Types of information physicians provide when prescribing antidepressants

Exploring mental health clients' current medication knowledge, beliefs and experience with healthcare providers in the community in South Australia

In Australia, mental illness has been recognised as a National Health Priority area, with the coronavirus pandemic adding a layer of urgency to the need to address the multiple health problems faced by clients with mental illnesses. Whilst much has been done in efforts to support these clients, little is known about their medication knowledge and experience with health professionals. The aim of the study was to explore the knowledge and beliefs of clients on the use of psychotropic medications and study their experiences with healthcare providers. Adult participants at a not-for-profit community-managed specialist mental health service provider in Adelaide, South Australia were recruited. Four focus group sessions were conducted between February 2020 and March 2021. All sessions were co-facilitated by a peer practitioner with lived experience. Sessions were audio recorded and transcribed verbatim. Participants (n = 27) reported that provision of medication education was inadequate and, in some cases, non-existent. There was an apparent lack of support for monitoring and managing common side effects, such as weight gain. Participants described not being involved in any decision-making processes and that establishing and maintaining a therapeutic relationship with their healthcare providers was challenging. Perceived stigma remains a barrier in accessing healthcare. Despite participants regularly interacting with a range of healthcare providers, findings highlight key gaps in care, particularly medication education and establishing a therapeutic relationship with their healthcare providers. Future mental health reforms should consider the provision of additional medication education in community settings, such as at not-for-profit organisations. Moreover, healthcare providers should take a proactive approach in establishing therapeutic relationships.

Experiences of the Medication Use Process by People with Intellectual Disabilities. What a Pharmacist Should Know!

There is a scarcity of information about the experience of people with intellectual disabilities in the medication use process. Six people with intellectual disabilities consented to be interviewed by a pharmacist to determine their knowledge and views of medication use. Data from semi-structured interviews were analysed using a grounded theory approach. Self-determination and risk to the quality of the medication use process were identified as theories. Literature review provided two explanations—vulnerabilities of people with intellectual disabilities in healthcare and pharmacists have a role to play in ensuring a quality medication use process for people with intellectual disabilities. People with intellectual disabilities may be ‘expert patients’ and can provide valuable insights into their experience of medication use. They may be ‘high risk’ patients but may not be recognized as such by pharmacists.

Withdrawal and Misuse Concerns of Consumers regarding Opioid Analgesic and Anxiolytic, Hypnotic and Sedative Medicines

Opioid analgesic (OA) and anxiolytic, hypnotic and sedative (AHS) medicines use raise community concerns about risks of dependence: dose escalation, unintentional misuse. Objectives: We aimed to identify common consumer OA and AHS information gaps and concerns that led to information seeking from a hotline. Methods: We conducted a retrospective, mixed-method observational study of consumers' OA and AHS-related calls to an Australian national medicines call center (September 2002-30 June 2010). We analyzed these medicines' call characteristics compared to their respective rest of calls (ROC) and thematically explored narratives concerning withdrawal and misuse. Results: Of 123,217 calls, 7,395 (6.0%) involved OA and 7,789 (6.2%) AHS, with consistency between call characteristics. While female middle-aged callers predominated, more males called for these medicines than their complementary ROC. Uncertainty about unresolved OA and AHS concerns led to help-seeking that was consistent over eight years. Main motivations were inadequate information (OA 44.5%; AHS 41.2%), seeking a second opinion (OA 24.2%; AHS 24.2%), worrying symptoms (OA 21.6%; AHS 23.1%), and conflicting information (OA 4.9%; AHS 5.1%). Callers focused on withdrawal and issues related to inadvertent overuse or deliberate misuse (OA 9.2% vs. non-OA ROC 2.9%; AHS 12.6% vs. non-AHS ROC 2.7%). Primary themes were similar for both cohorts: concern about harm or aiming to minimize harm by information seeking, requesting a strategy, or reassurance. Conclusions: Consumers have under-recognized perceptions of harm from OA and AHS use, particularly withdrawal and misuse. Resources based on real world consumer concerns can encourage open dialogue between patients and their prescribers.

A systematic review of the use of simulated patient methodology in pharmacy practice research from 2006 to 2016

OBJECTIVES

Simulated patient (SP) methodology (mystery shopping) is used increasingly to assess quality of pharmacy services, and evaluate impact of interventions. Our objective was to review papers reporting on the use of SP methodology in pharmacy practice research 2006-2016 in community pharmacies worldwide.

METHODS

We searched EMBASE and MEDLINE for papers reporting on the use of mystery shopping in pharmacy settings, using a wide range of terms for SPs, based on previous review. We removed irrelevant papers, duplicates, papers not written in English, and review papers and reviewed remaining papers. Two reviewers carried out data abstraction, using the same tool as the previous review and inserting data into Excel, focusing on how the SP methodology is used.

