Abstract
Objective:
This observational study examined the association between the degree of adoption of two evidence-based psychotherapies, Prolonged Exposure and Cognitive Processing Therapy and patient outcomes in 39 residential posttraumatic stress disorder (PTSD) treatment programs in the Department of Veterans Affairs. We predicted that higher rates of adoption would be associated with better outcomes.
Method:
Providers (N=171) completed a qualitative interview and quantitative survey concerning their level of adoption of Prolonged Exposure delivered on an individual basis and Cognitive Processing Therapy delivered in individual and/or group formats.
Results:
Veterans (N=2,834) completed measures of PTSD symptoms and functioning at intake, discharge, and four-month post-completion of the program.
Conclusions:
Although there were moderate to large effects across all programs, programs that utilized Prolonged Exposure and Cognitive Processing Therapy with most or all their patients were not associated with greater reductions in PTSD or depression symptoms, or alcohol use than programs that do not utilize Prolonged Exposure or Cognitive Processing Therapy. Implications for assessing and potentially improving outcomes for veterans seeking care for PTSD are discussed.
Residential treatment for posttraumatic stress disorder (PTSD) was the first specialized treatment program for PTSD in the Department of Veterans Affairs (VA), starting in the 1980’s (1). When these programs were developed, there was a general expectation that the combination of communal experience with fellow veterans and intensive therapies would lead to increased efficacy over individual psychotherapy and medication management models (2). However, over time, informal empirical studies (3, 4) and more rigorous empirical investigations (5–8) revealed poor to modest outcomes.
Beginning in 2006, the VA initiated national training programs for mental health providers to enhance veterans’ access to two evidence-based psychotherapies (EBPs) for PTSD (9): Cognitive Processing Therapy (10) and Prolonged Exposure (11). Both of these treatments are considered first-line, trauma-focused EBPs for PTSD (12, 13). VA mandated that all sites of care must offer access to one or both Prolonged Exposure and Cognitive Processing Therapy either in-person, via tele-mental health, or referral to non-VA care.
The national training initiatives in Prolonged Exposure and Cognitive Processing Therapy offered an opportunity to improve services for veterans with severe, chronic PTSD in residential care. Two studies in residential programs found that patients who received Cognitive Processing Therapy had improvements pre-to post-treatment (14, 15). Chard et al. (15) found that post-Cognitive Processing Therapy, nearly 60% of veterans who served in Iraq and Afghanistan and 40% of veterans who served in Vietnam no longer met PTSD diagnostic criteria. In Chard et al. (14), 42 veterans with comorbid PTSD and Traumatic Brain Injury completed a residential program that was augmented with a modification of Cognitive Processing Therapy. There was a large effect size from pre-to post-treatment for PTSD and depression. However, neither investigation had a comparison group. In one study that did (16), veterans treated following program-wide implementation of Cognitive Processing Therapy were compared to a historical control group of those treated in the program prior to implementation. Veterans who received Cognitive Processing Therapy had greater symptom improvement relative to those who did not. The effect sizes for depression and psychological distress were small and moderate respectively, while the effects for PTSD were not initially significant, but then improved over time.
We conducted a five-year mixed-methods longitudinal investigation of the use of Prolonged Exposure and Cognitive Processing Therapy in VA residential programs (17, 18). EBP adoption data have been reported from the first two years of the study. Although many providers received VA training, use of PE in these programs ranged from no usage to only select patients receiving the treatment. In contrast, Cognitive Processing Therapy adoption ranged from no use, to use of only one aspect (e.g., specific worksheets), to strict manual adherence with all patients.
