Effect of depression onset on adherence to medication among hypertensive patients: a longitudinal modelling study

Depressive symptoms and non-adherence to treatable cardiovascular risk factors' medications in the CONSTANCES cohort

AIMS

Depression is associated with increased risk of cardiovascular disease (CVD) and the role of poor medical adherence is mostly unknown. We studied the association between depressive symptoms and non-adherence to medications targeting treatable cardiovascular risk factors in the CONSTANCES population-based French cohort.

METHODS AND RESULTS

We used CONSTANCES data linked to the French national healthcare database to study the prospective association between depressive symptoms (assessed at inclusion with the Center for Epidemiological Studies Depression scale) and non-adherence to medications (less than 80% of trimesters with at least one drug dispensed) treating type 2 diabetes, hypertension, and dyslipidaemia over 36 months of follow-up. Binary logistic regression models were adjusted for socio-demographics, body mass index, and personal history of CVD at inclusion. Among 4998 individuals with hypertension, 793 with diabetes, and 3692 with dyslipidaemia at baseline, respectively 13.1% vs. 11.5%, 10.5% vs. 5.8%, and 29.0% vs. 27.1% of those depressed vs. those non-depressed were non-adherent over the first 18 months of follow-up (15.9% vs. 13.6%, 11.1% vs. 7.4%, and 34.8% vs. 36.6% between 19 and 36 months). Adjusting for all covariates, depressive symptoms were neither associated with non-adherence to medications for hypertension, diabetes, and dyslipidaemia over the first 18 months of follow-up, nor afterwards. Depressive symptoms were only associated with non-adherence to anti-diabetic medications between the first 3-6 months of follow-up.

CONCLUSION

Non-adherence to medications targeting treatable cardiovascular risk factors is unlikely to explain much of the association between depressive symptoms and CVD at a population level. Clinicians are urged to search for and treat depression in individuals with diabetes to foster medications adherence.

Factors Associated With Medication Adherence in Vascular Surgery Patients

INTRODUCTION

Patients with vascular disease have higher mortality rates than age-matched peers and medical management of coexisting diseases may alter these outcomes. We sought to understand factors associated with medication nonadherence in vascular surgery patients at a single University vascular surgery clinic over a 3-month period.

MATERIALS AND METHODS

Consecutive vascular surgery patients were surveyed from June to August 2019. The survey included demographic questions, the validated Morisky Medication Adherence Scale, the 4-item Patient Health Questionnaire for Anxiety and Depression scales, and other medication-related questions. Medical and surgical histories were retrospectively collected from charts. Univariate and multivariate analyses were used to compare among high, intermediate, and low adherence.

RESULTS

A total of 128 (74%) of 174 patients met study inclusion criteria. On univariate analysis, lower medication adherence was associated with younger age (P = .004), anxiety and depression (P = .001), higher daily pain (P < .001), and patients who believed their medications were less important for treating their vascular disease (P < .001). Adherence was not associated with symptomatic vascular disease, gender, education level, marital status, employment, insurance, or the use of medication usage reminders. Multivariate analysis significantly predicted high adherence relative to low adherence with 5-year increase in age (odds ratio [OR] = 1.252, P = .021) and low adherence relative to high adherence with greater perceived pain (OR = 0.839, P = .016).

CONCLUSIONS

Younger age and high level of pain were associated with lower medication adherence. Informing patients of the importance of prescribed medication and addressing anxiety or depression symptoms may improve adherence.

Depression among Peruvian adults with hypertension and diabetes: Analysis of a national survey

BACKGROUND AND AIMS

Hypertension and diabetes are global health problems with an incidence that is rapidly increasing worldwide. Depression is the most frequent mental health co-morbidity and is considered an important risk factor for the development of both diseases. This study aimed to determine the prevalence and factors associated with depression among Peruvian adults with hypertension and diabetes.

METHODS

We performed a secondary analysis of the 2017 Peru Demographic and Family Health Survey, using data from 10,566 adults aged 40 and older. The main outcome was depression assessed with the Patient Health Questionnaire-9 (PHQ-9). Other important variables were the diagnosis of hypertension or diabetes, sex, age, level of education, geographical region, wealth index, daily smoking, harmful alcohol consumption and physical disability.

