Antidepressant Adherence Research Articles

Is treatment adherence consistent across time, across different treatments and across diagnoses?

ObjectiveThe objective was to examine consistency of adherence across depression treatments and consistency of adherence between depression treatments and treatments for chronic medical illness. MethodsFor 25,456 health plan members beginning psychotherapy for depression between 2003 and 2008, health plan records were used to examine adherence to all episodes of psychotherapy, antidepressant medication, antihypertensive medication and lipid-lowering medication. ResultsWithin treatments, adherence to psychotherapy in one episode predicted approximately 20% greater likelihood of subsequent psychotherapy adherence [odds ratio (OR)=2.20, 95% confidence interval (CI) 1.83–2.64]. Similarly, adherence to antidepressant medication in one episode predicted approximately 20% greater likelihood of subsequent antidepressant adherence (OR=1.99, 95% CI 1.74–2.28). Across treatments, adherence to antidepressant medication predicted approximately 10% greater likelihood of concurrent or subsequent adherence to psychotherapy (OR=1.52, 95% CI 1.42–1.63), a 4% greater likelihood of adherence to antihypertensive medication (OR=1.24, 95% CI 1.14–1.37) and a 3% greater likelihood of adherence to lipid-lowering medication (OR=1.16, 95% CI 1.03–1.32). Adherence to psychotherapy predicted a 2% greater likelihood of concurrent or subsequent adherence to antihypertensive medication (OR=1.11, 95% CI 1.04–1.19) and was not a significant predictor of adherence to lipid-lowering medication (OR=0.99, 95% CI 0.90–1.18). ConclusionsAdherence is moderately consistent across episodes of depression treatment. Depression treatment adherence is a statistically significant, but relatively weak, predictor of adherence to antihypertensive or lipid-lowering medication.

Correlates of Antiretroviral and Antidepressant Adherence Among Depressed HIV-Infected Patients

Although crucial for efficacy of pharmacotherapy, adherence to prescribed medication regimens for both antiretrovirals and antidepressants is often suboptimal. As many depressed HIV-infected individuals are prescribed both antiretrovirals and antidepressants, it is important to know whether correlates of nonadherence are similar or different across type of regimen. The HIV Translating Initiatives for Depression into Effective Solutions (HI-TIDES) study was a single-blinded, longitudinal, randomized controlled effectiveness trial comparing collaborative care to usual depression care at three Veterans Affairs HIV clinics. The current investigation utilized self-report baseline interview and chart-abstracted data. Participants were 225 depressed HIV-infected patients who were prescribed an antidepressant (n=146), an antiretroviral (n=192), or both (n=113). Treatment adherence over the last 4 days was dichotomized as "less than 90% adherence" or "90% or greater adherence." After identifying potential correlates of nonadherence, we used a seemingly unrelated regression (SUR) bivariate probit model, in which the probability of adherence to HIV medications and the probability of adherence to antidepressant medications are modeled jointly. Results indicated that 75.5% (n=146) of those prescribed antiretrovirals reported 90%-plus adherence to their antiretroviral prescription and 76.7% (n=112) of those prescribed antidepressants reported 90%-plus adherence to their antidepressant prescription, while 67% of those prescribed both (n=113) reported more than 90% adherence to both regimens. SUR results indicated that education, age, and HIV symptom severity were significant correlates of antiretroviral medication adherence while gender and generalized anxiety disorder diagnosis were significant correlates of adherence to antidepressant medications. In addition, antiretroviral adherence did not predict antidepressant adherence (β=1.62, p=0.17), however, antidepressant adherence did predict antiretroviral adherence (β=2.30, p<0.05).

