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Baier AL, Nugent S, Horton DM, Salameh H, Kehle-Forbes SM. Rates and reasons for veteran mental health service utilization following completion of evidence-based trauma-focused treatment for PTSD. Psychol Serv 2024; 21:560-568. [PMID: 37917477 PMCID: PMC11063117 DOI: 10.1037/ser0000815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Despite the effectiveness of prolonged exposure (PE) and cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) in reducing symptoms of PTSD and co-occurring symptoms, emerging research suggests continued mental health service utilization (MHSU) following the completion of these interventions. Reasons for continued MHSU remain unknown despite its relevance to PE/CPT outcomes and implementation. The present study employed a mixed methods approach to explore rates and reasons for VA MHSU post PE/CPT. A national sample of 5,634 U.S. veterans who completed either PE or CPT were identified to quantitatively determine the frequency, type, and location of MHSU in the 12 months following PE/CPT completion. A random subsample of 60 veterans completed semistructured qualitative interviews to explore reasons for MHSU post PE/CPT. Findings suggest high MHSU; 98.4% of veterans attended at least one mental health appointment in the year following completion of PE/CPT, with an average attending 27.64 appointments in the year following treatment completion. Qualitatively, veterans, particularly those with low-to-moderate residual symptoms, described a preference for additional treatment to continue practicing and applying skills learned in treatment. Veterans expressed low self-efficacy to maintain treatment gains without support and accountability from their therapists and viewed ongoing treatment as a safety net until they felt more confident in their skills and stability of gains. Veterans with high residual symptoms indicated needing additional PTSD-specific treatment or treatment for a co-occurring condition. Notably, some veterans reported no additional treatment needs, despite continued engagement in care. Evidence-based strategies for facilitating self-efficacy and ongoing application of PE/CPT principles posttreatment are needed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Allison L. Baier
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, MA, USA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Sean Nugent
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA
| | - David M. Horton
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA
| | - Hope Salameh
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA
| | - Shannon M. Kehle-Forbes
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, MA, USA
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA
- University of Minnesota, Department of Medicine, Minneapolis, MN, USA
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McGuier EA, Kolko DJ, Aarons GA, Schachter A, Klem ML, Diabes MA, Weingart LR, Salas E, Wolk CB. Teamwork and implementation of innovations in healthcare and human service settings: a systematic review. Implement Sci 2024; 19:49. [PMID: 39010100 PMCID: PMC11247800 DOI: 10.1186/s13012-024-01381-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 07/07/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Implementation of new practices in team-based settings requires teams to work together to respond to new demands and changing expectations. However, team constructs and team-based implementation approaches have received little attention in the implementation science literature. This systematic review summarizes empirical research examining associations between teamwork and implementation outcomes when evidence-based practices and other innovations are implemented in healthcare and human service settings. METHODS We searched MEDLINE, CINAHL, APA PsycINFO and ERIC for peer-reviewed empirical articles published from January 2000 to March 2022. Additional articles were identified by searches of reference lists and a cited reference search for included articles (completed in February 2023). We selected studies using quantitative, qualitative, or mixed methods to examine associations between team constructs and implementation outcomes in healthcare and human service settings. We used the Mixed Methods Appraisal Tool to assess methodological quality/risk of bias and conducted a narrative synthesis of included studies. GRADE and GRADE-CERQual were used to assess the strength of the body of evidence. RESULTS Searches identified 10,489 results. After review, 58 articles representing 55 studies were included. Relevant studies increased over time; 71% of articles were published after 2016. We were unable to generate estimates of effects for any quantitative associations because of very limited overlap in the reported associations between team variables and implementation outcomes. Qualitative findings with high confidence were: 1) Staffing shortages and turnover hinder implementation; 2) Adaptive team functioning (i.e., positive affective states, effective behavior processes, shared cognitive states) facilitates implementation and is associated with better implementation outcomes; Problems in team functioning (i.e., negative affective states, problematic behavioral processes, lack of shared cognitive states) act as barriers to implementation and are associated with poor implementation outcomes; and 3) Open, ongoing, and effective communication within teams facilitates implementation of new practices; poor communication is a barrier. CONCLUSIONS Teamwork matters for implementation. However, both team constructs and implementation outcomes were often poorly specified, and there was little overlap of team constructs and implementation outcomes studied in quantitative studies. Greater specificity and rigor are needed to understand how teamwork influences implementation processes and outcomes. We provide recommendations for improving the conceptualization, description, assessment, analysis, and interpretation of research on teams implementing innovations. TRIAL REGISTRATION This systematic review was registered in PROSPERO, the international prospective register of systematic reviews. REGISTRATION NUMBER CRD42020220168.
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Affiliation(s)
- Elizabeth A McGuier
- Department of Psychiatry, School of Medicine, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA, 15213, USA.
| | - David J Kolko
- Department of Psychiatry, School of Medicine, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA, 15213, USA
| | - Gregory A Aarons
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- ACTRI Dissemination and Implementation Science Center, UC San Diego, La Jolla, CA, USA
- Child and Adolescent Services Research Center, San Diego, CA, USA
| | - Allison Schachter
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Mary Lou Klem
- Health Sciences Library System, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew A Diabes
- Tepper School of Business, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Laurie R Weingart
- Tepper School of Business, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Eduardo Salas
- Department of Psychological Sciences, Rice University, Houston, TX, USA
| | - Courtney Benjamin Wolk
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Bernardy NC, Cuccurullo LAJ, Montano M, Bowen M, Breen K, Matteo R, Cole B. Implementation strategies to improve posttraumatic stress disorder care in rural veterans. J Rural Health 2024; 40:411-418. [PMID: 37596917 DOI: 10.1111/jrh.12790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/11/2023] [Accepted: 08/07/2023] [Indexed: 08/21/2023]
Abstract
PURPOSE Prior research has noted treatment inequalities in the care of rural veterans with posttraumatic stress disorder (PTSD). This project sought to increase the delivery, or reach, of recommended PTSD treatments in 2 rural health care systems of the Department of Veterans Affairs (VA) using implementation facilitation. METHODS The quality improvement project involved 6 months of facilitation to 2 low-reach PTSD clinics within 2 VA health care systems. The clinics were matched to a control clinic at another regional system similar in reach, rurality, and patient volume. We compared the delivery of evidence-based psychotherapies (EBPs) for PTSD at 3 timepoints: baseline, 6 months, and 1 year using difference-in-difference effect estimation. Facilitators and barriers of EBP reach were identified through interviews with clinic staff and informed specific implementation plans. We also measured reductions in benzodiazepine prescriptions and polypharmacy to determine the impact of an academic detailing intervention aimed at improving PTSD prescribing practices at the 2 sites. FINDINGS EBP reach at 6 months more than doubled in the 2 PTSD clinics that received facilitation, while our control clinic experienced a decrease in EBP reach (DID = 24.6; SE = 6.71%). Both intervention clinics identified similar administrative barriers to the delivery of EBPs, offering useful information for improvement at other rural clinics. The use of academic detailing as part of our facilitation intervention further appears to have positively impacted care. CONCLUSIONS In this preliminary work, facilitation is a promising strategy for increasing the delivery of PTSD EBPs to veterans seen in under-resourced rural VA clinics.
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Affiliation(s)
- Nancy C Bernardy
- White River Junction VA Medical Center Research Department, White River Junction, Vermont, USA
- National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, USA
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Lisa-Ann J Cuccurullo
- National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Macgregor Montano
- National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | | | - Kristen Breen
- National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Rebecca Matteo
- National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Bernard Cole
- Department of Mathematics and Statistics, University of Vermont, Burlington, Vermont, USA
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Sripada RK, Grau PP, Porath BR, Burgess J, Van T, Kim HM, Boden MT, Zivin K. Role of Institutional Support for Evidence-Based Psychotherapy in Satisfaction and Burnout Among Veterans Affairs Therapists. Psychiatr Serv 2024; 75:206-213. [PMID: 37880969 DOI: 10.1176/appi.ps.20230086] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
OBJECTIVE Burnout is widespread among psychotherapists and leads to negative mental and other health outcomes, absenteeism, and turnover. Job resources, including institutional support for evidence-based practices, can buffer against burnout and may improve satisfaction among therapists. The Veterans Health Administration (VHA) is the nation's largest integrated health system and employs 23,000 therapists, including psychologists, social workers, and counselors. The authors assessed associations between perceived institutional support for evidence-based treatment and satisfaction and burnout among VHA therapists. METHODS This analysis used data from the VHA's national 2018 Mental Health Provider Survey. Responding therapists (N=5,341) answered questions about the quality of mental health care and job satisfaction. Multilevel logistic regression models were used to predict burnout and satisfaction. The authors tested availability of evidence-based treatment and measurement-based care (MBC) as predictors; analyses were adjusted for therapist workload, demographic characteristics, and potential clustering by facility. RESULTS VHA therapists had less burnout and more job satisfaction when they perceived receiving institutional support for evidence-based psychotherapy (EBP) and MBC, irrespective of whether the analyses were adjusted for workload. Less difficulty in scheduling EBP was significantly associated with decreased likelihood of burnout (OR=0.83, p<0.001) and increased satisfaction (OR=1.09, p=0.008). Less difficulty ending psychotherapy was significantly associated with decreased likelihood of burnout (OR=0.89, p=0.002) and increased satisfaction (OR=1.12, p=0.004). CONCLUSIONS Support for evidence-based practices, including EBP and MBC, was closely linked to VHA therapists' satisfaction and burnout. Expanding support for therapists to provide evidence-based treatment may benefit therapists, patients, and the health care system.
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Affiliation(s)
- Rebecca K Sripada
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor (Sripada, Grau, Porath, Burgess, Van, Kim, Zivin); Department of Psychiatry, Michigan Medicine (Sripada, Grau, Zivin), and Consulting for Statistics, Computing and Analytics Research (Kim), University of Michigan, Ann Arbor; Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden)
| | - Peter P Grau
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor (Sripada, Grau, Porath, Burgess, Van, Kim, Zivin); Department of Psychiatry, Michigan Medicine (Sripada, Grau, Zivin), and Consulting for Statistics, Computing and Analytics Research (Kim), University of Michigan, Ann Arbor; Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden)
| | - Brittany R Porath
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor (Sripada, Grau, Porath, Burgess, Van, Kim, Zivin); Department of Psychiatry, Michigan Medicine (Sripada, Grau, Zivin), and Consulting for Statistics, Computing and Analytics Research (Kim), University of Michigan, Ann Arbor; Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden)
| | - Jennifer Burgess
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor (Sripada, Grau, Porath, Burgess, Van, Kim, Zivin); Department of Psychiatry, Michigan Medicine (Sripada, Grau, Zivin), and Consulting for Statistics, Computing and Analytics Research (Kim), University of Michigan, Ann Arbor; Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden)
| | - Tony Van
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor (Sripada, Grau, Porath, Burgess, Van, Kim, Zivin); Department of Psychiatry, Michigan Medicine (Sripada, Grau, Zivin), and Consulting for Statistics, Computing and Analytics Research (Kim), University of Michigan, Ann Arbor; Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden)
| | - H Myra Kim
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor (Sripada, Grau, Porath, Burgess, Van, Kim, Zivin); Department of Psychiatry, Michigan Medicine (Sripada, Grau, Zivin), and Consulting for Statistics, Computing and Analytics Research (Kim), University of Michigan, Ann Arbor; Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden)
| | - Matthew T Boden
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor (Sripada, Grau, Porath, Burgess, Van, Kim, Zivin); Department of Psychiatry, Michigan Medicine (Sripada, Grau, Zivin), and Consulting for Statistics, Computing and Analytics Research (Kim), University of Michigan, Ann Arbor; Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden)
| | - Kara Zivin
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor (Sripada, Grau, Porath, Burgess, Van, Kim, Zivin); Department of Psychiatry, Michigan Medicine (Sripada, Grau, Zivin), and Consulting for Statistics, Computing and Analytics Research (Kim), University of Michigan, Ann Arbor; Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden)
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McLean CP, Cook J, Riggs DS, Peterson AL, Young-McCaughan S, Borah EV, Comtois KA, Dondanville KA, Frick E, Haddock CK, Mann J, Reynolds D, Mistretta M, Neitzer A, Brzuchalski A, Clayton SP, Conforte AM, DuMars TD, Ekundayo K, Flores A, Hein J, Jinkerson J, Keith F, Kim HJ, Link JS, Nofziger D, Pollick K, Ringdahl EN, Waggoner J, Woodworth C, Rosen CS. Barriers and Potential Solutions to Implementing Evidence-Based PTSD Treatment in Military Treatment Facilities. Mil Med 2024; 189:721-731. [PMID: 35943175 DOI: 10.1093/milmed/usac240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/15/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Prolonged exposure therapy is an effective treatment for posttraumatic stress disorder that is underutilized in health systems, including the military health system. Organizational barriers to prolonged exposure implementation have been hypothesized but not systematically examined. This multisite project sought to identify barriers to increasing the use of prolonged exposure across eight military treatment facilities and describe potential solutions to addressing these barriers. MATERIALS AND METHODS As part of a larger project to increase the use of prolonged exposure therapy in the military health system, we conducted a needs assessment at eight military treatment facilities. The needs assessment included analysis of clinic administrative data and a series of stakeholder interviews with behavioral health clinic providers, leadership, and support staff. Key barriers were matched with potential solutions using a rubric developed for this project. Identified facilitators, barriers, and potential solutions were summarized in a collaboratively developed implementation plan for increasing prolonged exposure therapy tailored to each site. RESULTS There was a greater than anticipated consistency in the barriers reported by the sites, despite variation in the size and type of facility. The identified barriers were grouped into four categories: time-related barriers, provider-related barriers, barriers related to patient education and matching patients to providers, and scheduling-related barriers. Potential solutions to each barrier are described. CONCLUSIONS The findings highlight the numerous organizational-level barriers to implementing evidence-based psychotherapy in the military health system and offer potential solutions that may be helpful in addressing the barriers.
