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. Author manuscript; available in PMC: 2019 Nov 1.
Published in final edited form as: Psychol Serv. 2017 Dec 21;15(4):529–535. doi: 10.1037/ser0000204

Associations Between Residential Treatment Length, PTSD, and Outpatient Healthcare Utilization Among Veterans

Anne N Banducci 1, Marcel O Bonn-Miller 2, Christine Timko 3, Craig S Rosen 2
PMCID: PMC6542559  NIHMSID: NIHMS1014767  PMID: 29265844

Abstract

Premature discontinuation of PTSD treatment is generally associated with poorer outcomes for veterans with PTSD. What is less clear is whether treatment benefits, as a function of treatment length, persist, as well as predict less future mental healthcare utilization. We sought to determine whether length of stay (LOS) in residential PTSD treatment predicted discharge PTSD symptom severity and outpatient mental healthcare utilization. We hypothesized discharge PCL scores would mediate the relations between LOS in residential treatment and outpatient mental healthcare utilization. The current study included 740 veterans who received residential PTSD treatment within five VA hospitals and completed intake and discharge assessments, including the PTSD Checklist (PCL). Information about LOS in residential treatment and outpatient mental healthcare utilization was obtained from the National Patient Care Database. We examined the relations between residential LOS, discharge PCL, and outpatient mental healthcare utilization. Non-parametric bootstrapping was utilized to test for the significance of the indirect effect. Veterans who stayed in residential treatment longer had lower PCL scores at discharge (Est.=−2.50, SE=.51, p<.001) and veterans with lower PCL scores at discharge sought fewer outpatient mental health visits (Est.=.31, SE=.14, p=.03). A bias-corrected bootstrap confidence interval for the indirect effect (ab=−.77) based on 10,000 bootstrap samples was entirely below zero (−1.72 to −.05). This indicates discharge PCL mediated the relations between LOS and outpatient mental healthcare utilization, such that individuals with a longer LOS in residential PTSD treatment had lower PCL scores at discharge and thus utilized less outpatient mental healthcare.

Keywords: PTSD, healthcare utilization, residential treatment, outpatient treatment, length of stay

Approximately 500,000 veterans seek services for posttraumatic stress disorder (PTSD) annually, costing the Department of Veterans Affairs (VA) $3 billion per year (Galea et al., 2012). Despite receiving extensive treatment, including evidence-based psychotherapies, many veterans continue to struggle with and seek treatment for PTSD (Alvarez et al., 2011; Bradley, Greene, Russ, Dutra, & Westen, 2005; Rosen et al., 2013). Moreover, veterans, as compared to civilians, generally have poorer outcomes following PTSD treatment (Bisson et al., 2007; Bradley et al., 2005; Goodson et al., 2011; Steenkamp, Litz, Hoge, & Marmar, 2015; Watkins et al., 2011). Indeed, even among the most intensive PTSD treatment programs within VA (i.e., inpatient/residential PTSD treatment), pre-post treatment effect sizes are often small (Goodson et al., 2011) and symptomatology generally increases in the months following treatment, suggesting that even the most extensive treatment programs are not sufficiently addressing the needs of veterans with PTSD.

Although there are a number of factors that impact the poor outcomes observed among some veterans who have received PTSD treatment, the amount of treatment received stands out as a critical element. For example, within the context of outpatient psychotherapy, the majority of veterans with PTSD receive just 1–2 therapy sessions within a one-year period (Oliva, Bowe, Harris, & Trafton, 2013). These short-duration treatment stints may help explain why many veterans receiving outpatient psychotherapy do not see reductions in PTSD symptomatology (Tuerk et al., 2013), as they are unlikely to receive the active components of treatment prior to discontinuing treatment (Otto et al., 2012). This early discontinuation (Fortney et al., 2015; Mott et al., 2014) has been highlighted as a factor explaining lingering symptomatology, as well as elevated rates of later treatment utilization (Tuerk et al., 2013).

