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IIR 14-030 – HSR&D Study

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IIR 14-030
Dropout from Evidence-Based Therapy for PTSD: Reasons and Potential Interventions
Shannon M. Kehle-Forbes PhD
Minneapolis VA Health Care System, Minneapolis, MN
Minneapolis, MN
Funding Period: February 2015 - July 2018

The clinical effectiveness of the two trauma-focused treatments for PTSD with the strongest empirical evidence, prolonged exposure (PE) and cognitive processing therapy (CPT), is hampered by high rates of treatment dropout. Recently published data from Veterans receiving PE and CPT show higher rates of dropout, ranging from 19-38%. Interventions to reduce dropout from PE and CPT are needed. However, little is known about patients' reasons for discontinuing PE and CPT. The long-term goal of this project is to increase Veterans' rates of recovery from PTSD by decreasing rates of dropout from PE and CPT.

The specific aims are to: 1) Understand reasons for premature dropout from prolonged exposure (PE) and cognitive processing therapy (CPT) from both the patient and the provider perspective, 2) Identify factors that actively facilitate PE and CPT completion, and 3) Develop an intervention framework that can be used to improve retention in PE and CPT.

To achieve aim 1, we conducted semi-structured interviews, with a national sample of Veterans who initiated but failed to complete PE or CPT (n = 66). In order to ensure a full understanding of the range of reasons for dropout, we stratified our sample by service era, gender, and therapy modality (PE versus CPT) and purposely sample for race/ethnicity and time of dropout. To understand the providers' perspectives regarding Veteran drop-out, the PE and CPT therapists of the Veterans who dropped out were also interviewed (n = 33). In service of aim 2, we conducted semi-structured interviews with completers of PE and CPT (n = 60) using a sampling strategy similar to that in Aim 1. Veterans were queried about difficulties they encountered during PE and CPT and the factors that allowed them to complete treatment despite those challenges. Finally, to complete aim 3, we utilized a modified Delphi method and intervention mapping strategies to develop an interventional framework to reduce PE and CPT dropout. Specifically, we identified and interviewed 16 exemplary PE and CPT therapists and triangulated their expert opinions with relevant theory and empirical findings to develop the framework for an intervention that will: 1) intervene on precipitators of dropout, 2) enhance facilitators of completion, and 3) provide supervisory strategies to train PE and CPT therapists as to how to minimize veteran treatment drop-out.

We examined differences in the experiences of treatment completers and treatment dropouts using a mixed deductive and inductive coding approach in which top-level codes derived from the project's conceptual model were applied to all Aim 1 & Aim 2 transcripts. 2nd and 3rd level codes were inductively derived within each top-level code. 20% of transcripts were double-coded to ensure consistency and prevent drift. A modified constant comparative method was used to evaluate differences in each code between treatment dropouts and completers; common and unique themes were identified within each top level code. Initial identification of those themes was carried out by those who coded the top-level code under discussion and were verified by the full analytic team.

The sample was comprised of 34% women Veterans; 25% African American and 14% Hispanic / Latino Veterans, and 33% Vietnam era Veterans. Important differences between treatment completers and dropouts occurred across all top-level domains (therapeutic skill and alliance, reactions to treatment, factors outside PE/CPT treatment process, treatment-related beliefs, symptomology, and interventions applied to keep Veteran engaged in treatment). One important theme that cut across top-level codes was the availability and type of support available to Veterans during PE/CPT. While the vast majority of Veterans in both samples reported having good treatment-related support from their therapists and others in their lives, the type of support differed. Completers were more likely to have support that specifically targeted treatment challenges (e.g., problem-solving side effects, difficulty completing assignments), rather than non-specific emotional support.

Examples of other themes that emerged between to the groups include the differences in perceptions of symptom worsening, ability to cope with competing life demands, and reactions the structure of treatment. A majority of Veterans in both groups perceived that their symptoms worsened during the course of treatment; completers viewed that worsening as part of the treatment while those who dropped out viewed it as an indication that the treatment wasn't working. Those with symptoms worsening who dropped out feared the consequences of that worsening. Further, logistical barriers did not differ between groups, although those who dropped out were less likely to be able to simultaneously cope with the demands of treatment and daily life stressors. Those who dropped out of treatment were more likely to have negative reactions to the structure of the treatment (e.g., use of writing / recording; weekly, time-limited treatment, focus on a single trauma); likely due to a combination of treatment preferences and less flexibility employed by these Veterans' providers.

Finally, important differences exist between how providers and patients view treatment dropout. Only a small minority of providers expressed a predominately negative attitude towards their Veteran's dropout, while Veterans often viewed it as a personal failure and reported hopelessness following dropout. Further, approximately 15% of Veteran dropouts who we interviewed believed they were still engaged in PE/CPT at the time of the interview, despite being identified as treatment dropouts by their providers.

Treatment with PE or CPT significantly reduces the cost and suffering associated with PTSD. Completion of PE or CPT results in large and clinically-significant reductions in PTSD symptoms, with up to one-half of Veterans losing their PTSD diagnosis. The long-term goal of this project is to increase Veterans' rates of recovery from PTSD through decreasing rates of dropout from PE and CPT. Reducing rates of dropout will positively impact Veterans' health and well-being, lower the cost of treating PTSD, and decrease Veterans' long-term demand for PTSD services. Study findings will be used to develop a provider-facing intervention to increase rates of completion in these effective treatments.

None at this time.

DRA: Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational
Keywords: PTSD
MeSH Terms: none