Barriers and Facilitating Factors of Adherence to Antidepressant Treatments: An Exploratory Qualitative Study with Patients and Psychiatrists
Abstract
:1. Introduction
2. Materials and Methods
2.1. Design
2.2. Participants Selection
- a.
- Semi-structured interviews
- b.
- Focus groups
2.3. Data Collection
- a.
- Focus groups
- b.
- Semi-structured interviews
2.4. Analysis
3. Results
3.1. Characteristics of Participants
3.2. Perception of Patients and Professionals Regarding the Disease and Its Treatment
3.2.1. Patient Experience of Depression
“I think depression must be differentiated from having a specific bad spell, (…) but hardly anyone understands depression.”(Patient 2)
“It is a disease that is not diagnosed with a blood test, so people do not understand it.”(Patient 4)
“(…) But, we really need someone to help family members understand what we’re going through.”(Patient 2)
“For me, information is essential and the support of relatives, too.”(Patient 7)
“Information to relatives is very important so that they understand what is happening.”(Patient 8)
“Sometimes, when you get a very severe depression you don’t recognize yourself, nor do your relatives recognize you, because you seem to be another person. The information in this moment is important.”(Patient 6)
“I have had depression before and I got better on my own, but in this case, I needed medication. It was impossible to get better alone; therefore, medication was essential in this case.”(Patient 1)
“I think that medical support is essential. It (depression) is something that we do not understand, we cannot find an explanation for it, and so you have to seek help from people who are trained in the matter, who know, to start getting out of it. Then, of course, you must also do your bit, that is, you cannot wait for the medication to take effect, but you must also put in a little on your part.”(Patient 7)
“The help of a psychiatrist has been very good for me. The advice he gives you, the guidelines you can follow.”(Patient 8)
3.2.2. Need of Information
“Yes, on the part of the psychiatrist, yes.”(Patient 3)
“I received all the information. He told me what each thing was for, how I was going to take it, how I was going to start, and he explained everything to me… He explained everything to me, the entire medication process.”(Patient 8)
“Yes, people search on the internet. Another thing is that they search on the correct website.”(Psychiatrist 5)
“It’s a bad sign when a patient comes with what the neighbor told him/her. That’s a bad sign, it’s worse than googling.”(Psychiatrist 5)
“My experience is that it depends on the information. Many times, it is not entirely correct or the websites where patients find information are not entirely reliable. Then, they come with wrong expectations.”(Resident doctor 1)
“The information is accessible (…). On professional websites, Spanish Society of Psychiatry and Ministry of Health, there are specific guides on depression. In other words, access is not the problem.”(Psychiatrist 5)
“I prefer informed patients, well-informed patients, because I think that teamwork is necessary. At least, we are two experts.”(Psychiatrist 5)
“I prefer they come informed, and they consult with me about their doubts, because they can sometimes come misinformed…”(Psychiatrist 1)
“I don’t prefer the savvy patient, who knows everything, who has read up on it… I like to explain a little bit to them, but today, when you mention serotonin, they say ‘yes, yes, serotonin sounds familiar to me’.”(Psychiatrist 2)
“I admit that it’s sometimes easier for me if they come and don’t object… I’m a bit ambivalent about that.”(Resident doctor 1)
“New patients (patients who have not received information) who come for the first time to receive a treatment generally do not cause problems; I explain the treatment and that’s it.”(Psychiatrist 5)
3.2.3. Treatment of Depression
3.2.3.1. Depression Management and Treatment Decision
“Severe depression depletes resources, but when it is a mild or moderate depression, it requires a normal effort.”(Psychiatrist 4)
“Real depressions are those that require less work. On the other hand, depressions with personality disorders, with family and social problems are the ones that require the most work.”(Psychiatrist 4)
“An endogenous depression hits you and you want to cure yourself, like any other disease. People who have an underlying neurosis do not always want to be cured, and the most difficult thing is being able to cure them when they don’t want to be cured; it’s quite complicated.”(Psychiatrist 5)
“You have to be very meticulous, identifying what the characteristics of the patient are in all senses, that is, in the personal sphere, in the field of health, what are the other pathologies that they have.”(Psychiatrist 3)
