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Globally, posttraumatic stress disorder (PTSD) is a significant mental health issue among military service members and veterans. Within the US, around 13% of veterans have a PTSD diagnosis, (Dursa et al., 2014; Eber et al., 2013), with the prevalence of PTSD increasing significantly post-9/11 with conflicts in Iraq and Afghanistan, resulting in about 11-20 out of every 100 Veterans having PTSD (US Department of Veterans Affairs n.d.).
While the U.S. Department of Veterans Affairs (VA) provides crucial resources for veteran behavioral health care, with the implementation of the Veterans Choice Program and MISSION Act legislation (which provides financial coverage for eligible military-affiliated individuals to engage in mental health services outside the VA) many Veterans seek mental health services through community settings (community-based mental health provider). Despite this, little is known about outcomes among military-affiliated patients in community settings.
To better understand these outcomes, our study undertook a direct comparison between civilian and military-affiliated patient outcomes on PTSD and depression symptoms in community settings. To do this we looked at drop-out rates, and used two measures post treatment:

  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

Results of the study showed that in community settings treating PTSD, there were no differences in dropout rates between civilian and military-affiliated patients; that both military-affiliated and civilian patients had significant reductions in PTSD following treatment, though these reductions were smaller in military-affiliated patients.  Specifically:

  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

Jacoby, V. M., Straud, C. L., Bagley, J. M., Tyler, H., Baker, S. N., Denejkina, A., ... & STRONG STAR Training Initiative. (2022). Evidence‚Äźbased posttraumatic stress disorder treatment in a community sample: Military‚Äźaffiliated versus civilian patient outcomes. Journal of Traumatic Stresshttp://doi.org/10.1002/jts.22812

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

Anna Denejkina, PhD. Dr Anna Denejkina is a lecturer and research at Western Sydney University, Graduate Research School; member of the Translational Health Research Institute, and the Young & Resilient Research Center; and founding member of the Trauma and Resilience Research Group. Her research focuses on intergenerational trauma transmission, specifically in defence families. She additionally conducts research in the Veterans in higher education space, and is an LGBTQIA+ advocate. Twitter: @AnnaDenejkina

References Cited

American Psychological Association. (2017). Clinical practice guideline for the treatment of posttraumatic stress disorder.https://www.apa.org/ptsd-guideline/ptsd.pdf

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Dillon, K. H., LoSavio, S. T., Henry, T. R., Murphy, R. A., & Resick, P. A. (2019). The impact of military status on cognitive processing therapy outcomes in the community. Journal of Traumatic Stress32(2), 330–336. https://doi.org/10.1002/jts.22396

Dursa, E., Reinhard, M., Barth, S., & Schneiderman, A. (2014). Prevalence of a positive screen for PTSD among OEF/OIF and OEF/OIF-era veterans in a large population-based cohort. Journal of Traumatic Stress27(5), 542–549. https://doi.org/10.1002/jts.21956

Eber, S., Barth, S., & Kang, H. (2013). The national health study for a new generation of United States veterans: Methods for a large-scale study on the health of recent veterans. Military Medicine178(9), 966–969. https://doi.org/10.7205/MILMED-D-13-00175

Evans, L., Cowlishaw, S., Forbes, D., Parslow, R., & Lewis, V. (2010). Longitudinal analyses of family functioning in veterans and their partners across treatment. Journal of consulting and clinical psychology, 78(5), 611–622. https://doi.org/10.1037/a0020457

Kimerling, R., Allen, M. C., & Duncan, L. E. (2018). Chromosomes to social contexts: Sex and gender differences in PTSD. Current Psychiatry Reports, 20(12), 114. https://doi-org.libproxy.uthscsa.edu/10.1007/s11920-018-0981-0

Kitchiner, N. J., Lewis, C., Roberts, N. P., & Bisson, J. I. (2019). Active duty and ex-serving military personnel with post-traumatic stress disorder treated with psychological therapies: Systematic review and meta-analysis. European Journal of Psychotraumatology10(1), Article 1684226. https://doi.org/10.1080/20008198.2019.1684226

Lee, D. J., Schnitzlein, C. W., Wolf, J. P., Vythilingam, M., Rasmusson, A. M., & Hoge, C. W. (2016). Psychotherapy versus pharmacotherapy for posttraumatic stress disorder: Systemic review and meta-analyses to determine first-line treatments.Depression and Anxiety33(9), 792–806. https://doi.org/10.1002/da.22511

Litz, B. T., Lebowitz, L., Gray, M. J., & Nash, W. P. (2016). Adaptive disclosure: A new treatment for military trauma, loss, and moral injury. The Guilford Press.

Meis, L. A., Noorbaloochi, S., Hagel Campbell, E. M., Erbes, C. R., Polusny, M. A., Velasquez, T. L., Bangerter, A., Cutting, A., Eftekhari, A., Rosen, C. S., Tuerk, P. W., Burmeister, L. B., & Spoont, M. R. (2019). Sticking it out in trauma-focused treatment for PTSD: It takes a village. Journal of consulting and clinical psychology87(3), 246–256. https://doi.org/10.1037/ccp0000386

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