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The influence of hispanic ethnicity on patients' expression of complaints about and problems with adherence to antidepressant therapy
The Influence of Hispanic Ethnicity on Patients’ Expression of Complaints About and Problems with Adherence to Antidepressant Therapy Betsy Sleath, PhD, 1,2 Richard H. Rubin, MD,3 and Keele Wurst, MS, RPh4 lSchool of Pharmacy and 2Cecil G. Sheps Centerfor Health Services Research, University of North Carolina at Chapel Hill, North Carolina, 3Department of Internal Medicine, University ofNew Mexico Health Sciences Center, Albuquerque, New Mexico, and 4Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, North Carolina
ABSTRACT
Background: Although Hispanics constitute the most rapidly growing ethnic group in the United States, few studies have examined the relationship between Hispanic ethnicity and patients’ experiences with the use of antidepressant medications. Objective: The purpose of this study was to examine the influence of Hispanic ethnicity on patients’ expression of complaints about and problems of adherence with antidepressant medications and physicians’ reactions to these complaints and adherence problems. Methods: Data were collected as part of a larger cross-sectional study of physicianpatient communication conducted during 1995 in the general medicine and family practice clinics of the University of New Mexico. Between March and December 1995, patients’ medical visits were recorded on audiotape, patients were interviewed after each visit, and patients’ medical records were reviewed. The present analysis focused on patients who received a prescription for an antidepressant on the day of the audiotaped visit. Because this was a cross-sectional study, only 1 visit was recorded for each patient. Results: Ninety-eight patients were identified who received a new or refill prescription for an antidepressant on the day of the audiotaped visit. Twenty-eight (28.6%) patients expressed a complaint about their antidepressant therapy Younger patients and non-Hispanic white patients were more likely to express such a complaint than were older patients and Hispanic patients. Ten (10.2%) patients reAmptedfor Printed
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ported an adherence problem. Patients who rated their physical health as better were more likely to express adherence problems with antidepressant therapy than were patients who rated their physical health as worse. Physicians were generally responsive to patients’ expression of complaints and adherence problems. Conclusions: Patients’ ethnicity was related to their expression of complaints about antidepressant therapy hut not to their expression of adherence problems or to physicians’ reactions to patients’ expression of either. Because many patients express complaints about and adherence problems with antidepressant therapy, providers should he prepared to educate patients about their prescribed therapy or change the antidepressant regimen. (Chin Thev: 2003;25:1739-1749) Copyright 0 2003 Excerpta Medica, Inc. Key words: Hispanic ethnicity, antidepressants, adherence, communication, harriers.
INTRODUCTION
Hispanics constitute the most rapidly growing ethnic group in the United States.l Few studies have examined the relationship between Hispanic ethnicity and patients’ experiences with the use of antidepressant medications. A previous study reported that Hispanic patients required less antidepressant medication than nonHispanic white patients and that Hispanic patients reported more adverse effects than non-Hispanic white patients.2 It is important to examine how Hispanic ethnicity influences patients’ expression of complaints about or adherence problems with antidepressant therapy during primary care visits and physicians’ reactions to these complaints or adherence problems so that we can better understand whether there are any disparities. A search of the literature indexed on MEDLINE and International Pharmaceutical Abstracts for articles published in English between 1965 and 2002 identified only 2 studies specifically examining patients’ expression of complaints about and adherence problems with medications in genera13,+; these studies did not focus on antidepressants. The study by Svarstad3 did not assess how demographic characteristics may have influenced patients’ expression of complaints or adherence problems or physicians’ reactions to these complaints or problems, whereas Sleath et al3 found that in a sample of primarily white and African American patients, race did not influence patients’ expression of complaints about or adherence problems with medications. The purpose of the present study was to examine whether Hispanic ethnicity influences patients’ expression of complaints about or adherence problems with antidepressant medications during primary care medical visits or physicians’ reactions to these complaints or adherence problems. 1740
B. Sleath et al.
PATIENTS
AND
METHODS
Data were collected between March and December of 1995 at the general medicine and family practice clinics of the University of New Mexico Health Sciences Center in Albuquerque. Resident physicians in general internal medicine or family practice were invited to participate in the study, and those who agreed to participate gave their informed consent. Adult Hispanic and non-Hispanic white patients who were able to communicate fluently in English or Spanish were eligible for inclusion in the study Bilingual research assistants obtained patients’ written informed consent in English or Spanish. The study was approved by the University of New Mexico Institutional Review Board. Data Sources Audiotapes
Medical visits with physicians’ English- and Spanish-speaking patients were recorded on audiotape. Because this was a cross-sectional study, only 1 visit was recorded for each patient. The audiotapes were transcribed into English or Spanish and edited by pharmacy research assistants. Having transcripts of physicianpatient interactions has been shown to make coding of the audiotapes more reliable.5 The transcribing rules used in this study were adapted from those used by researchers in physician-patient communication.5,6 The transcripts were coded using a detailed coding instrument designed to measure patients’ expression of complaints about and adherence problems with antidepressant medications. This coding tool has been used with reliable results in previous research on patients’ expression of complaints about and adherence problems with medications.+ The same pharmacy research assistant coded all transcripts. The coder recorded the following: (1) whether an antidepressant was discussed; (2) whether the patient expressed a complaint about an antidepressant; (3) whether the patient expressed a problem with adherence to an antidepressant; and (4) the physicians reaction to the patient’s expression of a complaint or adherence problem. The physicians reaction to the patient’s expression of a complaint or adherence problem was classified in 1 of 3 categories: ignored the complaint or adherence problem, educated the patient, or changed the antidepressant regimen. Patient Interviews
Immediately after each audiotaped physician-patient interaction, a bilingual research assistant interviewed the patient about the visit. The interview instruments were translated into Spanish, and the translations were validated by hack-translation into English by 2 different persons. The following information was collected: age, sex, ethnicity (Hispanic or non-Hispanic white), practice setting (family medicine or general internal medicine), and schooling completed (less than high school, 1741
CLINICALTHERAPEUTIC?
