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CDA 09-020 – HSR&D Study

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CDA 09-020
Dissemination & Implementation of Exposure Treatments for PTSD
Shannon M. Kehle-Forbes PhD
Minneapolis VA Health Care System, Minneapolis, MN
Minneapolis, MN
Funding Period: July 2011 - June 2015

BACKGROUND/RATIONALE:
Evidence-based psychotherapies (EBPs) for PTSD have been shown to be efficacious in reducing symptoms of PTSD among Veterans. The Veterans Health Administration (VHA) implemented several initiatives designed to increase the adoption of EBPs for PTSD. Early data suggest that significant barriers still exist and few Veterans receive these treatments.

OBJECTIVE(S):
The overall objective of my CDA was to examine factors related to the dissemination and implementation of EBPs for PTSD. Within that objective I pursued three inter-related lines of research: 1) Veteran factors impacting the implementation of EBPs for PTSD; 2) system-level barriers and facilitators to accessing EBPs for PTSD, and 3) Veterans' adherence to EBPs for PTSD. The specifics of the first line of research are detailed in this abstract because they most closely aligned with the projects proposed in my funded CDA application. The primary aims of this line of research were to (1) Identify facilitator and barriers to the implementation of EBPs for PTSD and (2) Develop and pilot an intervention designed to enhance the implementation of EBPs for PTSD.

METHODS:
Aim 1 was completed in two phases. First, we conducted key informant interviews with five of the eight evidence-based coordinators within VISN 23. The key informant interviews with the evidence-based psychotherapy coordinators suggested that little attention had been paid to Veteran-facing implementation interventions, which resulted in limited Veteran demand for EBPs. Therefore, we sought to develop a Veteran-facing social marketing campaign designed to increase demand for EBPs for PTSD. The second phase of Aim 1 involved semi-structured interviews with 31 Veterans with full or subthreshold PTSD (intervention target population) at the Minneapolis VA Medical Center. The interviews focused on Veterans' knowledge of EBPs for PTSD, how they prefer to receive information regarding PTSD treatment, their attitudes towards EBPS for PTSD, and perceived barriers and facilitators to participating in the treatments. Following the analysis of the Veterans interviews, we created draft versions of the intervention materials (Aim 2). We then invited the 31 Veterans who completed the semi-structured interviews back to participate in focus groups to refine and pilot test the materials. Thirteen Veterans attended one of three focus groups. Finally, three experts in the treatment of PTSD completed key informant interviews to further refine the intervention. Details regarding the findings from the Veteran interviews and focus groups can be found in the abstract for RRP 12-512, which funded the study.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
PTSD is one of the most commonly occurring and debilitating health conditions following deployment to a combat zone. By facilitating the implementation of EBPs for PTSD, this research has the potential to increase the number of Veterans receiving effective PTSD treatments, thereby improving Veterans health and functioning.

PUBLICATIONS:

