Please cite this article in press as: McLean, C. P., & Foa, E.B. Dissemination and implementation of prolonged exposure therapy for posttraumatic stress disorder. Journal of Anxiety Disorders (2013), http://dx.doi.org/10.1016/j.janxdis.2013.03.004 ARTICLE IN PRESS G Model ANXDIS-1488; No. of Pages 5 Journal of Anxiety Disorders xxx (2013) xxx–xxx Contents lists available at SciVerse ScienceDirect Journal of Anxiety Disorders Dissemination and implementation of prolonged exposure therapy for posttraumatic stress disorder Carmen P. McLean * , Edna B. Foa Department of Psychiatry, University of Pennsylvania, 3535 Market Street, 6th floor, Philadelphia, PA 19104, United States a r t i c l e i n f o Article history: Received 20 February 2013 Received in revised form 13 March 2013 Accepted 13 March 2013 Keywords: Posttraumatic stress disorder Prolonged exposure therapy Evidence-based treatment Dissemination a b s t r a c t Posttraumatic stress disorder (PTSD) is a highly prevalent, often chronic and disabling psychiatric disorder that is associated with significant adverse health and life consequences. Although several evidence-based treatments (EBTs), including Prolonged Exposure therapy (PE), have been found effective and efficacious in reducing PTSD symptomology, the majority of individuals with this disorder receive treatments of unknown efficacy. Thus, it is imperative that EBTs such as PE be made available to PTSD sufferers through widespread dissemination and implementation. We will review some of the efforts to increase the avail- ability of PE and the common barriers to successful dissemination and implementation. We also discuss novel dissemination strategies that are harnessing technology to overcome barriers to dissemination. © 2013 Elsevier Ltd. All rights reserved. 1. Introduction Posttraumatic Stress Disorder (PTSD) is a highly prevalent psy- chiatric disorder that affects 3.4% of men and 8.5% of women during their lifetime (McLean, Asnaani, Litz, & Hofmann, 2011). In the absence of effective treatment, PTSD frequently becomes a chronic and disabling disorder that is often comorbid with major depres- sion, other anxiety disorders, substance abuse disorders (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Breslau, Davis, & Schultz, 2003), medical problems (Schnurr, Spiro, & Paris, 200) and is asso- ciated with low quality of life (Zatzick et al., 1997; Zayfert, Dums, Ferguson, & Hegel, 2002). Given the substantial personal distress, public health and societal costs associated with chronic PTSD, it is heartening that there are effective interventions for PTSD avail- able. Evidence-based treatments (EBTs) for PTSD include prolonged exposure therapy (PE; e.g., Bryant et al., 2008; Foa et al., 1999, 2005; Resick, Nishith, Weaver, Astin, & Feuer, 2002; Schnurr et al., 2007; for a review and meta-analysis see Powers, Halpern, Ferenschak, Gillihan & Foa, 2010), cognitive processing therapy (CPT; Chard, 2005; Monson et al., 2006; Resick et al., 2008, 2002), cognitive therapy (e.g., Ehlers et al., 2003; Tarrier & Sommerfield, 2004), stress-inoculation therapy (e.g., Foa et al., 1991; 1999) and eye movement desensitization and reprocessing (EMDR; e.g., Power et al., 2002; Rothbaum, Astin, & Marsteller, 2005; Taylor et al., 2003). * Corresponding author. Tel.: +1 215 746 3327; fax: +1 215 746 3311. E-mail address: mcleanca@mail.med.upenn.edu (C.P. McLean). EBT for PTSD is greatly underutilized (e.g., Foa, Gillihan, & Bryant, in press, Kessler, 2000; Rosen et al., 2004), resulting in unnecessary suffering, increased healthcare costs, and workplace absenteeism (Greenberg et al., 1999; Hoge, Terhakopian, Castro, Messer, & Engel, 2007), despite a wealth of evidence that EBTs for PTSD can be effectively disseminated. While much of this research has focused on PE, dissemination studies have also examined other EBTs. For example, Gillespie, Duffy, Hackmann, and Clark (2002) found com- munity therapists who received training in cognitive therapy for PTSD and ongoing supervision effectively administered treatment in an open trial. Similarly, a study by Neuner et al., 2008 showed that a manualized exposure treatment called narrative exposure ther- apy was effectively delivered to refugees in southern Uganda by lay counselors chosen from within the refugee community. While acknowledging these promising results, we focus on the dissemina- tion of PE, which has the greatest supportive evidence and has been the subject of wider dissemination efforts than other treatments for PTSD. This review provides an overview of efforts to disseminate PE, and a description of the successes, barriers, and challenges involved in promoting the adoption of PE in mental health systems. 1.1. Prolonged exposure therapy for PTSD Prolonged exposure (PE) is a specific exposure therapy pro- gram designed to help PTSD sufferers to emotionally process their traumatic experiences through repeated revisiting and recounting their trauma memories (imaginal exposure), and repeated, gradual approach to trauma-related, safe, situations that the person avoids because there are trauma reminders (in vivo exposure). PE con- sists of two principal components: (a) in vivo exposure to trauma 0887-6185/$ – see front matter © 2013 Elsevier Ltd. 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