Oscar Brook *, Hein van Hout, Hugo Nieuwenhuyse, Eibert Heerdink

Transcription

1 Europen Neuropsychophrmcology 13 (003) locte/ euroneuro Impct of coching y community phrmcists on drug ttitude of depressive primry cre ptients nd cceptility to ptients; rndomized controlled tril,, c Oscr Brook *, Hein vn Hout, Hugo Nieuwenhuyse, Eiert Heerdink Interntionl Helth Foundtion, Utrecht, The Netherlnds VU University Medicl Centre Amsterdm, EMGO, Deprtment of Generl Prctice, Amsterdm, The Netherlnds c University of Utrecht, Deprtment of Phrmcotherpy nd Epidemiology, Utrecht, The Netherlnds Received 1 April 00; ccepted in revised form 15 July 00 Astrct Ojective: To investigte whether n intervention y Dutch community phrmcists improves the drug ttitude of depressive ptients, who re prescried nontricyclic ntidepressnt y their generl prctitioner (GP). Method: A rndomized controlled tril with 3-month follow-up ws conducted mong consecutive generl prctice ptients who go to 19 phrmcists for ntidepressnts. The tril consisted of control group (n579) tht received usul cre nd n intervention group (n569) tht received three drug coching contcts t the phrmcy nd 5-min tke-home video on the ckground of depression nd the effects of mediction. Outcome mesure: Drug ttitude (DAI). Results: At the seline mesurement there were no significnt differences etween the intervention nd control group on ny demogrphic nd helth sttus vriles or on clinicl symptoms. At the 3-month follow-up intervention ptients hd etter drug ttitude (P50.03) thn their controls nd evluted the coching of their phrmcist s more positive. They lso felt the video to e useful. It hd chnged their ides out mediction. Conclusions: Coching y community phrmcists is n effective wy to improve drug ttitude of depressive primry cre ptients nd it is cceptle to them. 00 Elsevier Science B.V./ECNP All rights reserved. Keywords: Rndomized controlled tril; Depressed primry cre ptients; Drug ttitude; Coching y community phrmcists 1. Introduction effects they cn expect cn contriute to improved drug ttitude (Priest et l., 1996). Being gtekeepers of the Although ntidepressnts (ADs) re effective mediction specilized helth cre is considerle tsk for generl ginst depressive disorders, mny ptients hve negtive prctitioners (GPs) (Boerm nd Fleming, 1998), which ttitude towrds ADs. This my cuse nondherence limits their time in drug coching of depressive ptients. It (Agrs, 1989). Nturlistic dt suggest tht etween 30 is quite possile tht GPs lck time to offer their ptients nd 60% do not tke their ADs s prescried (Crmer, pproprite drug coching. In review of studies on the 1995; Demyttenere, 1997; Vergouwen et l., 00). reltion etween depression nd ptient dherence, regrd- Positive expecttions nd eliefs in the enefits nd less of wht clss of mediction ws used, DiMtteo et l. efficcy of tretment hve een shown to e essentil to (000) found tht, compred with nondepressed ptients, ptient dherence (DiMtteo et l., 000). It is elieved depressed ptients re three times more likely to e tht drug coching y informing ptients on wht (side)- noncomplint with tretment recommendtions. We hypothesized tht if community phrmcists gve dequte written, orl nd visul informtion to depressive primry *Corresponding uthor. Tel.: ; fx: cre ptients, their drug ttitude would e enhnced in E-mil ddresses: orook@ihf.nl (O. Brook), (O. positive direction nd their dherence to mediction would Brook). therefore improve. To our knowledge little or no ttention X/0/$ see front mtter PII: S X(0) Elsevier Science B.V./ECNP All rights reserved.

