A formative evaluation of two evidence-based psychotherapies for PTSD in VA residential treatment programs

Determinants of Exposure Therapy Implementation in Clinical Practice for the Treatment of Anxiety, OCD, and PTSD: A Systematic Review

Exposure therapy (ET) forms a vital part of effective psychotherapy for anxiety-related presentations including anxiety disorders, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD), and is often underutilised in clinical practice. Using the Theoretical Domains Framework (TDF), this systematic review synthesised existing literature on the determinants of ET implementation for anxiety-related presentations and examined differences across presentations and developmental subgroups. Fifty-two eligible studies were assessed using the Mixed Methods Appraisal Tool, with 389 results (99%) mapped onto the TDF. Results suggested that clinicians' negative beliefs about the consequences of ET were commonly associated with reduced implementation. It also appeared that whilst broad unspecified ET training may be related to improved implementation for anxiety disorders; greater implementation for complex presentations (i.e., PTSD) likely requires more specialised training involving practical components. A subset of domains (e.g., social/professional role and identity) accounted for most results, whilst some remain unexplored (i.e., optimism; reinforcement; memory, attention, and decision processes) or underexplored (i.e., behavioural regulation). Likewise, specific presentations and developmental subgroups (i.e., PTSD and adults) represented a greater proportion of results in the literature than others (i.e., OCD and youth). Future research exploring ET implementation, across specific presentations and developmental subgroups, would benefit from integrating implementation science frameworks to guide the development of targeted, comprehensive strategies to close the research-practice gap of ET for the treatment of anxiety-related presentations.

Formative evaluation prior to implementation of a brief treatment for posttraumatic stress disorder in primary care

BACKGROUND

Successful implementation of evidence-based treatments (EBT) for posttraumatic stress disorder (PTSD) in primary care may address treatment access and quality gaps by providing care in novel and less stigmatized settings. Yet, PTSD treatments are largely unavailable in safety net primary care. We aimed to collect clinician stakeholder data on organizational, attitudinal, and contextual factors relevant to EBT implementation.

METHODS

Our developmental formative evaluation was guided by the Consolidated Framework for Implementation Research (CFIR), including (a) surveys assessing implementation climate and attitudes towards EBTs and behavioral health integration and (b) semi-structured interviews to identify barriers and facilitators to implementation and need for augmentation. Participants were hospital employees (N = 22), including primary care physicians (n = 6), integrated behavioral health clinicians (n = 8), community wellness advocates (n = 3), and clinic leadership (n = 5). We report frequency and descriptives of survey data and findings from directed content analysis of interviews. We used a concurrent mixed-methods approach, integrating survey and interview data collected simultaneously using a joint display approach. A primary care community advisory board (CAB) helped to refine interview guides and interpret findings.

RESULTS

Stakeholders described implementation determinants of the EBT related to the CFIR domains of intervention characteristics (relative advantage, adaptability), outer setting (patient needs and resources), inner setting (networks and communication, relative priority, leadership engagement, available resources), and individuals involved (knowledge and beliefs, cultural considerations). Stakeholders described strong attitudinal support (relative advantage), yet therapist time and capacity restraints are major PTSD treatment implementation barriers (available resources). Changes in hospital management were perceived as potentially allowing for greater access to behavioral health services, including EBTs. Patient engagement barriers such as stigma, mistrust, and care preferences were also noted (patient needs and resources). Recommendations included tailoring the intervention to meet existing workflows (adaptability), system alignment efforts focused on improving detection, referral, and care coordination processes (networks and communication), protecting clinician time for training and consultation (leadership engagement), and embedding a researcher in the practice (available resources).

CONCLUSIONS

Our evaluation identified key CFIR determinants of implementation of PTSD treatments in safety net integrated primary care settings. Our project also demonstrates that successful implementation necessitates strong stakeholder engagement.

Using Client Narratives to Identify Predictors of Outcome in Written Exposure Therapy and Cognitive Processing Therapy

Written exposure therapy (WET) is a brief, five-session treatment for posttraumatic stress disorder (PTSD) that aims to improve access to care. WET has been demonstrated to be an efficacious PTSD treatment with lower rates of dropout and noninferior PTSD symptom outcome compared to cognitive processing therapy (CPT), a 12-session, gold-standard treatment. To identify predictors of treatment outcome in both WET and CPT, the current study examined the content of participants' written narratives. Participants were 123 adults with PTSD who were randomly assigned to receive WET (n = 61) or CPT (n = 62). The Change and Growth Experiences Scale (CHANGE) coding system was used to code all available narratives in both treatment conditions for variables hypothesized to be relevant to therapeutic change. Linear regression analyses revealed that in WET, higher average levels of accommodated (healthy, balanced) beliefs and an increase in accommodated beliefs from the first to the final impact statement predicted better PTSD symptom outcome at 12 weeks postrandomization. In CPT, higher average levels of overgeneralized and accommodated beliefs and lower levels of avoidance expressed in the narratives predicted better PTSD outcome. There were no significant predictors of outcome in analyses of change from the first to final impact statement in CPT. These findings add to research identifying predictors of change in WET and CPT by highlighting the importance of low avoidance in CPT and of trauma-related cognitions in both CPT and WET, even though WET is a brief written intervention that does not explicitly target cognitive change.

Veterans receiving a second course of cognitive processing therapy or prolonged exposure therapy: is it better to switch or stay the same?