KEY FINDINGS

A total of 148 papers from 52 countries from all regions of the world were included in the review. A wide range of terms described the method, and simulated patient was the most common (49 papers). Most studies were cross-sectional (124), and most investigated only community pharmacies (115). The most common aim was to evaluate some aspect of pharmacists' or other staff's advice and counselling (94). Number of visits is 2-7785. Many papers did not cover details, such as number of visits planned, and carried out, scenario used, training and background of SPs, and ethical approval for the study.

CONCLUSIONS

The use of SP methodology has increased substantially in the field of pharmacy over the past decade. This is a useful method in a wide range of countries and settings. Greater detail is required in reporting.

Does consumer medicines interest reflect medicines use? An observational study comparing medicines call center queries with medicines use

BACKGROUND

Consumers have questions about their medication but the nature of these concerns and how they reflect medication use is unknown.

OBJECTIVES

To determine the characteristics and medicines interests of callers to an Australian medicines call center and whether the medicines interest of callers corresponds with medicines utilization.

METHODS

Data from consumers who contacted a national medicines call center between September 2002 and June 2010 were analyzed. Patterns of consumer medicines interest were described. Medicines were class-matched by Anatomical Therapeutic Classification, and compared with dispensed use (January 2006-June 2010).

RESULTS

In total 125,951 calls were received between 2002 and 2010. Callers were mainly female (76.8%), median age 48 years, calling for themselves (71.7%). Motivation to call related to safety (34.7%), efficacy (24.1%) and interactions (14.9%). For the comparison with medicines utilization, 85,416 calls with 124,177 individual medicine counts were analyzed (2006 and 2010). There were 976 unique 'medicines of interest'. Half (49.4%) of these questions involved just fifty unique medicines. Nervous system medicines (antiepileptics, psycholeptics, analgesics) and antibacterials consistently ranked highest for interest compared with use. Conversely, agents acting on the renin-angiotensin system, statins and drugs for acid related disorders ranked low for interest despite widespread use.

CONCLUSIONS

Consumer questions about medicines correlate poorly with overall medicines utilization. To promote quality health outcomes, clinicians should target their education to the relatively small number of medicines of real concern to patients.

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.

Recommendations for Providers on Person-Centered Approaches to Assess and Improve Medication Adherence

Medication non-adherence is a significant clinical challenge that adversely affects psychosocial factors, costs, and outcomes that are shared by patients, family members, providers, healthcare systems, payers, and society. Patient-centered care (i.e., involving patients and their families in planning their health care) is increasingly emphasized as a promising approach for improving medication adherence, but clinician education around what this might look like in a busy primary care environment is lacking. We use a case study to demonstrate key skills such as motivational interviewing, counseling, and shared decision-making for clinicians interested in providing patient-centered care in efforts to improve medication adherence. Such patient-centered approaches hold considerable promise for addressing the high rates of non-adherence to medications for chronic conditions.

Gist and verbatim communication concerning medication risks/benefits

OBJECTIVES

To describe the information about medication risks/benefits that rheumatologists provide during patient office visits, the gist that patients with rheumatoid arthritis (RA) extract from the information provided, and the relationship between communication and medication satisfaction.

METHODS

Data from 169 RA patients were analyzed. Each participant had up to three visits audiotaped. Four RA patients coded the audiotapes using a Gist Coding Scheme and research assistants coded the audiotapes using a Verbatim Coding Scheme.

RESULTS

When extracting gist from the information discussed during visits, patient coders distinguished between discussion concerning the possibility of medication side effects versus expression of significant safety concerns. Among patients in the best health, nearly 80% reported being totally satisfied with their medications when the physician communicated the gist that the medication was effective, compared to approximately 50% when this gist was not communicated.

CONCLUSION

Study findings underscore the multidimensional nature of medication risk communication and the importance of communication concerning medication effectiveness/need.

PRACTICE IMPLICATIONS

Health care providers should ensure that patients understand that medication self-management practices can minimize potential risks. Communicating simple gist messages may increase patient satisfaction, especially messages about benefits for well-managed patients. Optimal communication also requires shared understanding of desired therapeutic outcomes.

Understanding the non-pharmacological correlates of self-reported efficacy of antidepressants

OBJECTIVE

To explore the non-pharmacological correlates of the perceived effectiveness of antidepressants (ADs), thereby enhancing understanding of the mechanisms involved in recovery from depression while taking ADs.

METHOD

An online survey was completed by 1781 New Zealand adults who had taken ADs in the previous 5 years.