“The problem is that many of the patients are resistant (to treatment). (…) So, first, you have to investigate more, especially the psychopharmacological approach that has been used.”(Psychiatrist 1)
“Pharmacological treatment has some protocols, that is, this part is not very complex”(Psychiatrist 2)
“Those depressions with social, anxiety, family factors (…) are the ones that involve more work. In my opinion, due to the lack of psychological support.”(Psychiatrist 2)
“Psychotherapeutic work is harder, that is, with the person, trying to understand their situation… These activities are more typical of psychology, but the conditions are not met, especially in the hospital setting.”(Psychiatrist 2)
“Psychologists, due to their scarcity, cannot apply the therapies as they should and that ends up with overloading.”(Psychiatrist 2)
“The system is not oriented so that the patient can receive regulated psychotherapy (because of a lack of psychologists).”(Psychiatrist 3)
“So, honestly, I didn’t like them (psychotherapists).”(Patient 8)
“Every time I go to a psychologist, it’s like going to a slaughterhouse.”(Patient 3)
“In the end, the psychiatrist ends up trying to do psychotherapy, without being the right professional, because the right professional should be a psychologist to do therapy properly.”(Resident doctor 1)
“I can’t do it with everyone (psychotherapy), I don’t have time.”(Psychiatrist 5)
“I try, but I recognize that I cannot provide regulated psychotherapy (due to lack of time)”(Psychiatrist 4)
“It (motivational interview) is useful, but (…) you have to be trained. It is true that I have been half trained in motivational interviews. The truth is that I need the second half.”(Psychiatrist 3)
“If we are treating a very, very severe case of major depression, (…) we have to prioritize the drug treatment before using another type of strategy.”(Psychiatrist 1)
“If there is not enough time to attend to a patient, there is no motivational interview or anything, because you cannot dedicate yourself to them calmly.”(Psychiatrist 3)
“There are patients who ask you this (pseudoscience). I think that the patient’s decision must be respected as long as they are well informed.”(Psychiatrist 3)
“I would take into account the functionality of the patient, and by functionality, I mean work or daily living activities (…), and then I would also take into account the patient’s preferences.”(Psychiatrist 3)
“This has to be done, I can’t tell you if it is done regularly, but it has to be done.”(Psychiatrist 3)
“There is a lack of time for professionals to explain not only what is happening but also what the therapeutic possibilities are.”(Psychiatrist 3)
“Well, it is true that I do not always do it perfectly. Sometimes the time is pressing and well…”(Psychiatrist 4)
“I really like to involve the patient in treatment options.”(Psychiatrist 2)
“Involving the patient is essential in the improvement process.”(Psychiatrist 4)
“I think the decision is made by the patient, it is clear, no matter how many pills you prescribe.”(Resident doctor 1)
“Many times, they leave the decision to us (professionals), even if you tell them, they tell yo, whatever you think is best, I don’t understand.”(Resident doctor 1)
“There are many patients who are not very interested in that (SDM), but what they simply want is for the doctor to prescribe something and they don’t even get into discussing anything.”(Psychiatrist 1)
“Few psychiatrists say, ‘we would have this and that treatment and you choose’.”(Resident doctor 1)
“It is true that there are colleagues who feel more comfortable with paternalism: ‘you must take this because I say so’.”(Psychiatrist 3)
“The time, the lack of time. If you have little time, you cannot apply shared decision-making because it requires time.”(Psychiatrist 3)
“Yes, the psychiatrist and I were talking about it, and she listened to me. Then, we made the decision together.”(Patient 3)
“In my case, he explained the pros and cons to me, but since it’s an issue I don’t understand, I take the medication, and then, if I feel bad, I ask him to change it.”(Patient 3)
“I think the main problem is when the diagnosis is not correct. In other words, if you are scrupulous about the psychopathology of depression, you will apply a treatment that will be effective, but on many occasions, there are patients who are diagnosed with depression when they are not depressed. Generally, the first diagnosis is made by a PC physician (…) the diagnosis is not always the right one.”(Psychiatrist 3)
“They (family doctors) have to cover many things. So, many times there is an underdiagnosis.”(Psychiatrist 3)
“PC doctors have five or seven minutes per patient. Many times, they prescribe a standard medication. However, when the patient is treated by a psychiatrist, then we have more time to get to know the patient, and the treatment is more tailored.”(Psychiatrist 3)
