Introduction:
Common mental disorders (CMDs) such as depression and anxiety affect about 10%-15% of the general population resulting in significant disability and burden (1,2). Despite being recognized and recommended as the first line of intervention in many CMDs (3,4), the application of evidence based psychological treatments is suboptimal (5). Only a minority of patients referred for psychological interventions ever enter treatment (6-8). Moreover, attrition in psychotherapy is common and has attracted significant research attention as a factor influencing treatment outcomes (9,10). These observations highlight the need to look beyond the effectiveness of an intervention in order to understand various factors that may influence its utilization in healthcare settings. These factors can operate at multiple levels such as individual, treatment provider, organizational and policy level in addition to the sociocultural contexts (11,12). The present study focuses on examining one such factor namely, treatment acceptability. Treatment acceptability is defined as "the judgments about the treatment procedures by non-professionals, laypersons, clients, and other potential consumers of treatments" (13). The last decade has witnessed an increased interest in exploring treatment acceptability in complex interventions (14,15). Successful implementation of an intervention depends on its acceptability to both the professionals delivering the interventions and recipients (e.g. patients) (16,17). Acceptability is seen as both, a static and dynamic concept as its perception may change with the actual experience of the intervention (18,19).
Available literature suggests that the most acceptable interventions are those that are least restrictive, require little time (20), have fewest side effects (21), are consistent with the caregiver's and patient's training and orientation, are presented with appropriate rationales, are applied when necessary (e.g., applied to more severe problems), and promise to be most effective. Treatments with higher levels of social validity may be more likely to be sought after by clients and carried out by the clinician (13).
A review of relevant literature suggests a higher preference for psychotherapy over medication in patients with CMDs (22-28). Preferred treatments have been associated with better treatment acceptability (29) and with positive outcomes such as lesser attrition rates (30), higher treatment satisfaction, better clinical outcomes and increased completion rate (31). There is a dearth of studies examining treatment acceptability for psychotherapies in the Indian context. The current study attempted to explore treatment acceptability of medication and psychotherapy in a sample of out-patients with CMDs, seeking psychiatric outpatient services in a tertiary care setting. Treatment acceptability was also examined in association with relevant socio-demographic and clinical variables in the sample.
Methods
This study used a single group cross sectional design, carried out from October 2018 to March 2019. The sample was drawn from the out-patient mental health services at a tertiary care institute in southern India, using purposive sampling. CMDs were referred to as anxiety and depressive disorders (F 32-34, 38, F 40-45, 48 and F 60-62) of the ICD-10. Participants fulfilled the following inclusion criteria: a) File diagnosis of depression, neurotic, stress related and somatoform disorders (F 32-34, 38, F 40-45, 48 and F60-62 on ICD-10) as established through detailed clinical assessment. b) age between 18-54 years c) fluency in English language d) minimum of 8 years of formal education. Participants were excluded if a) they had a diagnosis of Bipolar Affective disorder, Schizophrenia or a history suggestive of major neurological illness or those with organic psychiatric disorders, b) had a clinical history suggestive of intellectual disability /those with current psychoactive substance dependence (except nicotine use) and c) had undergone/were undergoing structured psychotherapy sessions and had completed more than two sessions of the same. During recruitment of participants, an attempt was made to have equal gender representation in two age groups: 18-29 years and 30-54 years. In addition, attempts were made to ensure heterogeneity within the sample in terms of level of education and disorders. The study was reviewed and approved by the Institute Ethics Committee.
Procedure: The individuals who fulfilled the sample selection criteria were approached in the outpatient services for obtaining written informed consent. The tools for the data collection were administered on a one-to-one basis in a single session, after receiving consent. The information regarding the clinical variables under study were collected from the patient's medical records and from their respective therapist/psychiatrist.
Measures:
Basic and Clinical Data sheets: A basic data sheet was developed during the pilot phase of the study which was used to gather relevant socio-demographic details, namely - age, gender, education, socio economic status, marital status, occupation and place of stay. A clinical data sheet was used to collect information regarding illness and treatment related variables such as duration of illness, duration since diagnosis, and information seeking over the internet about psychotherapy or other forms of psychological treatment and whether psychotherapy was recommended by a significant other or a health professional.
Treatment Acceptability and Preference (TAP) (29) measure was used to assess treatment preference and acceptability. It contains descriptions of treatment options, items assessing perception of treatment acceptability, and items inquiring about participants' choice. The first section presented a description of treatment options (psychotherapy and medication separately within the context of the study) and 9 items each for rating acceptability of each treatment option. The treatment descriptions provided before rating acceptability are aimed at reducing variability in awareness about the treatment, by presenting uniform basic information and these descriptions can be customized to suit the nature of treatments being examined in any given study. Treatment descriptions (psychotherapy and medication) for CMDs were developed for the study by the authors in consultation with three mental health professionals and literature review. The nine items which followed the treatment description assessed specific attributes of a given treatment such as effectiveness, appropriateness, severity of risks or side effects, convenience and willingness to undergo the treatment on a 0 to 4 Likert scale. Minor modifications in phrasing of a few items were made with permission of the authors. The total score provided a measure of the overall acceptability of the treatment under investigation. The last section includes an item inquiring about preferences. In the present study, medication alone, psychotherapy alone and combined treatment (medication and psychotherapy) were the options presented to the participants.
