Unlike the post-Vietnam era, effective, specialized treatments for posttraumatic stress disorder (PTSD) now exist, although these treatments have not been widely available in clinical settings. The U.S. Department of Veterans Affairs (VA) is nationally disseminating 2 evidence-based psychotherapies for PTSD throughout the VA health care system. The VA has developed national initiatives to train mental health staff in the delivery of Cognitive Processing Therapy (CPT) and Prolonged Exposure therapy (PE) and has implemented a variety of strategies to promote local implementation. In this article, the authors examine VA's national CPT and PE training initiatives and report initial patient, therapist, and system-level program evaluation results. Key issues, lessons learned, and next steps for maximizing impact and sustainability are also addressed.

osttraumatic stress disorder (PTSD) affects more than 6% of the US population and up to 13% of US military personnel returning from deployment in Iraq and Afghanistan. 1-3 It is associated with substantially reduced quality of life through both impaired role functioning and higher risk of cardiovascular disease, diabetes mellitus, and substance use conditions. 4-8 There is an especially critical need for effective treatments for PTSD as increasing numbers of veterans return from Iraq and Afghanistan. Since 2001, the number of veterans with diagnosed PTSD receiving care in the Veterans Health Administration (VHA), the health care arm of the US Department of Veterans Affairs (VA), has tripled. 9 In recent years, there have been significant advances in the treatment of PTSD, with development of a variety of efficacious treatments. Exposure-based psychotherapies are among the treatments with the most empiric al support. 10-16 Exposure therapy is recommended as a firstline treatment for PTSD in all clinical treatment guidelines in the United States and other countries. 17 A rigorous review of P TSD treatments conduc ted by the Institute of Medicine 18 concluded that exposure therapy was the only psychological or psychopharmacological intervention with sufficient data to support its efficacy in the treatment of PTSD. IMPORTANCE Posttraumatic stress disorder (PTSD) is a pervasive and often debilitating condition that affects many individuals in the general population and military service members. Effective treatments for PTSD are greatly needed for both veterans returning from Iraq and Afghanistan and veterans of other eras. Prolonged exposure (PE) therapy has been shown to be highly efficacious in clinical trials involving women with noncombat trauma, but there are limited data on its effectiveness in real-world clinical practice settings and with veterans. OBJECTIVE To evaluate the effectiveness of PE as implemented with veterans with PTSD in a large health care system. DESIGN, SETTING, AND PARTICIPANTS This evaluation included 1931 veterans treated by 804 clinicians participating in the Department of Veterans Affairs (VA) PE Training Program. After completing a 4-day experiential PE training workshop, clinicians implemented PE (while receiving consultation) with a minimum of 2 veteran patients who had a primary diagnosis of PTSD. MAIN OUTCOMES AND MEASURES Changes in PTSD and depression symptoms were assessed with the PTSD Checklist and the Beck Depression Inventory II, measured at baseline and at the final treatment session. Multiple and single imputation were used to estimate the posttest scores of patients who left treatment before completing 8 sessions. Demographic predictors of treatment dropout were also examined. RESULTS Intent-to-treat analyses indicate that PE is effective in reducing symptoms of both PTSD (pre-post d= 0.87) and depression (pre-post d= 0.66), with effect sizes comparable to those reported in previous efficacy trials. The proportion of patients screening positive for PTSD on the PTSD Checklis...

Emotion regulatory strategies such as higher expressive suppression and lower cognitive reappraisal may be associated with increased psychopathology (Gross & John, 2003). Yet, it is unclear whether these strategies represent distinct cognitive styles associated with psychopathology, such that there are individuals who are predominantly “suppressors” or “reappraisers.” Using cluster analysis, we examined whether women with and without exposure to potentially traumatic events evidence distinct patterns of emotion regulation frequency, capacity, suppression, and cognitive reappraisal. Four patterns emerged: high regulators; high reappraisers/low suppressors; moderate reappraisers/low suppressors; and low regulators. Individuals who reported infrequently and ineffectively regulating their emotions (low regulators) also reported higher depression, anxiety, and posttraumatic stress disorder (PTSD). In contrast, individuals who reported frequently and effectively using reappraisal and low levels of suppression (high reappraisers/low suppressors) reported the lowest levels of these symptoms, suggesting that this specific combination of emotion regulation may be most adaptive. Our findings highlight that the capacity to regulate emotions and the ability to flexibly apply different strategies based on the context and timing may be associated with reduced psychopathology and more adaptive functioning.

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.