Evidence-based Psychotherapies For Posttraumatic Stress Disorder Research Articles

The effects of Religiosity, Spirituality, and sense of purpose on posttraumatic stress disorder treatment outcomes among Veterans

BackgroundReligion/spirituality (R/S) is an important and commonly used resource for coping with difficult experiences and has been shown to reduce the development of posttraumatic stress disorder (PTSD) symptoms following a trauma. However, it is not clear how R/S affects response to treatment of PTSD. ObjectiveThe aim of this paper was to understand how Veterans’ R/S and sense of purpose were related to clinical outcomes when engaging in Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE). It was predicted that Veterans identifying as R/S would have a higher sense of purpose, be more likely to complete treatment, and have greater symptom change during treatment. MethodThe study included 91 military Veterans from a VA Medical Center outpatient PTSD Clinical Team who initiated CPT or PE and responded to a question about the importance of R/S in their lives at intake. Results: Forty nine percent of the Veterans in this sample reported R/S were important to them and had mixed feelings about whether their life had a clear sense of purpose. Neither R/S nor sense of purpose were associated with treatment completion or response to PTSD treatment. ConclusionThese findings suggest that once PTSD has developed, R/S or sense of purpose may not play a significant role in completion of or response to evidence-based psychotherapies (EBPs) for PTSD. EBPs for PTSD are equally effective for Veterans identifying as R/S and those who do not, which may be reflective of administering EBPs in a culturally responsive manner.

"Pitching" posttraumatic stress disorder treatment: A qualitative study of how providers discuss evidence-based psychotherapies with patients.

The two widely available evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) are cognitive processing therapy and prolonged exposure. Although the U.S. Department of Veterans Affairs (VA) has invested in intensive clinical training to provide these first-line treatments, most military veterans do not receive these therapies. Prior research indicates that patient interest and motivation depend on how patients are educated, and differences in how information is presented shape their decision-making. To our knowledge, no studies have addressed how clinicians "pitch" EBPs for PTSD and examined whether certain approaches are more effective than others. We recorded and thematically analyzed 25 treatment planning sessions across 10 VA sites in the United States to better understand how providers talk to patients about treatment options. Five themes were identified: using rich description, integrating various forms of questioning to engage the patient, sharing prior patient success stories, using inviting and direct language, and tailoring therapy talk to fit patient needs. Providers learning to offer EBPs can use these strategies to serve as a "menu" of options that will allow them to present EBPs in a way that appeals to a particular patient.

Enhancing social functioning in older veterans with PTSD: Rationale and design of an intervention and initial RCT

BackgroundOlder Veterans with Posttraumatic Stress Disorder (PTSD) are often socially isolated and have complex comorbid physical health problems. Aging-related stressors can exacerbate PTSD symptoms. These factors contribute to greater impairment in social functioning and decreased quality of life (QoL). Evidence-based psychotherapies for PTSD often address these issues, but not all older Veterans with PTSD seek help for these challenges, some don't want to engage in trauma-focused treatment, some drop out prematurely, and some still have residual symptoms upon completion. Thus, additional interventions that directly target social functioning among older Veterans with PTSD are needed. MethodsIn this paper we describe the development of and feasibility evaluation plan for, “Enhancing Social Functioning for older Veterans with PTSD (ESVP),” a social functioning group intervention for older (>60 years) Veterans with PTSD. This project involved four phases of work: 1) Intervention development, 2) Review of intervention and potential modifications using focus groups, 3) Intervention pilot testing and modification, and 4) A randomized feasibility trial comparing the intervention with a support group control. Intervention modules address interpersonal relationships, effective communication, anger management, social skills, social support/activities, and behavioral activation. ConclusionThis project details the iterative process used to develop the ESVP intervention designed to enhance social functioning in older Veterans with PTSD, and to evaluate feasibility. Analyses are underway to examine feasibility of conducting ESVP with a sample of older Veterans with PTSD. Findings from the final project phase, the randomized feasibly trial, will inform the design and implementation of a future trial.Clinicaltrials.gov Identifier: NCT02803125

Assessment of modifications to evidence-based psychotherapies using administrative and chart note data from the US department of veterans affairs health care system.

