LIBERTY, TYRANNY AND THE WILL OF GOD: THE PRINCIPLE OF TOLERATION IN EARLY MODERN EUROPE AND COLONIAL INDIA Jakob De Roover1 & S.N. Balagangadhara2 Abstract: Early modern political thought transformed toleration from a prudential consideration into a moral obligation. Three questions need to be answered by anyexplanation of this transition: Did religious toleration really become
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Ppa-23439-a-review-of-studies-concerning---treatment-adherence-of-patiPatient Preference and Adherence
open access to scientific and medical research A review of studies concerning treatment adherence of patients with anxiety disorders This article was published in the following Dove Press journal: Patient Preference and Adherence22 August 2011Number of times this article has been viewed Objective: This paper aimed at describing the most consistent correlates and/or predictors of
nonadherence to treatment of patients with different anxiety disorders.
Method: The authors retrieved studies indexed in PubMed/MedLine, PsycINFO, and ISI Web
of Knowledge using the following search terms: attrition OR dropout OR attrition rates OR patient dropouts OR treatment adherence AND anxiety disorders. Research was limited to articles published before January 2010.
Results: Sixteen studies were selected that investigated the impact of sociodemographic, clini-
cal, or cognitive variables on adherence to treatment for anxiety disorders. While no consistent pattern of sociodemographic or clinical features associated with nonadherence emerged, all
studies that investigated cognitive variables in panic disorder, social anxiety disorder, and
obsessive-compulsive disorder found that expectations and opinions about treatment were
related to adherence.
Conclusion: The findings of this study suggest that it is essential to consider anxiety disorder
patients’ beliefs about illness and treatment strategies to increase their compliance with the
Keywords: attrition, dropout, OCD, obsessive-compulsive disorder, social anxiety disorder
Pathological anxiety and fear, ie, functioning impairing mood states associated with
preparation for possible or imminent negative events, are the core features of the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(DSM-IV-TR) anxiety disorders. Current conditions subsumed under its epithet include,
among others, generalized anxiety disorder, obsessive-compulsive disorder (OCD),
panic disorder, agoraphobia, specific phobias, social anxiety disorder (SAD) or “social
phobia,” posttraumatic stress disorder, and acute stress disorder. Epidemiological
studies show that anxiety disorders are the most common class of mental disorders,
affecting up to 28.8% of the general population at some point during their lives.1 People
with anxiety disorders present significant functional and occupational impairments. In
addition, they use public health services more often, thus leading to greater financial
expenditures.1,2 These findings illustrate the importance of access to treatment and
adherence to therapeutic strategies for patients with these conditions.
Although the dropout rate of patients with various psychiatric disorders for treat- ments in progress is approximately 50%,3–5 the situation for anxiety disorders may be particularly problematic. For instance, it has been suggested that up to 85% of patients with social phobia who were initially interviewed do not attend follow-up submit your manuscript
Patient Preference and Adherence 2011:5 427–439 2011 Santana and Fontenelle, publisher and licensee Dove Medical Press Ltd. This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.
treatment sessions.2 Although no clear information on the clinical, functional, and economic impact of treatment drop- A MedLine search resulted in 287 studies, of which 10 met out anxiety disorders is available, the high level of attrition the inclusion criteria. A PsycInfo search found 304 stud- compromises the effectiveness of treatment. Identifying the ies, of which two satisfied the inclusion criteria; however, risk factors for dropout in patients with anxiety disorders these studies had already been selected in the MedLine would allow clinicians to develop strategies that promote search. Finally, an ISI Web of Knowledge search resulted higher adherence to an established therapeutic plan (either in 318 articles, of which five met inclusion criteria, four of which had already been identified in the MedLine search. The objective of this review is to identify the sociodemo- Another five relevant articles were found in the references of graphic, clinical, and cognitive variables that predict attrition/ these studies that had not appeared in the database searches. dropout from different DSM-IV anxiety disorder treatments. Thus, a total of 16 articles were selected. A psychologist and Of note, studies including treatment adherence of patients a psychiatrist evaluated all of these articles jointly.