Findings are more mixed when attempting to determine what constitutes an adequate dose of inpatient/residential PTSD treatment, which often is measured as the length of stay in treatment (number of days), rather than in number of treatment sessions. Initial work has compared PTSD outcomes between programs offering shorter versus longer lengths of stay, as well as within programs that have changed the amount of treatment offered over time. In one study examining 35 treatment programs, programs that reduced their length of stay (LOS) by 6–21%, or converted from a more intensive inpatient to a less intensive residential model, had equivalent outcomes to programs that did not change their care models, or that increased their LOS by 1–12% (Rosenheck & Fontana, 2001). In a separate study comparing veterans receiving care in long-stay PTSD programs (M length of stay = 100 days), short-stay PTSD programs (M length of stay = 37 days), and general psychiatric units (M length of stay = 30 days), veterans receiving care in short-stay and general psychiatric units had greater improvements in PTSD symptoms, as compared to veterans in long-stay units (Fontana & Rosenheck, 1997). Taken together, this work suggests programs offering longer lengths of stay do not necessarily have superior outcomes to programs offering shorter lengths of stay.

Although prior research indicates that programs that either decrease their length of stay in general, or have a comparatively shorter length of stay, do not have poorer outcomes (e.g., Fontana & Rosenheck, 1997; Rosenheck & Fontana, 2001), it is less clear whether individuals receiving less treatment than their peers within the same programs have poorer outcomes. Recent studies have begun to examine this question. In contrast to the aforementioned studies examining LOS at the program level, this work suggests that individuals who receive less residential treatment than their peers have poorer outcomes. For example, veterans (majority of sample had PTSD), who received more than 30 days of residential treatment had greater improvements in psychiatric symptoms at a one-year follow-up as compared to veterans who received less than 30 days of residential treatment, within the same treatment program (Harpaz-Rotem, Rosenheck, & Desai, 2011). Similarly, a longer LOS in residential PTSD treatment was associated with improved alcohol-related outcomes, and those with improved alcohol outcomes had reductions in PTSD symptoms (Coker, Stefanovics, & Rosenheck, 2016). Although these studies suggest individuals with a longer LOS have improved outcomes, it is unclear whether an individual’s LOS actually predicts PTSD symptom severity following treatment discharge. Since residential treatment is particularly costly (i.e., $21,353 per veteran receiving residential/inpatient care versus $1,754 per veteran receiving outpatient care in FY13; Northeast Program Evaluation Center, 2013), it is important to examine whether individuals who receive more treatment, as compared to their peers, actually have improved symptomatology at discharge.

Beyond the importance of examining the impact of LOS on PTSD symptoms, it is also critical to consider whether veterans require additional courses of treatment following residential care. Higher levels of outpatient mental health treatment utilization can help indicate whether veterans continue to experience persistent symptoms of PTSD following intensive residential PTSD treatment. Given that findings are mixed regarding whether improvements in PTSD symptoms are maintained following residential treatment (Goodson et al., 2011; Humphreys, Westerink, Giarratano, & Brooks, 1999; Murphy et al., 2015), it is possible that veterans’ outpatient mental healthcare treatment seeking differs as a function of PTSD symptom severity post-treatment. That is, those veterans who differentially improve as a function of LOS might also seek outpatient mental healthcare at different rates. Linked to this, it has been argued that mental healthcare treatment utilization over time is a particularly useful metric of prior treatment effectiveness (i.e., those who use more treatment have more persistent symptoms) (Jerrell & Ridgely, 1995). Thus, examining relations between treatment duration, symptom severity at discharge, and outpatient mental healthcare utilization post-discharge, can provide important insights into the impact of residential treatment on long-term outcomes.

Current Study

The current study aimed to determine whether LOS in residential PTSD treatment was associated with PTSD symptom severity at discharge, and whether discharge symptom severity was associated with later outpatient mental healthcare utilization. We hypothesized that longer LOS in residential PTSD treatment would predict less severe PTSD symptoms at discharge (controlling for intake symptoms), which would predict less outpatient mental healthcare utilization in the year following treatment; that is, PTSD symptom severity would mediate relations between LOS and mental healthcare utilization. Given that depressive symptoms (Horesh, Lowe, Galea, Uddin, & Koenen, 2015), substance use (Petrakis, Rosenheck, & Desai, 2011), and gender (Jacobson, Donoho, Crum-Cianflone, & Maguen, 2015) have been associated with PTSD symptomatology in prior studies, we examined these as potential covariates within our analyses.

