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2.  VA Residential Provider Perceptions of Dissuading Factors to the Use of Two Evidence-Based PTSD Treatments 
Providers (N = 198) from 38 Department of Veterans Affairs residential posttraumatic stress disorder treatment programs across the United States completed qualitative interviews regarding implementation of 2 evidence-based treatments: prolonged exposure and cognitive processing therapy. As part of this investigation, providers were asked how they decide which patients are appropriate for these treatments. Many indicated that they did not perceive any patient factors that dissuade their use of either evidence-based treatment. However, 3 broad categories emerged surrounding reasons that patients were perceived to be less suitable candidates for the treatments: the presence of psychiatric comorbidities, cognitive limitations, and low levels of patient motivation. Interestingly, providers’ perceived reasons for limited or nonuse of a treatment did not correspond entirely to those espoused by treatment developers. Possible solutions to address provider concerns, including educational and motivational interventions, are noted.
PMCID: PMC4193802  PMID: 25309031
evidence-based treatment; posttraumatic stress disorder; provider perspectives
3.  Changes in Implementation of Two Evidence-Based Psychotherapies for PTSD in VA Residential Treatment Programs: A National Investigation 
Journal of traumatic stress  2014;27(2):137-143.
There has been little investigation of the natural course of evidence-based treatments (EBTs) over time following the draw-down of initial implementation efforts. Thus, we undertook qualitative interviews with the providers at 38 U.S. Department of Veterans Affairs’ residential treatment programs for posttraumatic stress disorder (PTSD) to understand implementation and adaptation of 2 EBTs, prolonged exposure (PE), and cognitive processing therapy (CPT), at 2 time points over a 4-year period. The number of providers trained in the therapies and level of training improved over time. At baseline, of the 179 providers eligible per VA training requirements, 65 (36.4%) had received VA training in PE and 111 (62.0%) in CPT with 17 (9.5%) completing case consultation or becoming national trainers in both PE and CPT. By follow-up, of the increased number of 190 eligible providers, 87 (45.8%) had received VA training in PE and 135 (71.1%) in CPT, with 69 (36.3%) and 81 (42.6%) achieving certification, respectively. Twenty-two programs (57.9%) reported no change in PE use between baseline and follow-up, whereas 16 (42.1%) reported an increase. Twenty-four (63.2%) programs reported no change in their use of CPT between baseline and follow-up, 12 (31.6%) programs experienced an increase, and 2 (5.2%) programs experienced a decrease in use. A significant number of providers indicated that they made modifications to the manuals (e.g., tailoring, lengthening). Reasons for adaptations are discussed. The need to dedicate time and resources toward the implementation of EBTs is noted.
PMCID: PMC4036220  PMID: 24668757
4.  Integration of Women Veterans into VA Quality Improvement Research Efforts: What Researchers Need to Know 
Journal of General Internal Medicine  2010;25(Suppl 1):56-61.
The Department of Veterans Affairs (VA) and other federal agencies require funded researchers to include women in their studies. Historically, many researchers have indicated they will include women in proportion to their VA representation or pointed to their numerical minority as justification for exclusion. However, women’s participation in the military—currently 14% of active military—is rapidly changing veteran demographics, with women among the fastest growing segments of new VA users. These changes will require researchers to meet the challenge of finding ways to adequately represent women veterans for meaningful analysis. We describe women veterans’ health and health-care use, note how VA care is organized to meet their needs, report gender differences in quality, highlight national plans for women veterans’ quality improvement, and discuss VA women’s health research. We then discuss challenges and potential solutions for increasing representation of women veterans in VA research, including steps for implementation research.
PMCID: PMC2806960  PMID: 20077153
quality improvement; disparities; implementation research; women’s health; veterans
5.  RESPECT-PTSD: Re-Engineering Systems for the Primary Care Treatment of PTSD, A Randomized Controlled Trial 
Although collaborative care is effective for treating depression and other mental disorders in primary care, there have been no randomized trials of collaborative care specifically for patients with Posttraumatic stress disorder (PTSD).
To compare a collaborative approach, the Three Component Model (3CM), with usual care for treating PTSD in primary care.
The study was a two-arm, parallel randomized clinical trial. PTSD patients were recruited from five primary care clinics at four Veterans Affairs healthcare facilities and randomized to receive usual care or usual care plus 3CM. Blinded assessors collected data at baseline and 3-month and 6-month follow-up.
Participants were 195 Veterans. Their average age was 45 years, 91% were male, 58% were white, 40% served in Iraq or Afghanistan, and 42% served in Vietnam.
All participants received usual care. Participants assigned to 3CM also received telephone care management. Care managers received supervision from a psychiatrist.
PTSD symptom severity was the primary outcome. Depression, functioning, perceived quality of care, utilization, and costs were secondary outcomes.
There were no differences between 3CM and usual care in symptoms or functioning. Participants assigned to 3CM were more likely to have a mental health visit, fill an antidepressant prescription, and have adequate antidepressant refills. 3CM participants also had more mental health visits and higher outpatient pharmacy costs.