Cognitive processing therapy (CPT) and prolonged exposure therapy (PE) are effective psychotherapies for post-traumatic stress disorder (PTSD). However, these treatments also have high rates of dropout and non-response. Therefore, patients may need a second course of treatment. We compared outcomes for patients who switched between CPT/PE and those who repeated CPT/PE during a second course of treatment. We collected data from Iraq and Afghanistan war veterans (n = 2,958) who received a second course of CPT/PE in the Veterans Health Administration from 2001 to 2017 and had symptom outcomes (PTSD checklist; PCL). We measured the association between treatment sequence and change in PCL score over the second course of treatment using hierarchical Bayesian regression, adjusted for sociodemographic and clinical characteristics. All treatment sequences showed a significant reduction in PCL score over time (β = -4.80; HDI₉₅: -5.74, -3.86). Veterans who switched from CPT to PE had modestly greater PCL reductions during the second course than those who repeated CPT. However, no significant difference in PCL change during the second course was observed between veterans who repeated PE and those who switched from PE to CPT. Veterans participating in a second course of CPT/PE can benefit, and switching treatment may be slightly more beneficial following CPT.

Racial Disparities in Clinical Outcomes of Veterans Affairs Residential PTSD Treatment Between Black and White Veterans

OBJECTIVE

Racial disparities across various domains of health care are a long-standing public health issue that affect a variety of clinical services and health outcomes. Mental health research has shown that prevalence rates of posttraumatic stress disorder (PTSD) are high for Black veterans compared with White veterans, and some studies suggest poorer clinical outcomes for Black veterans with PTSD. The aim of this study was to examine the impact of racial disparities longitudinally in the U.S. Department of Veterans Affairs (VA) residential rehabilitation treatment programs (RRTPs).

METHODS

Participants included 2,870 veterans treated nationally in VA PTSD RRTPs in fiscal year 2017. Veterans provided demographic data upon admission to the program. Symptoms of PTSD and depression were collected at admission, discharge, and 4-month follow-up. Hierarchical linear modeling was used to examine symptom change throughout and after treatment.

RESULTS

Black veterans experienced attenuated PTSD symptom reduction during treatment as well as greater depression symptom recurrence 4 months after discharge, relative to White veterans.

CONCLUSIONS

This study adds to the body of literature that has documented poorer treatment outcomes for Black compared with White veterans with PTSD. Although both Black and White veterans had an overall reduction in symptoms, future research should focus on understanding the causes, mechanisms, and potential solutions to reduce racial disparities in mental health treatment.

Medical cannabis for treatment-resistant combat PTSD

Targeting the endocannabinoid system may have a role in the treatment of post-traumatic stress disorder (PTSD). However, few studies have examined the effectiveness of cannabis on symptoms of PTSD, and more research is needed to ascertain cannabis' effectiveness. In this retrospective naturalistic study, we followed 14 relatively mature (32-68 years of age), treatment-resistant, chronic combat post-traumatic patients who remained severely symptomatic despite treatment with many lines of conventional treatment prior to receiving medicinal cannabis. Our findings show that total sleep score, subjective sleep quality, and sleep duration significantly improved (p < 0.01). Total PTSD symptom score and its subdomains (intrusiveness, avoidance, and alertness) showed improvement (p < 0.05). However, there was no improvement in the frequency of nightmares (p = 0.27). The mean follow-up time was 1.1 ± 0.8 years (range of 0.5 to 3 years).

Therapeutic alliance across trauma-focused and non-trauma-focused psychotherapies among veterans with PTSD

Trauma-focused psychotherapies for posttraumatic stress disorder (PTSD) are not widely utilized. Clinicians report concerns that direct discussion of traumatic experiences could undermine the therapeutic alliance, which may negatively impact retention and outcome. Studies among adolescents with PTSD found no difference in alliance between trauma-focused and non-trauma-focused psychotherapies, but this has not been tested among adults. The present study is a secondary analysis of a randomized trial of collaborative care, also known as care management, for PTSD. We examined patient-reported therapeutic alliance among 117 veterans with PTSD who participated in cognitive processing therapy (CPT, now called CPT + A; n = 54) or non-trauma-focused supportive psychotherapy for PTSD (n = 73) at VA community outpatient clinics. We tested the hypothesis that alliance in CPT would be noninferior to (i.e., not significantly worse than) non-trauma-focused psychotherapy using patient ratings on the Revised Helping Alliance Questionnaire. Patients' therapeutic alliance scores were high across both groups (CPT: M = 5.13, SD = 0.71, 95% CI [4.96, 5.30]; non-trauma-focused psychotherapy: M = 4.89, SD = 0.64, 95% CI [4.73, 5.05]). The difference between groups (0.23, 95% CI [0.01, 0.48]) was less than the "noninferiority margin" based on suggested clinical cutoffs (0.58 points on a 1-6 scale). These results held even after adjusting for veterans' demographic and clinical characteristics and change in PTSD symptoms from baseline to follow-up. Although there are concerns that direct discussion of traumatic experiences could worsen therapeutic alliance, patients report similar levels of alliance in CPT and non-trauma-focused supportive psychotherapy. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Gender Difference in Substance Use and Psychiatric Outcomes Among Dually Diagnosed Veterans Treated in Specialized Intensive PTSD Programs

OBJECTIVES

Posttraumatic stress disorder (PTSD) is a problem of growing importance among female veterans, which is especially challenging when accompanied by comorbid substance use disorder (SUD). Since women are still a small minority of Veterans Health Administration (VHA) patients, there is concern that outcomes among dually diagnosed women may be worse than among men.

METHOD

National program evaluation data were collected at admission and 4 months after discharge from 7,074 dually diagnosed veterans including 203 women (2.9%) treated at 57 specialized intensive VHA PTSD treatment programs between 1993 and 2011. Multiple regression was used to compare clinical change in women and men adjusting for baseline differences.

RESULTS

Women showed no significant differences from men in measures of substance use or total PTSD symptoms at admission although they were more likely to have experienced sexual trauma and less likely to report combat exposure. With adjustment for these differences, there were no significant gender differences in length of stay, satisfaction with treatment, or measures of change in substance use or total PTSD symptoms 4 months after discharge. Reductions in an index of days of substance use was associated with reduction in total PTSD symptoms among both women (R = 0.33; p = .01) and men (R = 0.44, p < .0001) with no significant gender difference.

