Patient Perceived Barriers and Enablers to Medication Adherence in the Treatment of Depression: A Qualitative Study

Abstract

Background:

Depression affects approximately 280 million individuals globally and it is a leading cause of disability. Despite effective medication options, 50% of patients prematurely discontinue antidepressants within 6 months. We sought to understand patients’ perspectives regarding their needs and expectations related to antidepressants.

Objectives:

To identify and describe enablers and barriers that influence adult patients’ medication adherence in depression treatment and to explore patients’ educational needs on initiating or continuing antidepressant therapy.

Methods:

Qualitative descriptive study was conducted using individual, semi-structured interviews of adult patients with depression who were prescribed an antidepressant within 3 months of study recruitment at an urban primary care clinic in Toronto, Canada. Thirteen participants were interviewed. Interviews were recorded and transcribed verbatim for inductive thematic analysis.

Results:

Six themes emerged: safety and effectiveness of antidepressant, understanding of depression and its management, medication administration, healthcare experiences in the treatment of depression, and social influences and relationships. Barriers to adherence included adverse effects of antidepressants, preference for non-pharmacological therapies, uncertainty about therapeutic effects, and social stigma. In contrast, enablers were positive responses from antidepressants, fear of relapse, reminder aids, established routine, and a trusting patient-provider relationship. Participants desired access to reliable, evidence-based, and personalized educational information delivered through verbal, written, and digital formats to support antidepressant adherence.

Conclusion:

To overcome the identified barriers, educational strategies should involve both patients and their prescribers to identify patient-specific needs and treatment goals, engage in shared decision-making, and maintain consistent follow-up to support antidepressant adherence.

Keywords

depression antidepressant medication adherence qualitative methods patient perspectives primary care barriers and enablers

Introduction

Depression affects approximately 280 million individuals globally, making it the second most prevalent mental health disorder following anxiety.¹ In Canada, the annual prevalence of major depressive episodes has increased from 4.7% in 2012 to 7.6% in 2022.² According to the Global Burden of Diseases, Injuries, and Risk Factors Study, depressive disorders are the most prevalent mental health disorder causing disability. Depressive disorders rank 13^th overall among leading causes of global disability-adjusted life-years and rank second in specific noncommunicable causes of years living with disability.³ The annual economic cost of mental illness in Canada is estimated at over $50 billion per year, which includes healthcare costs, loss of productivity, and reductions in health-related quality of life.⁴

Treatment for depression involves a multi-faceted approach, including psychotherapy and pharmacotherapy options, such as selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI).⁵ Pharmacotherapy is indicated in major depressive episodes of moderate to severe severity.⁶ Treatment duration can range from 6 months to 2 years or longer if clinically indicated. Antidepressant medications are typically taken by mouth once or multiple times a day routinely. While effective medications are available, non-adherence to antidepressants among individuals with depression is well-described in literature.^7
-11 One study suggests a 50% premature discontinuation of antidepressant therapy by 6 months.⁷ Early discontinuation is associated with poor treatment outcomes, including relapse, increased suicide risk, and greater economic burden.^12,13 Non-adherence can be patient-related (eg, individual attitudes and beliefs, tolerability of medications, and comorbid conditions), clinician-related (eg, inadequate patient education, lack of shared decision-making, time constraints, and poor follow-up), or structural factors (eg, access, cost, and stigma).¹⁴ A qualitative study conducted in Malaysia interviewed participants on perceived facilitators and barriers to antidepressant adherence. Need for treatment and health benefits were identified as facilitators while patient-related factors and medication side effects were barriers.¹⁵ To our knowledge, only a few studies have gained insights from patients in a qualitative manner.^15
-18 Historically, most studies related to medication adherence have been quantitative in nature and have a high variability in definitions and measurements.^18,19 No comparable, qualitative study has been conducted in Canada. Thus, there exists a gap in the literature concerning a comprehensive understanding of patients’ attitudes and beliefs regarding antidepressant therapy and adherence within the Canadian primary healthcare context.

A systematic review comparing the effectiveness of various strategies to improve antidepressant adherence found that patient education alone was ineffective.¹³ Rather, optimizing antidepressant adherence requires multi-faceted interventions that combine educational, behavioral, affective, and provider-targeted strategies.¹³ Therefore, our study aimed to identify and describe adult patients’ perspectives on enablers and barriers to medication adherence in the treatment of depression and to explore patients’ educational needs and preferences for initiating and continuing antidepressant therapy.

