Background: An estimated 33-46% of clients seen in urban low-income primary care or behavioral health clinics have a current diagnosis of posttraumatic stress disorder (PTSD), yet only 13% receive PTSD treatment. Further, only 57% of those who access care for PTSD receive a minimally adequate dose of therapy. The shortage of trained mental health specialists has led to concerning inequities in access to and quality of care in low-income community settings. To address workforce shortages, as well as client preferences, leaders in the field have advocated for the development of stepped care approaches that begin with brief, patient-centered interventions before progressing to intensive treatments. Despite promise, stepped approaches have not been developed for adults with PTSD.
Specific Aims : This current study applies the Replicating Effective Programs Framework to guide the refinement and pre-implementation of a ?Step 1? evidence-based treatment (EBT) for PTSD in primary care. A full stepped care approach will be tested in a future R01 (Step 1: brief, low intensity EBT in a non-specialty setting; Step 2: high intensity EBT in a specialty setting).
Aim 1 : To conduct a mixed-methods formative evaluation based on surveys and semi-structured interviews (N=25; 10 social worker and community health worker interventionists; 15 primary care stakeholders) to characterize the local integrated primary care setting and identify the need for augmentation to the intervention, protocol, or implementation blueprint.
Aim 2 : To optimize the intervention and operational procedures and to finalize the formal implementation blueprint (based on Aim 1 findings and consultation with the community advisory board [CAB]; N=10).
Aim 3 : To conduct a nonrandomized hybrid type 1 implementation-effectiveness pilot (N=60 clients) to assess the feasibility, effectiveness, and implementation of the adapted PTSD intervention (v. treatment as usual) in a primary care clinic. Candidate: This Mentored Patient-Oriented Research Career Development Award (K23) builds upon the candidate?s previous experiences in clinical research focused on psychological adjustment following exposure to violence or discrimination among multiple minority populations. The candidate?s long-term goal is to be an independent implementation scientist focused on optimizing EBTs and care delivery models for PTSD. Training Objectives: (1) The development of implementation packages for delivery of EBTs in non-specialty settings; (2) Advanced training in pragmatic clinical trial design and mixed-methods data analysis and integration; and (3) Integrated primary care and stepped care models for mental health service delivery. Training Activities: Training will be achieved through mentorship by experts (Drs. A. Rani Elwy, Lisa Fortuna, Marylene Cloitre, Alisa Lincoln, Mark Bauer, Margarita Alegria, and Bindu Kalesan), formal coursework at Boston University School of Public Health, seminars, trainings, conferences, and workshop attendance.

Public Health Relevance

Only 13% of individuals with posttraumatic stress disorder (PTSD) in urban low-income communities receive mental health treatment; of those who receive treatment, only 56% receive minimally adequate psychotherapy. Low access to evidence-based psychotherapies for PTSD is foremost due to a shortage of trained mental health specialists; however, additional barriers exist, including: consumer preferences for care in non-specialty settings. Stepped care approaches that begin with the implementation of brief evidence-based psychotherapies for PTSD in non-specialty settings have the potential to improve the availability and quality of PTSD treatment in community settings.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Mentored Patient-Oriented Research Career Development Award (K23)
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Special Emphasis Panel (ZMH1)
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Hill, Lauren D
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Boston Medical Center
United States
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