RESULTS

The overall prevalence of depression was 23.15% (CI 95%: 21.42%-24.88%) and among adults with hypertension and diabetes it was 34.96% (CI 95%: 29.33%-40.59%) and 35.56% (CI 95%: 24.49%-46.63%), respectively. Whereas the prevalence of depression among adults with type 2 diabetes mellitus (T2DM) was higher in the physical disability group (PRa: 1.28; CI 95%: 1.12-1.45), the prevalence of depression among adults with hypertension was higher in the female group (PRa: 1.36; CI 95%: 1.20-1.54) and among those with harmful alcohol consumption (PRa: 1.50; CI 95%: 1.01-2.24).

CONCLUSION

Peru has a considerable burden of depression in the hypertensive and diabetic populations. While the variables positively associated with depression in hypertensive adults were female gender and harmful alcohol consumption, in adults with diabetes it was the presence of physical disability.

Drug exposure in register-based research-An expert-opinion based evaluation of methods

Background

In register-based pharmacoepidemiological studies, construction of drug exposure periods from drug purchases is a major methodological challenge. Various methods have been applied but their validity is rarely evaluated. Our objective was to conduct an expert-opinion based evaluation of the correctness of drug use periods produced by different methods.

Methods

Drug use periods were calculated with three fixed methods: time windows, assumption of one Defined Daily Dose (DDD) per day and one tablet per day, and with PRE2DUP that is based on modelling of individual drug purchasing behavior. Expert-opinion based evaluation was conducted with 200 randomly selected purchase histories of warfarin, bisoprolol, simvastatin, risperidone and mirtazapine in the MEDALZ-2005 cohort (28,093 persons with Alzheimer’s disease). Two experts reviewed purchase histories and judged which methods had joined correct purchases and gave correct duration for each of 1000 drug exposure periods.

Results

The evaluated correctness of drug use periods was 70–94% for PRE2DUP, and depending on grace periods and time window lengths 0–73% for tablet methods, 0–41% for DDD methods and 0–11% for time window methods. The highest rate of evaluated correct solutions for each method class were observed for 1 tablet per day with 180 days grace period (TAB_1_180, 43–73%), and 1 DDD per day with 180 days grace period (1–41%). Time window methods produced at maximum only 11% correct solutions. The best performing fixed method TAB_1_180 reached highest correctness for simvastatin 73% (95% CI 65–81%) whereas 89% (95% CI 84–94%) of PRE2DUP periods were judged as correct.

Conclusions

This study shows inaccuracy of fixed methods and the urgent need for new data-driven methods. In the expert-opinion based evaluation, the lowest error rates were observed with data-driven method PRE2DUP.

Long-term patterns of adherence to medication therapy among patients with type 2 diabetes mellitus in Denmark: The importance of initiation

AIMS

Poor adherence to medication therapy among type 2 diabetes patients is a clinical challenge. We aimed to determine which factors are associated with the three phases of long-term adherence to medication: initiation, implementation and discontinuation in a register-based study.

METHODS

Adherence to six medicine groups (metformin, sulfonylureas, acetylsalicylic acid, thiazide diuretics, renin angiotensin system inhibitors, and statins) were analysed among 5,232 patients with type 2 diabetes at a tertiary referral hospital during 1998-2009. Rate-ratios of initiation of treatment, recurrent gaps in supply of medication, and discontinuation of treatment were analysed using Poisson regression.

RESULTS

Poor initiation rather than poor implementation or discontinuation was the main contributor to medication nonadherence. Polypharmacy was a risk factor for slower initiation of treatment for all six medicine groups (rate ratio ranging 0.79 95%CI [0.72-0.87] to 0.89 95%CI [0.82-0.96] per already prescribed medicine), but once patients were in treatment, polypharmacy was not associated with recurrence of gaps in supply of medication, and polypharmacy was associated with lower risk of discontinuation (rate ratio ranging 0.93 95%CI [0.86-1.00] to 0.96 95%CI [0.93-0.99] per prescribed medicine). Other identified risk factors for slow initiation, poor implementation, and discontinuation were diabetes duration, younger age, and Turkish/Pakistani origin.

DISCUSSION

This study showed that a risk factor does not necessarily have the same association with all three elements of adherence (initiation, implementation and discontinuation), and that efforts supporting patients introduced to more complex drug combinations should be prioritized.

