Using the Multiphase Optimization Strategy to Adapt Cognitive Processing Therapy

背景：在VHA的911事件后，三分之一的退伍军人患有创伤后应激障碍(PTSD)，以及 在那些开始接受认知加工治疗(CPT)的人中，高达70%的人在接受认知加工治疗之前就辍学了 足够的治疗剂量。不幸的是，过早退学的退伍军人可能永远不会得到最多 CPT的有效成分。因此，迫切需要使用经验方法来确定大多数 CPT的有效组成部分，使CPT可以改编成更简短的格式。这条线路的长期目标是 研究的重点是对患有创伤后应激障碍的退伍军人进行适应、测试和实施简短的循证治疗。这个 当前应用程序的总体目标是将CPT改编成简短、有效的格式。理由是 确定最有效的干预组件并只交付这些组件将使CPT 在更短的时间内交付，从而提高效率，减少因治疗不当而导致的辍学 回应，并确保退伍军人得到最有益的治疗部分，这将 显著提高他们的生活质量。 意义/影响：在这个项目完成后，我们预计将产生一个基于经验的、简要的 CPT的版本。这一贡献可能会改善患有创伤后应激障碍的退伍军人的临床实践 在较早的一届会议上最有效的成分，从而提高治疗和治疗的总体效果 减轻未经治疗的创伤后应激障碍的负面后果，如生产力下降、药物使用、晚年生活 身体残疾，生活质量下降，自杀风险增加。 创新：创伤后应激障碍治疗的现状是在专门的心理健康环境中进行漫长的心理治疗， 它很少被完整地交付。这项拟议的研究具有创新性，因为它将使用一部小说 受工程启发的框架，多阶段优化策略(MOST)，以有效地适应这一点 心理治疗变成了一种简短的形式。开发一个简短的、基于经验的CPT版本将开辟新的天地 对于创伤后应激障碍的治疗，通过将CPT扩展到治疗环境，在这些环境中，较长的治疗不是 可行。它还将为希望更短疗程的退伍军人提供有效的选择。 具体目标：具体目标1：使用高效的实验设计，确定五种CPT中的哪一种 成分对减轻创伤后应激障碍症状有重要意义。我们将测试每种方法的有效性 组件以及组件之间的每个双向交互。具体目标2：确定 组件的有效性。我们假设，影响将通过参与/坚持和变化来调节 在创伤后认知中。探索性目标1：确定组件有效性的调节变量。 方法：MOST是一个受工程启发的创新框架，它使用优化试验来 评估多组分干预措施中各个干预组件的性能，例如 CPT。在社会变革管理计划框架的指导下，拟议项目的目标是从经验上为一个缩写的 CPT版本通过高效的部分析因设计。在两家VAMC工作的退伍军人(N=270) 符合最低限度纳入/排除标准的严重创伤后应激障碍症状将随机接受一个或 更多CPT组件。该设计将测试每个组件和每个双向的有效性 临床医生应用创伤后应激障碍症状减轻来衡量组件之间的相互作用 6个月的DSM-5(CAPS-5)创伤后应激障碍评定量表。 执行/下一步：在完成这些目标后，我们的预期结果是经过调整的， CPT的缩写版本，由干预的最有效要素组成。改编版 干预措施将为未来的大规模、全功率有效性试验做好准备。适应性干预 可通过退伍军人协会CPT培训计划轻松传播，并将对健康产生积极影响 以及患有创伤后应激障碍的退伍军人的福祉。

Background: One third of post-9/11 Veterans in VHA suffer from posttraumatic stress disorder (PTSD), and among those who initiate Cognitive Processing Therapy (CPT), up to 70% drop out before receiving an adequate dose of treatment. Unfortunately, Veterans who drop out prematurely may never receive the most effective components of CPT. Thus, there is an urgent need to use empirical approaches to identify the most effective components of CPT, so that CPT can be adapted into a briefer format. The long-term goal of this line of research is to adapt, test, and implement brief, evidence-based treatment for Veterans with PTSD. The overall objective of the current application is to adapt CPT into a brief, effective format. The rationale is that identifying the most effective intervention components and delivering only those components will make CPT deliverable in a shorter timeframe, thus improving efficiency, reducing drop-out related to poor treatment response, and ensuring that Veterans receive the most beneficial components of treatment, which will significantly improve their quality of life. Significance/Impact: Upon completion of this project, we expect to have produced an empirically-based, brief version of CPT. This contribution is likely to improve clinical practice for Veterans with PTSD by providing the most effective components at an earlier session, thus increasing the overall effectiveness of treatment and mitigating the negative consequences of untreated PTSD, such as lost productivity, substance use, later-life physical disability, reduced quality of life, and increased risk of suicide. Innovation: The status quo for PTSD treatment is lengthy psychotherapy in a specialty mental health setting, which is rarely delivered in its entirety. The proposed research is innovative because it will use a novel engineering-inspired framework, the multiphase optimization strategy (MOST), to adapt this effective psychotherapy into a brief format. Developing a brief, empirically-based version of CPT will open new horizons for PTSD treatment by expanding CPT access to treatment settings where lengthier treatments are not feasible. It will also provide effective options for Veterans who desire a briefer treatment course. Specific Aims: Specific Aim 1: Using a highly efficient experimental design, identify which of five CPT components contribute meaningfully to reduction in PTSD symptoms. We will test the effectiveness of each component and each two-way interaction between components. Specific Aim 2: Identify mediators of component effectiveness. We hypothesize that effects will be mediated by engagement/adherence and change in posttraumatic cognitions. Exploratory Aim 1: Identify moderators of component effectiveness. Methodology: The MOST is an innovative engineering-inspired framework that uses an optimization trial to assess the performance of individual intervention components within a multicomponent intervention such as CPT. Guided by the MOST framework, the goal of the proposed project is to empirically inform an abbreviated version of CPT via a highly efficient fractional factorial design. Veterans (N = 270) at two VAMCs with clinically significant PTSD symptoms who meet minimal inclusion/exclusion criteria will be randomized to receive one or more CPT components. This design will test the effectiveness of each component and each two-way interaction between components, as measured by PTSD symptom reduction on the Clinician-administered PTSD scale for DSM-5 (CAPS-5) across six months of follow-up. Implementation/Next Steps: Upon completion of these aims, our expected outcome is an adapted, abbreviated version of CPT that consists of the most effective elements of the intervention. The adapted intervention will be primed for a future large scale, fully powered effectiveness trial. The adapted intervention can be easily disseminated through the VA CPT training program and will have a positive impact on the health and wellbeing of Veterans with PTSD.