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Dropping out of outpatient psychiatric treatment: a preliminary report of a 2-year follow-up of 1500 psychiatric outpatients in Kermanshah, Iran
General Hospital Psychiatry 35 (2013) 314–319
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Dropping out of outpatient psychiatric treatment: a preliminary report of a 2-year follow-up of 1500 psychiatric outpatients in Kermanshah, Iran☆ Habibolah Khazaie, M.D. a, Leeba Rezaie, M.Sc. a,⁎, Desiree M. de Jong, Ph.D. b a b
Sleep Research Center, Department of Psychiatry, Kermanshah University of Medical Sciences, Kermanshah 6719851151, Iran Developmental Cognitive Neuroscience Laboratory, University of Nebraska–Lincoln, Lincoln, NE 68588, USA
a r t i c l e
i n f o
Article history: Received 15 August 2012 Revised 12 October 2012 Accepted 15 October 2012 Keywords: Dropout Outpatient Psychiatry Iran
a b s t r a c t Background: Outpatient psychiatric treatment provides both psychotherapy and pharmacotherapy for a large portion of psychiatric patients. Dropping out, or early termination of treatment, may be considered a common barrier to outpatient's psychiatric treatment. There are limited studies on this issue in Iran. The current study aimed to examine rates, predictors and reasons of dropping out of an outpatient psychiatric treatment. Materials and Method: In this 6-month cohort study, 1500 outpatients who visited 10 psychiatrist's offices in the Iranian city of Kermanshah were recruited and followed for 2 years (2009–2011) for recommended treatments including admission to hospital, pharmacotherapy, psychotherapy and a combination of both psychotherapy and pharmacotherapy. Characteristics of patients who dropped out of the current study were collected, and reasons for dropping out were collected via phone or in person interview. Results: Dropouts were prevalent in prescribed treatments. Pretreatment (primary) dropout rates in psychotherapy treatment were 4 times greater than dropout rates in pharmacotherapy treatment (80% and 20%, respectively). There were significance differences between dropouts and non-dropouts of pharmacotherapy with respect to patient characteristics; younger age, male gender, low level of education, unemployment, lack of insurance, new cases and divorce were more prevalent among dropouts (Pb.001). With regard to diagnosis, dropping out was more prevalent among patients with substance-related disorders, schizophrenia and other psychotic disorders when compared to other diagnoses (Pb .001). Commonly reported reasons for dropping out included overslept and too ill to attend treatment and fear of becoming addicted to prescribed psychotropic medication (30% and 18%, respectively). Lack of confidence in therapist ability and lack of confidence in the efficacy of the treatment were more prevalent in patients who dropped out of psychotherapy (Pb .001). Conclusion: Patient dropout is a common problem in outpatient psychiatric treatment, particularly in psychotherapy treatment. Further research on reasons for dropping out and strategies to reduce rates of dropouts is recommended. © 2013 Elsevier Inc. All rights reserved.
1. Background Outpatient psychiatric treatment can provide an extended range of different therapies, including pharmacotherapy and psychotherapy. Perhaps mainly due to noticeable advances in both pharmacotherapy and psychotherapy and thus a lack of need for patients to remain in an inpatient hospital setting, there is a trend toward outpatient treatment for a number of disorders [1,2]. However, dropping out, or premature termination of treatment, is a common and considerable problem in outpatient psychiatric services. Patients often interrupt their contact with psychiatric services before their treatment has been
☆ Conflict of Interest: The authors have no financial or personal relationships with other individuals or organizations that could inappropriately influence (bias) their work. ⁎ Corresponding author. Tel.: +98 918 8364414; fax: +98 831 8264163. E-mail address: [email protected] (L. Rezaie). 0163-8343/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.genhosppsych.2012.10.008
completed. When treatment is provided in the context of research, the consequences of high rates of dropouts include, but are not limited to, incomplete treatment and concern about patients' improvement, a sense of wasted time and economic funds for psychiatric professions (including psychiatrists and psychologists) and adverse effects on study results [3–5]. Dropping out as a barrier to appropriate psychiatric service delivery has been the focus of several studies. Some estimate that dropping out occurs in approximately 20–60% of outpatients, and factors such as patient expectations of therapy, male gender, younger age, lower income and suboptimal health status have been identified as important predictors [5–12]. Higher rates of dropouts have also been reported among patients with no history of psychiatric disorders (i.e., new cases) [13]. In addition to patients' demographic characteristics, psychiatric diagnosis has been a predictor for dropout. Specifically, patients with severe symptoms of schizophrenia were more likely to drop out of treatment. Personality disorders and posttraumatic stress disorder were other
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diagnoses that predicted dropout [11]. Research examining the reason(s) for dropping out of outpatient psychiatric treatment services is warranted, particularly in the context of sociocultural differences in attitude toward treatment. In Iran, there are limited studies examining reasons for and rates of dropouts among outpatient psychiatric treatment. Most research has focused on the outcomes of outpatient treatment for specific cases, such as substance-related disorders; however, dropping out of treatment has not been studied directly, despite the fact that many studies mention dropouts in their results [14–17]. Therefore, we designed a prospective follow-up study to examine rates, predictors and reasons of dropping out of outpatient psychiatric treatment in private offices of an Iranian western province, Kermanshah. 2. Methods 2.1. Setting The current study was conducted in the city of Kermanshah, the capital of the Kermanshah Province in Western Iran, with a population 822,921 (2005 census). There are 10 psychiatric offices in Kermanshah; each consists of a treatment team directed by a psychiatrist and including one or two psychologists and social workers. Typical procedure in the offices involves each patient primarily receiving treatment from a psychiatrist and, if deemed necessary, patients may be referred to other team members. Different types of treatments such as pharmacotherapy and several types of psychotherapy are provided to patients. Additionally, admission to a psychiatric hospital may be considered if the severity of the patient's illness requires such treatment. It should be noted that all types of insurance in Iran cover psychiatric visits, but psychotherapy is typically not covered by insurance. These 10 offices were targets for our study. After the study design was established, all 10 offices were contacted by mail to determine the team's willingness to participate. Once responses were received, the study began in March of 2009, with a total of 10 psychiatrists and 15 psychologists, who had agreed to participate in the current study. 2.2. Participants In accordance with the study protocol, 150 patients were randomly selected from each of the 10 offices using a table of random numbers. Participants included both patients with a history of previous psychiatry contact and patients with a new referral to a psychiatrist (i.e., new cases). A trained member of the research team, or one personnel from each office, was responsible for collecting information about treatment type for each patient referred to the office. Data collection began upon participant completion of the registration form, which consisted of an informed consent form, as well as a demographic questionnaire. Informed consent was obtained first through verbal explanation of the study design, including the duration of the study (2 years) and that participants would be contacted to request information regarding their reason for dropping out. Then, the informed consent form was signed by the patient or a close family member if he/she was unable to independently make the decision to participate. Patients were then seen by the psychiatrist who performed a thorough assessment by interview, psychological tests (e.g., Beck Depression Inventory — Second Edition, Minnesota Multiphasic Personality Inventory, intelligence measures, etc.) and any other examination deemed necessary (e.g., magnetic resonance imaging, electroencephalogram, etc.). Initial diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, prescribed treatment type (i.e., pharmacotherapy, psychotherapy) and next scheduled appointment were recorded in each patient's chart. Psychiatric visits (pharmacotherapy) were scheduled monthly, while psychotherapy was scheduled weekly.
