Dropout prediction in cognitive behavior therapy for panic disorder

doi:10.1016/S0005-7894(01)80018-6

Behavior Therapy

Volume 32, Issue 4, Autumn 2001, Pages 739-749

https://doi.org/10.1016/S0005-7894(01)80018-6 Get rights and content

The aim of this study was to attempt to identify reliable factors associated with dropout risk in a sample of 161 panic disorder patients treated with manualized cognitive behavior therapy. Four possible predictors of dropout were selected from the literature: level of education, treatment motivation, personality psychopathology, and initial symptom severity. Thirty-two patients (19.9%) were dropouts. Level of education and motivation were significantly associated with dropout, but the associations were small. Personality psychopathology and initial symptom severity were not associated with dropout. It is concluded that, at present, we are unable to make precise dropout risk predictions, even in a homogeneous group of patients treated using standardized treatment.

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Dropout from psychotherapy is common and can have negative effects for patients, providers, and researchers. A better understanding of when and why patients stop treatment early, as well as actionable factors contributing to dropout, has the potential to prevent it. Here, we examined dropout from a large randomized controlled trial of transdiagnostic versus single-diagnosis cognitive-behavioral treatment (CBT) for patients with anxiety disorders (n = 179; Barlow et al., 2017). We aimed to characterize the timing of and reasons for dropout and test whether participants who dropped out had different symptom trajectories than those who completed treatment. Results indicated that overall, the greatest risk of dropout was prior to the first treatment session. In single-diagnosis CBT, dropout risk was particularly elevated before the first session and after other early sessions, whereas in transdiagnostic CBT, dropout risk was low and stable before and during treatment. Participants most often dropped out due to failure to comply with study procedures or dissatisfaction with or desiring alternative treatment. Results from multilevel models showed that trajectories of anxiety symptoms did not significantly differ between dropouts and completers. These findings suggest that there may be specific time windows for targeted and timely interventions to prevent dropout from CBT.
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Previous methods of measuring motivation and resistance include self-report questionnaires (e.g. Change Questionnaire: Miller & Johnson, 2008; Client Motivation for Therapy Scale: Pelletier, Tuson, & Haddad, 1997; University of Rhode Island Change Assessment Scale: McConnaughy, Prochaska, & Velicer, 1983) and third party observer ratings (e.g. CLEAR: Client Language Easy Rating System, Glynn & Moyers, 2012). Several studies have shown that client motivation is predictive of treatment outcome and symptom reduction during CBT for anxiety disorders (Haan et al., 1997; Huppert, Barlow, Gorman, Shear, & Woods, 2006; Keijsers, Hoogduin, & Schaap, 1994; Keijsers, Kampman, & Hoogduin, 2001). Furthermore, higher motivation has been shown to improve therapeutic alliance (Hunter, Button, & Westra, 2014), increase treatment adherence (Simpson & Zuckoff, 2011), and reduce client drop out (Bados, Balaguer, & Saldaña, 2007; Keijsers et al., 2001;).
Motivational Interviewing (MI) has been suggested as an adjunct to Cognitive Behavior Therapy (CBT) for anxiety disorders. Although preliminary evidence suggests that MI as a prelude to CBT (MI + CBT) improves various aspects of treatment from initial engagement, overall symptom reduction, and treatment drop out rate, results are inconsistent. The current meta-analysis combined the findings of 12 trials examining the efficacy of MI + CBT in comparison to CBT alone. Across studies, MI + CBT outperformed standard CBT in terms of overall anxiety symptom reduction, Hedges g = 0.59. Drop out rates were not significantly different between groups. Moderator analyses revealed no significant differences based on specific anxiety diagnosis or dose of MI. The findings of this meta-analysis suggest that MI as an adjunct to CBT for anxiety disorders improves treatment outcome, in comparison to CBT alone. Limitations of the study and future research directions are explored.
Adherence to a web-based pre-treatment for phobias in outpatient clinics
2017, Internet Interventions
Citation Excerpt :
This makes it important to examine factors that influence non-adherence to psychological treatments. Previously found factors associated with treatment non-adherence in FtF psychotherapy were a lower educational level (Keijsers et al., 2001), higher baseline depression scores, or being in specialised (outpatient) rather than in primary care, although the latter may be indicative of worse clinical status. Research on the influence of gender on adherence has produced equivocal results, with some indicating higher adherence in men (Issakidis and Andrews, 2004), some in women (Herbert et al., 2005; McEvoy, 2007), and others reporting no differences (Erwin et al., 2002; Hofmann and Suvak, 2006; Santana and Fontenelle, 2011).
Non-adherence in Internet interventions is a persistent and multifaceted issue and potentially limits the applicability and effectiveness of these interventions. Factors that influence non-adherence are poorly understood, especially in outpatient samples with more complex symptoms.
The current study is a secondary analysis of data from a randomised controlled trial that examined the cost-effectiveness of offering an Internet-based exposure treatment to phobic outpatients on a wait-list to receive face-to-face psychotherapy.
We collected baseline demographic and clinical information, and adherence data of the Internet-based intervention and conducted regression analyses to predict non-adherence to the intervention.
The adherence to the intervention was low, with only 13.3% of 105 patients completing all five lessons of the intervention. The median number of exercises completed (out of a possible 8) was 3. In a multi-predictor model, a higher baseline score of anxiety (OR = 0.94, 95% CI 0.90–0.99) was a risk factor for low adherence. Higher age (OR = 1.05, 95% CI 1.00–1.09) was a protective factor against non-adherence. Participants who adhered to the intervention were more likely to complete post-test assessments, further biasing results. However, overall participant attrition was high. The results are based on a small subset of participants and should be interpreted with caution.