with major depressive disorder with concomitant anxiety The data were organized into two subsections. The first symptoms were excluded for not describing individuals with part (Studies’ designs) addressed the informative value of a primary anxiety disorder. The authors of this present review the reviewed studies, while the second one (Studies’ results) hypothesize that patients with lower socioeconomic levels, described the results that can be inferred from these studies. less education, more comorbidities, and negative beliefs or The first subsection included tables listing studies that inves- expectations regarding treatment will be more likely to drop tigated treatment adherence in anxiety disorders in general out before completion compared with those without these (Table 1), in panic disorder (Table 2), in SAD (Table 3), and in OCD (Table 4), their sample sizes, the type of treatments they offered and/or were applied, the instruments that were employed, the attrition and dropout treatment indices, and the The authors of this review identified studies that investigated cognitive, clinical, and sociodemographic variables that pre- predictors of attrition/dropout for anxiety disorder treatments dicted these features. The second subsection included one table through searches on PubMed/MedLine, PsycInfo, and ISI (Table 5) describing the results associated with each potential Web of Knowledge. The following search terms were used: predictor. This latter table describes the potential predictor, the attrition OR dropout OR attrition rates OR patient dropouts number of studies investigating it, and the number of studies OR treatment adherence AND anxiety disorders. Research reporting a positive or negative association with adherence.
was restricted to articles published before January 2010. Additionally, the references of the selected studies were exam- ined to find others related to the subject matter of interest.
A total of 16,766 patients with anxiety disorders were Studies that investigated adherence to pharmacological, assessed with regard to treatment adherence, including psychological, or both types of treatment in adults with a 13,085 patients from a single retrospective study using a large primary diagnosis of anxiety disorder were included. The managed care database. The impact of sociodemographic, studies that were included evaluated both the absence of clinical, and cognitive variables on adherence to treatment treatment adherence after the initial interview but before was evaluated in 14, 15, and seven studies, respectively. the treatment had begun (ie, attrition) and the absence of Seven papers assessed adherence to treatment in randomized treatment adherence after the treatment had begun (ie, controlled trials, six in naturalistic studies, three in open stud- “ dropout”). Studies addressing attrition or dropout in ies, and one in a retrospective study. One study combined data randomized controlled trials, open studies, naturalistic from an open and a controlled trial in a single analysis.
follow-ups, and retrospective assessments were included. Most (12) studies assessed adherence to cognitive Excluded studies were those that (1) focused on appraising behavioral therapies, eight studies evaluated adherence to the attrition or dropout of treatment in patients with pri- pharmacotherapy, and three investigated adherence to the mary major depression associated with secondary anxiety, combined treatment. Three papers included assessment of (2) described the index of attrition or dropout but did not the three forms of treatment (pharmacotherapy, cognitive evaluate its predictors, (3) investigated predictors of attrition behavioral, or combined treatments). Treatment included or dropout in children or adolescents with anxiety disorders, serotonin reuptake inhibitors in four and individual cognitive and (4) included qualitative methods.
behavioral treatment in five studies. Statistical analysis submit your manuscript |
Studies that investigate adherence to treatment for anxiety disorders in general orry Questionnaire; MOSSF-12, Medical Outcome Study Short Form 12.
submit your manuscript
Studies that investigate treatment adherence for panic disorder Abbreviations:
PDQ-R, Personality Diagnostic Questionnaire-Revised.
submit your manuscript |
Type of treatment
Studies that investigate treatment adherence in patients with SAD Abbreviations:
submit your manuscript
ersion; HRSD: Hamilton Rating Scale for Depression.
Type of treatment
Studies that investigate treatment adherence in patients with OCD Abbreviations:
ADQ, Adherence Determinants Questionnaire; TAS-P, Treatment Adherence Survey – Patient submit your manuscript |
Table 5 Sociodemographic, clinical, and cognitive predictors of treatment adherence in anxiety disorders and the number of studies
Anxiety disorders in general
Anxiety disorders in general
Abbreviations: OCD, obsessive-compulsive disorder; SAD, social anxiety disorder.
also varied greatly, but most studies used chi-square tests, regression analysis, and correlations to find the predictors The same studies assessed the impact of participants’ sex on Among these studies, Issakidis and Andrews4 studied patients with various anxiety disorders and found that women A summary of findings, describing different classes of socio- dropped out of CBT more frequently than men.
demographic, clinical, and cognitive predictors of treatment adherence, is depicted in Table 5, along with the number of studies assessing each dimension and the number of studies Nine studies investigated the influence of education showing a positive and negative association between each level on treatment adherence in patients with anxiety predictor and treatment adherence. Of note, for the sake of disorders.2,4,6,11,13–17 Of these studies, four found significant clarity, the data on sociodemographic aspects of different results.2,6,13,17 In a univariate analysis, Grilo et al6 found that anxiety disorders and the severity of key anxiety symptoms, patients with panic disorder who dropped out of a treatment comorbidities, and personality factors have been collapsed trial comparing CBT, imipramine, and placebo had less into single variables for each anxiety disorder.
