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183Journal of Mood Disorders Volume: 6, Number: 4, 2016 - www.jmood.org
Original Paper DOI: 10.5455/jmood.20161123023646
ABS TRACT:
Relationship between depression literacy and medication adherence in patients with depression
Objective: To find out the relationship between depression literacy and adherence to medications in subjects with major
depressive disorder in remission.
Methods: In this cross-sectional hospital-based study, 130 subjects with major depressive disorder were assessed by
using socio-demographic data form and clinical proforma designed for this study, Depression Literacy Questionnaire and
Medication Adherence Rating Scale.
Results: Median scores on D-Lit and MARS were 13.2 and 0.00 respectively. Two patterns of common incorrect responses
were regarding the cognitive and treatment aspect of depression. Female gender had statistically significant higher D-Lit
score (p=0.025) than male, and Score on D-Lit had statistically significant negative predictive value of score on MARS
(R2=0.059, df=5, F=1.55, p=0.020).
Conclusion: Cognitive and treatment aspect of depression literacy is lower in patients with depression in India.
Depression literacy is more in women and positively associated with medication adherence.
Keywords: health literacy, medication adherence, depression
Journal of Mood Disorders (JMOOD) 2016;6(4):183-8
Relationship Between Depression Literacy and Medication Adherence in Patients with Depression
Dushad Ram1, Neetu Benny2, Basavana Gowdappa3
1Department of Psychiatry, JSS Medical College, Mysore2Department of Clinical Pharmacy, JSS Medical Pharmacy College, Mysore3Department of Medicine, JSS Medical College, Mysore
Corresponding Author:Dushad Ram,Department of Psychiatry, JSS Medical College, Mysore
E-ma il add ress:dushadram@hotmail.com
Date of received:September 21, 2016
Da te of ac cep tan ce:November 23, 2016
Declaration of interest:D.R., N.B., B.G.: The authors reported no conflict of interest related to this article.
INTRODUCTION
Depression is a common mental disorder characterized
by sadness, loss of interest or pleasure, feelings of guilt or
low self-esteem, disturbed sleep or appetite, fatigability,
and poor concentration. The World Health Organization
(WHO) has predicted that major depressive disorder (MDD)
will be second only to ischemic heart disease as a cause of
disability by the year 2020, and is projected to become the
foremost contributor to disease in high income countries by
2030 (1,2) . It is a leading cause of disability worldwide, and
prevalence in India is 35.9 percent (3). More than half of the
patients with depression do not seek help (4). Among those
who seek treatment, up to 66% will be non-adherent to the
medication (5). Poor knowledge about depression may
mediate non-adherence in depression (6).
Depression is still not well-understood by health
professionals, patients, and the public in general
particularly with regards to etiology, signs and symptoms,
and treatment of depression (7). Thus large proportions of
patients with depression may not seek help, may not know
where to seek help, may have negative attitudes to
treatments, or may be fearful of being stigmatized if they
seek help (7).
Depression literacy is a specific type of mental health
literacy and is defined as the ability to recognize depression
and make informed decisions about treatment (8).
Published literature indicates poor depression literacy
184 Journal of Mood Disorders Volume: 6, Number: 4, 2016 - www.jmood.org
Relationship between depression literacy and medication adherence in patients with depression
among patients and general population which has a bearing
on help-seeking behavior (7,9). Treatment or need for
treatment of depression may be under-recognized due to
poor depression literacy.
Antidepressants are the major treatment option for
depression. Medication adherence is an important
predictor of illness course and therapeutic outcome in
psychiatric illnesses. Adherence to treatment may be
related to knowledge of depression (6). Medication
adherence usually refers to whether patients take their
medications as prescribed as well as whether they continue
to take prescribed medications till the course of therapy
ends. Non-adherence to medications is a major barrier for
the recovery of depression (10). There is paucity of literature
that specifically assesses the relationship of depression
literacy and medication adherence. Few attempts have
been made to address awareness of depression among
students in India, but major limitation being use of
un-standardized tools. One report reveals that only 13.1%
graduate student identified depression, while in other
reports it increased up to 29.04 percent (11,12). Nigam et al.
