Most people don't stay the course with antidepressants

Most people who take antidepressants give them up before they are supposed to. Researchers from the Catalan Institute of Health studied 7,525 people who were starting antidepressant treatment. They found that 56% stopped taking their medication during the first four months and only 25% continued their treatment for more than 11 months. Only 22% of the sample completed their treatment although women were more likely to carry on taking the pills than men and those who took more than one kind of medication stuck with their pills better than those who just took antidepressants. Doctors recommend taking antidepressants for at least six months.

Non-adherence and crisis in Newcastle

In the U.K. people with mental-health problems who are very ill are referred by community mental-health services to crisis-resolution home treatment (CRHT) services which decide whether to treat them themselves or to refer them on to hospital. Both these things are very expensive so anything which cuts down on their use could potentially save a lot of money. Researchers from Northumberland Tyne and Wear NHS Trust and Newcastle University looked into the impact of non-adherence (people not taking their drugs properly) on referral to CRHTs. They found that 30% of people referred to CRHTs had not been taking their medication properly in the month beforehand. These people were three times as likely to have a drug problem as well as a mental-health one and were two-and-a-half times as likely to be admitted to a psychiatric hospital.

Sreenath, San ... [et al] - Medication adherence in crisis? Journal of Mental Health, October 2010; 19(5): 470–474

Poor drug taking sends people into crisis

In the U.K. people who might previously have been admitted to a psychiatric hospital are now often referred to Crisis Resolution Home Treatment (CRHT) services who decide whether to treat people themselves or send them on to hospital. CRHTs are an expensive service so finding out what factors make people likely to be referred to them is quite important. One factor that leads people's mental health to go downhill is not taking their medication but there has been little research into how this affects referrals to CRHTs so far. A team of researchers from Northumberland Tyne and Wear NHS Trust and Newcastle University looked at this issue in a study of 172 referrals to a CRHT. They found that 30% of the referrals had not taken their medication properly in the last month. These people were significantly more likely to have a dual diagnosis - i.e. a drug problem as well as a mental-health problem.

Sreenath, San ... [et al] - Medication adherence in crisis? Journal of Mental Health October 2010, 19(5), 470-474

Compliance and motivational interviewing

Non-compliance, or non-adherence (people not taking their medication) is a big worry for health professionals. This problem is particularly bad among people with schizophrenia where the rates of non-compliance are estimated at between 40-53% depending on the definition used. Motivational interviewing is sometimes used to improve compliance. It attempts to get over people's mixed feelings about changing their behaviour by bringing out their inner motivation to change. It has been used to get people with diabetes and asthma to take their medication, to treat drink and drugs problems and to get people to eat more healthily and take more exercise. Researchers from Marquette University in Wisconsin, U.S. carried out a review of studies into the effectiveness of motivational interviewing at improving compliance among people with schizophrenia. They found only five studies between 1965 and 2006. Two of them showed that motivational interviewing was effective but the other three found that it made no difference. The researchers concluded that the small sample of studies and their methodological limitations made it difficult to draw any meaningful conclusions.

Drymalski, Walter M. and Campbell, Todd C. - A review of motivational interviewing to enhance adherence to antipsychotic medication in patients with schizophrenia: evidence and recommendations Journal of Mental Health February 2009, 18(1), 6-15

Child psychology dropouts

People dropping out of treatment is a significant issue in all mental-health services but particularly so in child and adolescent mental-health services, with previous studies reporting dropout rates of between 28-75%. Dropping out can affect the effectiveness of treatment and lead to considerable costs for mental-health services. Researchers in Australia reviewed the files of 520 cases over a 12-month period and looked at the relationship between diagnosis and drop-out rate. Clients experiencing family problems, conduct disorder and ADHD were more likely to drop out of treatment whereas children experiencing negative life events, anxiety disorders and with no diagnosis were least likely to drop out.