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Patient attendance for his or her scheduled appointments was closely monitored. For the purposes of this study, dropout was defined as incomplete termination of treatment and lack of contact with the offices lasting at least 365 consecutive days (1 year). If a patient met these criteria, dropout was recorded. In contrast, non-dropout patients were those who did not terminate their treatment without initially establishing agreement with his or her psychiatrist or psychotherapist, though there may be one or more nonattendance or cancelled appointments in their scheduling program. Noticeably, especially with psychotherapy, we were confronted with two types of dropout patients. One type was patients that had dropped out from the beginning of the study prior to attending any of their appointments, despite their expressed willingness to participate in the study, and thus we called this group the primary (early) dropouts. The second type of dropouts was patients who had dropped out after attending one or more of their appointments and thus were called the secondary dropouts. After a patient was identified as having dropped out of treatment, the team member who initially collected the patient's data contacted him/her by phone call if he/she had dropped out of both pharmacotherapy and psychotherapy. For patients who had drop out from psychotherapy but still attended pharmacotherapy, reasons for drop out were asked in the offices at the time of their pharmacotherapy appointment. In fact, patient attendance in psychiatry offices for appointments provided a good opportunity for asking about reasons for drop out in a large proportion of the patients. All other patients who dropped out of treatment were contacted by phone. In this way, all patients who had dropped out of psychotherapy, pharmacotherapy or both were asked for reasons for dropping out of treatment either in person or by phone and we were not confronted with any problems obtaining this information from any of the dropout patients. Since there is no standard scale for measuring reason(s) for treatment dropout in Persian, a semi-structured interview using open-ended questions was performed to collect information regarding the reasons for dropping out. In some cases, data were gathered from a close relative of the patient. It should be kept in mind that reasons for dropping out of pharmacotherapy and psychotherapy were asked separately. Psychotherapy is usually referred to as “consultation” by patients. Therefore, we asked for reasons for dropping out of psychotherapy using the commonly used term “consultation” (e.g., “Why he/she did not continue his/ her consultation sessions?”). For pharmacotherapy, questions focused on drugs and psychiatrist visits (e.g., “What was his/her reasons for discontinuation of pharmacotherapy or psychiatrist visits?”). All answers were documented and similar responses were subsequently categorized.
2.3. Measures For each patient, the following data were collected from study entry through study completion or once the patient dropped out of treatment: • Sociodemographic data (including age, gender, marital status, education, occupation, income, insurance, home, past history of illness and referral to psychiatrist, address and phone number) were recorded using a specified form. For two variables (i.e., insurance and past history of illness and referral to psychiatrist), dichotomous responses of “yes” and “no” were used. • Diagnosis according to psychiatric assessment, which was recorded in each patient's chart. • Prescribed treatment type including pharmacotherapy, psychotherapy or a combination of both. • Patient's attendance or nonattendance in the scheduling treatment program (weekly for psychotherapy and monthly for pharmacotherapy).
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• Patient's status of non-dropping out or dropping out of treatment according to our definition of non-dropout and dropout. • Patient's status of primary and secondary dropout according to our definition of primary and secondary dropout. • Patient's reason(s) for dropping out of treatment assessed by semi-structured interview.
patient's illness, each has a unique process in terms of type of treatment, service provider and focus of treatment, which may be contributing factors to study results. Therefore, separated results seem reasonable. Finally, we believe that the separated results can be considered as good bases for further research in this area. 3.1. Dropout among outpatients treated with pharmacotherapy
2.4. Statistical analysis We divided patients into two groups: dropout and non-dropout. Dropout occurred in different stages of follow-up. Fig. 1 demonstrates whether dropouts occurred at the second, third or fourth visit (or later), as well as the follow-up procedures among non-dropouts. Demographic characteristics of all outpatients treated with pharmacotherapy are listed in Table 1. As reported in Table 1, dropout rates for pharmacotherapy were 20%, i.e., only 1 out of 5 patients had dropped out. Comparisons of demographic characteristics between the dropout and non-dropout groups demonstrated significant differences for a number of characteristics. Dropout was more prevalent in younger patients and in males (Pb.001). Those patients who were unemployed, had lower levels of education, were divorced, had no previous history of contact with psychiatric services (i.e., new cases) and without insurance support were more likely to drop out of treatment (Pb.001). There were significant differences between the dropout and non-dropout groups with respect to psychiatric diagnosis. Patients with substance-related disorders had higher rates of dropouts than other diagnoses (Pb.001). Several reasons for dropping out of treatment were reported by patients or their relatives and are listed in Table 2. The most commonly reported reason for dropping out was overslept and too ill to attend (30%). Fear of admission to a psychiatric hospital was the least frequently reported reason (1.3%).
We performed our analyses in two parts: (1) using SPSS Version 16.5 software (Chicago, IL) to analyze quantitative data including frequencies of dropouts in pharmacotherapy and psychotherapy and comparisons of characteristics between dropout and non-dropout groups of pharmacotherapy. Chi-square tests of independence were employed for all analyses, except when age was the variable of interest, in which case a t test was employed to examine differences between dropouts and non-dropouts. A P value of .05 was used study wide; (2) all other data gathered regarding reason(s) for dropping out were analyzed using methods for analyzing qualitative data (particularly content analysis), although this was not a comprehensive qualitative study. For this propose, patients' answers were coded and similar codes were categorized. Then, frequencies for every category were obtained. After categorizing reasons for dropping out, comparisons of reasons between primary and secondary dropouts of psychotherapy were performed using chi-square tests. 3. Results A total of 1500 patients were followed over the course of 2 years. Concurrent pharmacotherapy and psychotherapy were prescribed to 78.7% (n= 1180) of patients. Electroconvulsive therapy and hospital admission occurred in 0.77% (n=10) and 12.9% (n= 194) of patients, respectively. It is important to note that, of the 194 patients who were referred for psychiatric hospital admission, 158 (81.4%) refused and requested that they continue to receive pharmacotherapy alone. Of the remaining 36 patients (18.55%) who were successfully admitted to a psychiatric hospital, only 17 (8.7%) completed treatment in hospital. We present these results in two sections: (1) dropout among outpatients treated with pharmacotherapy and (2) dropout among outpatients treated with psychotherapy. There are several reasons to justify this presentation that may be somewhat different from previous studies: (1) As the first study with a commendable sampling pool to examine dropout in psychiatric outpatients in Iran, we want to better understand the dropout process in detail. (2) Dropout rates, and thus reason for dropping out, were different for the two types of treatment (pharmacotherapy and psychotherapy). Separated results may better explain these differences. (3) Although both pharmacotherapy and psychotherapy are provided in an effort to improve the
3.2. Dropout among outpatients treated with psychotherapy Dropping out of psychotherapy treatment was more prevalent than pharmacotherapy. A total of 944 (80%) of the 1180 patients who were prescribed a type of psychotherapy treatment did not actually attend psychotherapy and preferred to be treated by pharmacotherapy alone. Two patterns of dropouts were evident: one group never attended psychotherapy, which we called the primary or early dropouts (n= 944, 80%), and one group dropped out after the first, second or later sessions of psychotherapy, which we called the secondary dropouts (n= 141, 11.95%). Dropout after the initial session occurred in 82 (6.95%) patients while dropout after the second session or later occurred in 59 (5.00%) patients, and 95 (8.05%) patients completed psychotherapy treatment (i.e. they attended the initial recommended sessions and any other sessions that were recommended by their psychologist. For these patients, treatment 1,500 (patients)
100 (second visit)
300
1200
(total dropout)
(non-dropout)
80 (third visit)
120 (fourth visit or later)
340 (patient report of improvement)a
62 (recurrence of psychiatric symptoms)
860 (continued visits)
278 (no reccurence)
Fig. 1. Diagram of a 2-year follow-up of patients receiving pharmacotherapy. aThese patients reported improvements in psychiatric symptoms and requested that they discontinue their involvement in pharmacotherapy but continued to be followed monthly via telephone calls.
