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Alan was a 36-year-old noncommissioned Army officer who I saw in outpatient practice for approximately two months. His initial intake assessment found high levels of generalized anxiety and depression. His anxiety symptoms interfered with daily living and were his primary concern. Accordingly, we pursued an evidence-based treatment for generalized anxiety. However, after a month of weekly sessions, Alan’s anxiety symptoms became less generalized and, instead, centered increasingly on avoidance of deployment related objects. He also started to have nightmares. Because this change in symptomatology now met diagnostic criteria for posttraumatic stress disorder (PTSD), I began a trauma-focused treatment. In the first five sessions of prolonged exposure (PE), Alan had difficulty relaying his index trauma as if it were actually occurring; his retelling changed over time (and not in a way that showed learning or remembering forgotten elements). It changed as though he were writing a novel but without a plot outline to guide his writing. During his imaginal exposure I encouraged him to use present tense language, and report what he could see, smell, hear in that moment. Despite my prompts, however, Alan had a difficult time not retelling his trauma without going into an interior monologue of worries- for example, what he might have thought at the time, what the guy inside the burning trailer must have thought and felt as he died. Alan’s PTSD symptoms did improve over the five sessions of PE, but he withdrew from treatment before receiving a full dose. 
Various factors might have contributed to Alan’s early treatment dropout: Alan’s personality style and clinical presentation made providing a trauma-focused treatment, as outlined in the manual, less than optimal. Not only did Alan have an unusual way of retelling his imaginal exposure, he also had a “dramatic” personality style (as seen in Cluster B personality disorders) that influenced his response to treatment. The session agenda was often disrupted by “crises of the day.” While this case may not translate specifically to other active duty PTSD patients, it does illustrate the varying symptom combinations, personality styles, life circumstances, and other unique patient factors that might disrupt administering a manualized treatment in the way it was originally tested in randomized controlled trials (RCTs). 
The case of Alan helps illuminate some of the findings from a recently published systematic review (SR) of dropout rates among military personnel from PTSD treatment (Edwards-Stewart et al., 2021). This SR investigated between-study dropout rates from RCTs of first-line PTSD treatments among military samples. It also compared dropout rates within-studies. What did the study find? Overall, PTSD treatment dropout rates, while slightly higher than those found previously in a SR of mixed military and civilian samples, did not appear to be larger than would be expected (only 24% vs. 18% expected [Imel et al., 2013]; although the study did not compare study dropout rates directly between civilians and military samples). The study also found that the risk of dropping out of a trauma-focused treatment (TFT) was greater than the risk of dropping out of a non-TFT. This SR concluded that dropout rates seemed to be a function of within-study rather than between-study differences; i.e. a study’s treatment dropout rates tended to be similarly high or low across treatment groups. How do these findings translate into clinical practice? They seem to indicate that population type is not influencing study dropout, but treatment type and unique study variables might be.  
This SR and meta-analysis needs to be expanded. A direct comparison of military to civilian PTSD treatment dropout rates is missing from the literature. The authors noted one considerable limitation to how dropout is reported in RCTs. Current CONSORT standards make the reporting of dropout numbers by treatment stage necessary but few studies report PTSD symptom level at dropout. It is possible that Alan dropped out of treatment because he felt his symptoms had improved sufficiently. As his therapist, however, I believe his symptom assessment score could have continued to improve with further treatment. Changing RCT dropout reporting standards might help clarify this question and further improve future PTSD treatments.

Discussion Questions

  1. What is the PTSD treatment dropout rate among military samples?
  2. What study related variables influence PTSD treatment dropout rates? 

Reference Article

Edwards-Stewart, A., Smolenski, D., Cyr, B., Beech, E. H., Skopp, N. A., Belsher, B. E., & Bush, N. E. (2021). Dropout from exposure-based treatments among military study samples: A systematic review and meta-analysis. Journal of Traumatic Stress, 0, 1-11. http://dx.doi.org/10.1002/jts.22653

About the Author

Amanda Edwards-Stewart
, Ph.D., ABPP. Dr. Edwards-Stewart is a research psychologist for the Defense Health Agency, Psychological Health Center of Excellence. She has a clinical specialty in military trauma and can be contacted at amanda.e.stewart7.civ@mail.mil.