Method

Participants and Procedures

Institutional review boards at each study site oversaw and approved of study procedures. All participants gave written consent to participate. The current study is a secondary data analysis that includes data from 740 veterans (see Table 1) who received residential PTSD treatment in five VA hospitals from 2006–2009. Veterans were recruited into a telephone monitoring intervention within two weeks of admittance to residential treatment. Given that the telephone intervention did not impact PTSD symptoms or outpatient mental healthcare utilization in the year following residential PTSD treatment (Rosen et al., 2013), we did not control for the intervention in our analyses. Exclusion criteria for the telephone intervention study included being: unable to provide informed consent, discharged prior to receiving at least 15 days of residential treatment, transferred directly to a different inpatient treatment program, and active-duty (active-duty personnel receive outpatient care outside of the VA system).

Table 1.

Demographic and Clinical Characteristics

Factor N = 740 (M, SD) or %
Age 50.07 years (12.45)
Sex 86.7% male (n=646)
Race/Ethnicity 63% White (n = 468)
21.7% Black (n= 161)
5.5% Latino (n = 41)
2.4% Native American/Alaskan Native (n = 18)
7.4% other or missing (n = 55)
Marital Status 43.7% married (n = 325)
38.1% divorced/separated (n = 283)
2.6% widowed (n = 19)
14.7% never married
.9% missing (n = 7)
Era of Service 59.1% Vietnam and prior (n = 439)
30.7% Gulf War to current (n = 228)
8.2% multiple eras (n = 61)
Served in a War Zone? 81.8% Yes (n = 608)
Experienced Military Sexual Trauma? 20.5% Yes (n= 152)
Service-Connected for PTSD? 68.5% Yes (n = 509)
Baseline PCL-S Total Scorea 67.69 (11.26)
91.9% above PCL-S cutoff of 50 (n = 683)
Discharge PCL-S Total Score 60.29 (14.34)
75.4% above PCL-S cutoff of 50 (n = 560)
Clinically Significant PCL-S Change?b 35.4% Yes (n = 263)
Length of Stay 47.43 days (25.15)
Number of Outpatient Visits 36.05 (43.33)
Baseline CESD-R Score 40.73 (9.64)
Baseline ASI Alcohol Composite Score 0.11 (.15)
Baseline ASI Drug Composite Score 0.03 (.05)
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Notes. PCL = PTSD Checklist Specific, CESD-R = Center for Epidemiological Studies Depression Scale-Revised, ASI = Addiction Severity Index.

a

A cutoff of 50 on PCL-S was utilized to determine whether PTSD was present.

b

Clinically significant change was defined as a decrease of 10 or more points on the PCL from intake to discharge.

The residential PTSD treatment programs included in this study followed a therapeutic milieu model; services varied across the programs and across veterans based on treatment needs. Treatment included medication management, skills-focused therapy (e.g., anger management, cognitive behavioral therapy), process groups, and evidence-based psychotherapy for PTSD (i.e., Cognitive Processing Therapy (Resick, Monson, & Chard, 2014) or Eye Movement Desensitization and Reprocessing (Shapiro & Forrest, 2004). The mean length of treatment ranged from 30.23 to 65.09 days across sites; on average, veterans received 47.43 days of residential treatment (SD = 25.15). This is comparable to the average LOS reported to the Northeast Program Evaluation Center (M = 41.4 days, SD = 24.2), which collects data on all VA residential PTSD programs (NEPEC, 2013). Veterans were referred to the parent study (Rosen et al., 2013) by clinicians providing care at the treatment sites. Interested veterans met with a research assistant who explained the study, obtained informed consent, and provided an intake assessment. Veterans completed a discharge assessment prior to discharging from residential treatment.

Measures

Length of stay and outpatient mental healthcare utilization.

Information about the number of days of residential treatment veterans completed, as well as the number of outpatient mental health and substance use treatment sessions veterans received in the year following residential treatment, were obtained from the VA National Patient Care Database (Table 1). A summed score was created that indicates the total number of outpatient mental health and substance use visits received within VA during the year following receipt of residential PTSD treatment, which is hereafter referred to as outpatient mental healthcare utilization.

PTSD symptoms.

