Adherence to Maintenance-Phase Antidepressant Medication as a Function of Patient Beliefs About Medication

The paper by Aikens et al. in this issue of Annals is worthy of attention for several reasons. It addresses an important question – how do patients decide to continue prescribed medication over the long term? The choice of study measures is driven by a useful conceptual model that views adherence decisions as an interplay between the self-perceived necessity of a medication and concerns about taking it. The self-reported adherence measures used in the study can be easily adapted for use in clinical practice. These measures correlated with each other and with an independent pharmacy-based measure of refill adherence. The central finding of the study – that adherence behavior was better predicted by the balance of necessity and concerns than by sociodemographic or clinical considerations – reminds us that our patients’ assessments of their ongoing medication use resemble our clinical efforts to balance treatment benefits and harms. Finally, the paper proposes a typology of belief groups – skepticism, ambivalence, indifference, and acceptance - that should prompt confirmatory research. If this categorization proves to be robust, it may lead to tailored behavioral intervention strategies to improve adherence.

Peaks of interest in adherence research have coincided with the development of new diseases or new approaches to therapy. In the 1950s and early 1960s, researchers assessed adherence to new antibiotic treatments for infectious diseases such as tuberculosis. In the late 1960s, the research emphasis turned to adherence in cardiovascular diseases, particularly hypertension. The strong relationship between adherence to antiretroviral medications and clinical outcomes in HIV infection re- invigorated the field in the early 1990s. This paper may presage a fourth “renaissance” of interest in adherence, in the context of behaviorally- based disease management efforts for chronic conditions such as depression, asthma, and diabetes.

Studies such as this one provide a cautionary tale for systems that undertake disease management. They remind us that patients hold veto power over our clinical recommendations. Our patients’ decisions about medications, diet, exercise, and other aspects of self-care are based not on ignorance or rebelliousness, but rather on their earnest attempts to optimize a broad array of benefits and concerns that they will probably share with us if we are wise enough to ask. (1) This study further reminds us that “disease management” may be a misnomer – it’s not just about the disease, but about the human context in which it occurs. And we don’t manage the problems – the patient does.

1. Bayliss EA, Steiner JF, Fernald DH, Crane LA, Main DS. Descriptions of barriers to self-care by persons with comorbid chronic diseases. Annals of Family Medicine 2003;1:15-21.

Competing interests:   None declared