High medication discontinuation rates in psychiatry: how often is it understandable?

Antidepressant effect of Perilla frutescens essential oil through monoamine neurotransmitters and BDNF/TrkB signal pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional Chinese medicine posits that affect-mind ill-being is the primary cause of depression, with Qi movement stagnation as its pathogenesis. As such, clinical treatment for depression should prioritize regulating Qi and relieving depressive symptoms. The pharmacological properties of traditional Chinese medicine indicate that Perilla frutescens may have potential therapeutic effects on depression and other neuropsychiatric diseases due to its ability to regulate Qi and alleviate depressive symptoms. Although previous studies have reported the antidepressant effects of Perilla frutescens, the mechanism underlying PFEO inhalation-mediated antidepressant effect remains unclear.

AIM OF THE STUDY

The aim of this investigation is to elucidate the antidepressant mechanisms of PFEO by examining its effects on monoamine neurotransmitters and the BDNF/TrkB signaling pathway.

MATERIALS AND METHODS

The CUMS rat model of depression was established, and the depressive state of the animals was assessed through sucrose preference and forced swim tests. ELISA assays were conducted to determine monoamine neurotransmitter levels in the hippocampus and cerebral cortex of rats. Immunohistochemistry, western blotting, and RT-PCR experiments were employed to investigate the BDNF/TrkB signaling pathway's regulation of depression via PFEO inhalation.

RESULTS

It has been observed that inhalation administration of PFEO can significantly enhance the preference for sugar water in CUMS rats and reduce their immobility time during forced swimming. Additionally, there was an increase in the levels of monoamine transmitters in both the hippocampus and cerebral cortex of these rats. Furthermore, there was an upregulation in the expression levels of BDNF and TrkB positive cells as well as BDNF and TrkB proteins within both regions, along with increased BDNF mRNA and TrkB mRNA expression levels.

CONCLUSION

The antidepressant effect of PFEO via inhalation administration is speculated to be mediated through the monoamine neurotransmitters and BDNF/TrkB signaling pathway.

How can we improve antidepressant adherence in the management of depression? A targeted review and 10 clinical recommendations

Adherence to antidepressants is crucial for optimal treatment outcomes when treating depressive disorders. However, poor adherence is common among patients prescribed antidepressants. This targeted review summarizes the main factors associated with poor adherence, interventions that promote antidepressant adherence, pharmacological aspects related to antidepressant adherence, and formulates 10 clinical recommendations to optimize antidepressant adherence. Patient-related factors associated with antidepressant non-adherence include younger age, psychiatric and medical comorbidities, cognitive impairment, and substance use disorders. Prescriber behavior-related factors include neglecting medical and family histories, selecting poorly tolerated antidepressants, or complex antidepressant regimens. Multi-disciplinary interventions targeting both patient and prescriber, aimed at improving antidepressant adherence, include psychoeducation and providing the patient with clear behavioral interventions to prevent/minimize poor adherence. Regarding antidepressant choice, agents with individually tailored tolerability profile should be chosen. Ten clinical recommendations include four points focusing on the patient (therapeutic alliance, adequate history taking, measurement of depressive symptoms, and adverse effects improved access to clinical care), three focusing on prescribing practice (psychoeducation, individually tailored antidepressant choice, simplified regimen), two focusing on mental health services (improved access to mental health care, incentivized adherence promotion and monitoring), and one relating to adherence measurement (adherence measurement with scales and/or therapeutic drug monitoring).

