It is well known among psychiatrists and researchers that many mental health patients — more than half, according to some studies — end their cognitive behavioral therapy (CBT) before the recommended course of treatment is complete, but why this happens has remained a mystery.
“We don’t know why,” says Partha Krishnamurthy, Ph.D., director of the Institute for Health Care Marketing at the Bauer College of Business at the University of Houston (UH). “The person just doesn’t show up.”
In a quest to find some answers, Krishnamurthy and colleagues conducted a new study involving patients who were being treated with CBT for anxiety. Their findings revealed that patients who improved the most quickly as well as patients with the highest baseline anxiety levels are the two groups most likely to drop out early.
“We believe the heartbeat of the finding is the speed of improvement, rather than the level of improvement,” said Krishnamurthy, lead author of the paper and professor of marketing at UH. “The faster they get better compared to where they started, the more likely they are to abandon treatment.”
The stigma connected to mental health disorders may contribute as well. Although there is no direct evidence, Krishnamurthy said the patient might be thinking of the stigma and reasoning, “I’ve gotten better, so why should I continue being seen seeking treatment?”
The research involved 139 people enrolled in a 12-week CBT course at an anxiety disorder research clinic run by the university. The patients’ anxiety levels were assessed during each session.
Since CBT and other forms of psychotherapy are intended to take a number of sessions, patients regularly must decide if the benefits are worth the financial and emotional costs, the researchers wrote.
Traditional decision-making research suggests patients should continue treatment as long as they are improving. But the new findings showed a correlation between reduced symptoms and stopping treatment, meaning those traditional decision-making factors may not apply to mental health care.
“As the patient starts experiencing improvement, the desire to get better becomes less pronounced compared to the social, emotional, financial, and time costs of continuing therapy,” they wrote.
“Clients who approached their symptom reduction goal were more likely to discontinue treatment activities. More importantly, we found … that faster improvement leads to greater discontinuation.”
“Patients who started with the highest anxiety levels also were more likely to drop out. That could be because the illness influenced their ability to decide they needed treatment,” Krishnamurthy said, “as well as their ability to get to appointments and other issues.”
The researchers suggested patients with the highest anxiety levels could benefit “from immediate symptom relief strategies, such as relaxation exercises or medication.”
Krishnamurthy added that, while the work isn’t intended to offer specific solutions, strategies such as focusing on future gains, rather than simply recognizing progress already made, could be helpful.
Financial incentives — reducing copays for patients after they reach a certain point in the treatment, for example — also might help, he said.
“How do you make people do those things that are not easy or fun?” he asked. “We need to reframe the issue. At the end of the day, good health outcomes are the result of patients’ choice process, as much as they are based on drugs and devices. Understanding how patients make decisions is a critical component of improving health care.”
The paper is published in the Journal of Clinical Psychology.
Source: University of Houston