Antidepressant prescriptions and adherence in primary care in India: Insights from a cluster randomized control trial

Research on treatment-related aspects of depression from India in the preceding decade (2014-2023): An updated systematic review

Background

The National Mental Health Survey reports a prevalence of 2.7% for depressive disorders in India. The services for depression patients may be organized differently in India as compared to Western countries. It is important to consider studies conducted in India to determine effective interventions for depression catered specifically to the needs of the Indian population. We intended to systematically review the articles studying the usefulness of various treatment modalities in the management of depression in the Indian context.

Materials and Methods

We searched PubMed, Google Scholar, and ScienceDirect to identify studies published in peer-reviewed English language journals. All articles from India evaluating the clinical efficacy of anti-depressants, electro-convulsive therapy, repetitive transcranial magnetic stimulation, and psychological interventions for the management of depression were evaluated. Data were extracted using standard procedures.

Results

A total of 36 studies were included in the review. Out of those, 15 were studies on drug efficacy, five on neuro-modulation, nine on psycho-social interventions, four on adverse effects, and three on miscellaneous studies. Innovations were seen in the field of neuro-modulation and psycho-social intervention. Trials on drug efficacy and adverse drug reactions require larger sample sizes, more studies on newer agents, and more robust study designs.

Conclusion

More research is needed to understand the effectiveness and potential negative effects of depression treatments in India. Studies on ketamine have been inconclusive, and existing research on pharmacological agents is limited. Neuro-modulation studies show promise, but larger-scale studies are needed. Innovative psychological interventions tailored to the Indian population include community-based and digital technology-driven care.

Factors influencing adherence to non-communicable disease medication in India: secondary analysis of cross-sectional data from WHO - SAGE2

Background: Non-communicable diseases (NCDs) are a leading cause of death globally and disproportionately affect those in low- and middle-income countries lower-middle-income countries. Poor medication adherence among patients with NCDs is prevalent in India due to lack of initiation, missed dosing or cessation of treatment, and represents a growing healthcare and financial burden. Objective: This study aimed to identify factors influencing medication adherence in adults with NCDs in India. Methods: We performed a cross-sectional study, conducting secondary data analysis on the second wave of the World Health Organisation's 'Study on global AGEing and adult health (SAGE)', a survey that collected data from predominantly older adults across India. Bivariate analysis and multivariate logistic regression modelling were conducted to specifically interrogate the reasons for lack of initiation and cessation of treatment. Reporting of this study was informed by the STROBE guidelines. Results: The average medication adherence rate was 51% across 2,840 patients with one or more NCDs, reflecting non-initiation and lack of persistence of treatment. The strongest factor significantly predicting non-adherence to medication across these components was multimorbidity (odds ratio 0.47, 95% CI 0.40-0.56). Tobacco use (OR = 0.76, CI 0.59-0.98) and never having attended school (OR = 0.75, CI 0.62-0.92) were significantly associated with poor medication adherence (p < 0.05) while rural living (OR = 0.70, CI 0.48-1.02), feelings of anxiety (OR = 0.84, CI 0.66-1.08) and feelings of depression (OR = 0.90, CI 0.70-1.16) were factors lacking statistically significant association with medication adherence on multivariate analysis. Older age (OR = 2.02, CI 1.51-2.71) was significantly associated with improved medication adherence whilst there was a weak association between increased wealth and improved medication use. Limitations: The SAGE2 survey did not capture whether patients were taking their medication doses according to prescribed instructions-as a result our findings may under-estimate the true prevalence of medication non-adherence. Conclusion: Our analysis provides evidence that poor medication adherence in India is multifactorial, with distinct socioeconomic and health-system factors interacting to influence patient decision making. Future large-scale surveys interrogating adherence should assess all components of adherence specifically, whilst public health interventions to improve medication adherence should focus on barriers that may exist due to multimorbidity, comorbid depression and anxiety, and low educational status.

Interventions to promote medication adherence for chronic diseases in India: a systematic review

Introduction

Cost-effective interventions that improve medication adherence are urgently needed to address the epidemic of non-communicable diseases (NCDs) in India. However, in low- and middle-income countries like India, there is a lack of analysis evaluating the effectiveness of adherence improving strategies. We conducted the first systematic review evaluating interventions aimed at improving medication adherence for chronic diseases in India.

Methods

A systematic search on MEDLINE, Web of Science, Scopus, and Google Scholar was conducted. Based on a PRISMA-compliant, pre-defined methodology, randomized control trials were included which: involved subjects with NCDs; were located in India; used any intervention with the aim of improving medication adherence; and measured adherence as a primary or secondary outcome.

Results

The search strategy yielded 1,552 unique articles of which 22 met inclusion criteria. Interventions assessed by these studies included education-based interventions (n = 12), combinations of education-based interventions with regular follow up (n = 4), and technology-based interventions (n = 2). Non-communicable diseases evaluated commonly were respiratory disease (n = 3), type 2 diabetes (n = 6), cardiovascular disease (n = 8) and depression (n = 2).