Poor baseline clinical status and age are factors to consider when deciding whether to offer an Internet-based intervention to outpatients. Low adherence among those patients might be related to intrinsic motivation and might even be lower in outpatient settings where participants expect to receive face-to-face treatment. It might be worthwhile to develop a concise instrument to assess intrinsic motivation and treatment expectations for using Internet-based interventions, and for the therapist to review the range of possible (Internet-based) intervention options to suit personal preferences and expectations.
Netherlands Trial Register, NTR2233.
Applying a novel statistical method to advance the personalized treatment of anxiety disorders: A composite moderator of comparative drop-out from CBT and ACT
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No prior studies have examined moderators of dropout between distinct treatments for anxiety disorders. This study applied a novel statistical approach for examining moderators of dropout from traditional cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT).
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Four baseline variables comprised the final composite moderator: self-reported degree of control over internal anxiety, current psychiatric medication use, religiosity, and endurance in a voluntary hyperventilation stressor. This composite moderator predicted differential dropout from ACT vs. CBT with a medium effect size (r = 0.28), and had a significantly larger effect size than any individual moderator.
Findings reveal that specific patient profiles predict differential dropout from ACT vs. CBT for anxiety disorders. In the first investigation of a composite moderator with a dichotomous outcome, findings also support the superiority of composite over individual moderators.
Low pre-treatment end-tidal CO<inf>2</inf> predicts dropout from cognitive-behavioral therapy for anxiety and related disorders
2017, Behaviour Research and Therapy
Recent clinical trial research suggests that baseline low end-tidal CO₂ (ETCO₂, the biological marker of hyperventilation) may predict poorer response to cognitive-behavioral therapy (CBT) for anxiety-related disorders. The present study examined the predictive value of baseline ETCO₂ among patients treated for such disorders in a naturalistic clinical setting. Sixty-nine adults with a primary diagnosis of a DSM-5 anxiety disorder, obsessive-compulsive disorder, or posttraumatic stress disorder completed a 4-min assessment of resting ETCO₂, and respiration rate (the first minute was analyzed). Lower ETCO₂ was not associated with a diagnosis of panic disorder, and was associated with lower subjective distress ratings on certain measures. Baseline ETCO₂ significantly predicted treatment dropout: those meeting cutoff criteria for hypocapnia were more than twice as likely to drop out of treatment, and ETCO₂ significantly predicted dropout beyond other pre-treatment variables. Weekly measurement suggested that the lower-ETCO₂ patients who dropped out were not responding well to treatment prior to dropout. The present results, along with previous clinical trial data, suggest that lower pre-treatment ETCO₂ is a negative prognostic indicator for CBT for anxiety-related disorders. It is suggested that patients with lower ETCO₂ might benefit from additional intervention that targets respiratory abnormality.
The effects of aggression on symptom severity and treatment response in a trial of cognitive behavioral therapy for panic disorder
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In three large studies of cognitive behavioral therapy for PD, this sample included [37], researchers examined many potential factors related to attrition (in one study, over 50 variables). Across these previous investigations, greater negative attitudes toward treatment [35], lower motivation for treatment [36], lower household income [35], younger age [37], and lower education [36] were the only variables that emerged as predictors of attrition. Thus, the identification of aggression as a significant predictor of attrition is of interest in a small literature characterized by limited findings.
Previous research suggests that patients with panic disorder exhibit higher levels of aggression than patients with other anxiety disorders. This aggression is associated with more severe symptomatology and interpersonal problems. However, few studies have examined whether higher levels of aggression are associated with a worse treatment response in this population.
The present study sought to examine the association of aggression with panic disorder symptom severity in a sample of 379 patients who participated in a trial examining long-term strategies for the treatment of panic disorder.
We found that aggression was significantly associated with higher baseline levels of panic disorder symptoms, anxiety, depression, and functional impairment. Further, we found that patients higher in aggression did not achieve the same level of improvement in general anxiety symptoms during treatment compared to patients lower in aggression, even when controlling for baseline anxiety symptom severity.
These results suggest that more research is needed concerning patients with anxiety disorders with higher aggression, as they may be a group in need of additional treatment considerations.

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Original ResearchDropout prediction in cognitive behavior therapy for panic disorder

Behavior Therapy

Behaviour Research and Therapy

Comprehensive Psychiatry

Journal of Psychiatric Research

Comprehensive Psychiatry

Behaviour Research and Therapy

Comprehensive Psychiatry

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Diagnostic and statistical manual of mental disorders

Dropping out of treatment: A critical review

Psychological Bulletin

Predicting patient dropout in psychotherapy

Psychotherapy

Dutch version of the Anxiety Disorders Interview Schedule for DSM-IV, ADIS-IV-NL

Treatment choice for agoraphobic woman: Exposure or cognitive-behaviour therapy?

British Journal of Clinical Psychology

Patient dropout from a couples' group treatment for panic disorder with agoraphobia

Professional Psychology: Research and Practice

Predicting the effect of cognitive therapy for depression: A study of unique and common factors

Journal of Consulting and Clinical Psychology

Assessment of fear of fear in agoraphobics: The Body Sensations Questionnaire and the Agoraphobic Cognitions Questionnaire

Journal of Consulting and Clinical Psychology

Panic disorder and agoraphobia

Original Research
Dropout prediction in cognitive behavior therapy for panic disorder