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Publication Briefs

Study Examines Factors Related to Low, Moderate and High Use of Psychotherapy among Veterans

BACKGROUND: The number of Veterans seeking VA mental healthcare has increased dramatically over the past decade. In response, VA hired many new mental health providers and rolled out training programs for evidence-based psychotherapies, which appears to have increased the use of psychotherapy. However, the full distribution of psychotherapy use, including rates and predictors of both low use (i.e., too few psychotherapy sessions to likely produce any benefit) and high use (i.e., psychotherapy extending well beyond the traditional length of most evidence-based treatments) remains under-examined. This study sought to examine predisposing, enabling, and need factors related to low, moderate, high, and very high levels of psychotherapy use among Veterans newly diagnosed with PTSD, depression, and anxiety. Using VA data, investigators identified 130,331 Veterans who received one or more of these diagnoses in VA outpatient facilities during FY10, and who received at least one outpatient psychotherapy session in the year following diagnosis. The total number of psychotherapy sessions was calculated for the 12-month study period and included individual, group, and family therapy. Investigators also examined predisposing (i.e., age, gender, and marital status), enabling (i.e., distance to nearest VA), and need factors (i.e., psychiatric diagnoses, comorbidities) as predictors of the amount of psychotherapy.


  • Overall, need factors appeared to be most strongly linked to psychotherapy utilization. Very high psychotherapy users had higher rates of PTSD and substance use disorders, more comorbid psychiatric diagnoses, and more inpatient psychiatric stays.
  • In the year after initiating psychotherapy, half of the sample (51%) received only 1-3 psychotherapy sessions (low-users); 42% received 4-18 sessions (moderate-users); 5% received 19-51 sessions (high-users), and 2% received more than 52 sessions (very high-users). Low-users predominantly received individual psychotherapy; very high-users received relatively more group psychotherapy.
  • Younger (<35) and older (65+) Veterans were proportionately more likely to be low-users. Low-users also had lower psychiatric comorbidity, fewer inpatient days, and were less likely to be diagnosed with PTSD and SUD.
  • Results suggest many Veterans may not receive a clinically optimal dose of psychotherapy, highlighting the need to enhance retention in therapy for low utilizers and examine whether very high utilizers are benefitting from extensive courses of treatment.


  • VHA administrative databases lacked information on patients' race/ethnicity, problems on presentation, whether an evidence-based treatment was received, or response to treatment.

This study was partly funded by HSR&D. Drs. Hundt and Barrera are part of HSR&D's Center for Innovations in Quality, Effectiveness and Safety located in Houston, TX. Dr. Mott is currently affiliated with the VA National Center for PTSD in White River Junction, VT.

PubMed Logo Hundt N, Barrera T, Mott J, et al. Predisposing, Enabling, and Need Factors as Predictors of Low and High Psychotherapy Utilization in Veterans. Psychological Services. May 19, 2014;e-pub ahead of print.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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