Journal of Traumatic Stress June 2014, 27, 265–273
Characteristics of U.S. Veterans Who Begin and Complete Prolonged Exposure and Cognitive Processing Therapy for PTSD Juliette M. Mott,1,2,3 Sasha Mondragon,1,2 Natalie E. Hundt,1,2,3 Melissa Beason-Smith,1,2 Rebecca H. Grady,1,2,3 and Ellen J. Teng1,2,3 1
2
Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine, Houston, Texas, USA 3 South Central Mental Illness Research, Education, and Clinical Center, Houston, Texas, USA
This retrospective chart-review study examined patient-level correlates of initiation and completion of evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) among treatment-seeking U.S. veterans. We identified all patients (N = 796) in a large Veterans Affairs PTSD and anxiety clinic who attended at least 1 individual psychotherapy appointment with 1 of 8 providers trained in EBP. Within this group, 91 patients (11.4%) began EBP (either Cognitive Processing Therapy or Prolonged Exposure) and 59 patients (7.9%) completed EBP. The medical records of all EBP patients (n = 91) and a provider-matched sample of patients who received another form of individual psychotherapy (n = 66) were reviewed by 4 independent raters. Logistic regression analyses revealed that Iraq and Afghanistan veterans were less likely to begin EBP than veterans from other service eras, OR = 0.48, 95% CI = [0.24, 0.94], and veterans who were service connected for PTSD were more likely than veterans without service connection to begin EBP, OR = 2.33, 95% CI = [1.09, 5.03]. Among those who began EBP, Iraq and Afghanistan veteran status, OR = 0.09, 95% CI = [0.03, 0.30], and a history of psychiatric inpatient hospitalization, OR = 0.13, 95% CI = [0.03, 0.54], were associated with decreased likelihood of EBP completion.
Given that posttraumatic stress disorder (PTSD) is one of the most common mental health diagnoses among U.S. military veterans (Barrera et al., 2014; Cohen et al., 2010), providing high-quality PTSD treatment is a critical mission to the Veterans Health Administration (VHA). To increase access to care, the VHA implemented large-scale efforts to train clinicians in two evidence-based psychotherapy (EBP) protocols for PTSD: cognitive processing therapy (CPT) and prolonged exposure (PE). Both are manualized, cognitive–behavioral interventions that typically consist of 8–12 weekly sessions (Foa, Hembree,
& Rothbaum, 2007; Resick, Monson, & Chard, 2008). To date, more than 2,300 VHA clinicians have been trained in CPT, and more than 1,500 have been trained in PE (Eftekhari et al., 2013; Karlin et al., 2010). These dissemination efforts have increased the VHA’s potential to provide evidence-based care to veterans with PTSD (Cook, Dinnen, Thompson, Simiola, & Schnurr, 2014). To evaluate the impact of EBP dissemination initiatives, several recent studies have assessed the use of CPT and PE within the VHA. Although VHA administrative databases do not contain information on the type of psychotherapy delivered, prior studies have used these databases to determine the number of patients who received at least 8 or 9 psychotherapy sessions, and therefore could have potentially completed a full course of EBP. Consistently, these studies indicate that less than 10% of veterans with PTSD could have feasibly completed an EBP (Mott, Hundt, Sansgiry, Mignogna, & Cully, 2014; Seal et al., 2010). To estimate EBP initiation more precisely, Shiner and colleagues (2012) reviewed the text of psychotherapy notes from more than 1,900 patients across 6 VHA facilities and reported that only 6% of veterans received one or more EBP sessions in the 6 months following enrollment in a PTSD clinic. This suggests that most veterans who receive psychotherapy in specialized PTSD care settings are receiving treatments other than VHA-recommended EBPs.