education than those who completed treatment. However, a multivariate regression that controlled for other variables (eg, sociodemographic characteristics, severity of panic disorder, psychiatric comorbidity, attitude toward treatment, coping Fourteen studies attempted to evaluate the impact of par- style, and personality style) found that educational level did ticipants’ age on treatment adherence.2,4–16 Coles et al2 not significantly contribute to dropouts, unlike family income investigated the pre-treatment phase of a trial of group cognitive-behavior therapy (CBT), phenelzine, and placebo In the Coles et al2 SAD study, treatment-seeking people for SAD. They found that these patients displayed a high pre- with less education, who were non-Caucasian and either treatment attrition rate (85%) and that older patients turned unemployed or employed fulltime, were significantly more down treatment more often than younger ones.
likely to schedule, but not attend, an initial interview. submit your manuscript
Furthermore, Coles et al2 conducted a logistic regression to Similarly, in a study on adherence to pharmacological determine the extent to which demographic variables deter- treatments in 13,085 patients with anxiety disorders, mined interview attendance. A model that included race, Stein et al9 observed that patients who were treated by a age, and level of education explained 70.7% of the variance mental health specialist adhered to treatment more than those who were not seen by a specialist. Finally, Grilo et al6 found Keijsers et al17 studied 161 patients with panic disorder that panic disorder patients with a history of previous and and also found that educational level predicted treatment brief treatments, defined by a Likert scale varying from 1 (no adherence to CBT (panic control therapy). They found that previous treatment) to 4 (more than a year of treatment), were less education was associated with dropping out of treatment. more susceptible to dropping out from a controlled treatment Although educational level did not emerge as a predictor in a trial with CBT, imipramine, and placebo compared with univariate analysis, a regression model that included motiva- tion found that educational level was significantly associated with dropping out of treatment.
Unlike the studies above, Santana et al13 conducted a naturalistic follow-up study on 223 patients with OCD at a Hunt and Andrews8 investigated 1045 patients who sought university clinic for anxiety disorders that offered free phar- CBT for anxiety disorders from 1986 to 1988. Of these macological treatment. In that study, the follow-up time of patients, 546 met the diagnostic criteria of panic disorder, the patients (up to 10 years) was considered to be a measure agoraphobia, SAD, and generalized anxiety disorder. Of of treatment adherence. Through a logistic regression, the these patients, 432 patients accepted treatment. The clinical authors of that study found that patients with less education variables investigated were diagnosis, the severity of psy- chiatric symptom scale score (Symptoms Checklist-90 or SCL-90), the locus of behavioral control scale score and the Eysenck Personality Inventory (EPI) neuroticism subscale Seven studies investigated socioeconomic level, includ- score. There were no significant differences found between ing family income and employment status.2,4,6,7,13,16 Two the group who completed treatment (n = 357) and those who studies found significant differences between adherent and nonadherent patients in terms of socioeconomic Wingerson et al7 hypothesized that personality factors levels.6,13 As previously described, Grilo et al6 found that might contribute to dropping out of treatment. They inves- panic disorder patients who dropped out of a treatment tigated 112 patients with anxiety disorders treated with trial comparing CBT, imipramine, and placebo presented pharmacotherapy (including 5-hydroxytryptamine (5HT) a significantly lower income than patients who continued reuptake blockers, benzodiazepines, and 5HT agonists). treatment. These findings were detected with regression For panic disorder and generalized anxiety disorder patients models. On the other hand, Santana et al13 used a linear combined, early dropouts scored higher on total novelty regression model to find that unemployed OCD patients seeking of the Tridimensional Personality Questionnaire, as remained in treatment longer at a public service compared well as on the novelty-seeking traits of both disorderliness/ dislike of regimentation and impulsiveness. Patients who dropped out of treatment (40%) did not differ from those who remained with regard to history of depression, alcohol Santana et al13 examined 223 patients with OCD and found or drug abuse, psychiatric hospitalization, attempted suicide, a relationship between the patients’ places of residence and treatment adherence. Patients who lived in the city where Issakidis and Andrews4 investigated 731 patients who the clinic was located remained in treatment longer than sought and received treatment in a clinic specialized in those who lived in a different city. Issakidis and Andrews4 anxiety disorders. To analyze the data, they defined two used regression models to observe that patients with differ- dependent variables: attrition in pre-treatment (either refusal ent anxiety disorders who had at least one child and who of treatment or nonappearance) and dropping out of treat- were treated at a general clinic rather than by a specialist ment once it has started. They analyzed primary psychiatric in a mental health clinic were more likely to turn down the diagnosis, severity of symptoms, psychiatric comorbidities, and degree of incapacity. Attrition at pre-treatment (30.4%) submit your manuscript |
