CAP Profiles

Bio

Bio

Shannon Wiltsey Stirman received her PhD in Clinical Psychology from the University of Pennsylvania. She completed an internship at the VA Palo Alto Healthcare System, and returned to Philadelphia for postdoctoral training, where she received an NIMH-funded K99/R00 award to study implementation and sustainability of CBT in a partnership between Penn and the City of Philadelphia’s Department of Behavioral Health and disAbility Services to implement cognitive therapy across the city’s network of providers. In 2009, Dr. Stirman joined the Women's Health Sciences Division of the VA National Center for PTSD and the Department of Psychiatry at Boston University. She was a Fellow of the NIMH and VA-funded Implementation Research Institute, and later served as an expert faculty member. In 2015, Dr. Stirman transitioned to the Dissemination and Training Division of the National Center for PTSD, where she currently serves as Acting Deputy Director, and joined the Stanford faculty in 2016. She was awarded the Association of Behavior and Cognitive Therapy's Mid-Career Innovator award in 2018 and serves on the board of the Society for Implementation Research Collaboration. Her research has been funded by the National Institute of Mental Health and the Canadian Institute for Health Research.

Academic Appointments

  • Associate Professor - Med Center Line, Psychiatry and Behavioral Sciences

Administrative Appointments

  • Acting Deputy Director, Dissemination and Training Division, National Center for PTSD (2018 - Present)

Boards, Advisory Committees, Professional Organizations

  • Member-at-Large, Board of Directors, American Psychological Association (2019 - Present)
  • Senior Leader, Dissemination and Implementation Special Interest Group, Association for Behavioral and Cognitive Therapy (2018 - Present)
  • Board of Directors, Chair of the Established Network of Expertise, Society for Implementation Research Collaboration (2018 - Present)

Community and International Work

  • Sonoma County Wildfire Mental Health Collaborative

    Topic

    Program Evaluation

    Partnering Organization(s)

    Healthcare Foundation Northern Sonoma County

    Populations Served

    Individuals impacted by wildfires in Sonoma County

    Location

    California

    Ongoing Project

    Yes

    Opportunities for Student Involvement

    Yes

Contact

Links

Research & Scholarship

Current Research and Scholarly Interests

The overarching goal of my program of research is to determine how to facilitate the high quality delivery of evidence-based psychosocial interventions (EBPs) in public sector mental health settings. Areas of emphasis include training and consultation, treatment fidelity and adaptation, and the identification of strategies that promote sustained implementation of EBPs. In my early work, I examined the degree to which the randomized controlled trial (RCT) literature included individuals with characteristics like those seen in routine care settings. This work highlighted some gaps in the literature, but largely demonstrated that the RCT literature may be more applicable to typical clients in routine care settings than previously assumed.

This early work also led me to become interested in developing and studying strategies to promote the implementation and sustained use of EBPs in public sector settings. My research group’s systematic review of research on sustainability suggested that EBPs are often fully or partially discontinued a short time after they are introduced into routine care settings. Identification of factors associated with sustained implementation is therefore an important step in promoting the long-term success of implementation efforts. Through my recently completed K99/R00 award, I used qualitative and quantitative methods to examine system, organizational, clinician, and patient-level influences on the long-term trajectory of clinicians’ use of cognitive therapy.

The degree of fidelity (adherence to the protocol and skill of delivery) with which EBPs are delivered, and adaptations to EBPs made in routine care, are key implementation outcomes. Without time- and cost-intensive direct observation, these outcomes are difficult to assess. I received an R21 to develop a strategy for assessing EBP fidelity that uses materials generated during routine sessions. If this effort is successful, the burden associated with fidelity assessment and support in both clinical trials and in implementation initiatives could be reduced dramatically.

As a first step toward understanding the implications of different types of adaptations to EBPs, my colleagues and I also developed a framework for identifying and classifying adaptations that are made to EBPs in routine care. This framework makes it possible to determine whether specific types of adaptations lead to different clinical or implementation outcomes. Using the framework, we have identified evidence that clinicians do make changes to EBPs in their own practice, and that certain clinician characteristics predict the use of adaptations that are inconsistent with the protocol.

While the work described above is based on observation of implementation efforts and has laid important groundwork for future research, my larger goal is to develop and test strategies to facilitate high-quality implementation of EBPs in routine care settings. Beyond the growing recognition that workshops, web-based trainings, and manuals alone are insufficient, little is known about strategies to train and prepare clinicians to deliver EBPs with fidelity in public sector mental health settings. My collaborators and I recently completed data collection for a fully-powered hybrid implementation/effectiveness RCT that compares consultation alone, consultation combined with observation, and a fidelity-monitoring alone strategy for training clinicians to deliver Cognitive Processing Therapy (CPT) for PTSD.

The next step is to find ways to sustain the use of EBPs after initial training and implementation. In one of the first studies of strategies to promote sustainment of EBPs, my collaborators and I are following up with a study that compares a fidelity-oriented learning collaborative strategy to a continuous quality improvement-oriented learning collaborative to support the ongoing use of an EBP in three large mental health systems.

Clinical Trials

  • Sustaining and Improving Clinicians' Use of Evidence-Based Psychotherapy (EBP) for PTSD Recruiting

    The purpose of the study is to compare the impact of two strategies to sustain and improve the delivery of an evidence-based psychotherapy for PTSD, Cognitive Processing Therapy (CPT) in three different mental health systems. These approaches are based on two different theories of what is necessary to promote successful implementation. We will examine whether these strategies lead to improved patient outcomes, clinician skill, proportion of clients who receive CPT, and other outcomes that are relevant to the implementation of evidence-based psychosocial treatments. By examining these questions in 3 different mental health systems, we will also examine whether the implementation strategies yield different results in different systems.

    View full details

Projects

  • Innovative Methods to Assess Psychotherapy Practices (imAPP), National Center for PTSD and Stanford University

    Compares strategies to assess what occurs in CBT sessions for Depression, Anxiety, and PTSD. Recruiting clinicians, interns/externs and postdoctoral fellows from VA Palo Alto, VA Boston, MGH, Penn and the Beck Community Initiative, as well as clinicians in private and group practices. Clinicians who practice cognitive behavioral treatments are eligible.

    More information can be found at http://med.stanford.edu/fastlab/research/imapp.html

    Location

    Various Locations in the US (Philadelphia, PA, Boston, MA, Palo Alto, CA, and private/group practices in the US)

    Collaborators

  • Improving and Sustaining CPT for PTSD in Mental Health System, National Center for PTSD, Stanford University

    This study compares two strategies for supporting clinicians and treatment programs that have previously trained in/implemented cognitive processing therapy for PTSD.

    VA treatment programs, mental health clinics in Texas, and treatment programs in Canada are being recruited for participation. More information can be found here: http://med.stanford.edu/fastlab/research/cpt-sustainability-study.html

    Location

    Texas, U.S. VA programs, Canada

Teaching

Stanford Advisees

Publications

All Publications

  • Examining patterns of dose response for clients who do and do not complete cognitive processing therapy. Journal of anxiety disorders Holmes, S. C., Johnson, C. M., Suvak, M. K., Sijercic, I., Monson, C. M., Wiltsey Stirman, S. 2019: 102120

    Abstract

    Trauma-focused therapies, including Cognitive Processing Therapy (CPT; Resick et al., 2016), are effective at reducing clients' PTSD symptoms. A limitation to these treatments, however, is client completion of them. The current study examined temporal patterns of treatment non-completion and the relationships among non-completion, PTSD, and overall mental health functioning outcomes, among clients in a randomized controlled CPT implementation trial. Two models of symptom change were tested: 1) dose-effect model (i.e., clients uniformly improve with additional sessions at a negatively accelerating rate); and 2) the good-enough level model (i.e., clients remain in therapy until they have achieved sufficient improvement, thus clients who attend fewer sessions improve at quicker rates). Results indicated that 42% of clients did not complete treatment, with most discontinuing between sessions two and five. Data did not fit the dose-effect or good-enough level model. Rather, clients who improved at a greater rate in their PTSD symptoms and overall mental health functioning attended more sessions. The average client had the best outcomes when they completed all 12 sessions. Identifying clients who may be at risk for discontinuing treatment, and making a concerted effort toward retaining them, is imperative to reduce non-completion rates and ultimately improve client outcomes.

    View details for DOI 10.1016/j.janxdis.2019.102120

    View details for PubMedID 31585686

  • The Association Between Clinician and Perceived Organizational Factors withEarly Fidelity to Cognitive Processing Therapy for Posttraumatic Stress Disorder in a Randomized Controlled Implementation Trial. Administration and policy in mental health Sijercic, I., Lane, J. E., Gutner, C. A., Monson, C. M., Stirman, S. W. 2019

    Abstract

    A common metric for determining implementation success is the measurement of clinician adherence to, and competence in, delivering a psychotherapy. The present study examined clinician and organizational factors as predictors of early adherence and competence among 78 clinicians delivering cognitive processing therapy (CPT), an evidence-based psychotherapy (EBP) for posttraumatic stress disorder, in a randomized controlled implementation trial. Results indicated that clinicians' willingness to adopt an EBP if required to do so was significantly associated with early adherence and competence in CPT delivery. Level of clinician education was significantly associated with early competence in delivering CPT. Organizational factors did not predict early adherence or competence. Implications of the findings are discussed.

    View details for DOI 10.1007/s10488-019-00966-7

    View details for PubMedID 31463667

  • Intimate Partner Violence Screening Programs in the Veterans Health Administration: Informing Scale-up of Successful Practices. Journal of general internal medicine Iverson, K. M., Adjognon, O., Grillo, A. R., Dichter, M. E., Gutner, C. A., Hamilton, A. B., Stirman, S. W., Gerber, M. R. 2019

    Abstract

    OBJECTIVES: Screening women for intimate partner violence (IPV) is increasingly expected in primary care, consistent with clinical prevention guidelines (e.g., United States Preventive Services Task Force). Yet, little is known about real-world implementation of clinical practices or contextual factors impacting IPV screening program success. This study identified successful clinical practices, and barriers to and facilitators of IPV screening program implementation in the Veterans Health Administration (VHA).DESIGN: Descriptive, qualitative study of a purposeful sample of 11 Veterans Affairs Medical Centers (VAMCs) categorized as early and late adopters of IPV screening programs within women's health primary care clinics. VAMCs were categorized based on performance measures collected by VHA operations partners.PARTICIPANTS: Thirty-two administrators and clinician key informants (e.g., Women's Health Medical Directors, IPV Coordinators, and physicians) involved in IPV screening program implementation decisions from six early- and five late-adopting sites nationwide.MAIN MEASURES: Participants reported on IPV screening and response practices, and contextual factors impacting implementation, in individual 1-h semi-structured phone interviews. Transcripts were analyzed using rapid content analysis with key practices and issues synthesized in profile summaries. Themes were identified and iteratively revised, utilizing matrices to compare content across early- and late-adopting sites.KEY RESULTS: Five successful clinical practices were identified (use of two specific screening tools for primary IPV screening and secondary risk assessment, multilevel resource provision and community partnerships, co-location of mental health/social work, and patient-centered documentation). Multilevel barriers (time/resource constraints, competing priorities and mounting responsibilities in primary care, lack of policy, inadequate training, and discomfort addressing IPV) and facilitators (engaged IPV champions, internal and external supports, positive feedback regarding IPV screening practices, and current, national attention to violence against women) were identified.CONCLUSIONS: Findings advance national efforts by highlighting successful clinical practices for IPV screening programs and informing strategies useful for enhancing their implementation within and beyond the VHA, ultimately improving services and women's health.

    View details for DOI 10.1007/s11606-019-05240-y

    View details for PubMedID 31420827

  • Treatment selection among posttraumatic stress disorder (PTSD) specialty care providers in the Veterans Health Administration: A thematic analysis. Psychological trauma : theory, research, practice and policy Finley, E. P., Garcia, H. A., Ramirez, V. A., Haro, E. K., Mignogna, J., DeBeer, B., Wiltsey-Stirman, S. 2019

    Abstract

    OBJECTIVE: Although efforts to implement evidence-based psychotherapies (EBPs) require understanding how providers view and initiate these interventions, little is known regarding provider treatment selection in posttraumatic stress disorder (PTSD) care. The current study examines how specialty PTSD clinic providers within the Veterans Health Administration (VHA) describe reasons for selecting specific psychotherapies in PTSD treatment planning.METHOD: VHA psychotherapists in specialty PTSD care clinics completed a national online survey of treatment attitudes and practices, including an open-ended item inquiring about treatment selection. Thematic analysis was used to develop a framework describing factors in VHA providers' PTSD treatment selection.RESULTS: Of 250 survey participants, 219 provided description of their treatment selection process. Providers identified four domains of factors impacting treatment planning: (1) provider factors (e.g., training), (2) perceived characteristics of the intervention (e.g., structural features), (3) patient factors (e.g., characteristics of the patient and symptom presentation), and (4) organizational context (e.g., VHA policy). Assessment of appropriate treatments for an individual patient was described as resulting from interaction across these domains, particularly perceived fit between patient needs and specific treatments.CONCLUSIONS: Provider decision making has been understudied in implementation science. Although prior research has emphasized the role of organizational context in EBP reach, our findings suggest that other factors are salient when decisions are made at the level of the individual patient. Results suggest that increased attention to treatment selection and focused training in use of decision aids and shared decision making may have utility in increasing uptake, reach, and sustainment of EBPs among VHA PTSD specialty providers. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

    View details for DOI 10.1037/tra0000477

    View details for PubMedID 31204813

  • Strides Toward Recovery From Intimate Partner Violence: Elucidating Patient-Centered Outcomes to Optimize a Brief Counseling Intervention for Women. Journal of interpersonal violence Grillo, A. R., Danitz, S. B., Dichter, M. E., Driscoll, M. A., Gerber, M. R., Hamilton, A. B., Wiltsey-Stirman, S., Iverson, K. M. 2019: 886260519840408

    Abstract

    Women in the United States continue to experience intimate partner violence (IPV) at unprecedented rates, necessitating the development and implementation of personalized, effective healthcare-based interventions. Methods of developing patient-centered interventions for IPV should elicit the voice of the target population (i.e., women who experience IPV) while assuring that outcomes identified as important are incorporated into the refined intervention. This pilot study is part of a multiphase, larger study aiming to refine an IPV intervention and clinical outcome measurements prior to formal evaluation of the effectiveness of the intervention. Specifically, this study elucidates patient-centered outcomes identified by women who have experienced IPV. Women patients of the Veterans Health Administration (VHA) in New England participated in focus groups to provide feedback and desired outcomes of a new IPV intervention. Patient-centered outcomes were defined by the participants. Focus groups were transcribed and analyzed using conventional content analysis and matrix analysis. A total of 25 women participated in focus groups ( n = 5) at two large VHA facilities. Participant feedback revealed five common themes related to desired outcomes. Women opined increased feelings of empowerment as a key outcome of engaging in an IPV intervention. Women desired increased social connectedness and support to be gained during treatment, citing providers and other survivors of IPV as exemplary sources. Self-esteem was viewed as critical to enhancing recovery, as was increased knowledge across domains of IPV (e.g., warning signs, the link between mental and physical health for self and children). Finally, women identified valued action and goal setting, such as achieving more independence, as an optimal outcome. Addressing IPV against women requires patient-centered interventions that specifically target the types of outcomes deemed important by the end users: women who experience IPV. Findings have implications for tailoring treatments for IPV and selecting measures that tap into women's desired outcomes.