Symptoms of PTSD at intake and discharge were assessed with the Posttraumatic Stress Disorder Checklist- Specific (PCL-S) (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996), a 17-item, self-report measure of past month PTSD symptoms, based on DSM-IV diagnostic criteria, and associated with a specific traumatic event. Items on the PCL-S are scored on a five-point Likert scale (scores = 1–5), with higher scores indicating the individual is more bothered by the symptom during the prior month (Total score range = 17 – 85). Psychometric support for the PCL-S has been previously established (Blanchard et al., 1996). A cutoff score of 50 has been utilized in prior research to indicate whether an individual has PTSD (Forbes, Creamer, & Biddle, 2001) and a 10+ point decrease is considered clinically significant change on this measure (Monson et al., 2008). Cronbach’s alpha for the total PCL-S score at intake was .91 and at discharge was .94.

Potential covariates.

Demographic information, including age, gender, race, and period of military service were collected by self-report at intake. The Center for Epidemiological Studies Depression Scale Revised (CESD-R) (Eaton, Smith, Ybarra, Muntaner, & Tien, 2004), a well-established, 20-item, self-report measure of depression symptom severity was administered at intake. Cronbach’s alpha for the total CESD-R score was .88 at intake. The Addiction Severity Index (ASI) (McLellan et al., 1992), a reliable and valid self-report assessment of seven domains of functioning related to addiction, was administered at baseline. In the current study, we examined alcohol use and drug use composites from the self-report version of the ASI at intake (McLellan et al., 1992; Rosen, Henson, Finney, & Moos, 2000). Cronbach’s alpha for the alcohol use composite was .89 and for the drug use composite was .87.

Analytic Strategy

Preliminary analyses.

All data were analyzed using SPSS v23 to determine the impact of LOS in residential PTSD treatment on post-treatment PTSD symptom severity and outpatient mental healthcare utilization. Prior to conducting the primary analyses, descriptive statistics were computed to examine means, standard deviations, and ranges across all measures. Correlations between LOS, the potential mediator (PCL score at discharge), the dependent variable (outpatient mental healthcare utilization), and theoretically relevant risk factors for elevated PCL scores at discharge and increased outpatient mental healthcare utilization (i.e., more severe baseline PTSD symptoms, depressive symptoms, and ASI scores; female gender) were initially examined. Variables that were significantly correlated with discharge PCL and outpatient mental healthcare utilization were then included in the mediation model (described below) as covariates. The model was run both with and without covariates to ensure model effects were not inflated or dependent on the inclusion of covariates (Simmons, Nelson, & Simonsohn, 2011).

Within our analyses, we wanted to examine the impact of LOS across programs more broadly, as well as LOS of individual patients relative to their peers within the same programs more specifically, on outcomes. The former helps determine whether longer treatment in general is beneficial, whereas the latter helps determine whether receiving more treatment within a given program impacts outcomes. Given that mean LOS varied significantly across the five sites (F(4, 736) = 120.28, p < .001), examining LOS, both across programs and within programs was important, As such, two LOS variables were constructed. An untransformed LOS variable indicates the total number of days of treatment a veteran received. A program-specific LOS variable was constructed to indicate LOS for each veteran, relative to LOS for other veterans within the same program. That is, LOS for each veteran was z-score transformed, using the mean and standard deviation for LOS for the program where the veteran received treatment, to indicate LOS relative to peers within the same program. Separate analyses were conducted using the transformed and non-transformed LOS variable to determine the impact of length of stay more broadly (non-transformed LOS), as well as individual LOS relative to peer LOS (z-score transformed) more specifically, on discharge PCL scores and outpatient mental healthcare utilization.

Model building.

To determine whether LOS in residential PTSD treatment was predictive of PTSD symptoms at discharge from residential treatment (controlling for intake PTSD symptoms) and whether this, in turn, predicted outpatient mental healthcare utilization in the year following residential treatment, we conducted mediation analyses using bootstrapping with replacement (Preacher & Hayes, 2008) to estimate the indirect effects of residential LOS on outpatient mental healthcare utilization via discharge PCL scores. Bias-corrected bootstrapping with 10,000 bootstrap samples was used to maximize the power to detect mediation (Fritz & MacKinnon, 2007; Hayes & Scharkow, 2013; Preacher & Hayes, 2008). Mediation analyses were conducted using the SPSS PROCESS macro with bootstrapping (Hayes, 2012), which allows for non-normality (Preacher & Hayes, 2008). This modeling technique estimates simultaneous regression analyses and generates confidence intervals that correct for bias in estimating the indirect effect. As noted above, variables significantly correlated with PCL scores at discharge, as well as outpatient mental healthcare utilization, were included in the model as covariates. The model was examined using the non-transformed LOS variable, as well as the z-score transformed LOS variable.

