Economic factors in of patients' nonadherence to antidepressant treatment

Reasons for non-adherence with antidepressants using the Medication Adherence Reasons Scale in five European countries and United States

BACKGROUND

Depression affects approximately 280 million people worldwide. 50 % of individuals with depression discontinue antidepressant therapy within six months of initiation. The study objective was to determine the extent and reasons for non-adherence with antidepressants in the United States (US) and five European Countries (EU).

METHODS

Data from the National Health and Wellness Study (NHWS), a self-administered, internet-based cross-sectional survey of US adults in 2019 and 5 EU countries in 2020 was included. NHWS participants who self-reported taking daily prescription medication(s) to treat depression responded to the 19 reasons for non-adherence and one global item in the Medication Adherence Reasons Scale (MAR-Scale). Frequencies were used to identify the reasons for non-adherence.

RESULTS

Based on data from 7506 US patients and 4230 EU patients, 46.19 % of patients reported non-adherence to at least one reason in the EU, and 42.9 % in the US. The most common reason for non-adherence in the EU was concern about long-term effects and possible side effects from the medication; and in the US, it was simple forgetfulness. Non-adherence lasted longer due to lack of beliefs in needing medication anymore in both US and EU.

LIMITATIONS

The self-reported MAR-Scale can have recall bias and an underestimation of non-adherence. The cross-sectional study design captures the adherence behavior only at one point of time.

CONCLUSION

Individuals on antidepressants have to be educated about the need for the medication and their concerns about long term effects and possible side effects from the medication have to be addressed.

Towards measuring effective coverage: critical bottlenecks in quality- and user-adjusted coverage for major depressive disorder in São Paulo metropolitan area, Brazil

BACKGROUND

Major depressive disorder (MDD) contributes to a significant proportion of disease burden, disability, economic losses, and impact on need of treatment and health care in Brazil, but systematic information about its treatment coverage is scarce. This paper aims to estimate the gap in treatment coverage for MDD and identify key bottlenecks in obtaining adequate treatment among adult residents in the São Paulo Metropolitan area, Brazil.

METHODS

A representative face-to-face household survey was conducted among 2942 respondents aged 18+ years to assess 12-month MDD, characteristics of 12-month treatment received, and bottlenecks to deliver care through the World Mental Health Composite International Diagnostic Interview.

RESULTS

Among those with MDD (n = 491), 164 (33.3% [SE, 1.9]) were seen in health services, with an overall 66.7% treatment gap, and only 25.2% [SE, 4.2] received effective treatment coverage, which represents 8.5% of those in need, with a 91.5% gap in adequate care (66.4% due to lack of utilization and 25.1% due to inadequate quality and adherence). Critical service bottlenecks identified were: use of psychotropic medication (12.2 percentage points drop), use of antidepressants (6.5), adequate medication control (6.8), receiving psychotherapy (19.8).

CONCLUSIONS

This is the first study demonstrating the huge treatment gaps for MDD in Brazil, considering not only overall coverage, but also identifying specific quality- and user-adjusted bottlenecks in delivering pharmacological and psychotherapeutic care. These results call for urgent combined actions focused in reducing effective treatment gaps within services utilization, as well as in reducing gaps in availability and accessibility of services, and acceptability of care for those in need.

Determinants of effective treatment coverage for posttraumatic stress disorder: findings from the World Mental Health Surveys

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with significant morbidity, but efficacious pharmacotherapy and psychotherapy are available. Data from the World Mental Health Surveys were used to investigate extent and predictors of treatment coverage for PTSD in high-income countries (HICs) as well as in low- and middle-income countries (LMICs).

METHODS

Seventeen surveys were conducted across 15 countries (9 HICs, 6 LMICs) by the World Health Organization (WHO) World Mental Health Surveys. Of 35,012 respondents, 914 met DSM-IV criteria for 12-month PTSD. Components of treatment coverage analyzed were: (a) any mental health service utilization; (b) adequate pharmacotherapy; (c) adequate psychotherapy; and (d) effective treatment coverage. Regression models investigated predictors of treatment coverage.