CONCLUSION

No significant gender differences were observed in substance use or PTSD outcomes, despite the extreme minority status of women in VHA programs. Highly vulnerable women can benefit as much as men, even when treatment is not formally tailored to address gender-specific needs.

Implementation Patterns of Two Evidence-Based Psychotherapies in Veterans Affairs Residential Posttraumatic Stress Disorder Programs: A Five-Point Longitudinal National Investigation

The present study examined the patterns of adoption of two evidence-based psychotherapies (EBPs)-prolonged exposure (PE) and cognitive processing therapy (CPT)-in U.S. Department of Veterans Affairs (VA) residential posttraumatic stress disorder (PTSD) treatment programs. A total of 526 providers from 39 programs nationwide completed online quantitative surveys and qualitative interviews, collected at five assessment points between 2008 and 2015, concerning the use of PE and CPT. By the midpoint of the study period, responders from most programs reported having adopted one or both EBPs as either core components of their programs or "tracks" for certain patients within their programs, adoption rates were 52.8% of programs at Time 3, 61.0% at Time 4, and 66.7% at Time 5. Evaluation of adoption patterns over time suggested that CPT was used in more programs and with more patients within programs compared to PE. At Time 5, respondents from half of the programs reported little or no adoption of PE, whereas the CPT adoption rate was reported to be "little or none" for one-fifth of the programs. The adoption of PE was generally slower compared to CPT adoption. The slower rate of adoption may be related to the resource-intensive nature of implementing PE on an individual basis in a residential setting as compared to the multiple ways CPT can be delivered: individually or in group settings, and with or without the inclusion of the trauma narrative. Strategies to improve sustainability measurement and implications for implementation science are discussed.

The Impact of Treatment Description Format on Patient Preferences for Posttraumatic Stress Disorder Treatment

The present study examined how the format in which treatment information is presented impacts individuals' preferences for posttraumatic stress disorder (PTSD) treatments. Adults who screened positive for PTSD (N = 301) were randomized into groups to learn about five first-line treatments; participants either read sequential text descriptions or reviewed a comparison chart that presented side-by-side information. Participants rated treatment acceptability, rank ordered treatments from most to least preferred, and indicated their confidence in this ranking. Compared with participants in the text group, those in the chart group assigned more favorable acceptability ratings to prolonged exposure therapy (PE) and more moderate ratings to medications. Cognitive processing therapy was the most common first-choice treatment (43.6%). Forced-choice treatment rankings were similar across conditions, although participants in the chart group ranked PE more favorably than those in the text group, odds ratio (OR) = 0.54, 95% CI [0.35, 0.82], p = .004. Confidence in treatment rankings did not differ across conditions. The results suggest that perceptions of treatment acceptability can be influenced by the format in which treatment information is presented. In settings where the goal is to increase treatment acceptability, side-by-side formats may offer an advantage over sequential descriptions of each treatment.

Does exposure exacerbate symptoms in veterans with PTSD and alcohol use disorder?

OBJECTIVE

Patients with posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are often not offered exposure therapy for PTSD due to concerns that symptoms may worsen. This study examined whether initiating exposure would cause exacerbation of PTSD, alcohol use, depression, or suicidal ideation (SI) among patients with PTSD/AUD participating in exposure therapy for PTSD.

METHOD

Veterans were randomized to either concurrent treatment of PTSD and substance use disorders using prolonged exposure (COPE) or seeking safety, a nonexposure intervention, and were included in this study if they had data to at least Session 5 available (n = 81). They completed measures of PTSD, alcohol use, and depression/SI symptom severity throughout treatment and posttreatment. The reliable exacerbation method examined the number of participants who demonstrated clinically meaningful symptom exacerbation from Sessions 3 to 5 (capturing the prepost window for the start of exposure in COPE). Hierarchical/logistic regressions examined whether treatment condition predicted exacerbation of symptoms. T tests/chi-square analyses examined whether clinical exacerbation led to worse posttreatment outcomes.

RESULTS

Few participants endorsed exacerbation in symptoms of PTSD (15.8%), alcohol use (5.1%), depression (10.2%), or SI (12.8%). No significant treatment condition differences existed. Participants who experienced symptom exacerbation had higher rates of depression posttreatment compared to those who did not experience symptom exacerbation, but there were no differences in PTSD, alcohol use, or SI.

CONCLUSIONS

Exposure therapy did not lead to more clinical exacerbation than nonexposure therapy during the course of treatment, providing support that exposure therapy should not be withheld from patients with PTSD/AUD. This was a secondary analysis. and future studies that are sufficiently powered may demonstrate different results. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Feasibility of a 3-week intensive treatment program for service members and veterans with PTSD

OBJECTIVE

The purpose of the present study was to detail the patient flow and establish the feasibility of a brief 3-week intensive treatment program (ITP) for veterans with posttraumatic stress disorder (PTSD).

METHOD

The present study examined data from 648 veterans referred to a non-Veterans Affairs ITP for PTSD from January 2016 to February 2018 to determine the flow of patients into and through the ITP and evaluate individuals' satisfaction with treatment.

RESULTS

On average, 25.9 individuals contacted the ITP each month expressing interest in the program. A large proportion of individuals who completed an intake evaluation were accepted (72.2%) into the ITP. Of those accepted, 70.6% ultimately attended the ITP, and the vast majority of veterans who attended the ITP completed treatment (91.6%). Logistic regression results suggested that among veterans who were accepted to the program, those who were legally separated or divorced had significantly greater odds of attending the program compared to single veterans. Veterans were highly satisfied with the 3-week ITP and rated cognitive processing therapy components as the most helpful part of the program.

