Cited by 264Psychotherapy Techniques and ApplicationsMental Health Treatment and AccessAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

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Dropout from individual psychotherapy for major depression: A meta-analysis of randomized clinical trials

Cooper, Andrew A., Conklin, Laren R.·2015·Clinical Psychology Review

DOI 10.1016/j.cpr.2015.05.001

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Abstract

Dropout from mental health treatment poses a substantial problem, but rates vary substantially across studies and diagnoses. Focused reviews are needed to provide more detailed estimates for specific areas of research. Randomized clinical trials involving individual psychotherapy for unipolar depression are ubiquitous and important, but empirical data on average dropout rates from these studies is lacking. We conducted a random-effects meta-analysis of 54 such studies (N=5852) including 80 psychotherapy conditions, and evaluated a number of predictors of treatment- and study-level dropout rates. Our overall weighted dropout estimates were 19.9% at the study level, and 17.5% for psychotherapy conditions specifically. Therapy orientation did not significantly account for variance in dropout estimates, but estimates were significantly higher in psychotherapy conditions with more patients of minority racial status or with comorbid personality disorders. Treatment duration was also positively associated with dropout rates at trend level. Studies with an inactive control comparison had higher dropout rates than those without such a condition. Limitations include the inability to test certain potential predictors (e.g., socioeconomic status) due to infrequent reporting. Overall, our findings suggest the need to consider how specific patient and study characteristics may influence dropout rates in clinical research on individual therapy for depression.

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Background
Single-dose psilocybin for U.S. military Veterans with severe treatment-resistant depression – A first-in-kind open-label pilot study
Ellis, S., Bostian, C. M., Feng, W., Fischer, E. G., Schwartz, G., Eisen, K., Lean, M., Conlan, E., Ostacher, M. J., Aaronson, S. T., et al. (2024) · Journal of Affective Disorders · doi:10.1016/j.jad.2024.09.133 · Cited by 34
Digital Interventions to Enhance Readiness for Psychological Therapy: Scoping Review
Jardine, J., Bowman, R., & Doherty, G. J. (2022) · Journal of Medical Internet Research · doi:10.2196/37851 · Cited by 34
“Low use and high dropout rates are persistent problems when it comes to digital solutions [15], although similar problems also affect FTF modalities; between 17% and 25% of clients are estimated to drop out of FTF psychotherapy [8,16,17].”
Impact of dissociation on treatment of depressive and anxiety spectrum disorders with and without personality disorders
Praško, J. P., Grambal, A., Kasalová, P., Kamarádová, D., Ocisková, M., Holubová, M., Vrbová, K., Sigmundova, Z., Látalová, K., Šlepecký, M., et al. (2016) · Neuropsychiatric Disease and Treatment · doi:10.2147/ndt.s118058 · Cited by 28
“There are several studies that reported worse treatment results in patients with depressive disorders comorbid with PDs. 57,90,91 94 Differences in the results of these studies can be explained by the different patient populations studied.”
Influential
The influence of comorbid anxiety on the effectiveness of Cognitive Therapy and Interpersonal Psychotherapy for Major Depressive Disorder
van Bronswijk, S. C., Lemmens, L. H. J. M., Huibers, M. J. H., Arntz, A. R., & Peeters, F. P. M. L. (2018) · Journal of Affective Disorders · doi:10.1016/j.jad.2018.02.003 · Cited by 29
“…low motivation for change, poor therapeutic alliance, low treatment credibility and failure to improve early in treat-ment (Arnow et al., 2007; Cooper and Conklin, 2015; Schindler et al., 2013; Taylor et al., 2012)), individual risks for dropout should be estimated, and speci ﬁ c…”
Efficacy of guided self-help behavioural activation and physical activity for depression: a randomized controlled trial
Soucy, I., Provencher, M. D., Fortier, M., & McFadden, T. (2017) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2017.1337806 · Cited by 26
“…self-help interventions ranging between 2.2 and 45.5% (Cuijpers, Donker, van Straten, Li, & Andersson, 2010; Newman, Szkodny, Llera, & Przeworski, 2011), psychotherapy interventions estimated at 17.5% (Cooper & Conklin, 2015), and exercise interventions estimated at 17.2% (Stubbs et al., 2016).”