The US Department of Veterans Affairs (VA) has over 15 years of experience in delivery of evidence-based psychotherapies (EBPs). This paper describes strategies for using clinical documentation and administrative data to understand adherence and modifications to EBPs for Posttraumatic Stress Disorder (PTSD). This study focused on two EBPs for PTSD, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). The sample included VA therapists from across the US who provided CPT and PE and the patients they treated over a 1-year period. The data sources for this study were templated EBP chart notes and VA administrative data. We used a manual review of note content and administrative data rules to code therapy adherence and modifications in 7,297 EBP sessions for 1,257 patients seen by 182 therapists. Two trained coders rated each therapy note and resolved discrepancies through consensus. To contextualize and explain variation in adherence and modifications, we conducted brief 30-45-min semi-structured interviews with a purposive subsample of these therapists (n = 32). Combining manual chart review and administrative data allowed for identification of 11 types of modifications. Raters disagreed on adherence for 30% of notes. The disagreement stemmed from the presence of therapy modifications that were not clearly documented, necessitating the development of decision rules and strategies for modification coding. Both therapists and patients contributed to the variance in the extent to which different modifications occurred. Therapist interviews demonstrated therapist awareness of modifying the protocols in the ways identified through chart review. Healthcare systems can use data collected as part of routine care to understand how and when EBPs are modified but need to develop scalable strategies to document adaptations and modifications to EBPs in routine care.

Comparative effectiveness of trauma-focused and non-trauma-focused psychotherapy for PTSD among veterans with comorbid substance use disorders: Protocol & rationale for a randomized clinical trial

BackgroundCo-occurrence of posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) is common and concurrent treatment is recommended. Relatively little is known about which evidence-based psychotherapies for PTSD are most effective for patients with varying substance use profiles. We aim to examine the comparative effectiveness of trauma-focused therapy (TFT) and non-trauma-focused therapy (NTFT) among Veterans with PTSD and SUD. TFT has been found to be effective among those with PTSD/SUD, though effects are smaller and rates of treatment non-completion are higher than in those without SUD. NTFTs suggested for the treatment of PTSD, such as Present Centered Therapy, (PCT) have not been examined among those with co-occurring SUD, despite lower rates of treatment dropout. We will also examine the comparative effectiveness of TFT and NTFT for patients with varying SUD severity, type of substances used, and patient treatment preference. Method420 Veterans with PTSD and SUD will be randomized in a prospective, pragmatic comparative effectiveness trial at 14 Veterans Health Administration facilities. Participants will receive either TFT (Prolonged Exposure or Cognitive Processing Therapy) or NTFT (PCT) after enrolling in concurrent SUD treatment-as-usual. Assessments will occur at baseline, posttreatment, 3- and 6 -months posttreatment. Main outcomes are PTSD symptom severity and PTSD treatment dropout. Clinician, patient, and leadership stakeholder panels advise study activities, and a process evaluation will identify strategies to enhance the implementation of evidence-based PTSD treatments in SUD care settings. ConclusionsResults will provide critical information to guide clinicians when recommending PTSD treatments to patients with comorbid SUD.ClinicalTrials.gov Identifier: NCT04581434.

Intensive Cognitive Processing Therapy Associated With Reduced PTSD Treatment Dropout in a Case-Controlled Study of Treatment-Seeking Veterans