Data Analysis
Quantitative data was coded and entered in the SPSS (version 20). Descriptive statistics in terms of frequencies and percentages were used to describe the socio-demographic and clinical data. Normality of the data was examined through Kolmogorov- Smirnov Z test. Quantitative data was analyzed using appropriate descriptive and inferential statistics, depending on the normality of the respective score distributions.
Results
Socio-demographic and Clinical characteristics of the sample:
A total of 50 participants who met the inclusion and exclusion criteria were recruited into the study. The mean age of the participants was 29.42±8.06 years, with relatively equal representation in the two age groups: 18-29 years and 30-54 years. Both men (52%) and women (48%) were fairly well represented, with a majority of the sample being single (70%). About 42% had either completed or were pursuing graduation and 38% in post-graduation, while about 20% of the sample had 12 years or less of education. (Table 1)
| Table 1: Socio-demographic characteristics of the sample (N=50) |
| Variables |
Frequency |
Percentage |
Age (In Years): Mean Age (SD): 29.42 (8.06) |
18 - 29 |
28 |
56 |
30 - 54 |
22 |
44 |
Gender |
Female |
24 |
48 |
Male |
26 |
52 |
Marital Status |
Never Married |
35 |
70 |
Married |
13 |
26 |
Separated |
1 |
2 |
Divorced |
1 |
2 |
Widowed |
0 |
0 |
Type of Family |
Nuclear |
41 |
82 |
Extended |
3 |
6 |
Joint |
6 |
12 |
Religion |
Hindu |
41 |
82 |
Muslim |
4 |
8 |
Christian |
4 |
8 |
Others |
1 |
2 |
Education |
Class 8 - 10 |
1 |
2 |
Upto PUC |
9 |
18 |
Graduate |
21 |
42 |
Post-Graduate |
19 |
38 |
Work Status |
Not working |
19 |
38 |
Searching for work |
5 |
10 |
Going to work but not regular |
2 |
4 |
Going regularly to work |
24 |
48 |
Income (Per Annum) |
Below 14,000 |
23 |
46 |
14,000 - 25,000 |
3 |
6 |
25,000 - 35,000 |
4 |
8 |
35,000 - 50,000 |
6 |
12 |
Above 50,000 |
14 |
28 |
Majority was from the state of Karnataka (78%) and from the city of Bangalore (76%), while the remaining sample belonged to other states (22%).
About 74% of the sample had a continuous illness and the rest reported episodic illness. Nearly half the sample (48%) reported an illness duration of one year or less, whereas 28% of the sample had a total duration of more than five years. In contrast, the duration since diagnosis was a year or less in about 88% of the sample. (Table 2)
| Table 2: Clinical and other characteristics of the sample (N=50) |
| Variables |
Frequency |
Percentage |
Course |
Continuous |
37 |
74 |
Episodic |
13 |
26 |
Total Duration of Illness |
Up to 1 year |
24 |
48 |
1 - 5 years |
12 |
24 |
Above 5 years |
14 |
28 |
Duration Since Diagnosis |
Up to 1 month |
30 |
60 |
1 month to 1 year |
14 |
28 |
Above 1 year |
6 |
12 |
On Medication |
Yes |
24 |
48 |
No |
26 |
52 |
Duration Since Starting Psychiatric Treatment |
0 to 1 month |
32 |
64 |
1 month to 1 year |
14 |
28 |
Above 1 year |
4 |
8 |
Current Use of Alcohol |
Yes |
13 |
26 |
No |
37 |
74 |
The most common clinical diagnoses in the sample were depression (34%) followed by adjustment disorders (26%). Other diagnoses were anxiety spectrum disorders such as social anxiety disorder (10%), GAD (8%), OCD (6%), specific phobia (4%) to dissociative disorders (4%). Only a small proportion of the sample had comorbid psychiatric conditions (12%).
The sample included participants who were on medication (44%) as well as those who were not on medications (56%) at the time of the study (Table 2). Slightly more than half of the sample (52 %) reported that psychotherapy was not suggested as an option/recommended by their mental health professional. Fifty two percent of the sample reported that psychotherapy was recommended to them by family/friends at some point of time. About 70% of the overall sample had not undergone any psychotherapy sessions while the remaining had undergone one to two initial sessions, mostly in the form of therapy intake/history clarification at the time of data collection.