Age Group Differences Among Veterans Enrolled in a Clinical Service for Behavioral Health Issues in Primary Care

: To examine age group differences in the identification, engagement, clinical outcomes, and monitoring of older, relative to middle aged and younger, veterans with behavioral health needs enrolled in an integrated care management program : Cross-sectional and longitudinal : Primary care clinics affiliated with two Veterans Affairs Medical Centers : A total of 9,087 veterans were referred to the Behavioral Health Laboratory (BHL) for a behavioral health assessment and 7,251 completed an initial assessment : Data on consult source and reason for the referral, clinical assessment outcomes, and engagement were collected during a 3-year period. Variations in process and patient-level factors were examined as a function of age group. : Although all age groups evidenced high rates of engagement in clinical assessment calls, older adults were slightly more likely to complete the assessments than young/middle-aged veterans. Clinical assessment outcomes revealed that although older adults were less likely to meet criteria for more complex, severe conditions, rates of disorder remained clinically significant, and comorbidity was common. Finally, older veterans receiving treatment monitoring for a newly prescribed antide- pressant consistently reported high rates of antidepressant adherence during the course of the monitoring calls and showed significant reductions in depressive symptomatology during the course of monitoring. : Results indicate age-related variability in processes and outcomes among veterans referred to the BHL and suggest that older veterans are just as likely to benefit from a program designed to facilitate the identification, engagement, monitoring, and care management of primary care patients experiencing behavioral health issues.

P-951 - Medicare Part D, generic prescribing and adherence to antidepressant therapy

Introduction In the U.S., Medicare Part D coverage gap poses concern for antidepressant adherence, but wide availability of generic antidepressants may mitigate the effect. Objectives and aims To assess the effects of coverage gap and generic prescribing on antidepressant adherence among a cohort of Medicare patients experiencing a new episode of depression. Methods We used 2007 Medicare Part D drug event file to examine antidepressant use over the 6 months following antidepressant initiation. We estimated Cox proportional hazard models to assess the effects of the two factors on the risk of antidepressant treatment disruption. We estimated mixed-effects linear models to assess the effects on monthly days of antidepressant possession. All analyses were stratified by Part D low-income subsidy (LIS) status and Medicare entitlement (aged vs. disabled). Results Receiving a generic (vs. brand) antidepressant on the first script was associated with a significantly reduced risk of treatment disruption across all four populations: hazard ratios ranged from 0.66 (p = 0.006) among disabled patients not receiving LIS to 0.88 (p = 0.020) among aged patients receiving LIS. For patients not receiving LIS, experience of coverage gap was associated with increased risk of disruption only among the disabled (hazard ratio = 2.15, p = 0.006). Analysis of monthly antidepressant possession produced consistent results and indicated that the beneficial effect of generic first script was comparable with or outweighed the detrimental effect of coverage gap. Conclusions Part D coverage gap adversely affected antidepressant adherence by disabled patients not receiving LIS. Increased generic prescribing may help improve adherence among all patients.

Impact of Medicare Part D on Antidepressant Treatment, Medication Choice, and Adherence Among Older Adults With Depression

Depression in older adults is often undertreated due, in part, to medication costs. We examined the impact of improved prescription drug coverage under Medicare Part D on use of antidepressants, medication choice, and adherence. Observational claims-based study of older adults with depression (ICD-9: 296.2, 296.3, 311, 300.4) continuously enrolled in a Medicare managed care plan between 2004 and 2007. Three groups with limited ($150 or $350 quarterly caps) or no drug coverage in 2004-2005 obtained Part D benefits in 2006. A comparison group had stable employer-sponsored coverage throughout. Any antidepressant prescription fill, antidepressant choice (tricyclics or monoamine oxidase inhibitors versus newer antidepressants), and adherence (80% of days covered) in the first 6 months of treatment. : Part D was associated with increased odds of any antidepressant use among those who previously lacked coverage (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.41-1.85) but odds of use did not change among those with limited prior coverage. Use of older antidepressant agents did not change with Part D. All three groups whose coverage improved with Part D had significantly higher odds of 80% of days covered with an antidepressant (OR = 1.86 [95% CI: 1.44-2.39] for no coverage, 1.74 [95% CI: 1.25%3.42] for $150 cap; and 1.19 [95% CI: 1.06-1.34] for the $350 cap groups). Medicare Part D was associated with improvements in antidepressant use and adherence in depressed older adults who previously had no or limited drug coverage but not with changes in use of older agents. use and adherence in depressed older adults who previously had no or limited drug coverage but not with changes in use of older agents.

