Adherence to anti-depressant medication: A medicine-taking career
Introduction
This paper is a report on a prospective interview study of Danish depressed patients' views on taking anti-depressant medication. The prescription of medicine is a common healthcare intervention, but it embraces an intractable clinical challenge, because many patients have difficulties following prescriptions and conforming to treatment regimes (WHO, 2003). Medicine taking is controversial because it often indicates a fundamental mismatch between clinicians' therapeutic advice and patients' actual illness behaviour (Horne et al., 2005). This mismatch was first conceptualised as patients' level of compliance to doctors' prescriptions. However, this term was criticised for implying and legitimising a paternalistic relationship between, on the one side, authoritative and rational doctors and, on the other side, irrational and uncritical patients (Malpass et al., 2009). Later, adherence was suggested as an alternative, more acceptable concept. Like compliance, the concept of adherence carries paternalistic connotations, but it seeks to emphasise the patients' perspective by stressing that treatment regimes must be negotiated and agreed upon by patients and healthcare providers (WHO, 2003).
A central social science approach to studying adherence and medicine taking has been to explore the meaning patients impute to medicine and to using medicine in the wider context of their everyday lives. This focus on patients' perspective has emphasised the personal and situated rationality in self-regulated use of medicine, see for instance (Conrad, 1985). Pound et al. (2005) reviewed and synthesised 37 qualitative studies of lay experiences of medicine taking. The synthesis indicated that people are actively engaged in managing their medicine taking and that they to varying degrees resist taking medication out of concerns about the medicine per se. The authors suggest that this latter finding should not be interpreted as proof of patients' misperception of their medicine, but, on the contrary, as evidence of legitimate worries about medicine, which is not entirely effective and has adverse effects (Pound et al., 2005). The present paper will contribute to a better understanding of medicine users' situated and evolving reasons for adhering to prescribed treatment by focussing on depressed patients' views on medicine taking and how they change over time.
Section snippets
Background: depression and taking antidepressants
Depression is most often a persistent relapsing-remitting illness that causes severe impairment of social and occupational functioning (National Institute for Health and Clinical Excellence (NICE), 2009). The most common treatment of depression is antidepressant medication, but treatment efficacy is often reduced because 30–60% of patients discontinue taking the prescribed antidepressant medication within the first 12 weeks of treatment (Lingam and Scott, 2002, WHO, 2003). Antidepressants are
Methods
The study design was consecutive semi-structured interviews (Holstein and Gubrium, 1995) four times during a one-year period. These interviews were supplemented by a diagnostic interview (SCAN) (Wing et al., 1998) and self-report measures: Antidepressant Compliance Questionnaire (ADCQ) (Kessing et al., 2005), Beck Depression Inventory II (BDI-II) (Beck et al., 2005), and Symptoms Checklist 92 (SCL-92) (Derogatis, 2007). Detailed results from the diagnostic interview and the questionnaires will
Theoretical perspective
The study was designed within an interactionist perspective (Atkinson and Housley, 2003). From this perspective, it is asserted that the meaning of objects, events, and situations are imputed on to them through people's interactions with them. Identity and situational understanding are formed by an interactive meaning-making process, which is based on people's situated expectations to others and the negotiated and situated responses from others. A person perceives his/her environment through a
Setting, sample and interviews
The study was conducted at a regional healthcare trust in Southern Denmark in 2008–2009. Participants were recruited into the study from three general psychiatric wards at two general hospitals that admitted patients from urban and suburban areas. The Danish healthcare system is a public healthcare system financed by means of general taxes.
Purposeful, non-probability sampling was used to recruit adult persons discharged with a diagnosis of a depressive episode/disorder (ICD-10 F32.0-F33.9) (
Analysis
The thematic analysis had four iterative stages (Miles and Huberman, 1994), which all contributed to memo-writing and theorising on how the participants perceived their illness and the treatment of the illness in the context of their everyday lives.
First, the résumés written after each interview were used to develop and test initial ideas about the participants' perspectives. This was done by organising story lines, plots and sub-plots in the narrative accounts and, when it was possible, having
Ethics
In line with Danish legislation the regional research ethics committee and the Danish Data Protection Agency were notified about the study; neither agencies had any objections to the study. All participants gave their consent to participate based on written and verbal information about the study. Data were handled confidentially and the data extracts reported in this paper were anonymised.
Results
The participants' perspectives on their everyday lives taking anti-depressant medication were characterised by continual uncertainty regarding depressive symptoms and the effects of the medicine, which required extensive – and sometimes anxiety provoking – interpretative work. The analysis identified a medication-taking career with two distinct stages, the basic restitution and the frustrated search. Career movement was caused by experiences of prolonged psychosocial distress, which changed the
Discussion
The present study adopted an interactionist conception of an antidepressant-taking career and explored the idea by means of a prospective design, which focused on how the participants' perspectives evolved through a one-year period after an admission for depression. The analysis identified two distinct stages: The basic restitution stage, in which participants perceived control of their situation by taking antidepressants as prescribed by healthcare staff, and the frustrated search stage, in
Conclusion
The study contributes to a better understanding of the dynamic and staged social influences on the individual antidepressant users and their striving to make the best of their complicated and challenging lives. Antidepressant medicine is not highly effective and many frustrated users will search for and initiate alternative ways of managing their experienced problems. Trusting relationships between healthcare professionals and antidepressant medication users are regarded as a crucial influence
Acknowledgements
I wish to thank The Danish Ministry of Health and Prevention (grant no. 2007-13009-501) and Aase and Ejnar Danielsen's Foundation (grant no. 106529) for supporting the study. The funding agencies did not influence the research process.
References (39)
- et al.
Patient experiences of taking antidepressants for depression: a secondary qualitative analysis
Res. Soc. Adm. Pharm.: RSAP
(2013) - et al.
Explanatory models of depression and treatment adherence to antidepressant medication: a qualitative interview study
Int. J. Nurs. Stud.
(2012) The meaning of medications: another look at compliance
Soc. Sci. Med.
(1985)- et al.
“Medication career” or “moral career”? The two sides of managing antidepressants: a meta-ethnography of patients' experience of antidepressants
Soc. Sci. Med.
(2009) - et al.
Resisting medicines: a synthesis of qualitative studies of medicine taking
Soc. Sci. Med.
(2005) - et al.
The decision to continue or discontinue treatment: experiences and beliefs of users of selective serotonin-reuptake inhibitors in the initial months–a qualitative study
Res. Soc. Adm. Pharm.: RSAP
(2011) - et al.
Interactionism
(2003) - et al.
Concordance with antidepressant medication in primary care
Nurs. Stand.
(2006) - et al.
BDI-II. Beck Depression Inventory 2. Udgave
(2005) Outsiders: Studies in the Sociology of Deviance
(1963)