2 O. Brook et l. / Europen Neuropsychophrmcology 13 (003) 1 9 is pid to the phrmcy s setting for drug coching of vried etween 3 nd 1 months. Inclusion criteri for ptients with ADs. In the Netherlnds, community phr- ptients were: (1) 18 yers old or over; () coming to the mcies re implementing three new tsks, viz. mediction phrmcy with new prescription from their GP for monitoring, informing prescriing physicins nd ptient nontricyclic AD mediction, i.e. not hving used n mediction eduction. The eduction of phrmcists nd ntidepressnt in the 6-month months efore the inclusion. ssistnts includes communiction skills (Pronk et l., This ws checked in the phrmcy records; (3) the ility 00). In the phrmcists 6-yer university curriculum, to understnd nd complete the Dutch questionnires nd communiction skills re tught in the 5th nd 6th yer. In (4) tking the ntidepressnts in reltion to depressive so-clled postgrdute phrmcist registrtion courses, complints. The phrmcists provided orl nd written ttention is given to phrmceuticl cre spects such s informtion out the study to eligile ptients nd sked communiction with ptients. Phrmcy ssistnts receive written informed consent of ptients. The prescriing GPs trining in communiction skills in their 3-yer voctionl were sked to complete nd return rief questionnire to trining course. Communiction is trined weekly through provide the primry dignosis, its severity nd possile out the curriculum, totlling t lest 40 student hours. In comoridity. the first yer, sic principles of verl nd nonverl Study sujects were rewrded»10 for completing ll communiction re emphsized. In the second yer questionnires from seline to follow-up. The phrmcists converstion module is tught nd prctice trining received»30 for ech ptient they enrolled in the study. integrtes vrious sujects in the third yer. For oth The RCT ws pproved y the medicl ethicl commitphrmcists nd ssistnts, postgrdute courses on com- tee of the University Medicl Centre Utrecht. muniction nd drug knowledge re ville. Hence, community phrmcists re well equipped nd well trined to provide drug coching to ptients. Since most ptients in.3. Bseline nd follow-up fter 3 months the Netherlnds visit only one phrmcy, phrmcists cn The prticipting ptients of oth rms received their esily monitor ptients. There is little shopping or mediction t the phrmcy nd filled out the self-rting switching etween phrmcies. Phrmcies hve more questionnires t the seline mesurement nd t 3-month time to provide coching to depressive ptients. Despite follow-up, nd sent the questionnires in reply envelopes these dvntges it is uncler whether phrmcies re le to the reserch institute. to effectively offer n eductionl pckge to ptients nd whether this improves drug ttitude. It is uncertin if the phrmcy is n cceptle setting to ptients for such.4. Rndomiztion pckge. The ojective of this rndomized controlled tril (RCT) Rndomiztion occurred on ptient level nd on ws to investigte whether n intervention of community one-to-one rtio using lock rndomiztion to ensure equl phrmcists would influence drug ttitude of depressive numers of intervention nd control ptients per phrmcy. primry cre ptients in positive direction. The dt dministrtion forms of the whole smple were rndomized efore delivery to the phrmcies. These forms were precoded nd delivered in seled envelopes.. Experimentl After receiving written informed consent from the ptient, the phrmcist lerned which group the ptient ws.1. Design ssigned to y opening the envelope. A rndomized controlled tril with follow-up t 3.5. Intervention months ws conducted mong consecutive ptients who ttended the phrmcy for nontricyclic ntidepressnts. All The phrmcists provided two distinct service pckges: of these ptients prticipted in lrger rndomized usul cre nd extr cre. controlled tril tht ssessed the effects of coching Ptients in the control group received the usul orl nd progrm y community phrmcists designed to improve written informtion when they picked up their prescripdherence. The tril consisted of two rms (usul cre nd tions t the phrmcy. extr cre). Neither ptients nor phrmcists were linded Ptients ssigned to the extr cre group hd three for group ssignment coching contcts during the study. For the se coching contcts the ptients were invited into seprte room to.. Setting nd sujects discuss their mediction use in privte. In few cses the ssistnt ttended to the ptients ecuse the phrmcist From April 000 up to April 001 totl of 19 ws usy. At first contct they were informed out the phrmcists ech sought informed consent of pproprite use, the eneficil s well s the side effects of consecutively ttending ptients. The enrolment period the mediction. The phrmcists were sked to use list of