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Affiliation(s)
- Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA 94305, USA
| | - Jeffrey Cook
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - David S Riggs
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX 78229, USA
- Department of Psychology, University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX 78229, USA
| | - Elisa V Borah
- Steve Hicks School of Social Work, University of Texas at Austin, Austin, TX 78712, USA
| | - Katherine Anne Comtois
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195, USA
| | - Katherine A Dondanville
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Erin Frick
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | | | - Jeffrey Mann
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - David Reynolds
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Melissa Mistretta
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Andrea Neitzer
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA
| | - Amy Brzuchalski
- William Beaumont Army Medical Center, El Paso, TX 79920, USA
- Kimbrough Ambulatory Care Center, Fort Meade, MD 20755, USA
| | - Spencer P Clayton
- 49th Medical Group, Holloman Air Force Base, Alamogordo, NM 88330, USA
- Nellis Air Force Base, NV 89191, USA
| | - Allison M Conforte
- Blanchfield Army Community Hospital, Fort Campbell, KY 42223, USA
- 3d Marine Division, UNIT 35840, Okinawa FPO AP 96602-5840, Japan
| | - Tyler D DuMars
- William Beaumont Army Medical Center, El Paso, TX 79920, USA
| | - Kendra Ekundayo
- 49th Medical Group, Holloman Air Force Base, Alamogordo, NM 88330, USA
| | - Araceli Flores
- William Beaumont Army Medical Center, El Paso, TX 79920, USA
| | - Jessica Hein
- Blanchfield Army Community Hospital, Fort Campbell, KY 42223, USA
| | - Jeremy Jinkerson
- 81st Medical Group, Keesler Air Force Base, Biloxi, MS 39534, USA
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX 78234, USA
| | - Felicia Keith
- David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA 94533, USA
- Spangdahlem Air Base, Spangdahlem 09123, Germany
| | - Hana J Kim
- Naval Hospital Jacksonville, Naval Air Station Jacksonville, Jacksonville, FL 32214, USA
| | - Jared S Link
- 81st Medical Group, Keesler Air Force Base, Biloxi, MS 39534, USA
| | - Debra Nofziger
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX 78234, USA
| | - Kirsten Pollick
- Naval Hospital Jacksonville, Naval Air Station Jacksonville, Jacksonville, FL 32214, USA
| | - Erik N Ringdahl
- David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA 94533, USA
| | - John Waggoner
- 81st Medical Group, Keesler Air Force Base, Biloxi, MS 39534, USA
| | - Craig Woodworth
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX 78234, USA
| | - Craig S Rosen
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA 94305, USA
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Sayer NA, Maieritsch KP, Yamokoski CA, Orazem RJ, Clothier BA, Noorbaloochi S. Evaluation of implementation facilitation integrated into a national mentoring programme to improve access to evidence-based psychotherapy for post-traumatic stress disorder within the veterans health administration: a quality improvement report. BMJ Open Qual 2024; 13:e002449. [PMID: 38216294 PMCID: PMC10806576 DOI: 10.1136/bmjoq-2023-002449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 12/07/2023] [Indexed: 01/14/2024] Open
Abstract
Despite the resources dedicated to specialised mental healthcare for patients with post-traumatic stress disorder (PTSD) within the US Veterans Health Administration, evidence-based psychotherapies (EBPs) for PTSD have been underutilised, as evidenced by low EBP reach to patients. A research-operation collaboration evaluated whether implementation facilitation delivered by regional PTSD mentors as part of a national mentoring programme improved EBP reach compared with less-intensive quality improvement interventions. We used a non-equivalent comparison-group design that included all PTSD clinics with low EBP reach at baseline (n=51). Clinics were grouped into one of four quality improvement conditions according to self-selection by regional PTSD mentors: facilitation (n=6), learning collaborative (n=15), mentoring as usual in the regions that had facilitation-target clinics (n=15) and mentoring as usual in other regions (n=15). The primary outcome was EBP reach among therapy patients with PTSD at preintervention baseline and postintervention sustainment periods. We used the ratio of odds ratios (ROR) between the two time periods to evaluate the effectiveness of facilitation compared with the other conditions, adjusting for patient-level and clinic-level confounders. 26 126 veterans with PTSD received psychotherapy in one of 51 low-reach PTSD clinics during preintervention baseline and postintervention sustainment periods. The odds of a patient receiving an EBP increased over time across conditions. The adjusted ORs of a patient receiving an EBP from baseline to sustainment were 1.35-1.69 times larger in clinics that received facilitation compared with the three comparison conditions (adjusted RORs of comparison condition versus facilitation ranged from 0.59 (95% CI 0.47 to 0.75) to 0.74 (95% CI 0.58 to 0.94)). Implementation facilitation can be integrated into a national programme for quality improvement for PTSD specialty care and may be particularly useful when less-intensive approaches are not sufficiently effective.
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Affiliation(s)
- Nina A Sayer
- CCDOR, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Kelly P Maieritsch
- Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Cynthia A Yamokoski
- Executive Division, National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Robert J Orazem
- CCDOR, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | | | - Siamak Noorbaloochi
- CCDOR, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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7
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Sripada RK, Walters HM. "I wish people could come together like we have," patient and provider perspectives on VA residential PTSD treatment. Psychol Serv 2023; 20:809-819. [PMID: 36136833 PMCID: PMC10249047 DOI: 10.1037/ser0000713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although most posttraumatic stress disorder (PTSD) care in the Veterans health administration (VHA) is provided on an outpatient basis, the VHA has 40 residential rehabilitation treatment programs (RRTPs) designed to treat Veterans who require more intensive and closely monitored care. Unfortunately, the clinical outcomes of these programs are modest, and previous attempts to identify key drivers of outcomes have uncovered few modifiable factors. The present study, informed by the model of resources, life events and changes in psychological state, was designed to identify factors associated with treatment response among RRTP patients and providers. Semistructured interviews were conducted with 24 patients and 12 providers at three regional RRTPs, using interview guides based on the theoretical model. Data were analyzed using rapid analysis. Results showed that patients and providers agreed on several factors critical to RRTP success. These factors included the provision of evidence-based psychotherapy (EBP), support and understanding from fellow patients, and skill and support from providers. Patients and providers also noted the importance of psychological flexibility, openness, and willingness to change. Patients who experienced less symptom improvement over the course of treatment were more likely to report poor therapeutic alliance. These findings underscore the importance of continued emphasis on EBP delivery but also suggest that RRTPs might find additional ways to capitalize on the residential milieu to encourage engagement in treatment and a focus on therapeutic change. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Rebecca K. Sripada
- VA Center for Clinical Management Research, Ann Arbor, MI
- VA Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Heather M. Walters
- VA Center for Clinical Management Research, Ann Arbor, MI
- VA Ann Arbor Healthcare System, Ann Arbor, MI
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Ackland PE, Koffel EA, Goldsmith ES, Ullman K, Miller WA, Landsteiner A, Stroebel B, Hill J, Wilt TJ, Duan-Porter W. Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder: A Systematic Review. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2023; 50:792-812. [PMID: 37326899 DOI: 10.1007/s10488-023-01279-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 06/17/2023]
Abstract
Guidelines strongly recommend trauma-focused therapies to treat posttraumatic stress disorder. Implementation of cognitive processing therapy (CPT) and prolonged exposure (PE) in Veterans Health Administration (VHA) and non-VHA settings began in 2006. We conducted a systematic review of implementation facilitators and challenges and strategies to address barriers. We searched MEDLINE, Embase, PsycINFO, and CINAHL from inception until March 2021 for English-language articles. Two individuals reviewed eligibility and rated quality. Quantitative results were abstracted by one reviewer and verified by a second. Qualitative results were independently coded by two reviewers and finalized through consensus. We used RE-AIM and CFIR frameworks to synthesize findings. 29 eligible studies addressed CPT/PE, mostly conducted in VHA. Training/education with audit/feedback was the primary implementation strategy and was linked to improved provider CPT/PE perceptions and self-efficacy. Use was not widespread. Only six studies tested other implementation strategies with mixed impact. Following VHA implementation, strong support for training, perceived effectiveness for patients and benefits for clinics, and positive patient experiences and relationships with providers were reported. However, barriers persisted including perceived protocol inflexibility, complex referral processes and patient complexity and competing needs. In non-VHA settings, providers perceived fewer barriers, but few were CPT/PE trained. Across both settings, fewer studies targeted patient factors. Training/education with audit/feedback improved perceptions and the availability of CPT/PE, but not consistent use. Studies testing implementation strategies to address post-training challenges, including patient-level factors, are needed. A few studies are underway in VHA to test patient-focused and other implementation strategies. Research assessing actual vs perceived barriers in non-VHA settings is needed to elucidate unique challenges experienced.
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Affiliation(s)
- Princess E Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA.
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
| | | | - Elizabeth S Goldsmith
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Kristen Ullman
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Wendy A Miller
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Adrienne Landsteiner
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Benjamin Stroebel
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Jessica Hill
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Psychology, Binghamton University, Binghamton, NY, 13902, USA
| | - Timothy J Wilt
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Wei Duan-Porter
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
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Valentine SE, Fuchs C, Olesinski EA, Sarkisova N, Godfrey LB, Elwy AR. Formative evaluation prior to implementation of a brief treatment for posttraumatic stress disorder in primary care. Implement Sci Commun 2023; 4:48. [PMID: 37143109 PMCID: PMC10161536 DOI: 10.1186/s43058-023-00426-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 04/04/2023] [Indexed: 05/06/2023] Open
Abstract
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.
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Affiliation(s)
- Sarah E Valentine
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA.
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
| | - Cara Fuchs
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | | | | | - Laura B Godfrey
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA
| | - A Rani Elwy
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA.
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA.
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Frank HE, Rifkin LS, Sheehan K, Becker-Haimes E, Crane ME, Phillips KE, Palitz SA, Kemp J, Benito K, Kendall PC. Therapist perceptions of experiential training for exposure therapy. Behav Cogn Psychother 2023; 51:214-229. [PMID: 36805734 PMCID: PMC11006093 DOI: 10.1017/s1352465822000728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND Despite evidence for its efficacy, exposure therapy for anxiety is rarely used in routine care settings. Efforts to address one major barrier to its use - therapists' negative beliefs about exposure - have included therapist-level implementation strategies, such as training and consultation. Experiential training, in which therapists themselves undergo exposures, has recently demonstrated feasibility, acceptability and preliminary effectiveness for increasing exposure use. AIMS This study aimed to assess: (1) therapists' perceptions of experiential training and (2) barriers and facilitators to implementing exposure following training. METHOD Therapists who underwent experiential training (n=12) completed qualitative interviews and quantitative questionnaires. Interviews were coded using an integrated approach, combining both inductive and deductive approaches. Mixed methods analyses examined how themes varied by practice setting (community mental health versus private practice) and exposure use. RESULTS Results highlight how therapist-level factors, such as clinician self-efficacy, interact with inner- and outer-setting factors. Participants reported positive perceptions of exposure after training; they noted that directly addressing myths about exposure and experiencing exposures themselves improved their attitudes toward exposure. Consistent with prior literature, issues such as insufficient supervisory support, organizational constraints, and client characteristics made it challenging to implement exposures. DISCUSSION Results highlight the benefits of experiential training, while also highlighting the need to consider contextual determinants. Differences in responses across practice settings highlight areas for intervention and the importance of tailoring implementation strategies. Barriers that were specific to therapists who did not use exposure (e.g. hesitancy about its appropriateness for most clients) point to directions for future implementation efforts.
