Understanding Medication Discontinuation in Depression
By Alex J. Mitchell, MBBS, MSc, BMedSci |
April 1, 2007
Dr Mitchell is consultant and senior lecturer in liaison psychiatry at the Leicester Royal Infirmary in the United Kingdom. He reports that he has no conflicts of interest regarding the subject matter of this article.
The role of the physician
The potential for physicians to reduce unexpected discontinuations is often more signficant than many imagine. Conversely, the potential for physicians to do nothing is also high. This is even with the knowledge that of all those who discontinue medication, 60% have not informed their doctor by 3 months, and a quarter have not done so by 6 months. Thus, all physicians must maintain a high index of suspicion for possible treatment-emergent problems (adverse events and missed medication)—but this should be manifested in a supportive rather than doubting manner.
Simply discussing the possibility of an adverse event reduces the rate of unanticipated discontinuation by half. Similarly, the chance of discontinuation is about 60% less in patients who are simply told to take medication for at least 6 months, compared with those who did not recall being given this information.50 Like most patients, those who have depression want to be involved in decision making.51,52 Indeed, there is some evidence that adherence improves if more relevant information is given.53 Yet analysis of doctor-patient discourses illustrates that clinicians only ask about 1 of 5 patients how well their antidepressants are working and only 1 of 10 patients if they are experiencing any adverse effects.54
Two recent studies analyzed audio recordings of interactions between 152 physicians (internists and primary care) and patients for whom antidepressants were prescribed. Loh and coauthors55 observed 34 primary care physicians in Freiburg, Germany. Only 5% of time was spent discussing treatment options and information about these options. Young and colleagues56 discovered a mixed picture of communication. Whereas drug purpose and side effects were usually mentioned, barriers to use and "what to do if you miss a dose" were mentioned less than 2% of the time.
Furthermore, advice to continue to take the medicine even when feeling better and advice to continue to take the medication until further review were discussed in only 5.4% and 3.9% of the visits, respectively. Physicians provided information about the duration of antidepressant treatment in 35% of interactions, which is interesting because investigators had previously found that although 71% of physicians claimed to specify treatment duration, 64% of patients recalled no such instructions.50 This has led some to suggest it is physician behavior that is the major remediable barrier to poor concordance.57
Most patients for whom an antidepressant is prescribed will experience some kind of problem with insufficient information, adverse effects, or lack of efficacy. This often leads to missed doses of medication and later discontinuation. Rather than being an aberration, I suggest that partial nonadherence should be considered normal. Missing doses and even stopping completely may be the most rational approach to health, given patients' understanding of their illness and the information available to them.58 As a consequence, many patients for whom medication is prescribed to be taken regularly will, in fact, take their medication "as required," ie, for symptomatic relief only.59 This may well conflict with evidence-based guidance to continue medication for 6 months or longer once well to prevent future relapse.2
Physicians who are alert to patients' medication problems and patients who are considering stopping medication will be able to discuss alternatives that prevent unmonitored discontinuation. Patients who have difficulty in remembering to take their medication might be helped by simple reminder systems. Both partial nonadherence and discontinuation can be helped by enhanced collaborative care for depression.
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