Antidepressant Adherence: Are Patients Taking Their Medications?

| June 6, 2012 | 0 Comments

by Randy A. Sansone, MD, and Lori A. Sansone, MD
Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician (civilian) and Medical Director, Family Health Clinic, Wright-Patterson Medical Center in WPAFB, Ohio. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or position of the United States Air Force, Department of Defense, or US government.

Innov Clin Neurosci. 2012;9(5–6):41–46

This ongoing column is dedicated to the challenging clinical interface between psychiatry and
primary care—two fields that are inexorably linked.

Funding: There was no funding for the development and writing of this article.

Financial Disclosures: The authors have no conflicts of interest relevant to the content of this article.

Key words: Adherence, antidepressants, compliance, nonadherence

Abstract: Depression is a relatively common clinical disorder and can be difficult to effectively treat according to findings from the Sequenced Treatment Alternatives to Relieve Depression study. Given this working terrain, patient adherence with antidepressant therapy is a critical aspect of effective clinical management. However, according to contemporary data (i.e., over the past 10 years), approximately 50 percent of psychiatric patients and 50 percent of primary care patients prematurely discontinue antidepressant therapy (i.e., are nonadherent when assessed at six-months after the initiation of treatment). The reasons behind patient nonadherence to antidepressants are varied and include both patient factors (e.g., concerns about side effects, fears of addiction, belief that these medications will not really address personal problems) as well as clinician factors (e.g., lack of sufficient patient education, poor follow-up). An awareness of the high rates of antidepressant nonadherence among patients hopefully will underscore to the prescriber the importance of carefully exploring patient concerns about these medications and closely monitoring patients while on therapy.

Introduction

According to the findings of the study, Sequenced Treatment Alternatives to Relieve Depression (STAR*D),[1] depressive disorders can be challenging to treat. Indeed, after exposure to four different treatment levels or intervention options, approximately one-third of patients in this study (the largest of its kind) never achieved remission.[1] The potential challenge in treating patients with depression invites the following clinical query—what is the expected antidepressant nonadherence rate among patients in clinical samples, particularly in psychiatric and primary care populations?

The current Practice Guideline for the Treatment of Patients with Major Depressive Disorder[2] describes phasic pharmacological treatment of depression with the acute phase lasting 4 to 8 weeks, the continuation phase lasting 4 to 9 months, and a discontinuation phase lasting “several weeks,” indicating that the minimum duration of treatment with antidepressants for new-onset depression would seem to be six months, with routine treatment duration of up to one year. Given this guideline, Trivedi et al[3] indicate that only 25 to 50 percent of patients with major depression adhere to treatment.[3] In this same vein, Keller et al[4] indicate that patient adherence with antidepressant medication is poor.

Given this backdrop, we now examine the empirical terrain of antidepressant nonaderence among patients. To do so, we undertook a literature search of the PubMed and PsycINFO databases back to 2001 (i.e., approximately 10 years), entering the following search terms: antidepressant, compliance, adherence, and nonadherence, and collected studies with patient samples from both psychiatric and primary care settings. Because these types of studies appear to be described with various key words, we may have missed several studies, and therefore refer to our review as a sampling of recent studies. In addition, we excluded studies in foreign languages if data could not be extracted from the English abstract.

Antidepressant NonAdherence in Psychiatric Populations

Through a literature search of antidepressant nonadherence in psychiatric populations, we encountered five studies (Table 1).[5–9] One study[5] was from the United States whereas the remaining four studies were from various countries in Asia. Sample sizes ranged from 76 to 2,405 individuals. As expected, the methodologies in these studies varied and included retrospective, current, and prospective designs. Data collection was diverse and obtained through a review of medical records or healthcare data, administered surveys, or utilization of a medication tracking system. In addition, across these studies, investigators used differing definitions of nonadherence. In summarizing findings, the overall nonadherence rates for antidepressant prescriptions ranged from 13 percent (at the outset of prescription) to 55.7 percent. In averaging those studies that examined antidepressant nonadherence at six months (2 studies), the nonadherence rate was 52 percent.



Antidepressant NonAdherence in Primary Care Populations

Through a literature search of antidepressant adherence in primary care populations, we encountered considerably more studies (Table 2).[5,10–21] Of these 13 studies, seven were from the United States and six were from various other countries (the majority from Europe). Sample sizes ranged from 272 to 266,665 individuals. As expected, there were various methodologies in these studies, as well, including retrospective approaches, current patient impressions, and prospective designs. Data were elicited through a review of patient or pharmacy records, pharmacy claims, or national registries. In these studies, investigators used differing definitions of antidepressant nonadherence, as well. The overall nonadherence rates for antidepressant prescriptions ranged from 5.4 to 87.6 percent. In parceling out the eight studies that examined nonadherence during a six-month period,[5,10–12,14,15,18,21] the averaged rate of antidepressant nonadherence was 46.2 percent (in determining this overall average, we used an averaged percentage for the range presented in the Sheehan et al study,[15] which resulted in a rate of 77.5%).

