Implementation of Cognitive Therapy for PTSD in routine clinical care: Effectiveness and moderators of outcome in a consecutive sample

• Published in: Behaviour research and therapy 2013-11, Vol.51 (11), p.742-752
• Main Authors: Ehlers, Anke, Grey, Nick, Wild, Jennifer, Stott, Richard, Liness, Sheena, Deale, Alicia, Handley, Rachel, Albert, Idit, Cullen, Deborah, Hackmann, Ann, Manley, John, McManus, Freda, Brady, Francesca, Salkovskis, Paul, Clark, David M.
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; Adult and adolescent clinical studies; Aged; Aged, 80 and over; Anxiety disorders. Neuroses; Anxiety-Depression; Behavior therapy. Cognitive therapy; Biological and medical sciences; Clinical outcomes; Clinical trials; Cognitive behavior therapy; Cognitive Behavioral Therapy; Cognitive therapy; Dissemination; Dropping out; Effectiveness studies; Female; Humans; Implementation; Male; Medical sciences; Mental Health Services; Middle Aged; Models, Psychological; Outcome and Process Assessment (Health Care) - statistics & numerical data; Outpatient Clinics, Hospital; Patient Dropouts; Post traumatic stress disorder; Posttraumatic stress disorder; Predictors of outcome; Psychology. Psychoanalysis. Psychiatry; Psychopathology. Psychiatry; Stress Disorders, Post-Traumatic - diagnosis; Stress Disorders, Post-Traumatic - therapy; Symptom Assessment; Symptoms; Therapists; Treatment effectiveness; Treatment Outcome; Treatments
• ISSN: 0005-7967; 1873-622X
• DOI: 10.1016/j.brat.2013.08.006

Trauma-focused psychological treatments are recommended as first-line treatments for Posttraumatic Stress Disorder (PTSD), but clinicians may be concerned that the good outcomes observed in randomized controlled trials (RCTs) may not generalize to the wide range of traumas and presentations seen in clinical practice. This study investigated whether Cognitive Therapy for PTSD (CT-PTSD) can be effectively implemented into a UK National Health Service Outpatient Clinic serving a defined ethnically mixed urban catchment area. A consecutive sample of 330 patients with PTSD (age 17–83) following a wide range of traumas were treated by 34 therapists, who received training and supervision in CT-PTSD. Pre and post treatment data (PTSD symptoms, anxiety, depression) were collected for all patients, including dropouts. Hierarchical linear modeling investigated candidate moderators of outcome and therapist effects. CT-PTSD was well tolerated and led to very large improvement in PTSD symptoms, depression and anxiety. The majority of patients showed reliable improvement/clinically significant change: intent-to-treat: 78.8%/57.3%; completer: 84.5%/65.1%. Dropouts and unreliable attenders had worse outcome. Statistically reliable symptom exacerbation with treatment was observed in only 1.2% of patients. Treatment gains were maintained during follow-up (M = 280 days, n = 220). Few of the selection criteria used in some RCTs, demographic, diagnostic and trauma characteristics moderated treatment outcome, and only social problems and needing treatment for multiple traumas showed unique moderation effects. There were no random effects of therapist on symptom improvement, but therapists who were inexperienced in CT-PTSD had more dropouts than those with greater experience. The results support the effectiveness of CT-PTSD and suggest that trauma-focused cognitive behavior therapy can be successfully implemented in routine clinical services treating patients with a wide range of traumas. •Cognitive Therapy for PTSD can be effectively implemented in routine clinical care.•The intent-to-treat analysis showed very large treatment effects.•Patients found the treatment acceptable, and the majority showed clinically significant change.•Few patient characteristics moderated treatment outcome.•Inexperienced therapists had more dropouts.