    View details for PubMedID 30994401

  • Randomized Cost-Effectiveness Trial of Group Interpersonal Psychotherapy (IPT) for Prisoners With Major Depression JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Johnson, J. E., Stout, R. L., Miller, T. R., Zlotnick, C., Cerbo, L. A., Andrade, J. T., Nargiso, J., Bonner, J., Wiltsey-Stirman, S. 2019; 87 (4): 392–406

    Abstract

    This study tested the effectiveness and cost-effectiveness of interpersonal psychotherapy (IPT) for major depressive disorder (MDD) among prisoners. It is the first fully powered randomized trial of any treatment (pharmacological or psychosocial) targeting MDD among incarcerated individuals.One hundred eighty-one male (n = 117) and female (n = 64) prisoners from prison facilities in 2 states were randomized to group IPT (delivered by master's-level and nonspecialist prison counselors) for MDD plus prison treatment as usual (TAU) or to TAU alone. Participants' average age was 39 (range = 20-61); 20% were African American and 19% were Hispanic. Outcomes assessed at posttreatment and 3-month follow-up included depressive symptoms (primary; assessed using the Hamilton Rating Scale for Depression), suicidality (assessed with the Beck Scale for Suicide Ideation and Beck Hopelessness Scale), in-prison functioning (i.e., enrollment in correctional programs; discipline reports; aggression/victimization; and social support), remission from MDD, and posttraumatic stress disorder symptoms.IPT reduced depressive symptoms, hopelessness, and posttraumatic stress disorder symptoms, and increased rates of MDD remission relative to prison TAU alone. Effects on hopelessness were particularly strong. Cost per patient was $2,054 including costs for IPT training and supervision or $575 without these costs. For providers running their second or subsequent IPT group, cost per additional week in remission from MDD (relative to TAU alone) was $524 ($148 excluding training and supervision costs, which would not be needed for established programs).IPT is effective and cost-effective and we recommend its use for MDD among prisoners. It is currently the only treatment for MDD evaluated among incarcerated individuals. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

    View details for DOI 10.1037/ccp0000379

    View details for Web of Science ID 000461486100007

    View details for PubMedID 30714749

    View details for PubMedCentralID PMC6482450

  • Provider Fidelity and Modifications to Cognitive Processing Therapy in a Diverse Community Health Clinic: Associations With Clinical Change JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Marques, L., Valentine, S. E., Kaysen, D., Mackintosh, M., De Silva, L., Ahles, E. M., Youn, S., Shtasel, D. L., Simon, N. M., Wiltsey-Stirman, S. 2019; 87 (4): 357–69

    Abstract

    The purpose of this study is to examine associations between therapist adherence, competence, and modifications of an evidence-based protocol (EBP) delivered in routine clinical care and client outcomes.Data were derived from a NIMH-funded implementation-effectiveness hybrid study of Cognitive Processing Therapy (CPT) for PTSD in a diverse community health center. Providers (n = 19) treated clients (n = 58) as part of their routine clinical care. Clients completed the PCL-S and PHQ-9 at baseline, after each CPT session, and posttreatment. CPT sessions were rated for treatment fidelity and therapist modifications.Overall, therapist adherence was high, although it decreased across sessions suggesting potential drift. Therapist competence ratings varied widely. Therapists made on average 1.6 fidelity-consistent and 0.4 fidelity-inconsistent modifications per session. Results show that higher numbers of fidelity-consistent modifications were associated with larger reductions in posttraumatic stress and depressive symptoms. High adherence ratings were associated with greater reductions in depressive symptoms, whereas higher competence ratings were associated with greater reduction in posttraumatic stress symptoms.The results highlight the importance of differentially assessing therapist adherence, competence, and modifications to EBP in usual care settings. The findings also suggest that effective EBP delivery in routine care may require minor adaptations to meet client needs, consistent with previous studies. Greater attention to fidelity and adaptation can enhance training so providers can tailor while retaining core components of the intervention. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

    View details for DOI 10.1037/ccp0000384

    View details for Web of Science ID 000461486100004

    View details for PubMedID 30883163

    View details for PubMedCentralID PMC6430611

  • The FRAME: an expanded framework for reporting adaptations and modifications to evidence-based interventions. Implementation science : IS Wiltsey Stirman, S., Baumann, A. A., Miller, C. J. 2019; 14 (1): 58

    Abstract

    This paper describes the process and results of a refinement of a framework to characterize modifications to interventions. The original version did not fully capture several aspects of modification and adaptation that may be important to document and report. Additionally, the earlier framework did not include a way to differentiate cultural adaptation from adaptations made for other reasons. Reporting additional elements will allow for a more precise understanding of modifications, the process of modifying or adapting, and the relationship between different forms of modification and subsequent health and implementation outcomes.We employed a multifaceted approach to develop the updated FRAME involving coding documents identified through a literature review, rapid coding of qualitative interviews, and a refinement process informed by multiple stakeholders. The updated FRAME expands upon Stirman et al.'s original framework by adding components of modification to report: (1) when and how in the implementation process the modification was made, (2) whether the modification was planned/proactive (i.e., an adaptation) or unplanned/reactive, (3) who determined that the modification should be made, (4) what is modified, (5) at what level of delivery the modification is made, (6) type or nature of context or content-level modifications, (7) the extent to which the modification is fidelity-consistent, and (8) the reasons for the modification, including (a) the intent or goal of the modification (e.g., to reduce costs) and (b) contextual factors that influenced the decision. Methods of using the framework to assess modifications are outlined, along with their strengths and weaknesses, and considerations for research to validate these measurement strategies.The updated FRAME includes consideration of when and how modifications occurred, whether it was planned or unplanned, relationship to fidelity, and reasons and goals for modification. This tool that can be used to support research on the timing, nature, goals and reasons for, and impact of modifications to evidence-based interventions.

    View details for DOI 10.1186/s13012-019-0898-y

    View details for PubMedID 31171014

  • Usual Care Among Providers Treating Women Veterans: Managing Complexity and Multimorbidity in the Era of Evidence-Based Practice. Administration and policy in mental health Hamilton, A. B., Wiltsey-Stirman, S., Finley, E. P., Klap, R., Mittman, B. S., Yano, E. M., Oishi, S. 2019

    Abstract

    To better understand VA providers' approaches to and perspectives on providing care to women Veterans, providers (n = 97) in primary care and mental health settings were interviewed about women's perceived treatment needs, types of care provided, and perceptions of evidence-based treatments (EBTs) for this population. Providers perceived that women Veteran VA users are often diagnostically complex and require a coordinated approach to treatment planning. They struggled with decisions about how to offer services such as EBTs and collaborative care in light of comorbidity and psychosocial stressors, and endorsed the belief that a tailored approach and consideration of these factors is essential in providing care.

    View details for DOI 10.1007/s10488-019-00961-y

    View details for PubMedID 31468284

  • Stakeholder Preferences on Transdiagnostic Psychosocial Treatment for Trauma-Exposed Veterans. Administration and policy in mental health Gutner, C. A., Canale, C. A., Vento, S. A., Wiltsey Stirman, S. 2019

    Abstract

    While modular and transdiagnostic approaches may address implementation challenges, there remains limited investigation into the fit within large healthcare systems. The current study examines qualitative interviews from patients, clinicians and administrative stakeholders in the Veterans Administration about experiences with, and views of, the Unified Protocol (UP; Barlow et al. in The unified protocol for transdiagnostic treatment of emotional disorders: therapist guide, Oxford University Press, New York, 2011) to understand potential for implementation. Qualitative interviews were conducted based on an established implementation framework and speak to implementation of transdiagnostic treatment in veterans, including insight into barriers, facilitators, intervention characteristics, patient characteristics, and system level variables. The UP demonstrated promise for improving efficiency, satisfaction and personalizing mental healthcare.

    View details for DOI 10.1007/s10488-019-00948-9

    View details for PubMedID 31187316

  • What are we even trying to implement? Considering the relative merits of promoting evidence-based protocols, principles, practices, or policies CLINICAL PSYCHOLOGY-SCIENCE AND PRACTICE Stirman, S., Comer, J. S. 2018; 25 (4)

    View details for DOI 10.1111/cpsp.12269

    View details for Web of Science ID 000453048600008

  • A randomized controlled effectiveness trial of training strategies in cognitive processing therapy for posttraumatic stress disorder: Impact on patient outcomes BEHAVIOUR RESEARCH AND THERAPY Monon, C. M., Shields, N., Suvak, M. K., Lane, J. M., Shnaider, P., Landy, M. H., Wagner, A. C., Sijercic, I., Masina, T., Wanklyn, S. G., Stirman, S. 2018; 110: 31–40

    Abstract

    This randomized controlled hybrid implementation/effectiveness trial aimed to compare the impact of three different models of training and consultation by examining the PTSD treatment outcomes achieved by therapists who were learning a front-line recommended psychotherapy for posttraumatic stress disorder (PTSD), Cognitive Processing Therapy (CPT; Resick, Monson, & Chard, 2017). Therapists (N = 134) were randomized into one of three conditions after attending a standard CPT training workshop: No Consultation with delayed feedback on CPT fidelity, Standard Consultation involving discussion and conceptualization of cases without session audio review, and Consultation Including Audio Review, which included a review of segments of audiorecorded CPT sessions. Across all training conditions, the patients treated by these therapists (N = 188) evidenced statistically significant reductions in PTSD symptoms, (d = -0.95 to -1.78), comorbid symptoms and functioning (d = -0.27 to -0.51). However, patients of therapists in the Standard Consultation condition (ΔPTSD = - 19.64, d = -1.78) experienced significantly greater improvement than those in the No Consultation condition (ΔPTSD = - 10.54, d = -0.95, ΔDEV = 6.30, ΔParms = 2, p = .043). This study demonstrates that patients who receive evidence-based psychotherapy for PTSD in routine care settings can experience significant symptom improvement. Our findings also suggest that to maximize patient benefit, therapist training should include consultation, but that audio review of sessions during consultation may not be necessary, at least for structured protocols. Implications for implementation, including the reduction of burden and cost of post-workshop support, are discussed.

    View details for PubMedID 30218837

  • Homework Completion, Patient Characteristics, and Symptom Change in Cognitive Processing Therapy for PTSD. Behavior therapy Stirman, S. W., Gutner, C. A., Suvak, M. K., Adler, A., Calloway, A., Resick, P. 2018; 49 (5): 741–55

    Abstract

    We evaluated the impact of homework completion on change in PTSD symptoms in the context of two randomized controlled trials of Cognitive Processing Therapy for PTSD (CPT). Female participants (n = 140) diagnosed with PTSD attended at least one CPT session and were assigned homework at each session. The frequency of homework completion was assessed at the beginning of each session and PTSD symptoms were assessed every other session. Piecewise growth models were used to examine the relationship between homework completion and symptom change. CPT version (with vs without the written trauma account) did not moderate associations between homework engagement and outcomes. Greater pretreatment PTSD symptoms predicted more Session 1 homework completion, but PTSD symptoms did not predict homework completion at other timepoints. More homework completion after Sessions 2 and 3 was associated with less change in PTSD from Session 2 to Session 4, but larger pre-to-post treatment changes in PTSD. Homework completion after Sessions 2 and 3 was associated with greater symptom change among patients who had fewer years of education. More homework completion after Sessions 8 and 9 was associated with larger subsequent decreases in PTSD. Average homework completion was not associated with client characteristics. In the second half of treatment, homework engagement was associated with less dropout. The results suggest that efforts to increase engagement in homework may facilitate symptom change.

    View details for PubMedID 30146141

  • Use of Reflective Journaling to Understand Decision Making Regarding Two Evidence-Based Psychotherapies for PTSD: Practice Implications. Practice innovations (Washington, D.C.) Cook, J. M., Simiola, V., McCarthy, E., Ellis, A., Wiltsey Stirman, S. 2018; 3 (3): 153–67

    Abstract

    As part of a longitudinal investigation on implementation of 2 evidence-based psychotherapies (EBPs) for posttraumatic stress disorder, psychotherapists from 38 Department of Veterans Affairs residential treatment programs across the United States were asked to complete reflective journals every 4 months for a 1-year time period in regard to their successes and challenges in using prolonged exposure and cognitive processing therapy. This paper provides content analysis on the reflective journals of 24 of these providers. Five main themes were identified: EBPs are great but not sufficient for patients in residential treatment with chronic posttraumatic stress disorder and complicated life circumstances, and thus, more treatment is necessary after discharge. Modifications were made or thought needed for optimal outcome and successful delivery of these 2 EBPs; some providers blended aspects of prolonged exposure and cognitive processing therapy; what happens when providers and patients do not agree on choice of which EBP to first implement; and provider concerns on when to discontinue an EBP. Reflective journaling appears to be a promising way for trainers and treatment developers to gather important information about the clinical application and decision-making process for front-line providers, which may offer insight into how to improve EBP implementation and sustainability. Incorporating reflective journaling and strategies for accomplishing this into training, supervision, and consultation may also be 1 strategy for increasing feedback, expanding implementation, and informing ways to increase sustainability of EBPs in populations with multiple clinical and psychosocial needs.