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Table 1 Comparison of demographic characteristic between dropouts and non-dropouts in pharmacotherapy treatment Variable
Age (years, mean±S.D.) Gender, N (%) Male Female Marital status, N (%) Married Single Divorced Education, N (%) Illiterate Primary Secondary High school University Occupation, N (%) Unemployed Employed Student Other Previous psychiatric contact, N (%) Yes No Insurance, N (%) Yes No Diagnosis, N (%) Psychosis/schizophrenia Neurosis/anxiety Substance-related disorders Mood disorders Other
Group
P value
Dropouts
Non-dropouts
25.0±9.2
28.9±9.9
191 (63.7) 109 (36.3)
461 (38.4) 739 (61.6)
50 (16.6) 80 (26.7) 170 (56.7)
652 (54.3) 418 (34.8) 130 (10.8)
62 78 80 42 38
64 (5.3) 234 (19.5) 400 (33.3) 232 (19.3) 270 (22.5)
.007 b.001
b.001
b.001 (20.7) (26.0) (26.6) (14.0) (12.7)
Fig. 2. Diagram of the psychotherapy treatment process during a 2-year follow-up. b.001
150 (50.0) 40 (13.3) 40 (13.3) 70 (23.3)
362 270 268 300
(30.2) (22.5) (22.3) (25.0)
154 (51.3) 146 (48.7)
1046 (87.2) 154 (12.8)
reasons for dropping out among patients in the secondary dropout group (Pb.001). b.001
b.001 100 (33.3) 200 (66.7)
1030 (85.8) 170 (14.2)
61 60 89 50 40
159 418 156 220 247
b.001 (20.3) (20.0) (29.7) (16.7) (13.3)
(13.3) (34.8) (13.0) (18.3) (20.6)
Note: chi-square test of independence employed for all analyses, except when age was the variable of interest, where a t test was employed to examine differences between dropouts and non-dropouts.
termination was decided based upon agreement between a given patient and his/her psychologist. However, patients could return to treatment, if they expressed a need for additional psychotherapy sessions). Fig. 2 depicts the psychotherapy treatment process. Due to the high rate of dropouts in psychotherapy treatment, comparisons between dropout and non-dropout groups are not listed here. The different types of psychotherapy and frequency of patients who completed each treatment were as follows: supportive psychotherapy (n= 55, 57.90%), cognitive behavior therapy (n=25, 26.31%) and behavior therapy (n= 15, 15.79%). Reasons for dropping out among each of the two dropout groups (i.e., primary vs. secondary dropouts) are reported in Table 3. Results indicated economic difficulties and lack of confidence in therapist ability as the two most commonly reported reasons for dropping out among patients in the primary dropout group (Pb .001), while lack of confidence in therapist ability and efficacy of treatment were the two most commonly reported
Table 2 Reasons for dropping out of pharmacotherapy Reason
N (%)
Economic difficulties Overslept and too ill to attend Felt better Repeating prescribed drugs Treatment considered useless Fear of addiction Fear of admission to psychiatric hospital Fear of stigma Forgot about appointment
40 (13.3) 90 (30.0) 38 (12.7) 25 (8.3) 15 (5.0) 54 (18.0) 4 (1.3) 18 (6.0) 7 (2.3)
Note: N=300.
4. Discussion As one of the first studies to address dropping out of outpatient psychiatric treatment services in Iran, the relatively long-term period of follow-up (2 years) allowed for the examination of dropout patterns in both psychotherapy and pharmacotherapy treatment. Contrary to reports in other countries [4,8,10,11], the results of the current study indicate that dropping out is a relatively prevalent problem in outpatient psychiatric treatment in Kermanshah. However, the large early dropout rates (80%) in psychotherapy are noteworthy and cannot be compared with other studies [3,4]. As previously noted, these results can be discussed with respect to two separate categories: dropouts from (1) pharmacotherapy and dropouts from (2) psychotherapy. 4.1. Dropout among outpatients treated with pharmacotherapy Results indicated that 20% of patients referred to receive pharmacotherapy dropped out of treatment, with 80% of patients completing their prescribed treatment. This rate suggests that pharmacotherapy is an acceptable treatment in outpatient psychiatric services in Iran. It is possible that the primary reason for such high rates of completion of pharmacotherapy in our study is related to cultural context. In fact, pharmacotherapy has been viewed as a more effective treatment compared to other forms of psychiatric treatment in Iran. Comparison between dropout and non-dropout groups indicated that there were significant differences between the two groups with respect to patient characteristics and diagnoses (see Table 1). Briefly, we discussed each item below: Age: Contrary to previous research [6,8,9,11,18,19], younger age may be considered a predictor for dropout in our study. The Table 3 Comparison of reasons for dropping out among primary and secondary dropout groups of psychotherapy Reason
Economic difficulties Lack of confidence in therapist ability Distance from office Lack of confidence in treatment efficacy
Group, n (%)
P value
Primary dropouts (n=944)
Secondary dropouts (n=141)
290 (30.72) 240 (25.42)
36 (25.53) 45 (31.91)
b.001 b.001
197 (20.87) 217 (22.99)
20 (14.18) 40 (28.37)
b.001 b.001
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association between younger age and other factors such as unemployment, fear of stigma [20] and lack of family support (i.e., marital support) may also shed light on the higher rates of dropout in this group. However, it remains necessary that service providers consider specific strategies for encouraging younger patients to complete their treatment. Gender: Consistent with previous studies [11,21], male patients were more likely to drop out of treatment than female patients (Pb .001). These studies report that help-seeking behavior is more prevalent in females than males; thus, there is a greater probability that female patients will complete treatment. Culturally, there is also an apparent tendency for males to not exhibit help-seeking behaviors. Considering the adverse effects of uncompleted treatment of mental illnesses, further investigation of the reasons for such gender differences is recommended. Marital status: Results illustrate that divorced status was more prevalent among dropout groups. It is possible that feelings of loneliness and lack of family support may explain the high dropout rates among divorced patients in our study, which may also serve as a viable explanation for previously reported findings that patients who are single are more prone to drop out of treatment [9,11]. Collaboration between psychiatric service providers and both government and nongovernment organizations may be helpful for providing appropriate support for these patients. Education: Dropping out was more prevalent among patients with lower levels of education, particularly those who had only achieved a secondary level of education (i.e., less than a high school education). Low level of education as a predictor of dropping out has been reported in previous research [8,22]. Obviously, education is an important factor for motivating patients to continue their treatment and psychoeducational programs that have been modified for these patients can be helpful. Occupation: In line with other studies [4,9], unemployed patients had higher rates of dropouts in our study (Pb.001). Financial difficulties faced by unemployed patients are a lucid reason for dropping out of treatment. However, there may be other feasible explanations for the high rates of dropouts among unemployed patients, warranting the need for further research. Previous history contact: Our results showed that dropout was more prevalent in patients with no previous history of contact with a psychiatrist and/or psychologist (Pb.001). However, as reported by Reneses et al. [11], there is no apparent interpretation for this issue. Perhaps patient confusion about illness and appropriate treatment due to a lack of experience with psychiatric services may be a reason for the high rates of dropouts among patients without a history of contact with psychiatric treatment. Insurance: Dropping out was more prevalent among patients who did not have any insurance (Pb .001). Given that psychiatric treatments are relatively long term, insurance support can be useful for motivating patients to continue their treatment. Lack of insurance as a predictor for dropout has also been reported in other studies [4,23]. Obviously, lack of insurance among patients with financial difficulties is likely an important factor for dropping out of treatment. Diagnosis: A greater proportion of dropouts in the current study had a history of substance-related disorders compared to nondropouts (29.7% vs. 13.0%). Less prevalent diagnoses among dropouts included other diagnoses (e.g., sleep disorders, somatoform disorders, sexual disorders, etc.), mood disorders and anxiety disorders (13.3%, 16.7% and 20.0%, respectively). The impact of diagnosis on dropping out has been previously reported in several studies [4–6,8–10,18]. Higher rates of dropouts were reported for patients with substancerelated disorders alone in these studies. On the other hand, the finding of lower rates of dropout in patients with mood disorders and other diagnosis are inconsistent with previous research [1,2,4]. It is possible that some type of strategy, such as motivational interviews, may be
