Datapoints: False Starts in Psychotherapy for Substance Use Disorders and PTSD in the VHA

As part of the push toward evidence-based mental health treatment, there is interest in increasing the proportion of patients who engage in evidence-based psychotherapy. However, attrition is a common phenomenon, especially at the beginning of psychotherapy. Using Veterans Health Administration (VHA) data, we examined psychotherapy utilization patterns among patients diagnosed as having a substance use disorder or posttraumatic stress disorder (PTSD) in fiscal year (FY) 2008. Start of a psychotherapy treatment episode was defined as the first psychotherapy visit after 60 days with no VHA psychotherapy visits within VHA. Thus psychotherapy visits more than 60 days apart were viewed as separate treatment episodes. This is consistent with a widely used definition of a treatment episode for a substance use disorder (1). Among patients who initiated psychotherapy, we also examined attrition—defined as attending only one or two psychotherapy visits.

In FY 2008, of the 380,231 patients with an inpatient or outpatient encounter that included a substance use disorder diagnosis, 210,168 (55%) had at least one outpatient psychotherapy episode start, and among those, 121,257 (58%) attended only one or two visits. Of the 442,359 patients with an inpatient or outpatient encounter in FY 2008 that included a PTSD diagnosis, 297,831 (67%) had at least one outpatient psychotherapy episode start, and, among those, 183,801 (62%) attended only one or two visits (Figure 1). Repeated attempts at psychotherapy engagement were not rare; 40% of those with a substance use disorder and 48% of those with PTSD who started one outpatient psychotherapy episode had at least one additional episode start in the same year.

These observations may have significant clinical and measurement implications. Clinically, these results suggest that more needs to be done to encourage patients to initiate and engage in treatment. Although attrition from care is common, both clinicians and patients should be aware that a significant number of patients who initially disengage from care will later make attempts at reengagement. Efforts to reengage patients may improve engagement rates and mental health outcomes. Explaining these rates to patients may reduce discouragement and self-stigma among those having difficulty with adherence during attempts at treatment seeking. Moreover, many patients with PTSD or a substance use disorder may need more than one attempt at psychotherapy to be successful.

Some widely used measures of treatment engagement examine only the first episode of care in a year (1). Our results suggest that this approach could underestimate the proportion of patients who engage in treatment during a year because it overlooks subsequent treatment episodes. Our results underscore the importance of the adage, “If at first you don’t succeed, try, try again.”