Compliance with antidepressant therapy and antidepressant discontinuation symptoms

Impact of trazodone once-a-day on quality of life and functional recovery in adults with major depressive disorder: A prospective, observational study

BACKGROUND

Health-related quality of life (HRQL) is an important goal for patients with major depressive disorder (MDD), but whether antidepressants improve HRQL in these patients is unclear. Here, we describe the real-world effects of trazodone once-a-day (TzOAD) and selective serotonin reuptake inhibitor (SSRI) treatments on HRQL and functioning in adults with MDD.

METHODS

This 8-week prospective, observational, open-label, multicenter study was conducted in adults with moderate or severe MDD for whom TzOAD or SSRI were prescribed as monotherapy. The primary outcome was life enjoyment and satisfaction assessed via the patient-reported Quality-of-Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q-SF) from baseline to week 8. Secondary outcomes included change in Q-LES-Q-SF from baseline to weeks 1 and 2; severity of depressive symptoms using the Montgomery Åsberg Depression Rating Scale (MADRS) and sleep disturbance via the PROMIS SF-SD 8b questionnaire at weeks 1, 2, and 8; and overall functioning via the Sheehan Disability Scale (SDS), hedonic capacity using the Snaith-Hamilton Pleasure Scale (SHAPS), and cognitive dysfunction using the Perceived Deficits Questionnaire (PDQ-5) at baseline and week 8.

RESULTS

The study included 208 adults with MDD (mean [SD] age = 50.2 [14.3] years; 68.6% female; 98.4% White). Life enjoyment and satisfaction improved from baseline to week 8 for both treatment groups: Q-LES-Q-SF mean (SD) scores were 27.5 (20.4) for the SSRI group and 39.0 (22.1) for the TzOAD group. Depressive symptoms and sleep disturbances also reduced from baseline to week 8: MADRS (SSRI, -15.7 [8.3]; TzOAD, -21.0 [9.8]); PROMIS SF-SD 8b (SSRI, -9.9 [12.6]; TzOAD, -22.0 [12.6]). Mean change scores in Q-LES-Q-SF, MADRS, and PROMIS SF-SD 8b improved as early as week 1 in both groups. Mean scores also improved from baseline to week 8 on SDS (SSRI, -9.2 [7.4]; TzOAD, -14.3 [7.5]), SHAPS (SSRI, -6.6 [4.3]; TzOAD, -8.3 [4.4]), and PDQ-5 (SSRI, -5.8 [4.5]; TzOAD, -7.7 [5.0]).

CONCLUSIONS

In adults with MDD who received TzOAD or SSRIs, overall and individual HQRL domains improved rapidly and in parallel with improvements in depressive symptoms, with a slightly greater improvement observed in the TzOAD group.

Treatment Non-adherence Patterns Among Patients With Mental Illness: A Study From the District Mental Health Care Center in India

INTRODUCTION

The success of any medical intervention, including mental health treatment, depends largely on patient adherence to the prescribed regimen. In psychiatric illnesses, one of the biggest problems is getting people to adhere to their treatment schedule, representing a treatment gap that increases the burdens of patients, families, communities, and countries. Globally, it has become necessary for community health organizations to actively work towards reducing this gap and treatment non-adherence. Therefore, in this study, we aimed to examine treatment non-adherence patterns among patients with mental illness.

MATERIALS AND METHODS

This work used a retrospective study design and consecutive sampling. The data source was secondary data obtained from the healthcare records of patients registered in the outpatient department of the District Mental Health Care Center, India, from January 2022 to December 2022.

RESULTS

Out of a total of 883 patients recruited for the study, 35.7% (n=315) were on regular follow-up over a duration of more than one year. Among patients with severe mental illness, 46% (n=46) had regular follow-ups and were compliant with therapy. About 49% of patients (n=433) discontinued their treatment after the initial contact with the therapist, with the highest rate among those with substance use disorders (77.0%; n=57). The remaining 15.3% (n=135) of recruited patients discontinued their follow-up appointments over a duration of 1 week to 12 months. Overall, 64.3% (n=568) of the recruited patients discontinued their treatment within one year.

CONCLUSION

There was considerable early treatment dropout among patients with mental illness. However, this treatment discontinuation can be avoided because the individual identities of these patients are well-known to the therapist or facility, as they have had at least one interaction with the therapist. In order to improve treatment adherence, patients with mental illnesses must receive consistent support through community outreach programs, home visits, and new strategies to promote treatment compliance.

Magnitude and factors associated with treatment non-adherence among patients with depressive disorders at St. Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia, 2019: A cross sectional study

Background

Inadequate adherence to treatment is among the main underlying causes of depression becoming a chronic problem. In developing countries due to limited access to health care, inaccurate diagnoses, and scarcity of medications, poor adherence may become an even larger obstacle in the treatment of depression. The current study aims to assess the magnitude and factors related to treatment non-adherence among patients with depressive disorders.

Objective

To assess the magnitude and factors associated with treatment non adherence among patients with depressive disorders at St. Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia, 2019.

Methods

A hospital-based cross-sectional study was conducted among 415 respondents using systematic random sampling technique. Medication adherence was assessed by using Medication Adherence Rating Scale. Data was entered to Epi-data version 3.1 and analyzed using SPSS version 20. Binary logistic analysis was done and P-values less than 0.05 were considered statistically significant.

Results

The prevalence of treatment non-adherence among patients with depressive disorders was 26% (95%CI; 21.2, 32.5). Previous suicide attempt (AOR = 3.05, 95%CI; 1.82, 5.12), medication side effects (AOR = 2.46, 95%CI; 1.47, 4.11), moderate to high self-stigma (AOR = 2.60, 95%CI; 1.45, 4.66), and poor quality of life (AOR = 2.47, 95%CI; 1.42, 4.28) were significantly associated with treatment non-adherence among patients with depressive disorders.

Conclusion and recommendation

Treatment non-adherence is a common problem among patients being treated for depressive disorders. Previous suicide attempts, medication side effects, moderate to high self-stigma, and poor quality of life were significantly associated with treatment non-adherence. Appropriate interventions should be developed to promote measures to facilitate adherence in this group of patients, and address the associated factors when applicable.

Measuring and reporting treatment adherence: What can we learn by comparing two respiratory conditions?

