The therapeutic alliance and therapist adherence as predictors of dropout from cognitive therapy for depression when combined with antidepressant medication

Abstract

Background: Previous psychotherapy research has examined the therapeutic alliance and therapist adherence as correlates or predictors of symptom change. While some initial evidence suggests the alliance is associated with risk of dropout in cognitive behavioral treatment for depression, evidence of such relations has been limited to date. We examined the relation of these psychotherapy process variables and dropout in the context of cognitive therapy for depression when provided in combination with pharmacotherapy.

Methods: Patients were randomized to the CT plus pharmacotherapy condition of a clinical trial for chronic or recurrent depression. Consistent with the spirit of personalized medicine, patients were treated until they met remission and recovery criteria (or reached the maximum allowable time in the study). In a sample of 176 patients, we examined observer-rated alliance and therapist adherence in the first three CT sessions as potential predictors of treatment dropout.

Results: The therapeutic alliance and one facet of therapist adherence (i.e., Behavioral Methods/Homework) predicted reduced odds of dropout. Therapist use of Negotiating/Structuring predicted greater likelihood of dropout, but only when other variables were included in the model.

Limitations: Process ratings were not available for concurrent pharmacotherapy sessions. A minority of patients did not have session recordings available.

Conclusions: Results are consistent with the possibility that the therapeutic alliance and therapists' focus on homework and behavioral methods promote treatment retention in combined treatment for depression.

Keywords: Adherence; Alliance; Cognitive therapy; Depression; Dropout.