Juliette Mott is currently affiliated with the National Center for PTSD in White River Junction, Vermont USA. This research was supported in part by the Office of Academic Affiliations VA Advanced Fellowship Program in Mental Illness Research and Treatment, by the Houston VA HSR&D Center of Excellence (Houston Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413), and by a VA Clinical Sciences Research and Development (CSR&D) Career Development Award (#CADE-MHN/F09) awarded to Ellen J. Teng at the Michael E. DeBakey Veterans Affairs Medical Center. The views expressed reflect those of the authors and not necessarily the Department of Veterans Affairs/Baylor College of Medicine. Correspondence concerning this article should be addressed to Juliette Mott, National Center for PTSD, VA Medical Center (116D), 215 North Main Street, White River Junction, VT 05009. E-mail: [email protected] Published 2014. This article is a US Government work and is in the public domain in the USA. View this article online at wileyonlinelibrary.com DOI: 10.1002/jts.21927
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Although the VHA mandates that all patients with PTSD have access to CPT or PE, the decision of whether a veteran receives one of these treatments is left to the veteran and provider (McHugh & Barlow, 2010). Patients and providers may find little empirical guidance for treatment selection, as research informing evidence-based treatment decisions based on patient characteristics such as age or trauma type is only in the beginning stages (Sharpless & Barber, 2011). Prior research has demonstrated the effectiveness of CPT and PE in veteran populations that are diverse with respect to gender (Schnurr et al., 2007), service era (Yoder et al., 2012), trauma type (Rauch et al., 2009), and psychiatric comorbidities (Monson et al., 2006), suggesting that these treatments have the potential for broad patient reach. Practice guidelines and EBP manuals offer differing perspectives on which patients are likely appropriate for CPT or PE. The VHA/Department of Defense (DoD) clinical practice guideline for management of PTSD (2010) endorses PE and CPT at the highest possible level, indicating “a strong recommendation that clinicians provide the intervention to eligible patients” (p. 201). PE and CPT therapist manuals, however, indicate that not all patients with PTSD are appropriate for these treatments. The PE manual recommends that PE not be initiated in the presence of imminent threat of suicide or homicide, serious self-injurious behavior, current psychosis, current high risk of being assaulted or insufficient memory of the trauma (Foa et al., 2007). The CPT manual (Resick et al., 2008) cautions against the treatment of patients who are in imminent danger, suffer from severe dissociation or panic attacks that may interfere with treatment, and recommends case-by-case decisions for patients with substance dependence and self-harming behaviors. Both manuals indicate that comorbid depression is not a rule-out and note that patients with subthreshold PTSD symptoms may be appropriate. Thus, these manuals suggest that PE and CPT are not appropriate for all patients with PTSD and may be useful for patients without a full PTSD diagnosis. Although VHA policies and therapist manuals each provide unique perspectives on which patients should receive EBP for PTSD, a burgeoning body of research has attempted to describe the population of veterans who actually receive these treatments. A number of studies have found that veterans who received PE in VHA PTSD clinics were predominately White, male, high-school educated, and service-connected for PTSD (Gros, Yoder, Tuerk, Lozano, & Acierno, 2011; Rauch et al., 2009; Tuerk, Yoder, Ruggiero, Gros, & Acierno, 2010; Yoder et al., 2012). This mirrors the general population of veterans who seek treatment (not necessarily EBP) for PTSD (Seal et al., 2010; Spoont, Murdoch, Hodges, & Nugent, 2010). Given that these studies did not compare directly the characteristics of patients who received EBP to those who received an alternative treatment, the degree to which observed patient characteristics are specific to those who engage in EBP remains unclear. Further examination of EBP patients’ clinical profiles—with particular attention to factors that are likely to influence EBP referrals, such as comorbid pathology, suicidality, and mental
health treatment history—is needed. Identification of patient characteristics associated with an increased likelihood of EBP engagement can enhance knowledge of which patients are likely to participate in these therapies and, importantly, may aid in the identification of underserved populations who are not currently accessing these effective treatments. Toward this end, this study examined a sample of veterans who received individual psychotherapy from a provider trained in CPT or PE to examine patient-level correlates of EBP initiation and completion.
