The role of the primary care physician in patients' adherence to antidepressant therapy

The relationship between relational continuity and family physician follow-up after an antidepressant prescription in older adults: a retrospective cohort study

BACKGROUND

Side effects can occur within hours to days of starting antidepressant medications, whereas full therapeutic benefit for mood typically takes up to four weeks. This mismatch between time to harm and lag to benefit often leads to premature discontinuation of antidepressants, a phenomenon that can be partially reversed through early doctor-patient communication and follow-up. We investigated the relationship between relational continuity of care - the number of years family physicians have cared for older adult patients - and early follow-up care for patients prescribed antidepressants.

METHODS

A retrospective cohort study was conducted on residents of Ontario, Canada aged 66 years or older who were dispensed their first antidepressant prescription through the provincial drug insurance program between April 1, 2016, and March 31, 2019. The study utilized multivariable regression to estimate the relationship between relational continuity and 30-day follow-up with the prescribing family physician. Separate estimates were generated for older adults living in urban, non-major urban, and rural communities.

RESULTS

The study found a small positive relationship between relational continuity of care and follow-up care by the prescribing family physician for patients dispensed a first antidepressant prescription (RRR = 1.005; 95% CI = 1.004, 1.006). The relationship was moderated by the patients' location of dwelling, where the effect was stronger for older adults residing in non-major urban (RRR = 1.009; 95% CI = 1.007, 1.012) and rural communities (RRR = 1.006; 95% CI = 1.002, 1.011).

CONCLUSIONS

Our findings do not provide strong evidence of a relationship between relational continuity of care and higher quality management of antidepressant prescriptions. However, the relationship is slightly more pronounced in rural communities where access to continuous primary care and specialized mental health services is more limited. This may support the ongoing need for the recruitment and retention of primary care providers in rural communities.

Sociodemographic and clinical predictors of adherence to antidepressants in depressive disorders: a systematic review with a meta-analysis

Introduction: Current evidence reveals concerning rates of non-adherence to antidepressant treatment, possibly influenced by various relevant determinants such as sociodemographic factors or those related to the health system and their professionals. The aim of this paper is to review the scientific evidence on sociodemographic and clinical predictors of adherence to pharmacological treatment in patients diagnosed with a depressive disorder. Methods: a systematic review (SR) was conducted. The search for a previous SR was updated and de novo searches were performed in Medline, EMBASE, Web of Science (WoS) and PsycInfo (last 10 years). The risk of bias was assessed using the Cochrane tool for non-randomized studies-of Exposure (ROBINS-E). Meta-analyses were conducted. Results: Thirty-nine studies (n = 2,778,313) were included, 24 of them in the meta-analyses. In the initiation phase, no association of adherence was found with any of the predictors studied. In the implementation and discontinuation phases, middle-aged and older patients had better adherence rates and lower discontinuation rates than younger ones. White patients adhered to treatment better than African-American patients. Discussion: Age and ethnicity are presented as the predictive factors of pharmacological adherence. However, more research is needed in this field to obtain more conclusive results on other possible factors. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023414059], identifier [CRD42023414059].

Care Delivery for Patients with Leiomyomas: Failures, Real-Life Experiences, Analysis of Barriers, and Proposed Restorative Remedies

In this narrative review, we describe historical and contemporary influences that prevent patients with fibroids from getting appropriate medical care. Using patient stories as examples, we highlight how misogyny on all levels hurts patients and prevents medical teams from doing their best. Importantly, inequity and disparities result in massive gaps in care delivery. We suggest that we, as gynecologists and surgeons, must join public discourse on this topic to highlight the inadequacies of care delivery and the reasons behind it, suggest potential solutions, and join patients and communities in formulating and implementing remedies.

Botulinum Toxin Treatment for Depression: A New Paradigm for Psychiatry

Multiple randomized double-blind placebo-controlled trials have shown that botulinum toxin A (BoNT/A), when injected into the frown musculature, is an antidepressant. This review outlines the conceptual narrative behind this treatment modality, starting with theory developed by Charles Darwin. We develop the concept of emotional proprioception and discuss how the muscles of facial expression play an important role in relaying valenced information to the brain's emotional neuroanatomical circuit. We review the role of facial frown musculature as the brain's barometer and transmitter of negatively valanced emotional information. The direct connections between the corrugator muscles and the amygdala are reviewed, and these provide a neuroanatomical circuit that is a logical target for treatment with BoNT/A. The centrality of amygdala dysfunction in the pathogenesis of many psychiatric disorders, and the evidence that BoNT/A modulates amygdala activity, provides the mechanistic link between BoNT/A and its antidepressant activity. Animal models of BoNT/A's antidepressant effects confirm the evolutionary conservation of this emotional circuit. The clinical and theoretical implications of this evidence, as it relates to the potential treatment of a broad range of psychiatric disorders by BoNT/A, is discussed. The ease of administration, long duration, and favorable side effect profile of this therapy is reviewed in the context of existing antidepressant treatments.

Differences in sexual adverse events for premature ejaculation medications from a public federal database

American Urological Association (AUA) guidelines recommend selective serotonin reuptake inhibitors (SSRI) as first-line pharmacotherapy for premature ejaculation (PE). While previous studies have described sexual adverse events (AE) associated with each medication, there is limited data directly comparing rates of specific sexual AEs across SSRIs. This study investigates the Food and Drug Administration Adverse Event Reporting System (FAERS) database for reports of monotherapy use of fluoxetine 20 mg, paroxetine 20 mg, sertraline 50 mg, and sertraline 100 mg in males from January 2004-June 2021. We examined 2608 reports from patients using SSRIs for PE or other psychiatric conditions. The average number of AEs was significantly different (p < 0.01) with paroxetine 20 mg having the highest (5.1 AEs/case report). Changes in libido was the most common sexual AE for fluoxetine 20 mg (6.7% of reports), paroxetine 20 mg (4.2%), and sertraline 50 mg (7.2%) while orgasm disorder was the most reported for sertraline 100 mg (3.9%). The SSRIs had different rates of changes in libido, erection disorder, orgasm disorder, and other sexual dysfunction (outside those listed). The SSRIs also differed in the rates of fatigue, ear/hearing changes, headache, and psychological AEs. The differences in specific AEs warrant future studies to determine true differences that would affect patient counseling.

Evolutionary Aspects of Diverse Microbial Exposures and Mental Health: Focus on "Old Friends" and Stress Resilience

The prevalence of inflammatory disease conditions, including allergies, asthma, and autoimmune disorders, increased during the latter half of the twentieth century, as societies transitioned from rural to urban lifestyles. A number of hypotheses have been put forward to explain the increasing prevalence of inflammatory disease in modern urban societies, including the hygiene hypothesis and the "Old Friends" hypothesis. In 2008, Rook and Lowry proposed, based on the evidence that increased inflammation was a risk factor for stress-related psychiatric disorders, that the hygiene hypothesis or "Old Friends" hypothesis may be relevant to psychiatric disorders. Since then, it has become more clear that chronic low-grade inflammation is a risk factor for stress-related psychiatric disorders, including anxiety disorders, mood disorders, and trauma- and stressor-related disorders, such as posttraumatic stress disorder (PTSD). Evidence now indicates that persons raised in modern urban environments without daily contact with pets, relative to persons raised in rural environments in proximity to farm animals, respond with greater systemic inflammation to psychosocial stress. Here we consider the possibility that increased inflammation in persons living in modern urban environments is due to a failure of immunoregulation, i.e., a balanced expression of regulatory and effector T cells, which is known to be dependent on microbial signals. We highlight evidence that microbial signals that can drive immunoregulation arise from phylogenetically diverse taxa but are strain specific. Finally, we highlight Mycobacterium vaccae NCTC 11659, a soil-derived bacterium with anti-inflammatory and immunoregulatory properties, as a case study of how single strains of bacteria might be used in a psychoneuroimmunologic approach for prevention and treatment of stress-related psychiatric disorders.

Patients' attitudes toward conventional and herbal treatments for depression and anxiety: A cross-sectional Israeli survey

BACKGROUND

As many patients view conventional antidepressants and anxiolytics negatively, it is not surprising that the willingness to apply these treatments is far from ideal, thus posing a critical barrier in promoting an effective and durable treatment.

AIM

The present study aimed to explore patients' attitudes toward conventional and herbal treatments for depression and anxiety, while considering cultural and demographic factors, to further elucidate the antecedes that putatively determine the treatment's outcome.

METHODS

During June 2017, a cross-sectional survey was conducted using stratified sampling from a large-scale Israeli volunteer online panel. The final sample included 591 Jewish Israeli adults that reported they were suffering from depression or anxiety.

