Posted October 27, 2020

Craig Rosen, Ph.D. and Carmen McLean, Ph.D., Palo Alto Veterans Institute of Research

In 2013, the National Research Action Plan (NRAP) was developed by the Department of Defense (DoD), Department of Veterans Affairs (VA), and the National Institutes of Health in response to an Executive Order to initiate interagency research to improve the diagnosis, prevention, and treatment of Post-Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI), as well as suicide prevention. As a result, interagency teams of investigators from the government, industry, and academia have come together to conduct studies ranging from basic biomarker and etiology research (to understand the physiological nature of PTSD and TBI) to applied clinical research (to assess efficacy of various PTSD behavioral health treatments and interventions). Despite significant bodies of research supporting various psychological health treatment modalities, a number of challenges and barriers remain concerning mental health treatment accessibility, engagement, and utilization that slow the implementation of various evidence-based practices (EBPs) into clinical environments, such as the Military Health System (MHS). EBP refers to the purposeful integration of the best available research evidence, practitioner expertise, and consumer values in decisions relating to clinical care and is one of many considerations in health care delivery and decision-making. A number of challenges exist in implementing EBPs, including provider adoption, adherence to manualized interventions, and sustained use in clinical care settings. Presently, EBP for PTSD is under-utilized in military treatment facilities (MTFs)/clinics despite VA/DoD clinical practice guideline recommendations and EBP training initiatives. Additionally, barriers to use of EBPs for PTSD in the MHS are complex and are likely to vary across MTFs/clinical environments and organizational structures. 

In an effort to better understand and resolve challenges to implementation of evidence-based PTSD treatments, the DoD’s Military Operational Medicine Research Program/Joint Program Committee-5 (MOMRP/JPC-5), in consultation with the Defense Health Agency’s (DHA) Mental Health Working Group (MHWG, now the Behavioral Health Clinical Community, BHCC), funded a multi-disciplinary research team led by researchers Dr. Craig Rosen and Dr. Carmen McLean at the National Center for PTSD at the VA Palo Alto Health Care System. Their study, entitled, “Targeted Strategies to Increase Evidence-Based Psychotherapy in Military Settings,” seeks to develop and test a novel approach, Targeted Assessment and Context-Tailored Implementation of Change Strategies (TACTICS), to increase implementation of Prolonged Exposure (PE) therapy, a manualized intervention for the treatment of PTSD, into MTF care facilities and to test the impact on patient outcomes when compared to standard clinician training in PE alone. The project uses a stepped-wedge design with tri-service representation at multiple clinical sites and seeks to identify barriers and facilitators of PE use at each clinical site. Once barriers are identified, the study team customizes (for each clinical site) specific implementation strategies to utilize local strengths, reduce barriers, and improve overall care. The overall aims of the study are to (1) evaluate the impact of TACTICS over and above standard PE training on the proportion of PTSD patients receiving PE, as measured by coded electronic medical record data; (2) assess the impact of TACTICS over and above PE training on improvement in patients’ PTSD symptoms, as measured by a change in the PTSD Checklist (a symptom measure routinely collected during behavioral health appointments); (3) determine the usability of and overall satisfaction with TACTICS among senior leaders, clinical leaders, and providers; and (4) identify successful components to inform refinements of TACTICS. Outcomes of this research are expected to facilitate accelerated translation, adoption, and sustainment of evidence-based practices, regardless of injury; improve delivery of care in support of the Warfighter by improving military readiness by maximizing successful return to duty; and decrease future burdens in the VA and other disability systems. 

A critical facet of this study has been the integration of major stakeholders, such as MHWG/BHCC, throughout the planning and execution of the effort. The MHWG/BHCC identified the specific PTSD EBP (PE) for this initial effort, as well as guidance for ensuring tri-service representation in study site selection, to allow researchers to address unique considerations of care in different Service environments. Within the DHA’s NRAP, MOMRP/JPC-5 has supported TACTICS as part of the next major steps in the plan to help resolve the issue of EBP implementation. Initiation of TACTICS came at a time when the DHA was beginning to establish leadership over certain MTFs, which facilitated the choice of clinical sites for TACTICS participation. Further, MOMRP/JPC-5 and the BHCC worked to help TACTICS team identify sites with the capacity required for the study (patient volume and personnel availability), and site selection focused on MTFs/clinics where EBP was heavily utilized. As of January 2020, eight MTFs/clinics are participating in TACTICS: Fort Sam Houston (Texas), Fort Campbell (Kentucky), Fort Bliss (Texas), Fort Wainwright (Alaska), Travis Air Force Base (California), Holloman Air Force Base (New Mexico), Keesler Air Force Base (Mississippi), and Naval Hospital Jacksonville (Florida). Another example of stakeholder integration has been a collaboration with the DHA’s Solution Delivery Division (SDD), a component of Informatics Operations (J6). SDD has partnered with the research team on data extraction, analysis, integration, and delivery activities that are critical to the success of this effort. 

On behalf of MOMRP/JPC-5, the Congressionally Directed Medical Research Programs manages the TACTICS effort, as the multidisciplinary team includes leading researchers from the VA National Center for PTSD; Center for Deployment Psychology at the Uniformed Services University; Social Sciences Innovations, Corp; University of Texas, Austin; University of Texas Health Science Center San Antonio; and University of Washington. Additional collaborations in the DoD include the DHA’s SDD and Walter Reed National Military Medical Center. Similar to the NRAP, the TACTICS effort involves interagency collaboration to address challenges and find much needed solutions for EBP implementation within the MHS. 

Link:

Public and Technical Abstracts: Targeted Strategies to Accelerate Evidence-Based Psychotherapies Implementation in Military Settings

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