A Review of Studies on the System-Wide Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration.

Since 2006, the Veterans Health Administration (VHA) has instituted policy changes and training programs to support system-wide implementation of two evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). To assess lessons learned from this unprecedented effort, we used PubMed and the PILOTS databases and networking with researchers to identify 32 reports on contextual influences on implementation or sustainment of EBPs for PTSD in VHA settings. Findings were initially organized using the exploration, planning, implementation, and sustainment framework (EPIS; Aarons et al. in Adm Policy Ment Health Health Serv Res 38:4-23, 2011). Results that could not be adequately captured within the EPIS framework, such as implementation outcomes and adopter beliefs about the innovation, were coded using constructs from the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework (Glasgow et al. in Am J Public Health 89:1322-1327, 1999) and Consolidated Framework for Implementation Research (CFIR; Damschroder et al. in Implement Sci 4(1):50, 2009). We highlight key areas of progress in implementation, identify continuing challenges and research questions, and discuss implications for future efforts to promote EBPs in large health care systems.

Improving depression care in a psychiatry resident psychopharmacology clinic: measurement, monitoring, feedback and education.

OBJECTIVE: Better outcomes for major depressive disorder (MDD) are associated with proactive treatment, including timely follow-up, systematic assessment and treatment changes for inadequate improvement. The effectiveness of an intervention to facilitate proactive treatment for MDD in a resident psychopharmacology clinic was studied. METHODS: A quality improvement program with administrative process changes to improve flow and a 40-week pre/post study to evaluate the effect of education and feedback was conducted. A systematic assessment and reengineered scheduling system were implemented. During the first 20 weeks, baseline data were collected; during the second 20 weeks, feedback to residents and attending psychiatrists about adherence to evidence-based treatment recommendations was added. RESULTS: Reengineering our system to improve flow was successful. By linking outcomes collection to completion of billing sheets, outcomes at 90% of visits for MDD throughout the 40-week study was assessed. By centralising our scheduling system, the percentage of active-phase patients with MDD seen for follow-up within 6 weeks was improved from 19% to 59%. In response to feedback, residents did not make significant changes to their overall practice patterns. Patient outcomes did not improve as a result of feedback to residents. Residents did improve their practice patterns for a subset of patients including those without comorbid psychiatric disorders and those whose depressive episodes had lasted <1 year. CONCLUSIONS: Improving administrative processes for the treatment of patients with MDD resulted in rapid changes that were associated with improvements in the delivery of evidence-based care. Feedback to residents was more difficult and less successful.

The use of flumazenil in the anxious and benzodiazepine-dependent ECT patient.

Many patients who receive electroconvulsive therapy (ECT) are benzodiazepine dependent or are anxious and require benzodiazepine drugs. Because these agents may diminish the therapeutic effectiveness of ECT, we explored the dosing, safety, and efficacy of pre-ECT flumazenil administration, a benzodiazepine-competitive antagonist, in patients receiving benzodiazepine medications. We report our experience with 35 patients who received both flumazenil and benzodiazepine drugs during their ECT course. We compared seizure duration with and without flumazenil and compared treatment efficacy to 49 patients who received ECT without either of these medications. Flumazenil could be safely administered with ECT. A few subjects taking higher chronic benzodiazepine dosages experienced breakthrough anxiety or withdrawal symptoms, which were well managed by dosing flumazenil immediately before the anesthetic agent and by immediate posttreatment benzodiazepine administration. A dose of 0.4-0.5 mg was adequate for all but those taking the highest benzodiazepine dosages, where 0.8-1.0 mg resulted in a clinically more effective reversal. No differences in efficacy or seizure duration were found as a function of flumazenil administration. Flumazenil offers the promise of safe and effective ECT in patients receiving benzodiazepine drugs. Follow-up outcome investigation on a random assignment basis will be necessary for definitive assessment of the value of flumazenil. In addition, the direct effect of benzodiazepine drugs and the flumazenil/benzodiazepine combination on ECT seizures remains to be determined.