Journal Articles

  1. Kehle-Forbes SM, Chen S, Polusny MA, Lynch KG, Koffel E, Ingram E, Foa EB, Van Horn DHA, Drapkin ML, Yusko DA, Oslin DW. A randomized controlled trial evaluating integrated versus phased application of evidence-based psychotherapies for military veterans with comorbid PTSD and substance use disorders. Drug and Alcohol Dependence. 2019 Dec 1; 205:107647.
  2. Mohr DC, Rosen CS, Schnurr PP, Orazem RJ, Noorbaloochi S, Clothier BA, Eftekhari A, Bernardy NC, Chard KM, Crowley JJ, Cook JM, Kehle-Forbes SM, Ruzek JI, Sayer NA. The Influence of Team Functioning and Workload on Sustainability of Trauma-Focused Evidence-Based Psychotherapies. Psychiatric services (Washington, D.C.). 2018 Aug 1; 69(8):879-886.
  3. Kehle-Forbes SM, Harwood EM, Spoont MR, Sayer NA, Gerould H, Murdoch M. Experiences with VHA care: a qualitative study of U.S. women veterans with self-reported trauma histories. BMC women's health. 2017 May 30; 17(1):38.
  4. Kehle-Forbes SM, Campbell EH, Taylor BC, Scholten J, Sayer N. Does Co-Occurring Traumatic Brain Injury Affect VHA Outpatient Health Service Utilization and Associated Costs Among Veterans With Posttraumatic Stress Disorder? An Examination Based on VHA Administrative Data. The Journal of head trauma rehabilitation. 2017 Jan 1; 32(1):E16-E23.
  5. Rosen CS, Matthieu MM, Wiltsey Stirman S, Cook JM, Landes S, Bernardy NC, Chard KM, Crowley J, Eftekhari A, Finley EP, Hamblen JL, Harik JM, Kehle-Forbes SM, Meis LA, Osei-Bonsu PE, Rodriguez AL, Ruggiero KJ, Ruzek JI, Smith BN, Trent L, Watts BV. 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. 2016 Nov 1; 43(6):957-977.
  6. Kehle-Forbes SM, Drapkin ML, Foa EB, Koffel E, Lynch KG, Polusny MA, Van Horn DH, Yusko DA, Charlesworth M, Blasco M, Oslin DW. Study design, interventions, and baseline characteristics for the Substance use and TRauma Intervention for VEterans (STRIVE) trial. Contemporary clinical trials. 2016 Sep 1; 50:45-53.
  7. Kehle-Forbes SM, Meis LA, Spoont MR, Polusny MA. Treatment initiation and dropout from prolonged exposure and cognitive processing therapy in a VA outpatient clinic. Psychological trauma : theory, research, practice and policy. 2016 Jan 1; 8(1):107-14.
  8. Spoont MR, Williams JW, Kehle-Forbes S, Nieuwsma JA, Mann-Wrobel MC, Gross R. Does This Patient Have Posttraumatic Stress Disorder?: Rational Clinical Examination Systematic Review. JAMA. 2015 Aug 4; 314(5):501-10.
  9. Nelson NW, Anderson CR, Thuras P, Kehle-Forbes SM, Arbisi PA, Erbes CR, Polusny MA. Factors associated with inconsistency in self-reported mild traumatic brain injury over time among military personnel in Iraq. The British Journal of Psychiatry; The Journal of Mental Science. 2015 Mar 1; 206(3):237-44.
  10. Kehle-Forbes SM, Polusny MA, Erbes CR, Gerould H. Acceptability of prolonged exposure therapy among U.S. Iraq war veterans with PTSD symptomology. Journal of traumatic stress. 2014 Aug 1; 27(4):483-7.
  11. Polusny MA, Kumpula MJ, Meis LA, Erbes CR, Arbisi PA, Murdoch M, Thuras P, Kehle-Forbes SM, Johnson AK. Gender differences in the effects of deployment-related stressors and pre-deployment risk factors on the development of PTSD symptoms in National Guard Soldiers deployed to Iraq and Afghanistan. Journal of psychiatric research. 2014 Feb 1; 49(2):1-9.
  12. Kehle-Forbes SM, Polusny MA, Murdoch M, Meis LA, Wilt TJ. A Systematic Review of the Efficacy of Adding Nonexposure Components to Exposure Therapy for Posttraumatic Stress Disorder. Psychological trauma : theory, research, practice and policy. 2013 Jul 1; 5(4):317-322.
  13. Meyers LL, Strom TQ, Leskela J, Thuras P, Kehle-Forbes SM, Curry KT. Service utilization following participation in cognitive processing therapy or prolonged exposure therapy for post-traumatic stress disorder. Military medicine. 2013 Jan 1; 178(1):95-9.
  14. Arbisi PA, Kaler ME, Kehle-Forbes SM, Erbes CR, Polusny MA, Thuras P. The predictive validity of the PTSD Checklist in a nonclinical sample of combat-exposed National Guard troops. Psychological assessment. 2012 Dec 1; 24(4):1034-40.
  15. Kehle SM, Ferrier-Auerbach AG, Meis LA, Arbisi PA, Erbes CR, Polusny MA. Predictors of postdeployment alcohol use disorders in National Guard soldiers deployed to Operation Iraqi Freedom. Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors. 2012 Mar 1; 26(1):42-50.
  16. Wolf GK, Strom TQ, Kehle SM, Eftekhari A. A preliminary examination of prolonged exposure therapy with Iraq and Afghanistan veterans with a diagnosis of posttraumatic stress disorder and mild to moderate traumatic brain injury. The Journal of head trauma rehabilitation. 2012 Jan 1; 27(1):26-32.
  17. Kehle SM, Greer N, Rutks I, Wilt T. Interventions to improve veterans' access to care: a systematic review of the literature. Journal of general internal medicine. 2011 Nov 1; 26 Suppl 2:689-96.
  18. Erbes CR, Kehle-Forbes SM, Polusny MA. The distinctiveness of hardiness, positive emotionality, and negative emotionality in National Guard soldiers. Journal of Research in Personality. 2011 Oct 1; 45(5):508-512.
  19. Widome R, Kehle SM, Carlson KF, Laska MN, Gulden A, Lust K. Post-traumatic stress disorder and health risk behaviors among Afghanistan and Iraq War veterans attending college. American Journal of Health Behavior. 2011 Jul 1; 35(4):387-92.
HSR&D or QUERI Publications

