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. Author manuscript; available in PMC: 2026 Jun 9.
Published in final edited form as: Adm Policy Ment Health. 2023 Jun 20;50(5):813–823. doi: 10.1007/s10488-023-01280-z

Factors Associated with Engaging in Evidence-Based Psychotherapy During the First Year of Posttraumatic Stress Disorder Treatment Between 2017 and 2019

David Cameron 1,2, Brian Shiner 3,4,5, Allison O’Neill 1, Maya O’Neil 1,2
PMCID: PMC13244751  NIHMSID: NIHMS2176090  PMID: 37338657

Abstract

To address the burden of posttraumatic stress disorder (PTSD), the Veterans Health Administration (VHA) implemented evidence-based psychotherapies (EBPs) for PTSD at all VHA medical centers. Prior investigations show EBP utilization has increased following the initial nationwide implementation. However, most patients still do not engage in EBPs and those who do often have substantial delays between diagnosis and treatment which is associated with poorer treatment outcomes. The goal of the current study is to identify patient and clinical factors associated with initiating EBP and completing a minimally adequate dose of treatment within the first year of a new PTSD diagnosis. Overall, 263,018 patients started PTSD treatment between 2017 and 2019 and 11.6% (n = 30,462) initiated EBP during their first year of treatment. Of those who initiated EBP, 32.9% (n = 10,030) received a minimally adequate dose. Older patients were less likely to initiate EBP, but more likely to receive an adequate dose when they did initiate. Black, Hispanic/Latino/a, and Pacific Islander patients’ likelihood of initiating EBP was not significantly different than White patients, but these patients were less likely to receive an adequate dose. Patients with comorbid depressive disorders, bipolar disorder, psychotic disorders, or substance use disorders were less likely to initiate EBP, while patients reporting MST were more likely to initiate EBP. This study identifies several patient-level disparities that could be prioritized to increase EBP utilization. In our evaluation, most patients did not engage in EBP during their first year of PTSD treatment, which is consistent with previous evaluations of EBP utilization. Future research should focus on understanding the flow of patients from PTSD diagnosis to treatment to support effective PTSD care delivery.

Keywords: Evidence-based psychotherapy, Posttraumatic stress disorder, Treatment initiation, Health factor, Veterans health administration

Introduction

Posttraumatic Stress Disorder (PTSD) is common among military Veterans; prevalence estimates range between 10 and 30% (Kang et al., 2003; Kudler, 1991; Tanielian et al., 2008), and are highest among patients who receive care at the Veterans Health Administration (VHA) (Harpaz-Rotem, 2015). The VHA/Department of Defense (DOD) Clinical Practice Guideline (CPG) recommends trauma-focused evidence-based psychotherapies (EBPs) as first-line treatment for PTSD (Department of Veterans Affairs, 2010). In 2006, the VHA began a nationwide effort to disseminate and implement two EBPs: cognitive processing therapy (CPT) and prolonged exposure (PE). CPT generally consists of 12 individual or group therapy sessions and PE consists of at least five individual therapy sessions (Foa, 2011; Resick et al., 2016); prior research has established at least eight sessions as being a minimally adequate dose for both of these treatments (Maguen et al., 2019). A 2008 mandate required all VHA medical centers to provide access to either CPT or PE (Affairs & of V., 1160; Karlin et al., 2010). However, available evaluations have found that most patients starting PTSD treatment do not receive CPG-recommended EBP treatment.

In the VHA, patients who are diagnosed with PTSD should be offered EBP treatment once they establish care in a mental health clinic (Department of Veterans Affairs 2010). CPT and PE have strong efficacy and are effective in patients with complex presentations and comorbidities (Foa & Rothbaum, 2001; Foa et al., 2005; Lee et al., 2016; Resick & Schnicke, 1993; Resick et al., 2002, 2013). While CPT and PE are widely available in the VHA, most patients do not receive these therapies (Maguen et al., 2020). Patients who do initiate EBPs often have substantial delays between diagnosis and initiation (Holder et al., 2020), which has been associated with poorer treatment outcomes (Maguen et al., 2014). While there are many factors that may influence PTSD treatment engagement (Cook et al., 2014, 2017; Lu et al., 2016; Osei-Bonsu et al., 2017), understanding EBP utilization patterns is particularly important given the existing delays in EBP treatment among VHA patients diagnosed with PTSD.