“I think that a PC physician prescribing an antidepressant treatment for 6–12 months before referring them to a psychiatrist is too much.”(Psychiatrist 4)
“There are depressions that are very easy to treat and that is also another reason for overloading psychiatrists with work. (…) There are a lot of patients who are not even minimally treated by their family doctors before referral to a psychiatrist.”(Psychiatrist 2)
3.2.3.2. The Perception of the Impact of Medication and the Patient’s Treatment Experience
“I think that no one likes to take medicine, no one. You take it because you have no other solution.”(Patient 4)
“I think that if you read the prospectus, you won’t take the medication, but, of course, if you don’t take this medication, there is often no other option.”(Patient 3)
“In my case, medication was positive to stop having dark and obsessive thoughts and I imagine that without medication I would not have been able to do it.”(Patient 3)
“I think medication has some danger, at least in my case it has…, and what I mean is that I have had the intention and desire to take all the medication at the same time, the entire bottle.”(Patient 4)
3.3. Modifying Factors of Pharmacological Adherence
3.3.1. Factors Related to the Health System
3.3.1.1. Doctor–Patient Relationship
3.3.1.2. Coordination with PC
3.3.1.3. Accessibility to and Availability of Professionals
3.3.1.4. Information Available to the Patient
3.3.1.5. Shared Decision-Making and Other Methods
3.3.1.6. Factor Related to Patients and Socio-Family Context
3.3.2. Factors Related to Depression and the Pharmacological Treatment Itself
4. Discussion
4.1. Consistency of Main Results with Previous Studies
4.2. Limitations
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Acknowledgments
Conflicts of Interest
Appendix A
Block 1. Experience of depression | ||
1. | Do you know that depression is one of the most common health problems and is one of the most important causes of disability? Do you think it is given the importance it deserves? | |
2. | Do you think that the people around you are aware of the problem of depression and how difficult it is for those who suffer from it? | |
3. | What do you think are the keys to recovering quickly and well? | |
Block 2. Information received by the patients | ||
1. | When you were diagnosed, were you informed of all the treatment options for depression (drugs, psychotherapy, others…)? What about their risks and benefits? | |
2. | Do you think the information you received was enough? Would you have liked to have received more information? | |
3. | Did you receive information about how the drugs work and why they are used? Did you receive the same information for all the drugs or for some more than others? | |
4. | Do you consider that the information received about drugs was sufficient? Have you ever had any doubts about how a drug should be taken? Which one(s) and why? | |
Block 3. Doctor–patient relationship | ||
1. | Who made the decision about the treatments you were going to receive (between the two of you, you alone, or the doctor)? Would you have liked to participate more actively in the decision? Why? | |
2. | If you are concerned about a treatment issue, how do you resolve it? Do you consult your doubts with the doctor or look for information on your own? | |
3. | How would you describe the relationship you have with your doctor (psychiatrist)? Does he/she encourage you to ask all the questions you have? Do you feel that your preferences are considered? | |
Block 4. The perception of the impact of the drug(s) | ||
1. | What positive and/or negative impacts does pharmacological treatment have on your daily life? | |
2. | Do you feel different since you started taking antidepressant drugs? Why and in what way? | |
3. | Are you satisfied with the treatment? Why? Do you think it suits your needs, preferences, and lifestyle? | |
Block 5. Adherence to anti-depressive medication | ||
1. | Do you think your therapeutic adherence is correct? | |
2. | What do you think are the most common difficulties in adhering to the treatment? | |
3. | How do you think the following aspects influence you when taking or not taking a drug as prescribed by your doctor? | |
Severity or type of disease | ||
Concern about the state of your health (symptoms of depression) | ||
Motivation to get better | ||
Optimal medication knowledge | ||
Trust in the healthcare professional | ||
Fear of side effects | ||
Duration and complexity of the treatment | ||
4. | In case you have not complied with the treatment, has it been your own decision? | |
If it was not your own decision, what was the reason? | ||
Forgetfulness | ||