(2013) reported a highest of 45.6% of students who could
identify symptoms of depression (13).
In this study, we examined the relationship between
depression literacy and its effect on patient’s adherence to
medications, with a hypothesis that depression literacy and
medication adherence are positively associated. In this
study, evaluating the relationship between depression
literacy and medication adherence, we have used
medication adherence rating scale to check the medication
compliance and depression literacy questionnaire to assess
depression literacy.
METHODS
This single centre, hospital-based cross-sectional study
was conducted at an outpatient psychiatry department of
tertiary care centre in the South India. Over a period of
three months, 142 consecutive patients who came for
follow-up were screened and 130 met study selection
criteria and were recruited in this study after obtaining an
informed consent. The inclusion criteria were outpatient
males and females, diagnosis of depression as per ICD-10
criteria, age between 14-65 years and ≥ 2 consultation visits.
Diagnosis was made by treating psychiatrist as per the
guidelines given in ICD-10 Diagnostic Criteria for Research.
Any subject who participated in any depression related
research was excluded from this study. Selected participants
were further assessed with;
Socio-demographic data and clinical proforma: The
proforma included socio demographic variables such as
age, gender, occupation, marital status, residence, family
type, socioeconomic status, religion, history of mental
illness in their family.
Depression Literacy Questionnaire: In this study, we
have used Depression Literacy Questionnaire, a self-report
measure to evaluate literacy of depression in patients (14).
The questionnaire comprises of 22 questions. It was
translated in different languages and widely used.
Chronbach’s alpha coefficient varies from 0.70–0.78, while
test-retest reliability (rr) ranges from 0.7 to 0.91.
Medication Adherence Rating Scale: It measures the
patient’s attitude in taking medication (15). MARS
comprises of 10 questions related to the administration of
medications and attitude towards the medicines. For each
question, score ranges from 0–1. Higher total score indicate
lower adherence.
The data were analyzed using SPSS Version 16 for
Windows. Descriptive statistics were used to express socio-
demographic and clinical characteristic. The distribution
and normality of the sample was assessed with the
Kolmogorov-Smirnov and the Shapiro-Wilk test and was
found to be significantly skewed. Since analysis required
comparison of more than two variables, Kruskal-Wallis H
test was used to know the group difference of socio-
demographic and clinical variables on the score of different
scales and a post-hoc analysis was done (for comparison of
≥ 3 groups). A linear regression analysis was conducted to
know if patients who score on measure of depression
literacy can predict the values of scores on measure of
medication adherence. The level of statistical significance
was kept at p<0.05 for all tests.
RESULT
Median score of age was 38.5 (min=14, max=70) years,
duration of illness was 1 (Min=1, max=10) year, D-Lit score
was 13.21 (min=6, max=19), and MARS score was 0 (min=0.
185Journal of Mood Disorders Volume: 6, Number: 4, 2016 - www.jmood.org
D. Ram, N. Benny, B. Gowdappa
Max=1) (Table 1). Other socio-demographic and clinical
features were characterized by more participants who were
female, unemployed, married, hindus, rural, nuclear family
without family history of mental illness, and were referred
by family member (Table 3A and 3B).
Two patterns of common incorrect responses were
observed (Table 2). First about the cognitive aspect of
depressive symptoms; in response to “People with
depression may feel guilty when they are not at fault”, and
“Depression does not affect your memory and
concentration”. Second with regards to pharmacological
and non-pharmacological treatment of depression - while
responding “Counseling is as effective as cognitive
behavioural therapy for depression”, and “People with
depression should stop taking antidepressants as soon as
they feel better”.
Depression literacy was more among females,
employed, married, residing in urban area, living in joint
family, belonging to high socioeconomic status, and among
muslims. Only female gender was associated with
statistically significant higher D-Lit score (p=0.025) (Table
3A and 3B). In linear regression analysis, score on D-Lit
predicted statistically significant positive value on MARS
score; however, the coefficient of determination
(predictiveness) was poor-weak (R2=0.059, df=5, F=1.55,
p=0.020) (Table 4).
