Engaging Depressed Patients: An Essential Step in Optimizing Care.

In this issue of the Journal, Dunlop et al. (1) conducted a definitive, 12-week randomized controlled trial with moderately symptomatic, treatment-naive, depressed outpatients that compared well-delivered cognitive-behavioral therapy (CBT), escitalopram, and duloxetine with rater-blinded 17-item Hamilton Depression Rating Scale scores. These “treatment-naive” study patients, recruited largely by advertising, were substantially burdened by illness. About 50% had recurrent major depressive disorder; 30%were in a chronic major depressive episode (greater than 2 years); 7% had previously attempted suicide; and nearly half were unemployed. On average, 10 years had lapsed between the onset of the first major depressive episode and study entry. These features may reflect lack of access (although 50% had insurance), lack of awareness, or fear of treatment or stigmatization by entering treatment. Overall, remission (48%), response (60%), and retention (60%–75%) rates were comparable across the three treatments. The onset of benefit seemed to be a bit slower with CBT than with medications, analogous to other reports (2). Treatment assignment was randomized, but patients expressed their preferences (if any) for medication or psychotherapy before randomization. One-third had no preference, and one-third preferred CBT or medication, respectively. Importantly, minority patients preferred CBT over antidepressant medication (81% for Hispanics; 46% for African Americans). Whether these preferences were due to distrust of medication, those prescribing it, or the desire to talk through problems, was not evaluated. Retention rates, but not remission rates, were related to whether or not the treatment received was matched to patients’ preferences. Whether the type of mismatch affects remission rates is unclear. Those who preferred medication but received CBT (due to the randomization) had only a 33% remission rate; 45%of thosewhopreferredCBTbut received medication reached remission. This numerical difference wasnot statistically significant, possibly due to small samples. Retention rates were higher (82%) for those whose treatment assignment matched their preferences compared with those who were mismatched (68%). This difference (driven by those with moderate to strong preferences) yielded a clinically meaningful number needed to treat of 7, which approximates the magnitude of drug-placebo differences reported in randomized controlled trials conducted for regulatory purposes. Thesefindings argue for the importance of expectations and attitudes, which in turn affect engagement and retention in treatment. Had patients’ preferences first been solicited and then had treatments been assigned to match (or not match) these preferences, results might differ from this observational study. Why would retention but not remission be affected by treatment match/mismatch? Sample sizes might have been too small to detect a differential effect on remission rates. Alternatively, perhaps depressed patients seeking treatment will acceptwhatever is available, but once less depressed and notmatched to their preferred treatment, theirmotivation to continue on may simply wane. These results have implications for care systems, patients, and clinicians. One important implication, especially for depressed, minority public sector patients, is that providing greater access totime-limiteddepressiontargeted therapies might improve patient engagement and retention, as opposed to the nearly universal reliance on a “medication first” approach that may increase the risk of attrition in at least some. Secondly, systems that care for a defined patient population would logically want to reduce attrition from treatment because many depressed patients who drop out, especially thosewithachronicor recurrenthistory,will likely continue to use medical and mental health resources. In the Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) study, patients who dropped out had more severe symptoms of depression and anxiety and more concurrent anxiety disorders at pretreatment, all of which portend a poorer prognosis. Another concern is that the overall outcomes in this acute treatment study are far from what we desire, even in these “treatment-naive” patients. If we regarded patients who completed the 12 weeks of treatment and achieved remission as full successes, then 344 eligible/randomized patients resulted in 234 patients who completed treatment, of whom 109 achieved remission. The 32% success rate (109/344) is The typical several-minute discussion before recommending either medication or therapy is unlikely to affect attitudes, expectations, or preferences.