Immediate and persistent antidepressant-like effects of Chaihu-jia-Longgu-Muli-tang are associated with instantly up-regulated BDNF in the hippocampus of mice

Conventional antidepressants have a disadvantage in delayed onset of efficacy. Here, we aimed to evaluate the immediate and persistent antidepressant-like action of a classic herbal medicine Chaihu-jia-Longgu-Muli decoction (CLM) as well as the action of CLM on hippocampal brain-derived neurotrophic factor (BDNF) over time. CLM consists of Xiaochaihu decoction (XchD), Longgu-Muli (LM) and several other herbs. The contribution of constituent herbal formula XchD and other parts of CLM was also assessed. Following a single dose of CLM, tail suspension test (TST), forced swim test (FST), and novelty-suppressed feeding test (NSF) were performed. The antidepressant activity of XchD, its interaction with LM or remaining parts of CLM was also examined after a single administration. BDNF expression in the hippocampus was examined at 30 min and 24 hr post a single CLM. A single administration of half of clinical dose of CLM elicited antidepressant effects at TST 30 min post administration, and lasted for 72 hr. Furthermore, CLM also reduced the latency to eat in NSF test. A single proportional dose of XchD induced antidepressant effects at 30 min and lasted for 48 hr, whereas the effect lasted for 72 hr when combined with either LM or the remaining parts of CLM. BDNF expression increased at 30 min and persisted at least for 24 hr after a single dose of CLM. The results support that Chaihu-jia-Longgu-Muli decoction was capable to immediately and enduringly elicit antidepressant activity via enhancement of hippocampal BDNF expression, in which the constituent Xiaochaihu decoction played the primary role.

Why don't patients take their medicine? Reasons and solutions in psychiatry

Over the course of a year, about three-quarters of patients prescribed psychotropic medication will discontinue, often coming to the decision themselves and without informing a health professional. Costs associated with unplanned discontinuation may be substantial if left uncorrected. Partial non-adherence (much more common than full discontinuation) can also be detrimental, although some patients rationally adjust their medication regimen without ill-effect. This article reviews the literature on non-adherence, whether intentional or not, and discusses patients' reasons for failure to concord with medical advice, and predictors of and solutions to the problem of non-adherence.

Common Factors in Pediatric Psychiatry: A Review of Essential and Adjunctive Mechanisms of Treatment Outcome

OBJECTIVE

The purpose of this article is to review the literature on hypothesized behavioral correlates of pharmacotherapy treatment response. A particular focus is placed on what have been referred to as "common factors" across mental health treatments, including medication adherence, therapeutic alliance, motivation for behavior change, and expectancies for positive treatment outcomes. These understudied factors may provide unique explanations for mechanisms of symptom change, patient risk as a result of protocol deviation, and attenuated treatment outcomes.

METHOD

A literature search was conducted to evaluate the relationship between treatment processes in pediatric psychiatry and medication adherence, therapeutic alliance, motivation for behavior change, and expectancies for positive treatment outcomes.

RESULTS

Substantial variability and room for improvement was identified for each common factor. Behavioral protocols have already been developed to address many aspects of common factors in pediatric psychiatric treatment, but are not yet a part of many practice parameters.

CONCLUSION

Interventions to improve common factors can be used immediately in tandem with psychopharmacological interventions to provide increased symptom relief and reduce patient risk. Furthermore, incorporating instruction in common factors interventions can positively affect training of future providers and enhance understanding of the mechanisms of effect of medications. An increased focus on common factors, with a particular emphasis on quantifying the magnitude and mechanisms of their effects on psychopharmacological interventions stand to benefit child patients, their families, treatment providers, training facilities, and pharmaceutical manufacturers.

What’s in a name? Compliance, adherence and concordance in chronic psychiatric disorders