Early in the VHA’s nationwide dissemination efforts, program evaluation data demonstrated low utilization rates of EBPs for PTSD (Rosen et al., 2016). A study of VHA patients initiating PTSD specialty care in six New England outpatient clinics in 2010 showed that only 6.3% received any EBP sessions within their first year of treatment (Shiner et al., 2013). A similar study following VHA patients in the Pacific Northwest who initiated EBP for PTSD between 2006 and 2008 showed that only one third received a minimally adequate number of therapy sessions (Lu et al., 2011). Thus, based on early reports, there were concerns that few patients initiated EBP for PTSD and even fewer patients completed treatment (Shiner et al., 2012). At this time, national evaluations of EBP utilization were challenging because accurately identifying EBPs required manual review of Veterans’ health records (Shiner et al., 2012).

To address this challenge and improve the methods for measuring EBP utilization, Shiner and colleagues developed an approach to identify CPT and PE from electronic health record (EHR) note text using natural language processing (NLP) (Shiner et al., 2013). Maguen and colleagues extended this method and scaled it to a national population of Veterans (Maguen et al., 2018). This approach has been used to evaluate the VHA’s nationwide implementation of EBPs (Maguen et al., 2020). Overall, EBP utilization has increased following the VHA’s implementation efforts, however, available evaluations show that many patients still do not engage in EBPs. Accurate and timely measurement of EBP utilization can support the VHA’s mission of providing access EBPs to all patients diagnosed with PTSD.

Recently, the VHA implemented a strategy for measuring EBP utilization that relies on therapists completing structured note templates to document EBPs in the EHR. In 2015, the VHA mandated all providers use the structured note templates to document EBP delivery (Karlin & Cross, 2014). Structured note templates make it possible to measure EBP utilization without the use of manual chart review or NLP. The VHA maintains a dashboard that tracks EBP template use monthly to monitor the reach of these treatments. Over time, template use has increased and become a close approximation to the true rate of EBP delivery as measured by NLP (Shiner et al., 2021). These templates are an easily accessible, discrete measurement of EBP utilization that can be leveraged to identify patient factors associated with engaging in EBP treatment.

Previous evaluations have described several patient and clinical factors associated with lower likelihood of initiating EBP or completing a minimally adequate dose of treatment, including older age (Dufort et al., 2021; Lu et al., 2012) and mental health comorbidities (Holder et al., 2020; Maguen et al., 2019; Rosen et al., 2019). These evaluations of EBP utilization have typically included all post-9/11 Veterans with a prevalent diagnosis of PTSD (Dufort et al., 2021; Maguen et al., 2018, 2020; Rosen et al., 2019; Sripada et al., 2018a). Yet the timing of treatment initiation following a new PTSD diagnosis is an important determinant of treatment outcomes. Patients who wait longer to engage in EBPs are less likely to experience significant PTSD symptom improvement (Maguen et al., 2014). Further investigation of factors associated with EBP utilization among patients with an incident diagnosis of PTSD will provide important information about engaging patients in treatment during the critical period of time following a new PTSD diagnosis.

The goal of the current study is to identify patient characteristics and clinical comorbidities associated with initiating EBP and completing a minimally adequate dose of treatment after a new PTSD diagnosis in a recent clinical cohort. We focused our evaluation on measuring patients’ EBP utilization over the first 12-months following a new PTSD diagnosis to provide clinically relevant information about patients’ EBP utilization. The purpose of this study is to (1) describe the proportion of patients who initiate EBP within one year of being diagnosed with PTSD, (2) identify patient and clinical factors (e.g. comorbidities, reported history of miliary sexual trauma) associated with initiating EBP within one year of being diagnosed with PTSD, (3) describe the proportion of patients who receive a minimally adequate dose of EBP within one year of being diagnosed with PTSD, and (4) identify patient and clinical factors associated with completing a minimally adequate dose of EBP. We measured EBP utilization starting in 2017 to account for the initial adoption of the templates following the VHA mandate. Additionally, our evaluation did not extend beyond 2019 because of changes in VHA EHR documentation due to the pandemic and the implementation of a new EHR system in the VHA, both of which started in 2020. This study provides an updated estimate of national EBP utilization and is the first study to our knowledge that uses structured note templates to investigate factors associated with initiating EBP and completing a minimally adequate dose of treatment in patients newly diagnosed with PTSD.

Methods

Data Sources

We obtained patients’ VHA utilization history, sociodemographic information, and mental health diagnoses from the VHA Corporate Data Warehouse (CDW). This study was approved by the Institutional Review Board (IRB) at the Portland Veterans Affairs Healthcare System located in Portland, Oregon.