In this study, in collaboration with the VA’s Northeast Program Evaluation Center (NEPEC), which performs national program evaluation of mental health services including VA’s PTSD clinical programs, the effects of Prolonged Exposure and Cognitive Processing Therapy adoption at the program level were examined on patient outcomes at the program level in a naturalistic sample of veterans receiving VA residential PTSD treatment across the U.S. Given that the evidence supporting the use of Prolonged Exposure and Cognitive Processing Therapy is based on outpatients, the generalizability to residential settings is unknown. In a study of veterans who received Cognitive Processing Therapy, outpatients reported lower PTSD symptoms at both pre-and post-treatment compared with residential patients (19). However, based on the evidence showing that Prolonged Exposure and Cognitive Processing Therapy are effective treatments (13), as well as the research showing positive outcomes of Cognitive Processing Therapy in individual programs (14–16), we predicted that patients in programs that used Cognitive Processing Therapy and Prolonged Exposure more regularly would have better patient outcomes.
Method
This study was exempted for review by the Yale Human Research Protection Program, and approved by the VA Connecticut Health Care System’s Institutional Review Board.
Procedure
Data presented in this paper are part of a larger study on the implementation of two EBPs for PTSD in VA residential treatment programs (17, 18). All programs providing outcome data to NEPEC were invited to participate. Of the 48 VA residential PTSD programs, 39 who reported outcome data to NEPEC were surveyed as part of this study. No significant differences were found between those who participated and those who did not with regard to numbers of beds or full-time employees, and the average length of stay. During our investigation, NEPEC changed two key aspects of their outcome monitoring, using different measures and adding an additional follow-up point collection immediately after discharge. Therefore, only data from the final year of collection (2015) were used in the analyses.
Participants
Programs and Providers.
Of the 214 providers approached in the larger investigation, 171 (80%) participated in this wave of data collection (Fiscal Year 2015). Twenty-five providers (11.7%) in the original recruitment sample had retired or left their position and 18 (8.4%) did not respond to recruitment attempts. Of the providers who participated, the majority were White (n=141; 86.5%). Their mean age was 44.57±10.88. The primary professions represented included psychologists (n=76; 46.9%), social workers (n=61; 37.7%), psychiatrists (n=13; 8%), nurses (n=5; 3.1%) or others (n=7; 4.3%).
Veterans.
Out of 4,153 veterans who received residential PTSD care at one of the 39 programs in FY 2015, 3,029 (73%) had NEPEC evaluation data and completed the civilian version of the PTSD Symptom Checklist (PCL) (20) at treatment entry. Of the 3,029 Residential Rehabilitation Treatment Program (RRTP) participants who completed the PCL at treatment entry, 2,447 completed the PCL at program discharge, and 784 completed it four-month post-discharge. The total N was 2,834 participants who had two or more observations, and one of them had to be at treatment entry. For participants with more than one episode of care during the observation period, we examined the first episode of care for which the participant completed at least two PCLs.
Baseline PTSD symptom severity on the PCL did not differ between veterans who completed discharge and follow-up (M=58.47±13.05) and veterans who did not (M=58.54±11.96); t=0.18, df=4,151, p= 0.86, ns, nor were there significant differences on any other clinical measure. There were minor demographic differences between the veterans included in the study and those excluded for missing data. Participants were slightly younger (M=45.35±13.40 vs. M=46.99±13.51), t=3.49, df=4,151, p < 0.01. They were also more likely to have served in the wars in Iraq or Afghanistan (55.9% vs. 49.2%, p < 0.01), be male (89.2% vs. 86.6%, p=0.02), be classified as “other” race (10.7% vs. 7.5%, p < 0.01), and were less likely to be classified as Black (23.0% vs. 27.1%, p < 0.01). The study sample, therefore, is generally representative of the entire population served in the VA RRTPs.
Measures
NEPEC collects pre-post measures for all VA PTSD residential treatment programs at intake, discharge, and four-months post-discharge. Clinical data, in addition to PTSD symptom severity, included length of stay, alcohol and substance use, and distress.
The PCL, a 17-item self-report measure based on DSM-IV criteria, was used to measure PTSD symptoms. Veterans rated the extent to which they were bothered by each symptom during the past month on a 5-point scale ranging from 1=Not at all to 5=Extremely.