CONCLUSIONS

The present study demonstrates that ITP formats for PTSD are of interest and acceptable to veterans, and this format allows individuals to receive high doses of evidence-based treatments in a short amount of time. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Comparing the effectiveness of VA residential PTSD treatment for veterans who do and do not report a history of MST: A national investigation

The Department of Veterans Affairs (VA) has implemented initiatives to promote veterans' recovery from the health sequelae of military sexual trauma (MST), including posttraumatic stress disorder (PTSD). MST can impact emotion regulation, interpersonal functioning, and perceptions of trust and safety, as well as increase risk for psychiatric comorbidity, which may impede PTSD treatment.. VA PTSD Residential Rehabilitation Treatment Programs (RRTPs) may facilitate the therapeutic process by offering increased structure, support, and adjunctive services. Limited research has examined the effect of MST on PTSD RRTP outcomes. Utilizing data from 7918 men and women veterans participating in a VA PTSD RRTP, the impact of the experience of MST on rates of program completion and changes in PTSD symptoms during and after treatment were examined. Rates of program completion were similar between those who did and did not report experiencing MST. Multilevel modeling was utilized to examine the impact of MST on PTSD symptoms after accounting for gender, age, race/ethnicity, and program completion. MST survivors endorsed more severe PTSD symptoms at admission; however, PTSD symptom severity scores were similar to those who did not report experiencing MST by discharge. Additionally, MST survivors had larger initial reductions in PTSD symptoms, followed by a greater recurrence of PTSD symptoms over time, compared to those who did not report experiencing MST. MST survivors appear able to participate in and benefit from PTSD RRTPs. Nonetheless, the increased recurrence of PTSD symptoms following discharge from residential treatment indicates the need for strategies to maintain post-treatment gains among MST survivors.

Courses of suicidal ideation among military veterans in residential treatment for posttraumatic stress disorder

BACKGROUND

Suicidal thoughts are common among veterans with posttraumatic stress disorder (PTSD). The aim of this study was to examine the prevalence and correlates of four courses of suicidal (SI) among veterans receiving residential PTSD treatment.

METHODS

A total of 1,807 veterans receiving residential PTSD treatment at Department of Veterans Affairs medical facilities who completed self-report measures at admission and discharge were included.

RESULTS

The prevalence of SI courses were No SI (33.6%), Remitted SI (23.0%), SI onset (6.0%), and Chronic SI (37.4%). There were group differences between the four SI courses in PTSD symptoms at baseline, magnitude of PTSD symptom change during treatment, race/ethnicity and baseline depression, substance use, physical functioning, and pain. Chronic SI was associated with highest baseline PTSD, depression, substance use, pain and worse physical functioning. Remitted SI course was associated with greatest pre-posttreatment PTSD improvement, followed by No SI, Chronic SI, and SI Onset. Multinomial logistic regressions revealed that PTSD symptom improvement and baseline PTSD symptoms most consistently related to symptomatic SI courses compared to less symptomatic or No SI courses. Receipt of trauma-focused psychotherapy (none, some, or adequate) and length of stay were not related to SI courses and did not differ between groups.

CONCLUSIONS

Findings indicate that treating PTSD symptoms could be impactful for reducing suicidal thoughts. Although many veterans had remitted or reduced severity of SI at discharge, a significant proportion of veterans reported SI at discharge (43.4%), potentially highlighting the need for suicide specific treatment interventions within the context of PTSD treatment.

Provider Perspectives on Choosing Prolonged Exposure or Cognitive Processing Therapy for PTSD: A National Investigation of VA Residential Treatment Providers

As part of a longitudinal mixed-methods investigation on implementation of two evidence-based psychotherapies (EBPs) for Posttraumatic Stress Disorder, 164 mental health providers from 38 Department of Veterans Affairs (VA) residential treatment programs across the U.S. were asked questions about their decision-making for using Prolonged Exposure and Cognitive Processing Therapy. Many providers viewed both EBPs as equally efficacious and encouraged veterans to decide for themselves which treatment they wished to engage in. Some providers said that it was hard to know which EBP would be the most effective for a given patient, and that occasionally they started work with a veteran thinking that a particular EBP would work and were surprised when the veteran did not receive the full potential benefit of the intervention. Other providers noted that their decision-making regarding which EBP to use depended on the type and nature of the veterans' index trauma, memory of the trauma, and traumatic stress symptoms (e.g., fear versus guilt). Additional factors that impacted the choice of EBP included whether the patient already had one of the treatments before or if a provider deemed one as more compatible with their previous training. Implications for clinical practice as well as the design and improvement of training and implementation efforts are discussed.

Comparing Outcomes of Women-Only and Mixed-Gender Intensive Posttraumatic Stress Disorder Treatment for Female Veterans

Although most female veterans treated in specialized intensive Veterans Health Administration (VHA) posttraumatic stress disorder (PTSD) programs receive services in settings in which over 95% of participants are men, two programs include only women. Whether outcomes for women with PTSD are superior in women-only programs has not been evaluated. National program evaluation data on 1,357 women veterans from 57 sites were collected at program entry and 4 months after discharge. With adjustment for differences in baseline characteristics, outcomes of women in two women-only programs (n = 469) were compared with those from 55 mixed-gender programs (n = 888), using mixed models with random effect for site. The primary outcome was total PTSD symptom level, with supplementary information on PTSD assessment subscales, substance use, and other outcomes. At program entry, female veterans in women-only programs had lower scores on measures of total PTSD symptoms, p = .013, d = -0.24, and on several subscales. Adjusting for these differences, there were no significant differences between program types in terms of PTSD total score or scores on secondary measures. In women-only programs, veterans had longer lengths of stay and were rated by their clinicians to have a higher level of commitment to therapy at discharge. Thus, women-only programs did not show superior outcomes; however, compared to participants in mixed-gender programs, those in women-only programs had longer lengths of stay, higher levels of commitment to therapy, and were more likely to participate in posttreatment outcome assessments following discharge.