Because when you travel or leave home, you forget to take your medication with you | ||
Due to difficulty in taking the medication or difficulty in identifying them | ||
Other(s) | ||
If it was your own decision, what was the reason? | ||
Believing that it was not necessary | ||
Not agreeing with the treatment (type of drug, dose…) | ||
Because the symptoms had disappeared or diminished | ||
Side effects | ||
Fear of dependency | ||
Fear of other causes (polymedication…) | ||
Due to mistrust or poor relationship with the doctor | ||
Economic reasons | ||
Other(s) | ||
5. | Have you ever reduced or stopped taking antidepressants without telling your doctor? Why? | |
6. | Do you think that the individual characteristics of a person may have an influence when taking a medication as prescribed? Why? | |
Age | ||
Gender | ||
Marital status | ||
Educational level | ||
Due to being affected by more than one health problem | ||
7. | What kinds of support have you received to follow the treatment? Have they helped you? | |
8. | Do you think that health professionals can help the patient to take the medication as prescribed? How? | |
9. | Do you think that the following aspects can make it easier for a person to take the medication as prescribed? Why? | |
The possibility of deciding together with the doctor which is the best treatment.\ | ||
The possibility of asking and clarifying all the doubts that the person may have about how they should take the medication | ||
The existence of a system that simplifies or facilitates taking the medication | ||
Have a reminder system | ||
Have healthy lifestyle | ||
The support of family and/or friends | ||
Do you want to add any other aspects that you consider important and that were not included in the interview? |
Appendix B
Block 1. Experience of medication management | ||
1. | What is your experience with managing depression (particularly, burden of treatment)? | |
2. | In general, what attitude(s) do you face with depression and its management compared to other mental illnesses? | |
3. | In your opinion, what aspects of depression present greater complexity or difficulty when treating patients? | |
Block 2. Depression treatment | ||
1. | In clinical practice, could it be the case that depression is not treated adequately? What factors can influence this? | |
2. | Antidepressants: what factors do you consider when prescribing them? | |
3. | Normally, do you prescribe one treatment or another depending on the severity of the depression? | |
4. | Do you think that patients have enough information about the different treatment options? | |
Where do they get this information from? | ||
Do you think it influences the expectations they have of the treatment? | ||
5. | How do you normally make decisions about treatment? | |
Do you apply a shared decision-making model in which the patient is informed of the therapeutic options and the treatment is agreed upon with him or her? | ||
What do you think are the greatest difficulties in following this model in practice? | ||
The advantages? | ||
6. | Do you usually apply motivational interviewing strategies in your clinical practice? | |
Do you find them useful? | ||
What barriers and facilitators do you think there are to applying them in the consultation? | ||
Block 3. Pharmacological adherence | ||
1. | Could you tell us about therapeutic adherence in depression from your own experience and professional career? (What is the situation we are in?) | |
2. | What would be the main determinants of therapeutic adherence? | |
Its main modifiers? (For example, in relation to the disease, socio-demographic variables, preference for other types of treatment (psychotherapy, others, such as relaxation, bibliotherapy, music therapy, physical exercise, etc.). | ||
3. | From your experience, is it possible to draw an adherent and non-adherent patient profile? Please describe them. | |
4. | From your own experience, do patients usually report aspects related to therapeutic non-adherence as a problem (adverse effects; difficulty keeping schedules; having to submit to restrictions, such as not consuming alcohol while taking the medication; cost; difficulty swallowing pills; etc.)? | |
Do they communicate these problems, or do they remain silent and hide them? | ||
5. | What do you consider to be the main barriers that patients encounter in complying with treatment? | |
The professionals? | ||
6. | Have you tried to overcome non-adherence in patients with depression/dysthymia in your clinical practice? | |
If the answer is affirmative, | ||
What methods have you applied? | ||
Which have been effective, and which have not? | ||
What do you consider to be the barriers to the implementation of this type of method in the Spanish health system? | ||
