“In addition to my other numerous acquaintances, I have one more intimate confidant. My depression is the most faithful mistress I have known–no wonder, then, that I return the love.”
Depressive disorders are a significant public health problem worldwide. Efficacious treatments for depression are available, including psychotherapy, pharmacotherapy, or the combination. Despite this, less than half of depressed individuals seek professional help. Those suffering from depression fail to seek treatment for many reasons. They may feel that doing so is a sign of weakness, they may believe that they are just going through a “down” period and that their symptoms will resolve with time, or they may not recognize that their symptoms are indicative of serious depression (1).
Prior to seeking treatment for depression or any mental health concern, an individual must negotiate a number of steps. First, he/she must acknowledge there is a problem; understand that there are treatments for the problem; and then be motivated to seek appropriate treatment. Once the treatment is identified, the individual needs to actively engage in the treatment for it to be effective. The poorly engaged patient may never meaningfully initiate the treatment process, may dropout prematurely, and may not adhere to the treatment recommendations, rendering the treatments ineffective (2). This is a major challenge for practitioners treating patients suffering from depression.
A variety of methods to engage patients in the treatment process have been described. Therapist characteristics that enhance engagement include the therapist’s ability to build rapport, warmth, optimism, humor, and clear commitment to the patient as a person (3). Patient treatment modality preference, expectations concerning treatment, the alliance formed between patient and therapist, session attendance, and patient satisfaction also influence treatment engagement (4). Tailored communication is a refinement of the therapeutic alliance. This column will focus on the issues of tailored communication and patient preference as methods of motivating depressed individuals to seek treatment and to engage optimally in the treatment process.
“It seems that all doctors want to do is push medication,” Ms. O lamented when she was preparing to meet her psychiatrist for the first time. At her last primary care physician visit, she was asked to complete on-line screening assessments regarding substance use, lifestyle, and depression. She had scored in the clinically significant range on the depression scale. Her primary care physician had reviewed the scores with Ms. O, and noted that she reported feeling anxious, sad, had frequent crying spells, decreased energy, lack of motivation, and disrupted sleep and appetite since the breakup with her boyfriend 3 months ago. Ms. O was surprised at how many of the symptoms she had—the scale validated that what she was experiencing was a serious depression. The depression was also having an impact on her work productivity, as she had gotten her first-ever negative evaluation from a supervisor.
Her primary care physician encouraged her to schedule an evaluation with a psychiatrist to determine the types of treatment required. Ms. O wanted to feel better and was motivated for change, but she was wary of taking any medication and strongly felt that “talking it all out” with a professional would be most helpful. Ms. O had read on the Internet that psychiatrists primarily prescribe medication. She believed that she should follow the recommendations of a physician that knew best. However, she also felt strongly that she wanted to try psychotherapy before even considering taking a medication. How would she be able to explain this to the psychiatrist without being seen as difficult? Would the psychiatrist authorize psychotherapy, as required by her insurance? Would she feel pressured into taking a medication? Would she be able to find a psychotherapist that would help her? It was with all of these issues flooding her thoughts that Ms. O read the psychiatrist’s name on the office door, pursed her lips, and pushed open the door.
There is an emerging literature on the topic of “tailored communication”—the process of communicating whether in person, written, spoken, electronically, or through images or video in a manner that is as specific and relevant to the target audience as possible. Tailored communication is designed to promote a greater impact of the communication on the receiver because it takes into consideration the context of the communication and the needs of the recipient. This communication attempts to align the receiver’s own schemas for understanding the world with the communication he/she receives so as to enhance behavioral change (5).
Tailored communication is most often discussed in terms of public health educational campaigns designed to promote positive health behaviors. Tailored communication educational campaigns have been widely used to target such health concerns as cancer prevention and early detection, obesity and inactivity, and smoking. For communication to be tailored, an assessment of the wants, needs, and values of the recipient is required. This may be done via an online survey, health-related discussion with a primary care physician, via epidemiological data, or by other means. As noted in a volume entitled, Tailoring Health Messages: Bridging the Gap Between Social and Humanistic Perspectives on Health Communication (6), “strong empirical evidence suggests that tailoring messages to the recipients’ individual needs is more effective” in modifying health-related behaviors than educational campaigns that are based on the use of general health-promoting messages (p. 5).
