The American Psychological Association (APA) recently published a study finding that patients assigned to drug-only treatments were more likely to refuse treatment, and more likely to drop out before treatment completion, than patients assigned to psychotherapy only.
“For both psychotherapy and pharmacotherapy, the benefit of treatment can be found in the prospect of getting better; however, clients may perceive additional benefits to psychotherapy over medication in that psychotherapy typically includes more frequent contact with a caring individual who listens and offers support in a nonjudgmental manner.”
A corpus of research has sought to investigate the circumstances surrounding patient refusal of treatment and premature termination. Refusal of treatment has been seen to occur more often with pharmacotherapy than with psychotherapy in several studies. Yet, some individual studies have found the opposite to be the case, necessitating a more comprehensive investigation. Premature termination, or patient drop-out prior to treatment completion, is noted to occur when the benefits of treatment are perceived to be outweighed by the risks.
This perception is supported by meta-analyses estimating as many as 30% to 50% of patients drop out in pharmacotherapy treatment versus approximately 20% in psychotherapy. It is likely that these numbers vary across diagnoses, as they have been found to vary between diagnoses of depression and anorexia, yet overall numbers seem to suggest a patient preference for psychotherapy treatment.
The importance of this research is underscored by the deleterious effects individuals may experience as a result of not receiving appropriate treatment. Such effects range from failure to improve to death. These risks are placed alongside concerns that society at large incurs significant costs associated with increased mortality rates associated with ‘mental disorders.’
A number of reasons have been put forth to account for treatment refusal and premature termination including two major factors, the stigma associated with treatment (see recent MIA report) and specific costs. Financial costs are most directly cited, but a unique cost to psychotherapy involves the experience of opening up to another individual in a way that regularly involves confronting painful or distressing emotions and experiences. For some, this difficulty is enough to make the drug alternative seem more appealing, an alternative accompanied by its own unique costs most often seen in the form of negative side effects, and concerns that this treatment lacks long-term effectiveness.
In an effort to consolidate and comprehensively gather existing data on this topic, Joshua Swift and researchers examined 186 studies and compiled a meta-analysis specifically focused on comparing rates of premature termination and treatment refusal.
“Comparing rates of treatment refusal and dropout is important because even if one treatment shows to be more effective than another, that treatment can be of little benefit if clients are unwilling to engage in it.”
In this study, four treatment options were compared: patients receiving pharmacotherapy only, patients receiving psychotherapy only, patients receiving both, and patients receiving psychotherapy with a pill placebo. Naturalistic studies were excluded in favor of direct comparisons only, a decision made to ultimately increase the internal validity of the study. The researchers note that the circumstances surrounding dropout and treatment refusal in naturalistic studies are less controlled, making it difficult to discern whether the treatment itself is the reason behind patient refusal or dropout. Patients in this study spanned across a long list of diagnoses including, but not limited to, depression, anxiety, eating disorders, PTSD, schizophrenia, and OCD.
Results of this study demonstrate that overall, 8% of patients refused treatment and 20% of clients prematurely terminated. While an 8% refusal rate appears minimal, the researchers urge readers to consider that these clients had previously agreed to engage in treatment. These results support the researchers’ hypothesis, backed by existing literature, that patients are more likely to refuse pharmacotherapy treatment than they are to refuse psychotherapy treatment. Patients in this meta-analysis were about two times as likely to decline assigned pharmacotherapy, particularly clients diagnosed with depression (2.16), panic disorder (2.79), and social anxiety disorder (1.97).
However, the inconsistent rates of refusal across diagnoses emphasize the need to explore these reasons in future research. The authors comment on this finding:
“Regardless of the reason, it is important to recognize that clients with social anxiety disorder, depression, and panic disorder are going to be more likely to begin their treatment if they are given the option to receive psychotherapy.”
Similarly, patients assigned to pharmacotherapy treatment were 1.20 times more likely to drop out before the completion of treatment. Patients diagnosed with anorexia or bulimia were 2.46 times as likely to prematurely terminate from pharmacotherapy and patients diagnosed with depressive disorders were 1.26 times as likely. Data from an individual study in this meta-analysis indicated that patients diagnosed with PTSD were 10.8 times more likely to drop out from the pharmacotherapy-only condition than the psychotherapy with a pill placebo condition.
Comparisons between singular conditions and the combined treatments resulted in no significant findings. This means that across these studies, treatment refusal and dropout did not differ significantly between pharmacotherapy or psychotherapy alone and the combined treatment conditions (pharmacotherapy plus psychotherapy and psychotherapy plus pill placebo).
Meta-analytic study designs are limited in that it is impossible to include and account for all existing, relevant studies. Studies that were included may not provide complete information about treatment refusal or drop out, and those that do may be limited in providing all contextual circumstances surrounding patient decisions. Additionally, some results, such as those pertaining to particular diagnoses, can only be drawn from a small number of studies included, so must be carefully considered.
Results of this study support existing literature highlighting a client preference for psychotherapy-only conditions over pharmacotherapy-only treatments.
“Thus, the results of this meta-analysis provide additional support that psychotherapy should be considered a first-line treatment for many psychological disorders,” write the authors.
Additionally, little information exists to explain the reason for this adherence and preference, emphasizing a need to consult with patients about their preferences, monitor outcomes throughout treatment, check-in with patients about their experiences throughout treatment, and prioritize collaboration and fostering of the patient-provider relationship, as well as other common factors. Other strategies focusing on accommodating patients more likely to drop out or refuse treatment are outlined. The researchers note:
“Even though psychotherapy was seen to have lower refusal and dropout rates when compared with pharmacotherapy, many clients either refused or did not complete all of the treatment conditions. This finding suggests that one particular treatment may not be right for all clients. Instead, providers should work to incorporate clients’ preferences, values, and beliefs into the treatment decision-making process.”
Researchers point out that studies have traditionally focused on treatment outcomes, overlooking the rates of patient dropout or refusal, and suggesting a need for greater research and transparency of these occurrences within psychotherapy. This also carries with it implications for how much one can know about the effectiveness of current interventions.
“Based on these results, we believe that in addition to considering treatment efficacy, treatment referrers and providers and those who develop treatment guidelines, should consider refusal and dropout rates when making treatment recommendations. After all, a highly effective treatment can only work if clients are willing to engage in it.”
Swift, J. K., Greenberg, R. P., Tompkins, K. A., & Parkin, S. R. (2017). Treatment refusal and premature termination in psychotherapy, pharmacotherapy, and their combination: A meta-analysis of head-to-head comparisons. Psychotherapy, 54(1), 47-57. doi:10.1037/pst0000104 (Abstract)