Comparison of Samples

Given the limitations imposed by the variations in methodology, in comparing the six-month antidepressant nonadherence rates between psychiatric populations (52%) and primary care populations (46.2%), the percentages are very close. Findings indicate that approximately one-half of patients, either from psychiatric or primary care settings, will be nonadherent to antidepressant treatment. Interestingly, note that in both the Kennedy study[17] and the Fortney study,[21] rates of nonadherence were surprisingly low at 5.4 percent and 4.8 percent, respectively. Both of these low rates occurred in clinical populations with government-sponsored insurance (e.g., Veterans Administration, Medicare beneficiaries). This deviation from the general findings warrants further investigation (i.e., does low-cost or no-cost insurance improve antidepressant adherence?).

Reasons for Patient Nonadherence to Antidepressants

There appears to be a broad range of reasons why patients discontinue antidepressants prematurely. Bulloch and Patten[19] found that simply forgetting was the main reason for patient non-adherence. Fortney et al[21] found that side effects were a commonly reported reason for antidepressant discontinuation. Kennedy et al[17] found that lower adherence was associated with higher cost of the medication, medications not covered by insurance, the patient perception that the medication was not necessary, and patient’s fears of side effects. Deterrents to adherence may also include medication-induced sexual dysfunction;[22] patient fears that antidepressants will be difficult to discontinue after being taken for a long time, and concerns that antidepressants may alter personality;[23] patient belief that antidepressants do not really solve a person’s problems;[24] delayed onset of medication action;[25] poor instruction by the clinician about the antidepressant;[26] specific personality characteristics of patients such as extraversion[27] and/or Cluster B[28] or other personality disorder symptoms;29 patient substance abuse;[29] patient fears of addiction;[30] lower patient depression severity;[31] complicated titration or dosing schedule of the medication;32 lack of follow-up care by the clinician;[32] and low patient motivation.32 How these factors load with regard to specific clinical populations (e.g., psychiatric vs. primary care) remains unknown. Suffice it to say that there are numerous reasons why patients prematurely discontinue antidepressant therapy.

Conclusions

From our sampling and review of studies examining patient antidepressant nonadherence over the past 10 years, we can draw two general conclusions: 1) about 50 percent of patients discontinue antidepressant therapy prematurely; and 2) this percentage does not meaningfully differ between psychiatric and primary care populations. We may also conclude that patients prematurely discontinue antidepressant therapy for a number of possible reasons, some patient-related (e.g., side effects, misperceptions about the medication) and some clinician-related (e.g., poor instruction by the clinician about the medication, lack of follow-up care). Appreciating the high nonadherence rate to treatment with antidepressants will hopefully underscore the importance of carefully educating patients about this type of treatment, exploring questions and possible misperceptions that patients may have, and consistently monitoring patients for medication adherence.