Cognitive Processing Therapy (CPT) is an empirically supported psychotherapy for posttraumatic stress disorder (PTSD). The complex issue of treatment attrition is a frequently cited concern regarding CPT and other evidence-based psychotherapies for PTSD. The current study investigated the feasibility and effectiveness of “intensive” CPT, a treatment-consistent modification of CPT in which sessions are conducted more frequently than standard protocol. Fifty-four military veterans (20% female; Mage = 46; 80% Caucasian) seeking outpatient treatment for PTSD were included in this study. Patients who elected to receive intensive CPT (n = 27) were matched with archival records of individuals who received standard CPT (n = 27). Patients across treatment conditions were matched based on baseline symptom severity as measured by the PTSD Checklist for DSM-5 (PCL-5; MPCL-5 = 52.61). Treatment outcomes were compared and longitudinal multilevel modeling was used to compare rate of symptom change over time. Patients who elected to engage in intensive CPT were twice as likely to complete treatment (88.9%) as those who received standard CPT (44.4%), X2(1, N = 54) = 12.00, p = .001. On average, intensive CPT patients completed treatment in about 25% of the time as standard CPT patients (33.8 days vs. 125.7 days). Patients in intensive CPT also demonstrated greater benefit: 81.4% reported a clinically significant improvement in PCL-5 scores compared to 51.8% of those in standard CPT, X2(1, N = 54) = 5.33, p = .020, φ = −0.314. Intensive and standard CPT performed comparably in regard to final PCL-5 score, change over time, and screening cutoff. In addition, there were no differences in treatment outcomes based on licensure status of the provider nor whether treatment was delivered in person or virtually. Intensive CPT represents a novel, treatment-consistent adaptation that was utilized to treat a group of veterans with PTSD with minimal treatment dropout. Patients who elected to engage in more frequent treatment were more likely to complete treatment, did so in one quarter of the time, and reported similar to better treatment outcomes. Providers may consider encouraging their patients to participate in treatment as frequently as they are able. However, preliminary findings are based on a nonrandom sample and design limitations temper conclusions.

Valued living among veterans in breath-based meditation treatment or cognitive processing therapy for posttraumatic stress disorder: Exploratory outcome of a randomized controlled trial.

BackgroundValued living is the extent to which an individual’s behavior is consistent with what they believe is important or good. It is unknown whether many complementary and integrative treatments and psychotherapies for posttraumatic stress disorder enhance valued living, and for whom.ObjectivesMeasure within- and between-group changes in valued living in Veterans who completed cognitive processing therapy (CPT) and sudarshan kriya yoga (SKY) for posttraumatic stress disorder (PTSD); evaluate moderators of improvement.MethodsParticipants with clinically significant symptoms of PTSD were assigned to CPT, a first line, evidence-based psychotherapy for PTSD or SKY, an emerging breath-based meditation with strong preliminary empirical support in a parallel-groups randomized controlled trial at a single Veterans Affairs healthcare center. The Valuing Questionnaire subscales for progress in valued living (VQ-P) and obstruction in valued living (VQ-O) were exploratory outcome measures. Assessors were blind to treatment assignment.Results59 participants completed treatment (29 CPT, 30 SKY). Participants in the CPT group improved from baseline to end of treatment in both VQ-Progress (d=0.55, p=0.02) and VQ–Obstruction (d=-0.51, p=0.03), while the SKY group did not improve on either subscale (d=0.08, p=0.69; d=0.00, p=1.00). However, differences between treatments were not statistically significant (p=0.16, 0.11, respectively). Participants reporting less valued living and more depression symptoms at baseline reported greater improvements in valued living following treatment.ConclusionCPT may have a positive effect on valued living. Individuals lower in valued living and with more depression may derive relatively more benefit.

Engagement in and Benefits of a Short-Term, Brief Psychotherapy Intervention for PTSD During Pregnancy.

Trauma-related symptoms and post-traumatic stress disorder (PTSD) are common during pregnancy and have adverse effects on pregnancy and birth outcomes, post-partum maternal mental health, and child development. The arousal symptoms associated with PTSD, including heightened or dysregulated physiology, may contribute to these adverse outcomes. Low-income minoritized women may be at highest risk given more lifetime exposure to trauma and limited access to mental health care. While evidence-based psychotherapies for PTSD exist, none are targeted to non-treatment seeking individuals nor specifically integrated with prenatal care. Thus, we developed and tested the efficacy of a short-term (four sessions) brief (30–45 min) psychotherapeutic intervention designed to address PTSD symptoms in pregnant women receiving prenatal care at two urban medical centers. Participants were 32 pregnant women with an average gestational age of 18.5 weeks at the time of enrollment. The sample was overwhelmingly non-Caucasian, single, and reported very low income. Participants completed measures of trauma-related symptoms (Post-traumatic Stress Disorder Checklist, PCL), and depression (Edinburgh post-natal Depression Scale, EPDS) at baseline, twice during treatment, post-treatment, and at 10–14 weeks post-partum. The intervention was successful at significantly decreasing symptoms of PTSD (PCL score = −20.27, 95% CI: −25.62, −14.92, P < 0.001, W = −7.43) and depression (EPDS score = −4.81, 95% CI: −7.55, −2.06, P = 0.001, W = −3.23) by the final session. These benefits were sustained at post-treatment and post-partum follow ups. Future research should further explore the effectiveness of this treatment in a randomized controlled trial.

