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Objective: Trauma‐informed guilt reduction therapy (TrIGR), a six‐session cognitive behavioral therapy targeting trauma‐related guilt and distress, reduces guilt and symptoms of posttraumatic stress disorder (PTSD) and depression, yet little is known regarding how and why TrIGR may be effective. Method: This study examined treatment‐related changes in avoidant coping and trauma‐related guilt cognitions as possible mediators of treatment effects on PTSD and depression outcomes at 3‐ and 6‐month follow‐up. Data were from a randomized controlled trial for treatment of trauma‐related guilt comparing TrIGR and supportive care therapy among 145 post‐9/11 US veterans (Mage = 39.2 [8.1], 93.8% male). Results: At pretreatment, most (86%) met PTSD criteria. Intent to treat analyses using parallel mediation models indicated changes in guilt cognitions, but not avoidant coping, mediated the effect of TrIGR on reducing PTSD severity at 3‐month (a × b = −0.15, p < 0.01, 95% CI: [−0.24 to −0.06], p = 0.001) and 6‐month (a × b = −0.17, 95% CI: [−0.26 to −0.07], p = 0.001) follow‐up. Similarly, changes in guilt cognitions, but not avoidant coping, mediated the effect of TrIGR on reducing depression severity at 3‐month (a × b = −0.10, 95% CI: [−0.18 to −0.02], p = 0.02) and 6‐month (a × b = −0.11, 95% CI: [−0.20 to −0.03], p = 0.01) follow‐up. Conclusions: Compared to guilt cognitions, changes in avoidant coping were less integral to downstream PTSD and depression symptom reduction. Guilt cognition change may be a salient active ingredient of PTSD and depression treatment for those with trauma‐related guilt and a key therapy element to which providers should be attuned. [ABSTRACT FROM AUTHOR]

Background: Available empirical evidence on participant-level factors associated with dropout from psychotherapies for post-traumatic stress disorder (PTSD) is both limited and inconclusive. More comprehensive understanding of the various factors that contribute to study dropout from cognitive-behavioural therapy with a trauma focus (CBT-TF) is crucial for enhancing treatment outcomes., Objective: Using an individual participant data meta-analysis (IPD-MA) design, we examined participant-level predictors of study dropout from CBT-TF interventions for PTSD., Methods: A comprehensive systematic literature search was undertaken to identify randomised controlled trials comparing CBT-TF with waitlist control, treatment-as-usual or another therapy. Academic databases were screened from conception until 11 January 2021. Eligible interventions were required to be individual and in-person delivered. Participants were considered dropouts if they did not complete the post-treatment assessment., Findings: The systematic literature search identified 81 eligible studies (n=3330). Data were pooled from 25 available CBT-TF studies comprising 823 participants. Overall, 221 (27%) of the 823 dropped out. Of 581 civilians, 133 (23%) dropped out, as did 75 (42%) of 178 military personnel/veterans. Bivariate and multivariate analyses indicated that military personnel/veterans (RR 2.37) had a significantly greater risk of dropout than civilians. Furthermore, the chance of dropping out significantly decreased with advancing age (continuous; RR 0.98)., Conclusions: These findings underscore the risk of premature termination from CBT-TF among younger adults and military veterans/personnel., Clinical Implication: Understanding predictors can inform the development of retention strategies tailored to at-risk subgroups, enhance engagement, improve adherence and yield better treatment outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. Published by BMJ.)