Considerations for treating military-affiliated patients for PTSD in community clinics

Anna Denejkina

1. PTSD Checklist for DSM-5 (PCL-5); and 
2. Patient Health Questionnaire-9 (PHQ-9).

Participant details

• Of 502 participants in the analyses, 188 were military-affiliated (veteran, Guard/Reservist, active duty), and 314 were civilians. 
• All participants were receiving evidence-based treatments (EBTs), Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE) for PTSD in community clinics

1. Military-affiliated and civilian patients demonstrated significant reductions on the PCL-5 (military-affiliated d = -0.91; civilian d = -1.18) and PHQ-9 measures (military-affiliated d = -0.65; civilian d = -0.88) following treatment;
2. Military-affiliated patients demonstrated smaller reductions on the PCL-5 (Mdiff = 5.75, p = .003) and PHQ-9 (Mdiff = 1.71, p = .011), compared to civilians, after treatment. 
3. No difference in dropout rates between civilian and military-affiliated patients, with an overall dropout rate of 56.5% and no differences in time to dropout between civilian and military-affiliated patients (M = 4.64 sessions). 

Our team has raised several hypotheses to address the reason for this outcome

1. Military-affiliated patients are harder to treat due to having more severe baseline symptoms. Although our findings revealed no differences in baseline PTSD or depression symptoms between military-affiliated and civilian patients (consistent with Dillon et al. 2019), military-affiliated patients were more likely to be in inpatient care than civilians, and those in inpatient care had higher baseline PTSD severity scores compared with those in outpatient care. 
2. Military-affiliated patients were older and more likely to be men than their civilian counterparts. Women have demonstrated moderately greater PTSD treatment-related symptom reduction compared with men (Kimerling et al., 2018), and younger military personnel have shown a stronger response to CPT than older military personnel (Resick et al., 2020). However, a differential treatment response was found even after controlling for age and gender. 
3. Over half of military-affiliated patients in this study were married, whereas almost half of the civilians were single. While family encouragement is associated with PTSD treatment retention (Meis et al., 2019), PTSD is associated with relationship distress (Taft et al., 2011) and poorer family functioning predicts reduced PTSD treatment response among veterans (Evans et al., 2010). 
4. Combat-related PTSD may be more difficult to treat than PTSD resulting from other traumatic events (Bradley et al., 2005; Steenkamp et al., 2020) due to the unique culture and context of military trauma and a service member or veteran’s lived experience (Litz et al., 2016). 
5. Some evidence that patients sometimes “dropout” when they have improved (Szafranski et al., 2017) and could be less of a concern than previously considered. Our results showed that a portion of non-completers showed clinically significant improvement. 
6. While treatment resulted in significant, large reductions in PTSD symptoms for both groups, some patients were symptomatic at posttreatment. On average, military-affiliated clients just exceeded the threshold for likely PTSD diagnosis (PCL-5 > 32) at posttreatment. 

Clinical Implications

1. Trauma-focused EBTs like CPT and PE are the most effective options for service members and veterans (Kitchiner et al., 2019) in VA settings and community settings, with CPT and PE outperforming non-trauma-focused psychotherapies and medications (Lee et al., 2016). Current clinical practice guidelines (e.g., American Psychological Association, 2017; U. S. Department of Veterans Affairs & U.S. Department of Defense, 2017) recommend providers offer them as first-line treatments. 
2. Due to high dropout rates for PTSD treatment in community outpatient settings, providers are encouraged to use a variable-length approach in which treatment length is dependent on weekly PTSD scores and progress on ideographic treatment goals. This may reduce early dropout due to patient improvement and therefore potential disinterest in completing treatment (Szafranski et al., 2017). 
3. As community providers increase provision of services to veterans, they should seek military cultural competency training. Several reports call attention to the need for military cultural competence in providers (e.g., Tanielian et al., 2014), as a lack of competency here may lead to misdiagnosis and treatment dropout (e.g., Zwiebach et al., 2019). In a survey of combat veterans, 88% of participants agreed that community providers must be familiar with military culture, with 37% of participants reporting concern that their provider did not understand their experience (Stewart, 2012). 

Target Article

Discussion Questions

1. What variables could be affecting treatment outcomes for military-affiliated patients vs civilians in community settings and how do they intersect?
2. What needs to change and/or improve in community settings to improve EBTs outcomes for military personnel with PTSD?
3. “Military culture is one of unique practices, traditions and beliefs that represent a shared unifying language with a distinct set of guiding principles” (Sanghera 2017), yet military/defence/veteran cultural competency training is not part of business as usual within community settings, reflecting a systemic issue. How can individual service providers in community settings advocate and/or lobby for the introduction of such training to better support their military-affiliated patients?

About the Author

References Cited