Improving and sustaining delivery of CPT for PTSD in mental health systems: a cluster randomized trial

Shannon Wiltsey Stirman,James F Burgess,Cassidy A Gutner,David Gagnon,Erin P Finley,Vanessa Ramirez,Joan Cook,Kera Mallard,Tasoula Masina,Norman Shields,Kelly Koerner,Linda Dimeff,Matthew Beristianos,Candice Monson,Michael Suvak,Rachel Haine-Schlagel

doi:10.1186/s13012-017-0544-5

Abstract

BackgroundLarge-scale implementation of evidence-based psychotherapies (EBPs) such as cognitive processing therapy (CPT) for posttraumatic stress disorder can have a tremendous impact on mental and physical health, healthcare utilization, and quality of life. While many mental health systems (MHS) have invested heavily in programs to implement EBPs, few eligible patients receive EBPs in routine care settings, and clinicians do not appear to deliver the full treatment protocol to many of their patients. Emerging evidence suggests that when CPT and other EBPs are delivered at low levels of fidelity, clinical outcomes are negatively impacted. Thus, identifying strategies to improve and sustain the delivery of CPT and other EBPs is critical. Existing literature has suggested two competing strategies to promote sustainability. One emphasizes fidelity to the treatment protocol through ongoing consultation and fidelity monitoring. The other focuses on improving the fit and effectiveness of these treatments through appropriate adaptations to the treatment or the clinical setting through a process of data-driven, continuous quality improvement. Neither has been evaluated in terms of impact on sustained implementation.MethodsTo compare these approaches on the key sustainability outcomes and provide initial guidance on sustainability strategies, we propose a cluster randomized trial with mental health clinics (n = 32) in three diverse MHSs that have implemented CPT. Cohorts of clinicians and clinical managers will participate in 1 year of a fidelity oriented learning collaborative or 1 year of a continuous quality improvement-oriented learning collaborative. Patient-level PTSD symptom change, CPT fidelity and adaptation, penetration, and clinics’ capacity to deliver EBP will be examined. Survey and interview data will also be collected to investigate multilevel influences on the success of the two learning collaborative strategies. This research will be conducted by a team of investigators with expertise in CPT implementation, mixed method research strategies, quality improvement, and implementation science, with input from stakeholders in each participating MHS.DiscussionIt will have broad implications for supporting ongoing delivery of EBPs in mental health and healthcare systems and settings. The resulting products have the potential to significantly improve efforts to ensure ongoing high quality implementation and consumer access to EBPs.Trial registrationNCT02449421. Registered 02/09/2015

Highlights

Large-scale implementation of evidence-based psychotherapies (EBPs) such as cognitive processing therapy (CPT) for posttraumatic stress disorder can have a tremendous impact on mental and physical health, healthcare utilization, and quality of life
A second challenge is that research suggests that fidelity [12] may be low when these interventions are implemented [13, 14]
This study will capitalize on infrastructure created for a previous trial comparing EBP consultation strategies [59] as well as existing infrastructure in the participating mental health systems and strong collaborative relationships and experience with each participating mental health system

Summary

Introduction

Large-scale implementation of evidence-based psychotherapies (EBPs) such as cognitive processing therapy (CPT) for posttraumatic stress disorder can have a tremendous impact on mental and physical health, healthcare utilization, and quality of life. While some adaptation and latitude in EBP delivery may be appropriate [17], effective [18,19,20,21], or promote implementation [22], other adaptations result in discontinuation of core elements [15], integration of non-evidence-based strategies [13, 23], and worse outcomes [24, 25]. In addition to these challenges, local capacity can impact sustainability and quality of delivery. While EBPs are cost-effective [32], the budget impact of supporting implementation can be a barrier [33,34,35]

Methods

Findings

Discussion

Conclusion