A method that dramatically improves patient adherence to depression treatment

Experimental design

The point of this study was to determine whether a flow sheet (FIGURE 1) incorporating a checklist for comorbid disorders, medication reference guide, and a major depression reference guide (FIGURE 2), combined with patient education, would improve patient adherence with a pharmacologic regimen and reduce or eliminate depression symptoms without a subsequent relapse.

Doctors in the practice were informed of the project and educated by the author regarding its purpose, protocol, intended outcomes, and methodology.

Though a substantial number of illnesses could be considered comorbid with depression, it would be unrealistic and unwieldy to include them all. Nine conditions were included as sample characteristics, for 2 reasons. First, experience has shown that these particular comorbidities are prevalent among patients presenting to the family physicians. Second, a set of symptoms associated with each of these selected comorbidities often overlaps those of depression, and may therefore cloud the final diagnosis. The prevalence of diagnosed and documented comorbidities, which may interfere with a diagnosis of depression, is summarized in TABLE 1.

All patients who were thought to be depressed or who exhibited depressive symptoms were asked to complete a PHQ-9. None declined. All were educated by the attending physician during the initial office appointment, and given informational material to explain the disease and the necessity of adhering to a prescribed regimen for a period of no less than 9 months. A flow sheet, containing information relative to office calls, follow-up PHQ-9s, and other summaries of medication, comorbidities, and treatment regimens was inserted into their respective charts.

Following the initial appointment, patients were encouraged to schedule other visits at 4 weeks, within 4 to 9 months, and at one year. During these follow-up appointments, physicians stressed the need for continuing medication for no less than 9 months. Every patient who did not return for a follow-up appointment after 6 months, as indicated by a systematic chart review, was contacted by phone by a registered nurse employed by the practice. All of these patients subsequently scheduled an appointment, confirmed they were still following the regimen, or informed the nurse that they had discontinued their medication(s).

TABLE 1
Comorbidity summary of depression patients (n=91)

Data collection and analysis

Periodically throughout the study period of 1½ years, patient charts were audited to collect data on demographics and comorbidities, to quantify the number of patients adhering to prescribed medications for a minimum 9 months, and to compile results of the 2 PHQ-9 surveys. These data were then contrasted with existing clinical research data to demonstrate that the procedure significantly improved patient adherence to a prescribed regimen.

Results

Data from this study indicate that 61 of the 103 patients enrolled in the study completed at least 9 months’ follow-up. Based on patients’ verbal input, a second PHQ-9, notations in charts, subsequent appointments, phone follow-ups, and chart medication reviews, 40 of these 61 patients (66%) adhered to prescribed daily drug therapy for depression for at least 9 months—double the 33% adherence rate described in clinical literature.¹

Seventy-one (78%) of the patients followed in this study had 1 or more significant comorbid illnesses; 54 (76%) had 2 or more. The most common comorbidities included anxiety, migraine, and irritable bowel syndrome, with rates of 54%, 48%, and 32%, respectively (TABLE 1).

TABLE 2 summarizes the comparison of initial and follow-up PHQ-9 data after medication was begun and after an interval of at least 4 weeks. Based on the initial PHQ-9 score, 80% of patients presented with moderate, moderate-severe, or severe depressive symptoms. The average initial PHQ-9 score was 14.2±5.1 (SD).

On follow-up, only 40% of patients were documented to have the same range of severity of symptoms. The average follow-up PHQ-9 score was 8.3±6.2 (SD) (P<.001) vs initial score. Thirty-six of these 40 patients (90%) remained on their initially prescribed medications.

TABLE 2
Distribution of PHQ-9 scores

Discussion

Patients discontinue their medications many reasons (TABLE 3).^1,6,13-16 These obstacles to drug therapy often result in therapeutic failure. Given we now have better-tolerated medications, nonadherence may result more from poor patient commitment to treatment than from adverse drug effects.¹⁴

Communicate with patients. The literature also provides insight into persuasions likely to increase patient compliance. TABLE 4 lists indicative factors.^1,6,9,17

Explicit communication with patients regarding the expected duration of antidepressant therapy may reduce premature discontinuation of medication use.¹⁷

Better communication between patients and physicians about antidepressant treatment, both before and during treatment, may promote adherence.¹