Abstract
We sought to develop a quality standard for the delivery of psychotherapy for posttraumatic stress disorder (PTSD) that is both consistent with the underlying evidence supporting psychotherapy as a treatment for PTSD and associated with the best levels of symptom improvement. We quantified psychotherapy receipt during the initial year of PTSD treatment in a 10-year national cohort of Department of Veterans Affairs (VA) users who completed patient-reported outcome measurement as part of routine practice. We added progressively stringent measurement requirements. The most stringent requirement was associated with superior outcomes. Quality of psychotherapy for PTSD in the VA improved over time.
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20 April 2020
The original version of this article unfortunately contained a mistake. The co-author name was incorrectly published with the middle initial in the author list.
References
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Funding
A VA Health Services Research & Development Career Development Award to Dr. Shiner (CDA11-263) funded the development of this cohort. A DoD Joint Warfighter Medical Research Program Award to Dr. Maguen (JW140056) funded the refinement of our strategy to measure evidence-based psychotherapy, which was originally supported with a VA New England Early Career Development Award to Dr. Shiner (V1CDA10-03). A DoD Peer Reviewed Medical Research Program Award to Dr. Shiner (PR160206) funded the development of our strategy to leverage patient-reported outcomes data. The opinions expressed herein are those of the authors and do not necessarily reflect the positions of the United States Department of Veterans Affairs or the United States Department of Defense.
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Appendices
Appendix 1
Psychotherapy initiation in the year following initial PTSD diagnosis among patients with no psychotherapy encounters in the 2 years prior to PTSD diagnosis, by punitive quality standards
Fiscal years | 2004–2005 | 2006–2007 | 2008–2009 | 2010–2011 | 2012–2013 | Overall |
|---|---|---|---|---|---|---|
New PTSD episodes | n = 58,061 | n = 69,640 | n = 90,269 | n = 92,515 | n = 85,547 | 396,032 |
Total psychotherapy encounters, M (SD) | 8.0 (11.6) | 7.5 (10.8) | 7.7 (10.8) | 8.0 (10.7) | 7.9 (10.5) | 7.8 (10.8) |
Any receipt | ||||||
Any psychotherapy: procedural codes | 84.4% (49,022) | 85.2% (59,368) | 85.9% (77,548) | 88.1% (81,487) | 87.6% (74,956) | 86.5% (342,381) |
Individual | 79.6% (46,199) | 81.0% (56,410) | 82.6% (74,606) | 84.8% (78,430) | 83.8% (71,713) | 82.7% (327,358) |
Group | 30.2% (17,540) | 28.3% (19,714) | 26.1% (23,591) | 28.0% (25,933) | 29.7 (25,374) | 28.3% (112,152) |
Any psychotherapy: NLP | 54.2% (31,496) | 56.8% (39,537) | 59.4% (53,589) | 61.8% (57,182) | 63.0% (53,902) | 59.5% (235,706) |
Individual | 43.6% (25,307) | 47.4% (32,978) | 51.2% (46,204) | 52.9% (48,939) | 53.9% (46,115) | 50.4% (199,543) |
Group | 25.6% (14,835) | 24.6% (17,103) | 23.1% (20,885) | 25.4% (23,540) | 26.7% (22,822) | 25.0% (99,185) |
Any EBP: NLP | 0.6% (373) | 2.7% (1884) | 7.7% (6939) | 10.7% (9855) | 13.5% (11,542) | 7.7% (30,593) |
Group Cognitive Processing Therapy | 0.2% (104) | 0.6% (436) | 2.0% (1801) | 3.4% (3160) | 3.9% (3314) | 2.2% (8815) |
Individual Prolonged Exposure | 0.1% (82) | 0.3% (224) | 1.9% (1687) | 3.2% (2946) | 3.8% (3288) | 2.1% (8227) |
Individual Cognitive Processing Therapy | 0.4% (236) | 2.1% (1,449) | 4.9% (4454) | 6.0% (5545) | 8.1% (6900) | 4.7% (18,584) |
Eight or More Sessions | ||||||
