Frank Diamond

Depression has long been known to be a comorbidity for adults with diabetes. It’s associated with greater risk of complications because of nonadherence to medications and dementia.

“Patients who have depression often have poorer self-management and are more likely to smoke, have poor diet, and not exercise,” says Andrew Karter, PhD, a research scientist at Kaiser Permanente. Karter is the senior editor of an April 5 study in the Journal of General Internal Medicine pointing out that depression often goes undiagnosed by primary care physicians and that patients often fail to receive adequate antidepressant treatment.

Andrew Karter, PhD

“I found it surprising how important these nonclinical aspects of clinical care really are,” says Andrew Karter, PhD, of Kaiser Permanente.

However, when patients perceive that their providers include them in the decision-making process, they are more likely to stick to treatment regimens, said the study (“Associations Between Antidepressant Adherence and Shared Decision-Making, Patient-Provider Trust, and Communication Among Adults with Diabetes: Diabetes Study of Northern California [DISTANCE],” A.M. Bauer, lead author).

Communication matters

The authors wrote, “Premature discontinuation of antidepressant treatment is common, representing one contributor to low rates of adequate depression care. We recently reported that 40% of adults with diabetes prescribed an antidepressant medication did not refill it after the initial dispensing, and two thirds had discontinued within 12 months of initiating treatment.”

Patients rated the quality of communication over the preceding year, and those who felt uninvolved in the decision-making process were more than twice as likely (6.1% vs. 2.7%) to never fill a prescription for an antidepressant.

“Although this pattern is perhaps unsurprising,” the report said, “the magnitude of this association was much greater than for other stages of adherence examined, suggesting that patients’ perceptions of involvement may have particular significance for the initiation of new antidepressant treatment.”

Karter adds, “The impact of good communication on adherence was strongest at the initial stages of medication treatment, before patients became ongoing users.”

Intervene early when nonadherence is identified, the research team suggested.

About 1,500 adults with type 2 diabetes who completed a survey in 2006 and received a new antidepressant prescription from 2006 to 2010 were included in this study.

“I found it surprising how important these nontechnical aspects of clinical care really are,” says Karter. “The technical aspects are screenings, medical care, what kind and doses of prescription someone gets, and so on. We adjusted for patient level of education and other relevant sociodemographic and clinical factors. Despite that adjustment, we still see the link between providers’ shared decision making and adherence to a newly prescribed antidepressant.”

The study also stated, “Patient-provider relationships are potentially modifiable, and these findings suggest ways providers may further help patients with depression.... Adherence to antidepressant mediations is improved when treatment is provided in the context of a team-based collaborative care model.”

Pressing public concern

Good communication means “eliciting trust, explaining the situation and planning in a way that patients can easily understand,” says Karter.

The study stated, “Inadequate medication adherence across stages of treatment and across medication classes is common and a pressing public health concern. Because the patient-provider relationship is potentially modifiable, this serves as a promising target for interventions to improve adherence. Relevant interventions to encourage providers to engage in shared decision making and facilitate trust and communication can be developed at the level of the individual provider, clinic, provider network, or health care system.”

Kaiser Permanente Division of Research and the University of Washington School of Medicine conducted the study with members of Kaiser Permanente Northern Division, a large integrated health plan serving about 30% of Northern California patients.

Respondents were included if they were prescribed a selective serotonin reuptake inhibitor, a serotonin-norepinephrine reuptake inhibitor, bupropion, or mirtazapine based on physician orders in the Kaiser Permanente Northern California electronic medical record. To ensure that it was a new prescription, the authors excluded subjects prescribed any of the antidepressants in the 12 months preceding the prescription. Subjects had to have had continuous pharmacy benefits for at least 12 months before and after the prescription.

Just getting patients started on an antidepressant can be a challenge, says Karter. “That’s really the first hurdle and the provider relationship with the patient is really important. This is an opportunity for interventions to improve adherence.”

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