RESULTS

A heterogeneous range of attitudes toward treatment was found: for example, a large group of patients did not utilize prescription medications (39%), a professional consultation (12.9%), or any form of treatment (17.4%). Interestingly, these patients were significantly more likely to support naturally-derived treatments and were less concerned with scientific proof. Further, adverse effects were demonstrated as a prominent factor in the choice of treatment. A higher incidence of adverse effects was associated with an increased willingness to consider an alternative herbal treatment. Noteworthy attitudes were found in orthodox-Jewish individuals, who showed similar consultation rates, but utilized more psychological, rather than pharmacological treatments.

CONCLUSIONS

It is proposed that patients' perspectives and cultural backgrounds are needed to be taken into consideration during the clinical assessment and choice of treatment. The findings imply that a particular emphasis should be placed on patients that discard conventional pharmacological options and on distinct cultural aspects. Several recommendations for revising the current policy are advocated to promote more culturally-informed and patient-oriented care.

Association of Antidepressant Prescription Filling With Treatment Indication and Prior Prescription Filling Behaviors and Medication Experiences

BACKGROUND

Given the wide range of uses for antidepressants, understanding indication-specific patterns of prescription filling for antidepressants provide valuable insights into how patients use these medications in real-world settings.

OBJECTIVE

The objective of this study was to determine the association of antidepressant prescription filling with treatment indication, as well as prior prescription filling behaviors and medication experiences.

DESIGN

This retrospective cohort study took place in Quebec, Canada.

PARTICIPANTS

Adults with public drug insurance prescribed antidepressants using MOXXI (Medical Office of the XXIst Century)-an electronic prescribing system requiring primary care physicians to document treatment indications and reasons for prescription stops or changes.

MEASURES

MOXXI provided information on treatment indications, past prescriptions, and prior medication experiences (treatment ineffectiveness and adverse drug reactions). Linked claims data provided information on dispensed medications and other patient-related factors. Multivariable logistic regression models estimated the independent association of not filling an antidepressant prescription (within 90 d) with treatment indication and patients' prior prescription filling behaviors and medication experiences.

RESULTS

Among 38,751 prescriptions, the prevalence of unfilled prescriptions for new and ongoing antidepressant therapy was 34.2% and 4.1%, respectively. Compared with depression, odds of not filling an antidepressant prescription varied from 0.74 to 1.57 by indication and therapy status. The odds of not filling an antidepressant prescription was higher among adults filling < 50% of their medication prescriptions in the past year and adults with an antidepressant prescription stopped or changed in the past year due to treatment ineffectiveness.

CONCLUSION

Antidepressant prescription filling behaviors differed by treatment indication and were lower among patients with a history of poor prescription filling or ineffective treatment with antidepressants.

Adherence to Desvenlafaxine Versus Usual Care and Its Impact on Health Outcomes: A Comparative Real-world Clinical Study

BACKGROUND AND OBJECTIVE

Low adherence to treatment is associated with poorer clinical outcome and greater healthcare resources utilization (HRU). Limited data are available on the extent of adherence to each individual antidepressant. The goal of this study was to compare the adherence rate to desvenlafaxine versus usual care with selective serotonin reuptake inhibitors (SSRI) and/or other serotonin-norepinephrine reuptake inhibitors (SNRI), in subjects with major depressive disorder (MDD).

METHODS

Retrospective, multi-centric, observational study including 574 outpatients with MDD. Data were collected from mental and primary care centers. Adherence, persistence, effectiveness, and HRU was evaluated through multivariate regression models.

RESULTS

At 12-months, adjusted adherence rate was higher with desvenlafaxine versus SNRI/SSRI, 67.9% versus 59.9% (OR 1.66, 95% CI 1.07-2.59, p = 0.024). Remission rate was numerically higher with desvenlafaxine versus SNRI/SSRI, 55.9% versus 50.1% (OR 1.35, 95% CI 0.93-1.98, p = 0.118), as well as treatment response, 76.5% in desvenlafaxine group versus 70.8% in SNRI/SSRI group (OR 1.25, 95% CI 0.82-1.90, p = 0.300). Medical visits use was higher in SNRI/SSRI than in desvenlafaxine group [9.8 (4.8) versus 9.1 (6.0), p = 0.019].

CONCLUSIONS

Desvenlafaxine is significantly associated with a higher adherence rate at 12 months compared to usual care based on SSRI or other SNRI. This suggests that desvenlafaxine could improve disease management having a positive impact on disease-associated costs.

The selective 5-HT1A receptor biased agonists, F15599 and F13714, show antidepressant-like properties after a single administration in the mouse model of unpredictable chronic mild stress

RATIONALE

The prevalence of depression is ever-increasing throughout the population. However, available treatments are ineffective in around one-third of patients and there is a need for more effective and safer drugs.

OBJECTIVES

The antidepressant-like and procognitive effects of the "biased agonists" F15599 (also known as NLX-101) which preferentially targets postsynaptic 5-HT1A receptors and F13714, which targets 5-HT1A autoreceptors, were investigated in mice.

METHODS

Antidepressant-like properties of the compounds and their effect on cognitive functions were assessed using the forced swim test (FST) and the novel object recognition (NOR), respectively. Next, we induced a depressive-like state by an unpredictable chronic mild stress (UCMS) procedure to test the compounds' activity in the depression model, followed by measures of sucrose preference, FST, and locomotor activity. Levels of phosphorylated cyclic AMP response element-binding protein (p-CREB) and phosphorylated extracellular signal-regulated kinase (p-ERK1/2) were also determined.

RESULTS

F15599 reduced immobility time in the FST over a wider dose-range (2 to 16 mg/kg po) than F13714 (2 and 4 mg/kg po), suggesting accentuated antidepressant-like properties in mice. F15599 did not disrupt long-term memory consolidation in the NOR at any dose tested, while F13714 impaired memory formation, notably at higher doses (4-16 mg/kg). In UCMS mice, a single administration of F15599 and F13714 was sufficient to robustly normalize depressive-like behavior in the FST but did not rescue disrupted sucrose preference. Both F15599 and F13714 rescued cortical and hippocampal deficits in p-ERK1/2 levels of UCMS mice but did not influence the p-CREB levels.

CONCLUSIONS

Our studies showed that 5-HT1A receptor biased agonists such as F13714 and especially F15599, due to its less pronounced side effects, might have potential as fast-acting antidepressants.

Depression

Most psychiatric care is delivered in primary care settings, where depression is the most common presenting psychiatric symptom. Given the high prevalence of depression worldwide and the well-established consequences of untreated depression, the ability of primary care clinicians to effectively diagnose and treat it is critically important. This article offers up-to-date guidance for the diagnosis and treatment of major depressive disorder, including practical considerations for delivering optimal and efficient care for these patients.

Trajectories of depression in psychotherapy: How client characteristics predict clinical improvement

OBJECTIVE

The current study aims to ascertain the trajectories of psychotherapy clients' symptom change and identify client factors that predict treatment outcome.

METHOD

We conducted a latent growth mixture model (LGMM) to identify the change trajectories of 44 clients' depression scores during psychotherapy. Client characteristics were then explored to determine whether any were associated with change trajectories. We examined whether the number of physician visits and/or client self-concealment scores predict 63 clients' improvement after controlling for initial symptom severity.

RESULTS

Two trajectories of clients' symptom change were identified: nonimprovers (52.3%) and improvers (47.7%). Nonimprovers had higher levels of self-concealment and baseline depression than improvers. The number of physician visits was associated with higher depression scores at baseline and greater clinical improvement during psychotherapy.

CONCLUSION

Clients showed distinct trajectories of symptom change in psychotherapy. Early identification of clients at risk for treatment failure may increase the probability of therapeutic success.

Barriers and facilitators to GP-patient communication about emotional concerns in UK primary care: a systematic review

BACKGROUND

In the UK, general practitioners (GPs) are the most commonly used providers of care for emotional concerns.

OBJECTIVE

To update and synthesize literature on barriers and facilitators to GP-patient communication about emotional concerns in UK primary care.

DESIGN

Systematic review and qualitative synthesis.

METHOD

We conducted a systematic search on MEDLINE (OvidSP), PsycInfo and EMBASE, supplemented by citation chasing. Eligible papers focused on how GPs and adult patients in the UK communicated about emotional concerns. Results were synthesized using thematic analysis.

