title: Treatment Attendance Among Veterans With Depression, Substance Use Disorder, and Trauma.
abstract: OBJECTIVE
  Low attendance in psychotherapy, particularly among individuals with comorbid disorders, is a pervasive challenge. The present study examined predictors of treatment attendance in a sample of veterans with depression, substance use disorder, and trauma.
  
  
  METHODS
  This is an analysis of data collected as part of a larger clinical trial involving outpatients at a Veterans Administration dual diagnosis clinic. Individuals were excluded if they had significant memory deficits, schizophrenia, bipolar disorder, or substantial travel constraints. Participants (N = 146) received 12 weeks of group-delivered integrated cognitive behavioral therapy for depression and substance use, followed by randomization to 12 additional weeks of individually delivered cognitive behavioral therapy (n = 62) or cognitive processing therapy (n = 61) modified to address substance use and trauma. Participants, therapists, and researchers were not blinded to group assignment. For this study, we included only the 123 participants who were randomized into the second phase, analyzing predictors of treatment attendance categorized into predisposing factors, enabling factors, and need factors.
  
  
  RESULTS
  Participants were primarily male (89%) and Caucasian (76%) and averaged 47 years old (SD = 12). Forty-four percent had alcohol use disorder, 16% had drug use disorder, and 40% had polysubstance use disorder. Most met criteria for PTSD (82%), with 44% having combat-related trauma, 33% sexual trauma, and 28% other trauma. Treatment attendance did not differ between groups. More education was associated with increased group (r = .19, p = .04) and individual session attendance (r = .28, p = .002). Individuals with chronic housing problems attended fewer group sessions (r = -.19, p = .04), while individuals with sexual trauma, compared to those with other traumas, attended more individual sessions (r = .23, p = .01). Number of group sessions attended was positively associated with individual session attendance.
  
