Mental Health Providers’ Decision-Making Around the Implementation of Evidence-Based Treatment for PTSD

  • Princess E. Osei-Bonsu
  • Rendelle E. Bolton
  • Shannon Wiltsey Stirman
  • Susan V. Eisen
  • Lawrence Herz
  • Maura E. Pellowe
Article

Abstract

It is estimated that <15% of veterans with posttraumatic stress disorder (PTSD) have engaged in two evidence-based psychotherapies highly recommended by VA—cognitive processing therapy (CPT) and prolonged exposure (PE). CPT and PE guidelines specify which patients are appropriate, but research suggests that providers may be more selective than the guidelines. In addition, PTSD clinical guidelines encourage “shared decision-making,” but there is little research on what processes providers use to make decisions about CPT/PE. Sixteen licensed psychologists and social workers from two VA medical centers working with ≥1 patient with PTSD were interviewed about patient factors considered and decision-making processes for CPT/PE use. Qualitative analyses revealed that patient readiness and comorbid conditions influenced decisions to use or refer patients with PTSD for CPT/PE. Providers reported mentally derived and instances of patient-involved decision-making around CPT/PE use. Continued efforts to assist providers in making informed and collaborative decisions about CPT/PE use are discussed.

References

  1. 1.
    Resick PA, Schnicke MK: Cognitive processing therapy for sexual assault victims. Journal of Consulting and Clinical Psychology. 2002; 60: 748–756.CrossRefGoogle Scholar
  2. 2.
    Foa EB, Hembree EA, Rothbaum BO. Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences. New York, NY: Oxford University Press, 2007.Google Scholar
  3. 3.
    Chard KM, Schumm JA, Owens GP, et al. A comparison of OEF and OIF veterans and Vietnam veterans receiving cognitive processing therapy. Journal of Traumatic Stress. 2010; 23: 25–32.PubMedGoogle Scholar
  4. 4.
    Monson CM, Schnurr PP, Resick PA, et al. Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology. 2006; 74: 898–907.CrossRefPubMedGoogle Scholar
  5. 5.
    Rauch SAM, Defever E, Favorite T, et al. Prolonged exposure for PTSD in a Veterans Health Administration PTSD clinic. Journal of Traumatic Stress. 2009; 22: 60–64.CrossRefPubMedGoogle Scholar
  6. 6.
    Resick PA, Nishith P, Weaver TL, et al. A comparison of cognitive processing therapy with prolonged exposure and a waiting list condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology. 2002; 70: 867–879.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Yoder M, Tuerk PW, Price M, et al. Prolonged exposure therapy for combat-related posttraumatic stress disorder: comparing outcomes for veterans of different wars. Psychological Services. 2011; 14: 1–10.Google Scholar
  8. 8.
    Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for management of post-traumatic stress. Washington, DC: Authors, 2010.Google Scholar
  9. 9.
    Karlin BE, Ruzek JI, Chard KM, et al. Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. Journal of Traumatic Stress. 2010; 23: 663–673.CrossRefPubMedGoogle Scholar
  10. 10.
    Lu MW, Plagge JM, Marsiglio MC, et al. Clinician documentation on receipt of trauma-focused evidence-based psychotherapies in a VA PTSD clinic. Journal of Behavioral Health Services & Research. 2013; 1–16.Google Scholar
  11. 11.
    Watts BV, Shiner B, Zubkoff L, et al. Implementation of evidence-based psychotherapies for posttraumatic stress disorder in VA specialty clinics. Psychiatric Services. 2014; 65: 648–653.CrossRefPubMedGoogle Scholar
  12. 12.
    Rosenheck R, Stolar M, Fontana A. Outcomes monitoring and the testing of new psychiatric treatments: work therapy in the treatment of chronic post-traumatic stress disorder. Health Services Research. 2000; 35: 133–151.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Seal KH, Metzler TJ, Gima KS, et al. Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002–2008. American Journal of Public Health. 2009; 99: 1651–1658.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Jakupcak M, Cook J, Imel Z, et al. Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan war veterans. Journal of Traumatic Stress. 2009; 22: 303–306.CrossRefPubMedGoogle Scholar
  15. 15.
    Khaylis A, Polusny M, Erbes C, et al. Posttraumatic stress, family adjustment, and treatment preferences among National Guard soldiers deployed to OEF/OIF. Military Medicine. 2011; 176: 126–131.CrossRefPubMedGoogle Scholar
  16. 16.
    Lew HL, Otis JD, Tun C, et al. Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: Polytrauma clinical triad. Journal of Rehabilitation Research and Development. 2011; 48: 493–502.CrossRefGoogle Scholar
  17. 17.
    Sayer NA, Noorbaloochi S, Frazier P, et al. Reintegration problems and treatment interests among Iraq and Afghanistan combat veterans receiving VA medical care. Psychiatric Services. 2010; 61: 589–597.CrossRefPubMedGoogle Scholar
  18. 18.
    Smith MW, Schnurr PP, Rosenheck RA. Employment outcomes and PTSD symptom severity. Mental Health Services Research. 2005; 7: 89–101.CrossRefPubMedGoogle Scholar
  19. 19.
