Evaluation of Implementation Strategies for Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), and Mindfulness-Based Stress Reduction (MBSR): a Systematic Review.

BACKGROUND: Improving access to evidence-based psychotherapies (EBPs) is a Veterans Health Administration (VHA) priority. Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) are effective for chronic pain and several mental health conditions. We synthesized evidence on implementation strategies to increase EBP access and use. METHODS: We searched MEDLINE, Embase, PsycINFO, and CINAHL from inception until March 2021 for articles on EBP implementation within integrated health systems to treat chronic pain or chronic mental health conditions. Reviewers independently screened articles, extracted results, coded qualitative findings, and rated quality using modified criteria from Newcastle-Ottawa (quantitative results) or Critical Appraisal Skills Programme (qualitative results). We categorized implementation strategies using the Expert Recommendations for Implementing Change (ERIC) framework and classified outcomes using RE-AIM domains (Reach, Effectiveness, Adoption, Implementation, Maintenance). RESULTS: Twelve articles (reporting results from 10 studies) evaluated CBT (k = 11) and ACT (k = 1) implementation strategies in large integrated healthcare systems. No studies evaluated MBSR implementation. Eight articles evaluated strategies within VHA. Six articles reported on national VHA EBP implementation programs; all involved training/education, facilitation, and audit/feedback. CBT and ACT implementation demonstrated moderate to large improvements in patient symptoms and quality of life. Trainings increased mental health provider self-efficacy in delivering EBPs, improved provider EBP perceptions, and increased provider EBP use during programs, but had unclear impacts on Reach. It was unclear whether external facilitation added benefit. Provider EBP maintenance was modest; barriers included competing professional time demands and patient barriers. DISCUSSION: Multi-faceted CBT and ACT implementation programs increased provider EBP Adoption but had unclear impacts on Reach. Future implementation efforts should further evaluate Reach, Adoption, and Maintenance; assess the added value of external facilitation; and consider strategies targeting patient barriers. Future work should use implementation frameworks to guide evaluations of barriers and facilitators, processes of change, and outcomes. REGISTRATION: PROSPERO registration number CRD42021252038.

Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder: A Systematic Review.

Guidelines strongly recommend trauma-focused therapies to treat posttraumatic stress disorder. Implementation of cognitive processing therapy (CPT) and prolonged exposure (PE) in Veterans Health Administration (VHA) and non-VHA settings began in 2006. We conducted a systematic review of implementation facilitators and challenges and strategies to address barriers. We searched MEDLINE, Embase, PsycINFO, and CINAHL from inception until March 2021 for English-language articles. Two individuals reviewed eligibility and rated quality. Quantitative results were abstracted by one reviewer and verified by a second. Qualitative results were independently coded by two reviewers and finalized through consensus. We used RE-AIM and CFIR frameworks to synthesize findings. 29 eligible studies addressed CPT/PE, mostly conducted in VHA. Training/education with audit/feedback was the primary implementation strategy and was linked to improved provider CPT/PE perceptions and self-efficacy. Use was not widespread. Only six studies tested other implementation strategies with mixed impact. Following VHA implementation, strong support for training, perceived effectiveness for patients and benefits for clinics, and positive patient experiences and relationships with providers were reported. However, barriers persisted including perceived protocol inflexibility, complex referral processes and patient complexity and competing needs. In non-VHA settings, providers perceived fewer barriers, but few were CPT/PE trained. Across both settings, fewer studies targeted patient factors. Training/education with audit/feedback improved perceptions and the availability of CPT/PE, but not consistent use. Studies testing implementation strategies to address post-training challenges, including patient-level factors, are needed. A few studies are underway in VHA to test patient-focused and other implementation strategies. Research assessing actual vs perceived barriers in non-VHA settings is needed to elucidate unique challenges experienced.

"Sign Me Up, I'm Ready!": Helping Patients Prescribed Sleeping Medication Engage with Cognitive Behavioral Therapy for Insomnia (CBT-I).

