Differences between early and late drop-outs from treatment for obsessive–compulsive disorder
Highlights
► Attrition in psychological and pharmacological treatment for OCD was examined. ► Early (before session 6) drop-outs had elevated OCD symptoms at termination compared to completers. ► Late (session 6 or after) drop-outs did not differ from completers on OCD symptroms at termination. ► Pre-treatment depression significantly discriminated between early drop-outs and completers. ► Time of treatment attrition is associated with clinically relevant patient characteristics.
Introduction
Obsessive–compulsive disorder (OCD) is a common and debilitating psychological disorder experienced by 1.5–3% of the population (Bebbington, 1998, Stein et al., 1997). Individuals with OCD experience impairments in general functioning and poor quality of life (Koran, 2000, Norberg et al., 2008) as well as interpersonal problems and marital distress (Emmelkamp et al., 1990, Riggs et al., 1992). Effective treatments for OCD include cognitive-behavior treatment (CBT) or pharmacotherapy (Eddy et al., 2004, Fineberg and Gale, 2005, Kobak et al., 1998, Rosa-Alcázar et al., 2008), with both treatments being equally effective (Kobak et al., 1998, Rosa-Alcázar et al., 2008).
As is the case with other anxiety disorders, many individuals drop out prematurely from treatments for OCD. Individuals who drop out of treatment usually do so unilaterally, without agreement of the clinician, by not arriving at scheduled sessions (Pekarik, 1985). Moreover, some individuals do not even begin treatment and drop out before its inception (Hofmann et al., 1998). Mean attrition rates for cognitive-behavior therapy (CBT) of OCD are 13–27% (Abramowitz, 1997, Foa et al., 2005, Kobak et al., 1998, Taylor et al., 2003), and pharmacological treatments report comparable attrition rates (19–25%; Abramowitz, 1997, Kobak et al., 1998). Thus, attrition is a common and substantial phenomenon in CBT and pharmacotherapy for OCD.
Attrition can have many adverse effects (Ogrodniczuk, Joyce, & Piper, 2005). It can lead to reduced treatment efficacy (Clarkin & Levy, 2004), and loss of therapist hours (Pekarik, 1985), both of which have a negative effect on overall cost-effectiveness (April & Nicholas, 1996). Attrition can also affect the treating clinician, leading to feelings of failure which reduce clinician self-confidence and effectiveness (Ogrodniczuk et al., 2005). Finally, it can complicate the interpretation of results from treatment studies, as treatment completers may not be representative of treatment seekers (Westen, Novotny, & Thompson-Brenner, 2004), especially if drop-outs systematically differ from completers on clinically relevant variables (Little & Rubin, 1989). Due to these pernicious effects, many strategies for reducing and minimizing attrition have been suggested (see Ogrodniczuk et al., 2005 for a review).
Recent studies have examined differences between drop-outs and completers in treatments for anxiety disorders. For instance, Hofmann and Suvak (2006) followed individuals receiving CBT for social anxiety disorder and compared drop-outs (n = 34) with treatment completers (n = 99). No differences were found on demographic characteristics, clinical measures, or AXIS-I and II symptomatology. The only difference found was that drop-outs rated the treatment rationale as less logical than completers, and this difference was no longer significant after adjusting for multiple group comparisons. Similarly, Keijsers, Kampman, and Hoogduin (2001) compared drop-outs and completers in CBT for panic disorder and found differences only in education level and motivation. However, differences were very small in magnitude and the authors concluded they could not reliably differentiate completers and drop-outs.
Only a single study focused on attrition in the treatment of OCD (Hansen, Hoogduin, Schaap, & de Haan, 1992). In this study, the authors contacted 25 drop-outs, 2–7 years after treatment. Results could be obtained from 15 of the drop-outs (60%) who were matched with a group of 15 completers. The authors found that drop-outs had fewer OCD symptoms at intake, and experienced less anxiety during exposures, compared to treatment completers. However, it is difficult to interpret the results of this study due to the small sample size, high refusal rate (40%), and retrospective assessment (2–7 years after treatment). It is important to note that the majority of recent treatment studies in OCD report no differences between completers and drop-outs on pre-treatment measures (e.g., Foa et al., 2005, Taylor et al., 2003). To our knowledge, differences on OCD symptoms at the time of treatment termination between drop-outs and completers have not been investigated.
Although attrition has generally been regarded as a negative phenomenon, there is some evidence that certain drop-outs experience significant improvement before dropping out (April and Nicholas, 1996, Manthei, 1995, Pekarik, 1983b). Along these lines, Pekarik (1992) found that individuals who dropped-out late in the course of treatment improved considerably and were highly similar to completers whereas individuals who dropped-out early experienced aggravation or improved to a lesser extent. Thus, the timing of attrition may be related to different trajectories of change within treatment.
