title: Improving and sustaining delivery of CPT for PTSD in mental health systems: a cluster randomized trial.
abstract: Large-scale implementation of evidence-based psychotherapies (EBPs) such as cognitive processing therapy (CPT) for posttraumatic stress disorder can have a tremendous impact on mental and physical health, healthcare utilization, and quality of life. While many mental health systems (MHS) have invested heavily in programs to implement EBPs, few eligible patients receive EBPs in routine care settings, and clinicians do not appear to deliver the full treatment protocol to many of their patients. Emerging evidence suggests that when CPT and other EBPs are delivered at low levels of fidelity, clinical outcomes are negatively impacted. Thus, identifying strategies to improve and sustain the delivery of CPT and other EBPs is critical. Existing literature has suggested two competing strategies to promote sustainability. One emphasizes fidelity to the treatment protocol through ongoing consultation and fidelity monitoring. The other focuses on improving the fit and effectiveness of these treatments through appropriate adaptations to the treatment or the clinical setting through a process of data-driven, continuous quality improvement. Neither has been evaluated in terms of impact on sustained implementation.
  
  
  
  To compare these approaches on the key sustainability outcomes and provide initial guidance on sustainability strategies, we propose a cluster randomized trial with mental health clinics (n = 32) in three diverse MHSs that have implemented CPT. Cohorts of clinicians and clinical managers will participate in 1 year of a fidelity oriented learning collaborative or 1 year of a continuous quality improvement-oriented learning collaborative. Patient-level PTSD symptom change, CPT fidelity and adaptation, penetration, and clinics' capacity to deliver EBP will be examined. Survey and interview data will also be collected to investigate multilevel influences on the success of the two learning collaborative strategies. This research will be conducted by a team of investigators with expertise in CPT implementation, mixed method research strategies, quality improvement, and implementation science, with input from stakeholders in each participating MHS.
  
  
  
  It will have broad implications for supporting ongoing delivery of EBPs in mental health and healthcare systems and settings. The resulting products have the potential to significantly improve efforts to ensure ongoing high quality implementation and consumer access to EBPs.
  
  
  
  NCT02449421 . Registered 02/09/2015.
authors.affiliation: National Center for PTSD and Stanford University Department of Psychiatry and Behavioral Sciences, 795 Willow Road, Menlo Park, CA, 94025, USA. sws1@stanford.edu.
authors.forename: Shannon
authors.identifier: 0000-0001-9917-5078
authors.initials: S
authors.lastname: Wiltsey Stirman
authors.affiliation: The University of Texas Health Science Center at San Antonio, Department of Psychiatry and Medicine, 7703 Floyd Curl Dr, San Antonio, TX, 78229, USA.|South Texas Veterans Health Care System, 7400 Merton Minter St, San Antonio, TX, 78229, USA.
authors.forename: Erin P
authors.initials: EP
authors.lastname: Finley
authors.affiliation: Divisional Psychologist Occupational Health and Safety, Royal Canadian Mounted Police, 4225 Dorchester, Westmount, QC, Canada.
authors.forename: Norman
authors.initials: N
authors.lastname: Shields
authors.affiliation: Department of Psychiatry, Yale University, 950 Campbell Avenue, West Haven, CT, 06516, USA.
authors.forename: Joan
authors.initials: J
authors.lastname: Cook
authors.affiliation: San Diego State University, 5500 Campanile Dr, San Diego, CA, 92182, USA.
authors.forename: Rachel
authors.initials: R
authors.lastname: Haine-Schlagel
authors.affiliation: Boston University School of Public Health, Department of Health Law, Policy and Management, Boston, MA, 02215, USA.|Center for Healthcare Organization and Implementation Research (CHOIR), Department of Veterans Affairs Boston Healthcare System, Boston, MA, USA.
authors.forename: James F
authors.initials: JF
authors.lastname: Burgess
authors.affiliation: Evidence-Based Practice Institute, 3303 S Irving Street Seattle, Seattle, WA, 91844, USA.
authors.forename: Linda
authors.initials: L
authors.lastname: Dimeff
authors.affiliation: Evidence-Based Practice Institute, 3303 S Irving Street Seattle, Seattle, WA, 91844, USA.
authors.forename: Kelly
authors.initials: K
authors.lastname: Koerner
authors.affiliation: Suffolk University, 73 Tremont Street, Boston, MA, 01331, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Suvak
authors.affiliation: National Center for PTSD, VA Boston Healthcare System, 150 S. Huntington Ave, Boston, MA, 02130, USA.|Boston University School of Medicine, 72 E Concord St, Boston, MA, 02118, USA.
authors.forename: Cassidy A
authors.initials: CA
authors.lastname: Gutner
authors.affiliation: Boston University School of Public Health, Department of Health Law, Policy and Management, Boston, MA, 02215, USA.
authors.forename: David
authors.initials: D
authors.lastname: Gagnon
authors.affiliation: Ryerson University, 350 Victoria Street, Toronto, ON, M5B 2K3, Canada.
authors.forename: Tasoula
authors.initials: T
authors.lastname: Masina
authors.affiliation: National Center for PTSD and Palo Alto Veterans Institute of Research, 795 Willow Road, Menlo Park, CA, 94025, USA.
authors.forename: Matthew
authors.initials: M
authors.lastname: Beristianos
authors.affiliation: National Center for PTSD and Palo Alto Veterans Institute of Research, 795 Willow Road, Menlo Park, CA, 94025, USA.
authors.forename: Kera
authors.initials: K
authors.lastname: Mallard
authors.affiliation: The University of Texas Health Science Center at San Antonio, Department of Psychiatry and Medicine, 7703 Floyd Curl Dr, San Antonio, TX, 78229, USA.|South Texas Veterans Health Care System, 7400 Merton Minter St, San Antonio, TX, 78229, USA.
authors.forename: Vanessa
authors.initials: V
authors.lastname: Ramirez
authors.affiliation: Ryerson University, 350 Victoria Street, Toronto, ON, M5B 2K3, Canada.
authors.forename: Candice
authors.initials: C
authors.lastname: Monson
mesh_terms: D002170:Canada; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D006284:Health Plan Implementation / Q000379:methods*; D006801:Humans; D013313:Stress Disorders, Post-Traumatic / Q000628:therapy*; D013781:Texas; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans
keywords: CPT; Delivery; EBPs; Fidelity; Implementation; Learning collaborative; Sustainability