The Kessler Psychological Distress Scale (K6) (21) is an abbreviated version of the K10, a widely used measure of distress. It assesses, over the past 30 days, how often the person felt nervous, hopeless, restless or fidgety, so depressed that nothing can cheer them up, that everything was an effort, and feeling worthless on a 5-point Likert scale.
The Brief Addiction Monitor (BAM) (22) is a 17-item, multi-dimensional scale designed to assess frequency of substance (alcohol and drug) use. It includes both symptom and functional outcomes. We used the three items that sum the total amount of substances used in the past 30 days (alcohol, illegal drugs and prescribed medication) that are included in NEPEC’s outcome monitoring, coded as 0 (0 days), 1 (1–3 days), 2 (4–8 days), 3 (9–15 days), and 4 (16–30 days).
Participants reported their satisfaction at discharge with attaining their recovery goals and with the care they received. Response options ranged from 1=Not at all satisfied to 5=Completely satisfied.
EBP Adoption Codes.
Providers completed a web-based survey and semi-structured telephone interview on their use of Prolonged Exposure and Cognitive Processing Therapy. Detailed descriptions of the survey and interview guide are reported elsewhere (23). Using the adoption of Prolonged Exposure and Cognitive Processing Therapy codes we established in earlier waves of data collection (18, 24), we coded the level of adoption of Cognitive Processing Therapy and Prolonged Exposure in these programs for FY 2015. Six levels of adoption were coded for both Prolonged Exposure and Cognitive Processing Therapy: (one) the EBP was not adopted; (two) some elements of the EBP were offered; (three) the EBP was offered on a selective individual basis; (four) different treatment “tracks” were developed and those in a particular track received the EBP; (five) full EBP protocol was given to all patients; and (six) EBP was de-adopted.
This involved an interview and independent process by two licensed clinical psychologists with training in EBPs. JC and VS independently reviewed surveys and interview transcripts to determine what treatments were being offered and provider report of the percentages of patients receiving Prolonged Exposure and the percentage of patients receiving Cognitive Processing Therapy; established tentative codes (separately); discussed coding with one another and reached consensus when discrepancies existed and verified coding with survey data. For the purposes of these analyses, we then collapsed the six categories for both Prolonged Exposure and Cognitive Processing Therapy into three categories, combining Prolonged Exposure and Cognitive Processing Therapy adoption: little to no adoption of Prolonged Exposure or Cognitive Processing Therapy; some adoption of Prolonged Exposure or Cognitive Processing Therapy/adoption for select patients; and high adoption, with most to all elements of Prolonged Exposure or Cognitive Processing Therapy adopted or most to all patients receiving Prolonged Exposure or Cognitive Processing Therapy.
In an attempt to corroborate our self-report quantitative measure of Prolonged Exposure and Cognitive Processing Therapy use, we compared it to contemporaneous patient-level receipt of EBPs for PTSD using electronic medical record templates mandated for EBP documentation in FY15. Agreement between therapist self-reported EBP delivery and patient receipt of EBT as measured by progress note templates was good (r=.69 to .82) (25).
Data Analysis
Analyses were conducted using SAS version 9.4. First, we compared all the three adopter groups’ characteristics at time of admission, using χ2 for categorical variables and ANOVA for continuous variables and Tukey tests for post hoc comparisons. Variables for which there was a significant baseline difference were entered as covariates into the longitudinal data analysis model. A linear mixed model (PROC MIXED) was used to examine symptom change in a model defined by adoption level, time, and time*adoption level controlling for baseline symptom score and baseline group differences. Time was defined as categorical (i.e., discharge and follow-up, due to variation in time between intake and discharge at each RRTP program). Random effects in the model included Site (the effect of each RRTP program) and Individuals who were nested within sites that were nested within implementation group. Last, due to the different proportions in the return rates of NEPEC surveys among the three experimental groups, and the fact that the N for the entire population is known (all PTSD RRTP users in FY15) we have computed population weights corrections. These weights were then entered into the analyses to account for this bias.
