The role of symptom accommodation in trauma-focused treatment engagement and response.

Although trauma-focused treatments (TFTs) are generally effective, not all patients improve. Symptom accommodation (i.e., altering one's behavior in response to another's symptoms) by loved ones may be particularly relevant to TFT treatment response and engagement. We examined the role of symptom accommodation by support persons (SPs) in veterans' PTSD treatment response, including the mediating role of treatment engagement and the moderating role of relationship strain. Veterans engaging in prolonged exposure or cognitive processing therapy and a loved one (N = 172 dyads) were sampled at two time points approximately four months apart. Measures of treatment engagement (i.e., highest session completed from the treatment protocol and homework completion) were obtained from hospital records. We found that relationship strain moderated the effect of symptom accommodation on treatment response, ∆R2 = .02. Specifically, Time 1 (T1) accommodation predicted poorer treatment response (i.e., Time 2 [T2] PTSD symptom severity, controlling for T1 symptoms) among veterans who reported below-average relationship strain only. Additionally, symptom accommodation was indirectly related to treatment response such that T1 accommodation predicted higher T2 PTSD symptom severity specifically through reduced homework completion, ß = .01. The findings suggest that attending to accommodating behaviors of veterans' supportive partners may be an important way to boost both engagement in and response to TFTs for PTSD.

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

The present study examined whether certain Veterans Health Administration (VHA) therapists have more success than others in keeping patients engaged in evidence-based psychotherapies for posttraumatic stress disorder (PTSD). Our objective was to use multilevel modeling to quantify the variability between therapists in two indicators of patient engagement: early dropout (i.e., < 3 sessions) and adequate dose (i.e., ≥ 8 sessions). The phenomenon of systematic variability between therapists in patients' treatment experience and outcomes is referred to as "therapist effects." The sample included the 2,709 therapists who provided individual cognitive processing therapy (CPT) or prolonged exposure (PE) to 18,461 veterans with PTSD across 140 facilities in 2017. Data were extracted from administrative databases. For CPT, therapist effects accounted for 10.9% of the variance in early dropout and 8.9% of the variance in adequate dose. For PE, therapist effects accounted for 6.0% and 8.8% of the variance in early dropout and adequate dose, respectively. Facility only accounted for an additional 1.1%-3.1% of the variance in early dropout and adequate dose. For CPT, patients' odds of receiving an adequate dose almost doubled, OR = 1.41/0.72 = 1.96, if they were seen by a therapist in the highest compared with the lowest retention decile. For PE, the odds of a patient receiving an adequate dose were 84% higher, OR = 1.38/0.75 = 1.84, when treated by a therapist in the highest compared with the lowest retention decile. Therapist skills and work environment may contribute to variability across therapists in early dropout and adequate dose.

Serving Veterans in their Communities: Evaluation of an Online Resource for Behavioral Health Care Providers.

Many veterans receive behavioral health care services from providers in their communities. The Community Provider Toolkit (the Toolkit) is a website developed by the National Center for PTSD and the Department of Veterans Affairs intended to provide community mental health care providers with key veteran-focused educational resources. This mixed-methods study examined the potential impact of the Toolkit on provider knowledge and behaviors. Sixty-four clinicians in the community who currently or plan to provide services to veterans were surveyed. The majority of providers found the website useful and easy to navigate. After visiting the site, many providers found additional online and educational resources that they would add to a hypothetical treatment plan. Forty-five providers completed a 1-month follow-up survey focused on use of the Toolkit. Results indicate that the Toolkit may be a valuable tool for increasing provider knowledge about veteran-specific resources.

Evaluation of an Implementation Intervention to Increase Reach of Evidence-Based Psychotherapies for PTSD in US Veterans Health Administration PTSD Clinics.