Methods

Study Design, Setting, and Participants

We conducted a qualitative, descriptive study employing individual, semi-structured interviews with patients enrolled at an urban, interprofessional, team-based academic family medicine clinic located in downtown Toronto, Ontario, Canada. We included patients 18 years and older with depression managed primarily by their family physician and prescribed an antidepressant within 3 months of study recruitment. We excluded patients who did not speak English, were unable to provide informed consent, or were unable to complete the study. Patients with certain comorbid psychiatric conditions and/or cognitive impairment (eg, schizophrenia, bipolar disorder, and dementia) were excluded unless the patient’s family physician deemed them to be capable of providing informed consent and completing the study. Patients with comorbid anxiety disorder, post-traumatic stress disorder, attention deficit hyperactivity disorder, or obsessive-compulsive disorder were included. Potential eligible participants were identified through a general electronic medical record search conducted using the inclusion/exclusion criteria listed above (without accessing any individual files). These potential participants were then asked by their primary care providers (family physicians and nurse practitioners) if they would agree to be contacted by email about this research study. Those who agreed were then emailed more information about the study and were invited to contact study investigator CC or YM if they were interested in participating. Additional recruitment strategies included posting study advertisements in clinic waiting areas, on the clinic’s website, and providing a verbal introduction to the study if providers (eg, pharmacists, social workers, and nurses who were not study team members) encountered an eligible patient. Study investigators (CC and YM) used a standard script to share information related to the study, confirm eligibility and schedule an interview time with interested participants. At the scheduled interview time, informed participant consent was obtained prior to starting the interview. Participants were offered $25 CAD remuneration for participation in the study. We used convenience sampling given limited access to patients during the early stages of the COVID-19 pandemic as care was transitioned to telehealth. We subsequently employed purposive sampling to capture increased variation in age, gender, and race. The intended sample size was 12 to 15 participants to ensure data saturation.²⁰

Study Instrument

The semi-structured individual interview guide was informed by existing literature¹⁴ and developed by the research team, consisting of qualitative research experts, family physicians, and pharmacists. Core questions were designed to encourage participants to express themselves using their own words. Probing questions were embedded in the interview guide as prompts to further explore participants’ responses. Topics included (i) perception of antidepressants; (ii) medication adherence; (iii) enablers to adherence; (iv) barriers to adherence; and (v) educational needs (see Supplemental section). The interview guide was pilot tested with 2 participants and no further changes were made. The data derived from the 2 participants during the pilot testing were included in the analysis.

Data Collection

Data collection was conducted by 2 interviewers (CC and YM) who were pharmacy residents at the time (ie, practicing pharmacists) with novice-level experience in qualitative research. The interviewers received coaching and guidance from qualitative research experts on the study team. The interviewers had no professional or personal relationships with any of the participants. Data collection occurred at different time periods (July 21 to 30, 2020 and March 3 to June 6, 2023) due to a temporary halt in recruitment from 2021 to 2022 related to the COVID-19 pandemic and change in the research team personnel. Sociodemographic information (age, gender, race, education level, and annual household income), comorbid health conditions, duration of depression diagnosis, and history of antidepressant use were asked verbally and documented at the start of the interview. Interviews were conducted by videoconference using Microsoft Teams or over the phone and audio recorded. The recordings were transcribed verbatim and de-identified by an external professional transcriptionist (same transcriptionist for both time periods). Transcripts were reviewed by the interviewers for accuracy. Field notes were taken by the interviewers during the interviews to remember important aspects of the interaction. Additionally, any factors arising from the interview setting (eg, disruptions) and participants’ overall demeanors (eg, significant events that took place right before the interview) that might influence their responses were noted. Interviews lasted between 20 to 50 minutes.

Data Analysis

We used NVivo software (Version 12, QSR International, Doncaster, Victoria, Australia) for data storage, data organization, and coding. Inductive thematic analysis was performed.²¹ We took an iterative approach, conducting data collection and analysis simultaneously. This allowed for the continuous refinement of codes as new insights emerged from the interviews. Two coders (YM and MK) independently read through the raw transcripts twice on separate occasions to familiarize themselves with the data. They then conducted line-by-line coding, organized codes into a codebook, rearranged the data into categories, and identified emergent themes. The codebook was developed by comparing codes and resolving any discrepancies by consensus. If the two coders could not agree, it was discussed with the study team until consensus was achieved. A priori codebook was developed by CC and CP from the first 4 participants. To increase rigor, YM and MK reviewed and consolidated the priori codebook into the final codebook before developing themes. These measures were implemented to maintain rigor and increase trustworthiness of our findings.^22
-24 For example, we maintained an audit trail that outlined the decisions made during the development and refinement of data from codes to themes, thus increasing confirmability and objectivity of our findings. In addition, we performed member checking for 9 participants, investigator triangulation, and researcher reflexivity to increase credibility and dependability of our findings. Finally, to increase transferability or applicability of our results to other contexts or settings, strategies such as purposive sampling were employed.

