تفاوت های بین ترک تحصیل اولیه و اخیر از درمان اختلال وسواس

To examine characteristics of drop-outs from treatment for obsessive–compulsive disorder (OCD), we studied 121 participants who underwent exposure or cognitive treatment, either alone or with fluvoxamine. OCD symptoms were assessed at pre-treatment, post-treatment, and at every session. No differences in attrition were found between treatment conditions. Drop-outs from treatment (n = 31) were divided into early (before session 6) and late (session 6 or after) drop-outs. We found that early drop-outs had more severe OCD symptoms at termination compared to completers, whereas late drop-outs did not differ from treatment completers. Higher levels of depressive symptoms were associated with early drop-outs, and lower levels with completers. These findings suggest that individuals with high levels of pretreatment depression are at risk for early drop-out with elevated OCD symptoms. Conversly, late drop-outs may be treatment responders who drop out after experiencing substantial improvement. Implications for allocation of resources for attrition prevention are discussed.

Obsessive–compulsive disorder (OCD) is a common and debilitating psychological disorder experienced by 1.5–3% of the population (Bebbington, 1998 and Stein et al., 1997). Individuals with OCD experience impairments in general functioning and poor quality of life (Koran, 2000 and Norberg et al., 2008) as well as interpersonal problems and marital distress (Emmelkamp et al., 1990 and Riggs et al., 1992). Effective treatments for OCD include cognitive-behavior treatment (CBT) or pharmacotherapy (Eddy et al., 2004, Fineberg and Gale, 2005, Kobak et al., 1998 and Rosa-Alcázar et al., 2008), with both treatments being equally effective (Kobak et al., 1998 and Rosa-Alcázar et al., 2008). As is the case with other anxiety disorders, many individuals drop out prematurely from treatments for OCD. Individuals who drop out of treatment usually do so unilaterally, without agreement of the clinician, by not arriving at scheduled sessions (Pekarik, 1985). Moreover, some individuals do not even begin treatment and drop out before its inception (Hofmann et al., 1998). Mean attrition rates for cognitive-behavior therapy (CBT) of OCD are 13–27% (Abramowitz, 1997, Foa et al., 2005, Kobak et al., 1998 and Taylor et al., 2003), and pharmacological treatments report comparable attrition rates (19–25%; Abramowitz, 1997 and Kobak et al., 1998). Thus, attrition is a common and substantial phenomenon in CBT and pharmacotherapy for OCD. Attrition can have many adverse effects (Ogrodniczuk, Joyce, & Piper, 2005). It can lead to reduced treatment efficacy (Clarkin & Levy, 2004), and loss of therapist hours (Pekarik, 1985), both of which have a negative effect on overall cost-effectiveness (April & Nicholas, 1996). Attrition can also affect the treating clinician, leading to feelings of failure which reduce clinician self-confidence and effectiveness (Ogrodniczuk et al., 2005). Finally, it can complicate the interpretation of results from treatment studies, as treatment completers may not be representative of treatment seekers (Westen, Novotny, & Thompson-Brenner, 2004), especially if drop-outs systematically differ from completers on clinically relevant variables (Little & Rubin, 1989). Due to these pernicious effects, many strategies for reducing and minimizing attrition have been suggested (see Ogrodniczuk et al., 2005 for a review). Recent studies have examined differences between drop-outs and completers in treatments for anxiety disorders. For instance, Hofmann and Suvak (2006) followed individuals receiving CBT for social anxiety disorder and compared drop-outs (n = 34) with treatment completers (n = 99). No differences were found on demographic characteristics, clinical measures, or AXIS-I and II symptomatology. The only difference found was that drop-outs rated the treatment rationale as less logical than completers, and this difference was no longer significant after adjusting for multiple group comparisons. Similarly, Keijsers, Kampman, and Hoogduin (2001) compared drop-outs and completers in CBT for panic disorder and found differences only in education level and motivation. However, differences were very small in magnitude and the authors concluded they could not reliably differentiate completers and drop-outs. Only a single study focused on attrition in the treatment of OCD (Hansen, Hoogduin, Schaap, & de Haan, 1992). In this study, the authors contacted 25 drop-outs, 2–7 years after treatment. Results could be obtained from 15 of the drop-outs (60%) who were matched with a group of 15 completers. The authors found that drop-outs had fewer OCD symptoms at intake, and experienced less anxiety during exposures, compared to treatment completers. However, it is difficult to interpret the results of this study due to the small sample size, high refusal rate (40%), and retrospective assessment (2–7 years after treatment). It is important to note that the majority of recent treatment studies in OCD report no differences between completers and drop-outs on pre-treatment measures (e.g., Foa et al., 2005 and Taylor et al., 2003). To our knowledge, differences on OCD symptoms at the time of treatment termination between drop-outs and completers have not been investigated. Although attrition has generally been regarded as a negative phenomenon, there is some evidence that certain drop-outs experience significant improvement before dropping out (April and Nicholas, 1996, Manthei, 1995 and Pekarik, 1983b). Along these lines, Pekarik (1992) found that individuals who dropped-out late in the course of treatment improved considerably and were highly similar to completers whereas individuals who dropped-out early experienced aggravation or improved to a lesser extent. Thus, the timing of attrition may be related to different trajectories of change within treatment. In the present study we examined whether time of dropout (i.e., early vs. late in treatment) was associated with OCD symptomatology. Based on Pekarik (1992) we hypothesized that early drop-outs will have elevated OCD symptoms compared to late drop-outs and to completers at the time of treatment termination. We also wanted to explore whether pre-treatment measures could predict early and late drop-out.