Compliance with antidepressant medication in the treatment of major depressive disorder in primary care: a randomized comparison of fluoxetine and a tricyclic antidepressant

Association between childhood trauma and medication adherence among patients with major depressive disorder: the moderating role of resilience

BACKGROUND

Suboptimal medication adherence is a major reason for failure in the management of major depressive disorder (MDD), childhood trauma might be an essential risk factor of suboptimal medication adherence. This study aimed to comprehensively explore the associations between different types of childhood trauma and medication adherence among patients with MDD, and to test whether resilience has moderating effects on the foregoing associations.

METHODS

Participants were from the Depression Cohort in China (ChiCTR registry number 1900022145), 282 MDD patients with completed both baseline and 12-weeks follow-up investigations were included in this study. The diagnosis of MDD was assessed by trained psychiatrists using the Mini-International Neuropsychiatric Interview (M.I.N.I.). Childhood trauma was evaluated using the Childhood Trauma Questionnaire-28 item Short Form (CTQ-SF), and resilience was evaluated using the Connor-Davidson Resilience Scale (CD-RISC). Demographic characteristics, depression symptoms, anxiety symptoms, suicidal ideation, suicidal attempt, insomnia symptoms, and painful somatic symptoms were also investigated. Participants were divided into groups of optimal and suboptimal adherence based on their Medication Adherence Rating Scale scores. Logistic regression and stratified analyses were performed.

RESULTS

A total of 234 participants (83%) reported suboptimal medication adherence. After adjusting for covariates, CTQ total scores (AOR = 1.03, 95%CI = 1.01-1.06), CTQ measures of sexual abuse (AOR = 1.17, 95%CI = 1.01-1.37), and CTQ measures of physical neglect (AOR = 1.12, 95%CI = 1.02-1.23) were all associated with an increased likelihood of suboptimal adherence. There were significant moderating effects of resilience on the associations of childhood trauma (P = 0.039) and physical neglect (P = 0.034) with medication adherence. The stratification analyses showed that CTQ total scores and CTQ measures of physical neglect were independently associated with an increased risk of suboptimal adherence among patients with MDD with low-resilience or moderate-resilience, while not significantly associated with suboptimal adherence in those with high-resilience.

CONCLUSION

Childhood trauma was a significant risk factor of suboptimal adherence among patients with MDD, and resilience moderated the foregoing association. Obtaining a history of childhood trauma and assessing resilience may help identify patients with suboptimal adherence when providing MDD pharmacotherapy. Psychiatrists may consider enhancing resilience to cope with the adverse effects of childhood trauma on medication adherence.

The effect of initial antidepressant type on treatment adherence in outpatients with new onset depression

BACKGROUND

Continuous use of antidepressants can relieve depressive symptoms and prevent recurrence in people with depression; however, many studies have reported low drug compliance rates. This study aimed to investigate the relationship between the type of initial antidepressants and treatment adherence in outpatients with new onset depression.

METHODS

This was a retrospective cohort study using National Health Insurance claim data for services provided in 2012. We examined data from 142,336 individuals aged 18 years or older, who were continuously enrolled in treatment after a new episode of depression, and had initiated antidepressant treatment. A new diagnosis of depression, is defined as a first reported diagnosis of depression in the preceding five years. Adherence was operationally defined as the antidepressant being dispensed to the patient at least 80% of the time during the first three- and six-month treatment periods. To investigate the relationship between the initial type of antidepressants and treatment adherence, we estimated adjusted odds ratios and 95% confidence intervals using logistic regression analysis, adjusting for socio-demographic and health care utilization characteristics.

RESULTS

A statistically significant association was found between initial antidepressant type and adherence in the first three- and six-month treatment periods for employed and self-employed patients newly diagnosed with major depression. In addition, patients with starting prescriptions for tricyclic antidepressants had significantly lower adherence compared to selective serotonin reuptake inhibitors.

LIMITATIONS

This study used national insurance data; therefore, only variables on the claim form were available, and psychological and environmental factors were not considered.

CONCLUSIONS

This was the first study to demonstrate the relationship between initial antidepressant type and treatment adherence among Korean outpatients with new onset depression.

Psychotropic Medication Adherence in Children and Adolescents

Researchers believe that almost 20% of children and adolescents struggle with chronic and persistent mental health concerns. Mental health is the leading cause of disability in the United States. Youth can struggle with several impairing mental health disorders, such as attention-deficit/hyperactivity disorder, mood disorders, psychotic disorders, and autism spectrum disorder. Inadequately treated chronic mental illnesses can adversely affect the growing brain profoundly, including academic decline, early school dropout, cognitive deficits, interpersonal relationship concerns, aggression, suicide attempts or completion, substance use disorders, frequent hospital admissions, and inability to maintain employment. Even if diagnosed early in their course of illness, many of these individuals struggle to continue medications as prescribed. The factors predicting adherence to medications are underresearched in children and adolescents. Psychotropic medication compliance is a complicated issue that is tied to various aspects of caring for a minor individual. Hence, it is relevant to discuss factors that are predicted to contribute to noncompliance in this age group. The purpose of this review is to carefully consider the gaps in knowledge, suggesting interventions by using established instruments and clinical strategies to resolve the identified barriers for improving medication adherence. Compliance should be targeted at various levels, including the entire family tree and the treatment team.

Transdermal Route: A Viable Option for Systemic Delivery of Antidepressants

The high rise in the population suffering from depression depicts the need for improved and highly effective treatment options for this condition. Efforts to develop existing drugs into user-friendly dosage forms with a number of advantages in major depressive states, including but not limited to: sustained drug release, reduced drug dosing frequency, improved tolerance and adherence, suitability for use in diverse populations and different treatment scenarios, as well as less central nervous system side effects are required. One such non-invasive drug delivery route that could provide the aforementioned benefits in the treatment of depression is the transdermal route. A number of conventional and emerging transdermal delivery strategies have been investigated for some potent antidepressants and results depict the potential of this route as a viable means for systemic delivery of therapeutically relevant doses of the tested agents, with Emsam®, the commercially available patch of selegiline, being an evidence for the same. The investigated approaches include the formulation of transdermal patches, use of vesicular drug carriers, pro-drug approach, microemulsification, chemical as well as physical enhancement technologies. This review provides a comprehensive account of the rationale, developments made till date, scope and future prospects of delivering antidepressants via the transdermal1 route of administration.

Adherence to Antidepressants in Underserved Communities: A Comparison of Electronic Monitoring and Self-report Measures

Nonadherence to antidepressants is widespread and poses a significant barrier to optimal management and treatment of depression in community settings. The objective of this study was to compare self-reported and electronic monitoring of adherence to antidepressants and to examine the relationship of these measures with depressive symptoms in a medically underserved community. Adherence to antidepressants was measured in 38 primary care patients from the West Philadelphia area using self-report and electronic monitoring (Medication Event Monitoring System caps). Self-report and electronic monitoring of antidepressant adherence showed fair agreement at baseline, slight agreement at 6 weeks, and slight agreement at 12 weeks. Adherence to antidepressants as assessed by electronic monitors was significantly associated with depression remission at 12 weeks [adjusted odds ratio 18.6, 95% confidence interval (1.05, 330.56)]. Compared with electronic monitoring, self-reported adherence tended to overestimate medication adherence to antidepressants. Adherence assessed by electronic monitoring was associated with depression remission.

Treatment adherence and persistence in adult ADHD: Results from a twenty-four week controlled clinical trial with extended release methylphenidate

Purpose:

The aim of this analysis is to describe medication adherence, and treatment persistence, in adults with attention deficit/hyperactivity disorder (ADHD) treated for 24 weeks with extended release methylphenidate (MPH-ER). Additionally, patient-, disorder- and treatment-related factors associated with adherence and persistence will be identified.

Method:

Post-hoc analysis of the active treatment group of a placebo-controlled, randomised, 24 week trial with MPH-ER with univariate description and multiple logistic regression models and Hosmer and Lemeshow tests.

