Implementation of evidence-based treatment for PTSD in Norway: clinical outcomes and impact of probable complex PTSD.

Background: Posttraumatic stress disorder (PTSD) is a long-lasting and debilitating psychological disorder that affects a large portion of the population. Treatments such as Cognitive therapy for PTSD (CT-PTSD) and Eye movement desensitization and reprocessing (EMDR) have been shown to be effective and cost-efficient in clinical trials, but uptake and evidence of positive outcomes in real-world clinical services are limited. Implementation efforts have been hampered by providers' concerns about the feasibility of trauma-focused treatments in more complex presentations (i.e. Complex PTSD). Objective: To evaluate the effectiveness of CT-PTSD and EMDR in a real-world setting, as implemented in Norwegian outpatient mental health clinics for adults, and investigate the impact of probable Complex PTSD status on treatment outcomes. Methods: Clinicians from 15 different outpatient clinics received training and supervision in EMDR or CT-PTSD as part of a national implementation project. 104 clinicians recruited and treated 196 participants with PTSD. Symptoms of PTSD, depression and anxiety were assessed session-by-session and used to estimate pre-post effect sizes. Mixed-models were employed to investigate the impact of complex PTSD. Results: Both EMDR and CT-PTSD were associated with significant reductions in PTSD symptoms, with large effect sizes. Probable Complex PTSD was associated with higher levels of symptoms before and after treatment but did not significantly impact the effectiveness of treatment. Conclusion: The use of evidence-based treatments for PTSD in routine clinical service is associated with good treatment outcomes, also for patients with Complex PTSD.

Antecedentes: El trastorno de estrés postraumático (TEPT) es un trastorno psicológico duradero y debilitante que afecta a una gran parte de la población. Se ha mostrado que los tratamientos como la Terapia cognitiva para el TEPT (CT-PTSD en su sigla en inglés) y la Desensibilización y Reprocesamiento por Movimiento ocular (EMDR en su sigla en inglés) son efectivos y rentables en ensayos clínicos, pero la uso y la evidencia de resultados positivos en los servicios clínicos del mundo real son limitadas. Los esfuerzos de implementación se han visto obstaculizados por las preocupaciones de los proveedores sobre la viabilidad de los tratamientos centrados en el trauma en presentaciones más complejas (es decir, TEPT complejo).Objetivo: Evaluar la efectividad de CT-PTSD y EMDR en un entorno del mundo real, tal como se implementa en las clínicas noruegas de salud mental ambulatorias para adultos, e investigar el impacto del probable TEPT complejo en los resultados del tratamiento.Métodos: Los clínicos de 15 clínicas ambulatorias diferentes recibieron capacitación y supervisión en EMDR o CT-PTSD como parte de un proyecto de implementación nacional. 104 clínicos reclutaron y trataron a 196 participantes con TEPT. Los síntomas de TEPT, depresión y ansiedad se evaluaron sesión a sesión y se usaron para estimar los tamaños del efecto antes y después. Se emplearon modelos mixtos para investigar el impacto del TEPT complejo.Resultados: Tanto EMDR como CT-PTSD se asociaron con reducciones significativas en los síntomas de TEPT, con tamaño de los efectos de gran magnitud. El TEPT complejo probable se asoció con niveles más altos de síntomas antes y después del tratamiento, pero no tuvo un impacto significativo en la efectividad del tratamiento.Conclusión: El uso de tratamientos basados ⁣⁣en la evidencia para el TEPT en el servicio clínico de rutina se asocia con buenos resultados del tratamiento, también para pacientes con TEPT complejo.

A stepped-wedge randomized trial investigating the effect of the Leadership and Organizational Change for Implementation (LOCI) intervention on implementation and transformational leadership, and implementation climate.

