Study Homes In on Patients' Beliefs Affecting Antidepressant Adherence

Adherence promotion strategies based on patients' perceptions of necessity and harmfulness may be particularly worthwhile, according to Aikens, who is also associate professor of family medicine at the University of Michigan Health System.

Clinicians are well advised to assess both perceptions (necessity and harmfulness), and if one of them is putting the patient at risk for nonadherence, then they could address some of these concerns, he said.

"Belief-focused interventions to enhance adherence may be maximally effective if oriented toward patients who: (1) underestimate their symptom severity; (2) believe that their symptoms will be temporary despite past experiences to the contrary; (3) have not previously taken antidepressants; (4) believe that their symptoms are randomly caused; or (5) feel subjectively bewildered by their symptoms," Aikens and colleagues wrote in their journal article.

Clinical intervention
The article presented some examples of clinician interventions that could improve adherence. Because antidepressant-naive patients may be relying on information from the media, anecdotes from others, or their own experience with nonpsychotropic medications, Aikens' team recommended that clinicians clarify such patients' specific concerns. These concerns could include adverse effects, addiction, personality change, cost, and/or stigma. Then clinicians could offer treatment alternatives or additions that respect these sensitivities, such as adopting a conservative dosage and titration schedule or providing educational input.

There are numerous resources for education, Aikens said. They include support groups, online literature that the clinician has prescreened, and firsthand anecdotal accounts both online and in print form.

For patients who believe their symptoms are mild and transient, Aikens said, clinicians might want to talk with them about the typical chronicity of depression and the past impact of their symptoms.

On the other hand, he added, clinicians need to be open to the idea that the patient may be right—that the symptoms are transient, that an antidepressant is not warranted, and that the risk-benefit analysis is not favorable. For example, he said, "a patient may be presenting with a purely situation-driven set of distress symptoms that may have lasted for more than 2 weeks." Just as the situation may be transient or changeable, the symptoms may be transient as well. In those cases, he said, caution is recommended, since antidepressant therapy has certain risks, including sexual dysfunction, nausea, flattened affect, and agitation.

"Even depression that does not appear to be environmentally linked could very well be transient and best treated through watchful waiting. Studies of depression in primary care have proved that repeatedly," he added.

Aikens emphasized that the data his team has gathered could lead to the development of new belief-based adherence promotion strategies for clinicians as well as for those conducting clinical trials. These investigators are currently designing interventions based on assessment, monitoring, addressing beliefs, and/or pharmacological tailoring.

"We are preparing trials, and are currently doing some pilot work to define and refine cognitive and system interventions based the notion that these 2 key beliefs may be primary drivers of nonadherence," he said.