Client-level predictors of treatment engagement,outcome and dropout:moving beyond demographics

Background Despite the availability of evidence-based treatments for posttraumatic stress disorder(PTSD),significant heterogeneity in the effectiveness of PTSD treatment persists,especially in community settings.Client demographics used to understand this variability in treatment outcome and dropout have yielded mixed results.Despite increasing evidence for the importance of attending to treatment engagement in community settings,few studies have explored client-level predictors.Aim The purpose of this study is to explore client-level predictors of treatment outcome and dropout beyond client demographics,and to identify client-level predictors of treatment engagement in community settings.Method Secondary data analysis was conducted with data collected as part of an implementation-effectiveness hybrid study of cognitive processing therapy(CPT)for PTSD in a diverse community healthcentre.Providers(n=19)treated(n=52)clients as part of their routine clinical care.Non-demographic client-level predictors included barriers to treatment,quality of life,session-level language and employment history assessed at baseline.Treatment engagement included number of weeks in the study,number of sessions with repeated CPT content,number of unique CPT sessions attended,frequency of session attendance and consistency of session attendance.Results Results showed language as a significant predictor of treatment engagement.There were significant differences between Spanish and English-speaking clients,with the former having a tendency to repeat more session content than the latter(β=1.4 sessions,p=0.003),and also less likely to attend treatment frequently(r=0.62,p=0.009)and consistently(r=0.57,p=0.027)if high logistical and financial barriers were endorsed.Irrespective of language,clients who reported high quality of life at baseline were less likely to repeat CPT session content(β=-0.3,p=0.04),and those with increased baseline barriers to treatment had deceleration in PTSD symptom improvement over time(β=-0.62,p<0.05).In terms of treatment engagement moderators impacting treatment outcome,clients who repeated more session content were more likely to complete treatment(0R=1.84,p=0.037).Conclusion Identification of client-level predictors of treatment engagement,outcome and dropout is essential to optimise treatment,particularly in community settings.

In This Issue

Despite ongoing research on the aetiology,phenomenology and treatment of anxiety disorders,these conditions continue to afflict myriads of individuals worldwide.An estimated 11.6%of the global population meets criteria for an anxiety disorder each year,1 and individuals with anxiety disorders experience both functional impairment2 and increased risk for physical health problems.3 In addition to the personal suffering associated with anxiety disorders,these conditions lead to considerable costs for society,including medical expenditures and lost work productivity.4 Moreover,although efficacious interventions for anxiety disorders are available,many individuals do not respond to these treatments5 or struggle to access evidence-based care.6 Thus,much work remains to be done to reduce the global burden of anxiety disorders.

Towards a precision psychiatry approach to anxiety disorders with ecological momentary assessment:the example of panic disorder

Background Treatments for anxiety disorders are among the most effective in psychiatry.Yet,there is considerable room for improvement.Aim In this paper,we discuss the value of ecological momentary assessment as a research method and clinical tool.Methods We begin by describing ecological momentary assessment and its advantages,including the ability to collect ecologically valid information about mental disorders,in real time,in individual patients.We then illustrate the value of this approach for anxiety disorder treatment using two patients with panic disorder who completed ecological momentary assessments for 2 weeks before and after a cognitive-behavioural therapy intervention.We focus especially on two key pieces of information provided by ecological momentary assessment data:information about symptom dynamics and information about the relationships among symptoms as they unfold overtime within individual patients.Perspective Although considerable work is needed to further develop this methodology in the context of anxiety disorder treatment,we believe that these pieces of information may ultimately inform our understanding of how anxiety disorder treatments have their effect and how those treatments can be tailored to individual patients.