Medication non-adherence, defined as any deviation from the regimen recommended by their healthcare provider, can increase morbidity, mortality and side effects, while reducing effectiveness. Through studying two respiratory conditions, asthma and tuberculosis (TB), we thoroughly review the current understanding of the measurement and reporting of medication adherence. In this paper, we identify major methodological issues in the standard ways that adherence has been conceptualised, defined and studied in asthma and TB. Between and within the two diseases there are substantial variations in adherence reporting, linked to differences in dosing intervals and treatment duration. Critically, the communicable nature of TB has resulted in dose-by-dose monitoring becoming a recommended treatment standard. Through the lens of these similarities and contrasts, we highlight contemporary shortcomings in the generalised conceptualisation of medication adherence. Furthermore, we outline elements in which knowledge could be directly transferred from one condition to the other, such as the application of large-scale cost-effective monitoring methods in TB to resource-poor settings in asthma. To develop a more robust evidence-based approach, we recommend the use of standard taxonomies detailed in the ABC taxonomy when measuring and discussing adherence. Regimen and intervention development and use should be based on sufficient evidence of the commonality and type of adherence behaviours displayed by patients with the relevant condition. A systematic approach to the measurement and reporting of adherence could improve the value and generalisability of research across all health conditions.

Metabolomics in Psychiatric Disorders: What We Learn from Animal Models

Biomarkers are a recent research target within biological factors of psychiatric disorders. There is growing evidence for deriving biomarkers within psychiatric disorders in serum or urine samples in humans, however, few studies have investigated this differentiation in brain or cerebral fluid samples in psychiatric disorders. As brain samples from humans are only available at autopsy, animal models are commonly applied to determine the pathogenesis of psychiatric diseases and to test treatment strategies. The aim of this review is to summarize studies on biomarkers in animal models for psychiatric disorders. For depression, anxiety and addiction disorders studies, biomarkers in animal brains are available. Furthermore, several studies have investigated psychiatric medication, e.g., antipsychotics, antidepressants, or mood stabilizers, in animals. The most notable changes in biomarkers in depressed animal models were related to the glutamate-γ-aminobutyric acid-glutamine-cycle. In anxiety models, alterations in amino acid and energy metabolism (i.e., mitochondrial regulation) were observed. Addicted animals showed several biomarkers according to the induced drugs. In summary, animal models provide some direct insights into the cellular metabolites that are produced during psychiatric processes. In addition, the influence on biomarkers due to short- or long-term medication is a noticeable finding. Further studies should combine representative animal models and human studies on cerebral fluid to improve insight into mental disorders and advance the development of novel treatment strategies.

Psychobiotics as treatment for anxiety, depression, and related symptoms: a systematic review

Objective: Altering the gut microflora may produce health benefits in individuals suffering from mood disorders. The purpose of this review was to evaluate the efficacy of probiotics, prebiotics, or synbiotics as a potential treatment for symptoms of depression, anxiety, and stress (as psychobiotics).Methods: Google Scholar, PubMed, PsychINFO, and Web of Science were utilized to identify and evaluate studies through October 31, 2019. Studies were included if subjects were evaluated for altered mood or stress levels at start of the study and consumed probiotics, prebiotics, and/or synbiotics for intervention.Results: Search results yielded 142 articles, while only 12 studies met all inclusion criteria. Nine of the 12 studies identified evaluated the efficacy of various probiotic strains, while only two evaluated synbiotics and one evaluated prebiotics. Six out of 12 studies found probiotics to reduce depression, while two studies found probiotics to reduce anxiety.Discussion: Translational research in this field is limited and further investigation of the efficacy of psychobiotics in mood disorders is warranted.

Antidepressant utilisation and incidence of weight gain during 10 years' follow-up: population based cohort study

OBJECTIVE

To evaluate the long term association between antidepressant prescribing and body weight.

DESIGN

Population based cohort study.

SETTING

General practices contributing to the UK Clinical Practice Research Datalink, 2004-14.

PARTICIPANTS

136 762 men and 157 957 women with three or more records for body mass index (BMI).

MAIN OUTCOME MEASURES

The main outcomes were antidepressant prescribing, incidence of ≥5% increase in body weight, and transition to overweight or obesity. Adjusted rate ratios were estimated from a Poisson model adjusting for age, sex, depression recording, comorbidity, coprescribing of antiepileptics or antipsychotics, deprivation, smoking, and advice on diet.

RESULTS

In the year of study entry, 17 803 (13.0%) men and 35 307 (22.4%) women with a mean age of 51.5 years (SD 16.6 years) were prescribed antidepressants. During 1 836 452 person years of follow-up, the incidence of new episodes of ≥5 weight gain in participants not prescribed antidepressants was 8.1 per 100 person years and in participants prescribed antidepressants was 11.2 per 100 person years (adjusted rate ratio 1.21, 95% confidence interval 1.19 to 1.22, P<0.001). The risk of weight gain remained increased during at least six years of follow-up. In the second year of treatment the number of participants treated with antidepressants for one year for one additional episode of ≥5% weight gain was 27 (95% confidence interval 25 to 29). In people who were initially of normal weight, the adjusted rate ratio for transition to overweight or obesity was 1.29 (1.25 to 1.34); in people who were initially overweight, the adjusted rate ratio for transition to obesity was 1.29 (1.25 to 1.33). Associations may not be causal, and residual confounding might contribute to overestimation of associations.

CONCLUSION

Widespread utilisation of antidepressants may be contributing to long term increased risk of weight gain at population level. The potential for weight gain should be considered when antidepressant treatment is indicated.

A Comparison of Sexual Side Effects of Antidepressants With and Without Naltrexone

OBJECTIVE

The aim of the study was to compare the rate of sexual side effects of the selective serotonin reuptake inhibitor paroxetine versus the tricyclic antidepressant desipramine and to examine the effect of co-prescription of naltrexone on sexual side effects among participants in a randomized clinical trial.

METHODS

This was a secondary analysis (N = 88) of veterans who participated in a 12-week trial. All veterans were randomized into one of four treatment groups: (a) desipramine/naltrexone, (b) desipramine/placebo, (c) paroxetine/naltrexone, and (d) paroxetine/placebo. The main outcome measure was the frequency of sexual side effects consisting of "decreased sex drive" and/or "impotence" reported by veterans at each weekly visit.