Ethical Approval

This study was approved by the University Health Network Research Ethics Board (19-6222).

Results

Thirteen participants were interviewed by video call between July 2020 and June 2023. Table 1 includes the sociodemographic characteristics of the study participants. Median age was 47 years old, 54% of participants were female (n = 7), 69% were White (n = 9), 85% had post-secondary education (n = 11), and 61% had a household income of at least $50 000 CAD (n = 8). The median time since diagnosis of depression was 7.25 years; 69% of participants were prescribed an SSRI (n = 9), and 69% had prior experience with antidepressants (n = 9). The most prevalent comorbidities were anxiety (38%, n = 5) and hypertension (38%, n = 5). Eighty-five percent of participants (n = 11) expressed intent to continue their antidepressant at the time of interview. One participant never started their antidepressant, and another independently stopped after 7 weeks of treatment. With respect to self-reported adherence to the antidepressant in the two weeks prior to interview, 39% of participants (n = 5) reported no missed doses, 46% (n = 6) reported 1 or more missed doses, and 15% (n = 2) reported not having taken the medication.

Table 1.

Sociodemographic Characteristics of Study Participants.

Sociodemographic characteristics	Frequency, n (%)
All participants N = 13
Median age (range)—in years	47 (21-67)
Female gender	7 (54)
Race
White	9 (69)
Mixed	2 (15)
Black	1 (8)
Latin American	1 (8)
Education level
College/university diploma	4 (31)
Bachelor’s degree	4 (31)
Master’s degree	2 (15)
High school	2 (15)
Technical school	1 (8)
Annual household income (CAD)
Less than $25 000	2 (15)
$25 000-$50 000	2 (15)
$50 000-$100 000	5 (38)
$100 000-$200 000	3 (23)
Prefer not to answer	1 (8)
Median time since diagnosis (range)—in years	7.25 (0.2-30)
Comorbid conditions
Anxiety disorder	5 (38)
Hypertension	5 (38)
Attention deficit hyperactivity disorder	3 (23)
Low back pain	3 (23)
Migraine	3 (23)
Obstructive sleep apnea	2 (15)
Post-traumatic stress disorder	1 (8)
Obsessive-compulsive disorder	1 (8)
Antidepressant use
Antidepressant experienced	9 (69)
Antidepressant naïve	4 (31)
Number of chronic daily medications
0 or 1	5 (38)
2-3	4 (31)
4 or more	4 (31)
Antidepressant type
Selective serotonin reuptake inhibitor (SSRI)	9 (69)
Bupropion	2 (15)
Serotonin norepinephrine reuptake inhibitor (SNRI)	1 (8)
Mirtazapine	1 (8)
Antidepressant adherence in the 2 weeks prior to the interview (self-reported)
Missed 1 or more dose	6 (46)
No misses	5 (38)
Stopped or never started	2 (15)

We identified 6 emergent themes, each encompassing multiple barriers and enablers to antidepressant adherence. These are described below, along with additional illustrative quotes found in Tables 2 and 3.

Table 2.

Key Themes, Enablers, and Barriers to Antidepressant Adherence.

