Factors Associated With Receipt of Cognitive-Behavioral Therapy or Prolonged Exposure Therapy Among Individuals With PTSD
Abstract
Objective:
Methods:
Results:
Conclusions:
Methods
Procedure
Data Analysis
Results
Quality of Studies
Participants
Study | N | Sample | Dates | Design | Treatment | Outcomes |
---|---|---|---|---|---|---|
Baker et al., 2015 (23) | 156 | Veterans with PTSD | 2008–2012 | Retrospective chart review | PE, CBT | Initiation, completion of PE and CBT |
Chen et al., 2013 (44) | 200 | Treatment-seeking civilians with chronic PTSD | 2012–2013 | Cross-sectional survey | PE | Preference for PE versus SSRIs |
DeViva et al., 2017 (24) | 182 | Veterans with PTSD | 2012–2015 | RCT, retrospective chart review | CPT, PE | Initiation, education group |
Feeny et al., 2009 (45) | 74 | Women recruited through ads for PTSD treatment | 2008–2009 | Cross-sectional survey | PE | Preference for SSRIs versus PE |
Grubbs et al., 2015 (25) | 133 | Rural veterans with PTSD | 2013–2015 | Retrospective chart review | CPT | Initiation, engagement with CPT |
Harned et al., 2013 (46) | 46 | Women with PTSD and BPD | 2012–2013 | Cross-sectional survey | PE | Preference for DBT or DBT + PE |
Hundt et al., 2018 (26) | 201 | Veterans with PTSD | 2015–2016 | Retrospective chart review | PE, CPT | Initiation with PE/CPT |
Hundt et al., 2018 (27) | 24 | Veterans with PTSD who declined PE and CPT | 2015–2016 | Qualitative | PE, CPT | Initiation with PE/CPT |
Iversen et al., 2010 (43) | 821 | U.K. Iraq war military | 2003 | Cross-sectional survey | CBT, medications | Initiation, engagement with CBT, medications |
Kehle-Forbes et al., 2014 (42) | 58 | National Guard veterans | 2013 | Qualitative | PE, SSRIs | Preference for PE versus SSRIs |
Kehle-Forbes et al., 2016 (28) | 427 | Veterans with PTSD | 2010–2012 | Retrospective chart review | CPT, PE | Initiated PE and CPT, dropped out of PE and CPT |
Keller & Tuerk, 2016 (29) | 324 | Veterans with PTSD | 2015 | Cross-sectional survey | PE, CBT | PE and CBT noninitiation |
Lamp et al., 2014 (30) | 476 | Veterans with PTSD | 2013 | Retrospective chart review | PE, CPT | PE and CPT interest and initiation |
Lu et al., 2016 (31) | 63 | Veterans with PTSD | 2008 | Content analysis | PE, CBT | Receipt of PE and CBT |
Maguen et al., 2018 (32) | 2,960 | Veterans with PTSD | 2001–2015 | Retrospective chart review, content analysis | PE, CPT | Receipt of PE and CPT, N of sessions |
Mott et al., 2014 (33) | 796 | Veterans with PTSD | 2008–2012 | Retrospective chart review, content analysis | PE, CBT | Initiation and completion of PE and CBT |
Rosen et al., 2017 (34) | 61,128 | Veteran patients of clinicians trained in PE | 2015–2016 | Longitudinal survey | PE | Reach and maintenance of PE |
Shalev et al., 2012 (47) | 397 | ER trauma patients in Jerusalem | 2003–2007 | Cross-sectional survey | CBT, PE | Initiation, preference for PE versus SSRIs |
Shiner et al., 2013 (35) | 1,924 | Veterans with PTSD | 2009–2010 | Retrospective chart review, content analysis | PE, CBT | Use of PE and CBT |
Shiner et al., 2018 (36) | 13,473 | Veterans with PTSD | 2014–2016 | Retrospective chart review | PE, CPT | Use of EBP templates |
Sripada et al., 2018 (37) | 270,277 | Veterans with PTSD | 2015–2016 | Retrospective chart review | PE, CPT | Use of EBP templates |
Sripada et al., 2018 (38) | 273,694 | Veterans with PTSD | 2015–2016 | Retrospective chart review | PE, CPT | Use of EBP templates |