RESULTS

12-month PTSD prevalence in trauma exposed individuals was 1.49 (S.E., 0.08). A total of 43.0% (S.E., 2.2) received any mental health services, with fewer receiving adequate pharmacotherapy (13.5%), adequate psychotherapy (17.2%), or effective treatment coverage (14.4%), and with all components of treatment coverage lower in LMICs than HICs. In a multivariable model having insurance (OR = 2.31, 95 CI 1.17, 4.57) and severity of symptoms (OR = .35, 95% CI 0.18, 0.70) were predictive of effective treatment coverage.

CONCLUSION

There is a clear need to improve pharmacotherapy and psychotherapy coverage for PTSD, particularly in those with mild symptoms, and especially in LMICs. Universal health care insurance can be expected to increase effective treatment coverage and therefore improve outcomes.

Factors Associated With Non-adherence to Anti-depressant Medication in Adults: A Systematic Review and Meta-Analysis

The present meta-analysis has been conducted to review currently available literature to examine the factors associated with adherence to anti-depressant medications in adults. This meta-analysis and systematic review followed the MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines. According to this analysis, the three most important electronic resources for research were CINAHL, EMBASE, and Medline. Google Scholar was used to supplementing the articles already available for review. Keywords used to find relevant articles included "predictors," "non-adherence," "anti-depressants," and "adults." Medical subject headings (MeSH) terms and Boolean operators ("AND" and "OR") were used in the search strategy to refine the search further. Studies included in this meta-analysis had information on factors associated with non-adherence to anti-depressant medication. The study evaluated samples of adult participants over 18 years with a diagnosis of depression and who had been prescribed anti-depressants. In conclusion, this meta-analysis examined the relationship between demographic factors and non-adherence to anti-depressant medications. The findings revealed that gender, educational status, income level, marital status, and area of residence did not significantly predict non-adherence to anti-depressants. However, older age and polypharmacy were significant predictors of adherence to anti-depressants. The study also found that individuals living in urban areas were more likely to adhere to anti-depressants, but the difference was not statistically significant.

Antidepressant Adherence Among Hispanics: Patients in an Integrated Health Care Model

Purpose

We report on antidepressant (AD) adherence among Hispanics seeking mental health services in a community primary care clinic in Texas as an ancillary outcome from a National Institutes of Health-funded study that collected data on Hispanic AD adherence over a period of two years (February 2016-February 2018). Adherence to AD medications was measured throughout the year-long trial and compared across various demographic characteristics. Since Hispanic individuals often experience stigma and cultural barriers related to AD treatment, we sought to understand what factors may increase the likelihood of non-adherence in this population.

Patients and Methods

This study focused on 69 patients who were prescribed AD medications while receiving treatment through an integrated health care model. Adherence was measured with the Patient Adherence Questionnaire, a validated 2-item questionnaire that asks patients about their medication use (missed medications or dosage changes) over the past week. We looked at patient adherence at two key time points (4-weeks and 13-weeks) and utilized logistic regression to identify factors that may increase or decrease the likelihood of adherence in Hispanic patients at a community primary care clinic.

Results

Non-adherence to AD medication was 49.3% at 4-weeks and 57% at 13-weeks post-treatment initiation. Logistic regression analyses revealed that age was the only significant predictor of AD non-adherence. As age increased, the likelihood of adherence increased by 12.2% at 13-weeks post-treatment initiation and by 11.1% at 4-weeks post-treatment initiation.

Conclusion

The likelihood of Hispanic patients to adhere to AD therapy increased with the age of the patient. Since primary care is the most likely place to be prescribed an AD for Hispanic patients, further research to better understand adherence is essential. Integrated health care interventions designed to help identify, reduce, or eliminate barriers to adherence and improve cultural understanding may help address issues of non-adherence in primary care settings.

Determinants of effective treatment coverage for major depressive disorder in the WHO World Mental Health Surveys

Background

Most individuals with major depressive disorder (MDD) receive either no care or inadequate care. The aims of this study is to investigate potential determinants of effective treatment coverage.

Methods

In order to examine obstacles to providing or receiving care, the type of care received, and the quality and use of that care in a representative sample of individuals with MDD, we analyzed data from 17 WHO World Mental Health Surveys conducted in 15 countries (9 high-income and 6 low/middle-income). Of 35,012 respondents, 3341 had 12-month MDD. We explored the association of socio-economic and demographic characteristics, insurance, and severity with effective treatment coverage and its components, including type of treatment, adequacy of treatment, dose, and adherence.

