Predictors of Treatment Adequacy During Evidence-Based Psychotherapy for PTSD

This study used a national sample of 16,559 veterans in the VA health system who had at least one psychotherapy visit in any VA facility, had a diagnosis of PTSD coded as the primary diagnosis in the electronic medical record (EMR), used an EBP note template for PTSD treatment (CPT or PE), and began a course of treatment during fiscal year (FY) 2015. CPT and PE are recommended as first-line treatments for PTSD by the VA/Department of Defense clinical practice guidelines (30) and are currently the only PTSD treatments with associated EMR note templates in the VA system.Other psychotherapies that are indicated for PTSD, such as eye movement desensitization and reprocessing, do not have associated note templates and thus cannot be assessed through administrative data sources. All study data were obtained from the VA Corporate Data Warehouse (CDW), which provides national-level reporting capabilities.

The primary outcome of interest was whether an individual received a minimum of eight sessions of evidence-based treatment within 14 weeks of treatment initiation. This metric was based in previous explorations of psychotherapy treatment adequacy, which consistently defined adequate treatment as treatment consisting of between seven and nine sessions (17, 29, 31–38). Further, eight or more sessions was used as a current mental health performance measure by the VA (39), and clinical practice recommendations by the American Psychological Association are based on clinical trials that have generally included eight or more sessions of psychotherapy (40). Sensitivity analyses were conducted by using the outcome of 12 or more sessions within 6 months as criteria for adequate treatment. Participants were excluded from the sample if their first EBP visit was within the last 13 weeks of FY 2015 (or within the last 6 months for the sensitivity analysis), given that their course of treatment may have extended beyond the range of the study.

The number of sessions was quantified by the number of EBP note templates in the VA EMR. EBP templates are tools for writing clinical notes when administering an EBP. The templates list the essential components of the treatment, which vary by EBP type, on a session-by-session basis. Templates allow the provider to click on checkboxes to insert standardized descriptions of EBP components and session information into the note text. Usage of EBP templates generates data tags (i.e., searchable records) of therapy visit information, which become accessible in the CDW for research and program evaluation purposes on a national level.

Predictor variables were obtained through EMR data. Demographic variables of interest included age, gender, race, and ethnicity. Comorbid depression, bipolar or psychotic disorders, substance use disorders, and anxiety disorders other than PTSD were included as dichotomous variables. Service connection for PTSD was also included as a dichotomous variable indicating absence or presence of a current service-connected disability. Record of a symptom measure for PTSD (PTSD Checklist) within 30 days before or after the first session was coded dichotomously. Additionally, the total number of past-year mental health visits (not including the current course of EBP treatment) was included as a predictor of treatment adequacy. Number of past-year visits represents a behavioral indicator of treatment attendance and is readily accessible to VA providers.

Facility-level analyses were also conducted by using variables obtained though EMR and CDW data to predict the percentage of patients with PTSD who completed eight or more sessions within 14 weeks of initiating EBP treatment. All clinics and hospitals were grouped by parent facility. Variables of interest for each facility included geographic region, percentage of patients with a primary PTSD diagnosis who received a PCL during FY 2015, percentage of patients with a primary PTSD diagnosis who received an EBP, and number of certified EBP providers. The list of certified providers and their affiliated sites was obtained through the VA intranet training registry.

Individual-level analyses were conducted using generalized estimating equations (GEE) with the logit link function. GEE models accounted for correlated observations within each VA medical center. Using GEE, the binary variable indicating eight or more sessions of EBP within 14 weeks of initiating treatment was regressed on the predictors of interest in unadjusted and adjusted models. Primary analyses used the total sample, and secondary analyses examined the relationship between predictors of interest and treatment adequacy for CPT and PE, separately. Facility-level analyses used generalized linear models with the logit link function and binomial distribution to predict the overall percentage of EBP treatment adequacy among all patients who initiated an EBP at any of the VA facilities in the sample.

The sample characteristics for the 16,559 veterans are presented in Table 1. The majority of the sample was male (N=13,594, 82.1%), white (N=11,035, 66.6%), and identified as not Hispanic or Latino (N=15,025, 90.7%).

Overall, our results suggest that less than one third (31.1%) of veterans with a primary diagnosis of PTSD who initiate an EBP with a VA mental health provider receive an adequate dose of psychotherapy within 14 weeks, and only 14.3% complete 12 or more sessions within 6 months. In general, our findings using systemwide clinical data are consistent with previous reports of low rates of treatment completion during clinical trials of trauma-focused treatment and are concerning given evidence that attrition during the acute treatment phase is related to reduced effect sizes (7, 8, 13).

The results regarding the greater rate of completion during CPT are notable and necessitate further study. Several prior studies have compared dropout rates between CPT and PE, but they have produced equivocal results. For example, one study using retrospective chart review reported higher dropout rates in CPT (17) and another found higher attrition during PE (23). A recent study using secondary data found no difference in rates of dropout between PE and various forms of CPT (41). Last, a study using administrative data from one VA PTSD clinic reported greater use of CPT (N=231) relative to PE (N=188), with more attrition occurring during PE (44.9%) than during CPT (33.3%) (24). Additional data are needed from both randomized trials and routine care to clarify factors related to dropout and improve treatment completion for these frontline treatments.