    View details for PubMedID 30906873

  • Protocol for the ROSE sustainment (ROSES) study, a sequential multiple assignment randomized trial to determine the minimum necessary intervention to maintain a postpartum depression prevention program in prenatal clinics serving low-income women IMPLEMENTATION SCIENCE Johnson, J. E., Wiltsey-Stirman, S., Sikorskii, A., Miller, T., King, A., Blume, J. L., Xuan Pham, Simas, T., Poleshuck, E., Weinberg, R., Zlotnick, C. 2018; 13: 115

    Abstract

    More research on sustainment of interventions is needed, especially return on investment (ROI) studies to determine cost-benefit trade-offs for effort required to sustain and how much is gained when effective programs are sustained. The ROSE sustainment (ROSES) study uses a sequential multiple assignment randomized (SMART) design to evaluate the effectiveness and cost-effectiveness of a stepwise approach to sustainment of the ROSE postpartum depression prevention program in 90 outpatient clinics providing prenatal care to pregnant women on public assistance. Postpartum depression (PPD) is common and can have lasting consequences. Outpatient clinics offering prenatal care are an opportune place to provide PPD prevention because most women visit while pregnant. The ROSE (Reach Out, Stay Strong, Essentials for mothers of newborns) program is a group educational intervention to prevent PPD, delivered during pregnancy. ROSE has been found to reduce cases of PPD in community prenatal settings serving low-income pregnant women.All 90 prenatal clinics will receive enhanced implementation as usual (EIAU; initial training + tools for sustainment). At the first time at which a clinic is determined to be at risk for failure to sustain (i.e., at 3, 6, 9, 12, and 15 months), that clinic will be randomized to receive either (1) no additional implementation support (i.e., EIAU only), or (2) low-intensity coaching and feedback (LICF). If clinics receiving LICF are still at risk at subsequent assessments, they will be randomized to either (1) EIAU + LICF only, or (2) high-intensity coaching and feedback (HICF). Additional follow-up interviews will occur at 18, 24, and 30 months, but no implementation intervention will occur after 18 months. Outcomes include (1) percent sustainment of core program elements at each time point, (2) health impact (PPD rates over time at each clinic) and reach, and (3) ROI (costs and cost-effectiveness) of each sustainment step. Hypothesized mechanisms include sustainment of capacity to deliver core elements and engagement/ownership.This study is the first randomized trial evaluating the ROI of a stepped approach to sustainment, a critical unanswered question in implementation science. It will also advance knowledge of implementation mechanisms and clinical care for an at-risk population.Clinicaltrials.gov, NCT03267563 . Registered June 14, 2018.

    View details for PubMedID 30134941

  • Leveraging routine clinical materials and mobile technology to assess CBT fidelity: the Innovative Methods to Assess Psychotherapy Practices (imAPP) study IMPLEMENTATION SCIENCE Stirman, S., Marques, L., Creed, T. A., Gutner, C. A., DeRubeis, R., Barnett, P. G., Kuhn, E., Suvak, M., Owen, J., Vogt, D., Jo, B., Schoenwald, S., Johnson, C., Mallard, K., Beristianos, M., La Bash, H. 2018; 13: 69

    Abstract

    Identifying scalable strategies for assessing fidelity is a key challenge in implementation science. However, for psychosocial interventions, the existing, reliable ways to test treatment fidelity quality are often labor intensive, and less burdensome strategies may not reflect actual clinical practice. Cognitive behavioral therapies (CBTs) provide clinicians with a set of effective core elements to help treat a multitude of disorders, which, evidence suggests, need to be delivered with fidelity to maximize potential client impact. The current "gold standard" for rating CBTs is rating recordings of therapy sessions, which is extremely time-consuming and requires a substantial amount of initial training. Although CBTs can vary based on the target disorder, one common element employed in most CBTs is the use of worksheets to identify specific behaviors and thoughts that affect a client's ability to recover. The present study will develop and evaluate an innovative new approach to rate CBT fidelity, by developing a universal CBT scoring system based on worksheets completed in therapy sessions.To develop a scoring system for CBT worksheets, we will compile common CBT elements from a variety of CBT worksheets for a range of psychiatric disorders and create adherence and competence measures. We will collect archival worksheets from past studies to test the scoring system and assess test-retest reliability. To evaluate whether CBT worksheet scoring accurately reflects clinician fidelity, we will recruit clinicians who are engaged in a CBT for depression, anxiety, and/or posttraumatic stress disorder. Clinicians and clients will transmit routine therapy materials produced in session (e.g., worksheets, clinical notes, session recordings) to the study team after each session. We will compare observer-rated fidelity, clinical notes, and fidelity-rated worksheets to identify the most effective and efficient method to assess clinician fidelity. Clients will also be randomly assigned to either complete the CBT worksheets on paper forms or on a mobile application (app) to learn if worksheet format influences clinician and client experience or differs in terms of reflecting fidelity.Scoring fidelity using CBT worksheets may allow clinics to test fidelity in a short and effective manner, enhancing continuous quality improvement in the workplace. Clinicians and clinics can use such data to improve clinician fidelity in real time, leading to improved patient outcomes.ClinicalTrials.gov NCT03479398 . Retrospectively registered March 20, 2018.

    View details for PubMedID 29789017

  • A Pragmatic Approach to Guide Implementation evaluation Research: strategy Mapping for Complex Interventions FRONTIERS IN PUBLIC HEALTH Huynh, A. K., Hamilton, A. B., Farmer, M. M., Bean-Mayberry, B., Stirman, S., Moin, T., Finley, E. P. 2018; 6: 134

    Abstract

    Greater specification of implementation strategies is a challenge for implementation science, but there is little guidance for delineating the use of multiple strategies involved in complex interventions. The Cardiovascular (CV) Toolkit project entails implementation of a toolkit designed to reduce CV risk by increasing women's engagement in appropriate services. The CV Toolkit project follows an enhanced version of Replicating Effective Programs (REP), an evidence-based implementation strategy, to implement the CV Toolkit across four phases: pre-conditions, pre-implementation, implementation, and maintenance and evolution. Our current objective is to describe a method for mapping implementation strategies used in real time as part of the CV Toolkit project. This method supports description of the timing and content of bundled strategies and provides a structured process for developing a plan for implementation evaluation.We conducted a process of strategy mapping to apply Proctor and colleagues' rubric for specification of implementation strategies, constructing a matrix in which we identified each implementation strategy, its conceptual group, and the corresponding REP phase(s) in which it occurs. For each strategy, we also specified the actors involved, actions undertaken, action targets, dose of the implementation strategy, and anticipated outcome addressed. We iteratively refined the matrix with the implementation team, including use of simulation to provide initial validation.Mapping revealed patterns in the timing of implementation strategies within REP phases. Most implementation strategies involving the development of stakeholder interrelationships and training and educating stakeholders were introduced during the pre-conditions or pre-implementation phases. Strategies introduced in the maintenance and evolution phase emphasized communication, re-examination, and audit and feedback. In addition to its value for producing valid and reliable process evaluation data, mapping implementation strategies has informed development of a pragmatic blueprint for implementation and longitudinal analyses and evaluation activities.We update recent recommendations on specification of implementation strategies by considering the implications for multi-strategy frameworks and propose an approach for mapping the use of implementation strategies within complex, multi-level interventions, in support of rigorous evaluation. Developing pragmatic tools to aid in operationalizing the conduct of implementation and evaluation activities is essential to enacting sound implementation research.

    View details for PubMedID 29868542

  • In rape trauma PTSD, patient characteristics indicate which trauma-focused treatment they are most likely to complete DEPRESSION AND ANXIETY Keefe, J. R., Stirman, S., Cohen, Z. D., DeRubeis, R. J., Smith, B. N., Resick, P. A. 2018; 35 (4): 330–38

    Abstract

    Dropout rates for effective therapies for posttraumatic stress disorder (PTSD) can be high, especially in practice settings. Although clinicians have intuitions regarding what treatment patients may complete, there are few systematic data to drive those judgments.A multivariable model of dropout risk was constructed with randomized clinical trial data (n = 160) comparing prolonged exposure (PE) and cognitive processing therapy (CPT) for rape-induced PTSD. A two-step bootstrapped variable selection algorithm was applied to identify moderators of dropout as a function of treatment condition. Employing identified moderators in a model, fivefold cross-validation yielded estimates of dropout probability for each patient in each condition. Dropout rates between patients who did and did not receive their model-indicated treatment were compared.Despite equivalent dropout rates across treatments, patients assigned to their model-indicated treatment were significantly less likely to drop out relative to patients who did not (relative risk = 0.49 [95% CI: 0.29-0.82]). Moderators included in the model were: childhood physical abuse, current relationship conflict, anger, and being a racial minority, all of which were associated with higher likelihood of dropout in PE than CPT.Individual differences among patients affect the likelihood they will complete a particular treatment, and clinicians can consider these moderators in treatment planning. In the future, treatment selection models could be used to increase the percentage of patients who will receive a full course of treatment, but replication and extension of such models, and consideration of how best to integrate them into routine practice, are needed.

    View details for PubMedID 29489037

  • A comparison of two learning collaborative strategies to support newly trained clinicians in delivering cognitive processing therapy Wiltsey-Stirman, S., Beristianos, M., Shields, N., Mallard, K., Masina, T., Haine-Schalgel, R., Miller, C., Suvak, M., Johnson, C., Carreno, P. K., Monson, C. BIOMED CENTRAL LTD. 2018

    View details for Web of Science ID 000428649900060

  • Adaptation in dissemination and implementation science Baumann, A. A., Cabassa, L. J., Wiltsey-Stirman, S. BIOMED CENTRAL LTD. 2018

    View details for Web of Science ID 000428649900092

  • The effect of message board correspondence on therapist fidelity and adaptation in cognitive processing therapy for PTSD Johnson, C., Mallard, K., Carreno, P., Beristianos, M., Masina, T., Shields, N., Monson, C., Wiltsey-Stirman, S. BIOMED CENTRAL LTD. 2018

    View details for Web of Science ID 000428649900089

  • VA Residential Treatment Providers' Use of Two Evidence-Based Psychotherapies for PTSD: Global Endorsement Versus Specific Components PSYCHOLOGICAL TRAUMA-THEORY RESEARCH PRACTICE AND POLICY Thompson, R., Simiola, V., Schnurr, P. P., Stirman, S., Cook, J. M. 2018; 10 (2): 131–39

    Abstract

    Despite a growing body of knowledge about the dissemination of evidence-based psychotherapies (EBPs), their actual use in clinical settings is not well understood. The purpose of the current study was to compare self-reported component use with global use for 2 EBPs for posttraumatic stress disorder (PTSD), prolonged exposure (PE), and cognitive processing therapy (CPT).Around 174 providers from 38 VA PTSD residential treatment programs were asked about both global use and component use of PE and CPT.Among frequent users of these EBPs, component use was generally high, especially for low-intensity and nonspecific components. For each form of treatment, there were a small number of providers who reported using the treatment frequently but did not use most of the key components of the treatment.These findings highlight the importance of understanding the modifications that providers make to EBPs and suggest the importance of flexibility within fidelity to these treatments. (PsycINFO Database Record

    View details for DOI 10.1037/tra0000220

    View details for Web of Science ID 000427747400001

    View details for PubMedID 27893265

    View details for PubMedCentralID PMC5446934

  • Testing a Web-Based, Trained-Peer Model to Build Capacity for Evidence-Based Practices in Community Mental Health Systems PSYCHIATRIC SERVICES German, R. E., Adler, A., Frankel, S. A., Stirman, S., Pinedo, P., Evans, A. C., Beck, A. T., Creed, T. A. 2018; 69 (3): 286–92

    View details for DOI 10.1176/appl.ps.201700029

    View details for Web of Science ID 000435441100010

  • Impact of age of onset of psychosis and engagement in higher education on duration of untreated psychosis JOURNAL OF MENTAL HEALTH Hardy, K. V., Noordsy, D. L., Ballon, J. S., McGovern, M. P., Salomon, C., Stirman, S. 2018; 27 (3): 257–62

    Abstract

    The average age of onset of psychosis coincides with the age of college enrollment. Little is known about the impact of educational engagement on DUP in a college-aged population.To determine DUP, and the impact of educational engagement, for college-aged participants of the RAISE study (n = 404).We conducted secondary data analyses on the publicly available RAISE dataset. Subsamples were analyzed to determine the impact of age and educational engagement on DUP.DUP was significantly shorter (p < 0.02) for participants who were college-aged (18-22 years, n = 44) and engaged in post-secondary education (median = 12 weeks, mean = 29 weeks) compared with participants who were college-aged and not engaged in higher education (n = 92, median = 29 weeks, mean = 44 weeks).Educational engagement appears to be associated with a shorter DUP. This may be partially explained by the presence of on-site wellness centers in college settings. However, even among young people who engaged in post-secondary education DUP was still at, or beyond, the upper limit of WHO recommendations in this group. Future research exploring how colleges could improve their capacity to detect and refer at risk students for treatment at an earlier stage is recommended.

    View details for PubMedID 29707996

  • A hybrid type I randomized effectiveness-implementation trial of patient navigation to improve access to services for children with autism spectrum disorder. BMC psychiatry Broder-Fingert, S., Walls, M., Augustyn, M., Beidas, R., Mandell, D., Wiltsey-Stirman, S., Silverstein, M., Feinberg, E. 2018; 18 (1): 79

    Abstract

    Significant racial, ethnic, and socioeconomic disparities exist in access to evidence-based treatment services for children with autism spectrum disorder (ASD). Patient Navigation (PN) is a theory-based care management strategy designed to reduce disparities in access to care. The purpose of this study is to test the effectiveness of PN a strategy to reduce disparities in access to evidence-based services for vulnerable children with ASD, as well as to explore factors that impact implementation.This study uses a hybrid type I randomized effectiveness/implementation design to test effectiveness and collect data on implementation concurrently. It is a two-arm comparative effectiveness trial with a target of 125 participants per arm. Participants are families of children age 15-27 months who receive a positive screen for ASD at a primary care visit at urban clinics in Massachusetts (n = 6 clinics), Connecticut (n = 1), and Pennsylvania (n = 2). The trial measures diagnostic interval (number of days from positive screen to diagnostic determination) and time to receipt of evidence-based ASD services/recommended services (number of days from date of diagnosis to receipt of services) in those with PN compared to and activated control -Conventional Care Management - which is similar to care management received in a high quality medical home. At the same time, a mixed-method implementation evaluation is being carried out.This study will examine the effectiveness of PN to reduce the time to and receipt of evidence-based services for vulnerable children with ASD, as well as factors that influence implementation. Findings will tell us both if PN is an effective approach for improving access to evidence-based care for children with ASD, and inform future strategies for dissemination.NCT02359084 Registered February 1, 2015.

