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Purpose: Self-collected testing for human papillomavirus (HPV) is poised to transform cervical cancer screening. Self-tests demonstrate similar accuracy to clinician-collected tests, but for the half a million women served by the Veterans Health Administration (VA) and their clinicians, self-collected cervical cancer screening would be a new practice. We examined VA patient and staff perspectives to inform future implementation., Methods: Semi-structured telephone interviews were conducted between 2021 and 2022 with female veterans receiving VA care (n = 22) and VA women's health nurses, clinicians, and administrators (n = 27). Interviews were audio-recorded and transcribed. Interview questions addressed knowledge and interest, potential advantages or disadvantages, and any questions participants had about self-collected screening. Responses were analyzed using rapid qualitative methods., Main Findings: Five overarching themes were identified. Both patients and staff indicated high interest and enthusiasm for self-collected HPV testing, tempered by questions about test accuracy and logistical considerations. Familiarity with self-testing for other conditions such as colon-cancer screening or COVID made self-collection seem like a simple, convenient option. However, self-testing was not viewed as a good fit for all patients, and concerns about lost opportunities or missed incidental lesions were raised. Patients and staff described challenges with pelvic examinations for patients with past sexual trauma, particularly in the male-dominated VA environment. Pelvic exams can leave patients feeling vulnerable and exposed; self-collected testing was seen as a mechanism for patient empowerment., Principal Conclusions: Veteran patients and VA staff shared common perspectives about potential advantages and disadvantages of self-collected HPV testing. Self-collected HPV testing has the potential to improve trauma-informed preventive health care for veterans., (Published by Elsevier Inc.)

Posttraumatic stress disorder (PTSD) is associated with poor quality of life. Although randomized clinical trial data show improvements in quality of life following trauma-focused therapies (TFTs), including prolonged exposure therapy (PE) and cognitive processing therapy (CPT), less is known about how these improvements are experienced from the trauma survivor's perspective. A national sample of 60 veterans who recently completed TFT as part of routine care at U.S. Department of Veterans Affairs facilities participated in semistructured qualitative interviews during which the impact of treatment on quality of life was explored. Following a mixed deductive/inductive approach, six interrelated themes describing changes in quality of life emerged: full participation in social activities, greater emotional intimacy in relationships, improvements in parenting, expanded engagement in hobbies and community, increased occupational commitment and confidence, and more joy in life. The data highlight the positive impact of treatment on quality of life and provide depth to quantitative findings demonstrating improvements in quality of life following TFT., (© 2024 The Author(s). Journal of Traumatic Stress published by Wiley Periodicals LLC on behalf of International Society for Traumatic Stress Studies.)

