Early Engagement Is Key to Preventing CBT Dropout

Although cognitive-behavioral therapy (CBT) has been shown to be effective at treating a range of psychiatric disorders, many patients discontinue therapy prematurely. Withdrawing from therapy early can increase a patient’s risk of symptom relapse or, in the case of group therapy, compromise the dynamic of the group.

“Unfortunately, there is no simple answer that explains CBT dropout,” psychologist Joshua Swift, Ph.D., head of the Psychotherapy Process and Outcome Research Lab at Idaho State University, told Psychiatric News. “There are many factors that stem from both the nature of talk therapy and the nature of the patient’s disease.”

Swift and colleagues recently completed a meta-analysis on dropout data collected from over 100 CBT clinical studies (including over 20,000 patients) for a range of mental health problems. The analysis was published online in September in the Journal of Consulting and Clinical Psychology.

They found that dropout rate was associated with diagnosis, with depression having the highest dropout rate (36 percent) and anxiety disorders the lowest (19 percent). CBT format and the setting in which it was delivered also played a role: e-therapies had higher dropout rates (34 percent) than either individual or group sessions (25 percent), and the number of outpatient dropouts (26 percent) exceeded that of inpatient dropouts (19 percent).

Why are patients ending CBT before the recommended course of treatment is complete? While a natural inclination would be to think it’s related to a lack of improvement, some recent research suggests that the opposite is true and that patients who improve the fastest may be at the greatest risk of discontinuation.

A group at the University of Houston (UH), led by Partha Krishnamurthy, M.D., at UH’s Institute for Health Care Marketing, monitored 139 people enrolled in a 12-week CBT program for anxiety, assessing each participant’s anxiety levels during each session.

“Our approach was to view the patients through a different lens and consider them as customers,” Krishnamurthy told Psychiatric News. “What are the market forces that are driving their decisions?”

The researchers found that, among patients with mild or moderate anxiety, there was a correlation between reduced symptoms and stopping treatment early; patients who improved quickly were more likely to drop out in the first few sessions.

“So it is the speed of improvement, rather than the level of improvement, that affects dropout rate,” said Krishnamurthy.

He and his team are hoping to continue their marketing-style analysis and test whether certain interventions, such as altering payment structures to incentivize patients to stay in therapy longer, might reduce the dropout rate.

Judith Beck, Ph.D., president of the Beck Institute for Cognitive Behavior Therapy and an associate professor of psychology in psychiatry at the University of Pennsylvania, agreed that improvement can be a dropout factor, but believes that the underlying causes that lead a patient to withdraw from treatment are more complex.

“In anxiety, particularly, as patients get better and can expose themselves to their fears, their motivation to stay in treatment decreases,” she said. “As an example, if someone is deathly afraid of bridges, they may seek treatment. But as they improve, they start to rationalize, ‘As long as someone else is in the car with me, I’m OK, so I don’t need therapy anymore.’”

To maintain a patient in therapy, Beck said therapists must help their patients to recognize that progress is an important part of the therapy process. According to Beck, studies show that outcomes for CBT are better when therapists regularly ask patients to assess the progress they have made as well as the areas for improvement.

The first couple of CBT sessions are most important, said Swift. “The biggest thing early on for a therapist is to get the client invested in the process and develop that relationship. Don’t worry about getting results early on, as the initial progress has more to do with the patient’s overall well-being as opposed to a reduction in symptoms.”

He added that providers should not worry about trying to do too much too quickly, as one of the other interesting trends he found in his meta-analysis was that dropout rates decreased as the number of CBT sessions increased.

If the patients do end up discontinuing CBT, therapists should not be discouraged, as they are not alone, Swift noted. Swift’s meta-analysis suggests an overall 20 percent discontinuation rate for CBT, which is lower than earlier work examining CBT dropout had suggested. ■