To evaluate an implementation intervention to increase the uptake, referred to as reach, of two evidence-based psychotherapies (EBP) for posttraumatic stress disorder (PTSD) in Veterans Health Administration (VHA) PTSD specialty clinics. The implementation intervention was external facilitation guided by a toolkit that bundled strategies associated with high EBP reach in prior research. We used a prospective quasi-experimental design. The facilitator worked with local champions at two low-reach PTSD clinics. Each intervention PTSD clinic was matched to three control clinics. We compared the change in EBP reach from 6-months pre- to post-intervention using Difference-in-Difference (DID) effect estimation. To incorporate possible clustering effects and adjust for imbalanced covariates, we used mixed effects logistic regression to model the probability of EBP receipt. Analyses were conducted separately for PTSD and other mental health clinics. 29,446 veterans diagnosed with PTSD received psychotherapy in the two intervention and six control sites in the two 6-month evaluation periods. The proportion of therapy patients with PTSD receiving an EBP increased by 16.98 percentage points in the intervention PTSD clinics compared with .45 percentage points in the control PTSD clinics (DID = 16.53%; SE = 2.26%). The adjusted odd ratio of a patient receiving an EBP from pre to post intervention was almost three times larger in the intervention than in the control PTSD clinics (RoR 2.90; 95% CI 2.22-3.80). EBP reach was largely unchanged in other (not PTSD specialty) mental health clinics within the same medical centers. Toolkit-guided external facilitation is a promising intervention to improve uptake of EBPs in VHA. Toolkits that pre-specify targets for clinic change based on prior research may enhance the efficiency and effectiveness of external facilitation. Trial registration ISRCTN registry identifier: ISRCTN65119065. Available at https://www.isrctn.com/search?q=ISRCTN65119065 .

Present-centered therapy (PCT) for post-traumatic stress disorder (PTSD) in adults.