Themes	Enablers	Barriers	Illustrative quotes
1. Safety of antidepressant	• Transient adverse effect	• Experiencing or anticipating an adverse effect• Negative experiences reported by others• Long-term risks	Enablers If you can get over that first initial couple of weeks of the side effects, you don’t really feel them afterward. So, I am not really feeling the nausea or the wooziness, or the anxiety that I was feeling when I first started taking them. So, the fact that there are not ongoing side effects makes it easy to take it (Participant 9, Female)BarriersI felt that it sort of numbed me in terms of emotions or perceptions. I am a painter; I am an artist. So, the fact that it sort of dulled me was bothersome (Participant 10, Male)I was still looking to come off it because recently I have seen a lot of articles about how the long-term effects of taking antidepressants were not very well known or well-studied. And I was concerned about that. (Participant 3, Female)
2. Effectiveness of antidepressant	• Experiencing a beneficial effect• Previous positive experience personally or by others	• Uncertainty in therapeutic effect• Lack of effectiveness	Enablers I would find myself spiraling, I would find myself being unable to get out of bed, really struggling with regards to just operating day-to-day. Since taking it, I’m not having nearly as many of those episodes, starting to feel in control. It really reinforces the idea that I am taking a positive step for myself. (Participant 1, Male)The sense of getting more done in a day. Maybe the sense that it felt good that I was finally doing something for my depression, something concrete. Addressing it with medication was just a good feeling. It helped my self-confidence. I was doing something and therefore I could do something. And an immediate sense that you are being good to yourself. And looking after yourself. It feels good (Participant 4, Male)I was ready to try it because I had talked to a few other friends who have taken it. And they asked me what my fear was of taking it. And if it is something that could work at least even temporarily to get myself back to where I was. And get out of this rut. (Participant 13, Female)BarriersIt seems daunting to think if this one doesn’t work then to try the next one. And how is that going to make you feel. So, I think that is the difficult part of trying antidepressants to see what works. (Participant 6, Female)
3. Understanding depression and its management	• Receptive to drug therapy• Fear of depression and relapse• Recognizing the need to get help	• Preference for nondrug approach to treating depression• Lack of symptom insight or denial of depression	Enablers Antidepressants are a necessity for me to function as a human being, obviously. (Laughing). I don’t think that I would be able to partake in any other kind of therapy without medication. (Participant 11, Male) I was kind of more open to trying drugs to treat my depression because I think I was just tired of being depressed. And then I had an incident, I kind of had a breakdown. . . I kind of just laid down in the shower and I didn’t get up for like an hour. And then I called my boss, and I said I can’t come to work. (Participant 12, Male)BarriersMy head is like, no, I’m not depressed. That’s not depression. Depression is you just in bed and you can’t get out of bed. You can’t do anything. So I was like, okay, that’s not me because I’m not feeling like that. So I’m like, no, I’m not depressed. (Participant 5, Female)I have always tried to avoid medication. I don’t take it very often unless it is necessary. If I have a headache, I will take an Advil. (Participant 13, Female)
4. Medication administration	• Established routine for taking medication• Reminder aids• Ease of medication administration	• Change or lack of routine for taking medication• Forgetfulness• Pill burden	Enablers I have a dog and I have to walk and feed him. So, it is like a reminder like oh he has to eat, and I have to take a pill (Participant 2, Female)I have my pharmacist divide it up in a pill pack. So, when I wake up before I go to work in, my routine for getting ready for work I take my morning pills. And then after dinner I take my evening pills (Participant 8, Male)BarriersJust absent mindedness. Not paying attention. Taking my pills mechanically and routinely. Not consciously. And later wondering if I did remember (Participant 4, Male)
5. Healthcare experiences in the treatment of depression	• Trusting relationship with provider• Access to health care professionals• Shared decision-making	• Lack of follow-up• Limited access to care• Poor provider communication	Enablers I trust my physician you know more than I would almost say then I trust myself because I realize that obviously the doctors and pharmacists have the training and they have the knowledge. And I don’t. So, they are trying to do what is best for me. (Participant 8, Male)My family doctor answered all my questions and we talked through everything before starting the medication. It really felt like it was an informed decision as opposed to something that my family doctor was pushing on me. It did feel like it was still my choice. Like if I decided for whatever reason this medication was not beneficial for me, we could look at other options. It was something that was collaborative. (Participant 1, Male)BarriersI don’t really like how it is prescribed but you can’t tell me how it works. Even when I was being prescribed escitalopram, it was kind of a crapshoot because my doctor showed me multiple different ones on a sheet. And said which one do you want to go for? And I was like I don’t know. Um, she did give me suggestions but in the end, it was kind of spinning a roulette wheel. (Participant 3, Female)
6. Social influences and relationships	• Support from family and friends• Greater awareness of mental health	• Social and self-stigma• Lack of social supports• Negative effect on relationships	Enablers I told my boyfriend about them, and he was very supportive of me. He was the one reminding me, he was saying to put it on my phone or write it down and remind myself to take them. (Participant 2, Female)BarriersThey [family] will say you’re just going through a phase, you’ll get over it. They don’t want me to take medication like that. That’s not good for you. Those things will send you mad and you’ll have to depend on them all the time, you can’t get off it (Participant 5, Female)It [psychiatric condition] was treated very negatively within my family. I come from a very rural, poor family. So, my initial thoughts about these drugs were probably negative. Then a lot of my friends, through the years, you hear about kids being on it. . . I gradually started to get educated about the benefits and heard positive things from folks and different adults I know throughout the years that have taken antidepressants. (Participant 12, Male)A lot of my friends are on medication for mental illness, I would not bat an eye. I would just go, good for you. You are doing something for yourself. And all those niceties that you feel for other people. But I couldn’t do that for myself. I just thought taking medication meant that I had given up exploring the idea of getting better (Participant 7, Female)

