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The Effect of Adherence Therapy on Initial Treatment of Mood Disorders

A Clinical Scholarly Project by

Gary Brian

Brandman University

Marybelle and S. Paul Musco School of Nursing and Health Professions

Irvine, California

Submitted in partial fulfillment of the requirements for the degree of

Doctor of Nursing Practice

April 2020

Author Note

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[Shortened Title up to 50 Characters] 2

Abstract

A large proportion of medication prescriptions do not get filled and many that are filled are not

taken as prescribed. The obstacle of medication adherence is observed frequently in the treatment

of mood disorders such as anxiety and depression. Current literature purposes that adherence to

prescribed medication regimes can be improved with provider interventions. The purpose of this

project is to show how adherence therapy through a consultation-based telephone intervention,

can decrease medication nonadherence in adult patients that are diagnosed with mood disorders

by testing symptom severity before and after the interventions. A sample size of 30 patients

ranging in ages 18-64 receiving first-time treatment for mood disorders were utilized in the

project., can adherence therapy utilizing a consultation-based telephone intervention, compared

to current practice decrease 14-item Medication Adherence Scale scores and decrease Hamilton

Anxiety and Depression scores over a 2-month period? This project design and inferred

hypothesis are based on previous research studies that suggest that adherence therapy by the use

of a consultation-based telephone intervention can be beneficial for medication adherence. The

purpose of this project is to increase medication adherence and decrease symptom severity in

patients that have a diagnosis of mood disorders. Post-intervention, the project is hypothesized

that the participants will increase their 14-item Medication Adherence Scale scores by 50% and

decrease their Hamilton Anxiety and Depression scores by 30%.

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Chapter 1: Background and Significance

Anxiety, depression and other mood disorders are some of the most prevalent afflictions

affecting the world's population and occur in 46.4% of the populace in their lifetime (Ronald C.

Kessler, et al., 2005). Although most prevalent in adults, children and adolescents suffer from

them at a high rate with 7.1% experiencing anxiety and 3.2% experiencing depression (Reem M.

Ghandour, et al., 2019). Anxiety and other mood disorders have been prevalent and frequently

diagnosed since medicine was first practiced although originally known as “pantophobic”,

physicians began referring to individuals as pantophobic when they feared everything (Ahonen,

2014). Depression itself has also had a long history dating back to before Hippocrates and was

known then as melancholia (Tipton, 2014). Psychiatric and mental conditions predominately

present without a singular diagnosis but regularly present with symptoms that associated with

multiple others (Gao, et al., 2013). The difficulty with mood disorders such as anxiety and

depression is that they are not isolated and more often than not occur together in the majority of

cases that present (Ronald C. Kessler, Wai Tat Chiu, Olga Demler, & Ellen E. Walters, 2005). In

more than 90% of the patients diagnosed with generalized anxiety disorder, other psychiatric

diagnoses are present with the predominant secondary condition being major depressive disorder

in nearly half that population (Kessler, Keller, & Wittchen, The Epidemiology of Generalized

Anxiety Disorder, 2001) (Rickels & Rynn, 2002). When they do co-occur, they generally tend to


be more severe than they would on their own (Lydiard & Brawn-Mintzer, 1998). Therefore, it is

essential that they are treated holistically by practitioners with selected interventions that may

require a broader generalized approach to wellness than specific symptom treatments. (Osterberg

& Blaschke, 2005)

A significant obstacle that can further impede beneficial treatments and expected

outcomes is the issue of medication adherence. Adherence to prescribed medications continues to

be a momentous obstacle in healthcare (Patel & David, 2007) Medication adherence is a concern

and significant issue in both psychiatric and medical treatments (Osterberg & Blaschke, 2005).

Further compounding its significance is the commonality of its occurrence with an estimated

50% of patients that are not expected to be compliant with prescribed treatments (Brown T. &

Bussel K., 2011). To be considered adherent to a medication, a prescribed patient would need to

take the correct dose at the adequate frequency 80% of the time although some ailments such as

schizophrenia the adherence bar is lower at 70% (Brown T. & Bussel K., 2011) (Valenstein, et

al., 2002). In simpler terms, a patient would be considered compliant if they take the medication

correctly every 4 out of 5 days. Treatments and medications are made to be utilized and some

pharmaceuticals such as extended or sustained-release medications simplify the prescribed

regime by allowing medication dosages that only need to be taken once a day and remain

effective (Einarson, Arikian, Casciano, & Doyle, 1999). The continued high rate of

noncompliance despite strategies designed to reduce begs that question of what the best strategy

is that can increase medication adherence. Many studies and experiments have been conducted

on answering that question and this project aims to do the same.

