_______________________________________________________________________ Depression and Suicide
Enhance Treatment Adherence Patient nonadherence can result in nonresponse to the optimal antidepressant regimen, and intolerance of side effects strongly influences therapy nonadherence [240]. Poor adherence is a major problem for patients receiving antidepressant treatment, with discontinuation rates ranging from roughly 30% in clini- cal trial settings to as high as 60% in clinical practice [241; 242]. In an evaluation of patient adherence to antidepressant medications, 28% had discontinued treatment within the first month and 51.2% had stopped their antidepressant medica- tion by the fourth month [243]. At all timepoints, roughly 64% of patients cited side effects as the reason for stopping their medication. Compared with usual care, support programs (i.e., a collabora- tive care model) that educate patients on the value of medica- tion adherence and the potential side effects of antidepressants and provide follow-up to ensure continued compliance have been found to improve the efficacy of depression treatment ( Table 4 ) [244; 245]. Other research has shown that patients receiving five specific instructions were significantly more likely to continue their medication through the first month of therapy [64; 243]: • Take the antidepressant daily. • Antidepressants must be taken for at least two to four weeks to see a noticeable effect. • Continue to take the antidepressant even if you feel better. • Do not stop taking antidepressants without checking with your healthcare provider. • Follow instructions to contact your health-care provider when questions arise about antidepressants.
remains unresponsive to treatment, referral to a psychiatrist may be indicated. Optimize Treatment Optimizing treatment helps to ensure the patient is receiving the most potential benefit from their initial antidepressant. This involves optimizing the dosage and adherence to treat- ment. Increase the Dose of the Initial Antidepressant There is substantial evidence that many patients receive sub- therapeutic doses. When the antidepressant is tolerable but partial or no response is shown by three to four weeks, increase the dose by increments to the highest recommended dose [64]. SSRI dose escalation is supported by a 2016 meta-analysis that found greater response in high-dose ranges, with a plateau at doses greater than 250 mg imipramine-equivalent. This benefit is somewhat offset by decreased high-dose tolerability [239].
The American Psychiatric Association recommends optimizing the medication dose as a reasonable first step for patients treated with an antidepressant who have not responded fully to treatment if the side effect burden is tolerable and the upper limit of a
medication dose has not been reached. (https://psychiatryonline.org/pb/assets/raw/sitewide/ practice_guidelines/guidelines/mdd.pdf. Last accessed July 6, 2023.) Strength of Recommendation : II (Recommended with moderate clinical confidence)
EVIDENCE-BASED INTERVENTIONS TO IMPROVE PATIENT ADHERENCE TO ANTIDEPRESSANT MEDICATION Intervention Overview Patient education Inform patient of the causes and course of depression, and the effects, duration, and side effects of treatment. Patient-provider empathy/alliance Establish a good relationship between patient and provider, with an emphasis on communication, consensus, and understanding. Clinical management strategies Provide advice regarding a standardized approach to taking medications and compliance, and allow for frequent follow-up visits, especially during initial phases of treatment.
Simplicity of treatment
Minimize the number and doses per day of medication.
Active management of side effects
Inform patient about side effects, monitor their occurrence, provide reassurance, and adjust the treatment if needed. Help patients incorporate treatment into daily routine (e.g., modify schedule to fit medication routine, behavioral reminders, pill boxes, easy-to-read prescription labels). When possible, use SSRIs due to greater tolerability relative to TCAs. Improve skills on caring for patients with depression and patient adherence to treatment.
Behavioral feedback
Preference for SSRIs Physician training
Source: [242]
Table 4
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