high school, or more than high school). The patient’s perceived emotional and physical health compared with others of a similar age were measured using the following response categories: poor, fair, good, very good, and excellent. Whether the patient was prescribed a selective serotonin reuptake inhibitor (SSRI) or nonSSRI was also recorded. Physician Questionnaire
Each physician filled out a brief demographic questionnaire at the start of the study The following information was collected: age, sex, ethnicity (Hispanic or non-Hispanic white), whether the physician was fluent in Spanish, the practice setting (family medicine or general internal medicine), and whether the physician was in the first, second, or third year of residency Medical Records Review
All patients consented to a review of their medical records. The investigators or 1 of 3 trained medical students abstracted information about all antidepressant medications prescribed for the patient on the date of study enrollment, during the 12 months before enrollment, and during the 6 months after enrollment. This information was used to determine whether an antidepressant was prescribed on the day of the audiotaped visit and whether it was a new or refill prescription. Study Analyses
Only Hispanic and non-Hispanic white patients who received an initial or refill prescription for an antidepressant on the day of the audiotaped visit and who saw a Hispanic or non-Hispanic white physician were included in the study analyses. All analyses were performed using Stata version 6.0 (Stata Corporation, College Station, Texas). First, descriptive statistics were calculated. A zero-order correlation matrix was then generated to examine the hivariate relationships hetween variables. Generalized estimating equations (GEEs) were used to examine how the independent variables influenced whether patients expressed complaints about or adherence problems with their antidepressant therapy The GEEs were used to adjust the SEs of the regression coefficients to account for the fact that patients were nested within physicians-that is, each patient could not he considered a totally independent observation because the physician might have used a similar interaction style with different patients.7J RESULTS
Of 510 patients who were approached, 403 (79.0%) agreed to participate in the study; data from 98 patients were included in the study analyses. Fifty-five (56.1%) patients were Hispanic and 70 (71.4%) were women (Table I). Patients ranged in age from 23 to 83 years (mean, 48 years). Forty-five (45.9%) patients 1742
B. Sleath et al.
Table I. Patient
characteristics
(N = 98). Values are number
(%).
Sex
I .4)
Female
70 (7
Male
28 (28.6)
Race
55 (56.1)
Hispanic Non-Hispanic
43 (43.9)
white
Age group, y 23-39
21 (21.4)
40-50
29 (29.6)
51-54
20 (20.4)
55-83
28 (28.6)
Education
completed
Less than
30 (30.6)
high school
28 (28.6)
High school More Practice
than
40 (40.8)
high school
setting 49 (50.0)
Family practice General Type
‘SRI
=
internal
49 (50.0)
medicine
of antidepressant
SSRI
45 (45.9)
TCA
45 (45.9)
SSRI and TCA
7 (7. I )
Other
I (1.0)
selective
(trazodone)
serotonin
reuptake
inhibitor;
TCA
= tricyclic
antidepressant.
were either currently taking or received a prescription for an SSRI, and the same number were taking or received a prescription for a tricyclic antidepressant (TCA). There was no significant difference in the type of antidepressant prescribed to Hispanic patients or non-Hispanic white patients. Of 30 resident physicians who were approached, 27 (90.0%) agreed to participate in the study Each physician was recorded during 6 to 2 1 patient visits. Sixteen physicians were residents in general internal medicine and 11 were residents in family practice. The 98 study patients saw 25 of these physicians, whose characteristics are summarized in Table II. No patients had an interpreter present during their medical visit, and 7 visits were conducted entirely in Spanish. Thirteen patients stated that their medical visit was not conducted in their primary language, hut none of these patients said they would have preferred the visit to he conducted in their primary language. In the hivariate analyses, it was determined that whether the visit occurred in the 1743
CLINICALTHERAPEUTIC?
Table II. Characteristics number
of resident
physicians participating
in study (N = 25). Values are
(%).
