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.

Altered cortisol response in sober alcoholics: an examination of contributing factors.

We have previously reported an attenuated plasma cortisol stress response in alcoholics abstinent from alcohol up to 4 weeks. The present study replicates and extends these findings by examining urinary cortisol levels in detoxified alcoholics (n = 40) and controls (n = 14) at rest and following mental arithmetic and isometric handgrip stress. Although the groups had similar baseline cortisol levels, the alcoholics showed an attenuated cortisol response to the combined stressors. This cortisol response reduction was unrelated to potential confounds such as smoking, liver function, age, depression, or anxiety. A multivariate model showed a trend for an association between severity of withdrawal and alcoholics' poststress cortisol levels. Although these results indicate decreased adrenocortical response to biobehavioral stress in alcoholics abstinent up to four weeks, higher stress cortisol values were seen in the patients with the most severe withdrawal symptoms.

Hemodynamic alterations in alcohol-related transitory hypertension.

Alcoholic patients are often transiently hypertensive (tHT) during days 1-3 of withdrawal but become normotensive thereafter. However, at 3-4 weeks postwithdrawal these tHT patients may still show exaggerated blood pressure rises to isometric handgrip exercise. We examined the hemodynamic mechanisms associated with persistent altered pressure response. Forty-two alcoholic inpatients were equally divided into three subgroups based on admission BPs: transitory hypertensive (tHT;BP > or = 160/95 mmHg), transitory borderline hypertensive (tBH; 140/ 90 < or = BP < 160/95), and normotensive (NT; BP < 140/90). After 3-4 weeks of sobriety, the alcoholics and a normotensive nonalcoholic group (CONTs; n = 14) were tested during rest and an isometric handgrip task. Impedance cardiographic evaluation at both times showed elevated peripheral resistance, elevated heart rate, and reduced stroke volume in tHTs. Liquor consumption was found to be highly predictive of the altered hemodynamic and BP activity. Alcoholic patients with acute withdrawal hypertension (1-3 days) may show a persistent alteration of BP regulation even when resting pressures are normal.

Drinking history is related to persistent blood pressure dysregulation in postwithdrawal alcoholics.

We have previously demonstrated that alcoholics with transitory (< 72 hr) elevations in blood pressure (BP) during withdrawal continue to show residual cardiovascular dysregulation up to 4 weeks of abstinence. The present study replicates and extends these findings. Alcoholic inpatients were divided into three subgroups (ns = 14) based on BP during the first 72 hr of withdrawal: transitory hypertensives (tHTs; BP > 160/95 mm Hg), transitory borderline hypertensives (tBHs; 140/90 < or = BP < 160/95), and normotensives (NTs; all BPs < 140/90). All patients had normal resting pressures after 72 hr of withdrawal. At 3-4 weeks postadmission, the alcoholics and 14 nonalcoholic controls (CONTs) were tested at rest and during a 5-min handgrip task. The tHTs showed an exaggerated systolic and diastolic BP response to handgrip compared with NTs and CONTs, with tBHs intermediate (ps < 0.05). Drinking history showed the tHTs had the highest reported level of alcohol consumption and severity of withdrawal symptoms (ps < 0.05). Regression analyses indicated that consumption of hard liquor was the variable most predictive of admission BPs; further, parental history of hypertension potentiated this relationship for systolic BP. Age and consumption of nicotine and caffeine were not significant predictors of admission BP. The results suggest a persistent cardiovascular dysregulation in alcoholics showing transient hypertensive withdrawal BPs. These alcoholics may be at increased risk for future alcohol-related cardiovascular disorder.