European Journal of Clinical Pharmacology

, Volume 70, Issue 1, pp 89–98 | Cite as

Risk factors for non-adherence to antidepressant treatment in patients with mood disorders

  • Carlos De las CuevasEmail author
  • Wenceslao Peñate
  • Emilio J. Sanz
Pharmacoepidemiology and Prescription



Adherence to antidepressant therapy by patients with depressive disorders is essential not only to achieve a positive patient outcome but also to prevent a relapse. The aim of this study was to identify potential modelling factors influencing adherence to antidepressant treatment by patients with mood disorders in the community mental health care setting


A total of 160 consecutive psychiatric outpatients attending two Community Mental Health Centres on Tenerife Island between September 2011 and May 2012 were asked to participate in the study; of these, 145 accepted. The Morisky self-report scale was used to assess adherence. The potential predictors examined included socio-demographic, clinical and therapeutic variables. The Clinical Global Impression-Severity and -Improvement scales and the Beck Depression Inventory were used for clinical assessment. Drug treatment side-effects were assessed using the “Self-report Antidepressant Side-Effect Checklist.” All participants were also asked to complete the "Drug Attitude Inventory" (DAI), "Beliefs about Medicine Questionnaire" (BMQ), and "Leeds Attitude towards concordance Scale". Discriminant analyses were performed to predict non-adherence.


There was no clear correlation between adherence and the socio-demographic variables examined, but adherence was related to a positive attitude of the patients towards his/her treatment (DAI) and low scores in the BMQ-Harm and -Concern subscales. Non-adherence was also related to an increasing severity of depression and to the presence and severity of side-effects.


Among our study cohort, the profiles of adherent patients to antidepressant treatment were more closely associated with each patient’s attitudes and beliefs than to objective socio-demographic variables. The severity of depression played a relevant role in adherence, but whether this role is direct or an interaction with several concurrent factors is not yet clear. Side-effects were also closely related to adherence, as conditioned by frequent polypharmacy.


Risk factors Adherence Mood disorders Psychiatric outpatients Self-report 



This research was supported by Instituto de Salud Carlos III, FEDER Unión Europea (PI10/00955).