Results
In FY 2015, eight programs reported little to no Prolonged Exposure or Cognitive Processing Therapy adoption (n=613 veterans), nine reported some adoption (889 veterans), and 22 reported high adoption (1,527 veterans). Table 1 presents the general characteristics of the veterans in each of the groups at time of admission to the treatment programs. Among clinical variables, groups differed on baseline distress and substance use, but not on severity of PTSD symptoms or length of stay. In addition, we examined the proportion of veterans in each of the three adoption groups who completed discharge and follow-up assessments. Groups differed in the percentage of participants with discharge data (no adoption 81%, some adoption 73%, and high adoption 84%), χ2(2, N=2,447)=51.3, p < .001, and follow-up (no adoption 18%, some adoption 19%, and high adoption 22%), χ2(2, N=784)= 8.81, p=.012), suggesting higher proportion of assessment completers in the high adopter group.
Table 1.
Sample Characteristics at Baseline (N = 3,029)
| Variables | Little or No Adoption of PE or CPT n = 613 | Some Adoption of PE or CPT n = 889 | Most adoption of PE or CPT n = 1,527 | Group differences | |||
|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | ||
| Male | 532 | 89.3 | 795 | 92.2 | 1,305 | 88.3 | 1,2 |
| OIF/OEF/OND | 287 | 46.8 | 544 | 61.2 | 831 | 54.4 | 0,1; 0,2; 1,2 |
| White (not Hispanic) | 357 | 58.2 | 589 | 66.3 | 856 | 56.1 | 0,1; 1,2 |
| Black (not Hispanic) | 162 | 26.4 | 110 | 12.4 | 424 | 27.8 | 0,1; 1,2 |
| Hispanic | 49 | 8 | 74 | 8.3 | 144 | 9.4 | |
| Other race | 52 | 8.5 | 137 | 15.4 | 136 | 8.9 | 0,1; 1,2 |
| Married/Domestic Partner | 226 |
36.9 |
374 |
42.1 |
616 |
40.3 |
|
|
M |
SD |
M |
SD |
M |
SD |
||
| Age | 48.19 | 13.69 | 43.39 | 13.74 | 45.36 | 12.88 | 0,1; 0,2; 1,2 |
| Years of Education | 13.4 | 1.93 | 13.23 | 1.97 | 13.41 | 2.26 | |
| Length of Stay | 49.46 | 37.17 | 47.95 | 31.46 | 47.61 | 17.49 | |
| Distress | 2.49 | .78 | 2.56 | .77 | 2.6 | .77 | 0,2 |
| BAM Days Use (Alcohol+Drug) | 14.25 | 18.51 | 14.27 | 18.72 | 11.4 | 16.74 | 0,2; 1,2 |
| PCL at Admission | 58.39 | 12.33 | 58.16 | 11.68 | 58.68 | 11.97 | |
Note: OIF= Operation Iraqi Freedom; OEF = Operation Enduring Freedom; OND = Operation New Dawn; BAM = Brief Addiction Monitor; Distress = Kessler Psychological Distress Scale PCL = PTSD Checklist. All other races includes: American Indian, Alaskan, Asian, Pacific Islander, and Other.
Results of the linear mixed-model analyses are presented in Tables 2–4. PTSD, distress, and alcohol use symptoms improved over time. There were no effects of adoption group or a group by time interaction for any outcome. Predictors of lower PTSD were male gender, African-American race, and lower PTSD and distress at admission (Table 2). Predictors of lower distress were older age and lower distress at admission (Table 3). Predictors of lower alcohol use (Table 4) were Iraq/Afghanistan theater and lower alcohol use at admission. There was also no difference on satisfaction among groups (both ps > .1).
Table 2.
