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Adherence, in a medical context, refers to the degree to which a patient follows the treatment plan that has been agreed on between the prescriber (usually, but not always, a physician) and the patient. Although the term "compliance" is often used by caregivers, it is a less desirable term than "adherence," because it implies an all-or-nothing obedience to the will of others. Adherence, like a religious belief, involves recognition that there may be aspects that are less acceptable than to others; accordingly, the patient may subscribe more to certain tenets than others. This is often (and more so than we believe) what patients do in practice.1 They skip doses because of adverse effects or to use recreational drugs. They may forget the treatment plan or come to disagree with it on the basis of something they have heard or read on the Internet.
There are different degrees of adherence, from complete to rare or nonexistent adherence. This article seeks to examine what underlies difficulties and challenges with treatment adherence of major depressive disorder and identifies approaches that the clinician can use to improve patient adherence to treatment.
Perspectives on adherence
Adherence, from a dimensional perspective, can be defined as the percentage of time the patient takes his or her medicines as prescribed or how many times he perfoms the prescribed life-style interventions (eg, exercise). From a categorical perspective, nonadherence is often described in terms of the point below which a therapeutic benefit from an intervention is likely to be realized. Both definitions are dynamic and variable for each intervention and each patient.
Nonadherence may be willful or active: the individual consciously decides not to follow the prescribed treatment plan. One study found that 25% of patients told their doctors they were taking their medication when, in fact, the pharmacy database showed that they were not.1 Alternatively, nonadherence may be passive-patients forget or do not understand the instructions, or are unable to perform the activity correctly.2
Assessment of adherence has been both direct and indirect. The most common example of a direct measure is the serum blood levels that are routinely used for management of lithium as well as many of the tricyclic antidepressants (TCAs). The downside to measuring blood levels is that they reflect...