Integrated, exposure-based treatment for PTSD and comorbid substance use disorders: Predictors of treatment dropout

Abstract

High rates of comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD) have been noted in veteran populations. Fortunately, there are a number of evidence-based psychotherapies designed to address comorbid PTSD and SUD. However, treatments targeting PTSD and SUD simultaneously often report high dropout rates. To date, only one study has examined predictors of dropout from PTSD/SUD treatment. To address this gap in the literature, this study aimed to 1) examine when in the course of treatment dropout occurred, and 2) identify predictors of dropout from a concurrent treatment for PTSD and SUD. Participants were 51 male and female veterans diagnosed with current PTSD and SUD. All participants completed at least one session of a cognitive-behavioral treatment (COPE) designed to simultaneously address PTSD and SUD symptoms. Of the 51 participants, 22 (43.1%) dropped out of treatment prior to completing the full 12 session COPE protocol. Results indicated that the majority of dropout (55%) occurred after session 6, with the largest amount of dropout occurring between sessions 9 and 10. Results also indicated a marginally significant relationship between greater baseline PTSD symptom severity and premature dropout. These findings highlight inconsistencies related to timing and predictors of dropout, as well as the dearth of information noted about treatment dropout within PTSD and SUD literature. Suggestions for procedural changes, such as implementing continual symptom assessments during treatment and increasing dialog between provider and patient about dropout were made with the hopes of increasing consistency of findings and eventually reducing treatment dropout.

Substance use disorders and PTSD: Examining substance use, PTSD symptoms, and dropout following imaginal exposure

“…As our group showed in a previous study using data from the same trial, the results from the current study suggest the largest number of dropouts in this sample occurred between sessions 9 and 10 (Szafranski et al, 2017). This differs from research on PE in Veterans that demonstrates most participants drop out of treatment prior to session four (Garcia, Kelley, Rentz, & Lee, 2011; Mott et al, 2014).…”

“…Thus, particpants presumably had rapport built with the therapist and the coping skills needed to better tolerate the imaginal exposures. Alternatively, participants may have dropped out later because symptoms had improved (Szafranski et al, 2017; Zandberg, Rosenfield, Alpert, McLean, & Foa, 2016). …”

A lifeline in the dark: Breaking through the stigma of veteran mental health and treating America's combat veterans

“…In fact, Hoge et al () found that 59% of active‐duty US Army soldiers in their study who sought mental healthcare after receiving a postdeployment referral for PTSD treatment did not attend the minimum number of sessions (at least eight mental health sessions). Steenkamp, Litz, Hoge, and Marmar () and Szafranski et al () also identified similar trends for dropout rates for veterans in their studies, ranging from 13% to as high as 43%.…”

Heterogeneity of treatment dropout: PTSD, depression, and alcohol use disorder reductions in PTSD and AUD/SUD treatment noncompleters

“…In studies examining treatments for AUD, dropout rates range from 23% to 40% (Kelly & Moos, 2003;Yoon, Kim, Petrakis, & Westermeyer, 2016). Similarly high rates of dropout (32-61%) have been reported in studies examining treatments for comorbid PTSD and SUD (Brady, Dansky, Back, Foa, & Carroll, 2001;Foa et al, 2013;Najavits, Weiss, Shaw, & Muenz, 1998;Szafranski, Snead, et al, 2017;Zandberg, Rosenfield, Alpert, McLean, & Foa, 2016). In a recent meta-analysis of trauma-focused integrated treatments for PTSD and SUD, patients attended approximately 32-68% of sessions (Roberts, Roberts, Jones, & Bisson, 2015).…”