The problem of dropout from “gold standard” PTSD therapies

Abstract

Understanding of posttraumatic stress disorder (PTSD) has increased substantially in the past several decades. There is now more awareness of the many different types of trauma that can lead to PTSD, greater refinement of diagnostic criteria, and the development and testing of various treatments for it. As implementation of PTSD therapies has increased, there is also increased attention to the key issues of retention and dropout. Retention refers to the percentage of patients who stay in a treatment for its intended dose, and dropout is the opposite (the percentage who leave prior to the intended dose); both of which have major implications for treatment outcomes. The two PTSD therapies most studied in relation to retention and dropout are Prolonged Exposure and Cognitive Processing Therapy, which have been the subject of massive, formal, multi-year dissemination roll-outs. Both of these evidence-based treatments are defined as gold-standard therapies for PTSD and showed positive outcomes and reasonable retention of patients in randomized controlled trials (RCTs). But an emerging picture based on real-world practice indicates substantial dropout. Such real-world studies are distinct from RCTs, which have consistently evidenced far lower dropout rates, but under much more restricted conditions (e.g. a more selective range of patients and clinicians). In this paper, the phenomena of retention and dropout are described based on real-world studies of Prolonged Exposure and Cognitive Processing Therapy, including rates, characteristics of patients, clinicians, and programs in relation to retention and dropout, and identification of clinical issues and future research on these topics. It is suggested that the term “gold-standard” evidence-based treatments should be reserved for treatments that evidence both positive results in RCTs but also feasibility and strong retention in real-world settings.

Posttraumatic Stress Disorder: Overview of Evidence-Based Assessment and Treatment

“…Notably, researchers have found that dropout can be higher in community settings ([46,47] although dropout rates do not differ between exposure and non-exposure therapies for PTSD [47]. A meta-analysis pooled across 13 studies found large effect sizes of PE relative to control groups at post-treatment, and medium to large effects at follow up time points [41].…”

“…One of the most important concerns with the sole use of pharmacotherapy for PTSD treatment is the evidence that discontinuing treatment can be associated with relapse [81,83,90]. Although relapse is relatively infrequent after one responds to an evidence-based psychotherapy for PTSD [91], a proportion of patients either drop out of therapy prematurely or do not respond to therapy [46,47,54]. It is therefore critical to continue to investigate new strategies to improve upon the available treatments for PTSD.…”

Predictors of dropout in concurrent treatment of posttraumatic stress disorder and alcohol dependence: Rate of improvement matters

“…Inconsistent findings have been reported for employment status (e.g., Foa et al, 1999; but see Taylor et al, 2003), education (e.g., Rizvi, Vogt, & Resick, 2009; but see Hagenaars, van Minnen, & Hoogduin, 2010), depressive symptoms (e.g., Garcia, Kelley, Rentz, & Lee, 2011; but see Hagenaars, van Minnen, & Hoogduin, 2010), experience of childhood abuse (e.g., van Minnen, Arntz, & Keijsers, 2002; but see Zayfert et al, 2005), and greater PTSD severity (e.g., Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998; but see Eftekhari et al, 2013). An exception to these mixed findings is that comorbid SUDs have been predictive of dropout from PTSD treatment with some consistency (e.g., Najavits, 2015; Szafranski, Gros, Menefee, Wanner, & Norton, 2014; van Minnen et al, 2002). …”

Physical activity counseling promotes physical and psychological resilience in older veterans with posttraumatic stress disorder

“…It bears considering that PA interventions may be more palatable/approachable for older persons than traditional mental health therapies. We report that ten percent of veterans with PTSD in the intervention group withdrew from the study, while drop-out rates for evidence-based psychotherapy for PTSD are reportedly much higher ranging anywhere from 20–80% (Imel, Laska, Jakupcak, & Simpson, 2013; Najavits, 2015). PA programs for veterans with PTSD may also be of interest to clinicians and mental health providers alike, as both a primary and secondary prevention strategy.…”