BACKGROUND: Present-centered therapy (PCT) is a non-trauma, manualized psychotherapy for adults with post-traumatic stress disorder (PTSD). PCT was originally designed as a treatment comparator in trials evaluating the effectiveness of trauma-focused cognitive-behavioral therapy (TF-CBT). Recent trials have indicated that PCT may be an effective treatment option for PTSD and that patients may drop out of PCT at lower rates relative to TF-CBT. OBJECTIVES: To assess the effects of PCT for adults with PTSD. Specifically, we sought to determine whether (1) PCT is more effective in alleviating symptoms relative to control conditions, (2) PCT results in similar alleviation of symptoms compared to TF-CBT, based on an a priori minimally important differences on a semi-structured interview of PTSD symptoms, and (3) PCT is associated with lower treatment dropout as compared to TF-CBT. SEARCH METHODS: We searched the Cochrane Common Mental Disorders Controlled Trials Register, the Cochrane Library, Ovid MEDLINE, Embase, PsycINFO, PubMed, and PTSDpubs (previously called the Published International Literature on Traumatic Stress (PILOTS) database) (all years to 15 February 2019 search). We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished and ongoing trials. Reference lists of included studies and relevant systematic reviews were checked. Grey literature searches were also conducted to identify dissertations and theses, clinical guidelines, and regulatory agency reports. SELECTION CRITERIA: We selected all randomized clinical trials (RCTs) that recruited adults diagnosed with PTSD to evaluate PCT compared to TF-CBT or a control condition. Both individual and group PCT modalities were included. The primary outcomes of interest included reduced PTSD severity as determined by a clinician-administered measure and treatment dropout rates. DATA COLLECTION AND ANALYSIS: We complied with the Cochrane recommended standards for data screening and collection. Two review authors independently screened articles for inclusion and extracted relevant data from eligible studies, including the assessment of trial quality. Random-effects meta-analyses, subgroup analyses, and sensitivity analyses were conducted using mean differences (MD) and standardized mean differences (SMD) for continuous data or risk ratios (RR) and risk differences (RD) for dichotomous data. To conclude that PCT resulted in similar reductions in PTSD symptoms relative to TF-CBT, we required a MD of less than 10 points (to include the 95% confidence interval) on the Clinician-Administered PTSD Scale (CAPS). Five members of the review team convened to rate the quality of evidence across the primary outcomes. Any disagreements were resolved through discussion. Review authors who were investigators on any of the included trials were not involved in the qualitative or quantitative syntheses. MAIN RESULTS: We included 12 studies (n = 1837), of which, three compared PCT to a wait-list/minimal attention (WL/MA) group and 11 compared PCT to TF-CBT. PCT was more effective than WL/MA in reducing PTSD symptom severity (SMD -0.84, 95% CI -1.10 to -0.59; participants = 290; studies = 3; I² = 0%). We assessed the quality of this evidence as moderate. The results of the non-inferiority analysis comparing PCT to TF-CBT did not support PCT non-inferiority, with the 95% confidence interval surpassing the clinically meaningful cut-off (MD 6.83, 95% CI 1.90 to 11.76; 6 studies, n = 607; I² = 42%). We assessed this quality of evidence as low. CAPS differences between PCT and TF-CBT attenuated at 6-month (MD 1.59, 95% CI -0.46 to 3.63; participants = 906; studies = 6; I² = 0%) and 12-month (MD 1.22, 95% CI -2.17 to 4.61; participants = 485; studies = 3; I² = 0%) follow-up periods. To confirm the direction of the treatment effect using all eligible trials, we also evaluated PTSD SMD differences. These results were consistent with the primary MD outcomes, with meaningful effect size differences between PCT and TF-CBT at post-treatment (SMD 0.32, 95% CI 0.08 to 0.56; participants = 1129; studies = 9), but smaller effect size differences at six months (SMD 0.17, 95% CI 0.05 to 0.29; participants = 1339; studies = 9) and 12 months (SMD 0.17, 95% CI 0.03 to 0.31; participants = 728; studies = 5). PCT had approximately 14% lower treatment dropout rates compared to TF-CBT (RD -0.14, 95% CI -0.18 to -0.10; participants = 1542; studies = 10). We assessed the quality of this evidence as moderate. There was no evidence of meaningful differences on self-reported PTSD (MD 4.50, 95% CI 3.09 to 5.90; participants = 983; studies = 7) or depression symptoms (MD 1.78, 95% CI -0.23 to 3.78; participants = 705; studies = 5) post-treatment. AUTHORS' CONCLUSIONS: Moderate-quality evidence indicates that PCT is more effective in reducing PTSD severity compared to control conditions. Low quality of evidence did not support PCT as a non-inferior treatment compared to TF-CBT on clinician-rated post-treatment PTSD severity. The treatment effect differences between PCT and TF-CBT may attenuate over time. PCT participants drop out of treatment at lower rates relative to TF-CBT participants. Of note, all of the included studies were primarily designed to test the effectiveness of TF-CBT which may bias results away from PCT non-inferiority.The current systematic review provides the most rigorous evaluation to date to determine whether PCT is comparably as effective as TF-CBT. Findings are generally consistent with current clinical practice guidelines that suggest that PCT may be offered as a treatment for PTSD when TF-CBT is not available.

Community Clinicians and the Veterans Choice Program for PTSD Care: Understanding Provider Interest During Early Implementation.

BACKGROUND: In 2014, the Department of Veterans Affairs (VA) implemented the Veterans Choice Program (VCP) to provide reimbursement for community-based care to eligible veterans. Inadequate networks of participating providers may impact the utility of VCP for veterans with posttraumatic stress disorder (PTSD), a complex condition occurring at lower frequency among civilians. OBJECTIVES: To compare characteristics and attitudes of community-based primary care and mental health providers reporting interest or no interest in VCP participation during early implementation; and to examine perceptions and experiences of VCP among "early adopters." RESEARCH DESIGN: Cross-sectional surveys with 2 samples: a stratified random sample of mental health and primary care prescribers and psychotherapists drawn from state licensing boards (Community Sample); and a stratified random sample of prescribers and psychotherapists identified as VCP-authorized providers (VCP-Authorized). SUBJECTS: Five hundred fifty-three respondents in the Community Sample and 115 in the VCP-Authorized (total, n=668; 21.1% response). MEASURES: Surveys assessed provider and practice characteristics, attitudes to VA and VCP, and experiences and satisfaction with the VCP; an open-ended survey item assessed providers' reasons for interest or lack of interest in VCP participation. RESULTS: Few providers reported VCP participation during this period. Interest in VCP participation was associated across provider groups with factors including being a veteran and receiving VA reimbursement; currently providing treatment for PTSD was associated with interest in VCP participation among psychotherapists, but not prescribers. CONCLUSIONS: Developing networks of VCP providers to serve Veterans with PTSD is likely to require targeting more receptive provider groups, reducing barriers to participation, and more effectively communicating the value of VCP participation to providers.