Table 3.

Educational Needs.

Category	What participants desired	Illustrative quotes
Educational content	• Relevant, tailored information• Evidence-based, reputable information• Setting expectations/what to monitor	So, I asked him [pharmacist] about interactions with you know the ADD medication as well. I asked him if there were any supplements that I should or shouldn’t be taking which, I found the pharmacist is helpful because they understand interactions. (Participant 9, Female)Certainly, we talked about what the implications might be. And that there would be a transition period in terms of taking it, which is helpful. Increasing the dose, I did notice a bit of energy. There is definitely a transition in adopting the drug. And I was prepared for that. Or told about that. (Participant 10, Male)
Delivery	• Multiple healthcare providers offer various opportunities for education• Multimodal delivery	I get verbal information at the time from my doctor. And when I go to the pharmacist if there is something that I’ve forgotten or just need clarification on they are pretty good at clearing it out. (Participant 8, Male)I did find the verbal conversation to be very beneficial. It seemed like it was a conversation, it seemed like this was something that I was free to ask whatever questions came to mind. I was free to explore different options. But following up on that I think, online resources would be preferable to pamphlets just in terms of any kind of physical resource like that I find for myself has shorter shelf life where I may lose it. (Participant 1, Male)

Theme 1: Safety of Antidepressants

The safety of antidepressants included potential or actual harms or negative effects perceived or experienced by participants. This theme encompassed the most common barrier to adherence reported by participants as illustrated in Table 2. Firstly, all participants were apprehensive of, anticipated, or experienced a side effect from taking an antidepressant. Participants voiced concerns about side effects such as sexual dysfunction, suicidal feelings, and flattening of emotions. There was variation in the thresholds for both the willingness to experience and tolerate side effects. One participant self-discontinued their antidepressant, noticing a “difference in personality. . . more aggression and attitude” (Participant 2, Female) which negatively impacted their personal relationships. Another participant refrained from initiating their prescribed antidepressant, feeling overwhelmed by the multitude of potential side effects. Moreover, some participants raised concerns about the perceived uncertainties regarding the long-term risks of antidepressants, prompting 1 participant to contemplate discontinuing treatment. In contrast, an enabler with respect to this theme was the transient nature of many antidepressants side effects. Most participants who were informed about the initial adjustment period and short-term side effects while initiating antidepressant treatment showed a greater inclination to adhere to their prescribed regimen. One participant remarked, “the fact that there are no ongoing side effects makes it easy to take it. I can see how people would balk at the idea of taking medication because they think, am I always going to feel this way. It’s not worth it.” (Participant 9, Female)

Theme 2: Effectiveness of Antidepressants

The effectiveness of antidepressants was expressed as how participants perceive or experience therapeutic responses to antidepressant therapy. Most participants who took an antidepressant experienced benefits at one point, and this was a key enabler in promoting adherence. Participants cited positive responses and noticeable improvements in daily functioning, productivity, and self-worth (Table 2). Conversely, uncertainty in therapeutic effect and lack of effectiveness were barriers to adherence. This may have led to hesitancy in initiating and maintaining antidepressant therapy, given the prospect of trying multiple antidepressants. Several participants questioned the effectiveness of antidepressants, including those who had previous unsuccessful trials: “I haven’t had much success myself. My thoughts are that there is no real happy pill kind of deal. . . and I don’t think I am going to have very much success.” (Participant 8, Male)

