A brief intervention that emphasizes specific patient goals and possible treatment fears appears to significantly improve medication adherence in patients with depression, new research suggests.
The randomized controlled trial, which included more than 200 middle-aged and older adults treated in primary care, showed that those in the Treatment Initiation and Participation Program (TIP) were five times more likely to adhere to a newly prescribed antidepressant 6 weeks later than those who received usual care.
In addition, they were three times more likely to adhere to treatment, the primary outcome measure, at 6- and 12-week follow-up combined.
TIP targets barriers to medication use, whereas, in the study, usual care consisted of the initial visit only.
“We were pleased to see such a dramatic jump in adherence early on,” lead author Jo Anne Sirey, PhD, Department of Psychiatry, Weill Cornell Medical College, White Plains, New York, told Medscape Medical News.
Dr Jo Anne Sirey
Although the study was conducted in primary care, Dr Sirey noted that TIP, or at least parts of it, could be beneficial for clinicians in other settings.
“Helping a patient to set up their own personalized adherence strategy is what any good physician would do if they had a little more time, and primary care is very strapped for time. So we developed a simple intervention that helps people commit to their treatment,” she said.
“Anytime pharmacotherapy is being offered, it’s important for the prescribing physician to ask, ‘Do you have any concerns?’ and ‘What’s important to you?’.”
The findings were published online September 27 in JAMA Psychiatry.
Relapse, Suicide Risk Factor
Although nonadherence to antidepressant medications has been commonly reported in research and clinical practice, “early nonadherence is especially problematic,” the investigators write.
Nonadherence early on can lead to an increased risk for relapse and even vulnerability to suicide, they report. However, “with an early adherence intervention, you could get a jump start on the depression response,” said Dr Sirey.
Between January 2011 and December 2014, 231 adults aged 55 or older (mean age, 67.3 years; 72% women) were enrolled in the study at two primary care practices in New York and Michigan.
All were newly prescribed an antidepressant by their primary care physician. They were then randomly assigned to the TIP adherence intervention (n = 115) or to usual care (n = 116).
TIP consisted of five steps during three 30-minute visits over the first 6 weeks of antidepressant treatment:
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Assessing possible treatment barriers,
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Defining personal goals for adherence,
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Educating about depression and antidepressants,
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Collaborating on ways to address treatment barriers,
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Creating an adherence strategy and empowering patients to initiate discussions.
Self-reported adherence, as reported on the Brief Medication Questionnaire, was the primary outcome, “with adequate early adherence defined as taking 80% or more of the prescribed doses at 6 and 12 weeks,” write the investigators. Depression severity on the 24-item Hamilton Depression Rating Scale (HAM-D) was a secondary outcome.
As shown in the table below, the TIP group was significantly more likely to adhere to treatment than the usual-care group at all checkpoints.
Table. Rates of Adherence in TIP vs Usual-Care Groups by Period
| Adherence at | OR (95% CI)* | P Value |
|---|---|---|
| Week 6 | 5.54 (2.57 – 11.96) | < .001 |
| Weeks 6 and 12 combined | 3.27 (1.73 – 6.17) | < .001 |
| Week 12 | 2.84 (1.47 – 5.50) | .002 |
| *OR, odds ratio; CI, confidence interval | ||
Among patients with scores of 10 or greater on the HAM-D at baseline, signifying mild to moderate depression, the OR for treatment adherence at weeks 6 and 12 combined was a significant 2.2 for the TIP group vs the usual-care group (95% CI, 1.1 – 4.3; P = .03).
Dr Sirey noted that when patients set up an adherence strategy or a plan for taking their medications reliably, they are making a commitment. But in order to be successful, “they really need to define for themselves the concerns that they may have ― and what they want to get out of the care,” she said.
“The TIP plan really helped them elucidate for themselves what that commitment to treatment was and what the personal goal was they wanted to achieve.”
Effect on Depression?
At 6 weeks, the intervention group had a significant 24.9% improvement from baseline in depressive symptoms (P < .001), whereas improvement was not significant in the usual-care group (10.7%).
Although there were additional symptom improvements later in the study for those undergoing TIP, those changes were not significant. On the other hand, the usual-care group showed significant improvement at 12 weeks ( P = .04).
Interestingly, members of both treatment groups who were 80% adherent at 6- and 12-week assessments demonstrated the same mean improvement in depressive symptoms from baseline (15%), which missed statistical significance (P = .051).
“We were disappointed that we didn’t see a wide-ranging effect on depression over the long haul,” said Dr Sirey. “But the treatment that was offered was so diverse, including the type of medication, the dosing, and the adequacy of antidepressants, we should have understood earlier that that would affect our predictions of depression outcomes.”
Still, “the TIP intervention was more effective in helping patients achieve adequate adherence during the critical early adherence period,” write the investigators.
“Given the high rates of depression, nonadherence, and use of primary care as a mental health service, wide-scale implementation of a targeted adherence intervention, such as TIP, could have a meaningful impact on public health,” they add.
Dr Sirey said the investigators will be further testing the program to see if it is more effective in certain populations and subpopulations than others. “We definitely want to do more work. It’s a question of, can we disperse this more widely?”
Helpful in Primary Care, Psychiatry
“I thought this was a very important study,” said Jesse H. Wright, MD, PhD, Kolb Endowed Chair for Outpatient Psychiatry, professor, and director of the Depression Center, University of Louisville, Kentucky, when asked for comment.
Dr Jesse Wright
“Adherence is a huge problem in the treatment of depression. And it’s especially important in primary care patients, where they don’t have as much opportunity to be with a counselor or psychiatrist to help them understand the illness,” Dr Wright told Medscape Medical News.
“So it was encouraging that they were able to show a very significant impact on the adherence rates.”
He noted that a past study showed that about 50% of patients prescribed an antidepressant do not fill their second prescription.
“The predominant treatment for depression is pharmacotherapy, and one of the big reasons why it doesn’t work is that people just don’t take the medication for long enough for it to be given the chance to work.”
Dr Wright said that TIP’s targeting the understanding of a medication and working toward a specific adherence plan “sounds like an excellent idea.” He also noted that past research has suggested that cognitive-behavioral therapy can help with adherence, “and one of the ways to do that is by working out an adherence plan with the patient.”
Reiterating the study authors, Dr Wright stressed the importance of early adherence to a new treatment.
“Any new behavior typically works better if you can figure out a way to make it a routine part of your daily schedule, so it’s not something randomly done when you have the will or remembering capacity to put it into play.”
In a busy primary care setting, he noted that a typical visit lasts about 15 minutes, which can quickly pass if the patient has comorbid conditions. “So having an intervention like [TIP] that is systematic and really addresses the problem would be great, especially if it was online,” said Dr Wright.
As for psychiatric practices, “they’re having briefer sessions. In fact, most of my visits with patients are 20 minutes or a little bit more. It would be nice to have something systematic that would improve adherence.”
The study was supported by grants from the National Institute of Mental Health. The study authors and Dr Wright have reported no relevant financial relationships.
JAMA Psychiatry. Published online September 26, 2017. Abstract
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