Hostname: page-component-586b7cd67f-rdxmf Total loading time: 0 Render date: 2024-11-20T07:01:08.493Z Has data issue: false hasContentIssue false
  • English
  • Français

Predictors of Treatment Discontinuation During Prolonged Exposure for PTSD

Published online by Cambridge University Press:  03 July 2017

Daniel F. Gros ,
Nicholas P. Allan ,
Cynthia L. Lancaster ,
Derek D. Szafranski  and
Ron Acierno
Daniel F. Gros*
Affiliation:
Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC 29401 and Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425
Nicholas P. Allan
Affiliation:
Department of Psychology, Ohio University, Porter Hall, Athens, OH
Cynthia L. Lancaster
Affiliation:
Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC 29401 and Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425
Derek D. Szafranski
Affiliation:
Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC 29401 and Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425
Ron Acierno
Affiliation:
Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC 29401 and College of Nursing, Medical University of South Carolina, Charleston, SC 29425
*
Correspondence to Daniel F. Gros, Mental Health Service 116, Ralph H. Johnson VAMC, 109 Bee Street, Charleston, SC 29401, USA. E-mail: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Background: Post-traumatic stress disorder (PTSD) is a highly prevalent and impairing condition for which there are several evidence-based psychotherapies. However, a significant proportion of patients fail to complete a ‘sufficient dose’ of psychotherapy, potentially limiting treatment gains. Aims: The present study investigated predictors of premature treatment discontinuation during a trial of prolonged exposure (PE) therapy for PTSD. Method: Combat veterans with PTSD were recruited to participate in a randomized clinical trial of PE delivered in person or via telehealth technologies. Of the 150 initial participants, 61 participants discontinued the trial before the completion of eight sessions (of an 8‒12 session protocol). Treatment condition (telehealth or in person) and factors identified by prior research (age, combat theatre, social support, PTSD symptoms) were tested as predictors of treatment discontinuation. Results: A Cox proportional hazards model (a subtype of survival analysis) was used to evaluate predictors of treatment discontinuation. Disability status and treatment condition were identified as significant predictors of discontinuation, with a noted disability and use of telehealth demonstrating higher risk. Conclusions: The present findings highlight the influence of telehealth and disability status on treatment discontinuation, while minimizing the role of the previously identified variables from studies with less sensitive analyses.

Keywords

PTSDdrop-outdiscontinuationveterantelehealthdisability
Type
Research Article
Information
Behavioural and Cognitive Psychotherapy , Volume 46 , Issue 1 , January 2018 , pp. 35 - 49
Creative Commons
This is a work of the U.S. Government and is not subject to copyright protection in the United States.
Copyright
Copyright © British Association for Behavioural and Cognitive Psychotherapies 2017

