Effectiveness of training methods for delivery of evidence-based psychotherapies: a systematic review.

BACKGROUND: Extensive efforts have been made to train mental health providers in evidence-based psychotherapies (EBPs); there is increasing attention focused on the methods through which providers are trained to deliver EBPs. Evaluating EBP training methods is an important step in determining which methods are most effective in increasing provider skill and improving client outcomes. METHODS: We searched MEDLINE (Ovid) and PsycINFO for randomized controlled trials published from 1990 through June 2019 that evaluated EBP training methods to determine the effectiveness of EBP training modalities on implementation (provider and cost) and client outcomes. Eligible studies (N = 28) were evaluated for risk of bias, and the overall strength of evidence was assessed for each outcome. Data was extracted by a single investigator and confirmed by a second; risk of bias and strength of evidence were independently rated by two investigators and determined by consensus. RESULTS: Overall, EBP training improved short-term provider satisfaction, EBP knowledge, and adherence compared to no training or self-study of training materials (low to moderate strength of evidence). Training in an EBP did not increase treatment adoption compared to no training or self-study. No specific active EBP training modality was found to consistently increase provider EBP knowledge, skill acquisition/adherence, competence, adoption, or satisfaction compared to another active training modality. Findings were mixed regarding the additive benefit of post-training consultation on these outcomes. No studies evaluated changes in provider outcomes with regards to training costs and few studies reported on client outcomes. LIMITATIONS: The majority of included studies had a moderate risk of bias and strength of evidence for the outcomes of interest was generally low or insufficient. Few studies reported effect sizes. The ability to identify the most effective EBP training methods was limited by low strength of evidence for the outcomes of interest and substantial heterogeneity among studies. CONCLUSIONS: EBP training may have increased short-term provider satisfaction, EBP knowledge, and adherence though not adoption. Evidence was insufficient on training costs and client outcomes. Future research is needed on EBP training methods, implementation, sustainability, client outcomes, and costs to ensure efforts to train providers in EBPs are effective, efficient, and durable. TRIAL REGISTRATION: The protocol for this review is registered in PROSPERO (CRD42018093381).

Measuring perceived efficacy for coping with posttraumatic stress disorder in the workplace.

BACKGROUND: PTSD is associated with high levels of vocational difficulty, and research on relationships between PTSD and vocational adjustment may be relevant to vocational rehabilitation services to achieve optimal outcomes. Veteran perception of ability to cope with stressors in the workplace setting may play a role in rehabilitation outcome. OBJECTIVE: This article outlines preliminary steps in the development of the Vocational Efficacy in Trauma Survivors Scale (VETSS), to measure perceived efficacy in managing PTSD symptoms in the workplace. This has potential to expand future options for research in vocational rehabilitation for veterans with PTSD. METHODS: Veterans in outpatient treatment for PTSD at a large, mid-western Veterans Affairs Health Care System facility responded to items on the proposed instrument and items on other measures of vocational and psychological functioning to assess the potential validity of items for an instrument to measure vocational self-efficacy among veterans managing PTSD. RESULTS: In a sample of 63 working veterans who receive outpatient care for PTSD, exploratory factor analysis identified two viable subscales, one tapping Workplace Coping, and another tapping Self-Disclosure. CONCLUSIONS: Preliminary findings indicate that the measure demonstrated acceptable indications of reliability and validity, suggesting promise for future use in vocational rehabilitation research.

Employment outcomes from VA vocational services involving transitional work for veterans with a diagnosis of posttraumatic stress disorder.