Influences of Aging on PTSD Prevalence, Neurobiology, and Clinical Course

Posttraumatic stress disorder (PTSD) affects 6.8% of adults in the United States and is associated with high rates of disability, comorbid medical and psychiatric disorders, and suicide. Recent studies report increasing prevalence rates of PTSD among older adults, and this pattern is anticipated to accelerate as the population skews older and Veterans from recent conflicts age. Most older adults suffer from chronic PTSD, which is associated with at least one disability in nearly 80% of cases. Compared to those without PTSD, individuals with chronic PTSD have exceedingly high rates of Major Depressive Disorder (MDD), triple the rates of drug abuse, and significant functional impairment. Prompt diagnosis and treatment of PTSD in later life is complicated by its differing phenomenology in older compared to younger adults and age-related changes in treatment seeking. Whereas overall symptom severity, intrusive thoughts, and avoidance behaviors are lower among older adults with PTSD, they more frequently report somatic problems (e.g., pain, insomnia, gastrointestinal upset) relative to emotional issues (e.g., specific aspects of the trauma). Older patients may not spontaneously report traumatic experiences or minimize their importance, use generic terms such as “stress”, and generally present to primary medical doctors rather than specialty mental health settings. In terms of treatment, few studies of exposure-based psychotherapies are randomized, older adults are rarely enrolled, and almost none evaluate the most evidence-based psychotherapy for PTSD, Prolonged Exposure therapy. Analyses of prescribing trends using Veterans Affairs (VA) databases suggest that only about half of veterans (all ages) with PTSD receive first-line pharmacotherapy agents such as selective serotonin reuptake inhibitors (SSRIs), with even lower medication prescription in older compared to younger adults.In this symposium the influence of age-related factors will be discussed on the prevalence, development of PTSD given a traumatic stimulus, clinical presentation in terms of symptom profiles, underlying neurobiology, treatment responsivity, and illness course. Speakers will engage the audience in a discussion of what makes PTSD different in older adults compared to younger adults and what are the implications of these differences on clinical evaluation and treatment. Dr. Joan Cook will present data comparing characteristics of younger vs. older sexual assault survivors in order to discuss clinical and research implications. Next, Dr. Vanessa Simiola will present electronic health record and utilization data and discuss age-based differences between diagnoses made in primary care versus specialty mental health, differences in mental health treatment receipt, as well as clinical characteristics of the samples. Then, Dr. Xi Zhu will delve into data suggesting higher rates of MDD in older adults with PTSD and present her analyses of network connectivity differences discriminating PTSD from comorbid PTSD/MDD. Finally, Dr. Bret Rutherford will present data from an ongoing NIMH study in which older adults with PTSD are compared to trauma-exposed healthy controls (TEHCs) on cognitive, physical functioning, and neuroimaging indices. Two-year follow up data will be reviewed to consider the differing cognitive and physical functioning trajectories experienced over time between PTSD and TEHC participants. Finally, an audience discussion synthesizing all three of the talks will be held, with ample opportunity for audience members to ask questions of each speaker.

Symptom profiles and treatment status of older adults with chronic post-traumatic stress disorder.

