Acceptability of Prolonged Exposure Therapy Among U.S. Iraq War Veterans With PTSD Symptomology

Journal of Traumatic StressAugust 2014, 27, 483–487

BRIEF REPORT

Acceptability of Prolonged Exposure Therapy Among U.S.Iraq War Veterans With PTSD Symptomology

Shannon M. Kehle-Forbes,1,2 Melissa A. Polusny,1,3 Christopher R. Erbes,1,3 and Heather Gerould1

1Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA2Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA

3Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota, USA

Despite efforts to increase the availability of prolonged exposure therapy (PE) within the Department of Veterans Affairs, little is knownabout the acceptability of PE among veteran populations. We queried a sample of 58 U.S. National Guard Iraq War veterans previouslydeployed to combat who screened positive for posttraumatic stress disorder (PTSD) as to whether they would prefer PE, treatment withan antidepressant, or no treatment. We also gathered open-ended responses regarding the veterans’ reasons for their choice and potentialbarriers to engaging in that treatment. A majority (53.4%) of veterans who completed the interview said they would choose to participatein PE, 36.2% preferred antidepressant treatment, 8.6% chose no treatment, and 1.8% were unable to choose among the options. Credibilityof the treatment rationale and beliefs about the treatment’s efficacy were the most frequently given reasons for choosing PE (45.2%); pasttreatment experience was the most common reason for choosing antidepressant treatment (47.6%). The most commonly cited barrier forthose who chose both antidepressant treatment and PE was time to participate (52.4% and 77.4%, respectively). The findings suggest thatPE is a credible and acceptable treatment option for veterans with PTSD symptomology.

Positive findings from a large number of clinical trials ledto prolonged exposure therapy (PE) being endorsed as a first-line treatment for posttraumatic stress disorder (PTSD) by theU.S. Department of Veterans Affairs (VA; U.S. Department ofVeterans Affairs and the U.S. Department of Defense, 2010).As such, the VA has trained over 1,500 providers to deliverthe treatment (Eftekhari et al., 2013). Despite the availability oftrained providers, the only known evaluation of rates of deliverysuggests that few veterans have received PE. Within outpatientPTSD clinics in New England in fiscal year 2010, only 1.5% ofveterans received at least one session of PE within 6 months ofclinic enrollment (Shiner et al., 2012).

One potential explanation for the mismatch between theavailability of PE and the number of veterans who have re-

This material is based upon work support by VA Quality Enhancement Re-search Initiative (QUERI grant 10-056) and the U.S. Department of VeteransAffairs, Veterans Health Administration, Health Services Research and Devel-opment. Dr. Kehle-Forbes is supported by a VA Health Services Research &Development Career Development Award. The views expressed in this articleare those of the authors and do not necessarily represent the views of the U.S.Department of Veterans Affairs or the U.S. Department of Defense.

Correspondence concerning this article should be addressed to Shannon Kehle-Forbes, Center for Chronic Disease Outcomes Research, Minneapolis VAHealth Care System, One Veterans Drive (152), Minneapolis, MN 55417.E-mail: [email protected]

Published 2014. This article is a US Government work and is in the publicdomain in the USA. View this article online at wileyonlinelibrary.comDOI: 10.1002/jts.21935

ceived the treatment is that veterans do not view PE as an ac-ceptable treatment option, and thus, have not been interested inengaging in the therapy. Prior studies that examined the accept-ability of PE among civilian populations found that a majorityof individuals prefer PE as compared to other treatment options(Feeny, Zoellner, Mavissakalian, & Roy-Byrne, 2009). For ex-ample, 82% of women with a history of trauma exposure and74% of women with PTSD entering an open-choice trial chosePE over selective serotonin reuptake inhibitors (SSRIs; Feenyet al., 2009). Women reported that they chose PE because themechanism of action made sense; specifically, women felt asthough they needed to talk about their trauma to recover from it(Angelo, Miller, Zoellner, & Feeny, 2008). Reger and col-leagues (2012) studied 174 Operation Iraqi Freedom (OIF)soldiers’ attitudes towards PE, virtual reality exposure, andmedication for the treatment of PTSD. Soldiers reported morepositive attitudes towards PE and virtual reality exposure thanmedication across a variety of domains, including willingness torecommend the treatment and belief in treatment efficacy. Theauthors did not examine which treatment the soldiers wouldchoose for themselves.

