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Tiet QQ, Davis L, Rosen C, Norman SB, Leyva YE, Duong H. Factors Associated With Increased Substance Use Disorder Care in VA PTSD Specialty Outpatient Treatment. J Dual Diagn 2024; 20:223-235. [PMID: 38710212 DOI: 10.1080/15504263.2024.2348105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
OBJECTIVE Substance use disorders (SUDs) commonly co-occur with posttraumatic stress disorder (PTSD). Understanding PTSD clinics that serve higher percentages of patients with PTSD/SUD is crucial for improving SUD care in clinics with lower percentages of such patients. This study examined the differences between Veterans Affairs (VA) PTSD treatment sites with higher percentages ("High%") and lower percentages ("Low%") of patients with PTSD/SUD as well as exploring the roles of the PTSD/SUD specialists. METHODS The study collected quantitative and qualitative data from 18 clinic directors and 21 specialists from 33 VA PTSD specialty outpatient clinics from 2014 to 2016. The clinics were chosen from the top and bottom quartiles based on two criteria: (1) the percentage of patients with PTSD/SUD and (2) the percentage of patients with PTSD/SUD who completed at least three SUD visits within the first month of their SUD treatment. The interviews sought to identify distinguishing characteristics between the High% and Low% clinics in terms of treatment access and practices for patients with PTSD/SUD. RESULTS More of the High% clinics reported providing evidence-based, patient-centered, and integrated/concurrent PTSD/SUD treatment and had staff members with more up-to-date knowledge and skills than the Low% clinics. We also found the roles of the PTSD/SUD specialists were demanding and confusing, leading to high turnover rates. CONCLUSIONS The two groups of PTSD clinics differed in three key factors: Resources, knowledge and skills of staff members, and local policies. Future research should focus on addressing resource limitations, knowledge gaps, and local policy disparities in Low% clinics. By emulating the practices of High% clinics, VA PTSD clinics can improve SUD care for patients with PTSD/SUD.
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Affiliation(s)
- Quyen Q Tiet
- California School of Professional Psychology, Alliant International University, San Francisco Bay Area, CA, USA
- National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Laila Davis
- Kaiser Permanente Rancho Cordova Medical Center, Rancho Cordova, CA, USA
| | - Craig Rosen
- National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
| | - Sonya B Norman
- National Center for PTSD, White River Junction, VT, USA
- University of California San Diego School of Medicine, San Diego, CA, USA
| | - Yani E Leyva
- National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Heather Duong
- Kaiser Permanente San Leandro Medical Center, San Leandro, CA, USA
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Back SE, Jarnecke AM, Norman SB, Zaur AJ, Hien DA. State of the Science: Treatment of comorbid posttraumatic stress disorder and substance use disorders. J Trauma Stress 2024. [PMID: 38857125 DOI: 10.1002/jts.23049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 06/12/2024]
Abstract
Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) co-occur at high rates, with research showing that up to nearly 60% of individuals with PTSD also suffer from an alcohol and/or drug use disorder. PTSD/SUD is complex; associated with adverse health, social, and economic outcomes; and can be challenging to treat. Over the past decade, the landscape of treatment research addressing PTSD/SUD has significantly expanded. Ongoing efforts aimed at developing and evaluating novel treatments for PTSD/SUD, encompassing both psychotherapy and pharmacotherapy approaches, are steadily advancing. As such, this State of the Science paper reviews the literature on the latest scientific advances in treating PTSD/SUD. Clinical practice guidelines for the treatment of PTSD/SUD are discussed, along with evidence-based psychotherapies and emerging interventions. Rigorously conducted clinical trials demonstrate that individual, manualized, trauma-focused treatments are the most efficacious psychotherapies to use among individuals with PTSD/SUD. Moreover, patients do not need to be abstinent to initiate or benefit from evidence-based PTSD treatment. To date, no medications have been established for this comorbidity. We highlight ongoing research on novel treatments for PTSD/SUD, such as new forms of integrated trauma-focused psychotherapies, pharmacological augmentation strategies, and technology-based enhancements. Finally, promising future directions for the field are discussed.
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Affiliation(s)
- Sudie E Back
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
- Ralph H. Johnson VA Healthcare System, Charleston, South Carolina, USA
| | - Amber M Jarnecke
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sonya B Norman
- Department of Psychiatry, University of California San Diego School of Medicine, San Diego, California, USA
| | - Angela J Zaur
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Denise A Hien
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, New Brunswick, New Jersey, USA
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Riblet NB, Gottlieb DJ, Shiner B, Zubkoff L, Rice K, Watts BV, Rusch B. An Analysis of Irregular Discharges From Residential Treatment Programs in the Department of Veterans Affairs Health Care System. Mil Med 2023; 188:e3657-e3666. [PMID: 37167031 PMCID: PMC10644260 DOI: 10.1093/milmed/usad131] [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: 01/24/2023] [Revised: 03/15/2023] [Accepted: 04/21/2023] [Indexed: 05/13/2023] Open
Abstract
INTRODUCTION Veteran populations are frequently diagnosed with mental health conditions such as substance use disorder and PTSD. These conditions are associated with adverse outcomes including a higher risk of suicide. The Veterans Health Administration (VHA) has designed a robust mental health system to address these concerns. Veterans can access mental health treatment in acute inpatient, residential, and outpatient settings. Residential programs play an important role in meeting the needs of veterans who need more structure and support. Residential specialty types in the VHA include general mental health, substance use disorder, PTSD, and homeless/work programs. These programs are affiliated with a DVA facility (i.e., medical center). Although residential care can improve outcomes, there is evidence that some patients are discharged from these settings before achieving the program endpoint. These unplanned discharges are referred to using language such as against medical advice, self-discharge, or irregular discharge. Concerningly, unplanned discharges are associated with patient harm including death by suicide. Although there is some initial evidence to locate factors that predict irregular discharge in VHA residential programs, no work has been done to examine features associated with irregular discharge in each residential specialty. METHODS We conducted a retrospective cohort study of patients who were discharged from VHA residential treatment programs between January 2018 and September 2022. We included the following covariates: Principal diagnosis, gender, age, race/ethnicity, number of physical health conditions, number of mental health diagnostic categories, marital status, risk of homelessness, urbanicity, and service connection. We considered two discharge types: Regular and irregular. We used logistic regression to determine the odds of irregular discharge using models stratified by bed specialty as well as combined odds ratios and 95% CIs across program specialties. The primary purposes are to identify factors that predict irregular discharge and to determine if the factors are consistent across bed specialties. In a secondary analysis, we calculated facility-level adjusted rates of irregular discharge, limiting to facilities with at least 50 discharges. We identified the amount of residual variation that exists between facilities after adjusting for patient factors. RESULTS A total of 279 residential programs (78,588 patients representing 124,632 discharges) were included in the analysis. Substance use disorder and homeless/work programs were the most common specialty types. Both in the overall and stratified analyses, the number of mental health diagnostic categories and younger age were predictors of irregular discharge. In the facility analysis, there was substantial variation in irregular discharge rates across residential specialties even after adjusting for all patient factors. For example, PTSD programs had a mean adjusted irregular discharge rate of 15.3% (SD: 7.4; range: 2.1-31.2; coefficient of variation: 48.4%). CONCLUSIONS Irregular discharge is a key concern in VHA residential care. Patient characteristics do not account for all of the observed variation in rates across residential specialty types. There is a need to develop specialty-specific measures of irregular discharge to learn about system-level factors that contribute to irregular discharge. These data can inform strategies to avoid harms associated with irregular discharge.
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Affiliation(s)
- Natalie B Riblet
- Mental Health, White River Junction VA Healthcare System, White River Junction, VT 05009, USA
- Psychiatry, Geisel School of Medicine at Dartmouth College, Hanover, NH 03755, USA
- Dartmouth Institute, Geisel School of Medicine at Dartmouth College, Hanover, NH 03755, USA
| | - Daniel J Gottlieb
- Mental Health, White River Junction VA Healthcare System, White River Junction, VT 05009, USA
| | - Brian Shiner
- Mental Health, White River Junction VA Healthcare System, White River Junction, VT 05009, USA
- Psychiatry, Geisel School of Medicine at Dartmouth College, Hanover, NH 03755, USA
- Dartmouth Institute, Geisel School of Medicine at Dartmouth College, Hanover, NH 03755, USA
| | - Lisa Zubkoff
- Division of Preventive Medicine in the Department of Medicine, University of Alabama at Birmingham Marnix E. Heersink School of Medicine, Birmingham, AL 35233, USA
- Associate Director for Research, Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center (GRECC), Birmingham, AL 35233, USA
| | - Korie Rice
- Mental Health, White River Junction VA Healthcare System, White River Junction, VT 05009, USA
| | - Bradley V Watts
- Mental Health, White River Junction VA Healthcare System, White River Junction, VT 05009, USA
- Psychiatry, Geisel School of Medicine at Dartmouth College, Hanover, NH 03755, USA
- Clinical Director, VA Office of Rural Health, White River Junction, VT 05009, USA
| | - Brett Rusch
- Psychiatry, Geisel School of Medicine at Dartmouth College, Hanover, NH 03755, USA
- Leadership Team, White River Junction VA Healthcare System, White River Junction, VT 05009, USA
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Aase DM, Gorka SM, Soble JR, Bryan CJ, Luan Phan K. Impact of alcohol use, combat exposure, and posttraumatic stress on verbal and visual working memory performance in post-9/11 veterans. PSYCHOLOGICAL TRAUMA : THEORY, RESEARCH, PRACTICE AND POLICY 2023; 15:1288-1292. [PMID: 35587434 PMCID: PMC10201955 DOI: 10.1037/tra0001285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) and alcohol use (AU) are highly prevalent and comorbid among post-9/11 U.S. military veterans. Both issues are associated with working memory (WM) deficits, but have rarely been studied concurrently in cognitive studies of post-9/11 veterans. They also have been measured inconsistently, with variable outcomes, in prior veteran studies despite their relevance to new intervention paradigms involving WM. METHOD The present study evaluated 52 post-9/11 veterans [predominantly male (94.2%); White (44.2%) or Black (36.5%); 50% being diagnosed with PTSD based on CAPS-5 results] with objectively verified valid neuropsychological test performance on measures of PTSD, AU, combat exposure, and verbal and visual WM. RESULTS PTSD was not associated with verbal or visual WM performances, whereas AU and combat exposure were significantly associated with poorer visual WM performances. CONCLUSIONS AU and prior combat exposure may influence visual WM performances in post-9/11 veterans, which is relevant to novel PTSD treatment paradigms. This sample was limited to mostly male and White or Black participants, and future studies should focus on sampling more heterogeneous groups of veterans with regard to sex and ethnicity. Improvements in specification/multimodal WM assessment are important for future research, as these may directly impact developing intervention efforts. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Darrin M. Aase
- Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, OH, USA
- Mental Health Service Line, Jesse Brown VA Medical Center, Chicago, IL, USA
| | - Stephanie M. Gorka
- Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, OH, USA
- Institute for Behavioral Medicine Research, The Ohio State University, Columbus, OH, USA
| | - Jason R. Soble
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
- Department of Neurology, University of Illinois at Chicago, Chicago, IL, USA
| | - Craig J. Bryan
- Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, OH, USA
| | - K. Luan Phan
- Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, OH, USA
- Mental Health Service Line, Jesse Brown VA Medical Center, Chicago, IL, USA
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Cameron D, Shiner B, O'Neill A, O'Neil M. Factors Associated with Engaging in Evidence-Based Psychotherapy During the First Year of Posttraumatic Stress Disorder Treatment Between 2017 and 2019. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2023; 50:813-823. [PMID: 37338657 DOI: 10.1007/s10488-023-01280-z] [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: 06/21/2023]
Abstract
To address the burden of posttraumatic stress disorder (PTSD), the Veterans Health Administration (VHA) implemented evidence-based psychotherapies (EBPs) for PTSD at all VHA medical centers. Prior investigations show EBP utilization has increased following the initial nationwide implementation. However, most patients still do not engage in EBPs and those who do often have substantial delays between diagnosis and treatment which is associated with poorer treatment outcomes. The goal of the current study is to identify patient and clinical factors associated with initiating EBP and completing a minimally adequate dose of treatment within the first year of a new PTSD diagnosis. Overall, 263,018 patients started PTSD treatment between 2017 and 2019 and 11.6% (n = 30,462) initiated EBP during their first year of treatment. Of those who initiated EBP, 32.9% (n = 10,030) received a minimally adequate dose. Older patients were less likely to initiate EBP, but more likely to receive an adequate dose when they did initiate. Black, Hispanic/Latino/a, and Pacific Islander patients' likelihood of initiating EBP was not significantly different than White patients, but these patients were less likely to receive an adequate dose. Patients with comorbid depressive disorders, bipolar disorder, psychotic disorders, or substance use disorders were less likely to initiate EBP, while patients reporting MST were more likely to initiate EBP. This study identifies several patient-level disparities that could be prioritized to increase EBP utilization. In our evaluation, most patients did not engage in EBP during their first year of PTSD treatment, which is consistent with previous evaluations of EBP utilization. Future research should focus on understanding the flow of patients from PTSD diagnosis to treatment to support effective PTSD care delivery.