Sex Female
I3 (52.0)
Male
I2 (48.0)
Race Non-Hispanic
19 (76.0)
white
6 (24.0)
Hispanic
Age group, y 7 (28.0)
26-28 29-3
I
4 (I 6.0)
32-33
8 (32.0)
34-39
6 (24.0)
Fluent in Spanish No
I6 (64.0)
Yes
9 (36.0)
Practice setting Family practice
IO (40.0)
General internal medicine
I5 (60.0)
Year of residency IO (40.0)
First Second
8 (32.0)
Third
7 (28.0)
patient’s primary language was not related to patients’ expression of complaints about or adherence problems with antidepressant therapy; therefore, this factor was omitted from further analyses. Complaints
About Antidepressant
Medications
Twenty-eight (28.6%) of 98 patients expressed a complaint about their antidepressant medication: 12 (21.8%) of 55 Hispanic patients and 16 (37.2%) of 43 non-Hispanic white patients (Table III). The most commonly expressed complaints involved adverse effects and a perception that the medication was not working. The GEE results predicting whether patients expressed complaints about their antidepressant therapy are shown in Table IV Younger patients were significantly more likely to express a complaint about their antidepressant medication compared with older patients (P = 0.01). Non-Hispanic white patients were significantly more likely to express a complaint about their antidepressant medication compared with Hispanic patients (P = 0.04). Physicians were generally respon1744
B. Sleath et al.
Table III. Types of complaints expressed
about and adherence
by Hispanic
are number
not working
Adverse
effect
Believes
medication
Does
not think
Would
Type Not
Patients
Non-Hispanic
Values
White
medication
complaint
taking
4 (9.3)
5 (9.1)
9 (20.9)
0 (0)
I (2.3)
0 (0)
I (2.3)
0 (0) 43 (78.2)
27 (62.8)
is needed
a lower
dose
expressed
of adherence
7 ( 12.7)
is addichve
like to be taking
Ran out
Patients
problem
correctly
on purpose
of medication
Confused
I (2.3)
about
how
to take
medication
2 (3.6)
I (2.3)
I (1.8)
3 (7.0)
I (1.8)
0 (0)
Stopped
taking
medication
I (1.8)
0 (0)
Forgets
to take
medication
I (1.8)
No
therapy
(n = 43) patients.
of complaint
Medication
No
with antidepressant
white
(%). Hispanic
Type
problems
(n = 55) and non-Hispanic
adherence
problem
expressed
Table IV. Results of generalized
0 (0) 39 (90.7)
49 (89. I)
estimating
plaints about and adherence
equations
problems
predicting
patients’ expression
with antidepressant Expression
of
Complaint, OR
Patient
race non-Hispanic
Patient
sex female
Patient
age
Patient
educational
level
Patient
rating
of emotional
Patient
rating
of physical
Family medicine Antidepressant
white
health health
practice
as worse?
as worse*
setting
an SSRI
Physician
age
Physician
sex female
Physician
ethnicity
Physician
year
(95%
of residency
SSRI = selective serotonin
reuptake
of
Problem,
OR (95%
Cl)
3. I5 (I .049.62)*
0.63
(0. I 6-I
I .7 I (0.I420.50)
0.93
(0.8880.98)t
0.93
(0.86-I
.02)
0.93
(0.8G
I .08)
0.96
(0.788
I. 19)
I .04 (0.666
I .65)
2.05
(0.83-5.06)
0.70
I. I 3)
0.35
(0. I40.92)§
I. IO (0.37-3.26)
0.28
(0.042.04)
0.76
I 3)
2.26
(0.433
I .23)
0.94
(0.7 I ~ I .25)
0.98 white
Expression Adherence
Cl)
of com-
(N = 98).
0.52
(0.433
(0.27-2.
I .05 (0.899
non-Hispanic
therapy
.68)
(0. I l-3.73)
I I .90)
(0.30-3.24)
3.02
(0.799
I I .59)
0.39
(0.05-3.07)
0.98
(0.54-I
.78)
0.74
(0.2662.
I I)
inhibitor
“P = 0.04. tP = 0.01. *Patients’ perceived emotional using the following
health and physical health compared
with others
of a similar age were measured
response categories: poor; fair good, very good, and excellent.
SP < 0.03.
1745
CLINICAL THERAPEUTICS@
sive to patients’ complaints about their antidepressants. Among 28 patients who expressed a complaint, physicians ignored the complaint in 4 (14.3%), changed the regimen in 16 (57.1%), and educated 8 (28.6%). Physicians ignored the complaints of 1 (7.7%) of 13 Hispanic patients and 3 (20.0%) of 15 non-Hispanic white patients who expressed a complaint about their antidepressant medication (Table V). Problems
ofAdherence
with Antidepressant
Medication
Ten (10.2%) patients expressed an adherence problem with their antidepressant therapy: 6 (10.9%) of 55 Hispanic patients and 4 (9.3%) of 43 non-Hispanic white patients (Table III). Running out of medication and not taking the medication correctly on purpose were the most commonly expressed adherence prohlems. Five (50.0%) of 10 patients who expressed an adherence problem also expressed a complaint about their antidepressant therapy. The GEE results predicting whether patients expressed an adherence problem with their antidepressant therapy are shown in Table IV Patients who rated themselves as being in better physical health were significantly more likely to express a problem of antidepressant adherence compared with patients who rated themselves as being in worse physical health (P < 0.03). Hispanic and non-Hispanic white patients were equally likely to express an adherence problem. Physicians ignored the adherence problem in 5 (SO.O%>, changed the medication regimen of 1 (lO.O%), and educated 4 (40.0%) of the 10 patients who expressed an adherence problem (Table V) Physicians reacted similarly to Hispanic and non-Hispanic white patients’ adherence problems.
TableV.
