Erica C.G. van Geffen

Initiation of antidepressant therapy: do patients follow the GP's prescription?

BACKGROUND The question whether patients actually start drug taking after having received a first antidepressant prescription is often overlooked. AIM To determine the incidence of patients who do not fill or fill only a single antidepressant prescription at the pharmacy, and to identify associated patient characteristics. DESIGN OF STUDY Retrospective study linking a general practice to a pharmacy dispensing database. SETTING General practice in the Netherlands. METHOD STUDY POPULATION patients who received a first-time antidepressant prescription from a GP. Three patient groups were identified: patients who did not fill the prescription (non-fillers); patients who filled only a single prescription (single Rx-fillers); and patients who filled at least two consecutive prescriptions. Non-fillers and single Rx-fillers were combined into a group of decliners. RESULTS Of all 965 patients, 41 (4.2%) did not fill the prescription, and 229 (23.7%) filled only a single prescription. Patients who consulted their GP for a non-specific indication, rather than for depression, anxiety, panic, or obsessive-compulsive disorder, were almost three times more likely (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.8 to 3.9) to decline treatment. Further, the risk of declining was almost fivefold higher (OR = 4.8, 95% CI = 2.1 to 11.3) in non-Western immigrants, and almost twofold higher (OR = 1.8, 95% CI = 1.2 to 2.8) in patients >60 years of age. CONCLUSION Over one in four patients who receive a first-time antidepressant prescription decline treatment; they either do not initiate drug taking or do not persist with antidepressant use for longer than 2 weeks.

Characteristics and Reasons Associated with Nonacceptance of Selective Serotonin-Reuptake Inhibitor Treatment

Background: Studies have shown that up to 38% of patients who start treatment with antidepressants fill only a single prescription at the pharmacy, apparently not accepting treatment. Objective: To determine characteristics and reasons associated with nonacceptance of selective serotonin-reuptake inhibitor (SSRf) treatment, Methods: A retrospective study was conducted in 37 community pharmacies in the Netherlands; patients who presented a prescription from a general practitioner (GP) for a newly started SSRI treatment were selected, Nonaccepters were defined as patients who filled only one SSRI prescription; patients who received at least 3 fills of an SSRI prescription were defined as accepters. Patient characteristics were obtained from automated dispensing records and from questionnaires. Areas of evaluation included sociodemographics, disease, and treatment. Nonaccepters were asked their reasons for not filling second prescriptions. Results: Of the patients who started SSRI treatment, 22.0% were nonaccepters, filling only a single prescription. Fifty-seven nonaccepters and 128 accepters were included in our analysis. Nonacceptance was more common among patients with a low level of education (OR 2.6; 95% CI 1.1 to 5.9) and in patients who reported nonspecific symptoms like fatigue, stress, and restlessness as the reason for SSRI use (OR 2.7; 95% CI 1.4 to 5.5). Of the nonaccepters, 29.8% (n = 17) did not start SSRI use, and 70.2% (n = 40) discontinued SSRI use within 2 weeks. Fear of adverse effects and the actual occurrence of adverse effects were main reasons for not accepting SSRI treatment. Of the nonaccepters, 55.0% discontinued treatment without informing their GPs. Conclusions: Acceptance of SSRI treatment is a decisive moment in a patients adherence to treatment initiated by his or her GP and deserves more attention; GPs and pharmacists should address treatment issues, especially in groups at risk for nonacceptance.

Does the length of the first antidepressant treatment episode influence risk and time to a second episode