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Affiliation(s)
- David Cameron
- VA Portland Health Care System, (R&D 66), 3710, SW US Veterans Hospital Rd, Portland, OR, 97239, USA
- Oregon Health & Science University, Portland, OR, USA
| | - Brian Shiner
- White River Junction VA Medical Center, Hartford, VT, USA
- National Center for PTSD, Hartford, VT, USA
- Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - Allison O'Neill
- VA Portland Health Care System, (R&D 66), 3710, SW US Veterans Hospital Rd, Portland, OR, 97239, USA
| | - Maya O'Neil
- VA Portland Health Care System, (R&D 66), 3710, SW US Veterans Hospital Rd, Portland, OR, 97239, USA.
- Oregon Health & Science University, Portland, OR, USA.
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Meis LA, Polusny MA, Kehle-Forbes SM, Erbes CR, O’Dougherty M, Erickson EPG, Orazem R, Burmeister L, Spoont M. Making sense of poor adherence in PTSD treatment from the perspectives of veterans and their therapists. PSYCHOLOGICAL TRAUMA : THEORY, RESEARCH, PRACTICE AND POLICY 2023; 15:715-725. [PMID: 35324228 PMCID: PMC10948176 DOI: 10.1037/tra0001199] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Dropout rates from trauma-focused PTSD treatments (TFTs) in VA clinics are particularly high. We conducted in-depth qualitative interviews with 29 veterans and their therapists to better understand this phenomenon. METHOD Participants were part of a multisite, mixed-methods study of TFT adherence in VA clinics. Veterans were eligible for interviews if they exhibited poor TFT adherence and screened positive for PTSD in follow-up surveys. Interviews were analyzed using qualitative dyadic analysis approaches. RESULTS Therapists relied on stereotypes of poor adherence to understand veterans' experiences and were missing information critical to helping veterans succeed. Veterans misunderstood aspects of the therapy and struggled in ways they inadequately expressed to therapists. Therapist attempts at course corrections were poorly matched to veterans' needs. Many dyads reported difficulties in their therapeutic relationships. Veterans reported invalidating experiences that were not prominent in therapists' interviews. CONCLUSIONS Future work is needed to test hypotheses generated and find effective ways to help veterans fully engage in TFTs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Laura A. Meis
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN 55417
- University of Minnesota Medical School, Department of Medicine, 420 Delaware Street SE, MMC 194, Suite 14-110 Phillips-Wangensteen Building, Minneapolis, Minnesota 55455
| | - Melissa A. Polusny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN 55417
- University of Minnesota Medical School, Department of Psychiatry, 420 Delaware Street SE, MMC 194, Suite 14-110 Phillips-Wangensteen Building, Minneapolis, Minnesota 55455
| | - Shannon M. Kehle-Forbes
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN 55417
- University of Minnesota Medical School, Department of Medicine, 420 Delaware Street SE, MMC 194, Suite 14-110 Phillips-Wangensteen Building, Minneapolis, Minnesota 55455
- Women’s Division, National Center for PTSD, Boston, MA
| | - Christopher R. Erbes
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN 55417
- University of Minnesota Medical School, Department of Psychiatry, 420 Delaware Street SE, MMC 194, Suite 14-110 Phillips-Wangensteen Building, Minneapolis, Minnesota 55455
| | - Maureen O’Dougherty
- Metropolitan State University, Department of Social Science, Saint John’s Hall, 700 7th Street E, St. Paul, Minnesota 55106
| | - Emily P. G. Erickson
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN 55417
| | - Robert Orazem
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN 55417
| | - Lori Burmeister
- School of Social and Behavioral Sciences, Arizona State University, Tempe, AZ, 85012
| | - Michele Spoont
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN 55417
- University of Minnesota Medical School, Department of Medicine, 420 Delaware Street SE, MMC 194, Suite 14-110 Phillips-Wangensteen Building, Minneapolis, Minnesota 55455
- University of Minnesota Medical School, Department of Psychiatry, 420 Delaware Street SE, MMC 194, Suite 14-110 Phillips-Wangensteen Building, Minneapolis, Minnesota 55455
- Pacific Islands Division, National Center for PTSD, Honolulu, Hawaii
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Silverberg ND, Mikolić A. Management of Psychological Complications Following Mild Traumatic Brain Injury. Curr Neurol Neurosci Rep 2023; 23:49-58. [PMID: 36763333 DOI: 10.1007/s11910-023-01251-9] [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: 01/13/2023] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW It has been clear for decades that psychological factors often contribute to mild traumatic brain injury (mTBI) outcome, but an emerging literature has begun to clarify which specific factors are important, when, for whom, and how they impact recovery. This review aims to summarize the contemporary evidence on psychological determinants of recovery from mTBI and its implications for clinical management. RECENT FINDINGS Comorbid mental health disorders and specific illness beliefs and coping behaviors (e.g., fear avoidance) are associated with worse recovery from mTBI. Proactive assessment and intervention for psychological complications can improve clinical outcomes. Evidence-based treatments for primary mental health disorders are likely also effective for treating mental health disorders after mTBI, and can reduce overall post-concussion symptoms. Broad-spectrum cognitive-behavioral therapy may modestly improve post-concussion symptoms, but tailoring delivery to individual psychological risk factors and/or symptoms may improve its efficacy. Addressing psychological factors in treatments delivered primarily by non-psychologists is a promising and cost-effective approach for enhancing clinical management of mTBI. Recent literature emphasizes a bio-psycho-socio-ecological framework for understanding mTBI recovery and a precision rehabilitation approach to maximize recovery. Integrating psychological principles into rehabilitation and tailoring interventions to specific risk factors may improve clinical management of mTBI.
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Affiliation(s)
- Noah D Silverberg
- Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, BC, V6T 1Z4, Canada.
- Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, BC, V5Z 1M9, Canada.
| | - Ana Mikolić
- Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, BC, V6T 1Z4, Canada
- Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, BC, V5Z 1M9, Canada
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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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Grau PP, Sripada RK, Pietrzak RH, Ganoczy D, Harpaz-Rotem I. Treatment response trajectories in residential PTSD programs for veterans: A national cohort investigation. J Anxiety Disord 2022; 92:102645. [PMID: 36334317 DOI: 10.1016/j.janxdis.2022.102645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/05/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
Although improving residential PTSD care is a priority for the Department of Veterans Affairs, previous evaluations have been limited by a lack of systematic data collection across more than two timepoints. This study used recently available data to assess symptom trajectories in a large, national sample of veterans who engaged in residential PTSD treatment. Group-based trajectory analysis PROC TRAJ was used to identify PTSD residential treatment response in a national cohort of veterans (n = 10,832) and the subset of veterans (n = 6515) receiving evidence-based psychotherapy (EBP). PTSD symptoms were assessed at intake, discharge, and 4-month follow-up. Predictors of trajectory membership were estimated using multinomial models. For the full cohort, a three-group trajectory model provided the best fit with the following identified groups: "Severe/Stable" (51.8%), "Moderate/Rebound" (40.1%), and "Mild/Rebound" (8.1%). For the EBP sub-cohort, a three-group trajectory model was selected with the following groups: "Severe/Stable" (58.5%), "Moderate/Rebound" (34.1%), and "Mild/Rebound" (7.4%). Across all trajectories, psychological distress, pain severity, substance use, Iraq/Afghanistan combat era, non-White race, and treatment dropout were associated with poorer treatment response. In the EBP sub-cohort, homelessness and unemployment at the time of admission were also associated with poorer treatment outcomes to varying degrees. This study demonstrates that residential treatment for PTSD is associated with heterogeneous treatment trajectories which highlight the need to continue to explore and improve residential PTSD treatment outcomes. Our results underscore the importance of obtaining follow-up data and identifying ways to maintain therapeutic gains following discharge.
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Affiliation(s)
- Peter P Grau
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road, Bldg 16, Ann Arbor, MI 48109, United States; VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States.
| | - Rebecca K Sripada
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States; Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
| | - Robert H Pietrzak
- Veterans Affairs National Center for PTSD, Veteran Affairs Connecticut Healthcare System, West Haven, CT, United States; Yale University, Department of Psychiatry, New Haven, CT, United States
| | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
| | - Ilan Harpaz-Rotem
- Veterans Affairs National Center for PTSD, Veteran Affairs Connecticut Healthcare System, West Haven, CT, United States; Yale University, Department of Psychiatry, New Haven, CT, United States; Veterans Affairs Northeast Program Evaluation Center, West Haven, CT, United States
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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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Trauma Exposure and PTSD in Philadelphia Community Mental Health. Community Ment Health J 2022; 58:547-552. [PMID: 34052961 DOI: 10.1007/s10597-021-00853-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 05/26/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Based on feedback received during post-training consultation within a Prolonged Exposure (PE) implementation initiative, additional assessment training was added to help community providers identify patients who met criteria for posttraumatic stress disorder (PTSD) symptom severity and were considered appropriate for PTSD treatment. The current study investigated the rates of trauma exposure and PTSD in the community sample, as well as the percentage of individuals deemed "appropriate" for PE by community therapists. METHOD Clinicians involved in the PE Initiative administered the Post-traumatic Diagnostic Scale for DSM-5 (PDS-5) to 10,260 individuals across 13 community agencies. Clinicians were also asked to report whether patients were perceived as appropriate for PE. RESULTS Consistent with our hypothesis, the rates of potential PTSD in Philadelphia community mental health (58.2% of our total sample) far exceeded national averages (8.3%). Contrary to our hypothesis, 100% of patients who scored above the clinical cutoff for PTSD were considered appropriate for PE by their community clinician. CONCLUSIONS The results of this study emphasize the high prevalence of PTSD among individuals presenting for treatment to community mental health centers. Despite common misconceptions that patients are often perceived as ineligible or not appropriate for PE, 100% of patients in the PE Initiative who scored above the clinical cutoff for PTSD were considered good candidates for treatment according to their clinicians. This suggests that with sufficient training and post-training consultation, as provided in this community initiative, community clinicians may be more likely to perceive PE as an appropriate treatment option.
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McGuire A, Matthias MS, Kukla M, Henry N, Carter J, Flanagan M, Bair MJ, Murphy JL. A National Survey of Patient Completion of Cognitive Behavioral Therapy for Chronic Pain: The Role of Therapist Characteristics, Attempt Rates, and Modification. PROFESSIONAL PSYCHOLOGY-RESEARCH AND PRACTICE 2022; 52:542-550. [PMID: 35095180 DOI: 10.1037/pro0000399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The implementation of evidence-based psychotherapies, including patient-level measures such as penetration and rates of successfully completing a course of therapy, has received increasing attention. While much attention has been paid to the effect of patient-level factors on implementation, relatively little attention has been paid to therapist factors (e.g., professional training, experience). Objective The current study explores therapists' decisions to offer a particular evidence-based psychotherapy (cognitive behavioral therapy for chronic pain; CBT-CP), whether and how they modify CBT-CP, and the relationship between these decisions and patient completion rates. Methods The study utilized survey responses from 141 Veterans Affairs therapists certified in CBT-CP. Results Therapists reported attempting CBT-CP with a little less than one half of their patients with chronic pain (mean = 48.8%, s.d.=35.7). Therapist were generally split between reporting modifying CBT-CP for either very few or most of their patients. After controlling for therapist characteristics and modification, therapist-reported percentage of patients with attempted CBT-CP was positively associated with completion rates, t (111) = 4.57, p<.001. Conclusions Therapists who attempt CBT-CP more frequently may experience better completion rates, perhaps due to practice effects or contextual factors that support both attempts and completion. Future research should examine this relationship using objective measures of attempt rates and completion.