About half or more of the patients with chronic psychiatric illnesses, either do not take their medications correctly, or completely stop taking them. The problem of poor initial compliance or adherence is often compounded by a continued decline in compliance/adherence over time. The failure to take medicines, adversely affects the outcome of treatment, and places a huge burden of wasted resources on the society. Three terms have been used to describe medication-taking among patients with chronic psychiatric disorders. Compliance is defined as “the extent to which the patient’s behaviour matches the prescriber’s recommendations”. Though compliance has been frequently employed to describe medication-taking behaviour, it has proved problematic because it refers to a process where the clinician decides on a suitable treatment, which the patient is expected to comply with unquestioningly. Studies over the past few decades have emphasized the importance of patients’ perspectives in medication-taking, based on their own beliefs, their personal circumstances, the information and resources available for them. Adherence has been used as a replacement for compliance in an effort to place the clinician-patient relationship in its proper perspective. Adherence refers to a process, in which the appropriate treatment is decided after a proper discussion with the patient. It also implies that the patient is under no compulsion to accept a particular treatment, and is not to be held solely responsible for the occurrence of non-adherence. Adherence has been defined as “the extent to which a person’s behaviour, taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider”. To overcome certain problems in the concept of adherence, a third term concordance has been used. The concept of concordance has evolved from a narrower view, emphasizing an agreement between the clinician and the patient, which takes into account each other’s perspective on medication-taking, to a broader process consisting of open discussions with the patient regarding medication-taking, imparting information and supporting patients on long-term medication. It is a process, which entertains patients’ views on medication-taking, and acknowledges that patients’ views have to be respected even if they make choices, which appear to be in conflict with the clinician’s views. Although none of these terms are ideal solutions to understanding the complex process of medication-taking behaviour of patients, the move from compliance to adherence and concordance represents genuine progress in this field, which puts the patient’s perceptions at the centre of the whole process.

Epigenetic Modulation of Mood Disorders

BACKGROUND

Mood disorders are expressed in many heterogeneous forms, varying from anxiety to severe major clinical depression. The disorders are expressed in individual variety through manifestations governed by co-morbidities, symptom frequency, severity, and duration, and the effects of genes on phenotypes. The underlying etiologies of mood disorders consist of complex interactive operations of genetic and environmental factors. The notion of endophenotypes, which encompasses the markers of several underlying liabilities to the disorders, may facilitate efforts to detect and define, through staging, the genetic risks inherent to the extreme complexity of disease state.

AIMS

This review evaluates the role of genetic biomarkers in assisting clinical diagnosis, identification of risk factors, and treatment of mood disorders.

METHODS

Through a systematic assessment of studies investigating the epigenetic basis for mood disorders, the present review examines the interaction of genes and environment underlying the pathophysiology of these disorders.

RESULTS

The majority of research findings suggest that the notion of endophenotypes, which encompasses the markers of several underlying liabilities to the disorders, may facilitate efforts to detect and define, through staging, the genetic risks inherent to the extreme complexity of the disease states. Several strategies under development and refinement show the propensity for derivation of essential elements in the etiopathogenesis of the disorders affecting drug-efficacy, drug metabolism, and drug adverse effects, e.g., with regard to selective serotonin reuptake inhibitors. These include: transporter gene expression and genes encoding receptor systems, hypothalamic-pituitary-adrenal axis factors, neurotrophic factors, and inflammatory factors affecting neuroimmune function. Nevertheless, procedural considerations of pharmacogenetics presume the parallel investment of policies and regulations to withstand eventual attempts at misuse, thereby ensuring patient integrity.

CONCLUSIONS

Identification of genetic biomarkers facilitates choice of treatment, prediction of response, and prognosis of outcome over a wide spectrum of symptoms associated with affective states, thereby optimizing clinical practice procedures. Epigenetic regulation of primary brain signaling, e.g., serotonin and hypothalamic-pituitary-adrenal function, and factors governing their metabolism are necessary considerations. The participation of neurotrophic factors remains indispensable for neurogenesis, survival, and functional maintenance of brain systems.

Differences in the prescribing of medication for physical disorders in individuals with v. without mental illness: meta-analysis

BACKGROUND

There is some concern that patients with mental illness may be in receipt of inferior medical care, including prescribed medication for medical conditions.

AIMS

We aimed to quantify possible differences in the prescription of medication for medical conditions in those with v. without mental illness.

METHOD

Systematic review and random effects meta-analysis with a minimum of three independent studies to warrant pooling by drug class.