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Acierno, R., Knapp, R., Tuerk, P., Gilmore, A. K., Lejuez, C., Ruggiero, K. et al. (2017). A non-inferiority trial of prolonged exposure for post-traumatic stress disorder: in person versus home-based telehealth. Behaviour Research and Therapy, 89, 57–65.CrossRefGoogle ScholarPubMed
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (4th edition, text revision). Washington DC: American Psychiatric Association.Google Scholar
Babor, T. F., Higgins-Biddle, J. C., Saunders, J. B. and Monteiro, M. G. (2001). AUDIT: the Alcohol Use Disorders Identification Test guidelines for use in primary care. Geneva, Switzerland: World Health Organization.Google Scholar
Beck, A. T., Steer, R. A. and Brown, G. K. (1996). Manual for the Beck Depression Inventory-II. San Antonio: Psychological Corporation.Google Scholar
Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S. and Keane, T. M. (1995). The development of a clinician‐administered PTSD scale. Journal of Traumatic Stress, 8, 75–90.Google Scholar
Blanchard, E. B., Jones-Alexander, J., Buckley, T. C. and Forneris, C. A. (1996). Psychometric properties of the PTSD Checklist (PCL). Behaviour Research and Therapy, 34, 669–673.Google Scholar
Boscarino, J. A. (2004). Post-traumatic stress disorder and physical illness: results from clinical and epidemiologic studies. Annals of the New York Academy of Sciences, 1032, 141–153.CrossRefGoogle ScholarPubMed
Burriss, L., Ayers, E., Ginsberg, J. and Powell, D. A. (2008). Learning and memory impairment in PTSD: relationship to depression. Depression and Anxiety, 25, 149–157.Google Scholar
Clark, P. and Kimberly, C. (2014). Impact of fees among low-income clients in a training clinic. Contemporary Family Therapy, 36, 363–368.CrossRefGoogle Scholar
Duffy, M., Gillespie, K. and Clark, D. M. (2007). Post-traumatic stress disorder in the context of terrorism and other civil conflict in Northern Ireland: randomised controlled trial. British Medical Journal, 334, 1147–1150.Google Scholar
Dunn, B. E., Hongyung, C. and Almagro, A. (2000). Telepathology networking in VISN-12 of the Veterans Health Administration. Journal of Telemedicine and e-Health, 6, 349–354.Google Scholar
Ehlers, A., Grey, N., Wild, J., Stott, R., Liness, S., Deale, A. et al. (2013). Implementation of cognitive therapy for PTSD in routine clinical care: effectiveness and moderators of outcome in a consecutive sample. Behaviour Research and Therapy, 51, 742–752.Google Scholar
Erbes, C. R., Curry, K. T. and Leskela, J. (2009). Treatment presentation and adherence of Iraq/Afghanistan era veterans in outpatient care for posttraumatic stress disorder. Psychological Services, 6, 175–183.Google Scholar
First, M. B., Spitzer, R. L., Gibbon, M. and Williams, J. B. W. (1996). Structured Clinical Interview for DSM-IV Axis I Disorders – Clinician version (SCID-I/P, version 2.0). New York: New York Psychiatric Institute, Biometrics Research Department.Google Scholar
Foa, E. B., Hembree, E. A. and Rothbaum, B. O. (2007). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences, Therapist Guide. New York: Oxford University Press.Google Scholar
Foa, E. B., Keane, T. M., Friedman, M. J. and Cohen, J. A. (eds). (2008). Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. New York: Guilford Press.Google Scholar
Frueh, B. C., Grubaugh, A. L., Elhai, J. D. and Buckley, T. C. (2007). US Department of Veterans Affairs disability policies for posttraumatic stress disorder: administrative trends and implications for treatment, rehabilitation, and research. American Journal of Public Health, 97, 2143–2145.Google Scholar
Garcia, H. A., Kelley, L. P., Rentz, T. O. and Lee, S. (2011). Pretreatment predictors of dropout from cognitive behavioral therapy for PTSD in Iraq and Afghanistan war veterans. Psychological Services, 8, 1–11.CrossRefGoogle Scholar
Goetter, E. M., Bui, E., Ojserkis, R. A., Zakarian, R. J., Weintraub Brendel, R. and Simon, N. M. (2015). A systematic review of dropout from psychotherapy for posttraumatic stress disorder among Iraq and Afghanistan combat veterans. Journal of Traumatic Stress, 28, 1–9.CrossRefGoogle ScholarPubMed
Gradus, J. L., Qin, P., Lincoln, A. K., Miller, M., Lawler, E., Sørensen, H. T. and Lash, T. L. (2010). Post-traumatic stress disorder and completed suicide. American Journal of Epidemiology, 171, 721–727.Google Scholar
Gros, D. F., Lancaster, C. L., López, C. M. and Acierno, R. (2017). Treatment satisfaction of home-based telehealth versus in-person delivery of prolonged exposure for combat-related PTSD in veterans. Journal of Telemedicine and Telecare. doi: 10.1177/1357633X16671096 Google Scholar
