A review of studies concerning treatment adherence of patients with anxiety disorders

Figures & data

Table 1 Studies that investigate adherence to treatment for anxiety disorders in general

Study	Design	N	Type of treatment	Instrument	Attrition/dropout rate	Clinical predictors of adherence	Sociodemographic predictors of adherence	Cognitive predictors of adherence
Hunt and Andrews^Citation8	Naturalistic study	432	CBT	SCL-90 and EPI	17.0% dropout	Absent	Absent	Not evaluated
Wingerson et al^Citation7	Controlled clinical trial	112	Benzodiazepines; 5HT reuptake blockers and 5HT1A agonists	CGI and TPQ	40.0% dropout	Personality traits involving search for novelty reduced adherence.	Absent	Not evaluated
Issakidis and Andrews^Citation4	Naturalistic study	731	CBT, mostly in group	DASS, FQ, ACQ, BSQ, SPS, SPIS, PSWQ, and MOSSF-12	30.4% attrition and 10.3% dropout	A primary diagnosis different from panic disorder, the presence of depressive symptoms, and an offer of group treatment reduced adherence in the pre-treatment phase. Patients who had reported less severe psychiatric symptoms but with greater effects on physical health and more severe depressive symptoms adhered to treatment less than patients without these traits.	The presence of at least one child and an indication of treatment from a general clinic reduced adherence in the pre-treatment phase. Women adhered to treatment less than men.	Not evaluated
Stein et al^Citation9	Retrospective study	13,085	Serotonin reuptake inhibitors; serotonin-norepinephrine reuptake inhibitors	Charlson index	57.0% dropout	Patients without comorbid depression or a history of specialized treatment adhered less than those with these qualities.	Absent	Not evaluated

Abbreviations: 5HT, 5-hydroxytryptamine; ACQ, Agoraphobic Cognitions Questionnaire; BSQ, Body Sensations Questionnaire; CBT, cognitive-behavior therapy; FQ, Fear Questionnaire; CGI, Clinical Global Impression; SCL-90, Symptom Checklist-90; EPI, Eysenck Personality Inventory; TPQ, Tridimensional Personality Questionnaire; DASS, Depression, Anxiety and Stress Scale; SPS, Social Phobia Scale; SPIS, Social Phobia Interaction Scale; PSWQ, Penn State Worry Questionnaire; MOSSF-12, Medical Outcome Study Short Form 12.

Table 2 Studies that investigate treatment adherence for panic disorder

Study	Design	N	Type of treatment	Instrument	Attrition/dropout rate	Clinical predictors of adherence	Sociodemographic predictors of adherence	Cognitive predictors of adherence
Carter et al^Citation11	Open study	31	CBT in group accompanied by partner	ADIS-R, MI, STAI, BAI, BDI, ACQ, BSQ, DAS, MCIC, TNQ, and ATT	26.0% dropout	Absent	Absent	Patients who reported problems at the beginning of the sessions, whose partner did not wish to continue accompanying the patient to treatment, and who did not like CBT adhered less than those without these conditions.
Grilo et al^Citation6	Controlled clinical trial	162	CBT (ie, panic control therapy), imipramine, placebo, or combined treatments	ADIS-R, ASI, HMA, HMD, PAEQ, EMQ, and WCCL	24.7% dropout	Patients with more sensitivity to anxiety and low agoraphobic avoidance adhered less than those without these traits.	Patients with low family incomes, less education and who had undergone a prior treatment adhered less than those without these traits.	Patients who attributed their illness to stress or age, whose attitudes were less favorable to their specific treatment, and who presented a coping style for anxious situations based on the search for social support in accordance with responses to the WCCL adhered less than those without these conditions.
Hofmann et al^Citation18	Controlled clinical trial	628	CBT (ie, panic control therapy), imipramine, combined treatments, or placebo.	ADIS-R and SCID	48.6% attrition	Not evaluated	Not evaluated	Patients who did not want to take or interrupt their current medication adhered less than those who were willing to do so.
Keijsers et al^Citation17	Open study	161	CBT (panic control therapy)	NML-2, PDQ-R, ACQ, and MI	19.9% dropout	Absent	Patients with less education adhered less than those with more education.	Patients who were less motivated adhered less than those who were more motivated.
Toni et al^Citation5	Naturalistic study	326	Imipramine, clomipramine, or paroxetine	SCID, PDAI, and LIFE-UP	54.9% dropout	Less severe illness reduced treatment adherence.	Absent	Not evaluated