Symptom Presentation and Prescription of Sleep Medications for Veterans With Posttraumatic Stress Disorder.

This study tested whether sleep medications prescribed to veterans diagnosed with posttraumatic stress disorder (PTSD) are being targeted to patients who report more severe insomnia or nightmares. Secondary analysis of survey and pharmacy data was conducted in samples of veterans from two periods: from 2006 to 2008 and from 2009 to 2013. Logistic regression tested associations between self-reported insomnia and nightmare severity, and being prescribed trazodone, prazosin, zolpidem, and benzodiazepines, controlling for PTSD severity and other covariates. In both samples, insomnia severity independently predicted trazodone receipt, and nightmare severity independently predicted prazosin receipt. In the later study, insomnia severity predicted receipt of zolpidem. Veterans in the later sample were more likely to receive trazodone, prazosin, and non-benzodiazepine hypnotics, and less likely to receive benzodiazepines than those in the earlier sample. Further research is needed to evaluate and optimize pharmacological and psychosocial treatments for sleep problems among veterans with PTSD.

Maintenance and Reach of Exposure Psychotherapy for Posttraumatic Stress Disorder 18 Months After Training.

This study examined aspects of clinicians' work environment that facilitated sustained use of prolonged exposure (PE) therapy. Surveys were completed by 566 U.S. Department of Veterans Affairs clinicians 6 and 18 months after intensive training in PE. The number of patients treated with PE at 18 months (reach) was modeled as a function of clinician demographics, clinician beliefs about PE, and work context factors. There were 342 clinicians (60.4%) who used PE at 6 and 18 months after training, 58 (10.2%) who used PE at 18 but not 6 months, 95 (16.7%) who used PE at 6 but not 18 months, and 71 (12.5%) who never adopted PE. Median reach was 12% of clinicians' appointments with patients with posttraumatic stress disorder. Reach was predicted by flow of interested patients (incident response ratio [IRR] = 1.21 to 1.51), PE's perceived effectiveness (IRR = 1.04 to 1.31), working in a PTSD specialty clinic (IRR = 1.06 to 1.26), seeing more patients weekly (IRR = 1.04 to 1.25), and seeing fewer patients in groups (IRR = 0.83 to 0.99). Most clinicians trained in PE sustained use of the treatment, but on a limited basis. Strategies to increase reach of PE should address organizational barriers and patient engagement.

Context Matters: Team and Organizational Factors Associated with Reach of Evidence-Based Psychotherapies for PTSD in the Veterans Health Administration.

Evidence-based psychotherapies for PTSD are often underused. The objective of this mixed-method study was to identify organizational and clinic factors that promote high levels of reach of evidence-based psychotherapies for PTSD 10 years into their dissemination throughout the Veterans Health Administration. We conducted 96 individual interviews with staff from ten outpatient PTSD teams at nine sites that differed in reach of evidence-based psychotherapies for PTSD. Major themes associated with reach included clinic mission, clinic leader and staff engagement, clinic operations, staff perceptions, and the practice environment. Strategies to improve reach of evidence-based psychotherapies should attend to organizational and team-level factors.

Peer Support and Outcome for Veterans with Posttraumatic Stress Disorder (PTSD) in a Residential Rehabilitation Program.

This observational study aims to determine the characteristics of peer support that change attitudes toward recovery and PTSD symptom severity. The study respondents were a sample of 55 VA patients who were residents at a residential rehabilitation program for PTSD where they were the recipients of peer support. Veterans perceived greater support from other veterans (mean = 4.04 on 1-5 scale, SD = 0.78) than from any other source. Greater perceived support from the peer support provider, other veterans and mental health staff was associated with improvements from intake to discharge in recovery attitudes. Greater perceived support from other veterans and mental health staff was associated with an improvement in PTSD symptoms. Results from this study suggest that positive perceptions of peer support favorably influences attitudes toward recovery, from PTSD, in veterans who are the recipients of such support.

