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Varkovitzky RL, Sherrill AM, Reger GM. Effectiveness of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders Among Veterans With Posttraumatic Stress Disorder: A Pilot Study. Behav Modif 2017; 42:210-230. [PMID: 28845680 DOI: 10.1177/0145445517724539] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Effective treatment options are needed for veterans who do not participate in trauma-focused psychotherapy. Research has yet to examine the effectiveness of transdiagnostic psychotherapy in veterans with posttraumatic stress disorder (PTSD) and co-occurring psychological disorders. This pilot study examined the effectiveness of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) delivered in a 16-week group format. We examined treatment outcomes in male and female veterans ( n = 52) in an outpatient specialty PTSD clinic at a large Veterans Affairs (VA) medical center. We hypothesized significant decreases in emotion regulation difficulty (Difficulties in Emotion Regulation Scale), PTSD symptom severity (PTSD Checklist for DSM-5), and depressive symptom severity (Patient Health Questionnaire-9). In addition, we hypothesized that reductions in emotion regulation difficulty across treatment would negatively predict PTSD and depressive symptoms at posttreatment. PTSD symptoms, depressive symptoms, and emotion regulation difficulty all evidenced significant improvements at the end of treatment relative to baseline ( ps < .001). In addition, reductions in emotion regulation across treatment were associated with lower PTSD and depressive symptoms at posttreatment ( ps < .001). This pilot study provides preliminary evidence supporting use of UP among veterans with PTSD and co-occurring disorders. Well-designed clinical trials evaluating efficacy of UP among veterans are needed.
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Affiliation(s)
- Ruth L Varkovitzky
- 1 VA Puget Sound Health Care System-American Lake Division, Tacoma, WA, USA.,2 University of Washington School of Medicine, Seattle, WA, USA
| | | | - Greg M Reger
- 1 VA Puget Sound Health Care System-American Lake Division, Tacoma, WA, USA.,2 University of Washington School of Medicine, Seattle, WA, USA
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Wiltsey Stirman S, Finley EP, Shields N, Cook J, Haine-Schlagel R, Burgess JF, Dimeff L, Koerner K, Suvak M, Gutner CA, Gagnon D, Masina T, Beristianos M, Mallard K, Ramirez V, Monson C. Improving and sustaining delivery of CPT for PTSD in mental health systems: a cluster randomized trial. Implement Sci 2017; 12:32. [PMID: 28264720 PMCID: PMC5339953 DOI: 10.1186/s13012-017-0544-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 01/28/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND 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 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. METHODS To 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. DISCUSSION It 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 REGISTRATION NCT02449421 . Registered 02/09/2015.
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Affiliation(s)
- Shannon Wiltsey Stirman
- National Center for PTSD and Stanford University Department of Psychiatry and Behavioral Sciences, 795 Willow Road, Menlo Park, CA 94025 USA
| | - Erin P. Finley
- The University of Texas Health Science Center at San Antonio, Department of Psychiatry and Medicine, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA
- South Texas Veterans Health Care System, 7400 Merton Minter St, San Antonio, TX 78229 USA
| | - Norman Shields
- Divisional Psychologist Occupational Health and Safety, Royal Canadian Mounted Police, 4225 Dorchester, Westmount, QC Canada
| | - Joan Cook
- Department of Psychiatry, Yale University, 950 Campbell Avenue, West Haven, CT 06516 USA
| | | | - James F. Burgess
- Boston University School of Public Health, Department of Health Law, Policy and Management, Boston, MA 02215 USA
- Center for Healthcare Organization and Implementation Research (CHOIR), Department of Veterans Affairs Boston Healthcare System, Boston, MA USA
| | - Linda Dimeff
- Evidence-Based Practice Institute, 3303 S Irving Street Seattle, Seattle, WA 91844 USA
| | - Kelly Koerner
- Evidence-Based Practice Institute, 3303 S Irving Street Seattle, Seattle, WA 91844 USA
| | - Michael Suvak
- Suffolk University, 73 Tremont Street, Boston, MA 01331 USA
| | - Cassidy A. Gutner
- National Center for PTSD, VA Boston Healthcare System, 150 S. Huntington Ave, Boston, MA 02130 USA
- Boston University School of Medicine, 72 E Concord St, Boston, MA 02118 USA
| | - David Gagnon
- Boston University School of Public Health, Department of Health Law, Policy and Management, Boston, MA 02215 USA
| | - Tasoula Masina
- Ryerson University, 350 Victoria Street, Toronto, ON M5B 2K3 Canada
| | - Matthew Beristianos