A little more than half the sample (52%) reported that they had looked for/accessed information about psychotherapy and other forms of treatment from online sources or through friends who had been to therapy. Effectiveness, appropriateness subscales as well as total acceptability scale scores for both medication and psychotherapy had satisfactory internal consistency reliability (0.65-0.76) (Table 3).
|
Table 3: Descriptive statistics of the measures used
|
| Scale |
Treatment |
Min-Max Possible |
Min-Max Obtained |
Mean |
SD |
KS-Z |
Reliability
(α) |
Treatment Acceptability and Preference Questionnaire - Revised |
Effectiveness |
Psychotherapy |
0-4 |
1.40-3.80 |
2.62 |
0.58 |
0.74 |
0.69 |
Medication |
0-4 |
0.40-3.00 |
1.20 |
0.69 |
0.63 |
0.71 |
Appropriateness |
Psychotherapy |
0-4 |
0.50-4.00 |
2.93 |
0.77 |
1.11 |
0.65 |
Medication |
0-4 |
0.00-4.00 |
1.76 |
0.98 |
1.00 |
0.72 |
Severity Of Side Effects/Risks (Reverse Scored) |
Psychotherapy |
0-4 |
0-4 |
3.60 |
0.90 |
3.05* |
- |
Medication |
0-4 |
0-4 |
2.30 |
1.15 |
2.33* |
- |
Convenience |
Psychotherapy |
0-4 |
1-4 |
2.20 |
0.99 |
1.84* |
- |
Medication |
0-4 |
0-4 |
1.56 |
1.03 |
1.59* |
- |
Willingness |
Psychotherapy |
0-4 |
1-4 |
3.08 |
0.85 |
1.57* |
- |
Medication |
0-4 |
0-4 |
1.48 |
1.11 |
1.32 |
- |
Overall Acceptability |
Psychotherapy |
0-40 |
18-35 |
27.82 |
4.67 |
0.85 |
0.68 |
Medication |
0-40 |
6-31 |
18.84 |
6.42 |
0.58 |
0.76 |
|
*p<0.05, Scores on treatment acceptability are shown as average scores here to permit comparison across sub-scales.
|
Treatment acceptability of psychotherapy and medication
There were significant differences between acceptability scores for medication vs. psychotherapy in the overall sample. Psychotherapy was seen to be more effective (t = 6.67, p < 0.05) and appropriate (t = 7.11, p <0.05), having less severity or risks of side effects (z = 5.40, p <0.05), more convenient (z = 2.99, p < 0.05), associated with greater willingness to undergo (z = 5.07, p < 0.05) and had greater overall acceptability than medications (t = 9.65, p < 0.05) (Table 4).
| Table 4: Comparison of the Treatment Acceptability: Psychotherapy Versus Medication in the overall sample (N=50) |
| Variables |
Type of Treatment |
|
|
Treatment Acceptability
Measure |
Psychotherapy
Mean (SD) |
Medication
Mean (SD) |
t/z value |
p-values |
Effectiveness |
2.61 (0.58) |
1.99 (0.69) |
6.67 |
0.00 |
Appropriateness |
2.93 (0.76) |
1.76 (0.97) |
7.11 |
0.00 |
Severity Of Side Effects/Risks (Reverse Scored) |
3.60 (0.90) |
2.30 (1.15) |
5.40 # |
0.00 |
Convenience |
2.20 (0.99) |
1.56 (1.03) |
2.99 # |
0.00 |
Willingness |
3.08 (0.85) |
1.48 (1.11) |
5.07 # |
0.00 |
Overall Acceptability |
27.82 (4.66) |
18.84 (6.42) |
9.65 |
0.00 |
| # Wilcoxon Signed Rank test z value. Rest are paired t-test values |
Treatment acceptability and socio-demographic variables
There was no significant difference between the two age groups (<30 years and > 30 years) on the effectiveness, appropriateness, willingness to participate and overall acceptability of both psychotherapy and medication treatment conditions. However, the younger age group reported the view that the side effects resulting from medication would be of lesser severity than the older age group (Z = 2.28, p < 0.05). The younger age group also tended to perceive psychotherapy treatment to be a more convenient form of treatment than the older group (Z = 1.75, p = 0.08).
There were no differences across genders on the perceived effectiveness, appropriateness, severity of side effects/risks, convenience, willingness to undergo and the total acceptability of psychotherapy as well as severity of side effects related to medication. But men reported medication to be more effective (t = 3.72, p < 0.05) and appropriate (t = 2.02, p < 0.05) as well as more convenient (Z = 2.49, p < 0.05) and overall, more acceptable (t = 3.35, p < 0.05) as a treatment than women.
The education subgroups (graduation/above graduation) and income-based subgroups (>35000/- and <35000/-) did not exhibit significant differences on the acceptability of medication or psychotherapy.
Treatment acceptability and clinical correlates
The overall sample was divided into subgroups with illness- duration less than 5 years and more than 5 years. These two subgroups did not differ significantly on the effectiveness, appropriateness, risks/side effects, convenience, willingness and overall acceptability of psychotherapy. This was also seen in the effectiveness of medication. However, those with a shorter duration of illness reported medication to be more appropriate (t = 2.05, p = 0.05) and convenient (Z = 2.14, p < 0.05), perceived lower side effects related concerns (Z = 2.05, p < 0.05) and were more willing to undergo medication treatment (t = 2.28, p < 0.05) and had higher overall acceptability of medication (t = 2.06, p < 0.05) as compared to those with a longer duration of illness.