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

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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 Dropout From Residential Treatment for Posttraumatic Stress Disorder Among Military Veterans

Background: Successful psychotherapy for posttraumatic stress disorder (PTSD) necessitates initial and sustained engagement. However, treatment dropout is common, with rates of 50-70% depending on the setting, type of treatment and how dropout is calculated. Dropout from residential treatment is less understood and could be impacted by participation of more symptomatic patient populations and reduced day-to-day barriers to engagement. Gaining insight into predictors of treatment dropout is critical given that individuals with greater symptoms are the most in need of successful treatments but also at higher risk of unsuccessful psychotherapy episodes. Aim: The aim of the current study was to examine predictors of treatment dropout among veterans receiving residential treatment for PTSD. Methods: The study included 3,965 veterans who initiated residential PTSD treatment within a Department of Veterans Affairs program during Fiscal Year 2015 and completed self-report measures of demographics and psychiatric symptoms at admission. Results: In our sample (N = 3,965, 86.5% male, mean age = 45.5), 27.5% did not complete the residential program (n = 1,091). Controlling for age, marital status, combat/non-combat trauma, and facility, generalized estimating equation modeling analysis indicated greater PTSD symptoms and physical functioning at admission were associated with reduced likelihood of completing the residential program. There were significant differences in trauma-focused psychotherapy received by individuals who dropped out of residential treatment and those who did not. Among veterans who dropped out, 43.6% did not get any trauma-focused psychotherapy; 22.3% got some, but less than 8 sessions; and 34.1% got at least 8 sessions; compared to 37.3%, 4.8%, and 57.9%, respectively, among program completers. Conclusion: Dropout rates from residential PTSD programs indicate that at least one in four veterans do not complete residential treatment, with more symptomatic individuals and those who do not receive trauma-focused therapy being less likely to complete.

The effect of childhood sexual assault history on outpatient cognitive processing therapy for military sexual trauma-related posttraumatic stress disorder: A preliminary investigation

History of childhood sexual assault (CSA) may result in poorer emotion regulation and interpersonal functioning, potentially affecting the tolerability and effectiveness of evidence-based treatments (EBTs) for posttraumatic stress disorder (PTSD). Survivors of military sexual trauma (MST) have an increased incidence of CSA; however, research examining the role of CSA in EBTs for veterans with MST-related PTSD is limited. Data from 32 (9 male; 23 female) veterans with MST-related PTSD were used from a previously conducted randomized clinical trial examining the efficacy of an outpatient PTSD EBT (i.e., cognitive processing therapy [CPT]). Self-rated PTSD symptom severity was assessed at pretreatment, during treatment, and up to 6 months following treatment completion. Number of CPT sessions attended and treatment completion were also examined. Using a hierarchical linear modelling approach, results indicated both veterans with and without a history of CSA were found to benefit from CPT, and history of CSA did not significantly predict treatment response. Additionally, number of sessions attended and treatment completion did not significantly vary based on history of CSA. These preliminary findings provide support for the tolerability and efficacy of outpatient CPT in veterans with MST-related PTSD regardless of CSA history.

Measuring Use of Evidence-Based Psychotherapy for PTSD in VA Residential Treatment Settings with Clinician Survey and Electronic Medical Record Templates

OBJECTIVE

Available studies on implementation of evidence-based psychotherapy (EBP) for patients attending Department of Veterans Affairs (VA) residential post-traumatic stress disorder (PTSD) programs rely on therapist self-report of EBP delivery. Patient-level data on receipt of EBP are needed both to corroborate therapist self-report and to understand patient factors that predict receipt of EBPs for PTSD.

MATERIALS AND METHODS

We identified 159 therapists from 38 VA residential PTSD programs who responded to a survey about EBP implementation during the 2015 fiscal year (FY15). Therapists self-reported their use of two EBPs, including prolonged exposure delivered in an individual format (PE-I) and cognitive processing therapy delivered in individual and group formats (CPT-I and CPT-G). Using electronic medical record (EMR) templates mandated for EBP documentation in FY15, we measured contemporaneous patient-level receipt of EBPs for PTSD. We assessed the degree of correlation between therapist self-reported EBP delivery and patient receipt of EBT as measured by EMR templates using polychoric correlation coefficients. We determined patient and therapist factors that predicted the receipt of EBPs with multivariable logistic regression, using random effects and robust standard error estimation, and controlling for site. The Veterans IRB of Northern New England provided a waiver of informed consent; as this was a retrospective review, no patients or therapists were contacted, and all data were stored, transmitted, and analyzed on secure VA servers. The VA Connecticut Health Care System Human Research Protection Program approved secondary use of therapist survey data for this project.

RESULTS

When EMR template use became mandated in FY15, the proportion of patients in residential PTSD programs who received at least one EBP session that was recorded with an EMR template increased dramatically from 8.8% to 33.9%. There was adequate correlation and between survey-based and EMR-based measures of EBP receipt, with polychoric correlation values of 0.77 for PE-I, 0.69 for CPT-I, and 0.82 for CPT-G. Multiple patient factors were positive (e.g., female gender) and negative (e.g., depressive disorders) predictors of receipt of EBPs, even after controlling for site. Among therapist factors, only EBP consultant or trainer status was a positive predictor of EBP provision and only therapist race was a negative predictor of EBT provision after controlling for site.

CONCLUSION

Following a FY15 mandate, EMR templates documenting EBP delivery were widely used by therapists working in VA residential PTSD programs. EBP receipt measured using EMR templates was consistent with therapist self-report of EBT delivery. There were several patient-level predictors of EBP receipt and therapist-level predictors of EBP delivery. However, therapists most likely to deliver EBPs were clustered at a limited number of sites.