helpful in reducing dropout rates among patients with substancerelated disorders [4]. As depicted in Table 2, patients reported their reason(s) for dropping out of treatment during phone interviews. Overslept and too ill to attend was the most commonly reported reason among dropouts (30%). Given that patients self-reported reason(s) for dropping out of treatment, thus conveying difficulties experienced from their perspective, these results can provide a valuable source of information for further investigation and applied strategies for reducing rates of dropouts. 4.2. Dropout among outpatients treated with psychotherapy As illustrated in Fig. 2, dropping out commonly occurred in psychotherapy. Primary dropouts, or pretreatment refusal, occurred in approximately 80% of patients. Reasons for dropping out were compared between the primary and secondary dropout groups (Table 3). Rates of dropout in our study were higher than those reported in previous research [4,10,24]. Perhaps sociocultural context is a primary factor related to dropping out of psychotherapy in Kermanshah. As previously mentioned, there is a very strong positive attitude toward pharmacotherapy in Iran. In contrast with other studies [4,13,23], which report that a combination of pharmacotherapy and psychotherapy is associated with lower rates of dropout, pharmacotherapy alone was associated with lower rates of dropout in our study. However, further research is recommended in order to provide a better understanding of the reasons patients drop out of psychotherapy in Iran. In the current study, significant differences existed between primary and secondary dropouts with respect to the reason(s) for drop out. Reasons commonly reported in the primary dropout group (i.e., economic difficulties and lack of confidence in therapist ability) are two different types of reasons for dropping out. The first reason (economic difficulties) is not particularly specific reason and may be observed among many other patients who have dropped out of treatment. But the second reason (lack of confidence to therapist ability) seems to be specific one. Further research is recommended to examine how patients who did not have any experience with psychotherapy, expressed lack of confidence to therapist ability as a reason for dropping out of treatment. However, secondary dropouts typically reported a lack of confidence in therapist ability and efficacy of treatment as reasons for dropping out, an especially noteworthy finding. Findings from previous research indicate that the most commonly reported reasons for dropping out of treatment after the initial consult include patient perception of and assumption about treatment, the therapeutic relationship, the presence of personality disorders and younger age [4,10,20]. It is unclear whether lack of confidence in therapist ability and efficacy of treatment is relevant to patient characteristics or to therapist characteristics. Additional research examining patient satisfaction using standardized measures may allow for a more precise assessment of reasons for dropping out of psychotherapy. On the other hand, improvement of therapists' abilities through continued education and specified workshops may be useful in reducing rates of dropouts in psychotherapy. In conclusion, the current study measured rates of dropouts among outpatients receiving psychiatric treatment in Kermanshah, Iran. There are several implications for the aforementioned results. These results illustrate that patients' characteristics, psychiatric diagnosis and type of psychiatric treatment are important contributing factors for predicting dropout. With regard to the important patient characteristics identified in the current study (i.e., gender, marital status, education, occupation and previous history of contact with psychiatric services), psychiatric service providers should consider strategies for motivating patients who may be prone to drop out to actively participate in treatment. Family education and nongovernment organization involvement may be helpful strategies.
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Additionally, patients with psychiatric diagnoses, who may have higher tendency toward dropping out of treatment, should be provided with specific consideration in treatment programs. Finally, given that psychotherapy is considered an effective treatment for psychiatric patients, participation in psychotherapy should continue to be assessed and reasons for drop out should be further studied using standardized measures. Obviously, it is very difficult and challenging to eliminate cultural barriers of psychotherapy. However, this issue should not be overlooked. The current study should be seen in light of some limitations. First, our study included only private psychiatric offices in Kermanshah city; therefore, the results cannot be generalized to other psychiatric services in the Kermanshah Province. Secondly, we did not follow patients who were referred to psychiatric services in other provinces. Thirdly, we did not have access to a standardized questionnaire to collect reasons for drop out. Finally, basic information about other predictors of dropout such as distance from delivery service and quality of service delivery in private offices was not available. Thus, further research considering these limitations is recommended. References [1] Olfson M, Marcus SC, Druss B, Elinson L, Tanielian T, Pincus HA. National trends in the outpatient treatment of depression. JAMA 2002;287:203-9. [2] Moreno C, Laje G, Blanco C, Jiang H, Schmidt AB, Olfson M. National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry 2007;64:1032. [3] McIvor R, Ek E, Carson J. Non-attendance rates among patients attending different grades of psychiatrist and a clinical psychologist within a community mental health clinic. Psychiat Bull 2004;28:5-7. [4] Barrett MS, Chua WJ, Crits-Christoph P, Gibbons MB, Thompson D. Early withdrawal from mental health treatment: implications for psychotherapy practice. Psychother Theor Res Pract Train 2008;45:247-67. [5] Mitchell AJ, Selmes T. Why don't patients attend their appointments? Maintaining engagement with psychiatric services. Adv Psychiatr Treat 2007;13:423-34. [6] Centorrino F, Hernán MA, Drago-Ferrante G, Rendall M, Apicella A, Längar G, et al. Factors associated with noncompliance with psychiatric outpatient visits. Psychiatr Serv 2001;52:378-80. [7] Garcia JA, Weisz JR. When youth mental health care stops: therapeutic relationship problems and other reasons for ending youth outpatient treatment. J Consult Clin Psych 2002;70:439.
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[8] Killaspy H, Banerjee S, King M, Lloyd M. Non-attendance at psychiatric outpatient clinics: communication and implications for primary care. Br J Gen Pract 1999;49: 880. [9] Killaspy H, Banerjee S, King M, Lloyd M. Prospective controlled study of psychiatric out-patient non-attendance. Br J Gen Pract 2000;176:160-5. [10] Rossi A, Amaddeo F, Bisoffi G, Ruggeri M, Thornicroft G, Tansella M. Dropping out of care: inappropriate terminations of contact with community-based psychiatric services. Br J Gen Pract 2002;181:331-8. [11] Reneses B, Muñoz E, López-Ibor JJ. Factors predicting drop-out in community mental health centres. World Psychiatry 2009;8:173. [12] Issakidis C, Andrews G. Pretreatment attrition and dropout in an outpatient clinic for anxiety disorders. Acta Psychiat Scand 2004;109:426-33. [13] Berghofer G, Schmidl F, Rudas S, Steiner E, Schmitz M. Predictors of treatment discontinuity in outpatient mental health care. Soc Psych Psych Epid 2002;37: 276-82. [14] Ahmadi J, Babaee-Beigi M, Alishahi M, Maany I, Hidari T. Twelve-month maintenance treatment of opium-dependent patients. J Subst Abuse Treat 2004; 26:61-4. [15] Ahmadi J, Kampman KM, Oslin DM, Pettinati HM, Dackis C, Sparkman T. Predictors of treatment outcome in outpatient cocaine and alcohol dependence treatment. Am J Addict 2009;18:81-6. [16] Akuchekian S, Amanat S. The comparison of topiramate and placebo in the treatment of posttraumatic stress disorder: a randomized, double-blind study. J Res Med Sci 2004;9:240-4. [17] Assadi SM, Radgoodarzi R, Ahmadi-Abhari SA. Baclofen for maintenance treatment of opioid dependence: a randomized double-blind placebo-controlled clinical trial [ISRCTN32121581]. BMC Psychiatry 2003;3:16. [18] Killaspy H. Why do psychiatrists have difficulty disengaging with the out-patient clinic? Invited commentary on…Why don't patients attend their appointments? Adv Psychiatr Treat 2007;13:435-7. [19] Sirey JA, Bruce ML, Alexopoulos GS, Perlick DA, Raue P, Friedman SJ, et al. Perceived stigma as a predictor of treatment discontinuation in young and older outpatients with depression. Am J Psychiatr 2001;158:479-81. [20] Johansson H, Eklund M. Helping alliance and early dropout from psychiatric outpatient care. Soc Psych Psych Epid 2006;41:140-7. [21] Rhodes AE, Goering PN, To T, Williams JI. Gender and outpatient mental health service use. Soc Sci Med 2002;54:1–10. [22] Oosterbeek M. Differences between dropout rates and possible predictors for dropout in Turkish, Moroccan and Iranian minority groups in an outpatient setting in the Netherlands. Unpiblished manuscript, Faculty of Social and Behavioural Theses, Utrecht University, Utrecht, Netherlands 2011. [23] Kessler RC, Berglund PA, Bruce ML, Koch JR, Laska EM, Leaf PJ, et al. The prevalence and correlates of untreated serious mental illness. Health Serv Res 2001;36:987. [24] Edlund MJ, Wang PS, Berglund PA, Katz SJ, Lin E, Kessler RC. Dropping out of mental health treatment: patterns and predictors among epidemiological survey respondents in the United States and Ontario. Am J Psychiatr 2002; 159:845-51.