OBJECTIVE/BACKGROUND: Cognitive behavioral therapy for insomnia (CBT-I) provides safe and effective insomnia care without the risk of harm associated with sleeping medications. Unfortunately, few patients with insomnia engage with CBT-I, with most using sedative hypnotics instead. This study conducted focus groups with patients with insomnia who were treated with sleeping medication, including older adults, women, and patients with chronic pain. The goal was to explore the perspectives of high-risk, CBT-I naïve patients on increasing access and engagement with CBT-I. PARTICIPANTS: Participants included 29 Veterans with insomnia who had been prescribed sleeping medication in the last year and had not previously engaged with CBT-I. METHODS: Semi-structured 90-min focus groups were used to 1) explore messages and appropriate channels for a CBT-I social marketing campaign, 2) determine patient preferences for self-management CBT-I tools, and 3) determine patient opinions on alternative provider-delivered forms of CBT-I. Thematic analysis was used to identify conceptual themes. RESULTS: Three main themes were identified. First, patient education is necessary but not sufficient. Patients recommended multiple outreach attempts through multiple channels to motivate tired and overwhelmed insomnia patients to engage with CBT-I. Second, patients gravitated toward a stepped-care approach. Most would start with self-management CBT-I tools, moving on to provider-delivered CBT-I if needed. Finally, patients appreciated being able to choose from a menu of CBT-I delivery options and would use multiple options simultaneously. CONCLUSIONS: These findings suggest promising opportunities to increase the use of CBT-I for high-risk patients through patient education and provision of self-management CBT-I tools.

Exploring the Meaning of Cognitive Behavioral Therapy for Insomnia for Patients with Chronic Pain.

OBJECTIVE: Insomnia is one of the most common, persistent, and distressing symptoms associated with chronic pain. Cognitive behavioral therapy for insomnia (CBT-I) is the firstline treatment for insomnia, but patient preferences and perspectives about CBT-I within the context of chronic pain are unknown. The current qualitative study sought to understand the experience of CBT-I among patients with chronic pain, including aspects of CBT-I that were found to be difficult (e.g., pain as a specific barrier to adherence/dropout), changes in sleep and pain functioning after CBT-I, and aspects of CBT-I that were appreciated. DESIGN: Qualitative semistructured interviews. METHODS: We conducted individual semistructured interviews with 17 veterans with chronic pain and insomnia who had recently participated in CBT-I, as well as their CBT-I therapists, and used thematic analysis to identify conceptual themes. RESULTS: Results revealed that patients and CBT-I therapists found changing sleep habits during CBT-I challenging due to anxiety and temporary increases in fatigue, but did not identify major pain-related barriers to adhering to CBT-I recommendations; patients experienced better sleep, mood, energy, and socialization after CBT-I despite minimal changes in pain intensity; and patients highly valued CBT-I as a personalized treatment for sleep and strongly recommended it for other patients with chronic pain. CONCLUSIONS: Findings of improved sleep and functional outcomes support efforts to incorporate CBT-I into chronic pain treatment, including educating patients and providers about the strong feasibility of improving sleep and quality of life despite ongoing pain.

Sleep Disturbance Predicts Less Improvement in Pain Outcomes: Secondary Analysis of the SPACE Randomized Clinical Trial.

OBJECTIVE: Sleep disturbance may limit improvement in pain outcomes if not directly addressed in treatment. Moreover, sleep problems may be exacerbated by opioid therapy. This study examined the effects of baseline sleep disturbance on improvement in pain outcomes using data from the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial, a pragmatic 12-month randomized trial of opioid vs nonopioid medication therapy. DESIGN: Participants with chronic back pain or hip or knee osteoarthritis pain were randomized to either opioid therapy (N = 120) or nonopioid medication therapy (N = 120). METHODS: We used mixed models for repeated measures to 1) test whether baseline sleep disturbance scores modified the effect of opioid vs nonopioid treatment on pain outcomes and 2) test baseline sleep disturbance scores as a predictor of less improvement in pain outcomes across both treatment groups. RESULTS: The tests for interaction of sleep disturbance by treatment group were not significant. Higher sleep disturbance scores at baseline predicted less improvement in Brief Pain Inventory (BPI) interference (ß = 0.058, P = 0.0002) and BPI severity (ß = 0.026, P = 0.0164). CONCLUSIONS: Baseline sleep disturbance adversely affects pain response to treatment regardless of analgesic regimen. Recognition and treatment of sleep impairments that frequently co-occur with pain may optimize outcomes.