RESULTS

All 18 psychosocial variables measured were associated with depression reduction, and 16 with improved quality of life (QoL). Logistic regression models revealed that the quality of the relationship with the prescriber was related to both depression reduction and improved QoL. In addition, depression reduction was related to younger age, higher income, being fully informed about ADs by the prescriber, fewer social causal beliefs for depression and not having lost a loved one in the 2 months prior to prescription. Furthermore, both outcome measures were positively related to belief in 'chemical' rather than 'placebo' effects.

CONCLUSION

There are multiple non-pharmacological processes involved in recovery while taking ADs. Enhancing them, for example focusing on the prescriber-patient relationship and giving more information, may enhance recovery rates, with or without ADs.

Communication about ADHD and its treatment during pediatric asthma visits

The objectives of the study were to examine provider-family communication about attention deficit disorder during pediatric asthma visits. Children with asthma, aged 8 through 16 and their parents were recruited at five pediatric practices. All medical visits were audio-taped. There were 296 asthmatic children enrolled into the study and 67 of them also had attention deficit hyperactivity disorder (ADHD). ADHD communication elements suggested by national guidelines were discussed infrequently. Providers were more likely to discuss, educate, and ask one or more questions about ADHD medications if the visit was non-asthma related. Providers included child input into the ADHD treatment regimen during 3% of visits and they included parent input during 4.5% of visits. Only one child and three parents asked questions about ADHD. Providers may neglect essential aspects of good ADHD management and communication in children who have ADHD plus another chronic condition such as asthma. Providers should set appropriate treatment expectations, establish target symptoms, and encourage children and parents to ask questions so mutual decision-making can occur.

Communicating Numerical Risk: Human Factors That Aid Understanding in Health Care

In this chapter, we review evidence from the human factors literature that verbal and visual formats can help increase the understanding of numerical risk information in health care. These visual representations of risk are grounded in empirically supported theory. As background, we first review research showing that people often have difficulty understanding numerical risks and benefits in health information. In particular, we discuss how understanding the meanings of numbers results in healthier decisions. Then, we discuss the processes that determine how communication of numerical risks can enhance (or degrade) health judgments and decisions. Specifically, we examine two different approaches to risk communication: a traditional approach and fuzzy-trace theory. Applying research on the complications of understanding and communicating risks, we then highlight how different visual representations are best suited to communicating different risk messages (i.e., their gist). In particular, we review verbal and visual messages that highlight gist representations that can better communicate health information and improve informed decision making. This discussion is informed by human factors theories and methods, which involve the study of how to maximize the interaction between humans and the tools they use. Finally, we present implications and recommendations for future research on human factors in health care.

A systematic review on the effectiveness of group versus single-handed practice

BACKGROUND

Since the 1970s, many countries have employed the use of the General practitioner group practice, but there is contrasting evidence about its effectiveness. A systematic review was performed to assess whether group practice has a more positive impact compared with the single-handed practice on different aspects of health care.

METHODS

A systematic review was conducted by querying electronic databases and reviewing articles published between 1990 and 2012. A quality assessment was performed. The effect of group practice was evaluated by collecting all items analysed by the articles into four main categories: (1) studies of quality (measured in terms of clinical processes) and productivity (measured in terms of throughput), named "Clinical process measures and throughput"; (2) studies exploring physician's opinion--"Doctor's perspective"; (3) studies looking into the use of innovation, information and communication technology (ICT) and quality assurance--"Innovation, ICT and quality assurance"; (4) studies focused on patient's opinion--"Patient's perspective". The results were synthesized according to three levels of scientific evidence.

RESULTS

A total of 26 studies were selected. The most studied category was Clinical process measures and throughput (58%). A positive impact of group medicine on "Clinical process measures and throughput", "Doctor's perspective", "Innovation, ICT and quality assurance" was found. There was contrasting evidence considering the "Patient's perspective".

CONCLUSIONS

Group practice might be a successful organizational requirement to improve the quality of clinical practice in Primary Health Care. Further comparative studies are needed to investigate the impact of organizational and professional determinants such as physician's economic incentives, mode of payment, size of the groups and multispecialty on the effectiveness of medical primary care.

Child and caregiver reported problems in using asthma medications and question-asking during paediatric asthma visits

OBJECTIVES

The objectives of the study were to describe the extent to which lay caregivers and children who reported asthma medication problems asked medication questions during their medical visits.

METHODS

Children with asthma ages 8 through 16 years and their caregivers were recruited at five paediatric practices and their medical visits were audiotape recorded. Children were interviewed after their medical visits and caregivers completed questionnaires. A home visit was conducted 1 month later. Generalized estimating equations were used to analyse the data.