Tailored communication may be particularly relevant in screening for mental health concerns; to help motivate individuals to seek treatment early in the course of illness; and to follow-through with the agreed-upon treatment plan. In the clinical vignette above, Ms. O’s completion of the online depression scale served as the assessment of her symptoms, with the review of her results and focused discussion with her primary care physician serving as tailored communication—communication that addressed her symptom descriptions and the implications for her of her survey results and the treatment indicated. The basic elements of tailored communication are personalization, feedback, and content matching.
Personalization attempts to increase attention or motivation to process messages by conveying, explicitly or implicitly, that the communication is designed specifically for “you” (7, pg. 458). Feedback provides the individual with the results of their assessment to formulate a shared understanding of the targets for change. Content matching, often thought of as the essence of tailoring, attempts to direct messages based on the individual’s status on key theoretical determinants (knowledge, outcome expectations, normative beliefs, efficacy, or skills) of the behavior of interest (7, pg 462). For any given individual, content matching seeks to complement the individual’s needs and wishes by providing information and methods of communication that are most compatible.
Much like the initial sessions of cognitive-behavioral therapy, tailored communication attempts to individualize the communication by using the patient’s own knowledge, beliefs, skills, and outcome expectations to help her/him feel more capable of effecting positive change.
The preferences of patients for a given type of treatment for depression may influence their willingness to start treatment, complete treatment, and engage fully in the course of treatment (8–10). The literature on the relationship between the patient’s preference of type of treatment and outcomes is mixed. Primary outcomes of randomized controlled trials of patients, have most commonly suggested that depression improves with treatment, despite the patient’s initial preference for treatment modality (11, 12). However, there is also evidence to suggest that patients with a strong preference for a specific type of therapy have lower recruitment—they often will not enroll in a randomized clinical trial in the first place if there is the risk of not receiving the preferred treatment. Additionally, there is an increase in attrition of patients not randomly assigned to their preferred type of treatment—they often drop out of the trial after randomization, and they demonstrate lower rates of treatment completion (8, 13).
Kwan, Dimidjian, and Rizvi (8) found that patients in clinical treatment trials that were randomly assigned to a treatment that was a mismatch with their preference reported a less positive early therapeutic alliance with their treater than those individuals assigned to a preferred treatment. The findings converged with efforts in collaborative care highlighting the importance of patient preferences in staying in treatment for depression (8, pg. 802). The authors also reported that the patient’s attendance at appointments for psychotherapy or psychopharmacology accounted for 16% of the variance in depressive severity improvement, a medium effect size. Thus, patient preference was postulated to have an indirect effect on depression outcomes via level of engagement in therapy.
Early identification and treatment of MDD is crucial. However there are many barriers to seeking and fully engaging in treatment. Social stigma, the notion that depression can be treated by will-power, and the lack of motivation that accompanies depression all contribute to a low percentage of individuals that may benefit from treatment actually receiving it. Because tailored communication gathers individualized information from and about the patient, it assists the physician in giving specific feedback regarding symptoms and concerns. It can help the patient understand their own experience in context, as well as to motivate their follow-up with treatment. Tailored communication may provide an enormous opportunity to enhance patient-centered care through patient self-identification and more personalized communication about relevant health/mental health issues.
Once identified, patient preference for treatment modality must be considered. Again, assessment, feedback, and sharing of information about the disorder as relevant to the individual will assist the patient in making choices about treatment options. Research suggests that matching patient preference with treatment modality may improve treatment response to a moderate degree but likely enhances the potential for engagement and follow-through with the treatment substantially. An individual that only wants medication and no psychotherapy for depression may have unrealistic expectations of the “pill curing the disease,” and this will be an issue for ongoing therapeutic discussion. Likewise, an individual who refuses medication and only agrees to the continuation of psychotherapy that has been only partially effective for the depression after several months, also will benefit from ongoing engagement around treatment choices. Patient engagement and a trusting connection with the treater is the bedrock of all therapy. Patient-centered care that is tailored for the patient and takes into consideration patient preference is most likely to result in treatment engagement and subsequent symptom relief (14).