Adapting Treatment Delivery to Improve Retention in Evidence-Based PTSD Treatment

Background: Effective evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), such as Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) therapy, have competency- based trainings in place and are mandated to be available to Veterans with PTSD in the Veterans Health

Administration (VHA). Despite their effectiveness, at least a third of Veterans will prematurely drop out of PTSD EBPs, which is associated with poorer clinical outcomes and greater healthcare utilization. Delivery of PTSD EBPs in a massed format of three or more sessions weekly have demonstrated promise

for increasing treatment retention. It is hypothesized that massed EBPs will be feasible. Significance/Impact: The current proposal is highly significant: 1) PTSD EBP retention remains low, 2) prior research aimed to improve retention in PTSD EBPs has yielded only modest improvements, 3) research on massed treatments for PTSD outside of VHA suggest improved retention, but is limited by

observational design and lack of comparison groups, and 4) PTSD is a high priority HSR&D domain. Innovation: This CDA-2 application is innovative: 1) it adapts PTSD EBP delivery by increasing the frequency of delivery, 2) the proposed feasibility randomized clinical trial (RCT) will inform a subsequent

IIR to conduct the first RCT of massed PTSD EBPs in VHA, 3) the first study to examine multiple stakeholders' preferences, and perceived barriers and facilitators of massed PTSD EBPs, and 4) massed PTSD EBPs may improve PTSD treatment engagement and improve clinical outcomes. Specific Aims: Aim 1. Qualitatively explore through semi-structured interviews with stakeholders'

(Veterans [n=16], providers [n=12], and administrators [n=12]) perceived barriers and facilitators to implementation, and preferences for massed PTSD treatment delivery within VHA PTSD specialty clinics to inform the development of the massed PTSD treatment program to be piloted in Aim 2. Aim 2a. Conduct a pilot pragmatic randomized clinical trial (RCT; n=30) to examine the feasibility and

acceptability of massed EBP PTSD treatments (EBP-massed) compared to PTSD EBPs as they are typically delivered (EBP-TAU) in a VA PTSD Specialty Clinic. In addition, we will gather preliminary data on satisfaction, completion rates, session attendance, and PTSD, depression, and functioning outcomes. Aim 2b. Conduct a summative evaluation via qualitative interviews with all Veterans in the pilot trial

(n=30) and with providers (n=4) who delivered massed treatment to contextualize the quantitative findings and further refine massed PTSD treatments for a future IIR. Aim 3a. Characterize a national cohort of Veterans who begin 1) massed PTSD EBPs and 2) PTSD EBPs TAU. Aim 3b. Among Veterans who initiated treatment, compare treatment completion (i.e., 8 sessions) rates

between those who received massed EBPs and those who received EBP-TAU. Next Steps/Implementation: In Aim 1, we will conduct semi-structured qualitative interviews with Veterans (n=16), providers (n=12), and administrators (n=12). Social Cognitive Theory and the Consolidated Framework for Implementation Research will inform these interviews and results will

inform our pilot trial in Aim 2a. In Aim 2a, we will conduct a feasibility RCT to compare massed PTSD EBPs to PTSD EBPs delivered as usual in a VA PTSD Specialty Clinic. In Aim 2b, we will utilize semi- structured qualitative interviews with Veterans and providers in the pilot trial to evaluate satisfaction

and identify additional modifications to the massed treatment program. Aim 3a and 3b will utilize the VA's CDW.