Participants

We identified a cohort of patients who had a diagnosis of PTSD (International Classification of Diseases (ICD)-9: 309.81; ICD-10: F43.10, F43.11, or F43.12) at two or more outpatient mental health encounters over the course of 90 days between January 1, 2017 and December 31, 2019. The first qualifying encounter was defined as the index date. Patients who met these criteria prior to 2017 were excluded. We examined one year of treatment following the index date and patients who died before the end of follow up were excluded. We excluded patients who had any encounters for psychotherapy in a mental health clinic in the two years prior to their index date to focus on psychotherapy-naïve patients starting a new episode of PTSD treatment. This resulted in a cohort of 263,018 patients.

Evidence-Based Psychotherapy for PTSD

We evaluated whether patients in our cohort had engaged in EBP during their first year of PTSD treatment using health factors (hierarchical string-type data produced when standardized templates are completed). In 2015, the VHA mandated all providers use a standardized note template to document EBP delivery (Karlin & Cross, 2014), which automatically generate health factors that are stored in the VHA CDW. We used the health factor categories ‘MH CPT’ and ‘MH PEI’ to identify sessions that involved CPT and PE, respectively. We identified all encounters with a health factor for CPT or PE within one year of the index date. An EBP treatment session was defined as a health factor for EBP associated with an outpatient mental health encounter.

Initiating EBP was defined as at least one EBP treatment session during the follow up period. Patients without any EBP treatment sessions were categorized as Not Initiating EBP. For patients who initiated treatment, we identified patients who received a minimally adequate dose of treatment, which was defined as eight or more EBP treatment sessions, with the same therapist, within 14 weeks from the first session to the last session. This definition aligns with a VHA performance metric for delivery of minimally adequate EBP treatment (Maguen et al., 2019; Shiner et al., 2020). Unique treatment sessions were identified using visitSID, which identifies each unique encounter. Therapists were identified using providerSID, which is unique to each provider in the VHA. The providerSID is associated with the visitSID when an encounter is documented in the EHR and both unique identifiers are stored in the VHA CDW.

Covariates

We examined the following patient characteristics: age, gender, race, ethnicity, and VHA service-connected disability status. We also examined the following clinical comorbidities: history of military sexual trauma (MST), history of traumatic brain injury (TBI), and comorbid diagnoses of depression, anxiety, substance use disorder, bipolar disorder, and schizophrenia. Race and ethnicity are collected via selfreport during clinical care in the VHA. Patients who did not have any race category indicated in their health record were classified as “Not reported” and patients who indicated more than one race category were classified as “multi-racial.” Comorbid mental health diagnoses were identified by ICD-9/10 codes associated with any mental health encounter in the 12 months prior to the index date and consisted of other anxiety disorders, depressive disorders, bipolar disorder, psychotic disorders, and substance use disorders. History of TBI was assessed from the VHA’s Comprehensive TBI Evaluation module. Age and service-connected disability status were measured at the index date. All other covariates were measured in the two years prior to the index date.

Analysis

For the outcome of initiating treatment, we calculated the proportion of patients who initiated EBP in the first year of PTSD treatment. Among patients who initiated treatment, we calculated the proportion of patients who received a minimally adequate dose of treatment. We used generalized estimating equations (GEE) with a logit link to identify factors associated with initiating EBP versus not initiating EBP and to identify factors associated with receiving a minimally adequate dose of treatment versus initiating EBP and not receiving a minimally adequate dose of treatment. For the outcome of receiving a minimally adequate dose of treatment, analyses were restricted to patients who initiated EBP. For analyses of both outcomes, unadjusted bivariate models were estimated for each of the following covariates: age, gender, race, ethnicity, VHA service-connected disability status, history of MST, history of TBI, and comorbid diagnoses of depression, anxiety, substance use disorder, bipolar disorder, and schizophrenia. For the adjusted multivariable models, all covariates were entered into models simultaneously. GEE models were specified with a compound symmetry correlation structure to account for correlations between patients within VHA facilities, which violates the assumption of independent observations. All analyses were performed in SAS, Version 9.4 (Ii, 2018).

Results

The overall sample consisted of 263,018 patients who initiated a new course of PTSD treatment between 2017 and 2019 (Table 1). Patients were predominately male, white, and non-Hispanic or Latino/a, which is similar to the general VHA population. Forty-eight percent had a comorbid depressive disorder, 38% had a comorbid anxiety disorder, 28% had a comorbid substance use disorder, 14% had a history of military sexual trauma, and approximately 6% had a history of TBI.

Table 1.

