1
|
Cooper AA, Kline AC, Baier AL, Feeny NC. Rethinking Research on Prediction and Prevention of Psychotherapy Dropout: A Mechanism-Oriented Approach. Behav Modif 2023; 47:1195-1218. [PMID: 30079755 DOI: 10.1177/0145445518792251] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Dropout is a ubiquitous psychotherapy outcome in clinical practice and treatment research alike, yet it remains a poorly understood problem. Contemporary dropout research is dominated by models of prediction that lack a strong theoretical foundation, often drawing on data from clinical trials that report on dropout in an inconsistent and incomplete fashion. In this article, we assert that dropout is a critical treatment outcome that is worthy of investigation as a mechanistic process. After briefly describing the scope of the dropout problem, we discuss the many factors that limit the field's present understanding of dropout. We then articulate and illustrate a transdiagnostic conceptual framework for examining psychotherapy dropout in contemporary research, concluding with recommendations for future research. With a more comprehensive understanding of the factors affecting retention, research efforts can shift toward investigating key processes underlying treatment dropout, thus, boosting prediction and informing strategies to mitigate dropout in clinical practice.
Collapse
|
2
|
Stoycos SA, Berzenski SR, Beck JG, Unger W, Cappellano JM, Spofford CM, Sloan DM. Predictors of treatment completion in group psychotherapy for male veterans with posttraumatic stress disorder. J Trauma Stress 2023; 36:346-358. [PMID: 36782378 PMCID: PMC10101887 DOI: 10.1002/jts.22915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 12/13/2022] [Accepted: 12/13/2022] [Indexed: 02/15/2023]
Abstract
Group therapy is a frequently used therapy format for posttraumatic stress disorder (PTSD). However, factors contributing to treatment completion remain understudied. The current study examined predictors of treatment completion, defined as having completed 10 out of 14 sessions within 16 weeks, in veterans with PTSD who engaged in a hybrid efficacy-effectiveness randomized controlled trial of group psychotherapy for PTSD. Veterans (N = 198) were randomly assigned to 14 sessions of either group cognitive behavioral treatment (GBCT; n = 98) or group present-centered treatment (GPCT; n = 100). Four primary domains of predictors were examined, encompassing sociodemographic factors, the severity of PTSD and comorbid conditions, modifiable predictors, and treatment condition. Multilevel binomial logistic regression models following the Fournier analysis approach were used to examine significant predictors within domains, which were then included in a final model. Overall, 70.7% of participants completed treatment (GCBT = 61.6%, GPCT = 79.8%). Participants in the GPCT condition were 2.389 times, 95% CI [1.394, 4.092], more likely to complete treatment than those in the GCBT condition. Older age, a higher income and level of educational attainment, more lifetime and current mental health diagnoses, and higher use of positive reappraisal ER skills predicted treatment completion. Higher levels of depressive symptoms, cumulative trauma burden, and use of positive refocusing ER skills predicted treatment noncompletion. These findings are discussed in the context of current clinical and research practices for examining treatment noncompletion, with attention to the inclusion of translational predictors.
Collapse
Affiliation(s)
- Sarah A Stoycos
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Sara R Berzenski
- Department of Psychology, California State University Northridge, Northridge, California, USA
| | - J Gayle Beck
- Department of Psychology, University of Memphis, Memphis, Tennessee, USA
| | - William Unger
- VA Providence Medical Center, Providence, Rhode Island, USA
| | | | - Christopher M Spofford
- Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Denise M Sloan
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| |
Collapse
|
3
|
Karel MJ, Wray LO, Adler G, Hannum AOR, Luci K, Brady LA, McGuire MH. Mental Health Needs of Aging Veterans: Recent Evidence and Clinical Recommendations. Clin Gerontol 2022; 45:252-271. [PMID: 31971092 DOI: 10.1080/07317115.2020.1716910] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objectives: Large numbers of older Americans have a history of military service, which may be positively or negatively associated with mental health in late life. We reviewed literature with the aim of better understanding the mental health needs of older Veterans.Methods: Articles included those published in 2009-2018 and focused on prevalence/risk for mental illness and suicide among older Veterans; utilization of mental health services; effectiveness of evidence-based behavioral treatments; and pertinent care delivery models.Results: Older Veterans are generally resilient. A significant minority experience mental health concerns that are associated with poor outcomes including a substantial number of suicides. Most published research is based on the approximately one third of Veterans who use the Veterans Health Administration (VHA) for care. Older Veterans with mental health diagnoses are less likely to utilize mental health services compared to younger Veterans, but as likely to benefit once engaged. Integrated care models in primary and geriatric care settings are promising.Conclusions: Aging Veterans are a large subset of Americans whose mental health needs are complex and deserve attention.Clinical Implications: Clinicians should ask about history of military service (i.e., Veteran status) and utilize available resources when providing care for older Veterans.