What conditions do you see as being necessary for the implementation of this type of method? | ||
7. | On the contrary, what facilitators might be useful for the implementation of this type of method in the Spanish health system? | |
8. | In our project, we are going to evaluate a strategy consisting of the use of a mobile phone application and attention to a training program (series of telephone sessions (6–12) for fourteen weeks with the following content: education for depression, management of medication, behavioral activation, implemented by a psychologist) for the patient to improve therapeutic adherence. Do you think this could be useful? | |
If the answer is affirmative, | ||
Would you consider suggesting an intervention strategy like this to your patients? | ||
What if this strategy involved attending a four-hour training workshop spread over two sessions? | ||
What are the reasons for considering or not considering such an intervention, in each case? | ||
Would you like to add anything else that you consider important and that was not included in the interview? |
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Participants of the Focus Groups (Patients and Informal Caregivers) | N = 11 | |
---|---|---|
Age, mean (SD) | 50.72 (9.39) | |
Age range | 38–65 | |
Gender, n (%) | ||
Women | 8 (72.73) | |
Men | 3 (27.27) | |
Informal caregivers | 2 | |
Patients of the focus groups | N = 9 | |
Age, mean (SD) | 52.11 (9.81) | |
Age range | 38–65 | |
Marital status, n (%) | ||
Married/with a partner | 5 (55.55) | |
Single/separated/widowed | 4 (44.44) | |
Gender, n (%) | ||
Women | 6 (66.67) | |
Men | 3 (33.33) | |
Educational level, n | ||
No formal education/incomplete primary education | 3 | |
Primary education | 1 | |
Lower secondary education | 1 | |
Higher secondary education | 4 | |
University education | 0 | |
Diagnosis, n (%) | ||
F32-F33 Major depressive disorder | 8 (88.89) | |
F34 Dysthymic disorder | 1 (11.11) | |
Diagnosis duration, mean (SD) | 5.47 (6.65) | |
Total antidepressant drugs, mean (SD) | 2 | |
Antidepressant drug range | 1–4 | |
Adherence to antidepressant treatment (Sidorkiewicz), mean (SD) | 6.78 (2.77) | |
Adherence to antidepressant treatment (Sidorkiewicz), n (%) | ||
Yes | 1 (11.11) | |
No | 8 (88.89) | |
BDI-II, mean (SD) | 37.2 (9.55) | |
Participants in the semi-structured interviews (psychiatrists) | N = 6 | |
Age, mean (SD) | 39.43 (11.83) | |
Age range | 29–63 | |
Women | 3 (50) | |
Men | 3 (50) | |
Island | ||
Gran Canaria | 4 | |
Tenerife | 2 |
Participants of the Focus Groups | Age | Gender | Diagnosis | Antidepressant Drugs (n) | Years Since Diagnosis |
---|---|---|---|---|---|
Patient 1 | 50 | M | Dysthymia | 4 | 2 |
Patient 2 | 42 | W | Major depressive disorder | 1 | 3 |
Patient 3 | 52 | W | Major depressive disorder | 1 | 6 |
Patient 4 | 38 | W | Major depressive disorder | 2 | 2 |
Patient 5 | 48 | M | Major depressive disorder | 1 | 2 |
Patient 6 | 47 | W | Major depressive disorder | 2 | 1 |
Patient 7 | 64 | M | Major depressive disorder | 1 | 22 |
Patient 8 | 63 | W | Major depressive disorder | 2 | 6 |
Patient 9 | 65 | W | Major depressive disorder | 3 | 1 |
Caregiver 1 | 42 | W | Informal caregiver of patient 1 | NA | NA |
Caregiver 2 | 47 | W | Informal caregiver of patient 5 | NA | NA |
Participants in the Semi-Structured Interviews | Age | Gender | Professional Features |
---|---|---|---|
Psychiatrist 1 | 48 | M | Specialist doctor |
Psychiatrist 2 | 52 | M | Specialist doctor |
Psychiatrist 3 | 37 | W | Specialist doctor |
Psychiatrist 4 | 47 | W | Specialist doctor |
Psychiatrist 5 | 63 | W | Specialist doctor |
Resident doctor 1 | 29 | M | Doctor in the fourth year of residency training to become a psychiatrist |
Dimensions | Factors | Perspective and Illustrative Quotes | |
---|---|---|---|
Barriers | Facilitators | ||
Health system | Coordination with PC | Psychiatrists “The biggest barrier may be in primary care. It seems that primary care physicians are often better at first addressing hypertension training or diabetes problems or anything other than treating depression”; “There are depressions that are very easy to treat and that is also another reason for overloading psychiatrists with work. (…) There are a lot of patients who are not even minimally treated by their family doctors before referral to a psychiatrist.” (Psychiatrist 2) “I think the main problem is when the diagnosis is not correct. In other words, if you are scrupulous about the psychopathology of depression, you will apply a treatment that will be effective, but many times there are patients who are diagnosed with depression when they are not depressed. (…) Generally, the first diagnosis is made by a primary care physician (…) the diagnosis is not always the right one”; “Primary care doctors have