Identifying Risk for Attrition during Treatment for Depression

Abstract

Background: Understanding patients’ ambivalence about treatment persistence may be useful in tailoring retention interventions for individual patients with major depressive disorder. Methods: Participants (n = 265) with major depressive disorder were enrolled into an 8-week trial with a selective serotonin reuptake inhibitor. At baseline and week 2, the participants were asked about their intent to return for the next visit, complete the study and continue in the study should they experience side effects or no improvement. Dropouts were defined as participants who discontinued attending clinic visits before completing the trial. Results: Participants who at baseline reported an uncertain/negative intent to continue if they experienced side effects or no improvement dropped out at a significantly higher rate by weeks 6 and 8. Uncertain/negative intent at week 2 predicted attrition at all following visits. Dropouts without side effects were more likely to have reported an uncertain/negative intent to attend at both baseline and week 2, while dropouts who experienced side effects were more likely to have reported an uncertain/negative intent to attend only at baseline. Positive intent to continue was associated with greater symptom improvement in both dropouts and completers despite the possibility of lack of efficacy. Conclusions: Participants’ pretreatment concerns about continuing antidepressant treatment in the presence of side effects signals challenges to the completion of a full 8-week acute phase treatment, even if the participant does not develop side effects. Individualized review of concerns and tailoring appropriate interventions may be necessary to reduce attrition.

Patient and Clinician Perceptions of Therapeutic Alliance as Predictors of Improvement in Depression

“…This might in part explain dropout in the present sample as well. In line with Warden et al [34], we acknowledge that an individualized review of concerns and tailoring of appropriate interventions may be necessary to reduce attrition.…”

“…Analyses showed that for dropouts less improvement was reported than for patients continuing therapy, suggesting range restriction operating in the criterion measure. Recently, Warden et al [34] found that participants’ pretreatment concerns about continuing antidepressant treatment in the presence of side effects signals challenges to the completion of a full 8-week acute-phase treatment, even if the participant does not develop side effects. This might in part explain dropout in the present sample as well.…”

What Is the Best Sequential Treatment Strategy in the Treatment of Depression? Adding Pharmacotherapy to Psychotherapy or Vice Versa?

“…A study by Warden et al [72] indicated that the initial intent of the patient with respect to continuing treatment is more relevant for drop-out than perceived side effects or a lack of efficacy during treatment. Discussing intent with patients at risk of drop-out before the start of therapy could therefore enhance adherence, alongside telephone support [66] and motivational interviewing [73].…”

Are Treatment Preferences Relevant in Response to Serotonergic Antidepressants and Cognitive-Behavioral Therapy in Depressed Primary Care Patients? Results from a Randomized Controlled Trial Including a Patients’ Choice Arm

“…This can signal challenges to the completion of an acute phase treatment, as a recent study of Warden et al [29] has shown. The use of the HAMD-17 as a measure of outcome might be another limitation [30].…”