Results

High level of education (OR = 1.63; 1.19, 2.24), private insurance (OR = 1.62; 1.06, 2.48), and age (30–59yrs; OR = 1.58; 1.21, 2.07) predicted effective treatment coverage for depression in a multivariable logistic regression model. Exploratory bivariate models further indicate that education may follow a dose—response relation; that people with severe depression are more likely to receive any services, but less likely to receive adequate services; and that in low and middle-income countries, private insurance (the only significant predictor) increased the likelihood of receiving effective treatment coverage four times.

Conclusions

In the regression models, specific social determinants predicted effective coverage for major depression. Knowing the factors that determine who does and does not receive treatment contributes to improve our understanding of unmet needs and our ability to develop targeted interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00539-6.

Factors Associated with Antidepressant Medication Non-adherence

Medication non-adherence is one of the major problems in treating patients with depression. Non-adherence results in an increased risk of relapse and reduced quality of life. The objective of this review was to review and summarize studies that focused on the factors associated with antidepressant medication non-adherence in patients with depression. Literature searches were performed using PubMed/Medline and Google Scholar. The search was limited to articles published in the English language in peer-reviewed journals between January 2000 and December 2019. Studies that analyzed factors of non-compliance in patients with depressive disorders were included in the review. Patient-related factors such as forgetfulness, comorbidities, and misconceptions about the disease and medication, medication-related factors, polypharmacy, side effects, pill burden and cost, healthcare system-related factors, including physician-patient interactions, sociocultural factors such religious and cultural beliefs and stigma, and logistic factors were found to be the major factors associated with antidepressant non-adherence. Efforts should be made to increase patient adherence to antidepressants by strengthening physician-patient relationships, simplifying medication regimens, and rectifying myths and beliefs held by patients with scientific information and explanations.

Toward measuring effective treatment coverage: critical bottlenecks in quality- and user-adjusted coverage for major depressive disorder

BACKGROUND

Major depressive disorder (MDD) is a leading cause of morbidity and mortality. Shortfalls in treatment quantity and quality are well-established, but the specific gaps in pharmacotherapy and psychotherapy are poorly understood. This paper analyzes the gap in treatment coverage for MDD and identifies critical bottlenecks.

METHODS

Seventeen surveys were conducted across 15 countries by the World Health Organization-World Mental Health Surveys Initiative. Of 35 012 respondents, 3341 met DSM-IV criteria for 12-month MDD. The following components of effective treatment coverage were analyzed: (a) any mental health service utilization; (b) adequate pharmacotherapy; (c) adequate psychotherapy; and (d) adequate severity-specific combination of both.

RESULTS

MDD prevalence was 4.8% (s.e., 0.2). A total of 41.8% (s.e., 1.1) received any mental health services, 23.2% (s.e., 1.5) of which was deemed effective. This 90% gap in effective treatment is due to lack of utilization (58%) and inadequate quality or adherence (32%). Critical bottlenecks are underutilization of psychotherapy (26 percentage-points reduction in coverage), underutilization of psychopharmacology (13-point reduction), inadequate physician monitoring (13-point reduction), and inadequate drug-type (10-point reduction). High-income countries double low-income countries in any mental health service utilization, adequate pharmacotherapy, adequate psychotherapy, and adequate combination of both. Severe cases are more likely than mild-moderate cases to receive either adequate pharmacotherapy or psychotherapy, but less likely to receive an adequate combination.

CONCLUSIONS

Decision-makers need to increase the utilization and quality of pharmacotherapy and psychotherapy. Innovations such as telehealth for training and supervision plus non-specialist or community resources to deliver pharmacotherapy and psychotherapy could address these bottlenecks.

Predicting second-generation antidepressant effectiveness in treating sadness using demographic and clinical information: A machine learning approach

INTRODUCTION

Current guidelines for choosing antidepressant medications involve a trial-and-error process. Most patients try multiple antidepressants before finding an effective antidepressant. This study uses demographic and clinical information to create models predicting effectiveness of different antidepressants in treating sadness in a nationally representative sample of US adults.