RESULTS

We found 61 comparative analyses (from 23 publications) relating to the prescription of 12 classes of medication for cardiovascular health, diabetes, cancer, arthritis, osteoporosis and HIV in a total sample of 1 931 509 people. In those with severe mental illness the adjusted odds ratio (OR) for an equitable prescription was 0.74 (95% CI 0.63-0.86), with lower than expected prescriptions for angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ACE/ARBs), beta-blockers and statins. People with affective disorder had an odds ratio of 0.75 (95% CI 0.55-1.02) but this was not significant. Individuals with a history of other (miscellaneous) mental illness had an odds ratio of 0.95 (95% CI 0.92-0.98) of comparable medication with lower receipt of ACE/ARBs but not highly active antiretroviral therapy (HAART) medication. Results were significant in both adjusted and unadjusted analyses.

CONCLUSIONS

Individuals with severe mental illness (including schizophrenia) appear to be prescribed significantly lower quantities of several common medications for medical disorders, largely for cardiovascular indications, although further work is required to clarify to what extent this is because of prescriber intent.

Genome-wide pharmacogenomic study of citalopram-induced side effects in STAR*D

Affecting about 1 in 12 Americans annually, depression is a leading cause of the global disease burden. While a range of effective antidepressants are now available, failure and relapse rates remain substantial, with intolerable side effect burden the most commonly cited reason for discontinuation. Thus, understanding individual differences in susceptibility to antidepressant therapy side effects will be essential to optimize depression treatment. Here we perform genome-wide association studies (GWAS) to identify genetic variation influencing susceptibility to citalopram-induced side effects. The analysis sample consisted of 1762 depression patients, successfully genotyped for 421K single-nucleotide polymorphisms (SNPs), from the Sequenced Treatment Alternatives to Relieve Depression (STAR(*)D) study. Outcomes included five indicators of citalopram side effects: general side effect burden, overall tolerability, sexual side effects, dizziness and vision/hearing side effects. Two SNPs met our genome-wide significance criterion (q<0.1), ensuring that, on average, only 10% of significant findings are false discoveries. In total, 12 additional SNPs demonstrated suggestive associations (q<0.5). The top finding was rs17135437, an intronic SNP within EMID2, mediating the effects of citalopram on vision/hearing side effects (P=3.27 × 10(-8), q=0.026). The second genome-wide significant finding, representing a haplotype spanning ∼30 kb and eight genotyped SNPs in a gene desert on chromosome 13, was associated with general side effect burden (P=3.22 × 10(-7), q=0.096). Suggestive findings were also found for SNPs at LAMA1, AOX2P, EGFLAM, FHIT and RTP2. Although our findings require replication and functional validation, this study demonstrates the potential of GWAS to discover genes and pathways that potentially mediate adverse effects of antidepressant medications.

Pharmacogenomic study of side-effects for antidepressant treatment options in STAR*D

BACKGROUND

Understanding individual differences in susceptibility to antidepressant therapy side-effects is essential to optimize the treatment of depression.

METHOD

We performed genome-wide association studies (GWAS) to search for genetic variation affecting the susceptibility to side-effects. The analysis sample consisted of 1439 depression patients, successfully genotyped for 421K single nucleotide polymorphisms (SNPs), from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. Outcomes included four indicators of side-effects: general side-effect burden, sexual side-effects, dizziness and vision/hearing-related side-effects. Our criterion for genome-wide significance was a prespecified threshold ensuring that, on average, only 10% of the significant findings are false discoveries.

RESULTS

Thirty-four SNPs satisfied this criterion. The top finding indicated that 10 SNPs in SACM1L mediated the effects of bupropion on sexual side-effects (p = 4.98 × 10(-7), q = 0.023). Suggestive findings were also found for SNPs in MAGI2, DTWD1, WDFY4 and CHL1.

CONCLUSIONS

Although our findings require replication and functional validation, this study demonstrates the potential of GWAS to discover genes and pathways that could mediate adverse effects of antidepressant medication.

