A method that dramatically improves patient adherence to depression treatment: use of a flow sheet, coupled with patient education and diligent follow-up, improves medication adherence
by Gary Ruoff
J Fam Pract. 2005 Oct;54(10):846-52.

Premise

This pragmatically oriented article addresses adherence to medication by depressed patients although one suspects the same enhancements could well prove applicable to other diagnoses as well. Its premise, most of which is contained in the title, follows:

Study Parameters

While 103 patients were enrolled in the study, only 61 met criteria for the adherence measurement segment. No control group was used; comparisons were instead made to results from the clinical literature.

All patients completed a PHQ9,. were educated by their physicians, and were given explanations of the disease and the necessity of adhering to a prescribed 9 month regimen. A flow sheet, containing office calls, follow-up PHQ-9s, and other summaries of medication, comorbidities, and treatment regimens was completed for each patient. Patients were encouraged to schedule visits at 4 weeks, within 4 to 9 months, and at one year. At these appointments, physicians focused on the importance of continuing medication for at least 9 months. Nurses contacted patients who missed appointment to reschedule and to ascertain whether or not they were still following the regimen.

Results

According to the article,

Caveats

The author acknowledges certain limitations:

• The small number of subjects
• The lack of a control group (The author notes, “However, comparisons were made between this study and the adherence rates documented in other studies.”)
• Other than the PHQ-9, data collection was by patient self-report
• “Even though the project stressed patient adherence, the use of the flow sheet may very well have contributed to increased physician awareness and physician education, which therefore, in itself, may have resulted in improved patient compliance.”
• The results may be setting-specific

Author’s Recommendations

In keeping with the pragmatic tone of the article and the journal, the following recommendations are made (direct quotes):

1. Discuss with patients the need to continue medication for the prescribed period, to help ensure treatment success.
2. Be open about possible side effects of the drug you prescribe, and assure the patient that a change in medication can be made if the initial choice proves intolerable.
3. Consider using a treatment flow sheet as a means of tracking the patient’s course and as a prompt for regular communication with the patient.

Commentary

This is an article with built-in appeal; it’s straightforward, clinically oriented, and admirably audacious in its titular claim of a “method that dramatically improves patient adherence to depression treatment.”

From my perspective, however, the study’s limitations outweigh its utility. While its recommendations are at worst innocuous and, indeed, appear to compose a rational approach to compliance enhancement, there is little scientific evidence presented in their support.

Most egregious is the comparison of self-reported patient adherence, a data collection methodology repeatedly shown to produce overestimated rates of compliance, to a 33% adherence rate drawn from the literature. Indeed, the medication adherence issue in this study revolves around the finding that “40 of these 61 patients (66%) adhered to prescribed daily drug therapy for depression for at least 9 months — double the 33% adherence rate described in clinical literature.”

The reference given for the 33% compliance rate¹ lists, in turn, 6 other references as evidence for its declaration (as part of its general introduction) that “… rates of treatment discontinuation within 3 months after the start of treatment can reach 68%, depending on the type of antidepressant prescribed and the population studied.” My reading of that statement is that the worst case scenario is a noncompliance rate of 68%. If a researcher eschews a control group in favor of comparison to previous studies, it would seem that the comparison should be to a mean rate derived from several studies, to the rate from a study that is, for one reason or another, specifically congruent to the research being reported, or to the best results previously obtained. A quick search turns up a number of articles reporting higher compliance rates. Lin and associates, for example, found that “Approximately 28% of patients stopped taking antidepressants during the first month of therapy, and 44% had stopped taking them by the third month of therapy.”²

There may be valid reasons for using the Bull article’s 33% compliance rate; if so, it is incumbent on the author to make those reasons clear.

Footnotes

1. Discontinuation of Use and Switching of Antidepressants: Influence of Patient-Physician Communication.Bull et al. JAMA.2002; 288: 1403-1409. [back]
2. Lin EH, Von Korff M, Katon W, et al. The role of the primary care physician in patients’ adherence to antidepressant therapy. Med Care. 1995;33:67–74. [back]

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