Conflict of Interest



  1. 1.
    Ables AZ, Baughman OL III (2003) Antidepressants: update on new agents and indications. Am Fam Physician 67:547–554PubMedGoogle Scholar
  2. 2.
    Alonso J, Angermeyer M, Bernert S, Bruffaerts R, Brugha TS, Bryson H et al (2004) Prevalence of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand 420:21–27Google Scholar
  3. 3.
    Baldessarini RJ, Perry R, Pike J (2008) Factors associated with treatment nonadherence among US bipolar disorder patients. Hum Psychopharmacol 23(2):95–105PubMedCrossRefGoogle Scholar
  4. 4.
    Beck AT, Steer RA, Ball R, Ranieri W (1996) Comparison of Beck Depression Inventories -IA and -II in psychiatric outpatients. J Pers Assess 67(3):588–597PubMedCrossRefGoogle Scholar
  5. 5.
    Beléndez M, Hernández A, Horne R, Weinman J (2007) Evaluación de las creencias sobre el tratamiento: Validez y fiabilidad de la versión española del Beliefs about Medicines Questionnaire. Int J Health Clin Psychol 7:767–779Google Scholar
  6. 6.
    Blackwell B (1982) Antidepressant drugs: side effects and compliance. J Clin Psychiatry 43 (11 Pt 2):14–21PubMedGoogle Scholar
  7. 7.
    Bockting C, ten Doesschate MC, Spijker J, Spinhoven P, Koeter MW, Schene AH (2008) Continuation and maintenance use of antidepressants in recurrent depression. Psychother Psychosom 77(1):17–26PubMedCrossRefGoogle Scholar
  8. 8.
    Brown C, Battista DR, Bruehlman R, Sereika SS, Thase ME, Dunbar-Jacob J (2005) Beliefs about antidepressant medications in primary care patients: relationship to self-reported adherence. Med Care 43(12):1203–1207PubMedCrossRefGoogle Scholar
  9. 9.
    Bucci KK, Possidente CJ, Talbot KA (2003) Strategies to improve medication adherence in patients with depression. Am J Health Syst Pharm 60(24):2601–2605PubMedGoogle Scholar
  10. 10.
    Bull SA, Hu XH, Hunkeler EM, Lee JY, Ming EE, Markson LE, Fireman B (2002) Discontinuation of use and switching of antidepressants: influence of patient-physician communication. JAMA 288(11):1403–1409PubMedCrossRefGoogle Scholar
  11. 11.
    Castle T, Cunningham MA, Marsh GM (2012) Antidepressant medication adherence via interactive voice response telephone calls. Am J Manage Care 18(9):e346–e355Google Scholar
  12. 12.
    De las Cuevas C, Rivero A, Perestelo-Perez L, Gonzalez M, Perez J, Peñate W (2011) Psychiatric patients’ attitudes towards concordance and shared decision making. Patient Educ Couns 85:e245–e250PubMedCrossRefGoogle Scholar
  13. 13.
    De las Cuevas C, Rivero-Santana A, Perestelo-Pérez L, González-Lorenzo M, Pérez-Ramos J, Sanz EJ (2011) Adaptation and validation study of the Beliefs about Medicines Questionnaire in psychiatric outpatients in a community mental health setting. Hum Psychopharmacol Clin Exp 26:140–146CrossRefGoogle Scholar
  14. 14.
    De las Cuevas C, Sanz EJ (2004) Polypharmacy In psychiatric practice in the Canary Islands. BMC Psychiatry 4:18PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    De las Cuevas C, Sanz EJ (2005) Polypsychopharmacy. A frequent and debatable practice in psychiatric inpatients. J Clin Psychopharmacol 25(5):510–512PubMedCrossRefGoogle Scholar
  16. 16.
    Emilsson M, Berndtsson I, Lötvall J, Millqvist E, Lundgren J, Johansson A, Brink E (2011) The influence of personality traits and beliefs about medicines on adherence to asthma treatment. Prim Care Respir J 20(2):141–147PubMedCrossRefGoogle Scholar
  17. 17.
    Fawzi W, Abdel Mohsen MY, Hashem AH, Moussa S, Coker E, Wilson KC (2012) Beliefs about medications predict adherence to antidepressants in older adults. Int Psychogeriatr 24(1):159–169PubMedCrossRefGoogle Scholar
  18. 18.
    Food and Drug Administration (FDA) (2012) Antidepressant use in children, adolescents, and adults. Available at:
  19. 19.
    García Cabeza I, Hormaechea Beldarrain JA, Mr SA, Arango López C, González de Chávez M (2000) Drug attitude inventory, spanish-adapted version. Euro Neuropsychopharm 10(3):298–299CrossRefGoogle Scholar
  20. 20.
    Gardarsdottir H, Heerdink ER, van Dijk L, Egberts AC (2007) Indications for antidepressant drug prescribing in general practice in the Netherlands. J Affect Disord 98:109–115PubMedCrossRefGoogle Scholar
