Poor adherence to placebo or amiodarone therapy predicts mortality: results from the CAMIAT study. Canadian Amiodarone Myocardial Infarction Arrhythmia Trial

Harnessing placebo: Lessons from psychedelic science

The randomized controlled trial (RCT) research design assumes that a drug's "specific" effect can be isolated, added, and subtracted from the "nonspecific" effect of context and person. While RCTs are helpful in assessing the added benefit of a novel drug, they tend to obscure the curative potential of extra-pharmacological variables, known as "the placebo effect." Ample empirical evidence suggests that person/context-dependent physical, social, and cultural variables not only add to, but also shape drug effects, making them worth harnessing for patient benefits. Nevertheless, utilizing placebo effects in medicine is challenging due to conceptual and normative obstacles. In this article, we propose a new framework inspired by the field of psychedelic science and its employment of the "set and setting" concept. This framework acknowledges that drug and nondrug factors have an interactive and synergistic relationship. From it, we suggest ways to reintegrate nondrug variables into the biomedical toolbox, to ethically harness the placebo effect for improved clinical care.

Association of Medication Adherence With Health Outcomes in the ISCHEMIA Trial

BACKGROUND

The ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial randomized participants with chronic coronary disease (CCD) to guideline-directed medical therapy with or without angiography and revascularization. The study examined the association of nonadherence with health status outcomes.

OBJECTIVES

The study sought to compare 12-month health status outcomes of adherent and nonadherent participants with CCD with an a priori hypothesis that nonadherent patients would have better health status if randomized to invasive management.

METHODS

Self-reported medication-taking behavior was assessed at randomization with a modified 4-item Morisky-Green-Levine Adherence Scale, and participants were classified as adherent or nonadherent. Twelve-month health status was assessed with the 7-item Seattle Angina Questionnaire (SAQ-7) summary score (SS), which ranges from 0 to 100 (higher score = better). The association of adherence with outcomes was evaluated using Bayesian proportional odds models, including an interaction by study arm (conservative vs invasive).

RESULTS

Among 4,480 randomized participants, 1,245 (27.8%) were nonadherent at baseline. Nonadherent participants had worse baseline SAQ-7 SS in both conservative (72.9 ± 19.3 vs 75.6 ± 18.4) and invasive (71.0 ± 19.8 vs 74.2 ± 18.7) arms. In adjusted analyses, adherence was associated with higher 12-month SAQ-7 SS in both treatment groups (mean difference in SAQ-7 SS with conservative treatment = 1.6 [95% credible interval: 0.3-2.9] vs with invasive management = 1.9 [95% credible interval: 0.8-3.1]), with no interaction by treatment.

CONCLUSIONS

More than 1 in 4 participants reported medication nonadherence, which was associated with worse health status in both conservative and invasive treatment strategies at baseline and 12 months. Strategies to improve medication adherence are needed to improve health status outcomes in CCD, regardless of treatment strategy. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Adherence with protocol medication use and mortality from unrelated causes in a prevention trial

Several studies have shown that non-adherence to medication use is associated with lower use of preventive services and increased mortality. We aimed to study the relationship between initial adherence to medication use and mortality in the Prostate Cancer Prevention Trial (PCPT). The PCPT randomized men age 55 and over to a finasteride or placebo arm. Duration of treatment was seven years, followed by end-of-study prostate biopsy. Extended follow-up for mortality was performed by linkage to the National Death Index. Non-adherence was defined as taking under 80% of required pills during the first or second 6-month trial period. Proportional hazards models were used to assess the relationship between adherence and all-cause mortality (excluding prostate cancer deaths). Three models were developed as follows: Model I (controlling for demographics and trial arm), Model II (Model I factors plus specific medical conditions), Model III (Model II factors plus lifestyle factors). Of 18,667 men included in the analysis, 3082 (16.5%) were non-adherent. The most common reasons for non-adherence were side effects (33.9%) and forgetting to take pills (22%). Through 5 and 10 years of follow-up, 178 (5.9%) and 483 (15.7%) non-adherent men died versus 581 (3.7%) and 1887 (12.1%) adherent men. Hazard ratios (HRs) at 5 years were 1.62 (95% CI: 1.37-1.91), 1.55 (95% CI: 1.30-1.83) and 1.49 (95% CI: 1.25-1.76) for Models I-III. HRs at ten years were lower but still statistically significant. Non-adherence to taking protocol medications was associated with increased mortality from unrelated conditions.

Accountability in patient adherence

BACKGROUND

The accountability inherent in the social interaction between a patient and healthcare provider affects patients' motivation to adhere to treatment. To characterize the role of accountability as a tool to improve self-efficacy and self-management and thereby promote patients' adherence to treatment, a measure of accountability is needed.

AIMS

To develop and test the validity, reliability, and sensitivity of a new outcome measure designed to assess accountability.

METHODS

The accountability measurement tool was developed from the literature, expert consultation, and focus groups. A focus group and three pilot studies were performed both in clinic and through an online crowdsourcing platform. Principal Component Analysis evaluated constructs, and Cronbach's alpha measured internal consistency. Validity was established using convergent and divergent correlations to other validated scales.

RESULTS

A total of 292 participants took part in this study. The 12-item accountability scale demonstrated very good internal consistency (Cronbach's α=0.92). Components of the accountability measurement tool correlated with predicted validated measures, including the Treatment Self-Regulation Questionnaire. Divergent validity was established with no significant difference noted between age, sex, race, and education level.

CONCLUSION

Future use of this questionnaire will allow for the assessment of the interaction between accountability and adherence to treatment and lead to the development of new interventions to promote better adherence.

Association of functional and structural social support with medication adherence among individuals treated for coronary heart disease risk factors: Findings from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study

Background

Functional social support has a stronger association with medical treatment adherence than structural social support in several populations and disease conditions. Using a contemporary U.S. population of adults treated with medications for coronary heart disease (CHD) risk factors, the association between social support and medication adherence was examined.

Methods

We included 17,113 black and white men and women with CHD or CHD risk factors aged ≥45 years recruited 2003–2007 from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Participants reported their perceived social support (structural social support: being partnered, number of close friends, number of close relatives, and number of other adults in household; functional social support: having a caregiver in case of sickness or disability; combination of structural and functional social support: number of close friends or relatives seen at least monthly). Medication adherence was assessed using a 4-item scale. Multi-variable adjusted Poisson regression models were used to calculate prevalence ratios (PR) for the association between social support and medication adherence.

Results

Prevalence of medication adherence was 68.9%. Participants who saw >10 close friends or relatives at least monthly had higher prevalence of medication adherence (PR = 1.06; 95% CI: 1.00, 1.11) than those who saw ≤3 per month. Having a caregiver in case of sickness or disability, being partnered, number of close friends, number of close relatives, and number of other adults in household were not associated with medication adherence after adjusting for covariates.