Collapse
Affiliation(s)
- Michele J Karel
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs (VA) Central Office, Washington, DC, United States
| | - Laura O Wray
- VA Center for Integrated Healthcare, VA Western New York Health Care System, Buffalo, New York, United States.,Jacobs School of Medicine and Biomedical Sciences, SUNY University at Buffalo, Buffalo, New York, United States
| | - Geri Adler
- VA South Central Mental Illness Research, Education, and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, Texas, United States
| | - Alisa O' Riley Hannum
- Mental Health Service, VA Eastern Colorado Healthcare System, Colorado Springs, Colorado, United States
| | - Katherine Luci
- Center for Aging and Neurocognitive Services, Salem VA Medical Center, Salem, Virginia, United States.,Department of Psychiatry and Behavioral Medicine, Virginia Tech Carilion School of Medicine, Blacksburg, Virginia, United States
| | - Laura A Brady
- Jacobs School of Medicine and Biomedical Sciences, SUNY University at Buffalo, Buffalo, New York, United States
| | - Marsden H McGuire
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs (VA) Central Office, Washington, DC, United States
| |
Collapse
|
4
|
Doran JM, O'Shea M, Harpaz-Rotem I. In Their Own Words: Veteran Experiences with Evidence-Based Treatments for PTSD in the Veterans Health Administration. Psychiatr Q 2021; 92:961-980. [PMID: 33409926 DOI: 10.1007/s11126-020-09861-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2020] [Indexed: 11/29/2022]
Abstract
The aim of the present study was to increase the understanding of veteran experiences with receiving an evidence-based psychotherapy (EBPs) for PTSD (Cognitive Processing Therapy and Prolonged Exposure therapy) in the Veterans Affairs Healthcare System (VA). Eighteen veterans who participated in the study were being seen in the outpatient PTSD clinic at a New England VA and had elected to participate in an EBP. The study assessed veteran experiences with, and outcomes from, treatment through the use of both quantitative and qualitative assessment tools. A rigorous data analytic approach, Consensual Qualitative Research, was applied to narrative data. Results fell into seven domains: Previous EBP & Outcome, Barriers to Treatment, Treatment Process, Treatment Outcome, Treatment Drop Out, and Feelings about Treatment. Overall, veterans reported diverse reactions to the EBPs for PTSD and identified both positive and negative aspects of the treatments. They identified multiple barriers to treatment completion and provided insight into their thoughts and feelings during the treatment protocol. Veterans who chose to drop out of treatment prematurely identified the factors that contributed to this decision. In this way, the study offers an initial but important look at veteran perceptions of and experiences with EBPs for PTSD.
Collapse
Affiliation(s)
- Jennifer M Doran
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, USA. .,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
| | - McKenna O'Shea
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, USA.,Roosevelt University, Chicago, IL, USA
| | - Ilan Harpaz-Rotem
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.,Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, CT, USA
| |
Collapse
|
5
|
Farmer CC, Rossi FS, Michael EM, Kimerling R. Psychotherapy Utilization, Preferences, and Retention among Women Veterans with Post-traumatic Stress Disorder. Womens Health Issues 2020; 30:366-373. [PMID: 32680627 DOI: 10.1016/j.whi.2020.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 05/18/2020] [Accepted: 06/05/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Psychotherapy is the gold standard treatment for post-traumatic stress disorder (PTSD), yet psychotherapy use and retention among veterans is low. Little is known about the barriers to care and factors associated with women veterans' PTSD psychotherapy use and retention. Using a nationally representative sample of 986 women Veterans Health Administration primary care users with PTSD and a perceived need for mental health care, we examined 1) the proportion of women who used psychotherapy, 2) retention in psychotherapy among women who used any psychotherapy, and 3) individual factors related to psychotherapy use and retention. METHODS Women completed a survey on their mental health care experiences. Outpatient mental health care use in the year before the survey was obtained from Veterans Health Administration administrative data. RESULTS Most women (79.1%) used psychotherapy, and 41.7% of those women had a minimal therapeutic dose of psychotherapy (≥8 visits). Mental health diagnostic comorbidity and being African American/Black or identifying as neither African American/Black nor White were significantly associated with higher psychotherapy use. Mental health diagnostic comorbidity, exposure to military sexual trauma, and receiving treatment aligned with gender-related and group-related preferences were associated with higher psychotherapy retention. Being a parent was associated with lower retention. CONCLUSIONS Although a significant proportion of women veterans with PTSD are using psychotherapy, retention is enhanced when women are able to obtain treatment aligned with their preferences. Thus, efforts to promote patient-centered, shared decisions regarding mental health treatment options could increase the efficacy and efficiency of treatment for PTSD among women.
Collapse
Affiliation(s)
- Courtney C Farmer
- PGSP-Stanford Psy.D. Consortium, Palo Alto University, Palo Alto, California
| | - Fernanda S Rossi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California; Center for Primary Care and Outcomes Research and Center for Health Policy, Stanford University School of Medicine, Palo Alto, California
| | - Elizabeth M Michael
- PGSP-Stanford Psy.D. Consortium, Palo Alto University, Palo Alto, California
| | - Rachel Kimerling
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California; National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California.
| |
Collapse
|