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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 120-125

Antidepressant compliance in depression during the COVID pandemic: Identifying the potential poor compliers in an industrial hospital


Department of Psychiatry, Medical and Health, Hindustan Aeronautics Limited Hospital, Bengaluru, Karnataka, India

Date of Submission12-Mar-2021
Date of Decision30-Mar-2021
Date of Acceptance10-May-2021
Date of Web Publication28-Oct-2021

Correspondence Address:
Dr. Suhash Chakraborty
Department of Psychiatry, Hindustan Aeronautics Limited Hospital, Vimanapura Post, Bengaluru - 560 017, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_30_21

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  Abstract 


Background: Depression epidemic is likely to follow the COVID pandemic. Depression is treatable if compliance is good. The study was aimed at identifying risk factors of poor antidepressant compliance during a pandemic. Materials and Methods: Sixty-four poor compliers of antidepressants during COVID period were compared with equal number of poor compliers of pre-COVID period on sociodemographic and clinical characteristics. The retrospective study was designed in a way to eliminate biases due to usual patient, social, or clinical factors. The hypothesis was that there would be some factors of antidepressant poor compliance exclusive to pandemic and these factors would be beyond the usual factors. Results: Majority (n = 43, 67%) of COVID period poor compliers were family members of employees. Subjects who came for prescription refill (n = 17, 27%) than consultation were poor compliant during COVID period. COVID period poor compliers (n = 6, 9%) were admitted less compared to pre-COVID counterparts (n = 15, 23%). COVID period subjects had mood symptoms predominant depression (n = 44, 69%) than physical symptoms (n = 20, 31%). The presence of death wish or suicidal ideas was significant (n = 16, 25%) in COVID period. Poor compliers of pandemic (n = 26, 41%) had more psychosocial stress (P < 0.05). Conclusion: The study did find some exclusive factors apart from doctor–patient relationship for good compliance. Depressive patients who perceive improvement in mood symptoms are poor compliers during pandemic. Compliance improves if patients find some primary purpose to come out during pandemic. Ongoing stress also reduces compliance.

Keywords: Antidepressants, compliance, COVID, depression, pandemic


How to cite this article:
Chakraborty S. Antidepressant compliance in depression during the COVID pandemic: Identifying the potential poor compliers in an industrial hospital. Ann Indian Psychiatry 2021;5:120-5

How to cite this URL:
Chakraborty S. Antidepressant compliance in depression during the COVID pandemic: Identifying the potential poor compliers in an industrial hospital. Ann Indian Psychiatry [serial online] 2021 [cited 2021 Dec 6];5:120-5. Available from: https://www.anip.co.in/text.asp?2021/5/2/120/329432




  Introduction Top


The COVID pandemic has brought about drastic change in life. Periodic lockdown, work from home, inaccessible transportation, and fear of getting infection, all has restricted the movement. The pandemic is going to have a huge impact on mental health.[1] The psychological impact of COVID-19 is likely to be increase in depression and anxiety symptoms.[2] Depression is predicted to be the leading cause of disease burden globally by 2030.[3] The corona pandemic of 2020 might actually expedite this. Effective management of depression is possible through pharmacological measures.[4] Minimum duration of treatment ranges from 4 to 9 months after depression symptoms resolve.[5],[6] However, the barrier to successful treatment is poor persistence with doctor and poor compliance with medications (rates ranging from 30% to 97%).[7] Poor adherence of antidepressants is known to affect recovery as well as long-term outcome.[8] Multiple factors such as patient factors (concern about side effects, addiction, and hopelessness), clinical factors (delayed onset of action of antidepressants and poor knowledge about medicine role), social factors (stigma, isolation, poverty, and lack of social support), and drug factors (cost and side effects) are behind this.[9] During pandemic scenario, antidepressant compliance may further worsen. It would be interesting to analyze whether there are any noncompliance factors exclusive to pandemic and whether these are beyond the usual factors. With this objective, this retrospective study was conducted by studying the sociodemographic and clinical correlates of poor complaint patients of depression during the COVID pandemic and comparing with the poor compliers of pre-COVID period. The purpose of this study is to identify the risk factors for poor compliance with antidepressants should a similar situation occur in future.