Physicians’ reactions and adherence
to Hispanic and non-Hispanic
problems
with antidepressant Hispanic Patients
Reaction to Complaint
Ignored
(n =
I
it
13)
(7.7)
white
patients’ complaints
therapy. Values are number Non-Hispanic
White
(n =
3 (20.0)
the regimen
7 (53.8)
9 (60.0)
Educated
the patient
5 (38.5)
3 (20.0)
Hispanic Patients
Ignored
Non-Hispanic
White
(n = 6)
(n = 4)
3 (50.0)
2 (50.0)
Changed
the regimen
0 (0.0)
I
Educated
the patient
3 (50.0)
I (25.0)
1746
it
Problem
Patients
15)
Changed
Reaction to Adherence
about
(%).
(25.0)
Patients
B. Sleath et al.
DISCUSSION
Hispanic patients in this study were less likely to complain about their antidepressant therapy than were non-Hispanic white patients. One of 2 previous studies examining the use of antidepressants in Hispanic compared with non-Hispanic white patients found that Hispanic patients reported more adverse effects than did non-Hispanic white patients.2 However, the present findings reflect only the difficulties patients expressed to their physicians, and it is possible that patients experienced other problems with their antidepressant medications that they did not express to their physicians. Future research is needed that elicits and compares actual complaints and adherence problems experienced by Hispanic and non-Hispanic white patients with the complaints and adherence problems these patients express to their health care providers. Younger patients were more likely to complain about their antidepressant therapy than were older patients. This finding is supported by the results of previous studies reporting that younger patients have a stronger desire to he involved in the decision-making process that occurs during physician-patient encounters than do older patients. 9- l2 Patients who rated themselves as being in better physical health were more likely to express adherence problems with their antidepressant medications than were patients who rated themselves as being in worse physical health. Perhaps patients in better physical health feel less need for antidepressant medication and so are less adherent to therapy and more likely to tell their physicians that they are less adherent compared with patients in worse physical health. In this study, 28.9% of patients expressed complaints about their antidepressant therapy This rate was higher than that reported in previous studies.3,3 Based on a sample of medical visits collected from 1985 to 1986, Sleath et al3 found that only 21% of patients complained about their medications. Similarly, based on a sample of medical visits collected in the mid-1970s Svarstad3 found that only 14% of patients complained about their medications. More patients in the present study may have complained about their medications because of the focus on antidepressants, which may he associated with more adverse effects than some other types of medications. This finding may also he the result of a cohort effect, in that patients have become more actively involved in making decisions about their medications, in part by expressing complaints about the medications. For the most part, physicians were responsive to patients’ complaints about antidepressant therapy The majority of physicians changed the patient’s regimen or educated the patient about the therapy Physicians ignored only 7.7% of Hispanic patients’ complaints and 20.0% of non-Hispanic white patients’ complaints. The difference was not statistically significant. Future research might explore whether physicians are in fact more responsive to the complaints of Hispanic patients than to those of non-Hispanic white patients. 1747
CLINICALTHERAPEUTICS@
Physicians were not as responsive to patients’ expression of adherence problems as they were to complaints about antidepressant therapy Physicians ignored half of the adherence problems expressed by patients, possibly because of the failure of previous attempts to educate the patient or change the patient’s regimen. Whatever the reason, health care providers should attempt to educate patients or change antidepressant regimens to improve patients’ mental health. For optimal patient outcomes, medication regimens should he acceptable both to patients and to their physicians.13J3 The design of this study may have allowed a possible selection bias, in that patients who agreed to participate may have differed in some way from those who did not agree to participate. Also, patients and physicians may have behaved differently because they knew their conversations were being recorded. Another limitation is that we examined patients’ expression of complaints about and adherence problems with antidepressants without considering the reasons they were taking the medication. Future research might focus on patients taking antidepressants specifically for depression. Another limitation of the study is that it examined only the behavior of resident physicians. In addition, the study was conducted in an ethnically diverse state in which Hispanics are well integrated into local institutions. Future research on the influence of Hispanic ethnicity on patients’ expression of complaints about and adherence problems with antidepressants and physician reactions to these complaints and adherence problems should he conducted in other parts of the United States. ACKNOWLEDGMENTS
Funding for this study was provided by the Bayer Institute for Health Communication, West Haven, Connecticut, and a grant from the National Institute of Mental Health (R29-MH562 10). REFERENCES 1. Council
on Scientific Affairs. Hispanic health in the United States. JAMA. 1991;265:
248-252. 2. Marcos LR, Cancro R. Pharmacotherapy
of Hispanic depressed patients: Clinical ob-
servations. AmJ Psychother: 1982;36:505-512. 3. Svarstad B. Doctor-patient
communication.
In: Currie B, ed. Patient Education in the
Primary Care Setting. Kansas City, MO: Project for Patient Education
in Family Prac-
tice, St. Mary’s Hospital of Kansas City; 1978. 4. Sleath B, Chewning B, Svarstad B, Roter D. Patient expression of complaints and adherence problems with medications
during chronic disease medical visits. J Sot Ad-
min Pharm. 2000;17:71-80. 5. Waitzkin H. On studying the discourse of medical encounters.
A critique of quanti-
tative and qualitative methods and a proposal for a reasonable compromise. 1990:28:473-488. 1748
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6. Mishler
Ablex
E. The Discourse Publishing
7. Burton
P, Gurrin
correlated 8. Zeger
9. Lupton
approach.
the simple
An introduction
of Medical
Interviews.
Norwood,
NJ:
linear regression
to generalized
model
to account
for
estimating
equations
and multi-
Stat Med. 1998;17:1261-1291.
modelling.
