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...

Despite their established efficacy and recommendation--often as first-line treatments--in clinical practice guidelines, evidence-based psychotherapies (EBPs) have largely failed to make their way into mainstream clinical settings. Numerous attempts over the years to promote the translation of EBPs from science to practice, typically relying on one-dimensional dissemination approaches, have yielded limited success. As part of the transformation of its mental health care system, the Veterans Health Administration (VHA) of the U.S. Department of Veterans Affairs (VA) is working to disseminate and implement a number of EBPs for various mental and behavioral health conditions throughout the VA health care system. This article examines VHA's multidimensional model and specific strategies, involving policy, provider, local systems, patient, and accountability levels, for promoting the national dissemination and implementation of EBPs in VHA. In addition, the article identifies key lessons learned and next steps for further promoting EBP delivery and sustainability in the VA health care system. Beyond promoting the availability of effective treatments for veterans returning from Iraq and Afghanistan and for veterans of previous combat eras, VHA's EBP dissemination and implementation model and key lessons learned may help to inform other private and public health care systems interested in disseminating and implementing EBPs.

Strong evidence supports the effi cacy of cognitive behavioral therapy for insomnia (CBTI). A signifi cant barrier to wide dissemination of CBTI is the lack of qualifi ed practitioners. We describe challenges and decisions made when developing a CBTI dissemination program in the Veterans Health Administration (VHA). The program targets mental health clinicians from different disciplines (psychiatry, psychology, social work, and nursing) with varying familiarity and experience with general principles of cognitive behavioral therapies (CBT). We explain the scope of training (how much to teach about the science of sleep, comorbid sleep disorders, other medical and mental health comorbidities, and hypnotic-dependent insomnia), discuss adaptation of CBTI to address the unique challenges posed by comorbid insomnia, and describe decisions made about the strategy of training (principles, structure and materials developed/recommended). Among these decisions is the question of how to balance the structure and fl exibility of the treatment protocol. We developed a case conceptualizationdriven approach and provide a general session-by-session outline. Training licensed therapists who already have many professional obligations required that the training be completed in a relatively short time with minimal disruptions to training participants' routine work responsibilities. These "real-life" constraints shaped the development of this competency-based, yet pragmatic training program. We conclude with a description of preliminary lessons learned from the initial wave of training and propose future directions for research and dissemination.