RESULTS

Approximately 61% of the veterans reported sexual side effects at least once during the trial, and 26.4% reported sexual side effects throughout the study. There were no significant differences in the frequency of sexual side effects among the four treatment groups. The results were similar when the comparison was made between the two antidepressant groups. There were no significant differences in the reporting of sexual side effects between those receiving desipramine and paroxetine. Also, the comparison between naltrexone and placebo did not alter the results.

CONCLUSIONS

This is the first study to compare frequency of sexual side effect reporting between paroxetine and desipramine. We found no statistically significant differences in sexual side effect reporting between the two antidepressants. Also, the addition of naltrexone did not show any beneficial effect on the sexual side effect profile.

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

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

Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines

A revision of the 2008 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken in order to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in September 2012. Key areas in treating depression were reviewed and the strength of evidence and clinical implications were considered. The guidelines were then revised after extensive feedback from participants and interested parties. A literature review is provided which identifies the quality of evidence upon which the recommendations are made. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse and stopping treatment. Significant changes since the last guidelines were published in 2008 include the availability of new antidepressant treatment options, improved evidence supporting certain augmentation strategies (drug and non-drug), management of potential long-term side effects, updated guidance for prescribing in elderly and adolescent populations and updated guidance for optimal prescribing. Suggestions for future research priorities are also made.

Adherence to antidepressant treatment

Depression is a common disorder with painful symptoms and, frequently, social impairment and decreased quality of life. The disorder has a tendency to be long lasting, often with frequent recurrence of symptoms. The risk of relapse and the severity of the symptoms may be reduced by correct antidepressant medication. However, the medication is often insufficient, both in respect to dosage and length of time. The reasons for incorrect medication are many, with lack of adherence to treatment being the most important. Although some patients taking antidepressant medication experience side effects, this may not be the most frequent reason for immature discontinuation of treatment. Other reasons for decreased adherence have been investigated in recent years. The patient's beliefs about the disorder and beliefs about antidepressants, including lack of conviction that the medication is needed and fear of dependence of antidepressant medicine, have a great influence on adherence to treatment.

Factors Affecting Non-Adherence among Patients Diagnosed with Unipolar Depression in a Psychiatric Department of a Tertiary Hospital in Kolkata, India

Non-adherence to depression treatment is a common clinical problem globally. However, limited research is available from India. This cross-sectional study aimed to assess non-adherence to prescribed treatment among patients with unipolar depression at a psychiatric out-patient department (OPD) of a tertiary hospital in Kolkata, India. The Morisky Medication Adherence Scale (MMAS) was used and a questionnaire designed by the Principal Investigator (PI) was administered. A total of 239 patients with unipolar depression were interviewed of whom 66.9% (160) were non-adherent and 33.1% (79) were adherent to treatment. The difference was significant (Fisher's Exact <0.000). Women were nearly three times at a higher risk of being non-adherent compared to men (OR 2.7; 95% CI 1.0-7.1). The non-adherent group compared to the adherent group was significantly more likely to consume extra medicines than the recommended amount (OR 2.8; 95% CI 1.1-7.3) and had lower internal locus of control (LOC) (OR 4.5; 95% CI 2.4-8.3). Adherence to prescribed treatment in an out-patient clinical setting was a problem among patients with unipolar depression. Suitable interventions on individuals with the above mentioned attributes are required in India and in similar settings where non-adherence to depression therapy is an important public health problem.

The depressed patient in a biological world: on philosophical and diagnostic strategies

RATIONALE, AIMS AND OBJECTIVE

We questioned: what kind of relationships between mental and neurobiological levels of complexity is or could become useful in the psychiatric practice? The concept of mind and associated mood states defended here is that they are physically emergent, subjective, qualitative, unified features of the brain. We compared our neurobiological assessment also to psychoanalytical practice (first person's perspective).

ARGUMENT

Applied to recent work on major depressive disorder (MDD), our ideas are among other supported by clinical and experimental studies on sleep deprivation, deep brain stimulation and epidemiological assessments of time-to-recovery.

CLINICAL IMPLICATIONS

We suggest that depression is a transient state of the brain, that is mutually exclusive to the state of pleasure (in the Freudian context), rather than a disorder or disease with a characteristic time course (like many reversible somatic diseases). MDD can best be described with stochastic transition models, which is discussed in the context of a presumed brain serotonin dysfunction in depression. Our ideas invite a reconsideration of some concepts underlying current diagnostic and therapeutic approaches in the clinical practice.

Economic factors in of patients' nonadherence to antidepressant treatment

PURPOSE

Patients' nonadherence to antidepressant treatment hampers cost and efficacy of depression-specific treatment. However, previous studies have failed to find consistent findings in economic effect on nonadherence and also failed to reach consensus in how to measure nonadherence to treatment. The study attempts to investigate income effect on nonadherence to selective serotonin reuptake inhibitors (SSRIs) treatment with clear definitions of nonadherence: self discontinuation of SSRIs (nonpersistence) and under-dose of SSRIs (noncompliance).

METHODS

The study extracted data from the National Comorbidity Survey-Replication (NCS-R). The study sample (n = 280) includes adults between the ages of 18 and 64 who were diagnosed with Diagnostic Statistics Manual IV Major Depressive Episode (MDE) at some point during their lifetime and medicated with SSRIs in the past 12 months.

RESULTS

Just above poverty level of family income and no health insurance increased the risk of medication nonpersistence in SSRIs treatment. The study findings confirmed that African Americans were at higher risk of medication noncompliance than Whites (odds ratio, 4.53) and MDE comorbidity was positively associated with medication noncompliance (odds ratio, 4.25).

CONCLUSIONS

Low income level, combined with health insurance status, and race/ethnicity, predict nonadherence to antidepressant treatment. The study findings would help physicians and hospitals developing interventional strategies and programs to increase patients' adherence rates in antidepressant treatment.