Influential
Who will stay and who will go? Identifying risk factors for psychotherapy dropout
McGovern, C., Athey, A. J., Beale, E. E., Overholser, J. C., Gomez, S. H., & Silva, C. (2024) · Counselling and Psychotherapy Research · doi:10.1002/capr.12783 · Cited by 30
The acceptability of cognitive analytic therapy (CAT): Meta-analysis and benchmarking of treatment refusal and treatment dropout rates
Simmonds‐Buckley, M., Osivwemu, E.-O., Kellett, S., & Taylor, C. A. (2022) · Clinical Psychology Review · doi:10.1016/j.cpr.2022.102187 · Cited by 29
Männliche Formen der Depression und deren Behandlung
Walther, A., & Seidler, Z. E. (2020) · PiD - Psychotherapie im Dialog · doi:10.1055/a-0987-5902 · Cited by 25
“Während diese Hypothese substanzielle Unterstützung auf Basis einiger Primärstudien erhalten hat, wurde dies wiederum in einer Meta-Analyse nicht bestätigt, die ähnliche Abbrecherquoten einer individuellen Psychotherapie bei Männern und Frauen mit Depressionen zeigt [14].”
Background
Acceptability and Feasibility of an Intervention to Enhance Social Group Belonging: Evidence From Three Trials of Groups 4 Health
Cruwys, T., Haslam, C., Haslam, S. A., Rathbone, J. A., & Donaldson, J. L. (2022) · Behavior Therapy · doi:10.1016/j.beth.2022.06.011 · Cited by 23
Predicting and Moderating the Response to the Unified Protocol: Do Baseline Personality and Affective Profiles Matter?
Osma, J., Péris-Baquero, Ó., Suso‐Ribera, C., Sauer-Zavala, S. E., & Barlow, D. H. (2021) · Cognitive Therapy and Research · doi:10.1007/s10608-021-10208-6 · Cited by 25
Personalized digital intervention for depression based on social rhythm principles adds significantly to outpatient treatment
Frank, E., Wallace, M. L., Matthews, M. J., Kendrick, J., Leach, J., Moore, T., Aranovich, G. J., Choudhury, T., Shah, N. R., Framroze, Z., et al. (2022) · Frontiers in Digital Health · doi:10.3389/fdgth.2022.870522 · Cited by 24
“%) is among the lowest ever observed in a clinical trial of a depression intervention where drop-out rates in the 17.5% – 47.8% range are common (22).”
BackgroundInfluential
Simulating clinical trial visits yields patient insights into study design and recruitment
Lim, S.-Y., Kivitz, A., McKinnell, D., Pierson, M. E., & O'Brien, F. S. (2017) · Patient Preference and Adherence · doi:10.2147/ppa.s137416 · Cited by 24
“In addition, patients from racial minority groups have higher dropout rates in clinical trials compared with white patients.(5,7) This underrepresentation of African-Americans is particularly relevant for systemic lupus erythematosus (SLE) clinical trials.”
Background
Comparing Message-Based Psychotherapy to Once-Weekly, Video-Based Psychotherapy for Moderate Depression: Randomized Controlled Trial
Song, J., Litvin, B., Allred, R., Chen, S., Hull, T. D., & Areán, P. A. (2023) · Journal of Medical Internet Research · doi:10.2196/46052 · Cited by 25
“Still, on average, participants completed a considerable proportion of their treatment, and varying levels of treatment engagement are reflective of the psychotherapeutic treatments provided in community settings [38].”