These analyses identified several demographic characteristics associated with treatment adequacy. Our findings add support to the existing literature, which has found that older age is associated with increased odds of completing an EBP for PTSD (17, 22, 23). Our results are also consistent with findings from a review of psychotherapy, which reported that younger age is a significant predictor of dropout. Relative to men, women had greater odds of completing at least 12 sessions within 6 months (i.e., in the sensitivity analysis). This finding is consistent with recent reports that women are more likely than men to complete treatment for PTSD (31, 32, 36, 42), although this relationship was not observed in explorations of discontinuation from psychotherapy in general (10, 18). Differences in rates of treatment adequacy by race and ethnicity were also observed in several models. Consistent with previous reports of PTSD treatment adequacy (36), identifying as Hispanic or Latino was associated with lesser odds of receiving eight or more sessions within 14 weeks in the combined model; whereas identifying as Asian or American Indian was associated with greater odds of PE and CPT completion, respectively. Given that these associations have also been observed during non-EBP treatment of PTSD, these data may reflect general trends rather than EBP-specific patterns. Additional data are needed to clarify relationships between these demographic characteristics and EBP treatment completion among patients with PTSD.

The presence of a comorbid bipolar or psychotic disorder was related to reduced odds of completing an adequate course of treatment in the overall sample and among those who received CPT. This is somewhat inconsistent with prior studies showing that patients with and without comorbid serious mental illness may discontinue psychotherapy for PTSD at similarly high rates (43–45). However, previous research has suggested that, among those with comorbid serious mental illness, greater PTSD symptoms at baseline were related to increased risk of dropout (44). It is possible that treatment adequacy was negatively related to greater PTSD symptoms in our subsample with comorbid serious mental illness, although data regarding symptom severity were not available in the current study. These findings may also reflect differences between samples of patients receiving routine clinical care relative to those studied in trial and other research contexts. Nonetheless, our findings suggest that many individuals with comorbid PTSD and serious mental illness complete fewer than the recommended number of sessions of EBP for PTSD in routine care settings and highlight the need for more research with this population.

At the facility level, receipt of EBPs by a higher percentage of patients with PTSD and greater number of EBP-certified providers were related to a greater percentage of veterans receiving eight or more sessions of psychotherapy within 14 weeks. These preliminary findings suggest that the percentage of veterans completing adequate treatment during EBPs for PTSD may be higher at facilities that more frequently offer and have provider expertise in delivering EBPs. Nonetheless, further research is needed to explore reasons for this finding. The result that completing the PCL within the FY was associated with lower rates of treatment completion was unexpected. We have previously reported that greater rates of facility-level PCL administration are related to greater frequency of documented EBP use (46). Thus, facility-level PCL administration may be related to whether patients receive documented EBP but not to whether the treatment is adequate.

The finding that only 31.1% of veterans who begin EBPs for PTSD completed an adequate course of treatment suggests additional efforts are warranted at the individual and facility levels. At the individual level, patients at higher risk for receiving less than adequate treatment may benefit from adjunctive interventions, such as addressing comorbidity concurrently with or prior to initiating EBP for PTSD, or carefully assessing treatment barriers and motivations. At the facility level, future work may seek to examine whether promotion of EBPs through clinic policies and provider training may increase completion of adequate treatment. Further, Sayer and colleagues (47) identified qualitative themes that were associated with high use of EBPs for PTSD in VA clinics. These themes included factors such as leadership engagement and promotion of EBPs, effective screening and monitoring of patient progress, clinician beliefs about the effectiveness of EBPs, and scheduling flexibility. In light of our findings that the rate of EBP delivery and number of EBP providers were associated with EBP adequacy at the facility level, it is possible that efforts in these areas could help increase use and completion of EBPs for PTSD in the VA. Although overall rates of treatment completion were low, efforts have been made to increase treatment adequacy during EBPs. For example, some evidence suggests that shared decision making during treatment planning and ongoing feedback to patients and providers may reduce dropout (33, 48) and increase preference for EBPs (49). Additionally, it is important to obtain further data on those individuals who do not complete treatment, given that some may discontinue because of early treatment response (50).

This study had several limitations. First, treatment adequacy was calculated based on template data in the EMR and may underestimate the true rate of EBP usage. Some providers delivering EBPs for PTSD may not use templates or symptom measures, which introduces the potential for sample bias at the provider and facility levels. However, template usage is mandated by the VA for those delivering EBPs; thus, any sample bias is likely toward providers who are more adherent to EBP protocols (29, 51). It is also unlikely that providers who use EBP templates do so only with some patients and not others. Facility-level bias was likely mitigated through use of GEEs, which accounted for within-facility clustering of observations. Administrative efforts are underway in the VA to increase use of templates when delivering EBPs and to implement measurement-based care (2, 29). These efforts will likely lead to improvements in use of administrative data for systemwide estimates of EBP use, completion, and outcomes. Second, retrospective study data are based on standard clinical care, which has several implications. Although the clinical nature of the data represents a strength in that the results reflect rates of treatment adequacy in VA clinics and hospitals, lack of randomization precludes causal inference. Additionally, psychiatric diagnoses in the EMR data were based on providers’ clinical decisions during care and may not correspond with diagnostic interviews and self-reported sources (52). Unfortunately, at the time of EBP initiation, self-reported PTSD symptom measures were documented in the EMR for less than 30% of patients in the sample, precluding the analysis of symptom severity as a potential marker of treatment adequacy. Thus, these data are subject to biases related to misdiagnosis or underdiagnosis during routine care. Third, other aspects of care at the individual (e.g., treatment fidelity) and facility (e.g., promotion of EBPs by leadership and clinical operations designed to deliver and sustain EBP treatment) levels may be important for treatment completion; however, we were unable to address them with these administrative data. Such factors represent important areas for further exploration.

The rate of treatment completion during EBPs for PTSD was low in a national sample of veterans, according to national administrative data obtained during the usual course of care. Younger patients and those with comorbid bipolar or psychotic disorders were at greater odds of not receiving adequate psychotherapy. Facilities with a higher percentage of EBP use and more EBP trained providers had higher rates of treatment completion. Additional research is needed to clarify these factors and to develop strategies to increase the likelihood of PTSD treatment adequacy.