Background: Use of participatory research methods is increasing in research trials. Once partnerships are established with end-users, there is less guidance about processes research teams can use to successfully incorporate end-user feedback. The current study describes the use of a brief reflections process to systematically examine and evaluate the impact of end-user feedback on study conduct., Methods: The Comparative Effectiveness of Trauma-Focused and Non-Trauma- Focused Treatment Strategies for PTSD among those with Co-Occurring SUD (COMPASS) study was a randomized controlled trial to determine the effectiveness of trauma-focused psychotherapy versus non-trauma-focused psychotherapy for Veterans with co-occurring posttraumatic stress disorder and substance use disorder who were entering substance use treatment within the Department of Veterans Affairs. We developed and paired a process of "brief reflections" with our end-user engagement methods as part of a supplemental evaluation of the COMPASS study engagement plan. Brief reflections were 30-minute semi-structured discussions with the COMPASS Team following meetings with three study engagement panels about feedback received regarding study issues. To evaluate the impact of panel feedback, 16 reflections were audio-recorded, transcribed, rapidly analyzed, and integrated with other study data sources., Results: Brief reflections revealed that the engagement panels made recommended changes in eight areas: enhancing recruitment; study assessment completion; creating uniformity across Study Coordinators; building Study Coordinator connection to Veteran participants; mismatch between study procedures and clinical practice; therapist skill with patients with active substance use; therapist burnout; and dissemination of study findings. Some recommendations positively impact study conduct while others had mixed impact. Reflections were iterative and led to emergent processes that included revisiting previously discussed topics, cross-pollination of ideas across panels, and sparking solutions amongst the Team when the panels did not make any recommendations or recommendations were not feasible., Conclusions: When paired with end-user engagement methods, brief reflections can facilitate systematic examination of end-user input, particularly when the engagement strategy is robust. Reflections offer a forum of accountability for researchers to give careful thought to end-user recommendations and make timely improvements to the study conduct. Reflections can also facilitate evaluation of these recommendations and reveal end-user-driven strategies that can effectively improve study conduct., Trial Registration: ClinicalTrials.gov (NCT04581434) on October 9, 2020; https://clinicaltrials.gov/ct2/show/study/NCT04581434?term=NCT04581434&draw=2&rank=1 ., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objective: To assess the feasibility of a family-involved intervention, family support in mental health recovery (FAMILIAR), for veterans with posttraumatic stress disorder (PTSD) seeking psychotherapy at a single Veterans Administration Health System., Method: This mixed-methods study reports qualitative and quantitative findings from a single-group pilot of 24 veterans and their support partners (SPs) about experiences with the intervention and interviews with eight VA mental health clinicians and leaders and the study interventionist to explore intervention feasibility. Findings across data sources were merged within domains of Bowen and colleagues' pilot study feasibility framework., Results: Out of 24 dyads, 16 veterans and 15 associated SPs completed the intervention. Participants viewed the intervention to be valuable and feasible. Veterans and SPs reported that they enrolled in the study to develop a shared understanding of PTSD and treatment. While participants identified few logistical barriers, finding a time for conjoint sessions could be a challenge. Veterans, SPs, and providers discussed benefits of the intervention, including that it facilitated conversation between the veteran and SP about PTSD and mental health care and helped to prepare the dyad for treatment. Providers noted potential challenges integrating family-involved interventions into clinical workflow in VA and suggested the need for additional training and standardized procedures for family-centered care., Conclusions: Our study identified potential implementation facilitators (e.g., standard operating procedures about session documentation, confidentiality, and family ethics) and challenges (e.g., clinical workflow integration) that require further study to bring FAMILIAR into routine clinical care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Prolonged exposure (PE) and cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) are effective, but some patients do not respond adequately, and dropout rates are high. Patients' beliefs about treatment and perceptions of treatment components influence treatment outcomes and may be amenable to change through intervention. The present study sought to identify beliefs and reactions to PE and CPT that differentiated completers who screened negative for a PTSD diagnosis after treatment (PTSD-), completers who screened positive for a PTSD diagnosis after treatment (PTSD+), and discontinuers who attended six or fewer sessions. Thematic analysis was used to identify themes in qualitative data collected via retrospective semistructured interviews with 51 completers (19 PTSD- after treatment, 32 PTSD+ after treatment) and 66 discontinuers of PE/CPT. Participants were demographically diverse veterans across service eras. Treatment-related beliefs and reactions differentiating these groups included perceived helpfulness of treatment, self-efficacy in engaging in treatment, anticipatory anxiety and concerns, interpretations of ongoing symptoms, and perceived consequences of treatment on functioning. Further, some patterns seemed to differ in early treatment sessions compared to during the active components of treatment. Findings point to potentially malleable targets that could be intervened upon to improve trauma-focused treatment outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Social support is important for posttraumatic stress disorder (PTSD) recovery and emerging literature indicate that social support could increase engagement in PTSD therapy. However, there is a need to understand how and why family involvement can increase treatment engagement to inform strategies used in clinical practice. This study explores how individuals with PTSD and family members of individuals with PTSD experience therapy and how social interactions help or hinder therapy engagement. We interviewed 18 U.S. military veterans who had been referred for psychotherapy for PTSD in the Veterans Health Administration and 13 family members and used rapid content analysis to identify themes. We found that engaging in therapy was a family-level decision that participants expected to improve family life. Veterans were motivated to seek treatment to protect their relationships with loved ones. Family members generally encouraged veterans to seek treatment. Specifically, family members who viewed PTSD as a treatable illness versus a static aspect of the veteran's personality expressed positive attitudes about the effectiveness of therapy for reducing symptoms. Veterans whose social networks included individuals with prior military or trauma-related experiences reported that their loved ones possessed more understanding of PTSD and described positive subjective norms around therapy. Family members are often embedded in the therapy process because PTSD has a profound impact on the family. Positive subjective norms for therapy are created by family encouragement and may influence veteran perceptions about the value of treatment. Family members should be engaged early in mental health therapy and to the extent desired by the patient and family member. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Objective: Many patients who initiate prolonged exposure (PE) and cognitive processing therapy (CPT) do not complete a full course, although little is known about how providers view PE and CPT dropout among their own patients., Method: Semistructured interviews were conducted with providers ( n = 29) in the Veterans Health Administration to understand each provider's experience of dropout by a specific patient whom they treated using PE or CPT. Content analysis was used to categorize perceptions of dropout as negative, somewhat negative, or not negative. Themes associated with somewhat or not negative views of dropout were identified via inductive coding., Results: Fourteen percent of providers viewed their patient's dropout from PE or CPT as wholly negative, 38% as somewhat negative, and 48% as not a negative outcome. Themes associated with viewing dropout as something other than wholly negative included belief that the patient would not benefit from treatment if they were not ready, the importance of maintaining the therapeutic relationship, the view that trauma-focused therapy was not what the patient needed or that the patient could benefit from other approaches, the impression that the patient had made some gains, and that patients are responsible for treatment engagement and have the right to disengage., Conclusions: Providers' perceptions of dropout from PE or CPT for individual patients were rarely viewed as entirely negative. Research is needed to help providers determine when patient dropout is an undesirable outcome and when efforts to reengage patients in trauma-focused treatment are warranted. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Background: Barriers at the system, clinician, and patient level limit access to medications for opioid use disorder (MOUD). The Advancing Pharmacological Treatments for Opioid Use Disorder (ADaPT-OUD) study implemented an external facilitation strategy within the Veterans Health Administration (VHA) aimed at facility-level barriers to improve uptake of MOUD. During ADaPT-OUD, an independent Academic Detailing Services Opioid Agonist Treatment of OUD Campaign was co-occurring and aimed to increase evidence-based practice for OUD at the clinician level. While both these initiatives aim to increase MOUD reach, they address different barriers and did not intentionally collaborate. Thus, understanding the interaction between these two independent implementation initiatives and their effect on MOUD reach will further inform and mold future implementation efforts of MOUD., Methods: This was a secondary analysis of the ADaPT-OUD study that included 35 VHA facilities in the lowest quartile of MOUD reach; eight received the ADaPT-OUD external facilitation and 27 matched sites received implementation as usual. The number of academic detailing (AD) visits during ADaPT-OUD was used as a proxy for the intensity of Academic Detailing for OUD Campaign activity. The interaction between external facilitation status and AD intensity was evaluated by comparing the change in facility-level MOUD reach., Results: There was a general increase in the number of AD visits, in both external facilitation and implementation as usual sites, over the course of ADaPT-OUD's implementation period. A non-statistically significant, positively sloped, linear relationship was observed between average number of AD visits per quarter and change in MOUD reach in facilities also receiving ADaPT-OUD external facilitation that was not observed in the implementation as usual sites., Conclusion: Co-occurring initiatives focusing on different barriers to MOUD access have the potential to further increase MOUD in low-performing facilities, but further research into timing, quality, and collaboration between initiatives are warranted., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Background: Successful implementation can increase the availability of evidence-based treatments but continued patient access can be threatened if there is not deliberate focus on sustainment. Real-world examples are needed to elucidate contributors to sustainability., Objective: We examined sustainability of outcomes of a study which tested a 12-month external facilitation intervention. The study evaluated change in access to medications for opioid use disorder (MOUD) in Veterans Health Administration (VHA) facilities in the lowest quartile of MOUD prescribing., Design: Convergent mixed-methods design., Participants: Thirty-nine providers and leaders from eight VHA facilities., Approach: Thirty-minute post-implementation telephone interviews explored whether barriers identified pre-implementation were successfully addressed, the presence of any new challenges, helpfulness of external facilitation, and plans for sustaining MOUD access. Interviews were analyzed using a rapid turn-around approach. VHA administrative data were used to characterize the facilities and assess their ratio of patients with an OUD diagnosis receiving MOUD (MOUD/OUD ratio) at the end of a 9-month sustainability period., Key Results: Commonly reported contributors to sustained MOUD access included national attention on the opioid epidemic, accountability created by study participation, culture shift in MOUD acceptability, leadership support, and plans to build on initial progress. Frequently reported barriers included staffing issues and lack of MOUD-devoted time; the need to overhaul existing policies, practices, and/or processes; and fear and anxiety about MOUD prescribing. All facilities either maintained MOUD/OUD ratio improvement (n = 2) or further improved (n = 6) at the end of sustainability. Facilities with the highest and lowest ratio at the end of sustainability used a team-based approach to MOUD delivery; however, organizational setting differences may have impacted overall MOUD access., Conclusions: Ensuring stable and consistent staff, and sufficient time dedicated to MOUD are critical to sustaining access to evidence-based treatment in low-adopting facilities. This study highlights the importance of investing in local, system-level changes to improve and sustain access to effective treatments., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Guidelines strongly recommend trauma-focused therapies to treat posttraumatic stress disorder. Implementation of cognitive processing therapy (CPT) and prolonged exposure (PE) in Veterans Health Administration (VHA) and non-VHA settings began in 2006. We conducted a systematic review of implementation facilitators and challenges and strategies to address barriers. We searched MEDLINE, Embase, PsycINFO, and CINAHL from inception until March 2021 for English-language articles. Two individuals reviewed eligibility and rated quality. Quantitative results were abstracted by one reviewer and verified by a second. Qualitative results were independently coded by two reviewers and finalized through consensus. We used RE-AIM and CFIR frameworks to synthesize findings. 29 eligible studies addressed CPT/PE, mostly conducted in VHA. Training/education with audit/feedback was the primary implementation strategy and was linked to improved provider CPT/PE perceptions and self-efficacy. Use was not widespread. Only six studies tested other implementation strategies with mixed impact. Following VHA implementation, strong support for training, perceived effectiveness for patients and benefits for clinics, and positive patient experiences and relationships with providers were reported. However, barriers persisted including perceived protocol inflexibility, complex referral processes and patient complexity and competing needs. In non-VHA settings, providers perceived fewer barriers, but few were CPT/PE trained. Across both settings, fewer studies targeted patient factors. Training/education with audit/feedback improved perceptions and the availability of CPT/PE, but not consistent use. Studies testing implementation strategies to address post-training challenges, including patient-level factors, are needed. A few studies are underway in VHA to test patient-focused and other implementation strategies. Research assessing actual vs perceived barriers in non-VHA settings is needed to elucidate unique challenges experienced., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: The United States has been grappling with the opioid epidemic, which has resulted in over 75,000 opioid-related deaths between April 2020 and 2021. Evidence-based pharmaceutical interventions (buprenorphine, methadone, and naltrexone) are available to reduce opioid-related overdoses and deaths. However, adoption of these medications for opioid use disorder has been stifled due to individual- and system-level barriers. External facilitation is an evidence-based implementation intervention that has been used to increase access to medication for opioid use disorder (MOUD), but the implementation costs of external facilitation have not been assessed. We sought to measure the facility-level direct costs of implementing an external facilitation intervention for MOUD to provide decision makers with estimates of the resources needed to implement this evidence-based program., Methods: We performed a cost analysis of the pre-implementation and implementation phases, including an itemization of external facilitation team and local site labor costs. We used labor estimates from the Bureau of Labor and Statistics, and sensitivity analyses were performed using labor estimates from the Veterans Health Administration (VHA) Financial Management System general ledger data., Results: The average total costs for implementing an external facilitation intervention for MOUD per site was $18,847 (SD 6717) and ranged between $11,320 and $31,592. This translates to approximately $48 per patient with OUD. Sites with more encounters and participants with higher salaries in attendance had higher costs. This was driven mostly by the labor involved in planning and implementation activities. The average total cost of the pre-implementation and implementation activities were $1031 and $17,816 per site, respectively. In the sensitivity analysis, costs for VHA were higher than BLS estimates likely due to higher wages., Conclusions: Implementing external facilitation to increase MOUD prescribing may be affordable depending on the payer's budget constraints. Our study reported that there were variations in the time invested at each phase of implementation and the number and type of participants involved with implementing an external facilitation intervention. Participant composition played an important role in total implementation costs, and decision makers will need to identify the most efficient and optimal number of stakeholders to involve in their implementation plans., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Purpose: This study explored Veteran and family member perspectives on factors that drive post-traumatic stress disorder (PTSD) therapy engagement within constructs of the Andersen model of behavioral health service utilization. Despite efforts by the Department of Veterans Affairs (VA) to increase mental health care access, the proportion of Veterans with PTSD who engage in PTSD therapy remains low. Support for therapy from family members and friends could improve Veteran therapy use., Methods: We applied a multiple methods approach using data from VA administrative data and semi-structured individual interviews with Veterans and their support partners who applied to the VA Caregiver Support Program. We integrated findings from a machine learning analysis of quantitative data with findings from a qualitative analysis of the semi-structured interviews., Results: In quantitative models, Veteran medical need for health care use most influenced treatment initiation and retention. However, qualitative data suggested mental health symptoms combined with positive Veteran and support partner treatment attitudes motivated treatment engagement. Veterans indicated their motivation to seek treatment increased when family members perceived treatment to be of high value. Veterans who experienced poor continuity of VA care, group, and virtual treatment modalities expressed less care satisfaction. Prior marital therapy use emerged as a potentially new facilitator of PTSD treatment engagement that warrants more exploration., Conclusions: Our multiple methods findings represent Veteran and support partner perspectives and show that amid Veteran and organizational barriers to care, attitudes and support of family members and friends still matter. Family-oriented services and intervention could be a gateway to increase Veteran PTSD therapy engagement., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) have demonstrated effectiveness for improving outcomes in chronic pain. These evidence-based psychotherapies (EBPs) remain underutilized in clinical practice, however. To identify research gaps and next steps for improving uptake of EBPs, we conducted a systematic review of patient-, provider-, and system-level barriers and facilitators of their use for chronic pain. We searched MEDLINE, Embase, PsycINFO, and CINAHL databases from inception through September 2022. Prespecified eligibility criteria included outpatient treatment of adults with chronic pain; examination of barriers and facilitators and/or evaluation of implementation strategies; conducted in the United States (US), United Kingdom (UK), Ireland, Canada or Australia; and publication in English. Two reviewers independently assessed eligibility and rated quality. We conducted a qualitative synthesis of results using a best-fit framework approach building upon domains of the Consolidated Framework for Implementation Research (CFIR). We identified 34 eligible studies (33 moderate or high quality), most (n = 28) of which addressed patient-level factors. Shared barriers across EBPs included variable patient buy-in to therapy rationale and competing responsibilities for patients; shared facilitators included positive group or patient-therapist dynamics. Most studies examining ACT and all examining MBSR assessed only group formats. No studies compared barriers, facilitators, or implementation strategies of group CBT to individual CBT, or of telehealth to in-person EBPs. Conceptual mismatches of patient knowledge and beliefs with therapy principles were largely analyzed qualitatively, and studies did not explore how these mismatches were addressed to support engagement. Future research on EBPs for chronic pain in real-world practice settings is needed to explore provider and system-level barriers and facilitators, heterogeneity of effects and uptake, and both effects and uptake of EBPs delivered in various formats, including group vs individual therapy and telehealth or asynchronous digital approaches. PERSPECTIVE: This systematic review synthesizes evidence on barriers and facilitators to uptake of cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based stress reduction for chronic pain. Findings can guide future implementation work to increase availability and use of evidence-based psychotherapies for treatment of chronic pain. REGISTRATION: PROSPERO number CRD42021252038., (Published by Elsevier Inc.)

