outcomes were measured by self-reported surveys. The 17-item PTSD

Checklist-M (PCL-M)16

was used to evaluate PTSD symptom severity. The Symptom

Checklist-90-Revised (SCL-90-R)17

measured overall psychiatric functioning. The Beck

Depression Inventory (BDI)18

evaluated symptoms of depression. Patients were also

asked to rate their social activities inside the home, social activities outside the home, and

the quality of their social relationships as further evidence of their psychiatric

functioning.14

Of note was the change in the PCL scores from baseline to 3-month

follow-up. At 3-month follow up, the change from baseline in the TM group was -2.67.

In the same-room group the change from baseline at the 3-month follow up was 0.22. The

p-value was 0.67, which indicates there is no statistical significance between the two

groups. In other words, both groups showed little change in the severity of their PTS

symptoms. See Table II.

The authors cited several limitations to this study. High levels of pathology and

psychiatric comorbidity were hypothesized to be responsible for low rates of clinical

change (improvement) in both groups.19

Small sample size may have also resulted in low

power for detecting treatment differences. Finally, they noted, “high drop-out rate post

randomization may have resulted in bias comparison between samples.” Based on the

results with the noted limitations of the study, the authors cautiously suggest that

telemedicine may be effectively used in the treatment of PTSD.14

11

Morland et al

Morland et al12,20

is a non-inferiority-designed RCT comparing anger

management therapy delivered either by video teleconferencing or same-room therapy to

veterans with PTSD in a group setting. Patients were recruited from three VA clinical

sites and three vet Centers on the islands of Hawaii, Maui, and Oahu. To be included in

the study the veterans had to have a current or lifetime diagnosis of PTSD as determined

by Clinician-Administered PTSD Scale (CAPS)21

and a stable medication regimen for a

minimum of two months prior to beginning the study. Additionally, a score of ≥ 20 on the

10-item Trait Anger (T-ANG) subscale of the State-Trait Anger Expression Inventory-2

(STAXI-2) were needed in order to demonstrate a moderate to severe anger problem.22

Patients were excluded if they had active psychosis, suicidal or homicidal ideation, or

substance dependence. “Females veterans were excluded due to their small numbers at

participating clinics and the resulting inability to establish a therapeutic gender mix

within the groups.” 9

Significant history of other mental illnesses was also

disqualifying.12,20

After eligibility and consent, an off-site statistician randomly assigned patients to

a treatment group. The goal was to form nine groups of 14 patients (7=TM, 7=FTF) at

four different clinical sites. Of the 61 patients assigned to the TM group 11 were lost to

follow up over the course of the study. The FTF group began with 64 patients and 20

were lost to follow up. There were no statistically significant differences of baseline

characteristics between the groups.

The study consisted of two sessions per week for six weeks. Both groups received

Cognitive Processing Therapy with cognitive therapy only (CPT-C). Assessments of both

12

self-reported clinical and process outcomes were measured at baseline, mid-treatment,

post-treatment, and three and six months post-treatment. Clinical outcomes included

anger expression and trait (STAXI-2), PTSD symptoms (PCL-M), and the cognitive,

arousal, and behavioral aspects of anger (NAS-T).9,14

Attrition, treatment adherence,

treatment expectancy, and group therapeutic alliance were the measured process

outcomes. Patient satisfaction, measured by the CPOSS-VA, was also considered to be a

process variable.9,14

Both groups demonstrated improvement on the anger analysis surveys, STAXI-2,

PCL-M, and Novaco Anger Scale23

total score (NAS-T) at post-treatment and the 3-

month timeframe. “The upper limit of the CI is below the minimum clinically meaningful

difference, indicating that the video teleconferencing was non-inferior to in-person.”12

Results continued to demonstrate non-inferiority at six months post-treatment on the

STAXI-2 however the large Standard Deviation (SD) of the NAS-T scores prevented

analysis. Overall, the analysis demonstrated a slightly larger improvement with video

teleconferencing with regards to the anger trait. Evaluation of PTSD symptoms revealed

improvement across both groups but the data did not statistically prove non-

inferiority.12,20

The authors state that while the study does confirm that video teleconferencing is

an acceptable and safe way of providing psychotherapy to veterans with anger or PTSD

issues there are several items the study did not address. Some of the limitations discussed

include the lack of investigation of the overall effects of anger or PTSD symptom

improvement on other domains of life and the effectiveness of using video

teleconferencing to treat mental conditions with acute safety concerns. The study also

13

failed to assess whether patients used to traditional therapy would be able to transition

effectively to using video teleconferencing. More studies are needed to address these

concerns and to understand how to incorporate telemedicine into current health care

practices.12,20

Ziemba et al

Ziemba et al13

is a two-arm RCT with either active-duty or veterans of Operation

Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) comparing video

teleconferencing and in-person psychotherapy. Male or female active-duty and veterans

of OEF and/or OIF with either a suspicion or a previously confirmed diagnosis of PTSD

were recruited for the study using a combination of presentations, electronic, and print

media. Eligible subjects had the diagnosis of PTSD confirmed by a contracted

psychiatrist as part of the screening process. Any patients started on psychiatric

medication by the study psychiatrist had enrollment delayed by 30 days to ensure

medication stability. Enrolled patients were randomized in a 1:1 manner using a

computer algorithm.

