Adherence to Long-Term Therapies - Evidence for Action
(2003; 211 pages) View the PDF document
Table of Contents
View the documentPreface
View the documentAcknowledgements
View the documentScientific writers
View the documentIntroduction
View the documentTake-home messages
Open this folder and view contentsSection I - Setting the scene
Open this folder and view contentsSection II - Improving adherence rates: guidance for countries
Close this folderSection III - Disease-Specific Reviews
Open this folder and view contentsChapter VII - Asthma
Open this folder and view contentsChapter VIII - Cancer (Palliative care)
Close this folderChapter IX - Depression
View the document1. Research methods: measurement of adherence and sampling
View the document2. Rates of adherence
View the document3. Predictors of adherence
View the document4. Interventions to improve adherence
View the document5. Clinical implications and need for further research
View the document6. References
Open this folder and view contentsChapter X - Diabetes
Open this folder and view contentsChapter XI - Epilepsy
Open this folder and view contentsChapter XII - Human immunodeficiency virus and acquired immunodeficiency syndrome
Open this folder and view contentsChapter XIII - Hypertension
Open this folder and view contentsChapter XIV - Tobacco smoking cessation
Open this folder and view contentsChapter XV - Tuberculosis
Open this folder and view contentsAnnexes
Open this folder and view contentsWhere to find a copy of this book
 

4. Interventions to improve adherence

As mentioned above, one difficulty in the study of depression therapy is that unsatisfactory treatment may reflect a combination of poor patient adherence and medical advice that is inconsistent with expert guidelines. To be clinically effective, interventions should ideally deal with both aspects of quality improvement. In 1999, Peveler et al. were able to show that two brief sessions of counselling provided by a primary care nurse could greatly reduce rates of discontinuation of treatment at 12 weeks (from 61% to 37%), but clinical benefit was only seen in a post hoc analysis of the subgroup of patients receiving adequate doses of medication (5). A small feasibility study also suggested that similar benefits could be obtained by telephone counselling (22). Information alone, provided by leaflet (5) or by repeated mailings (23), did not appear to be effective in improving rates of adherence (see also Table 3).

Most other studies have tested complex, multi-faceted, interventions designed to improve the overall quality of care. For example, Katon et al. (24 - 27) evaluated the impact of increased involvement of secondary care specialist staff and closer surveillance of patients receiving treatment in primary care. They reported improved adherence, boosting the proportion of patients receiving an adequate dose of their medication at 90 days to 75%, but although this group initially had better clinical outcomes, these benefits were no longer evident at 19-month follow-up. Subsequent work has shown that a relapse prevention programme can also improve longer-term outcome (28).

Table 3 Factors affecting adherence to treatment for depression and interventions for improving it, listed by the five dimensions and the interventions used to improve adherence

Depression

Factors affecting adherence

Interventions to improve adherence

Socioeconomic-related factors

No information was found

No information was found

Health care team/health system-related factors

(-) Poor health education of the patient

(+) Multi-faceted intervention for primary care

Multidisciplinary care (24 - 27); training of health professionals on adherence; counselling provided by a primary care nurse (5); telephone consultation/ counselling (22); improved assessment and monitoring of patients (24)

Condition-related factors

(-) Psychiatric co-morbidity

(+) Clear instructions on management of disease (14); nature of the patient's illness; poor understanding of the disease and its symptoms

Education of patient on use of medicines (14)

Therapy-related factors

(-) High frequency of dose (13); co-prescribing of benzodiazepines (19); adequate doses of medication (5,24 - 27)

(+) Low frequency of dose (13); clear instructions on management of treatment (14)

Education on use of medicines (14); patient-tailored prescriptions (13); continuous monitoring and reassessment of treatment (28)

Patient-related factors

(-) Personality traits (20,21)

Counselling (24); relapse-prevention counselling; psychotherapy (15); family psychotherapy (15); frequent follow-up interviews (28); specific advice targeted at the needs and concerns of individual patients (24)

 

(+) Factors having a positive effect on adherence; (-) factors having a negative effect on adherence.

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