Forgetfulness: a role in noncompliance with antidepressant treatment

Validity of self-reports of medication treatment of depression in general population surveys

PURPOSE

To assess the concurrent validity of a single question on medication use for depression in a general population survey.

METHODS

Using data from 2015 to 2016 and 2017 to 2018 National Health and Nutrition Examination Survey, we compared responses to a single question on medication use for depression with responses to a detailed questionnaire confirmed by inspecting medication packages or pharmacy printouts.

RESULTS

There was a strong agreement (96.4%) between response to a single question about using medication for depression and responses to questions about using antidepressants or other psychiatric medications for depression on the detailed questionnaire. The single-question assessment had excellent sensitivity (93.8%) and specificity (96.7%), positive predictive value (71.5%), and kappa (0.79). Psychometric properties were mostly consistent across population subgroups.

CONCLUSIONS

Single-question assessments of medication use for depression have acceptable concurrent validity against more detailed assessments and provide an efficient method for assessing medication treatment of depression in population health surveys.

Assessing forgetfulness and polypharmacy and their impact on health-related quality of life among patients with hypertension and dyslipidemia in Greece during the COVID-19 pandemic

Purpose

We estimate the association between forgetfulness to take medications as prescribed and polypharmacy and health-related quality of life (HRQoL) among a cohort of patients with hypertension, dyslipidemia or both in Greece during the COVID-19 pandemic.

Methods

A telephone survey of 1018 randomly selected adults was conducted in Greece in June 2020. Participants were included in the survey, if they (a) had a diagnosis of hypertension, dyslipidemia or both and (b) were on prescription treatment for these conditions. HRQoL was calculated using the short form (SF) -12 Patient Questionnaire. A multivariable generalized linear regression model (GLM) was used to estimate the association between forgetfulness and polypharmacy and HRQoL, controlling for sociodemographic and health-related covariates.

Results

Overall, 351 respondents met the inclusion criteria, of whom 28 did not fully complete the questionnaire (response rate: 92%, n = 323). Of those, 37% were diagnosed with hypertension only, 28% with dyslipidemia only, and 35% with both. Most reported good to average physical (64.1%) and mental health (48.6%). Overall, 25% indicated that they sometimes forget to take their prescribed medications, and 12% took two or more pills multiple times daily. Total HRQoL score was 68.9% (s.d. = 18.0%). About 10% of participants reported paying less attention to their healthcare condition during the pandemic. Estimates of multivariable analyses indicated a negative association between forgetfulness (− 9%, adjusted β: − 0.047, 95% confidence interval − 0.089 to − 0.005, p = 0.029), taking two or more pills multiple times daily compared to one pill once a day (− 16%, adjusted β: − 0.068, 95% confidence interval − 0.129 to − 0.008, p = 0.028) and total HRQoL.

Conclusion

Our results suggest that among adult patients with hypertension, dyslipidemia or both in Greece, those who forget to take their medications and those with more complex treatment regimens had lower HRQoL. Such patients merit special attention and require targeted approaches by healthcare providers to improve treatment compliance and health outcomes.

Towards a better understanding of reasons for non-adherence to treatment among patients with rheumatoid arthritis: A focus group study

Objective:

To explore common reasons for non-adherence to treatment in patients with rheumatoid arthritis in Singapore.

Methods:

Patients diagnosed with rheumatoid arthritis for ⩾ 1 year being followed up at the Singapore General Hospital and meeting pre-defined criteria of non-adherence were invited to participate in focus groups to discuss issues related to adherence to their rheumatoid arthritis treatment. Each focus group was homogenous in terms of gender, language spoken and ethnicity. Discussions were audio recorded and subsequently transcribed verbatim for thematic analysis.

Results:

Of the 26 patients who participated in the study, seven reported non-adherence to medication, two reported non-adherence to doctors’ appointments, and 11 reported non-adherence to both. The most commonly mentioned reasons for non-adherence were forgetfulness ( n=13), low perceived need for treatment ( n=10), actual or perceived medication side effects ( n=6) and intentional delay due to busyness ( n=4). Eleven participants acknowledged more than one of these four reasons for non-adherence.