Failure to diagnose and treat post-traumatic stress disorder (PTSD) may help explain the substantial disability, increased cognitive decline, and adverse health outcomes suffered by older adults with this disorder. To evaluate this possibility, we examined symptom differences among older and younger individuals with PTSD and measured the frequency with which older adults receive standard of care treatment. Clinician-Administered PTSD Scale for DSM (CAPS) scores were compared between younger and older adults with PTSD. Profiles were calculated for the most dominant CAPS symptom cluster reported by each participant, and the age cutoff best differentiating symptom clusters between individuals was determined. Clinical interview data (older adult sample only) were evaluated by trained raters to determine rates at which PTSD participants accessed treatment. Among 108 individuals with PTSD, 69% of participants <67 years old had Criterion C (avoidance) symptoms as the most dominant cluster compared to 39% of participants ≥67 (p=0.016). Eight percent of participants <67 years had Criterion E (hyperarousal) symptoms as the most dominant cluster compared to 30% of participants ≥67 (p=0.016). Less than 25% of the older adults (N=53 subsample) were receiving a first-line pharmacotherapy option for PTSD, and 0% of participants were currently participating in an evidence-based psychotherapy for PTSD. Clinicians evaluating patients should be aware that different symptom profiles may be present between younger and older adults with PTSD. Despite their high risk for adverse neuropsychiatric and other health consequences, older adults with PTSD appear to infrequently receive first-line clinical treatment.

Effects of Workshop Training in the Dialectical Behavior Therapy Prolonged Exposure Protocol on Clinician Beliefs, Adoption, and Perceived Clinical Outcomes

Although extensive efforts have been made to train clinicians in evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), relatively few PTSD patients are considered appropriate for and therefore receive these treatments. The dialectical behavior therapy prolonged exposure (DBT PE) protocol was developed to expand the reach of EBPs for PTSD to suicidal patients with severe comorbidities, but methods of training clinicians to deliver this treatment have not been evaluated. We examined the impact of DBT PE workshops on clinician beliefs, adoption, and perceived patient outcomes. Clinicians (N = 266) attended 2- or 4-day workshops and completed surveys at pretraining, posttraining, and 3- and 6-month follow-ups. From pretraining to 6-month follow-up, there were significant improvements in clinician concerns regarding worsening, perceived treatment credibility, and self-efficacy that did not differ by workshop length, R2 s = .20-.45. At 6-months posttraining, 53.5% of clinicians (38.8% 2-day, 66.3% 4-day) reported using DBT PE with 241 patients. Higher posttraining ratings of self-efficacy and perceived treatment credibility predicted later DBT PE use, R2 = .28. Among adopting clinicians, 81.3% reported that, on average, their patients' PTSD improved and 66.7% reported that patients were much to very much improved on average. Most clinicians reported that their patients' comorbid problems did not worsen during DBT PE and if worsening occurred, it typically involved temporary increases in distress. Workshops may be an effective method of changing clinician beliefs and promoting the use of DBT PE in a manner that clinicians experience as effective and safe for their patients.

A Review of PTSD Augmentation Strategies for Older Adults and Case of rTMS-Augmented Prolonged Exposure

Evidence-based psychotherapies such as prolonged exposure therapy (PE) are recommended by clinical practice guidelines as first-line treatments for post-traumatic stress disorder (PTSD) and are safe and acceptable for use with older adults. One third to one half of all patients do not achieve a clinically meaningful response to standard outpatient PE and recent research suggests that older adults in particular may experience barriers to full engagement and response. Standard treatment may be challenging in older adults due to cognitive, medical, and psychosocial barriers. This article reviews the current state of the evidence on adjunctive and second-tier interventions that show promise for increasing response and/or engagement in evidence-based psychotherapy for PTSD, including medications such as d-cycloserine and 3,4-methylenedioxy-methamphetamine, neuromodulation techniques such as repetitive transcranial magnetic stimulation, and augmentations to the structure and content of psychotherapy, such as intensive outpatient formats. A case illustration of successful application of multiple augmentations to PE with an initially nonresponsive older adult patient is presented. A creative interdisciplinary approach based in available research may be beneficial for older adults who do not respond to first-line treatments.

Provider general attitudes versus specific perceptions of evidence-based psychotherapies for PTSD.