RESULTS

Across 30 studies involving 342 GPs and 720 patients, four themes relating to barriers were: (i) emotional concerns are difficult to disclose; (ii) tension between understanding emotional concerns as a medical condition or arising from social stressors; (iii) unspoken assumptions about agency resulting in too little or too much involvement in decisions and (iv) providing limited care driven by little time. Three facilitative themes were: (v) a human connection improves identification of emotional concerns and is therapeutic; (vi) exploring, explaining and negotiating a shared understanding or guiding patients towards new understandings and (vii) upfront information provision and involvement manages expectations about recovery and improves engagement in treatment.

CONCLUSION

The findings suggest that treatment guidelines should acknowledge: the therapeutic value of a positive GP-patient relationship; that diagnosis is a two-way negotiated process rather than an activity strictly in the doctor's domain of expertise; and the value of exploring and shaping new understandings about patients' emotional concerns and their management.

Reprint of: The role of the pharmacist in mental health: An investigation of the impact of pharmacist-led interventions on psychotropic medication adherence in patients with diabetes

OBJECTIVE

To evaluate the impact of targeted telepharmacist mental health adherence interventions for patients with type 2 diabetes.

METHODS

This retrospective review involved the analysis of a telepharmacist-led mental health intervention. The subjects included: patients aged 18 years or more with type 2 diabetes, enrolled in an adherence service and who had been prescribed psychotropics. Psychotropic medication adherence was measured using the proportion of days covered (PDC) 6 months before and after the telepharmacist-led medication intervention.

RESULTS

A total of 8167 patients (67% women), with a mean age of 63 ± 11 years, were included in the study. Most alerts for psychotropics were for selective serotonin reuptake inhibitors (SSRIs) (53%, n = 4334), selective norepinephrine reuptake inhibitors (SNRIs) (22%, n = 1775), second-generation antipsychotics (11%, n = 909), and bupropion (10%, n = 782). Alerts with the greatest volume of PDCs (above 85%) at postintervention follow up included SSRIs (51%, n = 2228), SNRIs (50%, n = 884), and second-generation antipsychotics (47%, n = 424). Before the alert, the mean PDC was 66% ± 12% across all medications studied. Post intervention, the mean PDC rose to 79% ± 19. A paired t-test revealed statistically significant improvement in adherence overall, with the greatest change observed in these alert groups: SSRIs (P < 0.001), alpha-2 antagonist (P < 0.001), SNRIs (P < 0.001), and bupropion (P < 0.001).

CONCLUSION

This retrospective review showed that pharmacist-led targeted, adherence interventions greatly improved psychotropic medication adherence in adult patients with type 2 diabetes. Future work is warranted to investigate the impact on type 2 diabetes medication adherence and health markers (e.g., HbA1c values) in larger and more diverse populations of patients with comorbid type 2 diabetes and a mental health condition.

The association between side effects and adherence to antidepressants among primary care community-dwelling older adults

Aims: To evaluate the association between adherence to antidepressants and self-reported side effects while considering their tolerability among primary care community-dwelling older adults.Methods: This is a secondary analysis of data available for 137 individuals participating in the third wave of the Étude sur la Santé des Aînés - Services study (2015-2017) conducted among older adults aged 65 years and older. Adherence to antidepressants was assessed with the 4-item Medication Assessment Questionnaire. Side effects were also self-reported from a list of 20 potential side effects related to antidepressant use, while considering their tolerability (tolerable and non-tolerable) and were then grouped into seven categories specific to organ or function systems. Multilevel logistic regression analyses were carried out to assess the association between adherence and the presence of side effects accounting for participants nested within primary health clinics.Results: In this study, 69.3% of participants were adherent to their antidepressants and 30.7% were non-adherent. Participants reporting sleep disturbance (OR = 0.58, 95% CI = 0.47-0.72), gastrointestinal system (OR = 0.64, 95% CI = 0.45-0.92), and nervous system (OR = 0.60, 95% CI = 0.48-0.78) related side effects were less likely to be adherent to their antidepressants. Participants reporting palpitations were more likely to adhere to antidepressants (OR = 2.20, 95% CI = 1.03-4.67). With regards to severity, participants reporting non-tolerable nervous system related side effects were less likely to be adherent (OR = 0.37, 95% CI = 0.26-0.53) and those reporting non-tolerable gastrointestinal system related side effects reported higher adherence to antidepressants (OR = 1.82, 95% CI = 1.08-3.08).Conclusion: Adherence to antidepressants was associated with side effects, and more precisely with sleep disturbance, gastrointestinal and nervous systems side effects.

Moving Towards Optimized Noncommunicable Disease Management in the ASEAN Region: Recommendations from a Review and Multidisciplinary Expert Panel

Introduction

Noncommunicable diseases (NCDs) are the leading cause of morbidity and mortality in the Association of Southeast Asian Nations (ASEAN) member states. Progress has been slow despite the World Health Organization action plan for the prevention and control of NCDs in the region. This paper presents recommendations focused on practical strategies for optimizing NCD management in the ASEAN region.

Methods

A multidisciplinary group of experts from six ASEAN member states convened for two face-to-face meetings to discuss barriers and possible recommendations for optimizing NCD management, focused on cardiovascular diseases and mental disorders, in the region. Multiple approaches, ie, analysis of insights from the meetings and a review of existing literature on NCD programs in the ASEAN region were followed. The proposed recommendations were also based on selected successful interventions in ASEAN member states, thus providing actionable strategies.

Results

The gaps identified in NCD management for cardiovascular diseases and mental disorders in the ASEAN region were classified into gaps relating to policies and to clinical and public health practice. The proposed solutions addressing policy gaps include fostering multisectoral public–private partnerships, employing “whole-of-government” and “whole-of-society” approaches and promoting “health-in-all policies approach” to manage issues with financing, accessibility, efficiency and quality of health services. Whereas proposed solutions to bridge clinical and public health practice gaps entail strengthening primary care services, building the capacity of trained healthcare workers and employing collaborative care for holistic management of patients.

Conclusion

The scale of premature and preventable deaths from NCDs in the ASEAN region remains a serious public health concern and requires a “whole-of-system approach”. The interventions proposed in this paper build on regional collaborations and knowledge sharing to help develop a concerted and targeted response to NCDs.

The role of the pharmacist in mental health: An investigation of the impact of pharmacist-led interventions on psychotropic medication adherence in patients with diabetes

OBJECTIVE

To evaluate the impact of targeted telepharmacist mental health adherence interventions for patients with type 2 diabetes.

METHODS

This retrospective review involved the analysis of a telepharmacist-led mental health intervention. The subjects included: patients aged 18 years or more with type 2 diabetes, enrolled in an adherence service and who had been prescribed psychotropics. Psychotropic medication adherence was measured using the proportion of days covered (PDC) 6 months before and after the telepharmacist-led medication intervention.

RESULTS

A total of 8167 patients (67% women), with a mean age of 63 ± 11 years, were included in the study. Most alerts for psychotropics were for selective serotonin reuptake inhibitors (SSRIs) (53%, n = 4334), selective norepinephrine reuptake inhibitors (SNRIs) (22%, n = 1775), second-generation antipsychotics (11%, n = 909), and bupropion (10%, n = 782). Alerts with the greatest volume of PDCs (above 85%) at postintervention follow up included SSRIs (51%, n = 2228), SNRIs (50%, n = 884), and second-generation antipsychotics (47%, n = 424). Before the alert, the mean PDC was 66% ± 12% across all medications studied. Post intervention, the mean PDC rose to 79% ± 19. A paired t-test revealed statistically significant improvement in adherence overall, with the greatest change observed in these alert groups: SSRIs (P < 0.001), alpha-2 antagonist (P < 0.001), SNRIs (P < 0.001), and bupropion (P < 0.001).

CONCLUSION

This retrospective review showed that pharmacist-led targeted, adherence interventions greatly improved psychotropic medication adherence in adult patients with type 2 diabetes. Future work is warranted to investigate the impact on type 2 diabetes medication adherence and health markers (e.g., HbA1c values) in larger and more diverse populations of patients with comorbid type 2 diabetes and a mental health condition.

Younger age negatively impacts depression-associated exacerbation of hemoglobin A1c levels in type 2 diabetes: Implications for intervention

Adults with type 2 diabetes (T2DM) and depression are associated with higher hemoglobin A_1C (HbA_1C ) compared to their nondepressed counterparts. Little is known about related clinical and demographic components contributing to these differences. We examined differences in HbA_1C between adults who have T2DM with and without major depression. T tests and chi-square analyses measured differences in HbA_1C and clinical/demographic variables. HbA_1C was statistically higher in depressed participants compared to nondepressed participants. The difference was no longer statistically significant after controlling for age. Age and HbA_1C were negatively correlated across the sample and were still correlated in each group independently. The interaction of age and HbA_1C was moderated by depression status. Additionally, mechanisms for diabetes severity differences were assessed using moderation analyses and Blinder-Oaxaca decomposition technique. Seventy-four percent of the mean outcome HbA_1C difference between depressed and nondepressed diabetic participants was explained by age. Furthermore, age was negatively correlated with clinical variables, such as diastolic blood pressure and cholesterol. Comparing age to smoking and nonsmoking participants, smokers were statistically younger. Younger adults with T2DM may require more attention regarding self-management, particularly in the context of depression. Depression should be screened and treated among individuals with diabetes since this exacerbates diabetes severity.

