Exploring Treatment Integrity and Drop-Out Rates in Low-Intensity CBT-based Interventions

Despite psychological interventions increasingly being used to provide accessible psychotherapy to the general population, the number of people dropping out of the support and the differences in their improvements requires research attention. Thus, this thesis aimed to investigate these phenomena by 1) combining the findings of multiple studies investigating the drop-out rate of patients accessing low-intensity interventions for depression in routine care, and 2) conducting a study developing and evaluating a facilitator group psychoeducational measure. A key component of whether a psychological intervention is effective is related to how often patients attend and/or drop-out. The drop-out rate for depression interventions has been researched, but this had mainly been under controlled study conditions. Unfortunately, these findings are unlikely representative of care provided by services in the real-world. Therefore, section one of this thesis reports a review, which combines the findings of 11 studies investigating the drop-out rate of patients accessing low-intensity interventions for depression in routine care. The review calculated a combined drop-out rate and investigated factors that may impact variations in drop-out rates between studies. Finally, the combined drop-out rate in this study was compared to other studies combining research for different treatments. Differences between the drop-out rates of the studies in this review were heavily influenced by country and therapy format. The current reviews’ drop-out rate was comparable to others within the field, but was considerably higher than one review that only included studies under controlled conditions. Findings propose that services should be wary of patients dropping out of low-intensity interventions for depression (perhaps more than existing research indicates), whilst looking to use strategies to reduce drop-out likelihood. Differences in how much patients improve after accessing therapeutic groups is thought to be moderated by the facilitator’s delivery. More specifically, a combination of how closely they follow the treatment manual, how skillfully they deliver the content and how much they differentiate the treatment from others (also known as ‘treatment integrity’). However, a measure to mark the treatment integrity of facilitators delivering such groups does not exist. Consequently, section two of the thesis is a study that developed and evaluated a novel group psychoeducational treatment integrity measure (GPTIM). A measure and manual were developed for the measure after consulting key references. Experts were consulted on the relevance of the measure items, prior to another batch of experts trialing the measure on a batch of recorded sessions. Data collected from the trial were then used to test the reliability and validity of the GPTIM. Results indicated that the measure had an array of acceptable properties, but scores between raters for the same recorded session were poorly correlated. Findings indicate that the GPTIM demonstrated promising potential, but requires fine-tuning prior to its use within routine service, training and research contexts. Limited sample sizes and the brevity of the rater training may have impacted the conclusions and require further exploration. Taken together, the two studies aim to inform and improve the psychological support that services and therapists deliver. One study provides clarity regarding ‘real-world’ drop-out rates, whilst the other presents a novel treatment integrity measure that (with further testing) could be utilised by services to aid psychoeducational group delivery. Research with an increased number of studies should further investigate the drop-out rates of low-intensity interventions for depression within routine care, which could provide practicable strategies to support its acceptability. Furthermore, additional research is also required to fine-tune the GPTIM, which could result in its application within routine care settings