was associated with primary diagnosis because patients with CBT, medication, or both. They investigated six domains of depression or another psychiatric disorder were more likely variables: sociodemographic characteristics, severity of panic to turn down treatment compared with those with panic disorder, psychiatric comorbidities, attitude toward treat- disorder. In addition, the presence of more severe depressive ment, coping style, and personality style. After conducting symptoms at the initial interview and selection for group multivariate regressions, the authors of that study verified (rather than individual) treatment also significantly predicted that patients with higher Anxiety Sensitivity Index (ASI) attrition. In total, 10.3% of patients dropped out of treatment, scores and low agoraphobic avoidance were more likely to and as in the pre-treatment phase, patients with comorbid depression or depressive symptoms dropped out of treatment As in the study above, Keijsers et al17 investigated 161 more often than those without these symptoms. Dropouts patients with panic disorder who were offered CBT. The also reported less severe symptoms before treatment but a clinical variables investigated were the severity of symp- greater impairment of physical health.
toms and dysfunctional personality traits. The severity of Stein et al9 examined patients with various anxiety symptoms was evaluated through three characteristics: disorders who were offered pharmacological treatments catastrophic agoraphobic cognition, agoraphobic avoid- and found divergent results from those of Issakidis and ance behavior, and the frequency of panic attacks via the Andrews.4 According to Stein et al,9 patients with comorbid Agoraphobic Cognitions Questionnaire and the Mobility depression adhered to antidepressants (5HT and serotonin- Inventory. Furthermore, these authors of that study evalu- noradrenaline reuptake blockers) more than those without ated psychopathic personality traits using the Personality such a comorbidity. They argued that a possible reason for Diagnostic Questionnaire-Revised to investigate whether the lower rates of adherence in the nondepressed group was patients with personality disorders or with higher scores on the lower likelihood of mental health specialty care within this scale were more likely to discontinue treatment. They this population. In their analysis,9 significantly fewer patients found no significant differences between dropouts (19.9%) with anxiety alone, compared with patients with comorbid depression, received mental health specialty care during the Toni et al5 investigated 326 patients diagnosed with panic disorder who were treated with antidepressants and In summary, studies that investigated anxiety disorders in followed up for 3 years. During this period, 179 (54.9%) general differed from each other with regard to their method- patients dropped out of treatment. The only statistically ologies and results. The prevalence of dropouts varied from significant difference between dropouts and those who 10.3% to 57.0%. Only one study investigated attrition during completed treatment was a lower severity of panic disorder pre-treatment.4 All of the studies investigated the impact of comorbidities and the severity of symptoms4,7–9 in adherence. To summarize, five studies investigated treatment adher- However, only two studies4,9 found significant differences ence in patients with panic disorder.5,6,11,17,18 Among this between adherent and nonadherent patients, with divergent sample, four studies5,6,11,17 investigated clinical variables results. Specifically, one study found that patients with comor- related to dropouts in patients with panic disorder and three bid depression were more likely to turn down pre-treatment studies included CBT.6,11,17 All of the studies evaluated the and drop out from treatment4 compared with patients without severity of panic disorder, but only two studies found signifi- comorbidities, whereas another study found that patients with cant findings, and these had divergent results. In one study,6 comorbid depression were more likely to adhere to treatment.9 patients with a more severe disorder withdrew from treatment more often than patients with a less severe disorder, whereas the reverse was true in the other study.5 None of these four Carter et al11 investigated 31 patients with panic disorder and studies5,6,11,17 evaluated attrition in pre-treatment.
agoraphobia who were offered group CBT. The patients’ partners accompanied them to each session. The clinical vari- ables investigated were the number of situations avoided and Turner et al15 investigated 84 patients with SAD who the severity of their panic disorder; however, no significant met the criteria for generalized or circumscribed forms. differences were found through a multivariate analysis.