"You're Missing Out on Something Great": Patient and Provider Perspectives on Increasing the Use of Cognitive Behavioral Therapy for Insomnia.

Objective/Background: Cognitive behavioral therapy for insomnia (CBT-I) is the most effective treatment for insomnia but is severely underutilized. One of the key reasons for underuse is lack of knowledge among patients and primary care providers, but effective methods and materials for increasing knowledge are unknown. This study conducted in-depth interviews with CBT-I patients and their CBT-I providers to explore their perceptions on increasing utilization of CBT-I. Participants: Participants included patients who had engaged in CBT-I (N = 17) and CBT-I providers (N = 7). Methods: Semistructured interviews were used to explore the CBT-I referral process, recommendations for increasing uptake of CBT-I, and opinions on CBT-I self-management, with thematic analysis used to identify conceptual themes. Findings were compared and contrasted across patients who completed versus prematurely discontinued therapy and patients versus CBT-I providers. Results: Three main themes of referral, selling, and delivery were identified. Regarding referral, patients had not heard of nor requested CBT-I. Proactive outreach is crucial in populations in which insomnia is so common that it becomes normalized. For selling, patients and CBT-I providers had powerful testimonials that could be used to "sell" treatment using a peer-to-peer approach. Finally, for delivery, patients and CBT-I providers were ambivalent about alternative delivery formats and emphasized the need for personal contact. Although technology may be useful in advertising and delivering CBT-I, it will be important to ensure that these approaches promote rather than discourage engagement in CBT-I. Conclusions: These findings suggest promising opportunities to increase the use of CBT-I, including direct-to-consumer marketing.

Provider Types and Outcomes in Obstructive Sleep Apnea Case Finding and Treatment: A Systematic Review.

Background: Obstructive sleep apnea (OSA) diagnosis and care models rely on sleep specialist physicians (SSPs) and can be expensive and inefficient. Purpose: To assess OSA case-finding accuracy and comparative effectiveness of care by non-sleep specialists (NSSs) and SSPs. Data Sources: MEDLINE and CINAHL from January 2000 through July 2017. Study Selection: English-language trials or observational studies comparing case finding or care by SSPs versus providers not specifically trained as SSPs (NSSs) for adults with suspected or diagnosed OSA. Data Extraction: One investigator extracted data and assessed risk of bias and strength of evidence, with confirmation by a second investigator. Primary outcomes were patient-centered (mortality, access to care, quality of life, patient satisfaction, adherence, symptom scores, and adverse events). Intermediate outcomes included resource use, costs, time to initiation of treatment, and case finding. Data Synthesis: Four observational studies (n = 580; mean age, 52 years; 77% male) reported good agreement between NSSs and SSPs on appropriate diagnostic testing and classification of OSA severity (low-strength evidence). Five randomized trials and 3 observational studies (n = 1515; mean age, 52 years; 68% male) found that care provided by NSSs and SSPs resulted in similar quality of life, adherence, and symptom scores (low-strength evidence). Evidence was insufficient for access to care and adverse events. Limitations: Many outcomes were reported infrequently or not at all. Many NSSs had extensive training or experience in sleep medicine, which limits generalizability of findings to providers with less experience. Conclusion: Care by NSSs and SSPs resulted in similar outcomes in adults with known or suspected OSA. Studies are needed to determine care model implementation and reproducibility of results in nonacademic settings and among less experienced NSSs. Primary Funding Source: Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative. (PROSPERO: CRD42016036810 [full Veterans Affairs Evidence-based Synthesis Program report]).