- National Center for PTSD and Palo Alto Veterans Institute of Research, 795 Willow Road, Menlo Park, CA 94025 USA
| | - Kera Mallard
- National Center for PTSD and Palo Alto Veterans Institute of Research, 795 Willow Road, Menlo Park, CA 94025 USA
| | - Vanessa Ramirez
- The University of Texas Health Science Center at San Antonio, Department of Psychiatry and Medicine, 7703 Floyd Curl Dr, San Antonio, TX 78229 USA
- South Texas Veterans Health Care System, 7400 Merton Minter St, San Antonio, TX 78229 USA
| | - Candice Monson
- Ryerson University, 350 Victoria Street, Toronto, ON M5B 2K3 Canada
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Rosen CS, Eftekhari A, Crowley JJ, Smith BN, Kuhn E, Trent L, Martin N, Tran T, Ruzek JI. Maintenance and Reach of Exposure Psychotherapy for Posttraumatic Stress Disorder 18 Months After Training. J Trauma Stress 2017; 30:63-70. [PMID: 28103401 DOI: 10.1002/jts.22153] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 10/18/2016] [Accepted: 10/28/2016] [Indexed: 11/05/2022]
Abstract
This study examined aspects of clinicians' work environment that facilitated sustained use of prolonged exposure (PE) therapy. Surveys were completed by 566 U.S. Department of Veterans Affairs clinicians 6 and 18 months after intensive training in PE. The number of patients treated with PE at 18 months (reach) was modeled as a function of clinician demographics, clinician beliefs about PE, and work context factors. There were 342 clinicians (60.4%) who used PE at 6 and 18 months after training, 58 (10.2%) who used PE at 18 but not 6 months, 95 (16.7%) who used PE at 6 but not 18 months, and 71 (12.5%) who never adopted PE. Median reach was 12% of clinicians' appointments with patients with posttraumatic stress disorder. Reach was predicted by flow of interested patients (incident response ratio [IRR] = 1.21 to 1.51), PE's perceived effectiveness (IRR = 1.04 to 1.31), working in a PTSD specialty clinic (IRR = 1.06 to 1.26), seeing more patients weekly (IRR = 1.04 to 1.25), and seeing fewer patients in groups (IRR = 0.83 to 0.99). Most clinicians trained in PE sustained use of the treatment, but on a limited basis. Strategies to increase reach of PE should address organizational barriers and patient engagement.
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Affiliation(s)
- Craig S Rosen
- National Center for PTSD Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, California, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Afsoon Eftekhari
- National Center for PTSD Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Jill J Crowley
- National Center for PTSD Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Brandy N Smith
- National Center for PTSD Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Eric Kuhn
- National Center for PTSD Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, California, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Lindsay Trent
- National Center for PTSD Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, California, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Nicole Martin
- National Center for PTSD Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Thuy Tran
- National Center for PTSD Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, California, USA
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Stirman SW, Gutner CA, Langdon K, Graham JR. Bridging the Gap Between Research and Practice in Mental Health Service Settings: An Overview of Developments in Implementation Theory and Research. Behav Ther 2016; 47:920-936. [PMID: 27993341 DOI: 10.1016/j.beth.2015.12.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 12/09/2015] [Accepted: 12/12/2015] [Indexed: 10/22/2022]
Abstract
Twenty years after Sobell's (1996) influential call to integrate advances in behavior therapy into clinical settings, significant progress has been made in implementation science. In this narrative review, we provide an overview of implementation research findings and highlight recent findings that can inform efforts to bridge the gap between research and practice in mental health service settings. Key findings are summarized, organized according to levels of influence described in two implementation frameworks: The Exploration, Planning, Implementation, and Sustainment Framework (EPIS; Aarons et al., 2011) and the Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009). Important levels of influence to consider when implementing new treatments include the outer context, inner context, characteristics of the individual, and characteristics of the innovation. Research on strategies to prepare clinicians to deliver evidence-based psychosocial treatments (EBPTs) and to address contextual barriers to implementation at each level is described, with discussion of implications for the implementation of EBPTs and next steps for research.
