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.

Purpose Much of the existing literature on shared decision making (SDM) in mental health has focused on the use of decision aids (DAs). However, DAs tend to focus on information exchange and neglect other essential elements to SDM in mental health. The purpose of this paper is to expand the review of SDM interventions in mental health by identifying important components, in addition to information exchange, that may contribute to the SDM process in mental health. Design/methodology/approach The authors conducted a systematic literature search using the Ovid-Medline database with supplementary scoping search of the literature on SDM in mental health treatment. To be eligible for inclusion, studies needed to describe (in a conceptual work or development paper) or evaluate (in any type of research design) a SDM intervention in mental health. The authors included studies of participants with a mental illness facing a mental health care decision, their caregivers, and providers. Findings A final sample of 31 records was systematically selected. Most interventions were developed and/or piloted in the USA for adults in community psychiatric settings. Although information exchange was a central component of the identified studies, important additional elements were: eliciting patient preferences and values, providing patient communication skills training, eliciting shared care planning, facilitating patient motivation, and eliciting patient participation in goal setting. Originality/value The review indicates that additional elements, other than information exchange such as sufficient rapport and trusting relationships, are important and needed as part of SDM in mental health. Future SDM interventions in mental health could consider including techniques that aim to increase patient involvement in activities such as goal settings, values, and preference clarification, or facilitating patient motivation, before and after presenting treatment options.

Objective Despite the success of empirically supported treatments for posttraumatic stress disorder (PTSD), sleep impairment frequently remains refractory following treatment for PTSD. This single-site, randomized controlled trial examined the effectiveness of sleep-directed hypnosis as a complement to an empirically supported psychotherapy for PTSD (cognitive processing therapy; CPT). Method Participants completed either 3 weeks of hypnosis (n = 52) or a symptom monitoring control condition (n = 56) before beginning standard CPT. Multilevel modeling was used to investigate differential patterns of change to determine whether hypnosis resulted in improvements in sleep, PTSD, and depression. An intervening variable approach was then used to determine whether improvements in sleep achieved during hypnosis augmented change in PTSD and depression during CPT. Results After the initial phase of treatment (hypnosis or symptom monitoring), the hypnosis condition showed significantly greater improvement than the control condition in sleep and depression, but not PTSD. After CPT, both conditions demonstrated significant improvement in sleep and PTSD; however, the hypnosis condition demonstrated greater improvement in depressive symptoms. As sleep improved, there were corresponding improvements in PTSD and depression, with a stronger relationship between sleep and PTSD. Conclusion Hypnosis was effective in improving sleep impairment, but those improvements did not augment gains in PTSD recovery during the trauma-focused intervention. Public Health Significance: This study suggests that hypnosis may be a viable treatment option in a stepped-care approach for treating sleep impairment in individuals suffering from PTSD.

BackgroundPrimary care clinics present challenges to implementing evidence-based psychotherapies (EBPs) for depression and anxiety, and frontline providers infrequently adopt these treatments. The current study explored providers’ perspectives on fidelity to a manualized brief cognitive behavioral therapy (CBT) as delivered in primary care clinics as part of a pragmatic randomized trial. Data from the primary study demonstrated the clinical effectiveness of the treatment and indicated that providers delivered brief CBT with high fidelity, as evaluated by experts using a standardized rating form. Data presented here explore challenges providers faced during implementation and how they adapted nonessential intervention components to make the protocol “fit” into their clinical practice.MethodsA multiprofessional group of providers (n = 18) completed a one-time semi-structured interview documenting their experiences using brief CBT in the primary care setting. Data were analyzed via directed content analysis, followed by inductive sorting of interview excerpts to identify key themes agreed upon by consensus. The Dynamic Adaptation Process model provided an overarching framework to allow better understanding and contextualization of emergent themes.ResultsProviders described a variety of adaptations to the brief CBT to better enable its implementation. Adaptations were driven by provider skills and abilities (i.e., using flexible content and delivery options to promote treatment engagement), patient-emergent issues (i.e., addressing patients’ broader life and clinical concerns), and system-level resources (i.e., maximizing the time available to provide treatment).ConclusionsThe therapeutic relationship, individual patient factors, and system-level factors were critical drivers guiding how providers adapted EBP delivery to improve the “fit” into their clinical practice. Adaptations were generally informed by tensions between the EBP protocol and patient and system needs and were largely not addressed in the EBP protocol itself. Adaptations were generally viewed as acceptable by study fidelity experts and helped to more clearly define delivery procedures to improve future implementation efforts. It is recommended that future EBP implementation efforts examine the concept of fidelity on a continuum rather than dichotomized as adherent/not adherent with focused efforts to understand the context of EBP delivery.Trial registrationClinicalTrials.gov, NCT01149772Electronic supplementary materialThe online version of this article (10.1186/s13012-018-0768-z) contains supplementary material, which is available to authorized users.

Taken together, these results suggest that providers are increasingly likely to view exposure-based EBPs for PTSD as effective, and that continued dissemination efforts to increase provider familiarity and comfort with these protocols will likely improve rates of EBP use across a variety of practice settings. (PsycINFO Database Record