Increasing access to and utilization of cognitive behavioral therapy for insomnia (CBT-I): a narrative review.

The American College of Physicians (ACP) recently identified cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment for insomnia. Although CBT-I improves sleep outcomes and reduces the risks associated with reliance on hypnotics, patients are rarely referred to this treatment, especially in primary care where most insomnia treatment is provided. We reviewed the evidence about barriers to CBT-I referrals and efforts to increase the use of CBT-I services. PubMed, PsycINFO, and Embase were searched on January 11, 2018; additional titles were added based on a review of bibliographies and expert opinion and 51 articles were included in the results of this narrative review. Implementation research testing specific interventions to increase routine and sustained use of CBT-I was lacking. Most research focused on pre-implementation work that revealed the complexity of delivering CBT-I in routine healthcare settings due to three distinct categories of barriers. First, system barriers result in limited access to CBT-I and behavioral sleep medicine (BSM) providers. Second, primary care providers are not adequately screening for sleep issues and referring appropriately due to a lack of knowledge, treatment beliefs, and a lack of motivation to assess and treat insomnia. Finally, patient barriers, including a lack of knowledge, treatment beliefs, and limited access, prevent patients from engaging in CBT-I. These findings are organized using a conceptual model to represent the many challenges inherent in providing guideline-concordant insomnia care. We conclude with an agenda for future implementation research to systematically address these challenges.

Resilience and Posttraumatic Stress Disorder Symptoms in National Guard Soldiers Deployed to Iraq: A Prospective Study of Latent Class Trajectories and Their Predictors.

This study examined the prospective course of posttraumatic stress disorder (PTSD) symptoms in a cohort of National Guard soldiers (N = 522) deployed to combat operations in Iraq. Participants were assessed 4 times: 1 month before deployment, 2-3 months after returning from deployment, 1 year later, and 2 years postdeployment. Growth mixture modeling revealed 3 distinct trajectories: low-stable symptoms, resilient, 76.4%; new-onset symptoms, 14.2%; and chronic distress, 9.4%. Relative to the resilient class, membership in both the new-onset symptoms and chronic distress trajectory classes was predicted by negative emotionality/neuroticism, odds ratios (ORs) = 1.09, 95% CI [1.02, 1.17], and OR = 1.22, 95% CI [1.09,1.35], respectively; and combat exposure, OR = 1.07, 95% CI [1.02, 1.12], and OR = 1.12, 95% CI [1.02, 1.24], respectively. Membership in the new-onset trajectory class was predicted by predeployment military preparedness, OR = 0.95, 95% CI [0.91, 0.98], perceived threat during deployment, OR = 1.07, 95% CI [1.03, 1.10], and stressful life events following deployment, OR = 1.44, 95% CI [1.05, 1.96]. Prior deployment to Iraq or Afghanistan, OR = 3.85, 95% CI [1.72, 8.69], predeployment depression, OR = 1.27, 95% CI [1.20, 1.36], and predeployment concerns about a deployment's impact on civilian/family life, OR = 1.09, 95% CI [1.02, 1.16], distinguished the chronic distress group relative to the resilient group. Identifying predeployment vulnerability and postdeployment contextual factors provides insight for future efforts to bolster resilience, prevent, and treat posttraumatic symptoms.

Pharmacologic Treatment of Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians.