3 O. Brook et l. / Europen Neuropsychophrmcology 13 (003) importnt themes (Lin et l., 1995; Nierenerg, 1999) to study ws 0.85, which only is slight lower thn in the discuss with the ptients study of Awd (1995). 1. Tke the mediction dily.6.. Other mesures. Tke the ADs for 4 weeks for noticele effect At seline mesurement depressive symptoms were 3. Continue to tke the medicine even when feeling etter mesured y the suscle of the self-rting Hopkins 4. Do not stop tking ADs without checking with the Symptom Checklist (SCL-13) (Derogtis et l., 1986). The physicin depression dimension of the SCL contins thirteen items. 5. Do not hesitte to sk the phrmcist or the GP if you Ech item is scored on 5-point scle: 05not t ll; 15 hve questions regrding ADs. little it; 5modertely; 35quite it; 45extremely. Reliility of the SCL is high. Internl consistency nd the To improve their knowledge nd ttitude towrds tking test retest reliility of the suscle re oth 0.90 (Detheir ADs the ptients received tke-home video. Both rogtis et l., 1986). The internl consistency of the SCL- intervention nd control ptients received the usul printed 13 in our study ws 0.88, which is somewht lower thn in mteril on ADs. The 5-min videotpe ws mde y the the study of Derogtis et l. In the self-rting questionnire study tem nd reviewed the multifctoril origin of ptients were sked to give their opinion out drug depression, the reltionship to stress, physicl nd emovideo. coching y the phrmcist nd out the tke-home tionl symptoms, how mediction nd psychotherpy cn relieve depression nd the importnce of mediction Demogrphic vriles were seen s potentil effect dherence. modifiers. Demogrphic vriles included ge, gender, The second contct took plce weeks efore their first mritl sttus, eduction, work sitution, income, severity prescription term ended, the third t 3 months from of depression s ssessed y the GP, numer of previous seline. During the second visit the phrmcist sked the episodes of ntidepressnt use nd/ or of depressive com- ptient whether he/ she hd experienced dverse or positive plints. effects. In oth cses ptients were stimulted nd motivted to continue to tke their ADs in order to decrese the.7. Dt nlysis nd power clcultion risk of relpse. This procedure ws repeted during the third visit. At the 3-month follow-up ll ptients (i.e. Using the softwre progrmme SPSS-10 (10) (SPSS, control nd intervention rm) filled out the self-rting 000) nd the DAI-30 s dependent vrile we performed questionnires gin, including questions on drug ttitude, x nlysis on ctegoril vriles, Spermn s correl- nd were sked to evlute their contcts with the phrmvriles (Mnn Whitney) nd we clculted the effect tion on ordinl vriles, nonprmetric test for skewed cist. size of the intervention (Cohen s d nd effect size r). In.6. Outcome mesures our originl study the primry outcome mesure ws dherence to ADs. In totl smple size of 150 sujects difference of 13% in dherence ws fesile t signifi Primry outcome cnce level of 0.05 (two-sided), with proility of 80% The primry outcome of this study ws the ttitude of nd ssuming stndrd devition (S.D.) in dherence of depressed ptients towrds mediction mesured t the 40%. We ssumed the sme significnce level, proility 3-month follow-up. nd S.D. to detect difference in drug ttitude of 13%. Drug ttitude ws mesured y the self-rting Drug Attitude Inventory (DAI), 30-item dichotomous nswer scle (Awd, 1995; Hogn et l., 1983) (see Appendix A). 3. Results The DAI scle predicts drug complince nd ws originlly constructed on schizophrenic ptients self-reports of their 3.1. Sujects experience of neuroleptic tretment. The internl consistency of the DAI ws found to e high (0.93) just like the Of 46 phrmcists who were pproched in 1999 to test retest reliility (0.8). The scle consists of 30 preset prticipte in the study, 0 declined. Resons for not questions in seven ctegories: sujective positive, sujec- prticipting were the following: no time (n515), not tive negtive, helth/ illness, physicin, control, prevention enough ssistnts (n53), GPs would e nnoyed (n51) nd hrm. Two memers of the tem trnslted the originl nd coching of ptients cnnot e comined with dily version into Dutch independently of ech other. In prctice (n51). Of the 6 phrmcists who initilly greed, consensus meeting the finl Dutch DAI ws estlished. seven of them stopped shortly fter the strt of the study; To serve the study one originl item ws chnged. In item one ecuse GPs refused to let their ptients prticipte, numer 4 the hospitl setting ws replced with n two ecuse of prolonged sick leve, two ecuse they multory one. The internl consistency of the DAI in our did not hve the time fter the deprture of ssistnts nd