Beliefs about depression and its treatments: associated variables and the influence of beliefs on adherence to treatment

Beliefs and attitudes about treatment in patients with depression are significant factors related to treatment adherence. Despite their importance, few studies have evaluated the determining factors of these beliefs, and the positive or negative attitudes towards treatment. This review looks at areas such as, adherence to antidepressants and psychotherapy, influence of beliefs and attitudes on adherence to treatment, beliefs and attitudes about depression and its treatment, their assessment, variables associated with these beliefs, and limitations of available studies. Acknowledging the importance of patient beliefs about depression and treatment, and their assessment are essential to optimize the chances of success of therapy by identifying and addressing misconceptions, prejudices and negative attitudes, as well as the consideration of these aspects in order to improve treatment choice.

Changes in patients' beliefs about their antidepressant during the acute phase of depression treatment

PURPOSE

To test hypotheses regarding medication beliefs in relation to adherence, side effects, and response during the acute phase of an antidepressant treatment episode.

METHODS

Participants were 163 patients with unipolar major depression participating in the acute phase of a multi-stage trial of medication and psychotherapy. Before starting citalopram, patients underwent measures of treatment beliefs and depression. They continued taking citalopram until either responding, discontinuing due to side effects, or failing to respond within 14 weeks. Assessments of adherence, side effects and depression were made at weeks 2, 4, 6, 9, 12 and 14 (as applicable) and at trial exit. Beliefs were reevaluated at exit.

RESULTS

Perceived need for medication increased between baseline and exit (P=.01) while perceived medication harmfulness dropped between baseline and exit (P<.0001). Adherence was related to baseline perceived need (P=.022), and side effects were related to baseline perceived harmfulness (P=.002). Change in depressive symptoms was significantly related to both baseline perceived need (P=.039) and mean adherence (P=.036) but not baseline perceived harmfulness (P=.184) or side effects (P=.102). At exit, perceived need was unrelated to change in depression severity (P=.565), while perceived harmfulness was related to prior side effects (P<.0001).

CONCLUSION

Patients' medication perceptions become more pro-adherence as treatment proceeds. Their perceptions of antidepressant necessity predict their subsequent medication adherence and response, while their perceptions about medication harmfulness show strong prospective associations with actual side effects. Clinicians ought to adjust their prescribing decisions accordingly. Interventions that target beliefs ought to capitalize upon the apparently bidirectional association between harm perceptions and actual side effects.

Therapeutic drug monitoring for drugs used in the treatment of substance-related disorders: literature review using a therapeutic drug monitoring appropriateness rating scale

BACKGROUND

The efficacy of drugs for the treatment of substance-related disorders is moderate at best. Therapeutic drug monitoring (TDM) could be an instrument to improve outcomes. Because TDM for most of those drugs is not established, the authors reviewed the literature and built a rating scale to detect the potential added value of TDM for these pharmacologic agents.

METHODS

A literature search was performed for acamprosate, bupropion, buprenorphine, clomethiazole, disulfiram, methadone, naltrexone, and varenicline. The rating scale included 22 items and was divided in five categories: efficacy, toxicity, pharmacokinetics, patient characteristics, and cost-effectiveness. Three reference substances with established TDM were similarly assessed for comparison: clozapine, lithium, and nortriptyline. The three reference substances achieved scores of 15, 12, and 14 points, respectively.

RESULTS

Drugs for treatment of substance-related disorders achieved 3 to 17 points, 17 for methadone, 11 for buprenorphine, 10 for disulfiram, also 10 for naltrexone for the indication opioid-dependence and 9 for the indication alcohol dependence as well as bupropion, 7 points for acamprosate, 6 points for clomethiazole, and 3 for varenicline.

CONCLUSIONS

It is concluded that systematic evaluation of drug- and patient-related variables with the new rating scale can estimate the appropriateness of TDM. Because their rating revealed similar scores as the three reference drugs, it is proposed that TDM should be established for bupropion, buprenorphine, disulfiram or a metabolite, methadone, and naltrexone. An objective rating of drug- and patient-related characteristics could help laboratories focus their method development on the most likely drugs to require TDM along with a thorough drug use evaluation.

Impact of pharmacist interventions on patients' adherence to antidepressants and patient-reported outcomes: a systematic review

BACKGROUND

Pharmacist intervention in improving patient adherence to antidepressants is coupled with better outcomes.

AIMS

The aim of this investigation was to systematically examine the published literature to explore different types of pharmacist interventions used for enhancing patient adherence to antidepressant medications. Three specific questions guided the review: what is the impact of pharmacist interventions on adherence to antidepressant medication? What is the impact of pharmacist interventions on patient-reported outcomes and patient satisfactions? What are the types of interventions used by pharmacists to enhance patients' adherence to antidepressants?

SEARCH STRATEGIES

A systematic review of the literature was conducted during August-November 2010 using PubMed, BIOSIS Previews(®) Web of Science, ScienceDirect, the Cochrane Library, PsycINFO(®), IngentaConnect™, Cambridge Journals Online, and Medscape databases. Key text words and medical subject headings included pharmacist intervention, medication intervention, depression, medication adherence, health-related quality of life, patient-reported outcomes, and antidepressants.

RESULTS

A total of 119 peer-reviewed papers were retrieved; 94 were excluded on the basis of abstract review and 13 after full-text analysis, resulting in twelve studies suitable for inclusion and intensive review. The most common intervention strategy that pharmacists utilized was a combination of patient education and drug monitoring. A cumulative patient adherence improvement in this review ranged from 15% to 27% attributed to utilization of different interventions and different combinations of interventions together with patient satisfaction with the treatment when depression improved.

CONCLUSION

This review suggests that pharmacist intervention is effective in the improvement of patient adherence to antidepressants. This may be a basis for more studies examining the effectiveness of innovative interventions by pharmacists to enhance patient adherence to antidepressant medications.

Treatment attitudes and adherence of psychiatric patients with major depressive disorder: a five-year prospective study

BACKGROUND

The prevalence, long-term temporal consistency and factors influencing negative attitudes and poor treatment adherence among psychiatric patients with major depressive disorder (MDD) are not well known.

METHODS

In the Vantaa Depression Study (VDS), a prospective 5-year study of psychiatric patients with DSM-IV MDD, 238 (88.5%) patients' attitudes towards and adherence to both antidepressants and psychotherapeutic treatments at baseline, 6 months, 18 months and 5 years was investigated.