    Kim PY, Britt TW, Klocko RP, et al. Stigma, negative attitudes about treatment, and utilization of mental health care among soldiers. Military Psychology. 2011; 23: 65–81.CrossRefGoogle Scholar
  20. 20.
    Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines?: A framework for improvement. Journal of the American Medical Association. 1999; 282: 1458–1465.CrossRefPubMedGoogle Scholar
  21. 21.
    Hoge CW. Interventions for war-related posttraumatic stress disorder: meeting veterans where they are. Journal of the American Medical Association. 2011; 306: 549–551.PubMedGoogle Scholar
  22. 22.
    Institute of Medicine. Treatment for posttraumatic stress disorder in military and veterans populations. Washington, DC: Author, 2012.Google Scholar
  23. 23.
    Lu MW, Duckart JP, O’Malley JP, et al. Correlated of utilization of PTSD specialty treatment among recently diagnosed veterans at the VA. Psychiatric Services. 2011; 62: 943–949.CrossRefPubMedGoogle Scholar
  24. 24.
    Resick PA, Monson CM, Chard KM. Cognitive processing therapy veteran/military version: therapist’s manual. Washington, DC: Department of Veteran Affairs, 2014.Google Scholar
  25. 25.
    Cook JM, Dinnen S, Simiola V, et al. VA residential provider perceptions of dissuading factors to the use of two evidence-based PTSD treatments. Professional Psychology Research and Practice. 2014; 45: 136–142.CrossRefGoogle Scholar
  26. 26.
    van Minnen A, Hendriks L, Olff M. When do trauma experts choose exposure therapy for PTSD patients? A controlled study of therapist and patient factors. Behaviour Research and Therapy. 2010; 48: 312–320.CrossRefPubMedGoogle Scholar
  27. 27.
    Elwyn G, Coulter A, Laitner S, et al. Implementing shared decision making in the NHS. British Medical Journal. 2010; 341: 971–975.CrossRefGoogle Scholar
  28. 28.
    Falsetti SA. The decision-making process of choosing a treatment for patients with civilian trauma-related PTSD. Cognitive and Behavioral Practice. 1997; 4: 99–121.CrossRefGoogle Scholar
  29. 29.
    Guest G, Bunce A, Johnson L. How many interviews are enough?: An experiment with data saturation and variability. Field Methods. 2006; 18: 59–82.CrossRefGoogle Scholar
  30. 30.
    QSR International Pty Ltd. NVivo qualitative data analysis software, 2008.Google Scholar
  31. 31.
    Hsieh H, Shannon SE. Three approaches to qualitative content analysis. Qualitative Health Research. 2005; 15: 1277–1288.CrossRefPubMedGoogle Scholar
  32. 32.
    Pope C, Ziiebland S, May N. Analysing qualitative data. British Medical Journal. 2000; 380: 114–116.CrossRefGoogle Scholar
  33. 33.
    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Washington, DC: American Psychiatric Publishing, 2013.Google Scholar
  34. 34.
    Kaysen D, Schumm J, Pedersen ER, et al. Cognitive processing therapy for veterans with comorbid PTSD and alcohol use disorders. Addictive Behaviors. 2014; 39: 420–427.CrossRefPubMedGoogle Scholar
  35. 35.
    Schnurr PP, Friedman MJ, Engel CC, et al. Cognitive behavioral therapy for posttraumatic stress disorder in women: A randomized controlled trial. Journal of the American Medical Association. 2007; 297: 820–830.CrossRefPubMedGoogle Scholar
  36. 36.
    Hamblen JL, Bernardy NC, Sherrieb K, et al. VA PTSD clinic director perspectives: How perceptions of readiness influence delivery of evidence-based PTSD treatment. Professional Psychology: Research and Practice. 2015; 46: 90–96.CrossRefGoogle Scholar
  37. 37.
    Légaré F, Ratté S, Stacey D, et al. Interventions for improving the adoption of shared decision making by healthcare professionals. The Cochrane Library. 2010.Google Scholar
  38. 38.
    Mott JM, Stanley MA, Street, Jr RL, et al. Increasing engagement in evidence-based PTSD treatment through shared decision-making: A pilot study. Military Medicine. 2014; 179: 143–149.CrossRefPubMedGoogle Scholar
  39. 39.
    Watts BV, Schnurr PP, Zayed M, et al. A randomized controlled clinical trial of a patient decision aid for posttraumatic stress disorder. Psychiatric Services. 2015; 66: 149–154.CrossRefPubMedGoogle Scholar

Copyright information

© National Council for Behavioral Health (outside the USA) 2016

Authors and Affiliations

  • Princess E. Osei-Bonsu
    • 1
    • 2
    • 3
  • Rendelle E. Bolton
    • 4
  • Shannon Wiltsey Stirman
    • 5
  • Susan V. Eisen
    • 6
  • Lawrence Herz
    • 7
  • Maura E. Pellowe
    • 7
  1. 1.Center for Chronic Disease Outcomes Research (CCDOR)Minneapolis VA Health Care SystemMinneapolisUSA
  2. 2.Center for Chronic Disease Outcomes Research (CCDOR)Minneapolis VA Health Care SystemMinneapolisUSA
  3. 3.Department of MedicineUniversity of MinnesotaMinneapolisUSA
  4. 4.Center for Healthcare Organization and Implementation Research (CHOIR)Edith Nourse Rogers Memorial Veterans HospitalBedfordUSA
  5. 5.Dissemination and Training Division, National Center for PTSDVA Palo Alto Healthcare SystemPalo AltoUSA
  6. 6.Department of Health Policy and ManagementBoston University School of Public HealthBostonUSA
  7. 7.Mental Health Service LineEdith Nourse Rogers Memorial Veterans HospitalBedfordUSA

Personalised recommendations