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Comment & Response
February 2014

Prolonged Exposure Therapy in Veterans AffairsThe Full Picture

Author Affiliations
  • 1VA Boston Healthcare System, Jamaica Plain, Massachusetts
JAMA Psychiatry. 2014;71(2):211. doi:10.1001/jamapsychiatry.2013.3305

To the Editor The Eftekhari et al study1 on the effectiveness of prolonged exposure therapy (PE) in the Department of Veterans Affairs (VA) demonstrates the vast strides that have been made in testing and disseminating evidence-based treatments for military-related posttraumatic stress disorder (PTSD). We applaud attempts to make PTSD care uniformly rigorous and systematically applied throughout the VA. However, Eftekhari et al fail to acknowledge an unfortunate reality: PE is rarely used in actual VA practice.2 Prolonged exposure therapy is a highly emotionally demanding “trauma-focused therapy” that requires significant patient buy-in, motivation, and readiness to disclose traumatic experiences in vivid detail. Its dissemination in the VA occurred with little patient or line-clinician input, and the veterans’ perspective of PE treatment has not been evaluated. Studies show that, despite significant dissemination efforts, only a small minority of VA patients are selected for or choose trauma-focused treatment. For example, in a recent study of the Northeast region (conducted after national dissemination rollouts), only 6.3% of VA patients with PTSD had received at least 1 session of trauma-focused therapy and most of the PTSD treatment they received was nontrauma focused.3 The dissemination evaluation of Eftekhari et al does not represent the full spectrum of treatment-seeking veterans with PTSD, but instead a small subset of self- or clinician-selected patients. Eftekhari et al, for example, state that clinicians in their study “used their clinical judgment in determining which patients were suitable candidates for PE”1(p951) but do not elaborate on what determined this suitability or, importantly, what portion of patients were deemed “suitable” for PE by clinicians.

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