Rethinking Research on Prediction and Prevention of Psychotherapy Dropout: A Mechanism-Oriented Approach.

Dropout is a ubiquitous psychotherapy outcome in clinical practice and treatment research alike, yet it remains a poorly understood problem. Contemporary dropout research is dominated by models of prediction that lack a strong theoretical foundation, often drawing on data from clinical trials that report on dropout in an inconsistent and incomplete fashion. In this article, we assert that dropout is a critical treatment outcome that is worthy of investigation as a mechanistic process. After briefly describing the scope of the dropout problem, we discuss the many factors that limit the field's present understanding of dropout. We then articulate and illustrate a transdiagnostic conceptual framework for examining psychotherapy dropout in contemporary research, concluding with recommendations for future research. With a more comprehensive understanding of the factors affecting retention, research efforts can shift toward investigating key processes underlying treatment dropout, thus, boosting prediction and informing strategies to mitigate dropout in clinical practice.

Who Benefits From a Cognitive vs. Behavioral Approach to Treating Depression? A Pilot Study of Prescriptive Predictors.

Although experts have suggested ways that cognitive behavioral therapy (CBT) of depression might be personalized for individual clients, there has been little empirical examination of this issue. We examine cognitive behavioral skills and vulnerabilities (i.e., dysfunctional thinking, behavioral inactivation, and avoidance) as potential prescriptive predictors to cognitive vs. behavioral interventions. Forty-two adults with major depressive disorder were randomized to eight weeks of cognitive-only (n = 21) or behavioral-only (n = 21) individual psychotherapy. Clients completed pre-treatment measures of cognitive and behavioral skills and vulnerabilities. Dropout rates were comparable across treatments (21% overall). Treatment outcomes did not differ significantly between treatments (g = .13). Cognitive skills were associated with superior outcomes in the behavioral-only treatment, but additional analyses suggested general skillfulness (i.e., the tendency to have high scores across cognitive and behavioral assessments), rather than cognitive skills per se, predicted a larger response to behavioral interventions. Similarly, behavioral avoidance of social and non-social domains were associated with worse outcomes in the behavioral-only treatment, indicating that behavioral approaches yield less positive outcomes for clients high in behavioral avoidance. If replicated, the results of this pilot study suggest ways that a cognitive behavioral therapist could select intervention strategies to suit individual clients and thereby improve treatment outcomes.

Latent Profiles of Comorbid Depression as Predictors of PTSD Treatment Outcome.

Posttraumatic stress disorder (PTSD) frequently co-occurs with major depressive disorder, and empirically supported PTSD treatments consistently improve depression. However, both diagnoses are heterogeneous and specific patterns of symptom overlap may be related to worse treatment outcome. Two hundred individuals with chronic PTSD participated in a doubly randomized preference trial comparing prolonged exposure and sertraline. Latent Profile Analysis was used to identify classes based on PTSD and depression symptoms prior to starting treatment. A three-class model best fit the data, with a high depression and PTSD severity class (distressed), a moderate depression and low PTSD avoidance class (depressive), and a low depression and high PTSD avoidance class (avoidant). The avoidant class showed the lowest rates of major depressive disorder diagnosis and transdiagnostic vulnerabilities to depression. Patients in the distressed class experienced more robust PTSD treatment response, with no differences between prolonged exposure and sertraline. These findings highlight the role of avoidance in nondepressed PTSD presentations while also demonstrating that co-occurring depression is not contraindicated in evidence-based PTSD treatment.

The Effect of Concurrent Depression on PTSD Outcomes in Trauma-Focused Psychotherapy: A Meta-Analysis of Randomized Controlled Trials.

The co-occurrence of depression with posttraumatic stress disorder (PTSD) is common and associated with greater severity and impairment than PTSD alone, but the effects on PTSD treatment outcomes are unclear. This study investigated the impact of baseline depression on PTSD symptom change and dropout in a meta-analysis of 44 randomized controlled trials (N = 4,866) of trauma-focused psychotherapies for PTSD. Analyses included 107 active (k = 71) and control (k = 36) conditions. Baseline depression was indexed within samples as (a) continuous symptom severity (e.g., Beck Depression Inventory), standardized across depression measures and (b) proportion of patients with comorbid depressive disorder diagnosis. Among active conditions reporting continuous depression scores (k = 62), greater depression severity predicted smaller PTSD treatment effect sizes (ß = -.36, p = .002), but not dropout (ß = .25, p = .18). Categorical depressive diagnosis rates (k = 29)-reported less frequently-were not associated with treatment effects or dropout in active conditions. Greater depression severity may reflect a risk factor for attenuated response in PTSD psychotherapies, potentially demanding complementary strategies within trauma-focused interventions. Variability between trials in baseline depression symptoms may suggest the need to consider this sample characteristic when comparing treatment outcomes across studies.