These patients were randomly divided into three groups: Grilo et al6 investigated 162 patients diagnosed with panic (1) exposure, (2) atenolol, and (3) placebo pill. Thirteen disorder, with or without agoraphobia, who were offered (15.5%) patients selected for this study declined to participate submit your manuscript
in the treatment protocol. These patients presented lower who already had a confirmed diagnosis and passed through severity scores on the Anxiety Diagnostic Interview Schedule the initial stages of treatment but who ultimately declined (ADIS)-Reviewed scale. Among those who participated in to participate. Two studies15,16 investigated the patients who this study, nine (12.7%) patients dropped out of treatment began treatment and dropped out; however, only one found over the course of the 12-week program and differed from that patients with less severe disease symptoms were more those who completed treatment in terms of a lower disorder severity as measured by the Fear Questionnaire Symptom Severity Scale and the Spielberger State-Trait Anxiety Hansen et al12 investigated nonadherence to therapy in patients Coles et al2 analyzed the treatment course for patients with OCD who had undergone CBT. They compared groups with SAD from the initial telephone contact to the begin- of 15 dropouts and 15 patients who successfully completed a ning of treatment. A total of 395 people made an initial treatment that consisted of 10 sessions of exposure and response telephone call; of these people, only 60 began treatment. prevention. Patients who abandoned treatment without inform- Thus, 85% of the patients who made initial contact with ing their therapist during the study period were considered to be the clinic did not begin treatment. Of the 395 patients who nonadherent. The researchers analyzed the severity of OCD as contacted the clinic, 131 completed an initial interview. Of measured by the Leyton Obsessional Inventory (LOI) and per- these patients, 126 people were diagnosed with SAD, and 60 sonality disorders determined using the Personality Diagnostic patients accepted and began treatment. No significant differ- Questionnaire-Revised. Patients who discontinued treatment ences were found between the group who began treatment had lower LOI disease-severity scores.
(n = 60) and those who did not (n = 66) with regard to the Mataix-Cols et al10 investigated whether different symp- following clinical variables: severity of symptoms, depres- tom dimensions in patients with OCD were associated with sive symptoms, quality of life (as measured by the Quality treatment adherence and behavioral therapy response. They of Life Inventory), and functional impairment (as measured investigated patients who participated in a controlled clinical by the Liebowitz Self-Rated Disability Scale).
trial of behavioral therapy either by computer or guided by a Hofmann and Suvak16 also investigated 133 patients clinician. They randomly selected 218 patients with OCD to with SAD who sought group behavioral therapy or group receive 10 sessions of treatment for (1) exposure and response CBT in a center for anxiety at Boston University. Of the 133 prevention guided by computer and a manual, (2) exposure patients, 34 (25.6%) dropped out of treatment. The authors and response prevention guided by a behavioral therapist, of that study investigated the following clinical variables: and (3) relaxation guided by audiotape. After a 3-month DSM-IV Axis-I diagnoses, anxiety and depression scores follow-up, the patients in the first two groups (exposure by (ie, the Social Phobia and Anxiety Inventory and the Beck computer or therapist) similarly improved, and both groups Depression Inventory, respectively), personality disorders, improved more than the relaxation control group. Of the and the index of disease severity stemming from social pho- patients who received at least one visit for post-evaluation, bia (as measured by the ADIS for DSM-IV [ADIS-IV]). They 153 completed the Yale-Brown Obsessive-Compulsive Scale compared the clinical and sociodemographic variables of the Checklist (Y-BOCS). The severity of obsessive-compulsive group that completed treatment with those of the group who symptoms at the beginning of treatment predicted response dropped out and did not find significant differences.
to therapy, and serious symptoms at the outset of therapy In summary, all of the studies reviewed here investigated continued to be more critical at the conclusion of treatment. the influence of clinical variables on the adherence to treat- Patients with high scores on the sexual/religious dimension of ment for SAD.2,15,16 Two studies2,15 analyzed attrition from the Y-BOCS had poorer responses to exposure and response treatment and obtained different results. Turner et al15 found prevention treatment. Regression analyses revealed that high that 15% of patients withdrew from study participation. Coles scores on the hoarding dimension predicted dropouts.