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Affiliation(s)
- Hannah E. Frank
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University
- Bradley Hospital, Lifespan Health System
- Department of Psychology, Temple University
| | | | - Kate Sheehan
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University
- Bradley Hospital, Lifespan Health System
| | - Emily Becker-Haimes
- Department of Psychiatry, University of Pennsylvania
- Hall Mercer Community Mental Health, University of Pennsylvania Health System
| | | | | | | | - Joshua Kemp
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University
- Bradley Hospital, Lifespan Health System
| | - Kristen Benito
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University
- Bradley Hospital, Lifespan Health System
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11
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Initiating Cognitive Processing Therapy (CPT) in Community Settings: A Qualitative Investigation of Therapist Decision-Making. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2023; 50:137-150. [PMID: 36370226 PMCID: PMC9832073 DOI: 10.1007/s10488-022-01229-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2022] [Indexed: 11/13/2022]
Abstract
Various organizations have provided treatment guidelines intended to aid therapists in deciding how to treat posttraumatic stress disorder (PTSD). Yet evidence-based psychotherapies (EBPs) for PTSD in the community may be difficult to obtain. Although strides have been made to implement EBPs for PTSD in institutional settings such as the United States Veterans Affairs, community uptake remains low. Factors surrounding clients' decisions to enroll in EBPs have been identified in some settings; however less is known regarding trained therapists' decisions related to offering trauma-focused therapies or alternative treatment options. Thus, the aim of the current study was to examine therapist motivations to initiate CPT in community settings. The present study utilizes data from a larger investigation aiming to support the sustained implementation of Cognitive Processing Therapy (CPT) in community mental health treatment settings. Enrolled therapists participated in phone interviews discussing their opinions of CPT, preferred treatments for PTSD, and process in assessing appropriate PTSD treatments for clients. Semi-structured interviews (N = 29) were transcribed and analyzed using a directed content analysis approach. Several themes emerged regarding therapists' decision-making in selecting PTSD treatments. Therapist motivations to use EBPs for PTSD, primarily CPT, were identified at the client (e.g., perceived compatibility with client-level characteristics), therapist (e.g., time limitations), and clinic levels (e.g., leadership support). The results provide insight into the complex array of factors that affect sustainability of EBPs for PTSD in community settings and inform future dissemination of EBPs, including training efforts in community settings.
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12
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Hooley C, Salvo D, Brown DS, Brookman-Frazee L, Lau AS, Brownson RC, Fowler PJ, Innes-Gomberg D, Proctor EK. Scaling-up Child and Youth Mental Health Services: Assessing Coverage of a County-Wide Prevention and Early Intervention Initiative During One Fiscal Year. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2023; 50:17-32. [PMID: 36289142 PMCID: PMC9977707 DOI: 10.1007/s10488-022-01220-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2022] [Indexed: 02/03/2023]
Abstract
PURPOSE In the U.S., the percentage of youth in need of evidence-based mental health practices (EBPs) who receive them (i.e., coverage rate) is low. We know little about what influences coverage rates. In 2010, the Los Angeles County Department of Mental Health (LACDMH) launched a reimbursement-driven implementation of multiple EBPs in youth mental health care. This study examines two questions: (1) What was the coverage rate of EBPs delivered three years following initial implementation? (2) What factors are associated with the coverage rates? METHODS To assess coverage rates of publicly insured youth, we used LACDMH administrative claims data from July 1, 2013 to June 30, 2014 and estimates of the size of the targeted eligible youth population from the 2014 American Community Survey (ACS). The unit of analysis was clinic service areas (n = 254). We used Geographic Information Systems and an OLS regression to assess community and clinic characteristics related to coverage. RESULTS The county coverage rate was estimated at 17%, much higher than national estimates. The proportion of ethnic minorities, individuals who are foreign-born, adults with a college degree within a geographic area were negatively associated with clinic service area coverage rates. Having more therapists who speak a language other than English, providing care outside of clinics, and higher proportion of households without a car were associated with higher coverage rates. CONCLUSION Heterogeneity in municipal mental health record type and availability makes it difficult to compare the LACDMH coverage rate with other efforts. However, the LACDMH initiative has higher coverage than published national rates. Having bilingual therapists and providing services outside the clinic was associated with higher coverage. Even with higher coverage, inequities persisted.
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Affiliation(s)
- Cole Hooley
- Brigham Young University, 84602, Provo, UT, USA.
| | - Deborah Salvo
- Department of Kinesiology and Health Education, The University of Texas at Austin, Bellmont Hall 822J, 2109 San Jacinto Blvd, Stp D3700, 78712, Austin, TX, United States
| | - Derek S Brown
- Brown School, Washington University in St. Louis, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Lauren Brookman-Frazee
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive #0812, 92093, La Jolla, CA, USA
| | - Anna S Lau
- UCLA Department of Psychology, 502 Portola Plaza, 90095, Los Angeles, CA, USA
| | - Ross C Brownson
- Prevention Research Center, Brown School, Department of Surgery, Division of Public Health Sciences, and Alvin J. Siteman Cancer Center, Washington University in St. Louis, Washington University School of Medicine, Washington University in St. Louis CDC U48DP006395, the Foundation for Barnes-Jewish Hospital, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Patrick J Fowler
- Brown School, Washington University in St. Louis, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Debbie Innes-Gomberg
- Los Angeles County Department of Mental Health, 510 S. Vermont Avenue, 17th Floor, 90020, Los Angeles, CA, USA
| | - Enola K Proctor
- Brown School, Washington University in St. Louis, 1 Brookings Drive, 63130, St. Louis, MO, USA
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13
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Thompson-Hollands J, Rando AA, Stoycos SA, Meis LA, Iverson KM. Family Involvement in PTSD Treatment: Perspectives from a Nationwide Sample of Veterans Health Administration Clinicians. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2022; 49:1019-1030. [PMID: 35930084 PMCID: PMC9362012 DOI: 10.1007/s10488-022-01214-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2022] [Indexed: 01/25/2023]
Abstract
Social support is bidirectionally linked to symptoms of posttraumatic stress disorder (PTSD). Evidence suggests that family involvement in veterans' mental health treatment is desired by both veterans and family members, and that such involvement has the potential to improve treatment outcomes. However, rates of family involvement are low in the Veterans Health Administration (VHA). We sought to understand VHA clinicians' perspectives on family involvement in PTSD treatment by conducting qualitative interviews with 31 providers at 10 VHA facilities across the U.S. The i-PARIHS framework was used to guide the interviews and analysis, and several major themes were identified. All clinicians reported that they at least occasionally offered family-inclusive sessions, and they frequently referenced both the influence of family behaviors or attitudes on veterans' functioning, and also how veterans' symptoms could cause tremendous disruption in the family. Clinicians' past experience with supervised family- or couple-based work strongly influenced their current comfort with family-inclusive sessions. Multiple potential avenues exist to support increased family involvement in PTSD treatment in VHA.
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Affiliation(s)
- Johanna Thompson-Hollands
- Behavioral Science Division of the National Center for PTSD at VA Boston Healthcare System, Boston, MA, USA.
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA.
| | | | - Sarah A Stoycos
- Behavioral Science Division of the National Center for PTSD at VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Laura A Meis
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Katherine M Iverson
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
- Women's Health Sciences Division of the National Center for PTSD at VA Boston Healthcare System, Boston, MA, USA
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14
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LoSavio ST, Holder N, Wells SY, Resick PA. Clinician Concerns About Cognitive Processing Therapy: A Review of the Evidence. COGNITIVE AND BEHAVIORAL PRACTICE 2022. [DOI: 10.1016/j.cbpra.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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15
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Clinical and Administrative Insights From Delivering Massed Trauma-Focused Therapy to Service Members and Veterans. COGNITIVE AND BEHAVIORAL PRACTICE 2022. [DOI: 10.1016/j.cbpra.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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16
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Fortney JC, Rajan S, Reisinger HS, Moeckli J, Nolan JP, Wong ES, Rise P, Petrova VV, Sayre GG, Pyne JM, Grubaugh A, Simsek-Duran F, Grubbs KM, Morland LA, Felker B, Schnurr PP. Deploying a telemedicine collaborative care intervention for posttraumatic stress disorder in the U.S. Department of Veterans Affairs: A stepped wedge evaluation of an adaptive implementation strategy. Gen Hosp Psychiatry 2022; 77:109-117. [PMID: 35596963 DOI: 10.1016/j.genhosppsych.2022.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/08/2022] [Accepted: 03/23/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To address barriers to trauma-focused psychotherapy for veterans with posttraumatic stress disorder (PTSD), we compared two implementation strategies to promote the deployment of telemedicine collaborative care. METHOD We conducted a Hybrid Type III Effectiveness Implementation trial at six VA medical centers and their 12 affiliated Community Based Outpatient Clinics. The trial used a stepped wedge design and an adaptive implementation strategy that started with standard implementation, followed by enhanced implementation for VA medical centers that did not achieve the performance benchmark. Implementation outcomes for the 544 veterans sampled from the larger population targeted by the intervention were assessed from chart review (care management enrollment and receipt of trauma-focused psychotherapy) and telephone survey (perceived access and PTSD symptoms) after each implementation phase. The primary outcome was enrollment in care management. RESULTS There was no significant difference between standard implementation and enhanced implementation on any of the implementation outcomes. 41.6% of sampled veterans had a care manager encounter, but only 6.0% engaged in trauma-focused psychotherapy. CONCLUSIONS While telemedicine collaborative care was shown to be effective at engaging veterans in trauma-focused psychotherapy in a randomized controlled trial, neither standard nor enhanced implementation strategies were sufficient to support successful deployment into routine care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02737098.
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Affiliation(s)
- John C Fortney
- VA HSR&D Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States of America; Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States of America.
| | - Suparna Rajan
- VA HSR&D Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States of America
| | - Heather S Reisinger
- VA HSR&D Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, IA, United States of America; Department of Internal Medicine, University of Iowa, Iowa City, IA, United States of America
| | - Jane Moeckli
- VA HSR&D Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, IA, United States of America
| | | | - Edwin S Wong
- VA HSR&D Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States of America; Department of Health and Systems and Population Health, University of Washington, Seattle, WA, United States of America
| | - Peter Rise
- VA HSR&D Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States of America
| | - Valentina V Petrova
- VA HSR&D Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States of America
| | - George G Sayre
- VA HSR&D Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States of America
| | - Jeffrey M Pyne
- VA HSR&D Center for Mental Health and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, AR, United States of America; Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Anouk Grubaugh
- VA HSR&D Charleston Health Equity and Rural Outreach Innovation Center, Charleston, SC, United States of America; Department of Psychiatry, Medical University of South Carolina, Charleston, SC, United States of America
| | - Fatma Simsek-Duran
- Iowa City VA Health Care System, IA, United States of America; Department of Psychiatry, University of Iowa, Iowa City, IA, United States of America
| | - Kathleen M Grubbs
- VA San Diego Healthcare System, San Diego, CA, United States of America; Department of Psychiatry, University of California-San Diego, San Diego, CA, United States of America
| | - Leslie A Morland
- VA San Diego Healthcare System, San Diego, CA, United States of America; Department of Psychiatry, University of California-San Diego, San Diego, CA, United States of America
| | - Bradford Felker
- VA HSR&D Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States of America; Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States of America
| | - Paula P Schnurr
- National Center for PTSD, VA Medical Center, White River Junction, VT, United States of America; Geisel School of Medicine at Dartmouth, Hanover, NH, United States of America
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Sayer NA, Wiltsey-Stirman S, Rosen CS, Bernardy NC, Spoont MR, Kehle-Forbes SM, Eftekhari A, Chard KM, Nelson DB. Investigation of Therapist Effects on Patient Engagement in Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration. J Trauma Stress 2022; 35:66-77. [PMID: 34048602 DOI: 10.1002/jts.22679] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 03/07/2021] [Accepted: 03/08/2021] [Indexed: 12/11/2022]
Abstract
The present study examined whether certain Veterans Health Administration (VHA) therapists have more success than others in keeping patients engaged in evidence-based psychotherapies for posttraumatic stress disorder (PTSD). Our objective was to use multilevel modeling to quantify the variability between therapists in two indicators of patient engagement: early dropout (i.e., < 3 sessions) and adequate dose (i.e., ≥ 8 sessions). The phenomenon of systematic variability between therapists in patients' treatment experience and outcomes is referred to as "therapist effects." The sample included the 2,709 therapists who provided individual cognitive processing therapy (CPT) or prolonged exposure (PE) to 18,461 veterans with PTSD across 140 facilities in 2017. Data were extracted from administrative databases. For CPT, therapist effects accounted for 10.9% of the variance in early dropout and 8.9% of the variance in adequate dose. For PE, therapist effects accounted for 6.0% and 8.8% of the variance in early dropout and adequate dose, respectively. Facility only accounted for an additional 1.1%-3.1% of the variance in early dropout and adequate dose. For CPT, patients' odds of receiving an adequate dose almost doubled, OR = 1.41/0.72 = 1.96, if they were seen by a therapist in the highest compared with the lowest retention decile. For PE, the odds of a patient receiving an adequate dose were 84% higher, OR = 1.38/0.75 = 1.84, when treated by a therapist in the highest compared with the lowest retention decile. Therapist skills and work environment may contribute to variability across therapists in early dropout and adequate dose.
