Non-adherence and non-response in the treatment of anxiety disorders

doi:10.1016/j.janxdis.2012.02.010

Journal of Anxiety Disorders

Volume 26, Issue 5, June 2012, Pages 583-589

https://doi.org/10.1016/j.janxdis.2012.02.010 Get rights and content

Abstract

Among the best established treatments for anxiety disorders are cognitive-behavioral interventions and serotonin reuptake inhibitors. Although clinically useful, these therapies are far from universally efficacious; some patients are unable to complete treatment, and many treatment completers fail to achieve clinically significant improvement. A review of meta-analyses on the treatment of anxiety disorders reveals that about a fifth of patients drop out prematurely and a third of treatment completers are classified as non-responders. In this article we examine the predictors of, and potential solutions for, the problems of treatment non-adherence and non-response to cognitive-behavioral and serotonergic treatments of adult anxiety disorders. Despite decades of research, few reliable predictors have been identified, and no predictor has been consistently supported in the literature. However, there is suggestive evidence that risk of premature dropout is associated with low treatment motivation, side effects, and practical barriers to attending sessions. There is also suggestive evidence that poor response is associated with severe pretreatment psychopathology and comorbidity, as well as high expressed emotion in the patient's family environment. Methods for better estimating treatment prognosis are proposed and possible directions for improving treatment outcome are discussed.

Highlights

► Nonadherence (NA) and nonresponse (NR) are common problems. ► NA and NR are poorly understood, despite decades of research. ► NA may arise from low treatment motivation, side effects, and practical barriers. ► NR is associated with disorder severity, comorbidity, and high expressed emotion. ► Recommendations for better predicting and overcoming NA and NR are proposed.

Section snippets

NA and NR: definition of concepts

According to the World Health Organization (2003), adherence is defined as the extent to which a person's behavior—for example, taking medications or making lifestyle changes—corresponds with mutually agreed-upon recommendations with a healthcare provider. In the treatment of adult anxiety disorders, adherence can be measured in terms of whether a patient attends therapy sessions (i.e., completes treatment or drops out), consumes the prescribed medication, or completes agreed upon homework

Scope of the problem

Studies of CBT or SRIs typically entail 10–12 weeks of treatment (Hofmann and Smits, 2008, Lurie and Levine, 2010). For this duration, meta-analyses of anxiety disorders have reported dropout rates in the range of 9–21% for CBT (across meta-analyses, M = 16%) and 18–30% for SRIs (M = 24%) (Bradley et al., 2005, Eddy et al., 2004, Fedoroff and Taylor, 2001, Kobak et al., 1998, Lurie and Levine, 2010, Mitte et al., 2005, Mitte, 2005, Westen and Morrison, 2001). A handful of meta-analyses of anxiety

Approaches to understanding NA and NR

There are four distinguishable but complementary approaches to understanding NA and NR for anxiety disorders. One is a purely exploratory, data-driven approach in which researchers conducting treatment studies take whatever variables that happen to be available (e.g., demographic factors, pretreatment clinical variables) and attempt to identify statistical predictors of NA and NR. A second approach is to conduct exit-interviews for patients dropping out of treatment in an effort to identify

Overview

Studies of prognostic factors (i.e., predictors of NA and NR) have produced many inconsistent findings, due, at least in part, to differences in sample size, and hence, statistical power. Demographic variables have emerged as either nonsignificant or inconsistent predictors of NA and NR across the anxiety disorders (e.g., Hofmann et al., 2010a, Keeley et al., 2008, Taylor, 2000, Taylor, 2006). Litigation or compensation-seeking for a given disorder (e.g., PTSD) is a nonsignificant predictor of

Overcoming NA

Fig. 1 presents a flowchart that characterizes contemporary approaches for addressing problems with NA for CBT or SRIs. Before initiating treatment it is important to fully describe to the patient the recommended therapy procedures, and provide a clear rationale for why CBT or SRIs are indicated (e.g., Abramowitz, Deacon, & Whiteside, 2011), and to review the pros (e.g., brief duration of CBT, low effort involved in taking SRIs) and cons (e.g., provocation of anxiety with CBT, side effects with

Future directions

Given the state of the literature to date, we remain a long way from identifying the most robust predictors of NA and NR. Those predictors that have been identified remain somewhat crude and have limited clinical value. It may be that alternative approaches, such a multivariate (actuarial) approach, will prove more fruitful. With multivariate analyses, scores on an array of predictors could be actuarially combined to predict a person's risk for NA and NR. Although such a goal is possible, it is

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ReviewNon-adherence and non-response in the treatment of anxiety disorders

Abstract

Highlights

Section snippets

NA and NR: definition of concepts

Scope of the problem

Approaches to understanding NA and NR

Overview

Overcoming NA

Future directions

Behavior Therapy

The Lancet

Clinical Psychology Review

Behaviour Research and Therapy

Behavior Therapy

Behaviour Research and Therapy

Clinical Psychology Review

American Journal of Preventive Medicine

Behaviour Research and Therapy

Behaviour Research and Therapy

Journal of Affective Disorders

Behavior Therapy

Behavior Therapy

Cognitive and Behavioral Practice

Comprehensive Psychiatry

Psychiatry Research: Neuroimaging

Exposure therapy for anxiety: principles and practice

Treatment compliance and outcome in obsessive–compulsive disorder

Behavior Modification

The new guidelines from the British Association for Psychopharmacology for anxiety disorders

International Journal of Psychiatry in Clinical Practice

Meta-analysis of the dose–response relationship of SSRI in obsessive–compulsive disorder

Molecular Psychiatry

The generalizability of the psychoanalytic concept of the working alliance

Psychotherapy: Theory, Research, and Practice

Introduction to meta-analysis

A multidimensional meta-analysis of psychotherapy for PTSD

American Journal of Psychiatry

Amygdala and ventral anterior cingulate activation predicts treatment response to cognitive behaviour therapy for post-traumatic stress disorder

Psychological Medicine

Expressed emotion and psychiatric relapse: a meta-analysis

Archives of General Psychiatry

Expressed emotion and behavior therapy outcome: a prospective study with obsessive–compulsive and agoraphobic outpatients

Journal of Consulting and Clinical Psychology

Multicenter, double-blind comparison of sertraline and placebo in the treatment of posttraumatic stress disorder

Archives of General Psychiatry

Clinical predictors of drug response in obsessive–compulsive disorder

Journal of Clinical Psychopharmacology

Psychological and pharmacological treatments of social phobia: a meta-analysis

Journal of Clinical Psychopharmacology

Avoiding treatment failure in social anxiety disorder

Review
Non-adherence and non-response in the treatment of anxiety disorders