Antidepressant treatment in primary care is inconsistent with treatment recommendations, and many patients discontinue treatment within 6 months. How this affects treatment outcomes is unknown. The aim of this study was to assess how length of the first antidepressant episode influences risk and time to a second treatment episode within 5 years. The study population included 9423 adults (67% women; mean age, 47.3 years) who initiated selective serotonin reuptake inhibitor use in 1998 or 1999. Based on the length of the first antidepressant treatment episode, patients were divided into early discontinuers (<6 months), continuing users (6-12 months), and persistent users (>12 months). The Cox proportional hazards model was used to estimate risk ratios (RRs) for the association between the length of the first antidepressant treatment episode and time to reinitiating antidepressant treatment. Time to a second treatment episode did not differ significantly between continuing users and early discontinuers (RR, 0.99; 95% confidence interval, 0.92-1.07). Persistent users showed a higher risk of experiencing a second treatment episode than early discontinuers (RR, 1.23; 95% confidence interval, 1.15-1.32). In conclusion, the risk of experiencing a second antidepressant treatment episode did not differ for those who used antidepressants for 6 to 12 months and those who discontinued early. In general, there is limited information on how length of an antidepressant treatment episode influences the risk of reinitiating treatment of patients in primary care. More research is needed to investigate the effectiveness of antidepressant drug treatment patterns in preventing relapse or recurrence in primary care populations.

Problems experienced by older people when opening medicine packaging

Medicine packages can cause problems in daily practice, especially among older people. This study aimed to investigate the prevalence of problems experienced by older people when opening medicine packaging and to investigate how patients manage these problems.

Problems with Medicine Packages: Experiences Reported to a Dutch Medicine Reporting System

Background: Practical issues such as ease of use and packaging appear to cause significant problems in daily use of medicines, but there are only few published studies about these aspects of medicine use. Objective: To assess the type of experiences related to practical aspects of medicine use reported to an Internet-based medicine reporting system (www.meklpuntmedicijnen.nl). Methods: All reports submitted from May 2004 to December 2007 to an Internet-based medicine reporting system in the Netherlands related to practical aspects of drug use were analyzed. The experiences were grouped Into the following categories: difficulty with opening the package, other difficulties with use, and problems with printed text on packages and the information leaflet. Results: Of the 5175 individuals who submitted a report, 530 submitted 611 reports on practical aspects of medicine use. More than half of the reports concerned difficulties with the opening of packages, mostly about opening blister packages (46.2%). One third of the reports were related to other problems with use, mainly package size (13.0%) and preference for different packaging (8.5%), About 1 in 10 reports was related to the printing and information on packages, mostly about unclear and confusing text print on the primary package (5.7%). In all, 25.2% of the reporters informed their prescribing physician of the problem and 38.2% informed the pharmacist or pharmacy staff. Conclusions: Some medicine users experience considerable difficulties with the packaging of their drugs; one of the major issues is opening a blister package. Packaging of pharmaceuticals needs more attention; issues need to be addressed by the pharmaceutical manufacturers, registration authorities, and, most immediately, community pharmacists.

Endocrine therapy for breast cancer: assessing an array of women's treatment experiences and perceptions, their perceived self-efficacy and nonadherence.

BACKGROUND Although adjuvant endocrine therapy effectively prevents breast cancer recurrence, nonadherence rates are substantial. We therefore examined associations of womens experiences and perceptions regarding the efficacy, side effects, and practical problems of endocrine therapy with nonadherence. Furthermore, we examined whether womens perceived self-efficacy moderated these associations. PATIENTS AND METHODS Two hundred forty-one breast cancer patients participated. Using the electronic Tailored Medicine Inventory, which enables skipping of irrelevant items, experiences and perceptions were assessed in a comprehensive yet feasible manner. Adherence was assessed according to self-report and evaluated for agreement with adherence estimated from pharmacy refill data. RESULTS A substantial number of women doubted the efficacy of endocrine therapy, were worried about and/or had experienced hot flushes, loss of libido, joint ache, and/or practical problems with regard to information, intake, and packaging. Experience of practical problems (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.0-5.8) and perceived self-efficacy with regard to medicine intake (OR, 0.5; 95% CI, 0.4-0.7) were associated with unintentional nonadherence. Number of side effects experienced (OR, 1.2; 95% CI, 1.05-1.4) and perceived self-efficacy with regard to learning about medication (OR, 0.6; 95% CI, 0.4-0.96) were associated with intentional nonadherence. Perceived self-efficacy did not moderate associations between womens treatment experiences and perceptions and nonadherence. CONCLUSION Endocrine therapy is challenging for many women. Targeting womens specific experiences and perceptions and improving their perceived self-efficacy is likely to decrease intentional and unintentional nonadherence.