Conclusions

Seeing multiple friends and relatives was associated with better medication adherence among individuals with CHD risk factors. Increasing social support with combined structural and functional components may help support medication adherence.

Self-reported Medication Adherence and CKD Progression

Introduction

In the general population, medication nonadherence contributes to poorer outcomes. However, little is known about medication adherence among adults with chronic kidney disease (CKD). We evaluated the association of self-reported medication adherence with CKD progression and all-cause death in patients with CKD.

Methods

In this prospective observational study of 3305 adults with mild-to-moderate CKD enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study, the baseline self-reported medication adherence was assessed by responses to 3 questions and categorized as high, medium, and low. CKD progression (50% decline in eGFR or incident end-stage renal disease) and all-cause death were measured using multivariable Cox proportional hazards.

Results

Of the patients, 68% were categorized as high adherence, 17% medium adherence, and 15% low adherence. Over a median follow-up of 6 years, there were 969 CKD progression events and 675 deaths. Compared with the high-adherence group, the low-adherence group experienced increased risk for CKD progression (hazard ratio = 1.27, 95% confidence interval = 1.05, 1.54) after adjustment for sociodemographic and clinical factors, cardiovascular medications, number of medication types, and depressive symptoms. A similar association existed between low adherence and all-cause death, but did not reach standard statistical significance (hazard ratio = 1.14 95% confidence interval = 0.88, 1.47).

Conclusion

Baseline self-reported low medication adherence was associated with an increased risk for CKD progression. Future work is needed to better understand the mechanisms underlying this association and to develop interventions to improve adherence.

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

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

The impact of adjunctive guanfacine extended release on stimulant adherence in children/adolescents with attention-deficit/hyperactivity disorder

Aim: To assess stimulant adherence among children/adolescents with attention-deficit/hyperactivity disorder (ADHD) augmenting stimulants with guanfacine extended-release (GXR). Patients & methods: Inclusion criteria: 6–17 years, ≥1 ADHD diagnosis, ≥1 long-acting and/or short-acting stimulant with GXR augmentation. Modified medication possession ratio (mMPR; days medication available/days in period, excluding medication holidays) was assessed; mMPR <0.80 nonadherent. Regression models assessed change in mMPR adjusting for demographic and clinical characteristics. Results: Among patients nonadherent to stimulants pre-augmentation (n = 165), unadjusted mean (SD) pre- and post-stimulant mMPRs were 0.68 (0.11) and 0.87 (0.16). Adjusted mean change in mMPR was 0.20 for long-acting versus 0.18 for short-acting stimulants (p = 0.34). Conclusion: Among patients nonadherent to stimulants, GXR augmentation was associated with increased stimulant adherence.

Using Animation to Improve Recovery from Acute Coronary Syndrome: A Randomized Trial

Background: Recovery from myocardial infarction has been associated with patients' perceptions of damage to their heart. New technologies offer a way to show patients animations that may foster more accurate perceptions and encourage medication adherence, increased exercise and faster return to activities.

PURPOSE

The purpose of this study was to investigate the effects of a brief animated intervention delivered at the patients' bedside on perceptions and recovery in acute coronary syndrome patients.

METHODS

Seventy acute coronary syndrome patients were randomly assigned to the intervention or standard care alone. Illness perceptions, medication beliefs and recovery outcomes were measured.

RESULTS

Post-intervention, the intervention group had significantly increased treatment control perceptions and decreased medication harm beliefs and concerns. Seven weeks later, intervention participants had significantly increased treatment control and timeline beliefs, decreased symptoms, lower cardiac avoidance, greater exercise and faster return to normal activities compared to control patients.

CONCLUSIONS

A brief animated intervention may be clinically effective for acute coronary syndrome patients (Trial-ID: ACTRN12614000440628).

Hawthorne effect with transient behavioral and biochemical changes in a randomized controlled sleep extension trial of chronically short-sleeping obese adults: implications for the design and interpretation of clinical studies

OBJECTIVE

To evaluate the effects of study participation per se at the beginning of a sleep extension trial between screening, randomization, and the run-in visit.

DESIGN

Subjects were screened, returned for randomization (Comparison vs. Intervention) after 81 days (median), and attended run-in visit 121 days later.

SETTING

Outpatient.

PATIENTS

Obese (N = 125; M/F, 30/95; Blacks/Whites/Other, N = 73/44/8), mean weight 107.6±19.7 kg, <6.5 h sleep/night.

INTERVENTION

Non-pharmacological sleep extension.

MEASUREMENTS

Sleep duration (diaries and actigraphy watch), sleep quality (Pittsburgh Sleep Quality Index), daily sleepiness (Epworth Sleepiness Scale), fasting glucose, insulin and lipids.

RESULTS

Prior to any intervention, marked improvements occurred between screening and randomization. Sleep duration increased (diaries: 357.4 ±51.2 vs. 388.1±48.6 min/night; mean±SD; P<0.001 screening vs. randomization; actigraphy: 344.3 ±41.9 vs. 358.6±48.2 min/night; P<0.001) sleep quality improved (9.1±3.2 vs. 8.2±3.0 PSQI score; P<0.001), sleepiness tended to improve (8.9±4.6 vs. 8.3±4.5 ESS score; P = 0.06), insulin resistance decreased (0.327±0.038 vs. 0.351±0.045; Quicki index; P<0.001), and lipids improved, except for HDL-C. Abnormal fasting glucose (25% vs. 11%; P = 0.007), and metabolic syndrome (42% vs. 29%; P = 0.007) both decreased. In absence of intervention, the earlier metabolic improvements disappeared at the run-in visit.

LIMITATIONS

Relatively small sample size.

CONCLUSIONS

Improvements in biochemical and behavioral parameters between screening and randomization changed the "true" study baseline, thereby potentially affecting outcome. While regression to the mean and placebo effect were considered, these findings are most consistent with the "Hawthorne effect", according to which behavior measured in the setting of an experimental study changes in response to the attention received from study investigators. This is the first time that biochemical changes were documented with respect to the Hawthorne effect. The findings have implications for the design and conduct of clinical research.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00261898.

The effect of placebo adherence on reducing cardiovascular mortality: a meta-analysis

OBJECTIVE

We aim to demonstrate the effect of placebo adherence on reducing CV mortality.

BACKGROUNDS

Good adherence, whether to drug or placebo treatment, is associated with lower CV mortality. However, current evidence for the positive effect of placebo adherence on reducing CV mortality is relatively weak.

METHODS

We conducted a fixed-effect meta-analysis of eight randomized clinical trials to evaluate the effect of placebo adherence on reducing CV mortality. We made a comparison between good placebo adherence and poor drug adherence.