five or seven minutes per patient. Many times, they prescribe a standard medication. (Psychiatrist 3) “I think that a PC physician prescribing an antidepressant treatment for 6–12 months before referring them to a psychiatrist is too much.” (Psychiatrist 4) | Psychiatrists “However, when the patient is treated by a psychiatrist, then we have more time to get to know the patient and the treatment is more tailored.”; “Interventions to promote adherence to treatment, either with group activities or with follow-up by phone (could improve adherence).”; “It (motivational interview) is useful, but (…) you have to be trained. It is true that I have been half trained in motivational interviews. The truth is that I need the second half.” (Psychiatrist 3) |
Accessibility and availability of professionals | Psychiatrists “There is a lack of time for professionals to explain, not only what is happening, but what the therapeutic possibilities are”; “The system is not oriented so that the patient can receive regulated psychotherapy (because of a lack of psychologists)”; “If there is not enough time to attend to a patient, there is no motivational interview or anything, because you cannot dedicate yourself to them calmly” (Psychiatrist 3) “Psychotherapeutic work is harder, that is, with the person, trying to understand their situation… These activities are more typical of psychology, but the conditions are not met, especially in the hospital setting”; “Psychologists, due to their scarcity, cannot apply the therapies as they should and that ends up with overloading.” (Psychiatrist 2) “In the end, the psychiatrist ends up trying to do psychotherapy, without being the right professional, because the right professional should be a psychologist to do therapy properly.” (Resident doctor 1) “If you are a psychiatrist, (psychotherapy) needs complementary training, and not all psychiatrists have it. It depends on the interest”; “I can’t do it with everyone (psychotherapy), I don’t have time.” (Psychiatrist 5) | Patients “I think it would be necessary to provide hospitals with more staff. I think we would reduce the treatment a lot if the doctors were not so overworked and could, perhaps, treat the illness in another way.” (Patient 8) | |
Psychiatrists “I think it is essential that patients are able to consult doubts to achieve adherence, that would improve adherence.” (Psychiatrist 4) “A greater availability of consultation by psychiatry and the availability of more frequent check-ups (would improve adherence).” (Psychiatrist 2) | |||
Information available to the patient | Psychiatrists “I admit that sometimes it’s easier for me if they come and don’t object… I am a bit ambivalent about that.” (Resident doctor 1). “People search on the internet. Another thing is that they search on the correct website”; “It’s a bad sign when a patient comes with what the neighbor told him/her. That’s a bad sign, it’s worse than googling”; “The information is accessible (…). On professional websites, Spanish Society of Psychiatry and Ministry of Health, there are specific guides on depression. In other words, access is not the problem”; “New patients (patients who have not received information) who come for the first time to receive a treatment generally do not cause problems, I explain the treatment and that’s it.” (Psychiatrist 5). “I don’t prefer the savvy patient, who knows everything, who has read… I like to explain a little bit to them, but today, when you mention serotonin, they say yes, yes, serotonin sounds familiar to me.” (Psychiatrist 2) | Patients “I received all the information. He told me what each thing was for, how I was going to take it, how I was going to start, and he explained everything to me… He explained everything to me, the entire medication process.” (Patient 8) | |
Psychiatrists “I prefer they come informed, and they consult with me about their doubts, because they can sometimes come misinformed…” (Psychiatrist 1). “I think that information prior to treatment is essential (to promote adherence). If you explain everything to them before giving them a treatment, and they understand what the process is going to be, they accept it many times”; “My experience is that it depends on the information. Many times, it is not entirely correct or the websites where patients find information are not entirely reliable. Then, they come with a bad expectation.” (Resident doctor 1) “I prefer informed patients, well-informed patients, because I think that teamwork is necessary. At least, we are two experts.” (Psychiatrist 5) | |||