Use of Reflective Journaling to Understand Decision Making Regarding Two Evidence-Based Psychotherapies for PTSD: Practice Implications

As part of a longitudinal investigation on implementation of 2 evidence-based psychotherapies (EBPs) for posttraumatic stress disorder, psychotherapists from 38 Department of Veterans Affairs residential treatment programs across the United States were asked to complete reflective journals every 4 months for a 1-year time period in regard to their successes and challenges in using prolonged exposure and cognitive processing therapy. This paper provides content analysis on the reflective journals of 24 of these providers. Five main themes were identified: EBPs are great but not sufficient for patients in residential treatment with chronic posttraumatic stress disorder and complicated life circumstances, and thus, more treatment is necessary after discharge. Modifications were made or thought needed for optimal outcome and successful delivery of these 2 EBPs; some providers blended aspects of prolonged exposure and cognitive processing therapy; what happens when providers and patients do not agree on choice of which EBP to first implement; and provider concerns on when to discontinue an EBP. Reflective journaling appears to be a promising way for trainers and treatment developers to gather important information about the clinical application and decision-making process for front-line providers, which may offer insight into how to improve EBP implementation and sustainability. Incorporating reflective journaling and strategies for accomplishing this into training, supervision, and consultation may also be 1 strategy for increasing feedback, expanding implementation, and informing ways to increase sustainability of EBPs in populations with multiple clinical and psychosocial needs.

Participatory System Dynamics Modeling: Increasing Stakeholder Engagement and Precision to Improve Implementation Planning in Systems

Implementation planning typically incorporates stakeholder input. Quality improvement efforts provide data-based feedback regarding progress. Participatory system dynamics modeling (PSD) triangulates stakeholder expertise, data and simulation of implementation plans prior to attempting change. Frontline staff in one VA outpatient mental health system used PSD to examine policy and procedural "mechanisms" they believe underlie local capacity to implement evidence-based psychotherapies (EBPs) for PTSD and depression. We piloted the PSD process, simulating implementation plans to improve EBP reach. Findings indicate PSD is a feasible, useful strategy for building stakeholder consensus, and may save time and effort as compared to trial-and-error EBP implementation planning.

A Review of Studies on the System-Wide Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration

Since 2006, the Veterans Health Administration (VHA) has instituted policy changes and training programs to support system-wide implementation of two evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). To assess lessons learned from this unprecedented effort, we used PubMed and the PILOTS databases and networking with researchers to identify 32 reports on contextual influences on implementation or sustainment of EBPs for PTSD in VHA settings. Findings were initially organized using the exploration, planning, implementation, and sustainment framework (EPIS; Aarons et al. in Adm Policy Ment Health Health Serv Res 38:4-23, 2011). Results that could not be adequately captured within the EPIS framework, such as implementation outcomes and adopter beliefs about the innovation, were coded using constructs from the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework (Glasgow et al. in Am J Public Health 89:1322-1327, 1999) and Consolidated Framework for Implementation Research (CFIR; Damschroder et al. in Implement Sci 4(1):50, 2009). We highlight key areas of progress in implementation, identify continuing challenges and research questions, and discuss implications for future efforts to promote EBPs in large health care systems.

Prospective associations between changes in mental health symptoms and health-related quality of life in veterans seeking posttraumatic stress disorder residential treatment

BACKGROUND AND OBJECTIVES

This study examined prospective associations between changes in mental health symptoms (posttraumatic stress disorder [PTSD], depression) and health-related quality of life (physical health, psychological well-being) for veterans with PTSD.

DESIGN

This study focused on 139 patients who completed a residential treatment program for PTSD in the Veterans Health Administration.

METHODS

Patients completed the veteran-specific, 12-item Medical Outcomes Study Short Form, PTSD Checklist - Military version, and Beck Depression Inventory at pre-treatment, discharge, and a four-month follow-up. When accounting for demographic factors, combat exposure, and baseline scores on the respective outcome variables (e.g. mental health, physical health, PTSD, and depressive symptoms), a series of multivariate analyses were conducted for treatment-related changes in mental and physical health on the outcome measures.

RESULTS

Reductions in PTSD symptomatology during the treatment period were prospectively linked with better health-related outcomes at the four-month follow-up. In addition, improved physical health and psychological well-being during treatment were each similarly associated with better PTSD and depression outcomes in the months following treatment.

CONCLUSIONS

Addressing concerns in mental and physical health might have synergistic effects across both domains, supporting the need for holistic models and integrated health care strategies for treating veterans with PTSD.

Treatment initiation and dropout from prolonged exposure and cognitive processing therapy in a VA outpatient clinic

Emerging data suggest that few veterans are initiating prolonged exposure (PE) and cognitive processing therapy (CPT) and dropout levels are high among those who do start the therapies. The goal of this study was to use a large sample of veterans seen in routine clinical care to 1) report the percent of eligible and referred veterans who (a) initiated PE/CPT, (b) dropped out of PE/CPT, (c) were early PE/CPT dropouts, 2) examine predictors of PE/CPT initiation, and 3) examine predictors of early and late PE/CPT dropout. We extracted data from the medical records of 427 veterans who were offered PE/CPT following an intake at a Veterans Health Administration (VHA) PTSD Clinical Team. Eighty-two percent (n = 351) of veterans initiated treatment by attending Session 1 of PE/CPT; among those veterans, 38.5% (n = 135) dropped out of treatment. About one quarter of veterans who dropped out were categorized as early dropouts (dropout before Session 3). No significant predictors of initiation were identified. Age was a significant predictor of treatment dropout; younger veterans were more likely to drop out of treatment than older veterans. Therapy type was also a significant predictor of dropout; veterans receiving PE were more likely to drop out late than veterans receiving CPT. Findings demonstrate that dropout from PE/CPT is a serious problem and highlight the need for additional research that can guide the development of interventions to improve PE/CPT engagement and adherence.