RESULTS

Compared with poor adherence to drug treatment, good adherence to placebo treatment was associated with lower CV mortality (OR = 0.68, 95% CI 0.60-0.77).

CONCLUSION

Good adherence to placebo has a positive effect on reducing CV mortality. The effect of adherence on reducing CV mortality may be independent of the drug effect.

Towards personalizing treatment for depression : developing treatment values markers

BACKGROUND

While 'personalized medicine' commonly refers to genetic markers or profiles associated with pharmacological treatment response, tailoring treatments to patient preferences and values is equally important.

OBJECTIVE

To describe and demonstrate a method to develop 'values markers,' or profiles based on the relative importance of attributes of depression treatment.

STUDY DESIGN

Discrete choice analysis was used to assess individuals' relative preferences for features of depression treatment. Preference profiles were developed using latent profile analysis.

PATIENTS OR OTHER PARTICIPANTS

Eighty-six adults participating in an internet-based discrete choice questionnaire.

MAIN OUTCOME MEASURE

Participants were presented with two depression scenarios representing mild and severe depression. For each scenario, they were asked to compare 18 choice sets based on the type of medication side effect (nausea, dizziness, and sexual dysfunction) and severity (mild, moderate, and severe); and for counseling frequency (once per week or every other week) and provider setting (the office of a mental health professional, primary care doctor, or spiritual counselor).

RESULTS

Three profiles were identified: profile 1 was associated with a preference for counseling and an avoidance of medication side effects; profile 2 with an avoidance of strong medication side effects and for receiving counseling in medical settings; and profile 3 with a preference for medication over counseling. When presented with a severe depression scenario, there was a higher prevalence for profile 1 and patients were more likely to prefer mental health over primary care and spiritual settings.

CONCLUSIONS

Values markers may provide a foundation for personalized medicine, and reflect current initiatives emphasizing patient-centered care. Next steps should assess whether values markers are predictive of treatment initiation and adherence.

The impact of medication adherence on coronary artery disease costs and outcomes: a systematic review

BACKGROUND

Given the huge burden of coronary artery disease and the effectiveness of medication therapy, understanding and quantifying known impacts of poor medication adherence for primary and secondary prevention is crucial. We sought to systematically review the literature on this topic area with a focus on quantified cost and clinical outcomes related to adherence.

METHODS

We conducted a systematic review of the literature between 1966 and November 2011 using a fixed search strategy, multiple reviewers, and a quality rating scale. We found 2636 articles using this strategy, eventually weaning them down to 25 studies that met our inclusion criteria. Three reviewers independently reviewed the studies and scored them for quality using the Newcastle Ottawa Scoring Scale.

RESULTS

We found 5 studies (4 of which focused on statins) that measured the impact of medication adherence on primary prevention of coronary artery disease and 20 articles that focused on the relationship between medication adherence to costs and outcomes related to secondary prevention of coronary artery disease. Most of these latter studies focused on antihypertensive medications and aspirin. All controlled for confounding comorbidities and sociodemographic characteristics, but few controlled for likelihood of adherent patients to have healthier behaviors ("healthy adherer effect"). Three studies found that high adherence significantly improves health outcomes and reduces annual costs for secondary prevention of coronary artery disease (between $294 and $868 per patient, equating to 10.1%-17.8% cost reductions between high- and low-adherence groups). The studies were all of generally of high quality on the Newcastle Ottawa Scale (median score 8 of 9).

CONCLUSIONS

Increased medication adherence is associated with improved outcomes and reduced costs, but most studies do not control for a "healthy adherer" effect.

Placebo adherence and mortality in the Heart and Estrogen/Progestin Replacement Study

BACKGROUND

Analyses from double-blind randomized trials have reported lower mortality among participants who were more adherent to placebo compared with those who were less adherent. We explored this phenomenon by analyzing data from the placebo arm of the Heart and Estrogen/Progestin Replacement Study (HERS), a randomized, double-blind, placebo-controlled trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Our primary aim was to measure and explain the association between adherence to placebo and total mortality among the placebo-allocated participants in the HERS. Secondary aims included assessment of the association between placebo adherence and cause-specific morbidity and mortality.

METHODS

Participants with "higher placebo adherence" were defined as having taken at least 75% of their placebo study medication during each individual's participation in the study, whereas those with "lower placebo adherence" took less than 75%. The primary outcome was in-study all-cause mortality.

RESULTS

More adherent participants had significantly lower total mortality compared with less adherent participants (hazard ratio, 0.52; 95% confidence interval, 0.29-0.93). Adjusting for available confounders did not change the magnitude or significance of the estimates. Analyses revealed that the association of higher adherence and mortality might be explained, in part, by time-dependent confounding.

CONCLUSIONS

Analyses of the HERS data support a strong association between adherence to placebo study medication and mortality. Although probably not due to simple confounding by healthy lifestyle factors, the underlying mechanism for the association remains unclear. Further analyses of this association are necessary to explain this observation.

Adherence to placebo and mortality in the Beta Blocker Evaluation of Survival Trial (BEST)

BACKGROUND

Randomized controlled trials have reported lower mortality among patients who adhere to placebo compared with those who do not. We explored this phenomenon by reanalyzing data from the placebo arm of the Beta Blocker Evaluation of Survival Trial (BEST), a randomized, double-blind, placebo-controlled trial of bucindolol and mortality.

AIMS

Our primary aim was to measure and explain the association between adherence to placebo and total mortality among the placebo-allocated participants in the BEST trial. Secondary aims included assessment of the association between placebo adherence and cause-specific mortality.

METHODS

Participants with "higher placebo adherence" were defined as having taken at least 75% of their placebo study medication over the entire course of each individual's participation in the study, while those with "lower placebo adherence" took <75%. Primary outcome was in-study all-cause mortality. To account for confounding, we adjusted for all available modifiable, non-modifiable and psychosocial variables.

RESULTS

Adherent participants had a significantly lower total mortality compared to less-adherent participants (HR=0.61, 95% Confidence Interval: 0.46-0.82). Adjusting for available confounders did not change the magnitude or significance of the estimates. When considering cause-specific mortality, CVD and pump failure showed similar associations.

CONCLUSIONS

Analyses of the BEST trial data support a strong association between adherence to placebo study medication and total mortality. While probably not due to publication bias or simple confounding by healthy lifestyle factors, the underlying explanation for the association remains a mystery. Prospective examination of this association is necessary to better understand the underlying mechanism of this observation.

