Dropout from Evidence-Based Therapy for PTSD: Reasons and Potential Interventions

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DESCRIPTION (provided by applicant): Impacts: The long-term goal of this project is to increase Veterans' rates of recovery from posttraumatic stress disorder (PTSD) through decreasing rates of dropout from prolonged exposure (PE) and cognitive processing therapy (CPT). Reducing rates of dropout will positively impact Veterans' health and well-being, lower the cost of treating PTSD, and decrease long-term demand for PTSD services. This project is highly responsive to the needs of our operational partners, the Office of Mental Health Services and the National Center for PTSD, and it addresses the HSR&D priority area of post-deployment mental and behavioral health. Background: Left untreated, PTSD is often chronic and is associated with functional impairments, medical morbidity, and high levels of healthcare utilization. Fortunately, 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. However, the clinical effectiveness of PE and CPT is hampered by high rates of treatment dropout. Recently published data show dropout rates ranging from 19-38% among Veterans. Little is known about Veterans' reasons for discontinuing these treatments. Prior research has focused on examining baseline characteristics associated with PE and CPT dropout and has failed to find consistent predictors. Further, emerging data suggest that knowledge regarding utilization of general PTSD services may not be directly applicable to PE and CPT, as Veterans who drop out of these treatments have been shown to use more mental health services in the subsequent year than Veterans who complete the treatment. These findings imply that precipitators of PE and CPT dropout are unique to the treatments. A comprehensive understanding of those reasons is needed to identify effective interventions aimed at reducing dropout. Objectives: The specific aims are to: 1) Understand reasons for premature dropout from PE and 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. Methods: Given the dearth of information regarding PE and CPT dropout and the complexity of treatment decisions, we propose to use qualitative methods to achieve these aims. Using Social Cognitive Theory as a framework, to achieve aim 1, we will conduct semi-structured interviews, with a national sample of Veterans who initiated but failed to complete PE or CPT. In order to ensure a full understanding of the range of reasons for dropout, we will stratify 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 will also be interviewed. In service of aim 2, we will conduct semi-structured interviews with completers of PE and CPT using a sampling strategy similar to that in Aim 1. Prior research suggests that those who successfully engage in mental health treatment have similar barriers to those who do not, but also have facilitators which enable engagement. Thus, Veterans will be 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 will utilize a modified Delphi method and intervention mapping strategies to develop an interventional framework to reduce PE and CPT dropout. Specifically, we will identify and interview 16 exemplary PE and CPT therapists and triangulate 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.