New Insights on Treatment Refusal of Pharmacotherapy and Psychotherapy

High rates of refusal for mental health treatment may be due to patient skepticism regarding pharmacotherapy according to new research published in the journal Psychotherapy.

The study is a meta-analysis from 186 trials involving thousands of patients that reported on treatment refusal or premature termination of treatment. Overall, the researchers found that the average treatment refusal rate was 8.2%.

They found that patients assigned to pharmacotherapy treatment alone were 1.76 times more likely to refuse treatment than those who were assigned psychotherapy alone. The differences were even starker in patients suffering from depressive, panic, and social anxiety disorders. Those suffering from depressive disorders were 2.16 times more likely to refuse treatment when prescribed pharmacotherapy alone, and patients with panic disorders were almost three times as likely to refuse treatment.

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Additionally, early treatment termination rates were 21.9% overall, with patients prescribed only pharmacotherapy treatments 1.2 times more likely to end treatment early. There were no significant differences in refusal or dropout rates found between prescribing either pharmacotherapy or psychotherapy alone versus a combination treatment.

Accordingto co-author Roger Greenberg, PhD, Professor of Psychology at the State University of New York's Upstate Medical University in Syracuse, these findings are especially interesting because, as a result of easier access, recent trends show that a greater percentage of mental health patients are engaging in pharmacotherapy than psychotherapy in the United States.

The research supports the argument that psychotherapy should be the first treatment option for many mental disorders, Greenberg said, in a statement about the study from the American Psychological Association. “Our findings support that argument, showing that clients are more likely to be willing to start and continue psychotherapy than pharmacotherapy,” he said. 

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Lead researcher Joshua Swift, PhD, of Idaho State University, Pocatello, ID, said in an interview with Drug Topics that "when it comes to mental health problems, what works for one patient may not work for another. That is why I think it is essential for health care providers to describe all of the options to patients. Not only should they mention different options, but education should be given about the pros and cons of both medication and psychotherapy. Then providers can really work with patients to help them weigh the pros and cons and make an informed choice."

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Though the research does not attempt to provide any specific reasons for patients refusing treatment (more research is needed into this), the authors suggest that one of the reasons patients are more likely to accept psychotherapy is due to the perception that their problems may not be entirely biological.

“Patients often desire an opportunity to talk with and work through their problems with a caring individual who might be able to help them better face their emotional experiences,” said Greenberg. “Psychotropic medications may help a lot of people, and I think some do see them as a relatively easy and potentially quick fix, but I think others view their problems as more complex and worry that medications will only provide a temporary or surface level solution for the difficulties they are facing in their lives.”

Swift added that, "Although medication may seem to be an easier fix, I think many who experience mental health problems recognize how complex their problems are and they would like the opportunity to work through their individual experiences with a professional."

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Swift emphasized that having options is important for patients. "I think many patients never attempt psychotherapy because their health care provider never suggested it to them. However, this research indicates that if it is suggested to them, they are more likely to start it and complete it than they are pharmacotherapy," he said. "Previous research has also indicated that psychotherapy is as effective or more effective than pharmacotherapy for many mental health problems. And it doesn't have to be one or the other. A combination of pharmacotherapy and psychotherapy has been shown to be effective for many disorders."

When asked what role pharmacists could play in increasing treatment acceptance, Swift stressed that education is a vital tool. "I believe that most patients' perceptions of drug therapy for mental health problems are based on advertisements," he said. "Pharmacists can provide accurate information about the pros and cons of medications and help patients develop accurate expectations regarding their effectiveness."

Reference: Swift, Joshua K. et al. "Treatment Refusal And Premature Termination In Psychotherapy, Pharmacotherapy, And Their Combination: A Meta-Analysis Of Head-To-Head Comparisons.". Psychotherapy 54.1 (2017): 47-57. Web. 7 Mar. 2017. DOI: 10.1037/pst0000104