How to improve adherence to antidepressant treatments in patients with major depression: a psychoeducational consensus checklist

Studies conducted in primary care as well as in psychiatric settings show that more than half of patients suffering from major depressive disorder (MDD) have poor adherence to antidepressants. Patients prematurely discontinue antidepressant therapy for various reasons, including patient-related (e.g., misperceptions about antidepressants, side-effects, and lack of tolerability), clinician-related (e.g., insufficient instruction received by clinicians about the medication, lack of shared decision-making, and follow-up care), as well as structural factors (e.g., access, cost, and stigma). The high rate of poor adherence to antidepressant treatments provides the impetus for identifying factors that are contributing to noncompliance in an individual patient, to implement a careful education about this phenomenon. As adherence to antidepressants is one of the major unmet needs in MDD treatment, being associated with negative outcomes, we sought to identify a series of priorities to be discussed with persons with MDD with the larger aim to improve treatment adherence. To do so, we analyzed a series of epidemiological findings and clinical reasons for this phenomenon, and then proceeded to define through a multi-step consensus a set of recommendations to be provided by psychiatrists and other practitioners at the time of the first (prescription) visit with patients. Herein, we report the results of this initiative.

The epidemiology of antidepressant use in South Korea: Does short-term antidepressant use affect the relapse and recurrence of depressive episodes?

Background

The duration of antidepressant use affects the treatment of depression. Using the National Health Insurance database, which covers almost the entire national population, we verified the factors associated with the inadequate short-term use of initially prescribed antidepressants and their effects on the relapse and recurrence of depressive episodes.

Methods

There were 752,190 patients included who had been newly prescribed antidepressants in 2012 with the diagnosis of depressive disorder. They were followed-up until December 31, 2015. They were classified as short-term and long-term antidepressant users depending on whether they used a specific initial antidepressant for at least four weeks. Sociodemographic, clinical, and medical utilization factors affecting the duration of antidepressant use were investigated. We also identified whether the duration of antidepressant use affected the risk of relapse and recurrence, which was defined by the restarting of antidepressants.

Results

Initial antidepressants were taken for less than 28 days by 458,057 (60.84%) patients. Tricyclic antidepressants were used as the initial antidepressant more frequently than selective serotonin reuptake inhibitors (64.5% versus 19.3%). The type of initial antidepressant, polypharmacy, psychiatric and medical comorbidities, type of insurance coverage, and type of medical institution visited were associated with short-term use. Short-term use marginally increased the risk of relapse and recurrence of depressive episodes (Hazard ratio: 1.06, 95% confidence intervals 1.048–1.075).

Conclusions

Short-term antidepressant use is widespread in Korea, and assessment in various aspects are necessary to set proper treatment plans.

Old Friends, immunoregulation, and stress resilience

There is a considerable body of evidence indicating that chronic adverse experience, especially chronic psychosocial stress/trauma, represents a major risk factor for the development of many somatic and affective disorders, including inflammatory bowel disease (IBD) and posttraumatic stress disorder (PTSD). However, the mechanisms underlying the development of chronic stress-associated disorders are still in large part unknown, and current treatment and prevention strategies lack efficacy and reliability. A greater understanding of mechanisms involved in the development and persistence of chronic stress-induced disorders may lead to novel approaches to prevention and treatment of these disorders. In this review, we provide evidence indicating that increases in immune (re-)activity and inflammation, potentially promoted by a reduced exposure to immunoregulatory microorganisms ("Old Friends") in today's modern society, may be causal factors in mediating the vulnerability to development and persistence of stress-related pathologies. Moreover, we discuss strategies to increase immunoregulatory processes and attenuate inflammation, as for instance contact with immunoregulatory Old Friends, which appears to be a promising strategy to promote stress resilience and to prevent/treat chronic stress-related disorders.

Non-adherence to antidepressants among older patients with depression: a longitudinal cohort study in primary care

BACKGROUND

Depression is common among older adults and is typically treated with antidepressants.

OBJECTIVE

To determine the non-adherence rates to antidepressants among older adults in primary care, based on non-initiation, suboptimal implementation or non-persistence.

METHODS

We selected all patients aged ≥60 years and diagnosed with depression in 2012, from the Netherlands Institute for Health Services Research (NIVEL) Primary Care Database. Non-initiation was defined as no dispensing within 14 days of the first prescription; suboptimal implementation, as fewer than 80% of the days covered by dispensed dosages; and non-persistence, as discontinuation within 294 days after first dispense. First, we determined the antidepressant non-initiation, suboptimal implementation and non-persistence rates. Second, we examined whether comorbidity and chronic drug use were associated with non-adherence by mixed-effects logistic regression (non-initiation or suboptimal implementation as dependent variables) and a clustered Cox regression (time to non-persistence).

RESULTS

Non-initiation, suboptimal implementation and non-persistence rates were 13.5%, 15.2% and 37.1%, respectively. As the number of chronically used drugs increased, the odds of suboptimal implementation (odds ratio, 0.89; 95% confidence interval, 0.83-0.95) and of non-persistence (hazard ratio, 0.87; 95% confidence interval, 0.82-0.92) reduced.

CONCLUSIONS

Non-adherence to antidepressants is high among older patients with depression in primary care settings. Adherence is better when patients are accustomed to taking larger numbers of prescribed drugs, but this only provides partial explanation of the variance. GPs should be aware of the high rates of non-adherence. Emphasizing the importance of adhering to the optimal length of antidepressant therapy might be prudent first steps to improving adherence.

The association between physician's affiliation and patients' adherence to their antihypertensive medication and pharmaceutical knowledge

BACKGROUND

The aim of this study was to examine whether or not the type of physician is associated with the knowledge of and adherence to hypertensive medication among patients.

METHODS

The study was a self-administered questionnaire survey among patients who submitted their prescriptions for antihypertensive drugs to 13 pharmacies in Japan in 2006. We compared patients' knowledge of their medications and the self-reported adherence according to the type of physician.

RESULTS

A total of 736 patients were surveyed, and 687 (362 from clinics and 325 from hospitals) were analyzed. In total, 51.8% of the patients correctly named their antihypertensive medicine, with no significant differences observed between clinics and hospitals (51.4% in clinics vs 52.3% in hospitals; P = 0.81, adjusted odds ratio (OR) to the hospital: 0.736, 95% confidence interval [CI]: 0.50-1.08). Significant differences were not observed in the knowledge of the frequency with which hypertensive medication was supposed to be taken (47.2% in clinics vs 46.5% in hospitals; P = 0.84, adjusted OR: 0.80, 95% CI: 0.55-1.16), nor observed in the knowledge of the side effects of the medication (53.2% in clinics vs 51.0% in hospitals; P = 0.57, adjusted OR: 1.14, 95% CI: 0.78-1.68). No significant difference was observed in self-reported adherence (75.1% in clinics vs 77.7% in hospitals; P = 0.42, adjusted OR: 0.73, 95% CI: 0.46-1.16).

CONCLUSIONS

About 75% answered that they were taking their medication as instructed. No significant differences were observed in responses based on the physician's affiliation. Further studies are needed to achieve better patient's adherence and pharmaceutical knowledge.

Whole-Body Heating: An Emerging Therapeutic Approach to Treatment of Major Depressive Disorder

Major depressive disorder is the leading cause of disability worldwide. Currently available pharmacological approaches to the treatment of depression (which are the mainstay of treatment in the United States) suffer from important shortcomings, including limited efficacy, delayed onset of action, increased relapse risk upon withdrawal, and significant side effects that impair quality of life and promote treatment nonadherence and/or discontinuation. There is an emerging interest in the potential use of evolutionarily conserved interoceptive pathways (i.e., pathways that relay sensory information, related to the internal, physiologic state of the body, from the periphery to the central nervous system) as "gateways" to neural systems controlling affective and cognitive function relevant to the pathophysiology of depression. In support of the potential utility of this approach, we have shown in open and randomized, double-blind, sham-controlled trials that infrared whole-body heating has significant and long-lasting antidepressant effects relative to a sham condition. In this review, we explore the potential role of thermosensory pathways in the etiology, pathophysiology, and symptomatology of major depressive disorder, as well as its potential as a novel therapeutic approach to the treatment of major depressive disorder.