RESULTS

Throughout the follow-up, most patients reported positive attitudes towards pharmacotherapy and psychosocial treatments, and good adherence. While attitudes became more critical over time, adherence to psychosocial treatment improved, but remained unchanged for pharmacotherapy. Employment predicted positive attitude (OR=1.97, 95% CI 1.01-3.83, P=0.046), and larger social network good adherence (OR=1.11, 95% CI 1.00-1.23, P=0.042) to pharmacotherapy at the last follow-up. Cluster B personality disorder symptoms predicted negative attitude (OR=0.82, 95% CI 0.70-0.96, P=0.012) and poor adherence (OR=0.83, 95% CI 0.72-0.95, P=0.007), but cluster C symptoms positive attitude (OR=1.30, 95% CI 1.09-1.54, P=0.003), and living alone good adherence (OR=3.13, 95% CI 1.10-9.09, P=0.032) to psychosocial treatment.

LIMITATIONS

Patients may exaggerate their adherence to treatments. Attrition from follow-up may occur due to undetected negative change in treatment attitude or adherence.

CONCLUSIONS

Among psychiatric MDD patients in long-term follow-up, treatment attitudes and adherence to pharmaco- and psychotherapy were and remained mostly positive. They were significantly predicted by personality features and social support. Attention to adherence of those with cluster B personality disorders, or poor social support, may be needed.

The effect of an educational leaflet on depressive patients' attitudes toward treatment

Improving patient adherence to antidepressant treatment is an important issue. Patients' attitudes toward symptoms, results, causes, disease course, and effective treatment of depression can influence their adherence to therapy. We aimed to assess the efficacy of an educational leaflet designed to improve patients' attitudes toward depression and antidepressant treatment. Participants were one hundred twenty-two outpatients of three psychiatric clinics in Japan who met the DSM-IV criteria for depression. Patients in the intervention group received an educational leaflet at the start of the study. Participants filled in The Antidepressant Compliance Questionnaire (ADCQ) and Beck Depression Inventory (BDI) before and after the intervention. Intervention group showed greater improvements on the total score of ADCQ, the score on the "positive beliefs regarding antidepressants" subscale. They maintained the scores on the "perceived doctor-patient relationship" subscale, where the control group lowered those scores. No significant difference in improvement in BDI scores was observed between groups. The intervention using an educational leaflet had a significant positive impact on patients' attitudes toward depression and antidepressant treatment. Our results indicate that the educational leaflet is an effective tool for enhancement of face-to-face education by medical professionals. Trial registration UMIN000002981, www.umin.ac.jp/ctr/index.htm.

Enhancing medication adherence in patients with bipolar disorder

OBJECTIVES

Medication adherence contributes to the efficacy-effectiveness gap of treatment in patients with bipolar disorder. This paper aims to examine the challenges involved in improving medication adherence in bipolar disorder, and to extract some suggestions for future directions from the core psychosocial studies that have targeted adherence as a primary or secondary outcome.

METHODS

A search was conducted for articles that focused on medication adherence in bipolar disorder, with emphasis on publications from 1996 to 2008 using Medline, Web of Science, CINAHL PLUS, and PsychINFO. The following key words were used: adherence, compliance, alliance, adherence assessment, adherence measurement, risk factors, psychosocial interventions, and psycho-education.

RESULTS

There are a number of challenges to understanding non-adherence including the difficulty in defining and measuring it and the various risk factors that need to be considered when aiming to enhance adherence. Nevertheless, the importance of addressing adherence is evidenced by the connection between adherence problems and poor outcome. Despite these challenges, a number of small psychosocial studies targeting adherence as a primary outcome point to the potential usefulness of psycho-education aimed at improving knowledge, attitudes, and adherence behavior, but more large scale randomized controlled trials are needed in this area. Evidence of improved outcomes from larger randomized controlled trials of psychosocial interventions that target medication adherence as a secondary outcome suggests that tackling other factors besides medication adherence may also be an advantage. While some of these larger studies demonstrate an improvement in medication adherence, the translation of these interventions into real life settings may not always be practical. A person centered approach that considers risk factors for non-adherence and barriers to other health behaviors may assist with the development of more targeted briefer interventions. Integral to improving medication adherence is the delivery of psycho-education, and attention needs to be paid to the implementation, and timing of psycho-education. Progress in the understanding of how medicines work may add to the credibility of psycho-education in the future.

CONCLUSIONS

Enhancement of treatment adherence in bipolar patients is a necessary and promising management component as an adjunct to pharmacotherapy. The current literature on psychosocial interventions that target medication adherence in bipolar disorder points to the possibility of refining the concept of non-adherence and adapting psycho-education to the needs of certain subgroups of people with bipolar disorder. Large scale randomized controlled trials of briefer or more condensed interventions are needed that can inform clinical practice.

Improving adherence in mood disorders: the struggle against relapse, recurrence and suicide risk

Medication nonadherence is a major obstacle to translating treatment efficacy from research settings into effectiveness in clinical practice for patients with affective disorders. Adherence to beneficial drug therapy is associated with lower mortality compared with poor adherence. Reduced adherence is associated with increased suicide risk, especially when lithium is discontinued. The aim of this paper is to review the prevalence, predictors and methods for improving medication adherence in unipolar and bipolar affective disorders. Studies were identified through Medline and PsycInfo searches of English language publications between 1976 and 2009. This was supplemented by a hand search and the inclusion of selected descriptive articles on good clinical practice. Estimates of medication nonadherence for unipolar and bipolar disorders range from 10 to 60% (median: 40%). This prevalence has not changed significantly with the introduction of new medications. There is evidence that attitudes and beliefs are at least as important as side effects in predicting adherence. The limited number of empirical studies on reducing nonadherence indicate that, if recognized, the problem may be overcome. Clinical data highlight the importance of extended courses of medication in improving the long-term prognosis of patients with affective disorders.

Attitudes and beliefs of patients of first episode depression towards antidepressants and their adherence to treatment

BACKGROUND

Treatment adherence is influenced by factors like illness and patient characteristics, side effects, time taken to improve and the doctor-patient relationship. One of the important patient characteristic which has been reported to influence treatment adherence is their attitudes and beliefs towards medication.