Posttraumatic stress disorder (PTSD) is disabling condition among United States Veterans. Training programs for evidenced-based therapies have been rolled out nationally in the Veterans Health Administration (VHA), but provider adoption of these treatments is limited and rates of Veteran dropout are high. Increasing support for mental health therapy within the Veteran's social network would improve treatment engagement. We discuss the adaptation of Recovery-Oriented Decisions for Relatives' Support (REORDER)-a family-based intervention for individuals with serious mental illness- to create Family Support in Mental Health Recovery (FAMILIAR), an intervention that seeks to strengthen support partners' abilities to help Veterans engage in therapy. Our goal was to apply modifications to meet the needs of Veterans with PTSD and their support partners. We used input from Veterans, support partners, clinicians and VA system leaders to inform the modifications. Then, a multi-disciplinary intervention development team met to determine which modifications would be applied and how. We used the domains from the Framework for Adaptations and Modification (FRAME) to systematically track and describe modifications. Adaptations made to REORDER included changes in content, structure, and delivery format. The resulting intervention, FAMILIAR, was a 3-4 session intervention beginning prior to EBP initiation and continuing through sessions 3, 4 or 5 of the EBP. Sessions were designed for maximum flexibility and could be offered either in-person or virtually, and sessions involve interactions between the interventionist with the Veteran and support partner alone and together. We learned the importance of including diverse stakeholder perspectives to develop a comprehensive understanding of the needs of the target population and the health system. While feasibility and effectiveness testing is needed, we applied a proactive adaptation approach that we anticipate will make FAMILIAR successful in addressing patient, clinical, and system considerations of a family approach to increase Veteran engagement in PTSD treatment.

