A method that dramatically improves patient adherence to depression treatment

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Original Research

A method that dramatically improves patient adherence to depression treatment

J Fam Pract. 2005 October;54(10):846-852

By

Gary Ruoff, MD

Use of a flow sheet, coupled with patient education and diligent follow-up, improves medication adherence.

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References

1. Bull SA, Hu XH, Hunkeler EM, et al. Discontinuation of use and switching of antidepressants: Influence of patient-physician communication. JAMA 2002;288:1403-1409.

2. Strock M. Plain talk about depression. NIH publication No. 02-3561. Bethesda, Md: National Institutes of Health; 2002.

3. Depression Guideline Panel. Depression in Primary Care, Vol. 2: Treatment of Major Depression Clinical Practice Guideline No. 5. Rockville, Md: US Department of Health and Human Services, Public Health Service, and Agency for Health Care Policy and Research;1993.

4. Schulberg HC, Katon W, Simon GE, Rush AJ. Treating major depression in primary care practice: an update of the Agency for Health Care Policy and Research Practice Guidelines. Arch Gen Psychiatry 1998;55:1121-1127.

5. American Psychiatric Association, Work Group on Major Depressive Disorder. Practice guideline for the treatment of patients with major depression [Web site]. Available at www.psych.org/psych_pract/treatg/pg/Depression2e.book.cfm. Accessed on September 1, 2005.

6. Bull SA, Hunkeler EM, Lee JY, et al. Discontinuing or switching selective serotonin-reuptake inhibitors. Ann Pharmacother 2002;36:578-584.

7. Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT). Clinical guidelines for the treatment of depressive disorders. Can J Psychiatry 2001;46(Suppl 1):5S-90S.

8. Mok H, Lin D. Major depression and medical comorbidity. Canadian Psychiatric Bulletin de I’APC 2002 (December);25-28.

9. Haynes RB, McDonald HP, Garg AX. Helping patients follow prescribed treatment: Clinical applications. JAMA 2002;288:2880-2883.

10. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA 1999;282:1737-1744.

11. Kroenke K, Spitzer RL, Williams JB. A new measure of depression severity: the PHQ-9. J Gen Intern Med 2000;15(Suppl):78.-

12. Agency for Healthcare Policy and Research. Depression in Primary Care: Detection and Diagnosis (AHCPR publication No. 93-0550). Vol. 1. Rockville, Md: Agency for Healthcare Policy and Research, US Department of Health and Human Services, 1993.

13. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment. Arch Intern Med 2000;160:2101-2107.

14. Urquhart J. New insight into patient noncompliance with prescribed drug regimens. Clin Res 2001;1:26-32.

15. Linden M, Gothe H, Dittmann RW, Schaaf B. Early termination of antidepressant drug treatment. J Clin Psychopharmacol 2000;20:523-529.

16. Haynes RB. Improving patient adherence: state of the art, with special focus on medication taking for cardiovascular disorders. In: Burke LE, Okene IS, eds. Patient Compliance in Health Care Research. American Heart Association Monograph Series. Armonk, NY: Futura Publishing Co; 2001;3-21.

17. Lin EH, von Korff M, Katon W, et al. The role of the primary care physician in patients’ adherence to antidepressant therapy. Med Care 1995;33:67-74

Practice recommendations

Discuss with patients the need to continue medication for the prescribed period, to help ensure treatment success.
Be open about possible side effects of the drug you prescribe, and assure the patient that a change in medication can be made if the initial choice proves intolerable.
Consider using a treatment flow sheet as a means of tracking the patient’s course and as a prompt for regular communication with the patient.

Abstract

This study focused on increasing patient adherence to a prescribed medical regimen for depression or depressive symptoms. The goal was to demonstrate that a depression flow sheet supported by physician instruction, patient education, and diligent follow-up could enable depressed patients to better adhere to treatment. The study documented reduction in depression severity over time. In addition to depression data, sample characteristics of comorbid disorders were obtained.
Methods: Patients tentatively diagnosed with depression were asked to complete a self-administered 9-item diagnostic survey (PHQ-9) to confirm the severity of depressive symptoms. Physicians in the practice then implemented a flow sheet to record pertinent data including comorbidities. All data were kept in patients’ medical charts. A second PHQ-9 survey was completed by patients after at least 4 weeks. A total of 103 subjects was analyzed during 2003–2004. Subsequently, patient charts were systematically audited throughout the study period to record adherence, reasons for nonadherence (if any), PHQ-9 survey results, and comorbidities.
Results: Patient adherence improved to a significantly greater extent among patients in our study compared with existing national research data on depression.
Conclusions: Use of a flow sheet, coupled with patient education and diligent follow-up, dramatically improved the rate of medication adherence in patients who initially presented with depressive symptoms—with or without comorbidities. A clinician or small group can adapt the PHQ-9 materials with modest effort and positively impact the care of their patients, including adherence to medication regimens.

Even when depression is properly diagnosed and treatment is prescribed, the rate of patient adherence to regimens can drop to as low as 33% within the first 3 months of therapy¹—far short of the universally recommended 4 to 9 months of treatment (see Minimum duration of treatment). The rate is even lower when lifestyle and other more behaviorally demanding regimens are instituted.⁹

This study demonstrated that use of a management flow sheet, in conjunction with suitable instructions to physicians and education of patients, overcame the usual causes of discontinuance and enabled far more patients to adhere to a prescribed medical regimen than is reported by other current research, ultimately alleviating depressive symptoms regardless of cause.

Minimum duration of treatment

To prevent relapse, the National Institute of Mental Health, the Agency for Health Care Policy and Research, and the American Psychiatric Association consistently recommend continual treatment with antidepressants for at least 4 to 9 months after depression symptoms resolve^2-5—a period of time considered crucial in obtaining a successful clinical outcome.⁶ Other guidelines establish 9 months as the minimum for a treatment regimen.⁷ Those high risk patients whose depression is recurrent, or whose symptoms are slow to resolve, or are refractory to traditional treatment regimens, may require more than 2 years of long-term maintenance therapy.⁸

Methods

Setting

The study was conducted during 2003 to 2004 in a private suburban/urban family medicine group in the Midwestern United States. Fifteen family physicians practice in the group, which cares for about 55,000 patients, most of whom are insured.

Subjects

One-hundred three patients at the clinic were newly diagnosed with varying degrees of depression by 3 doctors in the practice. All were included in the study.

Diagnoses were confirmed by patient history, physical examination, interview, and responses to a 9-item diagnostic survey (Patient Health Questionnaire [PHQ-9]—APPENDIX 1, available online at www.jfponline.com, and in our February 2003 issue [J Fam Pract 2003; 52:126]). The survey has a sensitivity of 73% and a specificity of 98% when compared with a Structured Clinical Interview administered by a mental health clinician.^10,11

No exclusion criteria were applied. Subjects were included regardless of age, gender, race, severity of depression, associated medical conditions, or insurance status. No patients refused to participate. However, of the 103 enrolled patients, 1 was later imprisoned, 2 died, and 3 transferred from the practice. Of the remaining 97, 36 were identified too late in the study to meet the 9-month protocol at the time of final analysis. Therefore, though their comorbidity and depression level data are included in this research, final conclusions relative to “measurement of adherence” were not.

The database for this study, therefore, is 97 subjects for whom data were secured, and 61 for whom adherence or nonadherence was measured. The practice continues to monitor all enrolled patients, and other enrollees for the purposes described in this project.