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Affiliation(s)
- Alan McGuire
- Clinical Research Psychologist at the Richard L. Roudebush VA Medical Center in the HSR&D Center for Health Information and Communication and an Associate Research Professor in the Department of Psychology at Indiana University-Purdue University at Indianapolis
| | - Marianne S Matthias
- Research Scientist at the Roudebush VA Medical Center and Regenstrief Institute in Indianapolis, IN, and Associate Research Professor in the Department of General Internal Medicine and Geriatrics at the Indiana University School of Medicine
| | - Marina Kukla
- Research Scientist and Clinical Psychologist at the Richard L. Roudebush VA Medical Center in the HSR&D Center for Health Information and Communication and an Associate Research Professor in the Department of Psychology at Indiana University-Purdue University at Indianapolis
| | - Nancy Henry
- project manager for the Richard L. Roudebush VA Medical Center in the HSR&D Center for Health Information and Communication and the Department of Psychology at Indiana University-Purdue University at Indianapolis
| | - Jessica Carter
- research assistant for the Richard L. Roudebush VA Medical Center in the HSR&D Center for Health Information and Communication
| | - Mindy Flanagan
- Senior Research Scientist at Parkview Health and Research Consultant at Richard L. Roudebush VA HSR&D Center for Health Information and Communication
| | - Matthew J Bair
- Research Scientist for the Richard L. Roudebush VA Health Services Research and Development Center for Health Information and Communication, Staff Physician at Richard L. Roudebush VA Medical Center, and Regenstrief Research Scientist
| | - Jennifer L Murphy
- Director of Behavioral Pain Medicine for the Veterans Health Administration and is Master Trainer for VA's Cognitive Behavioral Therapy for Chronic Pain (CBT-CP). Dr. Murphy is Associate Professor in the University of South Florida's Morsani College of Medicine and serves on the editorial board of Pain Medicine
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13
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Wang J, Huang X, Wang Y, Wang M, Xu J, Li X. COVID-19 Information Overload, Negative Emotions and Posttraumatic Stress Disorder: A Cross-Sectional Study. Front Psychiatry 2022; 13:894174. [PMID: 35693965 PMCID: PMC9186157 DOI: 10.3389/fpsyt.2022.894174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/14/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Under the context of the COVID-19 pandemic, a large amount of COVID-19-related information can cause an individual's perceived information overload, further halting the individual's psychological health. As a minor psychological discomfort could develop severe mental disorders such as posttraumatic stress disorder, it is necessary to understand the chain linkage of COVID-19 information overload turn to posttraumatic stress disorder to ensure timely intervention can be offered at each point of mental state transformation. Hence, we examined the negative outcomes of COVID-19 information overload and investigated the direct and indirect effects of COVID-19 on posttraumatic stress disorder. METHODS A convenient sample of Chinese adults (n = 1150) was investigated by an online survey from July 2020 to March 2021. The extent of COVID-19 information overload was measured by the information overload severity scale on the text of the COVID-19 pandemic. Psychological distress symptoms were measured using a 7-item anxiety scale (GAD-7), the 9-item Patient Health Questionnaire depression module (PHQ-9), and the psychometric properties of the PTSD Checklist (PCL-C). Structural equation modeling and bootstrap methods were utilized to analyze the relationships between variables. RESULTS COVID-19 information overload is positively related to an individual's anxiety, depression, and posttraumatic stress disorder. Furthermore, COVID-19 information overload can indirectly affect an individual's PTSD symptoms by increasing the feeling of depression. R2 values of anxiety, depression, and PTSD were 0.471, 0.324, and 0.795, respectively. CONCLUSION COVID-19 information overload, anxiety, depression, and PTSD are negative psychological states, and each variable is closely linked with the others, suggesting the need for potential psychological interventions at specific times. Practical public training, such as crisis coping and information filtering, is essential. Regulation of technology companies is also essential.
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Affiliation(s)
- Jingjun Wang
- West China School of Nursing and West China Hospital, Sichuan University, Chengdu, China
| | - Xia Huang
- West China School of Nursing and West China Hospital, Sichuan University, Chengdu, China
| | - Ya Wang
- Department of Nursing, West China Hospital and West China School of Nursing, Sichuan University, Chengdu, China
| | - Mengmeng Wang
- School of Nursing, Peking University, Beijing, China
| | - Jiajun Xu
- Mental Health Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaolin Li
- West China School of Nursing and West China Hospital, Sichuan University, Chengdu, China
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14
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Kasparik B, Saupe LB, Mäkitalo S, Rosner R. Online training for evidence-based child trauma treatment: evaluation of the German language TF-CBT-Web. Eur J Psychotraumatol 2022; 13:2055890. [PMID: 35401949 PMCID: PMC8986224 DOI: 10.1080/20008198.2022.2055890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Evidence-based trauma-focused interventions for treating PTSD in children and youth are barely used in practice. Web-based training has proven to be an effective way of transferring knowledge to healthcare professionals. OBJECTIVE TF-CBT Web is a web-based training programme designed to foster the dissemination of Trauma Focused Cognitive Behavioural Therapy (TF-CBT) for children and youth, and is run by the Medical University of South Carolina. This paper describes the characteristics of healthcare professionals who registered for the adapted German language version of TF-CBT Web. It evaluates the effectiveness and user friendliness of the programme. METHOD : Similar to the TF-CBT treatment manual, the German language TF-CBT Web contains 12 modules. Between 2018 and 2020, 4,020 users registered for the programme. During the registration process users provided demographic information. The knowledge of users regarding the TF-CBT components was assessed via pre-tests and post-tests in each module. RESULTS The programme was accessed by a sample of mostly German users with varying professional health care backgrounds and a wide-ranging spread of work experience. The results indicated a significant knowledge gain and high rates of user satisfaction with the programme. CONCLUSIONS In summary, the results of this study suggested that web-based training is an effective and well-accepted method for knowledge gain in trauma-focused interventions. Future research should evaluate the actual application of the taught methods in clinical practice. HIGHLIGHTS Children and adolescents with PTSD require trauma-focused treatment. However, evidence-based interventions for this patient population are barely used. Therefore, it is necessary to expand professional training for the treatment of traumatised children and adolescents.Our evaluation showed the effectiveness and feasibility of a web-based training programme for mental health practitioners in an evidence-based treatment for children and youth with PTSD (TF-CBT). Results show a significant knowledge gain of users who participate in the web-based training programme.The user satisfaction survey also revealed that users found the modus and content of the web-based training applicable and relevant for their clinical practice.
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Affiliation(s)
- Barbara Kasparik
- Department of Psychology, Catholic University Eichstätt-Ingolstadt Ingolstadt, Germany
| | - Laura B Saupe
- Department of Psychology, Catholic University Eichstätt-Ingolstadt Ingolstadt, Germany
| | - Svenja Mäkitalo
- Department of Psychology, Catholic University Eichstätt-Ingolstadt Ingolstadt, Germany
| | - Rita Rosner
- Department of Psychology, Catholic University Eichstätt-Ingolstadt Eichstätt, Germany
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15
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Roberge EM, Harris JA, Weinstein HR, Rozek DC. Treating Veterans at Risk for Suicide: An Examination of the Safety, Tolerability, and Outcomes of Cognitive Processing Therapy. J Trauma Stress 2021; 34:1228-1237. [PMID: 33650171 DOI: 10.1002/jts.22662] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/07/2021] [Accepted: 01/13/2021] [Indexed: 11/11/2022]
Abstract
Individuals with posttraumatic stress disorder (PTSD) are at increased risk for suicidal thoughts and behaviors; however, clinicians often report apprehension about recommending trauma-focused therapy to patients with an increased risk of suicide. The present study aimed to evaluate the safety, tolerability, and response to cognitive processing therapy (CPT) among a sample of military veterans with PTSD and increased suicide risk. A secondary aim was to provide a clinically useful definition of high suicide risk. Chart review was used to classify the suicide risk level of 290 veterans who participated in CPT at a Veterans Affairs clinic. Treatment outcomes in veterans with different suicide risk levels were also gathered and compared. Over 50% (n = 155) of the sample demonstrated increased suicide risk, and 1.0% (n = 3) engaged in suicidal behavior after initiating treatment. To date, hospital records show no suicide deaths since 2016 among clinic patients who received CPT. Suicide risk level was not associated with CPT tolerability, and PTSD symptom change was equivalent across groups, ps = .085-.976. Veterans across groups reported clinically significant reductions in PTSD symptoms. The tested suicide risk categorization schemes performed similarly in differentiating the odds of CPT completion and PTSD symptom reduction. These results suggest that veterans with PTSD and an increased risk of suicide, including those with previous suicide attempts and current ideation, can tolerate and benefit from CPT. Additional variables must be considered to truly determine the acute and imminent suicide risk that would deem CPT to be contraindicated.
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Affiliation(s)
- Erika M Roberge
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Julia A Harris
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, USA.,University of Utah, Salt Lake City, Utah, USA
| | - Harrison R Weinstein
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, USA.,University of Utah, Salt Lake City, Utah, USA
| | - David C Rozek
- University of Central Florida, Orlando, Florida, USA
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16
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Grekin R, Bohnert KM, Grau PP, Ganoczy D, Sripada RK. Rates and predictors of psychotherapy receipt among U.S. veterans with comorbid posttraumatic stress disorder and substance use disorders. DRUG AND ALCOHOL DEPENDENCE REPORTS 2021; 1:100010. [PMID: 36843911 PMCID: PMC9948867 DOI: 10.1016/j.dadr.2021.100010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/22/2021] [Accepted: 11/22/2021] [Indexed: 11/17/2022]
Abstract
Introduction Veterans with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) have complex needs and often do not receive adequate mental health treatment. The purpose of this study was to examine rates and predictors of PTSD-only, SUD-only, or PTSD and SUD psychotherapy receipt among newly diagnosed Veterans with PTSD and SUD. Design and setting An administrative dataset including Veterans Health Administration (VHA) users. Participants The sample comprised 32,779 United States Veterans with a new PTSD and a new SUD diagnosis in fiscal year 2015. Measurement Multinomial logistic regression was used to identify predictors of receipt of any and adequate psychotherapy for PTSD, SUD, or PTSD and SUD across settings. Binomial logistic regression was used to identify predictors of PTSD psychotherapy among those who received any psychotherapy. Findings A total of 13,824 (42.17%) Veterans in this sample received any PTSD- or SUD-related therapy in the year following diagnosis. Low rates of veterans received an adequate dose of PTSD-related psychotherapy (6.58%), SUD-related psychotherapy (7.72%), or both PTSD and SUD-related psychotherapy (<1%) In adjusted models, older age, service-connected disability, and psychiatric comorbidities were associated with decreased odds of treatment. Specific types of SUDs, including alcohol, cocaine, and opioid use disorders, along with receipt of diagnosis in a PTSD or SUD clinic, were associated with increased odds of treatment. Conclusions Low rates of PTSD and SUD related psychotherapy highlight a need to better engage and retain Veterans with these disorders in care. Predictors of decreased treatment utilization, such as older age, service connection, and bipolar and major depressive disorders, may inform efforts by the VHA to further target and engage Veterans with indicated treatments.
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Affiliation(s)
- Rebecca Grekin
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road, Bldg 16, Ann Arbor, MI 48109, United States
- Great Lakes Perinatal Wellness, Ann Arbor, MI 48105, United States
- Department of Psychological and Brain Sciences, University of Iowa, United States
| | - Kipling M. Bohnert
- Department of Epidemiology and Biostatistics, Michigan State University, United States
| | - Peter P. Grau
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road, Bldg 16, Ann Arbor, MI 48109, United States
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States
- Department of Psychiatry, University of Michigan Medical School, United States
| | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor Michigan, United States
| | - Rebecca K. Sripada
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States
- Department of Psychiatry, University of Michigan Medical School, United States
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor Michigan, United States
- Corresponding author at: Serious Mental Illness Treatment Resource and Evaluation Center, 2800 Plymouth Road, 016, Ann Arbor, MI 48109, United States.