et al2 found that 85% of people who sought clinical help Mancebo et al14 validated an instrument (ie, the Treat- withdrew before treatment. This between-study heterogeneity ment Adherence Survey – patient version) that investigates may be partially explained by the disparate approaches that adherence to pharmacological and psychological treatments the studies used to conduct their investigations. Coles et al2 in patients with OCD. This instrument is composed of two began their investigation with the first phone call for treat- parts. The first section investigates adherence to CBT, and the ment, whereas Turner et al15 investigated attrition in patients second section investigates adherence to pharmacotherapy. submit your manuscript |
Mancebo et al14 selected 80 patients who participated in the Grilo et al6 found significant differences in the attitudes of Brown Longitudinal OCD Study. Of these patients, 28% did dropout panic disorder patients regarding their treatment and not adhere to CBT and 57% did not adhere to medication. the reasons they provided with respect to the etiology of their Those who did not adhere to CBT replied that they felt too panic attacks. Patients who (1) attributed their panic attacks anxious or fearful to participate in therapy (55%). These to life stressors, (2) had less favorable attitudes toward their same patients also had more severe obsessive-compulsive treatment (group versus individual treatment), and (3) used and depressive symptoms as evaluated by the Y-BOCS a coping style based on social support were more likely to and the Modified Hamilton Rating Scale for Depression, respectively. Patients who did not adhere to medication more Hofmann and Suvak16 investigated attrition in patients frequently reported dissatisfaction with side effects (77%) with panic disorder who sought, or were referred to, two and anxiety or fear with respect to taking medication (41%). clinics during the pre-treatment phase. One of the clinics These patients also had more severe depressive symptoms offered a pharmacological treatment, whereas the other than those who adhered to treatment.
offered a psychological treatment. After an initial interview, Santana et al13 also investigated patients with OCD during which patients were assessed for a formal DSM-IV and, similarly to Hansen et al,12 found results that diverged diagnosis of panic disorder, they participated in a study from those of Mancebo et al.14 In this naturalistic study, that offered five randomly distributed treatment modalities: the only clinical variable that predicted adherence was (1) imipramine, (2) panic control (ie, psychological treat- comorbid major depression. However, patients who ment), (3) placebo, (4) imipramine and panic control, and presented with this comorbidity were more likely to adhere (5) placebo and panic control. The patients were informed that they had a 92% chance of receiving an active treatment. In summary, all the studies that investigated adherence Of 628 pre-selected patients, 115 were ultimately excluded to OCD treatment evaluated the impact of the disease’s from the study due to diagnosis changes, medical problems, severity.10,12–14 The results were divergent: Hansen et al12 or other reasons. Of those eligible for treatment, 305 patients found that patients with less severe obsessive-compulsive (48.6%) refused to participate. The principal reasons given by symptoms more frequently discontinued treatment, whereas the patients who turned down treatment were that they were Mancebo et al14 found that patients with more severe symp- not willing to take medication (33.8%) or that they were not toms more frequently dropped out of treatment. Mataix-Cols willing to interrupt their usual medication schedule (24.9%). et al10 found that the severity of OCD predicted response The latter reason occurred due to a study regulation in which to treatment but not adherence. One study14 observed that participants were required to interrupt the use of all current patients with comorbid depression and more severe depres- sive symptoms adhered to treatment less often than those Keijsers et al17 also found that patients with panic disorder without these symptoms, while another one13 described that who were less motivated for treatment were significantly comorbid depression increased adherence.
more likely to discontinue treatment. This result appeared in both a univariate analysis and a regression model. In addition, the authors of that study contacted 25 of the 32 dropouts; the most common reasons these former patients provided Carter et al11 asked patients with panic disorder who dropped for dropping out included dissatisfaction with CBT and its out CBT in group to complete a self-report questionnaire. protocol and their improvement to that point, as well as a These patients claimed not to have been satisfied with their treatment. In addition, they stated that their partner, who functioned as their co-therapist and accompanied them to all the sessions, did not want them to continue treatment. Hofmann and Suvak16 found that SAD patients who discon- Finally, they declared having “difficulties with the therapy tinued behavioral or group CBT treatment found therapy to sessions.” This last response appeared on a self-report be less logical than those who completed treatment. A self- questionnaire (Treatment Non-completer Questionnaire) report questionnaire administered after the first session also that lists 18 common reasons that influence interruptions of investigated the attitude of the patients toward their treatment. treatment; however, the authors of the study did not provide Hofmann and Suvak16 tried to contact patients who discon- explanations of these “difficulties.” tinued treatment, but only 50% responded. Despite a positive submit your manuscript
correlation between “lack of logic” and the dropout rate, the less education were more likely to turn down treatment,2,4,17 patients reported that they discontinued treatment because of whereas one study found the opposite result.13 The authors conflicts with work, feelings that the group environment was of this present review believe that the interpretation of these overwhelming or that the treatment was ineffective, moving contradictory findings should take into account the peculiari- to a different city, and personal reasons.
