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Ackland PE, Koffel EA, Goldsmith ES, Ullman K, Miller WA, Landsteiner A, Stroebel B, Hill J, Wilt TJ, Duan-Porter W. Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder: A Systematic Review. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2023; 50:792-812. [PMID: 37326899 DOI: 10.1007/s10488-023-01279-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 06/17/2023]
Abstract
Guidelines strongly recommend trauma-focused therapies to treat posttraumatic stress disorder. Implementation of cognitive processing therapy (CPT) and prolonged exposure (PE) in Veterans Health Administration (VHA) and non-VHA settings began in 2006. We conducted a systematic review of implementation facilitators and challenges and strategies to address barriers. We searched MEDLINE, Embase, PsycINFO, and CINAHL from inception until March 2021 for English-language articles. Two individuals reviewed eligibility and rated quality. Quantitative results were abstracted by one reviewer and verified by a second. Qualitative results were independently coded by two reviewers and finalized through consensus. We used RE-AIM and CFIR frameworks to synthesize findings. 29 eligible studies addressed CPT/PE, mostly conducted in VHA. Training/education with audit/feedback was the primary implementation strategy and was linked to improved provider CPT/PE perceptions and self-efficacy. Use was not widespread. Only six studies tested other implementation strategies with mixed impact. Following VHA implementation, strong support for training, perceived effectiveness for patients and benefits for clinics, and positive patient experiences and relationships with providers were reported. However, barriers persisted including perceived protocol inflexibility, complex referral processes and patient complexity and competing needs. In non-VHA settings, providers perceived fewer barriers, but few were CPT/PE trained. Across both settings, fewer studies targeted patient factors. Training/education with audit/feedback improved perceptions and the availability of CPT/PE, but not consistent use. Studies testing implementation strategies to address post-training challenges, including patient-level factors, are needed. A few studies are underway in VHA to test patient-focused and other implementation strategies. Research assessing actual vs perceived barriers in non-VHA settings is needed to elucidate unique challenges experienced.
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Affiliation(s)
- Princess E Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA.
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
| | | | - Elizabeth S Goldsmith
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Kristen Ullman
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Wendy A Miller
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Adrienne Landsteiner
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Benjamin Stroebel
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Jessica Hill
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Psychology, Binghamton University, Binghamton, NY, 13902, USA
| | - Timothy J Wilt
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Wei Duan-Porter
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
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Walter KH, Hunt WM, Otis NP, Kline AC, Miggantz EL, Thomsen CJ, Glassman LH. Comparison of behavioral activation-enhanced cognitive processing therapy and cognitive processing therapy among U.S. service members: A randomized clinical trial. Psychiatry Res 2023; 326:115330. [PMID: 37418778 DOI: 10.1016/j.psychres.2023.115330] [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: 05/10/2023] [Revised: 06/30/2023] [Accepted: 07/02/2023] [Indexed: 07/09/2023]
Abstract
Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) frequently co-occur and can cause significant impairment. Data are lacking as to whether interventions targeting both PTSD and MDD may improve treatment outcomes among individuals with this comorbidity compared with existing evidence-based PTSD treatments alone. This randomized trial compared the effectiveness of cognitive processing therapy (CPT) enhanced with behavioral activation (BA+CPT) versus CPT among 94 service members (52 women and 42 men; age M = 28.5 years) with comorbid PTSD and MDD. The primary outcome was clinician-administered depression symptom severity on the Montgomery-Åsberg Depression Rating Scale (MADRS) from pretreatment through 3-month follow-up. Intent-to-treat analyses using multilevel models showed statistically and clinically significant decreases in MADRS scores for both conditions over time, with no significant differences between BA+CPT and CPT. Secondary depression and PTSD symptom outcomes followed a similar pattern of results. For diagnostic MDD and PTSD outcomes using available data, no statistically significant differences between treatments emerged at posttreatment or 3-month follow-up. Sessions attended, dropout rate, and treatment satisfaction did not significantly differ between treatments. Outcomes were comparable for both treatments, suggesting that BA+CPT and CPT were similarly effective psychotherapy options for comorbid PTSD and MDD.
