A Systematic Review of Dropout From Psychotherapy for Posttraumatic Stress Disorder Among Iraq and Afghanistan Combat Veterans

Abstract

A significant number of veterans of the conflicts in Iraq and Afghanistan have posttraumatic stress disorder (PTSD), yet underutilization of mental health treatment remains a significant problem. The purpose of this review was to summarize rates of dropout from outpatient, psychosocial PTSD interventions provided to U.S. Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) veterans with combat-related PTSD. There were 788 articles that were identified which yielded 20 studies involving 1,191 individuals eligible for the review. The dropout rates in individual studies ranged from 5.0% to 78.2%, and the overall pooled dropout rate was 36%, 95% CI [26.20, 43.90]. The dropout rate differed marginally by study type (routine clinical care settings had higher dropout rates than clinical trials) and treatment format (group treatment had higher dropout rates than individual treatment), but not by whether comorbid substance dependence was excluded, by treatment modality (telemedicine vs. in-person treatment), or treatment type (exposure therapy vs. nonexposure therapy). Dropout is a critical aspect of the problem of underutilization of care among OEF/OIF/OND veterans with combat-related PTSD. Innovative strategies to enhance treatment retention are needed.

Art Therapy and Cognitive Processing Therapy for Combat-Related PTSD: A Randomized Controlled Trial

“…The dropout rate of the control group is consistent with a recent meta-analysis that showed a dropout rate for PTSD psychotherapies of 36% overall (Goetter et al, 2015). Although this study had a small sample size, our results suggest that art therapy may enhance engagement, which would be an important improvement in the treatment of PTSD.…”

“Do you expect me to receive PTSD care in a setting where most of the other patients remind me of the perpetrator?”: Home-based telemedicine to address barriers to care unique to military sexual trauma and veterans affairs hospitals

“…Previous studies have compared telemedicine to in-person modalities for the treatment of PTSD using cognitive processing therapy with Iraq/Afghanistan veterans (Maieritsch et al, 2015), cognitive processing therapy with female veterans (Morland et al, 2015), and PE among veterans in RCTs (Yuen et al, 2015) and in effectiveness settings (Gross et al, 2011; Tuerk et al, 2010). Further, in relation to attrition, a recent systematic review indicated that drop-out rates did not differ between those who were treated via telemedicine and those treated in-person across samples of veterans who served in Iraq and Afghanistan (Goetter et al, 2015). However, this review did not examine gender differences in attrition or differences based on MST status due to not having an adequate representation of women by which to examine these differences.…”

Mindfulness-based treatments for posttraumatic stress disorder: a review of the treatment literature and neurobiological evidence

“…129,131-134, 136-138,142,145 Critically, most of these studies reported low dropout rates (0%-29% attrition), 129,[131][132][133][134]137,138,142,[144][145][146] although higher rates were reported by Gallegos and colleagues, 139 (43% dropout) who cited reasons such as difficulty with childcare and transportation among a sample of mostly women of low socioeconomic status. Such low drop-out rates suggest high acceptability of mindfulness-based treatments among individuals with PTSD and are important given that recent studies highlight 35%-40% dropout rates among individuals receiving evidencebased treatments for PTSD (e.g., CPT, PE), [14][15][16] with PE having significantly higher dropout rates. 16 At present, MBSR is the most evidence-supported approach, with 2 RCTs reporting significantly greater improvements in PTSD and related symptomatology with MBSR than with active comparison therapies among veteran populations 137,138 (but see the studies by Kearney and colleagues 133 and Possemato and colleagues 136 ).…”

“…13 Moreover, attrition rates for leading treatment interventions were reported to fall between 35% and 40% in recent studies. [14][15][16] In addition, resistance to use interventions incorporating exposure for PTSD has been noted among some clinicians because of, for example, concerns about potential symptom exacerbation. 17 Thus, although traumafocused treatments, including CPT and PE, are considered effective treatments for PTSD, the need for potential adjunctive or alternative treatments is evident.…”