Acceptability of Health Information Exchange and Patient Portal Use in Depression Care Among Underrepresented Patients
Matthews, E. B., Savoy, M. L., Paranjape, A., Washington, D., Hackney, T., Galis, D., & Zisman‐Ilani, Y. (2022) · Journal of General Internal Medicine · doi:10.1007/s11606-022-07427-2 · Cited by 22
Music to improve sleep quality in adults with depression-related insomnia (MUSTAFI): randomized controlled trial
Lund, H. N., Pedersen, I. N., Heymann-Szlachcinska, A. M., Tuszewska, M., Bízik, G., Larsen, J. I., Drago, A., Kulhay, E., Larsen, A., Sørensen, H. Ø., et al. (2022) · Nordic Journal of Psychiatry · doi:10.1080/08039488.2022.2080254 · Cited by 22
“The study had a low dropout rate compared to the estimate of the protocol and to clinical trials of psychotherapy in depression [32].”
Result
Should rTMS be considered a first-line treatment for major depressive episodes in adults?
O’Sullivan, S. J., Buchanan, D. M., Batail, J.-M. V., & Williams, N. (2024) · Clinical Neurophysiology · doi:10.1016/j.clinph.2024.06.004 · Cited by 24
Guided Internet-based cognitive behavioral therapy for mild and moderate depression: A benchmarking study
Jakobsen, H., Andersson, G., Havik, O. E., & Nordgreen, T. (2016) · Internet Interventions · doi:10.1016/j.invent.2016.11.002 · Cited by 25
“This is however somewhat higher than what has been found for individual CBT in a meta-analysis by Cooper and Conklin (2015).”
Result
A smartphone-assisted brief online cognitive-behavioral intervention for pregnant women with depression: a study protocol of a randomized controlled trial
Zuccolo, P. F., Xavier, M. O., Matijasevich, A., Polanczyk, G. V., & Fatori, D. (2021) · Trials · doi:10.1186/s13063-021-05179-8 · Cited by 21
Predicting Dropout in Counseling Using Affect Coding of the Therapeutic Relationship: An Empirical Analysis
Luedke, A., Peluso, P. R., Diaz, P., Freund, R. R., & Baker, A. Z. (2017) · Journal of Counseling & Development · doi:10.1002/jcad.12125 · Cited by 20
Selecting the optimal treatment for a depressed individual: Clinical judgment or statistical prediction?
van Bronswijk, S. C., Lemmens, L. H. J. M., Huibers, M. J. H., & Peeters, F. P. M. L. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.09.135 · Cited by 24
Intelligent physical activity versus modified behavioral activation in adolescent and young adult cancer patients with psychological distress: A randomized, controlled pilot trial
Li, L., Wang, L., Duan, Y., Xiao, P., Zhou, Y., Luo, X., Liu, X., Xie, J., & Cheng, A. S. K. (2022) · Cancer Medicine · doi:10.1002/cam4.5030 · Cited by 18
Major Problems in Clinical Psychological Science and How to Address them. Introducing a Multimodal Dynamical Network Approach
Westhoff, M., Berg, M., Reif, A., Rief, W., & Hofmann, S. G. (2024) · Cognitive Therapy and Research · doi:10.1007/s10608-024-10487-9 · Cited by 28
“…effect sizes for anxiety and depression treatments remain moderate (Cuijpers et al., 2019; Weitz et al., 2018), with substantial therapy dropout (Cooper & Conklin, 2015; Gersh et al., 2017), high non-responder rates (Springer et al., 2018) and some patient subgroups deteriorating despite…”
Transcranial focused ultrasound targeting the default mode network for the treatment of depression
Schachtner, J. N., Dahill-Fuchel, J. F., Ehrmann, K., Bawiec, C. R., Hollender, P. J., Ornellas, S. B., Konecky, S. D., Achrol, A. S., & Allen, J. J. B. (2025) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2025.1451828 · Cited by 20
“…of participants dropped out due to lack of positive effects of the treatment, which is also signi ﬁ cantly better than dropout rates in traditional clinical depression trials, such as individual psychotherapy and pharmaceuticals with up to one-third drop out prior to treatment completion (40 – 42).”