This study examined the role of attitudes toward evidence-based psychotherapies (EBPs) in predicting use of prolonged exposure (PE) and cognitive processing therapy (CPT), two EBPs for posttraumatic stress disorder (PTSD) among PTSD treatment providers within the Department of Veterans Affairs. Providers' general attitudes toward EBPs, as well as their specific perceptions of PE and CPT, were examined as potential predictors of use. One hundred fifty-nine providers from 38 Department of Veterans Affairs' residential PTSD programs across the United States completed an online survey that included the predictors listed as well as self-reported use of PE on an individual basis and CPT on an individual and on a group basis. Although general attitudes toward EBPs were related to use of individually administered CPT, they were not related to use of PE or group-administered CPT. For each of the 3 treatments, however, specific positive perceptions were related to use. In examination of other training, skill, and delivery-related variables, general attitudes appear more in line with perceptions and delivery of CPT than PE. Perhaps this is because of the unique exposure component of PE. Assessing provider perceptions of specific EBPs may help providers in guiding their own practice as well as aid treatment developers, trainers, and administrators to more effectively tailor dissemination and implementation efforts. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Adoption by VA Residential Programs of Two Evidence-Based Psychotherapies for PTSD: Effect on Patient Outcomes.

This observational study examined the association between patient outcomes at 39 U.S. Department of Veterans Affairs residential treatment programs for veterans with posttraumatic stress disorder (PTSD) and the degree of adoption of two evidence-based psychotherapies, prolonged exposure and cognitive processing therapy. The hypothesis was that a higher degree of adoption would be associated with better outcomes. Providers (N=171) completed a qualitative interview and quantitative survey about their level of adoption of prolonged exposure delivered individually and cognitive processing therapy delivered in individual or group formats. On the basis of responses, programs were assigned to one of three adoption categories: little or no adoption of either therapy (N=8), some adoption, (N=9), and high adoption (N=22). A linear mixed model compared patient outcomes (e.g., PTSD and depression symptom severity, substance use, and distress) between adoption groups. The sample of veterans consisted of 2,834 who completed an assessment of PTSD symptoms and functioning at program intake and again at either program discharge or at 4 months postdischarge. Improvements in PTSD, distress, and alcohol use were noted over time for all programs, with decreases at follow-up. No effects of adoption group or a group × time interaction were noted for any outcome. Moderate to large effects were noted across all programs. However, programs that used prolonged exposure and cognitive processing therapy with most or all patients did not see greater reductions in PTSD or depression symptoms or alcohol use, compared with programs that did not use these evidence-based psychotherapies.

Predictors of Treatment Adequacy During Evidence-Based Psychotherapy for PTSD.

The U.S. Department of Veterans Affairs (VA) has placed increased emphasis on the availability and use of evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). However, many individuals do not complete a full course of EBP. The current study aimed to quantify the percentage of veterans receiving adequate EBP in VA hospitals and identify factors related to treatment completion. A national sample of 16,559 VA patients who began cognitive processing therapy (CPT) or prolonged exposure (PE) during fiscal year 2015 was obtained via administrative data. Generalized estimating equations were used to evaluate individual-level predictors of treatment adequacy, defined as eight sessions within 14 weeks. Generalized linear models were used to examine facility-level factors. A total of 5,142 (31.1%) veterans completed eight or more sessions of psychotherapy. Older age was associated with greater odds of completing eight or more sessions (odds ratio OR=1.02, 95% confidence interval [CI]=1.01, 1.02, p<0.001), and comorbid bipolar or psychotic disorders were associated with reduced odds of completion (OR=0.89, 95% CI=0.80, 0.99, p=0.03). The percentage of patients who completed eight or more sessions was higher at facilities with higher percentages of EBP use among all patients with PTSD (β=6.55, SE=1.97, p=0.001) and greater numbers of EBP-certified providers (β=0.004, SE=0.002, p=0.038) and lower at facilities with a higher percentage of patients receiving a PTSD Checklist (β=-1.16, SE=0.46, p=0.011). A minority of VA patients with PTSD complete an adequate dose of EBPs for PTSD. Individual and facility-level factors related to treatment adequacy may point to opportunities for intervention.

VA residential treatment providers' use of two evidence-based psychotherapies for PTSD: Global endorsement versus specific components.

Despite a growing body of knowledge about the dissemination of evidence-based psychotherapies (EBPs), their actual use in clinical settings is not well understood. The purpose of the current study was to compare self-reported component use with global use for 2 EBPs for posttraumatic stress disorder (PTSD), prolonged exposure (PE), and cognitive processing therapy (CPT). Around 174 providers from 38 VA PTSD residential treatment programs were asked about both global use and component use of PE and CPT. Among frequent users of these EBPs, component use was generally high, especially for low-intensity and nonspecific components. For each form of treatment, there were a small number of providers who reported using the treatment frequently but did not use most of the key components of the treatment. These findings highlight the importance of understanding the modifications that providers make to EBPs and suggest the importance of flexibility within fidelity to these treatments. (PsycINFO Database Record

Usual Care for Rural Veterans With Posttraumatic Stress Disorder.

