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Cited by 38Health Policy Implementation ScienceMindfulness and Compassion InterventionsPsychotherapy Techniques and Applications

Evaluation of Implementation Strategies for Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), and Mindfulness-Based Stress Reduction (MBSR): a Systematic Review

Open access
Goldsmith, Elizabeth S., Koffel, Erin, Ackland, Princess E., Hill, Jessica, Landsteiner, Adrienne, Miller, Wendy, Stroebel, Benjamin, Ullman, Kristen +2 more·2023·Journal of General Internal Medicine
DOI 10.1007/s11606-023-08140-4PMC PMC10069727
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Abstract

Background: Improving access to evidence-based psychotherapies (EBPs) is a Veterans Health Administration (VHA) priority. Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) are effective for chronic pain and several mental health conditions. We synthesized evidence on implementation strategies to increase EBP access and use. Methods: We searched MEDLINE, Embase, PsycINFO, and CINAHL from inception until March 2021 for articles on EBP implementation within integrated health systems to treat chronic pain or chronic mental health conditions. Reviewers independently screened articles, extracted results, coded qualitative findings, and rated quality using modified criteria from Newcastle–Ottawa (quantitative results) or Critical Appraisal Skills Programme (qualitative results). We categorized implementation strategies using the Expert Recommendations for Implementing Change (ERIC) framework and classified outcomes using RE-AIM domains (Reach, Effectiveness, Adoption, Implementation, Maintenance). Results: Twelve articles (reporting results from 10 studies) evaluated CBT (k = 11) and ACT (k = 1) implementation strategies in large integrated healthcare systems. No studies evaluated MBSR implementation. Eight articles evaluated strategies within VHA. Six articles reported on national VHA EBP implementation programs; all involved training/education, facilitation, and audit/feedback. CBT and ACT implementation demonstrated moderate to large improvements in patient symptoms and quality of life. Trainings increased mental health provider self-efficacy in delivering EBPs, improved provider EBP perceptions, and increased provider EBP use during programs, but had unclear impacts on Reach. It was unclear whether external facilitation added benefit. Provider EBP maintenance was modest; barriers included competing professional time demands and patient barriers. Discussion: Multi-faceted CBT and ACT implementation programs increased provider EBP Adoption but had unclear impacts on Reach. Future implementation efforts should further evaluate Reach, Adoption, and Maintenance; assess the added value of external facilitation; and consider strategies targeting patient barriers. Future work should use implementation frameworks to guide evaluations of barriers and facilitators, processes of change, and outcomes. Registration: PROSPERO registration number CRD42021252038. © 2023, This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.

Integrity signals

Registry

Crossref · 10.1007/s11606-023-08140-4

Cites

46 of 46 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

10 of 21 cited sources checked · 1 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    No prior systematic review has used implementation science frameworks to examine how these EBP uptake efforts have performed in VHA and comparable settings.

    “The results of such efforts to improve the uptake of these EBPs in VHA and similar clinical settings have not been systematically reviewed using implementation science frameworks.19”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [19] Verhey IJ, Ryan GK, Scherer N, Magidson JF. Implementation outcomes of cognitive behavioural therapy delivered by non-specialists for common mental disorders and substance-use disorders in low- and middle-income countries: a systematic review. Int J Ment Health Syst. 2020;14:40. source

      The Introduction says previous reviews had not synthesized implementation outcomes of CBT delivered by non-specialist health workers in low- and middle-income countries. The Methods says this review used an implementation-outcomes framework. Those passages support a review gap in that specific area, but do not establish a gap concerning EBP uptake in VHA or comparable clinical settings. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
  • Findingown data

    Trainings increased mental health provider self-efficacy in delivering EBPs.

    “Trainings increased mental health provider self-efficacy in delivering EBPs”
    Quote in the paperSubstantial claim
  • Findingown data

    Trainings improved provider EBP perceptions.

    “improved provider EBP perceptions”
    Quote in the paperSubstantial claim
  • Findingown data

    Competing professional time demands were a barrier to EBP maintenance.

    “barriers included competing professional time demands and patient barriers.”
    Quote in the paperNot a substantial claim
  • Findingown data

    No eligible study evaluated implementation strategies for MBSR.

    “No studies evaluated MBSR implementation.”
    • Also stated in: § Overview and Characteristics of Eligible Studies · plain
      “We did not identify any eligible study on implementation strategies for MBSR.”
    Quote in the paperSubstantial claim
  • May combine two claims. 13
  • Classified as probably not a substantial claim. 3

  • May combine two claims.