A One-Session Treatment of PTSD After Single Sexual Assault Trauma. A Pilot Study of the WONSA MLI Project: A Randomized Controlled Trial
Rajan, G., Wachtler, C., Lee, S., Wändell, P. E., Philips, B., Wahlström, L., Svedin, C. G., & Carlsson, A. C. (2020) · Journal of Interpersonal Violence · doi:10.1177/0886260520965973 · Cited by 20
“…the dropout rates for PTSD treatment are often high in real clinical settings as opposed to the clinical trial settings (Najavits, 2015); even in study settings however, meta-analysis finds dropout rates of between 16 and 18% (Cooper & Conklin, 2015; Imel et al., 2013; Lewis et al., 2020).”
Cognitive Behavioral therapy for tinnitus: addressing the controversy of its clinical delivery by audiologists
Henry, J. A., Goodworth, M.-C., Lima, E., Zaugg, T., & Thielman, E. J. (2022) · Ear & Hearing · doi:10.1097/aud.0000000000001150 · Cited by 18
“These average dropout rates of 14 to 16% are actually lower than the average of 17.5% observed from a meta-analysis of studies of in-person psychotherapy for depression (Cooper & Conklin 2015).”
BackgroundInfluential
The therapeutic alliance and dropout in cognitive behavioral therapy of depression
Murphy, S. T., Garcia, R. A., Cheavens, J. S., & Strunk, D. R. (2022) · Psychotherapy Research · doi:10.1080/10503307.2021.2025277 · Cited by 18
“…a common occurrence, with a meta-analysis estimating the rate of dropout for individual psychotherapy of major depression to be about 20% overall (Cooper & Conklin, 2015) The effects of dropout are important to consider, as dropout is related to a range of negative effects, chief among them…”
BackgroundResultInfluential
Acute and chronic effects of physical exercise in inflammatory biomarkers in people with depression: A systematic review with meta-analysis
Guimarães, M. E. A., Derhon, V., Signori, L. U., Seiffer, B., Wolf, S., & Schuch, F. B. (2024) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2024.08.025 · Cited by 31
Counseling dropout, retention, and ethnic/language match for Asian Americans.
Presley, S., & Day, S. X. (2018) · Psychological Services · doi:10.1037/ser0000223 · Cited by 18
Secondary outcomes of the guided self-help behavioral activation and physical activity for depression trial
Soucy, I., Provencher, M. D., Fortier, M., & McFadden, T. (2018) · Journal of Mental Health · doi:10.1080/09638237.2018.1466031 · Cited by 21
“While this attrition is comparable to other self-help (Newman et al., 2011), psychotherapy (Cooper & Conklin, 2015) and PA interventions (Stubbs et al., 2016), the authors consider it to be quite high given the many aspects of these guided selfhelp interventions that should promote adherence (e.g.…”
Result
Psychotherapy for Chronic In- and Outpatients with Common Mental Disorders: The "choose Change" Effectiveness Trial
Gloster, A. T., Haller, E., Villanueva, J., Block, V., Benoy, C., Meyer, A. H., Brogli, S., Kuhweide, V., Karekla, M., Bader, K., et al. (2023) · Psychotherapy and Psychosomatics · doi:10.1159/000529411 · Cited by 16
Symptoms of emotional disorders and sociodemographic factors as moderators of dropout in psychological treatment: A meta-review
Carpallo-González, M., Muñoz‐Navarro, R., González‐Blanch, C., & Vindel, A. C. (2023) · International Journal of Clinical and Health Psychology · doi:10.1016/j.ijchp.2023.100379 · Cited by 20
“…Imel, Laska, Jakupcak and Simpson (2013) 42 1850 PTSD Individual and group Hans and Hiller (2013) 34 1880 Depression Individual and group Cooper and Conklin (2015) 54 5852 Depression Individual Fern andez, Salem, Swift and Ramtahal (2015) 115 20995 Various disorders (DR disaggregated by disorder)…”
BackgroundMethodResultInfluential
Navigating treatment recommendations for PTSD: A rapid review
Lee, E., & Bowles, K. H. (2020) · International Journal of Mental Health · doi:10.1080/00207411.2020.1781407 · Cited by 21
“For example, two meta-analytic reviews note that the average dropout rate for depression as 19.9% (Cooper & Conklin, 2015) and anxiety as 16.99% (Gersh et al., 2017).”
