Predictors of treatment attendance in cognitive and dynamic therapies for major depressive disorder delivered in a community mental health setting.

Abstract

Objective: Our goal was to evaluate treatment attendance patterns, including both treatment completion and premature termination from treatment, for 2 evidence-based psychotherapies for major depressive disorder (MDD) delivered in a community mental health setting. We explored rates of premature termination across the course of treatment as well as the factors that predicted and moderated premature termination and treatment completion. Method: This investigation included 237 patients with MDD who participated in a noninferiority trial comparing short-term dynamic psychotherapy (DT) to cognitive therapy (CT). Patients in both conditions were offered 16 sessions of treatment and had up to 5 months to complete treatment. All patients completed an extensive self-report battery at treatment baseline as well as measures of the therapeutic alliance and opinions about treatment following Session 2. Results: Premature termination from both treatments was high with 27% of patients discontinuing treatment very early after only an intake session or a single treatment session. Patients in CT were significantly more likely to terminate treatment prematurely, 2 (3) ϭ 14.35, p ϭ .002. Baseline physical health functioning, subthreshold psychotic symptoms, Session 2 ratings of agreement on tasks, and Session 2 ratings of treatment sensibility all independently predicted premature termination of services. Trauma history significantly moderated very early termination of treatment, 2 (3) ϭ 10.26, p ϭ .017, with patients with high trauma histories more likely to complete DT but terminate prematurely from CT. Conclusions: Very early termination from services was higher in CT compared with DT. Including techniques to improve engagement in both therapies and matching patients to treatment based on predictors/moderators may be effective ways to optimize treatment engagement. What is the public health significance of this article?This study suggests that depressed patients with high trauma histories were more likely to discontinue cognitive therapy early compared with short-term dynamic therapy. It may be that dynamic techniques are useful to initially engage some patients in the treatment process.

The clinical characterization of the adult patient with depression aimed at personalization of management

“…The presence of early adversity may impact on treatment planning for depression in a number of ways. First, the presence of early adversity may be associated with premature treatment termination 213 , perhaps because of a weaker therapeutic alliance. This association may be present across psychotherapies; any particular therapy would therefore need to consider how best to address this issue, in accordance with its own theoretical framework.…”

The association between medical comorbidity and psychotherapy processes and outcomes for major depressive disorder in a community mental health setting.

“…These results suggested that those with self-reported poor physical health functioning initially engaged in treatment for MDD although discontinued treatment prior to completing the full course of therapy in later sessions. Building upon these findings, Connolly Gibbons et al (2021) also examined predictors and moderators of treatment outcome and found that physical health functioning as measured by the SF-36 was a significant predictor of outcome in a model including measures of psychiatric symptoms; however, when included in a final model that included other potential predictors of outcome, physical health functioning did not remain as a significant predictor. Given the high medical comorbidity seen in CMHC settings, it may be important to further explore other indicators of physical health functioning.…”

“…There is also emerging evidence that medical comorbidities may contribute to early attrition and poor outcomes from psychotherapy services in a community mental health setting. In the context of a noninferiority trial examining dynamic and cognitive therapies for MDD in a CMHC setting, Connolly Gibbons et al (2019) evaluated a broad range of potential predictors and poor physical health functioning emerged as an important predictor of early attrition in both cognitive and dynamic therapies. These results suggested that those with self-reported poor physical health functioning initially engaged in treatment for MDD although discontinued treatment prior to completing the full course of therapy in later sessions.…”

Insight as a mechanism of change in dynamic therapy for major depressive disorder.

“…Prior to the analyses, we calculated propensity scores to use as a covariate in later regression models. Previous analyses of the dataset (Gibbons et al, 2019) had shown that differential dropout and treatment outcome for the two treatment groups were predicted by several baseline covariates (age, education, race, physical functioning, psychotic symptoms, drug use, trauma history, emotional lability, interpersonal problems, and quality of life). To control for selection bias, propensity scores were calculated based on these variables and adjusted for subsequent analyses (D'Agostino, 1998).…”