Results:

In the sample of 241 adults with ADHD (mean age of 35.2 ± 10.1 years), 9.4% of the patients were non-adherent, taking less than 80% of the dispensed medication. Factors associated with non-adherence included age < 25 years, education level lower than secondary education, lacking family history of ADHD, lower ADHD baseline severity and lower self- and observer-rated medication efficacy. Lacking family history of ADHD, lower education level and lower self-rated medication efficacy, predicted non-adherence with a prediction accuracy of 16%. Seventeen percent of the patients discontinued early with most discontinuing within the first five weeks of the MPH-ER titration phase. Mean persistence in the discontinuing group was 63.4 ± 49.4 days. Factors associated with discontinuation included male gender, lower education level, lacking family history of ADHD and lower self- and observer-rated medication efficacy. Treatment non-response, male gender and lower education level predicted treatment discontinuation with a prediction accuracy of 22.7%.

Conclusion:

Male adults without relatives with ADHD, with lower educational level and lower self- and observer-rated medication efficacy, who are newly treated with MPH-ER, are at increased risk of non-adherence and treatment discontinuation. Patients are at increased risk of treatment discontinuation during the medication titration phase.

Determinants of suboptimal medication adherence in patients with a major depressive episode

BACKGROUND

Major Depression (MD) is often a chronic condition requiring a long-term pharmacologic treatment. Despite the efficacy of antidepressants, the medication adherence in those affected is usually very poor. In this scenario, further research concerning drivers of suboptimal adherence is needed. We aimed to explore medication adherence in patients with a MD episode, and to identify sociodemographic, clinical (psychiatric antecedents, comorbidities, medication, pain, and medication side effects), and psychosocial factors (negative life events, childhood trauma, and attitudes to medication) related to adherence status.

METHOD

The Medication Adherence Rating Scale (MARS) was completed by 370 patients at hospital admission. Participants were divided into groups of optimal and suboptimal adherence based on the medication adherence behavior score (MARS's factor 1), and were compared with respect to the study variables.

RESULTS

Twenty-nine percent of participants (n = 107) were found to be optimally adherents to their medication (score = 4/4). Compared to optimally adherents, suboptimally adherents (71%) presented a significantly higher depression severity, more psychiatric hospitalizations, suicidal ideation, physical pain, negative medication side effects, and antecedents of emotional maltreatment. Suboptimally adherents also had less favorable attitudes toward medication and were less in a relationship than optimally adherents. Multivariate analyses showed that depression severity, suicidal ideation, and physical pain increase the probability of belonging to the suboptimal adherent group.

CONCLUSION

These results suggest a vicious circle in which more vulnerable patients are less adherent to medication, which could worsen the clinical picture maintaining, in turn, low adherence. More efforts are needed to develop interventions aiming to improve medication adherence in MD patients.

Real-world persistence and adherence to oral antimuscarinics and mirabegron in patients with overactive bladder (OAB): a systematic literature review

PURPOSE

To evaluate persistence and adherence of oral pharmacotherapy used in the treatment of overactive bladder (OAB) in a real-world setting.

MATERIALS AND METHODS

Systematic literature searches of six electronic publication databases were performed to identify observational studies of patients with OAB treated with antimuscarinics and/or mirabegron. Studies obtaining persistence and adherence data from sources other than electronic prescription claims were excluded. Reference lists of identified studies and relevant systematic reviews were assessed to identify additional relevant studies.

RESULTS

The search identified 3897 studies, of which 30 were included. Overall, persistence ranged from 5% to 47%. In studies reporting data for antimuscarinics and mirabegron (n=3), 1-year persistence was 12%-25% and 32%-38%, respectively. Median time to discontinuation was <5 months for antimuscarinics (except one study (6.5 months)) and 5.6-7.4 months for mirabegron. The proportion of patients adherent at 1 year varied between 15% and 44%. In studies reporting adherence for antimuscarinics and mirabegron, adherence was higher with mirabegron (mean medication possession ratio (MPR): 0.59 vs 0.41-0.53; mean proportion of days covered: 0.66 vs 0.55; and median MPR: 0.65 vs 0.19-0.49). Reported determinants of persistence and adherence included female (sex), older age group, use of extended-release formulation and treatment experience.

CONCLUSION

Most patients with OAB discontinued oral OAB pharmacotherapy and were non-adherent 1 year after treatment initiation. In general, mirabegron was associated with greater persistence and adherence compared with antimuscarinics. Combined with existing clinical trial evidence, this real-world review merits consideration of mirabegron for first-line pharmacological treatment among patients with OAB.

PROSPERO REGISTRATION NUMBER

CRD42017059894.

The prospective, 24-week assessment of cost-efficacy of and compliance to antidepressant medications in a rural setting (PACECAR) study

BACKGROUND

Anxiety and depression are common mental health disorders that are responsible for considerable societal burden. There are no data on cost-efficacy and medication compliance related to the treatment of these disorders in rural India.

MATERIALS AND METHODS

All consenting adults (n = 455) diagnosed with generalized anxiety or (unipolar) depressive disorders in Suttur village, Karnataka, were treated with open-label fluoxetine (20-60 mg/day), sertraline (50-150 mg/day), escitalopram (10-20 mg/day), desvenlafaxine (50-150 mg/day), duloxetine (30-90 mg/day), amitriptyline (75-150 mg/day), or clomipramine (75-150 mg/day) in a structured, monotherapy dosing plan. The study was nonrandomized and otherwise naturalistic. Patients were followed up every 4 weeks for 24 weeks. Study discontinuation was defined as medication noncompliance for 3 or more days or withdrawal due to treatment nonresponse.

RESULTS

There was substantial discontinuation (34.5%) in the first 4 weeks; 55.4% had discontinued by 12 weeks. Subsequently, only 11.2% discontinued treatment. Only 33.4% of the subjects tolerated the treatment, responded to it, and remained compliant for 24 weeks. Such successful completion was highest for escitalopram and desvenlafaxine (46%-47%) and lowest for clomipramine and amitriptyline (10%-14%). Adverse events were the most common reason for noncompliance with clomipramine and amitriptyline (45%-46%); the experience of sufficient improvement was the most common reason for noncompliance with the remaining drugs (28%-49%). Whereas the average cost of efficacious treatment for a continuous period of 24 weeks was lowest for fluoxetine, an examination of the cost-efficacy tradeoff suggested maximum advantage for escitalopram, sertraline, and desvenlafaxine. The cost-efficacy profile for amitriptyline and clomipramine was poor.

CONCLUSIONS

Reasons for noncompliance vary by drug class and need to be considered when prescribing antidepressant drugs. Escitalopram, sertraline, and desvenlafaxine perhaps have the most favorable 24-week cost-efficacy profile; tricyclics are poorly tolerated. Rural subjects need to be educated that treatment must be continued even after improvement is established.

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.

Racial/ethnic variation in health care satisfaction: The role of acculturation

This study examined the role of acculturation and racial/ethnic variation in health care satisfaction among four different racial/ethnic groups. The study sample consisted of 41,560 adults from the 2011 California Health Interview Survey. Health care satisfaction was measured via two questions regarding doctors' listening and explanations. Guided by Andersen's behavioral model of health care use, multivariate logistic regressions were conducted. Hispanic and Asian respondents showed the lowest levels of satisfaction with their doctors' listening and explanations, respectively. Acculturation was found to be a significant predictor of health care satisfaction. Health care professionals should develop ways of expanding culturally competent health care professionals, who are aware of racial/ethnic variation in health care satisfaction.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

Moderate sample size. Data collected in 2002-2004.

CONCLUSIONS

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

[Adherence to psychopharmacological treatment: Psychotherapeutic strategies to enhance adherence]

Effective psychopharmacological medication with good tolerability represents the cornerstone of treatment for severe mental illness; however, the 1-year adherence rates are only approximately 50%. The term adherence emphasizes the collaborative responsibility of the clinician and the patient for a positive treatment outcome. Reasons for non-adherence are manifold and include patient-specific factors, such as self-stigmatization, lack of social and familial support, cognitive impairment and substance use besides insufficient effectiveness and the occurrence of side effects of the psychotropic drugs. To enhance adherence, both clinician and patient have to fully understand all the reasons for and against adherence to medication before a collaborative decision is made on future long-term treatment. A positive attitude towards medication critically depends on whether patients feel that the medication supports the attainment of the individual goals.