Patients were given 15 weeks to complete 10 therapy sessions. A licensed clinical

therapist was in charge of conducting therapy sessions while a research rater administered

both the pre and post assessments. The research rater was blinded to the subject’s therapy

type. A fidelity consultant was also used to review and rate therapy sessions to ensure

therapist adherence to and competence with the therapy protocol. Evaluations including

CAPS, Montgomery-Asberg Depression Rating Scale (MADRS),24

and Hamilton

Anxiety Rating Scale (HAM-A)25

which evaluated the symptoms of PTSD, depression,

and anxiety were conducted both prior to and following treatment. Physical health was

14

also evaluated by the Short Form 36 Health Survey (SF-36v2)26

as a means of evaluating

the effect of PTSD on quality of life. Finally, satisfaction with care was evaluated via a

survey developed for the study by Press Ganey (South Bend, IN) upon completion of the

trial.13

A total of 18 patients were randomized however, five were lost to follow up. Both

groups of patients demonstrated improvement with regards to mental health with the

telemedicine group improving more (TM +45.8%, FTF +37.9%). Physical health

remained relatively unchanged in both groups (TM + 4.4%, FTF + 4.5%).13

The greatest limitation of the study was its inability to demonstrate statistical

significance of results due to small sample size. Additionally, the travel distance needed

for some subjects to participate may have influenced the results. Overall, the authors

determined that the study could be used to estimate trends in the effectiveness and

clinical significance of video teleconferencing.13

DISCUSSION

Studies have had promising results in demonstrating that telemedicine,

specifically video teleconferencing, is an effective form of psychotherapy to provide care

to Veterans living in rural communities.12-14

While the primary focus of this review has

been using video teleconferencing to treat PTSD, there are other available studies which

demonstrate positive outcomes with other mental health conditions such as anger

management12

, depression,27

and anxiety.28

All three studies reviewed compare video

teleconferencing to in-person psychotherapy using a RTC model.

Of the three studies, the Morland et al study12,20

was the most complete

assessment in terms of diversity and quantity of veterans, but there was an imbalance in

15

the patients lost to follow up where 11 of 61 were lost in the telemedicine group while 20

of 64 were lost in the in person group. The Frueh et al14

and Ziemba et al13

had much

smaller sample sizes and thus no statistical significance is gleaned from the data.

However, conclusions were drawn based on encouraging trends. This lack of sample size

indicates a need for further studies. See Table I.

While research from these studies is encouraging, further RCT studies are needed

to fully address efficacy as well as long-term treatment effects. In order to gain the

sample size needed to see relevant effect non-veterans may need to be included. In that

case, researchers may need to further stratify the type of trauma associated with the

PTSD to ensure that a difference between study subjects does not create inconsistency in

the results.

The majority of the results of these studies were self-reported. While the

evaluations given are designed to produce an accurate picture of a patient’s symptoms

and severity of symptoms, it is still a subjective measurement. Further investigations

may try implementing a system incorporating both patient questionnaires and a separate

evaluation by an off-site mental health professional. A correlation between these two

types of evaluations may provide proof of efficacy.

The trends in the research do support using psychotherapy via video

teleconferencing as an alternative to in-person therapy. For patients in a rural setting or

without access to a mental health provider this type of intervention is recommended.

Both patients and providers should give close attention to progress and satisfaction in

order to ensure successful treatment of the patient.

16

CONCLUSION

Psychotherapy administered to veterans with PTSD living in rural areas via video

teleconferencing has been shown to be equivalent to traditional in-person therapy. Similar

levels of satisfaction with care are also noted when comparing the two methods.

Although recruitment can be challenging in remote areas, results have been consistent

over multiple studies. PTSD symptoms were the primary interest but other psychological

pathologies (anger) also showed improvement with video teleconferencing. The

combined quality of the evidence for the reviewed studies based on the GRADE criteria

is low; however, these studies show promise for broader application psychotherapy via

video teleconferencing to help with a shortage of mental health providers in rural areas.

