Treatment preference, engagement, and clinical improvement in pharmacotherapy versus psychotherapy for depression

Abstract

Pharmacotherapy and psychotherapy are generally effective treatments for major depressive disorder (MDD); however, research suggests that patient preferences may influence outcomes. We examined the effects of treatment preference on attrition, therapeutic alliance, and change in depressive severity in a longitudinal randomized clinical trial comparing pharmacotherapy and psychotherapy. Prior to randomization, 106 individuals with MDD reported whether they preferred psychotherapy, antidepressant medication, or had no preference. A mismatch between preferred and actual treatment was associated with greater likelihood of attrition, fewer expected visits attended, and a less positive working alliance at session 2. There was a significant indirect effect of preference match on depression outcomes, primarily via effects of attendance. These findings highlight the importance of addressing patient preferences, particularly in regard to patient engagement, in the treatment of MDD.Keywords patient preferences; depression treatment; working alliance; attrition; indirect effects; multiple mediation Major depressive disorder (MDD) remains a significant public health problem worldwide. Clinical research suggests that the use of pharmacotherapy and psychotherapy, both singly and in combination, are efficacious treatments for depression (see Hollon, Thase, & Markowitz, 2002). However, it is widely recognized that the efficacy of treatments for depression in clinical practice is limited by multiple factors, including premature dropout and non-adherence (e.g., Keller, Hirschfeld, Demyttenaere, & Baldwin, 2002;Melfi, Chawla, Croghan, Hanna, Kennedy, & Sredl, 1998). The preferences of patients for a given © 2010 Elsevier Ltd. All rights reserved.Corresponding author: Bethany M. Kwan, MA, MSPH University of Colorado at Boulder UCB 345 Boulder, CO 80309-0345 bethany.kwan@colorado.edu phone: 1-720-273-2715 fax: 1-303-492-2967. Correspondence concerning this article should be addressed to Sona Dimidjian, who is at the Department of Psychology, University of Colorado, Boulder, CO 80309-0345. sona.dimidjian@colorado.edu. 2 Data on early working alliance was only available for a portion of the sample (57 out of 73; 78.1% patients and therapists). Due to administrative error, fewer patients and providers completed the WAI in the pharmacotherapy condition (29 out of 42; 69.0%) than in the psychotherapy (28 out of 31, or 90.3%).Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Given the limited and at times equivocal findings, greater clarity of the relationship between preference and key clinic...

Three-Year Follow-Up Comparing Cognitive Behavioral Therapy for Depression to Cognitive Behavioral Therapy for Insomnia, for Patients With Both Diagnoses

“…12 It is also what most patients prefer but rarely get. 13,14 A way of increasing access to CBT-i is to provide it via the Internet (ICBT-i), which in many studies has been proven effective, 15,16 as has CBT for depression (ICBT-d). 17 There are, however, very few randomized controlled follow-ups of more than 6-12 months for depression and insomnia treatments.…”

Developing Pluralistic Practice in Counselling and Psychotherapy: Using What the Client Knows

“…One of the most consistent findings within this literature is that preferences exist: people differ in terms of the kinds of intervention and treatment that they believe to be credible and effective for conditions such as anxiety, depression and trauma (Bakker, Spinhoven, van Balkom, Vleugel, & van Dyck, 2000; Bragesjö, Clinton, & Sandell, 2004;Hemmings, 2000;Lang, 2005;McLeod & Sweeting, 2010;Sobel, 1979;Tarrier, Liversidge, & Gregg, 2006). Some studies have explored preferences for psychotherapy in contrast to drug treatments (Kocsis et al, 2009;Kwan, Dimidjian, & Rizvi, 2010;Lin et al, 2005;van Schaik et al, 2004) and have found support for both types of intervention in research participants. There is also evidence for differences in attitudes and preferences associated with gender, age, ethnicity and previous experience of therapy (e.g., Bragesjö et al,…”

The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults

“…Interventions have included antidepressant medication as compared with forms of psychotherapy (e.g., cognitivebehavioral therapy, cognitive behavioral analysis system of psychotherapy, supportive therapy) or combined treatment with antidepressant and psychotherapy. Findings of these studies are mixed, with some (Kocsis et al 2009;Lin et al 2005;Mergl et al 2011) but not all (Dunlop et al 2012;Kwan et al 2010;Leykin et al 2007;Steidtmann et al 2012) showing greater or more rapid symptom reduction among individuals who received their preferred treatment. Other secondary analyses showed better reported therapeutic alliance among individuals who received their preferred treatment in some studies (Iacoviello et al 2007;Kwan et al 2010).…”

“…Findings of these studies are mixed, with some (Kocsis et al 2009;Lin et al 2005;Mergl et al 2011) but not all (Dunlop et al 2012;Kwan et al 2010;Leykin et al 2007;Steidtmann et al 2012) showing greater or more rapid symptom reduction among individuals who received their preferred treatment. Other secondary analyses showed better reported therapeutic alliance among individuals who received their preferred treatment in some studies (Iacoviello et al 2007;Kwan et al 2010). Despite the variability of these results, these studies provide some indirect evidence that asking about patient preferences could influence the therapeutic alliance, adherence, or outcomes, at least in individuals with depression (Gelhorn et al 2011).…”