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Racz JI, Bialocerkowski A, Calteaux I, Farrell LJ. Determinants of Exposure Therapy Implementation in Clinical Practice for the Treatment of Anxiety, OCD, and PTSD: A Systematic Review. Clin Child Fam Psychol Rev 2024; 27:317-341. [PMID: 38630196 PMCID: PMC11222222 DOI: 10.1007/s10567-024-00478-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/28/2024]
Abstract
Exposure therapy (ET) forms a vital part of effective psychotherapy for anxiety-related presentations including anxiety disorders, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD), and is often underutilised in clinical practice. Using the Theoretical Domains Framework (TDF), this systematic review synthesised existing literature on the determinants of ET implementation for anxiety-related presentations and examined differences across presentations and developmental subgroups. Fifty-two eligible studies were assessed using the Mixed Methods Appraisal Tool, with 389 results (99%) mapped onto the TDF. Results suggested that clinicians' negative beliefs about the consequences of ET were commonly associated with reduced implementation. It also appeared that whilst broad unspecified ET training may be related to improved implementation for anxiety disorders; greater implementation for complex presentations (i.e., PTSD) likely requires more specialised training involving practical components. A subset of domains (e.g., social/professional role and identity) accounted for most results, whilst some remain unexplored (i.e., optimism; reinforcement; memory, attention, and decision processes) or underexplored (i.e., behavioural regulation). Likewise, specific presentations and developmental subgroups (i.e., PTSD and adults) represented a greater proportion of results in the literature than others (i.e., OCD and youth). Future research exploring ET implementation, across specific presentations and developmental subgroups, would benefit from integrating implementation science frameworks to guide the development of targeted, comprehensive strategies to close the research-practice gap of ET for the treatment of anxiety-related presentations.
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Affiliation(s)
- J I Racz
- School of Applied Psychology, Griffith University, Southport, QLD, Australia.
| | | | - I Calteaux
- School of Applied Psychology, Griffith University, Southport, QLD, Australia
| | - L J Farrell
- School of Applied Psychology, Griffith University, Southport, QLD, Australia
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Hien DA, Papini S, Saavedra LM, Bauer AG, Ruglass LM, Ebrahimi CT, Fitzpatrick S, López-Castro T, Norman SB, Killeen TK, Back SE, Morgan-López AA. Project harmony: A systematic review and network meta-analysis of psychotherapy and pharmacologic trials for comorbid posttraumatic stress, alcohol, and other drug use disorders. Psychol Bull 2024; 150:319-353. [PMID: 37971855 PMCID: PMC10939977 DOI: 10.1037/bul0000409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
We conducted a systematic review and network meta-analyses (NMA) of psychotherapy and pharmacologic treatments for individuals with co-occurring posttraumatic stress disorder (PTSD) and alcohol or other drug use disorder (AOD). A comprehensive search spanning 1995-2019 yielded a pool of 39 studies for systematic review, including 24 randomized controlled trials for the NMA. Study interventions were grouped by target of treatment (PTSD + AOD, PTSD-only, and AOD-only) and approach (psychotherapy or medication). Standardized mean differences (SMD) from the NMA yielded evidence that at the end of treatment, integrated, trauma-focused therapy for PTSD + AOD was more effective at reducing PTSD symptoms than integrated, non-trauma-focused therapy (SMD = -0.30), AOD-focused psychotherapy (SMD = -0.29), and other control psychotherapies (SMD = -0.43). End-of-treatment alcohol use severity was less for AOD medication compared to placebo medication (SMD = -0.36) and trauma-focused therapy for PTSD + placebo medication (SMD = -0.67), and less for trauma-focused psychotherapy + AOD medication compared to PTSD medication (SMD = -0.53), placebo medication (SMD = -0.50), and trauma-focused psychotherapy + placebo medication (SMD = -0.81). Key limitations include the small number of studies in the NMA for pharmacologic treatments and the lack of demographic diversity apparent in the existing literature. Findings suggest room for new studies that can address limitations in study sample composition, sample sizes, retention, and apply new techniques for conducting comparative effectiveness in PTSD + AOD treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Denise A Hien