Theme 3: Understanding Depression and Its Management

The third theme centered on an individual’s awareness of their condition, its impact on their lives and those around them, their perspectives on treatment approaches, and their need for treatment. Antidepressant adherence was largely influenced by these factors. Nearly all participants recognized the significance of addressing depression and expressing a desire or a need to improve their specific circumstances, which facilitated adherence. The fear of depression or symptom relapse were also quoted (Table 2) which were motivating factors to continue their medications, particularly in participants with recurrent episodes of depression. On the other hand, lack of symptom insight, denial of diagnosis, and false beliefs impeded adherence for a few participants, which historically led one individual to prematurely discontinue their antidepressant. One participant reflected that they previously would be in denial of their diagnosis: “[I used to say] I don’t think I’m depressed because this is just a phase that I’m going through. . . [but] I don’t even want to come out of bed.” (Participant 5, Female). This would lead them to stop medication once they felt better. Furthermore, some participants perceived a need to treat their depressive symptoms but preferred a non-pharmacological approach; this specifically impeded one participant from initiating an antidepressant. This obstacle appeared to be more evident among participants who were not accustomed to taking medications regularly and the antidepressant was their first chronic medication.

Theme 4: Medication Administration

The theme of medication administration related to the practical and logistical considerations of obtaining and taking an antidepressant. An established routine of taking medication enabled adherence in most participants. Some participants paired medication taking with other daily tasks to facilitate adherence. If the routine of taking medication became overly familiar, some participants would occasionally forget whether they had already taken the day’s dose. Moreover, deviation from normal routine (eg, event on the weekend, not sleeping at home) led to occasional missed doses. All participants found reminder aids such as pill organizers, notifications from mobile phone applications, and alarms to be helpful. Lastly, most participants had no major barriers to obtaining medication. However, one participant was frustrated with the difficulties encountered when picking up their antidepressant prescription: “I psych myself up for hours to go to the pharmacy and the fax that my doctor sent them did not go through. And I had a little scene there. I was thinking of quitting my whole pharmacy and go to another one or just go off the antidepressants altogether.” (Participant 4, Male)

Theme 5: Healthcare Experiences in the Treatment of Depression

In the context of our study, we defined this theme as the engagement of patients with healthcare providers, services, and systems for approaching depression treatment. A significant facilitator of antidepressant adherence, as acknowledged by most participants, was having a trusting and supportive patient-provider relationship. One participant described, “The thing that got me to agree to this decision to go on [an antidepressant] was the amount of compassion my doctors showed me. . . which was more important than the education.” (Participant 7, Female) Additionally, several participants engaged in shared decision-making with their providers, resulting in well-informed choices to commence an antidepressant trial. Conversely, healthcare providers can also pose as a barrier. For instance, one participant expressed dissatisfaction with the information that was poorly communicated by their physician. This resulted in a lack of trust in their physician’s knowledge, prompting the participant to consider discontinuation of their antidepressant. Moreover, while some participants conveyed satisfaction with the amount and access to care, others expressed a desire for increased follow-up. Therefore, the approachability of care and how it met a participant’s needs served as both an enabler and a barrier to adherence.

Theme 6: Social Influences and Relationships

The final theme encompassed the influences of both broader societal factors and personal relationships on an individual, which have implications for antidepressant adherence. Stigmatization of depression was a prevalent barrier. As such, some participants felt shame or embarrassment about having depression, resulting in an unwillingness to share their mental health struggles or disclose that they take an antidepressant to others. Stigma from a family member led one participant to refrain from bringing their antidepressant when visiting a family member’s home, fearing it might be discarded if discovered. On the contrary, greater societal recognition of mental health enabled one participant with longstanding depression to be forthcoming with taking an antidepressant, which led to gaining support from a loved one: “For years, I hid my depression. So, it has been a step forward saying I am going to take the drugs. He has welcomed me opening about it and I feel I have the support.” (Participant 7, Female)

Educational Needs

Overall, most participants felt their educational needs were met. Although participants’ needs are highly individualized, there were overarching themes. All participants preferred to receive relevant, tailored information; for example, whether the antidepressant can impact a comorbid condition or the rationale for selecting one drug over another based on the participant’s case. Evidence-based, reputable information was desired; one participant expressed a need for “more scientific, nondrug-company sponsored data in layman terms.” (Participant 3, Male) Many participants also emphasized setting expectations and having a strategy for self-monitoring response, including a suggestion for a “checklist to help report your state to yourself before, during, and after treatment.” (Participant 4, Female) Additionally, all participants preferred a multimodal approach to receiving information: verbal discussions with healthcare providers, written handouts, and reputable online resources. Lastly, several participants appreciated having multiple opportunities for education by different healthcare providers to clarify and reinforce information. Participants valued having adequate time for an initial discussion with their primary care providers. For more specific questions such as drug-drug interactions, one participant suggested “doctors to encourage people to utilize their pharmacists to ask more questions and get more information.” (Participant 9, Female)

Discussion

Our exploratory study aimed to identify and describe enablers and barriers that may influence adherence to antidepressant therapy in the treatment of depression in adult patients in a Canadian primary care setting. We also sought to explore patients’ educational needs with initiating and continuing antidepressant therapy.

