Investigation of Therapist Effects on Patient Engagement in Evidence‐Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration

Sayer, Nina A.; Stirman, Shannon Wiltsey; Rosen, Craig S.; Bernardy, Nancy C.; Spoont, Michele; Kehle‐Forbes, Shannon M.; Eftekhari, Afsoon; Chard, Kathleen M.; Nelson, David B.

doi:10.1002/jts.22679

Cited by 12 publications

(9 citation statements)

References 40 publications

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“…For our EOC cohort, the largest "cut" in creating the cohort was reducing the group who received any individual therapy (n = 103,389) to those who received at least eight sessions in 14 weeks (n = 6,697). Although not all contiguous care is EBP (approximately, 69% according to our results), other research examining the rates of EBP engagement using the Corporate Data Warehouse data has found similarly low rates, with approximately 20% of Veterans dropping out before the third session (Sayer et al, 2022) and nearly 70% receiving less than eight sessions (Hale et al, 2019). Our small n in the EOC is likely due to a mix of more patients receiving sporadic care as well as dropout, which is a known significant problem in PTSD treatment (Najavits, 2015).…”

Section: Discussionsupporting

confidence: 49%

Leveraging available metadata in VA PTSD clinics and generating benchmarks for clinically significant change.

Benfer¹,

Rusowicz-Orazem²,

Fielstein³

et al. 2023

Journal of Consulting and Clinical Psychology

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Objective: Measurement-based care is designed to track symptom levels during treatment and leverage clinically significant change benchmarks to improve quality and outcomes. Though the Veterans Health Administration promotes monitoring progress within posttraumatic stress disorder (PTSD) clinical teams, actionability of data is diminished by a lack of population-based benchmarks for clinically significant change. We reported the state of repeated measurement within PTSD clinical teams, generated benchmarks, and examined outcomes based on these benchmarks. Method: PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition data were culled from the Corporate Data Warehouse from the pre-COVID-19 year for Veterans who received at least eight sessions in 14 weeks (episode of care [EOC] cohort) and those who received sporadic care (modal cohort). We used the Jacobson and Truax (1991) approach to generate clinically significant change benchmarks at clinic, regional, and national levels and calculated the frequency of cases that deteriorated, were unchanged, improved, or probably recovered, using our generated benchmarks and benchmarks from a recent study, for both cohorts. Results: Both the number of repeated measurements and the cases who had multisession care in the Corporate Data Warehouse were very low. Clinically significant change benchmarks were similar across locality levels. The modal cohort had worse outcomes than the EOC cohort. Conclusions: National benchmarks for clinically significant change could improve the actionability of assessment data for measurement-based care. Benchmarks created using data from Veterans who received multisession care had better outcomes than those receiving sporadic care. Measurement-based care in PTSD clinical teams is hampered by low rates of repeated assessments of outcome.

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Section: Discussionsupporting

confidence: 49%

Leveraging available metadata in VA PTSD clinics and generating benchmarks for clinically significant change.

Benfer¹,

Rusowicz-Orazem²,

Fielstein³

et al. 2023

Journal of Consulting and Clinical Psychology

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“…Instead, other factors (e.g., clinic caseloads, scheduling constraints, and patient treatment motivation) may explain this relationship. On average, VHA medical record data suggests that sessions occur every two weeks (Sayer et al, 2019). Some studies have shown that feedback on intervention fidelity (e.g., the level of adherence and skill or competence) can support favorable training outcomes (Lu et al, 2012), and that supportive fidelity monitoring may reduce turnover, thereby preserving a trained workforce and EBP availability (Aarons, Sommerfeld, Hecht, Silovsky, & Chaffin, 2009).…”

Section: Introductionmentioning

confidence: 99%

An intervention mapping process to increase evidence-based psychotherapy within a complex healthcare system.