Characteristics of patients who did and did not initiate evidence-based psychotherapy within the first year of posttraumatic stress disorder treatment

Characteristic Overall
N = 263,018		 Did not initiate EBP
N = 232,556		 Initiated EBP
N = 30,462
Age (mean, SD) 48.76 (15.44) 49.12 (15.59) 46.00 (13.85)
Age Category (n, %)
 18—29 26,697 (10%) 23,240 (10.0%) 3,457 (11%)
 30—44 95,130 (36%) 82,924 (36%) 12,206 (40%)
 45—59 67,512 (26%) 58,463 (25%) 9,049 (30%)
 60 + 73,679 (28%) 67,929 (29%) 5,750 (19%)
Gender (n, %)
 Male 221,582 (84%) 197,332 (85%) 24,250 (80%)
 Female 41,436 (16%) 35,224 (15%) 6,212 (20%)
Race (n, %)
 American Indian/Alaskan Native 3,041 (1.2%) 2,675 (1.2%) 366 (1.2%)
 Asian 3,828 (1.5%) 3,391 (1.5%) 437 (1.4%)
 Black 64,172 (24%) 56,664 (24%) 7,508 (25%)
 Multi-raciala 3,556 (1.4%) 3,148 (1.4%) 408 (1.3%)
 Not reportedb 16,575 (6.3%) 14,716 (6.3%) 1,859 (6.1%)
 Pacific Islander 3,019 (1.1%) 2,697 (1.2%) 322 (1.1%)
 White 168,827 (64%) 149,265 (64%) 19,562 (64%)
Ethnicity (n, %)
 Hispanic or Latino/a 27,266 (10%) 23,998 (10%) 3,268 (11%)
Service-connected disability (n, %) 181,558 (69%) 160,666 (69%) 20,892 (69%)
History of military sexual trauma (n, %) 36,578 (14%) 30,364 (13%) 6,214 (20%)
 Other anxiety disorders (n, %) 99,942 (38%) 89,052 (38%) 10,890 (36%)
 Depressive disorders (n, %) 126,008 (48%) 112,696 (48%) 13,312 (44%)
 Bipolar disorder (n, %) 20,250 (7.7%) 18,579 (8.0%) 1,671 (5.5%)
 Psychotic disorders (n, %) 5,481 (2.1%) 5,157 (2.2%) 324 (1.1%)
 Substance use disorders (n, %) 73,888 (28%) 66,028 (28%) 7,860 (26%)
 History of traumatic brain injury (n, %) 17,344 (6.6%) 15,080 (6.5%) 2,264 (7.4%)
Open in a new tab
a

Patients with multiple races recorded in their health record were categorized as multiracial

b

Patients who did not have a race recorded in their electronic health record were categorized as missing; EBP = evidence-based psychotherapy

Approximately 11.6% (n = 30,462) of the overall sample initiated EBP treatment within the first year of their PTSD treatment. Patients who initiated EBP were an average of three years younger compared to patients who did not initiate EBP. Twenty percent of patients who initiated EBP had a history of military sexual trauma, compared to 13% of all patients starting PTSD treatment. Approximately 5.5% of patients who initiated EBP had comorbid bipolar disorder and 1.1% had a comorbid psychotic disorder, while 7.1% of all patients starting PTSD treatment had comorbid bipolar disorder and 2.1% had a comorbid psychotic disorder.

Unadjusted and adjusted GEE models predicting EBP treatment initiation are presented in Table 2. In the adjusted model, patients between 30 and 44 years old and between 45 and 59 years old had a 1.05 (95% CI: 1.01, 1.09) and 1.10 (95% CI: 1.05, 1.15) greater odds of initiating EBP, respectively, compared to patients between 18 and 29 years old. Patients identifying as Hispanic or Latino/a had a 1.05 (95% CI: 1.01, 1.09) greater odds of initiating EBP. Patients with a history of MST and patients with a history of TBI had a 1.65 (95% CI: 1.59, 1.71) and 1.05 (95% CI: 1.00, 1.09) greater odds of initiating EBP, respectively. Patients who were 60 years and older had a 0.65 (95% CI: 0.58, 0.72) lower odds of initiating EBP, compared to patients between 18 and 29 years old. Patients with a comorbid depressive disorder, bipolar disorder, psychotic disorder, or substance use disorder had a 0.83 (95% CI: 0.79, 0.87), 0.70 (95% CI: 0.64, 0.76), 0.59 (95% CI: 0.45, 0.73), 0.91 (95% CI: 0.87, 0.95) lower odds of initiating EBP, respectively.

Table 2.

