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Research Questions

  1. What patient characteristics are associated with treatment retention?
  2. What program characteristics are associated with treatment retention?
  3. What patient characteristics are associated with treatment response?
  4. What program characteristics are associated with treatment response?
  5. What patient characteristics are associated with remission?
  6. What program characteristics are associated with remission?

This systematic review synthesizes the evidence on pretreatment patient characteristics and program features associated with treatment retention, response, and remission in military populations with posttraumatic stress disorder (PTSD). The authors searched numerous databases and bibliographies of systematic reviews and retrieved full texts of all studies on the efficacy or effectiveness of PTSD interventions in military population; two reviewers screened texts for relevant outcomes and reports of predictors. Reviewers abstracted data and assessed each study's risk of bias. Results from studies reporting on the same potential predictor and outcome were pooled via meta-analysis where possible. Results of multivariate models were described narratively.

Eighty-four articles reporting on 70 studies met inclusion criteria; 21 were rated good quality, 33 were rated fair, and 16 were rated poor, using the Quality in Prognostics Studies (QUIPS) instrument. Quality of evidence was low or insufficient for most patient and treatment characteristics due to inconsistent results, imprecision, potential publication bias, and study limitations.

High-quality evidence indicates that length of stay is the strongest predictor of treatment response and that more severe PTSD is associated with lower response. Moderate-quality evidence indicates that older age is associated with better retention, that worse baseline mental health and more combat experience are associated with lower response to treatment, and that individual therapy (versus group therapy) is associated with greater response. Low-quality evidence supports a negative association of participation in atrocities with treatment response. Predictors of remission were rarely assessed.

Key Findings

  • Evidence suggests that older age, being married, higher treatment expectations, having more severe PTSD at baseline, and additional mental health comorbidities are associated with longer length of treatment and that depression and service-connected disability are associated with worse retention.
  • Few treatment characteristics were assessed in more than one study, but there is some evidence that health facility distance from patients is inversely associated with treatment retention.
  • Evidence indicates that higher levels of education, being employed, being married, more social support, and having better baseline mental and physical health are associated with better patient response, and that depression, anger, higher PTSD severity at baseline, and higher levels of combat exposure lead to lower response.
  • Patients who attended more treatment sessions had greater response, and individual therapy was found statistically superior to group therapy, but evidence suggests that there is no significant difference between in-person versus telehealth delivery of treatment or virtual reality exposure versus standard prolonged exposure.
  • Better social function and physical health are significantly associated with remission, while co-occurring psychiatric diagnosis has a significant negative association, but evidence was rated insufficient for these predictors due to lack of study replication.

Recommendations

  • Patients with service-connected disability could be identified at admission and focused efforts to retain them implemented.
  • The relationship between patient pain and response to PTSD treatment is an important area for future study, as no studies in this area were identified.
  • No studies of therapeutic alliance met inclusion criteria; more research in this area is suggested.
  • Longitudinal analyses of VA data regarding PTSD remission after treatment are strongly suggested to shed light on this important area.

This research was sponsored by the Psychological Health Center of Excellence and conducted within the Forces and Resources Policy Center of the RAND National Security Research Division (NSRD).

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