Placebo adherence and its association with morbidity and mortality in the studies of left ventricular dysfunction

BACKGROUND

A provocative finding from several double-blind clinical trials has been the association between greater adherence to placebo study medication and better health outcomes. We used data from the Studies of Left Ventricular Dysfunction (SOLVD) Treatment Trial (SOLVD-TT) and the SOLVD Prevention Trial (SOLVD-PT) to examine whether such associations could be validated and to examine several sources of bias and potential confounding.

METHODS

Survival analytic methods were used to estimate the association between placebo adherence and several health outcomes, employing a number of modeling techniques to test for the existence of alternative explanations for the association. Higher adherence was defined as having taken ≥75% of prescribed study medication.

RESULTS

Higher placebo adherence was associated with improved overall survival in both SOLVD-TT and SOLVD-PT [hazard ratio (HR) = 0.52, 95% confidence interval (CI): 0.35 to 0.79 and HR = 0.52, 95%CI: 0.38 to 0.71, respectively]. Associations were similar for fatal or non-fatal cardiovascular or coronary heart disease events. Adjustment for both modifiable and non-modifiable cardiac risk factors (including age, gender, diabetes, blood pressure, smoking, weight, alcohol use, and levels of education) had minimal effect on the strength of the association. Little evidence of bias was found as an explanation for this relationship.

CONCLUSIONS

In these two trials, better adherence to placebo was associated with markedly superior health outcomes, including total in-study mortality and incident cardiovascular events. No important confounders were identified. These data suggest there may exist strong but unrecognized determinants of health outcomes for which placebo adherence is a marker.

Depression in patients with heart disease: the case for more trials

Depression is common among patients with heart disease. It is an important comorbidity, both because of its well-known effect on the quality of life and also because it has a significant impact on the ability of patients with heart disease to engage in healthy behaviors and to avoid unhealthy ones. In addition, depression is associated with increased morbidity and mortality in those with established cardiovascular disease. However, no study has demonstrated that treatment of depression improves cardiac outcomes in patients with heart disease. Some have argued that additional trials are not necessary, and that the importance of depression argues for increased recognition and treatment even if it cannot be demonstrated that this improves morbidity and mortality. This article makes the case for more trials in this area, highlighting the importance of using the results of prior trials to generate hypotheses and provide directions for future studies in this area and noting the effect that demonstrating improved survival might have on clinical practice.

Prevalence and cost of medication nonadherence in Parkinson's disease: evidence from administrative claims data

We estimated the prevalence of medication nonadherence in Parkinson's disease (PD) and the association between treatment nonadherence and healthcare costs. Insurance claims from over 30 US health plans were analyzed. Inclusion criteria were as follows: PD diagnosis, >or=1 PD-related prescription between 1/1/1997 and 12/31/2004, continuous health plan enrollment for >or=6 months before and >or=12 months after first PD prescription. Adherence, all-cause healthcare utilization, and all-cause costs were evaluated over 12 months post-treatment initiation. Adherence was measured using the medication possession ratio (MPR), with MPR < 0.8 defining nonadherence. Among patients identified for inclusion (N = 3,119), 58% were male and mean age was 69 years. Mean MPR was 0.58 and 61% of patients were nonadherent. Unadjusted mean medical costs were significantly higher (P < 0.01) among nonadherers ($15,826) compared with adherers ($9,228), although nonadherers had lower prescription drug costs ($2,684 vs. $3,854; P < 0.05). After controlling for confounders in multivariable analyses, a large positive relationship between nonadherence and both medical and total healthcare costs remained (+$3,451, P < 0.0001 and +$2,383, P = 0.0053, respectively). Medication adherence in PD is suboptimal and nonadherence may be associated with increased healthcare costs despite offsets from reduced drug intake. Efforts to promote medication adherence in PD may lead to cost savings for managed care systems.

Antilipidemic adherence post-coronary artery disease diagnosis among those with and without an ICD-9 diagnosis of depression

OBJECTIVES

An association between depression and coronary artery disease (CAD) is well established. Poor adherence to cardiac treatments may be one way depression could contribute to the increased risk of coronary events among depressed patients. We sought to evaluate whether adherence to antilipid medication, a therapy shown to be beneficial in secondary prevention of coronary events, differs among CAD patients with and without an ICD-9 depression diagnosis.

METHODS

Patients were included if, at angiography, they were determined to have CAD (stenosis >or=70%), were discharged on an antilipid medication, and re-filled their prescriptions at a participating pharmacy. A patient was determined to have depression (ICD-9 codes 296.2-296.36, 311) if the diagnosis occurred prior to angiography or within 6 months of the CAD diagnosis. Adherence and long-term outcomes were evaluated at 6 months, 1 year, 18 months and 2 years.

RESULTS

A total of 585 patients were included, with 73 (12.5%) having a diagnosis of depression prior to or within 6 months of CAD diagnosis. At all time-points, those with depression had a lower mean adherence compared to those without depression. Differences in adherence rates after adjustment were 7% (P=.001), 6% (P=.02), 13% (P<.0001) and 5% (P=.18) at 6 months, 1 year, 18 months, and 2 years, respectively. Though not statistically significant, there were clinically important associations between adherence and depression on the combined outcome of death, myocardial infarction, and revascularization.

CONCLUSION

Depression was the strongest predictor of antilipidemic medication adherence after 2 years of follow-up among CAD patients. Such results suggest that poor antilipid adherence may be one mechanism by which depression contributes to CAD events.

Organizing services for cardiovascular prevention

With an aging population, cardiovascular disease (CVD) prevalence will continue to increase for at least the next 30 years. Current clinical trial evidence expands the indications for aggressive treatment of risk factors. Concurrently, the use of new screening and diagnostic technologies will expand the number of identified high-risk individuals requiring clinical care. These likely scenarios will force efficient resource allocation. The impression of the authors is that new models of shared responsibilities of care are needed to enable CVD prevention. All stages of care for those with CVD should entail cooperation among nurses, pharmacists, primary care providers, and cardiovascular specialists in delivering comprehensive, evidence-based care. The persistent treatment gap between current knowledge and clinical practice suggests old models of acute patient care by specialists require revision into fundamentally different systems of long-term care by a team of providers such as that proposed by the Chronic Care Model.

Relationship between non-specific prescription pill adherence and ischemic stroke outcomes

BACKGROUND

Adherence to non-specific prescription therapy may be associated with clinical outcomes beyond a given treatment effect. We assessed the association of blinded randomized pill prescription adherence with vascular outcomes after ischemic stroke.

METHODS

We analyzed the Vitamin Intervention for Stroke Prevention (VISP) study database. VISP was a double-blind randomized trial, designed to determine whether high doses of vitamins (vs. low doses) would reduce recurrent stroke risk in 3,680 participants over a 2-year period. We examined the independent association of adherence with a composite endpoint (stroke, myocardial infarction, death).

