پیش بینی رضایت از درمان در میان افراد مسن مضطرب در برنامه مراقبت های اولیه روانشناسی

Increasing numbers of patients are treated in integrated primary care mental health programs. The current study examined predictors of satisfaction with treatment in patients from a randomized clinical trial of late-life generalized anxiety disorder (GAD) in primary care. Higher treatment satisfaction was associated with receiving CBT rather than enhanced usual care. Treatment credibility, treatment expectancies, social support, and improvements in depression and anxiety symptoms predicted higher treatment satisfaction in the total sample. In the CBT group, only credibility and adherence with treatment predicted satisfaction. This suggests that older patients receiving CBT who believe more strongly in the treatment rationale and follow the therapist's recommendations more closely are likely to report satisfaction at the end of treatment. In addition, this study found that adherence mediated the relationship between treatment credibility and treatment satisfaction. In other words, patients’ perceptions that the treatment made sense for them led to greater treatment adherence which then increased their satisfaction with treatment.

Spurred by several influential healthcare policy statements recommending integrated primary care mental health programs (IOM, 2006 and WHO, 2008), increasing numbers of patients are being treated in these settings. Although there are many models for integrated programs, they generally involve primary care providers and behavioral health specialists working collaboratively to manage mental health conditions. Research suggests that these programs improve anxiety, depression (Roy-Byrne et al., 2005, Roy-Byrne et al., 2010 and Rollman et al., 2009), treatment attendance, and patient satisfaction (Katon et al., 1995 and Roy-Byrne et al., 2005). Such programs also improve generalized anxiety in older adults (Stanley et al., 2003, 2009) and depression in older adults (Unutzer et al., 2002). Older adults in particular are likely to be more satisfied with integrated mental health services rather than referrals to specialty mental health services (Chen et al., 2006), potentially due to the stigma of receiving care in specialty mental health services (Corrigan, 2004) and older adults’ greater burden of chronic illness (Druss & von Esenwein, 2006). Although research suggests that these programs improve patient satisfaction, less research examines the variables that predict patient satisfaction in such programs. Patient satisfaction with treatment is an important component of program evaluation. Although satisfaction with psychotherapy is not always highly correlated with outcome (Ankuta and Abeles, 1993 and Lambert et al., 1998), it may be important because satisfied patients may be more likely to return for future treatment, increasing rates of engagement in therapy (Sun, Adams, Orav, Rucker, Brennan, & Burstin, 2000). Additionally, satisfied patients may be more likely to recommend treatment to others (Lee, 2005) and to speak highly of their experiences, potentially improving the public's perceptions of the helpfulness of therapy and reducing the stigma of seeking psychological help. In medical care, patient satisfaction is considered an important outcome in itself (Cleary & McNeil, 1988) and the Joint Commission and the National Committee for Quality Assurance both assess patient satisfaction a marker of quality care (NCQA, 2011 and Joint Commission, 2010). Theories of patient satisfaction emphasize the roles of improvement in functioning and treatment expectations. Two different types of expectancies exist: outcome expectancies, or positive expectations for the helpfulness of treatment, and treatment expectations, or the degree to which the care meets patients’ expectations about what care will be like (reviewed in Constantino, Glass, Arnkoff, Ametrano, & Smith, 2011). Some theories state that satisfaction is determined by the degree to which patients hold positive expectations for the helpfulness of treatment (Linder-Pelz, 1982 and Ware et al., 1983) whereas others emphasize the degree to which the care meets patients’ expectations about care (Fitzpatrick, 1984, Linder-Pelz, 1982, Ware et al., 1983 and Williams, 1994). Another hypothesized predictor of satisfaction is quality of care and clinical improvement from care (Fitzpatrick, 1984, Linder-Pelz, 1982 and Ware et al., 1983). Finally, theories emphasize the importance of patients feeling their emotional needs have been met by interactions with providers (Fitzpatrick, 1984). Although theories of patient satisfaction do not propose an association between patients’ adherence with treatment and satisfaction, there are several reasons to believe it exists: (1) patients who adhere more closely to treatment may obtain more benefit from treatment and therefore be more satisfied, (2) patients who adhere more closely to treatment may experience cognitive dissonance (Festinger & Carlsmith, 1959) if they expended a great deal of effort on adhering to a