This is a fictional composite. It is not a description of an actual patient.
A psychiatrist reviews a patient's chart before follow-up. The record shows one psychotherapy visit, then no further sessions. The referral note now says, "Patient refused therapy."
That sentence sounds efficient. It is also more certain than the record allows.
The chart shows attendance followed by nonattendance. It does not show why the person stopped, what happened in the first session, whether the treatment matched the person's goals, whether cost or scheduling made return impossible, or whether therapy continued somewhere else.
What the new study measured
An August 2026 JAMA Network Open study examined psychotherapy dropout among 40,732 adults with depression who received care in two academic medical centers, six community hospitals, and affiliated outpatient networks in Massachusetts.[1]
The investigators used electronic health record data from 2008 through 2022. Included patients were 18 to 80 years old, had a major depressive disorder code, completed at least one individual psychotherapy session, had at least one year of medical history before that session, and had at least one health-care visit in the year after it.
The study defined dropout as attending one to three individual psychotherapy sessions within one month, then having no psychotherapy in the same health system for five months. Sessions were at least 45 minutes. Patients who returned to psychotherapy within five months were not counted as dropouts.[1]
Under that definition, 11,571 people, or 28.4 percent, were classified as dropouts. Of those, 60.9 percent stopped after the first session, 29.3 percent after the second, and 9.7 percent after the third.[1]
That is a clinically important pattern. It is not a measure of refusal.
A utilization pattern is not a motive
The word "dropout" in this study is an operational label. It describes a sequence in one record system. It does not reveal the patient's intention.
The researchers did not have data on the type of psychotherapy, the clinician's credentials or experience, or the patient's symptom severity. They could not determine whether someone continued therapy outside the health system. They also did not directly measure reasons for stopping.[1]
Several very different stories can therefore produce the same EHR pattern:
The first session did not match what the patient expected.
The patient preferred medication, a different psychotherapy, a group format, or another clinician.
The therapist recommended transfer to a different level or type of care.
Work, childcare, transportation, language, disability, cost, or technology made return impractical.
Depression, anxiety, trauma symptoms, substance use, cognitive difficulty, or medical illness interfered with attendance.
The person improved enough to decide not to continue.
The person felt misunderstood, unsafe, stigmatized, or culturally mismatched.
Therapy continued outside the observed system.
The study does not tell us how often each explanation occurred. That uncertainty is the point. A clinician should not replace missing information with a character judgment.
"Did not return" is an observation. "Refused treatment," "was unmotivated," and "was noncompliant" are interpretations that require evidence.
Prediction is not destiny
The researchers tested logistic-regression and random-forest models using demographic information, diagnoses, medications, procedures, and prior health-care encounters. The models discriminated between dropout and nondropout better than chance, but only modestly. Test area-under-the-curve values were 0.64 for logistic regression and 0.66 for the random forest.[1]
The authors explicitly caution that a feature identified as important may not be clinically meaningful or causally related to psychotherapy dropout. They give routine medical tests as an example: a urinalysis or pregnancy test should not be read as causing dropout. Such codes may instead mark contact with medical care.[1]
The same caution matters when demographic associations appear. In this cohort, patients who identified as White or non-Hispanic were less likely to meet the dropout definition. That finding should not become an individual prediction about motivation. Nor should race or ethnicity be treated as a biological explanation for attendance.
The clinically relevant question is what the association may reveal about the system. Cost, access, prior experiences, trust, language, cultural fit, discrimination, and whether the offered treatment reflects the person's goals can all affect engagement. The study did not adjudicate those mechanisms for individual patients.
A risk signal can justify asking earlier and more carefully. It cannot justify lowering expectations, withholding a referral, or writing the outcome in advance.
The first session is already a retention encounter
Among people classified as dropouts, most stopped after one visit. This means that engagement cannot be postponed until session three or four.
Current NICE depression guidance recommends discussing what the person believes contributes to the depression, previous treatment experiences, preferred options, hoped-for gains, delivery format, and factors most likely to support engagement. It also recommends addressing disability, language, and communication barriers, matching treatment to clinical needs and preferences, and reviewing treatment within two to four weeks.[2]
Those principles turn a vague instruction to "improve motivation" into a structured assessment of goals, treatment expectations, format, clinician fit, prior experience, and practical barriers. A companion Present/Absent/Unknown worksheet can make those domains visible without converting missing information into a conclusion.