  Materials and Methods Top


The study was conducted in the psychiatry department of an urban industrial hospital managed by a single psychiatrist. It has average inflow of 10 to 15 patients of depression including follow-up patients. The facility is accessible to all the employees and their eligible dependents. The department uses Hospital Management Inventory System (HMIS) software, where details of each patient on each visit are entered and all data are preserved. Once a patient visits the psychiatry department, detailed history is entered in HMIS, and diagnosis is made as per International Classification of Diseases-10 (ICD-10) criteria.[10] In case a patient requires medication, the standard practice is to prescribe for 10 days each time till the patient is clinically stable. Subsequently, the medications are issued periodically for 1 month, for which the patients have to come to the psychiatry department only.

The psychiatry department was fully functional during the epidemic. COVID period was defined as the period from the month of June 2020 to August 2020. Patients with ICD-10 diagnosis of depression (mild, moderate, and severe without psychotic features), on medication for minimum 3 months, stable, in partial remission, between 18 and 60 years of age, employees (both officers and workmen), or their eligible dependents and who were noncompliant during COVID period were taken as study subjects. Noncompliance was defined as failure to come for repeat medicines or follow-up for two or more consecutive months after complying with the previous appointments for minimum 3 months. Previous studies have used a criterion of one or more months for noncompliance.[11],[12] For this study, 2-month criterion was used as it is highly unlikely to be by chance after complying consistently for previous months. The months of March, April, and May 2020 were not included in COVID period as the pandemic was declared on March 11 by the WHO, and our criteria for poor compliers have to meet minimum 2 months.[13] Patients having psychotic features, bipolar depression, active substance abuse, impaired cognitive function, physical disability, or severe neurological illness which affects their mobility were excluded. Antidepressants include all classes irrespective of type or dosage, but patients on concurrent antipsychotics or mood stabilizer were not included. A total of 85 poor compliers were identified through the HMIS system during the COVID period. They were contacted when they came to meet the psychiatrist or refill medicine after the scheduled period of noncompliance. Out of 85 patients, 64 patients qualified for study subjects fulfilling the inclusion and exclusion criteria.

The pre-COVID period includes February 2020 and the previous months. The process of tracing poor compliers in the pre-COVID period started from February 2020 backward. Noncompliers during pre-COVID period were identified from the “Previous Visits” section in HMIS as per noncompliance criteria of our study. They were either called or contacted during follow-up visits for consent to participate in the study. Majority of data for the control group were in the system, but some additional information was taken at the time of taking consent. The process was stopped once a control group of 64 subjects was achieved who fulfilled inclusion and exclusion criteria. Subjects from both groups signed a written informed consent. The study was approved by the ethical committee of the hospital.

The study group was named as COVID period poor compliers, while the control group was called pre-COVID period poor compliers. Subjects from both groups were administered a semi-structured questionnaire which took details about their sociodemographic profile. The semi-structured questionnaire for this purpose was designed by the investigator [Table 1]. A migrant is one who is not a domicile of the state and staying in the state for <10 years. In some cases, the investigator is not the primary psychiatrist. This is because some patients avail treatment from the institution recognized referral hospitals. However, they need to come to the institute psychiatrist for medications. The clinical profile data were available in the case record of each subject and noted from there [Table 2]. The predominant symptoms were sorted from the chief complaints section of case record in HMIS system. The presence of psychosocial stress was as per history and no scale could be applied as it is not practiced practically. Primary diagnosis was the diagnosis mentioned in the HMIS as the first diagnosis and gives an idea about the ailment a patient preferred to visit the hospital for. A patient who was visiting hospital for diabetes management and subsequently developed depressive features and visited the psychiatrist would have diabetes as primary diagnosis. A poly-pharmacy criterion was for patients who were on more than three regular medications (include both psychiatry and nonpsychiatry medications). Nonpsychiatry medication compliance was not considered while selecting the subjects for our study. History about poor compliance in the past was a qualitative and not as per study criteria. For every patient, the psychiatrist prefers to record the mode of treatment requested by patients on their first visit. Those who cited “counselling” for which they were visiting the psychiatrist were included in the last parameter of clinical profile. Finally, the COVID period poor compliers group was compared with the pre-COVID period poor compliers on the basis of these sociodemographic and clinical characteristics. Descriptive statistics in terms of percentage were used for categorical variables. Group comparisons were done using Chi-square test. A P < 0.05 was considered as significant.
Table 1: Sociodemographic profile of COVID period and pre-COVID period poor compliers (n=64)

