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

https://doi.org/10.1016/j.brat.2010.04.003Get rights and content

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.

Section snippets

Participants

The University of Washington Institutional Review Board approved the protocol.1 All participants provided written informed consent prior to participation. Details regarding recruitment, eligibility criteria and screening are available elsewhere (Dimidjian

Treatment preferences

On the ETI, 51 participants (48.1%) preferred psychotherapy, 19 (17.9%) preferred ADM, and 36 (34.0%) expressed no preference.

Refusing randomization

Twelve of 106 participants (11.3%) refused randomization. Of those randomized to their non-preferred group, 7 out of 44 (15.9%) refused randomization. Five out of 36 individuals (13.9%) who expressed no preference refused randomization. No participants randomized to their preferred group refused randomization (vs. non-preferred, χ2 (N = 70, df = 1) = 4.60, p = .03; See

Discussion

This study examined the effects of patient preferences on a range of outcomes in an RCT of the treatment of major depression. Results suggest several negative implications of being randomly assigned to a non-preferred mode of treatment. Mismatch had an effect on whether patients started treatment, such that none of those who refused randomization received a preferred treatment. Similarly, those randomized to a non-preferred treatment were more likely to dropout of the study and attend fewer

Acknowledgments

This research was supported by National Institute of Mental Health Grants MH55502 (R01), and MH079636 (F31), a predoctoral fellowship awarded to Bethany Kwan. We wish to acknowledge the investigator group for the National Institute of Mental Health Grant MH55502 (R01): Bob Kohlenberg, Karen Schmaling, David Dunner, Keith Dobson, and Steve Hollon, for their willingness to make data for this report available. GlaxoSmithKline provided medications and pill placebos for the trial. Correspondence

References (32)

  • I. Elkin et al.

    “Patient-Treatment Fit” and early engagement in therapy

    Psychotherapy Research

    (1999)
  • J. Fawcett et al.

    Clinical management: imipramine/placebo administration manual

    Psychopharmacological Bulletin

    (1987)
  • M. Feeley et al.

    The temporal relation of adherence and alliance to symptom change in cognitive therapy for depression

    Journal of Consulting and Clinical Psychology

    (1999)
  • H.A. Flynn et al.

    The impact of a brief obstetrics clinic-based intervention on treatment use for perinatal depression

    Journal of Women’s Health

    (2006)
  • J.L. Givens et al.

    Older patients’ aversion to antidepressants: a qualitative study

    Journal of General Internal Medicine

    (2006)
  • J.L. Givens et al.

    Ethnicity and preferences for depression treatment

    General Hospital Psychiatry

    (2007)
  • Cited by (0)

    View full text