Protocol of an ongoing randomized controlled trial of care management for comorbid depression and hypertension: the Chinese Older Adult Collaborations in Health (COACH) study

Background

Depression and hypertension are common, costly, and destructive conditions among the rapidly aging population of China. The two disorders commonly coexist and are poorly recognized and inadequately treated, especially in rural areas.

Methods

The Chinese Older Adult Collaborations in Health (COACH) Study is a cluster randomized controlled trial (RCT) designed to test the hypotheses that the COACH intervention, designed to manage comorbid depression and hypertension in older adult, rural Chinese primary care patients, will result in better treatment adherence and greater improvement in depressive symptoms and blood pressure control, and better quality of life, than enhanced Care-as-Usual (eCAU). Based on chronic disease management and collaborative care principles, the COACH model integrates the care provided by the older person’s primary care provider (PCP) with that delivered by an Aging Worker (AW) from the village’s Aging Association, supervised by a psychiatrist consultant. One hundred sixty villages, each of which is served by one PCP, will be randomly selected from two counties in Zhejiang Province and assigned to deliver eCAU or the COACH intervention. Approximately 2400 older adult residents from the selected villages who have both clinically significant depressive symptoms and a diagnosis of hypertension will be recruited into the study, randomized by the villages in which they live and receive primary care. After giving informed consent, they will undergo a baseline research evaluation; receive treatment for 12 months with the approach to which their village was assigned; and be re-evaluated at 3, 6, 9, and 12 months after entry. Depression and HTN control are the primary outcomes. Treatment received, health care utilization, and cost data will be obtained from the subjects’ electronic medical records (EMR) and used to assess adherence to care recommendations and, in a preliminary manner, to establish cost and cost effectiveness of the intervention.

Discussion

The COACH intervention is designed to serve as a model for primary care-based management of common mental disorders that occur in tandem with common chronic conditions of later life. It leverages existing resources in rural settings, integrates social interventions with the medical model, and is consistent with the cultural context of rural life.

Trial registration

ClinicalTrials.gov ID: NCT01938963; First posted: September 10, 2013.

Associations Among Depressive Symptoms, Wellness, Patient Involvement, Provider Cultural Competency, and Treatment Nonadherence: A Pilot Study Among Community Patients Seen at a University Medical Center

Treatment nonadherence is a pernicious problem associated with increasing rates of chronic diseases, escalating healthcare costs, and rising mortality in some patients. Although researchers have suggested numerous factors related to treatment nonadherence, several understudied aspects warrant attention, such as primary-care settings, provider cultural competence, and patient involvement. Adding to the research base, the present pilot study examined 88 primarily Black American and White American community patients from a large university medical center in the southern part of the United States. The study explored two research questions: (a) To what extent are there associations among depressive symptoms, wellness, patient involvement, cultural competency, and treatment nonadherence in a racially diverse community patient population? And (b) to what extent do the study exploratory variables and background characteristics predict treatment nonadherence, both separately and jointly? Depressive symptoms, the patient's perception of a provider's cultural competence, and marital/partnered status were found to be statistically significantly associated with treatment nonadherence, but not entirely in the directions expected.

Saffron in the treatment of depression, anxiety and other mental disorders: Current evidence and potential mechanisms of action

BACKGROUND

Depression and anxiety are two common mental health problems with high economic and social costs. Currently, a number of treatments are available for patients with depression and anxiety disorders such as psychotherapy, electroconvulsive therapy and antidepressant drugs. Due to safety concerns, adverse effects, limited efficacy and low tolerability associated with many antidepressant and anti-anxiety medications, identification of novel agents with less toxicity and more favorable outcome is warranted.

METHODS

The current article provides a non-systematic review of the available in vitro, in vivo and clinical evidence on the efficacy, safety and mechanisms of action of saffron and its active ingredients in the treatment of anxiety, depression and other mental disorders.

RESULTS

Several interesting data have been reported about the antidepressant and anti-anxiety properties of saffron, the dried stigmas of Crocus sativus L., in several preclinical and clinical studies. In particular, a number of clinical trials demonstrated that saffron and its active constituents possess antidepressant properties similar to those of current antidepressant medications such as fluoxetine, imipramine and citalopram, but with fewer reported side effects.

CONCLUSION

Saffron may exert antidepressant effects and represents an efficacious and safe treatment.

Cognitive and behavioural approaches to medication adherence

Medication non-adherence is a major obstacle to translating treatment efficacy in research settings into effectiveness in clinical practice (Dickson & Kendall, 1986; Scott, 1995). Randomised controlled trials indicate that brief interventions such as cognitive-behavioural educational packages for depression, cognitive therapy for lithium clinic attenders and compliance therapy for people with schizophrenia may be beneficial (Cochran, 1984; Katon et al, 1995; Kemp et al, 1996). However, clinical psychiatry has been surprisingly slow to investigate individual risk factors for medication non-adherence or to use strategies to enhance adherence that have been used extensively in other chronic illness populations.

Comparative effectiveness of switching paroxetine formulation for treatment of major depressive disorder: an open-label multicenter study

AIM

To assess the effectiveness and safety of switching the antidepressant formulation from immediate-release (IR) to controlled-release (CR) paroxetine in patients with major depressive disorder (MDD).

PATIENTS AND METHODS

A total of 113 outpatients with MDD diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, and treated with a stable dose of IR paroxetine for at least 6 months were enrolled. Patients were then switched to CR paroxetine for 8 weeks. Effectiveness was evaluated by scores on the Himorogi Self-Rating Depression/Anxiety Scales (HSDS/HSAS) and the Clinical Global Impression - Severity (CGI-S). Safety was evaluated based on the reported adverse drug reactions (ADRs). Medication satisfaction and preference were assessed based on questionnaire responses using Likert-type scales.

RESULTS

The overall patient HSDS/HSAS scores significantly improved after switching from IR to CR paroxetine (P<0.001). Furthermore, CR paroxetine was superior to IR paroxetine (P<0.001) according to the results of the CGI-S evaluation. ADRs were experienced by 14 (12.4%) patients, including dry mouth, nausea/vomiting, somnolence/drowsiness, and wakefulness/arousal during sleep. Satisfaction and preference for paroxetine improved after switching to the CR formulation (P<0.001; chi-square test).

CONCLUSION

These results suggest that switching the treatment from IR to CR paroxetine could improve depressive symptoms and decrease ADRs. However, these results may have been caused by the psychological effect of drug switching. Hence, future studies with blinded evaluation methods are required to confirm and expand our findings.

Does Patient Adherence to Antidepressant Medication Actually Vary Between Physicians?

OBJECTIVE

Previous research and improvement efforts have presumed that patients' nonadherence to antidepressant medication reflects physicians' quality of care. We used population-based health records to examine whether adherence to antidepressant medication actually varies between prescribing physicians.

METHODS

Electronic health records and insurance claims data from 5 integrated health systems in Washington, Idaho, Minnesota, Colorado, Hawaii, and California were used to identify 150,318 adults starting new episodes of antidepressant treatment for depression between January 1, 2010, and December 31, 2012. Early adherence was defined as any refill or dispensing of antidepressant medication in the 180 days following an initial antidepressant prescription. Patient-level demographic and clinical characteristics potentially associated with adherence were identified from health system records.

RESULTS

Average probability of early adherence was 82% for psychiatrists and 74% for primary care physicians. Among individual physicians, the range of raw or unadjusted early adherence rates (5th to 95th percentiles) was from 33% to 100% for psychiatrists and from 0% to 100% for primary care physicians. After accounting for sampling variation and case mix differences, the range of adjusted early adherence rates (5th to 95th percentiles) was from 72% to 78% for psychiatrists and from 64% to 69% for primary care physicians.

CONCLUSIONS

After accounting for sampling variation and case mix differences, early adherence to antidepressant medication varies minimally among prescribing physicians. Early discontinuation of antidepressant treatment is not an appropriate measure of individual physician performance, and efforts to improve adherence should emphasize system-level interventions rather than the performance of individual physicians.

Whole-body hyperthermia and a subthreshold dose of citalopram act synergistically to induce antidepressant-like behavioral responses in adolescent rats

BACKGROUND

Open and randomized, double blind, placebo-controlled clinical trials have demonstrated clinical efficacy of infrared whole-body hyperthermia in treatment of major depressive disorder (MDD). Demonstration of antidepressant-like behavioral effects of whole-body hyperthermia in preclinical rodent models would provide further support for the clinical use of infrared whole-body hyperthermia for the treatment of MDD, and would provide additional opportunities to explore underlying mechanisms.

