Treatment preference, engagement, and clinical improvement in pharmacotherapy versus psychotherapy for depression

Abstract

Pharmacotherapy and psychotherapy are generally effective treatments for major depressive disorder (MDD); however, research suggests that patient preferences may influence outcomes. We examined the effects of treatment preference on attrition, therapeutic alliance, and change in depressive severity in a longitudinal randomized clinical trial comparing pharmacotherapy and psychotherapy. Prior to randomization, 106 individuals with MDD reported whether they preferred psychotherapy, antidepressant medication, or had no preference. A mismatch between preferred and actual treatment was associated with greater likelihood of attrition, fewer expected visits attended, and a less positive working alliance at session 2. There was a significant indirect effect of preference match on depression outcomes, primarily via effects of attendance. These findings highlight the importance of addressing patient preferences, particularly in regard to patient engagement, in the treatment of MDD.

Figure 1

Failure to start or complete treatment by preference match

Figure 2

Client- and Therapist-rated Session 2 WAI scores by preference match

Figure 3

Changes in depression severity by preference match. Note: Means at each time point were calculated based on the results of multilevel modeling.

Figure 4

Testing indirect effects of preference match on changes in HRSD scores. Paths represented with dashed lines were specified but not significant. Covariances between the preference match codes, between the mediators, and between HRSD slope and intercept were specified but not shown for clarity of presentation. *p < .05, ** p < .01