1. 53 Other Primary Diagnosis
Retrospective Evaluation of Treatment Engagement Among Veterans
With PTSD vs Veterans with PTSD & Co-Occurring SUD
Alan K. Davis, Ph.D.1,2, David Austern, Psy.D.1, Erin Romero, Ph.D.1,3,4
1VA Maryland Healthcare System, Baltimore, MD, 2Bowling Green State University, Bowling Green, OH,
3VA Capitol Network (VISN 5) MIRECC, Baltimore, MD, 4University of Maryland, School of Medicine, Baltimore, MD
Introduction
Sample Characteristics
Engagement & Outcomes of EBP for PTSD
No difference in proportion of veterans who initiated an EBP (44% with only PTSD; 53% with PTSD+SUD)
Veterans with PTSD+SUD completed more sessions (M=10, SD=5) compared to those with only PTSD (M=7, SD=4) but this was not statistically significant
A total of 19 veterans began an EBP (PE, CPT individual, CPT group) for PTSD and 11 completed (One removed for missing data and inconsistent measurement)
Of the 9 that did not complete, there were no differences by subsample in the number who dropped out prior to 3 sessions
100 Referred to PCT
47 PTSD
20 PTSD + SUD
27 PTSD
53 Other Primary Diagnosis
Anxiety; Mood; SUD
15 Engaged
25 Engaged
Annual Cost of PTSD - $3 billion (Kessler, 2000)
“Gold standard” evidence-based treatments (PE & CPT) for PTSD
Difficulty engaging in these treatments in “real-world” clinical settings (Najavits, 2015)
Prognosis may be worse with co-occurring SUD (Roberts, Roberts, Jones & Bisson, 2015; van Dam, Vedel, Ehring, Emmelkamp, 2012)
Treatment engagement factors (e.g., attendance, drop-out) are likely important regardless of the presence of co-occurring SUD.
High dropout rates for PE (44.4%) and CPT (32.2%) in outpatient clinical sample (Jeffreys et al., 2014)
Majority of sample (n=40 – Met Dx criteria and engaged in tx)
Male (83%)
African American (63%)
Service Eras
OEF/OIF/OND (40%)
Vietnam (33%)
Post-Vietnam/Other (15%)
Persian Gulf (13%)
Mean age was 47 (Range 25-65)
Subsamples (PTSD vs PTSD+SUD) identical except for gender
PTSD Symptoms
(PCL Scores - Pre/Post Tx)
There was a significant main effect for time, F(1) = 6.8, p=.031, ηp2 = .459.
No significant effect for interaction (time X subsample), although effect size is large (ηp2 = .105).
Present Study Aims
Evaluate whether there are differences in treatment engagement (initiation, attendance):
orientation group
open preparatory groups (PTSD education)
closed skills groups (Anxiety mgmt, Anger mgmt.)
individual or group EBP (PE or CPT)
Evaluate differences in PTSD severity (PCL and BDI-II scores) at initiation of EBP
Evaluate whether there are differences in outcomes based on diagnostic group
Clinic Flow & Treatment Engagement Results
Depression Symptoms
(BDI-II Scores - Pre/Post Tx)
Orientation Group
Assessment
Individual CPT/PE
CPT Grp
Closed Skills Grp
Open Entry Grp
There was a significant main effect for time, F(1) = 11.5, p=.009, ηp2 = .591.
No significant effect for interaction (time X subsample), although effect size is large (ηp2 = .073).
Summary and Future Directions
No differences in initial treatment engagement (i.e., attending orientation group) except that African Americans more likely to attend, X2 (1) = 4.67, p <0.05
Fewer of those with only PTSD began an open preparatory group (28%) vs. those with PTSD+SUD (60%), X2 (1) = 4.00, p <0.05
Among those that attended a prep group, no differences in average number of sessions attended
Same proportion with only PTSD (20%) began a closed group as those with PTSD+SUD (27%).
Veterans with only PTSD attended significantly more closed group sessions (M=13, SD=4), compared to those with PTSD+SUD (M=5, SD=4), F(1,7) = 9.78, p < 0.05
Not much difference in initial treatment engagement
Overall, both subsamples significantly improved following treatment with an EBP for PTSD although PTSD+SUD group still above cutoff (50) for PTSD diagnosis.
EBP dropout rates were lower compared to prior studies
~50% (PTSD only) to ~75% (PTSD+SUD) completed EBP in this sample – much higher than prior research (38%)
Approximately 50% of Veterans chose to engage in an EBP
Why not more? What influences treatment initiation? Would different treatment options provoke anxiety/avoidance?
Other treatment engagement factors?
Homework, working alliance, motivation, peer support
Method
Updated access data forms for the first 100 Veterans referred to the PCT clinic between Oct ‘12 - Dec ’12
Utilized coding rules for how to classify courses of treatment
Completed data forms for any treatment received between referral date and Oct ’14
Extracted demographic variables, engagement variables, and outcome data (PCL & BDI-II) from database for analyses
Data was analyzed using STATA MP13 and SPSS v22