Community-Based Outpatient Clinics (CBOCs) provide primary-care-based mental health services to rural veterans who live long distances from Veterans Affairs (VA) hospitals. Characterizing the composition of usual care will highlight the need and potential strategies to improve access to and engagement in evidence-based psychotherapy for posttraumatic stress disorder (PTSD). Veterans (N = 132) with PTSD recruited from 5 large- (5,000-10,000 patients) and 6 medium-sized (1,500-4,999) CBOCs were enrolled in the usual care arm of a randomized control trial for a PTSD collaborative care study. Chart review procedures classified all mental health encounters during the 1-year study period into 10 mutually exclusive categories (7 psychotherapy and 3 medication management). Seventy-two percent of participants received at least 1 medication management encounter with 30% of encounters being delivered via interactive video. More than half of veterans (58.3%) received at least 1 session of psychotherapy. Only 12.1% received a session of therapy classified as an evidence-based psychotherapy for PTSD. The vast majority of psychotherapy encounters were delivered in group format and only a small proportion were delivered via interactive video. Findings suggest that veterans diagnosed with PTSD who receive their mental health treatment in large and medium CBOCs are likely to receive medication management, and very few veterans received evidence-based psychotherapy. There may be ways to increase access to evidence-based psychotherapy by expanding the use of interactive video to connect specialty mental health providers with patients, hosted either in CBOCs or in home-based care, and to offer more group-based therapies.

Older Adults with PTSD: Brief State of Research and Evidence-Based Psychotherapy Case Illustration

Although lifetime exposure to potentially traumatic events among older adults is fairly high, rates of full-blown post-traumatic stress disorder (PTSD) are estimated at about 4.5%, a rate lower than that for middle-aged and young adults. Nevertheless, PTSD seems to be an under-recognized and under-treated condition in older adults. Assessment and treatment can be challenging in this population for various reasons, including potential cognitive or sensory decline and comorbid mental and physical disorders. This article provides highlights of the empirical research on PTSD in late life, including information on its effects on cognition and physical health. The bulk of this piece is spent on reviewing the theory, description of, and efficacy for an evidence-based psychotherapy, Prolonged Exposure (PE), for PTSD. A detailed successful application of PE with an older veteran with severe, chronic PTSD in the Department of Veterans Affairs Health Care System is presented. Evidence-based psychotherapy for PTSD can be safely and effectively used with older individuals.

Testing a comprehensive model of implementation and sustained use for EBTs for PTSD: A national investigation in VA residential settings