Is customization in antidepressant prescribing associated with acute-phase treatment adherence?

OBJECTIVES: The objective was to explore whether prescribing variation is associated with duration of antidepressant use during the acute phase of treatment. Improving quality of care and increasing the extent to which treatment is patient-centered and customized are interrelated goals. Prescribing variation may be considered a marker of customization, and could be associated with better antidepressant treatment adherence. METHODS: A cross-sectional secondary data analysis examining the association between providers' antidepressant prescribing variation and patient continuity of antidepressant treatment. The data source was two states' Medicaid claims for dual-eligible Medicaid/Medicare patients. The sample included 383 patients with new episodes of antidepressant treatment, representing 70 providers with at least four patients in the sample. We tested two alternate measures of prescribing concentration: 1) share of prescriber's initial antidepressant prescribing accounted for by the two most common regimens, and 2) Herfindahl index. The HEDIS performance measure of effective acute-phase treatment (at least 84 out of 114 days with antidepressant) was the dependent variable. KEY FINDINGS: In multivariate analyses, the concentration measure based on the top two regimens was significant and inversely related to duration adequacy (p <.05). The Herfindahl index measure showed a trend towards a similar inverse relationship (p<.10). CONCLUSIONS: The findings provide some support for the hypothesized relationship between prescribing variation and adequate antidepressant treatment duration during the acute phase of treatment. Future work with more detailed, clinical longitudinal data could extend this inquiry to better understand the causal mechanisms using a more direct measure of customized care.

The association of race, comorbid anxiety, and antidepressant adherence among Medicaid enrollees with major depressive disorder

BackgroundDepressed patients often have comorbid anxiety. African-Americans with depression are less likely to adhere to antidepressant treatment. Knowledge of the association between race, comorbid anxiety, and adherence among Medicaid enrollees with depression is limited. ObjectiveThe objective of this study was to evaluate the association of race, comorbid anxiety, and antidepressant adherence, and persistence among Medicaid enrollees with major depressive disorder (MDD). MethodsThe MarketScan® Multi-State Medicaid Database (Thomson Reuters, Ann Arbor, MI) was used in this retrospective cross-sectional study. Medicaid enrollees aged between 18 and 64 years, with MDD but without bipolar disorders, and with a newly initiated antidepressant between January 1, 2004 and December 31, 2006 were identified. An index date was assigned corresponding to the newly initiated antidepressant. Patients having claims for any antidepressant refills during the 12 months before the index date were excluded. Eligible patients were then followed-up for 12 months after the index date. Adherence was measured by a modified medication possession ratio. Adherence was evaluated using multivariate logistic regression. Persistence was assessed based on treatment discontinuation and examined by Kaplan-Meier survival curves and Cox-propositional hazard regression models. ResultsA total of 3083 Medicaid patients with MDD were included. Approximately, 25% of patients had comorbid anxiety. The odds of adhering to antidepressants were 40% lower among African-Americans than Caucasians, adjusting for covariates (AOR [adjust odds ratio]=0.60; 95% confidence interval [CI]=0.51-0.72, P<.001). MDD patients with comorbid anxiety were more likely to adhere to antidepressants than patients with MDD alone (AOR=1.55, 95% CI=1.27-1.90, P<.001). African-Americans had a higher hazard of not persistently taking antidepressants (hazard ratio=1.47, 95% CI=1.30-1.65, P<.001). The interaction between race and comorbid anxiety was not associated with adherence or persistence. ConclusionsAmong Medicaid enrollees with MDD, race and comorbid anxiety disorders are significantly associated with antidepressant adherence and persistence. Physicians need to recognize comorbid anxiety and race as 2 important determinants of antidepressant use behaviors when they encounter Medicaid patients with MDD.