Johnson, Emily, Mellor, David and Brann, Peter - Differences in dropout between diagnoses in child and adolescent mental health services Clinical Child Psychology and Psychiatry October 2008, 13(4), 515-530

Risk factors for medication non-adherence

Antipsychotic medications are a cornerstone of treatment and recovery for people with schizophrenia. However, many people have difficulty adhering to prescribed treatments and the average rate of non-adherence for schizophrenia is 50%. Failure to take medication is the most important risk factor leading to relapse and can result in a fivefold increase in the rate of relapse. An Australian study of 81 service users looked into the factors behind medication omission, including the participants' levels of insight into their condition and their experience and feelings of stigma as a consequence of their mental illness. Most participants had insight into their illness and were aware of the stigma attached to it. Around 70% of them had experienced annoying side effects while nearly half admitted alcohol consumption. About a fifth admitted they had missed taking medication in the previous week. A younger age, the perception of negative side effects and lack of access to a psychiatrist all made it less likely that people would adhere to their medication.

McCann, T.V.., Boardman, G. and Clark, E. - Risk profiles for non-adherence to anti-psychotic medications Journal of Psychiatric and Mental Health Nursing October 2008, 15(8), 622-629

Medication adherence and antidepressants

Major depression is a pervasive and debilitating mental disorder that affects families and individuals throughout their lives. The prevalence of major depression is 2.9% in Western societies with 12.6% of people suffering from minor depression. Antidepressants can be highly effective but it is important that patients keep taking them for four-to-six months with those people most at risk taking them for at least a year. However, patients with major depression do not always stick to their medication regimes which can drastically reduce the effectiveness of the drugs. A Taiwanese study of 181 patients looked at their compliance with their medication. About 50% of the patients reported good medication adherence. The predictors of adherence to medication were a higher income (even though patients do not pay for these drugs in Taiwan), a feeling that the antidepressants were effective and an understanding of the importance of continuing to take the drugs.

Yeh, Mei-Yu ... [et al] - Predictors of adherence to an antidepressant medication regimen among patients diagnosed with depression in Taiwan Issues in Mental Health Nursing 29(7), 701-717

Treatment compliance - second generation antipsychotics fail to live up to their promise

Long-term maintenance anti-psychotic treatment remains the most reliable means of preventing relapses, minimizing mortality and illness and ensuring independent living in people being treated for schizophrenia. However, treatment non-adherence remains a significant concern with the reported rates of non-adherence varying between 24-90% depending on the kind of patients being treated. One of the causes of non-adherence to treatment is the side effects of drugs. Second generation anti-psychotics were thought to have at least partially overcome this problem as they have fewer side effects than earlier drugs. However, a review of studies into compliance with treatment for schizophrenia has found that 'the data have failed to substantiate the notion that novel antipsychotic drug use leads to improved medication compliance and favourable clinical outcomes'.

Voruganti, Lakshmi P., Baker, Laura K. and Awad, George A. - New generation antipsychotic drugs and compliance behaviour Current Opinion in Psychiatry March 2008, 21(2), 133-139

Antidepressants, beliefs and adherence

Although most guidelines about depression recommend continuation of medication for at least 8 months after symptom remission 50-80% of patients prescribed antidepressants either discontinue their medication prematurely or take it too inconsistently to derive any clinical benefit, which appears to increase the risk for relapse and recurrence. A large body of literature indicates that patients' beliefs and attitudes about medication predict medication adherence and treatment outcome. Despite this growing literature little is known about what underlies patients' beliefs about antidepressants. A U.S. study of 165 patients found that perceived necessity of antidepressants was associated with older age, more severe symptoms, longer anticipated duration of symptoms and the attribution of symptoms to a chemical imbalance. Perceived harmfulness was highest among patients who had not taken antidepressants before, who attributed their symptoms to random factors and who had an unclear understanding of depression. Neither belief - in the necessity or harmfulness of antidepressants - was significantly associated with sex, education, age at first depressive episode, presence of melancholia or anxiety, other mental-health problems or clinical settings.