SL, Liang K, Albert
equation
Dialectics
1984: 17-58.
L, Sly P Extending
responses:
level mixed
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P Models
Biometrics.
D. Consumerism,
for longitudinal
data: A generalized
estimating
1988;44: 1049-1060.
reflexivity
and the medical
encounter.
Sot Sci Med. 1997;45:
373-381. 10. Ende J, Kazis L, Ash A, Moskowitz Decision
making
MA. Measuring
and information-seeking
preferences
patients’ among
desire medical
for autonomy: patients.
J Gen
Intern Med. 1989;4:23-30. 11. Thompson
SC, Pitts JS, Schwankovsky
decision-making:
Situational
L. Preferences
and demographic
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influences.
Patient
in medical
Educ Couns.
1993;
and predictors.
Med
22:133-140. 12. Hibbard
JH, Weeks
EC. Consumerism
in health
care. Prevalence
Care. 1987;25:1019-1032. 13. Chewning centered 14. Royal
B, Sleath model.
Pharmaceutical
Goals in Medicine
B. Medication
decision-making
and
management:
A client-
Sot Sci Med. 1996;42:389-398. Society
of Great
Taking. London:
Britain.
CornpZiance
Royal Pharmaceutical
to Concordance:
Society;
Toward
1997.
Address correspondence to: Betsy Sleath, PhD, University of North Carolina at Chapel Hill, School of Pharmacy, Beard Hall, CB #7360, Chapel Hill, NC 27599-7360. E-mail: [email protected] 1749
ABSTRACT
Background: Although Hispanics constitute the most rapidly growing ethnic group in the United States, few studies have examined the relationship between Hispanic ethnicity and patients’ experiences with the use of antidepressant medications. Objective: The purpose of this study was to examine the influence of Hispanic ethnicity on patients’ expression of complaints about and problems of adherence with antidepressant medications and physicians’ reactions to these complaints and adherence problems. Methods: Data were collected as part of a larger cross-sectional study of physicianpatient communication conducted during 1995 in the general medicine and family practice clinics of the University of New Mexico. Between March and December 1995, patients’ medical visits were recorded on audiotape, patients were interviewed after each visit, and patients’ medical records were reviewed. The present analysis focused on patients who received a prescription for an antidepressant on the day of the audiotaped visit. Because this was a cross-sectional study, only 1 visit was recorded for each patient. Results: Ninety-eight patients were identified who received a new or refill prescription for an antidepressant on the day of the audiotaped visit. Twenty-eight (28.6%) patients expressed a complaint about their antidepressant therapy Younger patients and non-Hispanic white patients were more likely to express such a complaint than were older patients and Hispanic patients. Ten (10.2%) patients reAmptedfor Printed
Copyright
pubkation
April 1, 2003.
in the USA. Reproduction
0
2003
Excerpta
Medica,
in whole
Inc.
or part is not permitted.
0 149-29 l8/03/$l9.00
1739
CLINICALTHERAPEUTICS@
ported an adherence problem. Patients who rated their physical health as better were more likely to express adherence problems with antidepressant therapy than were patients who rated their physical health as worse. Physicians were generally responsive to patients’ expression of complaints and adherence problems. Conclusions: Patients’ ethnicity was related to their expression of complaints about antidepressant therapy hut not to their expression of adherence problems or to physicians’ reactions to patients’ expression of either. Because many patients express complaints about and adherence problems with antidepressant therapy, providers should he prepared to educate patients about their prescribed therapy or change the antidepressant regimen. (Chin Thev: 2003;25:1739-1749) Copyright 0 2003 Excerpta Medica, Inc. Key words: Hispanic ethnicity, antidepressants, adherence, communication, harriers.
INTRODUCTION
Hispanics constitute the most rapidly growing ethnic group in the United States.l Few studies have examined the relationship between Hispanic ethnicity and patients’ experiences with the use of antidepressant medications. A previous study reported that Hispanic patients required less antidepressant medication than nonHispanic white patients and that Hispanic patients reported more adverse effects than non-Hispanic white patients.2 It is important to examine how Hispanic ethnicity influences patients’ expression of complaints about or adherence problems with antidepressant therapy during primary care visits and physicians’ reactions to these complaints or adherence problems so that we can better understand whether there are any disparities. A search of the literature indexed on MEDLINE and International Pharmaceutical Abstracts for articles published in English between 1965 and 2002 identified only 2 studies specifically examining patients’ expression of complaints about and adherence problems with medications in genera13,+; these studies did not focus on antidepressants. The study by Svarstad3 did not assess how demographic characteristics may have influenced patients’ expression of complaints or adherence problems or physicians’ reactions to these complaints or problems, whereas Sleath et al3 found that in a sample of primarily white and African American patients, race did not influence patients’ expression of complaints about or adherence problems with medications. The purpose of the present study was to examine whether Hispanic ethnicity influences patients’ expression of complaints about or adherence problems with antidepressant medications during primary care medical visits or physicians’ reactions to these complaints or adherence problems. 1740