BackgroundInfluential
Treatment dropout among veterans and their families: Quantitative and qualitative findings.
Amsalem, D., Lopez-Yianilos, A., Lowell, A., Pickover, A. M., Arnon, S., Zhu, X., Suarez-Jimenez, B., Ryba, M., Bergman, M., Such, S., et al. (2022) · Psychological Trauma: Theory, Research, Practice, and Policy · doi:10.1037/tra0001109 · Cited by 16
Dropout from treatment for mental disorders in six countries of the Americas: A regional report from the World Mental Health Surveys
Benjet, C. L., Borges, G. L. G., Orozco, R., Aguilar‐Gaxiola, S., Andrade, L. H., Cía, A. H., Hwang, I. H., Kessler, R. C., Piazza, M., Posada‐Villa, J., et al. (2022) · Journal of Affective Disorders · doi:10.1016/j.jad.2022.02.019 · Cited by 18
Predictors of Disengagement and Symptom Improvement Among Adults With Depression Enrolled in Talkspace, a Technology-Mediated Psychotherapy Platform: Naturalistic Observational Study
Darnell, D. A., Pullmann, M. D., Hull, T. D., Chen, S., & Areán, P. A. (2022) · JMIR Formative Research · doi:10.2196/36521 · Cited by 17
“Marital status did not appear to be related to psychotherapy or mental health service disengagement in previous face-to-face psychotherapy studies [23,28,36].”
Background
Prevalence and prediction of dropout during depression treatment in routine outpatient care: an observational study
van Dijk, D. A., Deen, M. L., van den Boogaard, T. M., Ruhé, H. G., Spijker, J., & Peeters, F. P. M. L. (2022) · European Archives of Psychiatry and Clinical Neuroscience · doi:10.1007/s00406-022-01499-1 · Cited by 16
“Co-morbidity such as personality disorders and eating disorders [6, 9, 29] are considered to be risk enhancing by some, but other studies describe no or even a protective effect of personality pathology [13, 21].”
BackgroundResultInfluential
Latent Profiles of Comorbid Depression as Predictors of PTSD Treatment Outcome
Burton, M. S., Cooper, A. A., Mello, P. G., Feeny, N. C., & Zoellner, L. A. (2021) · Behavior Therapy · doi:10.1016/j.beth.2020.12.005 · Cited by 20
Self-citation
Clinical effects of glabellar botulinum toxin injections on borderline personality disorder: A randomized controlled trial
Wollmer, M. A., Neumann, I., Jung, S., Bechinie, A., Herrmann, J., Müller, A., Wohlmuth, P., Fournier-Kaiser, L., Sperling, C., Peters, L., et al. (2022) · Journal of Psychopharmacology · doi:10.1177/02698811211069108 · Cited by 16
“With randomized open allocation to either BTX or ACU treatment, we intended to avoid disappointment, higher attrition rates, and nocebo effects that may arise from discovering allocation to the placebo group (Cooper and Conklin, 2015; Doering et al., 2014; Furukawa et al., 2014).”
Method
Dropout from physical activity interventions in children and adolescents with attention deficit hyperactivity disorder: A systematic review and meta-analysis
Vancampfort, D., Firth, J., Schuch, F. B., Rosenbaum, S., Probst, M., Ward, P. B., Damme, T. V., Binder, M. D., & Stubbs, B. (2016) · Mental health and physical activity · doi:10.1016/j.mhpa.2016.09.002 · Cited by 16
“…with its typical use in RCTs, and that adopted in other reviews of dropout in physical activity RCTs (Vancampfort et al 2016, Stubbs et al 2016), which was: ‘unexpected patient attrition among individuals who were randomized to a treatment but failed to complete it’ (Cooper & Conklin, 2015).”