Participatory System Dynamics Modeling: Increasing Stakeholder Engagement and Precision to Improve Implementation Planning in Systems.

Implementation planning typically incorporates stakeholder input. Quality improvement efforts provide data-based feedback regarding progress. Participatory system dynamics modeling (PSD) triangulates stakeholder expertise, data and simulation of implementation plans prior to attempting change. Frontline staff in one VA outpatient mental health system used PSD to examine policy and procedural "mechanisms" they believe underlie local capacity to implement evidence-based psychotherapies (EBPs) for PTSD and depression. We piloted the PSD process, simulating implementation plans to improve EBP reach. Findings indicate PSD is a feasible, useful strategy for building stakeholder consensus, and may save time and effort as compared to trial-and-error EBP implementation planning.

The effect of medical comorbidities on male and female Veterans' use of psychotherapy for PTSD.

BACKGROUND: Posttraumatic stress disorder (PTSD) is associated with an increased risk for medical comorbidities that may prevent participation in psychotherapy. The present study investigated whether medical comorbidities were associated with lower initiation rates and fewer psychotherapy visits for PTSD. Because women are more likely to initiate psychotherapy after traumatic events, we also assessed whether relationships were weaker among women. METHODS: Veterans (N=482, 47% women) recently diagnosed with PTSD completed a survey assessing demographics, mood, functional status, and interest in treatment. Data on medical comorbidities, psychotherapy visits, antidepressant prescriptions, and service connection were assessed longitudinally through administrative files. Logistic and negative binomial regressions assessed associations between number of medical comorbidities in the 2 years before the survey and the initiation and number of psychotherapy visits for PTSD in the year after the survey. All analyses were stratified by sex and controlled for survey and administrative variables. RESULTS: The relationship between medical comorbidities and number of psychotherapy visits was stronger among women than among men. A greater number of medical comorbidities was associated with significantly fewer psychotherapy visits in the total sample [incidence rate ratio: 0.91; 95% confidence interval (CI): 0.83, 1.00] and among women (incidence rate ratio: 0.87; 95% CI: 0.77, 0.99), but not among men (95% CI: 0.75, 1.01). Medical comorbidities were not associated with the initiation of psychotherapy among men or women. CONCLUSIONS: Addressing medical comorbidities may help individuals remain in psychotherapy for PTSD. Medical comorbidities may play a larger role in the number of psychotherapy visits among women than men.

TELEMEDICINE VERSUS IN-PERSON DELIVERY OF COGNITIVE PROCESSING THERAPY FOR WOMEN WITH POSTTRAUMATIC STRESS DISORDER: A RANDOMIZED NONINFERIORITY TRIAL.

BACKGROUND: This study examined the effectiveness of telemedicine to provide psychotherapy to women with posttraumatic stress disorder (PTSD) who might be unable to access treatment. Objectives were to compare clinical and process outcomes of PTSD treatment delivered via videoteleconferencing (VTC) and in-person (NP) in an ethnically diverse sample of veteran and civilian women with PTSD. METHODS: A randomized controlled trial of Cognitive Processing Therapy, an evidence-based intervention for PTSD, was conducted through a noninferiority design to compare delivery modalities on difference in posttreatment PTSD symptoms. Women with PTSD, including 21 veterans and 105 civilians, were assigned to receive psychotherapy delivered via VTC or NP. Primary treatment outcomes were changes in PTSD symptoms in the completer sample. RESULTS: Improvements in PTSD symptoms in the VTC condition (n = 63) were noninferior to outcomes in the NP condition (n = 63). Clinical outcomes obtained when both conditions were pooled together (N = 126) demonstrated that PTSD symptoms declined substantially posttreatment (mean = -20.5, 95% CI -29.6 to -11.4) and gains were maintained at 3- (mean = -20.8, 95% CI -30.1 to -11.5) and 6-month followup (mean = -22.0, 95% CI -33.1 to -10.9. Veterans demonstrated smaller symptom reductions posttreatment (mean = -9.4, 95% CI -22.5 to 3.7) than civilian women (mean = -22.7, 95% CI -29.9 to -15.5. CONCLUSIONS: Providing psychotherapy to women with PTSD via VTC produced outcomes comparable to NP treatment. VTC can increase access to specialty mental health care for women in rural or remote areas.