Conclusion:

There are multiple reasons for non-adherence to treatment among patients with rheumatoid arthritis in Singapore. Findings from this study provide important empirical evidence to inform strategies to improve adherence and in turn treatment outcomes for this group of patients in Singapore.

A systematic narrative review of the literature: adherence to pharmacological and nonpharmacological treatments among adolescents with mental disorders

AIMS AND OBJECTIVES

To review current research into the adherence to mental health treatment by adolescents.

BACKGROUND

Nonadherence to medication among adolescents has been studied much more extensively than nonadherence to other forms of treatment. Monitoring adherence to all recommended services is essential when assessing the long-term effectiveness of different treatment programmes. Healthcare professionals who treat patients with mental illness must be able to accurately determine which of their patients are adhering to all prescribed treatments.

DESIGN

This is a systematic narrative literature review of the current literature.

METHODS

Using a narrative synthesis, the data from 15 relevant articles concerning adolescents in inpatient or outpatient mental health care were extracted and synthesised.

RESULTS

The reviewed papers are discussed in terms of the methods used to study treatment adherence, the working definition of adherence used in each case and the results obtained concerning adherence in adolescents. Thirty-four to sixty-seven per cent of adolescents treated are fully adherent to their medication and exhibit reasonably good follow-through for the recommended treatments. However, rates of noncompliance with medication are quite high, and significant numbers of adolescents choose to discontinue their medication.

CONCLUSIONS

This review synthesises current published data on adherence to mental health treatment among adolescents in order to provide practitioners and researchers with a better understanding of this important area. It is recommended that future investigations should focus on adherence in inpatient care, adherence to nonpharmacological treatments and the identification of factors that influence adherence.

RELEVANCE TO CLINICAL PRACTICE

The monitoring and understanding of adherence to recommended services is important. Therefore, these findings can be used by healthcare professionals who treat patients with mental illness to help them assess which of their patients are adhering to the prescribed treatments.

An exploration of the experience of mental health service users when they decide they would like to change or withdraw from prescribed medications

This paper reports on a collaborative research project initiated by service user representatives and led by clinicians from the mental health service in Derbyshire. The study explored the experiences of mental health service users when they either changed or terminated their use of mental health-related medications. Three focus groups were conducted with mental health service users from across the county. An inductive thematic analysis identified six key themes, three of which are reported here: the 'two faces' of service provision, describing the positive and negative experiences of services; the general practice/mental health divide, relating to the lack of continuity between the two services; and becoming an informed service user, where participants discussed the importance of seeking information. It is important that mental health professionals always consider presenting their 'best face' to service users, and facilitate the prescribing process with general practitioners. The findings also highlight the potential for supporting service users in using different sources of information to become more informed about medication.

Supported self-management: a simple, effective way to improve depression care

OBJECTIVES

To introduce supported self-management (SSM) for depression, examine it through the use of a quality assessment framework, and show its potential for enhancing the Canadian health care system.

METHOD

SSM is examined in terms of quality criteria: relevance, effectiveness, appropriateness, efficiency, safety, acceptability, and sustainability. Critical research is highlighted, and a case study is presented to illustrate the use of SSM with depressed patients.

RESULTS

SSM is defined by access to a self-management guide (workbook or website) plus encouragement and coaching by health care provider, family member, or other supporter. It has high relevance to depression care in Canada, high cost-effectiveness, high appropriateness for most people with depression, and high safety. Acceptability of this intervention is more problematic: many providers remain doubtful of its acceptability to their poorly motivated patients. Sustainability of SSM as a component of mental health care will require ongoing knowledge exchange among policy-makers, health care providers, and researchers.

CONCLUSION

The introduction of SSM represents a unique opportunity to enhance the delivery of depression care in Canada. Actively engaging the distressed individual in changing depressive patterns can improve outcomes without mobilizing substantial new resources. Over time, we will learn more about making SSM compatible with constraints on provider time, increasing access to self-management tools, and evaluating the benefit to everyday clinical work.