OBJECTIVE: Transitional work (TW) for veterans with psychiatric disabilities is the predominant model of vocational rehabilitation in the Veterans Health Administration (VA). Although, on average, TW employment outcomes have been demonstrated to be inferior to supported employment, little is known about the potential subgroup of veterans for which TW may be most effective. This study of veterans with posttraumatic stress disorder (PTSD) examines differences in competitive employment outcomes and identifies characteristics of veterans who chose to engage in TW compared with those who did not. METHOD: A post hoc comparative subgroup analysis of veterans with PTSD randomly assigned to TW as part of a randomized controlled trial was conducted. Veterans were divided into 2 subgroups: those who engaged in TW (n = 141) and nonengagers (n = 129). Differences in baseline characteristics were examined and 18-month employment outcomes were compared. RESULTS: There were no differences in 18-month employment outcomes between TW engagers and nonengagers. Compared with TW engagers, those that did not engage in TW were 2.5 times more likely to get a competitive job within the first 6 months and were less likely to obtain lower skilled jobs. Younger age, adequate housing, personal means of transportation, and recent work history factor into the odds of gaining and maintaining competitive work. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Consistent with past research, engagement in TW did not result in improved long-term competitive employment outcomes for veterans with PTSD. Those who did not engage in TW were more likely to gain a competitive job within the first 6 months. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Comorbid Posttraumatic Stress Disorder and Traumatic Brain Injury: Generalization of Prolonged-Exposure PTSD Treatment Outcomes to Postconcussive Symptoms, Cognition, and Self-Efficacy in Veterans and Active Duty Service Members.

OBJECTIVES: To examine (a) generalization of the effectiveness of prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD) in improving postconcussive symptoms (PCSs) and other outcomes in military service members and Veterans (VA) with histories of mild to severe traumatic brain injury (TBI), and (b) factors associated with PCS reduction. SETTING: VA polytrauma medical center. PARTICIPANTS: Consecutive referrals for PTSD treatment of Active Duty (n = 17) or Veterans (n = 27) diagnosed with PTSD and TBI (N = 44). MAIN OUTCOME MEASURES: Neurobehavioral Symptom Inventory, Key Behaviors Change Inventory, Self-Efficacy for Symptom Management, Posttraumatic Stress Disorder Checklist, and Beck Depression Inventory, 2nd edition. DESIGN: Post hoc analysis of archival clinical effectiveness program evaluation data. INTERVENTIONS: PE for PTSD. RESULTS: There were significant improvements on all outcome measures with large effect sizes (Cohen's d ranging from 0.68 to 2.02). Improvement on PCS (Cohen's d = 1.21) was associated with lower levels of VA service-connected disability and PE treatment completion. CONCLUSION: PE treatment-related improvements for participants with comorbid PTSD and TBI generalize from PTSD outcomes to PCS and other TBI-related outcomes. Positive outcomes were independent of TBI severity, treatment setting, or Veteran status, but dependent upon PE treatment completion and lower levels of VA service-connected disability.

Workplace social support in job satisfaction among veterans with posttraumatic stress symptoms: A preliminary correlational study.

For Veterans managing PTSD symptoms, returning to vocational functioning is often challenging; identifying modifiable variables that can contribute to positive vocational adjustment is critical to improved vocational rehabilitation services. Workplace social support has proven to be important in vocational adjustment in both general population and vocational rehabilitation samples, but this area of inquiry has received little attention among Veterans with PTSD symptoms. In this small correlational study, employed Veterans (N = 63) presenting for outpatient PTSD treatment at a VA Health Care System completed surveys assessing demographic variables, PTSD symptoms, workplace social support, and job satisfaction. Workplace social support contributed to the prediction of job satisfaction. It is of note that workplace social support predicted a larger proportion of the variance in employment satisfaction than PTSD symptoms. Further research on workplace social support as a vocational rehabilitation resource for Veterans with PTSD is indicated.

Reducing suicidal ideation through evidence-based treatment for posttraumatic stress disorder.