    Premisecitation

    CBT, ACT, and MBSR are effective treatments for chronic pain and for depression, anxiety, and other mental health conditions prevalent in US veterans.

    “Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) are effective for chronic pain and several mental health conditions.”
    • Also stated in: § INTRODUCTION · boosted
      “Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) have demonstrated effectiveness for mental health conditions common among US military veterans, including depression and anxiety,1–7 and have more recently shown effectiveness for improving chronic pain outcomes.8,9”
    Quote in the paperSubstantial claim5 of 9 sources checked
    • cites [1] Bai Z, Luo S, Zhang L, Wu S, Chi I. Acceptance and commitment therapy (ACT) to reduce depression: A systematic review and meta-analysis. J Affect Disord. 2020;260:728-737. source
    • cites [2] Butler AC, Chapman JE, Forman EM, Beck AT. The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev. 2006;26(1):17-31. source

      Section 2.13 reports benefits of CBT for chronic pain, and Section 3 reports effectiveness for depression, anxiety disorders, and other mental health conditions. The paper does not establish the effectiveness of ACT or MBSR for those conditions, nor does it assess these treatments specifically in US veterans. Page numbers were not available in our copy. (LLM, conf=0.89)

      Experimental — accuracy not yet measured
    • cites [3] Coto-Lesmes R, Fernandez-Rodriguez C, Gonzalez-Fernandez S. Acceptance and commitment therapy in group format for anxiety and depression. A systematic review. J Affect Disord. 2020;263:107-120. source
    • cites [4] Fjorback LO, Arendt M, Ornbol E, Fink P, Walach H. Mindfulness-based stress reduction and mindfulness-based cognitive therapy: a systematic review of randomized controlled trials. Acta Psychiatr Scand. 2011;124(2):102-119. source
    • cites [5] Lepping P, Whittington R, Sambhi RS, et al. Clinical relevance of findings in trials of CBT for depression. Eur Psychiatry. 2017;45:207-211. source

      The Discussion reports a clinically relevant effect of CBT for depression. The paper does not establish that ACT or MBSR is effective, or that any of the therapies is effective for chronic pain, anxiety, or other conditions in US veterans. (LLM, conf=0.90)

      Experimental — accuracy not yet measured
    • cites [6] Li SYH, Bressington D. The effects of mindfulness-based stress reduction on depression, anxiety, and stress in older adults: A systematic review and meta-analysis. Int J Ment Health Nurs. 2019;28(3):635-656. source
    • cites [7] Lopez-Lopez JA, Davies SR, Caldwell DM, et al. The process and delivery of CBT for depression in adults: a systematic review and network meta-analysis. Psychol Med. 2019;49(12):1937-1947. source

      The Discussion reports that CBT reduced short-term depression scores in adults compared with treatment as usual. The Results identify ACT among the interventions but say its specific effect could not be estimated; the paper does not establish MBSR's effectiveness or effectiveness for chronic pain, anxiety, or US veterans. No page numbers were provided in our copy. (LLM, conf=0.91)

      Experimental — accuracy not yet measured
    • cites [8] Becker WC, DeBar LL, Heapy AA, et al. A research agenda for advancing non-pharmacological management of chronic musculoskeletal pain: findings from a VHA State-of-the-art Conference. J Gen Intern Med. 2018;33(Suppl 1):11-15. source

      The Psychological/Behavioral Therapies section (page not provided) identifies CBT, ACT, and MBSR as treatments with strong efficacy or effectiveness evidence in the context of chronic pain. It also says veterans with chronic pain frequently have comorbid mental health conditions, but does not establish that all three therapies are effective treatments for depression, anxiety, or other mental health conditions. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
    • cites [9] Kligler B, Bair MJ, Banerjea R, et al. Clinical policy recommendations from the VHA state-of-the-art conference on non-pharmacological approaches to chronic musculoskeletal pain. J Gen Intern Med. 2018;33(Suppl 1): 16–23. source

      The Psychological/Behavioral Therapies section supports CBT, ACT, and MBSR for chronic pain and reports improvements in mood, depression, distress, or pain-related anxiety among people treated for pain. It does not establish that all three are effective treatments for several mental health conditions as distinct diagnoses, or specifically establish that claim for US veterans. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Evidence-based psychotherapies are underutilized and underaccessed in clinical settings.

