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Posttraumatic stress disorder (PTSD) remains largely untreated among adults with severe mental illnesses (SMI). The treatment of psychotic symptoms usually takes precedence in the care of adults with SMI. Such oversight is problematic in that PTSD in SMI populations is common (19%-43%), contributes a significant illness burden, and hinders mental health care. Yet few public-sector mental health agencies routinely provide specialized services for PTSD. The purpose of the article is to describe strategies and efforts to disseminate trauma-focused empirically based practices in a public-sector mental health system. Identified challenges include limited resources and commitment; knowledge deficits, attitudes, and biases; and limited practice accountability at provider, facility, and system levels. Proposed strategies for overcoming these challenges are to set clear goals, nurture broad-based organizational commitment and key stakeholder involvement, implement specialty training efforts to provide information and change attitudes, provide ongoing supervision, conduct fidelity monitoring, and ensure accountability to the extent possible.

Using secondary analyses from a randomized trial comparing the effectiveness of manualized cognitive-behavioral therapy for posttraumatic stress disorder, we compared ratings of therapist competency and adherence between two service delivery modes: telepsychiatry (TP) and same room (SR). Patients were 38 male treatment-seeking veterans recruited from a veterans affairs medical center. Domains of therapist competence and adherence included structuring sessions, implementing session activities, providing feedback, dealing with difficulties, developing rapport, and conveying empathy. Only one difference emerged between the two treatment conditions, with more favorable ratings on this item in the TP condition. Findings suggest that therapist competence and adherence to cognitive-behavioral therapy is similar whether the treatment is delivered via TP or by traditional means, and TP does not compromise therapists' ability to effectively structure sessions or build rapport with patients. These data further support the use of TP to address shortages in access to mental health care. (Contains 2 tables.)

This study examined therapists' fidelity to a manualized, multi-component cognitive-behavioral intervention for posttraumatic stress disorder (PTSD), including exposure therapy, among public sector patients with a psychotic disorder. Independent raters assessed therapists' competence and adherence, rating 20% of randomly selected audio taped sessions (n = 57 sessions, coded by two raters, with strong interrater agreement). Adherence ratings indicated that therapists complied well with the protocol, and competency ratings typically averaged 'very good' or higher (6 on 7-point Likert scale). Findings suggest that therapists can effectively deliver a manualized cognitive-behavioral intervention for PTSD, with exposure therapy, to patients with severe mental illness without compromise to the structure of sessions and/or the therapeutic relationship. Keywords: PTSD; cognitive-behavioral therapy; therapist fidelity; severe mental illness DOI: 10.1002/jclp.20657

Objective: To examine rates of medical and psychiatric disorders among 187 female veterans recruited at four Veterans Affairs Medical Centers (VAMCs), the recognition of such disorders by VAMC care providers, and the use of relevant medical and mental health services by women both within and outside of the VA setting. Methods: We used a cross-sectional, epidemiological design incorporating self-report measures, structured interviews, and chart reviews to obtain relevant information for analyses. Results: Forty-four percent (43.9%) of women met criteria for at least one psychiatric disorder; 34.0% of these women met criteria for two or more additional psychiatric diagnoses, and concordance rates between interview and chart diagnoses were low. Ninety-five percent (95.2%) of women had a medical condition noted in their charts; 86.6% had two or more additional medical conditions, and a significant number of women had both medical and psychiatric diagnoses. Forty-four percent (43.9%) of women with an identified mental health condition received specialized mental health care by the VA in the past year. Conclusions: Findings from this study suggest that female veterans treated in VAMCs had significant medical and psychiatric problems, and these women might not be getting their health care needs adequately met through the VA health care system. In light of our findings, we discuss relevant implications and future directions for research. doi:10.1300/ J013v43n03_03 KEYWORDS. Primary care, female veterans, PTSD, service use, psychiatric status, medical functioning