Differences between early and late drop-outs from treatment for obsessive–compulsive disorder

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Abstract

To examine characteristics of drop-outs from treatment for obsessive–compulsive disorder (OCD), we studied 121 participants who underwent exposure or cognitive treatment, either alone or with fluvoxamine. OCD symptoms were assessed at pre-treatment, post-treatment, and at every session. No differences in attrition were found between treatment conditions. Drop-outs from treatment (n = 31) were divided into early (before session 6) and late (session 6 or after) drop-outs. We found that early drop-outs had more severe OCD symptoms at termination compared to completers, whereas late drop-outs did not differ from treatment completers. Higher levels of depressive symptoms were associated with early drop-outs, and lower levels with completers. These findings suggest that individuals with high levels of pretreatment depression are at risk for early drop-out with elevated OCD symptoms. Conversly, late drop-outs may be treatment responders who drop out after experiencing substantial improvement. Implications for allocation of resources for attrition prevention are discussed.

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.

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