B. Sleath et al.
PATIENTS
AND
METHODS
Data were collected between March and December of 1995 at the general medicine and family practice clinics of the University of New Mexico Health Sciences Center in Albuquerque. Resident physicians in general internal medicine or family practice were invited to participate in the study, and those who agreed to participate gave their informed consent. Adult Hispanic and non-Hispanic white patients who were able to communicate fluently in English or Spanish were eligible for inclusion in the study Bilingual research assistants obtained patients’ written informed consent in English or Spanish. The study was approved by the University of New Mexico Institutional Review Board. Data Sources Audiotapes
Medical visits with physicians’ English- and Spanish-speaking patients were recorded on audiotape. Because this was a cross-sectional study, only 1 visit was recorded for each patient. The audiotapes were transcribed into English or Spanish and edited by pharmacy research assistants. Having transcripts of physicianpatient interactions has been shown to make coding of the audiotapes more reliable.5 The transcribing rules used in this study were adapted from those used by researchers in physician-patient communication.5,6 The transcripts were coded using a detailed coding instrument designed to measure patients’ expression of complaints about and adherence problems with antidepressant medications. This coding tool has been used with reliable results in previous research on patients’ expression of complaints about and adherence problems with medications.+ The same pharmacy research assistant coded all transcripts. The coder recorded the following: (1) whether an antidepressant was discussed; (2) whether the patient expressed a complaint about an antidepressant; (3) whether the patient expressed a problem with adherence to an antidepressant; and (4) the physicians reaction to the patient’s expression of a complaint or adherence problem. The physicians reaction to the patient’s expression of a complaint or adherence problem was classified in 1 of 3 categories: ignored the complaint or adherence problem, educated the patient, or changed the antidepressant regimen. Patient Interviews
Immediately after each audiotaped physician-patient interaction, a bilingual research assistant interviewed the patient about the visit. The interview instruments were translated into Spanish, and the translations were validated by hack-translation into English by 2 different persons. The following information was collected: age, sex, ethnicity (Hispanic or non-Hispanic white), practice setting (family medicine or general internal medicine), and schooling completed (less than high school, 1741
CLINICALTHERAPEUTIC?
high school, or more than high school). The patient’s perceived emotional and physical health compared with others of a similar age were measured using the following response categories: poor, fair, good, very good, and excellent. Whether the patient was prescribed a selective serotonin reuptake inhibitor (SSRI) or nonSSRI was also recorded. Physician Questionnaire
Each physician filled out a brief demographic questionnaire at the start of the study The following information was collected: age, sex, ethnicity (Hispanic or non-Hispanic white), whether the physician was fluent in Spanish, the practice setting (family medicine or general internal medicine), and whether the physician was in the first, second, or third year of residency Medical Records Review
All patients consented to a review of their medical records. The investigators or 1 of 3 trained medical students abstracted information about all antidepressant medications prescribed for the patient on the date of study enrollment, during the 12 months before enrollment, and during the 6 months after enrollment. This information was used to determine whether an antidepressant was prescribed on the day of the audiotaped visit and whether it was a new or refill prescription. Study Analyses
Only Hispanic and non-Hispanic white patients who received an initial or refill prescription for an antidepressant on the day of the audiotaped visit and who saw a Hispanic or non-Hispanic white physician were included in the study analyses. All analyses were performed using Stata version 6.0 (Stata Corporation, College Station, Texas). First, descriptive statistics were calculated. A zero-order correlation matrix was then generated to examine the hivariate relationships hetween variables. Generalized estimating equations (GEEs) were used to examine how the independent variables influenced whether patients expressed complaints about or adherence problems with their antidepressant therapy The GEEs were used to adjust the SEs of the regression coefficients to account for the fact that patients were nested within physicians-that is, each patient could not he considered a totally independent observation because the physician might have used a similar interaction style with different patients.7J RESULTS
Of 510 patients who were approached, 403 (79.0%) agreed to participate in the study; data from 98 patients were included in the study analyses. Fifty-five (56.1%) patients were Hispanic and 70 (71.4%) were women (Table I). Patients ranged in age from 23 to 83 years (mean, 48 years). Forty-five (45.9%) patients 1742
B. Sleath et al.
Table I. Patient
characteristics
(N = 98). Values are number
(%).
Sex
I .4)
Female
70 (7
Male
28 (28.6)
Race
55 (56.1)
Hispanic Non-Hispanic
43 (43.9)
white
Age group, y 23-39
21 (21.4)
40-50
29 (29.6)
51-54
20 (20.4)
55-83
28 (28.6)
Education
completed
Less than
30 (30.6)
high school
28 (28.6)
High school More Practice
than
40 (40.8)
high school
setting 49 (50.0)
Family practice General Type
‘SRI
=
internal
49 (50.0)
medicine
of antidepressant
SSRI
45 (45.9)
TCA
45 (45.9)
SSRI and TCA
7 (7. I )
Other
I (1.0)
selective
(trazodone)
serotonin
reuptake
inhibitor;
TCA
= tricyclic
antidepressant.
were either currently taking or received a prescription for an SSRI, and the same number were taking or received a prescription for a tricyclic antidepressant (TCA). There was no significant difference in the type of antidepressant prescribed to Hispanic patients or non-Hispanic white patients. Of 30 resident physicians who were approached, 27 (90.0%) agreed to participate in the study Each physician was recorded during 6 to 2 1 patient visits. Sixteen physicians were residents in general internal medicine and 11 were residents in family practice. The 98 study patients saw 25 of these physicians, whose characteristics are summarized in Table II. No patients had an interpreter present during their medical visit, and 7 visits were conducted entirely in Spanish. Thirteen patients stated that their medical visit was not conducted in their primary language, hut none of these patients said they would have preferred the visit to he conducted in their primary language. In the hivariate analyses, it was determined that whether the visit occurred in the 1743
CLINICALTHERAPEUTIC?
