Elsevier

Social Science & Medicine

Volume 123, December 2014, Pages 105-113
Social Science & Medicine

Adherence to anti-depressant medication: A medicine-taking career

https://doi.org/10.1016/j.socscimed.2014.11.010Get rights and content

Highlights

  • Learning to take antidepressants was analysed as a social career.

  • Two stages were identified: The basic restitution and the frustrated search.

  • Career movement was caused by experiences of prolonged distress.

  • Career movement changed the participants' management and perspectives of medicine.

  • Participants at the frustrated search stage managed their medicine on their own.

Abstract

The study of medicine taking is controversial as it often reveals a discrepancy between healthcare professionals' advice and patients' actual behaviour. Qualitative researchers have examined depressed people's adherence to prescriptions of antidepressants by exploring the meaning they impute to the medicine and their use of the medicine in the wider context of their everyday lives. This paper contributes to this area of research by means of a prospective research study focussing on depressed patients' perspectives on taking medicine and how they change through time. The study included consecutive semi-structured interviews with 16 people four times during the year following an admission to hospital for depression. Data were collected in 2008–2009 in the Region of Southern Denmark. The study was based on an interactionist conception of social career and data were analysed thematically. Findings indicated that participants were confronted with recurrent challenges related to being depressed and taking medicine, and they learned how to manage these challenges in a post-admission career with two distinct stages: the basic restitution stage and the frustrated search stage. Medicine-taking depended on a number of career moving tensions and problems. The basic restitution stage was characterised by the participants' readiness to take medicine in accordance with healthcare professionals' prescriptions and advice. Half of the participants experienced being challenged by unacceptable prolonged mental, social, and/or physical distress, and they moved to the frustrated search stage, which was characterised by an alternative perspective on taking medicine that included increased self-regulation and less involvement of healthcare professionals and next of kin. Healthcare professionals played a very peripheral role in most participants' lives and unsatisfactory interactions often isolated participants and left them to solve their own problems.

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.

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