Persons Living With HIV/AIDS: Employment as a Social Determinant of Health

Purpose: For persons living with HIV/AIDS (PLWHA), the advent of highly active antiretroviral therapy has increased their longevity and quality of life. As HIV progresses, many PLWHA present declined domains of functioning that impede their ability to work. The authors explore employment as a social determinant of health to identify issues impacting employment outcomes for PLWHA.

Methods: The authors reviewed the literature addressing HIV across the domains of mental health functioning, neurocognitive functioning, and physical function and employment.

Results: When providing employment services to PLWHA, considerations for rehabilitation practitioners and educators include HIV/AIDS education, functional assessment, social support, considerations for women with HIV, highly active antiretroviral therapy (HAART), HIV/AIDS stigma, and employment resources for PLWHA.

Conclusion: With more than 1.2 million PLWHA in the United States, and most of new infections among persons 25–44 years of age, the prevalence of PLWHA seeking employment and inclusive of the U.S. workforce will continue to increase. Proving employment services for PLWHA is a complex process that is best served by an integrative service approach.

Rates and predictors of adherence to psychotropic medications in children with autism spectrum disorders

Medication adherence in children is poor, particularly among those with chronic or mental health disorders. However, adherence has not been fully assessed in autism spectrum disorders (ASDs). The validated proportion of days covered method was used to quantify adherence to psychotropic medication in Medicaid-eligible children who met diagnostic criteria for ASD between 2000 and 2008 (N = 628). Among children prescribed attention deficit hyperactivity disorder (ADHD) medications, antidepressants, or antipsychotics, 44, 40 and 52 % were adherent respectively. Aggressive behaviors and abnormalities in eating, drinking, and/or sleeping, co-occurring ADHD, and the Medication Regimen Complexity Index were the most significant predictors of adherence rather than demographics or core deficits of ASD. Identifying barriers to adherence in ASD may ultimately lead to improved treatment outcomes.

Fluoxetine versus other types of pharmacotherapy for depression

BACKGROUND

Depression is common in primary care and is associated with marked personal, social and economic morbidity, thus creating significant demands on service providers. The antidepressant fluoxetine has been studied in many randomised controlled trials (RCTs) in comparison with other conventional and unconventional antidepressants. However, these studies have produced conflicting findings.Other systematic reviews have considered selective serotonin reuptake inhibitor (SSRIs) as a group which limits the applicability of the indings for fluoxetine alone. Therefore, this review intends to provide specific and clinically useful information regarding the effects of fluoxetine for depression compared with tricyclics (TCAs), SSRIs, serotonin-noradrenaline reuptake inhibitors (SNRIs), monoamineoxidase inhibitors (MAOIs) and newer agents, and other conventional and unconventional agents.

OBJECTIVES

To assess the effects of fluoxetine in comparison with all other antidepressive agents for depression in adult individuals with unipolar major depressive disorder.

SEARCH METHODS

We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Review Group Controlled Trials Register (CCDANCTR)to 11May 2012. This register includes relevant RCTs from the Cochrane Central Register of Controlled Trials (CENTRAL) (all years),MEDLINE (1950 to date), EMBASE (1974 to date) and PsycINFO (1967 to date). No language restriction was applied. Reference lists of relevant papers and previous systematic reviews were handsearched. The pharmaceutical company marketing fluoxetine and experts in this field were contacted for supplemental data.

SELECTION CRITERIA

All RCTs comparing fluoxetine with any other AD (including non-conventional agents such as hypericum) for patients with unipolar major depressive disorder (regardless of the diagnostic criteria used) were included. For trials that had a cross-over design only results from the first randomisation period were considered.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by two review authors using a standard form. Responders to treatment were calculated on an intention-to-treat basis: dropouts were always included in this analysis. When data on dropouts were carried forward and included in the efficacy evaluation, they were analysed according to the primary studies; when dropouts were excluded from any assessment in the primary studies, they were considered as treatment failures. Scores from continuous outcomes were analysed by including patients with a final assessment or with the last observation carried forward. Tolerability data were analysed by calculating the proportion of patients who failed to complete the study due to any causes and due to side effects or inefficacy. For dichotomous data, odds ratios (ORs) were calculated with 95% confidence intervals (CI) using the random-effects model. Continuous data were analysed using standardised mean differences (SMD) with 95% CI.

MAIN RESULTS

A total of 171 studies were included in the analysis (24,868 participants). The included studies were undertaken between 1984 and 2012. Studies had homogenous characteristics in terms of design, intervention and outcome measures. The assessment of quality with the risk of bias tool revealed that the great majority of them failed to report methodological details, like the method of random sequence generation, the allocation concealment and blinding. Moreover, most of the included studies were sponsored by drug companies, so the potential for overestimation of treatment effect due to sponsorship bias should be considered in interpreting the results. Fluoxetine was as effective as the TCAs when considered as a group both on a dichotomous outcome (reduction of at least 50% on the Hamilton Depression Scale) (OR 0.97, 95% CI 0.77 to 1.22, 24 RCTs, 2124 participants) and a continuous outcome (mean scores at the end of the trial or change score on depression measures) (SMD 0.03, 95% CI -0.07 to 0.14, 50 RCTs, 3393 participants). On a dichotomousoutcome, fluoxetine was less effective than dothiepin or dosulepin (OR 2.13, 95% CI 1.08 to 4.20; number needed to treat (NNT) =6, 95% CI 3 to 50, 2 RCTs, 144 participants), sertraline (OR 1.37, 95% CI 1.08 to 1.74; NNT = 13, 95% CI 7 to 58, 6 RCTs, 1188 participants), mirtazapine (OR 1.46, 95% CI 1.04 to 2.04; NNT = 12, 95% CI 6 to 134, 4 RCTs, 600 participants) and venlafaxine(OR 1.29, 95% CI 1.10 to 1.51; NNT = 11, 95% CI 8 to 16, 12 RCTs, 3387 participants). On a continuous outcome, fluoxetine was more effective than ABT-200 (SMD -1.85, 95% CI -2.25 to -1.45, 1 RCT, 141 participants) and milnacipran (SMD -0.36, 95% CI-0.63 to -0.08, 2 RCTs, 213 participants); conversely, it was less effective than venlafaxine (SMD 0.10, 95% CI 0 to 0.19, 13 RCTs,3097 participants). Fluoxetine was better tolerated than TCAs considered as a group (total dropout OR 0.79, 95% CI 0.65 to 0.96;NNT = 20, 95% CI 13 to 48, 49 RCTs, 4194 participants) and was better tolerated in comparison with individual ADs, in particular amitriptyline (total dropout OR 0.62, 95% CI 0.46 to 0.85; NNT = 13, 95% CI 8 to 39, 18 RCTs, 1089 participants), and among the newer ADs ABT-200 (total dropout OR 0.18, 95% CI 0.08 to 0.39; NNT = 3, 95% CI 2 to 5, 1 RCT, 144 participants), pramipexole(total dropout OR 0.12, 95% CI 0.03 to 0.42, NNT = 3, 95% CI 2 to 5, 1 RCT, 105 participants), and reboxetine (total dropout OR0.60, 95% CI 0.44 to 0.82, NNT = 9, 95% CI 6 to 24, 4 RCTs, 764 participants).

AUTHORS' CONCLUSIONS

The present study detected differences in terms of efficacy and tolerability between fluoxetine and certain ADs, but the clinical meaning of these differences is uncertain.Moreover, the assessment of quality with the risk of bias tool showed that the great majority of included studies failed to report details on methodological procedures. Of consequence, no definitive implications can be drawn from the studies' results. The better efficacy profile of sertraline and venlafaxine (and possibly other ADs) over fluoxetine may be clinically meaningful,as already suggested by other systematic reviews. In addition to efficacy data, treatment decisions should also be based on considerations of drug toxicity, patient acceptability and cost.

Biopsychosocial determinants of self-management in culturally diverse South african patients with essential hypertension

Associations between self-management and biopsychosocial variables in a group of Afrikaans- (n= 102) and Sotho-speaking (n= 94) patients with essential hypertension (EH) were investigated. Self-management in terms of predetermined criteria for medical and lifestyle prescriptions was achieved by only 30.6 per cent of the participants. Significant differences were found between self-managing and non self-managing participants regarding language and culture, doctor-patient fit, complexity of prescriptions, medication side-effects, aspects of health beliefs, illness behaviour and health locus of control. In addition, a first empirical indication was found that self-management is also linked with psychological wellbeing, as manifested in a sense of coherence. The significantly accurate prediction of self-management by various biopsychosocial variables endorses the relevance of a biopsychosocial perspective in the treatment of patients with EH.