Barriers to achieving treatment goals: a focus on sleep disturbance and sexual dysfunction

BACKGROUND

Patients who meet the criteria for a major depressive episode experience a constellation of symptoms, and different symptom configurations may reflect distinct underlying neurological disturbances. Similarly, the differing receptor profiles of the various antidepressants may explain relatively low remission rates and persistent symptoms even after remission. In particular, depressed patients frequently display altered circadian rhythms, sleep disturbances, and diurnal mood variation. Exploring treatments that can restore mood while having a positive impact on circadian rhythms and sleep would greatly improve the ability to treat this core features of depression.

METHODS

The mechanisms of action of the various classes of antidepressants, their effects on sleep and issues beyond sleep, including sexual dysfunction, are explored, along with questions relating to adherence.

RESULTS

Unfortunately, persistent sleep problems are among the most difficult-to-treat residual symptoms of depression. Many of the currently available antidepressants have adverse effects on circadian processes, including sleep, and may actually worsen sleep problems. Tolerability is also an enduring issue; SSRI and SNRI antidepressants are associated with central nervous sysytem and gastrointestinal effects, sexual side effects and suicidality. Improved drug tolerability would not only minimize distressing adverse effects, but would also improve adherence, thus maximizing the chances of successful treatment.

CONCLUSIONS

The complexity of managing a major depressive episode is well illustrated by sleep disturbance and sexual dysfunction, two core symptoms of MDD that may also be caused or exacerbated by antidepressant therapy. Future antidepressants should alleviate symptoms without adversely affecting sleep or sexual function.

Knowledge of and attitudes towards depression and adherence to treatment: the Antidepressant Adherence Scale (AAS)

BACKGROUND

Non-adherence to treatment can result from forgetting, carelessness, stopping the drug when feeling worse, or stopping the drug when feeling better.

OBJECTIVE

To develop and psychometrically assess a brief instrument that can be easily used in clinical practice to measure adherence to antidepressants.

METHOD

We developed the Antidepressants Adherence Scale (AAS); a self report rating scale including four items to assess the degree to which forgetting, carelessness, and stopping due to feeling worse or feeling better interfere with adherence in the last 4 weeks. Our proposed four-item adherence instrument was developed based on previous research and theory.

PARTICIPANTS

Experts in mood disorders (n=12) participated in the formal validity assessment of the instrument, and the developed instrument was administered to patients who were prescribed antidepressants (n=63). All patients also completed a multiple choice question instrument to measure knowledge of depression, and a Likert self report questionnaire to assess attitudes towards depression and its treatment.

RESULTS

There was 90% agreement among experts that the items were highly relevant providing strong evidence for content validity. Also, there was empirical evidence for validity. There were significant correlations (p<0.05) between knowledge and attitude subscales and adherence items. The internal consistency reliability (Cronbach's alpha) was 0.66 for the instrument.

CONCLUSION AND SIGNIFICANCE

Knowledge of and attitudes to depression and its treatment may have significant impact on the adherence to antidepressants. The AAS can be used in clinical settings (2-3 min to administer) to evaluate patients' adherence to antidepressants.

Achieving adolescent adherence to treatment of major depression

When treatments are ordered for adolescent major depression, or for other adolescent medical illnesses, adherence and clinical outcomes are likely to be unsatisfactory, unless 4 basic principles of the medical treatment of adolescent illness are implemented. These comprise providing effective patient and parent/caregiver education, establishing effective patient and caregiver therapeutic alliances, providing effective treatment, and managing other factors associated with treatment adherence as indicated. The goals of treatment are to achieve the earliest possible response and remission. Failure to treat adolescent major depression successfully has potentially serious consequences, including worsened adherence, long-term morbidity, and suicide attempt. Accordingly, prescribed treatment must be aggressively managed. Doses of an antidepressant medication should be increased as rapidly as can be tolerated, preferably every 1-2 weeks, until full remission is achieved or such dosing is limited by the emergence of unacceptable adverse effects. A full range of medication treatment options must be employed if necessary. Treatment adherence, occurrence of problematic adverse effects, clinical progress, and safety must be systematically monitored. Adolescents with major depression must be assessed for risk of harm to self or others. When this risk appears significant, likelihood of successful outcomes will be enhanced by use of treatment plans that comprehensively address factors associated with treatment nonadherence. Abbreviated and comprehensive plans for the treatment of potentially fatal adolescent illnesses are outlined in this review.