Method Participants and Procedure All procedures were approved by the local institutional review board and by the Veterans Affairs (VA) Research and Development Committee. This study included both provider and patient participants. We identified nine EBP-trained providers in a PTSD and anxiety specialty clinic in a large VA medical center who had previously completed an optional multiday training in CPT, PE, or both. Of the nine providers identified, eight expressed willingness to participate. The provider sample included licensed psychologists (n = 4), psychology fellows (n = 2), and social workers (n = 2). All eight providers were trained in CPT and seven were trained in PE. Five providers were VA certified in at least one EBP (four in CPT, and five in PE). We included providers who attended an EBP training workshop, but were not fully certified because the completion of the additional training components required for certification (e.g., follow-up consultation) may potentially be impacted by a variety of factors (e.g., busy work schedule, inability to complete consultation within specified time frame, patient dropout), and does not necessarily reflect the provider’s receptiveness or attitude toward EBP. Certified and noncertified providers were similar with respect to the proportion of patients in their caseloads who began EBP, χ2 (1, N = 8) = 1.21, p = .271 and completed EBP χ2 (1, N = 8) = 2.52, p = .112. The length of time between providers’ first EBP training and data extraction ranged from 12 to 48 months. After training, two providers saw between 10 and 20 patients, four providers saw between 30 and 90 patients, and two providers saw more than 200 patients. Providers began EBP (ࣙ 1 EBP session) with between 2 and 40 patients, and the proportion of patients within each provider’s caseload who began EBP ranged from 3.4% to 69.6% (M = 20.6%, SD = 16.2%). Length of time since EBP training (r = −.06, p = .888) and total caseload (r = .30, p = .470) were unrelated to the number of patients who received at least one EBP session from the provider. The patient sample included all patients (n = 796) who attended at least one individual outpatient psychotherapy session with any of the eight EBP-trained providers since the provider’s training (for providers trained in both CPT and PE, we used the earliest training date), identified through the VA Computerized Patient Record System. All patients received treatment with their EBP-trained provider between 2008 and 2012. Per clinic
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Veterans in Evidence-Based Therapy for PTSD
policy, patients were required to have an anxiety disorder diagnosis; it was not required that clinic patients meet criteria for PTSD. Upon enrollment in the PTSD and anxiety clinic, all patients completed a comprehensive mental health assessment consisting of a semistructured diagnostic interview created for the purpose of the evaluation and expressed intent to initiate psychotherapy. Providers indicated which of their patients received at least one session of individual protocol-driven CPT and/or PE (providers maintained a list of EBP patients for administrative purposes and could consult this list). Patients who began EBP (i.e., received at least one session of individual CPT or PE) were deemed EBP initiators and patients who began a non-EBP (i.e., received a form of individual psychotherapy other than CPT or PE) were deemed non-EBP initiators. Examples of individual psychotherapies offered and anxiety that were for the purposes of this study classified as non-EBP included supportive psychotherapy, relaxation, and psychoeducation. Among the 796 patients who received at least one individual psychotherapy session with an EBP-trained provider, 91 patients (11.4%) were identified as EBP initiators; all others were identified as nonEBP initiators (n = 705; 88.6%). To obtain more detailed information on patients’ characteristics and use of psychotherapy, we reviewed the 91 medical records of EBP initiators and a randomly selected providermatched sample of 66 non-EBP initiators. Although we initially intended to include an equal number of EBP and non-EBP initiators from each provider, three providers had administered EBP to more than half of their patients. Data extraction was based on best-practice standards (Gilbert, Lowenstein, KoziolMcLain, Barta, & Steiner, 1996).
Measures A coding manual developed for the study included operational definitions, data extraction instructions, and decision rules regarding missing data and conflicting patient records. A data extraction form was designed to record patient demographic variables including age, gender, race, marital status, education level, annual income, employment status, military service era, religion, and PTSD service connection (i.e., disability rating that affords veterans increased access to VHA services and monthly disability payments) and clinical variables including number and type of psychotherapy visits (CPT, PE, or nonEBP), prior inpatient hospitalizations, prior group psychotherapy, Global Assessment of Functioning (GAF) scores, delayed therapy with EBP-trained provider (>6 months between intake and therapy initiation), and suicide risk (extracted from the comprehensive mental health assessment prior to the start of therapy). We also extracted mental health diagnoses (PTSD, other anxiety disorder, depressive disorder, bipolar disorder, substance use disorder, psychotic disorder, personality disorder); these diagnoses were not mutually exclusive, and it was not possible to discern which was the primary diagnosis.