Poor response to treatment: beyond medication

In psychiatry, one of the main factors contributing to poor response to pharmacological treatment is adherence. Noncompliance with maintenance treatments for chronic illnesses such as schizophrenia and affective disorders can exceed 50%, Poor adherence can be due to drug-related factors (tolerance, complexity of prescription, side effects, or cost), patient-related variables (illness symptoms, comorbidity, insight capacity, belief system, or sociocultural environment), and physician-related factors (communication or psychoeducational style). Psychosocial treatments must be used in conjunction with medication during the maintenance phase to improve adherence to treatment and to achieve - through the management of psychological variables - better social, work, and family functioning. This article reviews the concepts of adherence and noncompliance, and their impact on maintenance treatments, as well as the effect of dealing with psychosocial factors in psychiatric treatment.

Beliefs about medications predict adherence to antidepressants in older adults

BACKGROUND

Adherence to treatment is a complex and poorly understood phenomenon. This study investigates the relationship between older depressed patients' adherence to antidepressants and their beliefs about and knowledge of the medication.

METHODS

Assessment was undertaken of 108 outpatients over the age of 55 years diagnosed with depressive disorder and treated for at least four weeks with antidepressants. Adherence was assessed using two self-report measures: the Medication Adherence Rating Scale (MARS) and a Global Adherence Measure (GAM). Potential predictors of adherence investigated included sociodemographic, medication and illness variables. In addition, 33 carers were interviewed regarding general medication beliefs.

RESULTS

56% of patients reported 80% or higher adherence on the GAM. Sociodemographic variables were not associated with adherence on the MARS. Specific beliefs about medicines, such as "my health depends on antidepressants" (necessity) and being less worried about becoming dependant on antidepressants (concern) were highly correlated with adherence. General beliefs about medicines causing harm or being overprescribed, experiencing medication side-effects and severity of depression also correlated with poor adherence. Linear regression with the MARS as the dependent variable explained 44.3% of the variance and showed adherence to be higher in subjects with healthy specific beliefs who received more information about antidepressants and worse with depression severity and autonomic side-effects.

CONCLUSIONS

Our findings strongly support a role for specific beliefs about medicines in adherence. Challenging patients' beliefs, providing information about treatment and discussing side-effects could improve adherence. Poor response to treatment and medication side-effects can indicate poor adherence and should be considered before switching medications.

A cohort study of adherence to antidepressants in primary care: the influence of antidepressant concerns and treatment preferences

OBJECTIVE

Clinical guidelines recommend that antidepressant treatment should be continued for a minimum of 6 months following response in depression and anxiety disorders. However, adherence to antidepressants is low. This prospective cohort study investigated the influence of patients' antidepressant concerns, treatment preferences, and illness perceptions on adherence to antidepressants over a 6-month period.

METHOD

A cohort of 178 patients aged 18 to 74 years and newly issued with a prescription for antidepressants to treat any condition was followed up prospectively at 5 primary care practices in Southeast England. Adherence was measured through self-report and prescription refill data. Patient perceptions were quantified using validated outcome measures, the Beliefs about Medicine Questionnaire and the Illness Perception Questionnaire, at 4 timepoints. Patient treatment preferences were recorded using a specially designed questionnaire. Data collection took place between September 2000 and May 2002.

RESULTS

Of 147 participants (83%) who completed the study, 19% persisted with antidepressants in accordance with guideline recommendations throughout the 6-month period. Specific concern about antidepressant side effects (OR = 3.30, 95% CI = 2.20 to 4.97) and general worry about taking antidepressants (OR = 1.65, 95% CI = 1.13 to 2.40) were independent predictors of antidepressant nonuse. Preference for different treatment/uncertainty about preferred treatment was also a strong predictor (OR = 3.82, 95% CI = 1.35 to 10.77). However, illness perceptions were not associated with adherence.

CONCLUSIONS

Concerns about antidepressants and a mismatch between patients' preferred and prescribed treatment act as significant barriers to sustained adherence. This study highlights the central role of the patient-physician partnership in exploring antidepressant concerns, working with treatment preferences, and providing supportive continued management. The findings may inform the development of interventions within primary care programs to enhance commitment to treatment for common mental disorders.

Regimen complexity and prescription adherence in dialysis patients

OBJECTIVES

Poor medication adherence is common in end-stage renal disease and may cause suboptimal outcomes and increased healthcare costs. We assessed the association between regimen complexity, perceived burden of oral therapy (BOT) and medication adherence in a large sample of hemodialysis (HD) patients.

METHODS

1,238 HD patients in 54 Italian centers participated. Data were collected on patients' socio-demographic characteristics, perceived BOT, quality of life, healthcare satisfaction, social support and medication adherence with a self-administered questionnaire. Data on medication regimen, comorbidities, hospitalizations, and transplant listing status were provided by the nursing staff. We estimated the adjusted association of regimen complexity, BOT and medication adherence with logistic regression.

RESULTS

There were 789 (64%) men and the median age was 67 years. Mean daily burden was 9.7 tablets and 48% of patients were adherent to medication prescriptions. The number of tablets prescribed in the medication regimen was associated to adherence likelihood after adjustment for possible confounders. Perceived BOT moderated the association between tablet count and self-reported adherence.

CONCLUSION

Poor adherence was very common in our sample. Reducing tablet burden might help patients be adherent. However, our results suggest that modulating regimen complexity might be ineffective if patients' negative attitudes toward medications are not addressed concurrently.

Performance of Cpred/Cobs concentration ratios as a metric reflecting adherence to antidepressant drug therapy

BACKGROUND

Nonadherence is very common among subjects undergoing pharmacotherapy for schizophrenia and depression. This study aimed to evaluate the performance of the ratio of the nonlinear mixed effects pharmacokinetic model predicted concentration to observed drug concentration (ratio of population predicted to observed concentration (Cpred/Cobs) and ratio of individual predicted to observed concentration (Cipred/Cobs) as a measure of erratic drug exposure, driven primarily by variable execution of the dosage regimen and unknown true dosage history.

METHODS

Modeling and simulation approaches in conjunction with dosage history information from the Medication Event Monitoring System (MEMS, provided by the "Depression: The search for treatment relevant phenotypes" study), was applied to evaluate the consistency of exposure via simulation studies with scenarios representing a long half-life drug (escitalopram). Adherence rates were calculated based on the percentage of the prescribed doses actually taken correctly during the treatment window of interest. The association between Cpred/Cobs, Cipred/Cobs ratio, and adherence rate was evaluated under various assumptions of known dosing history.

RESULTS

Simulations for those scenarios representing a known dosing history were generated from historical MEMS data. Simulations of a long half-life drug exhibited a trend for overprediction of concentrations in patients with a low percentage of doses taken and underprediction of concentrations in patients taking more than their prescribed number of doses. Overall, the ratios did not predict adherence well, except when the true adherence rates were extremely high (greater than 100% of prescribed doses) or extremely low (complete nonadherence). In general, the Cipred/Cobs ratio was a better predictor of adherence rate than the Cpred/Cobs ratio. Correct predictions of extreme (high, low) 7-day adherence rates using Cipred/Cobs were 73.8% and 64.0%.

CONCLUSION

This simulation study demonstrated the limitations of the Cpred/obs and Cipred/obs ratios as metrics for actual dosage intake history, and identified that use of MEMS dosing history monitoring combined with sparse pharmacokinetic sampling is a more reliable approach.

Description of study population and analysis of factors influencing adherence in the observational Italian study "Evaluation of Pharmacotherapy Adherence in Bipolar Disorder" (EPHAR)

BACKGROUND

In patients with bipolar disorder, medication is effective in preventing relapses. Unfortunately, adherence to treatment in bipolar disorder, as in other chronic or recurrent conditions, is not optimal. Estimates of nonadherence to prescribed treatment range from 30% to 60% in epidemiological studies, and are at around 30% in clinical trials. Adherence to treatment is a potent predictor of effectiveness, both in clinical trials and cohort studies, therefore is a very relevant area of investigation. This study will try to show a picture of the real life care where adherence is influenced by a wide range of variables.