Download the Present/Absent/Unknown Psychotherapy Engagement Worksheet (PDF).
This assessment does not assume that every departure can or should be prevented. It makes the decision interpretable.
Medical burden can change the pathway
In the study, prior medical admission and several markers of medical care were associated with higher dropout likelihood. Prior psychiatric evaluation and group psychotherapy were associated with lower likelihood.[1]
These are associations, not intervention effects. The study did not randomize patients to an evaluation, group therapy, or integrated-care pathway. It therefore cannot prove that adding a brief encounter will retain a particular patient.
The authors interpret the pattern as support for testing approaches that integrate mental-health care into medical settings. For a psychiatrist, the immediate lesson is narrower. A person referred while managing acute medical problems may be entering psychotherapy with a different set of expectations and constraints than someone who independently sought it.
The assessment should make that context visible. Is therapy competing with diagnostic workup, pain, fatigue, medication changes, repeated appointments, or fear about physical illness? Was the referral explained as an option, or did it feel like dismissal of a medical concern? Does the person need a different pace, setting, or point of entry?
Medical complexity should invite coordination and adaptation. It should not become a shorthand explanation for disengagement.
Document the state you actually know
Documentation can preserve uncertainty without becoming vague.
Instead of "patient refused psychotherapy," a note might say:
The patient attended one individual psychotherapy session in this system. No subsequent psychotherapy visit is visible since [date of last session]. The reason for discontinuation is not established in the available record. At follow-up, clarify treatment preference, experience of the first session, access barriers, outside care, current symptoms, and safety.
If the patient directly declines, document that decision and the discussion around it. Record which option was offered, the person's stated reason if they wish to give one, alternatives considered, risk and safety assessment, and the follow-up plan. A documented choice is different from an inferred choice.
If the patient cannot be reached, say that. Record the outreach method and what remains unknown. An unsuccessful contact attempt is not evidence that the person rejected care.
If treatment continued elsewhere, update the care map rather than preserving the dropout label. The EHR boundary is not the boundary of the patient's life.
Four questions before calling it refusal
Before turning nonattendance into a judgment, ask:
What did the patient believe the referral was for?
Was psychotherapy the patient's choice, one option among several, or a condition attached to another service?
Did the first session leave the patient feeling understood and safe enough to return?
If the person chooses not to continue, what alternative and follow-up plan is acceptable?
The answers may confirm a clear decision, reveal a remediable barrier, or leave uncertainty. Each is more accurate than assuming refusal from the attendance pattern alone.
The distinction
Psychotherapy dropout can be a useful research outcome and a serious clinical signal. It tells us that a planned course did not continue in the observed setting. It can prompt earlier assessment of fit, access, medical burden, prior experience, culture, preference, symptoms, and safety.
It does not, by itself, tell us what the patient decided or why.
Treatment refusal is a choice. Dropout in an EHR is a pattern. Good psychiatric care does not confuse the two.
Sources
1. Giber B, Sharma A, Broadie D, et al. Identifying Patients at Risk for Psychotherapy Dropout in Community Settings. JAMA Network Open. 2026;9(8):e2631565. Open full text; DOI 10.1001/jamanetworkopen.2026.31565; PMID 42658492.
2. National Institute for Health and Care Excellence. Depression in adults: treatment and management. NG222. Recommendations. Full public guidance; recommendations on assessment, treatment choice, engagement, barriers, monitoring, and follow-up reviewed.
Educational Disclaimer: The Psychiatric Record provides general educational information for psychiatric and mental-health professionals. Content does not constitute medical, legal, regulatory, compliance, billing, or other professional advice; does not establish a standard of care; and is not a substitute for independent professional judgment. Appropriate assessment and treatment depend on the patient, setting, available interventions, evidence, and current authoritative guidance. This article does not recommend starting, continuing, stopping, or changing any medication or treatment for any individual, and it does not determine that any person refused, failed, or completed psychotherapy. The patient described is a fictional composite; no individual is depicted.