ties of each mental health service in question. For instance, while greater levels of education could foster adherence to a private and/or wealthy clinic, it could also lead to greater Hansen et al12 studied patients with OCD after a psychologi- dropout rates in a public service dedicated to lower income cal treatment and found similar reasons for dropout using a structured questionnaire. Dropouts stated that the therapy Further, six studies2,4,6,13,16 investigated the impact of did not correspond to their expectations and had criticisms socioeconomic levels on treatment adherence in anxiety concerning their therapist. Furthermore, these former patients disorders. Of note, only one study on patients with panic felt less “pressure” from someone close to them to continue disorder found an association between lower socioeconomic therapy compared with those who completed treatment. level and higher likelihoods of dropout,6 while a naturalistic These results highlight the importance of knowing and agree- study of OCD found a paradoxical association between higher ing to the proposed treatment, patients’ relationships with socioeconomic levels and greater adherence to treatment.13 In their therapist, and their attitudes toward treatment.
the latter study, Santana et al13 tracked patients for 10 years Mancebo et al14 found that 80 patients with OCD reported via a free university service. Thus, patients with more educa- perceived environmental barriers between CBT and their tion and higher socioeconomic levels might have sought treat- ability to complete treatment. Although there were no expla- ment in private services to avoid some of the inconveniences nations of these “environmental barriers,” the fact that the of public services such as lines and hours spent waiting for patients perceived them as a reason for not adhering to treat- ment indicates the presence of beliefs with regard to treat- In summary, although there is some evidence that both ment access which must be better investigated. With regard lower educational levels and socioeconomic status can to medication adherence, these patients also questioned the adversely affect adherence in anxiety disorders, studies showing no relationship outnumber those that do. Also, the relationship between adherence to treatment and educational Discussion
levels and socioeconomic status need to be examined in the A total of 16 studies were selected that investigated the light of the characteristics of the service being provided.
impact of sociodemographic or clinical variables on adher- Fifteen studies evaluated the impact of clinical variables ence to treatment for anxiety disorders. The greatest majority on dropping out of treatment.2,4–7,8–17 Despite the fact that of the available studies were unable to find sociodemographic many studies of depression show that comorbidity predicts differences between adherent and nonadherent patients adherence to treatment, the present review revealed that only with anxiety disorders. Only one naturalistic study reported four studies found a relationship between comorbidity and that women with anxiety disorders discontinued treatment treatment adherence. Furthermore, the results were diver- more frequently than men.4 Further, in just one study, older, gent. Stein et al9 and Santana et al13 found that patients with non-Caucasian and unemployed anxiety disorder patients comorbid depression adhere to treatment more often than displayed treatment attrition more frequently than those who those without this comorbidity. In contrast, Issakidis et al4 did not share these features.2 However, in a naturalistic study, and Mancebo et al14 found that patients with comorbid unemployed OCD patients were more likely to adhere to depression adhere less to treatment. Thus, our hypothesis treatment.13 Therefore, it seems that no consistent conclusion that comorbidity would predict adherence was not confirmed regarding the effect of gender, age, race, and employment based on studies with depressed patients.
on adherence of patients with anxiety disorders to treatment The five studies that investigated cognitive variables found similar results and emphasized the importance of treat- Nine studies2,4,6,11,13–17 investigated the influence of ment choice and favorable attitudes toward treatment.6,11,14,16,18 education level on treatment adherence of patients with Cognitive variables may be an important intervention factor anxiety disorders, but only four2,4,13,17 reported significant because they are more modifiable than clinical and socio- findings. Specifically, three studies found that patients with demographic variables. The results of this review suggest submit your manuscript |
that treatment programs need to consider these expectations 2. Coles ME, Turk CL, Jindra L, Heimberg RG. The path from initial and include structured interventions to motivate patients to inquiry to initiation of treatment for social anxiety disorder in an anxiety disorders specialty clinic. J Anxiety Disord. 2004;18(3):371–383.
participate in treatment even before it begins.