Patient factors associated with initiating evidence-based psychotherapy within the first year of posttraumatic stress disorder treatment

Variable Odds ratio 95% CI Adjusted Odds
ratio		 95% CI
Age category
 18–29 Ref Ref
 30—44 0.99 0.95, 1.03 1.05* (1.01, 1.09)
 45—59 1.05 1.00, 1.10 1.11* (1.06, 1.16)
 60 + 0.59* 0.52, 0.66 0.65* (0.58, 0.72)
Gender
 Male Ref Ref
 Female 1.43* 1.38, 1.48 1.01 (0.96, 1.06)
Race
White Ref Ref
 American Indian/Alaskan Native 1.06 0.95, 1.17 1.00 0.89, 1.11
 Asian 1.03 0.91, 1.15 0.96 0.86, 1.06
 Black 1.08* 1.04, 1.12 1.02 0.98, 1.06
 Multi-raciala 1.04 0.93, 1.15 0.95 0.85, 1.05
 Not reportedb 1.03 0.98, 1.08 0.97 0.92, 1.02
 Pacific Islander 0.97 0.87, 1.07 0.95 0.85, 1.05
Ethnicity
Not Hispanic or Latino/a Ref Ref
 Hispanic or Latino/a 1.09* 1.05, 1.13 1.05* 1.01, 1.09
 Service-connected disability 0.99 0.96, 1.02 0.98 0.95, 1.01
 History of military sexual trauma 1.67* 1.61, 1.73 1.65* 1.59, 1.71
 Other anxiety disorders 0.87* 0.83, 0.91 0.98 0.95, 1.01
 Depressive disorders 0.80* 0.76, 0.84 0.83* 0.79, 0.87
 Bipolar disorder 0.67* 0.60, 0.74 0.70* 0.64, 0.76
 Psychotic disorders 0.49* 0.33, 0.65 0.59* 0.45, 0.73
 Substance use disorders 0.85* 0.80, 0.90 0.91* 0.87, 0.95
 History of traumatic brain injury 1.14* 1.09, 1.19 1.05 1.00, 1.10
Open in a new tab

Odds ratios are from the bivariate models for the association between each variable and the outcome. Adjusted odds ratios are from the multivariable model where all covariates were entered simultaneously

*

Indicates a p-value of less than 0.05

a

Patients with multiple races recorded in their health record were categorized as multiracial

b

Patients who did not have a race recorded in their electronic health record were categorized as missing; CI = confidence interval; Ref = reference category

Of those who initiated EBP, approximately 33% (n = 10,030) received a minimally adequate dose of treatment (Table 3). Patients who received a minimally adequate dose of treatment were an average of two years older compared to patients who initiated EBP but did not receive a minimally adequate dose of treatment. The proportion of patients with a history of military sexual trauma was similar among patients who did and did not receive a minimally adequate dose of treatment. The prevalence of comorbid mental health disorders was similar among patients who did and did not receive a minimally adequate dose of treatment.

Table 3.

Characteristics of patients did and did not receive a minimally adequate dose of treatment within the first year of posttraumatic stress disorder treatment among who initiated evidence-based psychotherapy

Characteristic Overall
N = 30,4621		 Did not receive a Minimally adequate
dose of EBP treatment
N = 20,4321		 Received a minimally
adequate dose of EBP
treatment
N = 10,0301
Age (mean, SD) 46.00 (13.85) 45.03 (13.56) 47.97 (14.23)
Age Category (n, %)
 18—29 3,457 (11%) 2,504 (12%) 953 (9.5%)
 30—44 12,206 (40%) 8,604 (42%) 3,602 (36%)
 45—59 9,049 (30%) 5,916 (29%) 3,133 (31%)
 60 + 5,750 (19%) 3,408 (17%) 2,342 (23%)
Gender
 Male 24,250 (80%) 16,235 (79%) 8,015 (80%)
 Female 6,212 (20%) 4,197 (21%) 2,015 (20%)
Race (n, %)
 American Indian/Alaskan Native 366 (1.2%) 253 (1.2%) 113 (1.1%)
 Asian 437 (1.4%) 287 (1.4%) 150 (1.5%)
 Black 7,508 (25%) 5,197 (25%) 2,311 (23%)
 Multi-raciala 1,859 (6.1%) 1,238 (6.1%) 621 (6.2%)
 Not reportedb 408 (1.3%) 281 (1.4%) 127 (1.3%)
 Pacific Islander 322 (1.1%) 238 (1.2%) 84 (0.8%)
 White 19,562 (64%) 12,938 (63%) 6,624 (66%)
Ethnicity (n, %)
 Hispanic or Latino/a 3,268 (11%) 2,309 (11%) 959 (9.6%)
 Service-connected disability (n, %) 20,892 (69%) 13,964 (68%) 6,928 (69%)
 History of military sexual trauma (n, %) 6,214 (20%) 4,114 (20%) 2,100 (21%)
 Other anxiety disorders (n, %) 10,890 (36%) 7,424 (36%) 3,466 (35%)
 Depressive disorders (n, %) 13,312 (44%) 9,068 (44%) 4,244 (42%)
 Bipolar disorder (n, %) 1,671 (5.5%) 1,119 (5.5%) 552 (5.5%)
 Psychotic disorders (n, %) 324 (1.1%) 213 (1.0%) 111 (1.1%)
 Substance use disorders (n, %) 7,860 (26%) 5,268 (26%) 2,592 (26%)
 History of traumatic brain injury (n, %) 2,264 (7.4%) 1,631 (8.0%) 633 (6.3%)
Open in a new tab
a