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Dropping out of outpatient psychiatric treatment: a preliminary report of a 2-year follow-up of 1500 psychiatric outpatients in Kermanshah, Iran☆ Habibolah Khazaie, M.D. a, Leeba Rezaie, M.Sc. a,⁎, Desiree M. de Jong, Ph.D. b a b
Sleep Research Center, Department of Psychiatry, Kermanshah University of Medical Sciences, Kermanshah 6719851151, Iran Developmental Cognitive Neuroscience Laboratory, University of Nebraska–Lincoln, Lincoln, NE 68588, USA
a r t i c l e
i n f o
Article history: Received 15 August 2012 Revised 12 October 2012 Accepted 15 October 2012 Keywords: Dropout Outpatient Psychiatry Iran
a b s t r a c t Background: Outpatient psychiatric treatment provides both psychotherapy and pharmacotherapy for a large portion of psychiatric patients. Dropping out, or early termination of treatment, may be considered a common barrier to outpatient's psychiatric treatment. There are limited studies on this issue in Iran. The current study aimed to examine rates, predictors and reasons of dropping out of an outpatient psychiatric treatment. Materials and Method: In this 6-month cohort study, 1500 outpatients who visited 10 psychiatrist's offices in the Iranian city of Kermanshah were recruited and followed for 2 years (2009–2011) for recommended treatments including admission to hospital, pharmacotherapy, psychotherapy and a combination of both psychotherapy and pharmacotherapy. Characteristics of patients who dropped out of the current study were collected, and reasons for dropping out were collected via phone or in person interview. Results: Dropouts were prevalent in prescribed treatments. Pretreatment (primary) dropout rates in psychotherapy treatment were 4 times greater than dropout rates in pharmacotherapy treatment (80% and 20%, respectively). There were significance differences between dropouts and non-dropouts of pharmacotherapy with respect to patient characteristics; younger age, male gender, low level of education, unemployment, lack of insurance, new cases and divorce were more prevalent among dropouts (Pb.001). With regard to diagnosis, dropping out was more prevalent among patients with substance-related disorders, schizophrenia and other psychotic disorders when compared to other diagnoses (Pb .001). Commonly reported reasons for dropping out included overslept and too ill to attend treatment and fear of becoming addicted to prescribed psychotropic medication (30% and 18%, respectively). Lack of confidence in therapist ability and lack of confidence in the efficacy of the treatment were more prevalent in patients who dropped out of psychotherapy (Pb .001). Conclusion: Patient dropout is a common problem in outpatient psychiatric treatment, particularly in psychotherapy treatment. Further research on reasons for dropping out and strategies to reduce rates of dropouts is recommended. © 2013 Elsevier Inc. All rights reserved.
1. Background Outpatient psychiatric treatment can provide an extended range of different therapies, including pharmacotherapy and psychotherapy. Perhaps mainly due to noticeable advances in both pharmacotherapy and psychotherapy and thus a lack of need for patients to remain in an inpatient hospital setting, there is a trend toward outpatient treatment for a number of disorders [1,2]. However, dropping out, or premature termination of treatment, is a common and considerable problem in outpatient psychiatric services. Patients often interrupt their contact with psychiatric services before their treatment has been
☆ Conflict of Interest: The authors have no financial or personal relationships with other individuals or organizations that could inappropriately influence (bias) their work. ⁎ Corresponding author. Tel.: +98 918 8364414; fax: +98 831 8264163. E-mail address: [email protected] (L. Rezaie). 0163-8343/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.genhosppsych.2012.10.008
completed. When treatment is provided in the context of research, the consequences of high rates of dropouts include, but are not limited to, incomplete treatment and concern about patients' improvement, a sense of wasted time and economic funds for psychiatric professions (including psychiatrists and psychologists) and adverse effects on study results [3–5]. Dropping out as a barrier to appropriate psychiatric service delivery has been the focus of several studies. Some estimate that dropping out occurs in approximately 20–60% of outpatients, and factors such as patient expectations of therapy, male gender, younger age, lower income and suboptimal health status have been identified as important predictors [5–12]. Higher rates of dropouts have also been reported among patients with no history of psychiatric disorders (i.e., new cases) [13]. In addition to patients' demographic characteristics, psychiatric diagnosis has been a predictor for dropout. Specifically, patients with severe symptoms of schizophrenia were more likely to drop out of treatment. Personality disorders and posttraumatic stress disorder were other
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diagnoses that predicted dropout [11]. Research examining the reason(s) for dropping out of outpatient psychiatric treatment services is warranted, particularly in the context of sociocultural differences in attitude toward treatment. In Iran, there are limited studies examining reasons for and rates of dropouts among outpatient psychiatric treatment. Most research has focused on the outcomes of outpatient treatment for specific cases, such as substance-related disorders; however, dropping out of treatment has not been studied directly, despite the fact that many studies mention dropouts in their results [14–17]. Therefore, we designed a prospective follow-up study to examine rates, predictors and reasons of dropping out of outpatient psychiatric treatment in private offices of an Iranian western province, Kermanshah. 2. Methods 2.1. Setting The current study was conducted in the city of Kermanshah, the capital of the Kermanshah Province in Western Iran, with a population 822,921 (2005 census). There are 10 psychiatric offices in Kermanshah; each consists of a treatment team directed by a psychiatrist and including one or two psychologists and social workers. Typical procedure in the offices involves each patient primarily receiving treatment from a psychiatrist and, if deemed necessary, patients may be referred to other team members. Different types of treatments such as pharmacotherapy and several types of psychotherapy are provided to patients. Additionally, admission to a psychiatric hospital may be considered if the severity of the patient's illness requires such treatment. It should be noted that all types of insurance in Iran cover psychiatric visits, but psychotherapy is typically not covered by insurance. These 10 offices were targets for our study. After the study design was established, all 10 offices were contacted by mail to determine the team's willingness to participate. Once responses were received, the study began in March of 2009, with a total of 10 psychiatrists and 15 psychologists, who had agreed to participate in the current study. 2.2. Participants In accordance with the study protocol, 150 patients were randomly selected from each of the 10 offices using a table of random numbers. Participants included both patients with a history of previous psychiatry contact and patients with a new referral to a psychiatrist (i.e., new cases). A trained member of the research team, or one personnel from each office, was responsible for collecting information about treatment type for each patient referred to the office. Data collection began upon participant completion of the registration form, which consisted of an informed consent form, as well as a demographic questionnaire. Informed consent was obtained first through verbal explanation of the study design, including the duration of the study (2 years) and that participants would be contacted to request information regarding their reason for dropping out. Then, the informed consent form was signed by the patient or a close family member if he/she was unable to independently make the decision to participate. Patients were then seen by the psychiatrist who performed a thorough assessment by interview, psychological tests (e.g., Beck Depression Inventory — Second Edition, Minnesota Multiphasic Personality Inventory, intelligence measures, etc.) and any other examination deemed necessary (e.g., magnetic resonance imaging, electroencephalogram, etc.). Initial diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, prescribed treatment type (i.e., pharmacotherapy, psychotherapy) and next scheduled appointment were recorded in each patient's chart. Psychiatric visits (pharmacotherapy) were scheduled monthly, while psychotherapy was scheduled weekly.