- Department of Clinical Psychology, Center of Alcohol and Substance Use Studies, Graduate School of Applied and Professional Psychology, Rutgers University-New Brunswick
| | | | | | - Alexandria G Bauer
- Department of Clinical Psychology, Center of Alcohol and Substance Use Studies, Graduate School of Applied and Professional Psychology, Rutgers University-New Brunswick
| | | | - Chantel T Ebrahimi
- Department of Clinical Psychology, Center of Alcohol and Substance Use Studies, Graduate School of Applied and Professional Psychology, Rutgers University-New Brunswick
| | | | | | - Sonya B Norman
- Department of Psychiatry, University of California, San Diego
| | - Therese K Killeen
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina
| | - Sudie E Back
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina
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The Good, The Bad, The Uncertain: Diverse Provider Experiences with Telemental Health During COVID-19. Psychiatr Q 2022; 93:753-774. [PMID: 35689752 PMCID: PMC9187881 DOI: 10.1007/s11126-022-09990-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2022] [Indexed: 11/29/2022]
Abstract
This study assessed mental health provider attitudes and perceptions of telemental health (TMH) prior to and during the COVID-19 Pandemic. The study expands on earlier work by providing a more detailed qualitative analysis of provider perceptions of TMH, including its efficacy, advantages, and limitations. The current study is part of a larger mixed methods project utilizing a repeated cross-sectional design. An online survey was administered to a sample of 1,448 mental health providers. Of the survey participants, 934 offered narrative responses to open-ended questions and were included in the present study. Qualitative data was analyzed using a coding team and the Consensual Qualitative Research paradigm. Providers described both positive and negative feelings about using TMH during the COVID-19 Pandemic. Several advantages were identified, with providers clearly appreciating the role of TMH in allowing them to work continuously and safely during the public health emergency. An array of negative views and concerns were also expressed, including that TMH may not be optimal or effective in certain settings or situations. A portion of respondents also indicated a preference for face-to-face care and illuminated ways they found TMH lacking or limited.
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Holder N, Batten AJ, Shiner B, Li Y, Madden E, Neylan TC, Seal KH, Patterson OV, DuVall SL, Maguen S. Veterans receiving a second course of cognitive processing therapy or prolonged exposure therapy: is it better to switch or stay the same? Cogn Behav Ther 2022; 51:456-469. [PMID: 35475499 DOI: 10.1080/16506073.2022.2058996] [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: 11/03/2022]
Abstract
Cognitive processing therapy (CPT) and prolonged exposure therapy (PE) are effective psychotherapies for post-traumatic stress disorder (PTSD). However, these treatments also have high rates of dropout and non-response. Therefore, patients may need a second course of treatment. We compared outcomes for patients who switched between CPT/PE and those who repeated CPT/PE during a second course of treatment. We collected data from Iraq and Afghanistan war veterans (n = 2,958) who received a second course of CPT/PE in the Veterans Health Administration from 2001 to 2017 and had symptom outcomes (PTSD checklist; PCL). We measured the association between treatment sequence and change in PCL score over the second course of treatment using hierarchical Bayesian regression, adjusted for sociodemographic and clinical characteristics. All treatment sequences showed a significant reduction in PCL score over time (β = -4.80; HDI95: -5.74, -3.86). Veterans who switched from CPT to PE had modestly greater PCL reductions during the second course than those who repeated CPT. However, no significant difference in PCL change during the second course was observed between veterans who repeated PE and those who switched from PE to CPT. Veterans participating in a second course of CPT/PE can benefit, and switching treatment may be slightly more beneficial following CPT.