Model Parameter Estimates PTSD Symptoms Over Time
| Variable | Fixed Effects | ||||
|---|---|---|---|---|---|
| Estimate | SE | Test Statistic | df | p | |
| Male (Female ref) | −2.49 | .55 | t=4.51 | 1 | <.01 |
| Age | −.02 | .03 | t=.57 | 1 | .56 |
| Black (other ref) | −1.41 | .39 | t=3.58 | 1 | <.01 |
| OIF/OEF/OND | .04 | .47 | t=.08 | 1 | .94 |
| Distress at Admission | 1.81 | .52 | t=3.47 | 1 | <.01 |
| Alcohol use at Admission | .13 | .11 | t=1.19 | 1 | .23 |
| PTSD at Admission | .52 | .03 | t=15.80 | 1 | <.01 |
| Time | −2.57 | .29 | t=8.79 | 1 | <.01 |
| Group | F=.26 | 2 | .77 | ||
| Low (high ref) | −.82 | 1.49 | t=.55 | .59 | |
| Med (high ref) | 1.03 | 1.45 | t=.71 | .48 | |
| Time*Adoption Group | F=3.04 | 2 | .05 | ||
| Time*Low (Time*high ref) | 1.04 | .43 | t=2.42 | .02 | |
| Time*Med (Time*High ref) | .51 | .44 | t=1.17 | .24 | |
| Random Effect | |||||
| Component | SE | p - Wald | % of total variance | ||
| Site | 21.40 | 6.73 | <.01 | 7.92 | |
| Subjects (nested in site (nested in group)) | 91.86 | 7.49 | <.01 | 34.01 | |
Note: OIF= Operation Iraqi Freedom; OEF = Operation Enduring Freedom; OND = Operation New Dawn
Table 4.
Model Parameter Estimates Alcohol Use Over Time
| Variable | Fix Effects | ||||
|---|---|---|---|---|---|
| Estimate | SE | t Ratio | df | Significance | |
| Male (Female ref) | .10 | .07 | 1.36 | 1 | .17 |
| Age | .01 | .01 | 2.15 | 1 | .03 |
| Black (other ref) | −.01 | .05 | .16 | 1 | .87 |
| OIF/OEF/OND | −.17 | .06 | 2.79 | 1 | <.01 |
| Distress at Admission | .09 | .05 | 1.70 | 1 | .09 |
| Alcohol use at Admission | .20 | .1 | 14.17 | 1 | <.01 |
| Time | −.55 | .05 | 11.70 | 1 | <.01 |
| Group | F=.88 | 2 | .43 | ||
| Low (high ref) | .07 | .10 | .76 | .46 | |
| Med (high ref) | −.13 | .10 | 1.32 | .20 | |
| Time*Adoption Level | F=2.85 | 2 | .06 | ||
| Time*Low (Time*high ref) | .11 | .07 | 1.55 | .12 | |
| Time*Med (Time*High ref) | .03 | .07 | .44 | .66 | |
| Random Effect | |||||
| Component | SE | p -Wald | % of total variance | ||
| Site | .03 | .02 | .14 | .61 | |
| Subjects (nested in site (nested in group)) |
.56 | .15 | <.01 | 10.01 | |
Note: OIF= Operation Iraqi Freedom; OEF = Operation Enduring Freedom; OND = Operation New Dawn
Table 3.