Results

Preliminary Analyses

PTSD symptoms at discharge were positively correlated with baseline depressive symptoms and baseline PTSD symptoms (Table 2). Discharge PTSD symptoms were negatively correlated with LOS in residential treatment and the z-score transformed LOS in residential treatment score. Age, gender, and ASI were not significantly correlated with discharge PCL scores. Outpatient mental healthcare utilization was significantly correlated with gender (women received more care), baseline PTSD symptoms, discharge PTSD symptoms, and the z-score transformed LOS. LOS, age, depressive symptoms, and ASI were not significantly correlated with outpatient mental healthcare utilization.

Table 2.

Correlations between Demographic and Clinical Characteristics

Age Gender LOS T1 CES-D T1 PCL T1 ASI Alcohol T1 ASI Drugs T2 PCL LOS z-score
Gender −.18** —
LOS −.07 .23** —
T1 CES-D −.15** .11** −.02 —
T1 PCL −.14** .03 .11** .71** —
T1 ASI Alcohol −.13** .01 .05 .02 .08* —
T1 ASI Drugs −.05 −.02 .01 −.01 .05 .42** —
T2 PCL −.04 −.02 − .32** .44** .59** .04 .08 —
LOS z-score −.11** .54** .69** .05 −.05 .04 .01 −.17** —
Healthcare Utilization .02 .18** .06 .04 .10** .06 .08 .11** .10**
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Notes. LOS = length of stay, T1 = time 1 (intake), T2 = time 2 (discharge), ASI = Addiction Severity Index, Healthcare Utilization = outpatient mental healthcare utilization, for Gender female is the referent group.

Variables significantly correlated with T2 PCL and Healthcare Utilization are bolded and included as covariates in our models

*

p < .05;

**

p < .01.

Phi coefficients are reported for correlations within dichotomous variables. Otherwise, Pearson correlations are presented

Model Building

Impact of LOS on discharge PCL and outpatient mental healthcare utilization.

Discharge PCL was associated with LOS in residential treatment when controlling for intake PCL and baseline depressive symptoms, such that longer LOS was associated with less severe PTSD symptoms at discharge (Figure 1). Discharge PCL scores predicted outpatient mental healthcare utilization, when controlling for gender and intake PCL, such that less severe PTSD symptoms predicted less mental healthcare utilization in the year following residential treatment. A bias-corrected bootstrap confidence interval (CI) based on 10,000 bootstrap samples for the indirect effect of discharge PCL on the relations between LOS in residential treatment and outpatient mental healthcare utilization was significant and below zero (Figure 1). This demonstrates discharge PCL mediated the relations between LOS in residential treatment and outpatient mental healthcare utilization, such that veterans with a longer LOS in residential PTSD treatment had lower PCL scores at discharge, and thus utilized less outpatient mental healthcare during the one-year following residential treatment. The model effects held when the covariates were removed and the model was re-run, suggesting that model effects were not dependent on the inclusion of covariates (Simmons et al., 2011).

Figure 1.

Figure 1

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Discharge PTSD Mediates the Relations between Residential LOS and Outpatient Mental Healthcare Utilization

Notes. Length of stay is the number of days of residential treatment received by each veteran. For Gender, female is the referent group.

Values are unstandardized Betas. * p < .05, ** p < .01, *** p < .001.

Impact of z-score transformed LOS on discharge PCL and outpatient mental healthcare utilization.