Symptom exacerbations in trauma-focused treatments: Associations with treatment outcome and non-completion

Trauma-focused treatments are underutilized, partially due to clinician concerns that they will cause symptom exacerbation or dropout. We examined a sample of women undergoing Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and a version of CPT (CPT-C) without a written trauma narrative to investigate the possibility of symptom exacerbation. Participants (n = 192) were drawn from two RCT's. Participants were administered self-report measures of PTSD symptoms (i.e., the PTSD Symptom Scale or Posttraumatic Diagnostic Scale [PSS/PDS]) and the Clinician-Administered PTSD Scale. Exacerbations were defined as increases greater than 6.15 points on the PSS/PDS. A minority of participants experienced PTSD exacerbations during treatment, and there were no significant differences across treatment type (28.6% in CPT, 20.0% in PE, and 14.7% in CPT-C). Neither diagnostic nor trauma-related factors at pre-treatment predicted symptom exacerbations. Those who experienced exacerbations had higher post-treatment PSS/PDS scores and were more likely to retain a PTSD diagnosis (both small but statistically significant effects). However, even those who experienced an exacerbation experienced clinically significant improvement by end of treatment. Further, symptom exacerbations were not related to treatment non-completion. These results indicate that trauma-focused treatments are safe and effective, even for the minority of individuals who experience temporary symptom increases.

Prolonged Exposure Therapy With Veterans and Active Duty Personnel Diagnosed With PTSD and Traumatic Brain Injury

The present study used archival clinical data to analyze the delivery and effectiveness of prolonged exposure (PE) and ancillary services for posttraumatic stress disorder (PTSD) among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (N = 69) with histories of mild to severe traumatic brain injury (TBI). Data from standard clinical assessments of veterans and active duty personnel treated in both inpatient and outpatient programs at 2 Department of Veteran Affairs medical centers were examined. Symptoms were assessed with self-report measures of PTSD (PTSD Checklist) and depression (Beck Depression Inventory-II) before and throughout therapy. Mixed linear models were utilized to determine the slope of reported symptoms throughout treatment, and the effects associated with fixed factors such as site, treatment setting (residential vs. outpatient), and TBI severity were examined. Results demonstrated significant decreases in PTSD, B = -3.00, 95% CI [-3.22, -2.78]; t(210) = -13.5; p < .001, and in depressive symptoms, B = -1.46, 95% CI [-1.64, -1.28]; t(192) = -8.32; p < .001. The effects of PE treatment did not differ by clinical setting and participants with moderate to severe injuries reported more rapid gains than those with a history of mild TBI. The results provide evidence that PE may well be effective for veterans with PTSD and TBI.

A Quantitative Test of an Implementation Framework in 38 VA Residential PTSD Programs

This study examines the implementation of two evidence-based psychotherapies, Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), in the Department of Veterans Affairs residential Posttraumatic Stress Disorder treatment programs. Two hundred and one providers from 38 programs completed an online survey concerning implementation of PE delivered on an individual basis and CPT delivered in individual and group formats. For PE, a supportive organizational context (dedicated time and resources, and incentives and mandates) and overall positive view of the treatment were related to its implementation. For both group and individual CPT, only the supportive organizational context was significantly associated with outcome. Implications for implementation efforts are discussed.

The problem of dropout from "gold standard" PTSD therapies

Understanding of posttraumatic stress disorder (PTSD) has increased substantially in the past several decades. There is now more awareness of the many different types of trauma that can lead to PTSD, greater refinement of diagnostic criteria, and the development and testing of various treatments for it. As implementation of PTSD therapies has increased, there is also increased attention to the key issues of retention and dropout. Retention refers to the percentage of patients who stay in a treatment for its intended dose, and dropout is the opposite (the percentage who leave prior to the intended dose); both of which have major implications for treatment outcomes. The two PTSD therapies most studied in relation to retention and dropout are Prolonged Exposure and Cognitive Processing Therapy, which have been the subject of massive, formal, multi-year dissemination roll-outs. Both of these evidence-based treatments are defined as gold-standard therapies for PTSD and showed positive outcomes and reasonable retention of patients in randomized controlled trials (RCTs). But an emerging picture based on real-world practice indicates substantial dropout. Such real-world studies are distinct from RCTs, which have consistently evidenced far lower dropout rates, but under much more restricted conditions (e.g. a more selective range of patients and clinicians). In this paper, the phenomena of retention and dropout are described based on real-world studies of Prolonged Exposure and Cognitive Processing Therapy, including rates, characteristics of patients, clinicians, and programs in relation to retention and dropout, and identification of clinical issues and future research on these topics. It is suggested that the term “gold-standard” evidence-based treatments should be reserved for treatments that evidence both positive results in RCTs but also feasibility and strong retention in real-world settings.

Evaluation of an implementation model: a national investigation of VA residential programs

This national investigation utilizes qualitative data to evaluate an implementation model regarding factors influencing provider use of two evidence-based treatments for posttraumatic stress disorder (PTSD). Semi-structured qualitative interviews with 198 mental health providers from 38 Department of Veterans Affairs' (VA) residential treatment programs were used to explore these issues regarding prolonged exposure (PE) and cognitive processing therapy (CPT) in VA residential PTSD programs. Several unique and some overlapping predictors emerged. Leadership was viewed as an influence on implementation for both CPT and PE, while a lack of dedicated time and resources was viewed as a deterrent for both. Compatibility of CPT with providers' existing practices and beliefs, the ability to observe noticeable patient improvement, a perceived relative advantage of CPT over alternative treatments, and the presence of a supportive peer network emerged as influential on CPT implementation. Leadership was associated with PE implementation. Implications for the design and improvement of training and implementation efforts are discussed.

Utilization of evidence-based psychotherapies in Veterans Affairs posttraumatic stress disorder outpatient clinics

In response to the growing numbers of veterans with posttraumatic stress disorder (PTSD), the Department of Veterans Affairs (VA) has sought to make evidence-based psychotherapies for PTSD available at every VA facility. We conducted a national survey of providers within VA PTSD clinical teams (PCTs) to describe utilization of prolonged exposure (PE) and cognitive processing therapy (CPT) and to identify individual and organizational factors associated with treatment uptake and adherence. Participants (N = 128) completed an electronic survey assessing reported utilization of PE and CPT treatments, adherence to treatment manuals, and characteristics of the provider and workplace environment. Participants reported conducting a weekly mean of 4.5 hours of PE, 3.9 hours of CPT (individual format), 1.3 hours of CPT (group format), and 13.4 hours of supportive care. Perceived effectiveness of PE and CPT were significantly associated with utilization of and adherence to those treatments. Reported number of hours conducting supportive care was positively associated with feeling the clinic was not sufficiently staffed (p = .05). Adherence to the PE treatment manual was positively associated with receiving emotional support from coworkers (p < .01). Provider attitudes and organizational factors such as staffing and work relationships may have an important impact on treatment selection and the quality of PTSD care provided in VA PCTs.