Background: Identifying effective strategies to improve access to medication treatments for opioid use disorder (MOUD) is imperative. Within the Veterans Health Administration (VHA), provision of MOUD varies significantly, requiring development and testing of implementation strategies that target facilities with low provision of MOUD., Objective: Determine the effectiveness of external facilitation in increasing the provision of MOUD among VHA facilities with low baseline provision of MOUD compared to matched controls., Design: Pre-post, block randomized study designed to compare facility-level outcomes in a stratified sample of eligible facilities. Four blocks (two intervention facilities in each) were defined by median splits of both the ratio of patients with OUD receiving MOUD and number of patients with OUD not currently receiving MOUD (i.e., number of actionable patients). Intervention facilities participated in a 12-month implementation intervention., Participants: VHA facilities in the lowest quartile of MOUD provision (35 facilities), eight of which were randomly assigned to participate in the intervention (two per block) with twenty-seven serving as matched controls by block., Intervention: External facilitation included assessment of local barriers/facilitators, formation of a local implementation team, a site visit for action planning and training/education, cross-facility quarterly calls, monthly coaching calls, and consultation., Main Measures: Pre- to post-change in the facility-level ratio of patients with an OUD diagnosis receiving MOUD compared to control facilities., Key Results: Intervention facilities significantly increased the ratio of patients with OUD receiving MOUD from an average of 18% at baseline to 30% 1 year later, with an absolute difference of 12% (95% confidence interval [CI]: 6.6%, 17.0%). The difference in differences between intervention and control facilities was 3.0% (95% CI: - 0.2%. 6.7%). The impact of the intervention varied by block, with smaller, less complex facilities more likely to outperform matched controls., Conclusions: Intensive external facilitation improved the adoption of MOUD in most low-performing facilities and may enhance adoption beyond other interventions less tailored to individual facility contexts., (© 2021. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Background: Co-occurrence of posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) is common and concurrent treatment is recommended. Relatively little is known about which evidence-based psychotherapies for PTSD are most effective for patients with varying substance use profiles. We aim to examine the comparative effectiveness of trauma-focused therapy (TFT) and non-trauma-focused therapy (NTFT) among Veterans with PTSD and SUD. TFT has been found to be effective among those with PTSD/SUD, though effects are smaller and rates of treatment non-completion are higher than in those without SUD. NTFTs suggested for the treatment of PTSD, such as Present Centered Therapy, (PCT) have not been examined among those with co-occurring SUD, despite lower rates of treatment dropout. We will also examine the comparative effectiveness of TFT and NTFT for patients with varying SUD severity, type of substances used, and patient treatment preference., Method: 420 Veterans with PTSD and SUD will be randomized in a prospective, pragmatic comparative effectiveness trial at 14 Veterans Health Administration facilities. Participants will receive either TFT (Prolonged Exposure or Cognitive Processing Therapy) or NTFT (PCT) after enrolling in concurrent SUD treatment-as-usual. Assessments will occur at baseline, posttreatment, 3- and 6 -months posttreatment. Main outcomes are PTSD symptom severity and PTSD treatment dropout. Clinician, patient, and leadership stakeholder panels advise study activities, and a process evaluation will identify strategies to enhance the implementation of evidence-based PTSD treatments in SUD care settings., Conclusions: Results will provide critical information to guide clinicians when recommending PTSD treatments to patients with comorbid SUD., Clinicaltrials: gov Identifier: NCT04581434., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Inc.)

Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) are first-line treatments for posttraumatic stress disorder (PTSD) and have been disseminated throughout the U.S. Veterans Health Administration. Treatment non-completion is common and lessens clinical effectiveness; however, prior work has failed to identify factors consistently associated with non-completion. Semi-structured interviews were conducted with a national sample of veterans who recently completed (n = 60) or did not complete (n = 66) PE or CPT. Non-completer interviews focused on factors that contributed to veterans' decisions to drop out and efforts undertaken to complete PE/CPT. Completer interviews focused on challenges faced in completing treatment and facilitators of completion. Transcripts were coded using a mixed deductive/inductive approach; constant comparison was used to identify differences between completers and non-completers. Completers and non-completers differed in the extent of treatment-specific therapist support received, therapists' flexibility in treatment delivery, the type of encouragement offered by the care team and social supports, their interpretation of symptom worsening, the perceived impact of treatment on functioning, and the impact of stressors on their treatment engagement. Treatment-specific therapist support, more patient-centered and flexible treatment delivery, leveraging the full care team, and addressing functional concerns are potential targets for PE and CPT engagement interventions., (Published by Elsevier Ltd.)

Background: Posttraumatic stress disorder occurs in as many as one in five combat veterans and is associated with a host of negative, long-term consequences to the individual, their families, and society at large. Trauma-focused treatments, such as Prolonged Exposure, result in clinically significant symptom relief for many. Adherence to these treatments (i.e., session attendance and homework compliance) is vital to ensuring recovery but can be challenging for patients. Engaging families in veterans' treatment could prove to be an effective strategy for promoting treatment adherence while also addressing long-standing calls for better family inclusion in treatment for posttraumatic stress disorder. This paper describes the methods of a pragmatic randomized controlled trial designed to evaluate if family inclusion in Prolonged Exposure can improve treatment adherence., Methods: One hundred fifty-six veterans, with clinically significant symptoms of posttraumatic stress disorder, will be randomized to receive either standard Prolonged Exposure or Prolonged Exposure enhanced through family inclusion (Family-Supported Prolonged Exposure) across three different VA facilities. Our primary outcomes are session attendance and homework compliance. Secondary outcomes include posttraumatic stress disorder symptom severity, depression, quality of life, and relationship functioning. The study includes a concurrent process evaluation to identify potential implementation facilitators and barriers to family involvement in Prolonged Exposure within VA., Discussion: While the importance of family involvement in posttraumatic stress disorder treatment is non-controversial, there is no evidence base supporting best practices on how to integrate families into PE or any other individually focused trauma-focused treatments for posttraumatic stress disorder. This study is an important step in addressing this gap, contributing to the literature for both retention and family involvement in trauma-focused treatments., Trial Registration: ClinicalTrials.gov NCT03256227 . Registered on August 21, 2017., (© 2022. The Author(s).)