Abbreviations: CBT, cognitive-behavior therapy; ADIS-R: Anxiety Disorders Interview Schedule-Revised; MI, Mobility Inventory; STAI, State-Trait Anxiety Inventory; BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; ACQ, Agoraphobic Cognitions Questionnaire; BSQ, Body Sensations Questionnaire; DAS, Dyadic Adjustment Scale; MCIC, Modified Couples Interaction Checklist; TNQ, Treatment Non-completer Questionnaire; ATT, Attitudes Toward Treatment; ASI, The Anxiety Sensitive Index; HMA, Hamilton Anxiety Rating Scale; HMD, Hamilton Rating Scale for Depression; PAEQ, Patients’ Attitudes and Expectations Questionnaire; EMQ, Etiological Model Questionnaire; WCCL, The Ways of Coping Checklist; SCID, Structured Clinical Interview for DSM-II-R; PDAI, Panic Disorder-Agoraphobic Interview; LIFE-UP, Longitudinal Interview Follow-up Examination; NML-2, Nijmegen Motivation Questionnaire-2; PDQ-R, Personality Diagnostic Questionnaire-Revised.

Table 3 Studies that investigate treatment adherence in patients with SAD

Study	Design	N	Type of treatment	Instrument	Attrition/dropout rate	Clinical predictors of adherence	Sociodemographic predictors of adherence	Cognitive predictors of adherence
Turner et al^Citation15	Controlled clinical trial	84	Behavioral therapy (ie, inundation), atenolol, or placebo pill	ADIS-R, SCID-II, SPAI, SADS, FNE, FQ, STAI; HMA, CGI, SUDS, and SIST	15.5% attrition and 12.7% dropout	Patients with lower clinical severity scale scores and functional levels on the ADIS-R adhered less in the pre-treatment phase compared with those without these qualities. During treatment, patients who had lower disease severity scores on the STAI adhered less than patients with higher scores.	Absent	Not evaluated
Coles et al^Citation2	Controlled clinical trial and open study	395	CBT in group, phenelzine or placebo and CBT in group	ADIS-IV-L, GAF, BFNE, SIAS, SPS, BDI, LSRDS, and QOLI	85.0% attrition	Absent	Absent	Not evaluated
Hofmann and Suvak^Citation16	Controlled clinical trial	133	Behavioral therapy in group (ie, live exposure, video feedback, and instructive training; CBT in group (ie, cognitive restructuring and exposure).	ADIS-IV, SPAI, BDI, and PDQ-IV	25.6% dropout	Absent	Absent	Patients who considered the treatment to be less logical adhered less than those who did not share this thought.

Abbreviations: CBT, cognitive-behavior therapy; SAD, social anxiety disorder; ADIS-R, Anxiety Disorders Interview Schedule-Revised; MI, Mobility Inventory; STAI, State-Trait Anxiety Inventory; BDI, Beck Depression Inventory; HMA, Hamilton Anxiety Rating Scale; SCID, Structured Clinical Interview for DSM-II-R; PDQ-R, Personality Diagnostic Questionnaire-Revised; SADS, Social Avoidance and Distress Scale; FNE, Fear of Negative Evaluation Scale; FQ, Fear Questionnaire; CGI, Clinical Global Impression; SUDS, Subjective Units of Distress Scale; SIST, Social Interaction Self-Statement Test; ADIS-IV-L, Anxiety Disorders Interview Schedule for DSM-IV-Lifetime Version; GAF, The Global Assessment of Functioning; BFNE, The Brief Fear of Negative Evaluation Scale; SIAS, The Social Interaction Anxiety Scale; SPS, Social Phobia Scale; LSRDS, The Liebowitz Self-Rated Disability Scale; QOLI, Quality of Life Inventory; SPAI, Social Phobia and Anxiety Inventory.