Any psychotherapy: procedural codes | 30.9% (17,926) | 29.8% (20,757) | 32.0% (28,864) | 33.6% (31,079) | 33.6% (28,755) | 32.2% (127,381) |
Individual | 18.1% (10,506) | 19.0% (13,214) | 22.9% (20,635) | 23.5% (21,741) | 24.1% (20,608) | 21.9% (86,704) |
Group | 15.4% (8931) | 13.1% (9121) | 11.5% (10,371) | 12.4% (11,479) | 11.6% (9930) | 12.6% (49,832) |
Any psychotherapy: NLP | 19.3% (11,179) | 19.6% (13,656) | 21.3% (19,237) | 23.4% (21,603) | 24.0% (20,563) | 21.8% (86,238) |
Individual | 7.0% (4048) | 8.8% (6150) | 11.9% (10,745) | 12.8% (11,864) | 14.4% (12,303) | 11.4% (45,110 |
Group | 12.6% (7331) | 11.4% (7927) | 10.3% (9284) | 11.4% (10,519) | 10.5% (8963) | 11.1% (44,024) |
Any EBP: NLP | 0.2% (94) | 0.7% (494) | 2.6% (2326) | 4.4% (4060) | 5.1% (4379) | 2.9% (11,353) |
Group Cognitive Processing Therapy | 0.0% (23) | 0.2% (109) | 0.6% (579) | 1.4% (1,337) | 1.5% (1252) | 0.8% (3300) |
Individual Prolonged Exposure | 0.0% (11) | 0.0% (31) | 0.5% (493) | 1.1% (991) | 1.1% (914) | 0.6% (2440) |
Individual Cognitive Processing Therapy | 0.1% (63) | 0.5% (372) | 1.4% (1226) | 1.8% (1622) | 2.4% (2092) | 1.4% (5375) |
Eight or More Sessions with the Same Therapist | ||||||
Any psychotherapy: procedural codes | 23.1% (13,389) | 22.0% (15,288) | 22.9% (20,635) | 24.0% (22,204) | 24.4% (20,858 | 23.3% (92,374) |
Individual | 11.8% (6841) | 12.5% (897) | 15.2% (13,717) | 15.6% (14,397) | 16.7% (14,302) | 14.6% (57,954) |
Group | 12.7% (7367) | 10.9% (7595) | 9.2% (8317) | 10.0% (9237) | 9.2% (7830) | 10.2% (40,346) |
Any psychotherapy: NLP | 15.8% (9167) | 16.4% (11,389) | 17.8% (16,028) | 19.7% (18,189) | 19.9% (17,016) | 18.1% (71,789) |
Individual | 6.0% (3456) | 7.5% (5216) | 10.3% (9302) | 11.3% (10,464) | 12.6% (10,744) | 9.9% (39,182) |
Group | 10.2% (5941) | 9.4% (6528) | 8.2% (7377) | 9.1% (8379) | 8.1% (6899) | 8.9% (35,124) |
Any EBP: NLP | 0.1% (78) | 0.7% (458) | 2.3% (2042) | 3.9% (3562) | 4.5% (3840) | 2.5% (9980) |
Group Cognitive Processing Therapy | 0.0% (11) | 0.1% (74) | 0.4% (369) | 1.0% (924) | 1.0% (848) | 0.6% (2226) |
Individual Prolonged Exposure | 0.0% (11) | 0.0% (31) | 0.5% (460) | 1.0% (952) | 1.0% (862) | 0.6% (2316) |
Individual Cognitive Processing Therapy | 0.1% (55) | 0.5% (361) | 1.3% (1149) | 1.7% (1549) | 2.3% (1998) | 1.3% (5112) |
Eight or More Sessions in 14 Weeks with the Same Therapist | ||||||
Any psychotherapy: procedural codes | 13.2% (7678) | 12.6% (8747) | 12.7% (11,437) | 14.5% (13,390) | 15.6% (13,356) | 13.8% (54,608) |
Individual | 3.6% (2074) | 4.3% (2971) | 5.9% (5345) | 6.8% (6300) | 8.6% (6300) | 6.1% (24,050) |
Group | 9.6% (5584) | 8.4% (5853 | 7.0% (6304) | 7.9% (7297) | 7.4% (6365) | 7.9% (31,403) |
Any psychotherapy: NLP | 9.5% (5497) | 10.0% (6962) | 10.6% (9540) | 12.7% (11,763) | 13.1% (11,201) | 11.4% (44,963) |
Individual | 2.0% (1154) | 2.8% (1983) | 4.5% (4068) | 5.6% (5176) | 6.8% (5795) | 4.6% (18,176) |
Group | 7.2% (4209) | 7.0% (4863) | 6.0% (5440) | 7.1% (6534) | 6.3% (5422) | 6.7% (26,468) |
Any EBP: NLP | 0.1% (62) | 0.5% (359) | 1.7% (1557) | 3.2% (2924) | 3.7% (3156) | 2.0% (8058) |
Group cognitive processing therapy | 0.0% (8) | 0.1% (61) | 0.3% (302) | 0.8% (777) | 0.8% (719) | 0.5% (1867) |
Individual prolonged exposure | 0.0% (9) | 0.0% (22) | 0.4% (366) | 0.9% (801) | 0.8% (715) | 0.5% (1913) |
Individual cognitive processing therapy | 0.1% (44) | 0.4% (279) | 0.9% (833) | 1.3% (1245) | 1.9% (1604) | 1.0% (4005) |
PTSD Posttraumatic Stress Disorder, EBP Evidence-Based Psychotherapy for PTSD, NLP Natural Language Processing.
