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Research on Depression in the Workplace.

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MHM JOURNAL

Mental Health Matters Journal for Psychiatrists & GP's

MHM Volume 8 Issue1

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SPEAKING BOOKS

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Literacy is a luxury that many of us take for granted. That is why SADAG created SPEAKING BOOKS and revolutionized the way healthcare information is delivered to low literacy communities.

The customizable 16-page book, read by local celebrity audio recordings, ensures that vital health and social messages can be seen, heard, read and understood by everyone across the world.

We started with books on Teen Suicide prevention , HIV, AIDS and Depression, Understanding Mental Health and have developed over 100+ titles, such as TB, Malaria, Polio, Vaccines for over 45 countries.

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Matthew S. Keene, MD

Depression is among the most common psychiatric disorders in the United States, with lifetime prevalence rates in excess of 17%. It is not surprising, then, that depression places a substantial economic burden on the US healthcare system, and current costs exceed $81 billion per year. Worldwide, the economic toll of depression is far greater. By the year 2020, the World Health Organization projects depression to be the second leading cause of global disease burden.

One of the best ways for clinicians to reduce this staggering disease burden is to simply treat depressed patients correctly, for a long enough period of time. Data support the findings that antidepressant responders who remain on their antidepressants for up to 36 months have relapse rates of only 18%, whereas those who are switched to placebo have relapse rates that exceed 40%. Indeed, long-term antidepressant treatment works, but, unfortunately, patients often don't "sign up" for such long-term approaches.

Compliance with antidepressant treatment is abysmally low. In 1995, Lin and colleagues demonstrated that 28% of patients discontinued their antidepressants within the first month, often before the drug had much chance to work. Given that over half of the patients Lin followed were on tricyclic antidepressants (TCAs), one would now anticipate that since prescribing patterns have shifted to better-tolerated antidepressants (selective serotonin reuptake inhibitors [SSRIs], bupropion, etc.), compliance would have improved over the last few years. However, that doesn't seem to be the case.

In recently analyzed adherence data from over 740,000 newly initiated immediate-release SSRI patients, Eaddy and associates found that nearly 50% of patients failed to adhere to therapy for a minimum of 60 days, and only 28% were compliant at 6 months.

Why do patients prematurely discontinue antidepressants, medications that may improve and perhaps even save their lives? The reasons vary but typically distill down to one of the 3 Cs of noncompliance: confusion, costs, and complaints. Let's take a closer look at these critical factors.

Confusion Says...

"I took that medication for 3 days and didn't feel anything."

"I felt better so I didn't need it anymore."

"I don't want to get addicted." Whether it is unrealistic patient expectations for immediate results or blatant Hollywood hype, misperceptions and misinformation surrounding antidepressant treatment prevail, undeniably impeding compliance.

To compound matters, depression frequently impairs cognition, contributing to patient-physician misunderstanding. When Bull and colleagues[5] surveyed 137 prescribing physicians and 401 depressed patients, they found that even though 72% of the physicians reported that they had told their patients to take their antidepressants for at least 6 months, only 34% of these patients recalled being told this; 56% reported receiving no instruction at all.

Perhaps the simplest way to overcome confusion is with continued patient education. In Bull's analysis, patients who recalled receiving instructions were two thirds less likely to discontinue therapy early compared with patients who were not told or did not recall being told. Likewise, Katon and colleagues[6] demonstrated significantly improved adherence to antidepressant medications in a subset of 386 primary care patients who received educational "intervention" (self-study book, videotape, visits with a depression specialist, etc.) compared with the "usual care" subset.

One additional comment stemming from confusion is, "I can't remember the second dose." Dosing frequency impacts compliance. Taking a medication 2, 3, or 4 times a day is progressively more difficult than taking a medication once daily or even once weekly. To this end, delayed-release technology that decreases the frequency of dosing, has been shown to enhance antidepressant compliance.

For example, Claxton and colleagues[7] evaluated compliance in patients who initially received fluoxetine 20 mg daily for 1 month (Period 1) and then either were continued on fluoxetine 20 mg daily or switched to a 90-mg once-weekly version of fluoxetine for a subsequent 3 months (Period 2). By the end of Period 2, compliance had statistically worsened in the once-daily arm of the study but was either the same or improved in the once-weekly arm.

Similarly, a database review of more than 85,000 patients showed that those taking once-daily bupropion XL were 65% more likely to meet a 3-month adherence threshold than patients taking twice-daily bupropion SR.[8]

 

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