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Affiliation(s)
- Nina A Sayer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shannon Wiltsey-Stirman
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California, USA.,Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Craig S Rosen
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California, USA.,Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Nancy C Bernardy
- Executive Division, National Center for PTSD, White River Junction, Vermont, USA.,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Michele R Spoont
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shannon M Kehle-Forbes
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Afsoon Eftekhari
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Kathleen M Chard
- Cincinnati Department of Veterans Affairs (VA) Medical Center, Cincinnati, Ohio, USA.,University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David B Nelson
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Chen JA, Matson TE, Lehavot K, Raue PJ, Young JP, Silvestrini MC, Fortney JC, Williams EC. Provider Perspectives on Implementing Shared Decision Making for PTSD Treatment in VA Primary Care. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2021; 48:1046-1054. [PMID: 33625623 PMCID: PMC8382773 DOI: 10.1007/s10488-021-01119-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Abstract
Shared decision making is an important implementation "pull" strategy for increasing uptake of evidence-based mental health practices. In this qualitative study, we explored provider perspectives on implementing shared decision making at the point of mental health treatment initiation using a publicly available, patient-facing decision support tool for post-traumatic stress disorder (PTSD). We conducted semi-structured interviews with 22 mental health providers (psychiatrists, nurses, psychologists, and social workers) working in one of five VA primary care clinics. Interviewed were analyzed using thematic analysis. Provider were enthusiastic about using decision aids as a source of high quality information that could improve patient experience and confidence in treatment. However, providers had concerns about decision aid accessibility, time constraints to conduct shared decision making in-session, and patient motivation to engage in shared decision making. Providers stated they would prefer to use shared decision making with patients that they felt were most likely to follow through with treatment. While providers believed that shared decision making could improve PTSD treatment planning, they thought it most appropriate for patients with the highest levels of motivation and fewest barriers to care. These beliefs may limit widespread adoption and reflect missed opportunities to reach difficult-to-engage patients.
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Affiliation(s)
- Jessica A Chen
- Health Services Research & Development (HSR&D) Center of Innovation (COIN), Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, S-152, Seattle, WA, 98108, USA.
- Department of Psychiatry & Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Room BB1644, Box 356560, Seattle, WA, 98195-6560, USA.
| | - Theresa E Matson
- Department of Health Services, University of Washington, Magnuson Health Sciences Center, 1959 NE Pacific St., Room H-680, Box 357660, Seattle, WA, 98195-7660, USA
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101-1466, USA
| | - Keren Lehavot
- Health Services Research & Development (HSR&D) Center of Innovation (COIN), Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, S-152, Seattle, WA, 98108, USA
- Department of Psychiatry & Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Room BB1644, Box 356560, Seattle, WA, 98195-6560, USA
- Department of Health Services, University of Washington, Magnuson Health Sciences Center, 1959 NE Pacific St., Room H-680, Box 357660, Seattle, WA, 98195-7660, USA
| | - Patrick J Raue
- Department of Psychiatry & Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Room BB1644, Box 356560, Seattle, WA, 98195-6560, USA
| | - Jessica P Young
- Health Services Research & Development (HSR&D) Center of Innovation (COIN), Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, S-152, Seattle, WA, 98108, USA
| | - Molly C Silvestrini
- Health Services Research & Development (HSR&D) Center of Innovation (COIN), Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, S-152, Seattle, WA, 98108, USA
- Department of Psychiatry & Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Room BB1644, Box 356560, Seattle, WA, 98195-6560, USA
| | - John C Fortney
- Health Services Research & Development (HSR&D) Center of Innovation (COIN), Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, S-152, Seattle, WA, 98108, USA
- Department of Psychiatry & Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Room BB1644, Box 356560, Seattle, WA, 98195-6560, USA
- Department of Health Services, University of Washington, Magnuson Health Sciences Center, 1959 NE Pacific St., Room H-680, Box 357660, Seattle, WA, 98195-7660, USA
| | - Emily C Williams
- Health Services Research & Development (HSR&D) Center of Innovation (COIN), Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, S-152, Seattle, WA, 98108, USA
- Department of Health Services, University of Washington, Magnuson Health Sciences Center, 1959 NE Pacific St., Room H-680, Box 357660, Seattle, WA, 98195-7660, USA
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19
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Held P, Klassen BJ, Coleman JA, Thompson K, Rydberg TS, Van Horn R. Delivering Intensive PTSD Treatment Virtually: The Development of a 2-Week Intensive Cognitive Processing Therapy-Based Program in Response to COVID-19. COGNITIVE AND BEHAVIORAL PRACTICE 2021; 28:543-554. [PMID: 34629839 PMCID: PMC8488183 DOI: 10.1016/j.cbpra.2020.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/18/2020] [Indexed: 11/24/2022]
Abstract
Of the many vulnerable groups affected by the spread of COVID-19, veterans have been especially impacted by the pandemic. Beginning in March 2020, nationwide shelter-in-place orders rapidly led to widespread job loss and economic upheaval; disruption and breakdown of multiple support systems; and increases in family stress, all of which may exacerbate underlying PTSD symptoms. Although telehealth has proven an effective means of delivering evidence-based psychotherapies for PTSD, little is known about the delivery of these treatments in an intensive, daily format over telehealth. There is growing need for intensive treatment options to reduce treatment-interfering barriers such as high dropout rates. In order to address this gap in the literature, this paper details several design considerations as well as patient selection procedures for a 2-week virtual intensive treatment program (vITP) for veterans with posttraumatic stress disorder (PTSD), consisting of daily individual Cognitive Processing Therapy (CPT) and other adjunctive interventions. We also describe two cases of veterans who successfully completed the vITP including their clinical outcomes, therapist reflections on the process, feedback regarding the program, as well as challenges patients encountered with the telehealth platform. Intensive evidence-based psychotherapy for PTSD delivered through a virtual format seems to show promise, but more systemic research is needed.
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20
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Doran JM, O'Shea M, Harpaz-Rotem I. In Their Own Words: Veteran Experiences with Evidence-Based Treatments for PTSD in the Veterans Health Administration. Psychiatr Q 2021; 92:961-980. [PMID: 33409926 DOI: 10.1007/s11126-020-09861-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2020] [Indexed: 11/29/2022]
Abstract
The aim of the present study was to increase the understanding of veteran experiences with receiving an evidence-based psychotherapy (EBPs) for PTSD (Cognitive Processing Therapy and Prolonged Exposure therapy) in the Veterans Affairs Healthcare System (VA). Eighteen veterans who participated in the study were being seen in the outpatient PTSD clinic at a New England VA and had elected to participate in an EBP. The study assessed veteran experiences with, and outcomes from, treatment through the use of both quantitative and qualitative assessment tools. A rigorous data analytic approach, Consensual Qualitative Research, was applied to narrative data. Results fell into seven domains: Previous EBP & Outcome, Barriers to Treatment, Treatment Process, Treatment Outcome, Treatment Drop Out, and Feelings about Treatment. Overall, veterans reported diverse reactions to the EBPs for PTSD and identified both positive and negative aspects of the treatments. They identified multiple barriers to treatment completion and provided insight into their thoughts and feelings during the treatment protocol. Veterans who chose to drop out of treatment prematurely identified the factors that contributed to this decision. In this way, the study offers an initial but important look at veteran perceptions of and experiences with EBPs for PTSD.
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Affiliation(s)
- Jennifer M Doran
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, USA. .,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
| | - McKenna O'Shea
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, USA.,Roosevelt University, Chicago, IL, USA
| | - Ilan Harpaz-Rotem
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.,Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, CT, USA
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21
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Dufort VM, Bernardy N, Maguen S, Hoyt JE, Litt ER, Patterson OV, Leonard CE, Shiner B. Geographic Variation in Initiation of Evidence-based Psychotherapy Among Veterans With PTSD. Mil Med 2021; 186:e858-e866. [DOI: 10.1093/milmed/usaa389] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/14/2020] [Accepted: 09/23/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
The United States Department of Veterans Affairs (VA) has invested in implementation of evidence-based psychotherapy (EBP) for post-traumatic stress disorder (PTSD) for over a decade, resulting in slow but steady uptake of these treatments nationally. However, no prior research has investigated the geographic variation in initiation of EBP. Our objectives were to determine whether there is geographic variation in the initiation of EBP for PTSD in the VA and to identify patient and clinic factors associated with EBP initiation.
Materials and Methods
We identified VA patients with PTSD who had not received EBP as of January 2016 (N = 946,667) using retrospective electronic medical records data and determined whether they initiated EBP by December 2017. We illustrated geographic variation in EBP initiation using national and regional maps. Using multivariate logistic regression, we determined patient, regional, and nearest VA facility predictors of initiating treatment. This study was approved by the Veterans Institutional Review Board of Northern New England.
Results
Nationally, 4.8% (n = 45,895) initiated EBP from 2016 to 2017, and there was geographic variation, ranging from none to almost 30% at the 3-digit ZIP code level. The strongest patient predictors of EBP initiation were the negative predictor of being older than 65 years (OR = 0.47; 95% CI, 0.45-0.49) and the positive predictor of reporting military-related sexual trauma (OR = 1.96; 95% CI, 1.90-2.03). The strongest regional predictors of EBP initiation were the negative predictor of living in the Northeast (OR = 0.89; 95% CI, 0.86-0.92) and the positive predictor of living in the Midwest (OR = 1.47; 95% CI, 1.44-1.51). The only nearest VA facility predictor of EBP initiation was the positive predictor of whether the facility was a VA Medical Center with a specialized PTSD clinic (OR = 1.23; 95% CI, 1.20-1.26).
Conclusion
Although less than 5% of VA patients with PTSD initiated EBP, there was regional variation. Patient factors, region of residence, and nearest VA facility characteristics were all associated with whether patients initiated EBP. Strengths of this study include the use of national longitudinal data, while weaknesses include the potential for misclassification of PTSD diagnoses as well as the potential for misidentification of EBP. Our work indicates geographic areas where access to EBP for PTSD may be poor and can help target work improving access. Future studies should also assess completion of EBP for PTSD and related symptomatic and functional outcomes across geographic areas.
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Affiliation(s)
| | - Nancy Bernardy
- National Center for PTSD Executive Division, VT 05009, USA
- Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH 03755, USA
| | - Shira Maguen
- San Francisco VA Health Care System, San Francisco, CA 94121, USA
- Psychiatry, University of California San Francisco, San Francisco, CA 94115, USA
| | | | - Eric R Litt
- Veterans Rural Health Resource Center, Gainesville, FL 32608, USA
| | - Olga V Patterson
- VA Salt Lake City Health Care System, Salt Lake City, UT 84148, USA
- Internal Medicine, University of Utah, Salt Lake City, UT 84132, USA
| | | | - Brian Shiner
- White River Junction VA Medical Center, VT 05009, USA
- Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH 03755, USA
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22
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Sijercic I, Lane JEM, Gutner CA, Monson CM, Stirman SW. The Association Between Clinician and Perceived Organizational Factors with Early Fidelity to Cognitive Processing Therapy for Posttraumatic Stress Disorder in a Randomized Controlled Implementation Trial. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2021; 47:8-18. [PMID: 31463667 DOI: 10.1007/s10488-019-00966-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A common metric for determining implementation success is the measurement of clinician adherence to, and competence in, delivering a psychotherapy. The present study examined clinician and organizational factors as predictors of early adherence and competence among 78 clinicians delivering cognitive processing therapy (CPT), an evidence-based psychotherapy (EBP) for posttraumatic stress disorder, in a randomized controlled implementation trial. Results indicated that clinicians' willingness to adopt an EBP if required to do so was significantly associated with early adherence and competence in CPT delivery. Level of clinician education was significantly associated with early competence in delivering CPT. Organizational factors did not predict early adherence or competence. Implications of the findings are discussed.
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Affiliation(s)
| | | | | | | | - Shannon Wiltsey Stirman
- National Center for PTSD, VA Palo Alto Healthcare System & Stanford University, 795 Willow Road, NC-PTSD 334, Menlo Park, CA, 94025, USA.