Appendix 2
Raw and weighted covariates for comparisons of quality standards for patients receiving 8 or more sessions of evidence-based psychotherapy for PTSD and aligned PCL measurement, FY 2008–2013
Patient characteristics, N | Raw data | Weighted data | ||||||
|---|---|---|---|---|---|---|---|---|
(A) 8 n = 303 | (B) 8 ST n = 549 | (C) 8 14 W ST n = 1200 | p value | (A) 8 n = 303 | (B) 8 ST n = 549 | (C) 8 14 W ST n = 1200 | p value | |
Baseline PCL, M (SD) | 64.9 (9.9) | 63.2 (9.6) | 63.5 (9.8) | 0.041 | 64.2 (11.0) | 63.6 (10.1) | 63.6 (10.0) | 0.735 |
Days between baseline pcl and session 1, M (SD) | 2.4 (15.5) | 6.9 (23.0) | 0.8 (6.0) | < 0.001 | 3.1 (22.7) | 2.8 (10.4) | 1.1 (8.1) | 0.002 |
Days between follow-up PCL and session 8 M (SD) | 0.2 (5.8) | − 1.9 (13.7) | 0.3 (5.8) | < 0.001 | 0.2 (7.0) | − 0.4 (7.3) | 0.2 (6.4) | 0.230 |
Fiscal years 2008–2009 | 5.3 (16) | 7.7 (42) | 5.7 (68) | 0.220 | 6.3 (16) | 7.2 (42) | 6.1 (68) | 0.678 |
Fiscal years 2010–2011 | 37.3 (113) | 35.5 (195) | 39.4 (473) | 0.284 | 36.3 (113) | 36.1 (195) | 39.1 (473) | 0.468 |
Fiscal years 2012–2013 | 57.4 (174) | 56.8 (312) | 54.9 (659) | 0.625 | 57.4 (174) | 56.6 (312) | 54.9 (659) | 0.683 |
Age, M (SD) | 47.2 (14.6) | 42.8 (14.7) | 45.8 (15.5) | < 0.001 | 46.3 (16.4) | 16.3 (44.6) | 45.4 (15.4) | 0.326 |
Women, % (n) | 9.6 (29) | 14.6 (80) | 14.5 (174) | 0.070 | 13.6 (29) | 14.4 (80) | 14.3 (174) | 0.963 |
Married, % (n) | 68.6 (208) | 60.3 (331) | 62.4 (749) | 0.050 | 68.1 (208) | 61.8 (331) | 62.5 (749) | 0.252 |
White Non-Hispanic, % (n) | 48.2 (146) | 62.7 (344) | 65.8 (789) | < 0.001 | 55.3 (146) | 62.0 (344) | 63.8 (789) | 0.053 |
OEF/OIF/OND veteran, % (n) | 46.9 (142) | 55.2 (303) | 49.0 (588) | 0.024 | 48.8 (142) | 49.0 (303) | 50.2 (588) | 0.877 |
Rural, % (n) | 32.3 (98) | 33.2 (182) | 30.8 (369) | 0.580 | 30.5 (98) | 33.6 (182) | 30.5 (369) | 0.462 |
Combat exposure, % (n) | 28.7 (87) | 27.0 (148) | 26.6 (319) | 0.757 | 30.2 (87) | 25.7 (148) | 27.0 (319) | 0.466 |
Sexual trauma while in military, % (n) | 9.2 (28) | 12.4 (68) | 15.1 (181) | 0.020 | 12.8 (28) | 12.3 (68) | 14.8 (181) | 0.358 |
VA disability level 70% or greater, % (n) | 65.3 (198) | 62.7 (344) | 57.8 (694) | 0.023 | 62.1 (198) | 61.8 (344) | 58.5 (694) | 0.337 |
Charleson Comorbidity Index 1 or greater, % (n) | 15.8 (48) | 10.2 (56) | 12.4 (149) | 0.056 | 14.8 (48) | 11.1 (56) | 11.9 (149) | 0.355 |