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Patient attendance for his or her scheduled appointments was closely monitored. For the purposes of this study, dropout was defined as incomplete termination of treatment and lack of contact with the offices lasting at least 365 consecutive days (1 year). If a patient met these criteria, dropout was recorded. In contrast, non-dropout patients were those who did not terminate their treatment without initially establishing agreement with his or her psychiatrist or psychotherapist, though there may be one or more nonattendance or cancelled appointments in their scheduling program. Noticeably, especially with psychotherapy, we were confronted with two types of dropout patients. One type was patients that had dropped out from the beginning of the study prior to attending any of their appointments, despite their expressed willingness to participate in the study, and thus we called this group the primary (early) dropouts. The second type of dropouts was patients who had dropped out after attending one or more of their appointments and thus were called the secondary dropouts. After a patient was identified as having dropped out of treatment, the team member who initially collected the patient's data contacted him/her by phone call if he/she had dropped out of both pharmacotherapy and psychotherapy. For patients who had drop out from psychotherapy but still attended pharmacotherapy, reasons for drop out were asked in the offices at the time of their pharmacotherapy appointment. In fact, patient attendance in psychiatry offices for appointments provided a good opportunity for asking about reasons for drop out in a large proportion of the patients. All other patients who dropped out of treatment were contacted by phone. In this way, all patients who had dropped out of psychotherapy, pharmacotherapy or both were asked for reasons for dropping out of treatment either in person or by phone and we were not confronted with any problems obtaining this information from any of the dropout patients. Since there is no standard scale for measuring reason(s) for treatment dropout in Persian, a semi-structured interview using open-ended questions was performed to collect information regarding the reasons for dropping out. In some cases, data were gathered from a close relative of the patient. It should be kept in mind that reasons for dropping out of pharmacotherapy and psychotherapy were asked separately. Psychotherapy is usually referred to as “consultation” by patients. Therefore, we asked for reasons for dropping out of psychotherapy using the commonly used term “consultation” (e.g., “Why he/she did not continue his/ her consultation sessions?”). For pharmacotherapy, questions focused on drugs and psychiatrist visits (e.g., “What was his/her reasons for discontinuation of pharmacotherapy or psychiatrist visits?”). All answers were documented and similar responses were subsequently categorized.
2.3. Measures For each patient, the following data were collected from study entry through study completion or once the patient dropped out of treatment: • Sociodemographic data (including age, gender, marital status, education, occupation, income, insurance, home, past history of illness and referral to psychiatrist, address and phone number) were recorded using a specified form. For two variables (i.e., insurance and past history of illness and referral to psychiatrist), dichotomous responses of “yes” and “no” were used. • Diagnosis according to psychiatric assessment, which was recorded in each patient's chart. • Prescribed treatment type including pharmacotherapy, psychotherapy or a combination of both. • Patient's attendance or nonattendance in the scheduling treatment program (weekly for psychotherapy and monthly for pharmacotherapy).
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• Patient's status of non-dropping out or dropping out of treatment according to our definition of non-dropout and dropout. • Patient's status of primary and secondary dropout according to our definition of primary and secondary dropout. • Patient's reason(s) for dropping out of treatment assessed by semi-structured interview.
patient's illness, each has a unique process in terms of type of treatment, service provider and focus of treatment, which may be contributing factors to study results. Therefore, separated results seem reasonable. Finally, we believe that the separated results can be considered as good bases for further research in this area. 3.1. Dropout among outpatients treated with pharmacotherapy
2.4. Statistical analysis We divided patients into two groups: dropout and non-dropout. Dropout occurred in different stages of follow-up. Fig. 1 demonstrates whether dropouts occurred at the second, third or fourth visit (or later), as well as the follow-up procedures among non-dropouts. Demographic characteristics of all outpatients treated with pharmacotherapy are listed in Table 1. As reported in Table 1, dropout rates for pharmacotherapy were 20%, i.e., only 1 out of 5 patients had dropped out. Comparisons of demographic characteristics between the dropout and non-dropout groups demonstrated significant differences for a number of characteristics. Dropout was more prevalent in younger patients and in males (Pb.001). Those patients who were unemployed, had lower levels of education, were divorced, had no previous history of contact with psychiatric services (i.e., new cases) and without insurance support were more likely to drop out of treatment (Pb.001). There were significant differences between the dropout and non-dropout groups with respect to psychiatric diagnosis. Patients with substance-related disorders had higher rates of dropouts than other diagnoses (Pb.001). Several reasons for dropping out of treatment were reported by patients or their relatives and are listed in Table 2. The most commonly reported reason for dropping out was overslept and too ill to attend (30%). Fear of admission to a psychiatric hospital was the least frequently reported reason (1.3%).
We performed our analyses in two parts: (1) using SPSS Version 16.5 software (Chicago, IL) to analyze quantitative data including frequencies of dropouts in pharmacotherapy and psychotherapy and comparisons of characteristics between dropout and non-dropout groups of pharmacotherapy. Chi-square tests of independence were employed for all analyses, except when age was the variable of interest, in which case a t test was employed to examine differences between dropouts and non-dropouts. A P value of .05 was used study wide; (2) all other data gathered regarding reason(s) for dropping out were analyzed using methods for analyzing qualitative data (particularly content analysis), although this was not a comprehensive qualitative study. For this propose, patients' answers were coded and similar codes were categorized. Then, frequencies for every category were obtained. After categorizing reasons for dropping out, comparisons of reasons between primary and secondary dropouts of psychotherapy were performed using chi-square tests. 3. Results A total of 1500 patients were followed over the course of 2 years. Concurrent pharmacotherapy and psychotherapy were prescribed to 78.7% (n= 1180) of patients. Electroconvulsive therapy and hospital admission occurred in 0.77% (n=10) and 12.9% (n= 194) of patients, respectively. It is important to note that, of the 194 patients who were referred for psychiatric hospital admission, 158 (81.4%) refused and requested that they continue to receive pharmacotherapy alone. Of the remaining 36 patients (18.55%) who were successfully admitted to a psychiatric hospital, only 17 (8.7%) completed treatment in hospital. We present these results in two sections: (1) dropout among outpatients treated with pharmacotherapy and (2) dropout among outpatients treated with psychotherapy. There are several reasons to justify this presentation that may be somewhat different from previous studies: (1) As the first study with a commendable sampling pool to examine dropout in psychiatric outpatients in Iran, we want to better understand the dropout process in detail. (2) Dropout rates, and thus reason for dropping out, were different for the two types of treatment (pharmacotherapy and psychotherapy). Separated results may better explain these differences. (3) Although both pharmacotherapy and psychotherapy are provided in an effort to improve the
3.2. Dropout among outpatients treated with psychotherapy Dropping out of psychotherapy treatment was more prevalent than pharmacotherapy. A total of 944 (80%) of the 1180 patients who were prescribed a type of psychotherapy treatment did not actually attend psychotherapy and preferred to be treated by pharmacotherapy alone. Two patterns of dropouts were evident: one group never attended psychotherapy, which we called the primary or early dropouts (n= 944, 80%), and one group dropped out after the first, second or later sessions of psychotherapy, which we called the secondary dropouts (n= 141, 11.95%). Dropout after the initial session occurred in 82 (6.95%) patients while dropout after the second session or later occurred in 59 (5.00%) patients, and 95 (8.05%) patients completed psychotherapy treatment (i.e. they attended the initial recommended sessions and any other sessions that were recommended by their psychologist. For these patients, treatment 1,500 (patients)
100 (second visit)
300
1200
(total dropout)
(non-dropout)
80 (third visit)
120 (fourth visit or later)
340 (patient report of improvement)a
62 (recurrence of psychiatric symptoms)
860 (continued visits)
278 (no reccurence)
Fig. 1. Diagram of a 2-year follow-up of patients receiving pharmacotherapy. aThese patients reported improvements in psychiatric symptoms and requested that they discontinue their involvement in pharmacotherapy but continued to be followed monthly via telephone calls.