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23
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Ford JH, Gilson A. Influence of participation in a quality improvement collaborative on staff perceptions of organizational sustainability. BMC Health Serv Res 2021; 21:34. [PMID: 33413357 PMCID: PMC7791971 DOI: 10.1186/s12913-020-06026-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 12/17/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Sustainability capacity (SC), which is an organization's ability to implement and maintain change, is influenced by internal attributes, environmental contextual influencers, and intervention attributes. Temporal changes in staff SC perceptions, as well as the influence of quality improvement collaborative (QIC) participation, has generally not been explored. This project addresses this gap, measuring staff SC perceptions at four time points (baseline and every 9 months) for clinics participating in an intervention - the Network for the Improvement of Addiction Treatment QIC initiative (called NIATx200). METHODS A mixed linear model repeated measures analysis was applied to matched staff members (n = 908, representing 2329 total cases) across the evaluation timeframe. Three separate statistical models assessed potential predictors of SC perceptions: Time (Models I-III); NIATx200 intervention, staff job function, and tenure (Models II &III); and NIATx200 participation hours and four organizational variables (Model III). RESULTS For Model I, staff perceptions of total SC increased throughout most of the study (t1,4 = - 6.74, p < .0001; t2,4 = - 3.100, p < .036; t3,4 = - 0.23, p = ns). Model II did not change Model I's overall Time effect, but combined NIATx200 services (t = - 2.23, p = .026), staff job function (t = - 3.27, p = .001), and organizational administrators (t = - 3.50, p = .001) were also significantly associated with greater perceptions of total SC. Inclusion of additional variables in Model III demonstrated the importance of a higher participation level (t = - 3.09, p < .002) and being in a free-standing clinic (t = - 2.06, p < .04) on staff perceptions of total SC. CONCLUSION Although staff exposure to sustainability principals was minimal in NIATx200, staff perceptions about their organization's SC significantly differed over time. However, an organization's participation level in a QIC became the principal predictor of staff SC perceptions, regardless of other factors' influence. Given these findings, it is possible to develop and introduce specific sustainability content within the structure of a QIC to assess the impact on staff SC perceptions over time and the sustainment of organizational change. TRIAL REGISTRATION ClinicalTrials.gov , NCT00934141 . Registered July 6, 2009. Retrospectively registered.
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Affiliation(s)
- James H Ford
- University of Wisconsin - Madison School of Pharmacy, 777 Highland Ave, Madison, WI, 53705, USA.
| | - Aaron Gilson
- University of Wisconsin - Madison School of Pharmacy, 777 Highland Ave, Madison, WI, 53705, USA
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24
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Becker-Haimes EM, Byeon YV, Frank HE, Williams NJ, Kratz HE, Beidas RS. Identifying the organizational innovation-specific capacity needed for exposure therapy. Depress Anxiety 2020; 37:1007-1016. [PMID: 32390315 PMCID: PMC7822059 DOI: 10.1002/da.23035] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 09/15/2019] [Accepted: 04/20/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Current approaches to increasing the rates of clinician use of exposure therapy for anxiety disorders in community settings are limited. Research underscores the importance of addressing contextual variables to facilitate clinician use of evidence-based practices; however, no studies have identified the innovation-specific organizational capacity necessary to implement exposure therapy. Such work is critical to ensure that treatment-seeking individuals with anxiety receive effective care. METHODS We used a two-step process to identify the innovation-specific organizational capacity necessary to deliver exposure. First, 24 leaders of specialty anxiety clinics in the United States (50% female, mean [M]age = 47.7 years) completed a survey about the organizational innovation-specific capacity (e.g., policies and procedures) they employ to support their providers in delivering exposure therapy. Second, 19 community clinicians (79% female, M age = 42.9 years) reported on the extent to which these characteristics were present in their settings. RESULTS In Step 1, specialty clinic leaders unanimously endorsed six organizational characteristics as essential and five as important within the areas of organizational policies, supervisory support, and peer clinician support. These characteristics were present in more than 90% of specialty clinics. In Step 2, therapists in community clinics reported these characteristics were minimally present in their organizations. CONCLUSIONS Specialty clinic leaders exhibited consensus on the innovation-specific organizational capacity necessary to implement exposure therapy. Identified characteristics were largely absent from community clinics. Developing fiscal, policy, or organizational strategies that enhance the organizational capacity within community settings may improve the patients' access to effective treatment for anxiety disorders.
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Affiliation(s)
- Emily M. Becker-Haimes
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Young Vivian Byeon
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hannah E. Frank
- Department of Psychology, Temple University, Philadelphia, Pennsylvania
| | | | - Hilary E. Kratz
- Department of Psychology, La Salle University, Philadelphia, Pennsylvania
| | - Rinad S. Beidas
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, Pennsylvania,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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25
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Pace BT, Song J, Suvak MK, Shields N, Monson CM, Stirman SW. Therapist Self-Efficacy in Delivering Cognitive Processing Therapy in a Randomized Controlled Implementation Trial. COGNITIVE AND BEHAVIORAL PRACTICE 2020. [DOI: 10.1016/j.cbpra.2020.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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26
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Evaluation of an Implementation Intervention to Increase Reach of Evidence-Based Psychotherapies for PTSD in US Veterans Health Administration PTSD Clinics. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2020; 48:450-463. [PMID: 32944814 DOI: 10.1007/s10488-020-01086-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2020] [Indexed: 10/23/2022]
Abstract
To evaluate an implementation intervention to increase the uptake, referred to as reach, of two evidence-based psychotherapies (EBP) for posttraumatic stress disorder (PTSD) in Veterans Health Administration (VHA) PTSD specialty clinics. The implementation intervention was external facilitation guided by a toolkit that bundled strategies associated with high EBP reach in prior research. We used a prospective quasi-experimental design. The facilitator worked with local champions at two low-reach PTSD clinics. Each intervention PTSD clinic was matched to three control clinics. We compared the change in EBP reach from 6-months pre- to post-intervention using Difference-in-Difference (DID) effect estimation. To incorporate possible clustering effects and adjust for imbalanced covariates, we used mixed effects logistic regression to model the probability of EBP receipt. Analyses were conducted separately for PTSD and other mental health clinics. 29,446 veterans diagnosed with PTSD received psychotherapy in the two intervention and six control sites in the two 6-month evaluation periods. The proportion of therapy patients with PTSD receiving an EBP increased by 16.98 percentage points in the intervention PTSD clinics compared with .45 percentage points in the control PTSD clinics (DID = 16.53%; SE = 2.26%). The adjusted odd ratio of a patient receiving an EBP from pre to post intervention was almost three times larger in the intervention than in the control PTSD clinics (RoR 2.90; 95% CI 2.22-3.80). EBP reach was largely unchanged in other (not PTSD specialty) mental health clinics within the same medical centers. Toolkit-guided external facilitation is a promising intervention to improve uptake of EBPs in VHA. Toolkits that pre-specify targets for clinic change based on prior research may enhance the efficiency and effectiveness of external facilitation. Trial registration ISRCTN registry identifier: ISRCTN65119065. Available at https://www.isrctn.com/search?q=ISRCTN65119065 .
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27
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Cook JM, Simiola V, Thompson R, Mackintosh MA, Rosen C, Sayer N, Schnurr PP. Implementation Patterns of Two Evidence-Based Psychotherapies in Veterans Affairs Residential Posttraumatic Stress Disorder Programs: A Five-Point Longitudinal National Investigation. J Trauma Stress 2020; 33:432-442. [PMID: 32583606 PMCID: PMC7719091 DOI: 10.1002/jts.22557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/06/2020] [Accepted: 04/08/2020] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Joan M. Cook
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA,National Center for PTSD, West Haven, Connecticut, USA
| | - Vanessa Simiola
- Center for Integrated Health Care Research, Kaiser Permanente, Honolulu, Hawaii, USA
| | - Richard Thompson
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas, USA
| | | | - Craig Rosen
- National Center for PTSD, West Haven, Connecticut, USA,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Nina Sayer
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA,Departments of Medicine, Psychiatry, and Psychology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Paula P. Schnurr
- National Center for PTSD, West Haven, Connecticut, USA,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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28
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Rosen CS, Davis CA, Riggs D, Cook J, Peterson AL, Young-McCaughan S, Comtois KA, Haddock CK, Borah EV, Dondanville KA, Finley EP, Jahnke SA, Poston WSC, Wiltsey-Stirman S, Neitzer A, Broussard CR, Brzuchalski MA, Clayton MSP, Conforte LAM, Flores A, Hein J, Keith CF, Jinkerson CJ, Letendre M, Nofziger D, Pollick K, Santiago CK, Waggoner LCJ, Woodworth C, McLean CP. Targeted Assessment and Context-Tailored Implementation of Change Strategies (TACTICS) to increase evidence based psychotherapy in military behavioral health clinics: Design of a cluster-randomized stepped-wedge implementation study. Contemp Clin Trials 2020; 93:106008. [PMID: 32330670 DOI: 10.1016/j.cct.2020.106008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/21/2020] [Accepted: 04/13/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Despite efforts by the U.S. Department of Defense to train behavioral health (BH) providers in evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), numerous barriers limit EBP implementation. A context-tailored implementation approach called TACTICS (Targeted Assessment and Context-Tailored Implementation of Change Strategies) holds promise for increasing the use of EBPs such as prolonged exposure therapy (PE) in military treatment facilities. TACTICS combines a needs assessment, a rubric for selecting implementation strategies based on local barriers, an implementation toolkit, and external facilitation to support local champions and their implementation teams in enacting changes. This paper describes the rationale for and design of a study that will evaluate whether TACTICS can increase implementation of PE for PTSD and improve patient outcomes in military BH clinics relative to provider training in PE alone. METHODS The study is a multi-site, cluster randomized, stepped-wedge trial, with the military treatment facility as the unit of analysis. Eight facilities undergo a provider-training phase, followed by 5 months of TACTICS implementation. The timing of TACTICS at each facility is randomly assigned to begin 9, 14, or 19 months after beginning the provider-training phase. Primary analyses will compare the proportion of PTSD patients receiving PE and patients' mean improvement in PTSD symptoms before and after the onset of TACTICS. DISCUSSION TACTICS endeavors to balance standardization of empirically-supported implementation strategies with the flexibility of application necessary for success across varied clinical settings. If successful, TACTICS may represent a systematic and scalable method of promoting and supporting EBP implementation. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT03663452.
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Affiliation(s)
- Craig S Rosen
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, 795 Willow Rd, Menlo Park, CA, United States of America; Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Rd, Palo Alto, CA 94305, United States of America.
| | - C Adrian Davis
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, 795 Willow Rd, Menlo Park, CA, United States of America.
| | - David Riggs
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814, United States of America.
| | - Jeffery Cook
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814, United States of America.
| | - Alan L Peterson
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229, United States of America; Research and Development Service, South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229, United States of America; Department of Psychology, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249, United States of America.
| | - Stacey Young-McCaughan
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229, United States of America.
| | - Katherine Anne Comtois
- Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, United States of America.
| | - Christopher K Haddock
- Social Sciences Innovations Corporation, 71 W 23rd St 4th Floor, New York, NY 10010, United States of America.
| | - Elisa V Borah
- University of Texas at Austin, Steve Hicks School of Social Work, 1925 San Jacinto Blvd, Austin, TX 78712, United States of America.
| | - Katherine A Dondanville
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229, United States of America.
| | - Erin P Finley
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229, United States of America; Department of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229, United States of America; Veterans Evidence-based Research Dissemination and Implementation Center (VERDICT), South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229, United States of America.
| | - Sara A Jahnke
- Social Sciences Innovations Corporation, 71 W 23rd St 4th Floor, New York, NY 10010, United States of America.
| | - Walker S C Poston
- Social Sciences Innovations Corporation, 71 W 23rd St 4th Floor, New York, NY 10010, United States of America.
| | - Shannon Wiltsey-Stirman
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, 795 Willow Rd, Menlo Park, CA, United States of America; Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Rd, Palo Alto, CA 94305, United States of America.
| | - Andrea Neitzer
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, 795 Willow Rd, Menlo Park, CA, United States of America.
| | - Capt Rachel Broussard
- David Grant United States Air Force Medical Center, Travis Air Force Base, 101 Bodin Cir, Fairfield, CA, 94533, United States of America.
| | - Maj Amy Brzuchalski
- William Beaumont Army Medical Center, Ft. Bliss, 5005 N Piedras St, El Paso, TX 79920, United States of America.
| | - Maj Spencer P Clayton
- 49th Medical Group, Holloman Air Force Base, 280 1st St, Alamogordo, NM 88330, United States of America.
| | - Lt Allison M Conforte
- Naval Hospital Jacksonville, Naval Air Station Jacksonville, 2080 Child St, Jacksonville, FL 32214, United States of America.
| | - Araceli Flores
- William Beaumont Army Medical Center, Ft. Bliss, 5005 N Piedras St, El Paso, TX 79920, United States of America.
| | - Jessica Hein
- Blanchfield Army Community Hospital, Ft. Campbell, 650 Joel Dr, Fort Campbell, KY 42223, United States of America.
| | - Capt Felicia Keith
- David Grant United States Air Force Medical Center, Travis Air Force Base, 101 Bodin Cir, Fairfield, CA, 94533, United States of America.
| | - Capt Jeremy Jinkerson
- 81st Medical Group, Keesler Air Force Base, 500 Fisher St, Biloxi, MS 39534, United States of America.
| | - Margaret Letendre
- Bassett Army Community Hospital, Ft. Wainwright, 4076 Neely Rd, Fairbanks, AK 99703, United States of America.
| | - Debra Nofziger
- Brooke Army Medical Center, Joint Base San Antonio-Ft. Sam Houston, 3551 Roger Brooke Dr, San Antonio, TX, 78234, United States of America.
| | - Kirsten Pollick
- Naval Hospital Jacksonville, Naval Air Station Jacksonville, 2080 Child St, Jacksonville, FL 32214, United States of America.
| | - Capt Kyra Santiago
- 49th Medical Group, Holloman Air Force Base, 280 1st St, Alamogordo, NM 88330, United States of America.
| | - Lt Col John Waggoner
- 81st Medical Group, Keesler Air Force Base, 500 Fisher St, Biloxi, MS 39534, United States of America.
| | - Craig Woodworth
- Brooke Army Medical Center, Joint Base San Antonio-Ft. Sam Houston, 3551 Roger Brooke Dr, San Antonio, TX, 78234, United States of America.
| | - Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, 795 Willow Rd, Menlo Park, CA, United States of America; Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Rd, Palo Alto, CA 94305, United States of America.