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Application of the Unified Protocol for a Japanese Patient with Post-Traumatic Stress Disorder and Multiple Comorbidities: A Single-Case Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111644. [PMID: 34770156 PMCID: PMC8582839 DOI: 10.3390/ijerph182111644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 11/17/2022]
Abstract
(1) Background: The efficacy of the Unified Protocol (UP), a transdiagnostic cognitive-behavioral therapy, with trauma-focused exposure has not been sufficiently demonstrated for post-traumatic stress disorder (PTSD) with multiple comorbidities. This study examined the effects of UP treatment with trauma-focused exposure on symptoms of PTSD and comorbidities in a client who was hesitant about exposure. (2) Methods: The client, who had comorbid dysthymia, social anxiety disorder, agoraphobia, and bulimia nervosa, participated in the UP for 20 sessions over 6 months. The principal diagnosis and symptoms of the comorbid disorders were assessed at baseline, post-intervention, and at the 3-month follow-up. This treatment was conducted as part of a clinical study (UMIN000008322). (3) Results: The client showed improvement in the principal diagnosis and symptoms of the comorbid disorders post-intervention compared with baseline and no longer met the diagnostic criteria for any of the disorders. Considerable symptom improvement was observed with imaginal exposure to trauma memories. (4) Conclusions: The UP was an effective alternative treatment for PTSD and symptoms of comorbidities in this client who was hesitant about exposure to traumatic memories, and that the inclusion of trauma-focused exposure provided sufficient therapeutic effects. Further research is needed to examine the generalizability of our findings.
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18
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Schollar-Root O, Cassar J, Peach N, Cobham VE, Milne B, Barrett E, Back SE, Bendall S, Perrin S, Brady K, Ross J, Teesson M, Kihas I, Dobinson KA, Mills KL. Integrated Trauma-Focused Psychotherapy for Traumatic Stress and Substance Use: Two Adolescent Case Studies. Clin Case Stud 2021. [DOI: 10.1177/15346501211046054] [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] [Indexed: 11/17/2022]
Abstract
Post-traumatic stress disorder (PTSD) and substance use disorder (SUD) occur frequently as comorbid diagnoses among adolescents. Historically, these conditions have been treated using a sequential model; however, emerging evidence suggests that an integrated treatment model may be most effective. This article presents two de-identified clinical case studies from an ongoing randomised controlled trial examining the efficacy of an integrated, exposure-based, cognitive-behavioral psychotherapy (CBT) for PTSD and SUD among adolescents (COPE-A), relative to a supportive counselling control condition (person-centred therapy). In both case studies, participants were randomised to receive the COPE-A integrated treatment, which incorporates prolonged exposure (PE) including imaginal and in vivo exposure as a core treatment component alongside CBT for PTSD and SUD. The clinical profile and treatment response of each participant is discussed. Promising results were found in both cases, with substantially reduced traumatic stress symptoms and decreased or stable levels of substance use by the end of treatment. Clinical implications of these early findings are discussed.
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Affiliation(s)
- Olivia Schollar-Root
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, NSW, Australia
| | - Joanne Cassar
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, NSW, Australia
| | - Natalie Peach
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, NSW, Australia
| | - Vanessa E Cobham
- School of Psychology, University of Queensland, St Lucia, QLD, Australia
- Children’s Health Queensland, Child & Youth Mental Health Service, QLD, Australia
| | - Bronwyn Milne
- The Department of Adolescent Medicine, Sydney Children’s Hospital Network, Sydney, NSW, Australia
| | - Emma Barrett
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, NSW, Australia
| | - Sudie E. Back
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Sarah Bendall
- Orygen, Melbourne, NSW, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Sean Perrin
- Department of Psychology, Lund University, Lund, Sweden
| | - Kathleen Brady
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Joanne Ross
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Maree Teesson
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, NSW, Australia
| | - Ivana Kihas
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, NSW, Australia
| | - Katherine A Dobinson
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, NSW, Australia
| | - Katherine L Mills
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, NSW, Australia
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Werner P, Clay OJ, Goldstein D, Kermel-Schifmann I, Herz MK, Epstein C, Mittelman MS. Assessing an evidence-based intervention for spouse caregivers of persons with Alzheimer's disease: results of a community implementation of the NYUCI in Israel. Aging Ment Health 2021; 25:1676-1683. [PMID: 32496814 DOI: 10.1080/13607863.2020.1774740] [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] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Alzheimer's disease (AD) affects not only the person with the illness, but family caregivers as well. The NYU Caregiver Intervention (NYUCI), a psychosocial intervention which has demonstrated both short and long-term benefits for caregivers, has been used widely in the United States and in Australia and England. The Israeli study was a hybrid between a community implementation study and a randomized controlled trial (RCT) of the NYUCI in a non-English speaking country. METHOD A sample of 100 spouse caregivers participated in trial comparing the NYUCI provided by ten Israeli clinicians (enhanced care), to support group participation (usual care). The major outcome of interest was caregiver depressive symptoms, measured with the Geriatric Depression Scale. A linear random effects regression model controlling for factors associated with depressive symptoms was used to plot the longitudinal trajectories of depressive symptoms over the two-year study period and compare outcomes for the enhanced care and control groups. RESULTS One hundred spouse caregivers enrolled, of whom 81 provided data at baseline and at one or more post intervention assessments. The Israeli adaptation of the NYUCI was effective in reducing depressive symptoms reported by caregivers compared to their counterparts in the control group, b= -1.29 [95%CI (-2.43, -0.15)], p= .0265. CONCLUSION While implementing a randomized controlled trial of an intervention developed and tested in traditional research settings using community providers in Israel, posed unique challenges, the study demonstrated benefits to caregivers. As a result, 30 municipalities in Israel are currently implementing an ongoing adaptation of the NYUCI.
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Affiliation(s)
- Perla Werner
- Department of Community Mental Health, University of Haifa, Haifa, Israel
| | - Olivio J Clay
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Dovrat Goldstein
- Department of Community Mental Health, University of Haifa, Haifa, Israel
| | | | - Michal Karen Herz
- Association for Dementia Studies, University of Worcester, Worcester, UK
| | - Cynthia Epstein
- Department of Psychiatry, NYU School of Medicine, NYU Langone Health, New York, NY, USA
| | - Mary S Mittelman
- Department of Psychiatry, NYU School of Medicine, NYU Langone Health, New York, NY, USA
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20
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Fondren AH, Banducci AN, Cox R, Contractor AA. Processing of Positive Memories Technique among Clients Reporting Traumatic Experiences: A Case Series. Clin Case Stud 2021. [DOI: 10.1177/15346501211035841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Many current treatments for posttraumatic stress disorder (PTSD) emphasize processing and engaging with trauma memories as the key mechanism of therapeutic change. However, promising emerging research indicates links between PTSD symptoms and positive memories. Processing positive memories, to therapeutically impact health outcomes for trauma-exposed individuals, may have several benefits, including (a) increasing access to positive coping mechanisms via activating positive affect and thoughts; (b) addressing avoidance of positive affect and thoughts; and (c) honing skills that will aid in the eventual processing of trauma memories. The present article demonstrates the utility and effects of a novel Processing of Positive Memories Technique (PPMT) with three clients who reported a history of traumatic experiences. We outline the procedures of a 5-session PPMT, that incorporates symptom assessment, detailed imaginal experiencing of positive memories, and processing of associated positive values, affect, strengths, and thoughts. We utilize longitudinal assessment data to demonstrate the clinical benefits of PPMT, such as less PTSD severity, improved mood (e.g., less negative affect), and greater self-esteem. Finally, we discuss treatment considerations based on unique client factors and treatment modalities (i.e., in-person vs. video telehealth).
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Affiliation(s)
- Alana H. Fondren
- Department of Psychology, University of North Texas, Denton, TX, USA
| | - Anne N. Banducci
- The National Center for PTSD at VA Boston Healthcare System, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Randall Cox
- Department of Psychology, University of North Texas, Denton, TX, USA
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21
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Munro S, Wahl K, Soon JA, Guilbert E, Wilcox ES, Leduc-Robert G, Ansari N, Devane C, Norman WV. Pharmacist dispensing of the abortion pill in Canada: Diffusion of Innovation meets integrated knowledge translation. Implement Sci 2021; 16:76. [PMID: 34344393 PMCID: PMC8330203 DOI: 10.1186/s13012-021-01144-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 07/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Since Canadian drug regulatory approval of mifepristone for medical abortion in 2015 and its market availability in January 2017, the role of pharmacists in abortion provision has changed rapidly. We sought to identify the factors that influenced the initiation and provision of medical abortion from the perspectives of Canadian pharmacists, bridging two frameworks - Diffusion of Innovation in Health Service Organizations and integrated knowledge translation. METHODS We conducted one-on-one semi-structured interviews with pharmacists residing in Canada who intended to stock and dispense mifepristone within the first year of availability. Our data collection, analysis, and interpretation were guided by reflexive thematic analysis and supported by an integrated knowledge translation partnership with pharmacy stakeholders. RESULTS We completed interviews with 24 participants from across Canada: 33% had stocked and 21% had dispensed mifepristone. We found that pharmacists were willing and able to integrate medical abortion care into their practice and that those who had initiated practice were satisfied with their dispensing experience. Our analysis indicated that several key Diffusion of Innovation constructs impacted the uptake of mifepristone, including: innovation (relative advantage, complexity and compatibility, technical support), system readiness (innovation-system fit, dedicated time, resources), diffusion and dissemination (expert opinion, boundary spanners, champions, social networks, peer opinions), implementation (external collaboration), and linkage. Participants' experiences suggest that integrated knowledge translation facilitated evidence-based changes to mifepristone dispensing restrictions, and communication of those changes to front line pharmacists. CONCLUSIONS We illustrate how Diffusion of Innovation and integrated knowledge translation may work together as complimentary frameworks for implementation science research. Unlike in the USA, UK, and other highly regulated settings globally, pharmacists in Canada are permitted to dispense mifepristone for medical abortion. We contribute to literature that shows that mifepristone dispensed outside of hospitals, clinics, and medical offices is safe and acceptable to both patients and prescribers. This finding is of particular importance to the current COVID-19 pandemic response and calls for continued and equitable access to abortion care in primary practice.
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Affiliation(s)
- Sarah Munro
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, British Columbia, Canada. .,Department of Obstetrics & Gynaecology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Kate Wahl
- Department of Obstetrics & Gynaecology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Judith A Soon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Edith Guilbert
- Department of Obstetrics, Gynaecology and Reproduction, Laval University, Quebec City, Quebec, Canada
| | - Elizabeth S Wilcox
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Genevieve Leduc-Robert
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nadra Ansari
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Courtney Devane
- School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wendy V Norman
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada.,Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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22
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Klein AB, Kline AC, Bowling AR, Feeny NC. Bridging the science-practice gap in treatment for posttraumatic stress disorder: Testing strategies to enhance beliefs toward exposure therapy. J Clin Psychol 2021; 77:2765-2780. [PMID: 34273910 DOI: 10.1002/jclp.23221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/27/2021] [Accepted: 06/23/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Exposure therapies (e.g., prolonged exposure [PE]), are first-line interventions for posttraumatic stress disorder but remain underutilized, partially due to providers' negative beliefs about these interventions. We examined two experimental strategies aimed at enhancing beliefs towards PE and subsequent utilization. METHOD Clinicians (N = 155) were randomized to one of three conditions presenting a PE rationale: basic, empirically-based, or emotionally-based description. Participants were rerandomized to write or not write arguments for utilizing PE. Before and after PE rationales and 1-month later, participants completed questions about PE beliefs and utilization. RESULTS Participants reported small yet durable belief change across all rationale conditions, with greatest change following the empirically-based description. Across conditions, belief change was not impacted by writing condition or associated with utilization. CONCLUSION Addressing negative beliefs with empirical information may be a brief, cost-effective strategy to improve clinicians' beliefs toward PE. Complementary strategies that leverage belief modification to increase utilization are needed.