Effectiveness of interventions to improve antidepressant medication adherence: a systematic review

Non-adherence to antidepressant medications is a significant barrier to the successful treatment of depression in clinical practice. This review aims to systematically assess the effectiveness of interventions for improving antidepressant medication adherence among patients with unipolar depression, and to evaluate the effect of these interventions on depression clinical outcomes. MEDLINE, PsycINFO and EMBASE databases were searched for English-language randomised controlled trials published between January 1990 and December 2010 on interventions to improve antidepressant adherence. The impact of interventions on antidepressant medication adherence (compliance and persistence) and depression clinical outcomes was evaluated. Data concerning the quality of the included studies were also extracted. Twenty-six studies met the inclusion criteria. Interventions were classified as educational, behavioural and multifaceted interventions. A total of 28 interventions were tested, as two studies investigated two interventions each. Sixteen (57%) of the 28 interventions showed significant effects on antidepressant adherence outcomes, whereas 12 (43%) interventions demonstrated significant effects on both antidepressant adherence and depression outcomes. The interventions which showed significant improvement in outcomes were primarily multifaceted and complex, with proactive care management and involvement of mental health specialists. The most commonly used elements of multifaceted interventions included patient educational strategies, telephone follow-up to monitor patients' progress, as well as providing medication support and feedback to primary care providers. Overall, educational interventions alone were ineffective in improving antidepressant medication adherence. In conclusion, improving adherence to antidepressants requires a complex behavioural change and there is some evidence to support behavioural and multifaceted interventions as the most effective in improving antidepressant medication adherence and depression outcomes. More carefully designed and well-conducted studies are needed to clarify the effect of interventions in different patient populations and treatment settings.

Feasibility and impact of telemonitor-based depression care management for geriatric homecare patients.

The objective of this study was to test the feasibility, acceptability, and preliminary clinical outcomes of a method to leverage existing home healthcare telemonitoring technology to deliver depression care management (DCM) to both Spanish- and English-speaking elderly homebound recipients of homecare services. Three stand-alone, nonprofit community homecare agencies located in New York, Vermont, and Miami participated in this study. Evidence-based DCM was adapted to the telemonitor platform by programming questions and educational information on depression symptoms, antidepressant adherence, and side effects. Recruited patients participated for a minimum of 3 weeks. Telehealth nurses were trained on DCM and received biweekly supervision. On-site trained research assistants conducted in-home research interviews on depression diagnosis and severity and patient satisfaction with the protocol. An ethnically diverse sample of 48 English- and Spanish-only-speaking patients participated, along with seven telehealth nurses. Both patients and telehealth nurses reported high levels of protocol acceptance. Among 19 patients meeting diagnostic criteria for major depression, the mean depression severity was in the "markedly severe" range at baseline and in the "mild" range at follow-up. Results of this pilot support the feasibility of using homecare's existing telemonitoring technology to deliver DCM to their elderly homebound patients. This was true for both English- and Spanish-speaking patients. Preliminary clinical outcomes suggest improvement in depression severity, although these findings require testing in a randomized clinical trial. Implications for the science and service of telehealth-based depression care for elderly patients are discussed.

Factors Associated with Antidepressant Adherence for Medicaid-Enrolled Children and Adolescents

Antidepressants have been shown to be efficacious for the treatment of pediatric depression. However, many youths do not receive an adequate duration of treatment, and factors associated with nonadherence in this population remain poorly understood. To examine rates of antidepressant adherence for depressed youth and identify factors associated with adherence during the acute and continuation phases of treatment. A retrospective cohort analysis was conducted using claims data from a state Medicaid-enrolled population of 1650 youths (aged 5-17 years) with new episodes of depression between January 1, 2005, and December 30, 2007. These patients were treated with selective serotonin reuptake inhibitors or newer antidepressants and followed for 6 months from the first prescription fill date. Adherence measures were derived from the Health Plan Employer Data and Information Set (HEDIS) quality indicators on antidepressant management (3 months of continuous treatment for the acute phase and 6 months for the continuation phase) and assessed using the medication possession ratio. Multivariate logistic regression analyses evaluated the association between demographic, clinical, medication, and treatment factors, and adherence. About half (49.5%) of the youths were adherent to antidepressant medication during the acute phase, and 42% of these were adherent during the continuation phase; 21% were adherent across both treatment phases. Optimal follow-up visits and adequate antidepressant dosing was associated with better adherence during both treatment phases, as was use of other psychotropic medications. Youths prescribed trazodone for sleep had higher adherence rates during the acute phase. Minority youths and adolescents had lower adherence rates during the acute phase. Youths in foster care had higher adherence rates during both treatment phases. Nonadherence with antidepressant medications is common among Medicaid-covered children and adolescents. Study findings underscore the need for clinicians to deliver guideline-concordant care, assess adherence, and develop interventions that improve adherence, particularly for vulnerable subgroups.