Background: The Veterans Health Administration (VHA) is invested in expanding access to medication treatment for opioid use disorder (MOUD) to save lives. Access varies across VHA facilities and, thus, requires implementation strategies to promote system-wide adoption of MOUD. We conducted a 12-month study employing external facilitation that targeted MOUD treatment among low-adopting VHA facilities. In this study, we sought to evaluate the patterns of perceived barriers over 1 year of external implementation facilitation using the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework., Methods: We randomly selected eight VHA facilities from the bottom quartile of the proportion of Veterans with an OUD diagnosis receiving MOUD (< 21%). The 1-year external implementation intervention included developmental evaluation to tailor the facilitation, an on-site visit, and monthly facilitation calls. Facilitators recorded detailed notes for each call on a structured template. Qualitative data was analyzed by coding and mapping barriers to the constructs in the i-PARIHS framework (Innovation, Recipients, Context). We identified emerging themes within each construct by month., Results: Barriers related to the Innovation, such as provider perception of the need for MOUD in their setting, were minimal throughout the 12-month study. Barriers related to Recipients were predominant and fluctuated over time. Recipient barriers were common during the initial months when providers did not have the training and waivers necessary to prescribe MOUD. Once additional providers (Recipients) were trained and waivered to prescribe MOUD, Recipient barriers dropped and then resurfaced as the facilities worked to expand MOUD prescribing to other clinics. Context barriers, such as restrictions on which clinics could prescribe MOUD and fragmented communication across clinics regarding the management of patients receiving MOUD, emerged more prominently in the middle of the study., Conclusions: VHA facilities participating in 12-month external facilitation interventions experienced fluctuations in barriers to MOUD prescribing with contextual barriers emerging after a facilitated reduction in recipient- level barriers. Adoption of MOUD prescribing in low-adopting VHA facilities requires continual reassessment, monitoring, and readjustment of implementation strategies over time to meet challenges. Although i-PARIHS was useful in categorizing most barriers, the lack of conceptual clarity was a concern for some constructs., (© 2021. The Author(s).)

To evaluate an implementation intervention to increase the uptake, referred to as reach, of two evidence-based psychotherapies (EBP) for posttraumatic stress disorder (PTSD) in Veterans Health Administration (VHA) PTSD specialty clinics. The implementation intervention was external facilitation guided by a toolkit that bundled strategies associated with high EBP reach in prior research. We used a prospective quasi-experimental design. The facilitator worked with local champions at two low-reach PTSD clinics. Each intervention PTSD clinic was matched to three control clinics. We compared the change in EBP reach from 6-months pre- to post-intervention using Difference-in-Difference (DID) effect estimation. To incorporate possible clustering effects and adjust for imbalanced covariates, we used mixed effects logistic regression to model the probability of EBP receipt. Analyses were conducted separately for PTSD and other mental health clinics. 29,446 veterans diagnosed with PTSD received psychotherapy in the two intervention and six control sites in the two 6-month evaluation periods. The proportion of therapy patients with PTSD receiving an EBP increased by 16.98 percentage points in the intervention PTSD clinics compared with .45 percentage points in the control PTSD clinics (DID = 16.53%; SE = 2.26%). The adjusted odd ratio of a patient receiving an EBP from pre to post intervention was almost three times larger in the intervention than in the control PTSD clinics (RoR 2.90; 95% CI 2.22-3.80). EBP reach was largely unchanged in other (not PTSD specialty) mental health clinics within the same medical centers. Toolkit-guided external facilitation is a promising intervention to improve uptake of EBPs in VHA. Toolkits that pre-specify targets for clinic change based on prior research may enhance the efficiency and effectiveness of external facilitation. Trial registration ISRCTN registry identifier: ISRCTN65119065. Available at https://www.isrctn.com/search?q=ISRCTN65119065 .

Background: Despite the risk of negative sequelae from opioid use disorder (OUD) and clinical guidelines for the use of effective medication treatment for OUD (M-OUD), many Veterans Health Administration (VHA) providers and facilities lag in providing M-OUD. An intensive external facilitation intervention may enhance uptake in low-adopting VHA facilities by engaging stakeholders from multiple clinical settings within a facility (e.g., mental health, primary care, pain specialty clinic, substance use disorder clinics). Our study identified pre-intervention determinants of implementation through qualitative interviews, described strategies employed during the first 6 months of intensive external facilitation, and explored patterns of implementation determinants in relation to early outcomes., Methods: Guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, we interviewed stakeholders at low-adopting VHA facilities prior to external facilitation, employed a rapid qualitative analytic process, presented findings during facility visits, and collaboratively created facilitation action plans to achieve goals set by the facilities that would increase M-OUD uptake. The primary outcome was the Substance Use Disorder (SUD)-16, which is a VHA facility-level performance metric consisting of the percent of patients receiving M-OUD among those with an OUD diagnosis. We examined the relationship between pre-implementation factors and 6-month SUD-16 outcomes., Results: Across eight VHA facilities, we interviewed 68 participants. Implementation determinants included barriers and facilitators across innovation, context, and recipients constructs of i-PARIHS. Each facility selected goals based on the qualitative results. At 6 months, two facilities achieved most goals and two facilities demonstrated progress. The SUD-16 from baseline to 6 months significantly improved in two facilities (8.4% increase (95 % confidence interval [CI] 4.4-12.4) and 9.9% increase (95% CI 3.6-16.2), respectively). Six-month implementation outcomes showed that the extent to which M-OUD aligns with existing clinical practices and values was a primary factor at all facilities, with six of eight facilities perceiving it as both a barrier and facilitator. External health system barriers were most challenging for facilities with the smallest change in SUD-16., Conclusions: Early impacts of a multi-faceted implementation approach demonstrated a strong signal for positively impacting M-OUD prescribing in low-adopting VHA facilities. This signal indicates that external facilitation can influence adoption of M-OUD at the facility level in the early implementation phase. These short-term wins experienced by stakeholders may encourage continued adoption and long-term sustainability M-OUD.

Objectives: Nonpharmacological options to treat pain are in demand, in part to address the opioid crisis. One such option is acupuncture. Battlefield acupuncture (BFA) is an auricular needling protocol currently used to treat pain in the Veterans Health Administration. We aimed to identify the advantages and disadvantages of BFA from providers' perspectives., Methods: We rely on an inductive qualitative approach to explore provider perceptions through thematic analysis of semistructured interviews with 43 BFA providers across the nation., Results: We identified the following themes. Disadvantages included: (1) clinical guidelines are insufficient; (2) patients often request multiple BFA visits from providers; (3) BFA can be uncomfortable; (4) BFA may not be an effective treatment option unless it can be provided "on demand"; and (5) BFA can promote euphoria, which can have deleterious consequences for patient self-care. Perceived advantages included: (1) BFA can simultaneously effectively control pain while reducing opioid use; (2) BFA may alleviate the pain that has been unsuccessfully treated by conventional methods; (3) BFA gives providers a treatment option to offer patients with substance use disorder; (4) BFA helps build a trusting patient-provider relationship; (5) BFA can create the opportunity for hope., Conclusions: Providers perceive BFA to have many benefits, both clinical and relational, including ways in which it may have utility in addressing the current opioid crisis. BFA is easy to deliver and has potential clinical and relational utility. Efforts to better understand effectiveness are warranted.

