Initiation, execution and discontinuation of antidepressant therapy: considerations and decisions of patients

Abstract

Antidepressants have shown to be effective in the treatment of depression and anxiety by reducing symptoms, as well as the risk of relapse and recurrence. Yet, several obstacles have been acknowledged in the process of adequate diagnosis and treatment of patients with these diseases: underrecognition of the health problem by the patient, underconsultation among patients who need treatment, failure to recognise and diagnose the problem by the physician, failure to prescribe drug treatment for those who need so, and eventually, on the part of the patient, not taking the drug as instructed. This thesis aims to understand why patients deviate from the prescribed and advised treatment with antidepressant drugs. The studies presented are build upon the framework of the course of drug taking consisting of three phases, namely initiation, execution and discontinuation of therapy. In this thesis, we explore patients’ considerations and decisions, based on the three phases within the course of taking antidepressants. Initiation of antidepressant drug treatment has hardly been addressed in research. This thesis showed that over one in four patients who receive a first-time antidepressant prescription appeared to decline treatment; they either do not initiate drug taking or do not persist antidepressant use for longer than two weeks. Declining a first-time antidepressant prescription was more common in patients who consult their physician for a non-specific indication, in elderly and non-western immigrants. Illness perceptions and severity, treatment needs and concerns, and patients’ views on information revealed to be important factors in the initiation of antidepressant drug taking. Fundamental in exploring the execution phase of antidepressant therapy are changes in patients’ attitude towards antidepressant treatment in response to the experiences while taking them. Health beliefs and illness severity at start showed to influence patients’ decisions about antidepressant drug taking. Patients who discontinued treatment some months after start perceived the physician’s role as limited, both during initiation and execution of treatment. They seemed to be less involved in decision making, and often appeared to have little confidence in their physician. Discontinuers were often unconvinced about the necessity of using an antidepressant, and appeared to have a strong desire to discontinue treatment. Finally, assessing whether patients taper treatment as opposed to abrupt discontinuation is important to understand patients’ behaviour during discontinuation of antidepressant therapy. We showed that one in five patients abruptly discontinue their therapy. Abrupt discontinuation caused a larger increase in the number of discontinuation symptoms than tapering. Of all patients, only one-third used a physician-made tapering schedule. We recommend healthcare professionals to inform patients of the pros and cons of taking or not taking antidepressant medication, involve patients in the treatment decision, reflect progress with treatment over time, and elicit considerations as to whether continue or discontinue drug taking. In addition, we suggest that research could systematically incorporate patients’ perspectives on medicines. Evaluation of patients’ experienced advantages and disadvantages of drug taking may contribute to the understanding of why patients take certain decisions regarding their medication use.