The percentage of individuals diagnosed with mental disorders has been increasing and

current levels are comparable to those experienced during World War II (Klerman & Weissman,


1989) (Rochelle , et al., 2018). Suicide rates are also increasing at an alarming rate and have

risen 33% since 1999 (Ducharme, 2019). Suicide is currently the 10th largest cause of death in the

US across all age demographics and in particular age ranges, is actually the second leading cause

(CDC, 2020). At least half but up to two-thirds of suicide victims suffered from a mood disorder

such as anxiety or depression and even symptoms such as feelings of worthlessness have a strong

correlation to suicide (Cavanagh, Carson, Sharpe, & Lawrie, 2003), (Arsenault-Lapierre, Kim, &

Turecki, 2004) (Bolton, Belik, Enns, Cox, & Sareen, 2008). Of the many individuals with a

history of unsuccessful suicide attempts, over 70% possessed an anxiety disorder (Nepon, Belik,

Bolton, & Sareen, 2010). Anxiety disorders are currently the most prominent mental illnesses

and may be increasing yearly (Kessler, et al., 2005) (Newman, 2018). In a large study observing

over 9,000 adults, nearly 46% of them experienced a diagnosable psychiatric disorder at one

point in their lives (Kessler, et al., 2005). Of that group, the highest occurring disorders were

anxiety disorders (29%) and were followed by major depression (17%) (Kessler, et al., 2005).

This signifies that the successful treatment of mood disorder can reduce the mortality of a

leading cause of death by drastically improving suicide prevention.

The growing concern of mental illness requires multiple strategies at improvements in

treatment to allow more beneficial outcomes. Of these concerns requiring improvement,

medication compliance is a significant issue and requires being addressed thoroughly (Brown T.

& Bussel K., 2011). Although treatment adherence for mood disorder interventions does not

receive the attention that it does among schizophrenia, it continues to be a grave concern of

prescribers (Mitchell, 2007) (Monaco, 2019). In a given year, mental illness is diagnosable in

26.2% of the U.S. adult populations and 40.3% of its adolescent population (Bagalman &

Cornell, 2018) (Kessler, et al., 2012). This would mean that tens of millions suffer this a


psychiatric ailment annually based on the estimated US population of over 329 million (Census,

2020). This a widespread, frequently occurring and dramatically significant issue. Most of these

individuals do not receive any treatment for the condition ranging from adolescents at 62% to

adults at 56.4% (Howley, 2019). Of the individuals that do receive help from healthcare

professionals, 79% are prescribed medications and 57.4% were exclusively given medications

without contiguous therapy (Mechanic & Bilder, 2004), (Olfson & Marcus, National Trends in

Outpatient Psychotherapy, 2010). With the consideration the pharmaceutical interventions

compose the majority of prescribed treatment interventions, it becomes more crucial the

adherence to medications is of paramount importance in their care.

Although compliance is a considerable dilemma in all aspects of healthcare, it does not

affect them all equally. Acute ailments and their treatments have a greater adherence rate than

chronic conditions (Jeckevicius, Mamdani, & Tu, 2002), (Haynes, McDonald, & Garg, 2002).

For example, acute ailments such as infections and corresponding antibiotic therapy see a

compliance rate of 73.33% or higher, schizophrenia with associated antipsychotic medications

can see a compliance rate of around 25% (Rao, et al., 2019) (Kardas, 2002) (Masand, Roca,

Turner, & Kane, 2009) (Morken, Widen, & Grawe, 2008) (Higashi, et al., 2013). Medication

compliance across treatments and conditions is estimated to be around 50% but for mood

disorders such as the depression, it can be as low as 33% (Tierney, 2008) (Bucci, Possidente, &

Talbot, 2003). That is separate from the rate at which patients prematurely discontinue

antidepressant medications which can vary from 50% to 72.4% (Sansone & Sansone, 2012)