METHODS

A secondary analysis of the Collaborative Psychiatric Epidemiology Survey (CPES) was performed. Participants with or without a mental health diagnosis who reported sadness as a symptom, and were taking fluoxetine (n=156), sertraline (n=224), citalopram (n=91), paroxetine (n=156), venlafaxine (n=69), bupropion (n=92), or trazadone (n=26) within the past year were included. Two sets of principal component analyses (PCAs) and logistic regressions were performed: one determined associations between symptom clusters and antidepressant effectiveness for sadness, and the other created models to predict effectiveness. Both PCAs controlled for psychiatric and medical diagnoses, substance use, psychiatric medications, alternative treatments, and demographics.

RESULTS

Anxiety was associated with ineffectiveness of fluoxetine in treating sadness. Low mood scores were associated with ineffectiveness of paroxetine and venlafaxine, and fatigue was associated with ineffectiveness of sertraline. The models for predicting drug effectiveness had a mean accuracy of 83% and internal validity of 72%.

LIMITATIONS

CPES data were collected from 2001-2003, so newer drugs were not included. Effectiveness was for sadness, so results are not directly comparable to studies using overall depressive symptom reductions as outcomes.

CONCLUSION

Since fewer than 50% of patients currently respond to their first antidepressant, this model could provide modest improvement to choosing starting antidepressants in treating sadness.

Neighbourhood Material and Social Deprivation and Exposure to Antidepressant Drug Treatment: A Cohort Study Using Administrative Data

OBJECTIVE

To assess whether neighbourhood deprivation is associated with exposure to an antidepressant drug treatment (ADT) and its quality among individuals diagnosed with unipolar depression and insured by the Quebec public drug plan.

METHOD

We conducted an administrative database cohort study of adults covered by the Quebec public drug plan who were diagnosed with a new episode of unipolar depression. We assessed material and social deprivation using an area-based index. We considered exposure to an ADT as having ≥1 claim for an ADT within the 365 days following depression diagnosis. Among those exposed to ADT, ADT quality was assessed with 3 indicators: first-line recommended ADT, persistence with the ADT, and compliance with the ADT. Generalized linear models were used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (95% CI).

RESULTS

Of 100,432 individuals with unipolar depression, 65,436 (65%) were exposed to an ADT in the year following the diagnosis. Individuals living in the most materially deprived areas were slightly more likely to be exposed to an ADT than those living in the least deprived areas (aPR, 1.04; 95% CI, 1.03 to 1.06). The likelihoods of being exposed to a first-line ADT, persisting for the minimum recommended duration and complying with the ADT were independent of the deprivation levels.

CONCLUSIONS

Neighbourhood deprivation was not associated with ADT quality among individuals insured by the Quebec public drug plan. It might be partly attributable to the public drug plan whose goal is to provide equitable access to prescription drugs regardless of income.

Beliefs about antidepressant medication and associated adherence among older Chinese patients with major depression: A cross-sectional survey

Antidepressant non-adherence among people with depressive disorder is a major, ongoing public health issue, yet few studies have focused on older adults and their medication adherence. Although treatment adherence is determined by multiple factors, one of the important and modifiable predictors are patients' attitudes and beliefs about medication. We explored a sample of 135 older Chinese people with major depression, and the relationship between beliefs about antidepressants and medication adherence. Sociodemographic and illness variables were also examined. In all, high antidepressant adherence was reported in 37.8%, moderate adherence in 39.2%, and low adherence in 23%. Ordinal regression analysis showed perceived necessity (P < 0.01) and concern (P < 0.01) about antidepressants were significant influencing factors. Other variables with a positive association with higher adherence were lower average income (P < 0.05), fewer number of prior episodes of depression (P < 0.01), and comorbid anxiety (P < 0.05). The present study highlights low adherence in a sample of older depressed Chinese people, and highlights how beliefs about medication affect adherence. Therefore, more attention should be focused on non-adherence in older patients, and there is a need to establish accessible and systematic education programmes to correct misconceptions to improve their adherence.

The Impact of Post-Traumatic Stress Disorder on the Burden of Migraine: Results From the National Comorbidity Survey-Replication

BACKGROUND

Post-traumatic stress disorder (PTSD) has been linked with migraine in prior studies.

OBJECTIVE

To evaluate the individual and joint burdens of migraine and PTSD in a population-based cohort.

METHODS

The National Comorbidity Survey-Replication (NCS-R) is a general population study conducted in the United States from February 2001-April 2003. PTSD and migraine were assessed, and four groups defined based on their migraine and PTSD status. The four groups included those with no migraine and no PTSD (controls, n=4535), those with migraine and without PTSD (migraine alone, n=236), those with PTSD and without migraine (PTSD alone, n=244), and those with both migraine and PTSD (mig+PTSD, n=68). Logistic and Poisson regression models were used to assess the association between dichotomous/multilevel outcome variables indicating financial, health, and interpersonal burdens and each migraine/PTSD group.