Model Parameter Estimates Distress Index Scores Over Time
| Variable | Fixed Effects | ||||
|---|---|---|---|---|---|
| Estimate | SE | t | df | p | |
| Male (Female ref) | −.06 | .03 | 2.32 | 1 | .02 |
| Age | −.01 | .01 | 4.33 | 1 | <.01 |
| Black (other ref) | −.05 | .02 | 2.34 | 1 | .02 |
| OIF/OEF/OND | .02 | .02 | .71 | 1 | .48 |
| Distress at Admission | .45 | .02 | 22.18 | 1 | <.01 |
| Alcohol use at Admission | .01 | .01 | 1.10 | 1 | .27 |
| Time | −.21 | .02 | 13.94 | 1 | <.01 |
| Group | F=.80 | 2 | .46 | ||
| Low (high ref) | −.08 | .07 | 1.19 | .24 | |
| Med (high ref) | .03 | .06 | .46 | .65 | |
| Time*Group | F=2.84 | 2 | .06 | ||
| Time*Low (Time*high ref) | .05 | .02 | 2.26 | .02 | |
| Time*Med (Time*High ref) | −.02 | .02 | .83 | .41 | |
| Random Effect | |||||
| Component | SE | p -Wald | % of total variance | ||
| Site | .04 | .01 | <.01 | 5.33 | |
| Subjects (nested in site (nested in group)) | .18 | .02 | <.01 | 24.61 | |
Note: OIF= Operation Iraqi Freedom; OEF = Operation Enduring Freedom; OND = Operation New Dawn
Temporal effects are presented in Figure 1. For all outcomes and all groups, there was a similar pattern of change. Symptoms decreased at discharge and then increased somewhat at follow-up. The effect size for reduction in PTSD symptoms between admission and discharge was large across groups (no adoption, d=0.97, 95% CI=0.88–1.07; some adoption, d=0.92, 95% CI=0.82–1.01; and high adoption, d=0.96, 95% CI=0.90–1.02). The effect size between admission and follow-up was medium (no adoption, d=0.70, 95% CI=0.53–0.87; some adoption, d=0.47, 95% CI=0.32–0.62; and high adoption, d=0.54, 95% CI=0.44–0.65).
Figure 1A.
Change in PTSD Across Three Time Points by Adoption Level
Discussion
Veterans treated in programs with high levels of adoption of Prolonged Exposure or Cognitive Processing Therapy did not experience more improvement than those treated in programs with less or virtually no adoption. This finding is surprising given the recommendations of PTSD treatment guidelines (13, 26) as well as results of a prior study (16) showing superior outcomes in an RRTP following the adoption of Cognitive Processing Therapy compared with the outcomes before. Nevertheless, veterans treated in VA residential PTSD treatment programs experienced an improvement in PTSD symptoms severity in the course of residential treatment. These findings suggest that residential programs are helpful and may have improved over time (5, 8, 27). The improvement in symptoms veterans experienced, however, was not related to the degree EBPs for PTSD were adopted.
Following discharge, an increase in PTSD symptoms, distress and substance use was observed in all experimental groups suggesting that a better understanding of aftercare services provided following discharge is needed. These understandings will help to ensure that therapeutic gains will be maintained post-discharged from these expensive and intense treatment programs. It appears that the effect of decrease substance use during the residential stay (due to the nature of restricting access to substances and/or therapeutic intervention) as measured at discharged has diminished at 4-month follow-up (no significant difference between admission to 4-month use level in all 3 groups). This result suggests that residential program should prepare veterans to better cope with substance use issues when the return back to the community.
It may be harder to detect the impact of EBP use on outcomes in residential settings relative to outpatient settings, which is where the studies that have informed PTSD guidelines have been conducted. A prior study found that residential patients had greater PTSD symptom severity and more comorbidity and were less responsive to Cognitive Processing Therapy than outpatients (19). Also, most VA residential programs offer between 30–35 hours per week of programming during the weekday and then another six hours over the course of the weekend. Even in a high EBP site, the time spent actually doing Cognitive Processing Therapy or Prolonged Exposure is small in proportion to the total package of care, likely making it harder to detect Prolonged Exposure and Cognitive Processing Therapy’s true effects. Many of the programs reported using EBPs for other comorbidities common in individuals with PTSD, such as cognitive-behavioral treatment for insomnia. It is possible that the range of treatments now provided in the course of residential care as well as the treatment milieu also add to program effectiveness. It is also important to note that some programs that did not offer Prolonged Exposure or Cognitive Processing Therapy offered another EBP for PTSD, such as eye movement desensitization and reprocessing (17). Notably, while it may be more difficult to detect outcomes of Prolonged Exposure and Cognitive Processing Therapy in residential settings, this investigation still provides promising results related to the number of residential programs using these treatments, particularly when compared to some VA outpatient settings where relatively low use has been reported (28).