Participants who were receiving pharmacotherapy, viewed medications as being more effective (t = 1.97, p < 0.05), appropriate (t = 2.88, p < 0.05), convenient (Z = 2.42, p < 0.05) and more acceptable (t = 3.33, p < 0.05) and were also more willing to receive medication (t = 4.72, p < 0.05) than those who are not under medication. The group that was not under medication rated psychotherapy as a more convenient treatment (Z = 2.19, p < 0.05) than those who were on medication.
Those recommended by family members or social circle to try psychotherapy and those not recommended, did not differ significantly on the treatment acceptability for both psychotherapy and medications. However, a trend could be noticed in as much as those who were recommended to take up psychotherapy by family members tended to report greater willingness to undergo psychotherapy (t = 0.25, p = 0.09) and a lesser willingness to undergo medication treatment (t = 1.68, p = 0.09).
Participants who were recommended psychotherapy by professionals did not differ significantly from those who were not provided such recommendation by professionals on their ratings of effectiveness, appropriateness, and severity of side effects, convenience, willingness and the overall acceptability of psychotherapy or on perceived severity of side effects, convenience and willingness to take medication. However, those who were recommended by professionals to undergo psychotherapy treatment reported medication to be more effective (t = 2.44, p < 0.05), appropriate (t = 2.02, p = 0.05) and overall acceptable (t = 1.94, p = 0.06) as compared to those who did not receive the said recommendation.
Those who had accessed information earlier regarding psychotherapy reported greater willingness to undergo psychotherapy (Z = 3.49, p < 0.05) and also expected medications to result in lesser side effects (Z = 2.02, p < 0.05) as compared to those who did not access information regarding psychotherapy or other forms of psychological treatment.
Treatment preferences:
None of the sampled participants indicated a preference for medication alone. About 46% of the participants indicated a preference for combined treatment, while about 54% indicated a preference for psychotherapy alone.
Discussion
The study sample had fair heterogeneity in terms of age-range, gender, diagnoses of CMDs, and medication-status. The duration since diagnosis was short (1 year or less) in the majority of participants, in contrast to the duration since the onset of illness, which was 1 year or less in only 48% of the participants. This may be explained based on the literature that shows that there is often a significant delay in seeking professional help after onset of psychiatric symptoms (32,33). This may also be related to the sample selection processes which required exclusion of those who had been exposed to psychotherapy over the course of their treatment. Studies indicate the internet to be a major source of information on mental health treatments (34,35) and this was also noted in the present study wherein a significant proportion mentioned having looked up information about psychotherapy and other treatments online.
Acceptability of medication and psychotherapy in the overall sample
The findings suggest that the acceptability of psychotherapy was significantly higher than medication on all the subscales and the total scores of the Treatment Acceptability and preference measure. This indicated that that an average participant sampled in the study perceived psychotherapy to be more effective, appropriate, convenient, less risky and more convenient than medication and indicated greater willingness as well as overall acceptability of psychotherapy as compared to medication. The findings of this study echo the results of a meta-analytical review (23), which demonstrated that about 75% of participants prefer psychological over pharmacological treatment for management of depressive and anxiety disorders across settings and samples. The present study findings are also in keeping with the observations of a qualitative study from India on primary health care attendees suffering from common mental disorders (36). This study also noted that although the individuals presented their illness in somatic terms, probing revealed that they tended to link their illness to their psychosocial world and a substantial proportion used the construct of tension/worry to label their illness.
Treatment acceptability is likely to be related to treatment preference. Four attributes of an acceptability measure, namely perceived treatment effectiveness, appropriateness and risks and convenience of use in daily life, were found to contribute to preference in a previous study (37). In the present study, medication alone was not indicated as a preferred option by any of the participants. On the other hand, slightly more than half the sampled participants indicated a preference for psychotherapy alone while the remaining indicated a preference for combined treatment. Lack of preference for a stand-alone medication treatment corresponded with overall acceptability of psychotherapy in the present study as discussed above. There are several studies that suggest better acceptability and higher preference for psychotherapy for various common mental health issues. In another study (22) patients with first episode depression preferred psychotherapy over medication as antidepressants were perceived to have serious side-effects. However, they also reported that they might change their preferences if they were educated about the side effects of medications. Similar findings on preference for psychotherapy have been reported in other studies on common mental health conditions across settings (38-40).
Treatment acceptability and socio-demographic variables
Available research suggests that socio-demographic variables may influence utilization of psychotherapy services (41). Psychological openness/recognition of psychological problems, inclination to seek help and indifference to social stigma are a few factors that have been associated with sociodemographic variables (42).
In the present study, the younger age group viewed side effects/risks resulting from medication to be of lesser severity than the older age group. Also, the younger group tended to see psychotherapy as more convenient than the older group. This pattern suggests that younger treatment seekers with common mental health problems approaching a tertiary care center may be open to medication as well as psychotherapy options. Similar findings have been reported in other studies wherein younger patients were more likely than older patients to indicate willingness to undergo psychotherapy for a common mental disorder (43).
Significant gender differences were observed in the current study, primarily in terms of acceptability of medication. Medication was seen as more effective, appropriate, more convenient and overall, more acceptable as a treatment by men than women in the study. Gender differences in acceptability of medication may be partially linked to lay conceptualization of causes of mental health problems. Beliefs regarding biological causation may increase the likelihood of higher acceptability of pharmacological treatment. In the Indian study mentioned earlier (36), though tension and worry were the most common causes perceived by both the genders with CMDs, a higher proportion of women than men cited this as a causal explanation. Also, men were more likely than women to attribute their illness (CMDs) to other physical illnesses.
