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1.  The Influence of the Dissociative Subtype of Posttraumatic Stress Disorder on Treatment Efficacy in Female Veterans and Active Duty Service Members 
A dissociative subtype of posttraumatic stress disorder (PTSD) was recently added to the Diagnostic and Statistical Manual-5 (American Psychiatric Association, 2013) and is thought to be associated with poor PTSD treatment response.
We used latent growth curve modeling to examine data from a randomized controlled trial of Prolonged Exposure and Present-Centered Therapy for PTSD in a sample of 284 female veterans and active duty service members with PTSD to test the association between the dissociative subtype and treatment response.
Individuals with the dissociative subtype (defined using latent profile analysis) had a flatter slope (p = .008) compared to those with high PTSD symptoms and no dissociation such that the former group showed, on average, a 9.75 (95% CI = -16.94 to -2.57) lesser decrease in PTSD severity scores on the Clinician Administered PTSD Scale (Blake et al., 1995) over the course of the trial. However, this effect was small in magnitude. Dissociative symptoms decreased markedly among those with the subtype, though neither treatment explicitly addressed such symptoms. There were no differences as a function of treatment type.
Results raise doubt about the common clinical perception that exposure therapy is not effective or appropriate for individuals who have PTSD and dissociation and provide empirical support for the use of exposure treatment for individuals with the dissociative subtype of PTSD.
Public Health Significance
. This study found that female veterans and active duty service members with the dissociative subtype of posttraumatic stress disorder (PTSD) did not respond as well to PTSD treatment with Prolonged Exposure or Present-Centered Therapy as did those without the subtype. However, both PTSD and dissociation symptoms did improve markedly in the dissociative group, suggesting that the dissociative subtype is not a contraindication for the use of empirically supported treatments for PTSD.
PMCID: PMC4830387  PMID: 26167946
Dissociative subtype; PTSD; latent growth curve; treatment response
2.  PTSD-Related Cardiovascular Disease and Accelerated Cellular Aging 
Psychiatric annals  2016;46:527-532.
We reviewed the literature from 2010 to 2016 on the relationship between posttraumatic stress disorder (PTSD) and cardiometabolic health conditions, including metabolic syndrome, coronary artery disease, stroke, and myocardial infarction, among others. Collectively, PTSD was associated with increased risk of cardiometabolic health problems, with pre-clinical and clinical studies offering evidence of behavioral (e.g., poor sleep, cigarette use, poor diet and insufficient exercise) and biological (e.g., autonomic reactivity, inflammation) mediators of these associations. We discuss the possibility that these behavioral and biological mechanisms lead to accelerated cellular aging, as regulated in the epigenome, which contributes to premature cardiometabolic health decline. This has implications for the assessment, prevention, and treatment of cardiometabolic conditions among those with PTSD. It also highlights the need to better understand the mechanisms linking PTSD to accelerated aging and to develop interventions to attenuate or reverse this phenomenon.
PMCID: PMC5154362  PMID: 27990033
3.  Understanding and meeting information needs for patients with posttraumatic stress disorder 
BMC Psychiatry  2016;16:21.
Posttraumatic Stress Disorder (PTSD) is a commonly occurring mental illness. There are multiple treatments for PTSD that have similar effectiveness, but these treatments differ substantially in other ways. It is desirable to have well-informed patients involved in treatment choices. A patient decision aid (PtDA) is one method to achieve this goal. This manuscript describes the rationale and development of a patient decision aid (PtDA) designed for patients with PTSD.
We conducted an informational needs assessment of veterans (n = 19) to obtain their baseline information needs prior to the development of the PtDA. We also conducted a literature review of effective PTSD treatments, and we calculated respective effective sizes. A PtDA prototype was developed according to the guidelines from the International Patient Decision Aid Standards. These standards guided our development of both content and format for the PtDA. In accordance with the standards, we gathered feedback from patients (n = 20) and providers (n = 7) to further refine the PtDA. The information obtained from patients and the literature review was used to develop a decision aid for patients with PTSD.
