Patients with mental disorders opt for psychotherapy over drugs only

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People seeking help for mental disorders are considerably more likely to refuse or not complete the recommended treatment if it involves only psychotropic drugs, according to a review of research published by the American Psychological Association.

Researchers conducted a meta-analysis of 186 studies of patients seeking help for mental health issues that examined whether they accepted the treatment that was recommended and if they did, whether they completed it. They found 57 of the studies, comprising 6,693 patients, had a component that reported refusal of treatment recommendations, and 182 of the studies, comprising 17,891 patients, had a component reporting premature termination of treatment.

After diagnosis, patients in the studies were recommended to drug-only therapy (pharmaco-therapy), talk therapy (psychotherapy) or a combination of the two. “We found that rates of treatment refusal were about two times greater for pharmaco-therapy alone compared with psychotherapy alone, particularly for the treatment of social anxiety disorder, depressive disorders and panic disorder,” said lead researcher Dr Joshua Swift, of Idaho State University. “Rates of premature termination of therapy were also higher for pharmaco-therapy alone, compared with psychotherapy alone, particularly for anorexia/bulimia and depressive disorders.”

Across all the studies, the average treatment refusal rate was 8.2%. Patients who were offered pharmaco-therapy alone were 1.76 times more likely to refuse treatment than patients who were offered psychotherapy alone. Once in treatment, the average premature termination rate was 21.9%, with patients on drug-only regimens 1.2 times more likely to drop out early. There was no significant difference for refusal or dropout rates between pharmaco-therapy alone and combination treatments, or between psychotherapy alone and combination treatments.

While Swift said the findings overall were expected, the researchers were most surprised by how large the differences were for some disorders. For example, patients diagnosed with depressive disorders were 2.16 times more likely to refuse pharmaco-therapy alone and patients with panic disorders were almost three times more likely to refuse pharmaco-therapy alone.

The findings are especially interesting because, as a result of easier access, recent trends show that a greater percentage of mental health patients in the US are engaging in pharmaco-therapy than psychotherapy, according to co-author Dr Roger Greenberg, SUNY Upstate Medical University.

Some experts have argued that psychotherapy should be the first treatment option for many mental health disorders. Those arguments have been largely based on good treatment outcomes for talk therapy with fewer side effects and lower relapse rates, said Greenberg. “Our findings support that argument, showing that clients are more likely to be willing to start and continue psychotherapy than pharmaco-therapy.”

Swift and Greenberg theorised that patients may be more willing to engage in psychotherapy because many individuals who experience mental health problems recognise that the source of their problems may not be entirely biological.

“Patients often desire an opportunity to talk with and work through their problems with a caring individual who might be able to help them better face their emotional experiences,” said Greenberg. “Psychotropic medications may help a lot of people, and I think some do see them as a relatively easy and potentially quick fix, but I think others view their problems as more complex and worry that medications will only provide a temporary or surface level solution for the difficulties they are facing in their lives.”

While the meta-analysis provides information on refusal and dropout rates, the studies did not report the patients’ reasons for their actions, Swift noted. Going forward, research designed to identify these reasons could lead to additional strategies to improve initiation and completion rates for both therapies, he said. It is also important to note that participants in the research studies initially indicated they were willing to be assigned to any therapy, and therefore may not be representative of all consumers of treatment.

The purpose of this meta-analysis was to examine rates of treatment refusal and premature termination for pharmacotherapy alone, psychotherapy alone, pharmacotherapy plus psychotherapy, and psychotherapy plus pill placebo treatments. A systematic review of the literature resulted in 186 comparative trials that included a report of treatment refusal and/or premature termination for at least 2 of the 4 treatment conditions. The data from these studies were pooled using a random-effects analysis. Odds Ratio effect sizes were then calculated to compare the rates between treatment conditions, once across all studies and then again for specific client disorder categories. An average treatment refusal rate of 8.2% was found across studies. Clients who were assigned to pharmacotherapy were 1.76 times more likely to refuse treatment compared with clients who were assigned psychotherapy. Differences in refusal rates for pharmacotherapy and psychotherapy were particularly evident for depressive disorders, panic disorder, and social anxiety disorder. On average, 21.9% of clients prematurely terminated their treatment. Across studies, clients who were assigned to pharmacotherapy were 1.20 times more likely to drop out compared with clients who were assigned to psychotherapy. Pharmacotherapy clients with anorexia/bulimia and depressive disorders dropped out at higher rates compared with psychotherapy clients with these disorders. Treatment refusal and dropout are significant problems in both psychotherapy and pharmacotherapy and providers of these treatments should seek to employ strategies to reduce their occurrence.

Joshua K Swift, Roger P Greenberg, Kelley A Tompkins, Susannah R Parkin

American Psychological Association material
Psychotherapy abstract

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