Cognitive Processing Therapy for Veterans with Posttraumatic Stress Disorder: What is the Median Effective Dose?

Holder, Nicholas; Shiner, Brian; Li, Yongmei; Madden, Erin; Neylan, Thomas C.; Seal, Karen H.; Lujan, Callan; Patterson, Olga V.; DuVall, Scott L.; Maguen, Shira

doi:10.1016/j.jad.2020.04.030

Cited by 15 publications

(7 citation statements)

References 36 publications

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“…This finding matched previous research that has highlighted the crucial role of homework in establishing self-efficacy for using skills learned in psychotherapy (Jensen et al, 2020). Of the 581 Veterans who initiated treatment, 59% did not complete the recommended minimum dosage of eight sessions (Holder et al, 2020;Sripada et al, 2020), with findings being consistent with previous literature suggesting increased dropout rates for PTSD treatments among Veteran populations (Maguen et al, 2019). While Veterans attending sessions via VVC presented with slightly higher symptom scores initially, Veterans who engaged in clinic-to-clinic telehealth sessions while at a CBOC proved more likely to drop out of treatment compared to both other treatment modalities.…”

Section: Discussionsupporting

confidence: 85%

“…Attrition was defined as ending treatment prior to optimal benefit. While the 2017 Clinical Practice Guideline for the Treatment of PTSD (American Psychological Association, 2017) previously suggested that, on average, 12–20 sessions were required for 50% of patients to recover as indicated by self-reported symptom measures, and a growing number of studies have suggested symptom change within the first eight sessions is highly predictive of subsequent change and has suggested this as an adequate dosage for treatment (Holder et al, 2020; Sripada et al, 2020). Treatment completion was therefore defined as Veterans completing a minimum of eight sessions of PE and/or CPT.…”

Section: Methodsmentioning

confidence: 99%

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PTSD telehealth treatments for veterans: Comparing outcomes from in-person, clinic-to-clinic, and home-based telehealth therapies.

Knowlton¹,

Nelson²

2021

Journal of Rural Mental Health

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Section: Discussionsupporting

confidence: 85%

Section: Methodsmentioning

confidence: 99%

PTSD telehealth treatments for veterans: Comparing outcomes from in-person, clinic-to-clinic, and home-based telehealth therapies.

Knowlton¹,

Nelson²

2021

Journal of Rural Mental Health

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“…For instance, CPT and PE have been shown to be underused (Maguen et al., 2020; Sripada et al., 2018), and among individuals who initiate an EBP for PTSD, many drop out before completing an adequate treatment course (Kehle‐Forbes et al., 2016; Maguen et al., 2020). It is important to note that patients who discontinue treatment before receiving an adequate dose of an EBP for PTSD, particularly those who dropout early in the course of treatment, are less likely to experience significant symptom reductions (Holder et al., 2020; Holmes et al., 2019).…”

mentioning

confidence: 99%

“…The present study used multilevel modeling to estimate the magnitude of therapist effects on patient engagement in EBPs for PTSD in VHA routine care. The number of sessions a patient attends is an important indicator of patient engagement and has been associated with clinical outcomes (Holder et al., 2020; Holmes et al., 2019; Saxon, Firth, et al., 2017). Although a few studies have examined the variation between therapists with regard to patient dropout from psychotherapies for anxiety and depression (Saxon, Barkham, et al., 2017; Zimmermann et al., 2017), we are not aware of any study that has examined the systematic differences between therapists in terms of patient retention in EBPs for PTSD.…”

mentioning

confidence: 99%

Investigation of Therapist Effects on Patient Engagement in Evidence‐Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration

