It is well established that although prevalent, chronic, and treatable, depression remains significantly under recognized and under treated. Improving the ability to recognize and adequately treat depression, at the level of the public and the clinician, is a formidable challenge with comprehensive efforts making little headway. When depression is diagnosed and treated, the next challenge is to provide that treatment in a manner that will optimize the chance for a full response. Implicit here is that the treatment is adhered to by the patient and that non-compliance predicts a poor outcome.
Compliance specific to antidepressant therapy, which is usually intended for 4-12 (or more) consecutive months, is inadequate in general. Separate trials have observed that at 3 months 60-68 percent of antidepressant users interrupt their treatment course prematurely, apparently independent of which antidepressant is prescribed. Surmountable causes, including misconceptions and misguided expectations regarding antidepressant therapy and a lack of understanding of the course of illness, have contributed to poor treatment compliance. To overcome this, simple interventions such as the provision of patient leaflets about antidepressant drug therapy have failed to stem the tide of treatment non-compliance, as was demonstrated by Peveler et al in a randomized controlled trial. However, verbal counseling was associated with improved adherence.
Experience from the Depression Treatment and Research Program at the University of Pittsburgh, which include the completion of landmark controlled trials of long-term pharmacologic and psychotherapeutic interventions, has identified several factors important in optimizing treatment adherence. These include a multidisciplinary approach, education of patients and family about depression and its treatments, and a philosophy and approach that emphasizes alliance rather than compliance.
Visual aid to improve compliance
Offered here is a relatively simple and time efficient educational tool that I have used with individuals starting antidepressant treatment that conforms to the compliance-enhancing principles expressed by the researchers at the Pittsburgh program. The tool facilitates educating the patient about what to expect during the acute phase of antidepressant therapy and emphasizes the importance of long-term treatment adherence. The approach is specifically intended to minimize the number of avoidable premature treatment discontinuations, such as due to a lack of response early in the course of therapy or the development of side effects without any benefits, as revealed by Maddox et al. In addition, it encourages an educational discussion with the patient about depression and the role of antidepressant therapy.
There are several methods of providing patients with this illustration. It is important to be flexible and adjust the information based on the patient’s educational needs. From my experience, the most effective method is to build the figures freehand on blank paper adding the components and comments of each while giving a simultaneous verbal orientation. This allows for of any relevant, patient-specific information to be included. However, this approach does take a little more practice and experience. Depending on the situation, panels 1-3 usually are completed using the same axis. Panel 4 is often drawn at a later visit when the importance of adherence during the continuation phase is being emphasized. A simpler method is to provide a copy of the illustration (usually panel 3) and describe the components verbally with notes added onto the illustration as needed. It is not known if creating the illustration for a patient vs. providing them with a ready-made version differentially affects their treatment compliance or chance for response. Relapse probably should be addressed by a separate illustration if providing patients with a ready-made illustration. Regardless of which method is used, adding the patient’s name and medication (drug and brand) names further personalizes this communication and enhances its impact.
The following points outline the components of the illustration with verbal descriptions offered. The quantitative data were collectively derived and simplified from practice guidelines and randomized controlled trials (RCTs). The data represent the more optimistic end of the spectrum of RCT findings but may be achievable in general practice when the proper expectations are set and supports are in place.
Early in treatment, side effects can occur and can predominate over perceived benefits. However, for most people (~8/10) the side effects are tolerable and resolve within the first few days or weeks of treatment. Some individuals (~2/10) do stop treatment because of side effects early in therapy.
For many, the benefits of antidepressant therapy are not appreciated until several weeks of treatment have passed. Most individuals notice that they are beginning to feel better at around 4 weeks but continue to improve with therapy well beyond that time.
Nearing 8 weeks, approximately 7 people out of 10 who start therapy with an antidepressant achieve a good response and approximately 5 will have complete resolution of their symptoms of depression.
Unfortunately, 3 out of 10 people do not achieve the desired benefits from treatment, whether because of side effects or lack of response or a mixture of factors. · It is not possible to determine prior to starting therapy who will respond (a 7 in 10 chance) versus who will not respond adequately (3 in 10 chance).
If a good response does not occur there are other effective treatments available.
Due to the nature of the underlying depressive episode, stopping therapy too early is associated with a return of depressive symptoms in more than 50% of people, even if they have had a very good response to treatment
Once a good response has been achieved, treatment should continue as directed, which is commonly 6 months or more.
Admittedly, my evaluation of this teaching tool is anecdotal, derived from my experience and others who I have been able to influence to use it likewise. However, I have found that for patients unaccustomed to treatment with antidepressants, the effect of the message conveyed by the illustration along with a complementary verbal discussion can have a profound effect on their comfort and willingness at the start of treatment. It has also been effective in educating family members about the role of antidepressant treatment, leading to a therapeutic alliance that goes beyond the patient.
In their systematic review of medication compliance in chronic diseases, Haynes et al noted that current methods of improving adherence are mostly complex and not very effective. The illustration described here is simple, efficient and promotes the development of a therapeutic alliance.