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Affiliation(s)
- Kristen H Walter
- Health and Behavioral Sciences, Naval Health Research Center, San Diego, CA, USA.
| | - W Michael Hunt
- Directorate of Mental Health, Naval Medical Center San Diego, San Diego, CA, USA
| | - Nicholas P Otis
- Health and Behavioral Sciences, Naval Health Research Center, San Diego, CA, USA; Leidos, Inc., San Diego, CA, USA
| | - Alexander C Kline
- Health and Behavioral Sciences, Naval Health Research Center, San Diego, CA, USA; Leidos, Inc., San Diego, CA, USA
| | - Erin L Miggantz
- Health and Behavioral Sciences, Naval Health Research Center, San Diego, CA, USA; Leidos, Inc., San Diego, CA, USA
| | - Cynthia J Thomsen
- Health and Behavioral Sciences, Naval Health Research Center, San Diego, CA, USA
| | - Lisa H Glassman
- Health and Behavioral Sciences, Naval Health Research Center, San Diego, CA, USA; Leidos, Inc., San Diego, CA, USA
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Kelley ML, Strowger M, Chentsova VO, Bravo AJ, Gaylord SA, Burgin EE, Vinci C, Ayers KL, Agha E. Mindfulness to Manage Moral Injury: Rationale and development of a live online 7-week group intervention for veterans with moral injury. Contemp Clin Trials Commun 2022; 30:101011. [PMID: 36340697 PMCID: PMC9626875 DOI: 10.1016/j.conctc.2022.101011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/27/2022] [Accepted: 10/01/2022] [Indexed: 11/14/2022] Open
Abstract
Background Military service puts service members at risk for moral injury. Moral injury is an array of symptoms (e.g., guilt, shame, anger) that develop from events that violate or transgress one's moral code. Objective We describe adaption of in-person mindfulness training program, Mindfulness to Manage Chronic Pain (MMCP), to address symptoms of moral injury to be delivered live via the web. We discuss how we will assess benchmarks (i.e., recruitment, credibility and acceptability, completion rates, and adherence) of the Mindfulness to Manage Moral Injury (MMMI) program. Methods Aim 1: To develop and then adapt the MMCP program based on feedback from experts and veterans who took part in Study 1. Aim 2: To develop an equally intensive facilitator-led online Educational Support (ES) program to serve as a comparison intervention and conduct a run-through of each program with 20 veterans (10 MMMI; 10 ES). Aim 3: To conduct a small-scale randomized controlled trial (N = 42 veterans; 21 MMMI; 21 ES) in which we will collect pre-post-test and weekly benchmark data for both refined intervention arms. Results Study 1 and 2 are completed. Data collection for Study 3 will be completed in 2022. Conclusion MMMI is designed to provide a live facilitated mindfulness program to address symptoms of moral injury. If Study 3 demonstrates good benchmarks, with additional large-scale testing, MMMI may be a promising treatment that can reach veterans who may not seek traditional VAMC care and/or who prefer a web-based program.
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Affiliation(s)
- Michelle L. Kelley
- Old Dominion University, Old Dominion University, Norfolk, VA, USA
- Virginia Consortium Program in Clinical Psychology, Norfolk, VA, USA
- Corresponding author. Department of Psychology, Old Dominion University, 250 Mills Godwin Building, Norfolk, VA, 23529, USA.