Table II. Characteristics number
of resident
physicians participating
in study (N = 25). Values are
(%).
Sex Female
I3 (52.0)
Male
I2 (48.0)
Race Non-Hispanic
19 (76.0)
white
6 (24.0)
Hispanic
Age group, y 7 (28.0)
26-28 29-3
I
4 (I 6.0)
32-33
8 (32.0)
34-39
6 (24.0)
Fluent in Spanish No
I6 (64.0)
Yes
9 (36.0)
Practice setting Family practice
IO (40.0)
General internal medicine
I5 (60.0)
Year of residency IO (40.0)
First Second
8 (32.0)
Third
7 (28.0)
patient’s primary language was not related to patients’ expression of complaints about or adherence problems with antidepressant therapy; therefore, this factor was omitted from further analyses. Complaints
About Antidepressant
Medications
Twenty-eight (28.6%) of 98 patients expressed a complaint about their antidepressant medication: 12 (21.8%) of 55 Hispanic patients and 16 (37.2%) of 43 non-Hispanic white patients (Table III). The most commonly expressed complaints involved adverse effects and a perception that the medication was not working. The GEE results predicting whether patients expressed complaints about their antidepressant therapy are shown in Table IV Younger patients were significantly more likely to express a complaint about their antidepressant medication compared with older patients (P = 0.01). Non-Hispanic white patients were significantly more likely to express a complaint about their antidepressant medication compared with Hispanic patients (P = 0.04). Physicians were generally respon1744
B. Sleath et al.
Table III. Types of complaints expressed
about and adherence
by Hispanic
are number
not working
Adverse
effect
Believes
medication
Does
not think
Would
Type Not
Patients
Non-Hispanic
Values
White
medication
complaint
taking
4 (9.3)
5 (9.1)
9 (20.9)
0 (0)
I (2.3)
0 (0)
I (2.3)
0 (0) 43 (78.2)
27 (62.8)
is needed
a lower
dose
expressed
of adherence
7 ( 12.7)
is addichve
like to be taking
Ran out
Patients
problem
correctly
on purpose
of medication
Confused
I (2.3)
about
how
to take
medication
2 (3.6)
I (2.3)
I (1.8)
3 (7.0)
I (1.8)
0 (0)
Stopped
taking
medication
I (1.8)
0 (0)
Forgets
to take
medication
I (1.8)
No
therapy
(n = 43) patients.
of complaint
Medication
No
with antidepressant
white
(%). Hispanic
Type
problems
(n = 55) and non-Hispanic
adherence
problem
expressed
Table IV. Results of generalized
0 (0) 39 (90.7)
49 (89. I)
estimating
plaints about and adherence
equations
problems
predicting
patients’ expression
with antidepressant Expression
of
Complaint, OR
Patient
race non-Hispanic
Patient
sex female
Patient
age
Patient
educational
level
Patient
rating
of emotional
Patient
rating
of physical
Family medicine Antidepressant
white
health health
practice
as worse?
as worse*
setting
an SSRI
Physician
age
Physician
sex female
Physician
ethnicity
Physician
year
(95%
of residency
SSRI = selective serotonin
reuptake
of
Problem,
OR (95%
Cl)
3. I5 (I .049.62)*
0.63
(0. I 6-I
I .7 I (0.I420.50)
0.93
(0.8880.98)t
0.93
(0.86-I
.02)
0.93
(0.8G
I .08)
0.96
(0.788
I. 19)
I .04 (0.666
I .65)
2.05
(0.83-5.06)
0.70
I. I 3)
0.35
(0. I40.92)§
I. IO (0.37-3.26)
0.28
(0.042.04)
0.76
I 3)
2.26
(0.433
I .23)
0.94
(0.7 I ~ I .25)
0.98 white
Expression Adherence
Cl)
of com-
(N = 98).
0.52
(0.433
(0.27-2.
I .05 (0.899
non-Hispanic
therapy
.68)
(0. I l-3.73)
I I .90)
(0.30-3.24)
3.02
(0.799
I I .59)
0.39
(0.05-3.07)
0.98
(0.54-I
.78)
0.74
(0.2662.
I I)
inhibitor
“P = 0.04. tP = 0.01. *Patients’ perceived emotional using the following
health and physical health compared
with others
of a similar age were measured
response categories: poor; fair good, very good, and excellent.
SP < 0.03.
1745
CLINICAL THERAPEUTICS@
sive to patients’ complaints about their antidepressants. Among 28 patients who expressed a complaint, physicians ignored the complaint in 4 (14.3%), changed the regimen in 16 (57.1%), and educated 8 (28.6%). Physicians ignored the complaints of 1 (7.7%) of 13 Hispanic patients and 3 (20.0%) of 15 non-Hispanic white patients who expressed a complaint about their antidepressant medication (Table V). Problems
ofAdherence
with Antidepressant
Medication
Ten (10.2%) patients expressed an adherence problem with their antidepressant therapy: 6 (10.9%) of 55 Hispanic patients and 4 (9.3%) of 43 non-Hispanic white patients (Table III). Running out of medication and not taking the medication correctly on purpose were the most commonly expressed adherence prohlems. Five (50.0%) of 10 patients who expressed an adherence problem also expressed a complaint about their antidepressant therapy. The GEE results predicting whether patients expressed an adherence problem with their antidepressant therapy are shown in Table IV Patients who rated themselves as being in better physical health were significantly more likely to express a problem of antidepressant adherence compared with patients who rated themselves as being in worse physical health (P < 0.03). Hispanic and non-Hispanic white patients were equally likely to express an adherence problem. Physicians ignored the adherence problem in 5 (SO.O%>, changed the medication regimen of 1 (lO.O%), and educated 4 (40.0%) of the 10 patients who expressed an adherence problem (Table V) Physicians reacted similarly to Hispanic and non-Hispanic white patients’ adherence problems.
