title: Predictors of dropout in concurrent treatment of posttraumatic stress disorder and alcohol dependence: Rate of improvement matters.
abstract: OBJECTIVE
  The present study examined predictors and moderators of dropout among 165 adults meeting DSM-IV criteria for posttraumatic stress disorder (PTSD) and alcohol dependence (AD). Participants were randomized to 24 weeks of naltrexone (NAL), NAL and prolonged exposure (PE), pill placebo, or pill placebo and PE. All participants received supportive AD counseling (the BRENDA manualized model).
  
  
  METHODS
  Logistic regression using the Fournier approach was conducted to investigate baseline predictors of dropout across the entire study sample. Rates of PTSD and AD symptom improvement were included to evaluate the impact of symptom change on dropout.
  
  
  RESULTS
  Trauma type and rates of PTSD and AD improvement significantly predicted dropout, accounting for 76% of the variance in dropout. Accidents and "other" trauma were associated with the highest dropout, and physical assault was associated with the lowest dropout. For participants with low baseline PTSD severity, faster PTSD improvement predicted higher dropout. For those with high baseline severity, both very fast and very slow rates of PTSD improvement were associated with higher dropout. Faster rates of drinking improvement predicted higher dropout among participants who received PE.
  
  
  CONCLUSIONS
  The current study highlights the influence of symptom trajectory on dropout risk. Clinicians may improve retention in PTSD-AD treatments by monitoring symptom change at regular intervals, and eliciting patient feedback on these changes.
authors.affiliation: Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA. Electronic address: zandberg@mail.med.upenn.edu.
authors.forename: Laurie J
authors.initials: LJ
authors.lastname: Zandberg
authors.affiliation: Department of Psychology, Southern Methodist University, Dallas, TX, USA.
authors.forename: David
authors.initials: D
authors.lastname: Rosenfield
authors.affiliation: Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Alpert
authors.affiliation: Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Carmen P
authors.initials: CP
authors.lastname: McLean
authors.affiliation: Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Edna B
authors.initials: EB
authors.lastname: Foa
mesh_terms: D000328:Adult; D000437:Alcoholism / Q000188:drug therapy / Q000523:psychology* / Q000628:therapy*; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D007171:Implosive Therapy / Q000379:methods; D008297:Male; D008875:Middle Aged; D009271:Naltrexone / Q000008:administration & dosage*; D010352:Patient Dropouts / Q000523:psychology*; D011237:Predictive Value of Tests; D012720:Severity of Illness Index; D013313:Stress Disorders, Post-Traumatic / Q000188:drug therapy / Q000523:psychology* / Q000628:therapy*; D016896:Treatment Outcome
chemical_list: D009271:Naltrexone
keywords: Alcohol dependence; Attrition; Dropout; Post-traumatic stress disorder; Predictors; Prolonged exposure