Benzodiazepines and Adequacy of Initial Antidepressant Treatment for Depression

In short-term efficacy studies, coprescription of a benzodiazepine improves first-month adherence and response to antidepressant treatment. We used Veterans Health Administration data to examine the impact of coprescribed benzodiazepines on initial antidepressant adherence in routine clinical practice and the risks of long-term benzodiazepine use, abuse, and dependence. Our study population was 43,915 Veterans Health Administration patients diagnosed with depression and started on an antidepressant between October 2006 and September 2007. Using logistic regression, adjusting for demographic and clinical covariates, we predicted the likelihood that patients received antidepressant treatment for an adequate duration (90 days), with our primary independent variable of interest being receipt of a benzodiazepine on the same day as the start of the antidepressant. We also assessed the frequency and characteristics of patients whose benzodiazepine use persisted for 1 year or who were diagnosed with anxiolytic abuse or dependence after receiving combined treatment. The adjusted probability of receiving antidepressant treatment of adequate duration was 42.4% for patients who received a benzodiazepine with their initial antidepressant compared with 39.3% for patients initially treated with an antidepressant alone (P < 0.001). Among patients who received combined treatment, 14.1% subsequently used benzodiazepines for at least 1 year, and 0.7% were diagnosed with anxiolytic abuse or dependence. Anxiolytic abuse or dependence, but not long-term benzodiazepine use, was associated with other substance use disorders. These findings should be considered by clinicians when assessing the individual risks and benefits of combining a benzodiazepine with antidepressant treatment.

Response to Psychosocial Treatment in Poststroke Depression Is Associated With Serotonin Transporter Polymorphisms

The Living Well With Stroke study has demonstrated effectiveness of a brief psychosocial treatment in reducing depressive symptoms after stroke. The purpose of this analysis was to determine whether key variables associated with prevalence of poststroke depression also predicted treatment response. Response to a brief psychosocial/behavioral intervention for poststroke depression was measured with the Hamilton Rating Scale for Depression. Analysis of covariance models tested for interaction of potential predictor variables with treatment group on percent change in Hamilton Rating Scale for Depression from pre- to post-treatment as an outcome. Initial depression severity, hemispheric location, level of social support, age, gender, and antidepressant adherence did not interact with the treatment with respect to percent change in Hamilton Rating Scale for Depression when considered 1 at a time. Participants who carried 1 or 2 s-alleles at the 5-HTTLPR serotonin transporterpolymorphism or 1 or 2 9- or 12-repeats of the STin2 VNTR polymorphism had significantly better response to psychosocial treatment than those with no s-alleles or no 9- or 12-repeats. Opposite to the effects of antidepressant drug treatment with selective serotonin reuptake inhibitors, the Living Well With Stroke psychotherapy intervention was most effective in 5-HTTLPR s-allele carriers and STin2VNTR 9- or 12-repeat carriers. URL: www.clinicaltrials.gov/ct/show/NCT00194454?order_1. Unique identifier: NCT00194454.