The objective of this study was to expand previous work re-garding PTSD treatment choice to veterans with PTSD sympto-mology. We queried a sample of OIF National Guard veteranswho were previously deployed to combat and who screened pos-itive for PTSD as to whether they would prefer PE, treatmentwith an SSRI, or no treatment. Despite the small proportion of

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veterans receiving PE, the demonstrated acceptability of PE incivilian and military samples led us to hypothesize that a ma-jority of veterans would prefer PE. Further, we gathered open-ended responses regarding veterans’ reasons for choosing theirselected treatment and potential barriers to engaging in the treat-ment. Prior work has shown that agreement with a treatmentrationale is associated with treatment preference and accep-tance; as such, we hypothesized that the most common reasonfor choosing a treatment would be fit between the treatmentand the veteran’s understanding of what was needed to improve(Angelo et al., 2008; Johnson et al., 2000). Finally, we expectedthat reported barriers would be similar to those outlined in a re-view article regarding general mental health treatment-seekingamong OIF veterans: practical barriers, concerns about stigma,and negative beliefs about mental health treatment (Zinzow,Britt, McFadden, Burnette, & Gillispie, 2012).

Method

Participants and Procedure

Participants were 58 U.S. OIF National Guard veterans from alongitudinal project that had been approved by the Minneapo-lis VA Health Care System Institutional Review Board andNational Guard command. We recruited 91 individuals whoscreened positive for PTSD on the PTSD Checklist-Militaryversion (PCL-M) administered as part of a 3-year postdeploy-ment survey (Weathers, Litz, Herman, Huska, & Keane, 1993).A positive PTSD screen required participants to have a totalscore of at least 50 and to have endorsed one reexperiencing,three avoidance, and two arousal symptoms at a moderate levelor greater (Hoge et al., 2004). Only 59 veterans (64.8%) com-pleted interviews, however, one did not record; therefore, wehave complete data for 58 veterans. Interview participants werelargely enlisted (93.1%), male (98.3%), Caucasian (93.1%),and the average age was 35.44 years (SD = 7.54). Intervieweesdid not differ on PCL-M scores, enlisted status, gender, age, orrace from those not interviewed.

The phone interview included, a research assistant readingthe participant a script that described the treatments and ex-plained the treatment components, the treatment rationale, theevidence base, and the risks of two treatments for PTSD (PEand SSRI). The descriptions were a modified version of scriptspreviously used in a study of traumatized civilians (Feeny et al.,2009). The SSRI description was modified to better reflect thefrequency and length of appointments within the Minneapo-lis VA Healthcare System. Descriptions were counterbalancedand were parallel in terms of sentence structure, syntax, andgrade level. Veterans selected a preferred treatment; those whochose either PE or SSRIs then reported reasons for the treat-ment preference and potential barriers to engaging in the chosentreatment.

Participants’ responses to the open-ended items were audio-taped and transcribed. To create the qualitative codebook, twoinvestigators first read the interview transcripts independently,without consultation, to get a sense of the range of responses.

They then generated a complete list of reasons for treatmentchoice and barriers to engaging in treatment. Next, the investi-gators jointly reviewed their preliminary codes and developeda codebook that included key themes, a detailed description ofthe code, and a typical exemplar for each code. The final keythemes resulted from this process. To verify the trustworthinessof the coding scheme, 10% of the transcripts were randomlyselected to be coded by both investigators. Interrater reliabilitywas acceptable (κ = .85).

Measures

The PCL-M (Weathers et al., 1993) was administered as partof the 3-year postdeployment survey (Cronbach’s α = .76 forinterviewees). Postdeployment psychotherapy and psychiatricmedication use was assessed using two dichotomous (yes orno) items in the 3-year postdeployment survey (Erbes, West-ermeyer, Engdahl, & Johnsen, 2007). During the interview,participants were asked the forced choice question, “If youhad a choice between prolonged exposure therapy, medication(SSRI), and no treatment to help with trauma related symp-toms, which would you choose?” Participants who chose PEor SSRI treatment were then asked the open-ended questions,“What factors influenced your choice?” and “What might getin the way of you participating in your chosen treatment?”

