Impact of Race on Early Treatment Termination and Outcomes in Posttraumatic Stress Disorder Treatment

Women's Health Sciences Division, National Center for PTSD, Veterans Affairs Boston Healthcare System, Boston, MA, USA.
Journal of Consulting and Clinical Psychology (Impact Factor: 4.85). 08/2010; 78(4):480-9. DOI: 10.1037/a0019551
Source: PubMed


The present study investigated the influence of race on posttraumatic stress disorder (PTSD) treatment among 94 African American and 214 Caucasian female victims of interpersonal violence participating in 2 studies of cognitive-behavioral treatment for PTSD that were conducted sequentially and continuously.
In each study, participants were randomized into 1 of 3 conditions. The first study compared cognitive processing therapy with prolonged exposure and a delayed treatment condition. In the second study, cognitive processing therapy was compared with its constituent components: cognitive therapy only and written accounts. Participants were assessed with the Clinician Administered PTSD Scale and the Structured Clinical Interview for DSM-IV, as well as through self-report measures of PTSD.
Analyses revealed that African Americans were significantly less likely to complete treatment compared with Caucasians (45% vs. 73%, respectively, p < .001) and that the differences held even after controlling for education and income. Despite racial differences in treatment completion status, analyses with the intent-to-treat sample indicated no racial differences in outcomes on PTSD measures.
The lack of difference in treatment outcomes despite racial differences in dropout may be explained by greater symptom improvement of African Americans who dropped out compared with Caucasians who dropped out. Implications of these findings and practical approaches to addressing sociocultural barriers to care are explored.

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    • "Other studies have suggested Black women are at risk for not beginning, or not completing, treatment for PTSD. For example, one recent study found that Black women were less likely to start Cognitive Processing Therapy for PTSD after completing the initial pretreatment assessment sessions (Iverson et al., 2011), while another found that Black women were less likely than White women to complete PTSD treatment (Lester et al., 2010). The current study included medication use in our definition of MAC for PTSD, and so these results may partially reflect racial and ethnic differences in the utilization of specific types of treatment. "
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    ABSTRACT: Female veterans of Operations Enduring and Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) represent a growing segment of Department of Veterans Affairs (VA) health care users. A retrospective analysis used national VA medical records to identify factors associated with female OEF/OIF/OND veterans' completion of minimally adequate care (MAC) for PTSD, defined as the completion of at least nine mental health outpatient visits within a 15-week period or at least twelve consecutive weeks of medication use. The sample included female OEF/OIF/OND veterans with PTSD who initiated VA health care between 2007-2013, and were seen in outpatient mental health (N=2183). Multivariable logistic regression models examined factors associated with completing MAC for PTSD, including PTSD symptom expression (represented by latent class analysis), sociodemographic, military, clinical, and VA access factors. Within one year of initiating mental health care, 48.3% of female veterans completed MAC. Race/ethnicity, age, PTSD symptom class, additional psychiatric diagnoses, and VA primary care use were significantly associated with completion of MAC for PTSD. Results suggest that veterans presenting for PTSD treatment should be comprehensively evaluated to identify factors associated with inadequate completion of care. Treatments that are tailored to PTSD symptom class may help to address potential barriers. Copyright © 2015. Published by Elsevier Ireland Ltd.
    Full-text · Article · Aug 2015
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    • "In addition to the risk of being in the most symptomatic group in the current study, other studies have suggested African Americans are also at risk when it comes to beginning or completing treatment for PTSD. For example, Iverson et al. (2011) found that Black women were less likely to start Cognitive Processing Therapy for PTSD after completing the initial pretreatment assessment sessions, and Lester et al. (2010) found that Black women were less likely than White women to complete PTSD treatment. These results have direct clinical implications that may be especially relevant within the VA system. "
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    ABSTRACT: Background Recent studies have used latent class analysis (LCA) to identify subgroups of individuals who share similar patterns of PTSD symptom endorsement; however, further study is needed among female veterans, whose PTSD symptom expression may vary from that of their male counterparts. The current study examined latent PTSD symptom classes in female veterans who returned from recent military service in Iraq and Afghanistan, and explored military and demographic variables associated with distinct PTSD symptom presentations. Methods A retrospective analysis was conducted using existing medical records from female Iraq and Afghanistan veterans who were new users of VA mental health outpatient (MHO) care, had received a PTSD diagnosis anytime during the post-deployment period, and completed the PTSD checklist within 30 days of their first MHO visit (N=2425). Results The LCA results identified four latent classes of PTSD symptom profiles in the sample: High Symptom, Intermediate Symptom, Intermediate Symptom with High Emotional Numbing (EN), and Low Symptom. Race/ethnicity, age, time since last deployment, and distance from a VA facility emerged as predictors of PTSD symptom presentation. Limitations The current study was cross-sectional and utilized administrative data. The results may not be generalizable to female veterans from other service eras. Conclusions Longer times between end of last deployment and initiation of MHO services were associated with more symptomatic classes. Exploration of PTSD symptom presentation may enhance our understanding of the service needs of female veterans with PTSD, and suggests potential benefits to engaging veterans in MHO soon after last deployment.
    Full-text · Article · Sep 2014 · Journal of Affective Disorders
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    • "The two main findings concerning African American participants—higher drop out rates and larger reductions in EDE scores—merit additional consideration, given the apparent contradiction between these findings. One possible explanation is that African American participants who were not experiencing substantial reductions in symptoms were more likely to drop out of treatment and be lost to follow-up; another possible explanation is that African Americans who experienced substantial reductions in symptoms early in treatment felt less need to complete treatment given their positive response (Fortuna et al., 2010; Lester et al., 2010). Both principles may also have been operating simultaneously. "
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    ABSTRACT: Objective: Binge eating disorder (BED) is prevalent among individuals from minority racial/ethnic groups and among individuals with lower levels of education, yet the efficacy of psychosocial treatments for these groups has not been examined in adequately powered analyses. This study investigated the relative variance in treatment retention and posttreatment symptom levels accounted for by demographic, clinical, and treatment variables as moderators and predictors of outcome. Method: Data were aggregated from 11 randomized, controlled trials of psychosocial treatments for BED conducted at treatment sites across the United States. Participants were N = 1,073 individuals meeting criteria for BED including n = 946 Caucasian, n = 79 African American, and n = 48 Hispanic/Latino participants. Approximately 86% had some higher education; 85% were female. Multilevel regression analyses examined moderators and predictors of treatment retention, Eating Disorder Examination (EDE) global score, frequency of objective bulimic episodes (OBEs), and OBE remission. Results: Moderator analyses of race/ethnicity and education were nonsignificant. Predictor analyses revealed African Americans were more likely to drop out of treatment than Caucasians, and lower level of education predicted greater posttreatment OBEs. African Americans showed a small but significantly greater reduction in EDE global score relative to Caucasians. Self-help treatment administered in a group showed negative outcomes relative to other treatment types, and longer treatment was associated with better outcome. Conclusions: Observed lower treatment retention among African Americans and lesser treatment effects for individuals with lower levels of educational attainment are serious issues requiring attention. Reduced benefit was observed for shorter treatment length and self-help administered in groups.
    Full-text · Article · May 2013 · Journal of Consulting and Clinical Psychology
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