From the Editors’ Desk: The July Effect

While the heat outside may be stifling, at America’s teaching hospitals, July brings a waft of fresh air. Senior residents have graduated, new interns have arrived. The wards are abuzz with excitement. We know colleagues who ask for ward duty assignments in July, just for the thrill of it. “The interns hang on your every word,” they say. “It’s a good feeling.” This July brings a surfeit of good feelings, but there will be challenges as well. New residency work hour rules proposed by the Accreditation Council for Graduate Medical Education (ACGME) in 2010 are due to take effect this month. The rules call for increased supervision of physicians-in-training, tighter limits on moonlighting, and reduced work hours for first-year residents. With interns limited to shifts of 16 hours, residency programs have been scrambling to create new call schedules and systems for cross-coverage. No one really knows what will happen. By imposing uniform work hours on a national basis, the ACGIM has impeded our ability to learn about which specific standards result in better outcomes. As SGIM member Kevin Volpp and colleagues pointed out in the Annals of Internal Medicine late last year, “The main disadvantage of the [regulatory] approach is that there is no ability to determine whether different standards would have worked better to reduce resident fatigue while improving patient safety.” Fortunately, other initiatives to improve the quality and safety of patient care are undergoing more careful scientific scrutiny, many in the pages of this journal. For example, in this issue Simon et al. show that online messaging improves patient follow-up for depression compared with usual care. While prior randomized clinical trials have clearly demonstrated that care management programs improve clinical outcomes in depression, this study may well be the first that uses online messaging to deliver follow up care to patients initiating antidepressant treatment. Antidepressant adherence and patient satisfaction both improved in the intervention arm of the study. Conversations about resuscitation status are challenging for doctors. Worse, they often leave patients and families agitated and confused. As Yuen et al. argue in a comprehensive review of the topic, part of the reason is that DNR discussions occur too late to allow patient participation in the process. Proposed solutions include promoting cultural change within hospitals, imposing new standards for DNR discussions, providing better training to clinicians, and creating financial incentives that encourage more comprehensive DNR discussions. With the passage of the Affordable Care Act (ACA), health care reform is certain, but the exact form that it will take (and that will pass muster by the Supreme Court) is still unclear. The only certainty is that reform will be accompanied by acrimonious debate. We are pleased to announce that JGIM is leaping into the fray by launching a new series of Health Policy Perspectives by nationally renowned policy experts. Implementation of reform will impact the delivery system around the country for millions of Americans, and these changes will have important implications for general internists. In the current issue, we begin with a commentary by Mark Hall, JD, one of the nation's leading scholars in health care policy and law. Mr. Hall’s commentary serves as a good example of how health care reform may affect general internists, given the important role that many internists play in safety net organizations that serve those lacking adequate health insurance. In the coming months, stay tuned for more contributions tackling key aspects of health care reform. These Perspectives will explore topics as varied as the role of allied health care providers under the ACA and the impact of the ACA on Medicaid programs. One message that resounds throughout these contributions is that while it is tough to make predictions about where health care reform is going, general internists will continue to be key stakeholders in the debate.

Evaluating Patient Adherence to Antidepressant Therapy Among Uninsured Working Adults Diagnosed with Major Depression: Results of the Texas Demonstration to Maintain Independence and Employment Study

This study examined antidepressant adherence and persistence among uninsured working adults diagnosed with major depression enrolled in the Texas Demonstration to Maintain Independence and Employment (DMIE) program. Antidepressant adherence was measured between intervention and control cohorts using proportion of days covered (PDC) during a 365-day observation period. Persistence examined duration of time from drug initiation to discontinuation based on a ≥35-day refill supply gap. Older, non-minority patients with higher education were more adherent or persistent to antidepressant therapy. Adjusting for covariates, results showed no significant difference in PDC at the end of 12-months between intervention and control participants (b = .07, P = .054, semi-partial η (2) = .02). Exploratory analysis found subgroup differences in PDC among the study recruitment cohorts. No significant difference between intervention and control groups was found in persistence between the groups. Follow-up investigation is planned to assess the longer term impact of the DMIE program on antidepressant adherence and persistence.