Psychotic disorders, % (n) | 1.0 (3) | 1.6 (9) | 1.6 (19) | 0.721 | 0.4 (3) | 1.5 (9) | 1.6 (19) | 0.133 |
Bipolar mood disorders, % (n) | 3.6 (11) | 3.1 (17) | 3.5 (42) | 0.888 | 5.3 (11) | 3.0 (17) | 3.5 (42) | 0.382 |
Depressive mood disorders, % (n) | 68.3 (207) | 71.6 (393) | 71.3 (855) | 0.555 | 68.6 (207) | 72.1 (393) | 71.5 (855) | 0.610 |
Non-PTSD anxiety disorders, % (n) | 43.6 (132) | 41.3 (227) | 40.2 (482) | 0.550 | 42.1 (132) | 40.1 (227) | 40.0 (482) | 0.833 |
Traumatic brain injury, % (n) | 17.2 (52) | 22.8 (125) | 17.0 (204) | 0.013 | 17.8 (52) | 20.7 (125) | 17.6 (204) | 0.291 |
Alcohol use disorders, % (n) | 28.4 (86) | 27.0 (148) | 25.8 (310) | 0.643 | 24.8 (86) | 27.9 (148) | 25.8 (310) | 0.594 |
Opioid use disorders, % (n) | 2.3 (7) | 2.0 (11) | 2.0 (24) | 0.940 | 1.6 (7) | 2.0 (11) | 2.0 (24) | 0.901 |
Other drug use disorders, % (n) | 14.9 (45) | 13.8 (76) | 13.5 (162) | 0.830 | 12.1 (45) | 13.0 (76) | 13.3 (162) | 0.863 |
Adequate trial of evidence-based antidepressant for PTSD, % (n) | 41.3 (125) | 33.2 (182) | 32.0 (384) | 0.009 | 37.3 (125) | 33.0 (182) | 32.5 (384) | 0.363 |
PTSD outpatient clinical team use (540 or 561), % (n) | 84.5 (256) | 71.2 (391) | 68.3 (820) | < 0.001 | 78.3 (256) | 71.8 (391) | 70.4 (820) | 0.098 |
Outpatient mental health visits, M (SD) | 31.7 (16.3) | 27.6 (14.2) | 26.9 (14.4) | < 0.001 | 29.0 (15.5) | 27.7 (15.3) | 27.3 (14.8) | 0.228 |
Outpatient substance abuse visits, M (SD) | 5.3 (13.9) | 3.8 (15.3) | 4.1 (11.9) | 0.256 | 3.6 (9.8) | 3.9 (16.7) | 4.1 (12.0) | 0.804 |
Outpatient primary care visits, M (SD) | 3.8 (3.5) | 3.1 (2.5) | 3.2 (3.1) | 0.005 | 3.3 (3.2) | 3.2 (2.9) | 3.2 (3.2) | 0.752 |
Emergency Department visit for psychiatric indication, % (n) | 8.3 (25) | 7.1 (39) | 8.5 (102) | 0.607 | 6.9 (25) | 7.1 (39) | 8.5 (102) | 0.510 |
Acute mental health inpatient admission, % (n) | 6.3 (19) | 7.8 (43) | 6.6 (79) | 0.572 | 5.0 (19) | 7.5 (43) | 6.5 (79) | 0.426 |
Residential PTSD admission, % (n) | 15.8 (48) | 7.5 (41) | 7.0 (84) | < 0.001 | 9.8 (48) | 8.2 (41) | 7.6 (84) | 0.432 |
Residential substance abuse admission, % (n) | 4.6 (14) | 1.1 (6) | 2.2 (26) | 0.004 | 2.4 (14) | 1.1 (6) | 2.2 (26) | 0.241 |
Primary therapist characteristics, where known | ||||||||