Gros, D. F., Magruder, K. M., Ruggiero, K. J., Shaftman, S. R. and Frueh, B. C. (2012). Comparing the symptoms of posttraumatic stress disorder with the distress and fear disorders. Journal of Nervous and Mental Disease, 200, 967–972.CrossRefGoogle ScholarPubMed
Gros, D. F., Morland, L. A., Greene, C. J., Acierno, R., Strachan, M., Egede, L. E. et al. (2013a). Delivery of evidence-based psychotherapy via video telehealth. Journal of Psychopathology and Behavioral Assessment, 35, 506–521.Google Scholar
Gros, D. F., Price, M., Yuen, E. K. and Acierno, R. (2013b). Predictors of completion of exposure therapy in OEF/OIF veterans with posttraumatic stress disorder. Depression and Anxiety, 30, 1107–1113.CrossRefGoogle ScholarPubMed
Gros, D. F., Tuerk, P. W., Yoder, M. and Acierno, R. (2011a). Post-traumatic stress disorder. In M. Hersen and J. C. Thomas (eds), Handbook of Clinical Psychology Competencies, Volume II: Intervention and Treatment for Adults (pp. 785–809). New York: Springer.Google Scholar
Gros, D. F., Yoder, M., Tuerk, P. W., Lozano, B. E. and Acierno, R. (2011b). Exposure therapy for PTSD delivered to veterans via telehealth: predictors of treatment completion and outcome. Behavior Therapy, 42, 276–283.Google Scholar
Jensen, S. A. and Lowry, L. S. (2012). Payment schedules do not affect attendance/completion of group behavioral parent training. Psychological Services, 9, 101–109.Google Scholar
Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M. and Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM‐IV and DSM‐5 criteria. Journal of Traumatic Stress, 26, 537–547.Google Scholar
King, L. A., King, D. W., Vogt, D. S., Knight, J. and Samper, R. E. (2006a). Deployment Risk and Resilience Inventory: a collection of measures for studying deployment-related experiences of military personnel and veterans. Military Psychology, 18, 89–120.Google Scholar
King, D. W., Taft, C., King, L. A., Hammond, C. and Stone, E. R. (2006b). Directionality of the association between social support and posttraumatic stress disorder: a longitudinal investigation. Journal of Applied Social Psychology, 36, 2980–2992.Google Scholar
Kuhn, E., Kanuri, N., Hoffman, J. E., Garvert, D. W., Ruzek, J. I. and Taylor, C. B. (2017). A randomized controlled trial of a smartphone app for posttraumatic stress disorder symptoms. Journal of Consulting and Clinical Psychology, 85, 267–273.Google Scholar
McCauley, J. L., Killeen, T., Gros, D. F., Brady, K. T. and Back, S. E. (2012). Post-traumatic stress disorder and co-occurring substance use disorders: advances in assessment and treatment. Clinical Psychology: Science and Practice, 19, 283–304.Google Scholar
Miller, W. R. and Rollnick, S. (2012). Motivational interviewing: Helping people change. New York: Guilford Press.Google Scholar
Miller, M. W., Wolf, E. J., Kilpatrick, D., Resnick, H., Marx, B. P., Holowka, D. W. et al. (2013). The prevalence and latent structure of proposed DSM-5 posttraumatic stress disorder symptoms in US national and veteran samples. Psychological Trauma: Theory, Research, Practice and Policy, 5, 501–512.Google Scholar
Monson, C. M., Taft, C. T. and Fredman, S. J. (2009). Military-related PTSD and intimate relationships: from description to theory-driven research and intervention development. Clinical Psychology Review, 29, 707–714.Google Scholar
Morland, L. A., Mackintosh, M. A., Greene, C. J., Rosen, C. S., Chard, K. M. and Resick, P. (2014). Cognitive processing therapy for posttraumatic stress disorder delivered to rural veterans via telemental health: a randomized noninferiority clinical trial. Journal of Clinical Psychiatry, 75, 470–476.Google Scholar
Muthén, B. and Masyn, K. (2005). Discrete-time survival mixture analysis. Journal of Educational and Behavioral Statistics, 30, 27–58.Google Scholar
Muthén, L. K. and Muthén, B. O. (2012). Mplus User's Guide, 7th edition. Los Angeles, CA: Muthén and Muthén.Google Scholar
Orsillo, S. (2002). Measures for acute stress disorder and posttraumatic stress disorder. In M. M. Antony, S. Orsillo and L. Roemer (eds), Practitioner's Guide to Empirically Based Measures of Anxiety (pp. 255–307). New York: Kluwer Publications.Google Scholar
Otis, J. D., Keane, T. M. and Kerns, R. D. (2003). An examination of the relationship between chronic pain and post-traumatic stress disorder. Journal of Rehabilitation Research and Development, 40, 397 406.Google Scholar
Price, M. and Gros, D. F. (2014). Examination of prior experience with telehealth and comfort with telehealth technology as a moderator of treatment response for PTSD and depression in veterans. International Journal of Psychiatry in Medicine, 48, 57–67.Google Scholar