High expectancy and early response produce optimal effects in sertraline treatment for post-traumatic stress disorder.

BACKGROUND: Better indicators of prognosis are needed to personalise post-traumatic stress disorder (PTSD) treatments.AimsWe aimed to evaluate early symptom reduction as a predictor of better outcome and examine predictors of early response. METHOD: Patients with PTSD (N = 134) received sertraline or prolonged exposure in a randomised trial. Early response was defined as 20% PTSD symptom reduction by session two and good end-state functioning defined as non-clinical levels of PTSD, depression and anxiety. RESULTS: Early response rates were similar in prolonged exposure and sertraline (40 and 42%), but in sertraline only, early responders were four times more likely to achieve good end-state functioning at post-treatment (Number Needed to Treat = 1.8, 95% CI 1.28-3.00) and final follow-up (Number Needed to Treat = 3.1, 95% CI 1.68-16.71). Better outcome expectations of sertraline also predicted higher likelihood of early response. CONCLUSIONS: Higher expectancy of sertraline coupled with early response may produce a cascade-like effect for optimal conditions for long-term symptom reduction. Therefore, assessing expectations and providing clear treatment rationales may optimise sertraline effects. DECLARATION OF INTEREST: None.

Therapist Behaviors as Predictors of Immediate Homework Engagement in Cognitive Therapy for Depression.

Homework assignments are an integral part of cognitive therapy (CT) for depression, though facilitating homework engagement in patients with depression can be a challenge. We sought to examine three classes of therapist behaviors as predictors of homework engagement in early sessions of CT: therapist behaviors related to the review of homework, the assignment of homework, and efforts to help patients overcome obstacles to completing homework. In a sample of 66 depressed outpatients participating in CT, therapist behaviors involved in assigning homework predicted both CT-specific homework engagement and more general homework engagement. Therapist behaviors involved in homework review were not predictive of homework engagement. Our findings are consistent with the possibility that therapists' emphasis of key elements of the homework assignment process enhances patients' engagement in homework in early sessions of CT.

Long-term efficacy of psychotherapy for posttraumatic stress disorder: A meta-analysis of randomized controlled trials.

Psychotherapies are well established as efficacious acute interventions for posttraumatic stress disorder (PTSD). However, the long-term efficacy of such interventions and the maintenance of gains following termination is less understood. This meta-analysis evaluated enduring effects of psychotherapy for PTSD in randomized controlled trials (RCTs) with long-term follow-ups (LTFUs) of at least six months duration. Analyses included 32 PTSD trials involving 72 treatment conditions (N=2935). Effect sizes were significantly larger for active psychotherapy conditions relative to control conditions for the period from pretreatment to LTFU, but not posttreatment to LTFU. All active interventions demonstrated long-term efficacy. Pretreatment to LTFU effect sizes did not significantly differ among treatment types. Exposure-based treatments demonstrated stronger effects in the posttreatment to LTFU period (d=0.27) compared to other interventions (p=0.005). Among active conditions, LTFU effect sizes were not significantly linked to trauma type, population type, or intended duration of treatment, but were strongly tied to acute dropout as well as whether studies included all randomized patients in follow-up analyses. Findings provide encouraging implications regarding the long-term efficacy of interventions and the durability of symptom reduction, but must be interpreted in parallel with methodological considerations and study characteristics of RCTs.

An empirical review of potential mediators and mechanisms of prolonged exposure therapy.

Prolonged exposure (PE) is an empirically-supported treatment for posttraumatic stress disorder (PTSD), but the precise mechanism(s) by which PE promotes symptom change are not well established. Understanding how PE works is critical to improving clinical outcomes, advancing dissemination efforts, and enhancing transdiagnostic models of psychopathology. However, mechanisms research conducted in clinical treatment settings is complex, and findings may be difficult to interpret without appropriate context. This is the first review of potential mechanisms of PE to provide such context, by rigorously evaluating empirical findings in line with essential criteria for effective research on mechanisms (or mediators). We begin by describing six putative mechanisms identified by emotional processing theory and contemporary models of fear extinction, before thoroughly reviewing empirical findings from clinical research on PE and similar PTSD treatments. We provide a detailed description of each study and mechanism test, as well as ratings of strength of evidence and quality of evaluation based on a novel rating scheme. We highlight variables with strong evidence (belief change and between-session habituation), intermediate evidence (inhibitory learning and emotional engagement), and minimal support (narrative organization and within-session habituation). After discussing limitations of the extant literature and this review, we summarize specific challenges for research on PE mechanisms and highlight directions for future study based on clinical and research implications.

