Department of Psychiatry, University of Pennsylvania, Philadelphia
Department of Psychiatry, University of Pennsylvania, Philadelphia.
Psychol Sci Public Interest. 2013 May;14(2):65-111. doi: 10.1177/1529100612468841.
Posttraumatic stress disorder (PTSD) poses monumental public health challenges because of its contribution to mental health, physical health, and both interpersonal and social problems. Recent military engagements in Iraq and Afghanistan and the multitude of resulting cases of PTSD have highlighted the public health significance of these conditions. There are now psychological treatments that can effectively treat most individuals with PTSD, including active duty military personnel, veterans, and civilians. We begin by reviewing the effectiveness of these treatments, with a focus on prolonged exposure (PE), a cognitive-behavioral therapy (CBT) for PTSD. Many studies conducted in independent research labs have demonstrated that PE is highly efficacious in treating PTSD across a wide range of trauma types, survivor characteristics, and cultures. Furthermore, therapists without prior CBT experience can readily learn and implement the treatment successfully. Despite the existence of highly effective treatments like PE, the majority of individuals with PTSD receive treatments of unknown efficacy. Thus, it is crucial to identify the barriers and challenges that must be addressed in order to promote the widespread dissemination of effective treatments for PTSD. In this review, we first discuss some of the major challenges, such as a professional culture that often is antagonistic to evidence-based treatments (EBTs), a lack of clinician training in EBTs, limited effectiveness of commonly used dissemination techniques, and the significant cost associated with effective dissemination models. Next, we review local, national, and international efforts to disseminate PE and similar treatments and illustrate the challenges and successes involved in promoting the adoption of EBTs in mental health systems. We then consider ways in which the barriers discussed earlier can be overcome, as well as the difficulties involved in effecting sustained organizational change in mental health systems. We also present examples of efforts to disseminate PE in developing countries and the attendant challenges when mental health systems are severely underdeveloped. Finally, we present future directions for the dissemination of EBTs for PTSD, including the use of newer technologies such as web-based therapy and telemedicine. We conclude by discussing the need for concerted action among multiple interacting systems in order to overcome existing barriers to dissemination and promote widespread access to effective treatment for PTSD. These systems include graduate training programs, government agencies, health insurers, professional organizations, healthcare delivery systems, clinical researchers, and public education systems like the media. Each of these entities can play a major role in reducing the personal suffering and public health burden associated with posttraumatic stress.
创伤后应激障碍（PTSD）因其对心理健康、身体健康以及人际和社会问题的影响，给公共卫生带来了巨大挑战。最近在伊拉克和阿富汗的军事行动以及由此导致的大量 PTSD 病例凸显了这些情况的公共卫生意义。现在有一些心理治疗方法可以有效地治疗大多数 PTSD 患者，包括现役军人、退伍军人和平民。我们首先回顾这些治疗方法的有效性，重点是延长暴露（PE），一种 PTSD 的认知行为疗法（CBT）。许多在独立研究实验室进行的研究表明，PE 对治疗 PTSD 非常有效，适用于广泛的创伤类型、幸存者特征和文化。此外，没有 CBT 经验的治疗师也可以轻松学习并成功实施治疗。尽管存在像 PE 这样的高效治疗方法，但大多数 PTSD 患者接受的治疗方法效果未知。因此，确定必须解决的障碍和挑战以促进 PTSD 有效治疗方法的广泛传播至关重要。在这篇综述中，我们首先讨论了一些主要挑战，例如专业文化通常对循证治疗（EBT）持敌对态度、临床医生缺乏 EBT 培训、常用传播技术效果有限以及与有效传播模型相关的高昂成本。接下来，我们回顾了在本地、国家和国际范围内传播 PE 和类似治疗方法的努力，并说明了在促进心理健康系统采用 EBT 方面所涉及的挑战和成功。然后，我们考虑了如何克服前面讨论的障碍，以及在心理健康系统中进行持续组织变革所涉及的困难。我们还介绍了在发展中国家传播 PE 的努力及其在心理健康系统严重欠发达时所面临的挑战。最后，我们提出了 PTSD 的 EBT 传播的未来方向，包括使用新的技术，如基于网络的治疗和远程医疗。我们在讨论中得出结论，需要多个相互作用的系统之间协调行动，以克服传播的现有障碍并促进 PTSD 有效治疗方法的广泛应用。这些系统包括研究生培训计划、政府机构、健康保险公司、专业组织、医疗保健提供系统、临床研究人员以及公共教育系统（如媒体）。这些实体中的每一个都可以在减少 PTSD 相关的个人痛苦和公共卫生负担方面发挥重要作用。
