Unlike the post-Vietnam era, effective, specialized treatments for posttraumatic stress disorder (PTSD) now exist, although these treatments have not been widely available in clinical settings. The U.S. Department of Veterans Affairs (VA) is nationally disseminating 2 evidence-based psychotherapies for PTSD throughout the VA health care system. The VA has developed national initiatives to train mental health staff in the delivery of Cognitive Processing Therapy (CPT) and Prolonged Exposure therapy (PE) and has implemented a variety of strategies to promote local implementation. In this article, the authors examine VA's national CPT and PE training initiatives and report initial patient, therapist, and system-level program evaluation results. Key issues, lessons learned, and next steps for maximizing impact and sustainability are also addressed.

osttraumatic stress disorder (PTSD) affects more than 6% of the US population and up to 13% of US military personnel returning from deployment in Iraq and Afghanistan. 1-3 It is associated with substantially reduced quality of life through both impaired role functioning and higher risk of cardiovascular disease, diabetes mellitus, and substance use conditions. 4-8 There is an especially critical need for effective treatments for PTSD as increasing numbers of veterans return from Iraq and Afghanistan. Since 2001, the number of veterans with diagnosed PTSD receiving care in the Veterans Health Administration (VHA), the health care arm of the US Department of Veterans Affairs (VA), has tripled. 9 In recent years, there have been significant advances in the treatment of PTSD, with development of a variety of efficacious treatments. Exposure-based psychotherapies are among the treatments with the most empiric al support. 10-16 Exposure therapy is recommended as a firstline treatment for PTSD in all clinical treatment guidelines in the United States and other countries. 17 A rigorous review of P TSD treatments conduc ted by the Institute of Medicine 18 concluded that exposure therapy was the only psychological or psychopharmacological intervention with sufficient data to support its efficacy in the treatment of PTSD. IMPORTANCE Posttraumatic stress disorder (PTSD) is a pervasive and often debilitating condition that affects many individuals in the general population and military service members. Effective treatments for PTSD are greatly needed for both veterans returning from Iraq and Afghanistan and veterans of other eras. Prolonged exposure (PE) therapy has been shown to be highly efficacious in clinical trials involving women with noncombat trauma, but there are limited data on its effectiveness in real-world clinical practice settings and with veterans. OBJECTIVE To evaluate the effectiveness of PE as implemented with veterans with PTSD in a large health care system. DESIGN, SETTING, AND PARTICIPANTS This evaluation included 1931 veterans treated by 804 clinicians participating in the Department of Veterans Affairs (VA) PE Training Program. After completing a 4-day experiential PE training workshop, clinicians implemented PE (while receiving consultation) with a minimum of 2 veteran patients who had a primary diagnosis of PTSD. MAIN OUTCOMES AND MEASURES Changes in PTSD and depression symptoms were assessed with the PTSD Checklist and the Beck Depression Inventory II, measured at baseline and at the final treatment session. Multiple and single imputation were used to estimate the posttest scores of patients who left treatment before completing 8 sessions. Demographic predictors of treatment dropout were also examined. RESULTS Intent-to-treat analyses indicate that PE is effective in reducing symptoms of both PTSD (pre-post d= 0.87) and depression (pre-post d= 0.66), with effect sizes comparable to those reported in previous efficacy trials. The proportion of patients screening positive for PTSD on the PTSD Checklis...

Emotion regulatory strategies such as higher expressive suppression and lower cognitive reappraisal may be associated with increased psychopathology (Gross & John, 2003). Yet, it is unclear whether these strategies represent distinct cognitive styles associated with psychopathology, such that there are individuals who are predominantly “suppressors” or “reappraisers.” Using cluster analysis, we examined whether women with and without exposure to potentially traumatic events evidence distinct patterns of emotion regulation frequency, capacity, suppression, and cognitive reappraisal. Four patterns emerged: high regulators; high reappraisers/low suppressors; moderate reappraisers/low suppressors; and low regulators. Individuals who reported infrequently and ineffectively regulating their emotions (low regulators) also reported higher depression, anxiety, and posttraumatic stress disorder (PTSD). In contrast, individuals who reported frequently and effectively using reappraisal and low levels of suppression (high reappraisers/low suppressors) reported the lowest levels of these symptoms, suggesting that this specific combination of emotion regulation may be most adaptive. Our findings highlight that the capacity to regulate emotions and the ability to flexibly apply different strategies based on the context and timing may be associated with reduced psychopathology and more adaptive functioning.