Objectives: Veterans Health Administration (VHA) launched a national initiative to train providers in a specific, protocolized auricular acupuncture treatment (also called Battlefield Acupuncture or BFA) as a nonpharmacological approach to pain management. This evaluation assessed the real-world effectiveness of BFA on immediate pain relief and identified subgroups of patients for whom BFA is most effective., Research Design: In a cross-sectional cohort study, electronic medical record data for 11,406 Veterans treated with BFA at 57 VHA medical centers between October 2016 and September 2018 was analyzed. The multivariate analysis incorporated data on pain history, change in pain level on an 11-point scale, complications, and demographic information., Methods: A total of 11,406 Veterans were treated with BFA at 57 VHA medical centers between October 2016 and September 2018 and had effectiveness data recorded in their electronic medical record., Results: More than 3 quarters experienced immediate decreases in pain following administration of BFA, with nearly 60% reported experiencing a minimal clinically important difference in pain intensity. The average decrease in pain intensity was -2.5 points (SD=2.2) at the initial BFA treatment, and -2.2 points (SD=2.0) at subsequent treatments. BFA was effective across a wide range of Veterans with many having preexisting chronic pain, or physical, or psychological comorbid conditions. Veterans with opioid use in the year before BFA experienced less improvement, with pain intensity scores improving more among Veterans who had not recently used opioids., Conclusion: VHA's rapid expansion of training providers to offer BFA as a nonpharmacological approach to pain management has benefited many Veterans.

Objectives: Assess prevalence and severity of posttraumatic stress disorder, suicidal behavior, and depressive, substance use, and anxiety disorders in US service members or Veterans with and without a deployment-related mild traumatic brain injury (TBI) (mTBI)., Design: Systematic review using multiple databases (January 2000 to October 2017). We included national or geographically diverse samples., Main Measure: Prevalence and severity of psychiatric conditions based on diagnostic codes, clinician assessments, and self-report measures with results stratified by sample type., Results: We identified 11 studies on the basis of national samples and 22 studies on the basis of geographically diverse samples. Traumatic brain injury severity was not always ascertained or reported. In national studies, posttraumatic stress disorder, depressive disorder, substance use disorder, and anxiety disorder prevalence were higher in those with TBI than in those without. One national sample reported prevalence of suicide attempts. Across psychiatric conditions, strength of evidence ranged from insufficient to moderate. In geographically diverse samples, the pattern of findings was similar. National studies provided insufficient evidence on psychiatric condition severity; geographically diverse studies found greater severity of posttraumatic stress disorder symptoms with mixed results for symptoms of depressive or substance use disorders., Conclusions: Service members and Veterans with TBI history have higher prevalence and possibly severity of selected psychiatric conditions.

The actions needed to mitigate the spread of the coronavirus 2019 (COVID-19) have forged rapid paradigm shifts across healthcare delivery. In a time of crisis, continued access to and delivery of medication for opioid use disorder (M-OUD) is essential to save lives. However, prior to COVID-19, large variability in M-OUD adoption existed across the Veteran Health Administration (VHA) and it is unknown whether the COVID-19 pandemic exacerbated this divide. For the past two years, our team worked with eight VHA facilities to enhance adoption of M-OUD through a multi-component implementation intervention. This commentary explores these providers' responses to COVID-19 and the subsequent impact on their progress toward increasing adoption of M-OUD. Briefly, the loosening of regulatory restrictions fostered accelerated adoption of M-OUD, rapid support for telehealth offered a mechanism to increase M-OUD access, and reevaluation of current practices surrounding M-OUD strengthened adoption. Overall, during the COVID-19 crisis, facilities and providers responded positively to the call for increased access to M-OUD and appropriate care of patients with OUD. The VHA providers' responses and continued progress in enhancing M-OUD amidst a crisis may, in part, be attributable to their participation in an implementation effort prior to COVID-19 that established resources, expert support, and a community of practice. We anticipate the themes presented are generalizable to other healthcare systems grappling to deliver care to patients with OUD during a crisis. We propose areas of future research and quality improvement to continue to provide access and high quality, life-saving care to patients with OUD.

Background: Co-morbidity of psychiatric conditions with traumatic brain injury (TBI) is common among service members and Veterans from recent deployments. Practice guidelines for mild TBI (mTBI) recommend management of co-occurring psychiatric conditions with existing treatments, but it is unclear whether the effectiveness of treatments for psychiatric conditions is impacted by mTBI. We conducted a systematic literature review to examine the effectiveness and harms of pharmacological and non-pharmacological treatments for posttraumatic stress disorder, depressive disorders, substance use disorders, suicidal ideation or attempts, and anxiety disorders in the presence of co-morbid deployment-related mTBI., Methods: We searched bibliographic databases for peer-reviewed, English language studies published from 2000 to October 2017. Two reviewers independently completed abstract triage and full text review., Results: We identified 7 studies (5 pre-post and 2 secondary analysis). Six assessed psychotherapy and one reported on hyperbaric oxygen therapy (HBO 2 ). Studies comparing outcomes by TBI history found that a history of TBI does not affect treatment outcomes. Harms were reported only for HBO 2 and were mild. No study examined the effectiveness of treatments for substance use disorders or suicidal ideation, or the effectiveness of pharmacological interventions for the psychiatric conditions of interest in service members and Veterans with mTBI., Limitations: Studies lacked usual care or wait-list control groups and no randomized trials were found, making the strength of evidence insufficient., Conclusions: Evidence is insufficient to fully assess the impact of TBI on the effectiveness of treatments for psychiatric conditions. Higher quality evidence with definitive guidance for providers treating this population is needed., (Published by Elsevier B.V.)