KEY FINDINGS

Two hundred and ninety six families participated. Among those caregivers who reported asthma medication problems, only 35% had asked at least one medication question during the visit. Among children who reported asthma medication problems, only 11% had asked at least one medication question during their consultation. Caregivers and children who reported a problem with their asthma medications were significantly more likely to have asked medication questions if providers had asked more questions about control medications. Children who reported higher asthma management self-efficacy were significantly more likely to have asked an asthma medication question.

CONCLUSIONS

Only one in three caregivers and one in 10 children who reported an asthma medication problem asked a question during their medical visits and many still reported these problems 1 month later. Pharmacists should encourage caregivers and children to report problems they may be having using their asthma medications.

Treatment preferences in patients with first episode depression

BACKGROUND

Treatment preferences of patients suffering from depression may affect adherence and clinical outcomes. This study examines associations between patients' treatment preferences, their characteristics and illness representations of depression.

METHODS

Illness representations of depression (IPQ-R), treatment acceptability and preferences were assessed in 88 newly diagnosed patients with first episode depression. Other measures recorded: gender, age, education level, income, psychiatric comorbidity, depressive symptomatology (PHQ-9), a family history of depression, and current treatment of depression. Multiple logistic regression was used to identify factors associated with a preference for psychotherapy.

RESULTS

Psychotherapy was preferred by 41% of participants, while 31% favored antidepressants. Acceptability was strongly associated with preference. Patients preferring psychotherapy perceived that their depression has more serious consequences than those preferring medication and were more likely to attribute their depression to social causes than psychological or physical causes. Participants who preferred psychotherapy were more likely to be female, have a university degree and have a family history of depression.

LIMITATIONS

The cross-sectional design precludes causal interpretations.

CONCLUSIONS

Preferences vary according to gender, level of education, family history and illness representations. It may be important to provide accurate information on both treatments and discuss patients' preferences before prescribing treatment.

Adherence to antidepressant medications: an evaluation of community pharmacists' counseling practices

BACKGROUND

Recent studies have shown that pharmacists have a role in addressing antidepressant nonadherence. However, few studies have explored community pharmacists' actual counseling practices in response to antidepressant adherence-related issues at various phases of treatment. The purpose of this study was to evaluate counseling practices of community pharmacists in response to antidepressant adherence-related issues.

METHODS

A simulated patient method was used to evaluate pharmacist counseling practices in Sydney, Australia. Twenty community pharmacists received three simulated patient visits concerning antidepressant adherence-related scenarios at different phases of treatment: 1) patient receiving a first-time antidepressant prescription and hesitant to begin treatment; 2) patient perceiving lack of treatment efficacy for antidepressant after starting treatment for 2 weeks; and 3) patient wanting to discontinue antidepressant treatment after 3 months due to perceived symptom improvement. The interactions were recorded and analyzed to evaluate the content of consultations in terms of information gathering, information provision including key educational messages, and treatment recommendations.

RESULTS

There was variability among community pharmacists in terms of the extent and content of information gathered and provided. In scenario 1, while some key educational messages such as possible side effects and expected benefits from antidepressants were mentioned frequently, others such as the recommended length of treatment and adherence-related messages were rarely addressed. In all scenarios, about two thirds of pharmacists explored patients' concerns about antidepressant treatment. In scenarios 2 and 3, only half of all pharmacists' consultations involved questions to assess the patient's medication use. The pharmacists' main recommendation in response to the patient query was to refer the patient back to the prescribing physician.

CONCLUSION

The majority of pharmacists provided information about the risks and benefits of antidepressant treatment. However, there remains scope for improvement in community pharmacists' counseling practice for patients on antidepressant treatment, particularly in providing key educational messages including adherence-related messages, exploring patients' concerns, and monitoring medication adherence.

Pharmacists' provision of information to Spanish-speaking patients: a social cognitive approach

BACKGROUND

Hispanics with limited English proficiency face communication challenges that affect medication use and outcomes. Pharmacists are poised to help patients' use medications safely and effectively; however, scant research has explored factors that may impact pharmacists' communication with Spanish-speaking patients (SSPs).

OBJECTIVE

Guided by social cognitive theory (SCT), the purpose of this study was to examine the relationships between pharmacy environmental factors, pharmacists' cognition, and pharmacists' communication with SSPs.

METHODS

A cross-sectional survey used a vignette to quantify the amount of information pharmacists would provide to an SSP. Pharmacy environmental factors (language-assistance resources, Spanish-speaking staff, and number of SSPs) and pharmacists' cognition (self-efficacy beliefs and cultural sensitivity) that may influence communication also were assessed. The relationships between environmental factors, cognition, and pharmacists' communication with SSPs, including indirect relationships, were examined using composite indicator structural equation (CISE) modeling.