RESULTS

Among 3,357 (91%) subjects with complete data, women, non-White persons, current smokers, those not on statins and those without a history of coronary artery bypass surgery were significantly less likely to be optimally adherent. Over the trial, persons who adhered well to treatment were less likely to experience the combined outcome than those who adhered poorly (13.4 vs. 20.6%, p < 0.0001). After multivariable analysis using various adherence measures, there were no significant differences between >or=80% vs. <80% adherence, but compared to <65% adherence, pill adherence levels of >or=90 to <99% (HR 0.56, 95% CI = 0.34-0.91; p = 0.02) and >or=99% (HR 0.46, 95% CI = 0.29-0.73; p = 0.001) were associated with lower occurrence of the combined outcome at 18 months.

CONCLUSIONS

Long-term excellent adherence to non-specific pill prescription among ischemic stroke patients is independently associated with lower vascular risk, and is likely a marker of overall healthy behavior that may be helpful in targeting stroke patients with unhealthy practices.

Medication adherence: its importance in cardiovascular outcomes

Medication adherence usually refers to whether patients take their medications as prescribed (eg, twice daily), as well as whether they continue to take a prescribed medication. Medication nonadherence is a growing concern to clinicians, healthcare systems, and other stakeholders (eg, payers) because of mounting evidence that it is prevalent and associated with adverse outcomes and higher costs of care. To date, measurement of patient medication adherence and use of interventions to improve adherence are rare in routine clinical practice. The goals of the present report are to address (1) different methods of measuring adherence, (2) the prevalence of medication nonadherence, (3) the association between nonadherence and outcomes, (4) the reasons for nonadherence, and finally, (5) interventions to improve medication adherence.

Depression after coronary artery disease is associated with heart failure

OBJECTIVES

The purpose of this study was to evaluate the influence of post-coronary artery disease (CAD) depression diagnosis on heart failure (HF) incidence.

BACKGROUND

Depression has been shown to be a risk factor for poor outcomes among CAD patients. However, little is known about the influence of depression on HF development in CAD patients.

METHODS

Patients (n = 13,708) without a diagnosis of HF and depression (International Classification of Diseases-Ninth Revision [ICD-9] codes: 296.2 to 296.36 and 311) and who were not prescribed antidepressant medication (ADM) at the time of CAD diagnosis (>or=70% stenosis) were studied. For those with available medication records (n = 7,719), patients subsequently diagnosed with depression were stratified by use of ADM. Patients were followed until HF diagnosis (physician-diagnosed or ICD-9 code: 428) or death. Results were analyzed by Cox proportional hazards regression models.

RESULTS

A total of 1,377 patients (10.0%) had a post-CAD clinical depression diagnosis. The incidence of HF among those without a post-CAD depression diagnosis was 3.6 per 100 compared with 16.4 per 100 for those with a post-CAD depression diagnosis. Depression was associated with an increased risk for HF incidence (adjusted hazard ratio [HR]: 1.50, p < 0.0001). Results were similar among those with available follow-up medication information (vs. no depression: depression without ADM use [HR: 1.68, p < 0.0001]; depression with ADM use [HR: 2.00, p < 0.0001]). No difference was found between depressed patients with and without ADM treatment (HR: 0.84, p = 0.24).

CONCLUSIONS

Depression diagnosis was shown to be associated with an increased incidence of HF after CAD diagnosis, regardless of ADM treatment. This finding suggests the need to further study the effect of depression on HF risk among CAD patients.

The effects of reformulation: improved therapeutic index

Antimuscarinic agents are the treatment of choice for overactive bladder syndrome. Due to the development of novel delivery systems, extended-release formulations of oxybutynin, tolterodine, and trospium chloride are now available. In addition to the convenience of once-daily dosing, the new formulations of these commonly prescribed agents have improved their therapeutic index, striking a better balance between efficacy and tolerability.

New strategies are needed to improve the accuracy of influenza vaccine effectiveness estimates among seniors

OBJECTIVE

The magnitude of the benefit of influenza vaccine among elderly individuals has been recently debated. Existing vaccine effectiveness estimates derive primarily from observational studies, which may be biased. In this paper, we provide a methodological examination of the potential sources of bias in observational studies of influenza vaccine effectiveness in seniors and propose design and analysis strategies to reduce bias in future studies.

STUDY DESIGN AND SETTING

We draw parallels to bias documented in observational studies of therapies in other areas of medical research including pharmacoepidemiology, discuss reasons why existing adjustment methods in influenza studies may not adequately control for the bias, and evaluate statistical approaches that may yield more accurate estimation of influenza vaccine effectiveness.

RESULTS

There is strong evidence for the presence of bias in existing observational estimates of influenza vaccine effectiveness in the elderly and the failure of current adjustment methods to reduce bias.

CONCLUSION

Promising approaches for reducing bias include obtaining more accurate information on confounders, such as functional status, avoiding all-cause death in favor of outcomes, such as pneumonia or influenza-related pneumonia, and evaluating the extent to which bias is reduced by these and other methods using the 'control' period before influenza season.

Self-report adherence measures in chronic illness: retest reliability and predictive validity

BACKGROUND

Patient self-report is a practical method for measuring adherence, but little is known about its optimal use.

OBJECTIVES

To examine the retest reliability and predictive validity of 3 different types of self-report adherence measures among patients with common chronic illnesses.

RESEARCH DESIGN

Correlation and regression analyses of data from an ongoing randomized controlled trial.

SUBJECTS

Patients (N = 415) aged >or=40 years recruited from a primary care network with arthritis, asthma, chronic lung disease, congestive heart failure, depression, and/or diabetes mellitus, plus impairment in >or=1 basic activity and/or a score of >or=4 on the 10-item Center for Epidemiologic Studies Depression Scale.

MEASURES

: Self-report adherence (administered variously at baseline, 2, 4, and 6 weeks, and 6 months): number of pills taken/number of pills prescribed (PT/PP), using 1-7 days recall, and global reports of medication adherence and overall adherence tendencies. Six-month functional outcomes: Health Assessment Questionnaire (HAQ) and Short Form-36 (SF-36).

RESULTS

Correlation coefficients among contemporaneously administered 1-7 days PT/PP measures were >or=0.78. Correlations among PT/PP measures and global adherence measures, and among PT/PP measures at 2 and 4 weeks, ranged from 0.11 to 0.54. PT/PP measures using >or=3-4 days recall significantly predicted adjusted 6-month HAQ but not SF-36 score.

CONCLUSIONS

Self-report PT/PP and general medication adherence measures tap different behavioral constructs. Self-reported PT/PP at a given point in time is not necessarily representative of medication adherence over time. Among chronically ill patients, 3-4 days recall of PT/PP yield adherence estimates, which are practically as reliable and valid as longer intervals and which predict functional outcomes.