Screening for distress and depression in cancer settings: 10 lessons from 40 years of primary-care research

OBJECTIVE

There has been at least 40 years of active research on screening for depression and distress in primary care. Both successes and failures have been documented. The purpose of this focussed narrative review was to summarise this research and present the key lessons for clinicians and researchers working in psychosocial oncology.

METHODS

We searched for studies assessing the utility of screening in primary care in seven electronic bibliographic databases (CENTRAL, CINAHL, Embase, HMIC, Medline, PsycINFO, Web of Knowledge) from inception to December 2010. Results were reviewed and summarised into key areas.

RESULTS

We found that research could be distilled into the following key learning points. (1) Primary care is an important partner in psychosocial care. (2) Both over and under detection are problematic. (3) Barriers to identification involve patient and clinician factors. (4) Acceptability of screening is critical to implementation. (5) Underserved groups need special attention in screening. (6) Patient-clinician trust is an important modifiable variable. (7) Greater contact influences detection. (8) Clinician confidence/skills influence screening success and subsequent action. (9) Training may improve confidence but effects upon long-term outcomes are modest. (10) Screening is generally ineffective without aftercare.

CONCLUSIONS

Primary care has shown largely what does not work in relation to screening. Namely relying on clinicians' unassisted judgement without infrastructural support, using over-complex scales with low acceptability, looking for depression alone, using screening without linked treatment, treating in the absence of follow-up and failing to engage patients in their own care. These pitfalls can and should be avoided in psychosocial oncology.

Medication errors in psychiatry: a comprehensive review

Medication errors are among the most common medical errors and cause significant morbidity and in some cases mortality. The objective of this article is to review the literature on medication errors in psychiatry. We completed a comprehensive search of both peer- and non-peer-reviewed articles that investigated medication errors in psychiatry. Our primary focus was to examine patient-, provider- and system-related factors that contributed to medication errors. Due to differences in research design and denominators used to determine error rates, the reported prevalence rates of medication errors in psychiatry vary widely. Patient-related factors identified as contributing to medication errors included non-adherence to medication, failure of patients to inform their various care providers about the medications they are taking and symptoms of psychiatric illnesses. Provider-related factors identified as contributing to medication errors were also identified and included clinical practices associated with prescribing, transcription, dispensing, administration and monitoring. Finally, the healthcare system also has a major role to play in reducing medication errors by ensuring seamless continuity of care, mandating medication reconciliation programmes, ensuring adequate clinical pharmacy services and supporting a nonpunitive medication error reporting system. Although the literature raises awareness of these specific contributing factors, there is still a great need for more systematic evaluations of the problem including root cause analysis. Medication errors in psychiatry have been studied almost exclusively in the inpatient setting and thus little is known about the incidence and significance in outpatient and community settings.

Validity of the adherence estimator in the prediction of 9-month persistence with medications prescribed for chronic diseases: a prospective analysis of data from pharmacy claims

OBJECTIVE

The aim of this article was to assess the predictive validity of the Adherence Estimator--a 3-item instrument designed to estimate a patient's propensity to adhere to medications prescribed for chronic disease.

METHODS

The Adherence Estimator was a 3-item part of a larger survey mailed to adults aged >or=40 years who had a qualifying index prescription filled in June 2008. A qualifying prescription was defined as one for a medication indicated for the treatment of 1 of 5 chronic diseases (cardiovascular disease, dyslipidemia [lipid-lowering drugs], diabetes [oral antihyperglycemics], osteoporosis [oral bisphosphonates], or asthma). Outcomes were compared between the adherence risk groups derived from the Adherence Estimator (low risk = score of 0, medium risk = score of 2-7, and high risk = score of 8-36). Treatment persistence over a period of 9 months was measured using pharmacy claims data. The primary outcome was the median proportion of days covered (PDC) by >or=1 medication during the first 9 months after the index fill. Secondary outcomes included adherence to the index medication, defined as PDC dichotomized to >or=0.80 or <0.80; rate of obtaining a second fill within 30 days of the index fill; and medication possession ratio (MPR) for refill adherence.