RESULTS

Of the 183 respondents, most were white (91%) and male (63%) with a mean age of 47 years (SD = 12.77). The CISE modeling revealed that the number of SSPs served by the pharmacy and the pharmacist's self-efficacy in communicating with SSPs were significantly directly associated with pharmacist's provision of information to SSPs. Two environmental factors (presence of interpreter services and Spanish-speaking staff) operated indirectly through self-efficacy to significantly impact the provision of information.

CONCLUSIONS

Study findings identify both environmental factors and cognition that could contribute to pharmacists' communication behavior with SSPs. Thus, future interventions to improve pharmacists' communication with SSPs may include training pharmacists to integrate interpretative services and Spanish-speaking staff into service delivery and strengthening pharmacists' self-efficacy beliefs.

Child and caregiver involvement and shared decision-making during asthma pediatric visits

OBJECTIVE

The purpose of this study was to examine (1) the extent to which caregivers and children asked asthma management questions during pediatric asthma visits; (2) the extent to which providers engaged in shared decision-making with these caregivers and children; and (3) the factors associated with question asking and shared decision-making.

METHODS

Children aged 8-16 years with mild persistent asthma, moderate persistent asthma, or severe persistent asthma and their caregivers were recruited at five pediatric practices in non-urban areas of North Carolina. All of the medical visits were audio tape recorded. Generalized estimating equations were used to analyze the data.

RESULTS

Only 13% of children and 33% of caregivers asked one or more questions about asthma management. Caregivers were more likely to ask questions about their child's medications. Providers obtained child input into their asthma management plan during only 6% of encounters and caregiver input into their child's asthma management plan during 10% of visits.

CONCLUSION

Given the importance of involving patients during healthcare visits, providers need to consider asking for and including child and caregiver inputs into asthma management plans so that shared decision-making can occur more frequently.

Provider Discussion, Education, and Question-Asking about Control Medications during Pediatric Asthma Visits

Background. Few studies have explored how providers communicate about control medications during pediatric asthma visits. Objectives. The purpose of this study was to: (a) describe the extent to which providers discuss, educate, and ask children and their caregivers questions about control medications and (b) examine how child, caregiver, and provider characteristics are associated with provider communication about control medications during pediatric asthma visits. Methods. Children ages 8 through 16 with mild, moderate, or severe persistent asthma and their caregivers were recruited at five pediatric practices in nonurban areas of North Carolina. After audio-tape recording medical visits, caregivers completed questionnaires and children were interviewed. Generalized estimating equations were used to analyze the data. Results. Providers educated families about control medications during 61% of the visits, and they asked questions about control medications during 67% of visits. Providers were significantly more likely to discuss control medications if a child was taking a control medication, if the child had moderate to severe persistent asthma, and if the child was present for an asthma-related visit. Conclusion. Providers need to educate and ask more questions of families about side effects and how well control medications are working.

Psychotropic medication discussions in older adults' primary care office visits: So much to do, so little time

OBJECTIVES

To examine discussions of psychotropic medications during the older patient's visit to primary care physicians, identify how physician's competing demands influence these discussions, describe different scenarios physicians utilize to address mental health complaints of older adults, and recommend best practices for diagnosing and treating such patients.

METHOD

Convenience sample of 59 videotapes of primary care office visits involving mental health discussions in the United States complemented by patient and physician surveys. Videotaped visits were examined using logistic regression for grouped-level data to explore contributions of physician's competing demands to the likelihood of having psychotropic medication discussions. Tape transcripts were selected to provide examples of prescribing and referral behaviors.

RESULTS

One-third of these visits contained no psychotropic medication discussions despite its important role in treating mental illnesses. When prescribing psychotropic medicines, physicians presented information about the medication's purpose and brand name more often than adverse effects or usage. More competing demands (i.e., more topics discussed or more leading causes of disability addressed during the visit) were associated with less psychotropic medication discussions. Selected case scenarios illustrate the importance of acknowledging mental illness, prescribing psychotropic medications, explaining the medications, and/or referring patients to mental health providers to address their mental health complaints.

CONCLUSION

Competing demands may constrain discussions of psychotropic medications. Given the seriousness of mental illness in late life, system-level changes may be needed to correctly diagnose mental illness, take more proactive actions to improve mental health, and enhance information exchange concerning psychotropic medication in a manner that meets patients' needs.

Is the Internet replacing health professionals? A population survey on sources of medicines information among people with mental disorders

BACKGROUND

People with mental disorders often report unmet medicine information needs and may search for information on medicines from sources including the Internet, telephone services, books and other written materials.