In a meta-analytic review on patient preference for psychological versus pharmacological treatment of psychiatric disorders (23), it was seen that younger samples and females preferred psychological treatment over pharmacological interventions. Existing research suggests that men may be less inclined to seek psychotherapy, and this has been linked with gender role socialization, masculine stereotype, the ideas of control, self-reliance and resisting displays of vulnerability (44,45) and may result in a lesser likelihood of men approaching for help for their mental health. (46) Men have been reported to be more willing to engage in therapy when they felt it led to practical results (45) but men with more rigid gender roles may experience increased self-stigma and negative attitudes to therapy and are less likely to engage in therapy. (47,48)
Gender differences in acceptability of psychotherapy however were not observed in the present study. Another study also reported no gender differences on preference for psychotherapy in their sample of primary care patients with depression (43). This may be partly attributable to the fact that the present study did not involve non-treatment seekers in community but sampled participants who were already seeking or were referred for mental health services at a tertiary care center. Moreover, gender differences may emerge in actual initiation or continued engagement in psychotherapy, but these were beyond the scope of the study.
Education status and income status did not emerge as significant in terms of treatment acceptability for either medication or psychotherapy. This is likely to be related to insufficient heterogeneity within the present study sample on these variables. As mentioned earlier, those with less than college level education and lower income groups could not be sampled due to language constraints of the researcher.
Treatment acceptability and clinical variables
On examining the association of clinical variables with treatment acceptability, it was found that patients who were on medication viewed medication as more effective, convenient and more acceptable and they were also more willing to use medication as a treatment than those who were not on medication. Further it was seen that those patients who were not on medication saw psychotherapy as more convenient than those who were on medication.
Medication status also emerged as an important variable associated with treatment preferences. Majority of those who preferred psychotherapy alone were not on medication. This was either decided by the mental health professional or the patient. On the other hand, most of those who were on medication preferred a combined treatment. A review (49) indicated that those who did not receive the treatment of their preference were more likely to drop-out or had fewer visits compared to those who were given the treatment of their preference suggesting that treatment experiences and outcomes may influence acceptability. (20,50)
Patients with an illness duration of less than 5 years, reported medication to be more appropriate and convenient, perceived lower side effects related concerns, expressed more willingness to undergo medication treatment and had higher overall acceptability of medication as compared to those with longer duration of illness. This pattern raises the possibility that those with longer duration of illness and continuing to seek mental health outpatient services may come to experience more side effects of medication as well as residual symptoms and hence may rate medications to be less acceptable than those with shorter duration of illness.
Treatment acceptability and recommendations from family/professionals
In the current study, participants who were recommended to receive psychotherapy by either their family members or someone in their social circle, showed a tendency for increased willingness to use psychotherapy and lesser willingness to undergo medication. This finding is in line with previous studies (22, 51-53), which indicate that family involvement and acceptance or prior exposure can increase the patient's acceptability of and compliance to treatment. However, the acceptability of a given treatment may not automatically result in a higher preference for the same and factors and processes that influence decisions related to preferences need to be explored in depth.
Those patients who reported having been recommended psychotherapy by mental health professionals reported that they perceived medication to be more effective, appropriate, and overall acceptable than those who were not recommended psychotherapy. A closer inspection of the data was attempted to understand this seemingly counterintuitive finding. As mentioned in an earlier section, nearly half of the patients in the present study reported not being suggested/recommended psychotherapy by a mental health professional. A major proportion of those who reported that they did not receive professional recommendation for psychotherapy were also those who indicated a clear preference for psychotherapy as a stand-alone treatment rather than combined treatment. These patterns together suggest that individuals indicating a clear preference for psychotherapy alone may express the same to the treating professional at the outset hence resulting in lower rates (necessity) of professional recommendation about the same. Also, the overall findings raise the possibility that medication may be a default mode of treatment offered to individuals with common mental health problems, perhaps due to ease of offering the same, perceived patient convenience, challenges in finding a suitable (linguistically and otherwise compatible) therapist, felt needs to minimize delays in initiating some form of treatment, perceptions of the role of medication in management of common mental health problems as well as the need to offer rapid symptomatic relief from symptoms such as sleep and mood disturbance and other factors. In a study on psychiatric outpatient samples in a state- run setting in Turkey (54) it was found that most had first received mental health services from a psychiatrist and a small minority had subsequently received care from a psychologist. None had demanded psychotherapy. The authors concluded that mental health treatment in their setting was primarily provided by psychiatrists with psychologists contributing in a limited fashion and pharmacotherapy was the first choice of treatment. In a survey (55), it was seen that though psychotherapy was seen as efficacious by professionals, only few patients were offered the same, due to time constraints. Physicians sometimes do not refer patients to psychotherapy or to professionals who can provide the same (56-58).The situation is likely to be much better in a large tertiary care centre in urban India, with availability of a large pool of trained clinical psychologists. However, a complex set of factors may influence actual uptake of psychotherapy ranging from referral patterns, widespread geographical locations from where patients come to the setting, language barriers as well as workload in busy outpatient settings and referral practices etc. In the present study context, it appears that use of psychotherapy as a stand-alone modality may be more likely mostly in cases where clients proactively express a preference for the same. In another study carried out in the same mental health outpatient setting, it was observed that in an outpatient sub-sample of persons with common mental disorders, about 41% were receiving only pharmacological treatment (59). This is notwithstanding global research indicating effectiveness of psychological interventions for common mental disorders and practice guidelines recommending the same as first line of management for patients who have never received such treatments (60). The factors that give rise to professional recommendation for psychotherapy either alone or in combination with medication as well as the process of recommendation, rationale provided/explained, and the extent of opportunity provided to discuss/clarify doubts are some of the issues that require in- depth exploration.