Conclusions

Although the vast majority of primary studies supporting the conclusions were of mixed methodological quality, patient education by CHWs and pharmacists represent promising interventions to improve medication adherence, with further benefits from regular follow-up. There is need for systematic evaluation of these interventions with high quality RCTs and their implementation as part of wider health policy.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022345636, identifier: CRD42022345636.

Understanding the medication safety challenges for patients with mental illness in primary care: a scoping review

BACKGROUND

Mental illness and medication safety are key priorities for healthcare systems around the world. Despite most patients with mental illness being treated exclusively in primary care, our understanding of medication safety challenges in this setting is fragmented.

METHOD

Six electronic databases were searched between January 2000-January 2023. Google Scholar and reference lists of relevant/included studies were also screened for studies. Included studies reported data on epidemiology, aetiology, or interventions related to medication safety for patients with mental illness in primary care. Medication safety challenges were defined using the drug-related problems (DRPs) categorisation.

RESULTS

Seventy-nine studies were included with 77 (97.5%) reporting on epidemiology, 25 (31.6%) on aetiology, and 18 (22.8%) evaluated an intervention. Studies most commonly (33/79, 41.8%) originated from the United States of America (USA) with the most investigated DRP being non-adherence (62/79, 78.5%). General practice was the most common study setting (31/79, 39.2%) and patients with depression were a common focus (48/79, 60.8%). Aetiological data was presented as either causal (15/25, 60.0%) or as risk factors (10/25, 40.0%). Prescriber-related risk factors/causes were reported in 8/25 (32.0%) studies and patient-related risk factors/causes in 23/25 (92.0%) studies. Interventions to improve adherence rates (11/18, 61.1%) were the most evaluated. Specialist pharmacists provided the majority of interventions (10/18, 55.6%) with eight of these studies involving a medication review/monitoring service. All 18 interventions reported positive improvements on some medication safety outcomes but 6/18 reported little difference between groups for certain medication safety measures.

CONCLUSION

Patients with mental illness are at risk of a variety of DRPs in primary care. However, to date, available research exploring DRPs has focused attention on non-adherence and potential prescribing safety issues in older patients with dementia. Our findings highlight the need for further research on the causes of preventable medication incidents and targeted interventions to improve medication safety for patients with mental illness in primary care.

Successful ingredients of effective Collaborative Care programs in low- and middle-income countries: A rapid review

Integrating mental health care in primary healthcare settings is a compelling strategy to address the mental health treatment gap in low- and middle-income countries (LMICs). Collaborative Care is the integrated care model with the most evidence supporting its effectiveness, but most research has been conducted in high-income countries. Efforts to implement this complex multi-component model at scale in LMICs will be enhanced by understanding the model components that have been effective in LMIC settings. Following Cochrane Rapid Reviews Methods Group recommendations, we conducted a rapid review to identify studies of the effectiveness of Collaborative Care for priority adult mental disorders of mhGAP (mood and anxiety disorders, psychosis, substance use disorders and epilepsy) in outpatient medical settings in LMICs. Article screening and data extraction were performed using Covidence software. Data extraction by two authors utilized a checklist of key components of effective interventions. Information was aggregated to examine how frequently the components were applied. Our search yielded 25 articles describing 20 Collaborative Care models that treated depression, anxiety, schizophrenia, alcohol use disorder or epilepsy in nine different LMICs. Fourteen of these models demonstrated statistically significantly improved clinical outcomes compared to comparison groups. Successful models shared key structural and process-of-care elements: a multi-disciplinary care team with structured communication; standardized protocols for evidence-based treatments; systematic identification of mental disorders, and a stepped-care approach to treatment intensification. There was substantial heterogeneity across studies with respect to the specifics of model components, and clear evidence of the importance of tailoring the model to the local context. This review provides evidence that Collaborative Care is effective across a range of mental disorders in LMICs. More work is needed to demonstrate population-level and longer-term outcomes, and to identify strategies that will support successful and sustained implementation in routine clinical settings.

Explanatory Models and their Relationship with Drug Attitude in Patients with Depression in South India

BACKGROUND

The patient's understanding of the illness may mediate beliefs towards its treatment. There is a paucity of studies examining the relationships between these variables in depression. This study was conducted to know the relationships between explanatory models and attitude to medication in depression.

METHODS

494 patients with depression in remission were assessed with sociodemographic proforma, Drug Attitude Inventory, and Mental Distress Explanatory Model Questionnaire.

RESULTS

A favorable attitude toward medication was observed in 57.49% of participants. Mean scores on MDEMQ subscales Stress, Western Physiology, Non-Western Physiology, and Supernatural were 32.96, 21.87, 10.06, and 47.55, respectively. Statistically significant associations were found between attitude towards medication and the patient's marital status (more negative attitude with single status, χ2 = 11.72, df = 3, P = 0.008) and occupation (more negative attitude among unemployed patients, χ² = 4.17, df = 1, P = 0.041). The scores of explanatory models did not differ based on positive or negative drug attitude.