OBJECTIVE

This study aimed to identify and describe the sources of medicines information used by people with and without mental disorders.

METHODS

A cross sectional postal survey was mailed to a nationally representative sample (n = 5,000) of Finns aged 15-64 years in spring 2005. Completed responses were received from 3,287 people (response rate 66%), of whom 2,348 reported using one or more sources of medicines information during the past 12 months. Of those who reported one or more sources of medicines information, 10% (n = 228) reported being diagnosed with or treated for a mental disorder. The main outcome measures were the sources of medicines information used by people who did and did not report being diagnosed with or treated for a mental disorder.

RESULTS

Among respondents with and without a mental disorder, physicians (83 vs. 59%), pharmacists (56 vs. 49%) and patient information leaflets (53 vs. 43%) were the most common sources of medicines information. After adjusting for age, gender, level of education, working status and number of chronic diseases, respondents with mental disorders were more likely to use patient information leaflets (OR 1.47, 95% CI 1.06-1.98) and the Internet (OR 1.64, 95% CI 1.02-2.64) as sources of medicines information than respondents without mental disorders.

CONCLUSIONS

The results indicate that physicians and pharmacists are the most common sources of medicines information among people both with and without mental disorders. However, patient information leaflets and the Internet were more commonly used by people with mental disorders. There may be an opportunity for clinicians to better exploit these sources of medicines information when developing medicines information services for people with mental disorders.

Shared decision-making: benefits, barriers and current opportunities for application

OBJECTIVE

Patient preference and involvement are two important aspects for many psychiatric treatment decisions. Shared decision-making (SDM) has been proposed as the optimal model to include patient preferences and involve patients in such decisions. Decision-making tools called decision aids (DA) are the most common application of SDM. DAs have been demonstrated to increase patients' knowledge, reduce decisional conflict, and reduce the proportion of patients who are passive in the decision-making process or remain undecided. Unfortunately, there are few DAs available for treatment decisions for psychiatric disorders and implementing SDM can be a challenge for mental health professionals. There are also issues unique to psychiatry related to the development and implementation of DAs that need consideration. Despite this, mental health professionals can and do still employ SDM techniques. This article offers an overview of the skills required to implement a SDM model and the resources currently available.

CONCLUSIONS

The core features of SDM are advocated for in clinical guidelines, but more resources are needed to ensure these recommendations are implemented in practice. In particular, the benefits of freely available DAs developed according to international standards need to be assessed for suitability and effectiveness.

Barriers to medication counselling for people with mental health disorders: a six country study

Provision of medication information may improve adherence and prevent medication related problems. People with mental health disorders commonly receive less medication counselling from pharmacists than people with other common long term and persistent disorders.

Medication nonfulfillment rates and reasons: narrative systematic review

BACKGROUND

The literature on nonfulfillment of prescription medications spans over three decades of work. There is a wide variation in reported nonfulfillment rates, but no previous study has systematically reviewed this literature to explore the reasons behind this variation.

OBJECTIVE

The objective of this study was to review estimates of medication nonfulfillment rates and published reasons for nonfulfillment and explore whether nonfulfillment rates vary by study variables.

METHODS

Articles were identified through searches conducted on MEDLINE, CINAHL, Psych Info, and EMBASE, and review of relevant reference citations. Methodological variables, nonfulfillment rate, and unit of analysis (i.e., patient or prescription) were abstracted from each article selected for review. Mean and median nonfulfillment rates for groups categorized by unit of analysis and selected methodological variables (method for assessing nonfulfillment, sample characteristics, disease subgroup, sample size, country of data collection, recall period or time allowed before classifying as nonfulfillment, and year of study) were calculated. Reasons for nonfulfillment were abstracted from all articles that included a relevant discussion.

FINDINGS

A total of 79 studies reporting pure nonfulfillment rates (59 at the patient level and 20 at the prescription level) and six studies reporting nonfulfillment rates in combination with nonpersistence rates were included. There was a wide variation in nonfulfillment rates reported by the studies - from 0.5% to 57.1%. The three primary reasons for nonfulfillment identified from this review were perceived concerns about medications, lack of perceived need for medications, and medication affordability issues.

CONCLUSION

To the best of the authors' knowledge, this study is the first narrative systematic review on nonfulfillment of prescription medications. Despite the wide variation in individual study rates, the mean and median rates across different modes of data collection and sources of data were in a relatively narrow range (11% to 19%) and surprisingly close to the overall mean (16.4%) and median (15%.0) rates for all studies. The reasons for nonfulfillment identified through this review address barriers to nonfulfillment at the patient, physician, and health system level and thus bear important implications for policy makers.