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.

Abstract-Prolonged exposure (PE) is an effective first-line treatment for posttraumatic stress disorder (PTSD), regardless of the type of trauma, for Veterans and military personnel. Extensive research and clinical practice guidelines from various organizations support this conclusion. PE is effective in reducing PTSD symptoms and has also demonstrated efficacy in reducing comorbid issues such as anger, guilt, negative health perceptions, and depression. PE has demonstrated efficacy in diagnostically complex populations and survivors of single-and multiple-incident traumas. The PE protocol includes four main therapeutic components (i.e., psychoeducation, in vivo exposure, imaginal exposure, and emotional processing). In light of PE's efficacy, the Veterans Health Administration designed and supported a PE training program for mental health professionals that has trained over 1,300 providers. Research examining the mechanisms involved in PE and working to improve its acceptability, efficacy, and efficiency is underway with promising results.

Evidence-based psychotherapies for PTSD are often underused. The objective of this mixed-method study was to identify organizational and clinic factors that promote high levels of reach of evidence-based psychotherapies for PTSD 10 years into their dissemination throughout the Veterans Health Administration. We conducted 96 individual interviews with staff from ten outpatient PTSD teams at nine sites that differed in reach of evidence-based psychotherapies for PTSD. Major themes associated with reach included clinic mission, clinic leader and staff engagement, clinic operations, staff perceptions, and the practice environment. Strategies to improve reach of evidence-based psychotherapies should attend to organizational and team-level factors.Electronic supplementary materialThe online version of this article (doi:10.1007/s10488-017-0809-y) contains supplementary material, which is available to authorized users.

Objective-One in three veterans will dropout from trauma-focused treatments for PTSD. Social environments may be particularly important to influencing treatment retention. We examined the role of two support system factors in predicting treatment dropout: social control (direct efforts by loved ones to encourage veterans to participate in treatment and face distress) and symptom accommodation (changes in loved ones' behavior to reduce veterans' PTSD-related distress).Method-Veterans and a loved one were surveyed across four VA hospitals. All veterans were initiating Prolonged Exposure therapy or Cognitive Processing Therapy (n = 272 dyads). Dropout was coded through review of VA hospital records.Results-Regression analyses controlled for traditional, individual-focused factors likely to influence treatment dropout. We found that, even after accounting for these factors, veterans who reported their loved ones encouraged them to face distress were twice as likely to remain in PTSD treatment than veterans who denied such encouragement.Conclusions-Clinicians initiating trauma-focused treatments with veterans should routinely assess how open veterans' support systems are to encouraging veterans to face their distress. Outreach to support networks is warranted to ensure loved ones back the underlying philosophy of trauma-focused treatments.

Posttraumatic stress disorder (PTSD) is associated with functional impairment, co-occurring diagnoses, and increased health care utilization. Associated high demand for health care services is an important contributor to the large public-health cost of PTSD. Treatments incorporating exposure therapy are efficacious in ameliorating or eliminating PTSD symptoms. Accordingly, the Veterans Health Administration has made significant investments toward nationwide dissemination of a manualized exposure therapy protocol, prolonged exposure (PE). PE is effective with veterans; however, the relationship between PE and mental health service utilization is unknown. The current study investigates PE as it relates to actual tracked mental health service utilization in an urban VA medical center. A sample of 60 veterans with a diagnosis of PTSD was used to examine mental health service utilization in the 12-months prior to and 12-months after being offered PE. Hierarchical Linear Models and traditional repeated-measures ANOVA were used to estimate R²- and d-type effect sizes for service utilization. Associated estimated cost saving are reported. PE was associated with large reductions in symptoms and diagnosis remission. Treatment was also associated with statistically significant, large reductions in mental health service utilization for veterans who completed treatment. Findings suggest that expanding access to PE can increase access to mental health services in general by decreasing ongoing demand for specialty care clinical services.