Characteristics of U.S. Veterans Who Begin and Complete Prolonged Exposure and Cognitive Processing Therapy for PTSD

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  • Journal of Traumatic StressJune 2014, 27, 265273

    Characteristics of U.S. Veterans Who Begin and CompleteProlonged 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. Teng1,2,31Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA

    2Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine, Houston, Texas, USA3South 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 largeVeterans Affairs PTSD and anxiety clinic who attended at least 1 individual psychotherapy appointment with 1 of 8 providers trained inEBP. 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 anotherform of individual psychotherapy (n = 66) were reviewed by 4 independent raters. Logistic regression analyses revealed that Iraq andAfghanistan veterans were less likely to begin EBP than veterans from other service eras, OR = 0.48, 95% CI= [0.24, 0.94], and veteranswho 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 ofpsychiatric 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 themost common mental health diagnoses among U.S. militaryveterans (Barrera et al., 2014; Cohen et al., 2010), providinghigh-quality PTSD treatment is a critical mission to the Veter-ans Health Administration (VHA). To increase access to care,the VHA implemented large-scale efforts to train clinicians intwo evidence-based psychotherapy (EBP) protocols for PTSD:cognitive processing therapy (CPT) and prolonged exposure(PE). Both are manualized, cognitivebehavioral interventionsthat typically consist of 812 weekly sessions (Foa, Hembree,

    Juliette Mott is currently affiliated with the National Center for PTSD inWhiteRiver Junction, Vermont USA.

    This research was supported in part by the Office of Academic Affiliations VAAdvanced Fellowship Program in Mental Illness Research and Treatment, bythe Houston VA HSR&D Center of Excellence (Houston Center for Innova-tions in Quality, Effectiveness and Safety (CIN 13-413), and by a VA ClinicalSciences Research and Development (CSR&D) Career Development Award(#CADE-MHN/F09) awarded to Ellen J. Teng at the Michael E. DeBakeyVeterans Affairs Medical Center. The views expressed reflect those of the au-thors and not necessarily the Department of Veterans Affairs/Baylor Collegeof Medicine.

    Correspondence concerning this article should be addressed to Juliette Mott,National Center for PTSD, VAMedical Center (116D), 215 NorthMain Street,White River Junction, VT 05009. E-mail: Juliette.Mott@va.gov

    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.21927

    & Rothbaum, 2007; Resick, Monson, & Chard, 2008). To date,more than 2,300 VHA clinicians have been trained in CPT, andmore than 1,500 have been trained in PE (Eftekhari et al., 2013;Karlin et al., 2010). These dissemination efforts have increasedthe VHAs potential to provide evidence-based care to veteranswith PTSD (Cook, Dinnen, Thompson, Simiola, & Schnurr,2014).To evaluate the impact of EBP dissemination initiatives, sev-

    eral recent studies have assessed the use of CPT and PE withinthe VHA. Although VHA administrative databases do not con-tain information on the type of psychotherapy delivered, priorstudies have used these databases to determine the number ofpatients who received at least 8 or 9 psychotherapy sessions,and therefore could have potentially completed a full courseof 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 andcolleagues (2012) reviewed the text of psychotherapy notesfrom more than 1,900 patients across 6 VHA facilities andreported that only 6% of veterans received one or more EBPsessions in the 6 months following enrollment in a PTSD clinic.This suggests that most veterans who receive psychotherapy inspecialized PTSD care settings are receiving treatments otherthan VHA-recommended EBPs.

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    Although the VHA mandates that all patients with PTSDhave access to CPT or PE, the decision of whether a veteran re-ceives one of these treatments is left to the veteran and provider(McHugh & Barlow, 2010). Patients and providers may findlittle empirical guidance for treatment selection, as research in-forming evidence-based treatment decisions based on patientcharacteristics such as age or trauma type is only in the be-ginning stages (Sharpless & Barber, 2011). Prior research hasdemonstrated the effectiveness of CPT and PE in veteran pop-ulations that are diverse with respect to gender (Schnurr et al.,2007), service era (Yoder et al., 2012), trauma type (Rauchet al., 2009), and psychiatric comorbidities (Monson et al.,2006), suggesting that these treatments have the potential forbroad patient reach.Practice guidelines and EBP manuals offer differing per-

    spectives on which patients are likely appropriate for CPT orPE. The VHA/Department of Defense (DoD) clinical practiceguideline for management of PTSD (2010) endorses PE andCPT at the highest possible level, indicating a strong recom-mendation that clinicians provide the intervention to eligiblepatients (p. 201). PE and CPT therapist manuals, however, in-dicate that not all patients with PTSD are appropriate for thesetreatments. The PEmanual recommends that PE not be initiatedin the presence of imminent threat of suicide or homicide, seri-ous self-injurious behavior, current psychosis, current high riskof being assaulted or insufficient memory of the trauma (Foaet al., 2007). The CPT manual (Resick et al., 2008) cautionsagainst the treatment of patients who are in imminent danger,suffer from severe dissociation or panic attacks that may inter-fere with treatment, and recommends case-by-case decisionsfor patients with substance dependence and self-harming be-haviors. Both manuals indicate that comorbid depression is nota rule-out and note that patients with subthreshold PTSD symp-toms may be appropriate. Thus, these manuals suggest that PEand CPT are not appropriate for all patients with PTSD andmay 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 forPTSD, a burgeoning body of research has attempted to de-scribe the population of veterans who actually receive thesetreatments. A number of studies have found that veterans whoreceived 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; Yoderet al., 2012). This mirrors the general population of veteranswho seek treatment (not necessarily EBP) for PTSD (Seal et al.,2010; Spoont, Murdoch, Hodges, & Nugent, 2010). Given thatthese studies did not compare directly the characteristics of pa-tients who received EBP to those who received an alternativetreatment, the degree to which observed patient characteristicsare specific to those who engage in EBP remains unclear.Further examination of EBP patients clinical profileswith

    particular attention to factors that are likely to influence EBPreferrals, such as comorbid pathology, suicidality, and mental

    health treatment historyis needed. Identification of patientcharacteristics associated with an increased likelihood of EBPengagement can enhance knowledge ofwhich patients are likelyto participate in these therapies and, importantly, may aid in theidentification of underserved populations who are not currentlyaccessing these effective treatments. Toward this end, this studyexamined a sample of veterans who received individual psy-chotherapy from a provider trained in CPT or PE to examinepatient-level correlates of EBP initiation and completion.

    Method

    Participants and Procedure

    All procedures were approved by the local institutional reviewboard and by the Veterans Affairs (VA) Research and Devel-opment Committee. This study included both provider and pa-tient participants. We identified nine EBP-trained providers in aPTSD and anxiety specialty clinic in a large VA medical centerwho had previously completed an optional multiday trainingin CPT, PE, or both. Of the nine providers identified, eightexpressed willingness to participate. The provider sample in-cluded licensed psychologists (n = 4), psychology fellows (n =2), and social workers (n = 2). All eight providers were trainedin CPT and seven were trained in PE. Five providers were VAcertified in at least one EBP (four in CPT, and five in PE). Weincluded providers who attended an EBP trainingworkshop, butwere not fully certified because the completion of the additionaltraining components required for certification (e.g., follow-upconsultation) may

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