Patients with multiple races recorded in their health record were categorized as multiracial

b

Patients who did not have a race recorded in their electronic health record were categorized as missing; EBP = evidence-based psychotherapy

Unadjusted and adjusted GEE models predicting receipt of a minimally adequate dose of treatment are presented in Table 4. In the adjusted model, patients between 30 and 44 years old, between 45 and 59 years old, and patients 60 years and older had 1.14 (95% CI: 1.05, 1.23), 1.44 (95% CI: 1.34, 1.54) and 1.80 (95% CI: 1.69, 1.91) greater odds of receiving a minimally adequate dose of treatment, respectively, compared to patients between 18 and 29 years old. Patients with a service-connected disability had 1.06 (95% CI: 1.01, 1.11) greater odds of receiving a minimally adequate dose of treatment. Patients identifying as Black or as Pacific Islander had a 0.83 (95% CI: 0.76, 0.90) and 0.72 (95% CI: 0.47, 0.97) lower odds of receiving a minimally adequate dose of treatment, respectively, compared to white patients. Patients identifying as Hispanic or Latino/a had a 0.88 (95% CI: 0.79, 0.97) lower odds of receiving a minimally adequate dose of treatment. Patients with a comorbid depressive disorder had a 0.92 (95% CI: 0.85, 0.99) lower odds of receiving a minimally adequate dose of treatment compared to patients with PTSD only.

Table 4.

Patient factors associated with receiving a minimally adequate dose of evidence-based psychotherapy within the first year of posttraumatic stress disorder treatment

Variable Odds ratio 95% CI Adjusted Odds
Ratio		 95% CI
Age category
 18–29 Ref Ref
 30—44 1.12* 1.03, 1.21 1.14* 1.05, 1.23
 45—59 1.41* 1.31, 1.51 1.44* 1.34, 1.54
 60 + 1.80* 1.70, 1.90 1.80* 1.69, 1.91
Gender
 Male Ref Ref
 Female 0.99 0.92, 1.06 1.04 0.96, 1.12
 Race
White Ref Ref
 American Indian/Alaskan Native 0.84 0.60, 1.08 0.86 0.61, 1.11
 Asian 1.00 0.79, 1.21 1.04 0.85, 1.23
 Black 0.89* 0.83, 0.95 0.83* 0.76, 0.90
 Multi-raciala 0.89 0.70, 1.08 0.93 0.74, 1.12
 Not reportedb 0.99 0.90, 1.08 1.01 0.92, 1.10
 Pacific Islander 0.70* 0.46, 0.94 0.72* 0.47, 0.97
Ethnicity
Not Hispanic or Latino/a Ref Ref
 Hispanic or Latino/a 0.85* 0.76, 0.94 0.88* 0.79, 0.97
 Service-connected disability 1.06* 1.01, 1.11 1.06* 1.01, 1.11
 History of military sexual trauma 1.05 0.98, 1.12 1.07 0.99, 1.15
 Other anxiety disorders 0.92* 0.86, 0.98 0.98 0.91, 1.05
 Depressive disorders 0.92* 0.86, 0.98 0.92* 0.85, 0.99
 Bipolar disorder 0.98 0.87, 1.09 1.02 0.91, 1.13
 Psychotic disorders 1.02 0.81, 1.23 1.04 0.83, 1.25
 Substance use disorders 0.97 0.90, 1.04 1.02 0.95, 1.09
 History of traumatic brain injury 0.78* 0.68, 0.88 0.90 0.80, 1.00
Open in a new tab

Odds ratios are from the bivariate models for the association between each variable and the outcome. Adjusted odds ratios are from the multivariable model where all covariates were entered simultaneously

*

Indicates a p-value of less than 0.05.

a

Patients with multiple races recorded in their health record were categorized as multiracial

b

Patients who did not have a race recorded in their electronic health record were categorized as missing; CI = confidence interval; Ref = reference category

