Documentation of Evidence-Based Psychotherapy and Care Quality for PTSD in the Department of Veterans Affairs
This study measured the prevalence of evidence-based psychotherapy (EBP) templated notes in VA and tested the hypothesis that template use would be associated with care quality for posttraumatic stress disorder (PTSD). Across 130 facilities, an average of 3.6% of patients with a PTSD diagnosis received at least one EBP template in 2015. Among patients receiving psychotherapy for PTSD, an average of 8.5% received an EBP template. In adjusted models, facility-level EBP template use was associated with a greater proportion of PTSD-diagnosed patients treated in specialty clinics, greater facility-level rates of diagnostic assessment, and greater facility-level rates of psychotherapy adequacy.
KeywordsPosttraumatic stress disorder EBP Evidence-based treatment Template VA Veteran
Dr. Sripada is supported by Career Development Award (CDA) 15–251, IK2 HX-002095-01 from the United States (U.S.) Department of Veterans Affairs Health Services R&D (HSRD) Service. Dr. Bohnert is supported by CDA 11–245, IK2 HX-002095-01 from the HSRD Service.
Compliance with Ethical Standards
Conflict of interest
All the authors declare that they have no conflict of interest.
The VA Ann Arbor Healthcare System Institutional Review Board approved this study and granted a waiver of informed consent for access to protected health information.
Research Involving Human and Animals Participants
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
- APA. (2012). Mental Health Performance Measures. Retrieved from https://www.psychiatry.org/psychiatrists/practice/quality-improvement/mental-health-performance-measures.
- Brown, J., Scholle, S. H., & Azur, M. (2014). Strategies for measuring the quality of psychotherapy: A white paper to inform measure development and implementation. report submitted to the assistant secretary for planning and evaluation. Washington, DC: U.S. Department of Health and Human ServicesGoogle Scholar
- Chard, K. M. (2014). Cognitive processing therapy train-the-trainer workshop. Cincinnati, OH: University of CincinnatiGoogle Scholar
- Cifuentes, M., Davis, M., Fernald, D., Gunn, R., Dickinson, P., & Cohen, D. J. (2015). Electronic Health Record Challenges, Workarounds, and Solutions Observed in Practices Integrating Behavioral Health and Primary Care. Journal of the American Board of Family Medicine: JABFM, 28(Suppl 1), S63–S72. doi: 10.3122/jabfm.2015.S1.150133.CrossRefPubMedGoogle Scholar
- Cook, J. M., Dinnen, S., Simiola, V., Bernardy, N., Rosenheck, R., & Hoff, R. (2014). Residential treatment for posttraumatic stress disorder in the department of veterans affairs: a national perspective on perceived effective ingredients. Traumatology (Tallahass Fla), 20, 43–49. doi: 10.1037/h0099379.CrossRefGoogle Scholar
- Cook, J. M., Dinnen, S., Thompson, R., Ruzek, J., Coyne, J. C., & Schnurr, P. P. (2015). A Quantitative Test of an Implementation Framework in 38 VA Residential PTSD Programs. Administration and Policy in Mental Health, 42, 462–473. doi: 10.1007/s10488-014-0590-0.CrossRefPubMedPubMedCentralGoogle Scholar
- Finley, E. P., Garcia, H. A., Ketchum, N. S., McGeary, D. D., McGeary, C. A., Stirman, S. W., & Peterson, A. L. (2015). Utilization of evidence-based psychotherapies in Veterans Affairs posttraumatic stress disorder outpatient clinics. Psychological Services, 12, 73–82. doi: 10.1037/ser0000014.CrossRefPubMedGoogle Scholar
- Fulton, J. J., Calhoun, P. S., Wagner, H. R., Schry, A. R., Hair, L. P., Feeling, N., … Beckham, J. C. (2015). The prevalence of posttraumatic stress disorder in operation enduring freedom/operation iraqi freedom (OEF/OIF) veterans: A meta-analysis. Journal of Anxiety Disorders, 31, 98–107. doi: 10.1016/j.janxdis.2015.02.003.CrossRefPubMedGoogle Scholar
- Hamblen, J. L., Bernardy, N. C., Sherrieb, K., Norris, F. H., Cook, J. M., Louis, C. A., & Schnurr, P. P. (2015). VA PTSD clinic director perspectives: How perceptions of readiness influence delivery of evidence-based PTSD treatment. Professional Psychology: Research and Practice, 46, 90.CrossRefGoogle Scholar
- IOM. (2015). Psychosocial interventions for mental and substance use disorders: a framework for establishing evidence-based standards. Washington, DC: National Academies Press.Google Scholar
- Karlin, B. E., & Cross, G. (2014). From the laboratory to the therapy room: National dissemination and implementation of evidence-based psychotherapies in the U.S. Department of Veterans Affairs Health Care System. The American Psychologist, 69, 19–33. doi: 10.1037/a0033888.CrossRefPubMedGoogle Scholar
- Measurement Based Care (MBC) in Mental Health Initiative. (2016). Retrieved from http://www.mirecc.va.gov/visn4/docs/MBCinMHInitiative.pdf.
