Adaptive interventions to improve posttraumatic stress (PTSD) treatment access, engagement, and effectiveness in routine care - PROJECT ABSTRACT/SUMMARY Posttraumatic stress disorder (PTSD) prevalence can be as high as 50% in resource-constricted primary care clinics, wherein only 13% of people with PTSD receive any treatment. The U.S. behavioral health system’s struggle to provide access to high quality services and ensure good health outcomes for all populations has led to large treatment and health outcome gaps. The low availability of first line treatments for PTSD in routine care is due to high treatment demand, low availability of trained specialists, and high resource burdens associated with the delivery of intensive PTSD therapies in healthcare systems. Additionally, low treatment expectations, medical mistrust, and behavioral health stigma impact treatment initiation and retention. Innovative treatment approaches for PTSD are needed to broaden access to treatment in routine care. Leaders in health care have called for a research agenda focused on increasing access in highly constrained resource settings, sequencing treatments along care pathways, and personalizing treatments. Adaptive (stepped) interventions hold promise in advancing this research agenda yet have not been developed for PTSD. This study extends a program of research focused on developing adaptive interventions for PTSD. Our adaptive intervention sequences a digital behavioral health intervention and brief trauma- and skills-focused treatments for PTSD. The selected treatments are brief and scalable, less burdensome to systems of care, and highly acceptable to patients and care settings. Treatments can be tailored to individual needs by their clinician, and tailoring is supported by case consultation that permits fidelity-consistent modifications. These treatments are: web-administered Skills Training in Affective and Interpersonal Regulation (webSTAIR), Brief STAIR, and Written Exposure Therapy (WET). Selected implementation strategies include facilitation and enhancing engagement via web-administration and community health worker [CHW] support. Our overall approach is informed by the latest treatment outcome research, formative evaluations in the local setting, and pilot data from Dr. Valentine’s K23 trial which optimized web- and brief STAIR for primary care. In the proposed study, primary care patients will receive rapid access to webSTAIR following a positive PTSD screen. Using a Sequential Multiple Assignment Randomized Trial (SMART) design, nonresponders at 4 weeks will be randomized to stage 1 treatments: webSTAIR v. webSTAIR + CHW coaching. Initial and stage 1 treatments are offered while patients remain on behavioral health clinician waitlists. At 8 weeks, nonresponders will be re-randomized to clinician-administered stage 2 treatments: Brief STAIR v. WET. This study will (Aim 1) test one way to sequence brief, scalable, varied intensity PTSD treatments across settings, and will provide data on (Aim 2) mechanisms of change for engagement and effectiveness, (Aim 3) patient-level moderators of adaptive interventions, and (Aim 4) implementation outcomes and facilitation strategies.
