Journal of General Internal Medicine

, Volume 28, Issue 9, pp 1181–1187

Health Literacy and Antidepressant Medication Adherence Among Adults with Diabetes: The Diabetes Study of Northern California (DISTANCE)


    • Department of Psychiatry and Behavioral SciencesUniversity of Washington School of Medicine
  • Dean Schillinger
    • Division of General Internal Medicine, University of California, San Francisco
    • Center for Vulnerable PopulationsSan Francisco General Hospital and Trauma Center
  • Melissa M. Parker
    • Kaiser Permanente Northern California
  • Wayne Katon
    • Department of Psychiatry and Behavioral SciencesUniversity of Washington School of Medicine
  • Nancy Adler
    • Departments of Psychiatry and Pediatrics and Center for Health and CommunityUniversity of California, San Francisco
  • Alyce S. Adams
    • Kaiser Permanente Northern California
  • Howard H. Moffet
    • Kaiser Permanente Northern California
  • Andrew J. Karter
    • Kaiser Permanente Northern California
Original Research

DOI: 10.1007/s11606-013-2402-8

Cite this article as:
Bauer, A.M., Schillinger, D., Parker, M.M. et al. J GEN INTERN MED (2013) 28: 1181. doi:10.1007/s11606-013-2402-8



Previous studies have reported that health literacy limitations are associated with poorer disease control for chronic conditions, but have not evaluated potential associations with medication adherence.


To determine whether health literacy limitations are associated with poorer antidepressant medication adherence.


Observational new prescription cohort follow-up study.


Adults with type 2 diabetes who completed a survey in 2006 and received a new antidepressant prescription during 2006–2010 (N = 1,366) at Kaiser Permanente Northern California.


Validated three-item self-report scale measured health literacy. Discrete indices of adherence based on pharmacy dispensing data according to validated methods: primary non-adherence (medication never dispensed); early non-persistence (dispensed once, never refilled); non-persistence at 180 and 365 days; and new prescription medication gap (NPMG; proportion of time that the person is without medication during 12 months after the prescription date).


Seventy-two percent of patients were classified as having health literacy limitations. After adjusting for sociodemographic and clinical covariates, patients with health literacy limitations had significantly poorer adherence compared to patients with no limitations, whether measured as early non-persistence (46 % versus 38 %, p < 0.05), non-persistence at 180 days (55 % versus 46 %, p < 0.05), or NPMG (41 % versus 36%, p < 0.01). There were no significant associations with primary adherence or non-persistence at 365 days.


Poorer antidepressant adherence among adults with diabetes and health literacy limitations may jeopardize the continuation and maintenance phases of depression pharmacotherapy. Findings underscore the importance of national efforts to address health literacy, simplify health communications regarding treatment options, improve public understanding of depression treatment, and monitor antidepressant adherence.


health literacymedication adherenceantidepressive agentsdiabetes mellitushealthcare disparities

Supplementary material

11606_2013_2402_MOESM1_ESM.docx (31 kb)
ESM 1Sensitivity analyses demonstrating the associations between health literacy limitations, race/ethnicity, and antidepressant medication adherence (DOCX 31 kb)

Copyright information

© Society of General Internal Medicine 2013