Cognitive processing therapy (CPT) and prolonged exposure (PE) are two evidence-based psychotherapies (EBPs) that were "rolled out" in the VA to treat posttraumatic stress disorder (PTSD). Although a 2009 national survey revealed that these treatments are available in 96% of VA medical centers, studies suggest that many Veterans with PTSD are not receiving these treatments. CPT and PE manuals indicate that these treatments can be contraindicated for certain patients such as those with active suicidality, active psychosis, and severe dissociation. It is possible that these factors and others are interfering with routine use of CPT and PE.
This study was guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. The goal was to examine factors contributing to CPT and PE implementation at two VISN 1 medical centers. Specifically, we aimed to 1) estimate the proportion of veterans with PTSD who participated in CPT or PE (Reach); 2) assess changes in PTSD symptoms from baseline to 3- and 6-months post-treatment using local PTSD Checklist-Civilian Version (PCL-C) scores (Effectiveness); 3) explore the extent to which mental health providers use CPT or PE (Adoption); 4) identify patient-, provider-, and organizational-level facilitators and barriers to using CPT or PE (Implementation); and 5) identify organizational-level factors that impact the sustainability of CPT and PE (Maintenance).
We conducted CPRS medical record reviews of 100 veterans we randomly selected from a list of veterans from the two sites (50 per site) who received two PTSD-related outpatient visits in FY11. We stratified the sample by age (50% under 45 years; 50% over 45 years) to include veterans from prior and recent conflicts. We abstracted the following information and conducted descriptive statistics: demographics; comorbid diagnoses; CPT, PE and other individual or group psychotherapy received through FY12; PCL scores; and possible contraindications for CPT and PE (e.g., active suicidality).
Using Outlook email, we invited all licensed psychologists and licensed social workers from both sites who were treating at least one veteran with PTSD to participate in a semi-structured, qualitative interview. Providers who agreed to participate were asked to complete screening questions about their CPT/PE training and usage in the last 12 months. Recruitment continued until the target sample (16 providers; 8 per site) was reached. Interviews explored provider decision-making around treatment selection for their patients with PTSD and organizational facilitators and barriers that affect the use of CPT and PE. Interviews were analyzed using grounded thematic techniques.
The Veterans were mainly male (92%) and White (86%), had a mean age of about 51 years (SD=17), and had mainly served in OEF/OIF (44%) or Vietnam (32%). Just 17% had any sessions of CPT or PE through FY12. Only 22% of the charts mentioned offering CPT or PE. The great majority (87%) had comorbid conditions such as depression, bipolar disorder, or alcohol/drug dependence; however, contraindications for beginning CPT or PE (e.g., severe dissociation) for CPT and PE were not mentioned in any of the charts.
The remaining veterans received other PTSD (59%), other mental health (10%), substance use-related (14%), eye movement desensitization and reprocessing (5%), or no psychotherapy (18%) through FY12. PCL scores were scarcely recorded in the medical record and thus, effectiveness of treatment could not be assessed.
At each site, there were at least 20 providers who are trained in CPT and/or PE. Thirteen providers (9 licensed psychologists and 7 licensed social workers) who were interviewed were CPT- and/or PE-trained, and 9 had used one of the treatments in the last 12 months. Both trained and untrained providers reported discussing CPT or PE with many of their PTSD patients at some point during their care. Untrained providers reported making referrals for trauma-focused psychotherapy. Providers reported several factors influenced their decision to use CPT or PE or initiate a referral. One was patient readiness, which was defined as a willingness to engage in CPT or PE, having adequate coping skills to handle intense emotions, being stable (e.g., no active suicidality), and/or not having other major life priorities (e.g., homelessness). When these factors were present, providers were more likely to use or place a referral for CPT and/or PE. When these factors were not present, or if patients had comorbidities such as personality disorders and active substance use, providers reported using other approaches such as crisis management and Dialectical Behavior Therapy. Aside from patient-related factors, trained providers revealed that organizational-level factors such as leadership encouragement to use CPT and PE, lack of workload credit for joining consultation calls, and control over scheduling (e.g., scheduling 90-minute sessions) impacted CPT/PE use. Several providers mentioned that local provider "support groups" or consultation meetings and incentivizing training in and use of CPT and PE are possible avenues for boosting the use of these treatments.
This study highlights the need for local, in-depth investigations that use mixed methodology to assess factors that impact CPT and PE use. Mental health providers at these two sites report discussing CPT and PE with their patients with PTSD but as documented in prior studies, use of these treatments was substantially low. There is variation in factors providers consider before using these treatments, some of which may not be consistent with prior research, and providers also face institutional challenges. Implementation of local consultation meetings can provide guidance for providers in using CPT and PE with various patient presentations and providing support for managing local barriers. This may begin to close the gap between offering and using these evidence-based treatments. Furthermore, the low rate of documentation of CPT/PE discussions in CPRS highlights the potential need for a standard method for documenting EBP offering and usage (e.g., CPRS note template or clinical reminder).
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