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Table 2: Clinical profile of COVID period and pre-COVID period poor compliers (n=64)

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  Results Top


Majority of COVID period poor compliers were between 30 and 45 years (n = 30, 47%), nonmigrant (n = 43, 67%), and staying within campus (n = 47, 73%) with an adult family member (n = 56, 88%). For pre-COVID poor compliers, 22 (34%) were in age group 30–45 years, 37 (58%) were nonmigrant, 53 (83%) staying in campus, and for 53 (83%) family members was present. While male subjects dominated the COVID group (n = 37, 58%), pre-COVID had more female patients (n = 34, 53%). For both the groups, most subjects had 11–15 years of education. The study group had more dependents (n = 43, 67%) than employees (n = 21, 33%), while the control group had more employees (n = 36, 56%) than dependents (n = 28, 44%). Forty-nine out of 64 patients (77%) of COVID group approached the psychiatrist directly, while 44 (69%) of the pre-COVID period did so. For 27% (n = 17) of study group, investigator was not the primary psychiatrist against only five (8%) of the control group. Six patients (9%) of COVID group were admitted for depression at least once while almost a quarter (n = 15, 23%) of pre-COVID were admitted in hospital [Table 1].

COVID group poor compliers had primarily mood symptoms (n = 44, 69%) than somatic symptoms (n = 20, 31%). However, pre-COVID poor compliers had more somatic symptoms (n = 35, 55%) than mood symptoms (n = 29, 45%). One-fourth of study subjects (n = 16, 25%) had death wish or suicidal ideas compared to only seven (11%) of control group subjects. More people (n = 26, 41%) had ongoing psychosocial stress in the COVID group compared to the pre-COVID group (n = 15, 23%). Almost half of patients in both groups had depression as primary diagnosis. Majority in both groups were on more than three concurrent medications. Majority of study subjects had a negative history for past depression (n = 53, 83%), family depression (n = 58, 91%), and no history of poor compliance in the past (n = 48, 75%). Similar pattern was observed for the control group. Thirty-three patients (52%) of COVID and 40 (63%) of pre-COVID period were on antidepressant for more than 6 months. Counseling at first visit was preferred by 30 (47%) of study subjects and 27 (42%) of control subjects [Table 2].

Comparing the two groups, it was observed that while 67% of poor compliers in COVID period were dependents of employees, only 44% were so in the pre-COVID period. These data are statistically significant (P = 0.007). Significant data were also obtained when investigator was not the primary psychiatrist (P = 0.04). Both the groups vary significantly on admission status (P = 0.004); more of control group patients (23%) were admitted than study patients (9%). Comparing the clinical characteristics, both the groups differ significantly on the basis of predominant symptoms (P = 0.007). Poor compliers of COVID period had more mood symptoms (69%) than pre-COVID poor compliers who primarily had somatic symptoms (55%). Presence of death wish or suicidal ideation was a significant parameter (P = 0.03) for both groups. Finally, ongoing stress, which was more in study than control group, was statistically significant (P = 0.03). The groups did not show any significant difference on age, gender, presence of family member, residential, educational or migration status, and mode of referral. Neither did they vary on clinical parameters such as primary diagnosis, poly-pharmacy, past history, and family history of depression, previous poor compliance, duration of antidepressant, or whether preferred counseling at first visit (P > 0.05) [Table 1] and [Table 2].


  Discussion Top


Treatment adherence should be studied on the basis of two components: persistence and compliance.[11],[14] Persistence is used when patients come to doctor regularly as per appointment. However, this does not ensure they are taking medications correctly. The term “compliance” is used when patients take medicine as per prescribed dosage and schedule. In our study, we have used the term “compliance.” This is because our subjects in both the groups have ultimately come to us and were persistent. However, there was a mismatch between the number of treatment days and the number of days for which medicine was prescribed and hence poor compliance. The study was conducted in an industrial hospital where the procedure for availing treatment facility is well streamlined. The hospital outpatient department (OPD) hours are divided in such a way that employees can come to hospital without compromising the working hours. There is transportation facility for the family members to come to hospital. Consultation, investigation, medications, admission, treatment procedure, etc., are nonchargeable. Patients can be referred to designated tertiary care hospitals for specialized care. Patients get liberty to choose a doctor between the industrial hospital and referral hospitals. There are certain advantages of conducting a compliance study in such a set up. It eliminates biases such as treatment availability and affordability.