Do changes in trauma-related beliefs predict PTSD symptom improvement in prolonged exposure and sertraline?

OBJECTIVE: Negative trauma-related belief change has been found to predict subsequent improvement in symptoms of posttraumatic stress disorder (PTSD) in prolonged exposure (PE) and other therapies, consistent with several psychological theories of treatment change (e.g., Foa & Kozak, 1986). However, belief change has not been examined in selective serotonin reuptake inhibitors such as sertraline. We examined processes associated with symptom improvement in 2 treatments for PTSD, hypothesizing that belief change would robustly predict PTSD improvement in patients treated with PE but not those treated with sertraline, reflecting moderation by treatment. METHOD: Patients with chronic PTSD (N = 134; 78% women, 71.6% Caucasian, M = 38.1 years, SD = 11.8) received 10 weeks of PE or sertraline in a randomized, controlled trial. Patients reported PTSD and depression symptoms, and trauma-related beliefs (Post-Traumatic Cognitions Inventory; Foa, Ehlers, Clark, D Tolin, & Orsillo, 1999) at pretreatment, every treatment session, and posttreatment. RESULTS: Using time-lagged mixed regression models, change in trauma-related beliefs predicted subsequent PTSD symptom improvement, an effect moderated by treatment and particularly strong in PE (d = 0.93) compared with sertraline (d = 0.35). Belief change also predicted depressive symptom improvement but more modestly and bidirectionally, with no difference by treatment modality. CONCLUSIONS: Trauma-related belief change precedes PTSD improvement more robustly in PE than in sertraline and with greater specificity compared with depressive symptoms. These findings highlight potentially divergent processes contributing to symptom change in these PTSD treatments, with belief change as a key mechanism of PE. (PsycINFO Database Record

Homework "Dose," Type, and Helpfulness as Predictors of Clinical Outcomes in Prolonged Exposure for PTSD.

Homework is often viewed as central to prolonged exposure (PE) for posttraumatic stress disorder (PTSD), but its relationship with treatment outcome is not well understood. We evaluated homework type, dose, and patients' perceptions of helpfulness as predictors of symptom change and posttreatment outcomes in PE. Patients with chronic PTSD received PE in a randomized clinical trial. Independent evaluators assessed PTSD severity at pre- and posttreatment. Patients reported homework adherence and perceived helpfulness at the beginning of each session, separately for in vivo and imaginal exposure assignments. These variables were examined as predictors of change in PTSD symptoms, PTSD remission, and good end-state functioning (GESF; low PTSD, depression, and anxiety) at posttreatment. Higher imaginal homework adherence predicted greater symptom improvement between sessions and across treatment, as well as twice the odds of achieving remission and GESF. Patients who were at least moderately adherent to imaginal homework assignments (two or more times a week) reported more symptom gains than those who were least adherent but did not differ from those who were most adherent. In vivo adherence was not consistently associated with better outcome, perhaps due to heterogeneity in form and function of weekly assignments. Higher ratings of helpfulness of both types of homework predicted greater symptom improvement from pre- to posttreatment and between sessions. Overall, imaginal exposure homework may complement in-session exposures by enhancing key change processes, though perfect adherence is not necessary. Patients' perceptions of helpfulness may reflect buy-in or perceived match between homework completion and functional impairment. Clinically, in addition to targeting adherence to homework assignments, querying about perceived helpfulness and adjusting assignments appropriately may help augment clinical gains.

The therapeutic alliance and therapist adherence as predictors of dropout from cognitive therapy for depression when combined with antidepressant medication.

