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）和认知加工治疗（CPT）的辍学率，提高退伍军人从创伤后应激障碍（PTSD）中恢复的比率。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PTSD的成本，并减少对PTSD服务的长期需求。该项目高度响应我们的业务合作伙伴，心理健康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。背景资料：如果不进行治疗，PTSD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治疗显着降低了与PTSD相关的成本和痛苦。PE或CPT的完成导致PTSD症状的大量和临床显著减少，多达一半的退伍军人失去了他们的PTSD诊断。然而，PE和CPT的临床有效性受到高治疗脱落率的阻碍。最近公布的数据显示，退伍军人的辍学率在19-38%之间。很少有人知道退伍军人停止这些治疗的原因。先前的研究集中于检查与PE和CPT脱落相关的基线特征，未能找到一致的预测因子。此外，新出现的数据表明，关于利用一般PTSD服务的知识可能不直接适用于PE和CPT，因为退出这些治疗的退伍军人在随后的一年中使用的心理健康服务比完成治疗的退伍军人更多。这些发现意味着PE和CPT脱落的沉淀剂是治疗所独有的。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。目的：具体目标是：1）从患者和提供者的角度了解PE和CPT过早脱落的原因，2）确定积极促进PE和CPT完成的因素，3）制定可用于改善PE和CPT保留的干预框架。研究方法：由于缺乏有关PE和CPT辍学的信息和治疗决策的复杂性，我们建议使用定性方法来实现这些目标。使用社会认知理论作为框架，以实现目标1，我们将进行半结构化访谈，与全国样本的退伍军人谁发起，但未能完成PE或CPT。为了确保全面了解脱落原因的范围，我们将按服务时代、性别和治疗方式（PE与CPT）对样本进行分层，并特意按人种/种族和脱落时间进行采样。为了了解提供者对退伍军人辍学的看法，也将采访退伍军人辍学的PE和CPT治疗师。为了实现目标2，我们将采用与目标1类似的抽样策略，对完成体育和CPT的学生进行半结构化访谈。先前的研究表明，那些成功地参与心理健康治疗的人与那些没有参与的人有类似的障碍，但也有促进参与的促进者。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在这些挑战下完成治疗的因素。最后，为了完成目标3，我们将利用修改后的德尔菲方法和干预映射策略来开发一个干预框架，以减少PE和CPT脱落。具体来说，我们将确定和采访16个示范PE和CPT治疗师和三角他们的专家意见与相关的理论和实证研究结果，以制定干预框架，将：1）对辍学的沉淀物进行干预，2）加强完成的促进者，和3）提供监督策略，以培训PE和CPT治疗师如何最大限度地减少退伍军人治疗辍学。

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.