Table 4 Studies that investigate treatment adherence in patients with OCD

Study	Design	N	Type of treatment	Instrument	Attrition/dropout rate	Clinical predictors of adherence	Sociodemographic predictors of adherence	Cognitive predictors of adherence
Hansen et al^Citation12	Naturalistic study	30	Behavioral therapy (exposure and response prevention)	CTRT, LOI, and PDQ-R	Not evaluated	Patients with less severe disease adhered less than those with more severe diseases.	Absent	Patients whose expectations were not met by the therapy, who had a critical relationship with their therapist, who had less anxiety regarding household tasks, and who felt less pressure from those close to them to continue treatment adhered less than those without these conditions.
Mataix-Cols et al^Citation10	Controlled clinical trial	153	Behavioral therapy (exposure and response prevention) guided by computer and a manual; behavioral therapy (exposure and response prevention) guided by a therapist or relaxation guided by an audiotape.	Y-BOCS and HRSD	17% dropout	Patients with obsessions, hoarding compulsions, or both adhered less than those without these traits.	Not evaluated	Not evaluated
Mancebo et al^Citation14	Naturalistic study	80	CBT (unspecified); or medications (unspecified in the study)	SCID-P, Y-BOCS, MHRSD, ADQ, and TAS-P	57% of patients did not adhere to medication (as evaluated by the interruption of medication or the reduction of the dose prescribed but who did not dropout per se) and 28% of patients dropped out from CBT	Patients who described side effects, who were anxious or fearful toward their medication, and who had depressive symptoms adhered to medication less than those who did not have these qualities. Patients with more severe obsessive-compulsive or depressive symptoms and who felt anxious or fearful about participating in therapy adhered less to CBT compared with those without these traits.	Absent	Patients who reported that they did not see the usefulness of their medication adhered less to medication than those who did see its usefulness. Patients who perceived environmental barriers such as lack of time, money to pay for therapy or the availability of therapy at any moment adhered to CBT less than patients without these qualities.
Santana et al^Citation13	Naturalistic study	223	Different classes of antidepressants (primarily selective serotonin reuptake inhibitors), atypical antipsychotics and/or benzodiazepines	SCID, Y-BOCS and CGI	Not evaluated	Patients who did not have comorbid major depression adhered less than those who had depression.	Patients with more education, who were economically active, and resided in areas distant from the clinic adhered less than patients who did not share these qualities.	Not evaluated

Abbreviations: CBT, cognitive-behavior therapy; OCD, obsessive-compulsive disorder; PDQ-R, Personality Diagnostic Questionnaire-Revised; CGI, Clinical Global Impression; CTRT, Criticism of Treatment and/or Reason for Termination; LOI, Leyton Obsessional Card Inventory; SCID-P, Structured Clinical Interview for DSM-IV – Patient Version; Y-BOCS, Yale-Brown Obsessive-Compulsive Scale; MHRSD, Modified Hamilton Rating Scale for Depression; ADQ, Adherence Determinants Questionnaire; TAS-P, Treatment Adherence Survey – Patient Version; HRSD: Hamilton Rating Scale for Depression.

Table 5 Sociodemographic, clinical, and cognitive predictors of treatment adherence in anxiety disorders and the number of studies assessing them

	Potential predictor	Number of studies	Positive correlation with dropout/attrition	Negative correlation with dropout/attrition
Sociodemographic aspects
Anxiety disorders in general	Age	14	1	–
	Female sex	14	1	–
	Education level	9	1	3
	Lower socioeconomic level	6	1	1
Clinical aspects
Anxiety disorders in general	Severity of anxiety symptoms	3	–	1
	Comorbidities	3	1	1
	Personality factors	2	1	–
Panic disorder	Severity of panic symptoms	4	1	1
	Comorbidities	2	–	–
	Personality factors	3	–	–
SAD	Severity of SAD symptoms	3	–	1
	Comorbidities	3	–	–
	Personality factors	2	–	–
OCD	Severity of OCD symptoms	4	2	1
	Comorbidities	2	1	1
	Personality factors	1	–	–
Cognitive aspects
Panic disorder		4	4	–
SAD		1	1	–
OCD		2	2	–

Abbreviations: OCD, obsessive-compulsive disorder; SAD, social anxiety disorder.

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