Patients Commonly Stop Antidepressants, Don't Tell Docs

Fran Lowry

May 11, 2015

About 20% of patients who are prescribed antidepressants stop taking them without telling their doctor, new research shows.

Characteristics of those most likely to discontinue these medications include younger age, being diagnosed with anxiety or substance use disorder in addition to depression, and being treated in a general medical setting rather than by a psychiatrist or other mental health specialist.

The findings are published in the May issue of Psychiatric Services.

Side Effects, Lack of Efficacy

"Adherence to medication is not a new issue, but it is a particularly important one in the context of both depression and antidepressants," lead author Hillary Samples, MHS, a doctoral candidate at Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, told Medscape Medical News.

"Antidepressants can take weeks of regular use before they take effect, and adherence would be very important in that case. Depression itself has also been a factor in nonadherent behavior to medications, so we wanted to examine the extent and correlates of self-discontinuation of antidepressant medications without physician advice," Samples said.

Samples and coauthor Ramin Mojtabai, MD, PhD, professor of psychiatry at Johns Hopkins Bloomberg School of Public Health, compared sociodemographic (sex, age, race-ethnicity, education, income, and insurance status) and clinical (diagnosis, impairment, antidepressant medication class, and prescriber) characteristics of antidepressant users who discontinued medication with those who did not and assessed the self-reported reasons for self-discontinuation.

They analyzed data drawn from the Collaborative Psychiatric Epidemiology Survey on 1411 participants who reported taking one or more antidepressants at some point during 2001, 2002, or 2003.

Of these, 1098 participants (76%) reported continuing to take the medication, and 313 (22%) reported discontinuing their antidepressant without physician advice or approval.

Persons aged 18 to 30 years were most likely to self-discontinue (adjusted odds ratio [AOR], 3.09; 95% confidence interval [CI], 1.37 - 6.96; P = .007).

Any diagnosis of anxiety or substance use disorder was associated with higher odds of self-discontinuation (AOR for anxiety disorder, 2.58; 95% CI, 1.12 - 5.96; P = .026; AOR for substance use disorder, 2.84; 95% CI, 1.44 - 65/61; P = .003).

There was no association between the level of impairment and self-discontinuation.

For participants who were prescribed antidepressants by a primary care or other prescriber who was not a psychiatrist, the odds of self-discontinuation were higher compared with participants who were prescribed antidepressants by psychiatrists (AOR, 2.26; 95% CI, 1.23 - 4.14; P = .009).

In addition, participants with public insurance (Medicaid, Medicare, military benefit, or state-based programs) had significantly lower odds of self-discontinuation (AOR, .44; 95% CI, 0.22 - 0.87; P = .019) than those with private insurance.

The most common reasons for stopping antidepressants were side effects (20%) and the medication not helping (21%).

Also, a high number of self-discontinuations occurred because participants wanted to resolve their mental health problems without recourse to medications.

A smaller proportion stopped taking their antidepressants because the medication was unaffordable or because they were embarrassed. Almost one fourth stopped taking their antidepressants for other, unspecified reasons.

For Latinos, the odds of reporting side effects were higher compared with whites (OR = 2.19; CI = 1.12 - 4.33; P = .025). The odds of reporting attitudinal reasons for discontinuation were more than threefold higher for Latinos than for whites (OR = 3.33; 95% CI, 1.07-10.33; P = .038).

Individuals with more education were less likely to self-discontinue. Compared with participants who had attained up to 11 years of education, those with 12 years of education (OR = .45, 95% CI, 0.20 - 0.99, P = .049) and those with >16 years of education (OR = .40, 95% CI = 0.17 - 0.95; P = .039) said they discontinued their medication because it was not helping.

Key Issue

In an accompanying editorial, Mark Olfson, MD, MPH, from the New York State Psychiatric Institute and the Department of Psychiatry, College of Physicians and Surgeons of Columbia University, in New York City, notes that the study addresses a key issue "that is commonly hidden from physicians."

It is a challenge to develop an understanding of why patients self-discontinue because this often happens in the context of treatment termination, Dr Olfson writes.

"Because patients who discontinue medications without physician advice commonly leave treatment, treating physicians are frequently deprived of an opportunity to learn about the factors that contributed to their patients' decisions," he writes.

Dr Olfson adds that clinicians can easily underestimate their own level of ignorance "when it comes to patients who self-discontinue antidepressants."

"Without a sense of humility, we run the risk of assuming that we can simply intuit when our patients are preparing to stop or have recently stopped their antidepressant medications. The new report by Samples and Mojtabai serves a critical function by supplementing clinical intuition with objective data on risk factors for antidepressant self-discontinuation," he concludes.

Hillary Samples and Dr Olfson report no relevant financial relationships. Dr Mojtabai has financial relationships with Lundbeck Pharmaceuticals.

Psychiatr Serv. 2015;66:455-462, 449. Abstract, Editorial


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