METHODS

Adolescent male Wistar rats were habituated daily for 7days to an incubator (23°C, 15min), then exposed, 24h later, to an 85-min period of whole-body hyperthermia (37°C) or control conditions (23°C), with or without pretreatment with a subthreshold dose of the selective serotonin reuptake inhibitor, citalopram (5mg/kg, s.c., 23h, 5h, and 1h before behavioral testing in a 5-min forced swim test). Rectal temperature was monitored daily and immediately before and after the forced swim test to determine the relationship between body temperature and antidepressant-like behavioral responses.

RESULTS

Whole-body hyperthermia and citalopram independently increased body temperature and acted synergistically to induce antidepressant-like behavioral responses, as measured by increased swimming and decreased immobility in the absence of any effect on climbing behaviors in the forced swim test, consistent with a serotonergic mechanism of action.

CONCLUSIONS

Preclinical data support use of infrared whole-body hyperthermia in the treatment of MDD.

Impact of adherence to antidepressants on healthcare outcomes and costs among patients with type 2 diabetes and comorbid major depressive disorder

OBJECTIVE

To evaluate the association between adherence to antidepressants and an effect on clinical outcomes and healthcare costs in patients with major depressive disorder (MDD) and comorbid type 2 diabetes (T2D).

METHODS

This retrospective study used MarketScan claims data from January 2012 to March 2014. Study entry was the first claim for an antidepressant and a diagnosis code for MDD and T2D in the prior 6 months. Adherence and persistence with antidepressant therapy in the first 180 days were defined as medication possession ratio (MPR) ≥ 80% and length of therapy (LOT), with no treatment gap of >15 days, respectively. T2D control (HbA1c <7%), oral diabetes medication adherence, and healthcare costs were measured in the 12 month post-index period. The impact of antidepressant adherence and persistence on outcomes was assessed using multivariable analyses.

RESULTS

Among the 1361 patients included, the mean age was 59 years and 55% were women. About one-third of the patients were adherent (35.9%, mean MPR = 40%), persistent (32.0%, average LOT = 100 days), and adherent/persistent (31.2%) on antidepressants. Being adherent, persistent, or adherent/persistent to antidepressants was associated with a two-fold improvement in adherence to oral diabetes medications. Of those with HbA1c data (n = 121), adherence or adherence/persistence to antidepressants was associated with patients being five times more likely to have T2D control (odds ratio [OR]: 4.95; 95% confidence interval [CI]: 1.39, 17.59, p = .0134). Comparison between antidepressant-persistent and non-persistent patients was not significant. Mean difference in adjusted all-cause annual costs showed lower costs among antidepressant-adherent and adherent/persistent patients (adherent: -$350, 95% CI: -$462, -$247; adherent/persistent: -$1165; 95% CI: -$1280, -$1060).

CONCLUSIONS

Patients with better antidepressant adherence and adherence/persistence demonstrated better HbA1c control, with lower all-cause total and medical costs. Adherence, persistence, or adherence/persistence to antidepressants was associated with improved adherence to oral diabetes medications.

The Importance of Patient Satisfaction: A Blessing, a Curse, or Simply Irrelevant?

New regulations require that physician performance must be evaluated and graded in both objective and subjective ways. This represents a novel factor in American health care delivery driven by the reality that the United States spends more than any other nation on health care yet still lags behind in key outcome measures. Patient satisfaction has been established as a core component of physician rankings and reimbursement. In fact, it already has acted as both a powerful motivator and stressor. Patient feedback has driven hospital administrators' agendas to improve facilities and provide relative luxuries to inpatients, and individual providers have been tempted to ignore sound medical judgment by relenting to patient requests to increase their satisfaction scores. Unfortunately, there is little high-level evidence to support that patient satisfaction will improve medical outcomes, and there are plenty of contradictory data in smaller studies. Part of the difficulty of these studies may lie in the diversity of patient expectations, which are dependent on the disease process and the inherently subjective and labile nature of people's responses. Reliable tools are needed that will take into account what constitutes a superior quality of patient care in a more systematic, meaningful, and validated way.

Long-term efficacy and safety of lamotrigine for all types of bipolar disorder

BACKGROUND

We investigated whether the long-term efficacy and safety of lamotrigine (LTG) for bipolar disorder (BP) differs between disease types (BP-I, BP-II, or BP not otherwise specified [BP-NOS]), and the efficacy of the concomitant use of antidepressants (ADs).

METHODS

For >1 year, we observed 445 outpatients with BP (diagnosed by DSM-IV criteria) who initiated LTG treatment between July 1 and October 31, 2011, using the Himorogi Self-rating Depression (HSDS) and Anxiety Scales and the Clinical Global Impression-Improvement scale and also recorded adverse events.

RESULTS

Treatment efficacy was observed at week 4, with the improved HSDS scores sustained until week 52 for all types of BP; 50% of the patients with any type of BP could be treated with LTG for 1 year, whereas ~40% could be treated for >1.5 years. However, 25% of the patients were withdrawn within the first 4 weeks. The overall incidence of adverse events was 22.9% (104/455): 34.1% (14/41) for BP-I, 22.7% (15/66) for BP-II, and 22.2% (75/338) for BP-NOS. The most common adverse event was skin rash: 22.0% for BP-I, 16.7% for BP-II, and 12.1% for BP-NOS.

LIMITATIONS

There was no control group. Data were collected retrospectively.

CONCLUSION

With careful and adequate titration, long-term treatment with LTG is possible for any type of BP, with BP-NOS patients, the largest population in clinical practice, responding particularly well. Symptoms can improve with or without ADs. Large-scale prospective studies of the efficacy of ADs in bipolar treatment are warranted.

The effects of patient-centered depression care on patient satisfaction and depression remission

BACKGROUND

While health systems are striving for patient-centered care, they have little evidence to guide them on how to engage patients in their care, or how this may affect patient experiences and outcomes.

OBJECTIVE

To explore which specific patient-centered aspects of care were best associated with depression improvement and care satisfaction.

METHODS

Design: observational.

SETTING

83 primary care clinics across Minnesota.

SUBJECTS

Primary care patients with new prescriptions for antidepressants for depression were recruited from 2007 to 2009.

OUTCOME MEASURES

Patients completed phone surveys regarding demographics and self-rated health status and depression severity at baseline and 6 months. Patient centeredness was assessed via a modified version of the Patient Assessment of Chronic Illness Care. Differences in rates of remission and satisfaction between positive and negative responses for each care process were evaluated using chi-square tests.

RESULTS

At 6 months, 37% of 792 patients ages 18-88 achieved depression remission, and 79% rated their care as good-to-excellent. Soliciting patient preferences for care and questions or concerns, providing treatment plans, utilizing depression scales and asking about suicide risk were patient-centered measures that were positively associated with depression remission in the unadjusted model; these associations were mildly weakened after adjustment for depression severity and health status. Nearly all measures of patient centeredness were positively associated with care ratings.

CONCLUSION

The patient centeredness of care influences how patients experience and rate their care. This study identified specific actions providers can take to improve patient satisfaction and depression outcomes.

The DASH (Disabilities of the Arm, Shoulder and Hand) Outcome Measure: What do we know about it now?

Outcome measurement is an essential component for defining the effectiveness of clinicians’ practice (Reiman 1988) and standardised measures make that job more consistent, comparable and valid (Cole et al 1994). Hand therapists have long recognised the need for the standardisation of outcome measures, particularly for performance-based measures such as strength testing (Mathiowetz et al 1985, Woody et al 1988) or joint motion. More recently there has been an increased interest in outcome measures that capture the patient's perspective of their status, and that are standardised. The DASH (Disabilities of the Arm, Shoulder and Hand) is a standardised outcome measure that could be used for this purpose (Hudak et al 1996, McConnell et al 1999). The DASH reflects the impact of a disorder in terms of physical function and symptoms, which are the two main reasons patients seek care for a disorder of the musculoskeletal system. The DASH is becoming widely used by clinicians and researchers (McConnell et al 1999). It is now important to revisit what we know about how well the DASH is able to measure what it purports to measure.

The purpose of this paper is to review the research that has been done to date on the DASH outcome measure, and to describe the implications of this for future research and for clinical practice.

Pharmacological and psychosocial treatment of depression in primary care: Low intensity and poor adherence and continuity

BACKGROUND

Primary health care bears the main responsibility for treating depression in most countries. However, few studies have comprehensively investigated provision of pharmacological and psychosocial treatments, their continuity, or patient attitudes and adherence to treatment in primary care.

