Background: Posttraumatic stress disorder (PTSD) is one of the most common mental health diagnoses among Veterans. Cognitive processing therapy (CPT) and prolonged exposure therapy (PE) were widely disseminated in the Veterans Health Administration (VHA) as recommended PTSD treatments. Despite these efforts, few post-9/11 Veterans diagnosed with PTSD initiate CPT or PE. In the small percentage of Veterans who receive these therapies, CPT and PE are rarely the first treatment a Veteran receives. A common treatment sequence identified in implementation research, begins with “stabilization treatment,” combinations of psychosocial and medication treatments that prepare Veterans for CPT or PE. A gap in existing research is how treatment sequences, particularly stabilization treatment, influence initiation of CPT or PE. Significance/Impact: PTSD is an HSR&D priority condition due to its substantial negative biopsychosocial impact on Veterans lives. Novel strategies are needed to increase engagement, retention, and improve outcomes from recommended PTSD treatments, and to reduce disparities in access to this care. Understanding how to most effectively combine and sequence PTSD treatment is an HSR&D identified area of interest, and a research gap identified in the VHA PTSD clinical practice guideline. Innovation: Despite consistently identifying stabilization treatment as a common VHA practice, little research has investigated this treatment sequence. A novel approach to solving existing limitations in PTSD treatment delivery involves developing an intervention that both acknowledges the ubiquitous presence and benefits of stabilization treatment, while facilitating timely transition from stabilization treatment to CPT or PE. Specific Aims: This CDA-2 aims to improve delivery of PTSD services in the VHA, while simultaneously providing me with training in health services research methods to support my development into an independent VHA researcher. The proposed research aims are: (1) To qualitatively understand Veterans’ and clinicians’ perspectives on selecting stabilization treatments and how stabilization treatment serves as a barrier or facilitator of transition to CPT or PE; (2) To develop and conduct a randomized, pragmatic pilot trial of a brief, Veteran-centered intervention to support transition from stabilization treatment to CPT or PE; and (3) To identify sociodemographic disparities in treatment sequences and to determine how treatment sequences influence time to CPT or PE initiation across the VHA. Methodology: I will then conduct qualitative interviews with a national sample of Veterans (n=30) and clinicians (n=20; Aim 1). Using rapid qualitative analysis procedures, I will evaluate how treatment sequences, particularly stabilization treatment, are chosen and how they serve as a barrier or facilitator of transition to CPT and PE. I will then use knowledge gained from Aim 1 to develop a health services intervention that facilitates timely transition to CPT or PE. I will test this intervention in a randomized, pragmatic, pilot trial comparing the intervention (n=20) to treatment as usual (n=20; Aim 2). I will assess the proportion of Veterans who initiate CPT or PE within a year after beginning the intervention as a primary outcome and feasibility as a secondary outcome. Using electronic health record data from a national, longitudinal cohort of post-9/11 Veterans who received VHA PTSD treatment (anticipated n=400,000) from 10/05-12/23, I will identify treatment sequences; understand how treatment sequence impacts time to CPT or PE initiation using Cox proportional hazard regression; and identify disparities in treatment sequences based on sociodemographic characteristics (Aim 3). Implementation/Next Steps: I will apply the knowledge and training gained through this proposal to an HSR&D Merit application to test the benefits of the developed intervention on a large scale through a multisite hybrid type-II pragmatic trial. I will collaborate with organizational partners at the Office of Mental Health and Suicide Prevention to ensure that work supports efforts to promote clinical practice guideline-consistent care.

Cognitive processing therapy (CPT) and prolonged exposure therapy (PE) were widely disseminated as recommended posttraumatic stress disorder (PTSD) treatments. However, post-9/11 Veterans with PTSD rarely initiate CPT or PE, especially as an initial treatment. Little research has explored the combinations and sequences of psychosocial and medication treatments that Veterans receive (“treatment sequences”). One common and understudied treatment sequence begins with stabilization treatment, which is designed to prepare Veterans for CPT or PE. There is a significant research gap in understanding how treatment sequence affects initiation of CPT or PE. The proposed research is an innovative, mixed-methods approach to assessing the impact of variability in treatment sequence, including stabilization treatment, on initiation of CPT or PE and applying this knowledge by developing a health services intervention that facilitates timely transition to CPT or PE. Research aims can improve PTSD treatment by increasing initiation of and reducing disparities in CPT/PE.