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

描述(由申请人提供)： 影响：该项目的长期目标是通过降低长期暴露(PE)和认知处理疗法(CPT)的辍学率，提高退伍军人从创伤后应激障碍(PTSD)中的恢复率。降低辍学率将对退伍军人的健康和福祉产生积极影响，降低治疗创伤后应激障碍的成本，并减少对创伤后应激障碍服务的长期需求。该项目高度响应了我们的业务合作伙伴、精神卫生服务办公室和国家创伤后应激障碍中心的需求，并解决了部署后心理和行为健康的HSR&D优先领域。背景：如果不进行治疗，创伤后应激障碍通常是慢性的，并与功能障碍、医疗发病率和高水平的医疗保健利用有关。幸运的是，PE或CPT治疗显著减少了与创伤后应激障碍相关的费用和痛苦。完成PE或CPT后，PTSD症状大幅减少，临床上显著减少，多达一半的退伍军人失去了PTSD的诊断。然而，PE和CPT的临床疗效因高的治疗丢失率而受到阻碍。最近公布的数据显示，退伍军人的辍学率从19%到38%不等。人们对退伍军人停止这些治疗的原因知之甚少。先前的研究集中于检查与PE和CPT辍学相关的基线特征，但未能找到一致的预测因素。此外，新出现的数据表明，关于一般创伤后应激障碍服务利用的知识可能不直接适用于PE和CPT，因为已经证明，退出这些治疗的退伍军人在接下来的一年里使用的心理健康服务比完成治疗的退伍军人更多。这些发现表明，PE和CPT脱落的沉淀物是治疗所特有的。需要全面了解这些原因，以确定旨在减少辍学的有效干预措施。目标：具体目的是：1)从患者和提供者的角度了解PE和CPT过早退学的原因；2)确定积极促进PE和CPT完成的因素；3)开发可用于改善PE和CPT保留率的干预框架。方法：由于缺乏有关PE和CPT退出的信息，以及治疗决策的复杂性，我们建议使用定性方法来实现这些目标。以社会认知理论为框架，为达到目标1，我们将进行半结构式访谈，对全国范围内发起但未能完成体育或CPT的退伍军人进行访谈。为了确保充分了解辍学的各种原因，我们将按服役时代、性别和治疗方式(PE与CPT)对样本进行分层，并有目的地以种族/民族和辍学时间为样本。为了了解提供者对退伍军人的看法，退伍军人的PE和CPT治疗师也将接受采访。在服务于目标2的过程中，我们将使用类似于目标1的抽样策略，对完成PE和CPT的人进行半结构化访谈。先前的研究表明，那些成功地从事心理健康治疗的人与那些没有从事精神健康治疗的人有类似的障碍，但也有促进者能够参与。因此，退伍军人将被问及他们在PE和CPT期间遇到的困难，以及使他们能够完成治疗的因素，尽管这些挑战。最后，为了完成目标3，我们将利用改进的Delphi方法和干预映射策略来开发一个干预框架，以减少PE和CPT的退出。具体地说，我们将确定并采访16名模范PE和CPT治疗师，并将他们的专家意见与相关理论和实证研究结果进行三角整合，以制定干预框架，该框架将：1)干预辍学的诱因；2)加强完成治疗的促进者；3)提供监督策略，培训PE和CPT治疗师如何最大限度地减少退学治疗。

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.