    View details for PubMedID 29587698

    View details for PubMedCentralID PMC5870193

  • The Sustainability of Evidence-Based Interventions and Practices in Public Health and Health Care ANNUAL REVIEW OF PUBLIC HEALTH, VOL 39 Shelton, R. C., Cooper, B., Stirman, S., Fielding, J. E., Brownson, R. C., Green, L. W. 2018; 39: 55–76

    Abstract

    There is strong interest in implementation science to address the gap between research and practice in public health. Research on the sustainability of evidence-based interventions has been growing rapidly. Sustainability has been defined as the continued use of program components at sufficient intensity for the sustained achievement of desirable program goals and population outcomes. This understudied area has been identified as one of the most significant translational research problems. Adding to this challenge is uncertainty regarding the extent to which intervention adaptation and evolution are necessary to address the needs of populations that differ from those in which interventions were originally tested or implemented. This review critically examines and discusses conceptual and methodological issues in studying sustainability, summarizes the multilevel factors that have been found to influence the sustainability of interventions in a range of public health and health care settings, and highlights key areas for future research.

    View details for PubMedID 29328872

  • Empirical Examinations of Modifications and Adaptations to Evidence-Based Psychotherapies: Methodologies, Impact, and Future Directions CLINICAL PSYCHOLOGY-SCIENCE AND PRACTICE Stirman, S., Gamarra, J. M., Bartlett, B. A., Calloway, A., Gutner, C. A. 2017; 24 (4): 396–420

    Abstract

    This review describes methods used to examine the modifications and adaptations to evidence-based psychological treatments (EBPTs), assesses what is known about the impact of modifications and adaptations to EBPTs, and makes recommendations for future research and clinical care. One hundred eight primary studies and three meta-analyses were identified. All studies examined planned adaptations, and many simultaneously investigated multiple types of adaptations. With the exception of studies on adding or removing specific EBPT elements, few studies compared adapted EBPTs to the original protocols. There was little evidence that adaptations in the studies were detrimental, but there was also limited consistent evidence that adapted protocols outperformed the original protocols, with the exception of adding components to EBPTs. Implications for EBPT delivery and future research are discussed.

    View details for PubMedID 29593372

    View details for PubMedCentralID PMC5866913

  • Therapist Report of Adaptations to Delivery of Evidence-Based Practices Within a System-Driven Reform of Publicly Funded Children's Mental Health Services. Journal of consulting and clinical psychology Lau, A., Barnett, M., Stadnick, N., Saifan, D., Regan, J., Wiltsey Stirman, S., Roesch, S., Brookman-Frazee, L. 2017

    Abstract

    This study examined clinical adaptations reported by community therapists to multiple evidence-based practices (EBPs) currently implemented in children's mental health services. Based on an item set informed by Stirman and colleagues' model (2015), 2 factors emerged describing Augmenting adaptations and Reducing/Reordering adaptations. We used multilevel modeling to examine therapist- and practice-level predictors of therapist reports of each type of adaptation.Data were drawn from an online survey, including a novel therapist report measure of EBP adaptations, completed by 572 therapists (89.2% female, Mage = 37.08 years, 33.4% non-Hispanic White) delivering EBPs in the context of a system-driven, fiscally mandated implementation effort.Analyses revealed that the 2 types of therapist adaptations (Augmenting and Reducing/Reordering) could be readily discriminated, with therapists reporting significantly more Augmenting than Reducing/Reordering adaptations. Therapists of Hispanic/Latino ethnicity and with fewer years of experience reported more extensive Augmenting adaptations, but no therapist background characteristics were associated with Reducing/Reordering adaptations. Therapists' general attitudes that EBPs diverged from their personal approach to therapy were associated with reporting more Augmenting and Reducing/Reordering adaptations. In contrast, negative perceptions toward the specific EBP predicted Reducing/Reordering adaptations, but not Augmenting adaptations.Community therapist reports suggest that most adaptations undertaken involve engaging with the practice to augment the fit of the EBPs for local contexts; however, when practices were perceived negatively, therapists were more likely to make adaptations reducing or rearranging components. (PsycINFO Database Record

    View details for DOI 10.1037/ccp0000215

    View details for PubMedID 28471210

    View details for PubMedCentralID PMC5501960

  • Going off-script: modifications to Cognitive Processing Therapy (CPT) in a community mental health clinic Marques, L., Dixon, L., Ahles, E., Valentine, S., Monson, C., Shtasel, D., Stirman, S. BMC. 2017

    View details for Web of Science ID 000410978100097

  • Strategies for assessing fidelity to evidence-based interventions: a comparison of feasibility, accuracy, and associations with clinical outcomes Stirman, S., Carreno, P., Mallard, K., Masina, T., Monson, C. BMC. 2017

    View details for Web of Science ID 000410978100069

  • Planning for the long-term: considering sustainment Vogel, A., Stirman, S. BMC. 2017

    View details for Web of Science ID 000410978100005

  • Improving and sustaining delivery of CPT for PTSD in mental health systems: a cluster randomized trial. Implementation science Wiltsey Stirman, S., Finley, E. P., Shields, N., Cook, J., Haine-Schlagel, R., Burgess, J. F., Dimeff, L., Koerner, K., Suvak, M., Gutner, C. A., Gagnon, D., Masina, T., Beristianos, M., Mallard, K., Ramirez, V., Monson, C. 2017; 12 (1): 32-?

    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.

    View details for DOI 10.1186/s13012-017-0544-5

    View details for PubMedID 28264720

  • Testing a Web-Based, Trained-Peer Model to Build Capacity for Evidence-Based Practices in Community Mental Health Systems. Psychiatric services (Washington, D.C.) German, R. E., Adler, A., Frankel, S. A., Stirman, S. W., Pinedo, P., Evans, A. C., Beck, A. T., Creed, T. A. 2017: appips201700029

    Abstract

    Use of expert-led workshops plus consultation has been established as an effective strategy for training community mental health (CMH) clinicians in evidence-based practices (EBPs). Because of high rates of staff turnover, this strategy inadequately addresses the need to maintain capacity to deliver EBPs. This study examined knowledge, competency, and retention outcomes of a two-phase model developed to build capacity for an EBP in CMH programs.In the first phase, an initial training cohort in each CMH program participated in in-person workshops followed by expert-led consultation (in-person, expert-led [IPEL] phase) (N=214 clinicians). After this cohort completed training, new staff members participated in Web-based training (in place of in-person workshops), followed by peer-led consultation with the initial cohort (Web-based, trained-peer [WBTP] phase) (N=148). Tests of noninferiority assessed whether WBTP was not inferior to IPEL at increasing clinician cognitive-behavioral therapy (CBT) competency, as measured by the Cognitive Therapy Rating Scale.WBTP was not inferior to IPEL at developing clinician competency. Hierarchical linear models showed no significant differences in CBT knowledge acquisition between the two phases. Survival analyses indicated that WBTP trainees were less likely than IPEL trainees to complete training. In terms of time required from experts, WBTP required 8% of the resources of IPEL.After an initial investment to build in-house CBT expertise, CMH programs were able to use a WBTP model to broaden their own capacity for high-fidelity CBT. IPEL followed by WBTP offers an effective alternative to build EBP capacity in CMH programs, rather than reliance on external experts.

    View details for PubMedID 29137558

  • A Non-randomized Comparison of Strategies for Consultation in a Community-Academic Training Program to Implement an Evidence-Based Psychotherapy. Administration and policy in mental health Stirman, S. W., Pontoski, K., Creed, T., Xhezo, R., Evans, A. C., Beck, A. T., Crits-Christoph, P. 2017; 44 (1): 55–66

    Abstract

    Despite the central role of training and consultation in the implementation of evidence-based psychological interventions (EBPIs), comprehensive reviews of research on training have highlighted serious gaps in knowledge regarding best practices. Consultation after initial didactic training appears to be of critical importance, but there has been very little research to determine optimal consultation format or interventions. This observational study compared two consultation formats that included review of session audio and feedback in the context of a program to train clinicians (n = 85) in community mental health clinics to deliver cognitive therapy (CT). A "gold standard" condition in which clinicians received individual feedback after expert consultants reviewed full sessions was compared to a group consultation format in which short segments of session audio were reviewed by a group of clinicians and an expert consultant. After adjusting for potential baseline differences between individuals in the two consultation conditions, few differences were found in terms of successful completion of the consultation phase or in terms of competence in CT at the end of consultation or after a 2 year follow-up. However, analyses did not support hypotheses regarding non-inferiority of the group consultation condition. While both groups largely maintained competence, clinicians in the group consultation condition demonstrated increases in competence over the follow-up period, while a sub-group of those in the individual condition experienced decreases. These findings, if replicated, have important implications for EBP implementation programs, as they suggest that observation and feedback is feasible in community mental health setting, and that employing this method in a group format is an effective and efficient consultation strategy that may enhance the implementation and sustainability of evidence-based psychotherapies.

    View details for PubMedID 26577646

    View details for PubMedCentralID PMC5293547

  • The Role of Context in the Implementation of Trauma-Focused Treatments: Effectiveness Research and Implementation in Higher and Lower Income Settings. Current opinion in psychology Chen, J. A., Olin, C. C., Stirman, S. W., Kaysen, D. 2017; 14: 61–66

    Abstract

    In recent years, the implementation of trauma-focused treatments has expanded across settings that vary widely in the availability of resources, infrastructure, and personnel. The present review aims to inform researchers, policy makers, trainers, and administrators about this diverse range of research. Taking a global health perspective, this review of effectiveness trials and implementation studies compares strategies used in high-income countries to those in low- and medium-income countries. A primary difference between studies in high-income and low- and medium-income countries is the relative emphasis placed on fidelity or adaptation. Adaptations used in low- and medium-income countries might offer useful ideas for increasing the portability, impact, and accessibility of evidence-based interventions in high-income countries.

    View details for PubMedID 28713852

  • Implementation of Transdiagnostic Cognitive Therapy in Community Behavioral Health: The Beck Community Initiative JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Creed, T. A., Frankel, S. A., German, R. E., Green, K. L., Jager-Hyman, S., Taylor, K. P., Adler, A. D., Wolk, C. B., Stirman, S. W., Waltman, S. H., Williston, M. A., Sherrill, R., Evans, A. C., Beck, A. T. 2016; 84 (12): 1116-1126

    Abstract

    Progress bringing evidence-based practice (EBP) to community behavioral health (CBH) has been slow. This study investigated feasibility, acceptability, and fidelity outcomes of a program to implement transdiagnostic cognitive therapy (CT) across diverse CBH settings, in response to a policy shift toward EBP.Clinicians (n = 348) from 30 CBH programs participated in workshops and 6 months of consultation. Clinician retention was examined to assess feasibility, and clinician feedback and attitudes were evaluated to assess implementation acceptability. Experts rated clinicians' work samples at baseline, mid-, and end-of-consultation with the Cognitive Therapy Rating Scale (CTRS) to assess fidelity.Feasibility was demonstrated through high program retention (i.e., only 4.9% of clinicians withdrew). Turnover of clinicians who participated was low (13.5%) compared to typical CBH turnover rates, even during the high-demand training period. Clinicians reported high acceptability of EBP and CT, and self-reported comfort using CT improved significantly over time. Most clinicians (79.6%) reached established benchmarks of CT competency by the final assessment point. Mixed-effects hierarchical linear models indicated that CTRS scores increased significantly from baseline to the competency assessment (p < .001), on average by 18.65 points. Outcomes did not vary significantly between settings (i.e., outpatient vs. other).Even clinicians motivated by policy-change rather than self-nomination may feasibly be trained to deliver a case-conceptualization driven EBP with high levels of competency and acceptability. (PsycINFO Database Record

    View details for DOI 10.1037/ccp0000105

    View details for Web of Science ID 000389304500008

    View details for PubMedID 27379492

    View details for PubMedCentralID PMC5125881

  • A Review of Studies on the System-Wide Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration. Administration and policy in mental health Rosen, C. S., Matthieu, M. M., Wiltsey Stirman, S., Cook, J. M., Landes, S., Bernardy, N. C., Chard, K. M., Crowley, J., Eftekhari, A., Finley, E. P., Hamblen, J. L., Harik, J. M., Kehle-Forbes, S. M., MEIS, L. A., Osei-Bonsu, P. E., Rodriguez, A. L., RUGGIERO, K. J., Ruzek, J. I., Smith, B. N., Trent, L., Watts, B. V. 2016; 43 (6): 957-977

    Abstract

    Since 2006, the Veterans Health Administration (VHA) has instituted policy changes and training programs to support system-wide implementation of two evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). To assess lessons learned from this unprecedented effort, we used PubMed and the PILOTS databases and networking with researchers to identify 32 reports on contextual influences on implementation or sustainment of EBPs for PTSD in VHA settings. Findings were initially organized using the exploration, planning, implementation, and sustainment framework (EPIS; Aarons et al. in Adm Policy Ment Health Health Serv Res 38:4-23, 2011). Results that could not be adequately captured within the EPIS framework, such as implementation outcomes and adopter beliefs about the innovation, were coded using constructs from the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework (Glasgow et al. in Am J Public Health 89:1322-1327, 1999) and Consolidated Framework for Implementation Research (CFIR; Damschroder et al. in Implement Sci 4(1):50, 2009). We highlight key areas of progress in implementation, identify continuing challenges and research questions, and discuss implications for future efforts to promote EBPs in large health care systems.

    View details for PubMedID 27474040

  • Providers' Perspectives of Factors Influencing Implementation of Evidence-Based Treatments in a Community Mental Health Setting: A Qualitative Investigation of the Training-Practice Gap PSYCHOLOGICAL SERVICES Marques, L., Dixon, L., Valentine, S. E., Borba, C. C., Simon, N. M., Stirman, S. 2016; 13 (3): 322–31

    Abstract

    This study aims to elucidate relations between provider perceptions of aspects of the consolidated framework for implementation research (Damschroder et al., 2009) and provider attitudes toward the implementation of evidence-based treatments (EBTs) in an ethnically diverse community health setting. Guided by directed content analysis, we analyzed 28 semistructured interviews that were conducted with providers during the pre-implementation phase of a larger implementation study for cognitive processing therapy for posttraumatic stress disorder (Resick et al., 2008). Our findings extend the existing literature by also presenting provider-identified client-level factors that contribute to providers' positive and negative attitudes toward EBTs. Provider-identified client-level factors include the following: client motivation to engage in treatment, client openness to EBTs, support networks of family and friends, client use of community and government resources, the connection and relationship with their therapist, client treatment adherence, client immediate needs or crises, low literacy or illiteracy, low levels of education, client cognitive limitations, and misconceptions about therapy. These results highlight the relations between provider perceptions of their clients, provider engagement in EBT training, and subsequent adoption of EBTs. We present suggestions for future implementation research in this area. (PsycINFO Database Record

    View details for DOI 10.1037/ser0000087

    View details for Web of Science ID 000383106000014

    View details for PubMedID 27281696

    View details for PubMedCentralID PMC4980224

  • Cognitive Processing Therapy for Spanish-speaking Latinos: A Formative Study of a Model-Driven Cultural Adaptation of the Manual to Enhance Implementation in a Usual Care Setting. Journal of clinical psychology Valentine, S. E., Borba, C. P., Dixon, L., Vaewsorn, A. S., Guajardo, J. G., Resick, P. A., Wiltsey Stirman, S., Marques, L. 2016

    Abstract

    As part of a larger implementation trial for cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) in a community health center, we used formative evaluation to assess relations between iterative cultural adaption (for Spanish-speaking clients) and implementation outcomes (appropriateness and acceptability) for CPT.Qualitative data for the current study were gathered through multiple sources (providers: N = 6; clients: N = 22), including CPT therapy sessions, provider fieldnotes, weekly consultation team meetings, and researcher fieldnotes. Findings from conventional and directed content analysis of the data informed refinements to the CPT manual.Data-driven refinements included adaptations related to cultural context (i.e., language, regional variation in wording), urban context (e.g., crime/violence), and literacy level. Qualitative findings suggest improved appropriateness and acceptability of CPT for Spanish-speaking clients.Our study reinforces the need for dual application of cultural adaptation and implementation science to address the PTSD treatment needs of Spanish-speaking clients.