Preventive Interventions for the Second Half of Life: A Systematic Review

OBJECTIVE

Recent improvements in life expectancy globally require intensified focus on noncommunicable diseases and age-related conditions. The purpose of this article is to inform the development of age-specific prevention guidelines for adults aged 50 and above, which are currently lacking.

DATA SOURCE

PubMed, Cochrane database, and Google Scholar and explicit outreach to experts in the field.

STUDY INCLUSION AND EXCLUSION CRITERIA

Meta-analyses, intervention-based, and prospective cohort studies that reported all-cause mortality, disease-specific mortality, or morbidity in adults were included.

DATA EXTRACTION

A systematic review was undertaken in 2015 using search terms of a combination of <risk factor> and "intervention," "mortality," "reduction," "improvement," "death," and "morbidity."

DATA SYNTHESIS

Interventions were categorized according to the Center for Evidence-Based Medicine Level of Evidence framework.

RESULTS

A summary table reports for each intervention the impact, strength of evidence, initiation, duration, and details of the intervention. Age-decade-specific preventive recommendations have been proposed relating to physical activity, diet, tobacco and alcohol use, medication adherence, screening and vaccination, and mental and cognitive health.

CONCLUSION

Clear recommendations have been made according to the existing evidence base, but further research investment is needed to fill the many gaps. Further, personalized approaches to healthy aging complemented by population-wide approaches and broader cross-sector partnerships will help to ensure greater longevity is an opportunity, rather than a burden, for society.

Influence of Retirement on Adherence to Statins in the Insurance Medicine All-Sweden Total Population Data Base

Background

Retirement has been suggested to reduce medication adherence, but no evidence is available for statins. We investigated changes in adherence to statins among Swedish adults after retirement.

Methods

A prospective cohort study was carried out on all individuals living in Sweden on 31 December 2004, alive in 2010, having purchased statins in the second half of 2005, and retired in 2008 (n=11 718). We used prescription dispensing data in 2006–2010 to determine nonadherence (defined as <80% of days covered by filled prescriptions) before and after old-age or disability retirement. Using multiple repeat measurements of filled statin prescriptions, we calculated the annual prevalence rates of nonadherence for those who continued therapy. Discontinuation was defined as no statin dispensations during a calendar year.

Results

After adjustment for age at retirement, the prevalence ratio (PR) of nonadherence after retirement in comparison with those before retirement was 1.23 [95% confidence interval (CI) 1.17–1.29] for the men and 1.19 (95% CI 1.13–1.26) for the women. A post-retirement increase in nonadherence was consistently observed across the strata of age at retirement, marital status, education, income, type of retirement, and participants with and without cardiovascular disease, the largest increases being observed for statin use in secondary prevention (men: PR 1.38, 95% CI 1.26–1.54; women: PR 1.43, 1.18–1.72). For primary prevention, the corresponding prevalence ratios were 1.18 (95% CI 1.13‒1.25) and 1.18 (95% CI 1.11–1.24), respectively.

Interpretation

Retirement appears to be associated with increased nonadherence to statin therapy among Swedish men and women.

Childhood adversity as a predictor of non-adherence to statin therapy in adulthood

Purpose

To investigate whether adverse experiences in childhood predict non-adherence to statin therapy in adulthood.

Methods

A cohort of 1378 women and 538 men who initiated statin therapy during 2008–2010 after responding to a survey on childhood adversities, was followed for non-adherence during the first treatment year. Log-binomial regression was used to estimate predictors of non-adherence, defined as the proportion of days covered by dispensed statin tablets <80%. In fully adjusted models including age, education, marital status, current smoking, heavy alcohol use, physical inactivity, obesity, presence of depression and cardiovascular comorbidity, the number of women ranged from 1172 to 1299 and that of men from 473 to 516, because of missing data on specific adversities and covariates.

