Antidepressants and Nonadherence
They forget; they are not able to come up with the money for the refill; or they can't abide the side effects. Maybe they're feeling quite nice and don't see a reason to continue. Or perhaps the opposite is true--they're feeling hopeless and cannot see how any medication could possibly help.
The motives for nonadherence to antidepressant medicines are vast and complicated, representing a number of of the most challenging conundrums psychiatrists in clinical practice have to face.
"Beyond the primary explanations, there are several complex concerns that need to be considered," said Doctor. Carl B. Greiner in an interview.
Among them is the chance that stopping the medicine is a signal of "not liking the physician or basic disagreement about the therapy."
"The affected person can exercise power by not following advice," noted Dr. Greiner, professor of psychiatry and vice chair of medical affairs at the University of Nebraska's College of Medicine in Omaha.
Another possibility is that the patient might have suffered side effects from an antidepressant in the past and fears the same result.
"If the health practitioner does not inquire, the patient may merely not even fill the prescription," he stated. "The point is that the physician needs to deliberate broadly and communicate with the patient to figure out what brought them to [never start] or to stop the medication. The patient may not state the reason, but the offer of a discussion is a fine beginning."
The literature offers opinion on concerns underlying nonadherence, but no plain guidance on how to improve acquiescence.
Findings from research show that 50% to 75% of patients quit taking their antidepressants within six months of receiving a prescription.
In one big observational cohort review, patients treated by psychiatrists fared somewhat better in respect to adherence than did those taken care of by primary care physicians or other specialists. Nevertheless, 13% of psychiatrists' patients were immediately noncompliant (never refilling an antidepressant prescription), and 49% failed to finish 6 months of therapy even subsequent to refilling a prescription at least on one occasion (J. Clin. Psychiatry 2007;68:867-73).
Many reviews have tested risk factors for discontinuing antidepressants early on in the course of treatment, rather consistently pointing to increased nonadherence rates in the extremely young and very elderly, patients with comorbid psychiatric or physical conditions, substance users, lower earnings and less skilled patients, and the ones who are not similtaneously undergoing psychoanalysis.
Side effects, especially sexual side effects, emerge as significant barriers to sustained therapy.
But so, increasingly, is expenditure.
"The patient might cut back on utilization to prolong the prescription," Dr. Greiner said. "A more dire concern [for the patient] is whether or not to take the medicine or buy essentials such as food."
Even in Canada, where medication costs are not an important issue , noncompliance rates are substantial.
A telephone study of 5,323 adults carried out in the province of Alberta found noncompliance rates of between 42% and 47% in patients prescribed between one and three antidepressants (Can. J. Psychiatry 2006;51:719-22).
The chief explanation given for failing to comply, provided by close to 65% of patients prescribed one medication in the study, was absentmindedness, a possible symptom of major depressive disorder.
Additional factors directly connected to depressive indicators also could interfere with compliance.
Deep in the control of a depressive episode, "Some individuals think, "Why bother? It won't help, besides,' " stated Dr. Ellen Haller, professor of clinical psychiatry and director of the general adult residency education program at the University of California San Francisco's division of psychiatry.
"That sense of helplessness and hopelessness, which is a symptom of the condition, can also get in the way of people accepting help," she said.
Social stigma commonly prompts patients to quit taking their medicines, when family or acquaintances suggest that sustained utilization will lead to being "addicted" to antidepressants, she added.
"Once somebody stops taking their antihypertensive, and then their hypertension returns, no one states, 'You must be addicted to that antihypertensive.' But, if the identical situation happens with depressive disorder, people often do acquire the belief that they must be addicted, or people close to them take that belief.
"So, education, education, education!" Dr. Haller said.
Dr. Greiner said stigma also is at the root of helplessness conferred by the application of psychiatric medications in various populations, since it could be interpreted as "proof" that someone is "crazy."
"In penitentiary populations, some steer clear of taking drugs because it might be a sign of vulnerability to fellow inmates. In certain households, taking medication might be an indicator that the affected person does not need to be considered in conversations," he said.
Even patients suffering profound indicators may perhaps persuade themselves that if they are no longer taking medicines, their symptoms do not represent psychiatric illness.
Clearly, such beliefs require involved counseling and psychoeducation, sometimes involving family members as well as patients. These approaches take up more time than doing a concise assessment and writing a prescription, but they might translate into a more suitable result both in the short and long duration, psychiatrists interviewed for this article stated.
"I genuinely work vigorously to ensure that my patients are informed about depression and its fundamental history, and that they know the data regarding possibilities of reversion or recurrence," Doctor. Haller said. "I also, nonetheless, collaborate closely with them to minimize side effects as much as conceivable and to fight the stigma they might feel."
Paradoxically, a patient might have to undergo a relapse or recurrence to understand the significance of fastidiously taking medication as directed and for the time period recommended.
When clinical depression resurfaces, "at least in my practice ... they are more amenable to ongoing medication management," Dr. Haller said.
Neither Dr. Greiner nor Dr. Haller disclosed any pertinent fiscal conflicts of interest.