Treatment acceptability and access to information
The results in the present study also indicate that those patients who had accessed information regarding psychotherapy and other forms of psychological treatment for their illness reported greater willingness to undergo psychotherapy and also expected medication to result in lesser side effects as compared to their counterparts. Several studies (61,62) indicate that a treatment's acceptability may increase when patients have a better understanding of a treatment.
Limitations and future directions and implications
The sample consisted of participants who were mostly from a tertiary care center in an urban metropolitan city in India. Due to the language barrier of the researcher, the sample consisted mostly of urban, well-educated, English-speaking samples. On some variables, such as education and income, the group did not have enough heterogeneity. The generalizability of the findings needs to be examined in further studies across different treatment settings and for those with lower levels of education, lower income groups, and in persons from rural and semi-urban areas. The modest sample size (N=50) as well as exploratory nature of the study indicate a need for replication studies with larger and diverse samples of treatment seekers to arrive at a firmer conclusion.
Due to time constraints, in-depth information could not be obtained regarding nature/ quality/elaborateness of recommendations for psychotherapy received from family/friends or professionals. Some of the participants were already on medication at the time of meeting the researcher. This may have created a bias based on their experience of taking medications. On the other hand, it was not feasible to elicit treatment acceptability related responses before initiation of any treatment as most patients were prescribed medication, from the point of screening/ first contact, even before a detailed evaluation.
This may be one of the first studies in India, to the researcher's knowledge, that has assessed treatment acceptability of medication and psychotherapy in individuals seeking professional mental health services for common mental disorders. Factors associated with differential preference for psychotherapy, medication or combined treatment (medication with psychotherapy) need an in-depth examination in future research. Further, there is a need to examine the extent to which individuals seeking mental health services in the Indian context may proactively discuss treatment options or proactively express their preference. Further studies are needed to throw light on the processes related to recommendation of psychotherapy by mental health professionals and associated factors as well as its impact on psychotherapy utilization for common mental health problems in outpatient settings with multidisciplinary teams in India.
A default initial offering of pharmacotherapy when coupled with a patient's lack of clarity/ awareness/ disclosure of their inclinations may result in lack of informed decision making and underutilization of psychotherapy services and may result in sub-optimal treatment engagement, satisfaction and clinical outcomes. The present study shows that the participants with common mental disorders indicate a preference for psychotherapy, be it as a stand-alone treatment or in combination with medication. This observation as well as research on effectiveness of psychotherapy for common mental disorders and practice guidelines suggest the need for routinely and pro-actively exploring and addressing treatment options and preferences of individuals seeking outpatient mental health services, in order to enhance a match between patient preferences and treatment offered.
Declaration of Conflicting Interests: The authors declare there is no conflict of interests.
Funding: This research did not receive any grant from any funding agency in the public, non-commercial or not-for-profit sectors.
References
- Kendrick T, Pilling S. Common mental health disorders - Identification and pathways to care: NICE clinical guideline. Br J Gen Pract . 2012 Jan 1;62(594):47-9.
- Murthy RS. National Mental Health Survey of India 2015-2016. Indian J Psychiatry 2017;59(1):21-6.
- National Institute for Health and Clinical Excellence. Depression in adults: recognition and management [CG90] [Internet]. NICE. 2009 [cited 2021 Jul 22]. Available from: https://www.nice.org.uk/guidance/cg90/history.
- National Institute for Health and Clinical Excellence. Generalized anxiety disorder and panic disorder in adults: management [Internet]. NICE. 2011 [cited 2021 Jul 22]. Available from: https://www.nice.org.uk/guidance/cg113
- Stewart RE, Chambless DL. Does psychotherapy research inform treatment decisions in private practice? J Clin Psychol. 2007;63(3):267-81.
- Brody DS, Khaliq AA, Thompson TL. Patients' perspectives on the management of emotional distress in primary care settings. J Gen Intern Med. 1997;12(7):403-6.
- Weddington WW. Adherence by medical-surgical inpatients to recommendations for outpatient psychiatric treatment. Psychother Psychosom. 1983;39(4):225-35.