Resick, P. A., Monson, C. M. and Chard, K. M. (2007). Cognitive Processing Therapy: Veteran/Military Version. Department of Veterans’ Affairs: Washington, DC. Google Scholar
Sabesan, S., Allen, D., Caldwell, P., Loh, P. K., Mozer, R., Komesaroff, P. A. et al. (2014). Practical aspects of telehealth: doctor–patient relationship and communication. Internal Medicine Journal, 44, 101–103.Google Scholar
Schottenbauer, M. A., Glass, C. R., Arnkoff, D. B., Tendick, V. and Gray, S. H. (2008). Non-response and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry: Interpersonal and Biological Processes, 71, 134–168.Google Scholar
Schnurr, P. P., Lunney, C. A., Bovin, M. J. and Marx, B. P. (2009). Post-traumatic stress disorder and quality of life: extension of findings to veterans of the wars in Iraq and Afghanistan. Clinical Psychology Review, 29, 727–735.Google Scholar
Seal, K. H., Abadjian, L., McCamish, N., Shi, Y., Tarasovsky, G. and Weingardt, K. (2012). A randomized controlled trial of telephone motivational interviewing to enhance mental health treatment engagement in Iraq and Afghanistan veterans. General Hospital Psychiatry, 34, 450–459.Google Scholar
Shapiro, F. and Solomon, R. M. (1995). Eye Movement Desensitization and Reprocessing. New York, NY: Guilford Press.Google Scholar
Singer, J. D. and Willett, J. B. (2003). Applied Longitudinal Data Analysis: Modeling Change and Event Occurrence. New York, NY: Oxford University Press.Google Scholar
Singer, J. D. and Willett, J. B. (1993). It's about time: using discrete-time survival analysis to study duration and timing of events. Journal of Educational Statistics, 18, 155–195.Google Scholar
Skinner, H. A. (1982). The Drug Abuse Screening Test. Addictive Behavior, 7, 363–371.Google Scholar
Tanielian, T. and Jaycox, L. H. (2008). Invisible wounds of war: psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND.Google Scholar
Strachan, M., Gros, D. F., Yuen, E., Ruggiero, K. J., Foa, E. B. and Acierno, R. (2012). Home-based telehealth to deliver evidence-based psychotherapy in veterans with PTSD. Contemporary Clinical Trials, 33, 402–409.Google Scholar
Szafranski, D. D., Smith, B. N., Gros, D. F. and Resick, P. A. (2016). High rates of PTSD treatment dropout: a possible red herring? Journal of Anxiety Disorders, 47, 91–98.Google Scholar
Szafranski, D. D., Gros, D. F., Norton, P. J., Menefee, D. and Wanner, J. (2016). Treatment adherence: an examination of why OEF/OIF/OND Veterans discontinue inpatient PTSD treatment. Military Behavioral Health, 4, 25–31.Google Scholar
Szafranski, D. D., Gros, D. F., Wanner, J., Menefee, D. and Norton, P. J. (2014). Predictors of length of stay among OEF/OIF/OND Veteran inpatient PTSD non-completers. Psychiatry: Interpersonal and Biological Processes, 77, 263–274.Google Scholar
Trott, P. and Blignault, I. (1998). Cost evaluation of a telepsychiatry service in northern Queensland. Journal of Telemedicine and Telecare, 4, 66–68.Google Scholar
Tuerk, P. J., Yoder, M., Ruggiero, K. J., Gros, D. F. and Acierno, R. (2010). Open trial of prolonged exposure for post-traumatic stress disorder delivered via telehealth technology. Journal of Traumatic Stress, 23, 116–123.Google Scholar
Vogt, D. S., Proctor, S. P., King, D. W., King, L. A. and Vasterling, J. J. (2008). Validation of scales from the Deployment Risk and Resilience Inventory in a sample of Operation Iraqi Freedom veterans. Assessment, 15, 391–403.Google Scholar
Wangelin, B. C., Szafranski, D. D. and Gros, D. F. (2016). Telehealth technologies in evidence-based psychotherapy. In J. K. Lioselli and A. J. Fisher (eds), Computer-Assisted and Web-Based Innovations in Psychology (pp. 119–140). New York: Elsevier.Google Scholar
Wild, J., Warnock-Parkes, E., Grey, N., Stott, R., Wiedemann, M., Canvin, L. et al. (2016). Internet-delivered cognitive therapy for PTSD: a development pilot series. European Journal of Psychotraumatology, 7, doi: 10.3402/ejpt.v7.31019.Google Scholar
Yuen, E., Gros, D. F., Price, M., Zeigler, S., Tuerk, P. W., Foa, E. B. and Acierno, R. (2015). Randomized controlled trial of home-based telehealth versus in-person prolonged exposure for combat-related PTSD in Veterans: preliminary results. Journal of Clinical Psychology, 71, 500–512.Google Scholar
Zanarini, M. C. and Frankenburg, F. R. (2001). Attainment and maintenance of reliability of axis I and axis II disorders over the course of a longitudinal study. Comprehensive Psychiatry, 42, 369–374.Google Scholar
Submit a response

Comments

No Comments have been published for this article.