4 4 O. Brook et l. / Europen Neuropsychophrmcology 13 (003) 1 9 two ecme demotivted ecuse severl eligile ptients significnt differences etween the intervention group nd refused to prticipte. During the enrolment the 19 the control group on demogrphic nd helth sttus phrmcists included totl of 151 ptients of whom 70 vriles, or on clinicl symptoms (vn Hout et l., 001) (47%) were rndomized to the intervention rm nd 81 (Tle 1). (53%) to the control group. After the rndomiztion one Men ge for the whole group ws 4 yers nd 71% of intervention ptient nd three controls ptients decided not the ptients were femle. Of the 148 ptients the GPs rted to prticipte. One ptient felt the questionnire ws too 19% mildly, 64% modertely nd 17% s severely dislong, nother hd to e dmitted to hospitl due to ordered. On verge, ptients hd experienced two erlier crdic prolems nd fter seeing the video one ptient similr episodes of complints (S.D. 4.5). The men disgreed with the GP s dignosis nd stopped tking the durtion of the current depressive episode ws more thn 3 mediction.. The seline questionnire ws filled out y yers (S.D. 5.9). In the 3 months preceding inclusion, 135 (9%) of the remining 147 ptients. At the 3-month ptients clled in sick from work on verge of 1 dys follow-up 107 (73%) of them (50 intervention nd 57 (S.D. 16.7). In generl they visited their GP twice (S.D. control ptients) returned their follow-up questionnire.4) nd visited other helth professionls four times (S.D. with the DAI ). The men item score of oth ptient rms on the depression suscle ws 3.0 (S.D. 0.9). 3.. Dropouts Dropouts were defined s those ptients who did not 3.4. Differences in drug ttitude t 3-month follow-up send ck their questionnire t the 3-month follow-up nd (DAI-30) completers s those who completed the full 3-month tril nd returned their second questionnire. At 3-month At 3-month follow-up Fig. shows tht the intervention follow-up of the 135 ptients who hd returned the ptients hd significntly more positive drug ttitude seline questionnires, 8 (1%) were dropouts (see Fig. [men numer 14., stndrd error of the men (S.E.M.) 1). 1.4] compred to those in the control group (men numer Dropouts nd completers were evenly distriuted on 9.7, S.E.M. 1.5 (Mnn Whitney U51044, Z5.17, ge, gender, mritl sttus, eduction, work sitution, P50.033). income, severity of depression s estimted y their GPs, The effect size of the intervention on drug ttitude on numer of previous episodes of ntidepressnt use, nd ppered to e medium (Cohen s d50.4 nd effect size on receiving drug coching or not. There ws signifi- 1 r50.). cnt difference on previous episodes of depressive com- Ptients in the intervention rm hd more positive drug plints (P50.034); 67% of the dropouts did not hve such ttitude thn the controls (DAI-30 P#0.05). On item level n episode versus 4% of the completers. the following four ttitudes towrds drugs showed the strongest differences (see Tle nd lso Appendix A): 3.3. Bseline (1) I don t need to tke medictions once I feel etter (DAI-1); () Mediction is slow-cting poison (DAI- At the eginning of the rndomized tril there were no 14); (3) It is unnturl for my mind nd ody to e controlled y mediction (DAI-0); (4) I cnnot relx on mediction (DAI-8). Tle shows in detil tht the intervention ptients hd more positive ttitude towrds mediction on 8 (93%) of the 30 DAI-items. The more positive drug ttitude of the intervention rm (i.e. 14%) ws lso in line with the more positive evlution of the ntidepressnts y intervention ptients (88 versus 66%) ( x df 4, P50.0) Ptient opinions on drug coching y phrmcists At the 3-month follow-up, ptients of oth rms were sked to give their opinion out the contcts with the phrmcist. Tle 3 shows tht s to the guidnce provided y their phrmcist, intervention ptients were significntly more positive thn the controls (P,0.001), regrding the 1 Fig. 1. Rndomized controlled tril (RCT) scheme (the CONSORT Cohen s d 5 M1 M /spooled where spooled 5 œ[s 1 1 s / ]; effect Sttement) (Begg et l., 1996; Moher et l., 001). size rgl 5 d/œ(d 1 4).