3. Young BJ, Beidel DC, Turner SM, Ammerman RT, McGraw K, Coaston SC. Pretreatment attrition and childhood social phobia: Conclusion
parental concerns about medication. J Anxiety Disord. 2006;20(8): 1133–1147.
Few studies have researched correlates or predictors of 4. Issakidis C, Andrews G. Pretreatment attrition and dropout in an attrition and/or dropout in patients with anxiety disorders. outpatient clinic for anxiety disorders. Acta Psychiatr Scand. 2004; 109(6):426–433.
The heterogeneity of the findings described in this review 5. Toni C, Perugi G, Frare F, Mata B, Akiskal HS. Spontaneous treatment partially reflects the different methodologies used to identify discontinuation in panic disorder patients treated with antidepressants. Acta Psychiatr Scand. 2004;110(2):130–137.
the factors involved in the treatment adherence of patients 6. Grilo CM, Money R, Barlow DH, et al. Pretreatment patient factors with anxiety disorders. For example, many studies analyzed predicting attrition from a multicenter randomized controlled treatment the effects of pharmacological and psychological treatments study for panic disorder. Compr Psychiatry. 1998;39(6):323–332.
7. Wingerson D, Sullivan M, Dager S, Flick S, Dunner D, Roy-Byrne P. separately, whereas other studies investigated combined Personality traits and early discontinuation from clinical trials in anxious treatments. Also, given that researchers conceptualize patients. J Clin Psychopharmacol. 1993;13(3):194–197.
8. Hunt C, Andrews G. Drop-out rate as a performance indicator in “adherence” in different ways, a consensus definition is psychotherapy. Acta Psychiatr Scand. 1992;85(4):275–278.
necessary. For example, although some researchers consider 9. Stein MB, Cantrell CR, Sokol MC, Eaddy MT, Shah MB. Antidepressant dropping out to be the cessation of treatment before its offi- adherence and medical resource use among managed care patients with anxiety disorders. Psychiatr Serv. 2006;57(5):673–680.
cial conclusion, others consider dropouts to be people who 10. Mataix-Cols D, Marks IM, Greist JH, Kobak KA, Baer L. Obsessive- continue to attend treatment but do not appear at all of the compulsive symptom dimensions as predictors of compliance with and response to behaviour therapy: results from a controlled trial. Psychother sessions or who take medication less frequently or in smaller Psychosom. 2002;71(5):255–262.
11. Carter MM, Turovsky J, Sbrocco T, Meadows EA, Barlow DH. Despite this review’s negative findings regarding the Patient dropout from a couples group treatment for panic disorder with agoraphobia. Prof Psychol Res Pract. 1995;26(6):626–628.
impact of sociodemographic and clinical features of patients 12. Hansen AM, Hoogduin CA, Schaap C, de Haan E. Do drop-outs differ with anxiety disorders in treatment adherence, the studies are from successfully treated obsessive-compulsives? Behav Res Ther. 1992;30(5):547–550.
rather consistent in describing a high rate of nonadherence 13. Santana L, Versiani M, Mendlowicz MV, Fontenelle LF. Predictors among patients with anxiety disorders.9 Thus, the authors of adherence among patients with obsessive-compulsive disorder of this present review emphasize the importance of more undergoing naturalistic pharmacotherapy. J Clin Psychopharmacol. 2010;30(1):86–88.
research on this topic in order to develop strategies that help 14. Mancebo MC, Pinto A, Rasmussen SA, Eisen JL. Development of patients conclude their treatments. Furthermore, they empha- the Treatment Adherence Survey-patient version (TAS-P) for OCD. J Anxiety Disord. 2008;22(1):32–43.
size this review’s consistent results on cognitive variables, 15. Turner SM, Beidel DC, Wolff PL, Spaulding S, Jacob RG. Clinical which indicate that expectations and beliefs about the disease features affecting treatment outcome in social phobia. Behav Res Ther. and its treatment are important features to be considered in 16. Hofmann SG, Suvak M. Treatment attrition during group therapy for the management of patients with anxiety disorders.
social phobia. J Anxiety Disord. 2006;20(7):961–972.
17. Keijsers GPJ, Kampman M, Hoogduin CA. Dropout prediction in Disclosure
cognitive behavior therapy for panic disorder. Behavior Therapy. 2001;32:739–749.
The authors report no conflicts of interest in this work.
18. Hofmann SG, Barlow DH, Papp LA, et al. Pretreatment attrition in a comparative treatment outcome study on panic disorder. Am J References
1. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593–602.
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