METHODS

Prospective, observational, multicenter study in 650 adult patients with bipolar disorder, who had to initiate or change their treatment regimen, observed for 1 year. Adherence was measured by the Simplified Medication Adherence Questionnaire (SMAQ). Additional variables: Symptom severity, Montgomery-Åsberg Depression Rating Scale (MADRS), Young Mania Rating Scale (YMRS), Clinical Global Impression-Bipolar Disorder (CGI-BD), the Drug Attitude Inventory score (DAI-30), and quality of life (EuroQoL 5 Dimensions). The variables were recorded every 3 months for the next year.

RESULTS

Most subjects were out-patients (77.1%), female (58.8%), aged 31-50 years (50.1%) and overweight (41.8%) or obese (28.7%); 67.4% had type I bipolar disorder and 66.8% had depressive or mixed symptoms. Adherence was 39.9% at baseline (and increased up to 67.0% at completion. The main predictors of nonadherence were alcohol consumption, severe bipolar symptoms, young age at time of first treatment, negative attitude towards treatment.

CONCLUSIONS

The patient population of this observational trial was representative of the patients changing their therapy for bipolar disorder seen in clinical practice in Italy. Lack of adherence to pharmacotherapy for bipolar disorder is a serious issue, which is more likely to arise in alcohol users and patients with severe symptoms, negative attitude towards medication and/or initiation of treatment early in life. The findings could lead to a more adequate approach of adherence in patients with bipolar disorders.

Methodological challenges in psychiatric treatment adherence research

Reflecting an increasing awareness of the importance of treatment adherence on outcomes in psychiatric populations, the National Institute of Mental Health (NIMH) convened a panel of treatment adherence researchers on September 27-28, 2007 to discuss and articulate potential solutions for dealing with methodological adherence research challenges. Panel discussions and presentations were augmented with targeted review of the literature on specific topics, with a focus on adherence to medication treatments in adults with serious mental illness. The group discussed three primary methodological areas: participants, measures, and interventions. When selecting patients for adherence-enhancing interventions (AEIs), a three-tier model was proposed that draws from the universal (targeting all patients receiving medication treatment for a specific condition, regardless of current adherence), selective (targeting patients at risk for nonadherence), and indicated (targeting patients who are currently nonadherent) prevention model and emphasizes careful patient characterization in relevant domains and appropriate matching of interventions to the selected population. Proposals were also made to reduce problematic selection biases in patient recruitment and retention. The panel addressed the pros and cons of various methods that can be used to measure adherence, and concluded that it is appropriate to use multiple measures whenever possible. Finally, the panel identified a broad range of intervention approaches, and conditions under which these interventions are likely to be most effective at reducing barriers to adherence and reinforcing adherence behavior.

Psychiatric comorbidity in patients with epilepsy: a population-based study

PURPOSE

Patients with epilepsy often suffer from concomitant psychiatric disorders. Treatment patterns and the extent of comorbidity are insufficiently investigated and appropriate methods are scarce. The purpose of the study was to estimate the prevalence of psychiatric comorbidity in patients with epilepsy and to investigate prescription patterns of drugs prescribed for psychiatric disorders in epilepsy.

METHODS

Prescription data from the Norwegian Prescription Database (NorPD) regarding the use of CNS-active drugs included anonymous data from almost 190,000 patients and 1.1-1.3 million prescriptions per year (2004-2007). Searches were based upon use of specific drugs, defined daily doses, number of patients, prescriptions, gender, and age. Reimbursement codes related to psychiatric diagnosis were used as indicators for clinical use.

RESULTS

The prevalence of psychiatric comorbidity in patients with epilepsy was estimated to be 32%. There were 56% women and 44% men participating in the study. Among patients using antidepressants two thirds were women, but no gender differences were seen with antipsychotic medication. Antidepressants and antipsychotics were used 3.4 (20.9%) and 5.8 (13.4%) times more frequently than in the general population, accounting for 7.88 and 1.99 defined daily doses (DDDs)/1,000 inhabitants/day/year respectively. Lamotrigine was the most commonly used antiepileptic drug (AED) in epilepsy, accounting for 33% of the use of AEDs (in total 5.65 DDDs/1,000 inhabitants/day/year). The use of benzodiazepines was 9.55 DDDs/1,000 inhabitants/day/year. The patients had complex pharmacotherapy with two to eight concomitant drugs.

CONCLUSION

The present study gives an estimate of psychiatric comorbidity of 32% in patients with epilepsy in a nation-wide population. The pharmacotherapy in this patient population is complex. The results provide valuable data on prescription patterns that contribute to pharmacovigilance on a national scale.

Ocular adverse effects of common psychotropic agents: a review

All psychotropic medications have the potential to induce numerous and diverse unwanted ocular effects. Visual adverse effects can be divided into seven major categories: eyelid and keratoconjunctival disorders; uveal tract disorders; accommodation interference; angle-closure glaucoma; cataract/pigmentary deposits in the lens and cornea; retinopathy; and other disorders. The disorders of the eyelid and of the keratoconjunctiva are mainly related to phenothiazines and lithium. Chlorpromazine, at high dosages, can commonly cause abnormal pigmentation of the eyelids, interpalpebral conjunctiva and cornea. It can also cause a more worrisome but rarer visual impairment, namely corneal oedema. Lithium can rarely lead to a bothersome eye irritation by affecting sodium transport. Uveal tract problems are mainly associated with tricyclic antidepressants (TCAs), typical antipsychotics, topiramate and selective serotonin reuptake inhibitors (SSRIs). TCAs, typical antipsychotics and SSRIs can all cause mydriasis that is often transient and with no major consequences, but that can promote closure of angles in susceptible patients. Topiramate has been frequently associated with a number of significant ocular symptoms including acquired myopia and angle-closure glaucoma. Problems with accommodation are related to TCAs and to low-potency antipsychotics. TCAs cause transient blurred vision in up to one-third of patients. Angle-closure glaucoma is a serious condition that has been mainly associated with TCAs, low-potency antipsychotics, topiramate and, to a lesser extent, SSRIs. When patients with narrow angles are given TCAs, they all appear to experience induction of glaucomatous attacks. Antipsychotics and SSRIs may lead to an added risk of developing angle-closure glaucoma, but only in predisposed eyes. Topiramate can lead to an allergic-type reaction whereby structures of the lens and ciliary body are displaced, which results in angle-closure glaucoma. Cataractous changes can result from antipsychotics, mainly from high dosages of chlorpromazine or thioridazine. These two drugs, when used at high dosages and for prolonged periods, frequently cause lenticular opacifications. Retinopathy has been shown to be related to high dosages of typical antipsychotics, mainly chlorpromazine and thioridazine. The frequency of occurrence of retinal effects seems to be proportional to the total amount of drug used over a long period of time. Other visual problems of special concern are the ocular dystonias, other eye movement disorders, and decreased ability to perceive colours and to discriminate contrast. Ocular dystonias can occur with antipsychotics (especially high-potency ones), carbamazepine (especially in polytherapy), topiramate and, rarely, with SSRIs. Disturbance in various eye movements is frequently seen with benzodiazepines, antiepileptic drugs and lithium. Impairment in the perception of colours and the discrimination of contrasts has been shown to occur not uncommonly with carbamazepine and lorazepam. Thus, typical antipsychotics, TCAs, lithium, benzodiazepines, carbamazepine, topiramate and SSRIs appear to produce most of the currently recognized ocular problems. Psychiatrists, ophthalmologists and patients need to be aware of and prepared for any medication-induced adverse effect. Early prevention and intervention can avoid most of the serious and potentially irreversible ocular toxicities.

The clinical significance of antidepressant treatment effects cannot be derived from placebo-verum response differences

A placebo-verum difference in antidepressant response of at least three points on the Hamilton Depression Rating Scale has been proposed as the threshold for clinical significance in antidepressant trials. Given the considerable clinical and regulatory consequences of such a definition of clinical relevance it deserves a critical discussion. Eight arguments are presented indicating that using this definition as a criterion for assessing the clinical utility of antidepressants in daily practice would risk erroneously discarding treatments with a clear benefit for patients.