Sayer

Stirman

Rosen

et al. 2021

Journal of Traumatic Stress

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The present study examined whether certain Veterans Health Administration (VHA) therapists have more success than others in keeping patients engaged in evidence-based psychotherapies for posttraumatic stress disorder (PTSD). Our objective was to use multilevel modeling to quantify the variability between therapists in two indicators of patient engagement: early dropout (i.e., < 3 sessions) and adequate dose (i.e., ≥ 8 sessions). The phenomenon of systematic variability between therapists in patients' treatment experience and outcomes is referred to as "therapist effects." The sample included the 2,709 therapists who provided individual cognitive processing therapy (CPT) or prolonged exposure (PE) to 18,461 veterans with PTSD across 140 facilities in 2017. Data were extracted from administrative databases. For CPT, therapist effects accounted for 10.9% of the variance in early dropout and 8.9% of the variance in adequate dose. For PE, therapist effects accounted for 6.0% and 8.8% of the variance in early dropout and adequate dose, respectively. Facility only accounted for an additional 1.1%-3.1% of the variance in early dropout and adequate dose. For CPT, patients' odds of receiving an adequate dose almost doubled, OR = 1.41/0.72 = 1.96, if they were seen by a therapist in the highest compared with the lowest retention decile. For PE, the odds of a patient receiving an adequate dose were 84% higher, OR = 1.38/0.75 = 1.84, when treated by a therapist in the highest compared with the lowest retention decile. Therapist skills and work environment may contribute to variability across therapists in early dropout and adequate dose.The U.S. Veterans Health Administration (VHA) has invested considerable resources to disseminate two evidencebased psychotherapies (EBPs) for posttraumatic stress disorder (PTSD): cognitive processing therapy (CPT; Resick

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“…We used a previously published natural language processing (NLP) algorithm with 98% precision in identifying the correct score and version of the PCL to abstract scores from clinical notes. 10,11 Scores abstracted from structured data and from NLP of clinical notes were integrated into a single dataset.…”

Section: Ptsd Symptomsmentioning

confidence: 99%

Patient and Clinical Factors Associated With Response to Medications for Posttraumatic Stress Disorder

Shiner¹,

Gui²,

Rozema³

et al. 2021

J. Clin. Psychiatry

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Objective: Fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine have previously shown efficacy for posttraumatic stress disorder (PTSD) in randomized clinical trials. Two prior studies using Department of Veterans Affairs (VA) medical records data show these medications are also effective in routine practice. Using an expanded retrospective cohort, we assessed the possibility of differential patterns of response based on patient and clinical factors. Methods: We identified 6,839 VA outpatients with clinical diagnoses of PTSD between October 1999 and September 2019 who initiated one of the medications and met pre-specified criteria for treatment duration and dose, combined with baseline and endpoint PTSD checklist (PCL) measurements. We compared 12-week changes in PCL score within clinical subgroups defined by sex, race and ethnicity, and military exposures, as well as comorbidities. Comorbidities were identified using International Classification of Diseases diagnostic codes and grouped according to major diagnostic classifications in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (eg, Psychotic Disorders, Depressive Disorders). We used a propensity score weighting approach to balance covariates among medication arms within each clinical subgroup. In our exploratory analyses using unweighted data for the overall cohort, we built penalized logistic regression models to identify covariates that predicted meaningful improvement. Results: There were no significant differences between medications in our weighted subgroup analyses. In unweighted exploratory analyses, higher baseline PCL scores and concurrent receipt of evidence-based psychotherapy predicted meaningful improvement, while high levels of disability predicted not realizing meaningful improvement. Conclusions: In the largest real-world study of medications for PTSD to date, we did not observe a pattern of differential response among clinical subgroups. All patients taking medications for PTSD, especially those with the highest levels of disability, should consider combined treatment with evidence-based psychotherapy.

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Cognitive Processing Therapy for Veterans with Posttraumatic Stress Disorder: What is the Median Effective Dose?

Cited by 15 publications

References 36 publications

PTSD telehealth treatments for veterans: Comparing outcomes from in-person, clinic-to-clinic, and home-based telehealth therapies.

PTSD telehealth treatments for veterans: Comparing outcomes from in-person, clinic-to-clinic, and home-based telehealth therapies.

Investigation of Therapist Effects on Patient Engagement in Evidence‐Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration

Patient and Clinical Factors Associated With Response to Medications for Posttraumatic Stress Disorder

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