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Affiliation(s)
- Nicholas Holder
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Adam J Batten
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA.,Applied Statistics Unit, AB Evergreen Analytics LLC, Seattle, WA, USA
| | - Brian Shiner
- Mental Health Service, White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA.,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Executive Division Hanover, New Hampshire, USA.,Executive Division, National Center for Posttraumatic Stress Disorder, White River Junction, Vermont, USA
| | - Yongmei Li
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Erin Madden
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Thomas C Neylan
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Karen H Seal
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA.,Integrative Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Departments of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Olga V Patterson
- VA Informatics and Computing Infrastructure, Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Scott L DuVall
- VA Informatics and Computing Infrastructure, Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Shira Maguen
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA
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Abstract
The present study was designed to assess mental health provider attitudes and perceptions of telemental health (TMH) prior to and during the COVID-19 Pandemic, as well as the nature of their TMH utilization. The study aimed to gather information about positive and negative attitudes towards TMH, perceptions and correlates based on the modality of care, and beliefs about the overall effectiveness of TMH as compared to face-to-face care. The current study is part of a larger mixed methods project utilizing a repeated cross-sectional design. An online survey was administered to a sample of 1448 mental health providers and included demographic and professional information, experiences with and perceptions of TMH prior to and during the COVID-19 Pandemic, as well as a brief measure of pandemic-related stress. The COVID-19 Pandemic resulted in an increased use of TMH in the study sample. During COVID-19, providers reported increased agreement with TMH being necessary, important, and effective for care delivery. Providers who primarily used video, compared with telephone, reported that TMH was more useful, satisfying, and effective. While negative attitude towards TMH was predicted only by prior attitudes and belief in TMH effectiveness, positive attitude towards TMH was also predicted by female sex and current level of pandemic related stress. TMH use during the pandemic was predicted by primary use of video platform and previous TMH use. The 2020 COVID-19 Pandemic resulted in increased use of TMH and significantly increased positive perceptions about TMH among mental health providers.
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Affiliation(s)
- Jennifer M. Doran
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT USA
| | - Jessica L. Lawson
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT USA
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Gossmann K, Eilers R, Rosner R, Barke A. How do licensed psychotherapists in Germany feel about treating patients with posttraumatic stress symptoms? - an experimental study based on case vignettes. Eur J Psychotraumatol 2021; 12:1995265. [PMID: 34868487 PMCID: PMC8635540 DOI: 10.1080/20008198.2021.1995265] [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: 11/19/2022] Open
Abstract
BACKGROUND Previous research indicates that not all children, adolescents and adults suffering from PTSD receive psychotherapy and if they do, trauma is not always considered during therapy. One reason for this undertreatment might be a limited readiness of licenced psychotherapists (LPTs) to treat patients who have experienced a trauma and thus suffer from PTSD symptoms. OBJECTIVE The aim of this study is to explore the association between the readiness of LPTs to treat patients with PTSD symptoms and different patients' and therapists' characteristics. METHOD We used case vignettes to assess the readiness of LPTs in Germany in a nationwide online survey (N = 768). The vignettes described patients with PTSD and were adapted to the age group mainly treated by the therapists (children/adolescents vs. adults). The patients' characteristics in the otherwise identical vignettes were randomized for patient gender (female vs. male) and symptom cluster (internalizing vs. externalizing). Rating scales were used to assess readiness. Additionally, therapists' characteristics (age, trauma-specific training, perceived fears/doubts, and objective barriers to treating the vignette patient) were assessed. RESULTS The patients' characteristics did not influence the treatment readiness of the LPTs. Regarding therapists' characteristics, LPTs working mainly with children and adolescents, and those who had completed trauma-specific training reported a higher readiness to treat the vignette patient. CONCLUSIONS Regarding the treatment of patients suffering from PTSD symptoms of different ages, our study indicated that the assessed therapists' characteristics were more relevant for the treatment readiness of LPTs than the patients' characteristics of age or symptom type.