Discussion

The purpose of this study was to measure EBP utilization among VHA patients in their first year of PTSD treatment between 2017 and 2019. We used discrete data elements routinely collected in the VHA’s EHR and EBP-specific note templates to measure the proportion of patients who initiated EBP. Overall, 263,018 patients started a new course of PTSD treatment between 2017 and 2019 and 30,462 (approximately 11.6%) initiated EBP within the first year. We used a previously described minimally adequate dose of treatment that aligns with a VHA performance metric (Maguen et al., 2019; Shiner et al., 2020) to measure the proportion of patients who received an adequate number of guideline concordant EBP sessions during their first year of PTSD treatment. Among those who initiated EBP, 10,030 patients (approximately 32.9%) received eight or more EBP sessions in 14 weeks with the same therapist, which we defined as a minimally adequate dose of treatment. It is possible that patients engaged in other non-EBP mental health care and were not captured in our analysis because of our focus on EBP for PTSD. Overall, only 3.8% of all patients newly diagnosed with PTSD between 2017 and 2019 received a minimally adequate dose of EBP during their first year of treatment. This is because a small proportion (11.6%) of the patients seeking PTSD treatment initiated EBP, which is consistent with previous national evaluations of EBP utilization in the VHA (Maguen et al., 2020; Maguen et al., 2018; Shiner et al., 2020).

Several patient characteristics were associated with odds of initiating EBP and receiving a minimally adequate dose of EBP during the first year of PTSD treatment. In our sample, older patients had lower odds of initiating EBP, which is consistent with previous findings (Lu et al., 2012; Sripada et al., 2018b). Specifically, compared to patients 18–29 years old, patients 60 years and older had 35% lower odds of initiating EBP, while patients between 30 and 59 years old had greater odds. However, all patients 30 years and older had greater odds of receiving a minimally adequate dose of EBP, compared to patients 18–29 years old. While older patients initiated EBP at a lower rate, patients 60 years and older had an 80% greater probability of receiving a minimally adequate dose of therapy compared to patients between 18 and 29 years old. There may be several possible explanations why older patients were less likely to initiate EBP, including patient preference to engage in treatment, however these findings suggest that older patients should be offered EBP when they begin PTSD treatment because they are likely to complete a minimally adequate dose of therapy once they begin. In addition, EBP trials conducted with older adults have shown positive effects on reducing PTSD symptoms (Thorp et al., 2019; Yoder et al., 2013). Greater efforts to engage older patients in EBPs should be prioritized given that older patients are more likely to receive a minimally adequate dose of treatment once engaged in EBP.

Patients with comorbid depressive disorders, bipolar disorder, psychotic disorders, or substance use disorders had lower odds of initiating EBP, which is consistent with some (Hundt et al., 2018; Rosen et al., 2019; Shiner et al., 2018; Sripada et al., 2018b), but not all (Lu et al., 2011) previous studies of EBP utilization. In particular, patients with comorbid bipolar disorder or psychotic disorders had a 30% and 41% lower probability of initiating EBP treatment. However, these patients did not have a lower likelihood of receiving a minimally adequate dose of treatment once engaged in EBP. Differences between our findings on comorbid mental health disorders and the findings of previous evaluations could be explained by differing inclusion criteria. We focused on incident cases of PTSD during the first year after a new PTSD diagnosis while other evaluations have included all prevalent cases of PTSD. Our findings suggest that patients with comorbid mental health diagnoses are likely to follow through with a minimally adequate dose of treatment once they engage in EBP. One explanation of these findings is a potential bias against offering patients with more severe comorbid mental health disorders EBP treatment. Several studies investigating provider decisions to offer EBPs have found that patients who are not considered “ready” for PE or CPT may not be offered these treatments (Cook et al., 2017; Osei-Bonsu et al., 2017). Providers may be less likely to offer EBPs to those who they consider psychologically unstable (Cook et al., 2014) which limits access to patients who follow through with treatment when offered EBP. It is also possible that patients with mental health comorbidities may have other treatment priorities (Lu et al., 2016) which may partly explain our finding that patients with mental health comorbidities were less likely to engage in EBPs.

Patients with a history of MST had 65% greater odds of initiating EBP, which is consistent with previous evaluations of EBP utilization (Dufort et al., 2021; Maguen et al., 2019). Patients with a history of MST also received a minimally adequate dose of treatment at similar rates to patients with other trauma histories, which is encouraging given that MST can be associated with shame, stigma, and a lack of trust in the VHA (Monteith et al., 2020). This finding is consistent with prior research that has found Veterans with a history of MST have higher VHA utilization rates compared those without a history of MST. (Brignone et al., 2017; Turchik et al., 2012). The VHA’s efforts to provide EBP treatment to patients with a history of MST are promising and these patients successfully follow through with treatment once engaged.