CONCLUSION

Though explanatory models are not linked to patient attitudes toward medication, patients who are single or unemployed have a negative attitude toward medications. Such negative attitude may impair compliance and worsen patient outcomes.

Barriers and Facilitating Factors of Adherence to Antidepressant Treatments: An Exploratory Qualitative Study with Patients and Psychiatrists

This study examines the experiences and expectations of patients with depressive disorders regarding the disease and different antidepressants, as well as examining the barriers and facilitating factors that could affect their adherence to medications. An exploratory qualitative study was carried out. The study involved two focus groups made up of patients and caregivers and six semi-structured interviews with psychiatrists. In both cases, the participants were selected by intentional theoretical sampling, seeking maximum significance variation of social types. Prejudice about the side effects of medication was relevant. The importance of patients being well informed about the disease/treatments was noteworthy. The stigmatization of antidepressants by patients was identified as a barrier to medication adherence. The involvement of family members and the motivation of patients to be actively involved in the process to recover from the disease were identified as facilitating factors. The work carried out suggests the need for patients to have rigorous information about the disease/treatment to reduce the possible prejudices generated by beliefs. Maintaining greater contact and monitoring of patients/caregivers to help therapeutic adherence in patients with depressive disorders was also identified as being of great importance.

Analysis of Antidepressants Utilization for Patients Visiting Psychiatric Out-Patient Clinic in a Tertiary Care Hospital

Depression is a prevalent mental health condition treated with antidepressants and other psychotropic medications. This study aimed to assess the utilization pattern of antidepressants among patients visiting the outpatient clinic of the psychiatry department of a tertiary care hospital. The study included the patients who visited the study site and fulfilled the mental and behavioral diagnostic criteria for depression. The demographic and clinical details, including drugs prescribed, were documented in a study-specific data collection form. The ratio of Prescribed Daily Dose to Defined Daily Dose (PDD: DDD) was calculated to assess the adequacy of antidepressant utilization. Data total of 154 patients were collected. A total of 22 psychotropic drugs were used among the study patients as mono (n = 70), dual (n = 69), triple (n = 10), or quadruple therapy (n = 1). Escitalopram was the most often prescribed antidepressant out of the nine antidepressants alone and in combination and was used in slightly high doses (PDD: DDD ratio 1.6). Sertraline, paroxetine, and desvenlafaxine, were used in adequate doses (PDD: DDD between 1 and 1.1), and fluoxetine, duloxetine, amitriptyline, imipramine, and mirtazapine, were used in inadequate doses (PDD: DDD <0.5). Our study findings reveal the need for continuous assessment of antidepressants medications usage in a hospital set up.

Collaborative care compared to enhanced standard treatment of depression with co-morbid medical conditions among patients from rural South India: a cluster randomized controlled trial (HOPE Study)

BACKGROUND

Depression is common among primary care patients in LMIC but treatments are largely ineffective. In this cluster-randomized controlled trial, we tested whether depression outcomes are different among recipients of a collaborative care model compared to enhanced standard treatment in patients with co-morbid chronic medical conditions.

METHODS

We conducted a cluster randomized controlled trial among participants 30 years or older seeking care at 49 primary health centers (PHCs) in rural Karnataka, diagnosed with major depressive disorder, dysthymia, generalized anxiety disorder, or panic disorder on the MINI-International Neuropsychiatric Interview plus either hypertension, diabetes, or ischemic heart disease. From a list of all PHCs in the district, 24 PHCs were randomized a priori to deliver collaborative care and 25 PHCs enhanced standard treatment. The collaborative care model consisted of a clinic-based and a community-based component. Study assessment staff was blinded to treatment arm allocation. The primary outcome was the individual-level PHQ-9 score over time.

RESULTS

Between May 2015 and Nov 2018, 2486 participants were enrolled, 1264 in the control arm, and 1222 in the intervention arm. They were assessed at baseline, 3, 6 and 12 months. The mean PHQ-9 depression score was around 8.5 at baseline. At each follow-up PHQ-9 scores were significantly lower in the intervention (5.24, 4.81 and 4.22 at respective follow-ups) than in the control group (6.69, 6.13, 5.23, respectively). A significant time-by-treatment interaction (p < 0.001) in a multi-level model over all waves, nested within individuals who were nested within PHCs, confirmed that the decrease in depression score from baseline was larger for collaborative care than enhanced standard care throughout follow-up.

CONCLUSIONS

The collaborative care intervention resulted in significantly lower depression scores compared to enhanced standard care among participants with co-morbid physical conditions. The findings have potential implications for integrating mental health and chronic disease treatment in resource constrained settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02310932 , registered on December 8, 2014, and Clinical Trials Registry India CTRI/2018/04/013001 , registered on April 4, 2018. Retrospectively registered.