Patients' concerns about and problems experienced with discontinuation of antidepressants

Objective

Clinical trials and epidemiological studies have shown that premature discontinuation is a major problem during antidepressant therapy. Unfortunately, there is little information on how patients perceive treatment with antidepressants in clinical practice, and it is unclear whether patients perceive discontinuation as a problem. The objective of this study is to assess whether concerns and problems experienced with drug discontinuation occur more frequently in patients using antidepressants than in patients using benzodiazepines, antipsychotics or non-psychiatric medication.

Method

All calls to a national telephone medicines information service received between 1990 and 2004 were examined using retrospective examination. Calls about discontinuation were identified and classified either as a general question about discontinuation, or as a problem experienced with discontinuation. These calls were grouped into the following main classes: antidepressants, antipsychotics, benzodiazepines or non-psychiatric medicines.

Key findings

Of all 39 786 registered phone calls, 6159 (15,5%) related to antidepressants, 1658 (4.2%) to antipsychotics and 3916 (9.8%) to benzodiazepines. Patients calling about antidepressants called about discontinuation three times as often (odds ratio (OR) 2.8; 95% confidence interval (CI) 2.6–3.0), and reported a problem with discontinuation five times more often (OR 5.4; 95% CI 4.6–6.3), compared to patients who called about non-psychiatric medicines. The proportion of questions about discontinuation and problems experienced with discontinuation was also higher in patients calling about benzodiazepines and antipsychotics compared to patients calling about non-psychiatric medication.

Conclusion

Patients perceive discontinuation of antidepressants, as well as discontinuation of antipsychotics and benzodiazepines, as a problem. Discontinuation seems a general problem for all psychiatric medicines, and needs more attention in the communication between patients and healthcare providers.

Written information about individual medicines for consumers

BACKGROUND

Medicines are the most common intervention in most health services. As with all treatments, those taking medicines need sufficient information: to enable them to take and use the medicines effectively, to understand the potential harms and benefits, and to allow them to make an informed decision about taking them. Written medicines information, such as a leaflet or provided via the Internet, is an intervention that may meet these purposes.

OBJECTIVES

To assess the effects of providing written information about individual medicines on relevant patient outcomes (knowledge, attitudes, behaviours and health outcomes) in relation to prescribed and over-the-counter medicines.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, CINAHL, The Cochrane Library, PsycINFO and other databases to March 2007. We handsearched five journals' tables of contents, and the reference lists of included studies, and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of medicine users, comparing written medicines information with no written medicines information; or trials that compared two or more styles of written medicines information. We only included trials that measured a knowledge, attitudinal or behavioural outcome. There were no language restrictions.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data relating to the interventions, methods of the trials, and outcome measures; and reconciled differences by discussion. Heterogeneity of interventions and outcomes measured meant that data synthesis was not possible. The results are presented in narrative and tabular format.

MAIN RESULTS

We included 25 RCTs involving 4788 participants. Six of twelve trials showed that written information significantly improved knowledge about a medicine, compared with no written information. The inability to combine results means we cannot conclude whether written information was effective for increasing knowledge. The results for attitudinal and behavioural outcomes were mixed. No studies showed an adverse effect of medicines information.

AUTHORS' CONCLUSIONS

The combined evidence was not strong enough to say whether written medicines information is effective in changing knowledge, attitudes and behaviours related to medicine taking. There is some evidence that written information can improve knowledge. The trials were generally of poor quality, which reduces confidence in the results. Trials examining the effects of written information need to be better designed and use consistent and validated outcome measures. Trials should evaluate internet-based medicines information. It is imperative that written medicines information be based on best practice for its information design and content, which could improve its effectiveness in helping people to use medicines appropriately.

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.

Primary care physicians' evaluation and treatment of depression: Results of an experimental study using video vignettes

Little is known about how patient and primary care physician characteristics are associated with quality of depression care. The authors conducted structured interviews of 404 randomly selected primary care physicians after their interaction with CD-ROM vignettes of actors portraying depressed patients. Vignettes varied along the dimensions of medical comorbidity, attributions regarding the cause of depression, style, race/ethnicity, and gender. Results show that physicians showed wide variation in treatment decisions; for example, most did not inquire about suicidal ideation, and most did not state that they would inform the patient that there can be a delay before an antidepressant is therapeutic. Several physician characteristics were significantly associated with management decisions. Notably, physician age was inversely correlated with a number of quality-of-care measures. In conclusion, quality of care varies among primary care physicians and appears to be associated with physician characteristics to a greater extent than patient characteristics.

