Peter a 40 year old man, had become depressed following some money pressures which had put his livelihood and home under threat.
He had been to see his GP who had asked Peter to complete the self reporting Patient Health Questionnaire (PHQ9) to aid diagnosis and determine the level of depression. Peter scored 16 on this tool, which is indicative of a moderately severe depressive episode.
The GP suggested Peter should have a couple of weeks off work, make an appointment to see me for some psychological support and also prescribed the antidepressant drug Fluoxetine.
Peter did not attend the appointment given to him to attend my clinic, did not take anytime off work and did not use the prescription for medication. Peter later explained he had been rather shocked by his GP’s diagnosis as he felt that depression was a sign of weakness and had not considered himself to be a weak man. Therefore he decided he would try to sort himself out without any other intervention.
Unfortunately Peter was unable to deal with things himself and his depression worsened. When he attended the GP practice some 2 months later at the insistence of his wife, he was severely depressed and had a PHQ9 score of 25.
The GP immediately booked him into a space in my clinic and again urged Peter to start taking the Fluoxetine.
I saw Peter the following day and again assessed him to have a severe depression. I offered to commence a cognitive behavioural therapy approach to manage the depression and again suggested the antidepressant may be helpful to lift his mood. I explored his uncertainty around taking the medication and explained the potential side effects which may occur. Peter took the medication and after a week found that his symptoms were starting to lift. He experienced some gastro intestinal side effects, in particular, nausea which lasted for about 6 weeks but was manageable. I saw Peter on 4 further occasions when we worked on some behavioural activation work, which is known to be effective for depression, (NICE, 2009) and his mood began to lift further. His PHQ9 score dropped from 25 to 9, which is indicative of mild depression.
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At the 6tth session, some 12 weeks later, Peter informed me he had stopped taking the Fluoxetine as it was causing some sexual dysfunction which was affecting his ability to achieve orgasm. Peter found this very difficult to talk about but explained that he and his wife fond this very frustrating and so therefore had decided to stop the medication.
I tried to explore this with Peter and advised that another antidepressant could be prescribed which may not have this particular side effect. I also explained that his choice to stop the antidepressant may also increase his chances of relapse. Peter was reluctant to explore these issues further and although he made another appointment to see me, he did not attend that appointment and failed to respond to any further communication.
REFLECTION
On reflection, it would appear that Peter had several issues relating to his diagnosis of depression. Peter clearly had negative views about depression and what it meant for him as a person, unfortunately this is the case for many people as there is a great deal of stigma associated with depression.
He did not have enough information about taking the medication from his GP and although I felt I had covered the side effect profile in detail, it was clear that Peter had difficulty talking about sexual dysfunction side effects with me. He found this area particularly embarrassing to disclose.
I also feel that I did not wholly follow the 7 principles of prescribing thoroughly enough as I did not make Peter aware of the need to continue taking the medication for at least 6 months following remission in order to prevent relapse. I did not discuss this initially with Peter as I was conscious this could be information overload for him at the beginning of treatment when our main concerns were symptom reduction. I was planning to discuss this aspect as part of my discharge planning session but Peter opted out of treatment prior to this happening. With hindsight it may have been beneficial to introduce this concept earlier.
These 3 points affected Peter’s ability to adhere to his medication regime and so therefore I will explore the issue of adherence within the assignment attached to this case study.
ASSIGNMENT
This assignment will consider the issue of medication concordance relating to depression and the use of antidepressant medication as this was clearly an issue which became apparent within the case study. The assignment will explore what is meant by concordance in relation to the case study, factors affecting it and strategies which may be used to encourage concordance for the treatment of depression.
Depression is recognised as one of the major causes of ill health worldwide and in Britain it is the most common reason listed on incapacity benefit claims (World Health Organization (WHO) 2001). Despite this statistic, depression along with other mental health problems continues to have a great deal of stigma attached to it. Gray et al, (2008) supports this view and argues depression has been stigmatised due to widespread ignorance about the causes of the illness which has led it to be often perceived as a sign of personal weakness. Consequently, people experiencing depression often fail to seek help as they feel ashamed or embarrassed to disclose their symptoms or do not realize there are treatments available which may help.
The National Institute for Clinical Excellence, (NICE, 2004) recommended approaches to raise the profile of mental health by recommending ways of improving the recognition and treatment of common mental health problems, such as depression by the use of self help, Cognitive behavioural therapy and antidepressant medication.
The role of the mental health nurse prescriber also has the potential to improve the treatment of moderate to severe depression in primary care by combining the use of psychological treatments with medication management, (Badger, 2006). The level of depression can be determined by use of the Patient Health Questionnaire, (PHQ9) which states that a score above ten signifies a probable moderate to severe depressive episode, if the reporter has had these symptoms for longer than a two week period, (Anderson et al, 2008).
Several research articles have highlighted that only a proportion of antidepressants are taken as prescribed and discontinuation after one month is common. The figures for this vary between 30 to 68% depending on the article. Fox, (1999), Warrington et al, (2000) and Olfson et al, (2006) confirmed that 42% of people prescribed antidepressants stop taking them at one month.
Prior to 2005, the words compliance and adherence had been used to describe patients taking medication in accordance with instructions but since the NICE guidance …….. the term concordance has been used as this implies a negotiated agreement between the prescriber and the patient about the taking of medication. Despite this guidance, Hunot et al, (2007) argues concordance may not be any more than compliance, unless the patient believes they have an equal partnership with the prescriber.
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Between a third and a half of medicines1 that are prescribed for long-term conditions are not used as
recommended. This represents a health loss for patients and an economic loss for society.
Non-adherence should not be considered the patient’s problem. Rather, it usually results from a failure
to fully agree the prescription with the patient in the first place and to support the patient once the
medicine has been dispensed.
Non-adherence falls into two overlapping categories: intentional (the patient decides not to follow the
treatment recommendations) and unintentional (the patient wants to follow the treatment
recommendations but has practical problems).
To understand non-adherence we need to consider perceptual factors (beliefs and preferences) that
influence motivation to start and continue treatment as well as practical factors.
This requires:
_ an open, no-blame approach that encourages patients to discuss any doubts or concerns about
treatment
_ a patient-centred approach that encourages informed adherence
_ identification of perceptual and practical barriers to adherence at the time of prescribing and
during regular review.
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