Another possible explanation for the null effect of implementation is the frequent use of group versus individual Cognitive Processing Therapy. The VA/Department of Defense (13) PTSD guideline states that the limited data on the efficacy of group therapy, including group Cognitive Processing Therapy, indicates that it is not as effective as individual therapy (29). It is unlikely that this possibility can fully explain our findings, however, because group Cognitive Processing Therapy has evidence of efficacy, albeit a small difference between Cognitive Processing Therapy and present-centered therapy (30).
There were a number of unavoidable methodological issues that may temper inferences drawn from our results. There may have been low fidelity to Prolonged Exposure and Cognitive Processing Therapy protocols that was not captured by our measure of adoption. It is also possible that some of the 22 programs who report high use overestimated utilization, thereby further diluting results. In addition, while some programs might have had overall high adoption, there is no guarantee that every veteran in that program received or completed a full course of the EBP. A stronger design would involve linking patient outcomes to specific treatments received and assessing the quality and fidelity with which treatment was delivered. Finally, there was variable data collection across sites and significant loss to follow-up. Veterans in the no EBP adoption programs were less likely to fill the evaluation forms at discharge and follow-up. In addition, low 4-month follow-up rate (even though similar across programs) may also reduce ability to detect effects, especially if healthier veterans tend to respond.
The use of intention-to-treat analyses and adjustment for baseline differences among program types may have failed to adequately control bias due to these factors. It is entirely possible that unmeasured differences among sites who participated in measurement may be masking any effect of delivering an EBP. Unfortunately, because we used existing VA program evaluation data, we were limited to the data that were collected through this national evaluation process. In addition, the primary outcome was based on a self-report measure and not a clinician-administered measure of PTSD. Demand and allegiance effects cannot be ruled out.
These findings suggest a number of opportunities for further study. More carefully controlled and independent assessment protocols and information about the fidelity of EBP adoption are needed in order to yield a more conclusive answer about the relative benefit of EBP use in residential programs. Further understanding of the treatments being provided by programs with little or no adoption could also be helpful in developing treatments for individuals that may not be appropriate or benefit from EBPs.
Residential treatment for PTSD is a small and distinct faction of VA care, often serving the most chronic, severe patients with complicated symptom presentations. Despite the lack of differences among EBP adoption groups, our results are encouraging for the PTSD residential programs as they indicate meaningful improvement in this segment of the veteran population.
In conclusion, though veterans treated in VA residential PTSD treatment programs experienced a high degree of symptom improvement at discharge, veterans in programs that utilized Prolonged Exposure and Cognitive Processing Therapy with most or all their patients did not experience greater reductions in PTSD or depression symptoms, or alcohol use than veterans in programs that do not utilize Prolonged Exposure or Cognitive Processing Therapy. Failure to find a treatment effect should not be interpreted definitively as indicating that implementation of these two EBPs in VA residential treatment programs does not matter. It is possible that the multiple influences in residential programming may overshadow the effects of EBP. This conclusion, however, seems premature based on program evaluation data such as those collected here. More carefully controlled research is needed to ensure more complete data capture outside of routine clinical care, and to more specifically document the treatments actually received, as well as the amount and quality of EBP.
Figure 1B.
Change in Alcohol Use Across Three Time Points by Program Adoption Level
Figure 1C.
Change in Distress Across Three Time Points by Program Adoption Level
Highlights.
Residential treatment for PTSD is a small and distinct faction of VA care, often serving the most chronic, severe patients with complicated symptom presentations.
Veterans treated in VA residential PTSD treatment programs experienced a high degree of symptom improvement at discharge that somewhat worsened at follow-up.
Although there were moderate to large effects across all programs, programs that utilized Prolonged Exposure and Cognitive Processing Therapy with most or all their patients were not associated with greater reductions in PTSD or depression symptoms, or alcohol use than programs that do not utilize Prolonged Exposure or Cognitive Processing Therapy.
Acknowledgments
This project described was supported by Award Number R01 MH096810 from the National Institute of Mental Health (NIMH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIMH, the National Institutes of Health or the Department of Veterans Affairs.
Footnotes
The authors have no disclosures or financial conflicts of interest to report.
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