Background: In the US, emergency room visits and overdoses related to prescription opioids have soared and the rates of illicit opioid use, including heroin and fentanyl, are increasing. Opioid use disorder (OUD) is associated with higher morbidity and mortality, higher HIV and HCV infection rates, and criminal behavior. Opioid agonist therapy (OAT; methadone and buprenorphine) is proven to be effective in treating OUD and decreasing its negative consequences. While the efficacy of OAT has been established, too few providers prescribe OAT to patients with OUD due to patient, provider, or system factors. While the Veterans Health Administration (VHA) has made great strides in OAT implementation, national treatment rates remain low (35% of patients with OUD) and several facilities continue to have much lower prescribing rates., Methods: Eight VA sites with low baseline prescribing rates (lowest quartile, < 21%) were randomly selected from the 35 low prescribing sites to receive an intensive external facilitation implementation intervention to increase OAT prescribing rates. The intervention includes a site-specific developmental evaluation, a kick-off site visit, and 12 months of ongoing facilitation. The developmental evaluation includes qualitative interviews with patients, substance use disorders clinic staff, and primary care and general mental health leadership to assess site-level barriers. The site visit includes: (1) a review of site-specific barriers and potential implementation strategies; (2) instruction on using available dashboards to track prescribing rates and identify actionable patients; and (3) education on OAT, including, if requested, buprenorphine certification training for prescribers. On-going facilitation consists of monthly conference calls with individual site teams and expert clinical consultation. The primary outcomes is the proportion of Veterans with OUD initiating and sustaining OAT, with intervention sites expected to have larger increases in prescribing compared to control sites. Final qualitative interviews and a cost assessment will inform future implementation efforts., Discussion: This project will examine and respond to barriers encountered in low prescribing VHA clinics allowing refinement of an intervention to enhance access to medication treatment for OUD in additional facilities.

Objective: Battlefield Acupuncture (BFA) is an auricular needling protocol for pain. More than 1300 Veterans Health Administration (VHA) clinicians have been trained in BFA delivery. However, little is known about how well BFA has been implemented at the VHA. The aim of this research was to identify the challenges providers experience in implementing BFA and to look for any successful strategies used to overcome these challenges. Materials and Methods: Semistructured telephone interviews were conducted from June 2017 to January 2018, using an interview guide informed by the integrated Promoting Action on Research Implementation in Health Services framework to address several implementation domains: knowledge and attitudes about BFA; professional roles and training in BFA; organization of BFA delivery and resources to provide BFA; and implementation challenges and strategies to address challenges. The interviews were analyzed, using a grounded theory-informed approach. This research was conducted at 20 VHA facilities and involved 23 VHA BFA providers nationwide. Results: Nine main implementation themes were identified: (1) providers organizing BFA delivery in various ways; (2) insufficient time to provide BFA to meet patient demand; (3) beliefs and knowledge about BFA; (4) lack of BFA indication guidelines or effectiveness data; (5) self-efficacy; (6) time delay between training and practice; (7) limited access to resources; (8) key role of leadership and administrative buy-in, and (9) written consent an unwarranted documentation burden. Providers offered some possible strategies to address these issues. Conclusions: System- and provider-level challenges can impede BFA implementation. However, several providers discovered strategies to address some challenges that can be used within and outside the VHA, which, in turn, might improve access to this potentially promising pain-management intervention., Competing Interests: No financial conflicts of interest exist.

Objective: Previous studies suggest that group "mantram" (sacred word) repetition therapy, a non-trauma-focused complementary therapy for posttraumatic stress disorder (PTSD), may be an effective treatment for veterans. The authors compared individually delivered mantram repetition therapy and another non-trauma-focused treatment for PTSD., Method: The study was a two-site, open-allocation, blinded-assessment randomized trial involving 173 veterans diagnosed with military-related PTSD from two Veterans Affairs outpatient clinics (January 2012 to March 2014). The mantram group (N=89) learned skills for silent mantram repetition, slowing thoughts, and one-pointed attention. The comparison group (N=84) received present-centered therapy, focusing on currently stressful events and problem-solving skills. Both treatments were delivered individually in eight weekly 1-hour sessions. The primary outcome measure was change in PTSD symptom severity, as measured by the Clinician-Administered PTSD Scale (CAPS) and by self-report. Secondary outcome measures included insomnia, depression, anger, spiritual well-being, mindfulness, and quality of life. Intent-to-treat analysis was conducted using linear mixed models., Results: The mantram group had significantly greater improvements in CAPS score than the present-centered therapy group, both at the posttreatment assessment (between-group difference across time, -9.98, 95% CI=-3.63, -16.00; d=0.49) and at the 2-month follow-up (between-group difference, -9.34, 95% CI=-1.50, -17.18; d=0.46). Self-reported PTSD symptom severity was also lower in the mantram group compared with the present-centered therapy group at the posttreatment assessment, but there was no difference at the 2-month follow-up. Significantly more participants in the mantram group (59%) than in the present-centered therapy group (40%) who completed the 2-month follow-up no longer met criteria for PTSD (p<0.04). However, the percentage of participants in the mantram group (75%) compared with participants in the present-centered therapy group (61%) who experienced clinically meaningful changes (≥10-point improvements) in CAPS score did not differ significantly between groups. Reductions in insomnia were significantly greater for participants in the mantram group at both posttreatment assessment and 2-month follow-up., Conclusions: In a sample of veterans with PTSD, individually delivered mantram repetition therapy was generally more effective than present-centered therapy for reducing PTSD symptom severity and insomnia.