Age, M (SD) | 44.1 (12.3) | 43.3 (11.0) | 43.5 (10.9) | 0.664 | 43.1 (14.3) | 43.7 (12.9) | 43.4 (12.6) | 0.861 |
Women, % (n) | 44.2 (134) | 60.5 (332) | 55.0 (660) | < 0.001 | 64.7 (134) | 68.5 (332) | 68.5 (660) | 0.540 |
Psychologist, % (n) | 65.7 (199) | 67.8 (372) | 64.0 (768) | 0.327 | 69.9 (199) | 66.5 (372) | 65.2 (768) | 0.395 |
Social Worker, % (n) | 24.1 (73) | 27.0 (148) | 30.6 (367) | 0.046 | 25.2 (73) | 28.0 (148) | 29.5 (367) | 0.410 |
Nurse, % (n) | 0.3 (1) | 1.1 (6) | 1.6 (19) | 0.199 | 0.2 (1) | 1.3 (6) | 1.5 (19) | 0.102 |
Psychiatrist, % (n) | 0.7 (2) | 1.1 (6) | 0.8 (9) | 0.720 | 0.7 (2) | 1.2 (6) | 0.8 (9) | 0.683 |
Other, % (n) | 9.2 (28) | 3.1 (17) | 2.9 (35) | < 0.001 | 4.1 (28) | 3.0 (17) | 3.0 (35) | 0.510 |
Prescribing Privileges, % (n) | 5.6 (17) | 7.8 (43) | 7.9 (95) | 0.379 | 6.5 (17) | 7.7 (43) | 7.7 (95) | 0.813 |
Percentage of time in PTSD service, M (SD) | 72.0 (33.7) | 57.5 (38.0) | 55.2 (39.2) | < 0.001 | 63.8 (45.6) | 58.7 (41.2) | 57.9 (38.5) | 0.111 |
Percentage of time in substance abuse service, M (SD) | 3.4 (13.2) | 3.2 (10.7) | 3.7 (13.5) | 0.736 | 2.6 (9.5) | 3.0 (12.0) | 3.5 (12.3) | 0.338 |
Percentage of time in PTSD-substance abuse service, M (SD) | 1.1 (6.3) | 1.0 (6.5) | 0.8 (5.4) | 0.505 | 0.8 (4.0) | 0.8 (5.6) | 0.8 (6) | 0.973 |
Percentage of time in general mental health service, M (SD) | 17.5 (27.8) | 29.1 (33.8) | 31.2 (35.3) | < 0.001 | 24.8 (41.4) | 28.6 (35.9) | 29.2 (34.0) | 0.245 |
Percentage of time in integrated care service, M (SD) | 3.5 (12.6) | 5.8 (17.4) | 5.3 (16.2) | 0.120 | 4.5 (17.5) | 5.5 (17.2) | 5.0 (15.8) | 0.735 |
PTSD Posttraumatic Stress Disorder, PCL PTSD Checklist, 8 eight sessions of evidence-based psychotherapy (EBP), 8 ST eight sessions of EBP with the same the same psychotherapist, 8 14 W S eight sessions with the same therapist within 14 weeks, OEF/OIF/OND Operations Enduring Freedom/Iraqi Freedom/New Dawn.
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Shiner, B., Westgate, C.L., Gui, J. et al. Measurement Strategies for Evidence-Based Psychotherapy for Posttraumatic Stress Disorder Delivery: Trends and Associations with Patient-Reported Outcomes. Adm Policy Ment Health 47, 451–467 (2020). https://doi.org/10.1007/s10488-019-01004-2
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DOI: https://doi.org/10.1007/s10488-019-01004-2