Acute phase cognitive therapy for recurrent major depressive disorder: Who drops out and how much do patient skills influence response?

Abstract

Objective The aims were to predict cognitive therapy (CT) noncompletion and to determine, relative to other putative predictors, the extent to which the patient skills in CT for recurrent major depressive disorder predicted response in a large, two-site trial. Method Among 523 outpatients aged 18-70, exposed to 12-14 weeks of CT, 21.6% dropped out. Of the 410 completers, 26.1% did not respond. To predict these outcomes, we conducted logistic regression analyses of demographics, pre-treatment illness characteristics and psychosocial measures, and mid-treatment therapeutic alliance. Results The 17-item Hamilton Rating Scale for Depression (HRSD17) scores at entry predicted drop-out and nonresponse. Patients working for pay, of non-Hispanic white race, who were older, or had more education were significantly more likely to complete. Controlling for HRSD17, significant predictors of nonresponse included: lower scores on the Skills of Cognitive Therapy-Observer Version (SoCT-O), not working for pay, history of only two depressive episodes, greater pre-treatment social impairment. Mid-phase symptom reduction was a strong predictor of final outcome. Conclusions These prognostic indicators forecast which patients tend to be optimal candidates for standard CT, as well as which patients may benefit from changes in therapy, its focus, or from alternate modalities of treatment. Pending replication, the findings underscore the importance of promoting patients’ understanding and use of CT skills, as well as reducing depressive symptoms early. Future research may determine the extent to which these findings generalize to other therapies, providers who vary in competency, and patients with other depressive subtypes or disorders.

Non-attendance at psychological therapy appointments

“…Jarrett et al (2013) Higher levels of deprivation were found to be associated with increased drop-out, which supports studies by Hillis et al (1993), Grant et al (2012) and Self et al (2005). It may be that patients from more deprived areas have additional social, financial or health related problems and there may be competing demands on their time.…”

“…In secondary care mental health settings being younger, having a history of selfharm, higher levels of social deprivation (Hillis, Alexander and Eagles, 1993), higher levels of mental disorder (Killaspy, Banerjee, King and Lloyd, 2000) and the method of invitation to the appointment (Hillis and Alexander., 1990) are all influential in determining non-attendance. For psychological therapy settings minority racial status (Wierzbicki and Pekarik, 1993), low education (Keijsers, Kampman and Hoogduin, 2001;Wierzbicki and Pekarik, 1993), being younger (Saxon, Ricketts and Heywood, 2009;Jones, Carraretto and Deacon, 2008), low socio economic status (Wierzbicki and Pekarik, 1993), higher levels of social deprivation (Grant et al, 2012;Self, Oates, Pinnock-Hamilton and Leach, 2005), having a diagnosis of personality disorder (Schindler, Hiller and Witthöft, 2013;Swift and Greenberg, 2012) or eating disorder (Swift and Greenberg, 2012), greater psychological distress (Saxon et al, 2009), higher levels of measured agoraphobic avoidance (Lincoln et al, 2005), high depression scores (Jarrett et al, 2013), lower motivation (Keijsers et al, 2001), and being seen by a trainee therapist (Swift and Greenberg, 2012) are all related to increased drop-out. No significant differences have been found in drop-outs rates between psychological therapy approaches (Grant et al, 2012;Hembree et al, 2003), however the nature of the therapeutic relationship has been suggested to correlate to psychotherapy drop-out (Sharf, Primavera and Diener, 2010).…”

Assessing Patients’ Cognitive Therapy Skills: Initial Evaluation of the Competencies of Cognitive Therapy Scale

“…Jarrett et al’s SoCT has been validated in a large sample of depressed patients. Mid and post-treatment SoCT scores predicted odds of response to CT, controlling for initial depressive symptom severity (Jarrett et al, 2013). Factor analyses of our own measures and those of Jarrett et al identified single factor solutions of CT skill measures.…”

Differential role of CBT skills, DBT skills and psychological flexibility in predicting depressive versus anxiety symptom improvement

“…Studies using these measures have reported that greater depressive symptom improvement is associated with greater acquisition and use of CBT skills, as assessed by the SoCT (Jarrett et al, 2011; 2013), CBTSQ (Jacob et al, 2011; Webb et al, 2013) and CCTS (Strunk et al, 2014). However, causal inferences regarding the role of CBT skills in contributing to depressive symptom improvement are limited given that most of the associations reported within these studies are based on one or two concurrent assessments (e.g., only pre- and post-treatment) of CBT skills and depressive symptoms.…”

“…To our knowledge, the present study is the first to test whether patient-reported CBT skill use, assessed repeatedly throughout the course of therapy, predicts subsequent depressive symptom improvement. It should be noted that Jarrett et al (2011; 2013) reported that their SoCT measure, assessed at one mid-treatment timepoint, prospectively predicted post-treatment depression response (controlling for pre-treatment depression scores). However, the authors did not control for (1) concurrent symptoms (i.e., assessed at the time at which the SoCT was measured) or (2) prior symptom change (i.e., symptom improvement prior to the SoCT assessment), both of which represent plausible confounds.…”