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Affiliation(s)
- Alexandra B Klein
- Department of Psychological Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Alexander C Kline
- Clinical Psychology, VA San Diego Healthcare System, San Diego, California, USA
| | - Alexandra R Bowling
- Department of Psychological Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Norah C Feeny
- Department of Psychological Sciences, Case Western Reserve University, Cleveland, Ohio, USA
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Kline AC, Klein AB, Bowling AR, Feeny NC. Exposure Therapy Beliefs and Utilization for Treatment of PTSD: A Survey of Licensed Mental Health Providers. Behav Ther 2021; 52:1019-1030. [PMID: 34134819 DOI: 10.1016/j.beth.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 01/04/2021] [Accepted: 01/08/2021] [Indexed: 11/15/2022]
Abstract
Exposure-based therapies for posttraumatic stress disorder (PTSD) and anxiety disorders remain underutilized, despite their effectiveness and widescale dissemination efforts. This study surveyed a broad range of licensed providers (N = 155) to examine rates at which prolonged exposure (PE) and other interventions are used to treat PTSD and to investigate provider characteristics linked to exposure beliefs and utilization. While 92.3% of clinicians reported understanding of or training in exposure, only 55.5% of providers reported use of PE to treat PTSD. Clinicians with current cognitive behavioral therapy (CBT) orientation, CBT training orientation, a doctoral degree, and training in PE endorsed greater likelihood of exposure utilization for PTSD (ps < .001, ds = 0.82-1.98) and less negative beliefs about exposure (ps < .01, ds = 0.55-2.00). Exposure beliefs also differed based on healthcare setting (p < .001). Among providers trained in exposure (n = 106), master's degree and non-CBT current theoretical orientation were associated with high utilization yet also negative beliefs. Results suggest exposure training, accurate beliefs, and utilization still lag among some groups of providers. Additionally, negative beliefs and misunderstanding of the exposure rationale may persist even among providers who are trained and report high utilization.
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Affiliation(s)
- Alexander C Kline
- VA San Diego Healthcare System, University of California San Diego; Case Western Reserve University.
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Kline AC, Panza KE, Harlé KM, Angkaw AC, Trim RS, Back SE, Norman SB. Within-treatment clinical markers of dropout risk in integrated treatments for comorbid PTSD and alcohol use disorder. Drug Alcohol Depend 2021; 221:108592. [PMID: 33618193 DOI: 10.1016/j.drugalcdep.2021.108592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Integrated interventions for comorbid posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are effective, but many patients prematurely drop out from treatment. Little is known about within-treatment risk factors for dropout, limiting the ability during therapy to identify patients at risk for attrition. METHODS We examined measures assessing PTSD (PTSD Checklist for DSM-5; PCL-5), alcohol use (Substance Use Inventory; SUI), and patient satisfaction (Client Satisfaction Questionnaire; CSQ-8) as potential within-treatment markers of dropout risk, administered to 110 veterans in a randomized clinical trial of integrated exposure therapy versus integrated coping skills therapy for comorbid PTSD + AUD. Hierarchical Cox proportional hazard models with dropout status as the endpoint assessed effects of PCL-5, SUI, and CSQ-8 on dropout risk, and whether effects differed by treatment modality. RESULTS A significant interaction between treatment and changes in alcohol use was observed (HR = 2.86, p = .007), where between-session alcohol use was positively associated with dropout hazard rate for those receiving integrated exposure therapy (HR = 2.34, p = .004), but not coping skills therapy (HR = 0.73, p = .19). Specifically, an increase of one drink consumed per day in the interval since last assessment (typically 2-3 weeks) was associated with a 5-fold increase in dropout hazard rate. CONCLUSIONS The findings provide preliminary evidence of detectable within-treatment markers of dropout during integrated treatment for PTSD + AUD. Study of within-treatment indicators proximal to dropout may help identify at-risk patients and inform timely strategies to boost retention.
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Affiliation(s)
- Alexander C Kline
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA.
| | - Kaitlyn E Panza
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA
| | - Katia M Harlé
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA
| | - Abigail C Angkaw
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA; National Center for Posttraumatic Stress Disorder, 163 Veterans Dr, White River Junction, VT, 05009, USA
| | - Ryan S Trim
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA
| | - Sudie E Back
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC, 29425, USA; Ralph H. Johnson Veteran Affairs Medical Center, 109 Bee St, Charleston, SC, 29401, USA
| | - Sonya B Norman
- Department of Psychiatry, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA; National Center for Posttraumatic Stress Disorder, 163 Veterans Dr, White River Junction, VT, 05009, USA
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Banducci AN. Prolonged Exposure Therapy in the Time of COVID-19: Modifying PTSD Treatment for a Military Sexual Trauma Survivor Who Contracted COVID-19 Mid-Treatment. Clin Case Stud 2021. [DOI: 10.1177/1534650121993547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Prolonged exposure (PE) therapy is a gold-standard treatment for posttraumatic stress disorder (PTSD) that can be effectively delivered via telehealth modalities. The following case report describes a course of PE delivered to a veteran seeking PTSD treatment for military sexual trauma (MST), who contracted COVID-19 mid-treatment. Considerations for selecting PE as a treatment modality; modifications made due to the COVID-19 pandemic and transition to telehealth more broadly, and following the veteran contracting COVID-19 more specifically; strategies to increase treatment engagement; and assessment of progress over time, are discussed. In particular, treatment considerations during a global pandemic are explored at the patient-, provider-, and systems level, to inform treatment delivery for other providers during this ongoing pandemic. Although there were numerous technological, environmental, and pandemic-related difficulties, the veteran described here persisted through a course of PE and experienced clinically significant reductions in symptoms of PTSD and a great degree of functional recovery.
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Affiliation(s)
- Anne N. Banducci
- The National Center for PTSD at the VA Boston Healthcare System, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
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O'Brien KM, Dozier ME, Lopez J, Ruha A. A new treatment model for veterans?: Results from a program evaluation of a recovery-oriented intensive outpatient program for veterans with heterogeneous diagnostic presentations. JOURNAL OF CONTEXTUAL BEHAVIORAL SCIENCE 2021. [DOI: 10.1016/j.jcbs.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Song J, Johnson C, Suvak MK, Shields N, Lane JEM, Monson CM, Wiltsey-Stirman S. Patterns of change in physical functioning and posttraumatic stress disorder with cognitive processing therapy in a randomized controlled implementation trial. Eur J Psychotraumatol 2020; 11:1801166. [PMID: 33062209 PMCID: PMC7534295 DOI: 10.1080/20008198.2020.1801166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Physical health concerns (e.g. chronic pain, fatigue) are common among clients with posttraumatic stress disorder (PTSD). Prior research has indicated that clients report improved physical functioning and fewer physical health symptoms after receiving Cognitive Processing Therapy (CPT) for PTSD. However, less is known about the impact of physical functioning on the clients' PTSD symptom improvement in CPT. Objective: The current study examined the patterns of change of and between physical functioning and PTSD symptoms over the course of CPT among a diverse military, veteran, and community sample. Method: We collected clients' (N = 188) physical functioning and PTSD symptom severity prior to and during CPT using the 12-Item Short Form Health Survey and the PTSD Checklist. We used multilevel modelling to 1) evaluate the impact of baseline physical functioning on the PTSD symptom trajectory, 2) examine the trajectory of physical functioning, and 3) assess the dynamics between physical functioning and PTSD symptoms over the course of CPT. Results: Our multilevel analyses indicated that 1) physical functioning significantly improved for those with low levels of functioning prior to treatment, 2) poorer baseline physical functioning predicted slower improvements in PTSD symptoms, and 3) poorer physical functioning in one session predicted less PTSD symptom improvement by the next session. Conclusions: Our findings demonstrate that while physical functioning can interfere with PTSD symptom improvement, physical functioning can also improve over the course of CPT. In light of the interconnected nature of physical health and PTSD symptoms, clinicians may need to attend to lower levels of physical functioning when providing CPT or other trauma-focused therapies. Future research to determine whether specific treatment adaptations may benefit such clients is needed.
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Affiliation(s)
- Jiyoung Song
- National Center for PTSD, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Clara Johnson
- National Center for PTSD, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Michael K Suvak
- Department of Psychology, Suffolk University, Boston, MA, USA
| | | | - Jeanine E M Lane
- Department of Psychology, Ryerson University, Toronto, ON, Canada
| | - Candice M Monson
- Department of Psychology, Ryerson University, Toronto, ON, Canada
| | - Shannon Wiltsey-Stirman
- National Center for PTSD, VA Palo Alto Healthcare System, Menlo Park, CA, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
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28
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Dedert EA, LoSavio ST, Wells SY, Steel AL, Reinhardt K, Deming CA, Ruffin RA, Berlin KL, Kimbrel NA, Wilson SM, Boeding SE, Clancy CP. Clinical effectiveness study of a treatment to prepare for trauma-focused evidence-based psychotherapies at a veterans affairs specialty posttraumatic stress disorder clinic. Psychol Serv 2020; 18:651-662. [PMID: 32852996 DOI: 10.1037/ser0000425] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Posttraumatic stress disorder (PTSD) clinics in the Department of Veterans Affairs (VA) often provide psychoeducational or skill-building groups to prepare veterans for trauma-focused PTSD treatments. However, there has been limited evaluation of the effectiveness of this phase-based approach for treatment engagement and symptom reduction. Participants included 575 veterans seeking treatment for PTSD whose treatment outcomes were assessed in a VA outpatient PTSD clinic staffed by mental health professionals and trainees. Participants completed self-report measures of baseline characteristics and psychiatric symptoms as part of routine PTSD clinic treatment. We tested the association of preparatory group treatment with engagement in and treatment response to subsequent trauma-focused psychotherapies, cognitive processing therapy (CPT) and prolonged exposure therapy (PE), which are designated by VA as evidence-based psychotherapies (EBP). Following participation in preparatory treatments, 94/391 (24%) of veterans engaged in a subsequent trauma-focused EBP (CPT or PE). Relative to patients who had previously completed a preparatory group, patients initiating a trauma-focused EBP without having first attended preparatory PTSD treatment had similar rates of trauma-focused EBP completion and better treatment response, as measured by decreases on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; PCL-5), F(1, 3009) = 10.89, p = .001, and Patient Health Questionnaire 9 measure of depressive symptoms F(1, 3688) = 6.74, p = .010. Overall, veterans reported greater symptom reduction when engaging in trauma-focused EBP directly, without having previously attended a preparatory group. These data support veteran engagement in trauma-focused EBPs for PTSD without first being encouraged to complete psychoeducational or skill-building groups. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
- Eric A Dedert
- Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC)
| | | | | | | | | | | | | | | | - Nathan A Kimbrel
- Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC)
| | - Sarah M Wilson
- Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation
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29
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The effects of a prolonged exposure workshop with and without consultation on provider and patient outcomes: a randomized implementation trial. Implement Sci 2020; 15:59. [PMID: 32727509 PMCID: PMC7388467 DOI: 10.1186/s13012-020-01014-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/25/2020] [Indexed: 12/03/2022] Open
Abstract
Background Prolonged exposure therapy (PE) is an evidence-based treatment for posttraumatic stress disorder (PTSD) that is underutilized in the military health system. Standard workshop training in PE may not be sufficient to alter provider behavior, but post-workshop consultation requires significant resources. Therefore, it is important to determine the incremental utility of post-workshop consultation. Methods This study used a hybrid type III randomized implementation trial at 3 US Army installations. Providers were randomized to receive a 4-day prolonged exposure workshop (Standard training condition, n = 60), or the prolonged exposure workshop followed by 6–8 months of post-workshop expert case consultation (Extended training condition, n = 43). The effects training condition were examined on provider attitudes (self-efficacy in delivering PE, expectations for patient improvement, and beliefs about PE), use of PE and PE components, and clinical outcomes of patients with PTSD (using the Clinician-Administered PTSD Scale (CAPS-5)). Results Extended condition providers reported greater improvements in self-efficacy, b = .83, 95% CI [.38, 1.27], t(79) = 3.71, p = .001, and d = .63. A greater proportion of patients in the Extended condition (44%) than in the Standard condition (27%) received at least 1 PE session, b = .76, t(233) = 2.53, p = .012, and OR = 2.13. Extended condition providers used more PE components (M = .9/session) than did Standard condition providers (M = .5/session), b = .54, 95% CI [.15, .93], t(68) = 2.70, p = .007, and d = .68. Finally, decrease in patients’ PTSD symptoms was faster for patients of Extended condition providers than for patients of Standard condition providers, b = − 1.81, 95% CI [− 3.57, − .04], t(263) = − 2.02, p = .045, and d = .66, and their symptoms were lower at the second assessment, b = − 5.47, 95% CI [− 9.30, − 1.63], t(210) = − 2.81, p = .005, and d = .66. Conclusions Post-workshop consultation improved self-efficacy for delivering PE, greater use of PE, faster PTSD reduction, and lower PTSD severity at the second assessment. To our knowledge, this is the first demonstration that post-workshop case consultation for PE improves patient outcomes. Trial registration Clinicaltrials.gov, NCT02982538. Registered December 5, 2016; retrospectively registered
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30
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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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31
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Sansen LM, Saupe LB, Steidl A, Fegert JM, Hoffmann U, Neuner F. Daring to process the trauma: using a web-based training to reduce psychotherapists' fears and reservations around implementing trauma-focused therapy. Eur J Psychotraumatol 2019; 10:1696590. [PMID: 31853333 PMCID: PMC6913602 DOI: 10.1080/20008198.2019.1696590] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/22/2019] [Accepted: 10/26/2019] [Indexed: 11/29/2022] Open
Abstract
Although trauma-focused interventions are the first-line therapies for patients with posttraumatic stress disorder (PTSD), they are not frequently used in clinical practice. Factors preventing therapists from applying trauma-focused methods include a lack of training and negative attitudes towards trauma-focused therapy. The aim of the present study was to investigate which factors predict willingness to carry out trauma-focused therapy and to examine whether a web-based training is able to reduce negative attitudes and reservations about these interventions. In a wait-list controlled evaluation study, therapists (N = 499) were randomized into an intervention or a wait-list control group. Results show that trauma-treatment specific competencies and overcoming pre-existing concerns towards trauma-focused therapy significantly predict therapists' willingness to utilize trauma-focused interventions. Thus, the content alignment of the web-based course is appropriate for improving therapists' willingness to conduct trauma-focused therapy. A retrospective examination of therapists after the training and a comparison of fears and reservations before and after the training demonstrate a significant reduction of fears and reservations. In terms of perceived contraindications, no effects of the web-based training were found. The present study provides compelling evidence that web-based training in evidence-based PTSD therapy is able to reduce reservations that may prevent therapists from applying evidence-based trauma-focused interventions.