Results

Two in three respondents reported at least one of the following six adversities in the family: divorce/separation of the parents, long-term financial difficulties, severe conflicts, frequent fear, severe illness, or alcohol problem of a family member. 51% of women and 44% of men were non-adherent. In men, the number of childhood adversities predicted an increased risk of non-adherence (risk ratio [RR] per adversity 1.11, 95% confidence interval [CI] 1.01–1.21], P for linear trend 0.013). Compared with those reporting no adversities, men reporting 3–6 adversities had a 1.44-fold risk of non-adherence (95% CI 1.12–1.85). Experiencing severe conflicts in the family (RR 1.27, 95% CI 1.03–1.57]) and frequent fear of a family member (RR 1.27, 95% CI 1.00–1.62]) in particular, predicted an increased risk of non-adherence. In women, neither the number of adversities nor any specific type of adversity predicted non-adherence.

Conclusions

Exposure to childhood adversity may predict non-adherence to preventive cardiovascular medication in men. Usefulness of information on childhood adversities in identification of adults at high risk of non-adherence deserves further research.

Return to work after depression-related absence by employees with and without other health conditions: a cohort study

OBJECTIVE

Among employees with depression, diagnoses of other psychiatric and somatic conditions are common. However, few studies have examined whether the combined presence of depression and other psychiatric or somatic disorders adversely affects return to work after depression-related absence from work.

METHODS

We examined the association of present and recent psychiatric and somatic conditions and return to work after depression-related absence in a cohort of 9908 Finnish public sector employees with at least one such episode. The data included a total of 14,101 episodes during the period January 2005 to December 2011.

RESULTS

A total of 89% (n = 12,486) of depression-related absence episodes ended in return to work during the follow-up. For those episodes, the median length of absence was 34 days (interquartile range, 20-69 days). After adjustment for sex, age, socioeconomic status, and type of employment contract, present or recent psychiatric disorders other than depression (hazard ratio [HR] = 0.78, 95% confidence interval [CI] = 0.74-0.83), cancer (HR = 0.66, 95% CI = 0.47-0.92), diabetes (HR = 0.73, 95% CI = 0.62-0.86), cardiovascular disease (HR = 0.78, 95% CI = 0.62-0.99), hypertension (HR = 0.76, 95% CI = 0.67-0.85), musculoskeletal disorders (HR = 0.82, 95% CI = 0.77-0.87), and asthma (HR = 0.84, 95% CI = 0.75-0.94) were all associated with a lower likelihood of returning to work compared with depression episodes without other conditions.

CONCLUSIONS

Among employees with depression-related absence, return to work is delayed in the presence of other psychiatric and somatic conditions. These findings suggest that other diseases should be taken into account when evaluating the outcome of depression-related absence. Randomized controlled trials are needed to examine whether integrated treatment of mental and physical disorders improves successful return to work after depression.

Extent and reasons for nonadherence to antihypertensive, cholesterol, and diabetes medications: the association with depressive symptom burden in a sample of American veterans

OBJECTIVE

Persons with depressive symptoms generally have higher rates of medication nonadherence than persons without depressive symptoms. However, little is known about whether this association differs by comorbid medical condition or whether reasons for nonadherence differ by depressive symptoms or comorbid medical condition.

METHODS

Self-reported extent of nonadherence, reasons for nonadherence, and depressive symptoms among 1,026 veterans prescribed medications for hypertension, dyslipidemia, and/or type 2 diabetes were assessed.

RESULTS

In multivariable logistic regression adjusted for clinical and demographic factors, the odds of nonadherence were higher among participants with high depressive symptom burden for dyslipidemia (n=848; odds ratio [OR]: 1.42, P=0.03) but not hypertension (n=916; OR: 1.24, P=0.15), or type 2 diabetes (n=447; OR: 1.15, P=0.51). Among participants reporting nonadherence to antihypertensive and antilipemic medications, those with greater depressive symptom burden had greater odds of endorsing medication nonadherence reasons related to negative expectations and excessive economic burden. Neither extent of nonadherence nor reasons for nonadherence differed by depressive symptom burden among patients with diabetes.

CONCLUSION

These findings suggest that clinicians may consider tailoring interventions to improve adherence to antihypertensive and antilipemic medications to specific medication concerns of participants with depressive symptoms.

Incident depression increases medical utilization in Medicaid patients with hypertension

Hypertension is an important risk factor for cardiovascular disease and occurs disproportionately among patients with depression. Few studies have rigorously examined outcomes specifically among hypertensive patients with newly diagnosed comorbid depression.

AIM

We hypothesized that incident depression would exacerbate hypertensive disease and that this would be evident through greater utilization of medical services than would otherwise occur in the absence of depression.