BACKGROUND: Pharmacologic interventions are often prescribed for insomnia disorder. PURPOSE: To assess the benefits, harms, and comparative effectiveness of pharmacologic treatments for adults with insomnia disorder. DATA SOURCES: Several electronic databases (2004-September 2015), reference lists, and U.S. Food and Drug Administration (FDA) documents. STUDY SELECTION: 35 randomized, controlled trials of at least 4 weeks' duration that evaluated pharmacotherapies available in the United States and that reported global or sleep outcomes; 11 long-term observational studies that reported harm information; FDA review data for nonbenzodiazepine hypnotics and orexin receptor antagonists; and product labels for all agents. DATA EXTRACTION: Data extraction by single investigator confirmed by a second reviewer; dual-investigator assessment of risk of bias; consensus determination of strength of evidence. DATA SYNTHESIS: Eszopiclone, zolpidem, and suvorexant improved short-term global and sleep outcomes compared with placebo, although absolute effect sizes were small (low- to moderate-strength evidence). Evidence for benzodiazepine hypnotics, melatonin agonists, and antidepressants, and for most pharmacologic interventions in older adults, was insufficient or low strength. Evidence was also insufficient to compare efficacy within or across pharmacotherapy classes or versus behavioral therapy. Harms evidence reported in trials was judged insufficient or low strength; observational studies suggested that use of hypnotics for insomnia was associated with increased risk for dementia, fractures, and major injury. The FDA documents reported that most pharmacotherapies had risks for cognitive and behavioral changes, including driving impairment, and other adverse effects, and they advised dose reduction in women and in older adults. LIMITATIONS: Most trials were small and short term and enrolled individuals meeting stringent criteria. Minimum important differences in outcomes were often not established or reported. Data were scant for many treatments. CONCLUSION: Eszopiclone, zolpidem, and suvorexant may improve short-term global and sleep outcomes for adults with insomnia disorder, but the comparative effectiveness and long-term efficacy of pharmacotherapies for insomnia are not known. Pharmacotherapies for insomnia may cause cognitive and behavioral changes and may be associated with infrequent but serious harms. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. ( PROSPERO: CRD42014009908).

Psychological and Behavioral Interventions for Managing Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians.

BACKGROUND: Psychological and behavioral interventions are frequently used for insomnia disorder. PURPOSE: To assess benefits and harms of psychological and behavioral interventions for insomnia disorder in adults. DATA SOURCES: Ovid MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and PsycINFO through September 2015, supplemented with hand-searching. STUDY SELECTION: Randomized, controlled trials of psychological or behavioral interventions that were published in English and enrolled adults with insomnia disorder lasting 4 or more weeks. DATA EXTRACTION: Data extraction by single investigator confirmed by a second reviewer; dual investigator assessment of risk of bias; consensus determination of strength of evidence. DATA SYNTHESIS: Sixty trials with low to moderate risk of bias compared psychological and behavioral interventions with inactive controls or other psychological and behavioral interventions. Cognitive behavioral therapy for insomnia (CBT-I) improved posttreatment global and most sleep outcomes, often compared with information or waitlist controls (moderate-strength evidence). Use of CBT-I improved several sleep outcomes in older adults (low- to moderate-strength evidence). Multicomponent behavioral therapy improved several sleep outcomes in older adults (low- to moderate-strength evidence). Stimulus control improved 1 or 2 sleep outcomes (low-strength evidence). Evidence for other comparisons and for harms was insufficient to permit conclusions. LIMITATIONS: A wide variety of comparisons limited the ability to pool data. Trials did not always report global outcomes and infrequently conducted remitter or responder analysis. Comparisons were often information or waitlist groups, and publication bias was possible. CONCLUSION: Use of CBT-I improves most outcomes compared with inactive controls. Multicomponent behavioral therapy and stimulus control may improve some sleep outcomes. Evidence on other outcomes, comparisons, and long-term efficacy were limited. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. ( PROSPERO: CRD42014009908).

Sleep Disturbances in Posttraumatic Stress Disorder: Updated Review and Implications for Treatment.