The national roll-outs of evidence-based psychotherapies in the Department of Veterans Affairs (VA) afford an unusual opportunity to study both implementation and sustainability. Although unique in some aspects of management and resources, the VA also serves as an excellent laboratory to understand the implementation of best practices as it is a more organized and controlled environment, free of the barriers faced in other more fragmented segments of the U.S. health care system. In a two-year NIMH grant, we utilized a theory-based model to collect baseline data regarding the adoption of two evidence-based treatments for Posttraumatic Stress Disorder (PTSD), Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), in a national sample of 38 VA PTSD residential treatment programs with over 200 providers. In a subsequently funded NIMH R01, we are extending our investigation with the same population and model to see: (1) how well PE and CPT are sustained over time, (2) what organizational and individual factors influence sustainability, and (3) what effects implementation and sustained use of PE and CPT have on patient outcomes. Implications for implementation in and outside of the VA health care system will be discussed. Updates on measurement of a model of implementation for health care: advances toward a testable theory One comprehensive theoretical model for understanding implementation of innovations was initially developed by Rogers (1962) and elaborated on by others (Greenhalgh et al. 2005). This model construed implementation as a complex process influenced by five broad constructs: (a) perceived characteristics of innovation, (b) potential adopter characteristics, (c) communication and influence, (d) system antecedents and readiness, and (e) outer context. Although a considerable evidence-base was used to develop the model, the authors did not fully operationalize their model, making it difficult to test formally. Our group undertook a systematic review of the literature and, using an iterative process, we examined existing measures and utilized or adapted items. Where no one measure was deemed appropriate, we developed other items to measure the constructs through consensus. The review and iterative process of team consensus identified three types of data that could be used to operationalize the constructs in the model: survey items, interview questions and administrative data. Over three waves of data collection concerning the implementation of two evidence-based psychotherapies disseminated nationally within Department of Veterans Affairs, we have made changes to the quantitative measurement of aspects of this model including the exclusion of the measurement of some constructs (e.g., learning style, locus of control, tolerance of ambiguity) as well as refinement of others (e.g., needs, motivation, knowledge-seeking). This presentation will review these changes as well as psychometric properties of other constructs and their items. Testing the model using quantitative data for implementation of two evidence-based psychotherapies for PTSD in VA residential treatment programs: outcomes for two yearly time points This study examined the implementation of two evidence-based psychotherapies, Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), in the Department of Veterans Affairs (VA) residential Posttraumatic Stress Disorder treatment programs. The current analyses focused on continued implementation a year after an initial assessment of implementation and of provider and site variables thought to be related to implementation. Seventy-five providers from 38 programs provided complete quantitative data on both baseline and follow-up. At one year follow-up, there was continued effect of supportive organizational context (i.e., dedicated time and resources and incentives and mandates) on the implementation of both PE and CPT delivered in a group format. Unlike at baseline, effects of perceived characteristics of treatment on implementation of PE and of supportive organizational context on CPT delivered individually were no longer significant. Rather, social connections predicted a lower likelihood of implementation of CPT individually. These effects all remained, even after taking into account baseline levels of implementation. Implementation of two evidence-based psychotherapies for PTSD in VA residential treatment programs: patient-level outcomes This presentation will discuss the effects of implementation of two EBTs for PTSD (PE and CPT) in the U.S. Department of Veterans Affairs (VA) residential treatment programs on patients' PTSD symptom severity, alcohol and drug use, and treatment satisfaction. The instruments were administered to patients upon admission and four months post-discharge. The short form of the Mississippi Scale for Combat-Related PTSD was used to measure PTSD and alcohol and drug abuse were measured using the composite indexes from the Addiction Severity Index. Controlling for length of stay and baseline symptoms, implementation of PE and CPT predicted improvement in PTSD symptom severity and alcohol use. The implications of these findings are that two EBTs for PTSD can be feasibly and effectively disseminated to routine clinical settings and implementation produces favorable patient outcomes.

Changes in implementation of two evidence-based psychotherapies for PTSD in VA residential treatment programs: a national investigation.

There has been little investigation of the natural course of evidence-based treatments (EBTs) over time following the draw-down of initial implementation efforts. Thus, we undertook qualitative interviews with the providers at 38 U.S. Department of Veterans Affairs' residential treatment programs for posttraumatic stress disorder (PTSD) to understand implementation and adaptation of 2 EBTs, prolonged exposure (PE), and cognitive processing therapy (CPT), at 2 time points over a 4-year period. The number of providers trained in the therapies and level of training improved over time. At baseline, of the 179 providers eligible per VA training requirements, 65 (36.4%) had received VA training in PE and 111 (62.0%) in CPT with 17 (9.5%) completing case consultation or becoming national trainers in both PE and CPT. By follow-up, of the increased number of 190 eligible providers, 87 (45.8%) had received VA training in PE and 135 (71.1%) in CPT, with 69 (36.3%) and 81 (42.6%) achieving certification, respectively. Twenty-two programs (57.9%) reported no change in PE use between baseline and follow-up, whereas 16 (42.1%) reported an increase. Twenty-four (63.2%) programs reported no change in their use of CPT between baseline and follow-up, 12 (31.6%) programs experienced an increase, and 2 (5.2%) programs experienced a decrease in use. A significant number of providers indicated that they made modifications to the manuals (e.g., tailoring, lengthening). Reasons for adaptations are discussed. The need to dedicate time and resources toward the implementation of EBTs is noted.