5 O. Brook et l. / Europen Neuropsychophrmcology 13 (003) Tle 1 Demogrphic nd clinicl chrcteristics in the intervention (n564) nd control rm (n571) with depression t seline mesurement Intervention Controls df Test P vlue (n564) Femle 70% 7% 1 x 0.77 Age (yers) t 0.46 (n571) Severity of symptoms x Mild 18% 19% Moderte 66% 64% Severe 16% 17% Mritl sttus 3 x 0.15 Unmrried/ single 19% 8% Mrried/ living together 73% 56% Divorced 6% 9% Widowed % 7% Life/ working sitution 5 x Pid work 6% 64% Voluntry work 5% Domestic work 11% 16% Pensioner 8% 7% Unemployed/ incple working 14% 13% Month income 5 x 0.763,$680 36% 8% $680 $ % 8% $1000 $130 17% 4% $130 $1640 9% 1%.$1640 7% 8% Level of eduction (diplom) 5 x No eduction (not finished) 7% 1% Primry school 8% 10% 10 yers of eduction 7% 4% 14 yers of eduction 31% 40% 16 yers of eduction 7% 5% Helth sttus (in groups) Months of depressive t complints Numer previous episodes t use of AD Numer previous episodes t similr complints Numer of cigrettes dy t Alcohol units in 1 week t Lost lour dys lst 3 months t 0.99 Clinicl chrcteristics SCL-Depr. (totl numer) t (men SCL-Depr.-items) ( ) (.860.8) Vlues re men6s.d.; AD, ntidepressnts. SCL Hopkins Symptom Checklist. Degrees of freedom. cler explntion of the ADs (P,0.001), regrding the ptients hd not looked t the video on depression nd 13 ctive role (P50.016), the direct contct (P50.045), nd (3%) of the remining 43 ptients wtched it more thn the helpfulness of the coching in tking ADs (P,0.001). once. Nerly ll of the ptients (97%) found the video to Most of the intervention ptients would recommend drug e cler, 95% found it to e informtive, 90% of the coching y phrmcists to other depressive ptients (P, ptients felt tht the effects of ADs were clerly explined, 0.001). 74% sid the video corresponded with their own imge of depression, 59% reported the video hd een helpful in 3.6. Evlution of depression video strting the use of ADs, 46% sid the video hd chnged their ides out mediction nd 39% sid the video hd At 3-month follow-up, (5%) of the 45 intervention chnged their ides on depression nd 84% of the ptients

6 6 O. Brook et l. / Europen Neuropsychophrmcology 13 (003) 1 9 positive drug ttitude versus 16% who hd not chnged their ides. This difference ws significnt ( x , df 1, P50.03). 4. Discussion Fig.. Difference in drug ttitude (DAI-30) t 3-month follow-up of the intervention (n550) nd the control rm (n555). The ojective of this rndomized controlled tril (RCT) ws to investigte whether n intervention y community phrmcists would influence drug ttitude of depressive primry cre ptients in positive direction. Our study showed tht t the 3-month follow-up intervention ptients hd more positive drug ttitude thn the controls. We found medium effect size. Secondly, intervention ptients evluted the coching y their phrmcist s positive. Thirdly, intervention ptients experienced the video s informtive nd they would recommend it to other ptients. This leds to the following conclusions: would recommend the video to other ptients. Further 1. Drug coching y phrmcists hs positive effect on nlyses showed tht 4% of the ptients who reported tht ptients drug ttitude. Minly ecuse the phrmcist the video hd chnged their ides out mediction, hd is le to systemticlly monitor the GPs prescriptions nd ptients mediction use, s primry cre ptients rrely chnge phrmcies in prctice. In this wy, Tle coching y phrmcists improves the continuity of Positive drug ttitude of intervention (n547) nd control ptients (n5 phrmceuticl cre nd enles qulity ssurnce of 54) (DAI-30) mediction prescriptions. For exmple, Zermnsky et l. Intervention Control DF x P vlue (001) found tht clinicl phrmcists cn conduct (%) (%) effective consulttions with elderly ptients in generl DAI prctice to review their drug use. Such reviews resulted DAI in significnt chnges in ptients drugs nd sved more DAI DAI thn the cost of the intervention without ffecting the DAI worklod of GPs. DAI Depressive primry cre ptients with n AD prescrip- DAI tion of their GP re willing to comply with mediction DAI dvice given y phrmcists. Considering the fct tht DAI DAI in Europe nd in The Netherlnds especilly, GPs serve DAI more nd more s gtekeepers to specilized cre DAI (Boerm nd Fleming, 1998) nd