| | - Megan Strowger
- Old Dominion University, Old Dominion University, Norfolk, VA, USA
| | | | - Adrian J. Bravo
- Department of Psychological Sciences, William & Mary, Williamsburg, VA, USA
| | - Susan A. Gaylord
- Program on Integrative Medicine, Department of Physical Medicine and Rehabilitation, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Elizabeth E. Burgin
- School Psychology and Counselor Education, William & Mary, Williamsburg, VA, USA
| | - Christine Vinci
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA
| | - Kenneth L. Ayers
- Virginia Consortium Program in Clinical Psychology, Norfolk, VA, USA
| | - Erum Agha
- Program on Integrative Medicine, Department of Physical Medicine and Rehabilitation, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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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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Levinson DB, Halverson TF, Wilson SM, Fu R. Less dropout from prolonged exposure sessions prescribed at least twice weekly: A meta-analysis and systematic review of randomized controlled trials. J Trauma Stress 2022; 35:1047-1059. [PMID: 35278229 DOI: 10.1002/jts.22822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 11/06/2022]
Abstract
Trauma-focused psychotherapies, such as prolonged exposure (PE), are strongly recommended to treat posttraumatic stress disorder due to their effects in reducing symptoms. However, such therapies may also suffer from high dropout rates. To investigate how clients might benefit from trauma-focused therapy while minimizing dropout, we conducted a meta-analysis of 1,508 adults from 35 randomized controlled trials (RCTs) of outpatient PE programs to evaluate treatment frequency as a predictor of dropout. When an RCT prescribed PE sessions at least twice weekly compared to less frequently, the dropout rate was significantly lower at 21.0%, 95% CI [13.9%, 30.4%], compared to 34.0%, 95% CI [28.9%, 39.4%], OR = 0.52, 95% CI [0.30, 0.89], p = .018. It was not possible to draw causal conclusions, as only one RCT compared two PE treatment frequencies head-to-head. Nonetheless, the findings remained significant after controlling for study characteristics. These data invite reconsideration of the common practice of weekly psychotherapy in favor of twice-weekly sessions in standard outpatient treatment.
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Affiliation(s)
| | - Tate F Halverson
- Durham VA Health Care System, Durham, North Carolina, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, USA
| | - Sarah M Wilson
- Durham VA Health Care System, Durham, North Carolina, USA
- Division of Behavioral Medicine and Neurosciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rongwei Fu
- School of Public Health, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, USA
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Abstract
BACKGROUND Clinical guidelines recommend a phase-based approach to treatment for complex post-traumatic stress disorder (CPTSD), yet little is known about what interventions are being offered and which may be effective in the final 'reintegration' phase. OBJECTIVE To systematically review literature on reintegration interventions for CPTSD, describing the nature and effectiveness of interventions. METHOD We searched four electronic databases (Medline, PsycINFO, Embase, and PTSDpubs) for interventions aiming to facilitate reintegration for participants with probable CPTSD. We had two aims: firstly, to describe the interventions and secondly, to describe their effectiveness as measured through measures of reintegration, PTSD and/or disturbances in self-organization (DSO), or qualitative data describing changes experienced. Results are presented using narrative synthesis. RESULTS Fifteen studies met our inclusion criteria. Interventions included yoga, exercise, use of service dogs, residential treatment, education, self-defence and patient research involvement. Overall study quality was low, as assessed by critical appraisal tools. Of the six studies including a control group, two reported a statistically significant improvement in the measure of reintegration between the intervention and control group, four studies reported a statistically significant difference in the measure of PTSD symptoms, but none reported any significant differences between intervention and control groups in DSO. Of all eight quantitative studies, three reported a statistically significant difference in the reintegration measure pre- to post-intervention for the intervention group, five a statistically significant improvement in the measure of PTSD symptoms, and three a significant difference in the DSO measure. From eight studies reporting qualitative date we synthesized themes into eight categories, within which facilitation of connection with others was the most commonly reported benefit. CONCLUSIONS The interventions outlined may facilitate reintegration, however, research in this area is still in its infancy and quality research is lacking. Further research is needed to establish whether reintegration interventions enhance treatment for CPTSD.
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Affiliation(s)
- Lucy R Purnell
- Division of Psychiatry, University College London, London, UK
| | | | - Michael A P Bloomfield
- Division of Psychiatry, University College London, London, UK.,Translational Psychiatry Research Group, Mental Health Neuroscience Department, Division of Psychiatry, Institute of Mental Health, University College London, London, UK.,Traumatic Stress Clinic, St Pancras Hospital, Camden and Islington NHS Foundation Trust, London, UK.,National Hospital for Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK.,National Institute for Health Research, University College London Hospitals Biomedical Research Centre, London, UK
| | - Jo Billings
- Division of Psychiatry, University College London, London, UK
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