About a quarter of U.S. service members and veterans who start psychotherapy for post-traumatic stress disorder (PTSD) quit before they finish treatment, according to a recent study, with experts pushing for more effective long-term approaches to sustain mental health treatments.
The study, titled “The Protocol Matters: A Meta-analysis of Psychotherapy Dropout from Specific PTSD Treatment Approaches in U.S. Service Members and Veterans,” was published in mid-November in the journal Psychological Trauma: Theory, Research, Practice, and Policy through the American Psychological Association.
It examined treatment methodologies for the approximate 7% of veterans affected by PTSD, per the Department of Veterans Affairs, which represents a number slightly higher than the general adult population. Veterans are disproportionately affected by risks of stroke and heart disease, according to the American Heart Association.
The approximate 7% of veterans affected by PTSD represents a number slightly higher than the general adult population.
Elizabeth A. Penix-Smith, of Idaho State University, is the study’s lead author and also a National Research Council fellow at the Walter Reed Army Institute of Research.
“Every veteran and service member who seeks treatment for PTSD deserves quality care that helps them heal and meet their treatment goals,” Penix-Smith told Military.com. “To this end, there have been enormous strides in improving the accessibility of effective treatments for PTSD.
“Yet, many of these treatments ask clients to relive aspects of the worst moments of their lives and there has been emerging evidence that suggests that some of these approaches might be especially difficult for some veterans and service members to complete. So, we felt that having a systematic, comprehensive understanding of how frequently dropout was occurring across different PTSD treatments was an important next step in better understanding and improving care for military populations.”
The views expressed through the study are those of the authors and should not be construed to represent the positions of the U.S. Army or the Department of Defense.
Program Types Matter
Penix-Smith said the study involved meta-analytic methods to obtain average dropout rates, which involved systematic reviews of more than 34,000 titles and abstracts to search for relevant studies pertaining to the subject matter.
She and study co-author, Joshua Swift, also of Idaho State University, identified 181 articles that included dropout data from 124,092 veterans and service members initiating PTSD treatment. After averaging the dropout rates across all the individual studies, they found it resulted in a weighted dropout rate of 25.6% for overall PTSD treatments—a dropout rate for PTSD treatments that is fairly consistent with other meta-analyses.
“Previous research suggests that treatments that ask clients to relive aspects of their trauma might yield higher dropout rates than protocols that do not include these elements,” Penix-Smith said. “So, we were surprised by how nuanced this actually was when you look at dropout rates across individual treatments.”
She and Swift discovered that the lowest dropout rates were among trauma-focused intensive outpatient programs, where weekly formats of some trauma-focused approaches yielded relatively low dropout rates—such as 6.9% for group-based exposure therapy. Other non-trauma focused protocols had somewhat higher dropout rates, including 30.6% for psychoeducation interventions.
“The variability between dropout rates for individual protocols was especially interesting since this variability did not neatly fit into expectations that some groups of protocols would generally have higher or lower dropout rates,” Penix-Smith said. “This nuance is exciting, though, because it allows us to take a second look at what might be happening within these protocols that is potentially protective against dropout and see whether these elements could be used as dropout prevention strategies in the future.”
Dropout Rate Influences Are Iffy
There are disparities in terms of the different therapeutic approaches undertaken by veterans and service members with PTSD, such as weekly trauma-focused approaches like cognitive processing therapy and prolonged exposure having the highest dropout rates while present-centered therapy and mindfulness-based stress reduction showed lower dropout rates.
Penix-Smith said that due to the way PTSD treatments were initially developed, it’s difficult to pinpoint a specific explanation for why certain forms of therapy work and retain attention more consistently while others do not.
The difficulty stems from treatments being packaged in a way where a given PTSD treatment may include elements that are shared with other treatments but also includes elements unique to that treatment protocol, she said.
“Without being able to systematically isolate and evaluate dropout rates from individual treatment elements, this makes it challenging to precisely identify what about a specific treatment might be driving high or low dropout rates,” she said. “This is also a complicated challenge because there may be some groups of veterans and service members who benefit from some treatments but not others.
“Based on findings from our study, it’s also possible that there are factors that also influence dropout beyond just the protocol itself, such as whether the treatment uses an intensive treatment format or explicitly targets comorbid substance use.”
Maintaining, Improving Access 'Critical'
Penix-Smith said that improving such outcomes could be aided by systems and clinics offering diverse sets of effective treatments that in turn can empower therapists and clients to select the treatment—meeting clients where they are.
Improving outcomes also relies on improved access to evidence-based treatments that yield lower dropout rates, such as indicated in the study, which may include intensive outpatient programs for prolonged exposure therapy and cognitive processing therapy.
But access to such programs can be quite challenging for veterans and service members to access, she said, especially in rural areas.
Some treatments and products are developed by the Walter Reed Army Institute of Research (WRAIR), which is in tune with the mental health needs of service members. WRAIR’s Dropout Reduction in Outpatient Psychotherapy training decreased dropout rates by teaching therapists skills for improving and measuring progress during treatment.
Testing interventions that assist clients and therapists with identifying treatments that veterans are more likely to complete, such as therapist training, decision-making aids, and using technologies like machine learning, show a “promising” trajectory, Penix-Smith said.
Current protocols are still necessary and result in evidence-based, effective, and meaningful changes, she added. But moving forward, further investment in program identification and matching individuals with the most potent treatment programs could lead to better outcomes—not to mention continued investment in an era where health care costs can become huge financial burdens.
“Policymakers and administrators will have a critical role in creating an environment where these skills and interventions are clearly prioritized, such as protecting therapist time for related training opportunities,” Penix-Smith said.