    View details for DOI 10.1002/jclp.22337

    View details for PubMedID 27378013

    View details for PubMedCentralID PMC5215988

  • Dabblers, bedazzlers, or total makeovers: Clinician modification of a common elements cognitive behavioral therapy approach Meza, R. D., Dorsey, S., Stirman, S., Sedlar, G., Lucid, L. BMC. 2016

    View details for Web of Science ID 000410976900044

  • Leveraging routine clinical materials to assess fidelity to an evidence-based psychotherapy Stirman, S., Gutner, C. A., Gamarra, J., Vogt, D., Suvak, M., Wachen, J., Dondanville, K., Yarvis, J. S., Mintz, J., Peterson, A. L., Borah, E. V., Litz, B. T., Molino, A., McCaughan, S., Resick, P. A. BMC. 2016

    View details for Web of Science ID 000410976900014

  • Effects of consultation method on implementation of cognitive processing therapy for post-traumatic stress disorder Gutner, C. A., Monson, C. M., Shields, N., Mastlej, M., Landy, M. H., Lane, J., Stirman, S. BMC. 2016

    View details for Web of Science ID 000410976900046

  • Effectiveness of an Evidence-Based Quality Improvement Approach to Cultural Competence Training: The Veterans Affairs' "Caring for Women Veterans" Program. journal of continuing education in the health professions Fox, A. B., Hamilton, A. B., Frayne, S. M., Wiltsey-Stirman, S., Bean-Mayberry, B., Carney, D., Di Leone, B. A., Gierisch, J. M., Goldstein, K. M., Romodan, Y., Sadler, A. G., Yano, E. M., Yee, E. F., Vogt, D. 2016; 36 (2): 96-103

    Abstract

    Although providing culturally sensitive health care is vitally important, there is little consensus regarding the most effective strategy for implementing cultural competence trainings in the health care setting. Evidence-based quality improvement (EBQI), which involves adapting evidence-based practices to meet local needs, may improve uptake and effectiveness of a variety of health care innovations. Yet, to our knowledge, EBQI has not yet been applied to cultural competence training. To evaluate whether EBQI could enhance the impact of an evidence-based training intended to improve veterans affairs health care staff gender sensitivity and knowledge (Caring for Women Veterans; CWV), we compared the reach and effectiveness of EBQI delivery versus standard web-based implementation strategies of CWV and assessed barriers and facilitators to EBQI implementation.Workgroups at four diverse veterans affairs health care sites were randomized to either an EBQI or standard web-based implementation condition (SI). All EBQI sites selected a group-based implementation strategy. Employees (N = 84) completed pretraining and posttraining assessments of gender sensitivity and knowledge, and focus groups/interviews were conducted with leadership and staff before and after implementation.Reach of CWV was greater in the EBQI condition versus the SI condition. Whereas both gender sensitivity and knowledge improved in the EBQI condition, only gender sensitivity improved in the SI condition. Qualitative analyses revealed that the EBQI approach was well received, although a number of barriers were identified.Findings suggest that EBQI can enhance the uptake and effectiveness of employee trainings. However, the decision to pursue EBQI must be informed by a consideration of available resources.

    View details for DOI 10.1097/CEH.0000000000000073

    View details for PubMedID 27262152

  • Avoidance as an obstacle to preventing depression among urban women at high risk for violent trauma. Archives of women's mental health Silverstein, M., Kistin, C., Bair-Merritt, M., Wiltsey-Stirman, S., Feinberg, E., Diaz-Linhart, Y., Sandler, J., Chen, N., Cabral, H. 2016; 19 (1): 63-70

    Abstract

    The impact of depression interventions is often attenuated in women who have experienced trauma. We explored whether psychological avoidance could explain this phenomenon. We synthesized two pilot randomized trials of problem-solving education (PSE) among a total of 93 urban mothers. Outcomes included depressive symptoms and perceived stress. Mothers with avoidant coping styles experienced an average 1.25 episodes of moderately severe depressive symptoms over 3 months of follow-up, compared to 0.40 episodes among those with non-avoidant coping (adjusted incident rate ratio [aIRR] 2.18; 95 % CI 1.06, 4.48). PSE tended to perform better among mothers with non-avoidant coping. Among mothers with non-avoidant coping, PSE mothers experienced an average 0.24 episodes, compared to 0.58 episodes among non-avoidant controls (aIRR 0.27; 95 % CI 0.05, 1.34). Among mothers with avoidant coping, PSE mothers experienced an average 1.26 episodes, compared to 1.20 episodes among avoidant controls (aIRR 0.76; 95 % CI 0.44, 1.33). This trend toward differential impact persisted when avoidance was measured as a problem-solving style and among traumatized mothers with and without avoidant PTSD symptoms. Further research is warranted to explore the hypothesis that psychological avoidance could explain why certain depression treatment and prevention strategies break down in the presence of trauma.

    View details for DOI 10.1007/s00737-015-0521-4

    View details for PubMedID 25833808

  • Symptom exacerbations in trauma-focused treatments: Associations with treatment outcome and non-completion BEHAVIOUR RESEARCH AND THERAPY Larsen, S. E., Stirman, S. W., Smith, B. N., Resick, P. A. 2016; 77: 68-77

    Abstract

    Trauma-focused treatments are underutilized, partially due to clinician concerns that they will cause symptom exacerbation or dropout. We examined a sample of women undergoing Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and a version of CPT (CPT-C) without a written trauma narrative to investigate the possibility of symptom exacerbation. Participants (n = 192) were drawn from two RCT's. Participants were administered self-report measures of PTSD symptoms (i.e., the PTSD Symptom Scale or Posttraumatic Diagnostic Scale [PSS/PDS]) and the Clinician-Administered PTSD Scale. Exacerbations were defined as increases greater than 6.15 points on the PSS/PDS. A minority of participants experienced PTSD exacerbations during treatment, and there were no significant differences across treatment type (28.6% in CPT, 20.0% in PE, and 14.7% in CPT-C). Neither diagnostic nor trauma-related factors at pre-treatment predicted symptom exacerbations. Those who experienced exacerbations had higher post-treatment PSS/PDS scores and were more likely to retain a PTSD diagnosis (both small but statistically significant effects). However, even those who experienced an exacerbation experienced clinically significant improvement by end of treatment. Further, symptom exacerbations were not related to treatment non-completion. These results indicate that trauma-focused treatments are safe and effective, even for the minority of individuals who experience temporary symptom increases.

    View details for DOI 10.1016/j.brat.2015.12.009

    View details for Web of Science ID 000370899200009

    View details for PubMedID 26731171

  • Delivering cognitive processing therapy in a community health setting: The influence of Latino culture and community violence on posttraumatic cognitions. Psychological trauma : theory, research, practice and policy Marques, L., Eustis, E. H., Dixon, L., Valentine, S. E., Borba, C. P., Simon, N., Kaysen, D., Wiltsey-Stirman, S. 2016; 8 (1): 98-106

    Abstract

    Despite the applicability of cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) to addressing sequelae of a range of traumatic events, few studies have evaluated whether the treatment itself is applicable across diverse populations. The present study examined differences and similarities among non-Latino, Latino Spanish-speaking, and Latino English-speaking clients in rigid beliefs-or "stuck points"-associated with PTSD symptoms in a sample of community mental health clients. We utilized the procedures of content analysis to analyze stuck point logs and impact statements of 29 participants enrolled in a larger implementation trial for CPT. Findings indicated that the content of stuck points was similar across Latino and non-Latino clients, although fewer total stuck points were identified for Latino clients compared to non-Latino clients. Given that identification of stuck points is central to implementing CPT, difficulty identifying stuck points could pose significant challenges for implementing CPT among Latino clients and warrants further examination. Thematic analysis of impact statements revealed the importance of family, religion, and the urban context (e.g., poverty, violence exposure) in understanding how clients organize beliefs and emotions associated with trauma. Clinical recommendations for implementing CPT in community settings and the identification of stuck points are provided. (PsycINFO Database Record

    View details for DOI 10.1037/tra0000044

    View details for PubMedID 25961865

    View details for PubMedCentralID PMC4641844

  • Female veterans' preferences for counseling related to intimate partner violence: Informing patient-centered interventions. General hospital psychiatry Iverson, K. M., Stirman, S. W., Street, A. E., Gerber, M. R., Carpenter, S. L., Dichter, M. E., Bair-Merritt, M., Vogt, D. 2016; 40: 33–38

    Abstract

    Female veterans are at high risk for intimate partner violence (IPV). A critical issue in the provision of health care to women who experience IPV is the delivery of effective brief counseling interventions that address women's unique needs. We aimed to identify female veterans' priorities and preferences for healthcare-based IPV counseling.A 2014 Web-based survey was administered to a national sample of US female veterans. Among 411 respondents (75% participation rate), 55% (n=226) reported IPV during their lifetime. These women identified priorities for the content focus of IPV-related counseling and preferences for the delivery of these services.Women prioritized counseling that focuses on physical safety and emotional health, with learning about community resources being a relatively lower priority. Participants preferred counseling to focus specifically on enhancing coping skills and managing mental health symptoms. In addition, women want counseling to be individualized and preferred the option to meet with a counselor immediately following disclosure. Affordable services and attention to privacy concerns were of paramount importance in the context of IPV-related counseling.These findings can inform patient-centered brief counseling interventions for women who experience IPV, which may ultimately reduce health disparities and violence among this population.

    View details for PubMedID 27083252

  • Bridging the Gap Between Research and Practice in Mental Health Service Settings: An Overview of Developments in Implementation Theory and Research. Behavior therapy Stirman, S. W., Gutner, C. A., Langdon, K., Graham, J. R. 2016; 47 (6): 920–36

    Abstract

    Twenty years after Sobell's (1996) influential call to integrate advances in behavior therapy into clinical settings, significant progress has been made in implementation science. In this narrative review, we provide an overview of implementation research findings and highlight recent findings that can inform efforts to bridge the gap between research and practice in mental health service settings. Key findings are summarized, organized according to levels of influence described in two implementation frameworks: The Exploration, Planning, Implementation, and Sustainment Framework (EPIS; Aarons et al., 2011) and the Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009). Important levels of influence to consider when implementing new treatments include the outer context, inner context, characteristics of the individual, and characteristics of the innovation. Research on strategies to prepare clinicians to deliver evidence-based psychosocial treatments (EBPTs) and to address contextual barriers to implementation at each level is described, with discussion of implications for the implementation of EBPTs and next steps for research.

    View details for PubMedID 27993341

  • System-Wide Implementation of Routine Outcome Monitoring and Measurement Feedback System in a National Network of Operational Stress Injury Clinics. Administration and policy in mental health Ross, D. F., Ionita, G., Stirman, S. W. 2016; 43 (6): 927–44

    Abstract

    This manuscript reviews the development and implementation process of the Client Reported Outcome Monitoring Information System in the VA Canada Operational Stress Injury National Network, and reports on outcomes of an evaluation to assess usage, barriers, and facilitators to implementation. The majority of clinicians reported regular use of routine outcomes monitoring, although objective data suggested somewhat lower actual use. In general, clinicians endorsed all barriers and most facilitators as influencing their use of routine outcomes monitoring in a minor way. However, users and non-users differed in their endorsement of facilitators and barriers. Implications for research and implementation efforts are discussed.

    View details for PubMedID 27444375

  • Bridging the gap between research and practice in mental health service settings: An overview of developments in implementation theory and research Behavior Therapy Wiltsey Stirman, S., Gutner, C. A., Jessica, G., Langdon, K. 2016

    View details for DOI 10.1016/j.beth.2015.12.001

  • Relationships between clinician-level attributes and fidelity-consistent and fidelity-inconsistent modifications to an evidence-based psychotherapy IMPLEMENTATION SCIENCE Stirman, S. W., Gutner, C. A., Crits-Christoph, P., Edmunds, J., Evans, A. C., Beidas, R. S. 2015; 10

    Abstract

    Clinicians often modify evidence-based psychotherapies (EBPs) when delivering them in routine care settings. There has been little study of factors associated with or implications of modifications to EBP protocols. This paper differentiates between fidelity-consistent and fidelity-inconsistent modifications and it examines the potential influence of two clinician characteristics, training outcomes, and attitudes toward EBPs on fidelity-consistent and fidelity-inconsistent modifications of cognitive behavioral therapy in a sample of clinicians who had been trained to deliver these treatments for children or adults.Survey and coded interview data collected 2 years after completion of training programs in cognitive behavioral therapy were used to examine associations between successful or unsuccessful completion of training, clinician attitudes, and modifications. Modifications endorsed by clinicians were categorized as fidelity-consistent or fidelity-inconsistent and entered as outcomes into separate regression models, with training success and attitudes entered as independent variables.Successful completion of a training program was associated with subsequent fidelity-inconsistent modifications but not fidelity-consistent modifications. Therapists who reported greater openness to using EBPs prior to training reported more fidelity-consistent modifications at follow-up, and those who reported greater willingness to adopt EBPs if they found them appealing were more likely to make fidelity-inconsistent modifications.Implications of these findings for training, implementation, EBP sustainment, and future studies are discussed. Research on contextual and protocol-related factors that may impact decisions to modify EBPs will be an important future direction of study to complement to this research.