Further studies are needed to investigate the extent to which telemedicine can be used to

treat different types of mental illness and if its effects are broad enough to positively

influence other domains of life.

17

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21

TABLE I. Characteristics of Reviewed Studies, Grade Profile

aRisk for performance bias due to inability to blind providers and patients in the Frueh et al, Morland et al, and Ziemba et al studies. bNon-inferiority analysis used in the Frueh et al study and the Morland et al study and strong use of self-reported data in all studies. cSmall sample sizes and/or large lost to follow up in all studies

Quality Assessment

Downgrade Criteria

Quality Studies Design Limitations Indirectness Imprecision Inconsistency

Publication bias likely

PTSD Symptoms

Frueh et al

RCT No serious limitationsa

Serious indirectnessb

Serious imprecisionc

No serious inconsistencies

No bias likely

Low

Morland et al

RCT

No serious limitationsa

Serious indirectnessb

Serious imprecisionc

No serious inconsistencies

No bias likely

Low

Ziemba et al

RCT

No serious limitationsa

Serious indirectnessb

Serious imprecisionc

No serious inconsistencies

No bias likely

Low

Patient Satisfaction

Frueh et al

RCT

No serious limitations

No serious indirectness

Serious imprecisionc

No serious inconsistencies

No bias likely

Moderate

Morland et al

RCT

No serious limitations

No serious indirectness

Serious imprecision

No serious inconsistencies

No bias likely

Moderate

Ziemba et al

RCT

No serious limitations

No serious indirectness

Serious imprecisionc

No serious inconsistencies

No bias likely

Moderate

22

Baseline Post-treatment Change from baseline Lower limit of

one-sided 95% CI

3 month follow-up 3 month follow-up change-from-baseline

Lower limit of

one-sided

95% CI

Survey

Same-room mean (SD, n)

Telepsychiatry mean (SD, n)

Same-room

mean (SD, n)

Telepsychiatry mean (SD, n)

Same-room

mean (SD, n)

Telepsychiatry mean (SD, n)

P

Same-room

mean (SD, n)

Telepsychiatry mean (SD, n)

Same-room

mean (SD, n)

Telepsychiatry mean (SD, n)

P

PCL 62.38 (12.8, 21) 67.00 (9.4, 17) 56.58 (10.1,12) 68.11 (11.0, 9) -2.58 (11.3, 12) 1.78 (11.0, 9) 0.39 -12.9 60.56 (9.8, 9) 61.43 (14.6, 7) 0.22 (11.0, 9) -2.67 (11.0, 6) 0.67 -7.2

BDI 24.43 (8.6, 21) 24.41 (11.2, 17) 25.17 (7.6, 12) 27.56 (11.9, 9) 1.42 (6.1, 12) 2.89 (8.6, 9) 0.65 -7.0 27.67 (7.6, 9) 28.71 (12.7, 7) 2.78 (8.5, 9) 3.67 (7.1, 6) 0.84 -8.2

SCL-90-R 2.02 (0.8, 21) 2.21 (0.8, 17) 1.85 (0.6, 12) 2.41 (0.9, 9) -0.02 (0.5, 12) -0.01 (0.6, 9) 0.97 -0.4 1.89 (0.9, 9) 2.22 (1.0, 7) -0.08 (0.4, 9) -0.07 (0.5, 6) 0.97 -0.4

Social activities

inside home

1.85 (3.4, 20) 0.81 (1.3, 16) 1.83 (2.0, 12) 2.25 (3.4, 8) 0.55 (1.1, 11) 1.86 (4.0, 7) 0.43 -0.9 0.78 (1.0, 9) 0.86 (1.1, 7) 0.00 (1.5, 8) 0.20 (1.8, 5) 0.83 -1.4

Social activities

outside home

1.63 (1.9, 19) 1.06 (0.9, 16) 4.83 (5.5, 12) 3.50 (3.8, 8) 1.90 (3.5, 10) 1.57 (2.4, 7) 0.83 -3.0 1.11 (1.6, 9) 1.57 (1.9, 7) -0.50 (2.4, 8) 0.40 (1.8, 5) 0.49 -1.3

Quality of social

relationships

4.10 (2.6, 20) 4.00 (2.5, 17) 5.75 (2.2, 12) 3.89 (2.6, 9) 1.00 (3.6, 11) 2.22 (8.6, 9) 0.70 -3.7 4.22 (2.2, 9) 7.00 (10.2, 7) 0.75 (3.0, 8) -0.40 (1.1, 5) 0.43 -3.2

TABLE II. Clinical Outcomes, Frueh et al