Data Analysis

A descriptive, inductive approach to coding and interpretiveanalysis of the content was used (Saldana, 2013). The investi-gators applied the coding scheme to the transcripts; every re-sponse was accounted for during the coding process. Each keytheme was subcoded as either a pro for the chosen treatmentor a con for the treatment that was not chosen. As a final step,each response was categorized into one of the key themes andthe proportion of veterans who endorsed each key theme wascalculated. Key themes that were endorsed by only one veteranwere categorized as other. Treatment choice was used as an in-dependent grouping variable in a one-way analysis of varianceand Pearson χ2 tests that examined differences across treatmentchoice by PTSD symptomology and previous treatment partici-pation. One veteran was unable to choose between the treatmentoptions and thus was excluded from the quantitative analyses.

Results

A majority (53.4%; n = 31) of veterans chose PE, 36.2% (n =21) preferred SSRI treatment, 8.6% (n = 5) chose no treatment,and 1.8% (n = 1) was unable to choose between the options.PTSD symptoms did not differ by treatment choice, F(2,54) =0.22, p = .805, η2 = .01. There was also not a significantdeviation from expected frequencies of treatment preferencefor those with and without prior psychotherapy, χ2 (2, N =57) = 1.01, p = .604. Such a deviation did exist amongthose with and without past use of psychiatric medicationsχ2 (2, N = 57) = 6.40, p = .041. The percentage of

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

PE Acceptability Among IRAQ War Veterans 485

Table 1Key Themes Regarding Reasons for Specific Treatment Choice

Prolonged exposure (n = 31) SSRI treatment (n = 21)

Endorsed asa pro forchosen

Endorsed asa con for thealternative

Endorsed asa pro forchosen

Endorsed asa con for thealternative

Key theme n % n % n % n %

Time to attend andparticipate intreatment

4 12.9 0 0.0 4 19.0 5 23.8

Past experience withtreatment

8 25.8 9 29.0 10 47.6 4 19.0

Timing of symptomrelief

1 3.2 0 0.0 2 9.5 1 4.8

Concerns about ordesire fortherapeuticrelationship

5 16.1 2 6.5 0 0.0 3 14.3

Concerns aboutstigma / privacy

0 0.0 1 3.2 1 4.8 0 0.0

Emotional intensityof treatment

1 3.2 0 0.0 0 0.0 2 9.5

Credibility of thetreatment/perceived efficacy

14 45.2 12 38.7 4 19.0 3 14.3

Perceived sideeffects

0 0.0 9 29.0 0 0.0 1 4.8

Note. Does not contain veterans who chose no treatment (n = 5) or those who couldn’t make a choice (n = 1). SSRI = selective serotonin reuptake inhibitor.

veterans that preferred SSRI treatment varied based on whetherthey had (81.0%) or had not (19.0%) previously received psy-chiatric medications.

Among veterans who chose either PE or SSRIs, the averagenumber of reasons given for treatment choice was 2.14 (SD =0.94), with an equal number of reasons to engage in the chosentreatment (M = 1.06, SD = 0.76) and to avoid the alternativetreatment (M = 1.08, SD = 0.74). Table 1 reports the final eightkey themes identified as reasons for treatment choice. Treatmentcredibility (e.g., the rationale made sense) and veterans’ beliefthat the treatment would help were the most common reasonsfor choosing PE. The second most common theme was concernabout the credibility and effectiveness of SSRIs. These themesoften appeared together, such as in this quote from a veteran whochose PE, “It helps to talk about it with people who understandit, instead of someone just handing you pills and saying ‘heretake these. If you need more, take those.’” Past experiencewith medications was given as a reason for choosing SSRItreatment considerably more often than any other reason. Oneveteran stated, “I suffered a little bit of PTSD previously andI took something similar to Zoloft and that actually helped.[It] brought [it] . . . under control, so that now I can cope witheveryday life stuff.”

Among veterans who chose either PE or SSRI treatment, theaverage number of reported barriers was 1.67 (SD = 0.74).The number of reported barriers did not differ by treatmentchoice. Table 2 reports the final key themes identified in re-sponse to the question about barriers to participating in theirchosen treatment. Sixteen unique themes were identified, al-though eight key themes were only endorsed by one veteranand were categorized as other. The most commonly cited bar-rier for those who chose both PE and SSRI treatment was timeto participate. This included time to attend appointments, travelto the nearest VA treatment facility, and complete homework.A veteran who chose PE stated, “The amount of time [it takes],scheduling with work, making sure I have enough family timewith my wife and daughter.” The second most often reportedbarrier was concern about the therapeutic relationship; the re-sponses focused around developing a trusting relationship witha provider, particularly one who had not served in combat.