BACKGROUND: Previous psychotherapy research has examined the therapeutic alliance and therapist adherence as correlates or predictors of symptom change. While some initial evidence suggests the alliance is associated with risk of dropout in cognitive behavioral treatment for depression, evidence of such relations has been limited to date. We examined the relation of these psychotherapy process variables and dropout in the context of cognitive therapy for depression when provided in combination with pharmacotherapy. METHODS: Patients were randomized to the CT plus pharmacotherapy condition of a clinical trial for chronic or recurrent depression. Consistent with the spirit of personalized medicine, patients were treated until they met remission and recovery criteria (or reached the maximum allowable time in the study). In a sample of 176 patients, we examined observer-rated alliance and therapist adherence in the first three CT sessions as potential predictors of treatment dropout. RESULTS: The therapeutic alliance and one facet of therapist adherence (i.e., Behavioral Methods/Homework) predicted reduced odds of dropout. Therapist use of Negotiating/Structuring predicted greater likelihood of dropout, but only when other variables were included in the model. LIMITATIONS: Process ratings were not available for concurrent pharmacotherapy sessions. A minority of patients did not have session recordings available. CONCLUSIONS: Results are consistent with the possibility that the therapeutic alliance and therapists' focus on homework and behavioral methods promote treatment retention in combined treatment for depression.

Dropout from individual psychotherapy for major depression: A meta-analysis of randomized clinical trials.

Dropout from mental health treatment poses a substantial problem, but rates vary substantially across studies and diagnoses. Focused reviews are needed to provide more detailed estimates for specific areas of research. Randomized clinical trials involving individual psychotherapy for unipolar depression are ubiquitous and important, but empirical data on average dropout rates from these studies is lacking. We conducted a random-effects meta-analysis of 54 such studies (N=5852) including 80 psychotherapy conditions, and evaluated a number of predictors of treatment- and study-level dropout rates. Our overall weighted dropout estimates were 19.9% at the study level, and 17.5% for psychotherapy conditions specifically. Therapy orientation did not significantly account for variance in dropout estimates, but estimates were significantly higher in psychotherapy conditions with more patients of minority racial status or with comorbid personality disorders. Treatment duration was also positively associated with dropout rates at trend level. Studies with an inactive control comparison had higher dropout rates than those without such a condition. Limitations include the inability to test certain potential predictors (e.g., socioeconomic status) due to infrequent reporting. Overall, our findings suggest the need to consider how specific patient and study characteristics may influence dropout rates in clinical research on individual therapy for depression.

Therapist use of Socratic questioning predicts session-to-session symptom change in cognitive therapy for depression.

Socratic questioning is a key therapeutic strategy in cognitive therapy (CT) for depression. However, little is known regarding its relation to outcome. In this study, we examine therapist use of Socratic questioning as a predictor of session-to-session symptom change. Participants were 55 depressed adults who participated in a 16-week course of CT (see Adler, Strunk, & Fazio, 2015). Socratic questioning was assessed through observer ratings of the first three sessions. Socratic ratings were disaggregated into scores reflecting within-patient and between-patient variability to facilitate an examination of the relation of within-patient Socratic questioning and session-to-session symptom change. Because we examined within-patient variability in Socratic questioning, the identification of such a relation cannot be attributed to any stable patient characteristics that might otherwise introduce a spurious relation. Within-patient Socratic questioning significantly predicted session-to-session symptom change across the early sessions, with a one standard deviation increase in Socratic-Within predicting a 1.51-point decrease in BDI-II scores in the following session. Within-patient Socratic questioning continued to predict symptom change after controlling for within-patient ratings of the therapeutic alliance (i.e., Relationship and Agreement), suggesting that the relation of Socratic questioning and symptom change was not only independent of stable characteristics, but also within-patient variation in the alliance. Our results provide the first empirical support for a relation of therapist use of Socratic questioning and symptom change in CT for depression.

The process of change in cognitive therapy for depression when combined with antidepressant medication: Predictors of early intersession symptom gains.

OBJECTIVE: Previous studies of cognitive therapy (CT) for depression have examined therapist adherence and the therapeutic alliance as predictors of subsequent symptom change. However, little is known about these CT process variables when CT is delivered in combination with antidepressant medication. METHOD: In a sample of 176 depressed outpatients randomized to the combined condition of a clinical trial, we examined ratings of adherence and alliance as predictors of subsequent session-to-session symptom change across early CT sessions. RESULTS: Both adherence to Behavioral Methods/Homework and the therapeutic alliance significantly predicted session-to-session symptom change. In models in which patients' medication regimen and prior symptom change were covaried, only Behavioral Methods/Homework remained a significant predictor of subsequent symptom change. CONCLUSIONS: Our findings highlight the utility of Behavioral Methods/Homework in combined treatment for promoting early session-to-session symptom change.