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Affiliation(s)
- Lisa M. Sansen
- Faculty of Psychology, Clinical Psychology
and Psychotherapy, Bielefeld University, Bielefeld,
Germany
| | - Laura B. Saupe
- Faculty of Psychology, Clinical Psychology
and Psychotherapy, Bielefeld University, Bielefeld,
Germany
| | - Annika Steidl
- Faculty of Psychology, Clinical Psychology
and Psychotherapy, Bielefeld University, Bielefeld,
Germany
| | - Jörg M. Fegert
- Department of Child and Adolescent
Psychiatry/Psychotherapy, University Hospital Ulm, Ulm,
Germany
| | - Ulrike Hoffmann
- Department of Child and Adolescent
Psychiatry/Psychotherapy, University Hospital Ulm, Ulm,
Germany
| | - Frank Neuner
- Faculty of Psychology, Clinical Psychology
and Psychotherapy, Bielefeld University, Bielefeld,
Germany
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Mikolić A, Polinder S, Retel Helmrich IRA, Haagsma JA, Cnossen MC. Treatment for posttraumatic stress disorder in patients with a history of traumatic brain injury: A systematic review. Clin Psychol Rev 2019; 73:101776. [PMID: 31707182 DOI: 10.1016/j.cpr.2019.101776] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 07/27/2019] [Accepted: 08/21/2019] [Indexed: 01/10/2023]
Abstract
Posttraumatic stress disorder (PTSD) frequently co-occurs with traumatic brain injury (TBI). We conducted a systematic review to evaluate the appropriateness and effectiveness of treatments for PTSD in adult patients with a history of TBI. We searched for longitudinal studies aimed at treatments for PTSD patients who sustained a TBI, published in English between 1980 and February 2019. Twenty-three studies were found eligible, and 26 case studies were included for a separate overview. The quality of eligible studies was assessed using the Research Triangle Institute item bank. The majority of studies included types of cognitive-behavioral therapy (CBT) in male service members and veterans with a history of mild TBI in the United States. Studies using prolonged exposure (PE), cognitive-processing therapy (CPT) or other types of CBT, usually in combination with additional treatments, showed favorable outcomes. A smaller number of studies described complementary and novel therapies, which showed promising results. Overall, the quality of studies was considered low. We concluded that CBT seem appropriate for the patient population with history of TBI. The evidence is less strong for other therapies. We recommend controlled studies of PTSD treatments including more female patients and those with a history of moderate to severe TBIs in civilian and military populations.
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Affiliation(s)
- Ana Mikolić
- Department of Public Health, Erasmus MC-University Medical Center, Rotterdam, the Netherlands.
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | | | - Juanita A Haagsma
- Department of Public Health, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Maryse C Cnossen
- Department of Public Health, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
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33
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Tong J, Simpson K, Alvarez-Jimenez M, Bendall S. Talking about trauma in therapy: Perspectives from young people with post-traumatic stress symptoms and first episode psychosis. Early Interv Psychiatry 2019; 13:1236-1244. [PMID: 30537145 DOI: 10.1111/eip.12761] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 10/19/2018] [Accepted: 11/04/2018] [Indexed: 11/29/2022]
Abstract
AIM Despite recommendations from national guidelines, individuals with first episode psychosis (FEP) are currently unlikely to have the effects of their traumatic experiences assessed and treated within psychosis treatment. This may be due to the mismatch between the objectives of trauma-specific treatments (directly targeting post-traumatic stress symptoms by talking about the trauma) and trauma-informed care (limiting practices that may retraumatise clients). We aimed to gain an understanding of what it was like for young people to talk about trauma in FEP treatment, and how their experiences related to the broad conceptualisations of trauma-informed and trauma-specific treatment approaches. METHODS Semi-structured interviews were conducted with eleven participants (18-27 years) with FEP and post-traumatic stress disorder (PTSD) symptoms after the completion of an intervention for the effects of trauma. Transcripts were analysed using an interpretative phenomenological approach. RESULTS Two superordinate themes were identified, each with subordinate themes. 1. Reluctance to approach the trauma memory: 1a. Not wanting to talk about trauma; 1b. Difficulty acknowledging that the trauma had occurred; 1c. Not wanting to re-experience emotions associated with trauma. 2. Factors aiding the process: 2a. Desire for change; 2b. Not being pushed to talk; 2c. Valuing the case manager; 2d. Time. CONCLUSIONS A majority of participants in the study experienced reluctance when recounting their trauma memories. Being in control of how trauma memories are shared and having time for the therapeutic relationship to develop enhanced participants' readiness for talking about trauma. Incorporating trauma-informed principles and motivational interviewing could aid in facilitating the processes around talking about trauma.
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Affiliation(s)
- Janet Tong
- School of Psychological Sciences, Monash University, Victoria, Australia
| | - Katrina Simpson
- School of Psychological Sciences, Monash University, Victoria, Australia
| | - Mario Alvarez-Jimenez
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Victoria, Australia.,Centre for Youth Mental Health, The University of Melbourne, Victoria, Australia
| | - Sarah Bendall
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Victoria, Australia.,Centre for Youth Mental Health, The University of Melbourne, Victoria, Australia
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Wagner AW, Jakupcak M, Kowalski HM, Bittinger JN, Golshan S. Behavioral Activation as a Treatment for Posttraumatic Stress Disorder Among Returning Veterans: A Randomized Trial. Psychiatr Serv 2019; 70:867-873. [PMID: 31337325 DOI: 10.1176/appi.ps.201800572] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Although evidence-based, trauma-processing treatments exist for posttraumatic stress disorder (PTSD), many individuals do not seek out, complete, or fully respond to these treatments, pointing to the need for alternative treatments. In this study, the authors evaluated the effectiveness of behavioral activation therapy modified to address PTSD among veterans. METHODS In a randomized trial, behavioral activation was compared with treatment as usual (referral to PTSD "standard care") among a sample of 80 veterans of the wars in Iraq and Afghanistan who were enrolled at the U.S. Department of Veterans Affairs (VA) Portland Health Care System and the VA Puget Sound Health Care System. RESULTS Levels of PTSD symptoms decreased for both groups across posttreatment and at 3-month follow-up as measured by clinical interview and self-report measures. The behavioral activation group had greater improvement on PTSD as evidenced by the self-report measure of symptom severity. Both groups also showed improvement on self-report measures of depression and overall functioning across time, with greater improvement on depression evidenced by the behavioral activation group. Ratings of treatment satisfaction were high for both groups. CONCLUSIONS Behavioral activation is a promising alternative treatment for PTSD.
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Affiliation(s)
- Amy W Wagner
- U.S. Department of Veterans Affairs (VA) Portland Health Care System, Portland, Oregon (Wagner, Kowalski); Department of Psychiatry, Oregon Health and Science University, Portland (Wagner); VA National Telemental Health Hub, Continental Region, Salt Lake City (Jakupcak); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Jakupcak); Department of Psychiatry, University of California, San Diego, La Jolla (Golshan). Dr. Bittinger, who was with the VA Puget Sound Health Care System, is now deceased
| | - Matthew Jakupcak
- U.S. Department of Veterans Affairs (VA) Portland Health Care System, Portland, Oregon (Wagner, Kowalski); Department of Psychiatry, Oregon Health and Science University, Portland (Wagner); VA National Telemental Health Hub, Continental Region, Salt Lake City (Jakupcak); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Jakupcak); Department of Psychiatry, University of California, San Diego, La Jolla (Golshan). Dr. Bittinger, who was with the VA Puget Sound Health Care System, is now deceased
| | - Halina M Kowalski
- U.S. Department of Veterans Affairs (VA) Portland Health Care System, Portland, Oregon (Wagner, Kowalski); Department of Psychiatry, Oregon Health and Science University, Portland (Wagner); VA National Telemental Health Hub, Continental Region, Salt Lake City (Jakupcak); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Jakupcak); Department of Psychiatry, University of California, San Diego, La Jolla (Golshan). Dr. Bittinger, who was with the VA Puget Sound Health Care System, is now deceased
| | - Joyce N Bittinger
- U.S. Department of Veterans Affairs (VA) Portland Health Care System, Portland, Oregon (Wagner, Kowalski); Department of Psychiatry, Oregon Health and Science University, Portland (Wagner); VA National Telemental Health Hub, Continental Region, Salt Lake City (Jakupcak); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Jakupcak); Department of Psychiatry, University of California, San Diego, La Jolla (Golshan). Dr. Bittinger, who was with the VA Puget Sound Health Care System, is now deceased
| | - Shahrokh Golshan
- U.S. Department of Veterans Affairs (VA) Portland Health Care System, Portland, Oregon (Wagner, Kowalski); Department of Psychiatry, Oregon Health and Science University, Portland (Wagner); VA National Telemental Health Hub, Continental Region, Salt Lake City (Jakupcak); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Jakupcak); Department of Psychiatry, University of California, San Diego, La Jolla (Golshan). Dr. Bittinger, who was with the VA Puget Sound Health Care System, is now deceased
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35
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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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Crocker LD, Jurick SM, Thomas KR, Keller AV, Sanderson-Cimino M, Hoffman SN, Boyd B, Rodgers C, Norman SB, Lang AJ, Twamley EW, Jak AJ. Mild traumatic brain injury characteristics do not negatively influence cognitive processing therapy attendance or outcomes. J Psychiatr Res 2019; 116:7-13. [PMID: 31174014 DOI: 10.1016/j.jpsychires.2019.05.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/16/2019] [Accepted: 05/23/2019] [Indexed: 01/07/2023]
Abstract
Some providers have expressed hesitation about the appropriateness of PTSD treatment for veterans with a history of mild traumatic brain injury (mTBI), given concerns that TBI-related sequelae may negatively affect PTSD treatment and/or should be the focus of treatment instead. However, research suggests that those with a history of mTBI can benefit from evidence-based PTSD treatment. To extend these findings, we examined whether specific mTBI injury markers were associated with PTSD treatment attendance and response. Iraq/Afghanistan-era veterans with PTSD and history of mTBI (N = 88) all received Cognitive Processing Therapy (CPT; either standard CPT without the trauma account or SMART-CPT, a modified version of CPT that included cognitive rehabilitation strategies). Analyses examined whether time since injury, presence of loss of consciousness (LOC) or posttraumatic amnesia (PTA), and number and mechanism of mTBIs were associated with treatment attendance or response. None of the five injury variables examined were associated with number of treatment sessions attended. Multilevel modeling indicated that injury variables did not moderate treatment response (across treatment conditions) in terms of change in PTSD and depression symptoms. There was a three-way interaction showing that individuals who denied ever experiencing LOC exhibited a greater decrease in PTSD and depression symptoms in standard CPT relative to those in the SMART-CPT. Thus, a history of mTBI should not preclude individuals from receiving standard CPT, regardless of injury characteristics. In fact, PTSD treatment should often be a first line of treatment for these veterans, given evidence of a mental health etiology to persistent post-concussive symptoms.