    “Nonetheless, these evidence-based psychotherapies (EBPs) remain underutilized and underaccessed in clinical settings.10–12”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites [10] Valenstein-Mah H, Greer N, McKenzie L, et al. Effectiveness of training methods for delivery of evidence-based psychotherapies: a systematic review. Implement Sci. 2020;15(1):40. source
    • cites [11] Becker WC, Dorflinger L, Edmond SN, Islam L, Heapy AA, Fraenkel L. Barriers and facilitators to use of non-pharmacological treatments in chronic pain. BMC Fam Pract. 2017;18(1):41. source

      The Background says chronic pain treatment is frequently solely pharmacologic and excludes evidence-based non-pharmacological treatments, including cognitive behavioral therapy. The Results (Barriers) identify obstacles to accessing those treatments. The paper supports underuse and limited access in chronic pain care, but not the broader claim about evidence-based psychotherapies across clinical settings. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [12] Shafran R, Clark DM, Fairburn CG, et al. Mind the gap: Improving the dissemination of CBT. Behav Res Ther. 2009;47(11):902-909. source

  • May combine two claims.

    Premisecitation

    Among EBPs, CBT, ACT, and MBSR are widely used and have the strongest evidence for treating chronic pain and mental health conditions prevalent in US veterans.

    “three of the most widely used EBPs with the strongest evidence for effectiveness in chronic pain as well as for multiple mental health conditions common among U.S. military veterans.8,9”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [8] Becker WC, DeBar LL, Heapy AA, et al. A research agenda for advancing non-pharmacological management of chronic musculoskeletal pain: findings from a VHA State-of-the-art Conference. J Gen Intern Med. 2018;33(Suppl 1):11-15. source

      The Psychological/Behavioral Therapies section identifies CBT, ACT, and MBSR as treatments commonly provided in the VA with strong evidence for chronic pain. It does not establish that they are the most widely used, or that all three have the strongest evidence for treating multiple mental health conditions common among veterans; it notes those conditions as potential comorbidities instead. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [9] Kligler B, Bair MJ, Banerjea R, et al. Clinical policy recommendations from the VHA state-of-the-art conference on non-pharmacological approaches to chronic musculoskeletal pain. J Gen Intern Med. 2018;33(Suppl 1): 16–23. source

      The Psychological/Behavioral Therapies section reviews evidence for CBT, ACT, and MBSR in chronic pain, including some improvements in mood or distress. It does not establish that all three are among the most widely used therapies or have the strongest evidence for multiple mental health conditions common among U.S. veterans. The veteran-specific evidence it discusses concerns CBT for chronic pain. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingown data

    Most included studies evaluated programs combining multiple implementation strategies, and their designs could not attribute outcomes to individual strategies.

    “Most studies assessed programs that combined various implementation strategies, and their study designs did not make it possible to determine which outcomes resulted from individual strategies.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Twelve articles, covering ten studies, assessed implementation strategies for CBT (eleven articles) and ACT (one article) in large integrated healthcare systems.

    “Twelve articles (reporting results from 10 studies) evaluated CBT (k = 11) and ACT (k = 1) implementation strategies in large integrated healthcare systems.”
    • Also stated in: § Overview and Characteristics of Eligible Studies · plain
      “Among 67 eligible articles, 10 studies (reported by k = 12 articles) addressed implementation strategies for CBT (9 studies) and ACT (1 study) (Table 2).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Six articles reported on national VHA EBP implementation programs, all of which involved training/education, facilitation, and audit/feedback.

    “Six articles reported on national VHA EBP implementation programs; all involved training/education, facilitation, and audit/feedback.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Ten of the included articles reported studies conducted in VHA settings.

    “Most eligible articles described studies conducted in the US (k = 11), with the vast majority in VHA settings (k = 10).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    This study reported qualitatively on Reach and Implementation.

    “This study reported qualitatively on Reach and Implementation”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    One study evaluated the impact of new financial resources on access to mental health treatments in primary care; the funding was used differently across sites and was not associated with structured training programs or facilitation.

    “One study evaluated the impact of new financial resources on access to mental health treatments in primary care; this new funding was used differently across clinical sites and not associated with structured training programs or facilitation.39”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Studies in the second group reported outcomes addressing Reach, Adoption, and Implementation; neither reported on Effectiveness or Maintenance.

    “Studies in this group reported outcomes addressing Reach, Adoption, and Implementation; neither reported on Effectiveness or Maintenance”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    This study reported on Reach and Effectiveness, indicating large reductions in depression and anxiety symptoms (Cohen's d 1.06-1.26).