METHODOLOGY

50 subjects of first episode unipolar depression (except for severe depression with psychotic symptoms), aged 18-50 years, duration of depression of more than 1 month, with no comorbid psychiatric disorders and comorbid medical illnesses were assessed twice. At first intake, antidepressant compliance questionnaire (ADCQ) was administered. Second intake was done after 3 months for assessment of treatment adherence by using the questionnaire for assessment of treatment adherence.

RESULTS

On component-1 of ADCQ (doctor-patient relationship), 92% agreed that doctor gave sufficient time to listen to their problem, explained the causes of depression sufficiently, felt confident that antidepressants are suitable treatment of their depression. On component-2 (preserved autonomy), most (88%) subjects believed that antidepressants are difficult to stop when taken over a long period of time and can alter patient's personality. On component-3 (positive beliefs on anti-depressants), 72% of the subjects felt, fewer tablets could be taken on days one feels better. On component-4 (partner agreement), 96% of subjects reported their partner's positive attitude towards diagnosis and treatment. At the time of second assessment, majority of the subjects (88%) missed the antidepressant medication on less than 25% days in the last 3 months whereas only 4% of the subjects missed antidepressants for more than 75% of the days. Thirty eight percent of the subjects dropped out of the follow up at 3 months of first assessment.

CONCLUSION

Most of the patients value the doctor-patient relationship & their partners are also supportive regarding diagnosis and treatment of depression. However, most patients have erroneous beliefs regarding antidepressants per se which in turn influence the drug compliance.

Change in formulation and its potential clinical and pharmacoeconomic value: example of extended release venlafaxine

INTRODUCTION

The 505(b)(2) route of a New Drug Application (NDA) allows published literature or previous FDA findings of safety and effectiveness to be used for approval. Such drugs are not therapeutic equivalents (i.e., generics); instead, the FDA calls them pharmaceutical alternatives. A recent example is the approval of venlafaxine extended-release (ER) tablets, developed as an alternative to the widely used ER venlafaxine capsules. The smaller size of the tablets makes them available in a 225-mg strength, which is the approved maximum dose in major depressive disorder after up-titration but currently unavailable in the capsule formulation, requiring patients on this dose to take two or three capsules; in addition, the tablets are priced at a discount compared to the capsules.

METHODS

The objective of this review was to investigate how the change in formulation of ER venlafaxine from capsules to tablets, as an example of such a change in formulation, can potentially offer value to patients and society, with a specific focus on pill burden, drug cost, and adherence. Based on a MEDLINE literature search, the pertinent literature was reviewed in a qualitative manner.

REVIEW OF THE LITERATURE

Simplifying treatment regimens, reducing pill burden, and reducing drug costs are recognized strategies for improving adherence. This can be of particular benefit in psychiatric illness because of high rates of nonadherence to treatment. Lack of adherence may negatively impact treatment outcomes and increase disease cost. As such, the ER venlafaxine tablets have the potential to reduce pill burden, improve adherence and outcomes, and reduce cost to patients and society. These preliminary findings need to be corroborated with more primary research and a systematic review of formulation changes.

CONCLUSION

A change in formulation of established therapies such as ER venlafaxine has the potential to offer clinical and pharmacoeconomic benefits to patients and society.

Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for Psychopharmacology guidelines

A revision of the 2000 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in May 2006. Key areas in treating depression were reviewed, and the strength of evidence and clinical implications were considered. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is provided, which identifies the quality of evidence to inform the recommendations, the strength of which are based on the level of evidence. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse, and stopping treatment.

Predictors of 12-month outcome in smokers who received bupropion sustained-release for smoking cessation

AIM

To examine heterogeneity in outcome at 12 months following 8 weeks of treatment for smoking cessation with bupropion sustained-release (SR) 150 or 300 mg/day combined with behavioural counselling.

DESIGN, SETTING, PARTICIPANTS

Smokers were recruited from a large healthcare system and then randomized to receive either bupropion SR 150 mg/day (n = 763) or 300 mg/day (n = 761) taken for 8 weeks in combination with either proactive telephone counselling or a tailored mail approach.

MEASUREMENTS AND FINDINGS

A comprehensive set of relevant individual pretreatment and treatment characteristics was included in the analysis. Smoking outcome at 12 months was defined as point-prevalence of any regular self-reported smoking within the 7 days prior to follow-up contact. Classification and regression tree analysis identified subgroups that varied with respect to likelihood of being nonsmokers at 12 months. Seven subgroups were identified among those receiving bupropion SR 150 mg/day (proportion of nonsmokers at 12 months ranged from 13.7% to 43.5%) and eight subgroups among those receiving bupropion SR 300 mg/day (proportion of nonsmokers at 12 months ranged from 9.6% to 51.7%). In the 150-mg/day group, those with the lowest rate reported no previous quit attempt of 1 month or more in duration while those with the highest rate all reported previous quit attempts of 1 month or longer. In the 300 mg/day group, those with the lowest rate had very high levels of dependence while those with the highest rate were more highly educated and smoked at a lower level. Across all subgroups, cost per 12-month quitter ranged from a low of USD302 to a high of USD2,502.

CONCLUSIONS

These results indicate the presence of a substantial amount of variation in outcome following treatment with both dosages of bupropion SR, with substantial cost consequences. Variation in outcome could be reduced by providing treatments tailored to subgroups of individuals who are at exceptionally high risk for smoking following a quit attempt.

The effects of antidepressant medication adherence as well as psychosocial and clinical factors on depression outcome among older adults

OBJECTIVE

To examine the contribution of medication adherence to 12-month depression scores in the context of other psychosocial and clinical predictors of depression in a sample of older adults treated for depression.

METHODS

Secondary analysis of a prospective cohort study involving 241 older patients undergoing depression treatment using a standardized algorithm. Depression was measured at baseline and 12-months post-baseline. Baseline predictor variables included antidepressant adherence, barriers to antidepressant adherence, four domains of social support, basic and instrumental activities of daily living (BADLs and IADLs), and clinical factors including past history of depression and medical comorbidities.

RESULTS

Nearly 28% of patients reported being nonadherent with their antidepressant medication. In bivariate analyses, greater antidepressant medication nonadherence, more medication barriers, poorer subjective social support, less non-family interaction, greater BADL and IADL limitations, poor self-rated health, higher baseline depression scores, and not having diabetes were related to higher 12-month depression scores. In multivariable analyses, greater medication nonadherence, not having diabetes, poorer subjective social support, greater BADL limitations, and higher baseline depression scores were related to higher 12-month depression scores.