Non-adherence with psychotropic medications in the general population

BACKGROUND

Non-adherence with medications is a general medical issue that has received much attention. However, the majority of studies have been on various clinical populations and the relevance of their results to the general population is unknown. In this study, we sought to determine the degree of non-adherence with antidepressants, antipsychotics, anxiolytics, mood stabilizers and sedative hypnotics, and to determine the reasons for non-adherence, in the general population of Canada.

METHODS

We used data from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2), conducted in 2002 (n = 36,984 adults), to produce population-based estimates of the degree of reported non-adherence with psychotropic medications and the reasons for non-adherence.

RESULTS

The number of individuals taking psychotropic medications was 6,201. The prevalence of antipsychotic use over the last 12 months was estimated at 0.4% (95% CI 0.3-0.4). The corresponding estimates for sedative-hypnotics, anxiolytics, mood stabilizers and antidepressants were 10.2% (95% CI 9.8-10.7), 5.5% (95% CI 5.2-5.8), 1.1% (1.0-1.3) and 5.8% (95% CI 5.5-6.2), respectively. Non-adherence was estimated to be 34.6% (95% CI 25.5-44.9) for antipsychotics, 34.7% (95% CI 32.2-37.4) for sedative-hypnotics, 38.1% (95% CI 35.0-41.4) for anxiolytics, 44.9% (95% CI 38.1-51.9) for mood stabilizers and 45.9% (95% CI 43.1-48.7) for antidepressants. The degree of non-adherence decreased with age for antidepressants and anxiolytics. Forgetting was the main reported reason for non-adherence, but its degree varied with medication class. The proportion of respondents that reported forgetting as a reason was 36.3% (95% CI 32.0-40.8) for sedative-hypnotics, 46.7% (95% CI 41.3-52.2) for anxiolytics, 72.7% (95% CI 55.5-85.0) for antipsychotics, 74.2% (95% CI 64.0-82.3) for mood stabilizers and 74.5% (95% CI 70.7-77.9) for antidepressants. The degree of non-adherence and the frequency of forgetting were not associated with the level of interference by the associated condition with usual activities. The majority of these estimates were also not impacted by educational status, employment status, rural/urban residence, income or the presence of a comorbid physical condition.

CONCLUSION

A high frequency of non-adherence was found with all five classes of psychotropic medication. Both the frequency of reported non-adherence and the reasons reported for it differ according to the medication. However, the degree of non-adherence was not affected by the level of interference of the associated condition.

Depression, medication adherence, and service utilization in systemic lupus erythematosus

OBJECTIVE

Forgetting to take medications is an important cause of nonadherence. This study evaluated factors associated with forgetting to take medications in a large cohort of persons with systemic lupus erythematosus (SLE) participating in the University of California, San Francisco Lupus Outcomes Study (LOS). Relationships among adherence problems and service utilization (outpatient visits, emergency department visits, and hospitalizations) were also evaluated.

METHODS

The cohort consisted of 834 LOS participants who provided self-reported frequency of forgetting to take medications as directed. Predictors of adherence and service utilization patterns included self-reported sociodemographics, disease-related characteristics (e.g., disease activity, recent SLE flare), and mental health characteristics (Center for Epidemiologic Studies Depression Scale and cognitive function screen). Health care utilization patterns included the presence and quantity of visits to rheumatologists, primary care physicians, other care providers, emergency departments, and hospitalizations.

RESULTS

Forty-six percent of the LOS cohort reported forgetting to take medications at least some of the time. Depressive symptom severity was a strong predictor of adherence difficulties (odds ratio [OR] 1.04, 95% confidence interval [95% CI] 1.02-1.05; P < 0.0001) after accounting for all other predictors. Persons reporting adherence difficulties had significantly greater numbers of outpatient rheumatology and primary care visits, and were more likely to visit the emergency department (OR 1.45, 95% CI 1.04-2.04; P = 0.03).