Adherence to Oseltamivir Guidelines during Influenza Pandemic, the Netherlands

To the Editor: In the Netherlands, the outbreak of pandemic influenza A (H1N1) 2009 led to a 100-fold increase from 2008 in prescriptions for the antiviral neuraminidase inhibitor oseltamivir (1). The guidelines for prescribing oseltamivir during the 2009 pandemic were adapted throughout the year. After August 7, prescribers were advised to restrict prescriptions to patients with influenza symptoms plus 1 additional risk factor (2) (Table). Table Reported risk factors of patients with and without influenza symptoms who were dispensed a prescription for oseltamivir, the Netherlands, 2009–10 Community pharmacists dispensed oseltamivir as a 5-day course of sachets produced exclusively for the Dutch government program and documented all prescriptions. Our objective was to assess whether oseltamivir dispensed through community pharmacies was prescribed according to the national guideline for the pandemic virus and to investigate how patients used oseltamivir. The Institutional Review Board of the Division of Pharmacoepidemiology and Clinical Pharmacology of Utrecht University approved the study. Pharmacists in 19 pharmacies belonging to the Utrecht Pharmacy Practice Network for Education and Research (UPPER) selected all patients who had filled a prescription for oseltamivir during May 1, 2009–February 8, 2010. These patients were contacted by phone and, after giving consent, completed a structured questionnaire. The questionnaire contained questions about potential risk factors, the reason for receiving the oseltamivir prescription (influenza symptoms or other reasons), and whether the oseltamivir course was started and completed. Of the 630 patients eligible for contact, 361 (57.3%) completed the questionnaire. To assess whether the current guidelines were adhered to, because of the changes in policy throughout the year, we analyzed only the 300 respondents who had filled the oseltamivir prescription at the height of the pandemic, i.e., after August 7, 2009. A total of 156 (52.0%) participants were female patients; most participants were 18–59 years of age. Of the 212 patients >18 years of age, education level was available for 195; of these, 55 (28.2%) had a low education level, 94 (48.2%) a middle education level, and 46 (23.6%) a high education level. Of the 300 respondents, 111 (37.0%) received a prescription while they did not meet guideline criteria (Table). They had risk factors but did not experience influenza symptoms (67 [22.3%] of all respondents); had influenza symptoms but not risk factors (34 [11.3%]); or had neither influenza symptoms nor any risk factors (10 [3.3%]). Compared with respondents who had a low education level, respondents >18 years of age who had a middle or high education level were 2× more likely to receive an oseltamivir prescription that was not in accordance with guideline criteria (odds ratio 2.20; 95% CI 1.12–4.32). Sex and age were not associated with the likelihood of receiving off-guideline oseltamivir. Of the 189 respondents who received oseltamivir in accordance with guideline criteria, 184 (97.4%) started treatment and 167 (90.8%) completed the oseltamivir course. Of the 111 respondents who received a prescription for oseltamivir that was not in accordance with guideline criteria, 62 (55.9%) started treatment, and 56 (90.3%) completed the course. We showed that during the pandemic the guideline criteria were not met by nearly one third of patients who received an oseltamivir prescription. Patients with a higher education level more often received a prescription, suggesting that they are more informed or empowered than patients with a lower education level to request a prescription. Another explanation for the inadequate adherence to guideline criteria is that prescribers themselves were not immediately aware of the current criteria, possibly because of changes throughout the year. In addition, in nearly half of instances in which guideline criteria were not met but in which oseltamivir was prescribed, the patients did not start the oseltamivir course. These prescriptions could have been used for stockpiling, which also occurred during the influenza A (H5N1) outbreak in 2005 (3). In the Netherlands, stockpiling did not lead to drug shortages, but in countries where oseltamivir is not reimbursed by the government, stockpiling might lead to problems with availability for patients truly in need of antiviral therapy but without the necessary means to acquire it. The limited effect of oseltamivir on reducing disease duration, usually only shortening the duration by 1 day in healthy persons (4), the possibility of serious side effects (5), the possibility of the virus developing resistance to neuraminidase inhibitors (6,7), and the cost to health care of unnecessary prescriptions are reasons to strive for better adherence to prescribing guidelines. Prescribers need to be properly informed about current guidelines to reduce overprescribing caused by lack of knowledge. Furthermore, improving communication between prescribers and patients might help relieve patients’ concerns and increase awareness about the limited benefits of oseltamivir treatment in healthy persons.