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Table 1 Comparison of demographic characteristic between dropouts and non-dropouts in pharmacotherapy treatment Variable
Age (years, mean±S.D.) Gender, N (%) Male Female Marital status, N (%) Married Single Divorced Education, N (%) Illiterate Primary Secondary High school University Occupation, N (%) Unemployed Employed Student Other Previous psychiatric contact, N (%) Yes No Insurance, N (%) Yes No Diagnosis, N (%) Psychosis/schizophrenia Neurosis/anxiety Substance-related disorders Mood disorders Other
Group
P value
Dropouts
Non-dropouts
25.0±9.2
28.9±9.9
191 (63.7) 109 (36.3)
461 (38.4) 739 (61.6)
50 (16.6) 80 (26.7) 170 (56.7)
652 (54.3) 418 (34.8) 130 (10.8)
62 78 80 42 38
64 (5.3) 234 (19.5) 400 (33.3) 232 (19.3) 270 (22.5)
.007 b.001
b.001
b.001 (20.7) (26.0) (26.6) (14.0) (12.7)
Fig. 2. Diagram of the psychotherapy treatment process during a 2-year follow-up. b.001
150 (50.0) 40 (13.3) 40 (13.3) 70 (23.3)
362 270 268 300
(30.2) (22.5) (22.3) (25.0)
154 (51.3) 146 (48.7)
1046 (87.2) 154 (12.8)
reasons for dropping out among patients in the secondary dropout group (Pb.001). b.001
b.001 100 (33.3) 200 (66.7)
1030 (85.8) 170 (14.2)
61 60 89 50 40
159 418 156 220 247
b.001 (20.3) (20.0) (29.7) (16.7) (13.3)
(13.3) (34.8) (13.0) (18.3) (20.6)
Note: chi-square test of independence employed for all analyses, except when age was the variable of interest, where a t test was employed to examine differences between dropouts and non-dropouts.
termination was decided based upon agreement between a given patient and his/her psychologist. However, patients could return to treatment, if they expressed a need for additional psychotherapy sessions). Fig. 2 depicts the psychotherapy treatment process. Due to the high rate of dropouts in psychotherapy treatment, comparisons between dropout and non-dropout groups are not listed here. The different types of psychotherapy and frequency of patients who completed each treatment were as follows: supportive psychotherapy (n= 55, 57.90%), cognitive behavior therapy (n=25, 26.31%) and behavior therapy (n= 15, 15.79%). Reasons for dropping out among each of the two dropout groups (i.e., primary vs. secondary dropouts) are reported in Table 3. Results indicated economic difficulties and lack of confidence in therapist ability as the two most commonly reported reasons for dropping out among patients in the primary dropout group (Pb .001), while lack of confidence in therapist ability and efficacy of treatment were the two most commonly reported
Table 2 Reasons for dropping out of pharmacotherapy Reason
N (%)
Economic difficulties Overslept and too ill to attend Felt better Repeating prescribed drugs Treatment considered useless Fear of addiction Fear of admission to psychiatric hospital Fear of stigma Forgot about appointment
40 (13.3) 90 (30.0) 38 (12.7) 25 (8.3) 15 (5.0) 54 (18.0) 4 (1.3) 18 (6.0) 7 (2.3)
Note: N=300.
4. Discussion As one of the first studies to address dropping out of outpatient psychiatric treatment services in Iran, the relatively long-term period of follow-up (2 years) allowed for the examination of dropout patterns in both psychotherapy and pharmacotherapy treatment. Contrary to reports in other countries [4,8,10,11], the results of the current study indicate that dropping out is a relatively prevalent problem in outpatient psychiatric treatment in Kermanshah. However, the large early dropout rates (80%) in psychotherapy are noteworthy and cannot be compared with other studies [3,4]. As previously noted, these results can be discussed with respect to two separate categories: dropouts from (1) pharmacotherapy and dropouts from (2) psychotherapy. 4.1. Dropout among outpatients treated with pharmacotherapy Results indicated that 20% of patients referred to receive pharmacotherapy dropped out of treatment, with 80% of patients completing their prescribed treatment. This rate suggests that pharmacotherapy is an acceptable treatment in outpatient psychiatric services in Iran. It is possible that the primary reason for such high rates of completion of pharmacotherapy in our study is related to cultural context. In fact, pharmacotherapy has been viewed as a more effective treatment compared to other forms of psychiatric treatment in Iran. Comparison between dropout and non-dropout groups indicated that there were significant differences between the two groups with respect to patient characteristics and diagnoses (see Table 1). Briefly, we discussed each item below: Age: Contrary to previous research [6,8,9,11,18,19], younger age may be considered a predictor for dropout in our study. The Table 3 Comparison of reasons for dropping out among primary and secondary dropout groups of psychotherapy Reason
Economic difficulties Lack of confidence in therapist ability Distance from office Lack of confidence in treatment efficacy
Group, n (%)
P value
Primary dropouts (n=944)
Secondary dropouts (n=141)
290 (30.72) 240 (25.42)
36 (25.53) 45 (31.91)
b.001 b.001
197 (20.87) 217 (22.99)
20 (14.18) 40 (28.37)
b.001 b.001
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association between younger age and other factors such as unemployment, fear of stigma [20] and lack of family support (i.e., marital support) may also shed light on the higher rates of dropout in this group. However, it remains necessary that service providers consider specific strategies for encouraging younger patients to complete their treatment. Gender: Consistent with previous studies [11,21], male patients were more likely to drop out of treatment than female patients (Pb .001). These studies report that help-seeking behavior is more prevalent in females than males; thus, there is a greater probability that female patients will complete treatment. Culturally, there is also an apparent tendency for males to not exhibit help-seeking behaviors. Considering the adverse effects of uncompleted treatment of mental illnesses, further investigation of the reasons for such gender differences is recommended. Marital status: Results illustrate that divorced status was more prevalent among dropout groups. It is possible that feelings of loneliness and lack of family support may explain the high dropout rates among divorced patients in our study, which may also serve as a viable explanation for previously reported findings that patients who are single are more prone to drop out of treatment [9,11]. Collaboration between psychiatric service providers and both government and nongovernment organizations may be helpful for providing appropriate support for these patients. Education: Dropping out was more prevalent among patients with lower levels of education, particularly those who had only achieved a secondary level of education (i.e., less than a high school education). Low level of education as a predictor of dropping out has been reported in previous research [8,22]. Obviously, education is an important factor for motivating patients to continue their treatment and psychoeducational programs that have been modified for these patients can be helpful. Occupation: In line with other studies [4,9], unemployed patients had higher rates of dropouts in our study (Pb.001). Financial difficulties faced by unemployed patients are a lucid reason for dropping out of treatment. However, there may be other feasible explanations for the high rates of dropouts among unemployed patients, warranting the need for further research. Previous history contact: Our results showed that dropout was more prevalent in patients with no previous history of contact with a psychiatrist and/or psychologist (Pb.001). However, as reported by Reneses et al. [11], there is no apparent interpretation for this issue. Perhaps patient confusion about illness and appropriate treatment due to a lack of experience with psychiatric services may be a reason for the high rates of dropouts among patients without a history of contact with psychiatric treatment. Insurance: Dropping out was more prevalent among patients who did not have any insurance (Pb .001). Given that psychiatric treatments are relatively long term, insurance support can be useful for motivating patients to continue their treatment. Lack of insurance as a predictor for dropout has also been reported in other studies [4,23]. Obviously, lack of insurance among patients with financial difficulties is likely an important factor for dropping out of treatment. Diagnosis: A greater proportion of dropouts in the current study had a history of substance-related disorders compared to nondropouts (29.7% vs. 13.0%). Less prevalent diagnoses among dropouts included other diagnoses (e.g., sleep disorders, somatoform disorders, sexual disorders, etc.), mood disorders and anxiety disorders (13.3%, 16.7% and 20.0%, respectively). The impact of diagnosis on dropping out has been previously reported in several studies [4–6,8–10,18]. Higher rates of dropouts were reported for patients with substancerelated disorders alone in these studies. On the other hand, the finding of lower rates of dropout in patients with mood disorders and other diagnosis are inconsistent with previous research [1,2,4]. It is possible that some type of strategy, such as motivational interviews, may be
helpful in reducing dropout rates among patients with substancerelated disorders [4]. As depicted in Table 2, patients reported their reason(s) for dropping out of treatment during phone interviews. Overslept and too ill to attend was the most commonly reported reason among dropouts (30%). Given that patients self-reported reason(s) for dropping out of treatment, thus conveying difficulties experienced from their perspective, these results can provide a valuable source of information for further investigation and applied strategies for reducing rates of dropouts. 4.2. Dropout among outpatients treated with psychotherapy As illustrated in Fig. 2, dropping out commonly occurred in psychotherapy. Primary dropouts, or pretreatment refusal, occurred in approximately 80% of patients. Reasons for dropping out were compared between the primary and secondary dropout groups (Table 3). Rates of dropout in our study were higher than those reported in previous research [4,10,24]. Perhaps sociocultural context is a primary factor related to dropping out of psychotherapy in Kermanshah. As previously mentioned, there is a very strong positive attitude toward pharmacotherapy in Iran. In contrast with other studies [4,13,23], which report that a combination of pharmacotherapy and psychotherapy is associated with lower rates of dropout, pharmacotherapy alone was associated with lower rates of dropout in our study. However, further research is recommended in order to provide a better understanding of the reasons patients drop out of psychotherapy in Iran. In the current study, significant differences existed between primary and secondary dropouts with respect to the reason(s) for drop out. Reasons commonly reported in the primary dropout group (i.e., economic difficulties and lack of confidence in therapist ability) are two different types of reasons for dropping out. The first reason (economic difficulties) is not particularly specific reason and may be observed among many other patients who have dropped out of treatment. But the second reason (lack of confidence to therapist ability) seems to be specific one. Further research is recommended to examine how patients who did not have any experience with psychotherapy, expressed lack of confidence to therapist ability as a reason for dropping out of treatment. However, secondary dropouts typically reported a lack of confidence in therapist ability and efficacy of treatment as reasons for dropping out, an especially noteworthy finding. Findings from previous research indicate that the most commonly reported reasons for dropping out of treatment after the initial consult include patient perception of and assumption about treatment, the therapeutic relationship, the presence of personality disorders and younger age [4,10,20]. It is unclear whether lack of confidence in therapist ability and efficacy of treatment is relevant to patient characteristics or to therapist characteristics. Additional research examining patient satisfaction using standardized measures may allow for a more precise assessment of reasons for dropping out of psychotherapy. On the other hand, improvement of therapists' abilities through continued education and specified workshops may be useful in reducing rates of dropouts in psychotherapy. In conclusion, the current study measured rates of dropouts among outpatients receiving psychiatric treatment in Kermanshah, Iran. There are several implications for the aforementioned results. These results illustrate that patients' characteristics, psychiatric diagnosis and type of psychiatric treatment are important contributing factors for predicting dropout. With regard to the important patient characteristics identified in the current study (i.e., gender, marital status, education, occupation and previous history of contact with psychiatric services), psychiatric service providers should consider strategies for motivating patients who may be prone to drop out to actively participate in treatment. Family education and nongovernment organization involvement may be helpful strategies.