CONCLUSION

Depression may be an important cause of medication adherence problems, and difficulties with adherence are significantly associated with high-cost service utilization, specifically emergency department visits. In an era of rapidly evolving treatments for lupus, identifying patients at risk for adherence problems may decrease medical expenditures and improve patient outcomes in SLE.

Medication use and nonadherence to psychoactive medication for mental health problems by community-living Canadian seniors with depression

OBJECTIVES

To determine the relation between level of depression and psychoactive medication use and nonadherence in Canadian seniors, given that late-life depression is a common, serious mental health problem in Canada.

METHODS

Canadian Community Health Survey-Mental Health and Well-Being respondents aged 65 years and older (n = 7,736) comprised the study sample. Using the Composite International Diagnostic Interview to assess depressive symptoms, we created 4 depression levels to capture a spectrum of depressive disorders and (or) symptoms: major depression, comorbid major depression, depressive symptoms, and no depressive symptoms. Psychoactive medications assessed included sleep aids, anxiolytics, and mood stabilizers and (or) antidepressants (AD). Nonadherence was defined as either not taking medication as recommended or taking medication at a lower dosage than prescribed.

RESULTS

In total, 22.5% of respondents took psychoactive medication for a mental health problem in the previous 12 months. Psychoactive medication use was 46.8% for major depression, 43.1% for comorbid major depression, 34.0% for depressive symptoms, and 17.6% for no depressive symptoms. Rates of psychoactive medication use ranged from 46.5% of those with major depression, to 17.6% of those with no depressive symptoms. Overall, the rate of nonadherence to psychoactive medication was 31%; rates were highest among those with depressive symptoms (37.4%) and lowest among those with no depressive symptoms (27.4%). All 3 depressive categories were associated with greater odds of use and nonadherence.

CONCLUSION

All 3 depression categories were associated with increased use of and nonadherence to psychoactive medication; however, rates of AD and (or) mood stabilizer use for clinically significant depression were low.

Behavioural Interventions in Primary Care: An Implementation Trial

Developing effective strategies to keep health care providers' practice current with best practice guidelines has proven to be challenging. This trial was conducted to determine the potential for using brief educational sessions to generate significant change in physician delivery of mental health and substance use interventions in primary care. A 1-hour educational session outlining interventions for depression and risky alcohol use was delivered to a sample of 85 family physicians. The interventions used a supported self-management approach and included free patient access to appropriate selfmanagement resources. The study initially evaluated physicians' implementation of these interventions over a 2-month period. Physician uptake of the depression intervention was significantly greater than uptake of the risky-drinking intervention (32% versus 10%). A follow-up at 6-months posttraining (depression intervention only) demonstrated fairly good maintenance of intervention delivery. Implications of these findings are discussed.

Non-remission of depression in the general population as assessed by the HAMD-7 scale

Remission from the symptoms of depression is the optimal outcome for depression treatment. Many studies have assessed the frequency of treatment, but there are none that have estimated the frequency of treated remission in the general population. We addressed this issue in the population of Alberta using a brief Hamilton Depression Rating Scale (HAMD)-7 scale (recently validated against the HAMD-17 scale in a clinical setting) that has been proposed as a suitable indicator for remission in primary care. We used data from a survey conducted within the Alberta Depression Initiative in 2005 (n=3,345 adults), to produce a population-based estimate of the number of respondents taking antidepressant medication for depression. From this group we selected a subpopulation that did not screen positive when the MINI module for major depression was administered (i.e., who did not have an active episode). Non-remission in this subpopulation was assessed with a version of the HAMD-7 scale adapted for telephone administration by a nonclinician. Of the survey respondents, 189 reported taking antidepressant medication for depression. Of these, 115 were found not to have an active episode. However, 49.0% of this subpopulation was not in remission as evaluated by the HAMD-7. We estimate that 1.3% (95% confidence interval, 0.9-2.0%) of the population is in treated non-remission for depression. Our study indicates a substantial degree of non-remission from depression in individuals taking antidepressants in the general population. This suggests that, in addition to increasing the frequency of treatment, increasing the effectiveness of treatment can have an impact on population health.