The study was conducted with the hypothesis that there would be some factors for noncompliance in depression specific to pandemic. With this purpose, precised inclusion and exclusion criteria were selected. The HMIS system has provisions for working diagnosis and ICD-10 diagnosis. Usually, in a busy OPD, working diagnosis is done, and final diagnosis is done during detailed workup sessions. For our study, we selected only those who have satisfied ICD-10 criteria for depression. Patients older than 60 years were not included for chance of cognitive dysfunction. This age group was also discouraged from coming out during lockdown. All the subjects have minimum 3-month duration of therapy. Earlier studies have shown that antidepressant discontinuation is highest in the first 3 months due to multiple factors.[15] We included patients who were clinically stable on antidepressants for eliminating bias of decision impairment during depression[16] and bias of drug-related side effects both of which can affect adherence. For this, we have taken clinical information from record sheets such as “doing well,” “no new symptoms,” or “better” in the follow-up columns. Further, to ensure remissions, patients whose medications were not changed, dosages were kept same, or reduced were taken as subjects.[17] Because of the retrospective nature of the study, no scales could be used for defining remission as it is not practiced in routine OPD. The antidepressants prescribed to patients were not classified, but majority of them were on selective serotonin reuptake inhibitors. Since it was a retrospective study, the psychiatrist was not biased while writing case history or deciding on antidepressants. Finally, comparing the study group with a similar population of the same setup, attempt was made to minimize the impact of bias due to patient, clinical, or social factors. The study findings may not be entirely extrapolated to general population. The logistics of an industrial hospital, in fact, has ensured pure clinical factors of noncompliance.

The findings of this study are quite interesting. Patients who were dependents of the employee, when investigator was not the primary psychiatrist and those who had less admission for depression had poor compliance during COVID period. The patient who was a “self” was more compliant. Here, the “self” was the employees. They were required to attend duties throughout the pandemic period. It was found that they came to hospital when they had come out for duty. The dependents were probably hesitant to come to hospital and preferred skipping dose. Did this imply that during pandemic, depression patients prefer to see doctors when they come out for other primary purposes? Another interesting finding revealed by this study, is relevant in the Indian context. COVID period depression patients were poor compliers when investigator was not the primary psychiatrist. This finding is significant and once again endorses the importance of relationship between the physician and patient. Kerse et al. found good concordance between the doctor and the patient as the single most important factor for good compliance.[18] If the purpose is only to collect medicine and not consultation, compliance becomes poor. In a large multicentric study done in Sweden on 3636 prescriptions, it was found that treatment adherence depended on who refilled the prescription. Adherence was better when the prescription refill was by chief physicians than other hospital physicians.[19] The third significant finding was the poor compliance during pandemic when patients never got admitted. It may be assumed that admitted patients are usually subjected to detailed investigation and holistic health checkup. They are usually seen by multiple specialists for physical symptoms. All these contribute to the greater bonding with the treating psychiatrist, more faith, and better following of instructions. Byrne et al. found that collaborative approach works best and when patients also get involved in decision-making process, compliance improves.[20] Admitted patients get more time from the doctor and feel free to express their concern on treatment compared to outpatient visitors. This factor remains strong even during pandemic.

Patients with predominant mood symptoms, death wish, or suicidal ideas as initial symptoms had poor compliance during pandemic. It is to be noted that these patients actually improved on medication (as per study criteria) and were apparently stable during COVID period. Researchers have found that patients often take decision themselves to adjust their medication based on their mood and physical state.[21] The study done by Chakraborty et al. in a tertiary care psychiatry hospital in India backed our findings. Patients with depression tend to take fewer tablets when they felt better and more when they felt depressed.[22] Our patients perceived improvement in mood symptoms, so probably discontinuing medication temporarily during epidemic was a preferable option than coming to psychiatrist. On the contrary, in patients with predominant somatic symptoms, antidepressant serves the dual purpose of giving symptomatic relief from somatic symptoms and depression.[23] Greco et al. in their study on “The outcome of physical symptoms with treatment of depression” found that improvement of physical symptoms happened as early as 4 weeks after starting antidepressant, but the effect leveled off during the remainder of the study period. However, when mood symptoms improved, it sustained over a period of time.[24] There is a possibility of our patients experiencing physical symptoms after a probable transient stoppage and this might have led to better compliance for them during COVID period. Finally, patients with ongoing psychosocial stress were poor compliers during the pandemic period. Studies have found that motivational interviewing improves poor adherence caused by psychosocial stressor.[25] Most of them had either poor interpersonal relationship issues with family members or financial stress. Although most of the subjects were salaried and continued to get salary during the pandemic, many of them had financial investments and liabilities which did not yield expected results during pandemic. Job stress and poor relationship with colleagues was also seen. It looks like this group was busy in problem-solving and neglected the medicine part during pandemic.