  21. 21.
    Gartlehner G, Hansen RA, Morgan LC, Thaler K, Lux L, Van Noord M, Mager U, Thieda P, Gaynes BN, Wilkins T, Strobelberger M, Lloyd S, Reichenpfader U, Lohr KN (2011) Comparative benefits and harms of second-generation antidepressants for treating major depressive disorder: an updated meta-analysis. Ann Intern Med 155(11):772–785PubMedCrossRefGoogle Scholar
  22. 22.
    Geddes JR, Carney SM, Davies C, Furukawa TA, Kupfer DJ, Frank E, Goodwin GM (2003) Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review. Lancet 361(9358):653–661PubMedCrossRefGoogle Scholar
  23. 23.
    Guy W (1976) Early Clinical Drug Evaluation Unit (ECDEU) Assessment manual for psychopharmacology. National Institute of Mental Health, BethesdaGoogle Scholar
  24. 24.
    Hogan TP, Awad AG (1992) Subjective response to neuroleptics and outcome in schizophrenia: a re-examination comparing two measures. Psychol Med 22:347–352PubMedCrossRefGoogle Scholar
  25. 25.
    Hogan TP, Awad AG, Eastwood R (1983) A self-report scale predictive of drug compliance in schizophrenics: reliability and discriminative validity. Psychol Med 13:177–183PubMedCrossRefGoogle Scholar
  26. 26.
    Horne R, Weinman J (1999) Patients' beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illnesss. J Psychosom Res 47:555–567PubMedCrossRefGoogle Scholar
  27. 27.
    Horne R, Weinman J, Hankins M (1999) The beliefs about medicines questionnaire: The development and evaluation of a new method for assessing the cognitive representation of medication. Psychol Health 14:1–24CrossRefGoogle Scholar
  28. 28.
    Judd LL, Akiskal HS, Schettler PJ, Coryell W, Endicott J, Maser JD, Solomon DA, Leon AC, Keller MB (2003) A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Arch Gen Psychiatry 60:261–269PubMedCrossRefGoogle Scholar
  29. 29.
    Judd LL, Akiskal HS, Schettler PJ, Endicott J, Maser J, Solomon DA, Leon AC, Rice JA, Keller MB (2002) The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry 59:530–537PubMedCrossRefGoogle Scholar
  30. 30.
    Kelly K, Posternak M, Alpert JE (2008) Toward achieving optimal response: understanding and managing antidepressant side effects. Dialogues Clin Neurosci 10(4):409–418PubMedCentralPubMedGoogle Scholar
  31. 31.
    Kessing LV, Hansen MG, Andersen PK (2004) Course of illness in depressive and bipolar disorders. Naturalistic study, 1994–1999. Br J Psychiatry 185:372–377PubMedCrossRefGoogle Scholar
  32. 32.
    Levkovitz Y, Tedeschini E, Papakostas GI (2011) Efficacy of antidepressants for dysthymia: a meta-analysis of placebo-controlled randomized trials. J Clin Psychiatry 72(4):509–514PubMedCrossRefGoogle Scholar
  33. 33.
    Mahler C, Hermann K, Horne R, Jank S, Haefeli WE, Szecsenyi J (2012) Patients' beliefs about medicines in a primary care setting in Germany. J Eval Clin Pract 18(2):409–413PubMedCrossRefGoogle Scholar
  34. 34.
    Miklowitz DJ, Simoneau TL, George EL, Richards JA, Kalbag A, Sachs-Ericsson N, Suddath R (2000) Family-focused treatment of bipolar disorder: 1-year effects of a psycho-educational program in conjunction with pharmacotherapy. Biol Psychiatry 48:582–592PubMedCrossRefGoogle Scholar
  35. 35.
    Morisky DE, Ang A, Krousel-Wood M, Ward HJ (2008) Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich) 10:348–354CrossRefGoogle Scholar
  36. 36.
    Morisky DE, Green LW, Levine DM (1986) Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care 24:67–74PubMedCrossRefGoogle Scholar
  37. 37.
    Murray M, Kroenke K (2001) Polypharmacy and medication adherence: Small steps on a long road. J Gen Intern Med 16:137–139PubMedCentralPubMedCrossRefGoogle Scholar
  38. 38.
    Rascati K (1995) Drug utilization review of concomitant use of specific serotonine reuptake inhibitors or clomipramine and antianxiety/sleep medications. Clin Ther 17:786–790PubMedCrossRefGoogle Scholar
  39. 39.
    Raynor DK, Thistlethwaite JE, Hart K, Knapp P (2001) Are health professionals ready for the new philosophy of concordance in medicine taking? Int J Pharm Pract 9:81–84CrossRefGoogle Scholar
  40. 40.