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Prior to chart review, four independent raters completed VA electronic medical record training and were trained by the first author in the use of the data extraction form. To establish initial interrater reliability, raters independently extracted data for the same six training cases (not eligible for study inclusion) and demonstrated acceptable agreement on demographic and clinical variables (κ> .80). Extracted data were entered into an electronic database. Throughout the project, raters attended weekly meetings to review coding rules and resolve disagreements. A fifth rater re-extracted data from a random 20% of patients and achieved good interrater agreement with original raters on clinical and demographic variables from double-coded cases (κ = .87–1.00). Demographic and clinical characteristics for the chart review sample (n = 157) are displayed in Table 1. Chart review data were also used to identify those patients who completed a full course of either CPT or PE. Participants were defined as EBP completers if they received at least seven EBP sessions (verified via chart review) and their provider indicated that they completed the full EBP protocol. We selected a 7-session benchmark based on prior research indicating that CPT patients meet good end-state criteria in an average of 7.5 sessions (Galovski, Blain, Mott, Elwood, & Houle, 2012) and because a 7-session cutoff has been used previously to define PE completion (Tuerk et al., 2012). A psychotherapy session was considered EBP if the provider identified the session as PE or CPT in the note (e.g., “This was session 2 of PE”) or described specific elements of PE (imaginal exposure, in vivo exposure) or CPT (impact statement, ABC sheets, trauma account, challenging beliefs worksheet). Given increasing recognition that some patients require sessions beyond the traditional protocol length to experience meaningful change in PTSD symptoms (Galovski et al., 2012), provider verification of EBP completion status offered increased assurance of treatment completion. Patients who began EBP, but failed to meet either completion criterion, were deemed EBP dropouts. Figure 1 displays the number of CPT and PE completers within the EBP initiator sample. Four EBP dropouts met one criterion for EBP completion, but not the other; three EBP dropouts had seven or more EBP sessions, but their provider did not consider them an EBP completer, and conversely, one EBP dropout was defined as an EBP completer by the provider, but attended only five EBP sessions. Excluding patients who were more than 3 standard deviations above the mean with respect to number of psychotherapy visits (n = 3), EBP initiators attended a mean of 16.07 (SD = 11.34) total therapy sessions with their provider; on average, 9.92 (SD = 6.02) of these were EBP sessions. Most EBP initiators (70.3%) received a mixture of EBP and non-EBP sessions from their provider. EBP completers attended an average of 17.50 (SD = 10.40) total therapy sessions including 13.17 (SD = 4.45) EBP sessions whereas EBP dropouts attended an average of 13.47 (SD = 12.62) total therapy sessions including 4.03 (SD = 3.46) EBP sessions. CPT dropouts most commonly discontinued treatment after three CPT sessions, and PE patients most commonly discontinued after two PE sessions.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
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Mott et al.
Table 1 Total Sample and Difference Between EBP Initiators and non-EBP Initiators on Demographic and Clinical Variables Full chart review sample (n = 157)
EBP initiators (n = 91)
Non-EBP initiators (n = 66)
Variable
n or M
% or SD
n or M
% or SD
n or M
% or SD
χ2 or t
PTSD diagnosis Non-PTSD anxiety disorder Depressive disorder Bipolar disorder Substance use disorder Psychotic disorder Personality disorder Prior group psychotherapy Prior inpatient stay >6 months delayed therapy Suicide risk PTSD service connection Ethnicitya (White) Gender (male) Educationa (> high school) Employmenta (employed) Marital statusa (married) Era (OEF/OIF/OND) Religiona Age (years) GAF Annual income ($)
138 50 100 5 42 7 5 85 33 104 23 116 98 142 93 63 86 79 119 46.64 54.91 35,000
87.9 31.8 63.7 3.2 26.8 4.5 3.2 54.1 21.0 66.2 14.6 73.9 64.9 90.4 64.6 41.7 55.8 50.6 84.4 16.00 7.76 28,000
86 26 58 2 20 3 2 58 16 70 10 75 53 83 50 42 56 37 70 50.42 55.65 36,000
94.5 28.6 63.7 2.2 22.0 3.3 2.2 63.7 17.6 77.0 11.0 82.4 60.9 91.2 59.5 46.2 61.5 40.6 84.3 16.06 6.06 27,000