TableV.
Physicians’ reactions and adherence
to Hispanic and non-Hispanic
problems
with antidepressant Hispanic Patients
Reaction to Complaint
Ignored
(n =
I
it
13)
(7.7)
white
patients’ complaints
therapy. Values are number Non-Hispanic
White
(n =
3 (20.0)
the regimen
7 (53.8)
9 (60.0)
Educated
the patient
5 (38.5)
3 (20.0)
Hispanic Patients
Ignored
Non-Hispanic
White
(n = 6)
(n = 4)
3 (50.0)
2 (50.0)
Changed
the regimen
0 (0.0)
I
Educated
the patient
3 (50.0)
I (25.0)
1746
it
Problem
Patients
15)
Changed
Reaction to Adherence
about
(%).
(25.0)
Patients
B. Sleath et al.
DISCUSSION
Hispanic patients in this study were less likely to complain about their antidepressant therapy than were non-Hispanic white patients. One of 2 previous studies examining the use of antidepressants in Hispanic compared with non-Hispanic white patients found that Hispanic patients reported more adverse effects than did non-Hispanic white patients.2 However, the present findings reflect only the difficulties patients expressed to their physicians, and it is possible that patients experienced other problems with their antidepressant medications that they did not express to their physicians. Future research is needed that elicits and compares actual complaints and adherence problems experienced by Hispanic and non-Hispanic white patients with the complaints and adherence problems these patients express to their health care providers. Younger patients were more likely to complain about their antidepressant therapy than were older patients. This finding is supported by the results of previous studies reporting that younger patients have a stronger desire to he involved in the decision-making process that occurs during physician-patient encounters than do older patients. 9- l2 Patients who rated themselves as being in better physical health were more likely to express adherence problems with their antidepressant medications than were patients who rated themselves as being in worse physical health. Perhaps patients in better physical health feel less need for antidepressant medication and so are less adherent to therapy and more likely to tell their physicians that they are less adherent compared with patients in worse physical health. In this study, 28.9% of patients expressed complaints about their antidepressant therapy This rate was higher than that reported in previous studies.3,3 Based on a sample of medical visits collected from 1985 to 1986, Sleath et al3 found that only 21% of patients complained about their medications. Similarly, based on a sample of medical visits collected in the mid-1970s Svarstad3 found that only 14% of patients complained about their medications. More patients in the present study may have complained about their medications because of the focus on antidepressants, which may he associated with more adverse effects than some other types of medications. This finding may also he the result of a cohort effect, in that patients have become more actively involved in making decisions about their medications, in part by expressing complaints about the medications. For the most part, physicians were responsive to patients’ complaints about antidepressant therapy The majority of physicians changed the patient’s regimen or educated the patient about the therapy Physicians ignored only 7.7% of Hispanic patients’ complaints and 20.0% of non-Hispanic white patients’ complaints. The difference was not statistically significant. Future research might explore whether physicians are in fact more responsive to the complaints of Hispanic patients than to those of non-Hispanic white patients. 1747
CLINICALTHERAPEUTICS@
Physicians were not as responsive to patients’ expression of adherence problems as they were to complaints about antidepressant therapy Physicians ignored half of the adherence problems expressed by patients, possibly because of the failure of previous attempts to educate the patient or change the patient’s regimen. Whatever the reason, health care providers should attempt to educate patients or change antidepressant regimens to improve patients’ mental health. For optimal patient outcomes, medication regimens should he acceptable both to patients and to their physicians.13J3 The design of this study may have allowed a possible selection bias, in that patients who agreed to participate may have differed in some way from those who did not agree to participate. Also, patients and physicians may have behaved differently because they knew their conversations were being recorded. Another limitation is that we examined patients’ expression of complaints about and adherence problems with antidepressants without considering the reasons they were taking the medication. Future research might focus on patients taking antidepressants specifically for depression. Another limitation of the study is that it examined only the behavior of resident physicians. In addition, the study was conducted in an ethnically diverse state in which Hispanics are well integrated into local institutions. Future research on the influence of Hispanic ethnicity on patients’ expression of complaints about and adherence problems with antidepressants and physician reactions to these complaints and adherence problems should he conducted in other parts of the United States. ACKNOWLEDGMENTS
Funding for this study was provided by the Bayer Institute for Health Communication, West Haven, Connecticut, and a grant from the National Institute of Mental Health (R29-MH562 10). REFERENCES 1. Council
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Address correspondence to: Betsy Sleath, PhD, University of North Carolina at Chapel Hill, School of Pharmacy, Beard Hall, CB #7360, Chapel Hill, NC 27599-7360. E-mail: [email protected] 1749