Stecker et al., 2013 (41) | 143 | Veterans with PTSD | 2009–2012 | Cross-sectional, qualitative | CBT | CBT noninitiation |
Tuerk et al., 2013 (39) | 60 | Veterans with PTSD | 2007–2009 | Retrospective chart review | PE | Completed minimum PE sessions |
Watts et al., 2014 (40) | 1,924 | Veterans with PTSD | 2009–2010 | Retrospective chart review | PE, CBT | N of veterans who received PE and CBT |
Zayfert et al., 2005 (48) | 115 | Civilian patients of an anxiety clinic | 2002–2004 | Cohort, longitudinal | CBT | Initiation and completion of CBT |
Initiation of TC-CBT Treatments
Participants | |||||
---|---|---|---|---|---|
Study | Setting | Male (%) | Average age | Diagnosis of PTSD (%) | Utilization of TC-CBT (%) |
Baker et al., 2015 (23) | VA PTSD clinic | 90.4 | 46.7 | 100.0 | 58.0 |
Chen et al., 2013 (44) | PTSD treatment study | 25.0 | 37.4 | 100.0 | 61.0 |
Deviva et al., 2017 (24) | VA PTSD clinic | 93.0 | 48.5 | 100.0 | 34.0 |
Feeny et al., 2009 (45) | Convenience | 0 | 31.8 | 100.0 | 82.0 |
Grubbs et al., 2015 (25) | VA clinic | 88.7 | 51.9 | 100.0 | 55.0 |
Harned et al., 2013 (46) | behavioral therapy clinic | 0 | 34.0 | 100.0 | 67.0 |
Hundt et al., 2018 (26) | VA PTSD clinic | 79.3 | 43.7 | 100.0 | 42.0 |
Hundt et al., 2018 (27)a | VA PTSD clinic | 79.0 | 44.6 | 100.0 | 0 |
Iverson et al., 2010 (43) | VHA | 90.0 | 34.0 | 79.7 | 7.3 |
Kehle-Forbes et al., 2014 (42) | Military | 98.3 | 35.4 | 100.0 | 53.0 |
Kehle-Forbes et al., 2016 (28) | VA PTSD clinic | 84.1 | 46.4 | 100.0 | 82.0 |
Keller and Tuerk, 2016 (29) | VA PTSD clinic | 77.0 | 42.9 | 100.0 | 43.2 |
Lamp et al., 2014 (30) | VA PTSD clinic | 93.9 | 48.6 | 100.0 | 43.7 |
Lu et al., 2016 (31) | VA PTSD clinic | 89.0 | 35.3 | 100.0 | 13.0 |
Maguen et al, 2018 (32) | VHA | 90.0 | 35.5 | 100.0 | 20.1 |
Mott et al., 2014 (33) | VA PTSD clinic | 90.0 | 46.6 | 87.9 | 11.0 |
Rosen et al., 2017 (34) | VHA clinicians | 12.0 | |||
Shalev et al., 2012 (47) | ER in Jerusalem | 54.0 | 38.0 | 100.0 | 72.0 |
Shiner et al., 2013 (35) | VHA | 93.0 | 53.0 | 100.0 | 6.0 |
Shiner et al, 2018 (36) | VHA | 88.8 | 100.0 | 28.0 | |
Sripada et al., 2018 (37) | VHA | 87.0 | 100.0 | 4.0 | |
Sripada et al., 2018 (38) | VHA | 87.0 | 100.0 | 4.0 | |
Stecker et al., 2013 (41)a | VHA | 84.0 | 28.0 | 100.0 | 0 |
Tuerk et al., 2013 (39)a | VA PTSD clinic | 95.0 | 41.4 | 100.0 | 100.0 |
Watts et al., 2014 (40) | VA PTSD clinic | 93.0 | 53.0 | 100.0 | 6.0 |
Zayfert et al., 2005 (48) | Anxiety clinic | 18.0 | 37.8 | 100.0 | 83.0 |
Predisposing, Enabling, and Need Variables Related to Initiation of TC-CBT
Factor | Qualitative themesa | Quantitative variablesb |
---|---|---|
Predisposing | ||
Demographic characteristics | None | Age (N=5), race (N=2), marital status (N=1), military era (N=2), gender (N=2) |
Mental health beliefs | Concerns about stigma (N=2), denial that treatment is necessary (N=2), readiness (N=2), trust and alliance with therapist (N=3), fear of repercussions related to military career (N=1), preference for psychopharmacology approaches (N=1), interest in trauma-centered therapies (N=2), credibility of treatment and perceived efficacy (N=1), emotional intensity of treatment (N=2), perceived side effects (N=2), timing of symptom relief (N=1), perception of VA (N=1) | Prior group psychotherapy (N=1), interest in trauma-centered therapies (N=1) |
Enabling | ||
Logistic issues | Time (N=4), affordability (N=2), distance (N=2), poor therapeutic relationship (N=2), redeployment and contracts (N=1) | Affordability (N=1), PTSD service connection (N=3) |
