Measuring Use of Evidence Based Psychotherapy for Posttraumatic Stress Disorder in a Large National Healthcare System

Abstract

To derive a method of identifying use of evidence-based psychotherapy (EBP) for post-traumatic stress disorder (PTSD), we used clinical note text from national Veterans Health Administration (VHA) medical records. Using natural language processing, we developed machine-learning algorithms to classify note text on a large scale in an observational study of Iraq and Afghanistan veterans with PTSD and one post-deployment psychotherapy visit by 8/5/15 (N = 255,968). PTSD visits were linked to 8.1 million psychotherapy notes. Annotators labeled 3467 randomly-selected psychotherapy notes (kappa = 0.88) to indicate receipt of EBP. We met our performance targets of overall classification accuracy (0.92); 20.2% of veterans received ≥ one session of EBP over the study period. Our method can assist with identifying EBP use and studying EBP-associated outcomes in routine clinical practice.

Appendices

Appendix 1

See Table 4.

Table 4 Psychotherapy procedure codes used in the VHA

Appendix 2

See Table 5.

Table 5 Comparing methods to estimate use of PE and CPT in first 4 years of psychotherapy

Appendix 3: CPT and PE Guidelines for Annotation

Cognitive Processing Therapy (CPT)—Individual Therapy

• If the title or body of the note states “CPT Session #n”, and is an individual session, consider it CPT—individual.

  • Examples of CPT notes:

    • “Content: this was the fifth session of cognitive processing therapy (CPT) for PTSD.”

    • “Cognitive processing therapy: initial session.”

• Not to be confused with CBT (cognitive behavioral therapy) or with CPT (current procedural terminology) code sets. If numbers follow the initials CPT, it is likely referring to a CPT code.

Cognitive processing therapy (CPT) is a cognitive-behavioral therapy for PTSD and related conditions. CPT typically consists of 12, 50-min therapy sessions. CPT utilizes trauma-specific cognitive challenging techniques to help patients move past inaccurate negative thoughts (called “stuck points”) and progress toward recovery. Additionally, this therapy can be conducted with or without a written trauma account and in individual or group formats.

• Additional phrases in the body of the text may identify a CPT session:

  • Safety module

  • Impact statement

  • Trust module

  • Intimacy module

  • Esteem module

  • Power/control module

  • Trauma account

  • Stuck point(s)

  • Challenging questions

  • Patterns of problematic thinking

  • Socratic questioning

  • Final impact statement

Cognitive Processing Therapy (CPT)—Group Therapy

• If the title or body of the note states “CPT Session #n”, and is a group session, consider it CPT—group therapy.

• Same criteria as listed in CPT-individual above, but note is clearly referring to a CPT group therapy session.

Prolonged Exposure (PE)—Individual Therapy

The goal of prolonged exposure therapy is to promote processing of the trauma memory and to reduce distress and avoidance evoked by the trauma reminders. The imaginal exposure typically occurs during the therapy session and consists of retelling the trauma to the therapist. For the in vivo exposure, the clinician works with the client to establish a fear and avoidance hierarchy and typically assigns exposures to these list items as homework progressively. Both components work by facilitating emotional processing so that the problematic traumatic memories and avoidances habituate (desensitize).

• To address the traumatic memories and triggers that are reminders of the trauma, the core components of prolonged exposure therapy are:

  • 1. Imaginal exposure, revisiting the traumatic memory, repeated recounting it aloud, and processing the revisiting experience, and

  • 2. in vivo exposure, the repeated confrontation with situations and objects that cause distress but are not inherently dangerous.

  • 3. Additional phrases found in the body of the text may identify a PE session:

    • In vivo hierarchy

    • Hot spots

• Examples of PE notes:

  • Prolonged exposure imaginal sessions.

  • Time in session (in minutes): 90.

  • Session Number: 5.

• If the title or body of the note says “PE Session #n”, and is an individual session, consider it PE-individual therapy.

• Check the note’s content carefully to make sure PE does not refer to “physical exam” or “pulmonary embolism”.

Prolonged Exposure (PE)—Group Therapy (Combined with Individual)

If the title or body of the note says “PE Session #n”, and is a group session, consider it PE-group therapy.

Same criteria as listed in PE-individual therapy above, but note is clearly referring to a PE-group therapy session.

Do not annotate as PE unless it is clearly only PE and not combined with DBT or some other modality. Only capture PE group for notes that indicate both imaginal and in vivo components were present, and another modality was not be used concurrently.