Antidepressant Utilization, Adherence, and Health Care Spending in the United States: The Case of MDD Patients 2000-2007

Objective Selective serotonin reuptake inhibitors have been widely adopted in the US as the first-line treatment for major depressive disorder (MDD). This study attempted to understand how patient factors and antidepressant choice influenced medication adherence and associated health care expenditures. Study Design A retrospective multiple-year cross-sectional study was conducted. This study used the 2004-2007 Medical Expenditure Panel Survey database; MDD patients who filled one or more prescriptions of antidepressants were extracted. Data were analyzed using weighted ordinary least squares regressions to examine MDD patient antidepressant adherence (measured by proportional days covered) and impacts of patient factors on associated health care expenditures. Results Sociological factors such as patient ethnicity and health insurance status were associated with differential levels of antidepressant adherence and associated health expenditures. Hispanic ethnicity was associated with the lowest antidepressant adherence among all. Patients covered by insurance were associated with better proportional days covered and spent more on MDD-specific drugs compared with uninsured patients. Use of newer antidepressants such as selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors was associated with an increase in MDD-specific drug expenditure. Conclusions Differences in antidepressant adherence and health care spending across patient factors could have important policy implications for health disparity; certain patient populations may be at higher risk for inadequate health care.

Antidepressant Treatment and Adherence to Antiretroviral Medications Among Privately Insured Persons with HIV/AIDS

In order to examine relationships between depression treatments (antidepressant and/or psychotherapy utilization) and adherence to antiretroviral therapy (ART), we conducted a retrospective analysis of medical and pharmacy insurance claims for privately insured persons living with HIV/AIDS (PLWHA) diagnosed with depression (n = 1,150). Participants were enrolled in 80 insurance plans from all 50 states. Adherence was suboptimal. Depression treatment initiators were significantly more likely to be adherent to ART than the untreated. We did not observe an association between psychotherapy utilization and ART adherence, yet given the limitations of the data (e.g., there is no information on types of psychological treatment and its targets), the lack of association should not be interpreted as lack of efficacy.

SAMe and sexual functioning

BackgroundSexual dysfunction is a known side effect of antidepressant treatment (ADT), affecting up to 58–73% of those who receive ADT, potentially affecting antidepressant adherence. Consequently, it is vital to develop novel treatments that target antidepressant-induced sexual dysfunction. MethodsWe examined whether adjunctive S-adenosyl-l-methionine (SAMe) is associated with greater improvement in sexual functioning than adjunctive placebo by measuring changes in sexual functioning using the Massachusetts General Hospital–Sexual Functioning Questionnaire (MGH-SFQ) during a 6-week, single-center, randomized, double-blind trial of SAMe augmentation for SSRI/SNRI- nonresponders. ResultsControlling for the degree of arousal dysfunction at baseline as well as the degree of change in HDRS-17 scale scores during the course of the study, men treated with adjunctive SAMe demonstrated significantly lower arousal dysfunction at endpoint than those treated with adjunctive placebo. In addition, controlling for the degree of erectile dysfunction at baseline as well as the degree of change in HDRS-17 scale scores, men treated with adjunctive SAMe demonstrated significantly lower erectile dysfunction at endpoint than those treated with adjunctive placebo. ConclusionsIn the present study, we have observed that adjunctive SAMe can have positive benefit on male arousal and erectile dysfunction, independent of improvement in depressive symptoms. These findings are preliminary, and warrant replication. Clinical trials.gov identifierNCT00093847; titled ‘Optimizing the Effectiveness of Selective Serotonin Reuptake Inhibitors (SSRIs) in Treatment-Resistant Depression’, accessible at: http://clinicaltrials.gov/ct2/show/NCT00093847.

Randomized trial of depression follow-up care by online messaging.