- Mind. We need to talk: Getting the right therapy at the right time. 2010; Available from: https://www.mentalhealth.org.uk/sites/default/files/we-need-to-talk.pdf (accessed on 24-02-2021)
- Kegel AF, Fluckiger C. Predicting Psychotherapy Dropouts: A Multilevel Approach. Clin Psychol Psychother. 2015;22(5):377-86.
- Swift JK, Greenberg RP, Tompkins KA, Parkin SR. Treatment refusal and premature termination in psychotherapy, pharmacotherapy, and their combination: A meta-analysis of head-to-head comparisons. Psychotherapy. 2017; 54(1) :7-57.
- Stirman SW, Gutner CA, Langdon K, Graham JR. Bridging the Gap Between Research and Practice in Mental Health Service Settings: An Overview of Developments in Implementation Theory and Research. Behav Ther. 2016 Nov;47(6):920-36.
- Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82(4):581-629.
- Kazdin AE. Acceptability of alternative treatments for deviant child behavior. J Appl Behav Anal. 1980;13(2):259-73.
- Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M, et al. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337a1655-a1655.
- Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. Br Med J 2015;350:h1258.
- Stok FM, De Ridder DTD, De Vet E, Nureeva L, Luszczynska A, Wardle J, et al. Hungry for an intervention? Adolescent's ratings of acceptability of eating-related intervention strategies. BMC Public Health 2016;16(1):1-8.
- Diepeveen S, Ling T, Suhrcke M, Roland M, Marteau TM. Public acceptability of government intervention to change health-related behaviours: A systematic review and narrative synthesis. BMC Public Health. 2013;13(1).
- Andrykowski MA, Manne SL. Are psychological interventions effective and accepted by cancer patients? I. Standards and levels of evidence. Ann Behav Med. 2006 Oct;32(2):93-7.
- Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: An overview of reviews and development of a theoretical framework. BMC Health Serv Res. 2017;17(1):1-13.
- Reimers TM, Wacker DP. Parents' Ratings of the Acceptability of Behavioral Treatment Recommendations Made in an Outpatient Clinic: A Preliminary Analysis of the Influence of Treatment Effectiveness. Behav Disord 1988;14(1):7-15.
- Kazdin AE. Acceptability of child treatment techniques: The influence of treatment efficacy and adverse side effects. Behav Ther. 1981;12(4):493-506.
- Houle J, Villaggi B, Beaulieu MD, Lesperance F, Rondeau G, Lambert J. Treatment preferences in patients with first episode depression. J Affect Disord. 2013;147(1-3):94-100.
- McHugh R, Whitton S. Patient Preference for Psychological vs. Pharmacological Treatment of Psychiatric Disorders: A Meta-Analytic Review. Clin Psychiatry. 2013;74(6):595-602.
- Moradveisi L, Huibers M, Renner F, Arntz A. The influence of patients' preference/attitude towards psychotherapy and antidepressant medication on the treatment of major depressive disorder. J Behav Ther Exp Psychiatry. 2014;45(1), 170-177.
- Soucy JN, Hadjistavropoulos HD. Journal of Behavior Therapy and Treatment acceptability and preferences for managing severe health anxiety: Perceptions of internet-delivered cognitive behaviour therapy among primary care patients. J Behav Ther Exp Psychiatry. 2017;57:14-24.
- Caporino NE, Karver MS. The acceptability of treatments for depression to a community sample of adolescent girls. J Adolesc. 2012;35(5):1237-45.
- Walker J, Vincent N, Furer P, Cox B, Kevin Kjernisted. Treatment preference in hypochondriasis. J Behav Ther Exp Psychiatry. 1999;30(4):251-8.
- Culver NC, Song Y, Kate McGowan S, Fung CH, Mitchell MN, Rodriguez JC, et al. Acceptability of Medication and Nonmedication Treatment for Insomnia Among Female Veterans: Effects of Age, Insomnia Severity, and Psychiatric Symptoms. Clin Ther. 2016;38(11):2373-85.
- Sidani S, Epstein DR, Bootzin RR, Moritz P, Miranda J. Assessment of preferences for treatment: Validation of a measure. Res Nurs Heal. 2009;32(4):419-31.
- Swift JK, Callahan JL. The impact of client treatment preferences on outcome: a meta-analysis. J Clin Psychol. 2009; 65(4):368-81.
- Lindhiem O, Bennett CB, Trentacosta CJ, McLear C. Client preferences affect treatment satisfaction, completion, and clinical outcome: A meta-analysis. Clin Psychol Review. 2014; (34): 506-17.
- Bagcchi S. Rethinking India's psychiatric care. The Lancet Psychiatry. 2014;1(7):503-4.
- Mishra N, Nagpal SS, Chadda RK, Sood M. Help-seeking behavior of patients with mental health problems visiting a tertiary care center in north India. Indian J Psychiatry 2011;53(3):234-8.
- Redmond N, Baer HJ, Clark CR, Lipsitz S, Hicks LRS. Sources of Health Information Related to Preventive Health Behaviors in a National Study. Am J Prev Med. 2010;38(6):620-7.
- Eichenberg C, Wolters C, Brähler E. The internet as a mental health advisor in Germany - Results of a national survey. PLoS One. 2013;8(11).