Military sexual assault, gender, and PTSD treatment outcomes of U.S. Veterans.

This study examined whether gender and military sexual assault (MSA) were associated with psychiatric severity differences at initiation of treatment for posttraumatic stress disorder (PTSD) and whether MSA and gender predicted psychiatric treatment outcomes. Male (n = 726) and female (n = 111) patients were recruited from 7 U.S. Department of Veterans Affairs (VA) PTSD specialty intensive treatment programs and completed an intake survey; 69% (n = 574) of the participants completed a 4-month postdischarge follow-up survey. Measures included current PTSD and depressive symptoms, aggressive/violent behaviors, alcohol and drug use severity, and quality of life. Multilevel multivariate regression analyses were conducted to examine the main and interaction effects of gender and MSA on psychiatric treatment outcomes at 4-month follow-up, including demographics, baseline severity, hostile fire, and treatment length of stay. Baseline PTSD severity did not differ by gender or MSA status, but women had more severe depressive symptoms (d = 0.40) and less aggressive/violent symptoms (d = -0.46) than men. Gender, MSA status, and the interaction between gender and MSA did not predict treatment outcomes as hypothesized. Male and female veterans with and without MSA responded equally well to treatment in VA PTSD intensive treatment programs.

Training in the implementation of prolonged exposure therapy: provider correlates of treatment outcome.

The authors examined the degree to which provider characteristics, such as profession, treatment orientation, prior experience in treating posttraumatic stress disorder (PTSD), prior experience with prolonged exposure (PE) therapy, and attitudes about PE, were related to the clinical outcomes of veterans receiving care from clinicians participating in the national Department of Veterans Affairs (VA) PE Training Program. Positive patient outcomes were achieved by providers of every profession, theoretical orientation, level of clinical experience treating PTSD, and prior PE training experience. With 1,105 providers and 32 predictors (13 provider variables), power was at least 90% power to detect an effect of ß = .15. Profession was the only provider characteristic significantly related to outcomes, but the mean effect (a 2 point difference on the PTSD Checklist) was too small to be clinically meaningful. The results support the intensive training model used in the VA PE training program and demonstrate that clinicians of varying backgrounds can be trained using interactive training workshops followed by case consultation to deliver PE effectively.

Factors related to clinician attitudes toward prolonged exposure therapy for PTSD.

This study examines pretraining attitudes toward prolonged exposure (PE) therapy in a sample of 1,275 mental health clinicians enrolled in a national PE training program sponsored by the U.S. Department of Veterans Affairs. Attitudes assessed via survey included values placed on outcomes targeted by PE, outcome expectancies (positive expectancies for patient improvement and negative expectancies related to patient deterioration, clinician time burden, and clinician emotional burden), and self-efficacy for delivering PE. Results indicated that clinicians were receptive to learning PE and had positive expectations about the treatment, but expressed concerns that PE might increase patient distress. Responses varied by clinician characteristics with psychologists, clinicians working in specialty PTSD treatment settings (as opposed to those in mental health clinics and other clinic types), and those with a primarily cognitive-behavioral orientation expressing attitudes that were most supportive of learning and implementing PE across various indicators. Implications for addressing attitudinal barriers to implementation of PE therapy are discussed.

Predictors of anger treatment outcomes.

OBJECTIVE: This study investigated predictors of therapeutic outcomes for veterans who received treatment for dysregulated anger. METHOD: Data are from a randomized controlled trial investigating the effectiveness of video teleconferencing compared to in-person delivery of anger management therapy (AMT) among 125 military veterans. Multilevel modeling was used to assess 2 types of predictors (demographic characteristics and mental health factors) of changes in anger symptoms after treatment. RESULTS: Results showed that while veterans benefited similarly from treatment across modalities, veterans who received two or more additional mental health services and who had longer commutes to care showed the greatest improvement on a composite measure of self-reported anger symptoms. CONCLUSION: Results highlight that veterans with a range of psychosocial and mental health characteristics benefited from AMT, while those receiving the most additional concurrent mental health services had better outcomes.