Discussion

Over 50% of veterans reported that they would participate inPE; however, the percentage was lower than has been found in


486 Kehle-Forbes et al.

Table 2Percentage of Veterans Who Reported Key Themes RegardingBarriers to Engaging in Chosen Treatment

Prolongedexposure(n = 31)

SSRItreatment(n = 21)

Key theme n % n %

Side effects 1 3.2 4 19.0Time to attend

appointments24 77.4 11 52.4

Concerns aboutdeploymentcycle

2 6.5 1 4.8

Poor therapeuticrelationship

14 45.2 2 9.5

Financialconcerns /cost

4 12.9 1 4.8

Concerns aboutstigma/privacy

9 29.0 1 4.8

Denial thattherapy isneeded

1 3.2 2 9.5

No identifiedbarriers

2 6.5 4 19.0

Other 2 6.5 6 28.6

Note. Does not contain veterans who chose no treatment (n = 5) or those whocouldn’t make a choice (n = 1). SSRI = selective serotonin reuptake inhibitor.

prior studies. There are several differences between this study’ssample and those of past studies that may explain the lowerrate. This was a veteran, largely male sample that had been ex-posed to combat-related traumas; whereas comparable studiesused civilian female samples with a preponderance of assaulttraumas (Feeny et al., 2009). There were too few women inthe current sample to examine gender differences; however, nogender differences were found in Reger et al.’s (2012) studyof soldiers’ attitudes toward PTSD treatment options. Differ-ences in treatment preference by trauma type and veteran statushave not been directly evaluated and should be examined infuture studies. Reasons for treatment choice given by veteranswere similar to those seen in both college and trauma-exposedsamples (Angelo et al., 2008; Cochran, Pruitt, Fukuda, Zoell-ner, & Feeny, 2008). Veterans, however, frequently cited pastexperiences with treatment as a factor in their decision mak-ing, unlike civilian women with similar rates of prior mentalhealth treatment (Feeny et al., 2009). Finally, consistent withour hypothesis, veterans’ reported barriers were similar to priorstudies that examined barriers to general mental health seekingamong veterans (Sayer et al., 2009).

An important limitation of this study was the exclusion ofother treatment options. VA clinics offer an array of servicesbeyond PE and SSRI treatment. It is possible that if presented

with a broader range of treatment options, fewer veterans wouldhave selected PE. Becker, Darius, and Schaumberg (2007) ex-amined this issue among an analogue college student sampleand found that when presented with a range of psychother-apy options, a majority of participants still selected exposuretherapy. It is unknown whether this finding would translate toa clinical veteran population. A final limitation is the lack ofracial and ethnic diversity in our sample. Prior research suggeststhat beliefs about mental illness and treatment vary across racialand ethnic groups, thus, caution should be taken in generaliz-ing these findings beyond Caucasian National Guard veterans(Stecker, Fortney, Hamilton, Sherbourne, & Ajzen, 2010).

Despite these limitations, the study demonstrates that OIFveterans with PTSD symptomology view PE as an acceptabletreatment option that is credible and likely to reduce symptoms.This suggests that patient acceptability is likely not a primaryfactor in the limited number of veterans who have received PE.Further, these findings imply that if clinicians were to providebrief psychoeducation regarding the rationale, evidence, risks,and benefits of PE a greater number of OIF veterans may ex-press interest in the treatment. Although it is unknown whethergreater interest would translate to higher rates of engagement,prior research with OIF veterans has shown that beliefs aboutthe beneficial impact of treatment on symptoms is associatedwith mental health treatment engagement (Stecker, Fortney,Hamilton, Sherbourne, & Ajzen, 2010). Future studies shouldexamine the impact of providing such information in a clinicalsetting, factors that facilitate treatment initiation among thosewho express interest in PE, and additional patient, provider,and system-level factors that limit the number of veterans whoinitiate PE.

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Acceptability of Prolonged Exposure Therapy Among U.S. Iraq War Veterans With PTSD Symptomology