Factors contributing to PTSD treatment dropout in veterans returning from the wars in Iraq and Afghanistan: A systematic review.

Abstract

Although treatment effectiveness among evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) has been well established, treatment dropout among veterans continues to be a concern within these treatments. Due to the uniqueness of the Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) veteran cohort, this article reviewed the literature examining factors contributing to treatment dropout from EBPs for PTSD among OEF/OIF/OND veterans. We conducted a systematic review of the published literature using PsycINFO, PubMed, and PTSDpubs with a restriction on year of publication beginning in 2007, following the first VA national initiative to roll-out EBPs for PTSD, through May 1st, 2020. Articles were retained if treatment dropout for EBPs was examined among OEF/OIF/OND veterans with PTSD, which yielded a total of 26 manuscripts. Common themes associated with treatment dropout were identified, including demographic, psychological, cognitive, practical, and treatment-related factors. Specifically, younger age, concurrent substance use, and practical concerns (e.g., balancing multiple life roles) emerged as factors that consistently contributed to treatment dropout. Other findings were mixed (e.g., pretreatment symptom severity and presence of traumatic brain injury). While factors contributing to dropout are complex and interact uniquely for each veteran, improved understanding of these factors in combination with innovative strategies for treating OEF/OIF/OND veterans utilizing EBPs is needed to enhance treatment engagement, retention, and outcomes. Implications for these factors are discussed. Impact StatementThis article provides a synthesis of factors contributing to treatment dropout from trauma-focused treatments among post-9/11 veterans. Trauma-focused treatments consistently yield high rates of treatment noncompletion, particularly among this cohort of veterans. The current review identified several consistent findings contributing to treatment dropout including: younger age (<35 years old), cooccurring substance use, and multiple life roles. Veterans with these characteristics might benefit from additional efforts at treatment engagement to reduce dropout or may require more innovative approaches to increase treatment engagement.

Posttraumatic stress disorder collaborative care: A quality improvement study in veterans affairs primary care.

“…Although the flexibility of telephone-based collaborative care would seem to address common treatment barriers by offering convenience and privacy, more tailored outreach efforts may be needed to make mental health interventions appealing to younger veterans (Keller & Tuerk, 2015). More intensive, massed interventions for PTSD may reduce treatment dropout for this population (Sciarrino et al, 2021).…”

Impact and efficiency of treatment across two PTSD clinical trials comparing in-person and telehealth service delivery formats.

“…Predictors of PTSD treatment dropout among veterans are varied (Berke et al, 2019; Hoge et al, 2014; Sciarrino et al, 2022). Sciarrino et al (2022) recently published a systematic review examining dropout from treatment among OEF, OIF, and Operation New Dawn veterans.…”

“…Predictors of dropout included demographic, cognitive, psychological, practical, and treatment-related factors (e.g., treatment type, modality, and format). Specifically, consistent dropout predictors included younger age, substance use disorders, and scheduling conflicts due to family responsibilities, college, and employment (Sciarrino et al, 2022). Additional practical reasons for dropout may include transportation issues and appointment travel time and cost, mobility limitations, finances, childcare needs, employment constraints, and long wait times at local VAs (Morland et al, 2019; Peterson et al, 2018).…”

Veterans’ reasons for dropping out of prolonged exposure therapy across three delivery modalities: A qualitative examination.

“…Several quantitative studies have attempted to identify factors that predict Veterans dropping out of PTSD EBPs by examining both demographic (e.g., war era, sex, age) and baseline clinical variables (e.g., PTSD severity). Broadly speaking, quantitative studies have typically yielded mixed results about the impact of sociodemographic factors on dropout (DeViva, 2014; Eftekhari et al, 2013; Holder et al, 2019; Lamkin et al, 2019; Sciarrino et al, 2022) with the exception that younger age has repeatedly been associated with greater dropout (Garcia et al, 2011; Kehle-Forbes et al, 2016; Mott et al, 2014; Sciarrino et al, 2022). In regard to the clinical variables, such as baseline symptom severity and PTSD service connection, studies have also largely yielded mixed findings (Eftekhari et al, 2013; Garcia et al, 2011; Szafranski et al, 2019; Sciarrino et al, 2022).…”

“…Broadly speaking, quantitative studies have typically yielded mixed results about the impact of sociodemographic factors on dropout (DeViva, 2014; Eftekhari et al, 2013; Holder et al, 2019; Lamkin et al, 2019; Sciarrino et al, 2022) with the exception that younger age has repeatedly been associated with greater dropout (Garcia et al, 2011; Kehle-Forbes et al, 2016; Mott et al, 2014; Sciarrino et al, 2022). In regard to the clinical variables, such as baseline symptom severity and PTSD service connection, studies have also largely yielded mixed findings (Eftekhari et al, 2013; Garcia et al, 2011; Szafranski et al, 2019; Sciarrino et al, 2022). For example, Holder et al (2019) found that higher self-blame cognitions protected against dropout from cognitive processing therapy (CPT), perhaps because of the effectiveness of this treatment on these cognitions, but this finding has not been yet been replicated.…”