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BackgroundLarge-scale implementation of evidence-based psychotherapies (EBPs) such as cognitive processing therapy (CPT) for posttraumatic stress disorder can have a tremendous impact on mental and physical health, healthcare utilization, and quality of life. While many mental health systems (MHS) have invested heavily in programs to implement EBPs, few eligible patients receive EBPs in routine care settings, and clinicians do not appear to deliver the full treatment protocol to many of their patients. Emerging evidence suggests that when CPT and other EBPs are delivered at low levels of fidelity, clinical outcomes are negatively impacted. Thus, identifying strategies to improve and sustain the delivery of CPT and other EBPs is critical. Existing literature has suggested two competing strategies to promote sustainability. One emphasizes fidelity to the treatment protocol through ongoing consultation and fidelity monitoring. The other focuses on improving the fit and effectiveness of these treatments through appropriate adaptations to the treatment or the clinical setting through a process of data-driven, continuous quality improvement. Neither has been evaluated in terms of impact on sustained implementation.MethodsTo compare these approaches on the key sustainability outcomes and provide initial guidance on sustainability strategies, we propose a cluster randomized trial with mental health clinics (n = 32) in three diverse MHSs that have implemented CPT. Cohorts of clinicians and clinical managers will participate in 1 year of a fidelity oriented learning collaborative or 1 year of a continuous quality improvement-oriented learning collaborative. Patient-level PTSD symptom change, CPT fidelity and adaptation, penetration, and clinics’ capacity to deliver EBP will be examined. Survey and interview data will also be collected to investigate multilevel influences on the success of the two learning collaborative strategies. This research will be conducted by a team of investigators with expertise in CPT implementation, mixed method research strategies, quality improvement, and implementation science, with input from stakeholders in each participating MHS.DiscussionIt will have broad implications for supporting ongoing delivery of EBPs in mental health and healthcare systems and settings. The resulting products have the potential to significantly improve efforts to ensure ongoing high quality implementation and consumer access to EBPs.Trial registration NCT02449421. Registered 02/09/2015

Studies exploring gender differences among substance abusers in treatment have been fairly consistent in finding that females who enter treatment express more severe psychological and psychosocial disturbances than males, despite presenting with shorter and less intense substance abuse histories. However, strands of evidence suggest that the presence of a spouse, generally perceived as an asset in the treatment of the substance abuser, may have different implications for females than for males. In order to clarify this issue, 67 male and 18 female married substance abusers in treatment and their spouses were questioned on their substance use and psychological and social functioning. Similar to other studies, the female substance abusers reported greater disturbance on dimensions of employment and psychological functioning, but less severity of alcohol abuse. Comparison of male and female spouses, however, revealed that male spouses were likely to present with the following characteristics: (1) more symptoms of substance abuse and depression, (2) less overall physical well-being, and (3) to be less inclined to help others or be involved with their children than the female spouses. These findings are consistent with the view that the process of substance abuse is telescoped in females and is associated with more disturbed functioning in women on admission to treatment than in men. However, contextual differences--specifically in terms of availability of spousal support--may contribute significantly both to the understanding of differences in female versus male substance abusers in treatment as well as to the development of guidelines for adapting treatment based on gender.

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