Discharge PCL was associated with z-score transformed LOS in residential treatment when controlling for intake PCL and baseline depressive symptoms, such that veterans with a longer LOS, relative to their peers in the same treatment program, had less severe PTSD symptoms at discharge (Figure 2). Discharge PCL scores predicted outpatient mental healthcare utilization, when controlling for gender and intake PCL, such that less severe PTSD symptoms predicted less mental healthcare utilization in the year following residential treatment. A bias-corrected bootstrap confidence interval (CI) based on 10,000 bootstrap samples for the indirect effect of discharge PCL on the relations between z-score transformed LOS in residential treatment and outpatient mental healthcare utilization was significant and below zero (Figure 2). This demonstrates discharge PCL mediated the relations between z-score transformed LOS in residential treatment and outpatient mental healthcare utilization, such that veterans with a greater LOS in residential PTSD treatment, relative to their peers in the same program, had lower PCL scores at discharge, and thus utilized less outpatient mental healthcare during the one-year following residential treatment. The model effects held when the covariates were removed and the model was re-run, suggesting that model effects were not dependent on the inclusion of covariates (Simmons et al., 2011).

Figure 2.

Figure 2

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Discharge PTSD Mediates the Relations between Z-Score Residential LOS and Outpatient Mental Healthcare Utilization

Notes. Length of stay is the z-score transformed variable that represents each veteran’s length of stay, relative to their peers within the same treatment program. For Gender, female is the referent group.

Values are unstandardized Betas. * p < .05, ** p < .01, *** p < .001.

Discussion

The current study demonstrates that veterans with a longer LOS in residential PTSD treatment have less severe PTSD symptoms at discharge and less outpatient mental healthcare utilization in the year following residential treatment. It may be that those veterans who receive less residential treatment, both relative to their peers within the same treatment programs, or in general, are those who are least likely to see treatment benefits. As such, veterans who leave treatment prior to receiving a full treatment dose, or against the recommendations of treatment providers, may be those who see fewer symptom improvements (Coker et al., 2016). Although it cannot be ascertained within the current study why some veterans left treatment sooner than others (e.g., early dropout, terminated from treatment), it is clear the dose of treatment received impacted outcomes in terms of PTSD symptom severity and outpatient treatment utilization. Similar to these findings, prior work has demonstrated that veterans who receive evidence-based treatment for PTSD utilize less healthcare following treatment (Meyers et al., 2013); however, only those who receive a “full course” of PTSD treatment, as compared to those who drop out prematurely, demonstrate reductions in later mental health service utilization (Tuerk et al., 2013). Thus, ensuring veterans do not drop out of residential treatment early (or are not discharged because of behavioral violations) may be critical in achieving the greatest level of symptom reductions for veterans with PTSD, and in reducing later mental health service utilization.

Although these initial findings examining the impact of LOS in residential PTSD treatment on PTSD symptomatology and outpatient visits are promising, limitations must be considered. First, findings may not be generalizable to all residential PTSD treatment programs within or outside VA, as program content varies. Second, precise data characterizing the treatment veterans received were not collected; thus, we cannot determine which treatment components might have been associated with decreases in PTSD symptoms. As veterans receiving evidence-based psychotherapies for PTSD would be those expected to see the greatest improvements, the frequent lack of provision of these services, even by clinicians trained in these treatments (Finley et al., 2015), is problematic. Third, these data were collected several years ago; it is possible there have been changes to residential PTSD treatment programs since the data were collected that could impact patterns of findings. Fourth, the parent study from which these data were extracted excluded veterans receiving fewer than 15 days of residential treatment, which prevents us from understanding this important group of veterans. Fifth, we do not have information characterizing the treatment veterans received outside of the VA. Sixth, it would have been preferable to have a clinician-administered assessment of PTSD symptoms, rather than a self-report assessment like the PCL-S. Seventh, it is possible there were cohort effects we were unable to control for within the context of this study. Finally, we do not have data clarifying why some veterans received considerably shorter residential PTSD treatment compared to their peers; that is, we cannot determine whether these veterans elected to drop out from treatment early, were asked to leave treatment early because they violated program rules, were transferred to another program, or had another reason for receiving fewer days of treatment. Despite these limitations, findings from the current study clarify how residential treatment dose impacts treatment outcomes and outpatient mental healthcare utilization. These findings have important implications and highlight the potential benefits of increasing treatment retention, both to reduce PTSD symptom severity and to decrease the need for later outpatient mental healthcare.

Funded by:

• U.S. Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development

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