Sleep disturbances are common in adults with PTSD and range from insomnia and nightmares to periodic leg movements and disruptive nocturnal behaviors. Together these findings suggest profound disturbances in rapid eye movement (REM) and non-REM (NREM) sleep, although there is a lack of consensus regarding a distinct profile of objective sleep disturbances associated with PTSD. Prospective, longitudinal studies have established that sleep disturbances represent a risk factor for the development and course of PTSD, suggesting that sleep is an important neurobiological mechanism in the etiology and maintenance of this disorder. This research highlights the importance of early identification and treatment of sleep disturbances in at-risk and trauma exposed populations. A number of psychological and pharmacological treatments are effective at treating sleep disturbances in PTSD. Additional research is needed to further develop clinical guidelines informing when and how to integrate sleep-specific treatment with PTSD focused clinical care.

Sleep health and aging: Recommendations for promoting healthy sleep among older adults: A National Sleep Foundation report.

OBJECTIVES: Sleep is a key health indicator in older adults; however, many older adults may experience less than ideal levels of sleep health. The objective of this report is to summarize the proceedings of the National Sleep Foundation's Sleep Health and Aging Conference. METHODS: The National Sleep Foundation held a Sleep Health and Aging Conference with sleep scientists and stakeholders in the field of aging. The primary goal of this conference was to identify critical sleep health recommendations for older adults. RESULTS: Essential recommendations aimed at promoting sleep health in older adults focus on light exposure, physical activity, meal timing, environmental conditions, and sleep schedules. Suggestions for promoting sleep health behavior change in older adults include tailored messaging and community support. CONCLUSIONS: There are unique challenges and opportunities around promoting sleep health in older adults, efforts toward change should include individual, community, and societal foci.

Barriers and Facilitators of Evidence-Based Psychotherapies for Chronic Pain in Adults: A Systematic Review.

Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) have demonstrated effectiveness for improving outcomes in chronic pain. These evidence-based psychotherapies (EBPs) remain underutilized in clinical practice, however. To identify research gaps and next steps for improving uptake of EBPs, we conducted a systematic review of patient-, provider-, and system-level barriers and facilitators of their use for chronic pain. We searched MEDLINE, Embase, PsycINFO, and CINAHL databases from inception through September 2022. Prespecified eligibility criteria included outpatient treatment of adults with chronic pain; examination of barriers and facilitators and/or evaluation of implementation strategies; conducted in the United States (US), United Kingdom (UK), Ireland, Canada or Australia; and publication in English. Two reviewers independently assessed eligibility and rated quality. We conducted a qualitative synthesis of results using a best-fit framework approach building upon domains of the Consolidated Framework for Implementation Research (CFIR). We identified 34 eligible studies (33 moderate or high quality), most (n = 28) of which addressed patient-level factors. Shared barriers across EBPs included variable patient buy-in to therapy rationale and competing responsibilities for patients; shared facilitators included positive group or patient-therapist dynamics. Most studies examining ACT and all examining MBSR assessed only group formats. No studies compared barriers, facilitators, or implementation strategies of group CBT to individual CBT, or of telehealth to in-person EBPs. Conceptual mismatches of patient knowledge and beliefs with therapy principles were largely analyzed qualitatively, and studies did not explore how these mismatches were addressed to support engagement. Future research on EBPs for chronic pain in real-world practice settings is needed to explore provider and system-level barriers and facilitators, heterogeneity of effects and uptake, and both effects and uptake of EBPs delivered in various formats, including group vs individual therapy and telehealth or asynchronous digital approaches. PERSPECTIVE: This systematic review synthesizes evidence on barriers and facilitators to uptake of cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based stress reduction for chronic pain. Findings can guide future implementation work to increase availability and use of evidence-based psychotherapies for treatment of chronic pain. REGISTRATION: PROSPERO number CRD42021252038.

A preliminary investigation of the new and revised symptoms of posttraumatic stress disorder in DSM-5.