METHODS

In the Vantaa Primary Care Depression Study, 1111 consecutive primary care patients in the City of Vantaa, Finland, were screened for depression with Prime-MD, and 137 were diagnosed with DSM-IV depressive disorders via SCID-I/P and SCID-II interviews. The 100 patients with current major depressive disorder (MDD) or partly remitted MDD at baseline were prospectively followed up to 18 months, and their treatment contacts and the treatments provided were longitudinally followed.

RESULTS

The median number of patients' visits to a general practitioner during the follow-up was five; of those due to depression two. Antidepressant treatment was offered to 82% of patients, but only 50% commenced treatment and adhered to it adequately. Psychosocial support was offered to 49%, but only 29% adhered to the highly variable interventions. Attributed reasons for poor adherence varied, including negative attitude, side effects, practical obstacles, or no perceived need. About one-quarter (23%) of patients were referred to specialized care at some time-point.

LIMITATIONS

Moderate sample size. Data collected in 2002-2004.

CONCLUSIONS

The majority of depressive patients in primary health care had been offered pharmacotherapy, psychotherapeutic support, or both. However, effectiveness of these efforts may have been limited by lack of systematic follow-up and poor adherence to both pharmacotherapy and psychosocial treatment.

Depression Increases Diabetes Symptoms by Complicating Patients’ Self-Care Adherence

PURPOSE

This study evaluated whether diabetes patients with depressive symptoms are more likely than other diabetes patients to report symptoms of glucose dysregulation, and whether this relationship is mediated by the impact of depressive symptoms on patients' adherence to their diabetes self-care regimen.

METHODS

Participants were English- and Spanish-speaking adults with type 2 diabetes. Interviewers assessed participants' depressive symptoms and diabetes-related symptoms at baseline. Self-care behaviors and diabetes symptoms were measured at a 1-year follow-up. Structural equation models were used to determine whether depression affected diabetes symptoms by limiting patients' ability to adhere to self-care recommendations.

RESULTS

An initial model identified direct effects of baseline depressive symptoms on self-care and diabetes symptoms at follow-up. The relationship between self-care behaviors and physical symptoms of poor glycemic control were assessed using a second model. Results explained the relationship between depressive symptoms at baseline and diabetes symptoms at 1 year.

CONCLUSIONS

Depressive symptoms impact subsequent physical symptoms of poor glucose control by influencing patients' ability to adhere to their self-care regimen. More aggressive management of depression among patients with diabetes may improve their physical health as well as their mental health.

Times to Discontinue Antidepressants Over 6 Months in Patients with Major Depressive Disorder

OBJECTIVE

The aim of the present study was to investigate differences in discontinuation time among antidepressants and total antidepressant discontinuation rate of patients with depression over a 6 month period in a naturalistic treatment setting.

METHODS

We reviewed the medical records of 900 patients with major depressive disorder who were initially prescribed only one kind of antidepressant. The prescribed antidepressants and the reasons for discontinuation were surveyed at baseline and every 4 weeks during the 24 week study. We investigated the discontinuation rate and the mean time to discontinuation among six antidepressants groups.

RESULTS

Mean and median overall discontinuation times were 13.8 and 12 weeks, respectively. Sertraline and escitalopram had longer discontinuation times than that of fluoxetine, and patients who used sertraline discontinued use significantly later than those taking mirtazapine. No differences in discontinuation rate were observed after 24 weeks among these antidepressants. About 73% of patients discontinued antidepressant treatment after 24 weeks.

CONCLUSION

Sertraline and escitalopram tended to have longer mean times to discontinuation, although no difference in discontinuation rate was detected between antidepressants after 24 weeks. About three-quarters of patients discontinued antidepressant maintenance therapy after 24 weeks.

The Effect of a Drug Adherence Enhancement Program on the Drug Adherence Behaviors of Patients With Major Depressive Disorder in Thailand: A Randomized Clinical Trial

This study aimed to compare drug adherence behaviors during the sixth week between patients with first diagnosed major depressive disorder who received the Drug Adherence Enhancement Program and those who received only the usual care. A randomized clinical trial, post-test only design was conducted in the outpatient-unit of a medical school hospital in Bangkok, Thailand. The experimental and control groups consisted of 30 and 26 participants respectively. Participants in the experimental group exhibited significantly higher drug adherence behaviors than the control group. This is important for nurses in promoting adherence to antidepressant drugs for patients with first diagnosed major depressive disorder.

Impact of emergency department visit on disease self-management in adults with depression

Unexpected health-endangering events that lead to an emergency department visit may be perceived as “wake-up calls” and induce significant changes in health-related behavior (“health shock” effect). This study uses two waves of a survey of 826 adults with depression and finds that having an emergency department visit(s) increased medication adherence by 7.6 percentage points ( p < 0.05) relative to non-emergency department visitors but had no significant effect on counseling attendance (0.02% points, p = 0.380). Emergency department visits may provide an opportune teachable moment to initiate targeted interventions for positive behavioral change in adults with depression.

Biological activities of Zn(II)-S-methyl-cysteine complex as antiradical, inhibitor of acid phosphatase enzyme and in vivo antidepressant effects

The antidepressant effect of simple Zn(II) salts has been proved in several animal models of depression. In this study, a coordination metal complex of Zn(II) having a sulfur containing ligand is tested as antidepressant for the first time. Forced swimming test method on male Wistar rats shows a decrease in the immobility and an increase in the swimming behavior after treatment with [Zn(S-Met)2] (S-Met=S-methyl-l-cysteine) being more effective and remarkable than ZnCl2. The thiobarbituric acid and the pyranine consumption (hydroxyl and peroxyl radicals, respectively) methods were applied to evaluate the antioxidant activity of S-Met and [Zn(S-Met)2] showing evidence of attenuation of hydroxyl but not peroxyl radicals activities. UV-vis studies on the inhibition of acid phosphatase enzyme (AcP) demonstrated that S-methyl-l-cysteine did not produce any effect but, in contrast, [Zn(S-Met)2] complex behaved as a moderate inhibitor. Finally, bioavailability studies were performed by fluorescence spectroscopy denoting the ability of the albumin to transport the complex.

Analysis of treatment patterns and persistence on branded and generic medications in major depressive disorder using retrospective claims data

BACKGROUND

In major depressive disorder (MDD), treatment persistence is critical to optimize symptom remission, functional recovery, and health care costs. Desvenlafaxine tends to have fewer drug interactions and better tolerability than other MDD drugs; however, its use has not been assessed in the real world.

OBJECTIVE

The aim of the present study is to compare medication persistence and concomitant MDD drug use with branded desvenlafaxine (Pristiq^®) compared with antidepressant drug groups classified as 1) branded selective serotonin reuptake inhibitors (SSRIs; ie, escitalopram [Lexapro™]) and selective serotonin-norepinephrine reuptake inhibitors (SNRIs; ie, venlafaxine [Effexor^®], duloxetine [Cymbalta^®]) and 2) generic SSRIs/SNRIs (ie, escitalopram, citalopram, venlafaxine, fluvoxamine, fluoxetine, sertraline, paroxetine, and duloxetine).

PATIENTS AND METHODS

MDD patients (ICD-9-CM codes 296.2, 296.3), with ≥2 prescription fills for study drugs and 12-month preindex continuous enrollment from the MarketScan Commercial Claims and Encounters Database (2009-2013), were included. Time-to-treatment discontinuation (prescription gap ≥45 days) was assessed using the Kaplan-Meier curve and Cox model. Concomitant MDD drug use was compared.

RESULTS

Of the 273,514 patients included, 14,379 patients were initiated with branded desvenlafaxine, 50,937 patients with other branded SSRIs/SNRIs, and 208,198 patients with generic SSRIs/SNRIs. The number of weeks for treatment discontinuation for branded desvenlafaxine were longer (40.7 [95% CI: 39.3, 42.0]) compared with other branded SSRIs/SNRIs (28.9 [95% CI: 28.4, 29.1]) and generic SSRIs/SNRIs (33.4 [95% CI: 33.1, 33.7]). Adjusting for baseline characteristics, patients who were prescribed with other branded SSRIs/SNRIs were 31% and generic SSRIs/SNRIs were 11% more likely to discontinue treatment compared with branded desvenlafaxine. In sensitivity analysis, the risk of discontinuation was within 10% of branded desvenlafaxine for branded duloxetine, generic escitalopram, and generic venlafaxine. Concomitant MDD drug use was higher among branded desvenlafaxine patients (43.8%) compared with other branded SSRIs/SNRIs (39.8%) and generic SSRIs/SNRIs (36.4%).