    View details for DOI 10.1186/s13012-015-0308-z

    View details for Web of Science ID 000359338100001

    View details for PubMedCentralID PMC4534152

  • System-Level Influences on the Sustainability of a Cognitive Therapy Program in a Community Behavioral Health Network. Psychiatric services Stirman, S. W., Matza, A., Gamarra, J., Toder, K., Xhezo, R., Evans, A. C., Hurford, M., Beck, A. T., Crits-Christoph, P., Creed, T. 2015; 66 (7): 734-742

    Abstract

    The purpose of this study was to examine influences on the sustainability of a program to implement an evidence-based psychotherapy in a mental health system.Interviews with program administrators, training consultants, agency administrators, and supervisors (N=24), along with summaries of program evaluation data and program documentation, were analyzed with a directed content-analytic approach.Findings suggested a number of interconnected and interacting influences on sustainability, including alignment with emerging sociopolitical influences and system and organizational priorities; program-level adaptation and evolution; intervention flexibility; strong communication, collaboration, planning, and support; and perceived benefit. These individual factors appeared to mutually influence one another and contribute to the degree of program sustainability achieved at the system level. Although most influences were positive, financial planning and support emerged as potentially both facilitator and barrier, and evaluation of benefits at the patient level remained a challenge.Several factors appeared to contribute to the sustainability of a psychosocial intervention in a large urban mental health system and warrant further investigation. Understanding interconnections between multiple individual facilitators and barriers appears critical to advancing understanding of sustainability in dynamic systems and adds to emerging recommendations for other implementation efforts. In particular, implications of the findings include the importance of implementation strategies, such as long-term planning, coalition building, clarifying roles and expectations, planned adaptation, evaluation, diversification of financing strategies, and incentivizing implementation.

    View details for DOI 10.1176/appi.ps.201400147

    View details for PubMedID 25828878

    View details for PubMedCentralID PMC4490058

  • Hormone therapy use in women veterans accessing veterans health administration care: a national cross-sectional study. Journal of general internal medicine Gerber, M. R., King, M. W., Pineles, S. L., Wiltsey-Stirman, S., Bean-Mayberry, B., Japuntich, S. J., Haskell, S. G. 2015; 30 (2): 169-175

    Abstract

    The majority of women Veterans using VA (Veterans Administration) care fall in the 45-65 year-old age range. Understanding how menopause is managed in this group is of importance to optimizing their health.National population estimates showed a prevalence of hormone therapy (HT) use by women over 45 years of 4.7 % (2009-2010). Our study described the frequency of HT use among women Veterans in VA, and examined whether mental health (MH) was predictive of HT use.This was a cross-sectional analysis of national VA administrative data for fiscal year 2009.Women Veterans over the age of 45 (N = 157,195) accessing VA outpatient care were included in the analysis.Logistic regression analyses using HT use as the dependent variable.Mean age was 59.4 years (SD =12.2, range =46-110), and 16,227 (10.3 %) of all women used HT. Hysterectomy (OR 3.99 [3.53, 4.49]) and osteoporosis (1.34 [1.27, 1.42]) were the strongest medical indicators of HT use. A total of 49,557 (31.5 %) women in the sample received at least one primary diagnosis of a MH disorder and were more likely to use HT than women with no MH diagnoses (unadjusted OR 1.56, 95 % CI [1.50, 1.61]). Women Veterans with a mood disorder (depression/bipolar) or anxiety disorder [post-traumatic stress disorder (PTSD), other anxiety diagnoses] were more likely to use HT after controlling for demographics and medical comorbidity.The prevalence of HT use among women Veterans using VA is more than twice that of the general population. Prior work suggested that women Veterans were discontinuing HT at comparable rates, but these data demonstrate that decline in VA HT use has not kept pace with that of civilian medical care. The association of MH diagnosis with HT use suggests that MH plays an important role in VA rates. Further study is needed to understand contributing patient and provider factors.

    View details for DOI 10.1007/s11606-014-3073-9

    View details for PubMedID 25373833

  • Assessing Variability and Implementation Fidelity of Suicide Prevention Safety Planning in a Regional VA Healthcare System CRISIS-THE JOURNAL OF CRISIS INTERVENTION AND SUICIDE PREVENTION Gamarra, J. M., Luciano, M. T., Gradus, J. L., Stirman, S. W. 2015; 36 (6): 433-439

    View details for DOI 10.1027/0227-5910/a000345

    View details for Web of Science ID 000368047200007

  • Relationships between clinician-level attributes and fidelity-consistent and fidelity-inconsistent modifications to an evidence-based psychotherapy. Implementation science : IS Wiltsey Stirman, S., Gutner, C. A., Crits-Christoph, P., Edmunds, J., Evans, A. C., Beidas, R. S. 2015; 10: 115

    Abstract

    Clinicians often modify evidence-based psychotherapies (EBPs) when delivering them in routine care settings. There has been little study of factors associated with or implications of modifications to EBP protocols. This paper differentiates between fidelity-consistent and fidelity-inconsistent modifications and it examines the potential influence of two clinician characteristics, training outcomes, and attitudes toward EBPs on fidelity-consistent and fidelity-inconsistent modifications of cognitive behavioral therapy in a sample of clinicians who had been trained to deliver these treatments for children or adults.Survey and coded interview data collected 2 years after completion of training programs in cognitive behavioral therapy were used to examine associations between successful or unsuccessful completion of training, clinician attitudes, and modifications. Modifications endorsed by clinicians were categorized as fidelity-consistent or fidelity-inconsistent and entered as outcomes into separate regression models, with training success and attitudes entered as independent variables.Successful completion of a training program was associated with subsequent fidelity-inconsistent modifications but not fidelity-consistent modifications. Therapists who reported greater openness to using EBPs prior to training reported more fidelity-consistent modifications at follow-up, and those who reported greater willingness to adopt EBPs if they found them appealing were more likely to make fidelity-inconsistent modifications.Implications of these findings for training, implementation, EBP sustainment, and future studies are discussed. Research on contextual and protocol-related factors that may impact decisions to modify EBPs will be an important future direction of study to complement to this research.

    View details for PubMedID 26268633

    View details for PubMedCentralID PMC4534152

  • Women Veterans' Preferences for Intimate Partner Violence Screening and Response Procedures Within the Veterans Health Administration RESEARCH IN NURSING & HEALTH Iverson, K. M., Huang, K., Wells, S. Y., Wright, J. D., Gerber, M. R., Wiltsey-Stirman, S. 2014; 37 (4): 302-311

    Abstract

    Intimate partner violence (IPV) is a significant health issue faced by women veterans, but little is known about their preferences for IPV-related care. Five focus groups were conducted with 24 women Veterans Health Administration (VHA) patients with and without a lifetime history of IPV to understand their attitudes and preferences regarding IPV screening and responses within VHA. Women veterans wanted disclosure options, follow-up support, transparency in documentation, and VHA and community resources. They supported routine screening for IPV and articulated preferences for procedural aspects of screening. Women suggested that these procedures could be provided most effectively when delivered with sensitivity and connectedness. Findings can inform the development of IPV screening and response programs within VHA and other healthcare settings.

    View details for DOI 10.1002/nur.21602

    View details for Web of Science ID 000340665400006

    View details for PubMedID 24990824

  • Community Mental Health Provider Modifications to Cognitive Therapy: Implications for Sustainability PSYCHIATRIC SERVICES Stirman, S. W., Calloway, A., Toder, K., Miller, C. J., Devito, A. K., Meisel, S. N., Xhezo, R., Evans, A. C., Beck, A. T., Crits-Christoph, P. 2013; 64 (10): 1056-1059

    Abstract

    This study identified modifications to an evidence-based psychosocial treatment (cognitive therapy) within a community mental health system after clinicians had received intensive training and consultation.A coding system, consisting of four types of contextual modifications, 12 types of content-related modifications, seven levels at which modifications can occur, and a code for changes to training or evaluation processes, was applied to data from interviews with 27 clinicians who treat adult consumers within a mental health system.Nine of 12 content modifications were endorsed, and four (tailoring, integration into other therapeutic approaches, loosening structure, and drift) accounted for 65% of all modifications identified. Contextual modifications were rarely endorsed by clinicians in this sample. Modifications typically occurred at the client or clinician level.Clinicians in community mental health settings made several modifications to an evidence-based practice (EBP), often in an effort to improve the fit of the intervention to the client's needs or to the clinician's therapeutic style. These findings have implications for implementation and sustainability of EBPs in community settings, client-level outcomes, and training and consultation.

    View details for DOI 10.1176/appi.ps.201200456

    View details for Web of Science ID 000327278200029

    View details for PubMedID 24081406

  • Longitudinal course of anxiety sensitivity and PTSD symptoms in cognitive-behavioral therapies for PTSD JOURNAL OF ANXIETY DISORDERS Gutner, C. A., Nillni, Y. I., Suvak, M., Wiltsey-Stirman, S., Resick, P. A. 2013; 27 (7): 728-734

    Abstract

    Anxiety sensitivity (AS) has been conceptualized as trait-like vulnerability and maintenance factor for PTSD. Although recent literature has demonstrated its malleability during treatment, few have examined its influence on and effect from PTSD treatment. Using multilevel regression analyses we examined: (a) changes in AS during treatment and (b) whether pre-treatment AS predicted PTSD treatment response, in sample of female victims of interpersonal trauma receiving one of three treatments (cognitive processing therapy, cognitive processing therapy-cognitive, and written accounts). Participants exhibited reductions in total ASI scores from pre- to post-treatment. Growth curve modeling revealed slightly different trajectories of PTSD symptoms as a function of pre-treatment AS, and overall decreases in PTSD symptoms during treatment were not associated with pretreatment AS. Pretreatment AS dimensions impacted PTSD total scores and symptoms clusters differentially. Clinical and theoretical implications for these results are discussed.

    View details for DOI 10.1016/j.janxdis.2013.09.010

    View details for Web of Science ID 000327685600014

    View details for PubMedID 24176804

  • A randomized controlled dismantling trial of post-workshop consultation strategies to increase effectiveness and fidelity to an evidence-based psychotherapy for Posttraumatic stress disorder IMPLEMENTATION SCIENCE Stirman, S. W., Shields, N., Deloriea, J., Landy, M. S., Belus, J. M., Maslej, M. M., Monson, C. M. 2013; 8

    View details for DOI 10.1186/1748-5908-8-82

    View details for Web of Science ID 000322964300001

  • Clinicians' Perspectives on Cognitive Therapy in Community Mental Health Settings: Implications for Training and Implementation ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH Stirman, S. W., Gutierrez-Colina, A., Toder, K., Esposito, G., Barg, F., Castro, F., Beck, A. T., Crits-Christoph, P. 2013; 40 (4): 274-285

    Abstract

    Policymakers are investing significant resources in large-scale training and implementation programs for evidence-based psychological treatments (EBPTs) in public mental health systems. However, relatively little research has been conducted to understand factors that may influence the success of efforts to implement EBPTs for adult consumers of mental health services. In a formative investigation during the development of a program to implement cognitive therapy (CT) in a community mental health system, we surveyed and interviewed clinicians and clinical administrators to identify potential influences on CT implementation within their agencies. Four primary themes were identified. Two related to attitudes towards CT: (1) ability to address client needs and issues that are perceived as most central to their presenting problems, and (2) reluctance to fully implement CT. Two themes were relevant to context: (1) agency-level barriers, specifically workload and productivity concerns and reactions to change, and (2) agency-level facilitators, specifically, treatment planning requirements and openness to training. These findings provide information that can be used to develop strategies to facilitate the implementation of CT interventions for clients being treated in public-sector settings.

    View details for DOI 10.1007/s10488-012-0418-8

    View details for Web of Science ID 000320338600004

    View details for PubMedID 22426739

  • Development of a framework and coding system for modifications and adaptations of evidence-based interventions IMPLEMENTATION SCIENCE Stirman, S., Miller, C. J., Toder, K., Calloway, A. 2013; 8: 65

    Abstract

    Evidence-based interventions are frequently modified or adapted during the implementation process. Changes may be made to protocols to meet the needs of the target population or address differences between the context in which the intervention was originally designed and the one into which it is implemented [Addict Behav 2011, 36(6):630-635]. However, whether modification compromises or enhances the desired benefits of the intervention is not well understood. A challenge to understanding the impact of specific types of modifications is a lack of attention to characterizing the different types of changes that may occur. A system for classifying the types of modifications that are made when interventions and programs are implemented can facilitate efforts to understand the nature of modifications that are made in particular contexts as well as the impact of these modifications on outcomes of interest.We developed a system for classifying modifications made to interventions and programs across a variety of fields and settings. We then coded 258 modifications identified in 32 published articles that described interventions implemented in routine care or community settings.We identified modifications made to the content of interventions, as well as to the context in which interventions are delivered. We identified 12 different types of content modifications, and our coding scheme also included ratings for the level at which these modifications were made (ranging from the individual patient level up to a hospital network or community). We identified five types of contextual modifications (changes to the format, setting, or patient population that do not in and of themselves alter the actual content of the intervention). We also developed codes to indicate who made the modifications and identified a smaller subset of modifications made to the ways that training or evaluations occur when evidence-based interventions are implemented. Rater agreement analyses indicated that the coding scheme can be used to reliably classify modifications described in research articles without overly burdensome training.This coding system can complement research on fidelity and may advance research with the goal of understanding the impact of modifications made when evidence-based interventions are implemented. Such findings can further inform efforts to implement such interventions while preserving desired levels of program or intervention effectiveness.

    View details for DOI 10.1186/1748-5908-8-65

    View details for Web of Science ID 000320714900001

    View details for PubMedID 23758995

    View details for PubMedCentralID PMC3686699

  • Research Setting Versus Clinic Setting: Which Produces Better Outcomes in Cognitive Therapy for Depression? COGNITIVE THERAPY AND RESEARCH Gibbons, C. R., Stirman, S. W., DeRubeis, R. J., Newman, C. F., Beck, A. T. 2013; 37 (3): 605-612

    View details for DOI 10.1007/s10608-012-9499-7

    View details for Web of Science ID 000318817000020

  • Developing the next generation of dissemination and implementation researchers: insights from initial trainees IMPLEMENTATION SCIENCE Stamatakis, K. A., Norton, W. E., Stirman, S. W., Melvin, C., Brownson, R. C. 2013; 8

    Abstract

    Dissemination and implementation (D&I) research is a relatively young discipline, underscoring the importance of training and career development in building and sustaining the field. As such, D&I research faces several challenges in designing formal training programs and guidance for career development. A cohort of early-stage investigators (ESI) recently involved in an implementation research training program provided a resource for formative data in identifying needs and solutions around career development.Responses outlined fellows' perspectives on the perceived usefulness and importance of, as well as barriers to, developing practice linkages, acquiring additional methods training, academic advancement, and identifying institutional supports. Mentorship was a cross-cutting issue and was further discussed in terms of ways it could foster career advancement in the context of D&I research.Advancing an emerging field while simultaneously developing an academic career offers a unique challenge to ESIs in D&I research. This article summarizes findings from the formative data that outlines some directions for ESIs and provides linkages to the literature and other resources on key points.