In the present study we examined whether time of dropout (i.e., early vs. late in treatment) was associated with OCD symptomatology. Based on Pekarik (1992) we hypothesized that early drop-outs will have elevated OCD symptoms compared to late drop-outs and to completers at the time of treatment termination. We also wanted to explore whether pre-treatment measures could predict early and late drop-out.
Section snippets
Participants
The study was approved by the VU-University, Medical Centre's Ethical Review Committee (Amsterdam, The Netherlands). The sample for the present study included participants from two 2-sited randomized controlled trials (RCTs) in the Netherlands, which were originally set up to compare the effectiveness of cognitive therapy (CT) and exposure therapy (ET) with and without Fluvoxamine for the treatment of OCD (van Balkom et al., 1998, van Oppen et al., 1995a). We combined data from these RCTs as
Drop-outs and completers
We compared the complete sample of drop-outs (i.e., early and late drop-outs) to treatment completers on all demographic and pre-treatment clinical measures. The only significant difference was for age (F(1,119) = 5.48, p < 0.05, partial η2 = 0.04). The difference was such that completers were slightly older than drop-outs. Table 1 presents descriptive statistics.
We also examined whether dropouts and completers differed in their response to treatment. More specifically, we examined whether reduction
Discussion
To the best of our knowledge, the present study is the first to explicitly examine early and late drop-outs during treatment for OCD. Early drop-outs did not respond to treatment and had significantly more OCD symptoms when dropping-out compared to both late drop-outs and treatment completers. Conversely, late drop-outs were found to be highly responsive to treatment, experiencing gains similar in magnitude to those of completers, in fewer sessions. These results indicate that drop-outs are not
Acknowledgement
Dr. Hofmann is a paid consultant by Merck/Schering-Plough and supported by NIMH grant 1R01MH078308 for studies unrelated to the present investigation.
References (61)
- et al.
Measuring obsessive-compulsive symptoms: Padua Inventory-Revised vs. Yale-Brown Obsessive Compulsive Scale
Journal of Anxiety Disorders
(2009) Cognitive therapy versus applied relaxation as treatment of generalized anxiety disorder
Behaviour Research and Therapy
(2003)- et al.
Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation
Clinical Psychology Review
(1988) - et al.
A multidimensional meta-analysis of psychotherapy and pharmacotherapy for obsessive-compulsive disorder
Clinical Psychology Review
(2004) - et al.
Do drop-outs differ from successfully treated obsessive-compulsives?
Behaviour Research and Therapy
(1992) - et al.
Treatment attrition during group therapy for social phobia
Journal of Anxiety Disorders
(2006) - et al.
Dropout prediction in cognitive behavior therapy for panic disorder
Behavior Therapy
(2001) Quality of life in obsessive-compulsive disorder
Psychiatric Clinics of North America
(2000)- et al.
Marital distress and the treatment of obsessive compulsive disorder
Behavior Therapy
(1992) - et al.
Psychological treatment of obsessive-compulsive disorder: a meta-analysis
Clinical Psychology Review
(2008)
Obsessional-compulsive problems: a cognitive-behavioural analysis
Behaviour Research and Therapy
Obsessions and compulsions: the Padua Inventory
Behaviour Research and Therapy
Early drop-outs, late drop-outs and completers: differences in the continuation phase of a clinical trial
Progress in Neuro-Psychopharmacology and Biological Psychiatry
Cognitive therapy for obsessive-compulsive disorder
Behaviour Research and Therapy
Cognitive therapy and exposure in vivo in the treatment of obsessive compulsive disorder
Behaviour Research and Therapy
The structure of obsessive-compulsive symptoms
Behaviour Research and Therapy
Reliability and validity of the Yale-Brown Obsessive-Compulsive Scale
Behaviour Research and Therapy
Effectiveness of psychological and pharmacological treatments for obsessive-compulsive disorder: a quantitative review
Journal of Consulting and Clinical Psychology
Sensitivity to change of the Obsessive Beliefs Questionnaire
Clinical Psychology & Psychotherapy
Premature termination of counselling at a university Counselling Centre
International Journal for the Advancement of Counselling
Epidemiology of obsessive-compulsive disorder
British Journal of Psychiatry
Cognitive therapy and the emotional disorder
Anxiety disorders and phobias: a cognitive perspective
An inventory for measuring depression
Archives of General Psychiatry
Impact of motivational interviewing on participation and outcome in residential alcoholism treatment
Psychology of Addictive Behaviors
Pretreatment expectancies and premature termination in a training clinic environment
Training and Education in Professional Psychology
The influence of client variables on psychotherapy
Reliability of DSM-III anxiety disorder categories using a new structured interview
Arch Gen Psychiatry
Phobic and obsessive-compulsive disorders: theory, research, and practice
Marital adjustment and obsessive-compulsive disorder
British Journal of Psychiatry
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