Race and ethnicity were associated with lower odds of receiving a minimally adequate dose of treatment. Patients identifying as Black or Pacific Islander had 18% and 27% decreased odds of receiving a minimally adequate dose of treatment, respectively, compared to White patients. Patients identifying as Hispanic or Latino/a had a 12% decreased odds of receiving a minimally adequate dose of treatment. These findings are consistent with previously described racial and ethnic disparities in psychotherapy for PTSD (Spoont et al., 2017). There are many factors that may contribute to EBP engagement, including patient preference, access to resources/supports, readiness to change, and specific skills to manage trauma-focused therapy. Additionally, trust in the VA, positive or negative prior experiences with healthcare providers, and provider cultural competencies may particularly affect historically marginalized racial and ethnic groups. The VHA has made efforts to engage historically marginalized racial and ethnic groups in care and should continue work to ensure that patients receive a minimally adequate dose of therapy once engaged in PTSD treatment.

Patients with a history of TBI also had slightly greater odds of initiating EBP treatment and a slightly decreased odds of receiving a minimally adequate dose of therapy. However, these results were not significant in the adjusted models. Nonetheless, engaging Veterans with TBI in PTSD treatment is important because there is significant overlap between TBI and PTSD symptoms (O’Neil et al., 2021). Treating the specific effects of PTSD may reduce the overall symptom burden of patients with comorbid PTSD and TBI. Given the effectiveness of PTSD treatment and far more limited TBI-specific treatment options, starting with PTSD treatment in patients with comorbid PTSD and TBI could be warranted in many cases.

There are several limitations to the current study. First, it is important to note that measuring EBP utilization using EBP-specific note templates is a proxy measure of EBP delivery. Many of the associations with EBP utilization that we observed are consistent with previously identified factors that predict the receipt of an EBP-specific note template (Sripada et al., 2018b). Our analyses accounted for clustering by VHA facility to mitigate the effect of system-level factors such as EBP documentation policies and focus on patient-level associations with EBP utilization. However, we cannot conclude with certainty that the observed associations reflect disparities in receipt of treatment versus disparities in the documentation of EBP templates. Second, EBP templates do not capture all instances EBP treatment in the VHA and likely underrepresent total EBP utilization (Shiner et al., 2021). Third, our approach to measuring EBP utilization only captures CPT and PE and does not include other trauma-focused PTSD treatments such as Eye Movement Desensitization and Reprocessing Therapy. And fourth, we used data routinely collected in the VHA’s EHR system and it is possible that variables we did not measure could be associated with initiating EBP or receiving a minimally adequate dose of therapy.

In conclusion, between 2017 and 2019, 11.6% percent of patients starting PTSD treatment in the VHA initiated EBP within the first year and 33% of patients who initiated EBP received a minimally adequate dose of treatment. Our work builds on previous research to provide an updated measurement of EBP utilization in the VHA following a VA-wide rollout of these interventions. Our examination of patient factors associated with receipt of EBP, along with updated treatment utilization estimates, can support efforts to engage patients diagnosed with PTSD in EBPs. We identified several patient-level disparities in EBP initiation, including older age and psychotic disorder diagnoses that are consistent with prior national evaluations of EBP utilization. Additionally, we found patients with comorbid psychotic disorder diagnoses and older patients had an equal or increased likelihood of following through with a minimally adequate dose of treatment, respectively. These findings suggest that the VHA should prioritize offering these patient populations EBP for PTSD as efforts to increase EBP utilization continue. We also found that patients identifying as Black, Pacific Islander, and Hispanic/Latino/a were less likely to receive a minimally adequate dose of therapy. The VHA should continue efforts to engage historically marginalized racial and ethnic groups in EBP treatment. Most VA patients do not engage in EBP within one year of being diagnosed with PTSD. Future research should focus on understanding the flow of patients from PTSD screening to diagnosis and treatment to identify potential access problems along this care pathway and support effective PTSD care delivery.

Acknowledgements

The VA Health Services Research and Development (HSR&D) Center to Improve Veteran Involvement in Care (CIVIC) provided support to David Cameron, Maya O'Neil and Allison O’Neill. Dr. O'Neil's work was supported in part by a Career Development Award from the VHA RR&D (1 IK2 RX002762-01A1). This material is the result of work supported with resources and the use of facilities at the Veterans Affairs Medical Centers in Portland, Oregon. The contents do not represent the views of the US Department of Veterans Affairs or the United States Government

Footnotes

Conflict of interest The authors declare no conflicts of interest.

Data Availability

Raw data were generated at Veterans Health Administration Corporate Data Warehouse. Derived data supporting the findings of this study are available from the corresponding author MEO on request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Raw data were generated at Veterans Health Administration Corporate Data Warehouse. Derived data supporting the findings of this study are available from the corresponding author MEO on request.

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