Patients with PTSD reported a strong preference to receive information about treatment options. They expressed interest in also learning about PTSD symptoms. The patients preferred information presented in a booklet format. From our literature review several treatments emerged as effective for PTSD: Cognitive Therapy, Exposure Therapy, Eye Movement Desensitization Therapy, Selective Serotonin Reuptake Inhibitors, venlafaxine, and risperidone.
It appears that the criteria set forth to develop decision aids can effectively be applied to PTSD. The resultant PTSD patient decision aid is a booklet that describes the causes, symptoms, and treatments for PTSD. Future work will examine the effects of use of the PTSD decision aid in clinical practice.
Trial registration identifier NCT00908440. Registered May 20, 2009.
Electronic supplementary material
The online version of this article (doi:10.1186/s12888-016-0724-x) contains supplementary material, which is available to authorized users.
PMCID: PMC4736082  PMID: 26830930
Shared decision making; Patient decision aid; Posttraumatic stress disorder; Patient-centered care
4.  A Quantitative Test of an Implementation Framework in 38 VA Residential PTSD Programs 
This study examines the implementation of two evidence-based psychotherapies, Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), in the Department of Veterans Affairs residential Posttraumatic Stress Disorder treatment programs. Two hundred and one providers from 38 programs completed an online survey concerning implementation of PE delivered on an individual basis and CPT delivered in individual and group formats. For PE, a supportive organizational context (dedicated time and resources, and incentives and mandates) and overall positive view of the treatment were related to its implementation. For both group and individual CPT, only the supportive organizational context was significantly associated with outcome. Implications for implementation efforts are discussed.
PMCID: PMC4362884  PMID: 25199813
Implementation; Evidence-based Practice; Posttraumatic stress disorder
5.  Cognitive–Behavioral Conjoint Therapy for PTSD: Pilot Results From a Community Sample 
Journal of traumatic stress  2011;24(1):97-101.
Seven couples participated in an uncontrolled trial of cognitive–behavioral conjoint therapy for posttraumatic stress disorder (PTSD). Among the 6 couples who completed treatment, 5 of the patients no longer met criteria for PTSD and there were across-treatment effect size improvements in patients’ total PTSD symptoms according to independent clinician assessment, patient report, and partner report (d = 1.32–1.69). Three of the 4 couples relationally distressed at pretreatment were satisfied at posttreatment. Partners reported statistically significant and large effect size improvements in relationship satisfaction; patients reported nonsignificant moderate to large improvements in relationship satisfaction. Patients also reported nonsignificant, but large effect size improvements in depression and state anger symptoms. Future directions for research and treatment of traumatized individuals and close others are offered.
PMCID: PMC4415858  PMID: 21351166
8.  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
9.  Effect of Cognitive-Behavioral Couple Therapy for PTSD 
JAMA  2012;308(7):700-709.
Posttraumatic stress disorder (PTSD) is a prevalent condition associated with intimate relationship problems, and intimate relationship factors have been shown to affect individual PTSD treatment outcomes.
To compare cognitive-behavioral conjoint therapy for PTSD (a manualized couple therapy delivered to patients with PTSD and their significant others to simultaneously treat PTSD symptoms and enhance relationship satisfaction) with a wait-list condition.
Design, Setting, and Participants
Randomized controlled trial of heterosexual and same-sex couples (n=40 couples; n=80 individuals) in which one partner met criteria for PTSD according to the Clinician-Administered PTSD Scale, conducted from 2008 to 2012 in a Department of Veterans Affairs outpatient hospital setting in Boston, Massachusetts, and a university-based research center in Toronto, Ontario, Canada. Symptoms of PTSD, comorbid conditions, and relationship satisfaction were collected by blinded assessors at baseline, at mid treatment (median, 8.00 weeks [range, 1.71–20.43 weeks] after baseline), and at posttreatment (median, 15.86 weeks [range, 7.14–38.57 weeks] after baseline). An uncontrolled 3-month follow-up (median, 38.21 weeks [range, 28.43–50.57 weeks] after baseline) was also completed.