treatment that they were not satisfied with, motivating them to reappraise their satisfaction level, or (3) early satisfaction with treatment may lead to continued “buy-in” and greater adherence later in treatment. Consistent with theories of treatment satisfaction, positive treatment expectancies predict greater satisfaction with treatment among students attending therapy at a university counseling center (Greenfield, 1983), patients in a short-term psychiatric inpatient unit (Hansson & Berglund, 1987) and youth receiving therapy in a community based outpatient clinic (Garland, Haine, & Lewczyk Boxmeyer, 2007). Symptom improvement sometimes predicts treatment satisfaction (Deane, 1993, Hasler et al., 2004 and Propst et al., 1994), with associated correlations ranging from r = .35 (Attkisson & Zwick, 1982) to r = .53 (Calsyn, Morse, Klinkenberg, Yonker, & Trusty, 2002), although other research suggests no relationship between symptom improvement and satisfaction (e.g., Lambert et al., 1998). Finally, although little research examined the effect of adherence on satisfaction in psychotherapy, some studies found that adherence predicts treatment satisfaction for substance abusing patients ( Dearing et al., 2005 and Hawkins et al., 2008). Additionally, adherence to psychiatric medication regimens is associated with greater treatment satisfaction (e.g., Katon et al., 1996). Overall, the literature on predictors of satisfaction with mental health treatment suggests that expectancies, symptom improvement, and adherence may predict satisfaction. Research on predictors of satisfaction with mental health treatment has focused primarily on younger adults in traditional mental health settings. However, the variables that predict satisfaction may be different in older adults and in integrated primary care programs. For example, older adults are less likely to perceive the need for mental health services (Karlin, Duffy, & Gleaves, 2008) and may be less psychologically minded (e.g., Burgmer & Heuft, 2004), indicating that the role of expectancies may be different. Although older adults report high levels of satisfaction with mental health treatment (Lippens & Mackenzie, 2011), not all psychosocial treatments have as large an effect for older adults (e.g., Wolitzky-Taylor, Castriotta, Lenze, Stanley, & Craske, 2010), so the role of clinical improvement may differ. Previous research on the predictors of satisfaction with psychiatric services in this age group has indicated that, consistent with findings in younger adults, treatment attendance and clinical improvement are important (Chen et al., 2006). Another study examined predictors of satisfaction with overall mental health services including services received from psychiatrists, family doctors, social workers, and psychologists. This study found that social support was associated with greater treatment satisfaction whereas demographic variables, chronic health conditions, and initial psychological distress were not (Lippens & Mackenzie, 2011). Finally, personality characteristics such as agreeableness and neuroticism have been found to predict older adults’ satisfaction with psychotherapy (Green, Hadjistavropoulos, & Sharpe, 2008). Overall, more research is needed on the predictors of older adults’ satisfaction with primary care mental health programs. The current study examined the predictors of satisfaction with cognitive-behavioral treatment in patients from a randomized clinical trial of late-life generalized anxiety disorder (GAD) in primary care (Stanley et al., 2009). We examined patients receiving CBT with GAD because it is the most common anxiety disorder in elderly individuals presenting to primary care, with prevalence rates ranging from 1 to 7.3%, and CBT is a well established as a treatment for late-life anxiety (Wolitzky-Taylor et al., 2010). We predicted that, consistent with theories of patient satisfaction (e.g., Linder-Pelz, 1982, Ware et al., 1983 and Williams, 1994) symptom improvement, positive treatment outcome expectancies, treatment credibility, and adherence to treatment would predict treatment satisfaction. Although theories of treatment satisfaction do not address the role of social support in predicting treatment satisfaction, a previous study with older adults did find an effect (Lippens & Mackenzie, 2011) and we believe that poorer social support may indicate difficulty with interpersonal relationships that may interfere with developing a satisfying therapeutic relationship and benefitting from treatment. Therefore, we also predicted that social support would be positively associated with satisfaction. Finally, we hypothesized that positive treatment credibility for CBT may lead to greater adherence to treatment which may in turn lead to greater satisfaction.

These results suggest that in order to maximize patient satisfaction with integrated treatments for primary care, programs should focus on improving treatment credibility by providing strong a rationale for the treatments provided and encouraging adherence throughout treatment.