hve less time to DAI provide drug coching, phrmcists cn reduce their DAI urden. Community phrmcists re willing nd le to DAI DAI coch ptients in drug use. DAI A tke-home informtive video is effective in terms of DAI influencing ptients ides out mediction nd is n DAI esy to use instrument s the ptient cn wtch it t DAI convenience. DAI DAI Effects of n intervention to improve drug ttitude of DAI depressed primry cre ptients cn e mesured y the DAI DAI DAI DAI DAI DAI Limittions DAI DAI There re some limittions to this study. Neither ptients Positive evlution P#0.05. nor phrmcists were linded for group ssignment. See Appendix A. Phrmcist nd ptient expecttion my hve ffected the

7 O. Brook et l. / Europen Neuropsychophrmcology 13 (003) Tle 3 Evlution of phrmcists coching y intervention (n547) nd control ptients (n554) with depression t 3-month follow-up Intervention Control DF x P vlue (%) (%) Guidnce* Explntion (side)effects* Apprecition ctive role of phrmcist* Apprecition direct contct with phrmcist Helpful in tking drugs* Recommendtion coching to other ptients* *, Positive evlution P#0.05; Degrees of freedom. results, ut to wht extent we do not know. This my hve phrmcist contcts nd which elements of these two cused Hwthorne effect (Frnke et l., 1998). The components contriute to positive drug ttitude, egging Hwthorne effect sttes tht, y merely prticipting in the question whether oth elements were required. As to tril the ptients hve etter experience ecuse they feel the contcts, the phrmcists were sked to use list of they get ttention, which is grtifying to them nd rewrd- importnt issues to discuss with the ptients. However, we ing in itself. If so, the effect on drug ttitude my in fct e did not mesure the qulity of ech of these contcts nd n underestimte of how successful the intervention relly whether the informtion ws conveyed correctly. In ws. future study it would e interesting to exmine whether As to the fesiility of coching y phrmcists in order miniml tril, e.g. either video or contcts, would led to to improve drug ttitude, only one phrmcist who refused comprle outcomes. to prticipte gve reson tht implied structurl It is uncertin whether GPs regrd drug coching s tsk impediment to its implementtion. In his view the inter- for the phrmcist. It is possile tht it is seen s n vention did not fit in the dily routine. In The Netherlnds infringement on the prctitioner s utonomy or uthority most of the community phrmcists hve implemented nd of the privcy of the ptient. However, we remin ptient eduction (Pronk et l., 00), nd we re therefore optimistic, s most of the GPs, who were pproched to optimistic out the fesiility of phrmcists coching. prticipte in the study, llowed their ptients tke prt. A The originl drug ttitude inventory ws developed in systemtic review of rndomized controlled trils y nother setting nd with nother popultion. Some items Hynes et l. (1999) showed tht even the most effective were oviously formulted for neuroleptic users ( I feel interventions to help ptients follow-up prescriptions of weird, like zomie on mediction ) in hospitl medictions did not led to sustntil improvements in ( Even when I m in hospitl I need mediction regulr- dherence nd tretment outcome. They recommended ly ). We djusted the DAI so it could e used in developing innovtive pproches to ssist ptients to depressed popultion, nd we crried out reliility follow tretment prescriptions. Still, the review of Hynes nlysis using Cronch s. Cronchs is coefficient et l. (1999) wrrnts remrk. In their review they did tht descries how well group of items covers single not include ntidepressnt trils ecuse of nrrow criteri ide or construct, the so-clled inter-item consistency. We e.g. t lest 6 months follow-up from the time of ptient found high internl consistency for the DAI-30 in our entry nd ptients with mjor disorders excluding deprespopultion of depressed primry cre ptients. sion. A systemtic review of controlled trils with ntide- In our study dropouts hd experienced less previous pressnts (Vergouwen et l., 00) reveled tht intervenepisodes of depressive complints thn completers of the tions in ptients with mjor depression hd modest ut tril. We did not exmine how mny of these dropouts hd significnt effects on