Discussion of alternatives, risks and benefits in pediatric acute care

OBJECTIVE

Across adult healthcare, discussions of alternatives, risks and benefits vary in inclusiveness or are even absent. We examine these discussions and their associated factors in pediatric visits.

METHODS

Coders noted speaker and recipient for alternatives, risks and benefits from 98 videotaped visits. Outcomes included discussion of alternatives, risks or benefits (yes/no) and involvement of parent or child in discussions (active or passive). Bivariate techniques were used to relate visit factors to outcomes.

RESULTS

Most visits included discussion of alternatives (58% of visits), risks (54%) and benefits (69%). Longer visits were more likely to include risk discussions. For alternatives, active parent/child involvement was more likely with college graduate parents; for risks active involvement was more likely with female and more experienced physicians. Parents and children raised risks more frequently than benefits, often focusing on disadvantages such as taste or frequency/duration of therapy.

CONCLUSION

Most pediatric visits include alternatives, risks and benefits but parent/child involvement in raising these topics is limited.

PRACTICE IMPLICATIONS

When parents or children initiate these discussions, they often mention risks salient to adherence. Future work could explore whether longer visits or interventions targeted for specific participants could foster such discussions.

Enhancing communication skills for pediatric visits through on-line training using video demonstrations

BACKGROUND

Training in communication skills for health professionals is important, but there are substantial barriers to individual in-person training for practicing clinicians. We evaluated the feasibility and desirability of on-line training and sought suggestions for future courses.

METHODS

Based on successful in-person curricula for communication skills and our previous on-line curricula, we created an on-line course consisting of 28 modules (4.75 hours CME credit) about communication skills during pediatric visits that included a mental health concern; each module included a brief case, a multiple choice question, an explanation, and a 1-2 minute video demonstrating key skills. Specific communication skills included: greeting, setting an agenda, discussing diagnosis and treatment, and managing negative interactions. The course was announced by emails in spring, 2007; the course was available on-line for 60 days; we aimed to enroll 50 clinicians. Outcomes were analyzed for those who evaluated the course within 75 days of its initial availability.

RESULTS

Overall, 61 clinicians registered, of whom most were nurses (N = 24), physicians (N = 22), or psychologists or social workers (N = 12). Of the 36 (59%) clinicians who evaluated the course, over 85% agreed that all course objectives had been met; over 90% reported greater confidence in greetings and agenda-setting; and over 80% reported greater confidence in discussing diagnosis and treatment and managing negative interactions. Nearly all, 97% would recommend the course to other clinicians and trainees. Suggestions for improvement included a library of additional video vignettes and written materials to accompany the on-line training.

CONCLUSION

On-line training in communication skills for pediatric mental health visits is feasible, desirable and associated with increased confidence in key skills. Positive feedback from clinicians suggests that a comparison of on-line versus in-person training is warranted.

Provider-patient communication about antidepressants among veterans with mental health conditions

BACKGROUND

Little is known about provider-patient communication regarding antidepressants in primary care settings.

OBJECTIVE

The purpose of the study was to describe the extent to which veterans and their providers discuss anti-depressants during primary care visits, and to examine how patient characteristics are related to elements of this communication.

METHODS

This study is a secondary analysis conducted of a data set of audiotaped clinic visits and previsit interviews with 253 adult male veterans seen in primary care. The study patients who were provided an initial antidepressant prescription or continued on an antidepressant on the day of the audiotaped visit and who had a diagnosis of depression, posttraumatic stress disorder, or bipolar disorder were included in the current analysis. Audiotapes were coded using a reliable instrument. Descriptive and bivariate statistics were calculated.

RESULTS

Forty veterans (mean [SD] age, 58.9 [10.4] years) were eligible for study. Of these 40 veterans with a documented prescription for an antidepressant, 62.5% (n = 25) discussed these medications with their provider during the visits. If antidepressants were discussed, the provider initiated the discussion 68.0% (n = 17) of the time. Only 2 patients asked questions about their antidepressants. Thirty-two of the 40 veterans were continued users of anti-depressants; 8 began their antidepressant on the date of the audiotaped visit. Providers asked 15.6% of veterans (n = 5) on continued therapy how well their antidepressants were working and 6.3% of veterans (n = 2) on continued therapy about adverse effects. Among continued users of antidepressants, 18.8% (n = 6) expressed a complaint about their antidepressant and 21.9% (n = 7) of patients expressed an adherence problem.

CONCLUSIONS

To detect and prevent problems with antidepressant therapy, primary care clinics should consider having nonphysician health care personnel ask patients taking antidepressant medication at least one open-ended question about how the antidepressant is working, another about possible adverse effects or barriers to use, and a third about adherence.