Tailored strategies to increase the use of an evidence-based psychotherapy for posttraumatic stress disorder: A stepped-wedge randomized trial in military clinics

Abstract

Clinician training is often not sufficient to increase the adoption of evidence-based psychotherapies (EBPs). To address organizational barriers that may limit use of EBPs, a tailored implementation strategy—Targeted Assessment and Context-Tailored Implementation of Change Strategies (TACTICS)—was developed. TACTICS involved external facilitation (appointing a local implementation team and external coach, conducting need assessment interviews, creating site-specific implementation plans, and weekly coaching for the site champion) augmented with a planning rubric and resources for making operational changes. The effect of adding TACTICS after clinician training was evaluated in a cluster-randomized stepped-wedge trial across eight military treatment facilities. Psychotherapists (n = 212) received training in prolonged exposure (PE) therapy. TACTICS was subsequently introduced with timing randomized by site. PE utilization was measured via natural language processing of notes from 26,429 psychotherapy encounters across 3459 patients. After accounting for time effects, TACTICS increased PE use compared to training alone (OR = 1.05–2.21, p < .03). Nonetheless, overall use of PE declined over time (OR = 0.067–0.316, p < .001). In post-hoc analyses, declining use of PE over time was strongly associated with a decreasing supply of psychotherapy appointments per patient (r = .98). These findings suggest that local implementation support improves EBP adoption beyond training alone. However, lasting use may require broader system supports such as adequate staffing and policies that encourage use of EBPs.