Prevalence and cost of nonadherence with antiepileptic drugs in an adult managed care population

PURPOSE

This study assessed the extent of refill nonadherence with antiepileptic drugs (AEDs) and the potential association between AED nonadherence and health care costs in an adult-managed care population.

METHODS

Retrospective claims from the PharMetrics database were analyzed. Inclusion criteria were: age > or =21, epilepsy diagnosis between January 01, 2000 and March 12, 2005, > or =2 AED prescriptions, and continuous health plan enrollment for > or =6 months prior to and > or =12 months following AED initiation. Adherence was evaluated using the medication possession ratio (MPR). Patients with an MPR <0.8 were classified as nonadherent. Multivariate regression was used to assess the effect of AED nonadherence on annualized cost outcomes. Regression covariates included patient demographics, Charlson Comorbidity Index (CCI), and follow-up duration.

RESULTS

Among patients meeting all inclusion criteria (N = 10,892), 58% were female, mean age was 44 years, mean CCI was 0.94, and mean follow-up was 27 months. Mean MPR was 0.78 and 39% of patients were nonadherent. AED nonadherence was associated with an increased likelihood of hospitalization (odds ratio [OR]= 1.110, p = 0.013) and emergency room (ER) admission (OR = 1.479, p < 0.0001), as well as increased inpatient and ER costs of $1,799 and $260 (both p = 0.001), respectively, per patient per year. Outpatient and other ancillary costs were not significantly affected by nonadherence. A large net positive effect of nonadherence on total annual health care costs remained (+$1,466, p = 0.034) despite an offset from reduced prescription drug intake.

DISCUSSION

Adherence with AEDs among adult epilepsy patients is suboptimal and nonadherence appears to be associated with increased health care costs. Efforts to promote AED adherence may lead to cost savings for managed care systems.

Self-reported medication adherence and cardiovascular events in patients with stable coronary heart disease: the heart and soul study

BACKGROUND

Nonadherence to physician treatment recommendations is an increasingly recognized cause of adverse outcomes and increased health care costs, particularly among patients with cardiovascular disease. Whether patient self-report can provide an accurate assessment of medication adherence in outpatients with stable coronary heart disease is unknown.

METHODS

We prospectively evaluated the risk of cardiovascular events associated with self-reported medication nonadherence in 1015 outpatients with established coronary heart disease from the Heart and Soul Study. We asked participants a single question: "In the past month, how often did you take your medications as the doctor prescribed?" Nonadherence was defined as taking medications as prescribed 75% of the time or less. Cardiovascular events (coronary heart disease death, myocardial infarction, or stroke) were identified by review of medical records during 3.9 years of follow-up. We used Cox proportional hazards analysis to determine the risk of adverse cardiovascular events associated with self-reported medication nonadherence.

RESULTS

Of the 1015 participants, 83 (8.2%) reported nonadherence to their medications, and 146 (14.4%) developed cardiovascular events. Nonadherent participants were more likely than adherent participants to develop cardiovascular events during 3.9 years of follow-up (22.9% vs 13.8%, P = .03). Self-reported nonadherence remained independently predictive of adverse cardiovascular events after adjusting for baseline cardiac disease severity, traditional risk factors, and depressive symptoms (hazards ratio, 2.3; 95% confidence interval, 1.3-4.3; P = .006).

CONCLUSIONS

In outpatients with stable coronary heart disease, self-reported medication nonadherence is associated with a greater than 2-fold increased rate of subsequent cardiovascular events. A single question about medication adherence may be a simple and effective method to identify patients at higher risk for adverse cardiovascular events.

Adherence to treatment of osteoporosis: a need for study

Adherence to anti-osteoporosis medications is currently low and is associated with poor anti-fracture efficacy. This manuscript reviews the potential design of clinical studies that aim to demonstrate improved adherence, with new chemical entities to be used in the management of osteoporosis.

INTRODUCTION

Several medications have been unequivocally shown to decrease fracture rates in clinical trials. However, in real life settings, long-term persistence and compliance to anti-osteoporosis medication is poor, hence decreasing the clinical benefits for patients.

METHODS

An extensive search of Medline from 1985 to 2006 retrieved all trials including the keywords osteoporosis, compliance, persistence or adherence followed by a critical appraisal of the data obtained through a consensus expert meeting.

RESULTS

The impact of non-adherence on the clinical development of interventions is reviewed, so that clinicians, regulatory agencies and reimbursement agencies might be better informed of the problem, in order to stimulate the necessary research to document adherence.

CONCLUSION

Adherence to therapy is a major problem in the treatment of osteoporosis. Both patients and medication factors are involved. Adherence studies are an important aspect of outcomes studies, but study methodologies are not well developed at the moment and should be improved. Performing adherence studies will be stimulated when registration authorities accept the result of these studies and include the relevant information in Sect. 5.1 of the summary of product characteristics. Reimbursement authorities might also consider such studies as important information for decisions on reimbursement.

Placebo and nocebo in cardiovascular health: implications for healthcare, research, and the doctor-patient relationship

Despite treatments proven effective by sound study designs and robust end points, placebos remain integral to elicit effective medical care. The authenticity of the placebo response has been questioned, but placebos likely affect pain, functionality, symptoms, and quality of life. In cardiology, placebos influence disability, syncope, heart failure, atrial fibrillation, angina, and survival. Placebos vary in strength and efficacy. Compliance to placebo affects outcomes. Nocebo responses can explain some adverse clinical outcomes. A doctor may be an unwitting contributor to placebo and nocebo responses. Placebo and nocebo mechanisms, not well understood, are likely multifaceted. Placebo and nocebo use is common in practice. A successful doctor-patient relationship can foster a strong placebo response while mitigating any nocebo response. The beneficial effects of placebo, generally undervalued, hard to identify, often unrecognized, but frequently used, help define our profession. The role of the doctor in healing, above the therapy delivered, is immeasurable but powerful. An effective placebo response will lead to happy and healthy patients. Imagine instead the future of healthcare relegated to a series of guidelines, tests, algorithms, procedures, and drugs without the human touch. Healthcare, rendered by a faceless, uncaring army of protocol aficionados, will miss an opportunity to deliver an effective placebo response. Wise placebo use can benefit patients and strengthen the medical profession.

Cognitive and psychiatric predictors of medical treatment adherence among older adults in primary care clinics

OBJECTIVES

Medical treatment non-adherence among older adults is common and represents a significant public health care concern. Treatment non-adherence has been associated with a number of factors in older adults; however few studies have delineated the role of cognition and psychiatric status.

PARTICIPANTS

Data were collected from 212 ethnically diverse older primary care patients as part of a larger study.