RESULTS

Compared to controls, those with Mig+PTSD were more likely to be in the low poverty index (48% vs 41%, AOR 2.16; CI: 1.10, 4.24) and were less likely to be working for pay or profit in the past week (50% vs 68%, AOR 0.42; CI: 0.24, 0.74) but not those with migraine or PTSD alone. Additionally, the number of days where work quality was cut due to physical or mental health or substance abuse in the past month was greater in all groups compared to controls: (1) migraine alone: mean 2.57 (SEM 0.32) vs mean 1.09 (SEM 0.08) days, ARR=2.39; CI: 2.19, 2.62; (2) PTSD alone: mean 2.43 (SEM 0.33) vs mean 1.09 (SEM 0.08) days, ARR=2.09; CI: 1.91, 2.29; (3) mig+PTSD: mean 8.2 (SEM 0.79) vs 1.09 (SEM 0.08) days, ARR 6.79; CI 6.16, 7.49; and was over 2.5-fold greater in those mig+PTSD than migraine alone (mean 8.0 [SEM 0.79] vs 2.6 days [SEM 0.72], ARR 2.77; CI: 2.45, 3.14). The likelihood of having difficulty getting along or maintaining a social life was also increased in all groups relative to controls: (1) migraine alone: 21% vs 5.4%, AOR 4.20; CI: 2.62, 6.74; (2) PTSD alone: 18% vs 5.4%, AOR 3.40; CI: 2.40, 4.82; (3) Mig+PTSD: 39% vs 5.4%, AOR 9.95; CI: 5.72, 17.32, and was 2-fold greater in those with Mig+PTSD as compared to those with migraine alone (AOR 2.32; CI: 1.15, 4.69).

CONCLUSIONS

These findings support the need for those who treat migraine patients to be aware of the comorbidity with PTSD, as these patients may be particularly prone to adverse financial, health, and interpersonal disease burdens.

Persisting Racial Disparities in Total Shoulder Arthroplasty Utilization and Outcomes

OBJECTIVE

The purpose was to study whether racial disparities in total shoulder arthroplasty (TSA) utilization and outcomes have declined over time.

METHODS

We used the US Nationwide Inpatient Sample from 1998 to 2011.We used chi-squared test to compare characteristics, Cochran-Armitage test to compare utilization rates, and Cochran-Armitage test and logistic regression to compare time-trends in outcomes by race.

RESULTS

From 1998 to 2011, 176,141 Whites and 7694 Blacks underwent TSA. Compared to Whites, Blacks who underwent TSA were younger (69.1 vs. 64.2 years; p<0.0001), more likely to be female (54.9 vs. 71.0 %; p<0.0001), and have rheumatoid arthritis or avascular necrosis as the underlying diagnosis (1.7 vs. 3.0%and 1.7 vs. 6.1 %; p<0.0001 for both) and a Deyo-Charlson index of 2 or higher (8.5 vs. 16.7 %; p<0.0001). Compared to Whites, Blacks had much lower TSA utilization rate/100,000 in 1998 (2.97 vs. 0.83; p<0.0001) and in 2011 (12.27 vs. 3.33; p<0.0001); racial disparities increased from 1998 to 2011 (p<0.0001). A higher proportion of Blacks than Whites had a hospital stay greater than median in 1998-2000, 62 vs. 51.4 % (p=0.02), and in 2009-2011, 34.4 vs. 27.3 % (p<0.0001); disparities did not change over time (p=0.31). These disparities in utilization were borderline significant in adjusted analyses. There were no racial differences in proportion discharged to inpatient medical facility in 1998-2000, 15.2 vs. 15.0 % (p=0.95), and in 2009-2011, 12.3 vs. 11.1%(p=0.37), respectively.

CONCLUSIONS

We found increasing racial disparities in TSA utilization. Some disparities in outcomes exist as well. Patients, surgeons, and policy-makes should be aware of these findings and take action to reduce racial disparities.

Depression and alcohol withdrawal syndrome: is antidepressant therapy associated with lower rates of hospital readmission?