Results suggest the need for careful examination of the way that collaborative care models are implemented for treating PTSD, and for additional supports to encourage primary care providers to manage PTSD.
PMCID: PMC3539037  PMID: 22865017
posttraumatic stress disorder; integrated primary care; veterans; randomized clinical trials; treatment
6.  Gender Differences in Prescribing Among Veterans Diagnosed with Posttraumatic Stress Disorder 
Journal of General Internal Medicine  2013;28(Suppl 2):542-548.
The Department of Veterans Affairs (VA) and Department of Defense (DoD) issued a revised posttraumatic stress disorder (PTSD) Clinical Practice Guideline (CPG) in 2010 with specific pharmacotherapy recommendations for evidence-based quality care. The authors examined prescribing frequencies over an 11-year period prior to the release of the new guideline to determine gender differences in pharmacotherapy treatment in veterans with PTSD.
National administrative VA data from 1999 to 2009 were used to identify veterans with PTSD using ICD-9 codes extracted from inpatient discharges and outpatient clinic visits. Prescribing of antidepressants, antipsychotics and hypnotics was determined for each year using prescription drug files.
Women were more likely than men to receive medication across all classes except prazosin where men had higher prescribing frequency. The proportion of women receiving either of the first-line pharmacotherapy treatments for PTSD, selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI), increased from 56.4 % in 1999 to 65.7 % in 2009, higher rates than seen in men (49.2 % to 58.3 %). Atypical antipsychotic prescriptions increased from 14.6 % to 26.3 % and nonbenzodiazepine hypnotics increased from 3.8 % to 16.9 % for women, higher frequencies than seen in men for both medications (OR = 1.31, 1.43 respectively). The most notable gender discrepancy was observed for benzodiazepines where prescriptions decreased for men (36.7 % in 1999 to 29.8 % in 2009) but steadily increased for women from 33.4 % to 38.3 %.
A consistent pattern of increased prescribing of psychotropic medications among women with PTSD was seen compared to men. Prescribing frequency for benzodiazepines showed a marked gender difference with a steady increase for women despite guideline recommendations against use and a decrease for men. Common co-occurring disorders and sleep symptom management are important factors of PTSD pharmacotherapy and may contribute to gender differences seen in prescribing benzodiazepines in women but do not fully explain the apparent disparity.
PMCID: PMC3695280  PMID: 23807063
gender; posttraumatic stress disorder; pharmacology
Psychotherapy (Chicago, Ill.)  2010;47(2):260-267.
Over 2,200 North American psychotherapists completed a Web-based survey concerning their clinical work, including theoretical orientation, client characteristics, and use of specific psychotherapy techniques. Psychotherapeutic integration was common, with the majority of respondents identifying with more than one theoretical orientation or as having an eclectic orientation. The modal patient was a White female adult suffering from a mood or anxiety disorder and interpersonal problems. Individual psychotherapy was the preferred treatment modality. The most frequently endorsed techniques were relationship-oriented such as conveying warmth, acceptance, understanding, and empathy. The least frequently endorsed techniques were biofeedback, neurofeedback, body and energy therapies, and hypnotherapy. Efforts to disseminate empirically based therapies require understanding and accommodating clinicians’ tendencies to integrate techniques.
PMCID: PMC3676965  PMID: 22402052
psychotherapy; professional practice; evidence-supported treatment
8.  Apples Don’t Fall Far From the Tree: Influences on Psychotherapists’ Adoption and Sustained Use of New Therapies 
The purpose of this investigation was to identify influences on the current clinical practices of a broad range of mental health providers as well as influences on their adoption and sustained use of new practices.
U.S. and Canadian psychotherapists (N=2,607) completed a Web-based survey in which they rated factors that influence their clinical practice, including their adoption and sustained use of new treatments.
Empirical evidence had little influence on the practice of mental health providers. Significant mentors, books, training in graduate school, and informal discussions with colleagues were the most highly endorsed influences on current practice. The greatest influences on psychotherapists’ willingness to learn a new treatment were its potential for integration with the therapy they were already providing and its endorsement by therapists they respected. Clinicians were more often willing to continue to use a new treatment when they were able to effectively and enjoyably conduct the therapy and when their clients liked the therapy and reported improvement.
Implications for dissemination and sustained use of new psychotherapies by community psychotherapists are discussed. For example, evidence-based treatments may best be promoted through therapy courses and workshops, beginning with graduate studies; to ensure future use of new therapies, developers of training workshops should emphasize ways to integrate their approaches into clinicians’ existing practices.
PMCID: PMC3675893  PMID: 19411356
9.  Measurement of a model of implementation for health care: toward a testable theory 
Greenhalgh et al. used a considerable evidence-base to develop a comprehensive model of implementation of innovations in healthcare organizations [1]. However, these authors did not fully operationalize their model, making it difficult to test formally. The present paper represents a first step in operationalizing Greenhalgh et al.’s model by providing background, rationale, working definitions, and measurement of key constructs.