BACKGROUND: Research has shown that posttraumatic stress disorder (PTSD) is highly comorbid with other mental disorders. The DSM-5 marks an opportunity to increase the differential diagnosis of PTSD by emphasizing symptoms that are specific to PTSD and deemphasizing symptoms that are common to many mental disorders. This study analyzes the new and revised PTSD symptom criteria proposed for DSM-5 by examining their relations with diagnoses and measures of PTSD. In addition, we report the specificity of DSM-5 symptoms with PTSD compared to depressive disorders and substance use. METHODS: This study utilized pre- and postdeployment data collected from a sample of 213 National Guard Brigade Combat Team soldiers who were deployed to Iraq. Questionnaire data were collected pre- and postdeployment and interview data were collected postdeployment. Scales to measure the DSM-5 symptoms were created using structural analyses and were correlated with interview and self-report measures of PTSD, depression, and substance use. RESULTS: The DSM-5 symptom of anger shows the most increase from pre- to postdeployment in participants diagnosed with PTSD. In addition, this scale showed the strongest relation to PTSD and showed some evidence of specificity. Other symptom scales, including those measuring negative expectations and aggressive behaviors, showed equivalent correlations with PTSD, depression, and substance use. CONCLUSIONS: It will be important to continue studying the specificity of anger with PTSD. Several of the other new and revised DSM-5 symptoms appear to be nonspecific, and it is unlikely that their inclusion in the diagnostic criteria for PTSD will improve differential diagnosis.

Provider perspectives of implementation of an evidence-based insomnia treatment in Veterans Affairs (VA) primary care: barriers, existing strategies, and future directions.

BACKGROUND: Cognitive behavioral therapy for insomnia (CBT-I) is a highly effective nonpharmacological intervention that is widely considered the gold standard for insomnia treatment. Insomnia is a prevalent and debilitating public health concern. Up to one third of the general population struggles with chronic insomnia, greatly increasing the risk for chronic pain and inflammation, depression and suicide, and cognitive decline. Over the last 10 years, the Veterans Health Administration (VHA) evidence-based psychotherapy training program has trained nearly 1000 providers to deliver CBT-I in hospitals and clinics nationwide. Despite increased access, most patients with insomnia receive sleeping medications instead of CBT-I. This is particularly concerning for vulnerable populations, like older adults, who may be at increased risk of harms from medications. The goal of this study was to obtain a broad range of perspectives on CBT-I implementation from providers who commonly utilize and deliver CBT-I. This work identifies barriers and successful strategies used to overcome these barriers to guide future implementation efforts promoting evidence-based sleep care. METHODS: Semi-structured interviews, using the Consolidated Framework for Implementation Research (CFIR) as a guide, were conducted with 17 providers from five Veterans Affairs (VA) facilities (8 primary care physicians, 4 primary care psychologists, and 5 CBT-I coordinators). We used a thematic analysis approach in which common ideas were identified across interviews and then grouped into larger conceptual themes. Data were concurrently collected and analyzed with rapid assessment process (RAP) techniques. RESULTS: Findings suggested implementation barriers and facilitators related to the CFIR constructs of intervention characteristic (e.g., providers unfamiliar with primary evidence of CBT-I effectiveness), inner setting (e.g., sleep as a low relative priority in primary care), and outer setting (e.g., lack of external incentives for increasing CBT-I use), as well as several successful strategies, including use of local champions and supportive opinion leaders. CONCLUSIONS: These findings suggest promising opportunities to improve implementation of CBT-I, especially at facilities with less well-established CBT-I programs. Formal implementation trials are needed to systematically determine the real-world impact of strategies such as enlisting CBT-I champions, informing opinion leaders about CBT-I services, and promoting network weaving among primary care, mental health, and sleep clinics.

Clinical Utility of the Inventory of Depression and Anxiety Symptoms (IDAS).

