Implementation of cognitive therapy for PTSD in routine clinical care: effectiveness and moderators of outcome in a consecutive sample.
OBJECTIVE
Trauma-focused psychological treatments are recommended as first-line treatments for Posttraumatic Stress Disorder (PTSD), but clinicians may be concerned that the good outcomes observed in randomized controlled trials (RCTs) may not generalize to the wide range of traumas and presentations seen in clinical practice. This study investigated whether Cognitive Therapy for PTSD (CT-PTSD) can be effectively implemented into a UK National Health Service Outpatient Clinic serving a defined ethnically mixed urban catchment area.


METHODS
A consecutive sample of 330 patients with PTSD (age 17-83) following a wide range of traumas were treated by 34 therapists, who received training and supervision in CT-PTSD. Pre and post treatment data (PTSD symptoms, anxiety, depression) were collected for all patients, including dropouts. Hierarchical linear modeling investigated candidate moderators of outcome and therapist effects.


RESULTS
CT-PTSD was well tolerated and led to very large improvement in PTSD symptoms, depression and anxiety. The majority of patients showed reliable improvement/clinically significant change: intent-to-treat: 78.8%/57.3%; completer: 84.5%/65.1%. Dropouts and unreliable attenders had worse outcome. Statistically reliable symptom exacerbation with treatment was observed in only 1.2% of patients. Treatment gains were maintained during follow-up (M=280 days, n=220). Few of the selection criteria used in some RCTs, demographic, diagnostic and trauma characteristics moderated treatment outcome, and only social problems and needing treatment for multiple traumas showed unique moderation effects. There were no random effects of therapist on symptom improvement, but therapists who were inexperienced in CT-PTSD had more dropouts than those with greater experience.


CONCLUSIONS
The results support the effectiveness of CT-PTSD and suggest that trauma-focused cognitive behavior therapy can be successfully implemented in routine clinical services treating patients with a wide range of traumas.
Department of Experimental Psychology, University of Oxford, South Parks Road, Oxford OX1 3UD, UK; Oxford Cognitive Health Clinical Research Facility, UK; National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, UK. Electronic address: anke.ehlers@psy.ox.ac.uk.
Anke
A
Ehlers
Nick
N
Grey
Jennifer
J
Wild
Richard
R
Stott
Sheena
S
Liness
Alicia
A
Deale
Rachel
R
Handley
Idit
I
Albert
Deborah
D
Cullen
Ann
A
Hackmann
John
J
Manley
Freda
F
McManus
Francesca
F
Brady
Paul
P
Salkovskis
David M
DM
Clark
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015928:Cognitive Behavioral Therapy; D005260:Female; D006801:Humans; D008297:Male; D008605:Mental Health Services; D008875:Middle Aged; D008960:Models, Psychological; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data*; D010044:Outpatient Clinics, Hospital; D010352:Patient Dropouts; D013313:Stress Disorders, Post-Traumatic / Q000175:diagnosis / Q000628:therapy*; D063189:Symptom Assessment; D016896:Treatment Outcome
Cognitive behavior therapy; Cognitive therapy; Dissemination; Implementation; Posttraumatic stress disorder; Predictors of outcome; Treatment effectiveness