A systematic review of the literature was conducted for key words representing 53 separate sub-constructs from six of the model’s broad constructs. Using an iterative process, we reviewed existing measures and utilized or adapted items. Where no one measure was deemed appropriate, we developed other items to measure the constructs through consensus.
The review and iterative process of team consensus identified three types of data that can been used to operationalize the constructs in the model: survey items, interview questions, and administrative data. Specific examples of each of these are reported.
Despite limitations, the mixed-methods approach to measurement using the survey, interview measure, and administrative data can facilitate research on implementation by providing investigators with a measurement tool that captures most of the constructs identified by the Greenhalgh model. These measures are currently being used to collect data concerning the implementation of two evidence-based psychotherapies disseminated nationally within Department of Veterans Affairs. Testing of psychometric properties and subsequent refinement should enhance the utility of the measures.
PMCID: PMC3541168  PMID: 22759451
10.  Does neuroimaging research examining the pathophysiology of posttraumatic stress disorder require medication-free patients? 
In an attempt to avoid unknown influence, most neuroimaging studies examining the pathophysiology of posttraumatic stress disorder (PTSD) exclude patients taking medications. Here we review the empirical evidence for relevant medications having a confounding effect on task performance or cerebral blood flow (CBF) in this population. The evidence for potentially confounding effects of psychotherapy in PTSD are also discussed.
The literature that we reviewed was obtained through a PubMed search from 1980 to 2009 using the search terms posttraumatic stress disorder, PTSD, psychotropic medications, neuroimaging, functional magnetic resonance imaging, positron emission tomography, cerebral blood flow, CBF, serotonin-specific reuptake blocker, benzodiazepine, ketamine, methamphetamine, lamotrigine and atypical antipsychotic agents.
The empirical evidence for relevant medications having a confounding effect on task performance or CBF in relevant areas remains sparse for most psychotropic medications among patients with PTSD. However, considerable evidence is accumulating for 2 of the most commonly prescribed medication classes (serotonin-specific reuptake inhibitors and benzodiazepines) in healthy controls. Compelling data for the potentially confounding effects on brain areas relevant to PTSD for psychotherapeutic interventions are also accumulating.
Neuroimaging studies examining the pathophysiology of PTSD should ideally recruit both medicated (assuming that the medication treatment has not resulted in the remission of symptoms) and unmedicated participants, to allow the findings to be generalized with greater confidence to the entire population of patients with PTSD. More research is needed into the independent effects of medications on task performance and CBF in regions of interest in PTSD. Neuro-imaging studies should also take into account whether patients are currently engaged in psychotherapeutic treatment.
PMCID: PMC2834789  PMID: 20184804
11.  Do all psychological treatments really work the same in posttraumatic stress disorder? 
Clinical Psychology Review  2010;30(2):269-276.
A recent meta-analysis by Benish, Imel, and Wampold (2008, Clinical Psychology Review, 28, 746–758) concluded that all bona fide treatments are equally effective in posttraumatic stress disorder (PTSD). In contrast, seven other meta-analyses or systematic reviews concluded that there is good evidence that trauma-focused psychological treatments (trauma-focused cognitive behavior therapy and eye movement desensitization and reprocessing) are effective in PTSD; but that treatments that do not focus on the patients' trauma memories or their meanings are either less effective or not yet sufficiently studied. International treatment guidelines therefore recommend trauma-focused psychological treatments as first-line treatments for PTSD. We examine possible reasons for the discrepant conclusions and argue that (1) the selection procedure of the available evidence used in Benish et al.'s (2008)meta-analysis introduces bias, and (2) the analysis and conclusions fail to take into account the need to demonstrate that treatments for PTSD are more effective than natural recovery. Furthermore, significant increases in effect sizes of trauma-focused cognitive behavior therapies over the past two decades contradict the conclusion that content of treatment does not matter. To advance understanding of the optimal treatment for PTSD, we recommend further research into the active mechanisms of therapeutic change, including treatment elements commonly considered to be non-specific. We also recommend transparency in reporting exclusions in meta-analyses and suggest that bona fide treatments should be defined on empirical and theoretical grounds rather than by judgments of the investigators' intent.
PMCID: PMC2852651  PMID: 20051310
Posttraumatic stress disorder; Meta-analysis; Cognitive behavior therapy; EMDR; Psychotherapy; Clinical trials
12.  Toward a VA Women's Health Research Agenda: Setting Evidence-based Priorities to Improve the Health and Health Care of Women Veterans 
Journal of General Internal Medicine  2006;21(Suppl 3):S93-S101.
The expansion of women in the military is reshaping the veteran population, with women now constituting the fastest growing segment of eligible VA health care users. In recognition of the changing demographics and special health care needs of women, the VA Office of Research & Development recently sponsored the first national VA Women's Health Research Agenda-setting conference to map research priorities to the needs of women veterans and position VA as a national leader in Women's Health Research. This paper summarizes the process and outcomes of this effort, outlining VA's research priorities for biomedical, clinical, rehabilitation, and health services research.
PMCID: PMC1513170  PMID: 16637953
women's health; research and development; research priorities; veterans; health care quality; access and evaluation

Results 1-12 (12)