Method
Determining maximal achievable effect sizes of antidepressant therapies in placebo‐controlled trials
Hieronymus, F., Lisinski, A., Hieronymus, M., Näslund, J., Eriksson, E., & Østergaard, S. D. (2021) · Acta Psychiatrica Scandinavica · doi:10.1111/acps.13340 · Cited by 14
Premature termination of the unified protocol for the transdiagnostic treatment of emotional disorders: The role of ambivalence towards change
Oliveira, J. T., Sousa, I., Ribeiro, A. P., & Gonçalves, M. M. (2021) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2694 · Cited by 15
Evaluation of a male-specific psychotherapeutic program for major depressive disorder compared to cognitive behavioral therapy and waitlist: study protocol for a six-arm randomized clinical superiority trial examining depressed eugonadal and hypogonadal men receiving testosterone
Walther, A., Ehlert, U., Schneeberger, M., Eggenberger, L., Flückiger, C., Komlenac, N., Heald, A. H., Rice, T., Palm, S., Seidler, Z. E., et al. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1129386 · Cited by 15
Effectiveness of attachment-based family therapy for suicidal adolescents and young adults: A systematic review and meta-analysis
Schulte-Frankenfeld, P. M., Breedvelt, J., Brouwer, M. E., van der Spek, N., Bosmans, G., & Bockting, C. (2024) · Clinical Psychology in Europe · doi:10.32872/cpe.13717 · Cited by 18
“%) and in line with estimates from other psychotherapy trials for depression in children and youth (Cooper & Conklin, 2015; Wright et al., 2021).”
What we know, what we do not know, and where are we heading? Efficacy and acceptability of psychological interventions for depression
Solomonov, N., & Barber, J. P. (2015) · Epidemiology and Psychiatric Sciences · doi:10.1017/s2045796015000815 · Cited by 15
“Meta-analyses comparing dropout rates in different psychotherapies have yielded mixed findings, from equal dropout rates across treatments (Cooper & Conklin, 2015), to significant differences between psychotherapies, with the highest rate in CBT and the lowest rate in PST (Cuijpers et al. 2008).”
BackgroundResultInfluential
Psychological interventions for symptoms of depression among informal caregivers of older adult populations: A systematic review and meta-analysis of randomized controlled trials
Mårtensson, E., Coumoundouros, C., Sörensdotter, R., von Essén, L., & Woodford, J. (2022) · Journal of Affective Disorders · doi:10.1016/j.jad.2022.09.093 · Cited by 19
“Future research should seek to enhance retention (Cooper and Conklin, 2015), and report intervention characteristics in detail, e.g. using the TIDieR checklist (Hoffmann et al., 2014).”

Authors: Cooper, A. A., & Conklin, L. R.
Affiliations: Case Western Reserve University (US)
Boston University (US)
Corresponding author: Cooper, Andrew A.
ORCID: Cooper, Andrew A.
Conklin, Laren R.
Venue: Clinical Psychology Review
Publisher: Elsevier BV
Published: 2015-08
Volume: 40
Pages: 57-65
ISSN: 0272-7358 (ISSN-L)
DOI: 10.1016/j.cpr.2015.05.001
OpenAlex: W243214355
Cited by: 264
References: 56
Citations by year: 2026: 35 · 2025: 32 · 2024: 30 · 2023: 30 · 2022: 29 · 2021: 24 · 2020: 25 · 2019: 9 · 2018: 18 · 2017: 14 · 2016: 11 · 2015: 4
FWCI: 2.23
Type: journal article
Language: en
Open access: closed
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/legal/tdmrep-license (tdm)
Locations: Clinical Psychology Review (publishedVersion)
PubMed (publishedVersion)
Funders: Social Sciences and Humanities Research Council of Canada
Topics: Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords: treatment discontinuation, individual psychotherapy, major depressive disorder, predictors of dropout, personality disorders, treatment duration, psychotherapy research
MeSH terms: Major Depressive Disorder, Humans, Patient Dropouts, Psychotherapy, Randomized Controlled Trials as Topic

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Dropout from individual psychotherapy for major depression: A meta-analysis of randomized clinical trials

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