CONCLUSION

MDD patients on branded desvenlafaxine were more persistent with treatment compared with those on other branded or generic SSRI/SNRI therapies. Future research should include assessments of underlying factors on the treatment persistence in MDD patients.

Treatment discontinuation and tolerability as a function of dose and titration of duloxetine in the treatment of major depressive disorder

PURPOSE

We sought to better understand how dose and titration with duloxetine treatment may impact tolerability and treatment discontinuation in patients with major depressive disorder.

PATIENTS AND METHODS

We investigated Phase III duloxetine trials. Group 1 was a single placebo-controlled study with a 20 mg initial dose and a slow titration to 40 and 60 mg. Group 2 was a single study with a 40 mg initial dose and final "active" doses of 40 and 60 mg (5 mg control group), with 1-week titration. Group 3 consisted of eight placebo-controlled studies with starting doses of 40, 60, and 80 mg/day with minimal titration (final dose 40-120 mg/day). Tolerability was measured by rate of discontinuation due to adverse events (DCAE).

RESULTS

The DCAE in Group 1 were 3.6% in the 60 mg group, 3.3% in the 40 mg group, and 3.2% in the placebo group. In Group 2, the DCAE were 15.0% in the 60 mg group, 8.1% in the 40 mg group, and 4.9% in the 5 mg group. In Group 3, the DCAE were 9.7% and 4.2% in the duloxetine and placebo groups, respectively.

CONCLUSION

This study suggests that starting dose and titration may have impacted tolerability and treatment discontinuation. A lower starting dose of duloxetine and slower titration may contribute to improving treatment tolerability for patients with major depressive disorder.

The effect of knowledge and expectations on adherence to and persistence with antidepressants

PURPOSE

Adherence to and persistence with antidepressants are often suboptimal. However, little is known about how patient knowledge and outcome expectations may influence antidepressant adherence and persistence.

METHOD

Individuals who had been prescribed their first antidepressant to treat depression in the preceding 6 months were recruited to an online survey via Facebook. Knowledge, education received, and initial outcome expectations were analyzed for associations with persistence and adherence.

RESULTS

Two hundred and twenty surveys were analyzed. A total of 117 participants had taken their antidepressant for at least 3 months; another 25 had never started or stopped after <3 months without consulting their doctor. Differences in expectations and various educational messages among persistent and nonpersistent participants were identified. Having received the instruction "don't stop it without checking with your doctor" was a significant independent predictor of persistence (odds ratio [OR] =5.9, 95% confidence interval [CI] =1.4-24.5). At the time of the survey, 82.7% of participants were taking an antidepressant and 77.9% were adherent. Significant independent predictors of adherence were a greater age (OR =1.1, 95% CI =1.0-1.2), knowledge (OR =1.6, 95% CI =1.1-2.3), being informed of common side effects (OR =5.5, 95% CI =1.1-29.0), and having discussed ways to solve problems (OR =3.9, 95% CI =1.1-14.5).

CONCLUSION

Improving outcome expectations and particular educational messages may increase adherence and persistence. Greater knowledge may enhance adherence. Further investigation is warranted to determine whether a focus on these simple educational messages will improve outcomes in patients who commence an antidepressant.

Physician perception regarding side-effect profile at the onset of antidepressant treatment: a survey of Israeli psychiatrists and primary care physicians

BACKGROUND

One of the major factors affecting treatment compliance and outcome in patients is the wide range of side effects (SEs) associated with antidepressants. In the present study, we aimed to assess the extent to which Israeli primary care (PC) physicians and psychiatrists discuss the SEs of selective serotonin reuptake inhibitors (SSRIs) with patients prior to the onset of treatment.

METHODS

A cross-sectional questionnaire survey was conducted among PC physicians (N = 123) and psychiatrists (N = 105). Questionnaires were distributed using a mixed-modality design, combining a web survey and in-person delivery of questionnaires.

RESULTS

A significant percentage of our respondents reported that they rarely discuss psychological (60 %) or severe (29 %) SEs of SSRIs. Nearly half (41 %) admitted to avoiding discussion of impact on suicidal ideation. Specialists were noted to discuss and evaluate SEs significantly more than residents, and Psychiatrists more than PC physicians. Specifically, psychiatrists more often discussed the possibility of sexual dysfunction (t (225) = 2.23; p < 0.05) and suicidal ideation (t (225) = 2.11; p < 0.05).

CONCLUSIONS

It seems that PC physicians and psychiatrists surveyed in this study do not share sufficient information regarding the SEs of SSRIs with their patients at the onset of treatment. In improving this practice, the integration of proper SE management into educational interventions has potential in enhancing compliance and improving expertise and level of care.

A medicinal herb, Melissa officinalis L. ameliorates depressive-like behavior of rats in the forced swimming test via regulating the serotonergic neurotransmitter

ETHNOPHARMACOLOGICAL RELEVANCE

Depression is a serious psychological disorder that causes extreme economic loss and social problems. However, the conventional medications typically cause side effects that result in patients opting to out of therapy. Lemon balm (Melissa officinalis L., MO) is an old and particularly reliable medicinal herb for relieving feelings of melancholy, depression and anxiety. The present study aims to investigate the antidepressant-like activity of water extract of MO (WMO) by evaluating its influence on the behaviors and the relevant neurotransmitters of rats performed to forced swimming test.

MATERIALS AND METHODS

Two phases of the experiment were conducted. In the acute model, rats were administered ultrapure water (control), fluoxetine, WMO, or the indicated active compound (rosmarinic acid, RA) three times in one day. In the sub-acute model, rats were respectively administered ultrapure water (control), fluoxetine, or three dosages of WMO once a day for 10 days. Locomotor activity and depression-like behavior were examined using the open field test and the forced swimming test, respectively. The levels of relevant neurotransmitters and their metabolites in the frontal cortex, amygdala, hippocampus, and striatum were analyzed by high performance liquid chromatography.

RESULTS

In the acute model, WMO and RA significantly reduced depressive-like behavior but the type of related neurotransmitter could not be determined. The results indicated that the effect of WMO administration on the reduction of immobility time was associated with an increase in swimming time of the rats, indicative of serotonergic neurotransmission modulation. Chromatography data validated that the activity of WMO was associated with a reduction in the serotonin turnover rate.

CONCLUSION

The present study shows the serotonergic antidepressant-like activity of WMO. Hence, WMO may offer a serotonergic antidepressant activity to prevent depression and to assist in conventional therapies.

Monitoring patients on chronic treatment with antidepressants between 2003 and 2011: analysis of factors associated with compliance

BACKGROUND

Clinical practice guidelines consider the use of antidepressants as one of the standard treatments for anxiety disorders, due to the significant improvements obtained in quality of life and functional disability. In addition, in patients who have not achieved a favorable response after 3 months of psychotherapy, antidepressants are recommended as part of a combined treatment approach. This combination with psychotropic drugs and psychotherapy appears to be indicated from baseline in patients with moderate, severe or recurrent depression. In the last decade, antidepressant prescription rates in general practice have increased between 4 and 10 times. Depression presents high rates of relapse and recurrence. Treatment is often interrupted prematurely, leading to increases in both relapse rates and health care costs. Few studies have analysed the chronic use of antidepressant drugs and long-term adherence.

OBJECTIVE

To evaluate compliance with antidepressant treatment between 2003 and 2011 and to explore the associated factors.

METHODS

Retrospective cohort study of antidepressant dispensing.

SETTING

Health Region of Lleida between 2003 and 2011.

PARTICIPANTS

Patients with chronic prescription of antidepressants (ATC code NO6A) during 2003 were followed up until December 2011. The sample comprised 3684 subjects.

MAIN MEASURES

The compliance rate was calculated on the basis of the number of units withdrawn from the pharmacy and the theoretical number of units required according to the scheduled duration of treatment: compliance was defined in cases with scores greater than or equal to 80%.

RESULTS

12.5% of patients received chronic antidepressant treatment for at least 4 years. Mean age was 54 years, and 73.2% of patients were female. Almost a third (32.4%) presented anxiety disorders and 26.5% mood disorders. The overall compliance rate was 22% (28% in patients with depression, and 21% in patients with anxiety). According to gender, compliance rates were 21.4% for males and 22.4% for females. Compliance was more likely in patients with polypharmacy.

CONCLUSIONS

One in 4 patients complied with treatment. Factors associated with better compliance were polypharmacy and diagnosis of depressive or mixed anxiety-depressive disorder.