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In this issue's commentary article, Dr. Zeiss
discusses expansion of VA Mental Health
Services and post-traumatic stress disorder
(PTSD) treatment initiatives in the VA; she
points out the importance of Clinical Practice
Guidelines as a means for improving clinical
care. She further discusses how the VA has
not only published and updated PTSD treatment
guidelines in conjunction with the DoD,
but has also taken impressive, practical steps
to ensure that guideline recommendations can
Following the growing evidence for psychotherapies
for PTSD, the VA leadership
chose not to simply rely on dissemination of
guidelines to make changes in VA clinician
practices, but proceeded with a massive and
unprecedented effort to "train up" and support
VA mental health clinicians in providing
these established PTSD psychotherapies.1
Starting in 2005-2006, the VA increased its
mental health workforce capacity, hiring
additional clinicians, beginning ongoing, systematic
training of these clinicians, and conducting
systems reorganization to support the
provision of evidence-based psychotherapies.
As of May 2010, over 2,700 VA mental health
clinicians had received training in either Prolonged
Exposure (PE) or Cognitive Processing
Therapy (CPT) for PTSD, through multi-day,
in-person trainings, and weekly systematic consultation
and small group supervision. VA has
also placed local evidence-based psychotherapy
coordinators at each medical facility to champion
implementation of these treatments and
to work with site leadership to organize clinic
flow for improved treatment implementation.
Importantly, an implementation model that established
structures and processes to maintain
the use of these therapies after the initial training
period was developed.
This ambitious effort raises new questions
regarding systems change and maintenance.
Both CPT and PE require weekly delivery of
treatment sessions for multiple weeks, presenting
a challenge in busy VA clinics facing
rising numbers of returning Veterans from
the OEF/OIF conflicts. Engaging Veteran
patients in completing treatment is also a challenge,
with HSR&D researchers recently reporting
that only a small minority (9.5 percent)
of OEF/OIF Veterans with new PTSD diagnoses
attended nine or more VA mental health
sessions within 15 weeks in the first year following
their diagnosis.2 Moving to decentralized
training and maintaining clinician expertise
over time presents additional challenges. VA
implementation scientists have the opportunity
to substantially contribute in these areas, studying
factors that affect the maintenance and improvement
of the system capacities to provide
these complex psychotherapies to increasing
numbers of Veterans with need.
The commentary article's co-author, Dr.
Kemp, outlines a second area of considerable
effort on the part of VA Office of Mental
Health Services'suicide prevention. As she
discusses, suicide prevention is integral to the
VA mental health services efforts, and enormous
resources have been devoted to decreasing
suicide among VA Health System users
and among Veterans in the community. These
efforts have included increasing overall mental
health capacity and quality, such as the efforts
described above to improve capacity and care
for PTSD. Efforts have also included suicidespecific
interventions, such as the Veteran Suicide
Hotline and placing Suicide Prevention
Coordinators (SPCs) and Care Managers at
each VA facility. The VA Crisis Line is one of
the few crisis lines that can, with the Veteran's
permission, integrate the call into the Veteran's
medical record and facilitate the connecconnection
of callers to VA care through outreach by
Suicide Prevention Coordinators.
However, despite these efforts, the evidence
base for suicide prevention interventions remains
limited and the goal of rapidly reducing
the suicide rate has remained elusive both
within the VA and nationwide.
VA HSR&D researchers have conducted
a synthesis of the evidence-based literature
on suicide prevention, finding that although
some approaches'such as multi-component
intervention in military populations are
promising, the quality of evidence for this
and most other suicide prevention strategies
is low, meaning that further research is likely
to have an important impact on or change
the estimate of the effect.3 Unfortunately,
insufficient studies exist of suicide prevention
programs specifically in Veterans from
which to draw conclusions, and no studies
exist that assessed the specific effectiveness of
hotlines, outreach programs, peer counseling,
treatment coordination programs, and other
important care initiatives on suicide rates.
Thus, there is a clear need for further randomized
controlled trials and high-quality
observational studies to advance knowledge
in the area of suicide prevention. HSR&D
research is well-positioned to contribute in
this high priority area for the VA, working
in tandem with the Office of Mental Health
Services on evaluating the impact of current
efforts to reduce suicide risks and on implementing
the strategies that are most effective.
Karlin, B.E. et al. "Dissemination of Evidence-based
Psychological Treatments for Posttraumatic Stress
Disorder in the Veterans Health Administration,"
Journal of Traumatic Stress 2010;23(6):663-73.
Seal, K.H. et al. "VA Mental Health Services
Utilization in Iraq and Afghanistan Veterans in the
First Year of Receiving New Mental Health Diagnoses,"
Journal of Traumatic Stress 2010;23(1):5-16.
Bagley, S.C. et al. "A Systematic Review of Suicide
Prevention Programs for Military or Veterans,"
Journal of Suicide and Life Threatening Behavior 2010;40(3):257-65.