BACKGROUND

Alcohol withdrawal syndrome (AWS) is a frequent cause of admission to acute care hospitals and many of these patients have a history of depression.

AIM

Our objective was to determine if antidepressant use in patients with a history of depression is associated with lower rates of hospital readmission for AWS.

METHODS

A retrospective study was performed of patients admitted with AWS between January 1, 2006 and December 31, 2008 to an academic tertiary referral hospital.

RESULTS

Three hundred and twenty-two patients were admitted with AWS during the study period. One hundred and sixty-one patients (50 %) had no history of depression, 111 patients (34 %) had a history of depression and antidepressant use, and 50 patients (16 %) had a history of depression and no antidepressant use. There was no significant difference in the number of hospitalizations for AWS between these three groups. Patients with a history of depression on antidepressant medication were more likely to be retired or work disabled compared to the other two groups (p < 0.05). The antidepressant class most commonly used was SSRI (63 %).

CONCLUSION

Our study highlights the high frequency of depression and antidepressant use in patients admitted with AWS to an acute care hospital. As alcohol withdrawal is associated with increased morbidity and mortality and depression is common in those with alcohol use disorder, further research is necessary to clarify the optimal treatment of comorbid depression and alcohol use disorder in reducing these revolving door admissions.

Factors predicting adherence to antidepressant treatment

PURPOSE OF REVIEW

Poor adherence and discontinuation of treatment are the major challenges of pharmacotherapy among patients with depression. This article reviews the factors predicting adherence to and persistence of antidepressant treatment identified in recent years.

RECENT FINDINGS

Study populations have been extended to subgroups of patients with depression or depressive patients with comorbid medical conditions. Some studies have investigated the issues by analysing medical claims databases. Socio-demographic variables, clinical features of depression, comorbidities, pharmacological factors, attitudes towards antidepressants, previous experiences of antidepressant treatment, patient-professional relationship and genes were found to be common factors. An older age, positive attitudes to antidepressants and previous experiences and vicarious experiences of depression or treatment were found to be factors predicting better adherence or persistence. Conversely, patients in minority groups, those with a low family income, pregnancy, experience of side effects, dissatisfaction with treatment and a poor patient-professional relationship were found to be associated with poorer adherence or persistence.

SUMMARY

The factors predicting adherence and persistence are complex and interactive. Different methods of studies have limitations in terms of exploring all these factors. Future studies should integrate these factors simultaneously and explore specific factors predicting adherence and persistence among subgroups of patients with depression.

Improving care for depression in obstetrics and gynecology: a randomized controlled trial

OBJECTIVE

To evaluate an evidence-based collaborative depression care intervention adapted to obstetrics and gynecology clinics compared with usual care.

METHODS

A two-site, randomized controlled trial included screen-positive women (Patient Health Questionnaire-9 score of at least 10) who met criteria for major depression, dysthymia, or both (Mini-International Neuropsychiatric Interview). Women were randomized to 12 months of collaborative depression management or usual care; 6-month, 12-month, and 18-month outcomes were compared. The primary outcomes were change from baseline to 12 months in depression symptoms and functional status. Secondary outcomes included at least 50% decrease and remission in depressive symptoms, global improvement, treatment satisfaction, and quality of care.

RESULTS

Participants were, on average, 39 years old, 44% were nonwhite, and 56% had posttraumatic stress disorder. Intervention (n=102) compared with usual care (n=103) patients had greater improvement in depressive symptoms at 12 months (P<.001) and 18 months (P=.004). The intervention group compared with usual care group had improved functioning over the course of 18 months (P<.05), were more likely to have at least 50% decrease in depressive symptoms at 12 months (relative risk [RR] 1.74, 95% confidence interval [CI] 1.11-2.73), greater likelihood of at least four specialty mental health visits (6-month RR 2.70, 95% CI 1.73-4.20; 12-month RR 2.53, 95% CI 1.63-3.94), adequate dose of antidepressant (6-month RR 1.64, 95% CI 1.03-2.60; 12-month RR 1.71, 95% CI 1.08-2.73), and greater satisfaction with care (6-month RR 1.70, 95% CI 1.19-2.44; 12-month RR 2.26, 95% CI 1.52-3.36).

CONCLUSION

Collaborative depression care adapted to women's health settings improved depressive and functional outcomes and quality of depression care.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01096316.