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Affiliation(s)
- Laura D Crocker
- Research Service, VA San Diego Healthcare System, USA; Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, USA.
| | - Sarah M Jurick
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, USA; Psychology Service, VA San Diego Healthcare System, USA
| | - Kelsey R Thomas
- Department of Psychiatry, University of California, San Diego, USA
| | | | - Mark Sanderson-Cimino
- San Diego State University, University of California San Diego Joint Doctoral Program in Clinical Psychology, USA
| | | | | | | | - Sonya B Norman
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, USA; Department of Psychiatry, University of California, San Diego, USA; (h)National Center for PTSD, White River Junction, VT, USA
| | - Ariel J Lang
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, USA; Department of Psychiatry, University of California, San Diego, USA
| | - Elizabeth W Twamley
- Research Service, VA San Diego Healthcare System, USA; Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, USA; Department of Psychiatry, University of California, San Diego, USA
| | - Amy J Jak
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, USA; Psychology Service, VA San Diego Healthcare System, USA; Department of Psychiatry, University of California, San Diego, USA
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Hamilton AB, Wiltsey-Stirman S, Finley EP, Klap R, Mittman BS, Yano EM, Oishi S. Usual Care Among Providers Treating Women Veterans: Managing Complexity and Multimorbidity in the Era of Evidence-Based Practice. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2019; 47:244-253. [DOI: 10.1007/s10488-019-00961-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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van den Berk Clark C, Moore R, Secrest S, Tuerk P, Norman S, Myers U, Lustman PJ, Schneider FD, Barnes J, Gallamore R, Ovais M, Plurad JA, Scherrer JF. Factors Associated With Receipt of Cognitive-Behavioral Therapy or Prolonged Exposure Therapy Among Individuals With PTSD. Psychiatr Serv 2019; 70:703-713. [PMID: 31010409 PMCID: PMC6702958 DOI: 10.1176/appi.ps.201800408] [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] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The aim of this study was to systematically review variables associated with initiation of trauma-centered cognitive-behavioral therapy (TC-CBT) among individuals with posttraumatic stress disorder (PTSD). METHODS PubMed, PsycINFO, Web of Science, Published International Literature on Traumatic Stress (PILOTS), and Scopus were searched in a systematic manner up to 2018, and 26 relevant studies were recovered and analyzed. RESULTS The average weighted initiation rate was 6% in larger hospital systems with a high rate of trauma and 28% in outpatient mental health settings (range 4%-83%). Older age (odds ratio [OR]=1.56, 95% confidence interval [CI]=0.51-1.61), female gender (OR=1.18, 95% CI=1.08-1.27), black or other racial-ethnic minority group (OR=1.16, 95% CI=1.03-1.28), Veterans Affairs PTSD service connection status (OR=2.30, 95% CI=2.18-2.42), mental health referral (OR=2.28, 95% CI=1.05-3.50), greater staff exposure to TC-CBT (OR=2.30, 95% CI=2.09-2.52), adaptability of TC-CBT to staff workflow (OR=4.66, 95% CI=1.60-7.72), greater PTSD severity (OR=1.46, 95% CI=1.13-1.78), and comorbid depression (OR=1.21, 95% CI=1.14-1.29) increased the likelihood of TC-CBT initiation, whereas delayed treatment reduced the likelihood of TC-CBT initiation (OR=0.93, 95% CI=0.92-0.95). Qualitative studies showed that mental health beliefs (stigma and lack of readiness), provider organizational factors (low availability, privacy issues), and patient lack of time (logistics) were perceived as barriers to initiation by patients and providers. CONCLUSIONS TC-CBT initiation increased among patients who were older and female. Initiation was also higher among providers who had more exposure to TC-CBT in their work environment and when TC-CBT fit into their existing workflow.
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Affiliation(s)
- Carissa van den Berk Clark
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Rachel Moore
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Scott Secrest
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Peter Tuerk
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Sonya Norman
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Ursula Myers
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Patrick J Lustman
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - F David Schneider
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Jacqueline Barnes
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Randy Gallamore
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Muhammad Ovais
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - James Alex Plurad
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Jeffrey F Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
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Ackland PE, Greer N, Sayer NA, Spoont MR, Taylor BC, MacDonald R, McKenzie L, Rosebush C, Wilt TJ. Effectiveness and harms of mental health treatments in service members and veterans with deployment-related mild traumatic brain injury. J Affect Disord 2019; 252:493-501. [PMID: 31028994 DOI: 10.1016/j.jad.2019.04.066] [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: 09/28/2018] [Revised: 03/08/2019] [Accepted: 04/08/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Co-morbidity of psychiatric conditions with traumatic brain injury (TBI) is common among service members and Veterans from recent deployments. Practice guidelines for mild TBI (mTBI) recommend management of co-occurring psychiatric conditions with existing treatments, but it is unclear whether the effectiveness of treatments for psychiatric conditions is impacted by mTBI. We conducted a systematic literature review to examine the effectiveness and harms of pharmacological and non-pharmacological treatments for posttraumatic stress disorder, depressive disorders, substance use disorders, suicidal ideation or attempts, and anxiety disorders in the presence of co-morbid deployment-related mTBI. METHODS We searched bibliographic databases for peer-reviewed, English language studies published from 2000 to October 2017. Two reviewers independently completed abstract triage and full text review. RESULTS We identified 7 studies (5 pre-post and 2 secondary analysis). Six assessed psychotherapy and one reported on hyperbaric oxygen therapy (HBO2). Studies comparing outcomes by TBI history found that a history of TBI does not affect treatment outcomes. Harms were reported only for HBO2 and were mild. No study examined the effectiveness of treatments for substance use disorders or suicidal ideation, or the effectiveness of pharmacological interventions for the psychiatric conditions of interest in service members and Veterans with mTBI. LIMITATIONS Studies lacked usual care or wait-list control groups and no randomized trials were found, making the strength of evidence insufficient. CONCLUSIONS Evidence is insufficient to fully assess the impact of TBI on the effectiveness of treatments for psychiatric conditions. Higher quality evidence with definitive guidance for providers treating this population is needed.
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Affiliation(s)
- Princess E Ackland
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota, Minneapolis, MN.
| | - Nancy Greer
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Minneapolis VA Evidence-based Synthesis Program Center, Minneapolis VA Health Care System, One Veterans Drive (111-O), Minneapolis, MN 55417, USA
| | - Nina A Sayer
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota, Minneapolis, MN; Department of Psychiatry, University of Minnesota, Minneapolis, MN
| | - Michele R Spoont
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota, Minneapolis, MN; National Center for PTSD, Honolulu, HI
| | - Brent C Taylor
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota, Minneapolis, MN; Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
| | - Roderick MacDonald
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Minneapolis VA Evidence-based Synthesis Program Center, Minneapolis VA Health Care System, One Veterans Drive (111-O), Minneapolis, MN 55417, USA
| | - Lauren McKenzie
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Minneapolis VA Evidence-based Synthesis Program Center, Minneapolis VA Health Care System, One Veterans Drive (111-O), Minneapolis, MN 55417, USA
| | - Christina Rosebush
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Minneapolis VA Evidence-based Synthesis Program Center, Minneapolis VA Health Care System, One Veterans Drive (111-O), Minneapolis, MN 55417, USA
| | - Timothy J Wilt
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota, Minneapolis, MN; Minneapolis VA Evidence-based Synthesis Program Center, Minneapolis VA Health Care System, One Veterans Drive (111-O), Minneapolis, MN 55417, USA
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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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Jak AJ, Jurick S, Crocker LD, Sanderson-Cimino M, Aupperle R, Rodgers CS, Thomas KR, Boyd B, Norman SB, Lang AJ, Keller AV, Schiehser DM, Twamley EW. SMART-CPT for veterans with comorbid post-traumatic stress disorder and history of traumatic brain injury: a randomised controlled trial. J Neurol Neurosurg Psychiatry 2019; 90:333-341. [PMID: 30554135 DOI: 10.1136/jnnp-2018-319315] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/19/2018] [Accepted: 11/18/2018] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To better concurrently address emotional and neuropsychological symptoms common in veterans with comorbid post-traumatic stress disorder (PTSD) and history of traumatic brain injury (TBI), we integrated components of compensatory cognitive training from the Cognitive Symptom Management and Rehabilitation Therapy (CogSMART) programme into cognitive processing therapy (CPT) for PTSD to create a hybrid treatment, SMART-CPT (CogSMART+CPT). This study compared the efficacy of standard CPT with SMART-CPT for treatment of veterans with comorbid PTSD and history of TBI reporting cognitive symptoms. METHODS One hundred veterans with PTSD, a history of mild to moderate TBI and current cognitive complaints were randomised and received individually delivered CPT or SMART-CPT for 12 weeks. Participants underwent psychological, neurobehavioural and neuropsychological assessments at baseline, on completion of treatment and 3 months after treatment. RESULTS Both CPT and SMART-CPT resulted in clinically significant reductions in PTSD and postconcussive symptomatology and improvements in quality of life. SMART-CPT resulted in additional improvements in the neuropsychological domains of attention/working memory, verbal learning/memory and novel problem solving. CONCLUSION SMART-CPT, a mental health intervention for PTSD, combined with compensatory cognitive training strategies, reduces PTSD and neurobehavioural symptoms and also provides added value by improving cognitive functioning.
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Affiliation(s)
- Amy J Jak
- Psychology Service, VA San Diego Healthcare System, San Diego, California, USA .,Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, California, USA.,Research Service, VA San Diego Healthcare System, San Diego, California, USA.,Department of Psychiatry, University of California, San Diego, California, USA
| | - Sarah Jurick
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, California, USA.,Department of Psychiatry, University of California, San Diego, California, USA
| | - Laura D Crocker
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, California, USA.,Research Service, VA San Diego Healthcare System, San Diego, California, USA
| | | | - Robin Aupperle
- Laureate Institute for Brain Research, University of Tulsa, Tulsa, Oklahoma, USA
| | | | - Kelsey R Thomas
- Psychology Service, VA San Diego Healthcare System, San Diego, California, USA.,Department of Psychiatry, University of California, San Diego, California, USA
| | - Briana Boyd
- Research Service, VA San Diego Healthcare System, San Diego, California, USA
| | - Sonya B Norman
- Psychology Service, VA San Diego Healthcare System, San Diego, California, USA.,Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, California, USA.,Department of Psychiatry, University of California, San Diego, California, USA.,National Center for PTSD, White River Junction, Vermont, USA
| | - Ariel J Lang
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, California, USA.,Department of Psychiatry, University of California, San Diego, California, USA
| | - Amber V Keller
- Research Service, VA San Diego Healthcare System, San Diego, California, USA
| | - Dawn M Schiehser
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, California, USA.,Research Service, VA San Diego Healthcare System, San Diego, California, USA.,Department of Psychiatry, University of California, San Diego, California, USA
| | - Elizabeth W Twamley
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, California, USA.,Department of Psychiatry, University of California, San Diego, California, USA
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42
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Kip KE, Berumen J, Zeidan AR, Hernandez DF, Finnegan AP. The emergence of accelerated resolution therapy for treatment of post‐traumatic stress disorder: A review and new subgroup analyses. COUNSELLING & PSYCHOTHERAPY RESEARCH 2019. [DOI: 10.1002/capr.12210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Kevin E. Kip
- College of Public HealthUniversity of South Florida Tampa Florida
| | - Jessica Berumen
- College of Public HealthUniversity of South Florida Tampa Florida
| | - Amina R. Zeidan
- University of Texas Health Sciences Center San Antonio Texas
| | | | - Alan P. Finnegan
- Westminster Centre for Research & Innovation in Veterans WellbeingUniversity of Chester Chester UK
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Using Explicit Case Formulation to Improve Cognitive Processing Therapy for PTSD. Behav Ther 2019; 50:155-164. [PMID: 30661556 DOI: 10.1016/j.beth.2018.04.003] [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: 12/07/2017] [Revised: 04/11/2018] [Accepted: 04/11/2018] [Indexed: 11/20/2022]
Abstract
We investigated the utility of explicit case formulation (CF) within Cognitive Processing Therapy (CPT) for individuals with posttraumatic stress disorder (PTSD). An uncontrolled pre-posttreatment design was used. Participants attended 12-16 weekly sessions of CPT with explicit CF, where CF guided treatment length and treatment components. Treatment was completed by 19 of the 23 participants who started therapy. Results revealed significant reductions in PTSD and depression severity as well as unhelpful PTSD-related beliefs from pre- to posttreatment (ds between 1.10 - 1.92) and treatment gains were maintained at 3-month follow-up. Of the participants available at posttreatment for assessment, 69% (n = 11/16) met good end-state functioning for PTSD and 62% (n = 8/13) did so at follow-up. Finally, 72% (n = 13/18) of those interviewed at posttreatment no longer met criteria for PTSD and this was found for 93% of those assessed at follow-up (n = 14/15). Treatment, and CF in particular, was found to be acceptable by participants. Explicit case formulation did not interfere with positive outcomes of Cognitive Processing Therapy for PTSD. Further clinical implications and future directions for research are discussed.