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Affiliation(s)
| | - Cassidy A Gutner
- National Center for PTSD, VA Boston Healthcare System; Boston University
| | - Kirsten Langdon
- Department of Psychiatry, Rhode Island Hospital, Providence, RI
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Cook JM, Simiola V, Hamblen JL, Bernardy N, Schnurr PP. The influence of patient readiness on implementation of evidence-based PTSD treatments in Veterans Affairs residential programs. PSYCHOLOGICAL TRAUMA-THEORY RESEARCH PRACTICE AND POLICY 2016; 9:51-58. [PMID: 27348065 DOI: 10.1037/tra0000162] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Mental health provider perceptions of patient readiness for trauma-focused evidence-based treatments (EBTs) for posttraumatic stress disorder (PTSD) have been found to impact outpatient care in the Department of Veterans Affairs (VA). METHOD One hundred and 72 mental health directors and providers from 36 VA residential PTSD treatment programs completed qualitative interviews regarding implementation of two EBTs, Prolonged Exposure (PE), and Cognitive Processing Therapy (CPT). Perceptions of patients' "readiness" for PE and CPT, including how to define and assess this construct and how it influences implementation of these EBTs, were discussed. RESULTS Patient readiness was identified as having three components: psychological and psychiatric stability, general readiness to change, and specific skills to manage trauma-focused EBTs (e.g., distress tolerance, affect regulation skills). Providers indicated that some patients who are deemed not ready are either screened out prior to entry or helped to get ready prior to or during their residential stay. Providers expressed difficulties predicting who is actually ready and described what they saw as differences between readiness for PE as compared with CPT. CONCLUSIONS The concept of readiness for trauma-focused EBTs impacted admission and access to services in the programs. Future research directions, such as empirically measuring readiness and formally assessing veterans' perceptions of and willingness to participate in these EBTs, are considered. (PsycINFO Database Record
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Affiliation(s)
- Joan M Cook
- Department of Psychiatry, Yale School of Medicine
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Mental Health Providers’ Decision-Making Around the Implementation of Evidence-Based Treatment for PTSD. J Behav Health Serv Res 2016; 44:213-223. [DOI: 10.1007/s11414-015-9489-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
The Perceived Characteristics of Intervention Scale (PCIS), a 20-item assessment measure, was developed to assess health care providers’ views of interventions. Two hundred and fifteen Department of Veterans Affairs’ residential treatment providers from 38 programs across the United States completed an online survey that included the PCIS as well as self-reported use of two evidence-based treatments. The PCIS was anchored to ask about two evidence-based psychotherapies for posttraumatic stress disorder, prolonged exposure, and cognitive processing therapy. The PCIS is a reliable measure of perceived characteristics of interventions, with some preliminary support for its validity. Consideration of providers’ perceptions of particular evidence-based treatments may serve as an aid to improve their dissemination, implementation, and sustained use.
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Affiliation(s)
- Joan M. Cook
- Yale School of Medicine, West Haven, CT, USA
- National Center for PTSD, West Haven, CT, USA
| | | | - Paula P. Schnurr
- National Center in White River Junction, CT, USA
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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Prescribing clinicians' perspectives on evidence-based psychotherapy for posttraumatic stress disorder. Behav Sci (Basel) 2014; 4:410-22. [PMID: 25431445 PMCID: PMC4287697 DOI: 10.3390/bs4040410] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 09/20/2014] [Accepted: 10/08/2014] [Indexed: 11/17/2022] Open
Abstract
Evidence-based psychotherapies (EBP) for Posttraumatic Stress Disorder are not utilized to their full extent within the Department of Veterans Affairs (VA). VA provides care to many persons with PTSD and has been in the forefront of clinical practice guidelines and EBP training and dissemination. Yet VA continues to find EBP implementation difficult. Veterans with PTSD often initially present to prescribing clinicians, who then help make care decisions. It is therefore critical that these clinicians correctly screen and triage appropriate mental health care. The purpose of this study was to assess VA prescribing clinicians’ knowledge, perceptions, and referral behaviors related to EBPs for PTSD and to identify facilitators and barriers to implementing EBPs within VA. We conducted qualitative interviews with 26 VA prescribing clinicians. Limited access to EBPs was the most commonly noted barrier. The clinicians we interviewed also held specific beliefs and behaviors that may delay or deter EBPs. Strategies to improve utilization also emerged. Findings suggest the need for increased access to EBPs, training to optimize the role of prescribing clinicians in helping Veterans with PTSD make appropriate care decisions, and specific organizational changes to facilitate access and effective referral systems for EBPs.
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