Couples were randomly assigned to take part in the 15-session cognitive-behavioral conjoint therapy for PTSD protocol immediately (n=20) or were placed on a wait list for the therapy (n=20).
Main Outcome Measures
Clinician-rated PTSD symptom severity was the primary outcome and was assessed with the Clinician-Administered PTSD Scale. Intimate relationship satisfaction, assessed with the Dyadic Adjustment Scale, patient- and partner-rated PTSD symptoms, and comorbid symptoms were secondary outcomes.
PTSD symptom severity (score range, 0–136) was significantly more improved in the couple therapy condition than in the wait-list condition (mean change difference, −23.21; 95% CI, −37.87 to −8.55). Similarly, patients’ intimate relationship satisfaction (score range, 0–151) was significantly more improved in couple therapy than in the wait-list condition (mean change difference, 9.43; 95% CI, 0.04–18.83). The time×condition interaction effect in the multilevel model predicting PTSD symptoms (t37.5=−3.09; P =.004) and patient-reported relationship satisfaction (t68.5=2.00; P=.049) revealed superiority of the couple therapy compared with the wait list. Treatment effects were maintained at 3-month follow-up.
Among couples in which one partner was diagnosed as having PTSD, a disorder-specific couple therapy, compared with a wait list for the therapy, resulted in decreased PTSD symptom severity and patient comorbid symptom severity and increased patient relationship satisfaction.
Trial Registration Identifier: NCT00669981
PMCID: PMC4404628  PMID: 22893167
10.  Evaluation of an Implementation Model: A National Investigation of VA Residential Programs 
This national investigation utilizes qualitative data to evaluate an implementation model regarding factors influencing provider use of two evidence-based treatments for posttraumatic stress disorder (PTSD). Semi-structured qualitative interviews with 198 mental health providers from 38 Department of Veterans Affairs’ (VA) residential treatment programs were used to explore these issues regarding prolonged exposure (PE) and cognitive processing therapy (CPT) in VA residential PTSD programs. Several unique and some overlapping predictors emerged. Leadership was viewed as an influence on implementation for both CPT and PE, while a lack of dedicated time and resources was viewed as a deterrent for both. Compatibility of CPT with providers’ existing practices and beliefs, the ability to observe noticeable patient improvement, a perceived relative advantage of CPT over alternative treatments, and the presence of a supportive peer network emerged as influential on CPT implementation. Leadership was associated with PE implementation. Implications for the design and improvement of training and implementation efforts are discussed.
PMCID: PMC4240747  PMID: 24817625
Implementation; Evidence-based practice; Posttraumatic stress disorders
11.  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
12.  Iraq and Afghanistan War Veterans with Reintegration Problems: Differences by Veterans Affairs Healthcare User Status 
We studied 1,292 Iraq and Afghanistan War veterans who participated in a clinical trial of expressive writing to estimate the prevalence of perceived reintegration difficulty and compare Veterans Affairs (VA) healthcare users to nonusers in terms of demographic and clinical characteristics. About half of participants perceived reintegration difficulty. VA users and nonusers differed in age and military background. Levels of mental and physical problems were higher in VA users. In multivariate analysis, military service variables and probable traumatic brain injury independently predicted VA use. Findings demonstrate the importance of research comparing VA users to nonusers to understand veteran healthcare needs.
PMCID: PMC4452614  PMID: 24913102
Veterans; Healthcare service needs; Mental health; Posttraumatic stress disorder; Traumatic brain injury; Department of Veterans Affairs Healthcare
13.  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
14.  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
15.  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
17.  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
18.  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
19.  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
20.  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
21.  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

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