In summary, participants expressed many concerns about adverse effects, while experiencing a positive response to an antidepressant was a key enabler. Understanding depression and its management considerably influenced adherence, with perceived need for treatment and symptom insight, acting as strong enablers. Another facilitator with regard to medication administration was integrating antidepressant therapy into a daily routine. Our findings demonstrated that a trusting patient-provider relationship was conducive to adherence while subpar communication and lack of trust were hindrances. With respect to social influences and relationships, stigma continues to be a prevalent barrier. As for educational needs, participants wanted evidenced-based, individualized information on antidepressant therapy shared through various modalities such as online resources, written handouts, and verbal communication.

Our findings underscore the interplay and complexity of multiple factors that are involved in an individual’s behaviors and decisions around antidepressant adherence. Many of our findings are consistent with results from previous literature.^25
-27 Experiencing a therapeutic benefit from the antidepressant is a commonly described enabler and prevalent among our participants. Similarly, Gonzalez de Leon et al.²⁷ (2022) described that patients would report becoming more adherent because they were associating the positive effect directly with taking the antidepressant.²⁷ Paradoxically, clinical improvement can sometimes impede adherence as patients may self-discontinue their antidepressants when they feel better and believe the medication is no longer necessary.^16,27 When stopping an antidepressant due to symptom improvement, it is necessary to differentiate between non-adherence, where patients independently cease their medication without consulting their healthcare provider, and a deliberate, medically supervised discontinuation following a thorough assessment of the patient’s stability to minimize relapse. What enables adherence for 1 individual may be a barrier for another, as the participant’s experiences with treatment and their perceived need for it significantly influence adherence. Consequently, adherence to antidepressant treatment is a dynamic and evolving process that requires timely and regular monitoring by the patient and their healthcare team.

Anticipating or experiencing an adverse effect was consistently perceived as a barrier by all participants. While participants did voice concerns about common side effects, several also held misconceptions, such as the belief that antidepressants could lead to unintended personality changes. Erroneous beliefs or misconceptions of antidepressants and depression were one the most significant barriers identified in Ho et al’s qualitative study based in Malaysia that involved Chinese, Indian, and Malay patients.¹⁵ Some erroneous beliefs included taking antidepressants only when depressive symptoms are present and that antidepressants cause kidney damage with long-term use.¹⁵ Nonetheless, It is important to note that different cultures may hold varying beliefs, and it would be pertinent to take cultural context into account to address possible misconceptions.

Our study demonstrated the meaningful impact of healthcare providers on antidepressant adherence, congruent to other studies.^15,17,27,28 In a 12-month cross-sectional, observational study of 241 general practice patients, the impact of improved communication and education by general practitioners (which included a flow sheet guided by physician instruction, patient education, and consistent follow-up) led to improvement in adherence rate of 66% at the 9-month mark.²⁸ Additional literature has suggested that the combination of adequate knowledge about disease and its treatment, coupled with trust in the physician, serves as motivation for patients to initiate and maintain medication usage.^25,29

The non-adherence rate of 15% among our participants was comparable with current literature which reported 13% to 56% non-adherence rate to antidepressants immediately after starting treatment irrespective of primary care or psychiatric setting.^7,9 That being said, most participants had relatively good adherence to their antidepressants and had no intentions of discontinuing them.

Implications

As our data suggest, antidepressant adherence is a complex behavior and can be influenced by many factors. By leveraging the findings of this study, future initiatives may include the development of a novel, patient-driven intervention to optimize antidepressant adherence, address patients’ individual barriers, and meet patient-specific treatment goals using a multifaceted approach.

Regularly scheduled follow-ups with healthcare providers are ideal during the initiation and maintenance phases of antidepressant therapy to address key concerns and benefits of treatment. Therapeutic alliance between patients and healthcare providers is associated with a greater likelihood of medication adherence and treatment outcomes in patients with depression.³⁰ Therefore, shared decision-making is an important strategy that can enhance patient engagement when embarking on antidepressant treatment. There are several patient-administered decision aids^31
-33 and a Canadian clinician-aimed support tool³⁴ available that can facilitate patient-provider shared decision-making of antidepressant treatment.

