The protocol matters: A meta-analysis of psychotherapy dropout from specific PTSD treatment approaches in U.S. service members and veterans.

Abstract

Objective: Service members and veterans (collectively, "military populations") are more likely to drop out of posttraumatic stress disorder (PTSD) psychotherapies than civilians, especially for trauma-focused treatments (Varker et al., 2021). Yet, it remains unclear whether specific protocols are linked with higher dropout risk, and no meta-analysis has investigated this for military populations. Therefore, this study aimed to conduct a secondary analysis of a large meta-analysis (Penix-Smith et al., 2025) to estimate dropout among specific PTSD treatments in United States military populations. Method: Overall, 181 articles provided PTSD dropout rates for 232 treatments (N = 124,092 clients) among military populations. Results: The weighted dropout rate for all PTSD interventions was 25.6%, 95% CI [22.9%, 28.5%] using a random effects model, where dropout significantly differed across treatments, Q(21) = 96.86, p < .001, I2 = 98.49. Treatments linked with higher dropout included weekly formats of cognitive processing therapy (CPT; 40.1%), prolonged exposure therapy (PE; 34.7%), and virtual reality exposure therapy (37.2%). Lower dropout was linked with weekly formats of present-centered therapy (PCT; 16.1%), mindfulness-based stress reduction (17.4%), and group-based exposure therapy (6.9%). Intensive outpatient programs (IOPs) yielded the lowest dropout rates overall, even when IOPs included CPT (8.5%) and PE (5.5%). Conclusions: Together, this study provided dropout benchmarks for specific PTSD treatments and identified treatments with the highest risk for dropout, including weekly CPT and PE. Findings suggest that resources targeting dropout and increasing the reach of treatments with lower dropout risk (e.g., PCT, IOPs) may facilitate psychotherapy engagement among military populations. (PsycInfo Database Record (c) 2026 APA, all rights reserved) Impact Statement Results from this meta-analysis (k = 181) suggest 25.6% of military populations drop out of posttraumatic stress disorder treatments. Some treatments yielded higher (e.g., weekly cognitive processing therapy, prolonged exposure therapy, virtual reality exposure therapy) and lower dropout (e.g., present-centered therapy, mindfulness-based stress reduction, intensive outpatient programs). (PsycInfo Database Record (c) 2026 APA, all rights reserved)