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Additionally, patients with psychiatric diagnoses, who may have higher tendency toward dropping out of treatment, should be provided with specific consideration in treatment programs. Finally, given that psychotherapy is considered an effective treatment for psychiatric patients, participation in psychotherapy should continue to be assessed and reasons for drop out should be further studied using standardized measures. Obviously, it is very difficult and challenging to eliminate cultural barriers of psychotherapy. However, this issue should not be overlooked. The current study should be seen in light of some limitations. First, our study included only private psychiatric offices in Kermanshah city; therefore, the results cannot be generalized to other psychiatric services in the Kermanshah Province. Secondly, we did not follow patients who were referred to psychiatric services in other provinces. Thirdly, we did not have access to a standardized questionnaire to collect reasons for drop out. Finally, basic information about other predictors of dropout such as distance from delivery service and quality of service delivery in private offices was not available. Thus, further research considering these limitations is recommended. References [1] Olfson M, Marcus SC, Druss B, Elinson L, Tanielian T, Pincus HA. National trends in the outpatient treatment of depression. JAMA 2002;287:203-9. [2] Moreno C, Laje G, Blanco C, Jiang H, Schmidt AB, Olfson M. National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry 2007;64:1032. [3] McIvor R, Ek E, Carson J. Non-attendance rates among patients attending different grades of psychiatrist and a clinical psychologist within a community mental health clinic. Psychiat Bull 2004;28:5-7. [4] Barrett MS, Chua WJ, Crits-Christoph P, Gibbons MB, Thompson D. Early withdrawal from mental health treatment: implications for psychotherapy practice. Psychother Theor Res Pract Train 2008;45:247-67. [5] Mitchell AJ, Selmes T. Why don't patients attend their appointments? Maintaining engagement with psychiatric services. Adv Psychiatr Treat 2007;13:423-34. [6] Centorrino F, Hernán MA, Drago-Ferrante G, Rendall M, Apicella A, Längar G, et al. Factors associated with noncompliance with psychiatric outpatient visits. Psychiatr Serv 2001;52:378-80. [7] Garcia JA, Weisz JR. When youth mental health care stops: therapeutic relationship problems and other reasons for ending youth outpatient treatment. J Consult Clin Psych 2002;70:439.
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[8] Killaspy H, Banerjee S, King M, Lloyd M. Non-attendance at psychiatric outpatient clinics: communication and implications for primary care. Br J Gen Pract 1999;49: 880. [9] Killaspy H, Banerjee S, King M, Lloyd M. Prospective controlled study of psychiatric out-patient non-attendance. Br J Gen Pract 2000;176:160-5. [10] Rossi A, Amaddeo F, Bisoffi G, Ruggeri M, Thornicroft G, Tansella M. Dropping out of care: inappropriate terminations of contact with community-based psychiatric services. Br J Gen Pract 2002;181:331-8. [11] Reneses B, Muñoz E, López-Ibor JJ. Factors predicting drop-out in community mental health centres. World Psychiatry 2009;8:173. [12] Issakidis C, Andrews G. Pretreatment attrition and dropout in an outpatient clinic for anxiety disorders. Acta Psychiat Scand 2004;109:426-33. [13] Berghofer G, Schmidl F, Rudas S, Steiner E, Schmitz M. Predictors of treatment discontinuity in outpatient mental health care. Soc Psych Psych Epid 2002;37: 276-82. [14] Ahmadi J, Babaee-Beigi M, Alishahi M, Maany I, Hidari T. Twelve-month maintenance treatment of opium-dependent patients. J Subst Abuse Treat 2004; 26:61-4. [15] Ahmadi J, Kampman KM, Oslin DM, Pettinati HM, Dackis C, Sparkman T. Predictors of treatment outcome in outpatient cocaine and alcohol dependence treatment. Am J Addict 2009;18:81-6. [16] Akuchekian S, Amanat S. The comparison of topiramate and placebo in the treatment of posttraumatic stress disorder: a randomized, double-blind study. J Res Med Sci 2004;9:240-4. [17] Assadi SM, Radgoodarzi R, Ahmadi-Abhari SA. Baclofen for maintenance treatment of opioid dependence: a randomized double-blind placebo-controlled clinical trial [ISRCTN32121581]. BMC Psychiatry 2003;3:16. [18] Killaspy H. Why do psychiatrists have difficulty disengaging with the out-patient clinic? Invited commentary on…Why don't patients attend their appointments? Adv Psychiatr Treat 2007;13:435-7. [19] Sirey JA, Bruce ML, Alexopoulos GS, Perlick DA, Raue P, Friedman SJ, et al. Perceived stigma as a predictor of treatment discontinuation in young and older outpatients with depression. Am J Psychiatr 2001;158:479-81. [20] Johansson H, Eklund M. Helping alliance and early dropout from psychiatric outpatient care. Soc Psych Psych Epid 2006;41:140-7. [21] Rhodes AE, Goering PN, To T, Williams JI. Gender and outpatient mental health service use. Soc Sci Med 2002;54:1–10. [22] Oosterbeek M. Differences between dropout rates and possible predictors for dropout in Turkish, Moroccan and Iranian minority groups in an outpatient setting in the Netherlands. Unpiblished manuscript, Faculty of Social and Behavioural Theses, Utrecht University, Utrecht, Netherlands 2011. [23] Kessler RC, Berglund PA, Bruce ML, Koch JR, Laska EM, Leaf PJ, et al. The prevalence and correlates of untreated serious mental illness. Health Serv Res 2001;36:987. [24] Edlund MJ, Wang PS, Berglund PA, Katz SJ, Lin E, Kessler RC. Dropping out of mental health treatment: patterns and predictors among epidemiological survey respondents in the United States and Ontario. Am J Psychiatr 2002; 159:845-51.