Effect of reminder cards on compliance with antihypertensive medication

Objective

Poor compliance to antihypertensive medications has been identified as a primary cause of uncontrolled blood pressure (BP), with consequent increases in hypertension-related morbidity and mortality. Therefore, any measure known to improve compliance should be encouraged. This study assessed the impact of reminder cards on compliance to antihypertensive therapy.

Method

A field trial was undertaken in pharmacies located in the districts of Lisbon and Porto. Eligible participants comprised those aged 30–74 years, prescribed an angiotensin-converting enzyme inhibitor (ACEI) in monotherapy, and taken on a once-daily regimen. Patients were allocated to control group (CG) or intervention group (IG), the latter being provided with a reminder card, an alarm-type device due to remind the patient of the time to take his medication. Patients were monitored monthly during 3 months for compliance and blood pressure control.

Key findings

Seventy-one patients participated in the study (intervention: 35; control group: 36). Compliance was similar between the groups in the first 2 months of follow-up (97.1% IG vs 94.9% CG at first follow-up and 97.5% IG vs 94.2% CG at second follow-up) and higher in the intervention group at the end of the study (97.3% IG vs 87.3% CG; P = 0.011). There were no mean blood pressure differences between compliant and non-compliant subjects at the end of the study (P value for differences in systolic BP (Psyst) = 0.580; and P value for differences in diastolic BP (Pdlast) = 0.175).

Conclusion

This small-scale study indicates a possible positive impact on patients' compliance resulting from the use of reminder cards. However, this needs confirming in larger scale studies with longer monitoring periods.

Concordance of adherence measurement using self-reported adherence questionnaires and medication monitoring devices

The primary objective of this review was to identify and examine the literature on the association between medication adherence self-reported questionnaires (SRQs) and medication monitoring devices. The primary literature search was performed for 1980-2009 using PubMed, PubMed In Process and Non-Indexed, Ovid MEDLINE, Ovid MEDLINE In-Process, PsycINFO (EBSCO), CINAHL (EBSCO), Ovid HealthStar, EMBASE (Elsevier) and Cochrane Databases and using the following search terms: 'patient compliance', 'medication adherence', 'treatment compliance', 'drug monitoring', 'drug therapy', 'electronic', 'digital', 'computer', 'monitor', 'monitoring', 'drug', 'drugs', 'pharmaceutical preparations', 'compliance' and 'medications'. We identified studies that included SRQs and electronic monitoring devices to measure adherence and focused on the SRQs that were found to be moderately to highly correlated with the monitoring devices. Of the 1679 citations found via the primary search, 41 full-text articles were reviewed for correlation between monitoring devices and SRQs. A majority (68%) of articles reported high (27%), moderate (29%) or significant (12%) correlation between monitoring devices (37 using Medication Event Monitoring System [MEMS®] and four using other devices) and SRQs (11 identified and numerous other unnamed SRQs). The most commonly used SRQs were the Adult/Pediatric AIDS Clinical Trial Group (AACTG/PACTG; 24.4%, 10/41) followed by the 4-item Morisky (9.8%, 4/41), Brief Medication Questionnaire (9.8%, 4/41) and visual analogue scale (VAS; 7.3%, 3/41). Although study designs differed across the articles, SRQs appeared to report a higher rate of medication adherence (+14.9%) than monitoring devices. In conclusion, several medication adherence SRQs were validated using electronic monitoring devices. A majority of them showed high or moderate correlation with medication adherence measured using monitoring devices, and could be considered for measuring patient-reported adherence prospectively.

Antiepileptic drugs in epilepsy and other disorders--a population-based study of prescriptions

PURPOSE

The aim of the study was to quantify the use of antiepileptic drugs (AEDs) in epilepsy and other indications in a nation-wide population using a prescription database.

MATERIALS AND METHODS

Prescription data of AEDs were collected from the Norwegian Prescription Database for the period 2004-2007, including 5.1 million prescriptions from 144,653 patients, all having at least one prescribed and dispensed AED. Diagnosis-related reimbursement codes were used as indicators for clinical use.

RESULTS

Of the AEDs used, 71% was in epilepsy, 15% in psychiatry, 13% in neuropathic pain, and <1% in migraine, trigeminus neuralgia and cancer adjuvance. The use in epilepsy increased steadily from 7.0 to 7.5 DDDs/1000 inhabitants/day (7%) from 2004 to 2007. The use of AEDs in other indications increased considerably more from 2004 to 2007: Neuropathic pain to 1.40 DDDs/1000 inhabitants/day (360%), psychiatry to 1.59 (200%), and migraine to 0.005 (642%). The prevalence of AED users increased and in 2007 it was 0.97% in epilepsy, 0.8% in neuropathic pain, 0.33% in psychiatry and 0.001% in migraine. In 2007, 49% of the AEDs used in epilepsy were a new drug, carbamazepine, lamotrigine and valproate being most frequently used. New AEDs were used in 96% in migraine prophylaxis, 94% in neuropathic pain, and 64% in psychiatry.

CONCLUSIONS

Based on a nation-wide prescription database, this study quantifies the wide and increasing use of AEDs, in particular the newer drugs.

The self-reported Montgomery-Asberg Depression Rating Scale is a useful evaluative tool in Major Depressive Disorder

BACKGROUND

The use of Patient-reported Outcomes (PROs) as secondary endpoints in the development of new antidepressants has grown in recent years. The objective of this study was to assess the psychometric properties of the 9-item, patient-administered version of the Montgomery-Asberg Depression Rating Scale (MADRS-S).

METHODS

Data from a multicentre, double-blind, 8-week, randomised controlled trial of 278 outpatients diagnosed with Major Depressive Disorder were used to evaluate the validity, reliability and sensitivity to change of the MADRS-S using psychometric methods. A Receiver Operating Characteristic (ROC) curve was plotted to identify the most appropriate threshold to define perceived remission.

RESULTS

No missing values were found at the item level, indicating good acceptability of the scale. The construct validity was satisfactory: all items contributed to a common underlying concept, as expected. The correlation between MADRS-S and physicians' MADRS was moderate (r = 0.54, p < 0.001) indicating that MADRS-S is complementary rather than redundant to the MADRS. Cronbach's alpha was 0.84, and the stability over time of the scale, estimated on a sub-sample of patients whose health status did not change during the first week of the study, was good (intraclass correlation coefficient of 0.78). MADRS-S sensitivity to change was shown. Using a threshold value of 5, the definition of "perceived remission" reached a sensitivity of 82% and a specificity of 75%.

CONCLUSION

Taking account of patient's perceptions of the severity of their own symptoms along with the psychometric properties of the MADRS-S enable its use for evaluative purposes in the development of new antidepressant drugs.

Working with reactant patients: are we prescribing nonadherence?

OBJECTIVE

In spite of high levels of antidepressant nonadherence frequently observed among depressed samples, relatively little research has investigated psychosocial predictors of adherence. Fostering greater collaboration in depression treatment to increase adherence has been advocated, but this strategy has not been adequately studied. The aim of this study was to examine the interaction of provider collaboration and patient reactance in the prediction of antidepressant adherence during the acute treatment phase.

METHOD

Fifty outpatients diagnosed with major depressive disorder beginning antidepressant treatment within psychiatry clinics of the VA San Diego Healthcare System comprised the study sample. Patients were administered questionnaires following their medication evaluations to measure predictor variables. Antidepressant adherence was assessed via brief telephone interviews 3, 6, 9, and 12 weeks after treatment initiation. The roles of provider collaboration, patient reactance, and their interaction in adherence were examined using multiple regression analyses.

RESULTS

The interaction between provider collaboration and patient reactance accounted for 18.3% of the variance in 3-week adherence (P<.01). Among more reactant patients, greater levels of collaboration predicted better adherence, whereas among patients lower in reactance less collaboration predicted better adherence. No relationships were observed beyond the initial 3 weeks of treatment.

CONCLUSIONS

This study demonstrates that interpersonal process variables are important in influencing antidepressant adherence and challenges the advocacy of more collaboration in antidepressant treatment as a "blanket strategy." Establishing a more collaborative set with reactant patients may ensure greater early treatment adherence, a critical period during which antidepressants have typically not yet taken effect.