RESULTS

There were 1676 usable responses. Ages ranged from 40 to 88 years, with a mean of 64.6 years. Almost two thirds (1076/1676 [64.2%]) of the sample were female, and 1483/1676 (88.5%) were white. Statistically significant associations for all 3 pairwise comparisons (low vs medium risk, low vs high risk, and medium vs high risk) were observed between the Adherence Estimator risk groups for: (1) median PDC (0.655, 0.598, and 0.484 in the low-, medium-, and high-risk groups, respectively [all, false discovery rate [FDR] <0.05]); (2) PDC categorized (293/711 [41.21%], 200/588 [34.01%], and 105/377 [27.85%] [all, FDR <0.05]); and (3) rate of obtaining a second fill for the index medication within 30 days (489/711 [68.78%], 374/588 [63.61%], and 207/377 [54.91%] [all, FDR <0.05]). The low- and high-risk groups differed from one another on: (1) persistence with the index medication at 9 months (265/711 [37.27%] and 95/377 [25.20%]); (2) persistence with >1 medication at 9 months (291/711 [40.93%] and 108/377 [28.65%]); and (3) obtaining a second fill for any medication within 30 days (501/711 [70.46%] and 219/377 [59.09%]) (all, P < 0.05). The low- and high-risk groups differed significantly from one another in MPR for refill adherence (0.912 vs 0.866). Results observed within diseases mirrored those for the total sample, but with less precision.

CONCLUSION

In the present analysis of the validity of the Adherence Estimator in predicting adherence, baseline propensity to adhere to medications prescribed for chronic diseases was statistically associated with several measures of adherence and persistence, as derived from pharmacy claims data, over a 9-month period.

Use of antidepressants and the risk of Parkinson's disease: a prospective study

BACKGROUND

Individuals with depression have a higher risk of Parkinson's disease (PD) but the timing of the association is unknown. Therefore, the relationship between initiation of antidepressant therapy and PD risk was assessed in a large population based database from the UK and the timing of this association was explored.

METHODS

A case control study nested in the General Practice Research Database cohort, a large computerised database with clinical information from more than 3 million individuals in the UK, was conducted. Cases of PD were identified from the computer records from 1995 to 2001 and matched with up to 10 controls by age, sex and practice. Use of antidepressants was obtained from the computer records.

RESULTS

999 PD cases and 6261 controls were included. The rate ratio (RR) and 95% CI of PD in initiators of antidepressant therapy compared with non-initiators was 1.85 (1.25 to 2.75). The association was stronger during the first 2 years after initiation of medication use (RR 2.19; 95% CI 1.38 to 3.46) than later (RR 1.23; 95% CI 0.57 to 2.67). Results were similar for selective serotonin reuptake inhibitors and tricyclic antidepressants separately.

CONCLUSION

Initiation of any antidepressant therapy was associated with a higher risk of PD in the 2 years after the start of treatment, which suggests that depressive symptoms could be an early manifestation of PD, preceding motor dysfunction.

The Adherence Estimator: a brief, proximal screener for patient propensity to adhere to prescription medications for chronic disease

OBJECTIVE

To conceptualize, develop, and provide preliminary psychometric evidence for the Adherence Estimator--a brief, three-item proximal screener for the likelihood of non-adherence to prescription medications (medication non-fulfillment and non-persistence) for chronic disease.

RESEARCH DESIGN AND METHODS

Qualitative focus groups with 140 healthcare consumers and two internet-based surveys of adults with chronic disease, comprising a total of 1772 respondents, who were self-reported medication adherers, non-persisters, and non-fulfillers. Psychometric tests were performed on over 150 items assessing 14 patient beliefs and skills hypothesized to be related to medication non-adherence along a proximal-distal continuum. Psychometric tests included, but were not limited to, known-groups discriminant validity at the scale and item level. The psychometric analyses sought to identify: (1) the specific multi-item scales that best differentiated self-reported adherers from self-reported non-adherers (non-fulfillers and non-persisters) and, (2) the single best item within each prioritized multi-item scale that best differentiated self-reported adherers from self-reported non-adherers (non-fulfillers and non-persisters).