MEASUREMENTS

Cognitive status was evaluated with the Mattis Dementia Rating scale (DRS). Psychiatric status was evaluated using the Geriatric Depression Scale (GDS) and the Beck Anxiety Inventory (BAI). Treatment adherence was assessed by the total number of missed healthcare appointments and by physician and patient ratings. Physician ratings of patients' understanding of medical instructions were also obtained.

DESIGN

A series of multiple regression analyses were conducted to determine cognitive and psychiatric predictors for each measure of treatment adherence.

RESULTS

GDS and DRS memory scores were both independent predictors of the total number of missed medical appointments, F(7,55) = 2.34, p = 0.038. GDS score was also shown to be a significant predictor of physician ratings of patients' understanding of medical instructions, F(7,33) = 0.89, p = 0.031. Neither cognitive performance nor psychiatric status was associated with patient or physician ratings of treatment adherence.

CONCLUSIONS

Measures of cognitive functioning and depression severity were supported as predictors of objective measures of treatment adherence but they were not associated with physician or patient ratings of adherence. Patient depression may influence physician ratings of patients' comprehension of medical instructions.

Adherence to cardioprotective medications and mortality among patients with diabetes and ischemic heart disease

BACKGROUND

Patients with diabetes and ischemic heart disease (IHD) are at high risk for adverse cardiac outcomes. Clinical practice guidelines recommend multiple cardioprotective medications to reduce recurrent events. We evaluated the association between cardioprotective medication adherence and mortality among patients with diabetes and IHD.

METHODS

In a retrospective cohort study of 3,998 patients with diabetes and IHD, we evaluated use of ACE inhibitors or angiotensin receptor blockers, beta-blockers, and statin medications. Receipt of cardioprotective medications was based on filled prescriptions. Medication adherence was calculated as the proportion of days covered (PDC) for filled prescriptions. The primary outcome of interest was all-cause mortality.

RESULTS

The majority of patients (92.8%) received at least 1 cardioprotective medication. Patients receiving any medications had lower unadjusted mortality rates compared to patients not receiving any medications (7.9% vs. 11.5%; p = 0.03). In multivariable analysis, receipt of any cardioprotective medication remained associated with lower all-cause mortality (OR 0.65; 95% CI 0.43-0.99). Among patients receiving cardioprotective medications, the majority (80.3%) were adherent (PDC > or = 0.80). Adherent patients had lower unadjusted mortality rates (6.7% vs. 12.1%; p < 0.01). In multivariable analysis, medication adherence remained associated with lower all-cause mortality (OR 0.52; 95% CI 0.39-0.69) compared to non-adherence. In contrast, there was no mortality difference between patients receiving cardioprotective medications who were non-adherent compared to patients not receiving any medications (OR 1.01; 95% CI 0.64-1.61).

CONCLUSION

In conclusion, medication adherence is associated with improved outcomes among patients with diabetes and IHD. Quality improvement interventions are needed to increase medication adherence in order for patients to maximize the benefit of cardioprotective medications.

Persistent depressive symptoms lower aspirin adherence after acute coronary syndromes

BACKGROUND

Even mild depressive symptoms during hospitalization are an independent risk factor for mortality after acute coronary syndromes (ACS). The mortality risk is highest for patients whose depressive symptoms persist after ACS. Low adherence to medications that reduce the risk of subsequent cardiac events may be one of the mechanisms underlying the relationship between persistent depression and risk of ACS recurrence. We compared electronically monitored adherence to aspirin in 3 groups of patients with ACS: persistently depressed, remittent depressed, and persistently nondepressed.

METHODS

Using an electronic device stored in the cap of a pill bottle, we monitored aspirin adherence over a 3-month period in 165 consecutive patients recruited within 1 week of an ACS event. Depressive symptom severity was assessed by using the Beck Depression Inventory at baseline and at 3 months. Adherence was determined by the percentage of days aspirin was taken as prescribed.

RESULTS

Among the patients, 10.5% of nondepressed patients, 9.8% of remittent depressed patients, and 42.1% of persistently depressed patients took aspirin < or of the time (P < .001). Examined a different way, the mean percentage of days that the correct aspirin dosage (1 pill per day for all patients) was taken was significantly lower in the persistently depressed patients (76.1%) than in the remittent depressed (87.4%) and persistently nondepressed (89.5%) patients (P < .01). Remittent depressed patients did not differ from nondepressed patients. Results remained unchanged after controlling for baseline depressive symptom severity and medical comorbidity.

CONCLUSIONS

Poor medication adherence--a potentially modifiable behavior--may contribute to the high mortality risk observed in patients with persistent symptoms of depression after ACS.

Adherence to Medications for the Treatment of Osteoporosis

Although there is a wide variety of osteoporosis medications with varying dosing intervals, adherence to therapies for postmenopausal- or glucocorticoid-induced osteoporosis remains poor. It is associated with long-term consequences, such as increased osteoporotic fractures, including nonvertebral hip fractures. There is a lack of understanding about why patients are not staying on therapy. Potential solutions include newer medications with extended dosing intervals, monitoring, and an open physician-patient relationship.

Economic implications of nonadherence to highly active antiretroviral treatment in HIV patients

Until now, the economic implications of nonadherence to drug therapies have been mostly assessed in a cost perspective and understood as the impact of nonadherence behaviours on the cost-effectiveness ratios of particular therapies. In HIV disease, some modelling approaches have suggested that high adherence levels might improve the cost-effectiveness of highly active antiretroviral treatment regimens. However, there is an urgent need for research directly observing and measuring the costs of nonadherence behaviours. In addition to this cost perspective, the authors argue that the economic impact of nonadherence should also be studied in a microeconomic--patient-oriented--perspective. Major implications of this microeconomic perspective are drawn. First, the microeconomic approach highlights that nonadherence may often be a rational choice of the patient, thus suggesting new ways for improving adherence. Second, it implies that the adherence behaviour can be interpreted as an indicator of patients' subjective valuation of highly active antiretroviral treatment therapies; in particular, higher levels of adherence are associated with higher patient well-being. Third, it shows that the adherence behaviour cannot be regarded as an exogenous variable when the impact of adherence on health outcome or on cost-effectiveness ratios is studied, thus requiring the use of specific statistical or econometric methods.

Prevalence, Predictors, and Outcomes of Premature Discontinuation of Thienopyridine Therapy After Drug-Eluting Stent Placement

Background— Although drug-eluting stents (DES) significantly reduce restenosis, they require 3 to 6 months of thienopyridine therapy to prevent stent thrombosis. The rate and consequences of prematurely discontinuing thienopyridine therapy after DES placement for acute myocardial infarction (MI) are unknown.

