Patricia Robinson

The Role of the Primary Care Physician in Patientsʼ Adherence to Antidepressant Therapy

In this study, the authors attempted to determine predictors of adherence to antidepressant therapy and to identify specific educational messages, side effects, and features of doctor-patient collaboration that influence adherence. Patients newly prescribed antidepressants for depression at a health maintenance organization were identified by using automated pharmacy data and medical records review. Patients (n = 155) were interviewed 1 and 4 months after starting antidepressant medication. Approximately 28% of patients stopped taking antidepressants during the first month of therapy, and 44% had stopped taking them by the third month of therapy. Patients who received the following five specific educational messages—1) take the medication daily; 2) antidepressants must be taken for 2 to 4 weeks for a noticeable effect; 3) continue to take medicine even if feeling better; 4) do not stop taking antidepressant without checking with the physician; and 5) specific instructions regarding what to do to resolve questions regarding antidepressants—were more likely to comply during the first month of antidepressant therapy. Asking about prior experience with antidepressants and discussions about scheduling pleasant activities also were related to early adherence. Side effects, only at severe levels, were associated with early noncompliance. Neuroticism, depression severity, and other patient characteristics did not predict adherence. Primary care physicians may be able to enhance adherence to antidepressant therapy by simple and specific educational messages easily integrated into primary care visits.

The predictors of persistence of depression in primary care

164 patients in primary care who were recognized as depressed by their physicians and started on antidepressants were interviewed at 1 and 4 months after initiation of treatment. Ten factors hypothesized to be related to persistence of depressive symptoms were entered into a multivariate analysis to determine predictors of persistence of affective symptoms. Patients with minor depression were significantly older, more likely to be married or cohabitating, more likely to have serious medical illness, and had significantly less comorbid panic disorder, recurrent depression and lower neuroticism scores compared to patients with major depression. Approximately half of the patients in this primary care sample with major depression and one-third of those with minor depression were still distressed at 4 months, although few met criteria for major depression. Severity of depression and high neuroticism scores were the best predictors of persistent depressive symptoms.

Impact of improved depression treatment in primary care on daily functioning and disability

BACKGROUND Few data are available regarding the impact of improved depression treatment on daily functioning and disability. METHODS In two studies of more intensive depression treatment in primary care, patients initiating antidepressant treatment were randomly assigned to either usual care or to a collaborative management programme including patient education, on-site mental health treatment, adjustment of antidepressant medication, behavioural activation and monitoring of medication adherence. Assessments at baseline as well as 4 and 7 months included several measures of impairment, daily functioning and disability: self-rated overall health, number of bodily pains, number of somatization symptoms, changes in work due to health, reduction in leisure activities due to health, number of disability days and number of restricted activity days. RESULTS Average data from the 4- and 7-month assessments in both studies, intervention patients reported fewer somatic symptoms (OR 0.68, 95% CI 0.46, 0.99) and more favourable overall health (OR 0.50, 95% CI 0.28, 0.91). While intervention patients fared better on other measures of functional impairment and disability, none of these differences reached statistical significance. CONCLUSIONS More effective acute-phase depression treatment reduced somatic distress and improved self-rated overall health. The absence of a significant intervention effect on other disability measures may reflect the brief treatment and follow-up period and the influence of other individual and environmental factors on disability.

Outcomes of "Inadequate" antidepressant treatment

AbstractOBJECTIVE: To examine outcomes of primary care patients receiving low levels of antidepressant treatment. DESIGN: Cohort study comparing patients receiving antidepressant treatment within and below the recommended dosing range. SETTING: Primary care clinics of a staff-model health maintenance organization. PATIENTS: Primary care patients initiating antidepressant treatment for depression. MEASUREMENTS AND MAIN RESULTS: Of 88 patients beginning antidepressant treatment, 49 (56%) used “adequate” doses for 30 days or more. Likelihood of “adequate” pharmacotherapy was not related to patient age, gender, medical comorbidity, or baseline depression severity. All the patients showed substantial clinical improvement after four months. Compared with those using “adequate” pharmacotherapy, the patients receiving low-intensity treatment had lower likelihood of clinical response (64% vs 84%; chi-square=4.44; df=1; p=0.035). At four months, however, those receiving low-intensity and those receiving higher-intensity treatment did not differ significantly in either the score on the 20-item Symptom Checklist depression scale (18.91 and 15.72, respectively; F=1.45; df=1, 86; p=0.23) or the proportion with persistence of major depression (10% and 4%, respectively; chi-square=1.30; df=1; p=0.25). A replication sample of 157 patients (assessed only at baseline and four months) yielded similar results. CONCLUSIONS: While the patients receiving recommended levels of pharmacotherapy showed somewhat higher improvement rates, many of the patients receiving “inadequate” treatment experienced good short-term outcomes. Efforts to increase the intensity of depression treatment in primary care should focus on the subgroup of patients who fail to respond to initial treatment.

Methodologic issues in randomized trials of liaison psychiatry in primary care.

&NA; Most anxiety, depressive, and substance abuse disorders are treated exclusively in the primary care health system. However, recognition and treatment of these disorders in primary care is deficient. Psychopharmacologic and psychotherapeutic interventions have been developed and proven effective in randomized trials in specialty care. However, the results of successful trials of mental health interventions in specialty settings may not generalize to primary care settings because of epidemiologic differences in patients, differences in skills of providers, as well as differences in the very structure of care. The importance of the development of innovative randomized trials to improve recognition and treatment of mental illness in primary care is emphasized, as well as the methodologic problems inherent in carrying out these trials.