    Reynolds CF, Butters MA, Lopez O, Pollock BG, Dew MA, Mulsant BH, Lenze EJ, Holm M, Rogers JC, Mazumdar S, Houck PR, Begley A, Anderson S, Karp JF, Miller MD, Whyte EM, Stack J, Gildengers A, Szanto K, Bensasi S, Kaufer DI, Kamboh MI, DeKosky ST (2011) Maintenance treatment of depression in old age: a randomized, double-blind, placebo-controlled evaluation of the efficacy and safety of donepezil combined with antidepressant pharmacotherapy. Arch Gen Psychiatry 68(1):51–60PubMedCentralPubMedCrossRefGoogle Scholar
  41. 41.
    Reynolds CF, Dew MA, Pollock BG, Mulsant BH, Frank E, Miller MD, Houck PR, Mazumdar S, Butters MA, Stack JA, Schlernitzauer MA, Whyte EM, Gildengers A, Karp J, Lenze E, Szanto K, Bensasi S, Kupfer DJ (2006) Maintenance treatment of major depression in old age. N Engl J Med 354(11):1130–1138PubMedCrossRefGoogle Scholar
  42. 42.
    Rivero-Santana A, Perestelo-Perez L, Pérez-Ramos J, Serrano-Aguilar P, Cuevas CDl (2013) Sociodemographic and clinical predictors of compliance with antidepressants for depressive disorders. A systematic review of observational studies. Patient Prefer Adherence 7:151–169PubMedCentralPubMedGoogle Scholar
  43. 43.
    Roca M, Armengol S, Monzón S, Salva J, Gili M (2011) Adherence to medication in depressive patients. J Clin Psychopharmacol 31:541–543PubMedCrossRefGoogle Scholar
  44. 44.
    Russell J, Kazantzis N (2008) Medication beliefs and adherence to antidepressants in primary care. N Z Med J 121(1286):14–20PubMedGoogle Scholar
  45. 45.
    Sanz J, García MP, Espinosa R, Fortún M, Vázquez C (2005) Adaptación española del Inventario para la Depresión de Beck-II (BDI-II): 3. Propiedades psicométricas en pacientes con trastornos psicológicos. Clín Salud 16:121–142Google Scholar
  46. 46.
    Shalansky SJ, Levy AR, Ignaszewski AP (2004) Self-reported Morisky score for identifying nonadherence with cardiovascular medications. Ann Pharmacother 38:1363–1368PubMedCrossRefGoogle Scholar
  47. 47.
    Stahl SM (2002) Antipsychotic polypharmacy: evidence based or eminence based? Acta Psychiatr Scand 106:321–322PubMedCrossRefGoogle Scholar
  48. 48.
    Tanaka E, Hisawa S (1999) Clinically significant pharmacokinetic drug interactions with psychoactive drugs: antidepressants and antipsychotics and the cytochrome P450 system. J Clin Pharm Ther 24:7–16PubMedCrossRefGoogle Scholar
  49. 49.
    Uher R, Farmer A, Henigsberg N, Rietschel M, Mors O, Maier W, Kozel D, Hauser J, Souery D, Placentino A, Strohmaier J, Perroud N, Zobel A, Rajewska-Rager A, Dernovsek MZ, Larsen ER, Kalember P, Giovannini C, Barreto M, McGuffin P, Aitchison KJ (2009) Adverse reactions to antidepressants. Br J Psychiatry 195(3):202–210PubMedCrossRefGoogle Scholar
  50. 50.
    Val JA, Amorós BG, Martínez VP, Fernández Ferre ML, León SM (1992) Descriptive study of patient compliance in pharmacologic antihypertensive treatment and validation of the Morisky and Green test. Aten Primaria 10(5):767–770Google Scholar
  51. 51.
    Vieta E, Blasco-Colmenares E, Figueira ML, Langosch JM, Moreno-Manzanaro M, Medina E (2011) WAVE-bd Study Group. Clinical management and burden of bipolar disorder: a multinational longitudinal study (WAVE-bd study). BMC Psychiatry 11:58PubMedCentralPubMedCrossRefGoogle Scholar
  52. 52.
    Wheeler K, Wagaman A, McCord D (2012) Personality traits as predictors of adherence in adolescents with type I diabetes. J Child Adolesc Psychiatr Nurs 25(2):66–74PubMedCrossRefGoogle Scholar
  53. 53.
    World Health Organization (2003) Investing in mental health. World Health Organization, GenevaGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Carlos De las Cuevas
    • 1
    • 2
    Email author
  • Wenceslao Peñate
    • 3
  • Emilio J. Sanz
    • 4
  1. 1.Department of Psychiatry, School of MedicineUniversity of La LagunaSan Cristóbal de La LagunaSpain
  2. 2.Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC)TenerifeSpain
  3. 3.Department of Personality, Assessment and Psychological TreatmentsUniversity of La LagunaSan Cristóbal de La LagunaSpain
  4. 4.Department of Clinical PharmacologyUniversity of La LagunaSan Cristóbal de La LagunaSpain

Personalised recommendations