- Andrew G, Alex C, Shruti S, Vikram P. The explanatory models of depression and anxiety in primary care: a qualitative study from India. BMC Res Notes. 2012;(5):499.
- Sidani S, Epstein DR, Fox M, Miranda J. Psychometric Properties of the Treatment Perception and Preferences Measure. Clin Nurs Res. 2018;27(6):743-61.
- Dimidjian S, Goodman SH. Preferences and attitudes toward approaches to depression relapse/recurrence prevention among pregnant women. Behav Res Ther 2014;54(1):7-11.
- Goodman SH, Dimidjian S, Williams KG. Pregnant african american women's attitudes toward perinatal depression prevention. Cult Divers Ethn Minor Psychol. 2013;19(1):50-7.
- Kwan BM, Dimidjian S, Rizvi SL. Treatment preference, engagement, and clinical improvement in pharmacotherapy versus psychotherapy for depression. Behav Res Ther. 2010;48(8):799-804.
- Judd F, Komiti A, Jackson H. How does being female assist help-seeking for mental health problems? Aust N Z J Psychiatry. 2008;42(1):24-9.
- Mackenzie CS, Gekoski WL, Knox VJ. Age, gender, and the underutilization of mental health services: The influence of help-seeking attitudes. Aging Ment Heal. 2006;10(6):574-82.
- Dorow M, Lobner M, Pabst A, Stein J, Riedel-Heller SG. Preferences for depression treatment including internet-based interventions: Results from a large sample of primary care patients. Front Psychiatry. 2018;9(May):1-13.
- Anstiss D, Lyons A. From men to the media and back again. J Health Psychol. 2013;19(11):1358-70.
- Emslie C, Ridge D, Ziebland S, Hunt K. Exploring men's and women's experiences of depression and engagement with health professionals: More similarities than differences? A qualitative interview study. BMC Fam Pract. 2007;8:1-10.
- Kaneko Y, Motohashi Y. Male Gender and Low Education with Poor Mental Health Literacy: A Population-based Study. J Epidemiol. 2007;17(4):114-9.
- Rice SM, Aucote HM, Parker AG, Alvarez-Jimenez M, Filia KM, Amminger GP. Men's perceived barriers to help seeking for depression: Longitudinal findings relative to symptom onset and duration. J Health Psychol. 2017;22(5):529-36.
- Pederson EL, Vogel DL. Male Gender Role Conflict and Willingness to Seek Counseling: Testing a Mediation Model on College-Aged Men. J Couns Psychol. 2007;54(4):373-84.
- Byrne N, Regan C, Livingston G. Byrne N. Curr Opin Psychiatry. 2006.pdf. 2006;44-9.
- Patel SR, Galfavy H, Kimeldorf MB, Dixon LB, Simpson HB. Patient Preferences and Acceptability of Evidence-Based and Novel Treatments for Obsessive-Compulsive Disorder. Psychiatr Serv. 2016;68(3):250-7.
- Edwards ME, Steinglass P. Family therapy treatment outcomes for alcoholism. J Marital Fam Ther. 1995;21(4):475-509.
- Mitrani VB, Prado G, Feaster DJ, Robinson-Batista C, Szapocznik J. Relational factors and family treatment engagement among low-income, HIV-positive African American mothers. Fam Process. 2003;42(1):31-45.
- Pemberton JR, Borrego J. The relationship between treatment acceptability and familism. Int J Behav Consult Ther. 2014;1(4):329-37.
- Dereboy C, Senel H, Safak Ozturk C, Sakiroglu M, Eskin M. Psychotherapy: Playing the three monkeys in mental health service provision? Noro Psikiyatri Ars. 2017;54(4):301-6.
- Hadjipavlou G, Hernandez CAS, Ogrodniczuk JS. Psychotherapy in contemporary psychiatric practice. Can J Psychiatry. 2015;60(6):294-300.
- Piek E, Van Der Meer K, Penninx BWJH, Verhaak PFM, Nolen WA. Referral of patients with depression to mental health care by Dutch general practitioners: An observational study. BMC Fam Pract 2011;12(1):41.
- Richards JC, Ryan P, McCabe MP, Groom G, Hickie IB. Barriers to the effective management of depression in general practice. Aust N Z J Psychiatry. 2004; 38(10):795-803.
- Wang J, Langille DB, Patten SB. Mental Health Services Received by Depressed Persons Who Visited General Practitioners and Family Doctors. Psychiatr Serv. 2003;54(6):878-83.
- Gandotra A, Mehrotra S, Bharath S. Psychological recovery and its correlates in adults seeking outpatient psychiatric services - An exploratory study from an Indian tertiary care setting. Asian J Psychiatr. 2017; 29: 77-82.
- NICE. Common Mental Health Disorders in Primary Care Overview. 2018;(May):9pp. Available from: http://pathways.nice.org.uk/pathways/common-mental-health-disorders-in-primarycare
- Tingstrom DH. Increasing acceptability of alternative behavioral interventions through education. Psychol Sch. 1989;26(2):188-94.
- Singh NN, Katz RC. On the modification of acceptability ratings for alternative child treatments. Behavior Modification. 1985; 9: 375-86.
|