52 24 42 3 22 4 3 27 17 34 13 41 45 59 43 21 30 42 49 41.44 54.00 33,000
78.8 36.4 63.6 4.5 33.3 6.1 4.5 41.0 25.8 51.5 19.6 62.1 70.3 89.4 71.7 31.8 45.5 63.6 84.5 14.43 9.24 29,000
18.32* 1.07 6 months delayed EBP Suicide risk EBP type (PE) PTSD service connection Ethnicitya (White) Gender (male) Educationa (> high school) Employmenta (employed) Marital statusa (married) Service era (OEF/OIF/OND) Religiona Age (years) GAFa Annual income ($)
16 37 12 45 7 50 6 46 46 31 55 37 24 38 14 46 55.53 55.48 38,000
27.6 63.8 20.7 77.6 12.1 86.2 10.3 79.3 79.3 56.4 94.8 67.3 42.9 66.7 24.1 85.2 13.67 6.25 29,000
10 21 8 13 9 20 4 21 29 22 28 13 18 18 23 24 41.87 55.28 33,000
30.3 63.6 24.2 39.4 27.3 60.6 12.1 63.6 87.9 68.8 84.8 44.8 53.6 54.5 69.7 82.8 15.94 5.87 22,000
0.08
Characteristics of U.S. Veterans Who Begin and Complete Prolonged Exposure and Cognitive Processing Therapy for PTSD Juliette M. Mott,1,2,3 Sasha Mondragon,1,2 Natalie E. Hundt,1,2,3 Melissa Beason-Smith,1,2 Rebecca H. Grady,1,2,3 and Ellen J. Teng1,2,3 1
2
Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine, Houston, Texas, USA 3 South Central Mental Illness Research, Education, and Clinical Center, Houston, Texas, USA
This retrospective chart-review study examined patient-level correlates of initiation and completion of evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) among treatment-seeking U.S. veterans. We identified all patients (N = 796) in a large Veterans Affairs PTSD and anxiety clinic who attended at least 1 individual psychotherapy appointment with 1 of 8 providers trained in EBP. Within this group, 91 patients (11.4%) began EBP (either Cognitive Processing Therapy or Prolonged Exposure) and 59 patients (7.9%) completed EBP. The medical records of all EBP patients (n = 91) and a provider-matched sample of patients who received another form of individual psychotherapy (n = 66) were reviewed by 4 independent raters. Logistic regression analyses revealed that Iraq and Afghanistan veterans were less likely to begin EBP than veterans from other service eras, OR = 0.48, 95% CI = [0.24, 0.94], and veterans who were service connected for PTSD were more likely than veterans without service connection to begin EBP, OR = 2.33, 95% CI = [1.09, 5.03]. Among those who began EBP, Iraq and Afghanistan veteran status, OR = 0.09, 95% CI = [0.03, 0.30], and a history of psychiatric inpatient hospitalization, OR = 0.13, 95% CI = [0.03, 0.54], were associated with decreased likelihood of EBP completion.
Given that posttraumatic stress disorder (PTSD) is one of the most common mental health diagnoses among U.S. military veterans (Barrera et al., 2014; Cohen et al., 2010), providing high-quality PTSD treatment is a critical mission to the Veterans Health Administration (VHA). To increase access to care, the VHA implemented large-scale efforts to train clinicians in two evidence-based psychotherapy (EBP) protocols for PTSD: cognitive processing therapy (CPT) and prolonged exposure (PE). Both are manualized, cognitive–behavioral interventions that typically consist of 8–12 weekly sessions (Foa, Hembree,
& Rothbaum, 2007; Resick, Monson, & Chard, 2008). To date, more than 2,300 VHA clinicians have been trained in CPT, and more than 1,500 have been trained in PE (Eftekhari et al., 2013; Karlin et al., 2010). These dissemination efforts have increased the VHA’s potential to provide evidence-based care to veterans with PTSD (Cook, Dinnen, Thompson, Simiola, & Schnurr, 2014). To evaluate the impact of EBP dissemination initiatives, several recent studies have assessed the use of CPT and PE within the VHA. Although VHA administrative databases do not contain information on the type of psychotherapy delivered, prior studies have used these databases to determine the number of patients who received at least 8 or 9 psychotherapy sessions, and therefore could have potentially completed a full course of EBP. Consistently, these studies indicate that less than 10% of veterans with PTSD could have feasibly completed an EBP (Mott, Hundt, Sansgiry, Mignogna, & Cully, 2014; Seal et al., 2010). To estimate EBP initiation more precisely, Shiner and colleagues (2012) reviewed the text of psychotherapy notes from more than 1,900 patients across 6 VHA facilities and reported that only 6% of veterans received one or more EBP sessions in the 6 months following enrollment in a PTSD clinic. This suggests that most veterans who receive psychotherapy in specialized PTSD care settings are receiving treatments other than VHA-recommended EBPs.