Tab le 1: Socio-demographic Characteristics
Variables (n=130) Minimum Maximum Median
Age 14.00 70.00 38.5Education 0.00 15.00 9.00Age at onset 1.00 70.00 37.00duration of Illness 1.00 10.00 1.00D-Lit score 6.00 19.00 13.21MARS Score 0.00 1.00 0.00
Tab le 2: Itemised response on D-Lit questionnaire
Incorrect / Correct don’t know response response
n % n %
1. People with depression often speak in a rambling and disjointed way. 92 70.8 38 29.22. People with depression may feel guilty when they are not at fault. 40 30.8 90 69.23. Reckless and foolhardy behaviour is a common sign of depression. 110 84.6 20 15.44. Loss of confidence and poor self-esteem may be a symptom of depression. 72 55.4 58 44.65. Not stepping on cracks in the footpath may be a sign of depression. 111 85.4 19 14.66. People with depression often hear voices that are not there. 98 75.4 32 24.67. Sleeping too much or too little may be a sign of depression. 94 72.3 36 27.78. Eating too much or losing interes1t in food may be a sign of depression. 85 65.4 45 34.69. Depression does not affect your memory and concentration. 48 36.9 82 63.110. Having several distinct personalities may be a sign of depression. 86 66.2 44 33.811. People may move more slowly or become agitated as a result of their depression. 107 82.3 23 17.712. Clinical psychologists can prescribe antidepressants. 62 47.7 68 52.313. Moderate depression disrupts a person’s life as much as multiple sclerosis or deafness. 55 42.3 75 57.714. Most people with depression need to be hospitalised. 114 87.7 16 12.315. Many famous people have suffered from depression. 86 66.2 44 33.816. Many treatments for depression are more effective than antidepressants. 60 46.2 70 53.817. Counseling is as effective as cognitive behavioural therapy for depression. 43 33.1 87 66.918. Cognitive behavioural therapy is as effective as antidepressants for mild to moderate depression. 90 69.2 40 30.819 Of all the alternative and lifestyle treatments for depression, vitamins are likely to be the most helpful. 74 56.9 56 43.120. People with depression should stop taking antidepressants as soon as they feel better. 43 33.1 87 66.921. Antidepressants are addictive. 83 63.8 47 36.222. Antidepressant medications usually work straight away. 65 50.0 65 50.0
186 Journal of Mood Disorders Volume: 6, Number: 4, 2016 - www.jmood.org
Relationship between depression literacy and medication adherence in patients with depression
DISCUSSION
Socio-demographic and clinical characteristics of this
study were similar to other reports from India. Female
gender, middle aged, unemployed, married, belonging to
rural area are known to be associated with depression (16).
Pattern of response in D-Lit questionnaire revealed a
lower literacy of cognitive aspects of depression. This
observation may be reflective of cultural influence in
conceptualizing depression. Studies indicate that Indians
have a tendency to conceptualize depression as more of a
somatic problem and less of a cognitive problem (17,18).
Lower mental health literacy helps to maintain such cultural
belief (19).