dherence nd on clinicl symptoms. stopped tking their ADs ecuse of n inpproprite drug Our study showed tht phrmcists re cple of ttitude. coching ech ptient long with surveillnce of continued A remrk regrding the dignosis of depression s mde refills of prescried mediction y the GP. In dily prctice y GP: it is possile tht ptients who were not the intensity of the contcts cn vry in time nd per exclusively depressive, were included in the tril. The ptient, the phrmcist s usy schedule my mke it phrmcist delivered the AD s prescried y the GP nd difficult to mke follow-up ppointments nd, lst ut not did not check whether the dignosis of depression ws lest, the phrmcy setting my hmper n intimte, vlid. It is therefore possile tht the phrmcologicl confidentil converstion. Whether it is the phrmcist or therpy ws not limited to depressive ptients lthough the his ssistnt, in our view it is importnt tht in the first video ws mde for ptients with depressive complints. contcts eductionl messges ssocited with etter We do not know the impct of the video compred to the dherence re given during the first month of ntidepres-

8 8 O. Brook et l. / Europen Neuropsychophrmcology 13 (003) 1 9 snt tretment. These messges re imed t correcting the 16 I cn t concentrte on nything T/F misconceptions of ptients tht will most likely dversely when I m tking mediction impct dherence (Lin et l., 1995; Nierenerg, 1999). In 17 I know etter thn the doctor when T/F our tril, phrmcists did deliver such messges nd they to go off mediction were lso on the videotpe. In conclusion, coching y 18 I feel more norml on mediction T/F community phrmcists cn e regrded s new fruitful 19 I would rther e sick thn tking T/F pproch to improving drug ttitude of depressive ptients. medictions 0 It is unnturl for my mind nd T/F ody to e controlled y mediction Acknowledgements 1 My thoughts re clerer on medic- T/F tion I should sty on mediction even if T/F We re grteful to Guy Goodwin (Professor t the I feel ll right University of Oxford, Deprtment of Psychitry, Wr- 3 Tking mediction will prevent me T/ F neford Hospitl, Oxford OX3 7JX, UK) for his contriu- from hving rekdown tion to this rticle. 4 It is up to the doctor when I go off T/F mediction 5 Things tht I could do esily re T/ F Appendix A much more difficult when I m on mediction Drug ttitude inventory (DAI-30)* (11) 6 I m hppier, feel etter, when T/ F tking medictions 7 I m given mediction to control T/ F Question Response ehviour tht other people (not myself) don t like 1 I don t need to tke medictions T/ F 8 I cn t relx on mediction T/F once I feel etter 9 I m in etter control of myself T/F For me the good things out medi- T/ F 30 By stying on mediction I cn T/ F ction outweigh the d prevent getting sick 3 I feel weird, like zomie on T/ F mediction *, Using the DAI-30 in popultion of depressed primry cre ptients we found Cronch s of Even when I m not in hospitl I T/ F need mediction regulrly Scoring DAI-30: The scle hs 15 items tht re scored 5 If I tke mediction it s only from T/F s True nd 15 s Flse if the person is fully complint ecuse of pressure from other peo- (positive sujective response). Positive nswers re ple scored s follows nd score s plus one: 6 I m more wre of wht I m T/ F doing, of wht is going on round 1F 11F 1T me, when I m on mediction T 1F T 7 Tking mediction will me do no T/ F 3 F 13 F 3 T hrm 4T 14F 4T 8 I tke mediction on my own free T/F 5F 15T 5F choice 6T 16F 6T 9 Mediction mke me feel more T/ F 7T 17F 7F relxed 8T 18T 8F 10 I m no different on or off medic- T/F 9T 19F 9T tion 10 F 0 F 30 T 11 The unplesnt effects of medic- T/ F Negtive nswers score s minus one e.g. circle tion re lwys present round the ove letters counts s plus one (e.g. circle or 1 Mediction mkes me feel tired nd T/F tick on the F of question will score plus one, circle or sluggish tick on the T of question one will score minus one). The 13 I tke mediction only when I m T/ F finl score for ech person t ech time is the positive sick score minus the negtive score. A positive totl finl score 14 Mediction is slow-cting poison T/ F mens positive sujective response (complint). A neg- 15 I get long etter with people when T/F tive totl score mens negtive sujective response I m on mediction (noncomplint).