Juliette Mott is currently affiliated with the National Center for PTSD in White River Junction, Vermont USA. This research was supported in part by the Office of Academic Affiliations VA Advanced Fellowship Program in Mental Illness Research and Treatment, by the Houston VA HSR&D Center of Excellence (Houston Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413), and by a VA Clinical Sciences Research and Development (CSR&D) Career Development Award (#CADE-MHN/F09) awarded to Ellen J. Teng at the Michael E. DeBakey Veterans Affairs Medical Center. The views expressed reflect those of the authors and not necessarily the Department of Veterans Affairs/Baylor College of Medicine. Correspondence concerning this article should be addressed to Juliette Mott, National Center for PTSD, VA Medical Center (116D), 215 North Main Street, White River Junction, VT 05009. E-mail: [email protected] Published 2014. This article is a US Government work and is in the public domain in the USA. View this article online at wileyonlinelibrary.com DOI: 10.1002/jts.21927
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Although the VHA mandates that all patients with PTSD have access to CPT or PE, the decision of whether a veteran receives one of these treatments is left to the veteran and provider (McHugh & Barlow, 2010). Patients and providers may find little empirical guidance for treatment selection, as research informing evidence-based treatment decisions based on patient characteristics such as age or trauma type is only in the beginning stages (Sharpless & Barber, 2011). Prior research has demonstrated the effectiveness of CPT and PE in veteran populations that are diverse with respect to gender (Schnurr et al., 2007), service era (Yoder et al., 2012), trauma type (Rauch et al., 2009), and psychiatric comorbidities (Monson et al., 2006), suggesting that these treatments have the potential for broad patient reach. Practice guidelines and EBP manuals offer differing perspectives on which patients are likely appropriate for CPT or PE. The VHA/Department of Defense (DoD) clinical practice guideline for management of PTSD (2010) endorses PE and CPT at the highest possible level, indicating “a strong recommendation that clinicians provide the intervention to eligible patients” (p. 201). PE and CPT therapist manuals, however, indicate that not all patients with PTSD are appropriate for these treatments. The PE manual recommends that PE not be initiated in the presence of imminent threat of suicide or homicide, serious self-injurious behavior, current psychosis, current high risk of being assaulted or insufficient memory of the trauma (Foa et al., 2007). The CPT manual (Resick et al., 2008) cautions against the treatment of patients who are in imminent danger, suffer from severe dissociation or panic attacks that may interfere with treatment, and recommends case-by-case decisions for patients with substance dependence and self-harming behaviors. Both manuals indicate that comorbid depression is not a rule-out and note that patients with subthreshold PTSD symptoms may be appropriate. Thus, these manuals suggest that PE and CPT are not appropriate for all patients with PTSD and may be useful for patients without a full PTSD diagnosis. Although VHA policies and therapist manuals each provide unique perspectives on which patients should receive EBP for PTSD, a burgeoning body of research has attempted to describe the population of veterans who actually receive these treatments. A number of studies have found that veterans who received PE in VHA PTSD clinics were predominately White, male, high-school educated, and service-connected for PTSD (Gros, Yoder, Tuerk, Lozano, & Acierno, 2011; Rauch et al., 2009; Tuerk, Yoder, Ruggiero, Gros, & Acierno, 2010; Yoder et al., 2012). This mirrors the general population of veterans who seek treatment (not necessarily EBP) for PTSD (Seal et al., 2010; Spoont, Murdoch, Hodges, & Nugent, 2010). Given that these studies did not compare directly the characteristics of patients who received EBP to those who received an alternative treatment, the degree to which observed patient characteristics are specific to those who engage in EBP remains unclear. Further examination of EBP patients’ clinical profiles—with particular attention to factors that are likely to influence EBP referrals, such as comorbid pathology, suicidality, and mental
health treatment history—is needed. Identification of patient characteristics associated with an increased likelihood of EBP engagement can enhance knowledge of which patients are likely to participate in these therapies and, importantly, may aid in the identification of underserved populations who are not currently accessing these effective treatments. Toward this end, this study examined a sample of veterans who received individual psychotherapy from a provider trained in CPT or PE to examine patient-level correlates of EBP initiation and completion.
