Refusal, Dropout Rates Differ Between Patients Receiving Psychotherapy, Pharmacotherapy

A meta-analysis published in March in the journal Psychotherapy found that patients prescribed pharmacotherapy may be more likely to refuse or prematurely end treatment than those who receive psychotherapy.

“No matter how efficacious a treatment may be for a given condition, its actual effectiveness depends upon the patient’s willingness to accept it,” said Mark Olfson, M.D., M.P.H., a professor of psychiatry at Columbia University School of Medicine, who was not involved with the study. “For this simple reason, it is important that we learn about the relative acceptability of different evidence-based treatments for common mental conditions.”

For the study, Joshua Swift, Ph.D., an assistant professor of psychology at Idaho State University, and colleagues analyzed data from trials that compared rates of treatment refusal or premature termination by patients with psychiatric disorders who were assigned to psychotherapy, pharmacotherapy, or a combination of the two.

Of the 186 studies included in the analysis, 57 (6,693 patients) included information on patients who refused treatment recommendations, and 182 (17,891 patients) included information on those who prematurely terminated treatment.

The researchers found that the average refusal rate was 8.2 percent across all studies. Patients assigned to pharmacotherapy alone were 1.76 times more likely to refuse initiation of treatment than patients who were assigned to psychotherapy alone. Further analyses comparing refusal rates by psychiatric disorder revealed rates of treatment refusal were greatest in patients with panic disorder and depression, who were found to be, respectively, 2.79 and 2.16 times more likely to refuse pharmacotherapy than their condition-matched counterparts who were assigned to psychotherapy.

For patients who initiated treatment, an average of 21.9 percent failed to complete the recommended regimen. Those assigned to pharmacotherapy alone were on average 1.20 times more likely to drop out compared with those assigned to psychotherapy. Rates of premature termination were highest in patients with anorexia/bulimia and patients with depression, who, respectively, were 2.46 times and 1.26 times more likely to terminate prematurely than their condition-matched counterparts who were assigned to psychotherapy.

There were no significant differences in rates of refusal or early termination when comparing the combination of the two treatments to pharmacotherapy or psychotherapy alone.

“Although combined treatments do require more effort from clients, when receiving a combined treatment, clients are guaranteed to receive a preferred treatment option,” the authors wrote. “Guarantee of a preferred intervention may provide clients with enough motivation to start and finish a treatment regimen, even if it comes at the cost of having to receive a nonpreferred intervention.”

Olfson noted that past depression trials have revealed that psychotherapy enhances adherence to antidepressants. Still, he said more research is needed to understand why patients refuse or terminate treatments early.

“[P]roviders should work to incorporate clients’ preferences, values, and beliefs into the treatment-decision process.” ■

An abstract of “Treatment Refusal and Premature Termination in Psychotherapy, Pharmacotherapy, and Their Combination: A Meta-Analysis of Head-to-Head Comparisons“ can be accessed here.