Association of Patient Treatment Preference With Dropout and Clinical Outcomes in Adult Psychosocial Mental Health Interventions: A Systematic Review and Meta-analysis

Abstract

Importance: Receiving a preferred treatment has previously been associated with lower dropout rates and better clinical outcomes, but this scenario has not been investigated specifically for psychosocial interventions for patients with a mental health diagnosis.

Objective: To assess the association of patient treatment preference with dropout and clinical outcomes in adult psychosocial mental health interventions via a systematic review and meta-analysis.

Data sources: The Cochrane Library, Embase, PubMed, PsychINFO, Scopus, Web of Science, Nice HDAS (Healthcare Databases Advanced Search), Google Scholar, BASE (Bielefeld Academic Search Engine), Semantic Scholar, and OpenGrey were searched from inception to July 20, 2018, and updated on June 10, 2019.

Study selection: Studies were eligible if they (1) were a randomized clinical trial; (2) involved participants older than 18 years; (3) involved participants with mental health diagnoses; (4) reported data from a group of participants who received their preferred treatment and a group who received their nonpreferred treatment or who were not given a choice; and (5) offered at least 1 psychosocial intervention.

Data extraction and synthesis: Two researchers extracted study data for attendance, dropout, and clinical outcomes independently. Both assessed the risk of bias according to the Cochrane tool. Data were pooled using random-effects meta-analyses.

Main outcomes and measures: The following 7 outcomes were examined: attendance, dropout, therapeutic alliance, depression and anxiety outcomes, global outcomes, treatment satisfaction, and remission.

Results: A total of 7341 articles were identified, with 34 eligible for inclusion. Twenty-nine articles were included in the meta-analyses comprising 5294 participants. Receiving a preferred psychosocial mental health treatment had a medium positive association with dropout rates (relative risk, 0.62; 0.48-0.80; P < .001; I2 = 44.6%) and therapeutic alliance (Cohen d = 0.48; 0.15-0.82; P = .01; I2 = 20.4%). There was no evidence of a significant association with other outcomes.

Conclusions and relevance: This is the first review, to our knowledge, examining the association of receiving a preferred psychosocial mental health treatment with both engagement and outcomes for patients with a mental health diagnosis. Patients with mental health diagnoses who received their preferred treatment demonstrated a lower dropout rate from treatment and higher therapeutic alliance scores. These findings underline the need to accommodate patient preference in mental health services to maximize treatment uptake and reduce financial costs of premature dropout and disengagement.

Figure 1.. PRISMA Flow Diagram

RCT indicates randomized clinical trial. ^aSome studies reported data that were included in more than 1 of the meta-analyses.

Figure 2.. Forest Plot of Dropout Rates

Weights are from random-effects analysis. The dashed line indicates the overall risk ratio (RR). The size of the squares is proportional to the study’s weight in the meta-analysis. The diamond represents the overall RR, with the edges of the diamond being the 95% CI.

Figure 3.. Forest Plot of Therapeutic Alliance

The dashed line indicates the overall effect size (ES). BLRI indicates Barret-Lennard Relationship Inventory; CALPAS, California Psychotherapy Alliance Scale; and VTAS, Vanderbilt Therapeutic Alliance Scale. The size of the squares is proportional to the study’s weight in the meta-analysis. The diamond represents the overall ES, with the edges of the diamond being the 95% CI.