CONCLUSION

Interventions should be directed toward improving antidepressant adherence and modifiable psychosocial variables.

"Add-On"-therapy with an individualized preparation consisting of free amino acids for patients with a major depression

The efficacy of a deficit oriented add-on therapy with free amino acids in depressive patients treated with the antidepressant Remeron was evaluated. About 40 in-patients were investigated by a randomised double-blind placebo-controlled study during 4 weeks. Plasma levels of 20 amino acids and measures of depression, suicidal behaviour and aggression were surveyed on admission and after a 4 weeks' therapy with Remeron plus an individualized amino acid mixture or placebo. The preparation of the amino acid mixture was based on an aminogram and consisted of essential amino acids plus vitamins and trace elements as co-factors for the amino acid metabolism. Patients of the experimental group showed a significantly better improvement of depression and a higher responder rate than those of the placebo group. The results suggest that oral application of a deficit oriented amino acid mixture can improve the therapeutic outcome of an antidepressant. Furthermore, lacking side effects of the amino acids resulting also in a better patient compliance may improve the benefit/risk ratio.

Predictors of premature antidepressant discontinuation in functional gastrointestinal disorders

OBJECTIVES

To identify factors responsible for premature antidepressant discontinuation that would assist in designing management strategies for patients with functional gastrointestinal disorders. Antidepressants are being used increasingly to manage patients with functional gastrointestinal disorders; poor patient adherence to treatment regimens, particularly in the period shortly after antidepressant initiation, is common and interferes with success.

METHODS

Clinical records were reviewed from 172 outpatients who attended a university-based practice and who had been prescribed antidepressants to manage their functional gastrointestinal symptoms. Survival analysis methods were used to determine independent predictors of premature antidepressant discontinuation (within 6 months of initiation). Logistic regression analyses were used to see if the same predictors were responsible for side effects or poor treatment response.

RESULTS

Premature antidepressant discontinuation occurred in 41 (23.8%) subjects. Somatization features (state or trait) and history of depression or an anxiety disorder were the most significant predictors of premature discontinuation (p < or = .01 for each). Advancing age and female sex also were independent predictors (p < .05 for each). Somatization features and psychiatric illness were each linked to poor treatment response, whereas somatization features most consistently were associated with antidepressant side effects.

CONCLUSIONS

Failure to maintain treatment occurs in nearly a quarter of outpatients given antidepressants for functional gastrointestinal disorders. Somatization features and history of depression or anxiety most significantly interfered with treatment by predicting side effects, poor treatment response, and premature antidepressant discontinuation. Management algorithms should include specific strategies targeted at patients with these risk factors for poor treatment adherence.

A connection between medication adherence, patient sense of uniqueness, and the personalization of information

Adherence to treatment regimens is important to achieve optimal disease management. However, nonadherence is evident across numerous clinical contexts, which leads to a higher disease burden on society. Among the various factors associated with patient adherence behavior, patient beliefs are the most influential set of factors. Several cognitive-social models and constructs that incorporate patient belief have been developed to explain patient health behaviors, such as the Health Belief Model, Self-Efficacy Model, Theory of Planned Behavior and so on. However, these models do not explain the formulation of health beliefs. The underlying mechanism accounting for patient variation in information processing that generates beliefs needs to be investigated, which will inform the development of interventions. We propose that patient's sense of uniqueness moderates the self-attribution of statistically-based information. Self-attribution is defined as a person's perceived probability that a statement applies to herself, and is influenced by experience and sense of uniqueness. Sense of uniqueness is a person's general belief regarding how unique she is. Statistically-based information is defined as information derived from or regarding aggregated effects or influences. Basically, the proposed hypothesis is that patients who have a stronger belief that they are unique are less likely to attribute to themselves statistically-based propositions regarding the majority of their group and are more likely to attribute to themselves statistically-based propositions regarding the minority. We further model the relationship between sense of uniqueness and self-attribution of information in terms of an idealized inexperienced person, and then extend the model to include the effect of personal experience. The estimation of hypothesis-specific effect parameters can be achieved by maximum likelihood. In conclusion, the sense of uniqueness hypothesis is general to the formulation of personal beliefs and consequently has implications for deliberate health behavior and indeed personal behavior in general.

Satisfaction with treatment among patients with depressive and bipolar disorders

BACKGROUND

Patients' satisfaction with care may be an important factor in relation to adherence to treatment and continued psychiatric care. Few studies have focused on satisfaction in patients with depressive and bipolar disorders.

METHOD

A comprehensive multidimensional questionnaire scale, the Verona Service Satisfaction Scale-Affective, was mailed to a large population of patients with depressive or bipolar disorders representative of outpatients treated at their first contact to hospital settings in Denmark.

RESULTS

Among the 1,005 recipients, 49.9% responded to the letter. Overall, patients were satisfied with the help provided, but satisfaction with the professionals' contact to relatives was low. Younger patients (age below 40 years) were consistently more dissatisfied with care especially with the efficacy of treatment, professionals' skills and behaviour and the information given. There was no difference in satisfaction between genders or between patients with depressive disorder and patients with bipolar disorder.

CONCLUSION

There is a need to strengthen outpatient treatment for patients discharged from a psychiatric hospital diagnosed of having affective disorders, focusing more on information and psychoeducation for patients and relatives.

Management of depression in primary care: a survey of general practitioners in Spain

OBJECTIVE

The objective of this study was to analyze the current situation of health care for depression in Spain according to general practitioners' (GPs') opinion and how it has evolved over the last 20 years on the basis of comparisons with the results of two previous social-health studies (published in 1997 and 1982).

METHOD

Throughout 2002, we recorded the opinions of 238 GPs after asking them to fill up structured questionnaires in which they rated care, clinical, therapeutic and care quality aspects.