Benefits of consumer psychoeducation: a pilot program in South Africa

OBJECTIVE

Previous studies have indicated that patient adherence to antidepressant treatment is unsatisfactory. There is, however, little published data on adherence in the South African context. In this pilot study we explore the possible benefits of a consumer psychoeducation program.

METHOD

First, drop-out rates during the first four months of paroxetine treatment were surveyed in patients participating in a psychoeducational program focused on depression and its treatment. Practitioners were also surveyed about their perceptions of the program. Second, drop-out rates during the first four months of paroxetine treatment were estimated from a pharmacy database of selective serotonin reuptake inhibitor (SSRI) prescriptions in South Africa.

RESULTS

Patients who participated in a psychoeducational program demonstrated comparatively lower drop-out rates during treatment compared with drop-out rates in patients on paroxetine (and other SSRIs) obtained from a national pharmacy database. Improved adherence on the psychoeducational program was attributed to an increased understanding of depression and the need to take medication, a realization that patients are not alone (i.e., depression is a widespread problem) and a better understanding and acceptance of the possible side-effects of medication. Both practitioners and patients were positive about their experience of the program and 80% of doctors judged the program to be very useful.

CONCLUSION

Drop-out rates during SSRI treatment in South Africa appear to be unacceptably high, whether or not patients receive concomitant benzodiazepines. Psychoeducational programs may prove valuable in increasing adherence to treatment regimes.

Six-month compliance with antidepressant medication in the treatment of major depressive disorder

The investigation of compliance in patients with major depressive disorder (in drop-outs versus completers and in first episode versus recurrent episode patients). A total of 85 outpatients with major depressive disorder were followed for 6 months. Different dimensions of compliance were investigated: drop-outs versus completers and their medication adherence (with electronic monitoring). General linear mixed models were applied to examine the time courses of adherence. Drop-out rates were higher in younger patients and in patients with a lower initial depression severity. The adherence during 6 months of treatment with selective serotonin reuptake inhibitors was above 80 in 70% of the patients. The adherence decreased by 2.5% per month and decreased more than three times more rapidly in drop-outs (from baseline to time of drop-out). A medical visit resulted in a temporary increase in pill intake. General linear mixed model analysis showed that the predicted outcome was worse in drop-outs than in completers and worse in recurrent episode patients than in first episode patients (the former showing a higher adherence). Adherence decreases with time during 6 months of treatment with antidepressants and is influenced by demographic and clinical variables. Completers show a higher adherence than drop-outs. The outcome was worse in recurrent episode patients than first episode patients although they had a higher adherence.

Limitations of current medical treatments for depression: disturbed circadian rhythms as a possible therapeutic target

The proportion of diagnosed depressives prescribed antidepressants has increased markedly over the last 20 years, mainly following the introduction of the selective serotonin reuptake inhibitors. However, currently available antidepressants have notable limitations, relating to their only moderate efficacy relative to placebo, relatively slow onset of action, possible withdrawal symptoms, and problems of compliance. Sleep disturbances are often used to identify newly presenting depressive patients, and may be part of a more general alteration of bodily rhythms. There are links between pharmacological treatments and circadian rhythms in depression, which might represent another, new option for the development of a therapeutic approach to depression treatment. Many antidepressants affect sleep, some are sedative, and others have been used specifically in severely insomniac depressives. Disturbances in circadian rhythms may be an integral part of depressive mechanisms, and normalising them via an innovative mechanism of antidepressant action may be a fruitful avenue in the search for improved antidepressant agents.

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.

A randomized trial of telemedicine-based collaborative care for depression

BACKGROUND

Evidence-based practices designed for large urban clinics are not necessarily portable into smaller isolated clinics. Implementing practice-based collaborative care for depression in smaller primary care clinics presents unique challenges because it is often not feasible to employ on-site psychiatrists.

OBJECTIVE

The purpose of the Telemedicine Enhanced Antidepressant Management (TEAM) study was to evaluate a telemedicine-based collaborative care model adapted for small clinics without on-site psychiatrists.

DESIGN

Matched sites were randomized to the intervention or usual care.

PARTICIPANTS

Small VA Community-based outpatient clinics with no on-site psychiatrists, but access to telepsychiatrists. In 2003-2004, 395 primary care patients with PHQ9 depression severity scores > or = 12 were enrolled, and followed for 12 months. Patients with serious mental illness and current substance dependence were excluded.

MEASURES

Medication adherence, treatment response, remission, health status, health-related quality of life, and treatment satisfaction.

RESULTS

The sample comprised mostly elderly, white, males with substantial physical and behavioral health comorbidity. At baseline, subjects had moderate depression severity (Hopkins Symptom Checklist, SCL-20 = 1.8), 3.7 prior depression episodes, and 67% had received prior depression treatment. Multivariate analyses indicated that intervention patients were more likely to be adherent at both 6 (odds ratio [OR] = 2.1, p = .04) and 12 months (OR = 2.7, p = .01). Intervention patients were more likely to respond by 6 months (OR = 2.0, p = .02), and remit by 12 months (OR = 2.4, p = .02). Intervention patients reported larger gains in mental health status and health-related quality of life, and reported higher satisfaction.

CONCLUSIONS

Collaborative care can be successfully adapted for primary care clinics without on-site psychiatrists using telemedicine technologies.

A randomized trial of telemedicine-based collaborative care for depression. J Gen Intern Med. 2007;22:1086-1093. [PMID: 17492326 DOI: 10.1016/s0084-3970(08)79147-3]

BACKGROUND

Evidence-based practices designed for large urban clinics are not necessarily portable into smaller isolated clinics. Implementing practice-based collaborative care for depression in smaller primary care clinics presents unique challenges because it is often not feasible to employ on-site psychiatrists.

OBJECTIVE

The purpose of the Telemedicine Enhanced Antidepressant Management (TEAM) study was to evaluate a telemedicine-based collaborative care model adapted for small clinics without on-site psychiatrists.

DESIGN

Matched sites were randomized to the intervention or usual care.

PARTICIPANTS

Small VA Community-based outpatient clinics with no on-site psychiatrists, but access to telepsychiatrists. In 2003-2004, 395 primary care patients with PHQ9 depression severity scores > or = 12 were enrolled, and followed for 12 months. Patients with serious mental illness and current substance dependence were excluded.

MEASURES

Medication adherence, treatment response, remission, health status, health-related quality of life, and treatment satisfaction.

RESULTS

The sample comprised mostly elderly, white, males with substantial physical and behavioral health comorbidity. At baseline, subjects had moderate depression severity (Hopkins Symptom Checklist, SCL-20 = 1.8), 3.7 prior depression episodes, and 67% had received prior depression treatment. Multivariate analyses indicated that intervention patients were more likely to be adherent at both 6 (odds ratio [OR] = 2.1, p = .04) and 12 months (OR = 2.7, p = .01). Intervention patients were more likely to respond by 6 months (OR = 2.0, p = .02), and remit by 12 months (OR = 2.4, p = .02). Intervention patients reported larger gains in mental health status and health-related quality of life, and reported higher satisfaction.

CONCLUSIONS

Collaborative care can be successfully adapted for primary care clinics without on-site psychiatrists using telemedicine technologies.

Psychosocial and pharmacological interventions for depressed adults in primary care: a critical review

Primary care settings are the principal context for treating clinical depression, with researchers beginning to explore the efficacy of psychosocial and pharmacological treatments for depression within this infrastructure. Feasibility and process variables also are being assessed, including issues of cost-effectiveness, viability of collaborative care models, predictors of treatment outcome, and effectiveness of treatment providers without specialized mental health training. The Agency for Health Care Policy and Research and American Psychiatric Association initially released guidelines for the treatment of depression in primary care [American Psychiatric Association, 1993. Practice Guidelines for major depressive disorder in adults. American Journal of Psychiatry, 150, 1-26., American Psychiatric Association, 2000. Practice Guideline for the treatment of patients with major depressive disorder (revision). American Journal of Psychiatry, 157, 1-45], however, a vast literature has accumulated over the past several years, calling for a systematic re-evaluation of the status of depression treatment in primary care. The present study provides a contemporary review of outcome data for psychosocial and pharmacological interventions in primary care and extends beyond AHCPR guidelines insofar as focusing on feasibility and process variables, including the training and proficiency of primary care treatment providers, cost-effectiveness of primary care interventions, and predictors of treatment response and relapse. Based on current guidelines, problem-solving therapy (PST-PC), interpersonal psychotherapy, and pharmacotherapy would be considered efficacious interventions for major depression, with cognitive-behavioral and cognitive therapy considered possibly efficacious. Psychotherapy and pharmacotherapy generally are of comparable efficacy, and both modalities are superior to usual care in treating depression. Methodological limitations and directions for future research are discussed.

