Relationship Between Depression Literacy and Medication ... · Relationship between depression literacy and medication adherence in ... JSS Medical College, Mysore 2 ... Relationship

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:[email protected]

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


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.


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



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


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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Relationship Between Depression Literacy and Medication ... · Relationship between depression literacy and medication adherence in ... JSS Medical College, Mysore 2 ... Relationship