Strengths and Limitations

Our recruitment process captured participants with a varying range of experiences with antidepressants, duration of depression diagnosis, medication complexity, age, and socioeconomic backgrounds. We initially screened more female than male participants, which was expected given the greater prevalence of reported depression in females than males.³⁵ As such, purposive sampling was utilized to increase recruitment of male participants. Qualitative descriptive design with inductive thematic analysis was an ideal method to authentically capture patients’ experiences with antidepressant adherence. Our study incorporated multiple strategies used in qualitative research to enhance trustworthiness and rigor of our findings (eg, member checking, audit trail, researcher reflexivity, and investigator triangulation).

There are limitations to this study. Patients’ perspectives from a single center may not be reflective of the larger population living with depression. Demographically, we did not capture older adults or a wide diversity of visible minorities representative of the Greater Toronto Area. This may have overlooked age or culture-specific factors related to adherence that could have emerged. Patients managed by psychiatrists or other specialist providers for depression treatment were not included, and their medication adherence experience may differ from those managed by family physicians. Our participants had a relatively good antidepressant adherence rate. Consequently, the applicability of our findings to understanding challenges faced by those with lower adherence rates in the broader population may be limited. Despite this, the barriers and enablers to adherence identified in our study still align with existing literature. Hence, our findings retain relevance and a degree of generalizability. Mental health stigma may have contributed to recruitment challenges. Thus, convenience sampling was employed, which potentially introduced selection bias and overlooked individuals who felt embarrassed or ashamed about living with depression, ultimately reducing generalizability. Additionally, there was a three-year span between the two data collection periods, which included the COVID-19 pandemic. We did not compare the two sets of collected data specifically from a COVID-19 pandemic impact lens, so it is uncertain whether there were any changes in the enablers and barriers potentially due to the pandemic and its impact on the healthcare system. Lastly, severity of depression was not formally assessed which may have impacted antidepressant adherence.

Conclusion

This study offers descriptive narratives of participants’ real-life experiences, along with their attitudes and beliefs regarding antidepressants for the treatment of depression. It emphasizes the importance of understanding patients’ values and preferences to overcome potential barriers to medication adherence and empowering them with high-quality, personalized education. Strategies for patients and prescribers such as shared decision-making, identifying patient-specific goals, and maintaining consistent follow-up to facilitate treatment adherence could be utilized to address these challenges. Future directions may include the development and validation of an innovative, patient-driven tool to enhance antidepressant adherence. The tool could be tailored for use in primary care settings and would address the enablers and barriers identified in this study.

Supplemental Material

sj-docx-1-jpc-10.1177_21501319241286313 – Supplemental material for Patient Perceived Barriers and Enablers to Medication Adherence in the Treatment of Depression: A Qualitative Study

Supplemental material, sj-docx-1-jpc-10.1177_21501319241286313 for Patient Perceived Barriers and Enablers to Medication Adherence in the Treatment of Depression: A Qualitative Study by Yuki Meng, Christopher Chiu, Mamta Kapoor, Shelly-Anne Li, Navaldeep Kaur, Patricia Marr, Debbie Kwan, Kori Leblanc, Catherine Ji and Christine Papoushek in Journal of Primary Care & Community Health

Footnotes

Acknowledgements

The authors thank the patients who participated in this study. The authors also thank Dr. Noah Crampton and Dr. Sarah Reid for their contributions to the study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project received financial support from The Honorable Charles & Anne R. Dubin Scholarship for Excellence in Family Practice at Toronto Western Hospital bestowed by the University Health Network Foundation and Department of Family and Community Medicine. The funder was not involved in the study design; collection, analysis, and interpretation of data; writing of the report; and in the decision to submit the article for publication.

Ethical Approval and Consent to Participate

All participants provided verbal informed consent prior to enrolling in the study. All methods were carried out in accordance with guidelines and regulations outlined by the hospital-affiliated Institutional Review Board. This study was approved by the University Health Network Research Ethics Board (19-6222).

ORCID iDs

Yuki Meng

Christopher Chiu

Mamta Kapoor

Shelly-Anne Li

Navaldeep Kaur

Patricia Marr

Debbie Kwan

Kori Leblanc

Catherine Ji

Christine Papoushek

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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