Depressive and anxiety disorders are severe and disabling conditions that result in substantial cost and global societal burden. Accurate and efficient identification is thus vital to proper diagnosis and treatment of these disorders. The Inventory of Depression and Anxiety Symptoms (IDAS) is a reliable and well-validated measure that provides dimensional assessment of both mood and anxiety disorder symptoms. The current study examined the clinical utility of the IDAS by establishing diagnostic cutoff scores and severity ranges using a large mixed sample (N = 5,750). Results indicated that the IDAS scales are good to excellent predictors of their associated Structured Clinical Interview for DSM-IV diagnoses. These findings were replicated using Diagnostic and Statistical Manual of Mental Disorders-Fifth edition(DSM-5) criteria assessed via the Mini-International Neuropsychiatric Interview. We provide three cutoff scores for each scale that can be used differentially depending on the goal of their use: screening, efficiency, or diagnosis confirmation. The identified severity ranges allow users to characterize individuals as mild, moderate, or severe, providing clinical information beyond diagnostic status. Finally, the 10-item IDAS Dysphoria scale and 20-item General Depression scale demonstrate strong ability to predict internalizing diagnoses and may represent an efficient way to screen for the presence of internalizing psychopathology.

A randomized controlled trial evaluating integrated versus phased application of evidence-based psychotherapies for military veterans with comorbid PTSD and substance use disorders.

OBJECTIVE: Recent clinical practice guidelines recommend the delivery of evidence-based psychotherapies for both substance use disorder (SUD) and posttraumatic stress disorder (PTSD) within the same treatment episode for patients with SUD/PTSD comorbidity. This randomized clinical trial evaluated the comparative effectiveness of integrating versus phasing evidence-based psychotherapies for SUD and PTSD among veterans with co-occurring SUD/ PTSD. METHOD: 183 veterans with DSM-IV PTSD and SUD at two VA Medical Centers were randomized to one of two psychotherapies during which Motivational Enhancement Therapy [MET] for SUD and Prolonged Exposure [PE] for PTSD were either phased or integrated throughout treatment. Primary outcomes as evaluated by blinded assessors were percent days with drug use or heavy drinking and PTSD symptomology. We hypothesized integrated MET/PE (n = 95) would yield better SUD and PTSD-related outcomes at posttreatment than phased MET/PE (n = 88). RESULTS: In intent-to-treat analyses (n=183), both treatment groups achieved clinically (d=0.46 - 1.06) and statistically significant reductions in SUD (p < 0.01) and PTSD (p < 0.01) symptomology; the time by treatment interactions were not significant. Post-hoc analyses could not confirm statistical non-inferiority; between-group effect sizes suggest a lack of clinically-meaningful differences between the two treatment approaches (d=0.08 - 0.27). CONCLUSIONS: Our hypothesis that integrated MET/PE would result in better outcomes than phased MET/PE across a range of PTSD and SUD measures was not supported; both strategies for combining two single-disorder treatments for co-occurring SUD/PTSD yielded significant symptom reduction.

Further validation of the IDAS: evidence of convergent, discriminant, criterion, and incremental validity.

The authors explicated the validity of the Inventory of Depression and Anxiety Symptoms (IDAS; D. Watson et al., 2007) in 2 samples (306 college students and 605 psychiatric patients). The IDAS scales showed strong convergent validity in relation to parallel interview-based scores on the Clinician Rating version of the IDAS; the mean convergent correlations were .51 and .62 in the student and patient samples, respectively. With the exception of the Well-Being Scale, the scales also consistently demonstrated significant discriminant validity. Furthermore, the scales displayed substantial criterion validity in relation to Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) mood and anxiety disorder diagnoses in the patient sample. The authors identified particularly clear and strong associations between (a) major depression and the IDAS General Depression, Dysphoria and Well-Being scales, (b) panic disorder and IDAS Panic, (c) posttraumatic stress disorder and IDAS Traumatic Intrusions, and (d) social phobia and IDAS Social Anxiety. Finally, in logistic regression analyses, the IDAS scales showed significant incremental validity in predicting several DSM-IV diagnoses when compared against the Beck Depression Inventory-II (A. T. Beck, R. A. Steer, & G. K. Brown, 1996) and the Beck Anxiety Inventory (A. T. Beck & R. A. Steer, 1990).