Provider Organizational structure and resources | Training of providers (N=1), timing of discussion of treatment options with providers (N=2), consistency of providers (N=1), concerns about privacy (N=3), negative experiences with VA (N=1) | Clinical exposure to prolonged exposure (PE) and cognitive-behavioral therapy (CBT) (N=2), referral source (N=2), access to PE and CBT champions (N=1), provider training (N=2), clinician believes PE effective, workflow for patients with PTSD (N=2), region (N=1), gender of clinician (N=1), race of clinician (N=1) |
Need | Clinical priorities (i.e., suicidality, substance dependence) (N=1), crisis (N=1), remission (N=1) | PTSD severity (N=3), comorbid depression (N=3), delay in treatment (N=2), length of stay (N=1) |
Factor | Total N | Studies (N) | Average OR | 95% CI | Weighted OR | 95% CI |
---|---|---|---|---|---|---|
Predisposing | ||||||
Demographic characteristic | ||||||
Age | 645,407 | 9 | 1.67 | 1.08 to 2.90 | 1.56 | 1.51 to 1.61 |
Vietnam era (reference: other military era) | 964 | 3 | 1.48 | .75 to 3.21 | 1.58 | 1.00 to 2.15 |
Female gender (reference: male) | 288,848 | 8 | 1.13 | .61 to 2.49 | 1.18 | 1.08 to 1.27 |
Black or other race-ethnicity (reference: white) | 288,470 | 9 | 1.38 | .47 to 12.65 | 1.16 | 1.03 to 1.28 |
Married (reference: unmarried) | 496 | 4 | 1.22 | .62 to 2.82 | 1.44 | .87 to 2.00 |
Income | 116 | 2 | 1.78 | .37 to 9.08 | 1.52 | −1.19 to 4.89 |
High school diploma or higher (no high school diploma) | 406 | 4 | .86 | .32 to 3.07 | .99 | .32 to 1.66 |
Mental health beliefb | ||||||
Concerns about stigma | 58 | 1 | 8.18 | .95 to 70.44 | 8.18 | .95 to 70.44 |
Readiness for treatment (reference: ambivalence) | 58 | 1 | .32 | .03 to 3.74 | .32 | .03 to 3.74 |
Side effects | 58 | 1 | .14 | .02 to 1.37 | .14 | .02 to 1.37 |
Preference for medication | 58 | 1 | .06 | .01 to .23 | .06 | .01 to .23 |
Previous psychotherapy | 274,206 | 5 | 1.67 | .90 to 3.47 | 1.01 | 1.01 to 1.02 |
Trauma-centered interest | 476 | 1 | 2.13 | 1.37 to 3.30 | 2.13 | 1.37 to 3.30 |
Enabling | ||||||
Motivators | ||||||
Disability claim (reference: none) | 133 | 1 | 2.01 | .38 to 10.65 | 2.01 | .38 to 10.65 |
Logistic issues | ||||||
Time | 58 | 1 | 3.12 | .94 to 10.36 | 3.12 | .94 to 10.36 |
Relocation | 58 | 1 | 1.38 | .12 to 16.26 | 1.38 | .12 to 16.26 |
Affordability | 58 | 1 | 2.96 | .31 to 28.57 | 2.96 | .31 to 28.57 |
VA service connection (reference: no service connection) | 631,067 | 3 | 1.89 | 1.31 to 3.22 | 2.30 | 2.18 to 2.42 |
Organizational structure | ||||||
Mental health referral source (reference: primary care) | 61,452 | 2 | 2.09 | 1.22 to 3.86 | 2.28 | 1.05 to 3.50 |
Staff training | 76,849 | 4 | 1.29 | 1.02 to 1.72 | 1.19 | .64 to 1.70 |
Staff exposure | 693,796 | 3 | 2.70 | 2.15 to 3.83 | 2.30 | 2.09 to 2.52 |
Adaptability of TC-CBT to workflow | 63,052 | 2 | 3.13 | 1.78 to 5.56 | 4.66 | 1.60 to 7.72 |
Need | ||||||
PTSD severity | 1,890 | 8 | 1.51 | 1.02 to 2.47 | 1.46 | 1.13 to 1.78 |
Amount of time treatment delayed | 274,490 | 2 | 1.67 | 1.13 to 2.63 | .93 | .92 to .95 |
Comorbid depression (reference: none) | 288,486 | 9 | 1.62 | .91 to 3.53 | 1.21 | 1.14 to 1.29 |
Comorbid substance misuse (reference: none) | 287,562 | 5 | 1.64 | .93 to 3.37 | 1.01 | .96 to 1.07 |
Predisposing characteristics.
Enabling resources.
Need factors.
Findings From Subgroups of High-Quality Studies
Heterogeneity of Predictors
Discussion and Conclusions
Acknowledgments
Supplementary Material
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