Adapting Treatment Delivery to Improve Retention in Evidence-Based PTSD Treatment

背景：创伤后应激障碍(PTSD)的有效循证心理疗法， 如认知加工疗法(CPT)和长时间暴露(PE)疗法，具有以下能力- 以培训为基础的培训已经到位，并被要求在退伍军人健康中心向患有创伤后应激障碍的退伍军人提供 管理(VHA)。尽管他们很有效，但至少有三分之一的退伍军人会过早退出 创伤后应激障碍EBPS，这与较差的临床结果和更高的医疗保健利用率有关。 以每周三次或三次以上的集中形式提供创伤后应激障碍循证计划显示出了希望 用于增加治疗留存率。据推测，大规模EBP将是可行的。 意义/影响：目前的提案具有非常重要的意义：1)创伤后应激障碍患者EBP保留率保持在较低水平，2) 先前旨在改善创伤后应激障碍EBPS保留率的研究只产生了轻微的改善，3) 对创伤后应激障碍在VHA外的集中治疗的研究表明，VHA可以改善保留，但受到以下限制 观察性设计和缺乏对照组，以及4)创伤后应激障碍是一个高度优先的HSR&D领域。 创新：此CDA-2应用程序具有创新性：1)它通过增加 分娩频率，2)拟议的可行性随机临床试验(RCT)将通知随后的 IIR将在VHA中进行大规模PTSD EBPS的第一次随机对照试验，3)第一项研究 利益相关者的偏好、感知到的障碍和大规模创伤后应激障碍的促进者，以及4)大规模 创伤后应激障碍EBPS可提高创伤后应激障碍的治疗参与度，改善临床结果。 具体目标：目标1.通过与利益相关者的半结构化访谈进行定性探索 (退伍军人[n=16]、提供者[n=12]和管理人员[n=12])认识到的障碍和促进者 在VHA创伤后应激障碍专科诊所内实施和优先提供大规模创伤后应激障碍治疗 告知将在目标2试行的大规模创伤后应激障碍治疗方案的发展情况。 目标2a。进行试点实用随机临床试验(RCT；n=30)，以检查可行性和 大规模EBP创伤后应激障碍治疗(EBP-MASED)与创伤后应激障碍EBPS的可接受性比较 在退伍军人事务部创伤后应激障碍专科诊所提供(EBP-TAU)。此外，我们还将收集有关 满意度、完成率、出席率、创伤后应激障碍、抑郁和功能结果。 目标2b。通过对试点试验中的所有退伍军人进行定性访谈，进行总结性评估 (n=30)和(n=4)提供集中治疗以使量化的 并为未来的IIR进一步完善大规模创伤后应激障碍的治疗。 目标3a。描述从1)大量创伤后应激障碍EBP和2)PTSD EBP开始的全国退伍军人队列 陶先生。 目标3b。在开始治疗的退伍军人中，比较治疗完成率(即8个疗程) 在接受成批EBPS的人和接受EBP-TAU的人之间。 下一步/实施：在目标1中，我们将对以下人员进行半结构化定性访谈 退伍军人(n=16)、提供者(n=12)和管理人员(n=12)。社会认知理论与 实施研究的综合框架将为这些访谈和结果提供信息 通知我们在AIM 2a进行的飞行员试验。在目标2a中，我们将进行一项可行性随机对照研究，以比较群集性创伤后应激障碍 退伍军人事务部创伤后应激障碍专科诊所照常向创伤后应激障碍患者提供EBPS。在目标2b中，我们将利用半 在试点试验中对退伍军人和提供者进行结构化的定性访谈，以评估满意度 并识别对集中处理程序的附加修改。目标3a和3b将利用 弗吉尼亚州CDW。

Background: Effective evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), such as Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) therapy, have competency- based trainings in place and are mandated to be available to Veterans with PTSD in the Veterans Health Administration (VHA). Despite their effectiveness, at least a third of Veterans will prematurely drop out of PTSD EBPs, which is associated with poorer clinical outcomes and greater healthcare utilization. Delivery of PTSD EBPs in a massed format of three or more sessions weekly have demonstrated promise for increasing treatment retention. It is hypothesized that massed EBPs will be feasible. Significance/Impact: The current proposal is highly significant: 1) PTSD EBP retention remains low, 2) prior research aimed to improve retention in PTSD EBPs has yielded only modest improvements, 3) research on massed treatments for PTSD outside of VHA suggest improved retention, but is limited by observational design and lack of comparison groups, and 4) PTSD is a high priority HSR&D domain. Innovation: This CDA-2 application is innovative: 1) it adapts PTSD EBP delivery by increasing the frequency of delivery, 2) the proposed feasibility randomized clinical trial (RCT) will inform a subsequent IIR to conduct the first RCT of massed PTSD EBPs in VHA, 3) the first study to examine multiple stakeholders' preferences, and perceived barriers and facilitators of massed PTSD EBPs, and 4) massed PTSD EBPs may improve PTSD treatment engagement and improve clinical outcomes. Specific Aims: Aim 1. Qualitatively explore through semi-structured interviews with stakeholders' (Veterans [n=16], providers [n=12], and administrators [n=12]) perceived barriers and facilitators to implementation, and preferences for massed PTSD treatment delivery within VHA PTSD specialty clinics to inform the development of the massed PTSD treatment program to be piloted in Aim 2. Aim 2a. Conduct a pilot pragmatic randomized clinical trial (RCT; n=30) to examine the feasibility and acceptability of massed EBP PTSD treatments (EBP-massed) compared to PTSD EBPs as they are typically delivered (EBP-TAU) in a VA PTSD Specialty Clinic. In addition, we will gather preliminary data on satisfaction, completion rates, session attendance, and PTSD, depression, and functioning outcomes. Aim 2b. Conduct a summative evaluation via qualitative interviews with all Veterans in the pilot trial (n=30) and with providers (n=4) who delivered massed treatment to contextualize the quantitative findings and further refine massed PTSD treatments for a future IIR. Aim 3a. Characterize a national cohort of Veterans who begin 1) massed PTSD EBPs and 2) PTSD EBPs TAU. Aim 3b. Among Veterans who initiated treatment, compare treatment completion (i.e., 8 sessions) rates between those who received massed EBPs and those who received EBP-TAU. Next Steps/Implementation: In Aim 1, we will conduct semi-structured qualitative interviews with Veterans (n=16), providers (n=12), and administrators (n=12). Social Cognitive Theory and the Consolidated Framework for Implementation Research will inform these interviews and results will inform our pilot trial in Aim 2a. In Aim 2a, we will conduct a feasibility RCT to compare massed PTSD EBPs to PTSD EBPs delivered as usual in a VA PTSD Specialty Clinic. In Aim 2b, we will utilize semi- structured qualitative interviews with Veterans and providers in the pilot trial to evaluate satisfaction and identify additional modifications to the massed treatment program. Aim 3a and 3b will utilize the VA's CDW.