Health Watch: Low Medication Compliance Among America's Depressed Elderly

Establishing maximum adherence to medication schedules is one of the greatest challenges of the healthcare field and medicine. Non-adherence to medicine schedules may have adverse effects for patients, and "may be compounded in populations with multiple morbidities which require multiple drug therapy" (Hughes, 2004, p.793). Unfortunately, elders constitute such a population. According to the American Heart Association's website (2006), "Medication non-adherence among older adults is a widespread and costly problem. Studies indicate that about 65 percent of people who are past retirement . . . have typical adherence rates that are 60 percent or less." I will attempt to explain non-compliance to anti-depressant regimens in the depressed elder population using the Theory of Reasoned Action and Theory of Planned Behavior.

The Theory of Reasoned Action was created in 1967 by Martin Fishbein. According to Montano and Kasprzyk (2002), the Theory of Reasoned Action (TRA) is a theory that focuses on "theoretical constructs that are concerned with individual motivational factors as determinants of the likelihood of performing a specific behavior" (p.67). The TRA provides explanations for behaviors and helps us understand the internal and external motivation factors that influence the behavior's taking place.

Main Constructs/Concepts

The TRA combines measures of perceived social norms and attitudes to explain the intentions behind a myriad of human behaviors (Montano & Kasprzyk, 2002). According to the model, perceived social norms are influenced by a person's normative beliefs (belief about whether people will approve or disapprove of action) and their desire to comply with those pressures (Montano & Kasprzyk, 2002). Attitudes toward behavior are directly influenced by behavioral beliefs and evaluations of behavioral outcomes. Together, attitudes and subjective norms influence a person's intention to perform a behavior, and that intention is what determines the likelihood that the behavior ever takes place (Montano & Kasprzyk, 2002). A third component, perceived behavioral control, also influences behavioral intentions and is the crux of an additional construct to the TRA known as the Theory of Planned Behavior (TPB). It is based on measures of a person's control beliefs and perceived power (Montano & Kasprzyk, 2002). Perceived behavioral control, unlike attitudes and perceived social norms, can directly affect behaviors without passing through the "intention check point" because it governs behaviors outside of volitional control (Montano & Kasprzyk, 2002).

Strengths and Weaknesses

One weakness of the TRA model was corrected with the invention of the Theory of Planned Behavior. While the TRA does an excellent job of identifying influences and beliefs that are within our realm of control, it says nothing of those influences that we have no control over. The TPB, with its emphasis on perceived control and power, plugged the holes of the TRA model. Also, using the TRA, it is very difficult to make sweeping generalizations about needs or community level interventions because the constructs are intrapersonal and focus directly on the individual. Individual differences often make it difficult to make broad generalizations about group issues.

Use of Theory

The Theory of Reasoned Action can be used to explain why the elderly avoid taking antidepressant medications for their depression mental illness. While this problem is admittedly more common in "community dwelling" elders, some institutionalized elders may also avoid complying with their medicine schedules (Hughes, 2004). When institutionalized elders are compliant, they may still express disdain for taking them. Some elders will avoid seeking treatment for depression all together to avoid being medicated and stigmatized by their health issue. I will examine anti-depressant medication non-compliance issues among the elderly as a function of attitudes and subjective norms.

Intervention
A sample intervention might attempt to explain elder's non-compliance with antidepressant medication by sampling elders who are currently prescribed an antidepressant regimen both in long term care facilities and those within the community. Participants would be given the Epidemiologic Studies Depression scale or the Hamilton Depression Rating Scale Givens, Datto, Ruckdeschel, Knott, Zubritsky, Oslin, Nyshadham, Vanguri, and Barg (2005) to determine baseline measures of depression and to determine if their compliance or non-compliance resulted in less or more depression. Elders would be interviewed using questioning developed from Kleinman's Explanatory Model, a model that allows patients to describe the personal "nature, cause, and course of their illness and has been used by others in the study of mental illness" (Givens et al., 2005). Compliers and non-compliers would be determined, and interview questions would be tailored to elicit specific information pertaining to the elder's attitudes, subjective norms, and perceived behavioral control.

