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Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder: A Systematic Review

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Abstract

Guidelines strongly recommend trauma-focused therapies to treat posttraumatic stress disorder. Implementation of cognitive processing therapy (CPT) and prolonged exposure (PE) in Veterans Health Administration (VHA) and non-VHA settings began in 2006. We conducted a systematic review of implementation facilitators and challenges and strategies to address barriers. We searched MEDLINE, Embase, PsycINFO, and CINAHL from inception until March 2021 for English-language articles. Two individuals reviewed eligibility and rated quality. Quantitative results were abstracted by one reviewer and verified by a second. Qualitative results were independently coded by two reviewers and finalized through consensus. We used RE-AIM and CFIR frameworks to synthesize findings. 29 eligible studies addressed CPT/PE, mostly conducted in VHA. Training/education with audit/feedback was the primary implementation strategy and was linked to improved provider CPT/PE perceptions and self-efficacy. Use was not widespread. Only six studies tested other implementation strategies with mixed impact. Following VHA implementation, strong support for training, perceived effectiveness for patients and benefits for clinics, and positive patient experiences and relationships with providers were reported. However, barriers persisted including perceived protocol inflexibility, complex referral processes and patient complexity and competing needs. In non-VHA settings, providers perceived fewer barriers, but few were CPT/PE trained. Across both settings, fewer studies targeted patient factors. Training/education with audit/feedback improved perceptions and the availability of CPT/PE, but not consistent use. Studies testing implementation strategies to address post-training challenges, including patient-level factors, are needed. A few studies are underway in VHA to test patient-focused and other implementation strategies. Research assessing actual vs perceived barriers in non-VHA settings is needed to elucidate unique challenges experienced.

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Acknowledgements

The authors gratefully acknowledge and thank the following individuals for their time and expertise in contributing to this project: Alicia Heapy, PhD; William Becker, MD; Erin Krebs, MD MPH; Jennifer Murphy, PhD; Robert Kerns, MD; Bradley Karlin, PhD; Amanda Midboe, PhD; Kristine Day, PhD; Hani Shabana, PhD.

Funding

This work is funded by the Veterans Health Administration, Health Services Research and Development, Evidence Synthesis Program (#09-009). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government.

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Authors and Affiliations

  1. Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA

    Princess E. Ackland, Elizabeth S. Goldsmith, Kristen Ullman, Wendy A. Miller, Adrienne Landsteiner, Benjamin Stroebel, Jessica Hill, Timothy J. Wilt & Wei Duan-Porter

  2. Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA

    Princess E. Ackland, Elizabeth S. Goldsmith, Wendy A. Miller, Timothy J. Wilt & Wei Duan-Porter

  3. Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA

    Kristen Ullman, Adrienne Landsteiner, Benjamin Stroebel, Jessica Hill, Timothy J. Wilt & Wei Duan-Porter

  4. Department of Psychology, Binghamton University, Binghamton, NY, 13902, USA

    Jessica Hill

  5. Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware St SE, Minneapolis, MN, 55455, USA

    Timothy J. Wilt

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  1. Princess E. Ackland
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  2. Erin A. Koffel
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  4. Kristen Ullman
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  8. Jessica Hill
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  9. Timothy J. Wilt
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  10. Wei Duan-Porter
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by PEA, EK, EG, KU, WAM, AL, BS, JH, TJW and WD-P. The first draft of the manuscript was written by PEA and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Princess E. Ackland.

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This systematic review did not involve participant recruitment or require ethical approval.

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This review followed the PRISMA guidelines.

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Ackland, P.E., Koffel, E.A., Goldsmith, E.S. et al. Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder: A Systematic Review. Adm Policy Ment Health 50, 792–812 (2023). https://doi.org/10.1007/s10488-023-01279-6

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