Method Participants and Procedure All procedures were approved by the local institutional review board and by the Veterans Affairs (VA) Research and Development Committee. This study included both provider and patient participants. We identified nine EBP-trained providers in a PTSD and anxiety specialty clinic in a large VA medical center who had previously completed an optional multiday training in CPT, PE, or both. Of the nine providers identified, eight expressed willingness to participate. The provider sample included licensed psychologists (n = 4), psychology fellows (n = 2), and social workers (n = 2). All eight providers were trained in CPT and seven were trained in PE. Five providers were VA certified in at least one EBP (four in CPT, and five in PE). We included providers who attended an EBP training workshop, but were not fully certified because the completion of the additional training components required for certification (e.g., follow-up consultation) may potentially be impacted by a variety of factors (e.g., busy work schedule, inability to complete consultation within specified time frame, patient dropout), and does not necessarily reflect the provider’s receptiveness or attitude toward EBP. Certified and noncertified providers were similar with respect to the proportion of patients in their caseloads who began EBP, χ2 (1, N = 8) = 1.21, p = .271 and completed EBP χ2 (1, N = 8) = 2.52, p = .112. The length of time between providers’ first EBP training and data extraction ranged from 12 to 48 months. After training, two providers saw between 10 and 20 patients, four providers saw between 30 and 90 patients, and two providers saw more than 200 patients. Providers began EBP (ࣙ 1 EBP session) with between 2 and 40 patients, and the proportion of patients within each provider’s caseload who began EBP ranged from 3.4% to 69.6% (M = 20.6%, SD = 16.2%). Length of time since EBP training (r = −.06, p = .888) and total caseload (r = .30, p = .470) were unrelated to the number of patients who received at least one EBP session from the provider. The patient sample included all patients (n = 796) who attended at least one individual outpatient psychotherapy session with any of the eight EBP-trained providers since the provider’s training (for providers trained in both CPT and PE, we used the earliest training date), identified through the VA Computerized Patient Record System. All patients received treatment with their EBP-trained provider between 2008 and 2012. Per clinic
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Veterans in Evidence-Based Therapy for PTSD
policy, patients were required to have an anxiety disorder diagnosis; it was not required that clinic patients meet criteria for PTSD. Upon enrollment in the PTSD and anxiety clinic, all patients completed a comprehensive mental health assessment consisting of a semistructured diagnostic interview created for the purpose of the evaluation and expressed intent to initiate psychotherapy. Providers indicated which of their patients received at least one session of individual protocol-driven CPT and/or PE (providers maintained a list of EBP patients for administrative purposes and could consult this list). Patients who began EBP (i.e., received at least one session of individual CPT or PE) were deemed EBP initiators and patients who began a non-EBP (i.e., received a form of individual psychotherapy other than CPT or PE) were deemed non-EBP initiators. Examples of individual psychotherapies offered and anxiety that were for the purposes of this study classified as non-EBP included supportive psychotherapy, relaxation, and psychoeducation. Among the 796 patients who received at least one individual psychotherapy session with an EBP-trained provider, 91 patients (11.4%) were identified as EBP initiators; all others were identified as nonEBP initiators (n = 705; 88.6%). To obtain more detailed information on patients’ characteristics and use of psychotherapy, we reviewed the 91 medical records of EBP initiators and a randomly selected providermatched sample of 66 non-EBP initiators. Although we initially intended to include an equal number of EBP and non-EBP initiators from each provider, three providers had administered EBP to more than half of their patients. Data extraction was based on best-practice standards (Gilbert, Lowenstein, KoziolMcLain, Barta, & Steiner, 1996).
Measures A coding manual developed for the study included operational definitions, data extraction instructions, and decision rules regarding missing data and conflicting patient records. A data extraction form was designed to record patient demographic variables including age, gender, race, marital status, education level, annual income, employment status, military service era, religion, and PTSD service connection (i.e., disability rating that affords veterans increased access to VHA services and monthly disability payments) and clinical variables including number and type of psychotherapy visits (CPT, PE, or nonEBP), prior inpatient hospitalizations, prior group psychotherapy, Global Assessment of Functioning (GAF) scores, delayed therapy with EBP-trained provider (>6 months between intake and therapy initiation), and suicide risk (extracted from the comprehensive mental health assessment prior to the start of therapy). We also extracted mental health diagnoses (PTSD, other anxiety disorder, depressive disorder, bipolar disorder, substance use disorder, psychotic disorder, personality disorder); these diagnoses were not mutually exclusive, and it was not possible to discern which was the primary diagnosis.