To determine the strength of attitudes toward taking antidepressants, questions like: "How do you feel about taking medication for your depression?" "What do you think will happen if you take the medicine?" "What do you think will happen if you do not?" should be asked.

To determine the strength of subjective norms related to taking antidepressant medication, questions like: "Who is someone you believe is very close to you?" How do you think Person X, your family members, or friends will feel about you taking your medication? How much does their opinion count for you regarding this particular behavior? should be asked.

To determine the strength of perceived behavioral control, questions like: Do you believe that taking your medications on time every time is always up to you? Do you perceive any barriers to your successfully completing this task? should be asked.

Finally the answers of those who routinely take medication as prescribed and those who do not should be compared to determine which types of attitudes and social norms most often preclude non-compliance.

Evidence that the theory will assist with the Problem

Aspects of the Theory of Reasoned Action have been used to understand the problem of drug, and specifically antidepressant, non-compliance in the elderly. Givens et al. (2005) studied this phenomenon using the fact that, "Patient beliefs about antidepressants are known to affect treatment initiation and adherence" (p.146) as a background. They found support for Theory of Reasoned Action constructs in anti-depression non-compliance in the elderly population and identified a series of beliefs that directly influence intention to perform or not perform this behavior. They write, "Four themes characterized resistance to antidepressants: (1) fear of dependence; (2) resistance to viewing depressive symptoms as a medical illness; (3) concern that antidepressants will prevent natural sadness; (4) prior negative experiences with medications for depression" (2005, p.146).

The resistance to view depression as an illness was one attitude that affected compliance. Because some elders attributed their depression to natural, social causes (i.e. death in the family) rather than clinical, genetic/biological problems (i.e. Parkinson's Disease), they believed that medication was the wrong treatment (Givens et al., 2005). Also the belief that medications provide an artificial joy when one should be experiencing raw, hard emotion was another reason for non-compliance. Others experienced negative side effects from prior treatments with the medicines so their evaluation of behavioral outcomes was negative and reduced the likelihood of compliance (Givens et al., 2005).

Aside from behavioral beliefs, Hughes (2004) also found that there are also factors beyond the elder's control that affected his/her ability to remain compliant or perceived behavioral control. According to Hughes (2004), Adherence may also be affected by access to medications which may be restricted by the use of formularies or insurance" companies (p. 794). If the elder experiences this obstacle with insurance coverage for example, this may affect his perceived behavioral control and ultimately impede compliance with medicine regimens. Givens et al.'s finding that the number one reason for non-compliance is fear of addiction is yet another facet of perceived behavioral control. The elder's felt that they had no control over how their body would respond to prolonged usage of the antidepressants (2005). The likelihood of there being obstacles to taking medications and whether or not the elder feels these obstacles can be overcome will determine whether he/she will remain compliant.

Potential for Empirical Testing

There is not much study into medication adherence patterns of depressed elders, though there is some research into overall medication adherence among the elderly with some specific to physical illnesses like heart disease (AHA, 2006). None of the current research has addressed the role of normative beliefs in influencing intention to take antidepressants for the elderly community. All in all, more research into the factors that specifically influence depressed elders to comply with prescription orders should be done so that effective strategies for combating these low compliance issues can be investigated.

References

American Heart Association. (2006). Convenience, education improves elderly's medication adherence, blood pressure and cholesterol levels. Retrieved April 15^th, 2007 from http://www.heart.org/presenter.jhtml?identifier= 3043441

Givens, J.L. Datto, C.J., Ruckdeschel, K., Knott, K. Zubritsky, C, Oslin, D., Nyshadham, S. Vanguri P., Barg, F.K. (2005) Older patients' aversion to antidepressants: a qualitative study. Journal of General Internal Medicine 21 (2), 146-151.

Hughes, C.M. (2004) Medication non-adherence in the elderly: How big is the problem?

Drugs & Aging. 21(12), 793-811.

Montano, D.E. & Kasprzyk, D. The theory of reasoned action and the theory of planned behavior. In K. Glanz, B. Rimer, & F.M. Lewis, (Eds.) Health Behavior and Health Education. (pp. 67-98) San Francisco: Jossey- Bass.

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