The US framework for understanding, preventing, and caring for the mental health needs of service members who served in combat in Afghanistan and Iraq: a brief review of the issues and the research

This paper reviews the psychological health research conducted in the United States in support of combat veterans from Iraq and Afghanistan, using the Military Psychological Health Research Continuum, which includes foundational science, epidemiology, etiology, prevention and screening, treatment, follow-up care, and services research. The review is limited to those studies involving combat veterans and military families. This review discusses perplexing issues regarding the impact of combat on the mental health of service members such as risk and resilience factors of mental health, biomarkers of posttraumatic stress syndrome (PTSD), mental health training, psychological screening, psychological debriefing, third location decompression, combat and suicide, the usefulness of psychotherapy and drug therapy for treating PTSD, role of advanced technology, telemedicine and virtual reality, methods to reduce stigma and barriers to care, and best approaches to the dissemination of evidence-based interventions. The mental health research of special populations such as women, National Guardsmen and reservists, and military families is also presented. The review concludes by identifying future areas of research.

Residential treatment for combat-related posttraumatic stress disorder: identifying trajectories of change and predictors of treatment response

BACKGROUND

Combat-related posttraumatic stress disorder (PTSD) can be a difficult condition to treat and has been associated with serious medical and economic issues among U.S. military veterans. Distinguishing between treatment responders vs. non-responders in this population has become an important public health priority. This study was conducted to identify pre-treatment characteristics of U.S. veterans with combat-related PTSD that might contribute to favorable and unfavorable responses to high value treatments for this condition.

METHOD

This study focused on 805 patients who completed a VHA PTSD residential program between 2000 and 2007. These patients completed the PTSD Clinical Checklist at pre-treatment, post-treatment, and a four-month follow-up assessment. Latent growth curve analysis (LCGA) was incorporated to determine trajectories of changes in PTSD across these assessments and whether several key clinical concerns for this population were associated with their treatment responses.

STUDY FINDINGS

LCGA indicated three distinct trajectories in PTSD outcomes and identified several clinical factors that were prospectively linked with changes in veterans' posttraumatic symptomatology. When compared to a group with high PTSD symptom severity that decreased over the program but relapsed at follow-up (41%), the near half (48.8%) of the sample with an improving trajectory had less combat exposure and superior physical/mental health. However, when compared to a minority (10.2%) with relatively low symptomatology that also remained somewhat stable, patients in the improving group were younger and also reported greater combat exposure, poorer physical/mental health status, and more problems with substance abuse before the start of treatment.

CONCLUSIONS

Findings suggest that veterans are most likely to benefit from residential treatment in an intermediate range of symptoms and risk factors, including PTSD symptom severity, history of combat exposure, and comorbid issues with physical/mental health. Addressing these factors in an integrative manner could help to optimize the effectiveness of treatments of combat-related PTSD in many cases.

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.

Trauma Informed Guilt Reduction Therapy With Combat Veterans

Guilt related to combat trauma is highly prevalent among veterans returning from Iraq and Afghanistan. Trauma-related guilt has been associated with increased risk for posttraumatic psychopathology and poorer response to treatment. Trauma Informed Guilt Reduction (TrIGR) therapy is a 4-module cognitive-behavioral psychotherapy designed to reduce guilt related to combat trauma. The goals of this study were to describe the key elements of TrIGR and report results of a pilot study with 10 recently deployed combat veterans. Ten combat veterans referred from a VA Posttraumatic Stress Disorder (PTSD) or mental health clinic completed TrIGR over 4 to 7 sessions. Nine veterans completed the posttreatment assessment. This initial pilot suggests that TrIGR may help to reduce trauma-related guilt severity and associated distress. Changes in trauma-related guilt were highly correlated with reductions in PTSD and depression symptoms over the course of treatment, suggesting a possible mechanistic link with severity of posttraumatic psychopathology. TrIGR warrants further evaluation as an intervention for reducing guilt related to traumatic experiences in combat.

VA Residential Provider Perceptions of Dissuading Factors to the Use of Two Evidence-Based PTSD Treatments

Providers (N = 198) from 38 Department of Veterans Affairs residential posttraumatic stress disorder treatment programs across the United States completed qualitative interviews regarding implementation of 2 evidence-based treatments: prolonged exposure and cognitive processing therapy. As part of this investigation, providers were asked how they decide which patients are appropriate for these treatments. Many indicated that they did not perceive any patient factors that dissuade their use of either evidence-based treatment. However, 3 broad categories emerged surrounding reasons that patients were perceived to be less suitable candidates for the treatments: the presence of psychiatric comorbidities, cognitive limitations, and low levels of patient motivation. Interestingly, providers' perceived reasons for limited or nonuse of a treatment did not correspond entirely to those espoused by treatment developers. Possible solutions to address provider concerns, including educational and motivational interventions, are noted.

Residential Treatment for Posttraumatic Stress Disorder in the Department of Veterans Affairs: A National Perspective on

Thirty-eight U.S. Department of Veterans Affairs's (VA) residential treatment programs for posttraumatic stress disorder took part in a formative evaluation of their programmatic services, including perceptions of effective treatment. From July 2008 through March 2011, face-to-face qualitative interviews were conducted with over 250 VA residential staff. A wide variety of perceived effective treatment elements were noted. The most frequently mentioned elements were evidence-based treatments, frequency and intensity of milieu, staff cohesion, varied programming, and individualized treatment. Implications for VA managers and policy-makers as well as non-VA health care systems and health care providers are discussed.