Clinician Burnout and Effectiveness of Guideline-Recommended Psychotherapies.

Importance: Clinician burnout has been associated with clinician outcomes, but the association with patient outcomes remains unclear. Objective: To evaluate the association between clinician burnout and the outcomes of patients receiving of guideline-recommended trauma-focused psychotherapies for posttraumatic stress disorder (PTSD). Design, Setting, and Participants: This cohort study was set at the US Veterans Affairs Health Care System and included licensed therapists who provided trauma-focused psychotherapies and responded to an online survey between May 2 and October 8, 2019, and their patients who initiated a trauma-focused therapy during the following year. Patient data were collected through December 31, 2020. Data were analyzed from May to September 2023. Exposures: Therapists completing the survey reported burnout with a 5-point validated measure taken from the Physician Worklife Study. Burnout was defined as scores of 3 or more. Main Outcomes and Measures: The primary outcome was patients' clinically meaningful improvement in PTSD symptoms according to the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Patient dropout, therapist adherence, and session spacing was assessed through electronic health records. Multivariable random-effects logistic regression examined the association of therapist burnout and clinically meaningful improvement, adjusted for case-mix. Results: In this study, 165 of 180 (91.7%) therapists (89 [53.9%] female) completed the burnout measure and provided trauma-focused psychotherapies to 1268 patients (961 [75.8%] male) with outcome data. Fifty-eight (35.2%) therapists endorsed burnout. One third of patients (431 [34.0%]) met criterion for clinically meaningful improvement. Clinically meaningful improvement in PTSD symptoms was experienced by 120 (28.3%) of the 424 patients seen by therapists who reported burnout and 311 (36.8%) of the 844 patients seen by therapists without burnout. Burnout was associated with lower odds of clinically meaningful improvement (adjusted odds ratio [OR],0.63; 95% CI, 0.48-0.85). The odds of clinically meaningful improvement were reduced for patients who dropped out (OR, 0.15; 95% CI, 0.11-0.20) and had greater session spacing (OR, 0.80; 95% CI, 0.70-0.92). Therapist adherence was not associated with therapy effectiveness. Adjusting for dropout or session spacing did not meaningfully alter the magnitude of the association between burnout and clinically meaningful improvement. Conclusions and Relevance: In this prospective cohort study, therapist burnout was associated with reduced effectiveness of trauma-focused psychotherapies. Studying when and how burnout affects patient outcomes may inform workplace interventions.

Telemedicine: a cost-reducing means of delivering psychotherapy to rural combat veterans with PTSD.

BACKGROUND: Although effective psychotherapies for posttraumatic stress disorder (PTSD) exist, high percentages of Veterans in need of services are unable to access them. One particular challenge to providing cost-effective psychological treatments to Veterans with PTSD involves the difficulty and high cost of delivering in-person, specialized psychotherapy to Veterans residing in geographically remote locations. The delivery of these services via clinical videoteleconferencing (CVT) has been presented as a potential solution to this access to care problem. MATERIALS AND METHODS: This study is a retrospective cost analysis of a randomized controlled trial investigating telemedicine service delivery of an anger management therapy for Veterans with PTSD. The parent trial found that the CVT condition provided clinical results that were comparable to the in-person condition. Several cost outcomes were calculated in order to investigate the clinical and cost outcomes associated with the CVT delivery modality relative to in-person delivery. RESULTS: The CVT condition was significantly associated with lower total costs compared with the in-person delivery condition. The delivery of mental health services via CVT enables Veterans who would not normally receive these services access to empirically based treatments. Additional studies addressing long-term healthcare system costs, indirect cost factors at the patient and societal levels, and the use of CVT in other geographic regions of the United States are needed. CONCLUSIONS: The results of this study provide evidence that CVT is a cost-reducing mode of service delivery to Veterans with PTSD relative to in-person delivery.