    View details for DOI 10.1186/1748-5908-8-29

    View details for Web of Science ID 000318418300001

    View details for PubMedID 23497462

  • Recruiting older men for geriatric suicide research INTERNATIONAL PSYCHOGERIATRICS Bhar, S. S., Wiltsey-Stirman, S., Zembroski, D., McCray, L., Oslin, D. W., Brown, G. K., Beck, A. T. 2013; 25 (1): 88-95

    Abstract

    Clinical research is required to develop and evaluate suicide prevention interventions in the elderly. However, there is insufficient information available about how to best recruit suicidal older adults for such research. This study evaluated the success and efficiency of five recruitment strategies for a clinical trial on the efficacy of cognitive therapy for suicidal older men.For each strategy, the numbers of individuals approached, screened, and enrolled were calculated, and the expenses and time associated with each enrollment estimated. Men who were 60 years or older and who had a desire for suicide over the past month were eligible for the trial.Of 955 individuals considered for trial, 33 were enrolled. Most enrollments were sourced from the Veterans Affairs Behavioral Health Laboratory. Recruiting form this source was also the most time and cost efficient recruitment strategy in the study.Recruitment strategies are effective when they are based on collaborative relationships between researchers and providers, and utilize an existing infrastructure for involving patients in ongoing research opportunities.

    View details for DOI 10.1017/S104161021200138X

    View details for Web of Science ID 000312528400011

    View details for PubMedID 22929086

    View details for PubMedCentralID PMC4583196

  • VA primary care providers’ perspectives on screening female Veterans for intimate partner violence: A preliminary assessment Journal of Family Violence Iverson, K. M., Wells, S. Y., Wiltsey Stirman, S., Vaughn, R., Gerber, M. R. 2013; 37: 302-311
  • Development of a framework and coding system for modifications made to evidence-based programs and interventions Implementation Science Wiltsey Stirman, S. 2013
  • A critical evaluation of the complex PTSD literature: Implications for DSM-5 JOURNAL OF TRAUMATIC STRESS Resick, P. A., Bovin, M. J., Calloway, A. L., Dick, A. M., King, M. W., Mitchell, K. S., Suvak, M. K., Wells, S. Y., Stirman, S. W., Wolf, E. J. 2012; 25 (3): 241-251

    Abstract

    Complex posttraumatic stress disorder (CPTSD) has been proposed as a diagnosis for capturing the diverse clusters of symptoms observed in survivors of prolonged trauma that are outside the current definition of PTSD. Introducing a new diagnosis requires a high standard of evidence, including a clear definition of the disorder, reliable and valid assessment measures, support for convergent and discriminant validity, and incremental validity with respect to implications for treatment planning and outcome. In this article, the extant literature on CPTSD is reviewed within the framework of construct validity to evaluate the proposed diagnosis on these criteria. Although the efforts in support of CPTSD have brought much needed attention to limitations in the trauma literature, we conclude that available evidence does not support a new diagnostic category at this time. Some directions for future research are suggested.

    View details for DOI 10.1002/jts.21699

    View details for Web of Science ID 000305576500003

    View details for PubMedID 22729974

  • A Qualitative Investigation of Practicing Psychologists' Attitudes Toward Research-Informed Practice: Implications for Dissemination Strategies PROFESSIONAL PSYCHOLOGY-RESEARCH AND PRACTICE Stewart, R. E., Stirman, S. W., Chambless, D. L. 2012; 43 (2): 100-109

    Abstract

    This article presents the results of a qualitative analysis of interviews with 25 psychologists in independent practice, investigating everyday treatment decisions and attitudes about treatment outcome research and empirically supported treatments (ESTs). Clinicians noted positive aspects about treatment outcome research, such as being interested in what works. However, they had misgivings about the application of controlled research findings to their practices, were skeptical about using manualized protocols, and expressed concern that nonpsychologists would use EST lists to dictate practice. Clinicians reported practicing in an eclectic framework, and many reported including cognitive-behavioral elements in their practice. To improve their practice, they reported valuing clinical experience, peer networks, practitioner-oriented books, and continuing education when it was not too basic. Time and financial barriers concerned nearly all participants. Clinicians suggested they might be interested in ESTs if they could integrate them into their current frameworks, and if resources for learning ESTs were improved.

    View details for DOI 10.1037/a0025694

    View details for Web of Science ID 000302968800005

    View details for PubMedCentralID PMC3361756

  • The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research IMPLEMENTATION SCIENCE Stirman, S. W., Kimberly, J., Cook, N., Calloway, A., Castro, F., Charns, M. 2012; 7

    Abstract

    The introduction of evidence-based programs and practices into healthcare settings has been the subject of an increasing amount of research in recent years. While a number of studies have examined initial implementation efforts, less research has been conducted to determine what happens beyond that point. There is increasing recognition that the extent to which new programs are sustained is influenced by many different factors and that more needs to be known about just what these factors are and how they interact. To understand the current state of the research literature on sustainability, our team took stock of what is currently known in this area and identified areas in which further research would be particularly helpful. This paper reviews the methods that have been used, the types of outcomes that have been measured and reported, findings from studies that reported long-term implementation outcomes, and factors that have been identified as potential influences on the sustained use of new practices, programs, or interventions. We conclude with recommendations and considerations for future research.Two coders identified 125 studies on sustainability that met eligibility criteria. An initial coding scheme was developed based on constructs identified in previous literature on implementation. Additional codes were generated deductively. Related constructs among factors were identified by consensus and collapsed under the general categories. Studies that described the extent to which programs or innovations were sustained were also categorized and summarized.Although "sustainability" was the term most commonly used in the literature to refer to what happened after initial implementation, not all the studies that were reviewed actually presented working definitions of the term. Most study designs were retrospective and naturalistic. Approximately half of the studies relied on self-reports to assess sustainability or elements that influence sustainability. Approximately half employed quantitative methodologies, and the remainder employed qualitative or mixed methodologies. Few studies that investigated sustainability outcomes employed rigorous methods of evaluation (e.g., objective evaluation, judgement of implementation quality or fidelity). Among those that did, a small number reported full sustainment or high fidelity. Very little research has examined the extent, nature, or impact of adaptations to the interventions or programs once implemented. Influences on sustainability included organizational context, capacity, processes, and factors related to the new program or practice themselves.Clearer definitions and research that is guided by the conceptual literature on sustainability are critical to the development of the research in the area. Further efforts to characterize the phenomenon and the factors that influence it will enhance the quality of future research. Careful consideration must also be given to interactions among influences at multiple levels, as well as issues such as fidelity, modification, and changes in implementation over time. While prospective and experimental designs are needed, there is also an important role for qualitative research in efforts to understand the phenomenon, refine hypotheses, and develop strategies to promote sustainment.

    View details for DOI 10.1186/1748-5908-7-17

    View details for Web of Science ID 000302479300001

    View details for PubMedID 22417162

    View details for PubMedCentralID PMC3317864

  • Perspectives on Cognitive Therapy Training within Community Mental Health Settings: Implications for Clinician Satisfaction and Skill Development. Depression research and treatment Wiltsey Stirman, S., Miller, C. J., Toder, K., Calloway, A., Beck, A. T., Evans, A. C., Crits-Christoph, P. 2012; 2012: 391084-?

    Abstract

    Despite the mounting evidence of the benefits of cognitive therapy for depression and suicidal behaviors over usual care, like other evidence-based psychosocial treatments (EBTs), it has not been widely adopted in clinical practice. Studies have shown that training followed by intensive consultation is needed to prepare providers to an appropriate level of competency in complex, multisession treatment packages such as cognitive therapy. Given the critical role of training in EBT implementation, more information on factors associated with the success and challenges of training programs is needed. To identify potential reasons for variation in training outcomes across ten agencies in a large, urban community mental health system, we explored program evaluation data and examined provider, consultant, and training program administrator perspectives through follow-up interviews. Perceptions of cognitive therapy, contextual factors, and reactions to feedback on audio recordings emerged as broad categories of themes identified from interviews. These factors may interact and impact clinician efforts to learn cognitive therapy and deliver it skillfully in their practice. The findings highlight experiences and stakeholder perspectives that may contribute to more or less successful training outcomes.

    View details for DOI 10.1155/2012/391084

    View details for PubMedID 23056933

  • Training Community Mental Health Agencies in Cognitive Therapy for Schizophrenia. The Behavior therapist Riggs, S. E., Wiltsey-Stirman, S., Beck, A. T. 2012; 35 (2): 34–39

    View details for PubMedID 26401068

  • A Qualitative Investigation of Practicing Psychologists' Attitudes Toward Research-Informed Practice: Implications for Dissemination Strategies. Professional psychology, research and practice Stewart, R. E., Stirman, S. W., Chambless, D. L. 2012; 43 (2): 100–109

    Abstract

    This article presents the results of a qualitative analysis of interviews with 25 psychologists in independent practice, investigating everyday treatment decisions and attitudes about treatment outcome research and empirically supported treatments (ESTs). Clinicians noted positive aspects about treatment outcome research, such as being interested in what works. However, they had misgivings about the application of controlled research findings to their practices, were skeptical about using manualized protocols, and expressed concern that nonpsychologists would use EST lists to dictate practice. Clinicians reported practicing in an eclectic framework, and many reported including cognitive-behavioral elements in their practice. To improve their practice, they reported valuing clinical experience, peer networks, practitioner-oriented books, and continuing education when it was not too basic. Time and financial barriers concerned nearly all participants. Clinicians suggested they might be interested in ESTs if they could integrate them into their current frameworks, and if resources for learning ESTs were improved.

    View details for PubMedID 22654246

    View details for PubMedCentralID PMC3361756

  • Changes in Psychotherapy Utilization Among Consumers of Services for Major Depressive Disorder in the Community Mental Health System ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH Gibbons, M. B., Rothbard, A., Farris, K. D., Stirman, S. W., Thompson, S. M., Scott, K., Heintz, L. E., Gallop, R., Crits-Christoph, P. 2011; 38 (6): 495-503

    Abstract

    The goal of this investigation was to explore changes in psychotherapy utilization for patients with major depressive disorder (MDD) treated in community mental health agencies across two cohorts. We used a Medicaid claims database including approximately 300,000 public sector clients. Although the use of psychotherapy alone showed a small decrease, there was a large increase in the use of combined medication and psychotherapy as a treatment for MDD. Race was a significant predictor of both treatment type received and length of treatment. African American consumers were more likely to receive psychotherapy alone than combined treatment and attended significantly fewer psychotherapy sessions.

    View details for DOI 10.1007/s10488-011-0336-1

    View details for Web of Science ID 000300092700006

    View details for PubMedID 21298475

    View details for PubMedCentralID PMC3350098

  • The Science of Training in Evidence-Based Treatments in the Context of Implementation Programs: Current Status and Prospects for the Future ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH Becker, K. D., Stirman, S. W. 2011; 38 (4): 217-222

    View details for DOI 10.1007/s10488-011-0361-0

    View details for Web of Science ID 000291804400001

    View details for PubMedID 21644028

  • Participation Bias among Suicidal Adults in a Randomized Controlled Trial SUICIDE AND LIFE-THREATENING BEHAVIOR Stirman, S. W., Brown, G. K., Ghahramanlou-Holloway, M., Fox, A. J., Chohan, M. Z., Beck, A. T. 2011; 41 (2): 203-209

    Abstract

    Although individuals who attempt suicide have poor compliance rates with treatment recommendations, the nature and degree of participation bias in clinical treatment research among these individuals is virtually unknown. The purpose of this study was to examine participation bias by comparing the demographic and diagnostic characteristics of adult suicide attempters who participated in a randomized controlled trial to a sample of nonparticipants. Results indicated that males and individuals with a diagnosis of substance abuse or dependence were more likely to be participants in the randomized controlled trial. The implications of these findings for suicide intervention research are discussed.

    View details for DOI 10.1111/j.1943-278X.2010.00011.x

    View details for Web of Science ID 000289247800009

    View details for PubMedID 21470296

    View details for PubMedCentralID PMC3367501

  • Developing the mental health workforce: Review and application of training strategies from multiple disciplines Administration and Policy in Mental Health and Mental Health Services Research Lyon, A. 2011: 238-253
  • The clinical effectiveness of cognitive therapy for depression in an outpatient clinic JOURNAL OF AFFECTIVE DISORDERS Gibbons, C. J., Fournier, J. C., Stirman, S. W., DeRubeis, R. J., Crits-Christoph, P., Beck, A. T. 2010; 125 (1-3): 169-176

    Abstract

    Cognitive therapy (CT) has been shown to be efficacious in the treatment of depression in numerous randomized controlled trials (RCTs). However, little evidence is available that speaks to the effectiveness of this treatment under routine clinical conditions.This paper examines outcomes of depressed individuals seeking cognitive therapy at an outpatient clinic (N=217, Center for Cognitive Therapy; CCT). Outcomes were then compared to those of participants in a large NIMH-funded RCT of cognitive therapy and medications as treatments for depression.The CCT is shown to be a clinically representative setting, and 61% of participants experienced reliable change in symptoms over the course of treatment; of those, 45% (36% of the total sample) met criteria for recovery by the end of treatment. Participants at CCT had similar outcomes to participants treated in the RCT, but there was some evidence that those with more severe symptoms at intake demonstrated greater improvement in the RCT than their counterparts at CCT.The CCT may not be representative of all outpatient settings, and the structure of treatment there was considerably different from that in the RCT. Treatment fidelity was not assessed at CCT.Depressed individuals treated with cognitive therapy in a routine clinical care setting showed a significant improvement in symptoms. When compared with outcomes evidenced in RCTs, there was little evidence of superior outcomes in either setting. However, for more severe participants, outcomes were found to be superior when treatment was delivered within an RCT than in an outpatient setting. Clinicians treating such patients in non-research settings may thus benefit from making modifications to treatment protocols to more closely resemble research settings.