Aikens, James E., Nease, Donald E. and Klinkman, Michael S. - Explaining patients' beliefs about the necessity and harmfulness of antidepressants Annals of Family Medicine 2008, 6: 23-29

Interventions for adherence

Research supports the effectiveness of numerous pharmacological and psychosocial interventions for helping individuals with serious mental illness reduce psychiatric symptoms and build more satisfying and productive lives. Treatment non-adherence, however, remains a major obstacle to recovery with between forty and sixty per cent of people with a severe mental illness failing to engage in aftercare treatment. Non-adherence is associated with more serious symptoms, suicidality, violent behaviour, functional limitations, higher relapse rates and hospital recidivism. A team of researchers from Chicago looked at 31 studies into interventions designed to prevent non-adherence to treatment. They found that assertive/intensive case management improved outpatient treatment retention and that behavioural therapy enhanced medication adherence.

Lehner, Renanah K. ... [et al] - Outpatient treatment adherence and serious mental illness : a review of interventions American Journal of Psychiatric Rehabilitation 10(4), 245-274

Side effects and medication compliance in people with depression

People taking drugs for mental-health problems often stop taking their medication. It is thought this is, at least partially, due to the side effects of the drugs but the exact relationship between side effects and non-adherence to medication is unclear. An eighteen-month U.S. study of 406 people between 18 and 75 followed them up three months after their admission for depression to see what side effects they had suffered and whether they were still taking their medication. One in four of the patients had stopped taking their drugs. Among the side effects noted only 'change in weight' and 'anxiety' were significant predictors of discontinuation. Experiencing one or more 'extremely' bothersome side effect(s) was associated with a doubling of the risks of discontinuation but side effects less severe than this were not significant predictors. There were no differences among the antidepressants in terms of side effects or discontinuation rates.

Goethe, John W. ... [et al] - Selective serotonin reuptake inhibitor discontinuation : side effects and other factors that influence medication adherence Journal of Clinical Psychopharmacology October 2007, 27(5), 451-458

Medication adherence - older patients stay the course

An increasing amount of research has identified treatment non-adherence as a pervasive problem that can lead to relapse and hospitalization. Around 40% of patients with bipolar disorder do not adhere to their medication but there has been little research into whether older patients are more or less likely to adhere to their treatment than younger ones. A study of 32,991 people in the U.S. compared adherence to antipsychotic medication in older (over 60) and younger patients with bipolar disorder. The researchers found that among the older group 61% were fully adherent, 19% were partially adherent and 20% were non-adherent compared to 49.5%, 21.8% and 28.7% respectively for the younger patients. The researchers measured adherence by comparing the medication the patients had actually been given to the medication they should have received had they been taking all their pills. For both groups of participants drug abuse and homelessness had a negative effect on treatment adherence.

Sajatovic, Martha ... [et al] - Age comparison of treatment adherence with antipsychotic medications among individuals with bipolar disorder International Journal of Geriatric Psychiatry October 2007, 22(10), 992-998

Religion, schizophrenia and adherence to treatment

Despite overwhelming evidence for its effectiveness many people with schizophrenia do not continue to take their medication. Medication non-adherence among patients with schizophrenia ranges from 50%-60% in the first year after being discharged from hospital. There is a growing amount of literature suggesting that religion and spirituality may help people cope better with schizophrenia but there has been no research into how they affect people's adherence to medication. A study of 103 people with schizophrenia in Geneva has found that two thirds of them considered spirituality to be very important or even essential in everyday life. 57% of patients had ideas about their illness directly influenced by their spiritual beliefs (31% positive and 26% negative). However, 31% of non-adherent patients and 27% of partially-adherent patients saw an incompatibility or contradiction between their religion and taking medication, compared to only 8% of the adherent patients.

Borras, L. ... [et al] - Religious beliefs in schizophrenia : their relevance for adherence to treatment Schizophrenia Bulletin September 2007 33(5), 1238-1246