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Prior to chart review, four independent raters completed VA electronic medical record training and were trained by the first author in the use of the data extraction form. To establish initial interrater reliability, raters independently extracted data for the same six training cases (not eligible for study inclusion) and demonstrated acceptable agreement on demographic and clinical variables (κ> .80). Extracted data were entered into an electronic database. Throughout the project, raters attended weekly meetings to review coding rules and resolve disagreements. A fifth rater re-extracted data from a random 20% of patients and achieved good interrater agreement with original raters on clinical and demographic variables from double-coded cases (κ = .87–1.00). Demographic and clinical characteristics for the chart review sample (n = 157) are displayed in Table 1. Chart review data were also used to identify those patients who completed a full course of either CPT or PE. Participants were defined as EBP completers if they received at least seven EBP sessions (verified via chart review) and their provider indicated that they completed the full EBP protocol. We selected a 7-session benchmark based on prior research indicating that CPT patients meet good end-state criteria in an average of 7.5 sessions (Galovski, Blain, Mott, Elwood, & Houle, 2012) and because a 7-session cutoff has been used previously to define PE completion (Tuerk et al., 2012). A psychotherapy session was considered EBP if the provider identified the session as PE or CPT in the note (e.g., “This was session 2 of PE”) or described specific elements of PE (imaginal exposure, in vivo exposure) or CPT (impact statement, ABC sheets, trauma account, challenging beliefs worksheet). Given increasing recognition that some patients require sessions beyond the traditional protocol length to experience meaningful change in PTSD symptoms (Galovski et al., 2012), provider verification of EBP completion status offered increased assurance of treatment completion. Patients who began EBP, but failed to meet either completion criterion, were deemed EBP dropouts. Figure 1 displays the number of CPT and PE completers within the EBP initiator sample. Four EBP dropouts met one criterion for EBP completion, but not the other; three EBP dropouts had seven or more EBP sessions, but their provider did not consider them an EBP completer, and conversely, one EBP dropout was defined as an EBP completer by the provider, but attended only five EBP sessions. Excluding patients who were more than 3 standard deviations above the mean with respect to number of psychotherapy visits (n = 3), EBP initiators attended a mean of 16.07 (SD = 11.34) total therapy sessions with their provider; on average, 9.92 (SD = 6.02) of these were EBP sessions. Most EBP initiators (70.3%) received a mixture of EBP and non-EBP sessions from their provider. EBP completers attended an average of 17.50 (SD = 10.40) total therapy sessions including 13.17 (SD = 4.45) EBP sessions whereas EBP dropouts attended an average of 13.47 (SD = 12.62) total therapy sessions including 4.03 (SD = 3.46) EBP sessions. CPT dropouts most commonly discontinued treatment after three CPT sessions, and PE patients most commonly discontinued after two PE sessions.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
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Table 1 Total Sample and Difference Between EBP Initiators and non-EBP Initiators on Demographic and Clinical Variables Full chart review sample (n = 157)
EBP initiators (n = 91)
Non-EBP initiators (n = 66)
Variable
n or M
% or SD
n or M
% or SD
n or M
% or SD
χ2 or t
PTSD diagnosis Non-PTSD anxiety disorder Depressive disorder Bipolar disorder Substance use disorder Psychotic disorder Personality disorder Prior group psychotherapy Prior inpatient stay >6 months delayed therapy Suicide risk PTSD service connection Ethnicitya (White) Gender (male) Educationa (> high school) Employmenta (employed) Marital statusa (married) Era (OEF/OIF/OND) Religiona Age (years) GAF Annual income ($)
138 50 100 5 42 7 5 85 33 104 23 116 98 142 93 63 86 79 119 46.64 54.91 35,000
87.9 31.8 63.7 3.2 26.8 4.5 3.2 54.1 21.0 66.2 14.6 73.9 64.9 90.4 64.6 41.7 55.8 50.6 84.4 16.00 7.76 28,000
86 26 58 2 20 3 2 58 16 70 10 75 53 83 50 42 56 37 70 50.42 55.65 36,000
94.5 28.6 63.7 2.2 22.0 3.3 2.2 63.7 17.6 77.0 11.0 82.4 60.9 91.2 59.5 46.2 61.5 40.6 84.3 16.06 6.06 27,000
52 24 42 3 22 4 3 27 17 34 13 41 45 59 43 21 30 42 49 41.44 54.00 33,000
78.8 36.4 63.6 4.5 33.3 6.1 4.5 41.0 25.8 51.5 19.6 62.1 70.3 89.4 71.7 31.8 45.5 63.6 84.5 14.43 9.24 29,000
18.32* 1.07 6 months delayed EBP Suicide risk EBP type (PE) PTSD service connection Ethnicitya (White) Gender (male) Educationa (> high school) Employmenta (employed) Marital statusa (married) Service era (OEF/OIF/OND) Religiona Age (years) GAFa Annual income ($)
16 37 12 45 7 50 6 46 46 31 55 37 24 38 14 46 55.53 55.48 38,000
27.6 63.8 20.7 77.6 12.1 86.2 10.3 79.3 79.3 56.4 94.8 67.3 42.9 66.7 24.1 85.2 13.67 6.25 29,000
10 21 8 13 9 20 4 21 29 22 28 13 18 18 23 24 41.87 55.28 33,000
30.3 63.6 24.2 39.4 27.3 60.6 12.1 63.6 87.9 68.8 84.8 44.8 53.6 54.5 69.7 82.8 15.94 5.87 22,000
0.08