Self-efficacy scale for Brazilians with type 1 diabetes

CONTEXT AND OBJECTIVE

Diabetes is a public health problem and good glycemic control is able to prevent or contain its complications. Self-efficacy is a key factor in successfully achieving behavior goals. The aim of this study was to analyze the psychometric properties of the insulin management diabetes self-efficacy scale (IMDSES) on type 1 diabetes patients from southern Brazil.

DESIGN AND SETTING

Validation study in two cities in southern Brazil.

METHODS

The psychometric properties of IMDSES were evaluated in a population of type 1 diabetes patients (n = 213), from September to December 2004, who were attended within the Brazilian public healthcare system. Principal component analysis was conducted to develop the subscales. Cronbach's alpha was used as the reliability coefficient.

RESULTS

The analysis of psychometric properties resulted in an IMDSES consisting of 20 items and three subscales: diet (alpha: 0.83), insulin (alpha: 0.92) and general management (alpha: 0.78) and accounted for 53% of the variance. Criteria validity was investigated through two parameters: glycohemoglobin, which showed significant association with self-efficacy on the insulin subscale (p = 0.04), and the variable "adherence", which was significantly associated with self-efficacy on two subscales (p < 0.05).

CONCLUSIONS

This study shows that the IMDSES is valid and reliable, and can be used to measure results from diabetes educational programs and to measure self-efficacy relating to diabetes management, for possible interventions.

Cost effectiveness of a pharmacy-based coaching programme to improve adherence to antidepressants

INTRODUCTION

The efficacy of antidepressants in the treatment of depression has been convincingly demonstrated in randomised trials. However, non-adherence to antidepressant treatment is common.

OBJECTIVE

To evaluate, from a societal perspective, the cost effectiveness of a pharmacy-based intervention to improve adherence to antidepressant therapy in adult patients receiving treatment in primary care.

METHODS

An economic evaluation was performed alongside a 6-month randomised controlled trial in The Netherlands. Patients who came to 19 pharmacies with a new prescription for a non-tricyclic antidepressant, i.e. those who had not received any prescription for an antidepressant in the past 6 months, were invited to participate. They were then randomly allocated to education and coaching by the pharmacist or to usual care. The coaching programme consisted of three contacts with the pharmacist, with a mean duration of between 13 and 20 minutes, and a take-home video reviewing important facts on depression and antidepressant treatment. The clinical outcome measures were adherence to antidepressant treatment measured using an electronic pill container (eDEM) and improvement in depressive symptoms measured using the Hopkins Symptom Checklist (SCL). Resource use was measured by means of questionnaires. The uncertainty around differences in costs and cost effectiveness between the treatment groups was evaluated using bootstrapping.

RESULTS

Seventy patients were randomised to the intervention group and 81 to the usual care group; of these, 40 in the intervention group and 48 in the control group completed all of the follow-up questionnaires. There were no significant differences in adherence, improvements in the SCL depression mean item score and costs over 6 months between the two treatment groups. Mean total costs (2002 values) were 3275 euros in the intervention group and 2961 euros in the control group (mean difference 315 euros; 95% CI -1922, 2416). The incremental cost-effectiveness ratio associated with the pharmacist intervention was 149 euros per 1% improvement in adherence and 2550 euros per point improvement in the SCL depression mean item score. Cost-effectiveness planes and acceptability curves indicated that the pharmacist intervention was not likely to be cost effective compared with usual care.

CONCLUSION

In patients starting treatment with antidepressants, there were no significant differences in adherence, severity of depression, costs and cost effectiveness between patients receiving coaching by a pharmacist and patients receiving usual care after 6 months. Considering the resources needed to implement an intervention like this in clinical practice, based on these results, the continuation of usual care is recommended.

Fluoxetine versus other types of pharmacotherapy for depression

BACKGROUND

Depression is common in primary care and it is associated with marked personal, social and economic morbidity, and creates significant demands on service providers in terms of workload. Treatment is predominantly pharmaceutical or psychological. Fluoxetine, the first of a group of antidepressant (AD) agents known as selective serotonin reuptake inhibitors (SSRIs), has been studied in many randomised controlled trials (RCTs) in comparison with tricyclic (TCA), heterocyclic and related ADs, and other SSRIs. These comparative studies provided contrasting findings. In addition, systematic reviews of RCTs have always considered the SSRIs as a group, and evidence applicable to this group of drugs might not be applicable to fluoxetine alone. The present systematic review assessed the efficacy and tolerability profile of fluoxetine in comparison with TCAs, SSRIs and newer agents.

OBJECTIVES

To determine the efficacy of fluoxetine, compared with other ADs, in alleviating the acute symptoms of depression, and to review its acceptability.

SEARCH STRATEGY

Relevant studies were located by searching the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDANCTR), the Cochrane Central Register of Controlled Trials (CENTRAL), Medline (1966-2004) and Embase (1974-2004). Non-English language articles were included.

SELECTION CRITERIA

Only RCTs were included. For trials which have a crossover design only results from the first randomisation period were considered.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by two reviewers using a standard form. Responders to treatment were calculated on an intention-to-treat basis: drop-outs were always included in this analysis. When data on drop-outs were carried forward and included in the efficacy evaluation, they were analysed according to the primary studies; when dropouts were excluded from any assessment in the primary studies, they were considered as treatment failures. Scores from continuous outcomes were analysed including patients with a final assessment or with the last observation carried forward. Tolerability data were analysed by calculating the proportion of patients who failed to complete the study and who experienced adverse reactions out of the total number of randomised patients. The primary analyses used a fixed effects approach, and presented Peto Odds Ratio (PetoOR) and Standardised Mean Difference (SMD).

MAIN RESULTS

On a dichotomous outcome fluoxetine was less effective than dothiepin (PetoOR: 2.09, 95% CI 1.08 to 4.05), sertraline (PetoOR: 1.40, 95% CI 1.11 to 1.76), mirtazapine (PetoOR: 1.64, 95% CI 1.01 to 2.65) and venlafaxine (Peto OR: 1.40, 95% CI 1.15 to 1.70). On a continuous outcome, fluoxetine was more effective than ABT-200 (Standardised Mean Difference (SMD) random effects: - 1.85, 95% CI - 2.25 to - 1.45) and milnacipran (SMD random effects: - 0.38, 95% CI - 0.71 to - 0.06); conversely, it was less effective than venlafaxine (SMD random effect: 0.11, 95% CI 0.00 to 0.23), however these figures were of borderline statistical significance. Fluoxetine was better tolerated than TCAs considered as a group (PetoOR: 0.78, 95% CI 0.68 to 0.89), and was better tolerated in comparison with individual ADs, in particular than amitriptyline (PetoOR: 0.64, 95% CI 0.47 to 0.85) and imipramine (PetoOR: 0.79, 95% CI 0.63 to 0.99), and among newer ADs than ABT-200 (PetoOR: 0.21, 95% CI 0.10 to 0.41), pramipexole (PetoOR: 0.20, 95% CI 0.08 to 0.47) and reboxetine (PetoOR: 0.61, 95% CI 0.40 to 0.94).

AUTHORS' CONCLUSIONS

There are statistically significant differences in terms of efficacy and tolerability between fluoxetine and certain ADs, but the clinical meaning of these differences is uncertain, and no definitive implications for clinical practice can be drawn. From a clinical point of view the analysis of antidepressants' safety profile (adverse effect and suicide risk) remains of crucial importance and more reliable data about these outcomes are needed. Waiting for more robust evidence, treatment decisions should be based on considerations of clinical history, drug toxicity, patient acceptability, and cost. We need for large, pragmatic trials, enrolling heterogeneous populations of patients with depression to generate clinically relevant information on the benefits and harms of competitive pharmacological options. A meta-analysis of individual patient data from the randomised trials is clearly necessary.