Crowe¹,

Collie²,

Johnson³

et al. 2020

American Psychologist

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In response to recommendations from the Special Committee on posttraumatic stress disorder (PTSD), the United States Department of Veterans Affairs, Veterans Health Administration (VHA) chartered a workgroup to identify strategies for improving the reach and fidelity of evidence-based psychotherapies (EBPs) implemented by VHA through clinician training initiatives. The workgroup, which comprised stakeholders in a variety of roles within the VHA, used an Intervention Mapping process, a practical approach to designing change strategies based on theory, evidence, and stakeholder input. High-level recommendations centered around implementation of recent VHA/Department of Defense (VA/DoD) treatment guidelines. In addition to recommended first-line and suggested second-line treatments, the guidelines include measurement-based care and shared decision making around EBPs and their alternatives to ensure that care is goal-oriented and patient-centered. To support increased reach and fidelity, the workgroup made four broad recommendations: (a) enhancing leadership support; (b) alignment of policies, programs, and processes that influence reach of EBPs as recommended in clinical practice guidelines, including implementation support to accompany EBP trainings; (c) use of clinical data to inform decision making at multiple levels, and to provide fidelity support when outcomes are lower than expected or desired; and (d) increasing veteran and stakeholder education and awareness of guideline recommendations and availability of EBPs. These recommendations accompanied a more detailed set of recommended steps for implementation. This article describes the Intervention Mapping process and a summary of resulting workgroup recommendations.Editor's note. This article is part of a special issue, "Expanding the Impact of Psychology Through Implementation Science," published in the November 2020 issue of American Psychologist. Shannon Wiltsey Stirman and Rinad S. Beidas served as editors of the special issue, with Anne E. Kazak as advisory editor and action editor for this article.

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“…CPT and PE typically require 8–15 sessions, with eight sessions often considered an adequate dose (e.g., Wang et al, 2005). However, fewer than 40% of VA patients who initiate these treatments complete eight or more sessions (Hale et al, 2019; Sayer et al, 2021). Both CPT and PE also require patient practice outside of sessions, which PTSD-related avoidance can make difficult (Cooper et al, 2017; Stirman et al, 2018).…”

mentioning

confidence: 99%

Effectiveness of written exposure therapy for posttraumatic stress disorder in the Department of Veterans Affairs Healthcare System.

LoSavio¹,

Worley²,

Aajmain³

et al. 2023

Psychological Trauma: Theory, Research, Practice, and Policy

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Objective: Written Exposure Therapy (WET) for posttraumatic stress disorder (PTSD) has been shown to be efficacious in clinical trials; however, research is needed to determine WET's effectiveness in clinical practice settings. Additionally, research is needed to understand whether patient characteristics or treatment delivery format moderate outcomes. Method: Patient outcomes (n = 277) were assessed as part of a multisite training and implementation program in the Department of Veterans Affairs (VA). During treatment, patients completed self-report measures of PTSD, depression, and functional impairment. Patient characteristics (i.e., demographics, psychiatric comorbidity, trauma type) and treatment delivery format (i.e., telehealth vs. in-person) were assessed as treatment moderators. Results: Intent-totreat analyses indicated that WET was effective in reducing PTSD symptoms (d = .84), depression symptoms (d = .47), and functional impairment (d = .36) during treatment. Approximately one quarter of patients dropped out of treatment prematurely. No moderators of PTSD treatment outcome were observed; however, telehealth delivery was associated with lower dropout. Conclusions: WET was an effective approach across a range of patient characteristics in this sample of veterans with PTSD. WET was also effective whether delivered in-person or via telehealth. WET is a promising treatment option for veteran patients in VA clinical care settings. Clinical Impact StatementVeterans receiving WET from therapists in the VA had significant symptom improvement. There was similar symptom reduction across patient characteristics and regardless of whether care was inperson or via telehealth. These findings provide support for WET's effectiveness and show it can be successfully delivered via telehealth.

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Investigation of Therapist Effects on Patient Engagement in Evidence‐Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration

Cited by 12 publications

References 40 publications

Leveraging available metadata in VA PTSD clinics and generating benchmarks for clinically significant change.

Leveraging available metadata in VA PTSD clinics and generating benchmarks for clinically significant change.

An intervention mapping process to increase evidence-based psychotherapy within a complex healthcare system.

Effectiveness of written exposure therapy for posttraumatic stress disorder in the Department of Veterans Affairs Healthcare System.

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