by Michael D. Anestis, M.S.
One of the tricks of psychotherapy research is ensuring that promising results found in controlled trials actually translate to real world results (click here for an example). In other words, once we can demonstrate that a particular form of treatment is especially helpful for particular conditions within a research laboratory, we need to make sure that, in every day practice, the people in need of help benefit from that treatment as well. Once we do that, we then need to examine how often that treatment is actually being utilized, how well it is being utilized, and, when folks in need are not receiving that (or even any) treatment, why that might be. Unfortunately, the results on that end are not always particularly promising (click here and here for examples). Today, I'd like to discuss a study currently in press at Behavior Therapy, published by Maria Macebo, Jane Eisen, Nicholas Sibrava, Ingrid Dyck, and Steven Rasmussen of Brown University Medical School (Butler Hospital) that addresses these issues very well.
In this particular study, the authors examined treatment utilization, reasons for avoiding particular treatments, and reasons for dropping out of particular treatments for obsessive compulsive disorder (OCD). The authors were particularly interested in learning whether patients with OCD were being advised to utilize the "gold standard" treatment - exposure plus response prevention (EXRP) - and, if so, whether they were actually taking that advice. For those who did not take that advice, they were curious why not. For those who did, but dropped out prior to completing treatment, again they were interested in what influenced that decision.
In total, the authors examined data on 202 patients diagnosed with OCD, collected over the course of a 2-year follow-up. Here's what they found:
Psychopharmacological results:
- 83% of the sample was on a selective serotonin reuptake inhibitor (SSRI) at intake and the majority of those patients continued on an SSRI during the course of the 2-year period.
- Of those receiving psychotropic medication, 90% reported receiving treatment from a psychiatrist, 9% from their primary care physician, and 1% from another professional.
EXRP results (the authors generally referred to cognitive behavioral therapy - CBT - here, so some of these individuals may not have been receiving the true EXRP protocol, as EXRP is a variant of CBT):
- 44% of the sample (89 individuals) received EXRP at some point during the follow-up period
- 53 were already already receiving EXRP, 23 initiated EXRP for the first time during follow-up, and 13 restarted EXRP after previous experience with the treatment
- The average number of EXRP sessions attended by folks who received the treatment was 33.1
- 82% of individuals who received EXRP received treatment from a doctoral-level therapist
- 29% of the individuals who received EXRP (19% of the full sample) received a "full dose" of EXRP, defined as at least 13 weekly sessions.
- 120 participants were advised to seek out EXRP. 26% of those individuals (n = 31) failed to attend any EXRP sessions.
- 31% of the 89 individuals who attended an EXRP session dropped out prematurely, which was significantly higher than some clinical trials (e.g., Franklin et al., 2000) but not others (e.g., Abramowitz et al., 2003).
- Individuals with more severe OCD symptoms were more likely to be advised to seek EXRP and also more likely to initiate EXRP sessions.
Reasons for not initiating EXRP or dropping out early:
- Environmental barriers were the most frequently endorsed reason for not participating in treatment. These include the inability to locate an EXRP provider, lack of funds for treatment, and difficulty scheduling appointments.
- Some individuals endorsed a belief that treatment would not be helpful
- 30% endorsed fear/anxiety about engaging in treatment (e.g., were nervous about exposure exercises designed to induce anxiety in session)
- Environmental barriers were also the most commonly endorsed reason for dropping out of treatment early; however financial reasons no longer factored into the equation, meaning that once an individual enters EXRP treatment, affordability typically is not an issue
- More that 25% endorsed dropping out due to fear/anxiety about treatment.
So what does all of this mean? First of all, it appears that pharmacological treatments are more commonly utilized in the treatment of OCD in particular settings. This is not particularly shocking given that many individuals receiving treatment for mental health concerns first enter the system through medical professionals. This is also not particularly troubling in this case, as SSRI's have been shown to be useful in the treatment of OCD. That being said, what is troubling here is that, even in a sample of individuals recruited from an OCD specialty clinic in an area of the country in which finding clinicians trained in EXRP, many individuals do not receive the "gold standard" treatment, even when advised specifically to do so. As the authors of the study noted, imagine how these results translate to areas of the country in which its hard to find any treatment for mental illness, nevermind evidence-based approaches.
Results like these highlight the difficulties inherent in the process of disseminating evidence-based mental health care within the current system. Individuals in need of help often don't know about the evidence behind particular treatments, are often unswayed by being presented with that evidence (as are many providers not trained in that particular treatment modality), and, even when they are, many have no access to such treatment or have to overcome significant barriers in order to get there.
What do you think is the best solution here? Better education of the public on particular treatments? Wider training of clinicians in evidence-based care? Development and testing of computer-based treatments available online? Acceptance of non-evidence-based treatments?
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Mike Anestis is a psychology resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology department at Florida State University
