Impact of Depression on Medication Compliance
Drug-related hospital admissions are common among all age groups,1 but particularly among older adults.1,2 Adverse drug reactions and issues related to noncompliance in older persons lead to many emergency department (ED) visits and hospital admissions. Depression is also common among elders and may result in poor medication compliance, including the underuse of medications or inappropriate drug discontinuation.3-5 Poor adherence to drug regimens may have an impact on a patient’s physical condition, such as worsening of illness and death.
In this report, we discuss the case of an elderly man who presented to the ED with chest palpitations and shortness of breath. The patient was grieving the recent death of his wife, and he expressed continuing emotional distress and feelings of depression. He informed his physicians that his sadness was making it difficult for him to remember to take his medications, including metoprolol, and that he often forgot to request prescription refills. This case illustrates the impact of depression on medication compliance.
Case Presentation
An 85-year-old man presented to the ED with chest palpitations and shortness of breath. He reported no chest pain, cough, fevers, chills, vomiting, or diarrhea. On arrival, his blood pressure was 139/90 mm Hg and pulse oximetry was 99% on room air. The cardiac examination revealed a heart rate of 145 beats per minute with regular rhythm. During the physical examination, the patient was awake, alert, and in no distress. His lungs were clear on auscultation and no extremity edema was noted. The patient’s abdomen was mildly tender in the right and lower-left quadrants on palpation.
The patient’s medical history was significant for coronary artery disease, hypertension, chronic obstructive pulmonary disease, chronic low back pain, anxiety, and depression. Over a 10-year period before his current presentation, he had experienced multiple severe panic attacks that resulted in several ED visits to another hospital for chest pain; the episodes were determined to be non–cardiac-related. During that period, the patient had been seeing a psychologist for his depression and anxiety, but he often cancelled appointments, which resulted in his mood worsening. He had declined taking the antidepressant prescribed by his primary care physician, fearing the side effects. His wife of 55 years had died 3 months prior to his current presentation. He had been her caretaker for several months before her death. During this time, the patient’s depression and anxiety had started worsening and he had found taking care of her to be quite stressful. After his wife’s death, the patient’s primary care physician referred him to a psychiatrist. For months following her death, the patient continued to be despondent and anxious, although he repeatedly denied suicidal ideation to his psychiatrist. He did not smoke, drink alcohol, or use illicit drugs. The patient, who was retired and had four children, expressed feelings of sadness and anxiety to his physician during the current presentation in the ED, but again denied suicidal ideation.
His medications included metoprolol, simvastatin, and albuterol. Nearly 3 months earlier, the patient’s psychiatrist prescribed venlafaxine as a treatment for depression, but the patient had stopped taking it after 6 days because of headaches. He stated that he often forgot to ask for all of his medication refills and that he had not taken the metoprolol for 3 or 4 days prior to his current presentation.
The initial electrocardiogram performed on presentation demonstrated supraventricular tachycardia at a rate of 145 beats per minute. After an intravenous push of metoprolol 5 mg, the repeat electrocardiogram showed normal sinus rhythm at a rate of 70 beats per minute. All of the laboratory and radiologic examinations were normal.
The patient was successfully stabilized with one dose of metoprolol in the ED; no additional treatment was required for his rapid heart rate. The importance of medication compliance was discussed with the patient, and he understood the possible ramifications of not adhering to his drug regimen. He agreed to accept help from his family to achieve this goal. He was discharged home after stabilization, which occurred 3 hours after he presented to the ED, with no change in his medication regimen. The patient is currently being treated by a multidisciplinary team consisting of a primary care physician, geriatrician, and psychiatrist. His son has been supportive and helpful in ensuring that the patient takes his medications appropriately, including the antidepressant, and the patient attends therapy sessions regularly. Since his presentation in the ED, the patient’s mood has improved and he has been compliant with all of his medications.