Doctor-patient relationship | Patients “In that aspect (adherence), I am super motivated by the doctor. I totally trust her”; “I think that medical support is essential. It is (depression) something that we don’t understand, we can’t find an explanation for it, and so you have to seek help from people who are trained in the matter, who know, to start getting out of it. Then, of course, you also have to do your bit, that is, you cannot wait for the medication to take effect, but you also have to put in a little on your part.” (Patient 9) “I have not read the prospects; I fully trust my psychiatrist.” (Patient 1) “The help of a psychiatrist has been very good for me. The advice he gives you, the guidelines you can follow.” (Patient 10) | ||
Psychiatrists “The therapeutic link, that is, the trust you have with the doctor who treats you (the psychiatrist or the primary care doctor) (is an important adherence factor).” (Psychiatrist 3) “If the patient normally trusts you, if you give him the option to consult doubts and such, he usually pays attention to you, but it is important that he trusts you.” (Psychiatrist 5) | |||
SDM | Psychiatrists “There are many patients who are not very interested in that (SDM), but what they simply want is for the doctor to prescribe them something and they don’t even get into discussing anything.” (Psychiatrist 1) “I try (do SDM), but I recognize that I cannot apply regulated psychotherapy (due to lack of time)”; “Well, it is true that I do not always do it perfectly. Sometimes the time is pressing and well…” (Psychiatrist 4) “Few psychiatrists say, ‘we would have this treatment and that and you choose’”; “Many times, they leave the decision to us (professionals), even if you tell them, they tell you, ‘Whatever you see best, I don’t understand.’” (Resident doctor 1) “This has to be done, I can’t tell you if it is done regularly, but it has to be done”; “There is a lack of time for professionals to explain not only what is happening but also what the therapeutic possibilities are”; “It is true that there are colleagues who feel more comfortable with paternalism:—‘you have to take this because I say so’”; “The time, the lack of time. If you have little time, you cannot apply shared decision-making because it requires time.” (Psychiatrist 3) | Patients “Yes, the psychiatrist and I were talking about it, and she listened to me. Then, we made the decision together”; “In my case, she explained the pros and cons to me, but since it’s an issue I don’t understand, I take the medication, and then if I feel bad, I ask her to change it.” (Patient 3) | |
Psychiatrists “If you give the patient options that are more appropriate to their preferences, I think that it becomes the main positive conditioning factor for adherence”; “I really like to involve the patient in treatment options.” (Psychiatrist 2). “This has to be done (SDM), I can’t tell you if it is done regularly, but it has to be done”; “There are patients who ask you this (pseudoscience). I think that the patient’s decision must be respected as long as he is well informed”; “I would take into account the functionality of the patient, and by functionality, I mean work or daily living activities (…), and then I would also take into account the patient’s preferences.” (Psychiatrist 3) “Involving the patient is essential in the improvement process.” (Psychiatrist 4) “Especially in adherence (it has a positive influence), when a patient feels that they have decided on their treatment, that they are not obliged, they take it more easily.” (Psychiatrist 5). “I think the decision is made by the patient, it is clear, no matter how many pills you prescribe.” (Resident doctor 1) | |||
Patient, family, and socioeconomic environmental | Socioeconomic and family context | Patients “Sometimes, when you get a very severe depression and you don’t recognize yourself, nor do your relatives recognize you, because you seem (to be) another person.” (Patient 8) | Psychiatrists “When there is family support, there is always greater adherence, because the family is there, saying ‘come on, you have to take it, you have to put up with it.’” (Resident doctor 1) “I think there should be more ‘society’, more neighborhood associations, more sense of having a family, a society, which you and others belong to” (Psychiatrist 4) “Illness awareness (favors adherence). That they know that they are sick and that they want to get better seems fundamental to me.” (Psychiatrist 4) “Apart from the information, the involvement of family members (is important). Asking a family member to prepare the medication and supervise it. I have also used that strategy”; “The involvement of family members, telling a family member to prepare the medication and supervise it. Yes, I have also used that strategy”; “The information and involvement of relatives (is very important) for taking treatment”. (Psychiatrist 3) “Another influence is that someone is supervising, especially older people, (…), because it is also a determining factor for the patient to take the medication”. (Psychiatrist 1) |