- Osei-Bonsu, P. E., Bolton, R. E., Stirman, Wiltsey, Eisen, S., Herz, S. V., L., & Pellowe, M. E. (2016). Mental health providers’ decision-making around the implementation of evidence-based treatment for PTSD. The Journal of Behavioral Health Services & Research. doi: 10.1007/s11414-015-9489-0.Google Scholar
- Rosen, C. S., Eftekhari, A., Crowley, J. J., Smith, B. N., Kuhn, E., Trent, L., … Ruzek, J. I. (2017). Maintenance and reach of exposure psychotherapy for posttraumatic stress disorder 18 months after training. Journal of Traumatic Stress, 30, 63–70. doi: 10.1002/jts.22153.CrossRefPubMedGoogle Scholar
- Rosen, C. S., Matthieu, M. M., Wiltsey Stirman, S., Cook, J. M., Landes, S., Bernardy, N. C., … Watts, B. V. (2016). A review of studies on the system-wide implementation of evidence-based psychotherapies for posttraumatic stress disorder in the veterans health administration. Administration and Policy in Mental Health, 43, 957–977. doi: 10.1007/s10488-016-0755-0.CrossRefPubMedGoogle Scholar
- Ruzek, J. I., Eftekhari, A., Crowley, J., Kuhn, E., Karlin, B. E., & Rosen, C. S. (2015). Post-training beliefs, intentions, and use of prolonged exposure therapy by clinicians in the veterans health administration. Administration and Policy in Mental Health. doi: 10.1007/s10488-015-0689-y.Google Scholar
- Sayer, N. A. (2015). A preliminary look at use of PE and CPT in VHA outpatient programs. Paper presented at the VA Health Services Research & Development Conference, Philadelphia, PA.Google Scholar
- Sripada, R. K., Pfeiffer, P. N., Rampton, J., Ganoczy, D., Rauch, S. A., Polusny, M. A., & Bohnert, K. M. (2017). Predictors of PTSD symptom change among Outpatients in the U.S. department of veterans affairs health care system. Journal of Traumatic Stress, 30, 45–53. doi: 10.1002/jts.22156.CrossRefPubMedGoogle Scholar
- Stirman, S. W., Shields, N., Deloriea, J., Landy, M. S., Belus, J. M., Maslej, M. M., & Monson, C. M. (2013). A randomized controlled dismantling trial of post-workshop consultation strategies to increase effectiveness and fidelity to an evidence-based psychotherapy for Posttraumatic stress disorder. Implementation Science, 8, 1.CrossRefGoogle Scholar
- VA. (2008). Uniform mental health services in VA medical centers and clinics. VHA handbook, 1160.01. West Haven, CT: Northeast Program Evaluation CenterGoogle Scholar
- VA. (2012). Local implementation of evidence-based psychotherapies for mental and behavioral health conditions. VHA handbook, 1160.05. West Haven, CT: Northeast Program Evaluation CenterGoogle Scholar
- VA. (2013). The long journey home XXII: Treatment of posttraumatic stress disorder (PTSD). West Haven, CT: Northeast Program Evaluation Center.Google Scholar
- VA. (2014). Memorandum on implementation of the evidence-based psychotherapy (EBP) documentation templates. October 9, 2014.Google Scholar
- VA/DoD. (2010). U.S. Department of Veterans Affairs & Department of Defense. VA/DoD clinical practice guidelines for the management of post-traumatic stress. Washington, DC: VA/DoD.Google Scholar
- Watts, B. V., Shiner, B., Zubkoff, L., Carpenter-Song, E., Ronconi, J. M., & Coldwell, C. M. (2014). Implementation of evidence-based psychotherapies for posttraumatic stress disorder in VA specialty clinics. Psychiatric Services, 65, 648–653. doi: 10.1176/appi.ps.201300176.CrossRefPubMedGoogle Scholar
- Weathers, F. W., Huska, J. A., & Keane, T. M. (1991). PCL-M for DSM-IV. Boston: National Center for PTSD—Behavioral Science Division.Google Scholar
- Zubkoff, L., Carpenter-Song, E., Shiner, B., Ronconi, J. M., & Watts, B. V. (2016). Clinicians’ perception of patient readiness for treatment: An emerging theme in implementation science? Administration and Policy in Mental Health, 43, 250–258. doi: 10.1007/s10488-015-0635-z.CrossRefPubMedGoogle Scholar