BACKGROUND: This study evaluates the Leadership and Organizational Change for Implementation (LOCI) strategy and its effect on implementation leadership, transformational leadership, and implementation climate. METHODS: A stepped wedge cluster randomized study design enrolling 47 first-level leaders from child- and adult-specialized mental health clinics within Norwegian health trusts across three cohorts. All therapists (n = 790) received training in screening of trauma exposure and posttraumatic stress, and a subgroup of therapists (n = 248) received training in evidence-based treatment methods for posttraumatic stress disorder (PTSD). First-level leaders and therapists completed surveys at baseline, 4, 8-, 12-, 16-, and 20-months assessing leadership and implementation climate. General linear mixed-effects models were used to investigate whether the LOCI strategy would lead to greater therapist-rated scores on implementation leadership, transformational leadership, and implementation climate. RESULTS: After introducing the LOCI strategy, there was a significant increase in therapist-rated implementation and transformational leadership and implementation climate. The increase was sustained at all measurement time points compared to non-LOCI conditions, which demonstrated a steady decrease in scores before LOCI. CONCLUSIONS: The LOCI strategy can develop better transformational and implementation leadership skills and contribute to a more positive implementation climate, which may enhance successful EBP implementation. Thus, LOCI can help leaders create an organizational context conducive for effective EBP implementation. TRIAL REGISTRATION: Retrospectively registered: ClinicalTrials NCT03719651 , 25th of October 2018. The trial protocol can be accessed from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6417075/ .

Good soldiers in implementation: validation of the Implementation Citizenship Behavior Scale and its relation to implementation leadership and intentions to use evidence-based practices.

BACKGROUND: Implementation citizenship behavior (ICB) describes extra-role behaviors performed by employees to support evidence-based practice (EBP) implementation. Such behaviors can be measured using the Implementation Citizenship Behavior Scale (ICBS), which divides ICB into two dimensions, namely helping others and keeping informed. The current study extends the use of the ICBS to a context outside the USA and adds to the literature by investigating how leader-perceived ICB relates to practitioner-perceived implementation leadership and practitioners' intentions to use EBPs. METHODS: Participants were 42 leaders and 152 practitioners in Norwegian mental health services implementing EBPs for post-traumatic stress disorder. Leaders rated each practitioner on ICB, and each practitioner rated their leader on implementation leadership and reported on their own intentions to use EBPs. The psychometric properties of the ICBS were assessed using confirmatory factor analysis and internal consistency reliabilities. The relationships between ICB, implementation leadership and intentions to use EBPs, were investigated through a series of bivariate correlation analyses and a path analysis of the total scales. RESULTS: The ICBS showed excellent psychometric properties. The hypothesized two-factor model provided an excellent fit to the data, and both subscales and the total scale were internally reliable. Leader-perceived ICB was positively and significantly correlated with both practitioner-perceived implementation leadership and practitioners' intentions to use EBPs. Correlations with intentions to use EBPs were stronger for the subscale of keeping informed than for the subscale of helping others. CONCLUSIONS: Results indicated that practitioners who rated their leader higher on implementation leadership received higher ICB ratings from their leader and reported higher intentions to use EBPs. The results provide evidence of a reciprocal social exchange relationship between leaders and practitioners during EBP implementation and a link to an important proximal implementation outcome (i.e., intentions to use EBPs). Results also suggest cultural differences in how ICB is perceived and relates to other phenomena. Scientific and practical implications are discussed. TRIAL REGISTRATION: Retrospectively registered in ClinicalTrials with ID NCT03719651 .

Testing the leadership and organizational change for implementation (LOCI) intervention in Norwegian mental health clinics: a stepped-wedge cluster randomized design study protocol.

BACKGROUND: Alignment across levels of leadership within an organization is needed for successful implementation of evidence-based practice. The leadership and organizational change for implementation (LOCI) intervention is a multi-faceted multilevel implementation strategy focusing on enhancing first-level general and implementation leadership while also engaging with organization upper management to develop an organizational climate for implementation. The aim of the project is to evaluate the effectiveness of LOCI in supporting the implementation of evidence-based treatment for PTSD in child- and adult-specialized mental health clinics in health trusts in Norway. METHODS: The study design is a stepped-wedge cluster randomized trial with enrollment of clinics in three cohorts. Executives, clinic leaders, and therapists will be asked to complete surveys assessing leadership and implementation climate. Surveys will be completed at baseline, 4, 8, 12, 16, and 20 months. Results from surveys will be shared with executives and clinic leaders to inform the subsequent creation of tailored leadership and climate development plans for enhanced implementation. Patients will complete surveys measuring traumatic events and post-traumatic stress symptoms during the therapy process. Therapy sessions will be audio or video recorded and scored for fidelity as part of training. DISCUSSION: This study aims to provide knowledge on how to improve leadership and organizational climate to enhance effective implementation of evidence-based treatments in mental health services. TRIAL REGISTRATION: The study has been registrated in ClinicalTrials with ID NCT03719651 .