BACKGROUND: Suicide is a major public health concern in military and civilian contexts. Veteran populations are at increased risk for suicide, especially veterans with mental health disorders such as Posttraumatic Stress Disorder (PTSD). Suicidal ideation (SI) is a primary risk factor for suicide. METHODS: We investigated changes in SI in a multi-site sample of treatment seeking veterans from three separate Veterans Health Administration (VA) medical centers (n = 289) who received Prolonged Exposure (PE) therapy, an evidence-based treatment (EBT) for PTSD. SI and PTSD symptoms were assessed, using self-report instruments, throughout routine clinical care. RESULTS: Both PTSD and SI symptoms reduced over the course of treatment (d-type effect sizes of 1.47 and 0.27, respectively). While SI was associated with PTSD symptoms at all time points, appropriately specified, time lagged models indicated that changes in PTSD symptoms were predictive of future declines in SI, while the converse was not true. CONCLUSIONS: Results indicate that treating PTSD symptoms with an EBT for PTSD can be an effective way to reduce SI, at least partially, and for some patients. These data are significant in light of the resources and programming devoted to addressing SI in the VA relative to available empirical evidence regarding the effectiveness of developed strategies. The findings demonstrate the importance of facilitating EBT referrals for specific disorders as a component of broad-based suicide outreach and preventions strategies.

Prolonged Exposure Therapy With Veterans and Active Duty Personnel Diagnosed With PTSD and Traumatic Brain Injury.

The present study used archival clinical data to analyze the delivery and effectiveness of prolonged exposure (PE) and ancillary services for posttraumatic stress disorder (PTSD) among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (N = 69) with histories of mild to severe traumatic brain injury (TBI). Data from standard clinical assessments of veterans and active duty personnel treated in both inpatient and outpatient programs at 2 Department of Veteran Affairs medical centers were examined. Symptoms were assessed with self-report measures of PTSD (PTSD Checklist) and depression (Beck Depression Inventory-II) before and throughout therapy. Mixed linear models were utilized to determine the slope of reported symptoms throughout treatment, and the effects associated with fixed factors such as site, treatment setting (residential vs. outpatient), and TBI severity were examined. Results demonstrated significant decreases in PTSD, B = -3.00, 95% CI [-3.22, -2.78]; t(210) = -13.5; p < .001, and in depressive symptoms, B = -1.46, 95% CI [-1.64, -1.28]; t(192) = -8.32; p < .001. The effects of PE treatment did not differ by clinical setting and participants with moderate to severe injuries reported more rapid gains than those with a history of mild TBI. The results provide evidence that PE may well be effective for veterans with PTSD and TBI.

Driving difficulties among military veterans: clinical needs and current intervention status.

Military personnel deployed to Iraq and Afghanistan often develop mental health difficulties, which may manifest as problematic driving behavior. Veterans may be more likely to engage in risky driving and to subsequently be involved in motor vehicle accidents and fatalities. This article reviews literature on driving difficulties among military veterans and evaluates available research on the potential pathways that underlie risky driving behavior. Current interventions for problematic driving behaviors are considered, and the necessity of modifying these interventions to address the unique difficulties encountered by military veterans is highlighted. The review concludes with a discussion of clinical implications of these findings and identification of possible avenues for future research and intervention.

Risk-taking behaviors and impulsivity among veterans with and without PTSD and mild TBI.

Military personnel commonly experience post-traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI), both of which are associated with premature mortality. The present study examined two factors that may play a role in premature mortality--impulsivity and risk-taking behaviors--in a sample of 234 veterans screening positive for PTSD, mTBI, PTSD + mTBI, and controls. Analyses of variance demonstrated that veterans with PTSD, regardless of mTBI status, reported engaging in more frequent risky behaviors and reported a greater tendency to engage in impulsive behaviors when in a negative affective state. They also reported more premilitary delinquent behaviors and more suicide-related behaviors than controls. The present study highlights associations between impulsivity, risk-taking behaviors, and PTSD, and suggests continuity across the lifespan in terms of a predisposition to engage in impulsive and/or risky behaviors. Thorough evaluation of impulsivity and potentially risky behaviors is important in clinical settings to guide interventions and reduce the mortality and public health impact of high-risk behaviors in veterans.

Cognitive-behavioral group treatment for driving-related anger, aggression, and risky driving in combat veterans: a pilot study.