  1. Spoont MR, Fu SS, Kehle-Forbes SM, Meis LA, Wilt TJ. Screening for Post-Traumatic Stress Disorder (PTSD) in Primary Care: A Systematic Review. 2013 Jan 1.
Conference Presentations

  1. Kehle-Forbes SM, Gerould H, Partin MR, Sayer NA, Slone L. The Development of Marketing Materials to Increase Veteran Demand for Evidence-Based Psychotherapies for PTSD. Poster session presented at: International Society for Traumatic Stress Studies Annual Symposium; 2015 Nov 5; New Orleans, LA.
  2. Kehle-Forbes SM, Harwood E, Spoont MR, Sayer NA, Murdoch M. Qualitative Analysis of Women Veterans’ Experiences Seeking VA Care: Findings from a Sample of Former PTSD Disability Applicants. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 10; Philadelphia, PA.
  3. Spoont MR, Nelson DB, Kehle-Forbes SM, Meis LA. Inequity in Psychotherapy Services among Racial and Ethnic Minority Veterans with PTSD. Presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 10; Philadelphia, PA.
  4. Sayer NA, Rosen CS, Nugent S, Kehle-Forbes SM, Chard K, Bernardy NC, Schnurr P, Orazem R, Mohr D. A Preliminary Look at Use of PE and CPT in VHA Specialty Outpatient PTSD Programs. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
  5. Taylor BC, Hagel Campbell EM, Fletcher LA, Nugent SM, Bidelspach DE, Kehle-Forbes SM, Scholten JD, Sayer NA. Three Year Trends in VHA Utilization and Costs Following Screening among Veterans with Deployment-Related Mild Traumatic Brain Injury. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
  6. Kehle-Forbes SM, Gerould HL, Polusny MA, Partin MR, Slone L, Sayer NA. Veterans’ perceptions of the role of relationships and social engagement in recovery from PTSD. Presented at: International Society for Traumatic Stress Studies Annual Symposium; 2014 Nov 6; Miami, FL.
  7. Kehle-Forbes SM, Partin MR, Slone L, Polusny MA, Sayer NA, Gerould HL. Veterans’ Attitudes towards Prolonged Exposure and Cognitive Processing Therapy. Poster session presented at: International Society for Traumatic Stress Studies Annual Symposium; 2014 Nov 6; Miami, FL.
  8. Spoont MR, Nelson DB, Kehle-Forbes SM, Meis LA, Bass D. Veteran race/ethnicity and variation in adjunctive pharmacotherapy for PTSD. Poster session presented at: International Society for Traumatic Stress Studies Annual Symposium; 2014 Nov 6; Miami, FL.
  9. Kehle-Forbes SM, Erbes CR, Polusny MA. A Longitudinal Investigation Examining Predictors of Change in Self-Reported Mild Traumatic Brain Injury In National Guard Veterans of the Iraq War. Poster session presented at: American Academy of Clinical Neuropsychology Annual Meeting; 2012 Jun 20; Seattle, WA.
  10. Kehle-Forbes SM, Polusny MA, Erbes CR, Meis LA, Arbisi PA. Treatment Preferences and Barriers in OIF Soldiers with PTSD and/or mTBI. Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2011 Nov 12; Toronto, Ontario, Canada.
  11. Kehle-Forbes SM, Polusny MA, Meis LA, Erbes CR, Arbisi PA, Marut E. PTSD Treatment Choice among OIF Veterans. Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2011 Nov 12; Toronto, Canada.
  12. Meyers L, Leskela J, Thuras P, Strom T, Kehle SM, Curry K. Service utilization following participation in Cognitive Processing Therapy (CPT) or Prolonged Exposure Therapy (PE) for Post-traumatic Stress Disorder. Poster session presented at: VA Mental Health Annual Conference; 2011 Aug 2; Baltimore, MD.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Comparative Effectiveness
Keywords: none
MeSH Terms: none

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