RESULTS

Only 40% of patients with depression visit a doctor, implying a very high level of "concealed epidemiology." The diagnostic instruments most commonly used are assessment of symptoms and patient interview. Pharmacological treatment is the option GPs most commonly choose once a depression diagnosis is established (80% vs. 50% in 1997; P<.001). Selective serotonin reuptake inhibitors (SSRIs), together with anxiolytics, are the drugs most commonly used in the treatment of depression. SSRIs are the first choice drugs, being preferred to tricyclic antidepressants and anxiolytics, which were the most popular options for GPs in the 1997 survey. Areas where there is a need for improvement are time devoted to consultation, coordination between GPs and psychiatrists and waiting lists.

CONCLUSIONS

The quality of health care for depression has improved in recent years, thanks to changes in the attitudes of GPs and the evolution of pharmacological treatment.

Dopamine receptor DRD2 genotype and smoking cessation outcome following treatment with bupropion SR

The A1 allele of the dopamine D2 receptor gene (DRD2) is associated with a reduced number of dopamine binding sites in the brain and with the increased likelihood of substance abuse and addictive behavior. In a study of smokers enrolled in an open-label, randomized effectiveness trial, we investigated whether variants in the DRD2 receptor gene are associated with smoking cessation outcomes following treatment with a combination of bupropion SR and behavioral counseling. Adherence to treatment and point-prevalent smoking status were assessed at 3 and 12 months, respectively, following a target quit date. Compared to women who carry both A2 alleles, women with at least one A1 allele were more likely to report having stopped taking bupropion due to medication side effects (odds ratio (OR)=1.91, 95% confidence interval (CI)=1.01-3.60; P<0.04) and at 12 months were somewhat more likely to report smoking (OR=0.76, 95% CI=0.56-1.03; P<0.076). Significant associations or trends were not observed in men. In women, individual variability in responsiveness to bupropion-based treatment may be partially due to differences in genetic variants influencing dopamine receptor function.

Clinical response to tricyclic antidepressants in functional bowel disorders is not related to dosage

BACKGROUND

As shown in the per protocol analysis of a recent randomized, controlled trial, when tolerated, Desipramine (DES) is effective over placebo (PLA) in treating moderate-to-severe functional bowel disorders (FBD). Clinical experience suggests that the benefit from tricyclic antidepressants (TCA) in FBD can be achieved at doses lower than those used to treat major depression. Within psychiatry, when using higher dosage of TCAs, plasma levels can be used to adjust daily dosage to optimize a treatment response. However, in FBD, it is not known whether plasma levels at the lower dosage are similarly related to a clinical response.

AIM

To determine in treating FBD, whether DES blood levels or dose taken can predict a clinical response.

METHODS

As part of a study of 12 wk of antidepressant and psychological treatment in 431 patients with FBD at UNC and U of Toronto, we studied those participants who completed treatment (per protocol analysis) taking DES (N = 97, dose 50-150 mg/day) or pill placebo (PLA) (N = 55 1-3 pills/day). The primary outcome measure was defined as a composite score (Satisfaction with Treatment, McGill Pain Questionnaire, Global Well-being, and IBS-QOL). The composite score was correlated with: (i) DES plasma levels at week 6, and (ii) number of pills taken over the duration of the 12-wk treatment period. In addition, we also compared DES dose with DES plasma levels.

RESULTS

There was a modest correlation between mean DES dose at weeks 5 and 6 and DES blood level at week 6 (R = 0.2 p < 0.07). However, there were no significant correlations between the composite score either with DES dose or with DES blood levels.

CONCLUSIONS

Detectable blood levels of DES are associated with a clinical response in FBD. However, with dosages up to 150 mg, there is no relationship between total dose or plasma level and the clinical response.

Heterogeneity in 12-month outcome among female and male smokers

AIMS

To examine heterogeneity in outcome following treatment for smoking cessation with combined bupropion SR and behavioral counseling in women and men.

DESIGN, SETTING, PARTICIPANTS

This study included 875 women and 649 men recruited from a large health-care system and randomized to one of four combinations of treatment [two dosage levels of bupropion SR (Zyban, 150 mg and 300 mg) were crossed with two counseling programs of lower and higher intensity to create a four-cell design].

MEASUREMENTS AND FINDINGS

A comprehensive set of relevant individual characteristics prior to treatment and treatment characteristics was included in the analysis. Smoking outcome at 12 months was defined as point-prevalence of any regular smoking within the 7 days prior to follow-up contact. Classification and regression tree analysis identified six subgroups in women that ranged in proportion of non-smokers from 9.8% to 42.9% and six subgroups in men that ranged in proportion of non-smokers from 17.3% to 50.0%.

CONCLUSIONS

These results indicate the presence of a substantial amount of variation in treatment outcome among women and men receiving combined bupropion SR and counseling. Variation in outcome could be reduced by providing treatments tailored to subgroups of individuals who are at exceptionally high risk for smoking following cessation.

Adherence to treatment for geriatric depression and anxiety

Patient nonadherence to pharmacologic and psychosocial treatments for geriatric depression and anxiety poses a serious barrier to effective clinical care. Rates of nonadherence may be as high as 60% in older adults. Factors associated with nonadherence include lack of information and misperceptions about mental illness and its treatment, stigma, lack of family support, cognitive impairment, adverse events, side effects, cost of treatments, poor physician-patient communication or relationship, and other barriers, such as lack of transportation. Effective interventions to improve adherence are personalized and include both behavioral and educational components. Several current projects that combine pharmacotherapy and psychotherapy for geriatric depression in an integrated care model show promise as interventions to improve rates of treatment and adherence.

Treatment non-adherence in affective disorders

OBJECTIVE

The aim of this paper is to review the prevalence, predictors and methods for improving medication adherence in unipolar and bipolar affective disorders.

METHOD

Studies were identified through Medline and PsycLit searches of English language publications between 1976 and 2001. This was supplemented by a hand search and the inclusion of selected descriptive articles on good clinical practice.

RESULTS

Estimates of medication non-adherence for unipolar and bipolar disorders range from 10 to 60% (median 40%). This prevalence has not changed significantly with the introduction of new medications. There is evidence that attitudes and beliefs are at least as important as side-effects in predicting adherence. The limited number of empirical studies of how to reduce non-adherence offer encouraging evidence that, if recognized, the problem can be overcome.

CONCLUSION

Only 1-2% of all publications on the treatment of affective disorders explore factors associated with medication non-adherence. This is disappointing as research and clinical data highlight the importance of extended courses of medication in improving the long-term prognosis of affective disorders.