Our esults also revealed poor knowledge about
psychological and pharmacological treatment of
depression. This may be again due to poor mental health
literacy and prevalent misconception about depression that
“There is no need to go to a medical doctor for treatment”,
“One can cure depression by will power”, “Drugs used for
Tab le 3B: Sociodemographic characteristics and its relationship on score D-Lit
n (%) D-Lit median (min-max) p
D-Lit score * SES Low 42 13.0 (8-17) 0.783 Middle 47 13.0 (7-19) High 41 16.0 (6-16) D-Lit score * Religion Hindu 109 13.0 (6-19) 0.295 Muslim 15 13.0 (7-17) Christian 6 14.0 (13-15) D-Lit score * referred by Self 23 14.0 (7-18) 0.328 Family 100 13.0 (6-19) Society 4 13.0 (12-14) Professional 3 15.0 (13-16)
Tab le 3A: Socio-demographic characteristics and its relationship on score D-Lit score
n (%) D-Lit median (min-max) p
D-Lit score * gender Male 54 13.0 (6-19) 0.025 Female 76 13.5 (11-18) D-Lit score * Occupation Unemployed 81 13.0 (7-17) 0.650 Employed 49 13.0 (6-19) D-Lit score * Marital status Single 37 13.0 (9-18) 0.365 Married 93 13.0 (6-19) D-Lit score * Residence Rural 94 13.0 (7-17) 0.230 Urban 36 14.0 (7-19) D-Lit score * Family type Nuclear 95 13.0 (6-19) 0.302 Joint 35 13.0 (9-19) D-Lit score * family mental illness Present 11 13.0 (12-16) 0.890 Absent 119 13.0 (6-19)
Tab le 4: Relationship of depression literacy and medication adherence
Standardized Unstandardized Coefficients Coefficients
Model B Std. Error Beta t p
1 (Constant) 3.842 1.055 3.642 0.000 Age 0.043 0.045 0.325 0.959 0.339 Age at onset -0.020 0.043 -0.156 -0.470 0.639 Duration of illness -0.010 0.007 -0.163 -1.495 0.137 Education 0.058 0.029 0.192 2.000 0.048 D-Lit Score -0.081 0.072 -0.101 -1.121 0.014
Dependent Variable: MARS Score, R2=0.059, df=5, F=1.55, p=0.020
187Journal of Mood Disorders Volume: 6, Number: 4, 2016 - www.jmood.org
D. Ram, N. Benny, B. Gowdappa
treating depressions are addictive” etc (20). Mental health
professionals are not a popular source of help seeking (12).
We have observed overall moderate level of depression
literacy than other reports from India (11,12). Though
number of studies specifically examining depression
literacy is few, review reveals poor literacy in both patients
and public (7).
However, one study from India examined non-
depressed adolescents and reported a highest of 45.6% of
students could identify symptoms of depression (13).
Possible reason of more level of depression could be
because the study sample were subjects with diagnosis of
depression, and this is worrisome as this indicates that
depressed though have higher level of literacy, they have
poor literacy regarding treatment aspect of depression (21).
We observed a higher D-Lit score for females, employed,
married, residing in urban area, living in joint family,
belonging to high socioeconomic status, and among
Muslims. As mentioned below female are known to have
high depression literacy, while those employed, urban
dwellers and higher socio-economic status were more
likely to have higher level of education and access to
information about depression. More literacy among
married and belonging to joint family might be due to good
social network that provide information about their illness.
Among different religions, muslim had more depression
literacy. This is interesting in the view of other reports
which found moderate level of literacy (22). Though low
literacy may be present in general population, being a
minority they might have come for treatment when they
experienced severe level of symptoms when other
measures have failed, making them to explore other
possible method of treatment.
In this study, we could not find statistically significant
difference in depression literacy except for more literacy
among females. There are similar findings reported in the
literature (8,21,23-25). Reasons could be that females were
outnumbered than males and are more likely to experience
depression hence more awareness about symptoms and
other aspect of depression. Research indicates that many
depressive symptoms are poorly understood or
differentiated from other mental illnesses (24). In addition,
dominant ideologies of masculinity are often associated
with poor mental health (25). This finding underscores
need of designing gender-sensitive and specific (i.e.,
discrete men-cantered and women-cantered approaches)
public health awareness programs to increase literacy
about male depression.
In this study, we found that medication adherence had
a statistically significant negative association with
depression literacy and levels of education. However,
coefficient of determination (predictiveness) was poor or
weak. Higher education level is reported to be associated
with higher adherence; probably due to more opportunity
of exposure to health related information (26,27). Low
health literacy has been associated with overall poor
outcome of medical illness (27), while higher health literacy
has been reported to mediate adherence and outcome (10).
This may apply to depression as well. Level of knowledge
about depression may facilitate or hamper adherence (6,7).
There is indirect evidence that poor knowledge of
depression is associated with medication non-adherence
in India (5). Findings of this study are also supported by a
report by Azocar and Branstrom (2006) who found that
education about depression helps to improve the
compliance (28). Poor or weak coefficient of determination
(predictiveness) may indicate that medication adherence
is determined by multiple factors apart from the knowledge
about depression.
CONCLUSION
Cognitive and treatment aspect of depression literacy is
lower in patients with depression in India. Depression
literacy is more in women and positively associated with
medication adherence.
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