    “This study reported on Reach and Effectiveness, indicating large reductions in depression and anxiety symptoms (Cohen’s d 1.06–1.26; Table 3 and Appendix D).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Included studies identified logistical barriers to EBP practice for patients and providers, but strategies to address these barriers were rarely evaluated.

    “While included studies noted logistical barriers to EBP practice for both patients and providers, strategies to address these were minimally evaluated.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Six studies, reported in eight articles, evaluated VHA training programs for CBT (five studies, seven articles) and ACT (one study, one article).

    “Six studies (k = 8 articles) evaluated VHA training programs for CBT (5 studies, k = 7)14–17,35–37 and ACT (1 study, k = 1),18”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Studies in the first group reported outcomes addressing Effectiveness, Adoption, Implementation, and Maintenance; none reported on Reach.

    “Overall, studies in this first group reported outcomes addressing Effectiveness, Adoption, Implementation, and Maintenance; none reported on Reach”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Eleven included articles were rated high or moderate quality; most used quantitative or mixed methods, and one reported only qualitative results.

    “Eleven articles were high or moderate quality, and most used quantitative (k = 10) or mixed methods (k = 1), with the remaining article reporting only qualitative results.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The review did not undertake a formal assessment of the overall certainty of evidence.

    “We did not undertake a formal assessment of the overall certainty of evidence.”
    Quote in the paperNot a substantial claim
16 of 16

  • The paper relies on this without support.

    Improving access to evidence-based psychotherapies is a priority for the Veterans Health Administration.

    “Improving access to evidence-based psychotherapies (EBPs) is a Veterans Health Administration (VHA) priority.”

  • The paper relies on this without support.

    There is very limited evidence on implementation of evidence-based psychotherapies specifically for chronic pain.

    “Recognizing that there is very limited evidence on the implementation of EBPs specifically for the treatment of chronic pain, we expanded the scope to include implementation studies of EBPs to treat chronic mental health conditions such as depression and anxiety.”

  • The paper relies on this without support.

    Large integrated healthcare systems are more similar to VHA than small community clinics are.

    “we limited eligible studies addressing key question 2 to those conducted within large integrated healthcare systems, as these settings may be more similar to VHA, compared with small community clinics.”

  • The paper relies on this without support.

    Integrated health systems in the included non-US countries have qualities similar to VHA and comparable economic, public health, and cultural contexts.

    “We expanded the setting beyond the US to these other countries because of the presence of integrated health systems with qualities similar to VHA, and comparable economic, public health, and cultural contexts including the dominant English language.”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • National VHA articles counted differently in two places

    Minor

    The abstract reports six articles on national VHA EBP implementation programs, while the Results section later states four studies in the first group evaluated national initiatives and refers to k = 5 articles. These descriptions of the same national VHA programs do not match.

  • Discussion confuses studies with articles

    Minor

    The discussion calls the twelve eligible items studies, whereas the results identify ten studies reported in twelve articles.

2 of 2

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Authors
Goldsmith, E. S., Koffel, E., Ackland, P. E., Hill, J., Landsteiner, A., Miller, W., Stroebel, B., Ullman, K., Wilt, T. J., & Duan-Porter, W.
Affiliations
  • University of Minnesota (US)
  • Minneapolis VA Health Care System (US)
  • Binghamton University (US)
  • University of California, San Francisco (US)
Corresponding author
Goldsmith, Elizabeth S.
ORCID
Venue
Journal of General Internal Medicine
Publisher
Springer Science and Business Media LLC
Published
2023-04-03
Volume
38
Issue
12
Pages
2782-2791
ISSN
  • 0884-8734 (ISSN-L)
  • 1525-1497
DOI
10.1007/s11606-023-08140-4
PMC
PMC10069727
OpenAlex
W4362521735
Semantic Scholar
ac3b85643a90009c6784c676b640b466092cfcd4
Cited by
38
References
47
Citations by year
2026: 19 · 2025: 12 · 2024: 7
FWCI
1.92
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of General Internal Medicine (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • eScholarship (California Digital Library) (submittedVersion)
Funders
Health Services Research and Development (#09-009)
Topics
  • Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
  • Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Keywords
implementation strategies, cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, Veterans Health Administration, chronic pain, provider training, external facilitation, audit and feedback, RE-AIM framework, provider self-efficacy, implementation barriers and facilitators
MeSH terms
Humans, Quality of Life, Stress, Psychological, Cognitive Behavioral Therapy, Chronic Pain, Mindfulness, Acceptance and Commitment Therapy

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