LEVEL OF EVIDENCE

I.

Medication adherence part two: predictors of nonadherence and adherence

PURPOSE

This is the second of a three-part series on medication adherence in which the authors describe the continuum of adherence to nonadherence of medication usage.

DATA SOURCES

Research articles through MEDLINE and PubMed.

CONCLUSIONS

Understanding the magnitude and scope of the problem of medication nonadherence is the first step in reaching better adherence rates (described in Part One of this series). The second step is to recognize the complexities of the reasons for medication adherence/nonadherence (described here). Reasons for nonadherence include beliefs related to the benefits of medication for physical and mental disorders, complexities of systems of health care and treatment plans, and lifestyle and demographic characteristics of patients. The final step is to evaluate each patient for medication adherence, tailoring the plan of care according to patient and system specific barriers (described in Part Three of this series).

IMPLICATIONS FOR PRACTICE

Nurse practitioners must recognize a critical element of thorough care is to assess medication adherence at each patient visit, countering patient and system barriers as indicated. Nurse practitioners also need to adjust assessment and prescribing practices according to the evidence for best practices to improve medication adherence.

Mechanisms of antidepressant resistance

Depression is one of the most frequent and severe mental disorder. Since the discovery of antidepressant (AD) properties of the imipramine and then after of other tricyclic compounds, several classes of psychotropic drugs have shown be effective in treating major depressive disorder (MDD). However, there is a wide range of variability in response to ADs that might lead to non response or partial response or in increased rate of relapse or recurrence. The mechanisms of response to AD therapy are poorly understood, and few biomarkers are available than can predict response to pharmacotherapy. Here, we will first review markers that can be used to predict response to pharmacotherapy, such as markers of drug metabolism or blood-brain barrier (BBB) function, the activity of specific brain areas or neurotransmitter systems, hormonal dysregulations or plasticity, and related molecular targets. We will describe both clinical and preclinical studies and describe factors that might affect the expression of these markers, including environmental or genetic factors and comorbidities. This information will permit us to suggest practical recommendations and innovative treatment strategies to improve therapeutic outcomes.

Major depressive episode among Brazilian adults: a cross-sectional population-based study

BACKGROUND

Despite the fact that there is extensive scientific research on depression very few population-based studies have been conducted in Brazilian cities.

METHODS

A sampling design of two-stage conglomerates with probability proportional to size. All adults aged 20 or more living in the selected households were invited to participate in the study. Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9) with a cutoff ≥9.

RESULTS

The study sample comprised 2925 respondents. The prevalence of depression in the sample studied was 20.4% (95% CI 18.9;21.8). After adjustment for confounding factors according to a conceptual analysis model the following variables were associated with a higher prevalence of depression: female gender; younger age; white skin color; lower socioeconomic condition; lower education; smoking; being single or separated; being unemployed; and reporting a heart condition. Alcohol use, arterial hypertension, and diabetes mellitus were not found to be associated with depression.

LIMITATIONS

The difference in the proportion of males among losses and refusals compared to that in the sample analyzed. Another limitation is reverse causality bias that is a problem inherent to cross-sectional studies.

CONCLUSIONS

Our findings support the relevance of depression as a prevalent condition among adults. It also provided evidence of the factors associated with depression, and that some are potentially modifiable risk factors may have implications for policy and health service planning.

Racial and gender disparities among patients with gout

Gout affects 8.3 million Americans according to NHANES 2007-2008, approximately 3.9 % of the US population. Gout has substantial effect on physical function, productivity, health-related quality of life (HRQOL), and health care costs. Uncontrolled gout is also associated with significant use of emergency care services. Women are less likely to have gout than men, but in the postmenopausal years the gender difference in disease incidence decreases. Compared with whites, racial and/or ethnic minorities, especially blacks, have higher prevalence of gout. Blacks are also less likely to receive quality gout care, leading to disproportionate morbidity. Women are less likely than men to receive allopurinol, and less likely to undergo joint aspirations for crystal analysis to establish diagnosis, but those on urate-lowering therapy are as likely as, or more likely than, men to undergo serum urate check within six months of initiation. Although a few studies provide the knowledge related to gender and race and/or ethnicity disparities for gout, several knowledge gaps exist in gout epidemiology and outcomes differences by gender and race and/or ethnicity. These should be investigated in future studies.