Posttraumatic stress disorder (PTSD) poses monumental public health challenges because of its contribution to mental health, physical health, and both interpersonal and social problems. Recent military engagements in Iraq and Afghanistan and the multitude of resulting cases of PTSD have highlighted the public health significance of these conditions. There are now psychological treatments that can effectively treat most individuals with PTSD, including active duty military personnel, veterans, and civilians. We begin by reviewing the effectiveness of these treatments, with a focus on prolonged exposure (PE), a cognitive-behavioral therapy (CBT) for PTSD. Many studies conducted in independent research labs have demonstrated that PE is highly efficacious in treating PTSD across a wide range of trauma types, survivor characteristics, and cultures. Furthermore, therapists without prior CBT experience can readily learn and implement the treatment successfully. Despite the existence of highly effective treatments like PE, the majority of individuals with PTSD receive treatments of unknown efficacy. Thus, it is crucial to identify the barriers and challenges that must be addressed in order to promote the widespread dissemination of effective treatments for PTSD. In this review, we first discuss some of the major challenges, such as a professional culture that often is antagonistic to evidence-based treatments (EBTs), a lack of clinician training in EBTs, limited effectiveness of commonly used dissemination techniques, and the significant cost associated with effective dissemination models. Next, we review local, national, and international efforts to disseminate PE and similar treatments and illustrate the challenges and successes involved in promoting the adoption of EBTs in mental health systems. We then consider ways in which the barriers discussed earlier can be overcome, as well as the difficulties involved in effecting sustained organizational change in mental health systems. We also present examples of efforts to disseminate PE in developing countries and the attendant challenges when mental health systems are severely underdeveloped. Finally, we present future directions for the dissemination of EBTs for PTSD, including the use of newer technologies such as web-based therapy and telemedicine. We conclude by discussing the need for concerted action among multiple interacting systems in order to overcome existing barriers to dissemination and promote widespread access to effective treatment for PTSD. These systems include graduate training programs, government agencies, health insurers, professional organizations, healthcare delivery systems, clinical researchers, and public education systems like the media. Each of these entities can play a major role in reducing the personal suffering and public health burden associated with posttraumatic stress.
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Each year, millions of individuals experience a trauma — whether it is a car accident, an assault, an injury, or a natural disaster. Although many individuals recover from a traumatic event, others go on to develop posttraumatic stress disorder (PTSD) — an anxiety disorder characterized by severe and persistent stress reactions in response to the trauma.
The individual and societal effects of PTSD are great; therefore, it is imperative to treat PTSD using the best and most effective methods available, as backed by psychological science. In this report, Edna B. Foa (University of Pennsylvania), Seth J. Gillihan (University of Pennsylvania), and Richard A. Bryant (University of New South Wales) review research examining evidence-based treatments (EBTs) for PTSD and the challenges disseminating these treatments on a local, national, and international scale.
One EBT specifically identified by the authors as having consistent success in reducing PTSD symptoms is a type of cognitive behavioral therapy known as prolonged exposure (PE). In PE therapy, individuals are asked to approach — in both imaginary and real-life settings — situations, places, and people they have been avoiding. The repeated exposure to the perceived threat disconfirms individuals’ expectations of experiencing harm and over time leads to a reduction in their fear.
Despite the existence of highly effective treatments such as PE therapy, few clinicians use such treatments. Why might this be the case? The authors cite lack of training in EBTs, skepticism that EBTs work better than currently used treatments, and significant costs associated with dissemination models.
Although there are many barriers to adopting and spreading the use of EBTs, the authors describe several examples of their own successful dissemination of PE therapy in both developed and developing countries. These real-world examples highlight the barriers that can occur during the dissemination of EBTs and provide guidance on how common obstacles can be overcome.
Although the authors have had success disseminating PE therapy on a smaller scale, larger scale dissemination efforts will require the cooperation of many different agencies, including training and professional organizations, government agencies, insurers, health care providers, and the media. Working together, these organizations can help spread the use of effective treatments for PTSD and reduce the individual and public health burden associated with this disorder.
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Editorial: Achieving the Promise of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder and Other Mental Health Conditions for Veterans
By Bradley E. Karlin, U.S. Department of Veterans Affairs, and Madhulika Agarwal, Deputy Under Secretary for Health for Policy and Services, U.S. Department of Veterans Affairs
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