The present study examined the preliminary effects of an 8-session group cognitive-behavioral treatment (CBT) designed to reduce driving-related anger, aggression, and risky driving behaviors in veterans. Participants (N = 9) with self-reported aggressive and risky driving problems completed self-report measures at pretreatment, posttreatment, and 1-month follow-up. Of those completing the treatment, 89% demonstrated reliable change in driving-related aggression and 67% evidenced reliable change in driving-related anger. Similar changes were found for secondary treatment targets.

Service utilization following participation in cognitive processing therapy or prolonged exposure therapy for post-traumatic stress disorder.

This study evaluated the impact of a course of prolonged exposure or cognitive processing therapy on mental health and medical service utilization and health care service costs provided by the Department of Veterans Affairs (VA). Data on VA health service utilization and health care costs were obtained from national VA databases for 70 veterans who completed prolonged exposure or cognitive processing therapy at a Midwestern VA medical center. Utilization of services and cost data were examined for the year before and after treatment. Results demonstrated a significant decrease in the use of individual and group psychotherapy. Direct costs associated with mental health care decreased by 39.4%. Primary care and emergency department services remained unchanged.

An exploratory examination of risk-taking behavior and PTSD symptom severity in a veteran sample.

The present study conducted an exploratory examination of the relationship between self-reported symptoms of post-traumatic stress disorder and an expanded definition of risk-taking behaviors among 395 veterans at a large Midwestern Veterans Affairs Medical Center. Post-traumatic stress disorder symptoms were associated with elevated rates of substance use, thrill seeking, aggression, risky sexual practices, and firearm possession. Results indicated that suicidal ideation and aggressive driving behavior were among the most frequently reported. The present findings hold significant public health implications and highlight the need to attend to risk-taking behaviors in treatment planning.

A preliminary examination of prolonged exposure therapy with Iraq and Afghanistan veterans with a diagnosis of posttraumatic stress disorder and mild to moderate traumatic brain injury.

OBJECTIVE: : Preliminary examination of the effectiveness of prolonged exposure (PE) therapy for the treatment of posttraumatic stress disorder (PTSD) with Operation Enduring Freedom and Operation Iraqi Freedom Veterans who have experienced traumatic brain injury (TBI). PARTICIPANTS: : Ten Veterans with a history of mild to moderate TBI and chronic PTSD. SETTING: : Outpatient Mental Health/PTSD clinics and polytrauma centers at 2 VA medical centers. MEASURES: : Comprehensive evaluation that included clinical interview, neuropsychologic evaluation, and/or neuroimaging; Posttraumatic Stress Disorder Checklist and Beck Depression Inventory-Second Edition. PROCEDURES: : Standard implementation of the PE manual was used in all cases with slight adjustments to account for Veterans' residual cognitive deficits. Veterans completed between 8 and 18 sessions. RESULTS: : Veterans demonstrated significant reductions in total PTSD and depression symptoms from pre- to posttreatment. Within-group effect sizes were large. CONCLUSIONS: : These findings suggest that PE can be safely and effectively implemented with Veterans with PTSD, a history of mild to moderate TBI, and current cognitive impairment.

Stress, appraisal and coping following mild traumatic brain injury.

PURPOSE: The present study tested a portion of the stress, appraisal and coping (SAC) model proposed by Godfrey, Knight and Partridge. METHODS: Using data gathered from 94 individuals who had sustained a traumatic brain injury, path analysis results indicated that a model based on Godfrey et al.'s SAC model did not fit the sample data. Based on relevant statistical output, previous research and theory, a re-specified model was tested. RESULTS: The final model was shown to meet common statistical measures for establishing model fit. The final model indicated that higher levels of perceived stress were predictive of higher levels of self-reported depression, higher levels of depression were predictive of lower levels of dispositional hope and dispositional hope was predictive of increased life satisfaction and work productivity. CONCLUSIONS: The present findings hold implications for both research and for clinical practice. The findings do suggest the need for additional research to further clarify factors that contribute to emotional adjustment following traumatic brain injury.