Client-level predictors of treatment engagement, outcome and dropout: moving beyond demographics

Abstract

BackgroundDespite the availability of evidence-based treatments for posttraumatic stress disorder (PTSD), significant heterogeneity in the effectiveness of PTSD treatment persists, especially in community settings. Client demographics used to understand this variability in treatment outcome and dropout have yielded mixed results. Despite increasing evidence for the importance of attending to treatment engagement in community settings, few studies have explored client-level predictors.AimThe purpose of this study is to explore client-level predictors of treatment outcome and dropout beyond client demographics, and to identify client-level predictors of treatment engagement in community settings.MethodSecondary data analysis was conducted with data collected as part of an implementation-effectiveness hybrid study of cognitive processing therapy (CPT) for PTSD in a diverse community health centre. Providers (n=19) treated (n=52) clients as part of their routine clinical care. Non-demographic client-level predictors included barriers to treatment, quality of life, session-level language and employment history assessed at baseline. Treatment engagement included number of weeks in the study, number of sessions with repeated CPT content, number of unique CPT sessions attended, frequency of session attendance and consistency of session attendance.ResultsResults showed language as a significant predictor of treatment engagement. There were significant differences between Spanish and English-speaking clients, with the former having a tendency to repeat more session content than the latter (β=1.4 sessions, p=0.003), and also less likely to attend treatment frequently (r=0.62, p=0.009) and consistently (r=0.57, p=0.027) if high logistical and financial barriers were endorsed. Irrespective of language, clients who reported high quality of life at baseline were less likely to repeat CPT session content (β=−0.3, p=0.04), and those with increased baseline barriers to treatment had deceleration in PTSD symptom improvement over time (β=−0.62, p<0.05). In terms of treatment engagement moderators impacting treatment outcome, clients who repeated more session content were more likely to complete treatment (OR=1.84, p=0.037).ConclusionIdentification of client-level predictors of treatment engagement, outcome and dropout is essential to optimise treatment, particularly in community settings.

Divergent experiences of U.S. veterans who did and did not complete trauma-focused therapies for PTSD: A national qualitative study of treatment dropout

“…Similarly, Larsen et al (2020) did not find that within treatment symptom increase predicted CPT dropout ( Larsen et al, 2020 ). In examining treatment process variables, Youn et al (2019) found that repeating treatment content during CPT to meet patient needs predicted treatment completion. While these quantitative studies examining potentially modifiable processes have furthered the literature on PE/CPT engagement, one-off findings without replication across studies continue to be the norm, and thus far, effective interventions for improving PE/CPT completion have remained elusive ( Kehle-Forbes & Kimerling, 2017 ).…”

What got in the way? Caregiver-reported challenges to home practice of assigned intervention skills

“…Finally, caregivers in our Spanish intervention groups reported overall challenges and daily stresses less frequently than those in English groups. Qualitative accounts often suggest that EBIs are less acceptable and feasible with non-English delivery and that non-English-speaking participants are less engaged ( Barrera et al, 2017 ; Youn et al, 2019 ). This was not the case for Bridges, which was initially developed for Mexican-heritage families ( Gonzales et al, 2012 ), suggesting EBIs specifically designed for cultural groups are engaging for the target families.…”

Treatment-related beliefs and reactions among trauma-focused therapy completers and discontinuers: A qualitative examination.

“…It is important to move beyond demographic characteristics and baseline symptom characteristics when examining predictors of PTSD treatment outcomes (Cooper et al, 2023; Rubel et al, 2017; Youn et al, 2019) and instead focus on identifying processes occurring during treatment that relate to outcomes. Such processes may be malleable and can serve as intervention targets to improve retention in care and symptom response.…”