(Olfson, Marcus, Tedeschi, & Wan, 2006). Although there are many factors that can contribute

to discontinuation of prescribed medications, the propensity antidepressant discontinuation may

be attributed to the belief that depression itself contributes to non-compliance outside of other


comorbidities as a significant risk factor (Grenard, et al., 2011) (DiMatteo, Lepper, & Croghan,

2000). Patients that do decide to discontinue treatment or partially follow medication regimes do

so solely and most often do not seek approval or consult with the prescriber (Sawada, et al.,

2009)

There are numerous factors that can contribute to affected individual’s decision to

discontinue or become non-adherent to prescribed medications. These barriers require

identification by prescribers to be addressed effectively (Clatworthy, Bowskill, Rank, Parham, &

Horne, 2007) (Delamater, 2006). Barriers to adherence may include dosage complexity,

treatment costs, social support, personal and spiritual beliefs, side effects, lack of insight, denial

of illness, and even issues with the provider (Grenard, et al., 2011) (Ehret & Wang, 2013).

Involuntary non-compliance can also occur where a patient may frequently forget to take

medications (Faroog & Naeem, 2014). Treatment non-compliance may also have significant

consequences such as relapse into depression and deteriorating mental health, poorer quality of

life, decrease in daily function and self-care, increased financial cost, as well as increased

suicidal ideation (Demyttenaere, et al., 2001) (PapaKostas, et al., 2004) (Ho, Chong,

Chaiyakunapruk, Tangiisuran, & Jacob, 2016). Treatment adherence has the opposite effect and

can increase quality of life, reduce likelihood of relapse and decrease costs (Sirey, et al., 2017). It

is for the purpose of increasing treatment adherent of this prevalent issue that this project is being

conducted.

Assessment of the Phenomena

Adherence therapy aims to improve medication and treatment compliance and ultimately

improve patient outcomes by reducing symptoms severity (Gray, et al., 2016). The goal is not to

benefit the prescriber but ultimately the patient as well as avoid the cost the society. There are


many different adherence therapies than can be utilized to promote treatment compliance

including psychoeducation, motivational interviewing, cognitive behavioral therapy and even

newly developed technology based interventions such as medication reminder applications

(Ehret & Wang, 2013) (Santo, et al., 2017). Medication adherence therapy is effective in

promoting medication compliance, improving treatment and ensuring more beneficial results in

the management of anxiety and depression (Simco, McCusker, & Sewitch, 2014) (Gray, et al.,

2016) (Ehret & Wang, 2013). The most beneficial interventions that significant improved

adherence rates and outcomes utilized a multifaceted approach including patient education,

telephone follow-ups, medication support as well as pro-active care and a feedback loop with the

treating practitioner (Chong, Aslani, & Chen, 2011). The multiple preficient interventions

utilized by this project could reduce morbidity and mortality on a broader scale if integrated into

regular practice in the treatment of mood disorders (DiMatteo, Lepper, & Croghan, 2000).

Historical and Societal Perspective

Although the diagnostic criteria for the conditions may change over time, the conditions

they refer to do not. The symptoms may change and present differently in each case, but the core

issue is always present. Anxiety and depression are both conditions of excess emotion. Anxiety is

excess fear and worry that is unreasonable, generalized, constant and debilitating to the

individual, their relationships and their milieu (APA, 2017). As mentioned previously, anxiety

has always been present but did not always have the recognition it does currently. Originally

known as panophobia in more archaic periods, it was called “anxiety neurosis” by Sigmund

Freud in 1895 then categorized with “psychoneurotic disorders” in the DSM-I, renamed

“neuroses” in the DSM-II before finally falling on its current title “GAD” in the DSM-III (Crocq,

2017). Depression is excess feelings of sadness, purposeless, hopeless and lack of motivation


without a consistent causative factor (Kessler, et al., 2005) (APA, 2017). Depression has a similar

and extensive history itself when it was known as melancholia to the current term of “MDD”

placed inside the DSM-III in 1980 (Ban, 2014) (Morin, 2020).

Societal and cultural perspectives play a role in the recognition, diagnosis and treatment

on anxiety and depression worldwide (Vaus, Hornsey, Kuppens, & Bastian, 2017)

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