RESULTS

The two rounds of psychometric testing identified and cross-validated three proximal drivers of self-reported adherence: perceived concerns about medications, perceived need for medications, and perceived affordability of medications. One item from each domain was selected to include in the Adherence Estimator using a synthesis of psychometric results gleaned from classical and modern psychometric test theory. By simple summation of the weights assigned to the category responses of the three items, a total score is obtained that is immediately interpretable and completely transparent. Patients can be placed into one of three segments based on the total score--low, medium, and high risk for non-adherence. Sensitivity was 88%--of the non-adherers, 88% would be accurately classified as medium or high risk by the Adherence Estimator. The three risk groups differed on theoretically-relevant variables external to the Adherence Estimator in ways consistent with the hypothesized proximal-distal continuum of adherence drivers.

CONCLUSIONS

The three-item Adherence Estimator measures three proximal beliefs related to intentional non-adherence (medication non-fulfillment and non-persistence). Preliminary evidence of the validity of the Adherence Evidence supports its intended use to segment patients on their propensity to adhere to a newly-prescribed prescription medication. The Adherence Estimator is readily scored and is easily interpretable. Due to its brevity and transparency, it should prove to be practical for use in everyday clinical practice and in disease management for adherence quality improvement. Study limitations related to sample representation and self reports of chronic disease and adherence behaviors were discussed.

Selective serotonin reuptake inhibitor discontinuation: side effects and other factors that influence medication adherence

OBJECTIVE

Patients with major depression discontinue taking their antidepressants for many reasons. Although side effects are often cited as the reason for discontinuation, few prospective studies have addressed this question, and none has specifically examined discontinuation in patients with severe depression.

METHOD

Inpatients and outpatients treated with a selective serotonin reuptake inhibitor for major depressive disorder were identified after admission. Three months later, patients were contacted and interviewed to determine antidepressant usage and the side effects experienced, including when these were experienced and their severity.

RESULTS

Between October 2001 and April 2003, 406 English- or Spanish-speaking patients aged 18 to 75 years were followed up. One in 4 patients discontinued the index antidepressant. Among specific side effects noted, only "change in weight" and "anxiety" were significant predictors of discontinuation after controlling for confounders. Experiencing 1 or more "extremely" bothersome side effects was associated with more than a doubling of the risk of discontinuation, but the presence of side effects and side effects less severe than "extremely" bothersome were not significant predictors. There were no differences among selective serotonin reuptake inhibitor antidepressants in either the presence/absence of side effects or in the discontinuation rates.

CONCLUSION

The results suggest that the contribution of side effects to antidepressant discontinuation is more complex than previously suggested. Disparate findings from earlier studies may reflect aspects of study design, such as examining populations whose severity of depression varied widely or not controlling for important confounding factors. Future research should separately examine high-risk groups (or control for severity of depression) and carefully rule out other potential contributors to discontinuation.

Evaluation of patients' experiences with antidepressants reported by means of a medicine reporting system

OBJECTIVE

To assess experiences related to antidepressant use reported to an internet-based medicine reporting system and to compare the nature of the side effects reported by patients with those reported by health care professionals (HCPs).

METHODS

All reports submitted from May 2004 to May 2005 to an internet-based medicine reporting system in The Netherlands related to the use of antidepressants were analysed. Spontaneous reports of adverse drug reactions on antidepressants from HCPs received by The Netherlands Pharmacovigilance Centre Lareb from May 2004 to May 2005 were included for comparison.