METHODS

Claims data for hypertensive patients enrolled in Maryland Medicaid (2005-2010) were used to estimate the change in annualized utilization following incident depression, compared to a matched cohort of hypertensive patients never diagnosed with depression. Multivariate regression was used to adjust for changes in antihypertensive medications, adherence and comorbidity that followed depression onset.

RESULTS

While medical utilization increased after incident depression, additional encounters tended to be for nonacute medical care and there was no significant increase in encounters specifically for cardiovascular or hypertension-related conditions.

DISCUSSION

The results contribute to the discussion on the relationship between depression and cardiovascular disease and will inform future studies that aim to look at longer term outcomes in patients with hypertension.

Patient-level medication regimen complexity in older adults with depression

PURPOSE

Polypharmacy and medication adherence are well known challenges facing older adults. Medication regimen complexity increases the demands of self-care in the home. Some medication regimens may be more complex than others, especially when dosage form, frequency of dosing, and additional usage directions are included in complexity along with the number of medications In older adults with depression, it is unknown what features of their medications most influence their medication regimen complexity.

METHODS

A sample cohort of 100 adults ≥65 years old with a diagnosis of depression was randomly selected from electronic medical records (EMR) in ambulatory clinics at the University of Colorado (CU) and University of San Diego (SD). Demographic, medical history, and medication-related information was extracted from the EMR. Complexity was determined using the Medication Regimen Complexity Index (MRCI). IRB approval was obtained.

FINDINGS

The cohort mean age was 74.3 years (SD) and 79.7 years (CU). The mean unweighted Charlson comorbidity index for 1.0 (SD) and 1.8 (CU). The mean number of medications was 7.1 and 8.0, with 1.1 and 1.2 depression meds, 5.4 and 4.3 non-depression prescription meds, and 0.6 and 2.4 OTC meds for the SD and CU cohorts, respectively. 66% of SD adults and 70% of CU adults took six or more meds. Individual MRCI scores were on average 17.62 (SD) and 19.36 (CU). Dosing frequency contributed to 57-58% of the MRCI score, with patients facing an average of 7-8 unique dosing frequencies in their regimen. In both cohorts, there was an average of 3 additional directions added to the regimens to clarify dosing.

IMPLICATIONS

As expected, in our older adult cohorts with depression the majority of patients took multiple medications. Using a standardized instrument, we characterized the regimen complexity and found that it was increasingly complex due to numerous dosing forms, frequencies and additional directions for use. Patient-level medication regimen complexity should go beyond depression medication to encompass the patient's entire regimen for opportunities to reduce complexity and improve ease of self-care.

Lifestyle factors as predictors of nonadherence to statin therapy among patients with and without cardiovascular comorbidities

BACKGROUND

Easily detectable predictors of nonadherence to long-term drug treatment are lacking. We investigated the association between lifestyle factors and nonadherence to statin therapy among patients with and without cardiovascular comorbidities.

METHODS

We included 9285 participants from the Finnish Public Sector Study who began statin therapy after completing the survey. We linked their survey data with data in national health registers. We used prescription dispensing data to determine participants' nonadherence to statin therapy during the first year of treatment (defined as < 80% of days covered by filled prescriptions). We used logistic regression to estimate the association of several lifestyle factors with nonadherence, after adjusting for sex, age and year of statin initiation.

RESULTS

Of the participants without cardiovascular comorbidities (n = 6458), 3171 (49.1%) were nonadherent with their statin therapy. Obesity (adjusted odds ratio [OR] 0.86, 95% confidence interval [CI] 0.74-0.99), overweight (adjusted OR 0.88, 95% CI 0.79-0.98) and former smoking (adjusted OR 0.82, 95% CI 0.74-0.92) predicted a reduced risk of nonadherence in this group after adjustment for sex, age and year of statin initiation. Of the participants with cardiovascular comorbidities (n = 2827), 1155 (40.9%) were nonadherent. In this group, high alcohol consumption (adjusted OR 1.55, 95% CI 1.12-2.15), extreme drinking occasions (adjusted OR 1.48, 95% CI 1.11-1.97) and a cluster of 3-4 lifestyle risks (adjusted OR 1.61, 95% CI 1.15-2.27) predicted increased odds of nonadherence after adjustment for sex, age and year of statin initiation.

