Nonadherence to antidepressants is the rule rather than the exception. A variety of factors contribute to the problem of nonadherence, including side effects, costs, and stigma. However, residual symptoms may represent the single major risk factor for nonadherence.

For clinicians, primary care physicians (PCPs), and other health professionals treating patients with any ailment, including depression, the first task in addressing nonadherence to treatment is to detect it. Patients conceal treatment nonadherence because it is a socially undesirable behavior, and patients want their clinicians or PCPs to think that they are “good” patients. They may hope that their clinicians will be understanding, but assume that clinicians will adopt a judgmental attitude. There is evidence that, as a result of these psychological barriers, self-report and physician interview assessments have poor correlation with adherence as measured by virtually any other methodology. Three studies have been conducted that dramatically indicate the force of this need to conceal nonadherence.

The 2001 Institute of Medicine Report “Crossing the Quality Chasm,” summarized the current care of chronic illness in the United States by emphasizing “Between the health care we have and the health care we could have lies not just a gap, but a chasm.” Across multiple chronic illnesses within primary and specialty care systems, this summary statement illustrates that clinicians and other health professionals are not adequately providing patients guideline levels of treatment–levels that can lower the risk for complications of those illnesses.

It is estimated that 15 million Americans have a depressive disorder, including major depressive disorder, and many of those afflicted do not receive recommended guideline levels of care. Of patients who are correctly diagnosed with depression, a majority of patients do not recover by 4-6 months, often due to discontinuing treatment prior to the initiation of therapeutic effect. It is important for clinicians to understand the factors involved in nonadherence to treatment for the depressive disorders, including presence of residual symptoms, younger age, and less educational attainment. Once clinicians believe a patient is at risk for nonadherence—which is the rule rather than the exception—health care professionals have various techniques available to increase treatment adherence, including communication techniques and other health care interventions.

In this Expert Panel Supplement, Richard C. Shelton, MD, reviews data from the Sequenced Treatment Alternatives to Relieve Depression study to determine the role residual depressive symptoms have in causing patients to become nonadherent to treatment as well as defines characteristics common to patients who discontinue their medications. Steven R. Hahn, MD, outlines several strategies for improving adherence among patients, including a four-step process to bolster patient comfort with treatment guidelines and “Ask-Tell-Ask,” a communication technique aimed to provide clinicians additional understanding as to patient attitudes and beliefs. Finally, Wayne J. Katon, MD, describes how collaborative care—a health care model that involves not only primary care but also additional health care providers in patient treatment—can be beneficial in improving adherence by providing further patient education and additional screening to ensure that patients remain adherent to antidepressants.