RESULTS

Of the 2232 individuals who submitted a report to the internet-based medicine reporting system, 258 submitted a report on antidepressants. Of these, 92 individuals (36%) reported on effectiveness, 40 (16%) of whom reported on ineffectiveness, and 217 (84%) submitted a report on side effects, with 202 (78%) reporting a total of 630 side effects that were experienced as negative. Fourteen individuals (5%) reported a practical issue and four (2%) reported a reimbursement issue. Of all 630 side effects reported, 48% resulted in the patient discontinuing the antidepressant therapy; of these 29% did not inform their HCP. Of all the side effects reported, 52% were perceived as "very negative". In comparison to the side effects reported by HCPs, patients more often reported apathy, excessive sweating, ineffectiveness, somnolence, insomnia, sexual problems and weight increase.

CONCLUSION

Patients report the ineffectiveness and side effects of antidepressant therapy as negative and leading to discontinuation of the therapy. Patients and HCPs differ in the nature of the reported side effects. Patient experiences should be included in the evaluation of antidepressant treatment in clinical practice.

Pharmacotherapy of Mood Disorders and Treatment Discontinuation

Depression is the most frequent and costly problem in primary care, where most of these patients are seen and treated. In many countries, the public regard antidepressant drugs as 'addictive', partly because of the withdrawal symptoms that can occur when they are discontinued. Indeed, discontinuation (withdrawal) symptoms can follow the stoppage of almost all classes of antidepressants, including selective serotonin receptor inhibitors (SSRIs). This is important because they are widely regarded as drugs of choice for both depression and the anxiety disorders. But is this true withdrawal or merely rebound? The antidepressant discontinuation syndrome is characterised by the time-locked emergence of new, clearly defined and quantifiable signs and symptoms that ensue on stopping or reducing the dose of an antidepressant. Thereby, it meets the criteria for a withdrawal syndrome. The symptoms are not usually severe or protracted. SSRIs vary in their propensity to be associated with a discontinuation syndrome: paroxetine appears to be the most likely. Patients should be warned of the possibility of developing such a reaction, but reassured that it is usually mild and self limiting. Tapering the dose, if practicable, is worthwhile. In severe cases, temporary reinstatement of the SSRI and slower tapering may be necessary. Escalation of antidepressant dosage, or 'street abuse', is rare with antidepressants. The use of antidepressants is generally beneficial, and efforts should be made to optimise our current use of these drugs as well as encouraging the development of newer, better and innovative compounds. To this end, physicians should educate themselves and the public about discontinuation and withdrawal, so that these clinical features can be put in a realistic context.

Adherence behaviour with psychotropic medication is a form of self-medication

Adherence with psychotropic medication is at least at poor as adherence with medication for physical health problems. There has been an assumption this was due to loss of insight resulting from psychiatric disorders themselves. Consequently, interventions have focussed on treating the underlying psychiatric disorder and generating psychological strategies to promote awareness. Recent surveys of patient preferences for information and involvement in health care decisions highlight that most individuals want to participate in the process of medical care. Patients often have strong pre-existing beliefs about different therapeutic options. This is supported by the self-determination theory which distinguishes between autonomous behaviour and behaviours that are influenced by external forces. When considering the patient perspective in medication adherence, it is useful to consider the self-medication hypothesis. This can equally be applied to prescribed and non-prescribed drugs. The self-medication hypothesis states that patients decide to start, adjust or stop prescribed medication according to perceived health needs. Such decisions are often conducted intentionally and rationally, given the information available to the patient and their understanding of their condition. In this narrative review, the evidence for and against intentionality in psychotropic adherence behaviour is examined. Studies of compliance and related predictors are examined in depression, schizophrenia and bipolar affective disorder. Results suggest that although concordance depends on patient, illness and clinician factors, patient choice is usually the final common pathway. Illness severity and insight is important in some cases but can act in concert with cognitive factors. Individuals appear to prefer to take medication "as required" (symptomatically) rather than prophylactically. Significant influences upon self-medication habits are prior health beliefs, medication attitudes, adverse effects and adequacy of communication from the health care professional. The self-medication hypothesis applied to prescribed psychotropic medication should assist rather than heed clinicians in improving adherence by taking a patient centred approach and where possible promoting patient autonomy.