  
  CONCLUSIONS
  Few variables were significantly predictive of treatment attendance, possibly due to the complex nature of comorbid disorders. Including a focus on trauma was not associated with lower attendance. Special consideration may need to be given to education level, homelessness, and trauma when trying to engage and retain patients with comorbid disorders in treatment. This clinical trial is registered at www.clinicaltrials.gov as NCT00958217.
authors.affiliation: a Veterans Affairs San Diego Healthcare System , San Diego , California , USA.|c Department of Psychology , West Virginia University , Morgantown , West Virginia , USA.
authors.forename: Ruifeng
authors.initials: R
authors.lastname: Cui
authors.affiliation: a Veterans Affairs San Diego Healthcare System , San Diego , California , USA.
authors.forename: Moira
authors.initials: M
authors.lastname: Haller
authors.affiliation: a Veterans Affairs San Diego Healthcare System , San Diego , California , USA.
authors.forename: Jessica R
authors.initials: JR
authors.lastname: Skidmore
authors.affiliation: a Veterans Affairs San Diego Healthcare System , San Diego , California , USA.
authors.forename: Kelly
authors.initials: K
authors.lastname: Goldsteinholm
authors.affiliation: a Veterans Affairs San Diego Healthcare System , San Diego , California , USA.|b Department of Psychiatry , University of California , San Diego , La Jolla , California , USA.|d VA Center of Excellence for Stress and Mental Health , San Diego , California , USA.|e National Center for PTSD , White River Junction , Vermont , USA.
authors.forename: Sonya
authors.initials: S
authors.lastname: Norman
authors.affiliation: a Veterans Affairs San Diego Healthcare System , San Diego , California , USA.|b Department of Psychiatry , University of California , San Diego , La Jolla , California , USA.
authors.forename: Susan R
authors.initials: SR
authors.lastname: Tate
mesh_terms: D015928:Cognitive Behavioral Therapy / Q000379:methods*; D003863:Depression / Q000150:complications* / Q000628:therapy*; D017831:Diagnosis, Dual (Psychiatry); D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance / Q000523:psychology / Q000706:statistics & numerical data; D000067073:Psychological Trauma / Q000150:complications*; D019966:Substance-Related Disorders / Q000150:complications* / Q000628:therapy*; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans / Q000523:psychology / Q000706:statistics & numerical data
keywords: Depression; PTSD; attendance; substance use; trauma; veterans
references.citation: J Behav Health Serv Res. 2002 May;29(2):138-43
references.pmid: 12032971
references.citation: J Consult Clin Psychol. 1992 Oct;60(5):748-56
references.pmid: 1401390
references.citation: Psychol Med. 2003 Aug;33(6):1051-9
references.pmid: 12946089
references.citation: J Stud Alcohol. 2004 Nov;65(6):774-81
references.pmid: 15700516
references.citation: J Subst Abuse Treat. 2001 Jul;21(1):47-54
references.pmid: 11516926
references.citation: J Psychiatr Res. 1990;24(4):335-50
references.pmid: 2090831
references.citation: Am J Drug Alcohol Abuse. 2004 Aug;30(3):605-25
references.pmid: 15540496
references.citation: Am J Addict. 2011 Jul-Aug;20(4):357-65
references.pmid: 21679267
references.citation: Am J Drug Alcohol Abuse. 2002;28(1):55-72
references.pmid: 11853135
references.citation: Drug Alcohol Depend. 2006 Feb 28;81(3):313-22
references.pmid: 16171953
references.citation: J Trauma Stress. 2003 Oct;16(5):495-502
references.pmid: 14584634
references.citation: J Gen Intern Med. 2007 Jun;22(6):711-8
references.pmid: 17503104
references.citation: J Trauma Stress. 2005 Oct;18(5):425-36
references.pmid: 16281240
references.citation: J Subst Abuse Treat. 2010 Jun;38(4):346-55
references.pmid: 20363091
references.citation: J Psychiatr Res. 1994 Jan-Feb;28(1):57-84
references.pmid: 8064641
references.citation: Eur Addict Res. 2011;17(2):97-105
references.pmid: 21228594
references.citation: J Subst Abuse Treat. 2016 Mar;62:38-48
references.pmid: 26718130
references.citation: AIDS Care. 2000 Jun;12(3):255-66
references.pmid: 10928201
references.citation: J Subst Abuse Treat. 2008 Oct;35(3):343-50
references.pmid: 18295436
references.citation: Psychol Med. 1978 Nov;8(4):577-88
references.pmid: 724871
references.citation: Psychol Addict Behav. 2010 Sep;24(3):453-65
references.pmid: 20853931
references.citation: J Subst Abuse Treat. 2006 Sep;31(2):143-50
references.pmid: 16919741
references.citation: J Health Soc Behav. 1995 Mar;36(1):1-10
references.pmid: 7738325
references.citation: J Consult Clin Psychol. 2012 Aug;80(4):547-59
references.pmid: 22506792
references.citation: Psychotherapy (Chic). 2008 Jun 1;45(2):247-267
references.pmid: 19838318
references.citation: Depress Anxiety. 2001;13(3):132-56
references.pmid: 11387733
references.citation: J Clin Exp Neuropsychol. 1991 Nov;13(6):933-49
references.pmid: 1779032
references.citation: J Neurol Neurosurg Psychiatry. 1960 Feb;23:56-62
references.pmid: 14399272
references.citation: Alcohol Alcohol. 2011 Sep-Oct;46(5):592-9
references.pmid: 21733833
references.citation: Clin Psychol Rev. 2015 Jun;38:25-38
references.pmid: 25792193
references.citation: Arch Gen Psychiatry. 1988 Dec;45(12):1069-77
references.pmid: 2848472
references.citation: Drug Alcohol Depend. 2001 Mar 1;62(1):9-17
references.pmid: 11173163
references.citation: Am J Psychiatry. 2008 Feb;165(2):179-87
references.pmid: 18198270
references.citation: J Behav Ther Exp Psychiatry. 2000 Mar;31(1):55-66
references.pmid: 10983747
references.citation: Am J Public Health. 2005 Jul;95(7):1259-65
references.pmid: 15983278
references.citation: J Trauma Stress. 1995 Jan;8(1):75-90
references.pmid: 7712061
references.citation: J Consult Clin Psychol. 2006 Oct;74(5):898-907
references.pmid: 17032094
references.citation: Alcohol Clin Exp Res. 2008 Mar;32(3):481-8
references.pmid: 18215214
references.citation: J Clin Psychol. 2006 Jul;62(7):815-35
references.pmid: 16703602