9 O. Brook et l. / Europen Neuropsychophrmcology 13 (003) References H. vn Hout, Brook O., Heerdink E., Nieuwenhuyse H., Goodwin G., 001. Improving dherence to ntidepressnts. In: New Reserch Astrcts, Americn Assocition, 154th nnul meeting, New Orlens 43, 63. Lin, E.H.B.,Von Korff, M., Kton, W. et l., The role of the primry cre physicin in ptients dherence to ntidepressnt therpy. Med. Cre 3, Moher, D., Schulz, K.F., Altmn, D.G., 001. The Consort Sttement: revised recommendtions for improving the qulity of reports of prllel-group rndomized trils. Lncet 357, Nierenerg, A.A., Mngement of ptients on ntidepressnt therpy. J. Clin. Psychit. Monogrph. 17, 5. Priest, R.G., Vize, C., Roerts, M., Tylee, A., Ly people s ttitude to tretment of depression: results of opinion poll for Defet Depres- sion Cmpign just efore its lunch. Br. Med. J. 313, Pronk, M., Blom, L., Jonkers, R. et l., 00. Community phrmcy nd ptient-oriented ctivities: the Dutch cse. Pt. Educ. Counsel. 46, SPSS for Windows, Rel SPSS, Chicgo. Vergouwen, A.C.M., Vn Hout, H.P.J., Bkker, A., 00. Therpietrouw ij het geruik vn ntidepressiv. Tijdschr. v. Geneesk. 146 (5), Zermnsky, A.G., Petty, R.D., Rynor, D.K. et l., 001. Rndomized controlled tril of clinicl mediction review y phrmcist of elderly ptients receiving repet prescriptions in generl prctice. Br. Med. J. 33, Agrs, W.S., Understnding complince with the medicl regimen: the scope of the prolem nd theoreticl perspective. Arthr. Cre Res. 3, 7. Awd, A.G., Drug therpy in schizophreni: vriility of outcome nd production of response. Cn. J. Psychitry 34, Begg, C. et l., Improving the Qulity of Reporting of Rndomized Controlled Trils. J. Am. Med. Assoc. Specil Commun. 76, Boerm, W.G.W., Fleming, D.M., The Role of Generl Prctice in Primry Helth Cre. WHO, London. Crmer, J.A., Prtil mediction complince: the enigm in poor medicl outcomes. Am. J. Mng. Cre 1, Demyttenere, K., Complince during tretment with ntidepressnts. J. Affect. Disord. 43, Derogtis, L.R., Rickels, K., Rock, A.F., The SCL-90 nd the MMPI: A step in the vlidtion of new self-report scle. Br. J. Psychit. 18, DiMtteo, M.R., Lepper, H.D., Croghn, T.W., 000. Depression is risk fctor for noncomplince with medicl tretment. Arch. Intern. Med. 160, Hynes, R.B., Montgue, P., Oliver, T. et l., In: Interventions to Help Ptients to Follow Prescriptions For Medictions. The Cochrne Lirry, pp Hogn, T.P., Awd, A.G., Estwood, R., A self-report scle predictive of drug complince in schizophrenics: reliility nd discrimintive vlidity. Psycholog. Med. 13,