    View details for DOI 10.1016/j.jad.2009.12.030

    View details for Web of Science ID 000281377100023

    View details for PubMedID 20080305

  • New psychotherapies for mood and anxiety disorders. Canadian journal of psychiatry. Revue canadienne de psychiatrie Wiltsey Stirman, S., Toder, K., Crits-Cristoph, P. 2010; 55 (4): 193-201

    Abstract

    To discuss psychotherapies for depression and anxiety that have emerged in recent years and to evaluate their current level of empirical support.An electronic and a manual literature search of psychotherapies for mood and anxiety disorders were conducted.Five new therapies for mood disorders and 3 interventions for posttraumatic stress disorder with co-occurring substance abuse met criteria for inclusion in this review. Fewer psychotherapies have been developed for other anxiety disorders. Although research for some of the psychotherapies has demonstrated superiority to usual care, none have firmly established efficacy or specific benefits over other established psychotherapies.A plurality of the new psychotherapies introduced and established in the past 5 years have been different assimilations of previously established cognitive-behavioural, interpersonal, or psychodynamic models. While initial results are promising for some, more rigorous efficacy trials and replications are necessary before conclusions can be drawn regarding their relative benefits.

    View details for PubMedID 20416142

  • Training and Consultation in Evidence-Based Psychosocial Treatments in Public Mental Health Settings: The ACCESS Model PROFESSIONAL PSYCHOLOGY-RESEARCH AND PRACTICE Stirman, S. W., Bhar, S. S., Spokas, M., Brown, G. K., Creed, T. A., Perivoliotis, D., Farabaugh, D. T., Grant, P. M., Beck, A. T. 2010; 41 (1): 48-56

    Abstract

    We present a model of training in evidence-based psychosocial treatments (EBTs). The ACCESS (assess and adapt, convey basics, consult, evaluate, study outcomes, sustain) model integrates principles and findings from adult education and training literatures, research, and practical suggestions based on a community-based clinician training program. Descriptions of the steps are provided as a means of guiding implementation efforts and facilitating training partnerships between public mental health agencies and practitioners of EBTs.

    View details for DOI 10.1037/a0018099

    View details for Web of Science ID 000274475600007

    View details for PubMedCentralID PMC3412177

  • Developing research and recruitment while fostering stakeholder engagement in an IP-RISP for Depression Progress in Community Health Partnerships: Research, Education, and Action Wiltsey Stirman, S. 2010: 299-303
  • Engagement and Retention of Suicide Attempters in Clinical Research Challenges and Solutions CRISIS-THE JOURNAL OF CRISIS INTERVENTION AND SUICIDE PREVENTION Gibbons, C. J., Stirman, S. W., Brown, G. K., Beck, A. T. 2010; 31 (2): 62-68

    Abstract

    High attrition rates in longitudinal research can limit study generalizability, threaten internal validity, and decrease statistical power. Research has demonstrated that there can be significant differences between participants who complete a research study and those who drop out prematurely, and that treatment outcomes may be dependent on retention in a treatment protocol.The current paper describes the challenges encountered when implementing a randomized controlled trial of cognitive therapy for the prevention of suicide attempts and the solutions developed to overcome these problems.Problems unique to suicide attempters are discussed, and strategies successfully implemented to boost retention rates are provided.The methods implemented appeared to increase retention rates in the randomized controlled trial.Many steps can be taken to work with this difficult population, and researchers are encouraged to be as involved and flexible with participants as possible.

    View details for DOI 10.1027/0227-5910/a000018

    View details for Web of Science ID 000277094400002

    View details for PubMedID 20418211

  • Unique and Common Mechanisms of Change Across Cognitive and Dynamic Psychotherapies JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Gibbons, M. B., Crits-Christoph, P., Barber, J. P., Stirman, S. W., Gallop, R., Goldstein, L. A., Temes, C. M., Ring-Kurtz, S. 2009; 77 (5): 801-813

    Abstract

    The goal of this article was to examine theoretically important mechanisms of change in psychotherapy outcome across different types of treatment. Specifically, the role of gains in self-understanding, acquisition of compensatory skills, and improvements in views of the self were examined. A pooled study database collected at the University of Pennsylvania Center for Psychotherapy Research, which includes studies conducted from 1995 to 2002 evaluating the efficacy of cognitive and psychodynamic therapies for a variety of disorders, was used. Patient samples included major depressive disorder, generalized anxiety disorder, panic disorder, borderline personality disorder, and adolescent anxiety disorders. A common assessment battery of mechanism and outcome measures was given at treatment intake, termination, and 6-month follow-up for all 184 patients. Improvements in self-understanding, compensatory skills, and views of the self were all associated with symptom change across the diverse psychotherapies. Changes in self-understanding and compensatory skills across treatment were predictive of follow-up symptom course. Changes in self-understanding demonstrated specificity of change to dynamic psychotherapy.

    View details for DOI 10.1037/a0016596

    View details for Web of Science ID 000270564400001

    View details for PubMedID 19803561

    View details for PubMedCentralID PMC2844256

  • Public-academic partnerships: the Beck Initiative: a partnership to implement cognitive therapy in a community behavioral health system. Psychiatric services Stirman, S. W., Buchhofer, R., McLaulin, J. B., Evans, A. C., Beck, A. T. 2009; 60 (10): 1302-1304

    Abstract

    The Beck Initiative is a partnership between researchers and clinicians at a large university and an urban behavioral health managed care system. Both partners share a commitment to ensuring that consumers in the community have access to competently delivered, individualized, evidence-based mental health care and that the providers who serve them have the support they need to deliver high-quality evidence-based treatments. Central features of the program are individualized training and consultation in cognitive therapy for each provider agency and policies to promote the sustainability of the initiative and its continuing evolution to meet the needs of providers and consumers.

    View details for DOI 10.1176/appi.ps.60.10.1302

    View details for PubMedID 19797367

    View details for PubMedCentralID PMC2964939

  • Suicide Risk Factors and Mediators Between Childhood Sexual Abuse and Suicide Ideation Among Male and Female Suicide Attempters JOURNAL OF TRAUMATIC STRESS Spokas, M., Wenzel, A., Stirman, S. W., Brown, G. K., Beck, A. T. 2009; 22 (5): 467-470

    Abstract

    The current study examined the manner in which childhood sexual abuse (CSA) history relates to risk factors for suicidal behavior among recent suicide attempters (n = 166). Men who recently attempted suicide and endorsed a CSA history had higher scores on measures of hopelessness and suicide ideation than men without a CSA history. Men with a CSA history were also more likely to have made multiple suicide attempts and meet diagnostic criteria for posttraumatic stress disorder and borderline personality disorder. In contrast, there were fewer group differences as a function of CSA history among the female suicide attempters. Hopelessness was a significant mediator between CSA history and suicide ideation in both men and women.

    View details for DOI 10.1002/jts.20438

    View details for Web of Science ID 000271493000016

    View details for PubMedID 19711488

    View details for PubMedCentralID PMC2767398

  • CHANGES IN POSITIVE QUALITY OF LIFE OVER THE COURSE OF PSYCHOTHERAPY PSYCHOTHERAPY Crits-Christoph, P., Gibbons, M. B., Ring-Kurtz, S., Gallop, R., Stirman, S., Present, J., Temes, C., Goldstein, L. 2008; 45 (4): 419-430

    Abstract

    The objective of this study was to examine patients' reports of positive quality of life over the course of multiple forms of psychotherapy and disorders. Data from five studies using a common assessment battery were pooled to evaluate the magnitude of change in positive quality of life and explore the relation of change in positive quality of life to change in symptoms, and how these relations vary by disorder. Positive quality of life was measured at intake, termination, and during two post-treatment visits 6 and 12 months following termination. Results revealed that positive quality of life improves moderately over the course of psychotherapy and sustains the improvement through follow-up. Levels of positive quality of life and the degree of change in positive quality of life varied considerably by disorder. There also were moderate sized correlations between changes in positive quality of life and changes in symptomatic response and interpersonal functioning from intake to termination. Implications of the findings for clinical practice and future research are discussed.

    View details for DOI 10.1037/a0014340

    View details for Web of Science ID 000262213000001

    View details for PubMedCentralID PMC2786220

  • The applicability of randomized controlled trials of psychosocial treatments for PTSD to a veteran population JOURNAL OF PSYCHIATRIC PRACTICE Stirman, S. W. 2008; 14 (4): 199-208

    Abstract

    The extent to which the results of randomized controlled trials can be expected to generalize to clinical populations has been the subject of much debate. To examine this issue among a population of individuals diagnosed with posttraumatic stress disorder (PTSD), the clinical characteristics of Veterans Affairs (VA) patients with PTSD were compared to the eligibility criteria for clinical trials of psychosocial treatments for PTSD. Administrative data for 239,668 patients who received a diagnosis of PTSD within the VA healthcare system during the 2003 fiscal year were compared with inclusion and exclusion criteria of 31 clinical trials for PTSD. Based on available data, all patients appeared to be eligible for at least one study, and half (50%) were eligible for between 16 and 21 (50% or more) of the 31 studies examined. The studies for which the most veterans with PTSD would have been eligible targeted combat-related trauma or did not specify type of trauma in their eligibility criteria. Veterans who exhibited psychotic symptoms (3% of the sample) were ineligible for most, but not all, of the studies. However, most veterans with comorbid Axis I conditions, such as depression, anxiety disorders, and substance use disorders, were eligible for multiple studies. These findings, which indicate that the existing literature on the efficacy of psychosocial treatment may inform the treatment of the majority of veterans who present with PTSD, have applications for the design of future clinical trials and for consultation of the literature regarding appropriate treatments for veterans with PTSD.

    View details for Web of Science ID 000258110500002

    View details for PubMedID 18664888

  • The applicability of randomized controlled trials of psychosocial treatments for Post-traumatic Stress Disorder to a Veteran population Journal of Psychiatric Practice Wiltsey-Stirman, S. 2008; 14: 199-208
  • Changes in Positive Quality of Life over the Course of Psychotherapy. Psychotherapy (Chicago, Ill.) Crits-Christoph, P., Connolly Gibbons, M. B., Ring-Kurtz, S., Gallop, R., Stirman, S., Present, J., Temes, C., Goldstein, L. 2008; 45 (4): 419–30

    Abstract

    The objective of this study was to examine patients' reports of positive quality of life over the course of multiple forms of psychotherapy and disorders. Data from five studies using a common assessment battery were pooled to evaluate the magnitude of change in positive quality of life and explore the relation of change in positive quality of life to change in symptoms, and how these relations vary by disorder. Positive quality of life was measured at intake, termination, and during two post-treatment visits 6 and 12 months following termination. Results revealed that positive quality of life improves moderately over the course of psychotherapy and sustains the improvement through follow-up. Levels of positive quality of life and the degree of change in positive quality of life varied considerably by disorder. There also were moderate sized correlations between changes in positive quality of life and changes in symptomatic response and interpersonal functioning from intake to termination. Implications of the findings for clinical practice and future research are discussed.

    View details for PubMedID 19960115

    View details for PubMedCentralID PMC2786220

  • Psychiatric telephone contact following emergency department discharge reduces suicide re-attempts in people originally admitted for attempted suicide. Evidence-based mental health Brown, G. K., Wiltsey Stirman, S. 2007; 10 (1): 19

    View details for PubMedID 17255388

  • Can the randomized controlled trial literature generalize to nonrandomized patients? JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Stirman, S. W., DeRubeis, R. J., Crits-Christoph, P., Rothman, A. 2005; 73 (1): 127-135

    Abstract

    To determine the extent to which published randomized controlled trials (RCTs) of psychotherapy can be generalized to a sample of outpatients, the authors matched information obtained from charts of patients who had been screened out of RCTs to inclusion and exclusion criteria from published RCT studies. Most of the patients in the sample who had primary diagnoses represented in the RCT literature were judged eligible for at least 1 RCT. However, many patients in the sample with substance use disorders or social anxiety disorder were not eligible for at least 2 RCTs. Common reasons that patients did not match with at least 2 published RCTs for psychotherapy included (a) patients were in partial remission, (b) patients failed to meet minimum severity or duration criteria, (c) patients were being treated with antidepressant medication, and (d) the disorder being studied was not primary (mostly for social anxiety patients). The implications of these findings for future research and clinical practice are discussed.

    View details for DOI 10.1037/0022.006X.73.1.127

    View details for Web of Science ID 000227000400014

    View details for PubMedID 15709839

  • Achieving successful dissemination of empirically supported adult psychotherapies: A synthesis of dissemination theory Clinical Psychology: Science and Practice Wiltsey Stirman, S. 2004; 11: 343-359
  • Are samples in randomized controlled trials of psychotherapy representative of community outpatients? A new methodology and initial findings JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Stirman, S. W., DeRubeis, R. J., Crits-Christoph, P., BRODY, P. E. 2003; 71 (6): 963-972

    Abstract

    To determine the extent to which published randomized controlled trials (RCTs) of psychotherapy can be generalized to a sample of community outpatients, the authors used a method of matching information obtained from outpatient charts to inclusion and exclusion criteria from published RCT studies. They found that 80% of the patients in their sample who had diagnoses represented in the RCT literature were judged eligible for at least 1 published RCT; however, 58% of the patients had primary diagnoses such as adjustment disorder or dysthymia, which were not represented in the existing psychotherapy outcome literature. The most common reasons that patients in their sample did not match with published RCTs for psychotherapy are listed, and the implications of these findings for research and practice are discussed.

    View details for DOI 10.1037/0022-006X.71.6.963

    View details for Web of Science ID 000186693600001

    View details for PubMedID 14622071

  • Word use in the poetry of suicidal and nonsuicidal poets PSYCHOSOMATIC MEDICINE Stirman, S. W., Pennebaker, J. W. 2001; 63 (4): 517-522

    Abstract

    The purpose of this study was to determine whether distinctive features of language could be discerned in the poems of poets who committed suicide and to test two suicide models by use of a text-analysis program.Approximately 300 poems from the early, middle, and late periods of nine suicidal poets and nine nonsuicidal poets were compared by use of the computer text analysis program, Linguistic Inquiry and Word Count (LIWC). Language use within the poems was analyzed within the context of two suicide models.In line with a model of social integration, writings of suicidal poets contained more words pertaining to the individual self and fewer words pertaining to the collective than did those of nonsuicidal poets. In addition, the direction of effects for words pertaining to communication was consistent with the social integration model of suicide.The study found support for a model that suggests that suicidal individuals are detached from others and are preoccupied with self. Furthermore, the findings suggest that linguistic predictors of suicide can be discerned through text analysis.

    View details for Web of Science ID 000170119800001

    View details for PubMedID 11485104