stigma and barriers to care - Uniformed Services University of the ...

Conceptualizing Stigma and Barriers to Care 59
tonin reuptake inhibitors (SSRI) and placebo, or a wait list control. The members of
the wait list control received late PE treatment provided five months later. The equipoise
stratified randomization allowed our subjects to choose among four treatment
options and they could refuse up to two of them. Participants were still randomized
to the other two treatment options so we kept almost everyone in the study. There
were two layers of longitudinal survey, both blinded and nested. The two layers
were telephone interviews and clinical interviews. The telephone interviewers did
not know whether the person came for a clinical assessment or not, and the clinical
interviewers were blinded as to whether the person went to the recommended
treatment, avoided it, or dropped out.
The ecologic sensitive approach, which gives me the opportunity to speak about
the threshold issue, is that we were all inclusive. If a person told us, “I need to see
someone,” he went to clinical evaluation regardless of meeting the threshold of
symptoms. If the assessor found that the particular person deserved a treatment for
Posttraumatic Stress Disorder (PTSD) symptoms, the individual went into treatment
regardless of meeting a DSM‐IV structured clinical interview derived diagnosis of
PTSD.
Here is the basic structure of the study. Telephone interviews occurred within
nine days of trauma, seven months later, and 14 months later. There was a layer of
clinical assessment before treatment, between treatment, and after treatment. Only
6% of those approached by telephone within nine days of the trauma declined to
speak with the telephone interviewers. These interviews could be up to 40 minutes
long, detailing the exposure and what the reactions were. This is a very low refusal
rate.
We invited 1,470 people to treatment, clinical assessment, and a face-to-face
interview, and about half declined. This is the barrier. People do not accept faceto-face
contact with a clinician at that early stage of traumatic event. The bias here
is that those who accept treatment have more symptoms than those who decline
treatment. If there is any bias, those who need care are more likely to opt for care.
In terms of declining treatment, after participating in the telephone interview and
a clinical assessment, 27% still said, “I am not going to start treatment.” All in all,
the majority of those who may require treatment declined treatment at the early
stages in this almost ideal condition. There was no difference in symptom intensity
or severity between those who declined treatment and those who did not.
Within those who accepted treatment there was an equipoise stratified randomization
and the patient could refuse a condition. The single condition that was
declined by almost a third was pharmacological treatment, SSRIs. Those who did
accept the pharmacological treatment had more severe illness. Those who are less
distressed are pickier about what treatment to accept. In terms of treatment adherence,
prolonged exposure had a lower rate than all the others. The results indicate
that five months after trauma, PE and CT appear the most effective in preventing
PTSD. Even those who had to wait four months for PE treatment had low rates of
PTSD. This shows that it does not matter if treatment is delayed.
We all think about stigma in terms of preventing care, but we ventured into
measuring what happens with those who decline care. At the end of seven months the
decline in symptoms in those who accepted treatment was significantly higher than
in those who declined treatment or declined clinical interview. Declining a clinical
interview within 19 days of a traumatic event affects your symptom trajectory. You
are less likely to recover. I think this is one of the first studies to look at the long-term