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Miller C, Gurewich D, Garvin L, Pugatch M, Koppelman E, Pendergast J, Harrington K, Clark JA. Veterans Affairs and Rural Community Providers' Perspectives on Interorganizational Care Coordination: A Qualitative Analysis. J Rural Health 2020; 37:417-425. [PMID: 32472724 DOI: 10.1111/jrh.12453] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To investigate challenges in care coordination between US Department of Veterans Affairs (VA) clinics and community providers serving rural veterans. METHODS We completed qualitative interviews in 2017-2018 with a geographically diverse sample of 57 VA and community staff. Interviews were audio-recorded and transcribed verbatim. We used Rapid Qualitative Inquiry (RQI) to guide analyses. RESULTS Results suggested 5 pivotal domains related to interorganizational care coordination at these sites: organizational mechanisms; organizational culture; relational coordination; contextual factors; and the role of the third party administrators charged with management of scheduling and reimbursement of community services through recent legislation. Across these domains, strategies to bridge gaps between organizations (eg, contracts with third party administrators, development of VA-based community care offices, provision of boundary-spanning staff) at times exacerbated coordination challenges. CONCLUSIONS Steps taken to improve interorganizational care coordination between VA and community clinics may inadvertently complicate an already complex process. Our findings emphasize the importance of attending to key contextual barriers in coordinating care for rural veterans, and they illustrate the value of fundamental structural and relational approaches to enhancing such care coordination.
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Affiliation(s)
- Christopher Miller
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Deborah Gurewich
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts
| | - Lynn Garvin
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts
- Boston University School of Public Health, Boston, Massachusetts
| | - Marianne Pugatch
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts
| | - Elisa Koppelman
- Boston University School of Public Health, Boston, Massachusetts
| | - Jacquelyn Pendergast
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts
| | - Katharine Harrington
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts
| | - Jack A Clark
- Boston University School of Public Health, Boston, Massachusetts
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Valenstein-Mah H, Greer N, McKenzie L, Hansen L, Strom TQ, Wiltsey Stirman S, Wilt TJ, Kehle-Forbes SM. Effectiveness of training methods for delivery of evidence-based psychotherapies: a systematic review. Implement Sci 2020; 15:40. [PMID: 32460866 PMCID: PMC7251851 DOI: 10.1186/s13012-020-00998-w] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 05/07/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Extensive efforts have been made to train mental health providers in evidence-based psychotherapies (EBPs); there is increasing attention focused on the methods through which providers are trained to deliver EBPs. Evaluating EBP training methods is an important step in determining which methods are most effective in increasing provider skill and improving client outcomes. METHODS We searched MEDLINE (Ovid) and PsycINFO for randomized controlled trials published from 1990 through June 2019 that evaluated EBP training methods to determine the effectiveness of EBP training modalities on implementation (provider and cost) and client outcomes. Eligible studies (N = 28) were evaluated for risk of bias, and the overall strength of evidence was assessed for each outcome. Data was extracted by a single investigator and confirmed by a second; risk of bias and strength of evidence were independently rated by two investigators and determined by consensus. RESULTS Overall, EBP training improved short-term provider satisfaction, EBP knowledge, and adherence compared to no training or self-study of training materials (low to moderate strength of evidence). Training in an EBP did not increase treatment adoption compared to no training or self-study. No specific active EBP training modality was found to consistently increase provider EBP knowledge, skill acquisition/adherence, competence, adoption, or satisfaction compared to another active training modality. Findings were mixed regarding the additive benefit of post-training consultation on these outcomes. No studies evaluated changes in provider outcomes with regards to training costs and few studies reported on client outcomes. LIMITATIONS The majority of included studies had a moderate risk of bias and strength of evidence for the outcomes of interest was generally low or insufficient. Few studies reported effect sizes. The ability to identify the most effective EBP training methods was limited by low strength of evidence for the outcomes of interest and substantial heterogeneity among studies. CONCLUSIONS EBP training may have increased short-term provider satisfaction, EBP knowledge, and adherence though not adoption. Evidence was insufficient on training costs and client outcomes. Future research is needed on EBP training methods, implementation, sustainability, client outcomes, and costs to ensure efforts to train providers in EBPs are effective, efficient, and durable. TRIAL REGISTRATION The protocol for this review is registered in PROSPERO (CRD42018093381).
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Affiliation(s)
- Helen Valenstein-Mah
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, 2450 Riverside Avenue, F282/2A West, Minneapolis, MN, 55454, USA.
| | - Nancy Greer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA.,Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Lauren McKenzie
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA.,Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Lucas Hansen
- Minneapolis VA Health Care System, Minneapolis, MN, USA.,University of St. Thomas, Minneapolis, MN, USA
| | - Thad Q Strom
- Oscar G. Johnson VA Medical Center, Iron Mountain, MI, USA
| | - Shannon Wiltsey Stirman
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Healthcare System, Palo Alto, CA, USA.,Stanford University, Palo Alto, CA, USA
| | - Timothy J Wilt
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA.,Minneapolis VA Health Care System, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Shannon M Kehle-Forbes
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA.,Minneapolis VA Health Care System, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA.,National Center for PTSD Women's Health Sciences Division, VA Boston Healthcare System, Boston, MA, USA
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Held P, Klassen BJ, Small CF, Brennan MB, Horn RV, Karnik NS, Pollack MH, Zalta AK. A Case Report of Cognitive Processing Therapy Delivered over a Single Week. COGNITIVE AND BEHAVIORAL PRACTICE 2020; 27:126-135. [PMID: 33041618 PMCID: PMC7543987 DOI: 10.1016/j.cbpra.2019.07.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Although evidence-based treatments for posttraumatic stress disorder (PTSD), such as Cognitive Processing Therapy (CPT), have been developed and widely disseminated, the rate of veterans engaging in and completing these therapies is low. Alternative methods of delivery may be needed to help overcome key barriers to treatment. Delivering evidence-based therapies intensively may address practical barriers to treatment attendance as well as problems with avoidance. This report details the case of a combat veteran who received 10 sessions of Cognitive Processing Therapy delivered twice per day over a single, five-day work week (CPT-5). Post-treatment, the veteran reported large and clinically meaningful decreases in PTSD and depression symptom severity as well as in guilt cognitions, which is a purported mechanism of successful treatment. These effects persisted six weeks after treatment ended. Despite the intensive nature of the treatment, the veteran found CPT-5 tolerable and could cite many benefits to completing therapy in one work week. In conclusion, CPT-5 holds promise as a way to efficiently deliver an evidence-based therapy that is both clinically effective and acceptable to patients, although more rigorous clinical trials are needed to test this treatment delivery format.
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Affiliation(s)
- Philip Held
- Rush University Medical Center, Chicago, IL 60612
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Held P, Klassen BJ, Boley RA, Wiltsey Stirman S, Smith DL, Brennan MB, Van Horn R, Pollack MH, Karnik NS, Zalta AK. Feasibility of a 3-week intensive treatment program for service members and veterans with PTSD. PSYCHOLOGICAL TRAUMA : THEORY, RESEARCH, PRACTICE AND POLICY 2020; 12:422-430. [PMID: 31318250 PMCID: PMC6980160 DOI: 10.1037/tra0000485] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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).
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Alyson K. Zalta
- Rush University Medical Center
- University of California - Irvine
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Maguen S, Holder N, Madden E, Li Y, Seal KH, Neylan TC, Lujan C, Patterson OV, DuVall SL, Shiner B. Evidence-based psychotherapy trends among posttraumatic stress disorder patients in a national healthcare system, 2001-2014. Depress Anxiety 2020; 37:356-364. [PMID: 31850650 DOI: 10.1002/da.22983] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 11/11/2019] [Accepted: 11/19/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Although evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) were implemented starting in 2005 in the veterans health administration (VHA), the largest national healthcare system in the U.S., the rate of initiation (uptake) and prevalence of these treatments in each calendar year have not been determined. We aimed to elucidate two metrics of EBP utilization, uptake and prevalence, following implementation. METHODS Cohort study of Iraq and Afghanistan veterans in VHA (N = 181,620) with a PTSD diagnosis and ≥1 psychotherapy-coded outpatient visit from 2001 to 2014. Using natural language processing techniques, annual and cumulative uptake and prevalence rates from 2001 to 2014 were calculated for each of the two EBPs for PTSD, cognitive processing therapy (CPT) and prolonged exposure (PE) therapy. RESULTS Annual uptake of CPT increased during most years, reaching a maximum of 11.1%. Annual uptake of PE showed little change until 2008 and then increased, reaching a maximum of 4.4%. The annual prevalence of CPT increased throughout the study, reaching a maximum of 14.6%. The annual prevalence of PE increased to a maximum of 5.0% in 2010, but then flattened and declined. Annual uptake of minimally adequate CPT increased a to maximum of 5% in 2014. Annual uptake of minimally adequate PE increased to a maximum of 1.2% in 2010. The cumulative prevalence of CPT was 19.9% and cumulative prevalence for PE was 7.5%. CONCLUSIONS Access to EBPs for PTSD modestly increased for Iraq and Afghanistan veterans after nationwide implementation efforts. Further expanding the reach to veterans is critical, given low rates of minimally adequate EBPs for PTSD.
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Affiliation(s)
- Shira Maguen
- Mental Health Service, San Francisco VA Health Care System, San Francisco, California.,Department of Psychiatry, University of California, San Francisco, California
| | - Nicholas Holder
- Mental Health Service, San Francisco VA Health Care System, San Francisco, California.,Department of Psychiatry, University of California, San Francisco, California
| | - Erin Madden
- Mental Health Service, San Francisco VA Health Care System, San Francisco, California
| | - Yongmei Li
- Mental Health Service, San Francisco VA Health Care System, San Francisco, California
| | - Karen H Seal
- Integrative Health Service, San Francisco VA Health Care System, San Francisco, California.,Departments of Medicine and Psychiatry, University of California, San Francisco, California
| | - Thomas C Neylan
- Mental Health Service, San Francisco VA Health Care System, San Francisco, California.,Department of Psychiatry, University of California, San Francisco, California
| | - Callan Lujan
- Mental Health Service, San Francisco VA Health Care System, San Francisco, California
| | - Olga V Patterson
- Informatics and Computing, VA Salt Lake City Health Care System, Salt Lake City, Utah.,Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Scott L DuVall
- Informatics and Computing, VA Salt Lake City Health Care System, Salt Lake City, Utah.,Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Brian Shiner
- Mental Health Service, White River Junction VA Medical Center, and National Center for Posttraumatic Stress Disorder, Executive Division, White River Junction, Vermont.,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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Cook JM, Thompson R, Simiola V, Wiltsey-Stirman S, Schnurr PP. Provider general attitudes versus specific perceptions of evidence-based psychotherapies for PTSD. Psychol Serv 2020; 17:46-53. [PMID: 30265069 PMCID: PMC6437015 DOI: 10.1037/ser0000280] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
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).