References
1.    Gaynes BN, Warden D, Trivedi MH, et al. What did STAR*D teach us? Results from a large-scale, practical, clinical trial for patients with depression. Psychiatr Serv. 2009;60:1439–1445.
2.    American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder, 3rd Edition. Washington, DC: American Psychiatric Press Inc; 2010.
3.    Trivedi MH, Lin EH, Katon WJ. Consensus recommendations for improving adherence, self-management, and outcomes in patients with depression. CNS Spectr. 2007;12:S1–27.
4.    Keller MB, Hirschfeld RM, Demyttenaere K, Baldwin DS. Optimizing outcomes in depression: focus on antidepressant compliance. Int Clin Psychopharmacol. 2002;17:265–271.
5.    Bambauer KZ, Soumerai SB, Adams AS, et al. Provider and patient characteristics associated with antidepressant nonadherence: the impact of provider specialty. J Clin Psychiatry. 2007;68:867–873.
6.    Yeh MY, Sung SC, Yorker BC, et al. Predictors of adherence to an antidepressant medication regimen among patients diagnosed with depression in Taiwan. Issues Ment Health Nurs. 2008;29:701–717.
7.    Sawada N, Uchida H, Suzuki T, et al. Persistence and compliance to antidepressant treatment in patients with depression: a chart review. BMC Psychiatry. 2009;9:38.
8.    Shigemura J, Ogawa T, Yoshino A, et al. Predictors of antidepressant adherence: results of a Japanese Internet-based survey. Psychiatry Clin Neurosci. 2010;64:179–186.
9.    Lee MS, Lee HY, Kang SG, et al. Variables influencing antidepressant medication adherence for treating outpatients with depressive disorders. J Affect Disord. 2010;123:216–221.
10.    Demyttenaere K, Enzlin P, Dewe W, et al. Compliance with antidepressants in a primary care setting, 1: beyond lack of efficacy and adverse events. J Clin Psychiatry. 2001;62:S30–33.
11.    Hansen DG, Vach W, Rosholm JU, et al. Early discontinuation of antidepressants in general practice: association with patient and prescriber characteristics. Fam Pract. 2004;21:623–629.
12.    Cantrell CR, Eaddy MT, Shah MB, et al. Methods for evaluating patient adherence to antidepressant therapy: a real-world comparison of adherence and economic outcomes. Med Care. 2006;44:300–303.
13.    Akincigil A, Bowblis JR, Levin C, et al. Adherence to antidepressant treatment among privately insured patients diagnosed with depression. Med Care. 2007;45:363–369.
14.    Hansen DG, Gichangi A, Vach W, et al. Early discontinuation: more frequent among general practitioners with high levels of prescribing. Eur J Clin Pharmacol. 2007;63:861–865.
15.    Sheehan DV, Keene MS, Eaddy M, et al. Differences in medication adherence and healthcare resource utilization patterns: older versus newer antidepressant agents in patients with depression and/or anxiety disorders. CNS Drugs. 2008;22:963–973.
16.    Vanelli M, Coca-Perraillon M. Role of patient experience in antidepressant adherence: a retrospective data analysis. Clin Ther. 2008;30:1737–1745.
17.    Kennedy J, Tuleu I, Mackay K. Unfilled prescriptions of Medicare beneficiaries: prevalence, reasons, and types of medicines prescribed. J Manag Care Pharm. 2008;14:553–560.
18.    Hrique A, Kahn J-P. Guidelines and reality in practical use of and compliance to antidepressants in the treatment of depression: incidence survey in Lorraine and Champagne-Ardenne. Encephale. 2009;35:73–79.
19.    Bulloch AG, Patten SB. Nonadherence with psychotropic medications in the general population. Soc Psychiatry Psychiatr Epidemiol. 2010;45:47–56.
20.    Serna MC, Cruz I, Real J, et al. Duration and adherence of antidepressant treatment (2003–2007) based on prescription database. Eur Psychiatry. 2010;25:206–213.
21.    Fortney JC, Pyne JM, Edlund MJ, et al. Reasons for antidepressant nonadherence among Veterans treated in primary care clinics. J Clin Psychiatry. 2011;72:827–834.
22.    Cohen S, Khn KU, Strter B, et al. Adverse side-effect on sexual function caused by psychotropic drugs and psychotropic substances. Nervenarzt. 2010;81:1129–1139.
23.    Chakraborty K, Avasthi A, Kumar S, Grover S. Attitudes and beliefs of patients of first episode depression towards antidepressants and their adherence to treatment. Soc Psychiatry Psychiatr Epidemiol. 2009;44:482–488.
24.    Hoencamp E, Stevens A, Haffmans J. Patients’ attitudes toward antidepressants. Psychiatr Serv. 2002;53:1180–1181.
25.    Keller MB, Hirschfeld RMA, Demyttenaere K, Baldwin DS. Optimizing outcomes in depression: focus on antidepressant compliance. Int Clin Psychopharmacol. 2002;17:265–271.
26.    Woolley SB, Fredman L, Goethe JW, et al. Hospital patients’ perceptions during treatment and early discontinuation of serotonin selective reuptake inhibitor antidepressants. J Clin Psychopharmacol. 2010;30:716–719.
27.    Cohen NL, Ross EC, Bagby RM, et al. The 5-factor model of personality and antidepressant medication compliance. Can J Psychiatry. 2004;49:106–113.
28.    Holma IA, Holma KM, Melartin TK, Isometsa ET. Treatment attitudes and adherence of psychiatric patients with major depressive disorder: a five-year prospective study. J Affect Disord. 2010;127:102–112.
29.    Akerblad AC, Bengtsson F, Holgersson M, et al. Identification of primary care patients at risk of nonadherence to antidepressant treatment. Patient Prefer Adherence. 2008;2:379–386.
30.    Brown C, Battista DR, Bruehlman R, et al. Beliefs about antidepressant medications in primary care patients: relationship to self-reported adherence. Med Care. 2005;43:1203–1207.
31.    Demyttenaere K, Adelin A, Patrick M, et al. Six-month compliance with antidepressant medication in the treatment of major depressive disorder. Int Clin Psychopharmacol. 2008;23:36–42.
32.    Massand PS. Tolerability and adherence issues in antidepressant therapy. Clin Ther. 2003;25:2289–2304.

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Category: Mood Disorders, Past Articles, Primary Care, Psychiatry, The Interface

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