A 17-year-old boy is brought to the office by his mother for follow-up. He was diagnosed with major depressive disorder 6 months ago; after failing to improve with cognitive-behavioral therapy, he was started on fluoxetine 20 mg daily 4 months ago. The physician discussed the risks and benefits of antidepressants and how they work, as well as how to take the medication; the patient reported that he understood the discussion. At today's visit, his mother says, "He was doing well on the medication at the start and really seemed to be improving. He was going out again with friends and enjoying school. He was smiling again and just seemed happier in general. But for the past month he has struggled to wake up in time for school and seems to have really low energy, and his grades have been dropping. He isn't smiling as much either. I am worried that he is becoming depressed again." When interviewed alone, the patient says, "My mother worries too much about me. I'm just in a slump because I missed a lot of schoolwork when I was really depressed and I'm struggling to make it up. I prefer not to take the medication every day and take it only when I have a really bad day." He has no loss of appetite, no difficulty sleeping, and no suicidal ideation. Which of the following is the most appropriate response to address this patient's nonadherence to medication?

Question

A 17-year-old boy is brought to the office by his mother for follow-up.  He was diagnosed with major depressive disorder 6 months ago; after failing to improve with cognitive-behavioral therapy, he was started on fluoxetine 20 mg daily 4 months ago.  The physician discussed the risks and benefits of antidepressants and how they work, as well as how to take the medication; the patient reported that he understood the discussion.  At today's visit, his mother says, "He was doing well on the medication at the start and really seemed to be improving.  He was going out again with friends and enjoying school.  He was smiling again and just seemed happier in general.  But for the past month he has struggled to wake up in time for school and seems to have really low energy, and his grades have been dropping.  He isn't smiling as much either.  I am worried that he is becoming depressed again."  When interviewed alone, the patient says, "My mother worries too much about me.  I'm just in a slump because I missed a lot of schoolwork when I was really depressed and I'm struggling to make it up.  I prefer not to take the medication every day and take it only when I have a really bad day."  He has no loss of appetite, no difficulty sleeping, and no suicidal ideation.  Which of the following is the most appropriate response to address this patient's nonadherence to medication?

Quizplus · Accepted Answer

Explanation: This patient has gone from taking his medication every day as counseled to taking it only sporadically. There are often multiple reasons why patients become nonadherent, including inadequate understanding of the illness or how the medication works, complicated treatment regimens, medication cost or side effects, and psychological factors such as denial of or stigma related to mental illness. Although this adolescent may not fully understand how to use the medication and may benefit from a review of instructions (Choice C), it is important to first rule out other possible reasons for nonadherence. For instance, sexual side effects are common with selective serotonin reuptake inhibitors such as fluoxetine and may be embarrassing to talk about. The best approach is to engage in a nonjudgmental, open-ended discussion to elicit the patient's perspective and specific concerns, rather than to assume the reason for nonadherence. The physician should create an environment that helps the patient feel comfortable discussing personal issues affecting medication use. When all reasons for nonadherence are understood, the physician can then work with the patient to make any necessary changes (eg, address side effects, simplify the regimen, reeducate the patient). (Choices A and B) These responses provide education without first exploring the patient's specific concerns. If the patient is having side effects, telling him to take the medication daily or for an additional period of time would not be helpful. (Choice D) Although this statement expresses concern, it is inappropriate to assume the patient is minimizing his symptoms so as not to worry his mother. An open-ended discussion about his reluctance to take his medication is the best initial approach. Educational objective: Common reasons for nonadherence to medication include lack of understanding, side effects, costs, complicated regimens, denial of illness, and stigma. Rather than make assumptions, physicians should explore patients' perspectives in an empathic, open-ended way. References: Physician communication and patient adherence to treatment: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/19584762)

A 17-Year-Old Boy Is Brought to the Office by His