Antidepressants in primary care: patients' experiences, perceptions, self-efficacy beliefs, and nonadherence.

Purpose Patient adherence to antidepressants is poor. However, this is rather unsurprising, given the equivocal efficacy, side effects, and practical problems of antidepressants. The aim of this study was to examine a wide array of patient experiences and perceptions regarding the efficacy, side effects, and practical problems of antidepressants, as well as their associations with nonadherence, and whether patients’ perceived self-efficacy moderated these associations. Patients and methods Experiences and perceptions of 225 patients, recruited through community pharmacies, were efficiently assessed with the Tailored Medicine Inventory. Nonadherence was assessed through self-report and pharmacy refill data. Results Many patients were not convinced of the efficacy, thought the efficacy to be limited or did not believe antidepressants to prevent relapse, were worried about or had experienced one or more side effects, and/or had experienced one or more practical problems regarding information, intake, and packaging. Being convinced of efficacy was associated with lower intentional nonadherence (odds ratio [OR] 0.9, 95% confidence interval [CI] 0.8–0.96). A higher number of practical problems experienced was associated with increased unintentional nonadherence (OR 1.3, 95% CI 1.1–1.7). Higher perceived self-efficacy regarding taking antidepressants was associated with lower unintentional nonadherence (OR 0.7, 95% CI 0.5–0.9). Perceived self-efficacy did not moderate associations of patient experiences and perceptions with nonadherence. Conclusion Assessing a wide array of patients’ experiences and perceptions regarding the efficacy, side effects, and practical problems of antidepressants contributes to better understanding of nonadherence to antidepressants. Guiding physician–patient conversations by patients’ experiences and perceptions may reduce both unintentional and intentional nonadherence. Also, it may give rise to considerations of prudent discontinuation, eg, when patients are not convinced of the efficacy.

Do the benefits of statins outweigh their drawbacks? Assessing patients' trade-off preferences with conjoint analysis.

Efficacious lowering of low-density lipoprotein cholesterol through prolonged statin therapy has become a major strategy for primary and secondary prevention of cardiovascular disease. From the perspective of patients, however, the prophylactic efficacy may be difficult to comprehend. It refers to prospective disease prevention at the population level and an uncertain risk reduction for individual patients. At the same time, actual side effects may occur and treatment entails a lifelong regimen. (aut. ref.)

Pharmacy Technicians’ Attention to Problems With Opening Medicine Packaging

Background: Pharmacy technicians seem to be well equipped to engage in conversations with patients about their experiences and problems with medication, but it is unclear whether or not they systematically explain or demonstrate to patients how to use medication packaging. Objective: To explore to what extent pharmacy technicians identify problems with opening medicine packaging and how they assist patients in solving these problems. Methods: We conducted a cross-sectional study that comprised semistructured interviews, with 31 pharmacy technicians in 31 pharmacies, to assess the occurrence and type of difficulties with packagings and to suggest solutions. Results: All pharmacy technicians recognize the occurrence of packaging problems, though patients rarely report them at the pharmacy counter. Not all pharmacy technicians are familiar with opening all packaging forms, but they all describe ways to find out how to open them, which usually only happens after patients bring up problems. Solutions suggested by the pharmacy technicians include informing and counseling, changing or manipulating the packaging, and providing assisting tools. Conclusions: This study shows that although pharmacy technicians are aware that medication packaging can cause problems and are able to name or find out solutions to all these problems, there is no systematic attention for packaging at drug dispensation in most pharmacies. Discussing the handling of medication packaging should become a fixed part of drug dispensation counseling. Pharmacists should draw up working procedures to support pharmacy technicians in their counseling activities.