Disease and treatment itself | Depression | Psychiatrists “Severe depression depletes resources, but when it is a mild or moderate depression, it (it) requires a normal effort”; “Real depressions are those that require less work. On the other hand, depressions with personality disorders, with family and social problems are the ones that require the most work.” (Psychiatrist 4) “An endogenous depression hits you and you want to cure yourself, like any other disease. People who have an underlying neurosis do not always want to be cured, and the most difficult thing is being able to cure them when they don’t want to be cured; it’s quite complicated.” (Psychiatrist 5) “If we are treating a very, very severe case of major depression, (…) we have to prioritize the drug treatment before using another type of strategy.” (Psychiatrist 1) “Those depressions with social, anxiety, family factors (…) are the ones that involve more work. In my opinion, due to the lack of psychological support.” (Psychiatrist 2) | Patients “I have had depression before and I got better on my own, but in this case, I needed medication. It was impossible to get better alone; therefore, medication was essential in this case.” (Patient 1) “I don’t care about the side effects. I was lying on a bed; I did not care what the pills did to me. The fear is what will happen when I stop taking the pills.” (Patient 3) |
Psychiatrists “You have to be very meticulous, identifying what the characteristics of the patient are in all senses, that is, in the personal sphere, in the field of health, what are the other pathologies that they have”; “I would take into account the functionality of the patient, and by functionality I mean work or daily living activities (…), and then I would also take into account the patient’s preferences.” (Psychiatrist 3) | |||
Medication | Patients “The times to take it, there are many a day. It makes it difficult for me on a day-to-day basis, at work…” (Patient 4) “Those of us who take pills have the hope of one day being the same as before.” (Patient 2) “The delay of the therapeutic effect, which many times both in the sense of beginning the treatment and at the end. That there is that delay between when you start taking the treatment and its effectiveness once you have a relapse. The truth is that this favors non-adherence a lot…” (Patient 9) “Antidepressants do not have an immediate effect; therefore, they take time to take effect and you start taking that and say: ‘Oh my God, this doesn’t do anything for me, what am I taking?’” (Patient 8) “In my case, I did a lot of research on medication side effects and that made me ask the doctor to reduce my medication. This matters a lot to me.” (Patient 3) “It is true that the medication has helped me, but it is also true that it has some very bad side effects and that sometimes I can’t stand it, I can’t stand it.” (Patient 10) | Psychiatrists “Pharmacological treatment has some protocols, in other words, this part is not very complex.” (Psychiatrist 2) “The problem is that many of the patients are resistant (to treatment). (…) So, first, you have to investigate more, especially the psychopharmacological approach that has been used.” (Psychiatrist 1) | |
Psychiatrists “The main reason for lack of adherence is side effects.” (Psychiatrist 3) |
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González de León, B.; Abt-Sacks, A.; Acosta Artiles, F.J.; del Pino-Sedeño, T.; Ramos-García, V.; Rodríguez Álvarez, C.; Bejarano-Quisoboni, D.; Trujillo-Martín, M.M. Barriers and Facilitating Factors of Adherence to Antidepressant Treatments: An Exploratory Qualitative Study with Patients and Psychiatrists. Int. J. Environ. Res. Public Health 2022, 19, 16788. https://doi.org/10.3390/ijerph192416788
González de León B, Abt-Sacks A, Acosta Artiles FJ, del Pino-Sedeño T, Ramos-García V, Rodríguez Álvarez C, Bejarano-Quisoboni D, Trujillo-Martín MM. Barriers and Facilitating Factors of Adherence to Antidepressant Treatments: An Exploratory Qualitative Study with Patients and Psychiatrists. International Journal of Environmental Research and Public Health. 2022; 19(24):16788. https://doi.org/10.3390/ijerph192416788
Chicago/Turabian StyleGonzález de León, Beatriz, Analía Abt-Sacks, Francisco Javier Acosta Artiles, Tasmania del Pino-Sedeño, Vanesa Ramos-García, Cristobalina Rodríguez Álvarez, Daniel Bejarano-Quisoboni, and María M. Trujillo-Martín. 2022. "Barriers and Facilitating Factors of Adherence to Antidepressant Treatments: An Exploratory Qualitative Study with Patients and Psychiatrists" International Journal of Environmental Research and Public Health 19, no. 24: 16788. https://doi.org/10.3390/ijerph192416788