Dropout from guideline-recommended psychological treatments for posttraumatic stress disorder: A systematic review and meta-analysis

Background: Many patients drop out of guideline-recommended treatments for posttraumatic stress disorder (PTSD), yet there has been little systematic investigation of this issue. We aimed to examine dropout proportions from randomized controlled trials (RCTs) of guideline-recommended treatments for PTSD and whether proportions differed by type of treatment or trauma, PTSD severity or chronicity, or medication being permitted. Methods: Systematic review and meta-analysis of RCTs of guideline-recommended treatments for PTSD. Results: Eighty-five trials, with data for 6804 participants were included in the meta-analyses. The mean dropout proportion for guideline-recommended treatment was 20.9% (95%CI 17.2, 24.9) with evidence of high heterogeneity across studies. Military trauma was associated with higher dropout than civilian trauma. The civilian trauma group had similar dropout rates from guideline-recommended treatments, and active, waitlist or treatment as usual controls. In the military trauma group, dropout was higher from guideline-recommended treatments compared to active, waitlist or treatment as usual controls. Within this group, dropout from trauma-focused treatment was significantly higher than from non-trauma focused treatments overall, with the greatest difference in dropout rates occurring between randomization and treatment initiation. Limitations: Most RCTs exclude participants who have comorbid substance use disorder, suicidal behaviour, or history of psychosis, which limits the generalizability of findings. Conclusion: Dropout from guideline-recommended treatment for PTSD is higher in populations who have experienced military trauma and this population dropout from treatment in higher proportions when it is trauma-focused. The reasons for disparate rates of dropouts from recommended PTSD treatments require further investigation.