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Affiliation(s)
- Katharina Gossmann
- Department of Psychology, Catholic University of Eichstaett-Ingolstadt, Eichstaett, Germany
| | - Rebekka Eilers
- Department of Psychology, Catholic University of Eichstaett-Ingolstadt, Eichstaett, Germany
| | - Rita Rosner
- Department of Psychology, Catholic University of Eichstaett-Ingolstadt, Eichstaett, Germany
| | - Antonia Barke
- Department of Psychology, Catholic University of Eichstaett-Ingolstadt, Eichstaett, Germany
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Penix EA, Clarke-Walper KM, Trachtenberg FL, Magnavita AM, Simon E, Ortigo K, Coleman J, Marceau L, Ruzek JI, Rosen RC, Wilk JE. Risk of Secondary Traumatic Stress in Treating Traumatized Military Populations: Results from the PTSD Clinicians Exchange. Mil Med 2020; 185:e1728-e1735. [PMID: 32588891 DOI: 10.1093/milmed/usaa078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 03/27/2020] [Accepted: 03/30/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION This study examined risk factors for secondary traumatic stress (STS) in behavioral health clinicians and whether access to the Post-Traumatic Stress Disorder (PTSD) Clinicians Exchange website mitigated STS risk. METHODS A diverse sample of clinicians (N = 605) treating traumatized military populations in Department of Veterans Affairs (VA), Department of Defense, and community practice settings were randomized to a newsletter-only control group or the exchange group. The exchange website included resources for treating PTSD and promoting clinician well-being. Online surveys were administered at 0-, 6-, and 12-months postrandomization. Regression analyses were used to examine the link among risk factors, exchange access, and STS. RESULTS Baseline clinician demographics, experience, total caseload, appeal of evidence-based practices (EBPs), and likelihood of adopting EBPs if required were not linked with STS at the 12-month assessment period. Providing care at the VA, more burnout, less compassion satisfaction, greater trauma caseload, less openness to new EBPs, and greater divergence from EBP procedures were linked with greater STS. Only burnout and divergence were associated with STS after accounting for other significant STS risk factors. Exchange and control group clinicians reported similar STS levels after accounting for burnout and divergence. CONCLUSIONS Given that burnout was linked with STS, future intervention may use techniques targeting burnout and STS (eg, emotion regulation strategies). Research exploring the link between divergence from EBPs and STS may inform EBP dissemination efforts and STS interventions. Finally, results highlight the need for research optimizing STS intervention efficacy among clinicians treating military populations.
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Affiliation(s)
- Elizabeth A Penix
- Military Psychiatry Branch, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910
| | - Kristina M Clarke-Walper
- Military Psychiatry Branch, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910
| | | | - Ashley M Magnavita
- New England Research Institutes, Inc., 480 Pleasant Street, Watertown, MA 02472
| | - Erica Simon
- Palo Alto Veterans Institute for Research, 3801 Miranda Avenue, Palo Alto, CA 94304.,Dissemination and Training Division, National Center for PTSD, 795 Willow Road, Menlo Park, CA 94025.,VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025
| | - Kile Ortigo
- Dissemination and Training Division, National Center for PTSD, 795 Willow Road, Menlo Park, CA 94025.,VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025
| | - Julia Coleman
- New England Research Institutes, Inc., 480 Pleasant Street, Watertown, MA 02472
| | - Lisa Marceau
- New England Research Institutes, Inc., 480 Pleasant Street, Watertown, MA 02472
| | - Josef I Ruzek
- Dissemination and Training Division, National Center for PTSD, 795 Willow Road, Menlo Park, CA 94025.,VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025.,Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Road, Stanford, CA 94305
| | - Raymond C Rosen
- New England Research Institutes, Inc., 480 Pleasant Street, Watertown, MA 02472
| | - Joshua E Wilk
- Military Psychiatry Branch, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910
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