  Conclusion Top


The study highlights the importance of doctor–patient relationship and recommends strengthening the bond between the client and psychiatrist for better antidepressant compliance. During pandemic, mood symptoms predominant depressive patients should be called for more frequent follow-up. We recommend that patients with depression in remission should come to hospital themselves rather than sending relatives to collect medicine. To our knowledge, this study is the first of its kind, at least in India which has tried to focus on noncompliance factors in depression during pandemic. The study has certain limitations. The severity of depression in the initial period and its impact on compliance was not assessed. We could not make the criteria of partial remission or psychosocial stress more objective as explained. Third, there could be biases due to individual drug compliance. Last but not the least, further in-depth statistical analysis would haven helpful. However, the strength of the study because of its homogenous population subjects has thrown some light on risk factors involved in poor compliance during a pandemic. This will lead to many studies in future in this area. The ultimate goal is to take these factors into account in planning strategy for effective management of depression.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Roca M, Gili M, Garcia-Campayo J, García-Toro M. Economic crisis and mental health in Spain. Lancet 2013;382:1977-8.  Back to cited text no. 1
    
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Spigset O, Mårtensson B. Fortnightly review: Drug treatment of depression. BMJ 1999;318:1188-91.  Back to cited text no. 4
    
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American Psychiatry Association, Work Group on Major Depressive Disorder. Practice Guideline for the Treatment of Patients with Major Depression. Available from: http://www.psych.org/psych_pract/treatg/pg/Depression2e. [Last accessed on 2020 Sep 01].  Back to cited text no. 5
    
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Sawada N, Uchida H, Suzuki T, Watanabe K, Kikuchi T, Handa T, et al. Persistence and compliance to antidepressant treatment in patients with depression: A chart review. BMC Psychiatry 2009;9:38.  Back to cited text no. 11
    
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Cooke CE, Fatodu H. Physician conformity and patient adherence to ACE inhibitors and ARBs in patients with diabetes, with and without renal disease and hypertension, in a medicaid managed care organization. J Manag Care Pharm 2006;12:649-55.  Back to cited text no. 12
    
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Bull SA, Hu XH, Hunkeler EM, Lee JY, Ming EE, Markson LE, et al. Discontinuation of use and switching of antidepressants: Influence of patient-physician communication. JAMA 2002;288:1403-9.  Back to cited text no. 15
    
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Leykin Y, Roberts CS, Derubeis RJ. Decision-making and depressive symptomatology. Cognit Ther Res 2011;35:333-41.  Back to cited text no. 16
    
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18.
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21.
Al Jumah K, Hassali MA, Al Qhatani D, El Tahir K. Factors associated with adherence to medication among depressed patients from Saudi Arabia: A cross-sectional study. Neuropsychiatr Dis Treat 2014;10:2031-7.  Back to cited text no. 21
    
22.
Chakraborty K, Avasthi A, Kumar S, Grover S. Attitudes and beliefs of patients of first episode depression towards antidepressants and their adherence to treatment. Soc Psychiatry Psychiatr Epidemiol 2009;44:482-8.  Back to cited text no. 22
    
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Mallinckrodt CH, Goldstein DJ, Detke MJ, Lu Y, Watkin JG, Tran PV. Duloxetine: A new treatment for the emotional and physical symptoms of depression. Prim Care Companion J Clin Psychiatry 2003;5:19-28.  Back to cited text no. 23
    
24.
Greco T, Eckert G, Kroenke K. The outcome of physical symptoms with treatment of depression. J Gen Intern Med 2004;19:813-8.  Back to cited text no. 24
    
25.
Interian A, Martinez I, Rios LI, Krejci J, Guarnaccia PJ. Adaptation of a motivational interviewing intervention to improve antidepressant adherence among Latinos. Cultur Divers Ethnic Minor Psychol 2010;16:215-25.  Back to cited text no. 25
    



 
 
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