Discussion
Medication noncompliance, which is estimated to occur in 26% to 59% of elders,6 leads to increased hospital admissions and accounts for a substantial number of medical emergencies in this population. Older patients more commonly underuse medications than overuse or misuse them, but this practice can still have deleterious effects. Numerous factors predispose patients to medication noncompliance, including cost, forgetfulness, side effects, switching to unconventional forms of treatment, and inadequate instructions. In addition, as the number of medications prescribed increases to three or more, or the number of physicians regularly seen increases to three or more, the greater the degree of noncompliance and the more difficulty patients have following the drug regimens and advice given.6 Other issues that may result in poor compliance in older patients include difficulty reading drug labels and opening bottles due to hard-to-open lids.7
Noncompliance among elders can also be the result of a medical condition. Depression and dementia may lead to the underuse of all medications, inappropriate drug discontinuation, and generally poor compliance.3-5 Depression has been shown to be a definite risk factor for noncompliance with taking all medications correctly, attending medical appointments, and adhering to lifestyle, diet, and exercise recommendations.8 Patients with depression are three times more likely to be noncompliant with medical treatment than patients without depression. It is postulated that the reasons for this include disbelief in effectiveness because of feelings of hopelessness, social isolation from those who might assist in ensuring compliance, and reductions in cognitive functioning of the patient; thus, depression that results in noncompliance with medical treatment may lead to worsening of multiple illnesses.8
Depression is a significant problem in the elderly population, with approximately 10% to 15% suffering from depressive symptoms that require intervention.9 Older patients who experience negative life events, such as death of a spouse, are at greater risk of depression.Elderly patients often ignore depression, which is the leading psychological factor related to suicide in this population.9 Although constituting 12% of the US population in 2004, people 65 years and older accounted for 16% of deaths by suicide that year.10 Depression is treatable with psychotherapy and antidepressant medication, but a full therapeutic effect may take 4 to 8 weeks to achieve. For a majority of older adults, particularly those in good general health, there can be up to an 80% recovery with a combined psychotherapy and antidepressant medication regimen10; however, many elderly patients with depression prematurely discontinue use of their antidepressant, generally within the first 2 to 4 weeks, as occurred with the case patient. These patients may feel the medication is not helping their symptoms or they may stop taking it because of side effects or because they falsely think that they are cured.8
Compliance with taking antidepressant medication in the treatment of major depressive disorder varies with length of treatment, severity of depression, medication prescribed, and whether it is a recurring problem. Noncompliance rates in patients taking antidepressant medications are reported to be between 10% and 60% in all age groups.11 A greater rate of noncompliance has been observed among younger patients, those with lower depression severity, and patients with a first episode of depression (compared with those who have recurrent episodes).11
Because elderly patients are at high risk for depression, especially after a negative life event, and because depression may lead to a greater risk of noncompliance with medications, including antidepressants, what is the best strategy for avoiding or correcting noncompliance? If the patient is not taking his or her antidepressants, informing his or her caregiver of the importance of compliance with the antidepressant medication regimen is advantageous in helping the patient adhere to the regimen. Improved communication between the physician and the patient as well as the physician and the patient’s family is helpful. As previously noted, noncompliance often increases with polypharmacy; thus, prescribing different medications with fewer side effects and simpler regimens is also useful.12-14 It is recommended that physicians take an active role when treating patients who are noncompliant or at risk of being noncompliant by providing these individuals with clarification on the importance of taking all of their prescribed medications and on their proper use.12-14
Conclusion
Many factors can lead to medication noncompliance in older adults, including depression, which may itself be caused by numerous factors, such as bereavement and the encountering of other negative life experiences. Although the use of antidepressant medications and psychotherapy may be beneficial in improving depressive symptoms, patients may not comply with this treatment regimen. Polypharmacy, adverse effects, and the belief that the medication is not helping them or that they are already cured may all be contributing factors. Regardless of the reason for medical noncompliance, the negative sequelae of deteriorating physical condition or even death may result. To prevent noncompliance in elders, especially in those with depression, an integrated and supportive approach is essential. Whenever possible, family members or friends should be enlisted to reinforce the importance of taking all prescribed medications and to provide clarification on their appropriate use. Physicians can also consider prescribing medications with the fewest side effects and that are easiest to use, making it easier for patients to remain compliant.
The authors report no relevant financial relationships.
References
1. Hallas J. Drug related hospital admissions in subspecialties of internal medicine. Dan Med Bull. 1996;43(2):141-155.
2. Olivier P, Bertrand L, Tubery M, Lauque D, Montastruc JL, Lapeyre-Mestre M. Hospitalizations because of adverse drug reactions in elderly patients admitted through the emergency department: a prospective survey. Drugs Aging. 2009;26(6):475-482.
3. Salzman C. Medication compliance in the elderly. J Clin Psychiatry.1995;56(suppl 1):18-22.
4. Topinková E, Fialová D, Carpenter GI, Bernabei R. Cross-national comparison of drug compliance and non-compliance associated factors in the elderly with polypharmacotherapy [in Czech]. Cas Lek Cesk. 2006;145(9):726-732.
5. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487-497.
6. Malholtra S, Karan RS, Pandhi P, Jain S. Drug related medical emergencies in the elderly: role of adverse drug reactions and non-compliance. Postgrad Med J. 2001;77(913):703-707.
7. Murray MD, Darnell J, Weinberger M, Martz BL. Factors contributing to medication noncompliance in elderly public housing tenants. Drug Intell Clin Pharm. 1986;20(2):146-152.
8. DiMatteo MR, Leppor HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment. Arch Intern Med. 2000;160(14):2101-2107.
9. Kraaij V, Arensman E, Spinhoven P. Negative life events and depression in elderly persons: a meta-analysis. J Gerontol B Psychol Sci Soc Sci. 2002;57(1):P87-P94.
10. National Institute of Mental Health. Older adults: depression and suicide facts (fact sheet). www.nimh.nih.gov/health/publications/older-adults-depression-and-suicide-facts-fact-sheet/index.shtml. Accessed June 5, 2012.
11. Demyttenaere K, Adelin A, Patrick M, Walthère D, Katrien de B, Michèle S. Six-month compliance with antidepressant medication in the treatment of major depressive disorder. Int Clin Psychopharmacol. 2008;23(1):36-42.
12. Boyle E, Chambers M. Medication compliance in older individuals with depression: gaining the views of family carers. J Psychiatr Ment Health Nurs. 2000;7(6):515-522.
13. Gasquet I, Bloch J, Cazeneuve B, Perrin E, Bouhassira M. Determinants of compliance with antidepressive drugs [in French]. Encephale. 2001;27(1):83-91.
14. Hérique A, Kahn JP. Guidelines and reality in practical use of and compliance to antidepressants: incidence survey in Lorraine and Champagne-Ardenne [in French]. Encephale. 2009;35(1):73-79.