Methods and Results— We used prospectively collected data from a 19-center study of MI patients to examine the prevalence and predictors of thienopyridine discontinuation 30 days after DES treatment. We then compared the mortality and cardiac hospitalization rates for the next 11 months between those who stopped and those who continued thienopyridine therapy. Among 500 DES-treated MI patients who were discharged on thienopyridine therapy, 68 (13.6%) stopped therapy within 30 days. Those who stopped were older, less likely to have completed high school or be married, more likely to avoid health care because of cost, and more likely to have had preexisting cardiovascular disease or anemia at presentation. They were also less likely to have received discharge instructions about their medications or a cardiac rehabilitation referral. Patients who stopped thienopyridine therapy by 30 days were more likely to die during the next 11 months (7.5% versus 0.7%, P <0.0001; adjusted hazard ratio=9.0; 95% confidence interval=1.3 to 60.6) and to be rehospitalized (23% versus 14%, P =0.08; adjusted hazard ratio=1.5; 95% confidence interval=0.78 to 3.0).

Conclusions— Almost 1 in 7 MI patients who received a DES were no longer taking thienopyridines by 30 days. Prematurely stopping thienopyridine therapy was strongly associated with subsequent mortality. Strategies to improve the use of thienopyridines are needed to optimize the outcomes of MI patients treated with DES.

Prevalence of depression in survivors of acute myocardial infarction

OBJECTIVES

To assess the prevalence and persistence of depression in patients with acute myocardial infarction (AMI) and the relationship between assessment modality and prevalence.

DATA SOURCES

MEDLINE, Cochrane, CINAHL, PsycINFO, and EMBASE.

REVIEW METHODS

A comprehensive search was conducted in March 2004 to identify original research studies published since 1980 that used a standardized interview or validated questionnaire to assess depression. The search was augmented by hand searching of selected journals from October 2003 through April 2004 and references of identified articles and reviews. Studies were excluded if only an abstract was provided, if not in English, or if depression was not measured by a validated method.

RESULTS

Major depression was identified in 19.8% (95% confidence interval [CI] 19.1% to 20.6%) of patients using structured interviews (N=10,785, 8 studies). The prevalence of significant depressive symptoms based on a Beck Depression Inventory score > or =10 was 31.1% (CI 29.2% to 33.0%; N=2,273, 6 studies), using a Hospital Anxiety and Depression Scale (HADS) score > or =8%, 15.5% (CI 13.2% to 18.0%; N=863, 4 studies), and with a HADS score > or =11%, 7.3% (CI 5.5% to 9.3%; N=830, 4 studies). Although a significant proportion of patients continued to be depressed in the year after discharge, the limited number of studies and variable follow-up times precluded specification of prevalence rates at given time points.

CONCLUSIONS

Depression is common and persistent in AMI survivors. Prevalence varies depending on assessment method, likely reflecting treatment of somatic symptoms.

Depression and medication adherence in outpatients with coronary heart disease: findings from the Heart and Soul Study

BACKGROUND

Depression leads to adverse outcomes in patients with coronary heart disease (CHD). Medication nonadherence is a potential mechanism for the increased risk of CHD events associated with depression, but it is not known whether depression is associated with medication nonadherence in outpatients with stable CHD.

METHODS

We examined the association between current major depression (assessed using the Diagnostic Interview Schedule) and self-reported medication adherence in a cross-sectional study of 940 outpatients with stable CHD.

RESULTS

A total of 204 participants (22%) had major depression. Twenty-eight (14%) of 204 depressed participants reported not taking their medications as prescribed compared with 40 (5%) of 736 nondepressed participants (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.7-4.7; P<.001). Twice as many depressed participants as nondepressed participants (18% vs 9%) reported forgetting to take their medications (OR, 2.4; 95% CI, 1.6-3.8; P<.001). Nine percent of depressed participants and 4% of nondepressed participants reported deciding to skip their medications (OR, 2.2; 95% CI, 1.2-4.2; P = .01). The relationship between depression and nonadherence persisted after adjustment for potential confounding variables, including age, ethnicity, education, social support, and measures of cardiac disease severity (OR, 2.2; 95% CI, 1.2-3.9; P = .009 for not taking medications as prescribed).

CONCLUSIONS

Depression is associated with medication nonadherence in outpatients with CHD. Medication nonadherence may contribute to adverse cardiovascular outcomes in depressed patients.

Adherence to candesartan and placebo and outcomes in chronic heart failure in the CHARM programme: double-blind, randomised, controlled clinical trial

BACKGROUND

Chronic heart failure (CHF) is an important cause of hospital admission and death. Poor adherence to medication is common in some chronic illnesses and might reduce the population effectiveness of proven treatments. Because little is known about adherence in patients with CHF and about the consequences of non-adherence, we assessed the association between adherence and clinical outcome in the CHARM (Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity) programme.

METHODS

CHARM was a double-blind, randomised, controlled clinical trial, comparing the effects of the angiotensin receptor blocker candesartan with placebo in 7599 patients with CHF. Median follow-up was 38 months. The proportion of time patients took more than 80% of their study medication was defined as good adherence and 80% or less as poor adherence. We used a Cox proportional hazards regression model, with adherence as a time-dependent covariate in the model, to examine the association between adherence and mortality in the candesartan and placebo groups.

FINDINGS

We excluded 187 patients because of missing information on adherence. In the time-dependent Cox regression model, after adjustment for predictive factors (demographics, physiological and severity-of-illness variables, smoking history, and number of concomitant medications), good adherence was associated with lower all-cause mortality in all patients (hazard ratio [HR] 0.65, 95% CI 0.57-0.75, p<0.0001). The adjusted HR for good adherence was similar in the candesartan (0.66, 0.55-0.81, p<0.0001) and placebo (0.64, 0.53-0.78, p<0.0001) groups.

INTERPRETATION

Good adherence to medication is associated with a lower risk of death than poor adherence in patients with CHF, irrespective of assigned treatment. This finding suggests that adherence is a marker for adherence to effective treatments other than study medications, or to other adherence behaviours that affect outcome. Understanding these factors could provide an opportunity for new interventions, including those aimed at improving adherence.

Methodological issues in clinical trials of drug and behavior therapies

Trials that compare drug and behavior therapies or evaluate combination therapy raise special methodological issues. This article reviews these methodological issues and, where possible, offers guidelines for addressing them. Sources of bias in the selection and recruitment of participants and in the measurement of treatment outcomes are discussed. In addition, methodological problems presented by the differing structures of behavior and drug therapy, by confounding variables, such as allegiance effects, differential expectations and preferences for drug or behavior therapy, and differential adherence with drug or behavior therapy also are reviewed. Issues in the selection of appropriate control groups are also discussed.