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44
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Stirman SW, Gutner CA, Suvak MK, Adler A, Calloway A, Resick P. Homework Completion, Patient Characteristics, and Symptom Change in Cognitive Processing Therapy for PTSD. Behav Ther 2018; 49:741-755. [PMID: 30146141 PMCID: PMC6112175 DOI: 10.1016/j.beth.2017.12.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 12/04/2017] [Accepted: 12/04/2017] [Indexed: 11/19/2022]
Abstract
We evaluated the impact of homework completion on change in PTSD symptoms in the context of two randomized controlled trials of Cognitive Processing Therapy for PTSD (CPT). Female participants (n = 140) diagnosed with PTSD attended at least one CPT session and were assigned homework at each session. The frequency of homework completion was assessed at the beginning of each session and PTSD symptoms were assessed every other session. Piecewise growth models were used to examine the relationship between homework completion and symptom change. CPT version (with vs without the written trauma account) did not moderate associations between homework engagement and outcomes. Greater pretreatment PTSD symptoms predicted more Session 1 homework completion, but PTSD symptoms did not predict homework completion at other timepoints. More homework completion after Sessions 2 and 3 was associated with less change in PTSD from Session 2 to Session 4, but larger pre-to-post treatment changes in PTSD. Homework completion after Sessions 2 and 3 was associated with greater symptom change among patients who had fewer years of education. More homework completion after Sessions 8 and 9 was associated with larger subsequent decreases in PTSD. Average homework completion was not associated with client characteristics. In the second half of treatment, homework engagement was associated with less dropout. The results suggest that efforts to increase engagement in homework may facilitate symptom change.
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Affiliation(s)
| | - Cassidy A Gutner
- National Center for PTSD at VA Boston Healthcare System; Boston University School of Medicine
| | | | - Abby Adler
- National Center for PTSD, VA Boston Healthcare System
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45
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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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46
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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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47
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Context Matters: Team and Organizational Factors Associated with Reach of Evidence-Based Psychotherapies for PTSD in the Veterans Health Administration. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2018; 44:904-918. [PMID: 28597238 PMCID: PMC5640758 DOI: 10.1007/s10488-017-0809-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Evidence-based psychotherapies for PTSD are often underused. The objective of this mixed-method study was to identify organizational and clinic factors that promote high levels of reach of evidence-based psychotherapies for PTSD 10 years into their dissemination throughout the Veterans Health Administration. We conducted 96 individual interviews with staff from ten outpatient PTSD teams at nine sites that differed in reach of evidence-based psychotherapies for PTSD. Major themes associated with reach included clinic mission, clinic leader and staff engagement, clinic operations, staff perceptions, and the practice environment. Strategies to improve reach of evidence-based psychotherapies should attend to organizational and team-level factors.
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48
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Chen JA, Owens MD, Browne KC, Williams EC. Alcohol-related and mental health care for patients with unhealthy alcohol use and posttraumatic stress disorder in a National Veterans Affairs cohort. J Subst Abuse Treat 2018; 85:1-9. [PMID: 29291765 PMCID: PMC5753430 DOI: 10.1016/j.jsat.2017.11.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 09/27/2017] [Accepted: 11/17/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Unhealthy alcohol use and posttraumatic stress disorder (PTSD) frequently co-occur. Patients with both conditions have poorer functioning and worse treatment adherence compared to those with either condition alone. Therefore, it is possible that PTSD, when co-occurring with unhealthy alcohol use, may influence receipt of evidence-based alcohol-related care and mental health care. We evaluated receipt of interventions for unhealthy alcohol use and receipt of mental health follow-up care among patients screening positive for unhealthy alcohol use with and without PTSD in a national sample from the Veterans Health Administration (VA). METHODS National clinical and administrative data from VA's electronic medical record were used to identify all patients who screened positive for unhealthy alcohol use (AUDIT-C score≥5) between 10/1/09-5/30/13. Unadjusted and adjusted Poisson regression models were fit to estimate the relative rate and prevalence of receipt of: brief interventions (advice to reduce or abstain from drinking≤14days after positive screening), specialty addictions treatment for alcohol use disorder (AUD; documented visit≤365days after positive screening), pharmacotherapy for AUD (filled prescription≤365days after positive screening), and mental health care ≤14days after positive screening for patients with and without PTSD (documented with ICD-9 CM codes). In secondary analyses, we tested effect modification by both severity of unhealthy alcohol use and age. RESULTS Among 830,825 patients who screened positive for unhealthy alcohol use, 140,388 (16.9%) had documented PTSD. Of the full sample, 71.6% received brief interventions, 10.3% received specialty AUD treatment, 3.1% received pharmacotherapy for AUD, and 24.0% received mental health care. PTSD was associated with increased likelihood of receiving all types of care. Adjusted relative rates were 1.04 (95% CI 1.03-1.05) for brief interventions, 1.06 (1.05-1.08) for specialty AUD treatment, 1.35 (1.31-1.39) for AUD pharmacotherapy, and 1.82 (1.80-1.84) for mental health care. Alcohol use severity modified effects of PTSD for specialty AUD treatment, AUD pharmacotherapy, and mental health care such that effects were maintained at lower severity but attenuated among patients with severe unhealthy alcohol use. Age modified all effects with the strength of the association between PTSD and care outcomes being strongest for younger (18-29years) and older veterans (65+ years) and weaker or non-significant for middle-aged veterans (30-44 and 45-64years). CONCLUSIONS In this large national sample of patients with unhealthy alcohol use, PTSD was associated with increased likelihood of receiving alcohol-related and mental health care. PTSD does not appear to be a barrier to care among VA patients with unhealthy alcohol use.
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Affiliation(s)
- Jessica A Chen
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Department of Health Services, University of Washington, 1959 NE Pacific St., Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA 98195-7660, USA.
| | - Mandy D Owens
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Department of Health Services, University of Washington, 1959 NE Pacific St., Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA 98195-7660, USA.
| | - Kendall C Browne
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Center of Excellence in Substance Abuse Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, USA; Department of Psychiatry & Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Box 356560, Room BB1644, Seattle, WA 98195-6560, USA.
| | - Emily C Williams
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Department of Health Services, University of Washington, 1959 NE Pacific St., Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA 98195-7660, USA.
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49
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Rosen CS, Matthieu MM, Wiltsey Stirman S, Cook JM, Landes S, Bernardy NC, Chard KM, Crowley J, Eftekhari A, Finley EP, Hamblen JL, Harik JM, Kehle-Forbes SM, Meis LA, Osei-Bonsu PE, Rodriguez AL, Ruggiero KJ, Ruzek JI, Smith BN, Trent L, Watts BV. A Review of Studies on the System-Wide Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2018; 43:957-977. [PMID: 27474040 DOI: 10.1007/s10488-016-0755-0] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Since 2006, the Veterans Health Administration (VHA) has instituted policy changes and training programs to support system-wide implementation of two evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). To assess lessons learned from this unprecedented effort, we used PubMed and the PILOTS databases and networking with researchers to identify 32 reports on contextual influences on implementation or sustainment of EBPs for PTSD in VHA settings. Findings were initially organized using the exploration, planning, implementation, and sustainment framework (EPIS; Aarons et al. in Adm Policy Ment Health Health Serv Res 38:4-23, 2011). Results that could not be adequately captured within the EPIS framework, such as implementation outcomes and adopter beliefs about the innovation, were coded using constructs from the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework (Glasgow et al. in Am J Public Health 89:1322-1327, 1999) and Consolidated Framework for Implementation Research (CFIR; Damschroder et al. in Implement Sci 4(1):50, 2009). We highlight key areas of progress in implementation, identify continuing challenges and research questions, and discuss implications for future efforts to promote EBPs in large health care systems.
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Affiliation(s)
- C S Rosen
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA. .,Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA.
| | - M M Matthieu
- School of Social Work, Saint Louis University, Saint Louis, MO, USA
| | - S Wiltsey Stirman
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA.,Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - J M Cook
- Evaluation Division, National Center for PTSD, VA Connecticut Health Care System, West Haven, CT, USA.,Yale School of Medicine, NEPEC/182, 950 Campbell Avenue, West Haven, CT, USA
| | - S Landes
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA
| | - N C Bernardy
- Executive Division, National Center for PTSD, Veterans Affairs Medical Center, White River Junction, VT, USA.,Department of Psychiatry, The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - K M Chard
- Cincinnati Department of Veterans Affairs (VA) Medical Center, Cincinnati, OH, USA.,University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - J Crowley
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA
| | - A Eftekhari
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA
| | - E P Finley
- South Texas Veterans Health Care System, San Antonio, TX, USA.,The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - J L Hamblen
- Executive Division, National Center for PTSD, Veterans Affairs Medical Center, White River Junction, VT, USA.,Department of Psychiatry, The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - J M Harik
- Executive Division, National Center for PTSD, Veterans Affairs Medical Center, White River Junction, VT, USA
| | - S M Kehle-Forbes
- Women's Health Sciences Division at VA Boston Healthcare System, National Center for PTSD, Boston, MA, USA.,Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - L A Meis
- Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - P E Osei-Bonsu
- Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - A L Rodriguez
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA
| | - K J Ruggiero
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - J I Ruzek
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA.,Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA.,Palo Alto University, Palo Alto, CA, USA
| | - B N Smith
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA
| | - L Trent
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA.,Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - B V Watts
- Department of Psychiatry, The Geisel School of Medicine at Dartmouth, Hanover, NH, USA.,Veterans Affairs Medical Center, White River Junction, VT, USA
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50
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Stirman SW, Gamarra J, Bartlett B, Calloway A, Gutner C. Empirical Examinations of Modifications and Adaptations to Evidence-Based Psychotherapies: Methodologies, Impact, and Future Directions. CLINICAL PSYCHOLOGY-SCIENCE AND PRACTICE 2017; 24:396-420. [PMID: 29593372 PMCID: PMC5866913 DOI: 10.1111/cpsp.12218] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This review describes methods used to examine the modifications and adaptations to evidence-based psychological treatments (EBPTs), assesses what is known about the impact of modifications and adaptations to EBPTs, and makes recommendations for future research and clinical care. One hundred eight primary studies and three meta-analyses were identified. All studies examined planned adaptations, and many simultaneously investigated multiple types of adaptations. With the exception of studies on adding or removing specific EBPT elements, few studies compared adapted EBPTs to the original protocols. There was little evidence that adaptations in the studies were detrimental, but there was also limited consistent evidence that adapted protocols outperformed the original protocols, with the exception of adding components to EBPTs. Implications for EBPT delivery and future research are discussed.
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Affiliation(s)
| | | | | | | | - Cassidy Gutner
- National Center for PTSD, VA Boston Healthcare System, and Boston University
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