Quality of antidepressant treatment remains disturbingly poor. Rates of medication adherence and follow-up contact are especially low in primary care, where most depression treatment begins. Telephone care management programs can address these gaps, but reliance on live contact makes such programs less available, less timely, and more expensive. Evaluate the feasibility, acceptability, and effectiveness of a depression care management program delivered by online messaging through an electronic medical record. Randomized controlled trial comparing usual primary care treatment to primary care supported by online care management Nine primary care clinics of an integrated health system in Washington state Two hundred and eight patients starting antidepressant treatment for depression. Three online care management contacts with a trained psychiatric nurse. Each contact included a structured assessment (severity of depression, medication adherence, side effects), algorithm-based feedback to the patient and treating physician, and as-needed facilitation of follow-up care. All communication occurred through secure, asynchronous messages within an electronic medical record. An online survey approximately five months after randomization assessed the primary outcome (depression severity according to the Symptom Checklist scale) and satisfaction with care, a secondary outcome. Additional secondary outcomes (antidepressant adherence and use of health services) were assessed using computerized medical records. Patients offered the program had higher rates of antidepressant adherence (81% continued treatment more than 3 months vs. 61%, p = 0.001), lower Symptom Checklist depression scores after 5 months (0.95 vs. 1.17, p = 0.043), and greater satisfaction with depression treatment (53% "very satisfied" vs. 33%, p = 0.004). The trial was conducted in one integrated health care system with a single care management nurse. Results apply only to patients using online messaging. Our findings suggest that organized follow-up care for depression can be delivered effectively and efficiently through online messaging.

Using primary care prescribing data to improve GP awareness of antidepressant adherence issues

Adherence to antidepressant therapy remains a major issue worldwide. Most people with depression are treated in a general practice setting, but many stop taking antidepressants before completing a six-month course as recommended by guidelines. To determine antidepressant adherence rates as indicated in primary care prescribing data and pharmacy dispensing data; to demonstrate commonly occurring patterns related to non-adherence, using a prescription visualisation tool we have developed; and to determine whether prescribing data is a good predictor of dispensing based adherence. We analysed general practice electronic prescribing data for the year ending 31 December 2006 and linked pharmacy dispensing records by National Health Index. We calculated medication adherence for patients starting antidepressants using a six-month evaluation period and a gap-based adherence measure. Patients with a gap of more than 15 days in antidepressant therapy were considered non-adherent. Using a prescription visualisation tool, we described common modes of non-adherence. Out of 2713 patients, 153 satisfied our inclusion criteria. Thirty-nine percent of patients showed poor adherence based on prescribing and 68% showed poor adherence on dispensing. Prescribing based non-adherence had a positive predictive value of 98% (95% CI 92%-99%) and negative predictive value of 51% (CI 47%-52%) for dispensing based non-adherence. Three broad categories of non-adherence were identified: 1) failure to return for re-prescription, 2) failure to maintain adherence despite initial attempts and 3) failure to return for re-prescription in a timely manner. Prescribing data identifies substantial adherence issues in antidepressant therapy. Clinicians should consider adherence issues as part of the overall treatment regime and discuss such issues during consultations.

Patient receipt of, and preferences for receiving, antidepressant information

Abstract Objective The purpose of the study was to examine patient receipt of, and preferences for receiving, antidepressant information. Method/setting The study had a cross-sectional design. Eight community pharmacies in central North Carolina participated in the study. Eighty-three English-speaking patients who were picking up antidepressant prescriptions were interviewed by a research assistant. The main outcome measures included: patient receipt of verbal antidepressant information; the number and type of educational messages contained in the written antidepressant leaflets that patients received; the percentage of patients who had a reading level below the reading level of the antidepressant information leaflet; whether patients reported reading the leaflets and how satisfied they were with the leaflets; and how patients preferred to receive antidepressant information. Key findings Seventeen per cent of patients did not receive verbal information about how long the medication would take to work from anyone. Only 50 per cent of patients were told what to do if a major side effect occurred. Almost 11 per cent of patients had a reading level below the level of the written pharmacy antidepressant information leaflet. Just over one-third (36 per cent) of patients preferred to receive only written antidepressant information. Less educated patients were significantly more likely to want to receive antidepressant information verbally. Of those patients who preferred to receive verbal antidepressant information or both verbal and written information, 92 per cent chose pharmacists as their first or second choice for providing them with verbal information. Conclusion The majority of patients taking antidepressants want to receive verbal information and view pharmacists as an important source of information. Pharmacists have the potential to improve antidepressant adherence if they take the time to educate patients verbally about their medications.