INTERPRETATION

People with cardiovascular comorbidities who had risky drinking behaviours or a cluster of lifestyle risks were at increased risk of nonadherence. Among individuals without cardiovascular comorbidities, information on lifestyle factors was unhelpful in identifying those at increased risk of nonadherence; that overweight, obesity and former smoking were predictors of better adherence in this group provides insight into mechanisms of adherence to preventive medication that deserve further study.

Initial persistence with antihypertensive therapies is associated with depression treatment persistence, but not depression

The purpose of this study was to examine the relationship between the presence of clinical depression and persistence to drug therapy treatment for depression with early nonpersistence to antihypertensive therapies in a large, diverse cohort of newly treated hypertension patients. Using a hypertension registry at Kaiser Permanente Northern California, the authors conducted a retrospective cohort study of 44,167 adults (18 years and older) with hypertension who were new users of antihypertensive therapy in 2008. We used multivariate logistic regression analysis to model the relationships between the presence of clinical depression and early nonpersistence (defined as failing to refill the first prescription within 90 days after the end of the first fill days' supply) to antihypertensive therapies, controlling for sociodemographic and clinical risk factors. Within the group of 1484 patients who had evidence of clinical depression in the 12 months prior to the initiation of antihypertensive therapy, the authors examined the relationship between drug therapy treatment for depression and 6-month persistence with antidepressant therapy with early nonpersistence with antihypertensive therapies. No association was found between the presence of clinical depression and early nonpersistence to antihypertensive therapies after adjustment for individual demographic and clinical characteristics and neighborhood-level socioeconomic status. However, among the subset of 1484 patients with documented evidence of clinical depression in the 12 months prior to the initiation of antihypertensive therapy, being prescribed and persistence with antidepressant therapy was strongly associated with lower odds of early nonpersistence to antihypertensive medications (odds ratio, 0.64; confidence interval, 0.42-0.96). In an integrated delivery system, the authors found that treatment for depression was associated with higher levels of antihypertensive persistence. Improving quality of depression care in patients with comorbid hypertension may be an important strategy in decreasing cardiovascular disease risk in these patients.

Exploring the impact of elevated depressive symptoms on the ability of a tailored asthma intervention to improve medication adherence among urban adolescents with asthma

BACKGROUND

In patients with asthma, medication adherence is a voluntary behavior that can be affected by numerous factors. Depression is an important co-morbidity in adolescents with asthma that may significantly impact their controller medication adherence and other asthma-related outcomes. The modifying effect of depressive symptoms on an asthma intervention's ability to improve asthma controller medication adherence among urban adolescents with asthma has not yet been reported.

OBJECTIVE

To assess self-reported symptoms of depression as an effect modifier of the relationship between randomization group and controller medication adherence at 6-month follow-up.

METHODS

These analyses use data from a randomized controlled trial (RCT) conducted in Detroit high schools to evaluate a tailored asthma management program. The intervention included referrals to school or community resources for students reporting symptoms of depression and other issues. "Elevated depressive symptoms" was defined as a positive answer to ≥ 5 of 7 questions from a validated tool included on the baseline questionnaire. Self-reported adherence to controller medication was collected at intervention onset (session 1) and at 6-month follow up. Analyses were restricted to students with report of a controller medication at baseline. Logistic regression was used to assess elevated depressive symptoms as an effect modifier of the relationship between randomization group and 6-month adherence.

RESULTS

Of the 422 students enrolled in the RCT, a controller medication was reported at intervention onset by n = 123 adolescents (29%). Analyzing this group, we observed an interaction between elevated depressive symptoms and adherence (p = 0.073). Stratified analysis showed better adherence in treatment group adolescents meeting criteria for elevated depressive symptoms at baseline as compared to the control group (adjusted Odds Ratio [aOR] = 9.50; p = 0.024). For adolescents without elevated depressive symptoms at baseline, differences in adherence by group assignment did not reach statistical significance (aOR 1.40, p = 0.49).

CONCLUSIONS

In this sample of students reporting controller medications at baseline, report of elevated depressive symptoms at baseline and randomization to the intervention group was associated with significantly better adherence at 6-month follow up when compared to that of a control group. Larger studies are needed to evaluate the impact of depression on the relationship between adherence and asthma intervention effectiveness.