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Simiola V, Ellis AE, Thompson R, Schnurr PP, Cook JM. Provider Perspectives on Choosing Prolonged Exposure or Cognitive Processing Therapy for PTSD: A National Investigation of VA Residential Treatment Providers. ACTA ACUST UNITED AC 2019; 4:194-203. [PMID: 33134522 DOI: 10.1037/pri0000091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Paula P Schnurr
- National Center for PTSD, Executive Division, White River Junction.,Geisel School of Medicine at Dartmouth
| | - Joan M Cook
- Yale School of Medicine.,National Center for PTSD, Evaluation Division, West Haven
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36
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Holder N, Shiner B, Li Y, Madden E, Neylan TC, Seal KH, Lujan C, Patterson OV, DuVall SL, Maguen S. Timing of evidence-based psychotherapy for posttraumatic stress disorder initiation among Iraq and Afghanistan war veterans in the Veterans Health Administration. PSYCHOLOGICAL TRAUMA-THEORY RESEARCH PRACTICE AND POLICY 2019; 12:260-271. [PMID: 31343206 DOI: 10.1037/tra0000496] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Cognitive processing therapy (CPT) and prolonged exposure therapy (PE) were widely disseminated to treat posttraumatic stress disorder (PTSD) in the Veterans Health Administration (VHA). However, few Iraq and Afghanistan war veterans (Operation Enduring Freedom [OEF], Operation Iraqi Freedom [OIF], Operation New Dawn [OND]) diagnosed with PTSD have received CPT/PE and many initiate CPT/PE after substantial delay. Veterans who do not initiate CPT/PE or initiate CPT/PE after delay may have poorer treatment outcomes. This study aimed to identify predictors of CPT/PE initiation and timing. METHODS Participants included OEF/OIF/OND veterans diagnosed with PTSD who received psychotherapy between 2001 and 2017 in the VHA (n = 265,566). Logistic regression analysis was utilized to predict initiating CPT/PE (vs. no CPT/PE). Multinomial logistic regression analysis was utilized to predict not initiating or initiating delayed CPT/PE versus "early CPT/PE" (< 1 year after first mental health visit). Analyzed predictors included demographic, military, and clinical complexity variables (e.g., comorbidities, reported military sexual trauma [MST] history). RESULTS Seventy-Seven percent of veterans did not initiate CPT/PE, with 7.4% initiating early and 15.4% initiating delayed CPT/PE. Reported MST history (odds ratio [OR] = 1.45, 95% CI [1.39, 1.51]) and history of suicidal ideation/attempt (OR = 1.42, 95% CI [1.38, 1.46]) were strong predictors of CPT/PE initiation versus no CPT/PE. Comorbid pain (relative risk ratio [RRR] = 1.35, 95% CI [1.30, 1.42]) and depressive disorders (RRR = 1.37, 95% CI [1.32, 1.43]) were associated with increased likelihood of delayed versus early CPT/PE. CONCLUSIONS Most veterans in our study did not initiate CPT/PE. Generally, clinical complexity variables increased likelihood of initiating CPT/PE and initiating CPT/PE more than 1 year after first mental health visit. Additional research is needed to understand whether CPT/PE delay results from receipt of alternative intervention due to clinical complexity variables. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
| | | | | | | | | | | | | | - Olga V Patterson
- Department of Veterans Affairs Salt Lake City Health Care System
| | - Scott L DuVall
- Department of Veterans Affairs Salt Lake City Health Care System
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Hale AC, Bohnert KM, Ganoczy D, Sripada RK. Predictors of Treatment Adequacy During Evidence-Based Psychotherapy for PTSD. Psychiatr Serv 2019; 70:367-373. [PMID: 30784379 DOI: 10.1176/appi.ps.201800361] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE 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. METHODS 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. RESULTS 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). CONCLUSIONS 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.
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Affiliation(s)
- Andrew C Hale
- U.S. Department of Veterans Affairs (VA) Center for Clinical Management Research, Ann Arbor, Michigan; Department of Psychiatry, University of Michigan, Ann Arbor (Hale, Bohnert, Sripada)
| | - Kipling M Bohnert
- U.S. Department of Veterans Affairs (VA) Center for Clinical Management Research, Ann Arbor, Michigan; Department of Psychiatry, University of Michigan, Ann Arbor (Hale, Bohnert, Sripada)
| | - Dara Ganoczy
- U.S. Department of Veterans Affairs (VA) Center for Clinical Management Research, Ann Arbor, Michigan; Department of Psychiatry, University of Michigan, Ann Arbor (Hale, Bohnert, Sripada)
| | - Rebecca K Sripada
- U.S. Department of Veterans Affairs (VA) Center for Clinical Management Research, Ann Arbor, Michigan; Department of Psychiatry, University of Michigan, Ann Arbor (Hale, Bohnert, Sripada)
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Lindholm LH, Koivukangas A, Lassila A, Kampman O. What is important for the sustained implementation of evidence-based brief psychotherapy interventions in psychiatric care? A quantitative evaluation of a real-world programme. Nord J Psychiatry 2019; 73:185-194. [PMID: 30888233 DOI: 10.1080/08039488.2019.1582698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE Behavioural activation and motivational interviewing, both evidence-based treatments (EBTs), were implemented in secondary psychiatric care. This longitudinal evaluation of a real-world programme focused on the penetration of EBT adoption and its associations with therapist-related and perceived intervention-related variables. The implementation plan was also compared to sub-processes of Normalization Process Theory. MATERIAL AND METHODS Six participating units employed 72 therapists regularly and they comprise the target group. Due to staff turnover, a total of 84 therapists were trained stepwise. Three survey points (q1, q2, q3) were set for a four-year cycle beginning a year after the initial training and completed 4-5 months after closing patient recruitment. The implementation plan included two workshop days, one for each EBT, and subsequent case consultation groups and other more general strategies. RESULTS Fifty-seven (68%) of programme-trained therapists responded to one or more of three questionnaires. The self-reported penetration covers about a third of the target group a few months after the completion of the programme. Therapists' favourable perceptions of the EBTs regarding relative advantage, compatibility and complexity were associated with their sustained adoption. Therapists' background factors (e.g. work experience) and positive adoption intention at q1 did not predict the actual adoption of the EBTs at q3. No specific sustainment strategies were included in the implementation plan. CONCLUSION Brief but multi-faceted training with subsequent case consultations promoted the adoption of EBTs in a real-world setting. Adding specific sustainment strategies to the implementation plan is proposed to ensure the long-term survival of the implementation outcomes.
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Affiliation(s)
- Lars H Lindholm
- a Department of Psychiatry , South Ostrobothnia Hospital District , Seinäjoki , Finland.,b Faculty of Medicine and Life Sciences , Tampere University , Tampere , Finland
| | - Antti Koivukangas
- a Department of Psychiatry , South Ostrobothnia Hospital District , Seinäjoki , Finland.,b Faculty of Medicine and Life Sciences , Tampere University , Tampere , Finland
| | - Antero Lassila
- a Department of Psychiatry , South Ostrobothnia Hospital District , Seinäjoki , Finland
| | - Olli Kampman
- a Department of Psychiatry , South Ostrobothnia Hospital District , Seinäjoki , Finland.,b Faculty of Medicine and Life Sciences , Tampere University , Tampere , Finland
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Rosen CS, Bernardy NC, Chard KM, Clothier B, Cook JM, Crowley J, Eftekhari A, Kehle-Forbes SM, Mohr DC, Noorbaloochi S, Orazem RJ, Ruzek JI, Schnurr PP, Smith BN, Sayer NA. Which patients initiate cognitive processing therapy and prolonged exposure in department of veterans affairs PTSD clinics? J Anxiety Disord 2019; 62:53-60. [PMID: 30550959 DOI: 10.1016/j.janxdis.2018.11.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/13/2018] [Accepted: 11/16/2018] [Indexed: 10/27/2022]
Abstract
The United States Department of Veterans Affairs (VA) provides Cognitive Processing Therapy (CPT) and Prolonged Exposure therapy (PE) for PTSD at all of its facilities, but little is known about systematic differences between patients who do and do not initiate these treatments. VA administrative data were analyzed for 6,251 veterans receiving psychotherapy over one year in posttraumatic stress disorder (PTSD) specialty clinics at nine VA medical centers. CPT and PE were initiated by 2,173 (35%) patients. Veterans' probability of initiating either CPT or PE (considered together) was 29% lower (adjusted odds ratio = .61) if they had a psychiatric hospitalization within the same year, and 15% lower (AOR = .78) if they had service-connected disability for PTSD. Veterans' probability of starting CPT or PE was 19% lower (AOR = .74) if they were Hispanic or Latino, 10% lower (AOR = .84), if they were male rather than female, and 9% lower (AOR = .87) if they were divorced, separated or widowed rather than currently married. Probability of receiving CPT or PE was also lower if verans had more co-occurring psychiatric diagnoses (AOR per diagnosis = .88), were older (AOR per every five years = .95), or lived further away from the VA clinic (AOR per every ten miles = .98). Nonetheless, most patients initiating CPT or PE had two or more comorbidities and were service-connected for PTSD. Observed gender, age and ethnic differences in initiation of CPT and PE appear unrelated to clinical suitability and warrant further study.
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Affiliation(s)
- Craig S Rosen
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Rd. Menlo Park, CA 94025, USA; Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305, USA.
| | - Nancy C Bernardy
- Executive Division, National Center for PTSD, 215N Main St. White River Junction, VT 05009, USA; Department of Psychiatry, Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH 03755, USA.
| | - Kathleen M Chard
- Cincinnati Department of Veterans Affairs (VA) Medical Center, 3200 Vine St, Cincinnati, OH 45220, USA; University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA.
| | - Barbara Clothier
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417, USA.
| | - Joan M Cook
- Evaluation Division, National Center for PTSD, VA Connecticut Health Care System, 950 Campbell Avenue, West Haven, CT 06516, USA; Yale School of Medicine, NEPEC/182, 950 Campbell Avenue, West Haven, CT, USA.
| | - Jill Crowley
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Rd. Menlo Park, CA 94025, USA.
| | - Afsoon Eftekhari
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Rd. Menlo Park, CA 94025, USA.
| | - Shannon M Kehle-Forbes
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455, USA.
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA 02130, USA; Boston University School of Public Health, 715 Albany St, Boston, MA 02118, USA.
| | - Siamak Noorbaloochi
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417, USA.
| | - Robert J Orazem
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417, USA.
| | - Josef I Ruzek
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Rd. Menlo Park, CA 94025, USA; Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305, USA; Palo Alto University, 1791 Arastradero Rd, Palo Alto, CA 94304, USA.
| | - Paula P Schnurr
- Executive Division, National Center for PTSD, 215N Main St. White River Junction, VT 05009, USA; Department of Psychiatry, Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH 03755, USA.
| | - Brandy N Smith
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Rd. Menlo Park, CA 94025, USA.
| | - Nina A Sayer
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455, USA; Department of Psychiatry, University of Minnesota, 2450 Riverside Ave, Minneapolis, MN 55454, USA; Department of Psychology, University of Minnesota, 75 E River Rd, Minneapolis, MN 55455, USA.
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Dissemination and Implementation of Cognitive Behavioral Therapy for Depression in the Kaiser Permanente Health Care System: Evaluation of Initial Training and Clinical Outcomes. Behav Ther 2019; 50:446-458. [PMID: 30824258 DOI: 10.1016/j.beth.2018.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 07/11/2018] [Accepted: 08/12/2018] [Indexed: 11/22/2022]
Abstract
Notwithstanding its empirical status and strong recommendation in clinical practice guidelines, cognitive behavioral therapy (CBT) continues to be delivered infrequently and with low fidelity on the clinical front lines. Recently, organized efforts and policies within the public sector to disseminate and implement CBT and other evidence-based psychotherapies have yielded encouraging results and provided optimism for bridging the research-to-practice-gap. Following from these efforts, the current article examines the initial impact and experience of the implementation of an individualized approach to CBT training and treatment within the Kaiser Permanente health care system. Initial training outcomes, including changes in general and specific competencies, were assessed using divergent assessment methods within the initial cohort of therapists undergoing training. Initial patient outcomes, including changes in depression and anxiety, were assessed among patients receiving treatment from therapists in training. Results revealed training in and implementation of CBT-D was associated with overall large improvements in therapist competencies and in clinically significant improvements in both depression and anxiety among patients. Findings from the initial phase of dissemination and implementation within a large private system provide support for, and extend recent findings related to, the feasibility and effectiveness of training in and implementation of CBT-D in a real-world context.
