How to overcome this barrier to nonadherence?

[shroomysoup]

There is this patient that has been on Lexapro since December, but she has not been taking it every day. I told her to take it every day, but when I called after one week she said she was taking it as needed. What is the proper way to deal with this according to professionals? She has been on the drug for about 6 months and has still felt depressed, but she did not take it every day. What would you write on a patient case? Continue to stress the importance of adherence or just recommend switching drug classes?

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[Priapism321]

There is this patient that has been on Lexapro since December, but she has not been taking it every day. I told her to take it every day, but when I called after one week she said she was taking it as needed. What is the proper way to deal with this according to professionals? She has been on the drug for about 6 months and has still felt depressed, but she did not take it every day. What would you write on a patient case? Continue to stress the importance of adherence or just recommend switching drug classes?

I would tell the patient she is on the right track, but it would be just as effective and less dangerous to discontinue the escitalopram all together. She should start an exercise program for her depression, or be offered formal counseling. If she must continue on an agent that treats depression as well as 20 mg of glucose daily but may induce new suicidal ideations, she should be switched to the cheaper version of the same drug, citalopram, and be properly educated on why it is important to take medications as they are prescribed.

The title of this thread mentions overcoming barriers to adherence; you may want to start by identifying this patient's barriers to adherence. This is not accomplished by simply telling a patient to "take it every day."

 

[shroomysoup]

There is this patient that has been on Lexapro since December, but she has not been taking it every day. I told her to take it every day, but when I called after one week she said she was taking it as needed. What is the proper way to deal with this according to professionals? She has been on the drug for about 6 months and has still felt depressed, but she did not take it every day. What would you write on a patient case? Continue to stress the importance of adherence or just recommend switching drug classes?

Okay, I made a mistake about the information. The patient wasn't very clear about what she was taking as needed. It was actually a different drug that she was taking as needed (not the Lexapro) and she is not on that medication anymore. She is actually taking the Lexapro every day now (it has been one week) after I told her that it would take awhile for it to kick in. So, in summary, she has been on Lexapro since December but did not take it every day until she met me. After I talked to her about it, she has taken it every day for about one week.

Now should I have her continue the Lexapro (and see how she does in about 3 weeks since it usually takes 4-6 weeks for it to work) or discontinue and switch agents? Thanks for the help.

EDIT: I'd like to also mention that the patient is also on amitriptyline for her trouble sleeping(?). So technically, she is on two antidepressants?

 

[Priapism321]

Okay, I made a mistake about the information. The patient wasn't very clear about what she was taking as needed. It was actually a different drug that she was taking as needed (not the Lexapro) and she is not on that medication anymore. She is actually taking the Lexapro every day now (it has been one week) after I told her that it would take awhile for it to kick in. So, in summary, she has been on Lexapro since December but did not take it every day until she met me. After I talked to her about it, she has taken it every day for about one week.

Now should I have her continue the Lexapro (and see how she does in about 3 weeks since it usually takes 4-6 weeks for it to work) or discontinue and switch agents? Thanks for the help.

Ask whoever is driving the prescribing bus why $4 citalopram at an equivalent dose could not be used in place of escitalopram. However, I wouldn't take an SSRI if the physician was paying me monthly.

 

[twester]

Is there some specific reason why whe's non-adherent? Is she having side-effect or cost issues? Those would warrant a switch. Or does she just not understand that SSRIs take 4-6 weeks to show an effect or is the the concept of a chronic medication foreign to her?

 

[Pharmavixen]

Personally, I'm skeptical of the SSRIs in general, and if depressed would instead pursue cognitive behaviour therapy.

The doctors at the methadone clinic where I sometimes work hand out citalopram like candy to the recovering addicts, and it doesn't seem to do much for them, other than reinforce their already overblown tendencies to turn to chemical solutions for life's problems.

Though with respect to this specific situation, sounds like you're on the right track. If she's only been compliant for a wk, no need to jump the gun and d/c or switch.

And I second (third?) what everybody's saying about escitalopram/citalopram. No diff as far as I have seen.

 

[shroomysoup]

Is there some specific reason why whe's non-adherent? Is she having side-effect or cost issues? Those would warrant a switch. Or does she just not understand that SSRIs take 4-6 weeks to show an effect or is the the concept of a chronic medication foreign to her?

She is adherent to the Lexapro now. Please see post #3 above.

 

[RxWildcat]

And I second (third?) what everybody's saying about escitalopram/citalopram. No diff as far as I have seen.

Citalopram is cheap ($4 thanks to wally) and escitalopram is expensive, so they're saying just use an equivalent dose of citalopram instead of escitalopram (usually double the dose)

 

[rxlynn]

EDIT: I'd like to also mention that the patient is also on amitriptyline for her trouble sleeping(?). So technically, she is on two antidepressants?

Since nobody has answered this question, yes technically she's on two. However, in my area the vast majority of people prescribed amitriptyline are getting it just for sleep purposes.

 

[Pharmavixen]

Citalopram is cheap ($4 thanks to wally) and escitalopram is expensive, so they're saying just use an equivalent dose of citalopram instead of escitalopram (usually double the dose)

Yeah. When I work at the jail, and someone comes in on escitalopram (we call it Cipralex), I direct the drs to do a therapeutic sub with 2x citalopram.

Re: amitriptyline. Lots of psychiatrists like to boost the SSRI with a modest dose of a TCA. Theoretically, you can get serotonin syndrome, and the drug interaction software flashes like crazy, but I've seen lots of people on this combination.

Also, a person might be getting amitripyline as an analgesic, like for fibromyalgia or neuropathic pain.

 

[RxWildcat]

Also, a person might be getting amitripyline as an analgesic, like for fibromyalgia or neuropathic pain.

^^ Extremely common