Depressive disorders are managed by medications and psychotherapy; both are combined at times for a more comprehensive approach. Mainstay of the treatment is by medication which are antide-pressants. Continued medications have beneficial effect, but only if the treatment regime is adhered to.

Treatment adherence is influenced by many factors and one of them is the perceived distress arising out of the disease. The reasons behind non-adherence are varied and can be due to patient factors or due to clinician factors or both.

Distress cannot be measured objectively but the severity of the illness can be measured. The other factors are in the domain of psychological and social spheres. Continued adherence to the treatment regime helps in maintaining improvement. Factors which impact on treatment adherence have been studied by various workers in India and abroad. This study is an effort to assess the relationship between severity of the illness and treatment adherence.

The STAR*D Trial was a landmark study done for the management of depression. ⁽¹⁾ The current Practice Guideline for the Treatment of Patients with Major Depressive Disorder ⁽²⁾ describes phasic pharmacological treatment of depression with the acute phase lasting 4 to 8 weeks, the continuation phase lasting 4 to 9 months. A study done by Trivedi et al concludes that only 25 to 50 percent of patients with major depression adhere to treatment ⁽³⁾. Another similar study done by Keller et al showed that patient adherence with antidepressant medication is poor ⁽⁴⁾.

Depressive symptoms can cause clinically significant impairment or distress in occupational, social or other important areas in functioning. Though the illness may be severe other factors like the lack of motivation, the depressogenic schemata, and a host of other factors may influence medication adherence. The mere presence of this disorder can significantly hamper a person to carry on with their daily activities and a lack of understanding of this disorder can contribute to non-adherence or even refusal to take medications.

Patient adherence to medications, in this case anti-depressant therapy is a critical aspect of effective clinical management. According to contemporary data attained over the past few years, about 50 percent of psychiatric patients and 50 percent of primary care patients prematurely discontinue antide-pressant therapy (i.e., are non-adherent when assessed at 6 months after the initiation of treatment).⁽⁵⁾ Treatment adherence and illness is not related only by the severity of the illness but by so many other factors which impact on seeking and continuing treatment.

The objectives of our study are to assess the relationship between the severity of depression [assessed by Hamilton Depression Rating scale (HAM-D)] and treatment adherence (specific questions addressed to the patient and the caregiver) and to study other factors associated with treatment non-adherence.

Of the 104 subjects participated in the study, 75 (72.1%) were not taking antidepressants regularly indicating medication adherence in depressive disorders is low (Fig 1). Regularly in this sense means taking their medications daily.

Of the 104 women, 44 (42.3%) have mild depression, 52 (50%) have moderate depression and 8 (7.7%) have severe depression. (Fig. 2)

The mean age of subjects on medication was 39.28 ± 3.29 and mean age of subjects not on medication was 30.27 ± 4.34. The mean difference 9.01 (95% CI 7.24 to 10.78) between two groups was statistically significant (P value < 0.001). n .

There was no difference between these groups on any of the parameters, especially the severity of depression.

Among the 75 patients who were on not taking medications regularly, 85.3% people had a low education about the nature and course of the illness, 80% people experienced some kind of side effects due to the antidepressant they were taking and 90.7% people had a poor family support.

Among the 104 patients included in the study, 27.9% adhered to their medication regularly as advised, while 72.1% did not adhere to their medication regularly. Among the study participants, 42.3% were assessed to have mild depression, 50% have moderate depression, and 7.7% have a severe form of depression. Adherence was measured by direct questioning and no structured questionnaire was used. Banerjee and Verma have stated that non adherence is three times more common in women.⁽⁶⁾ Our study concentrated on women patients only. This is in contrast to the study by Sri Chaitanya et al who have noted the incidence of non adherence in the age group of 41-50 whereas the incidence was more common in younger age group.⁽⁷⁾ This study has also identified patient related factors of poor education, single status and younger age as contributing to non adherence. Tamburrino et al have noted that women below 40 years were represented more in non adherence group.⁽⁸⁾ Lucca et al in their study of non adherence in psychiatric patients also have noted that low level of education is one of the factors associated with non adherence.⁽⁹⁾ In our study, the mean HAM-D score is not statistically significantly different from the drug adherent group. If the group is divided on the basis of scores in the HAM-D scale, it shows that the moderate depressives are represented more in the non-adherent group. As most of the patients in our sample was either mild or moderate in severity it is possible that we were unable to find a difference in outcome related to severity of the symptoms. Non-adherence in this group appears to be more related to social and individual factors rather than disease related factors. In contrast with our outcomes Rieckmann et al have noted that severity of depression was associated with medication non adherence in their study. ⁽¹⁰⁾

Other studies have found several factors that could contribute to non-adherence.Bulloch and Patten ⁽¹¹⁾ found that simply forgetting was the main reason for patient non-adherence. Fortney et al ⁽¹²⁾ concluded that the side effects of antidepressants were a commonly cited reason for it’s discontinuation. Kennedy et al ⁽¹³⁾ found that a lower adherence to antidepressants was associated with an increased cost of the medication, out of pocket costs, patients perception of the need and side effects of medication. Deterrents to adherence may also include : medication-induced sexual dysfunction;⁽¹⁴⁾ concerns that antidepressants might change their personality;⁽¹⁵⁾ patient beliefs against antidepressants ⁽¹⁶⁾ delayed onset of effect;⁽¹⁷⁾ poor psychoeducation⁽¹⁸⁾ specific personality characteristics of patients such as extraversion⁽¹⁹⁾ and/or Cluster B⁽²⁰⁾ or other personality disorder symptoms;⁽²¹⁾ patient substance abuse;⁽²¹⁵⁾ patient fears of addiction;⁽²²⁾ lower patient depression severity;⁽²³⁾ complicated titration or dosing schedule of the medication;⁽²⁴⁾ lack of follow-up care by the clinician;⁽²⁴⁾ and low patient motivation.⁽²⁴⁾

In this study, non adherence was simply assessed by drug taking and hospital seeking behaviour. Reason for non adherence was not assessed. A more comprehensive study including disease related and medication related factors would have added more value to the study.

In this study, severity of depression was not associated with medication non adherence, married status and paid work status are factors associated with adherence to antidepressants. Stated reasons for non-adherence of medications include less education about the nature and outcome of depression, side effect profile and poor family support. Psychoeducation of patients & caregivers,carefully monitoring of medication adherence an ongoing followup are crucial to enhance adherence.