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Meshberg-Cohen S, Black AC, DeViva JC, Petrakis IL, Rosen MI. Trauma treatment for veterans in buprenorphine maintenance treatment for opioid use disorder. Addict Behav 2019; 89:29-34. [PMID: 30243036 DOI: 10.1016/j.addbeh.2018.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/12/2018] [Accepted: 09/08/2018] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Opioid use disorder (OUD) rates are high among veterans. PTSD is also prevalent among veterans; those with comorbidity have worse outcomes than those without comorbidity. This study assessed buprenorphine retention rates in veterans initiating OUD treatment, comparing veterans without PTSD to veterans with PTSD who were receiving versus not receiving concurrent trauma treatment. METHODS This retrospective chart review examined consecutive referrals to buprenorphine maintenance (N = 140). PTSD diagnosis was identified by chart review and retention was defined as continuous buprenorphine maintenance 6-months post-admission. Logistic regression analyses compared buprenorphine retention for veterans without PTSD and PTSD-diagnosed veterans who received concurrent trauma treatment to a reference group of PTSD-diagnosed veterans who did not receive trauma treatment. Models adjusted for opioid type, age, and service-connected status. RESULTS Sixty-seven (47.9%) buprenorphine-seeking veterans carried a PTSD diagnosis; only 31.3% (n = 21) received trauma treatment while in buprenorphine maintenance, with 11.9% (n = 8) receiving evidence-based psychotherapy for PTSD. Among PTSD-diagnosed veterans who received trauma treatment, 90.5% (n = 19/21) were in buprenorphine maintenance at 6-months, compared to 23.9% (n = 11/46) of PTSD-diagnosed veterans without trauma treatment, and 46.6% (n = 34/73) of veterans without PTSD. In the full model, veterans with trauma treatment had 43.36 times greater odds of remaining in buprenorphine treatment than the reference group. CONCLUSIONS Most PTSD-diagnosed veterans in buprenorphine treatment were not receiving trauma treatment. Those receiving concurrent trauma treatment had better retention, suggesting OUD and trauma can be simultaneously addressed. Future clinical trials should investigate trauma-focused treatment for veterans with comorbid PTSD who are seeking buprenorphine for OUD.
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Affiliation(s)
- Sarah Meshberg-Cohen
- VA Connecticut Healthcare System, 950 Campbell Avenue, Psychology Service/Department of Psychiatry, 116A, West Haven, CT 06516, United States; Yale University School of Medicine, Department of Psychiatry, United States.
| | - Anne C Black
- VA Connecticut Healthcare System, 950 Campbell Avenue, Psychology Service/Department of Psychiatry, 116A, West Haven, CT 06516, United States; Yale University School of Medicine, Department of Psychiatry, United States
| | - Jason C DeViva
- VA Connecticut Healthcare System, 950 Campbell Avenue, Psychology Service/Department of Psychiatry, 116A, West Haven, CT 06516, United States; Yale University School of Medicine, Department of Psychiatry, United States
| | - Ismene L Petrakis
- VA Connecticut Healthcare System, 950 Campbell Avenue, Psychology Service/Department of Psychiatry, 116A, West Haven, CT 06516, United States; Yale University School of Medicine, Department of Psychiatry, United States
| | - Marc I Rosen
- VA Connecticut Healthcare System, 950 Campbell Avenue, Psychology Service/Department of Psychiatry, 116A, West Haven, CT 06516, United States; Yale University School of Medicine, Department of Psychiatry, United States
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Veterans' compensation claims beliefs predict timing of PTSD treatment use relative to compensation and pension exam. PLoS One 2018; 13:e0209488. [PMID: 30589882 PMCID: PMC6307722 DOI: 10.1371/journal.pone.0209488] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 12/06/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction In this study we developed the Disability Beliefs Scale to assess Veterans’ beliefs that engaging in treatment, as well as other behaviors, would affect the likelihood of a Veteran’s being awarded disability-related benefits. We posited that Veterans with stronger beliefs that attending mental health treatment would facilitate a service-connection award would be more likely to attend PTSD treatment before their compensation and pension examinations for PTSD. Methods Electronic health records for 307 post-9/11-era Veterans applying for compensation and pension for service-connected PTSD and engaging in a clinical trial of a treatment-referral intervention were analyzed for PTSD-specific and more general mental health treatment use around the time of their compensation examinations. All participants completed the Disability Beliefs Scale and other baseline assessments. Multilevel models assessed change in treatment use as a function of time relative to the C&P exam, compensation examination status (before or after), and the interaction between examination status and beliefs about treatment benefits. Results No main effects of time or examination status were observed. As hypothesized, beliefs about treatment benefits moderated the effect of examination status on PTSD treatment use. Veterans believing more strongly that mental health treatment would help a claim differentially attended PTSD treatment before the examination than after. The effect was not observed for general mental health treatment use. Conclusion The association between Veterans’ use of PTSD treatment and their service-connection examination status was moderated by beliefs that receiving treatment affects the service-connection decision. This suggests that factors reported to motivate seeking service-connection—finances, validation of Veterans’ experiences, and the involvement of significant others—might also help motivate Veterans’ use of effective PTSD treatments. However, the results reflect correlations that could be explained in other ways, and service-connection was one of many factors impacting PTSD treatment engagement.
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Asnaani A, Gallagher T, Foa EB. Evidence‐based protocols: Merits, drawbacks, and potential solutions. CLINICAL PSYCHOLOGY-SCIENCE AND PRACTICE 2018. [DOI: 10.1111/cpsp.12266] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sripada RK, Pfeiffer PN, Rauch SAM, Ganoczy D, Bohnert KM. Factors associated with the receipt of documented evidence-based psychotherapy for PTSD in VA. Gen Hosp Psychiatry 2018; 54:12-17. [PMID: 30029159 DOI: 10.1016/j.genhosppsych.2018.07.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 07/06/2018] [Accepted: 07/08/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The VA has mandated that evidence-based psychotherapies (EBPs) be offered to patients with PTSD, but only a small minority of the psychotherapy delivered to VA patients with PTSD is a documented EBP. It is unknown what factors are associated with receiving a documented EBP. METHOD Patients who received an EBP in FY2015 that was documented using a templated progress note (N = 21,808) were compared with patients who received psychotherapy for PTSD that was not documented using a template (N = 251,886). RESULTS Among psychotherapy recipients, VA patients with markers of clinical complexity such as service connection for PTSD, comorbid bipolar or psychotic disorder, longer duration of PTSD diagnosis, and a benzodiazepine prescription for PTSD had lower odds of receiving a documented EBP. CONCLUSIONS Recipients of documented EBPs differed from those who did not receive documented EBPs on several sociodemographic characteristics and indicators of treatment need. A limitation of our study is that some individuals in the group without EBP documentation may still have received an EBP, but did not receive EBP documentation in the electronic health record. Nevertheless, our results suggest that high-need or complex VA patients with PTSD may be less likely to receive documented EBPs.
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Affiliation(s)
- Rebecca K Sripada
- VA Center for Clinical Management Research, Ann Arbor, MI, USA; VA Ann Arbor Health Care System, Ann Arbor, MI, USA; University of Michigan, Department of Psychiatry, Ann Arbor, MI, USA.
| | - Paul N Pfeiffer
- VA Center for Clinical Management Research, Ann Arbor, MI, USA; VA Ann Arbor Health Care System, Ann Arbor, MI, USA; University of Michigan, Department of Psychiatry, Ann Arbor, MI, USA
| | - Sheila A M Rauch
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA; Atlanta VA Medical Center, Decatur, GA, USA
| | - Dara Ganoczy
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Kipling M Bohnert
- VA Center for Clinical Management Research, Ann Arbor, MI, USA; VA Ann Arbor Health Care System, Ann Arbor, MI, USA; University of Michigan, Department of Psychiatry, Ann Arbor, MI, USA
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Cook JM, Simiola V, McCarthy E, Ellis A, Wiltsey Stirman S. Use of Reflective Journaling to Understand Decision Making Regarding Two Evidence-Based Psychotherapies for PTSD: Practice Implications. ACTA ACUST UNITED AC 2018; 3:153-167. [PMID: 30906873 DOI: 10.1037/pri0000070] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Joan M Cook
- Department of Psychiatry Yale School of Medicine and National Center for PTSD, West Haven, Connecticut
| | - Vanessa Simiola
- Department of Psychiatry, Yale School of Medicine and Kaiser Permanente, Honolulu, Hawaii
| | | | - Amy Ellis
- Institutional Center for Scientific Research, Albizu University, Miami, Florida
| | - Shannon Wiltsey Stirman
- Department of Psychiatry and Behavioral Sciences, National Center for PTSD, Palo Alto, California and Stanford University of Medicine
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Van Minnen A, Hendriks L, Kleine RD, Hendriks GJ, Verhagen M, De Jongh A. Therapist rotation: a novel approach for implementation of trauma-focused treatment in post-traumatic stress disorder. Eur J Psychotraumatol 2018; 9:1492836. [PMID: 30034642 PMCID: PMC6052418 DOI: 10.1080/20008198.2018.1492836] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/27/2018] [Indexed: 12/03/2022] Open
Abstract
Background: Trauma-focused treatments (TFTs) for patients with post-traumatic stress disorder (PTSD) are highly effective, yet underused by therapists.Objective: To describe a new way of implementing (adequate use of) TFTs, using a therapist rotation model in which one patient is treated by several therapists.Method: In this article, we will present two examples of working with therapist rotation teams in two treatment settings for TFT of PTSD patients. We explore the experiences with this model from both a therapist and a patient perspective.Results: Our findings were promising in that they suggested that this novel approach reduced the therapists' fear of providing TFT to PTSD patients, increased perceived readiness for TFT, and decreased avoidance behaviour within TFT sessions, possibly leading to better implementation of TFT. In addition, the therapeutic relationship as rated by patients was good, even by patients with insecure attachment styles.Conclusions: We suggest that therapist rotation is a promising novel approach to improve implementation of TFT for PTSD.
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Affiliation(s)
- Agnes Van Minnen
- PSYTREC, Bilthoven, The Netherlands
- NIJCARE, Behavioural Science Institute (BSI), Radboud University Nijmegen, Nijmegen, The Netherlands
- Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands
| | - Lotte Hendriks
- NIJCARE, Behavioural Science Institute (BSI), Radboud University Nijmegen, Nijmegen, The Netherlands
- Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands
| | - Rianne De Kleine
- Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands
- Institute of Psychology, Leiden University, Leiden, The Netherlands
| | - Gert-Jan Hendriks
- NIJCARE, Behavioural Science Institute (BSI), Radboud University Nijmegen, Nijmegen, The Netherlands
- Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands
- Department of Psychiatry, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Ad De Jongh
- PSYTREC, Bilthoven, The Netherlands
- Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands
- School of Health Sciences, University of Salford, Manchester, UK
- Institute of Health and Society, University of Worcester, Worcester, UK
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Kilbourne AM, Beck K, Spaeth-Rublee B, Ramanuj P, O'Brien RW, Tomoyasu N, Pincus HA. Measuring and improving the quality of mental health care: a global perspective. World Psychiatry 2018; 17:30-38. [PMID: 29352529 PMCID: PMC5775149 DOI: 10.1002/wps.20482] [Citation(s) in RCA: 205] [Impact Index Per Article: 34.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Mental disorders are common worldwide, yet the quality of care for these disorders has not increased to the same extent as that for physical conditions. In this paper, we present a framework for promoting quality measurement as a tool for improving quality of mental health care. We identify key barriers to this effort, including lack of standardized information technology-based data sources, limited scientific evidence for mental health quality measures, lack of provider training and support, and cultural barriers to integrating mental health care within general health environments. We describe several innovations that are underway worldwide which can mitigate these barriers. Based on these experiences, we offer several recommendations for improving quality of mental health care. Health care payers and providers will need a portfolio of validated measures of patient-centered outcomes across a spectrum of conditions. Common data elements will have to be developed and embedded within existing electronic health records and other information technology tools. Mental health outcomes will need to be assessed more routinely, and measurement-based care should become part of the overall culture of the mental health care system. Health care systems will need a valid way to stratify quality measures, in order to address potential gaps among subpopulations and identify groups in most need of quality improvement. Much more attention should be devoted to workforce training in and capacity for quality improvement. The field of mental health quality improvement is a team sport, requiring coordination across different providers, involvement of consumer advocates, and leveraging of resources and incentives from health care payers and systems.
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Affiliation(s)
- Amy M Kilbourne
- Health Services Research and Development Service, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC, USA
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kathryn Beck
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brigitta Spaeth-Rublee
- Department of Behavioral Health Services and Policy Research, New York State Psychiatric Institute, New York, NY, USA
| | - Parashar Ramanuj
- RAND Europe, Cambridge, UK
- Royal National Orthopaedic Hospital, Stanmore, UK
| | - Robert W O'Brien
- Health Services Research and Development Service, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC, USA
| | - Naomi Tomoyasu
- Health Services Research and Development Service, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC, USA
| | - Harold Alan Pincus
- Department of Psychiatry and Irving Institute for Clinical and Translational Research, Columbia University and New York-Presbyterian Hospital, New York, NY, USA
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