Mediating roles of adherence attitude and patient education on antidepressant use in patients with depression

Addressing anhedonia to increase depression treatment engagement

Anhedonia, or reward system dysfunction, is associated with poorer treatment outcomes among depressed individuals. The role of anhedonia in treatment engagement, however, has not yet been explored. We review research on components of reward functioning impaired in depression, including effort valuation, reward anticipation, initial responsiveness, reward learning, reward probability, and reward delay, highlighting potential barriers to treatment engagement associated with these components. We then propose interventions to improve treatment initiation and continuation by addressing deficits in each component of reward functioning, focusing on modifications of existing evidence-based interventions to meet the needs of individuals with heightened anhedonia. We describe potential settings for these interventions and times at which they can be delivered during the process of referring individuals to mental health treatment, conducting intakes or assessments, and providing treatment. Additionally, we note the advantages of using screening processes already in place in primary care, workplace, school, and online settings to identify individuals with heightened anhedonia who may benefit from these interventions. We conclude with suggestions for future research on the impact of anhedonia on treatment engagement and the efficacy of interventions to address it. PRACTITIONER POINTS: Many depressed individuals who might benefit from treatment do not initiate it or discontinue early. One barrier to treatment engagement may be anhedonia, a core symptom of depression characterized by loss of interest or pleasure in usual activities. We describe brief interventions to improve treatment engagement in individuals with anhedonia that can be implemented during the referral process or early in treatment. We argue that interventions aiming to improve treatment engagement in depressed individuals that target anhedonia may be particularly effective.

Staying on, and coming off, antidepressants: The experiences of 752 UK adults

INTRODUCTION

Prescription rates for antidepressants (ADs) are high and continue to increase, despite evidence of significant adverse effects, including withdrawal symptoms, and marginal benefit relative to placebo only for short-term treatment of major depression. Such high rates seem to be explicable more in terms of long term usage and repeat prescribing rather than by increases in depression or new patients.

METHOD

This paper reports the responses of a convenience sample of 752 people who had taken antidepressants, but no other psychiatric drugs, 'within the last two years' and completed the Medications for Mental Health Survey online in the UK.

RESULTS

Most participants had either come off antidepressants (34%) or had tried and failed (36%). Of those still taking them 76% had been doing so for at least a year and 36% for five years or more. 26% expected to take them forever. About half (48%) did not have their drugs reviewed at least every three months. Most (65%) had never had a discussion with the prescriber about coming off. Nearly half (45%) of those who had stopped the drugs had done so without consulting their doctor. However, of those who came off after consulting their doctor, the majority (65%) experienced the doctor to be supportive.

CONCLUSIONS

The findings are consistent with the idea that high rates are largely explicable by chronic usage, which in turn is partially explained by withdrawal symptoms. Prescribers should strive to establish collaborative relationships in which patients are fully informed about withdrawal effects and their views, about starting and finishing medication, should be explored and valued.

The effect of knowledge and expectations on adherence to and persistence with antidepressants

PURPOSE

Adherence to and persistence with antidepressants are often suboptimal. However, little is known about how patient knowledge and outcome expectations may influence antidepressant adherence and persistence.

METHOD

Individuals who had been prescribed their first antidepressant to treat depression in the preceding 6 months were recruited to an online survey via Facebook. Knowledge, education received, and initial outcome expectations were analyzed for associations with persistence and adherence.

RESULTS

Two hundred and twenty surveys were analyzed. A total of 117 participants had taken their antidepressant for at least 3 months; another 25 had never started or stopped after <3 months without consulting their doctor. Differences in expectations and various educational messages among persistent and nonpersistent participants were identified. Having received the instruction "don't stop it without checking with your doctor" was a significant independent predictor of persistence (odds ratio [OR] =5.9, 95% confidence interval [CI] =1.4-24.5). At the time of the survey, 82.7% of participants were taking an antidepressant and 77.9% were adherent. Significant independent predictors of adherence were a greater age (OR =1.1, 95% CI =1.0-1.2), knowledge (OR =1.6, 95% CI =1.1-2.3), being informed of common side effects (OR =5.5, 95% CI =1.1-29.0), and having discussed ways to solve problems (OR =3.9, 95% CI =1.1-14.5).

CONCLUSION

Improving outcome expectations and particular educational messages may increase adherence and persistence. Greater knowledge may enhance adherence. Further investigation is warranted to determine whether a focus on these simple educational messages will improve outcomes in patients who commence an antidepressant.

Understanding the non-pharmacological correlates of self-reported efficacy of antidepressants

OBJECTIVE

To explore the non-pharmacological correlates of the perceived effectiveness of antidepressants (ADs), thereby enhancing understanding of the mechanisms involved in recovery from depression while taking ADs.

METHOD

An online survey was completed by 1781 New Zealand adults who had taken ADs in the previous 5 years.

RESULTS

All 18 psychosocial variables measured were associated with depression reduction, and 16 with improved quality of life (QoL). Logistic regression models revealed that the quality of the relationship with the prescriber was related to both depression reduction and improved QoL. In addition, depression reduction was related to younger age, higher income, being fully informed about ADs by the prescriber, fewer social causal beliefs for depression and not having lost a loved one in the 2 months prior to prescription. Furthermore, both outcome measures were positively related to belief in 'chemical' rather than 'placebo' effects.

CONCLUSION

There are multiple non-pharmacological processes involved in recovery while taking ADs. Enhancing them, for example focusing on the prescriber-patient relationship and giving more information, may enhance recovery rates, with or without ADs.

Enhancing placebo effects: insights from social psychology

Placebo effects are widely recognized as having a potent impact upon treatment outcomes in both medical and psychological interventions, including hypnosis. In research utilizing randomized clinical trials, there is usually an effort to minimize or control placebo effects. However, in clinical practice there may be significant benefits in enhancing placebo effects. Prior research from the field of social psychology has identified three factors that may enhance placebo effects, namely: priming, client perceptions, and the theory of planned behavior. These factors are reviewed and illustrated via a case example. The consideration of social-psychological factors to enhance positive expectancies and beliefs has implications for clinical practice as well as future research into hypnotic interventions.

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.

Ethnicity predicts perceptions of smoking and smoking cessation among veterans

The objective of this study was to determine if race/ethnicity predicts motivation to quit smoking and preferences for cessation services among smokers serviced by a primarily psychiatric Veterans Affairs hospital. A self-administered survey was given to a convenience sample of smokers (n=146) at the Battle Creek Veterans Affairs Medical Center. Univariate, bivariate and multivariate regression analyses were calculated to determine the association between race/ethnicity and motivation to quit smoking. Forty-two per cent of the sample was non-white. Non-white patients smoked significantly less cigarettes per day as compared with white patients (P=0.002). In the multivariate analyses, compared with whites, non-whites had 3.5 times greater odds of thinking that quitting smoking was extremely/very important to health (P= 0.01), 4.0 times greater odds of thinking of quitting using tobacco products in the next 30 days (P=0.004) and 3.4 times greater odds of being interested in receiving smoking cessation services (P=0.007). Yet, non-white patients were less likely to be interested in intensive nurse counselling and cessation medications. As the number of non-whites continues to increase in the military, novel strategies may be needed to capitalize on the high motivation to quit smoking and preference for non-traditional interventions among non-white smokers treated in Veterans Affairs hospitals.