Effects of physician communication style on client medication beliefs and adherence with antidepressant treatment

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Abstract

The goals of this study were to examine how physician communication style impacts client beliefs and medication taking behavior during treatment for depression. The study uses a communication framework and prospective design to examine physician communication and client beliefs as treatment is initiated and again 2 months later. Two telephone interviews were conducted with 100 clients enrolled from 23 community pharmacies. Clients report that physician communication styles vary. In follow-up, 25% of the clients were not satisfied with their medication and 82% reported missing doses or stopping treatment earlier than recommended. Path analysis showed that physician initial communication style positively influences client knowledge and initial beliefs about the medication. Clients with more positive beliefs about the treatment are more likely to see the physician in follow-up and are more satisfied with treatment after attempting medication use. Physician follow-up communication style and client satisfaction are both predictive of better medication adherence.

Introduction

Depression is among the most common problems found in general medical care, with one in 20 Americans developing symptoms serious enough to require treatment [1]. Depression causes marked distress, social impairment, pain, and disruption for the individual, his or her family, friends and colleagues [2]. The economic costs associated with depression also are extensive and estimated at nearly 44 billion dollars in 1990 [3]. Controlled studies now show that depression can be treated successfully with antidepressant medication [1] and use of these medications has increased dramatically over the past 10 years as new antidepressants have become available.

A common problem occurring with antidepressant use is client non-adherence with the prescribed regimen. For example, data show that 28% of consumers stop their antidepressant medication within the first month of treatment and 44% of consumers were no longer taking the antidepressant after 3 months [4]. In addition, clients often omit doses, compromising treatment outcomes [5]. Of special concern are individuals who continue to experience depression after discontinuing treatment due to poor understanding of the regimen and how the medication works, poor monitoring of side effects, and other problems that might be managed more effectively with better client–provider communication.

Little is known about client–provider communication when treating depression with medication. In fact, we found only one study examining the nature and quality of physician communication with consumers receiving antidepressant medication. Lin et al. [4] found that patients who received certain educational messages during the initial physician visit were more likely to continue their antidepressant treatment. For example, clients were more likely to continue treatment when they were given explicit directions about how to take their medications, when their physicians asked about previous use of antidepressants, and when there was encouragement to engage in pleasant activities. While these findings are provocative, many important questions remain unanswered.

First, we need theoretical studies examining the specific ways in which physician communication affects client adherence with antidepressant treatment. It is often assumed that physician communication influences adherence by influencing client knowledge and client beliefs about the medication and regimen. While Lin et al. [4] report the relationship between client knowledge of the regimen and medication compliance, client beliefs about antidepressant medication when beginning treatment have not been documented. Further, the relationship between physician communication and client beliefs about antidepressant treatment has not been studied. Second, previous research has focused largely on the physician’s style of instruction and inquiry during the initial physician visit. Prospective studies are needed to understand the relative importance of these initial communications as well as the physician’s follow-up communication style.

Sociologists and social psychologists have advanced a number of theoretical formulations to explain illness behavior [6], [7]; however, critics have noted that the physician–patient relationship occupies a marginal or nonexistent role in these theories of illness behavior [8], [9]. For example, the Health Belief Model (HBM) proposes that individuals will take recommended actions if they perceive themselves as susceptible to the condition being treated, if they perceive the condition as serious, if they believe the benefits of treatment outweigh the costs of treatment, and if they receive a ‘cue to action’ which is generally defined as a physical or environmental stimulus [10], [11]. While the HBM has been useful in explaining some of the variation in adherence among persons with various physical and mental health conditions [12], the model does not elaborate what ‘cues’ are necessary or sufficient to motivate help-seeking. Nor does the HBM spell out the specific ways in which health professionals can influence or modify their clients’ illness and treatment beliefs at various stages in the treatment process.

Other critics have noted that there are many empirical studies of the physician–patient relationship, but little theoretical work on the specific ways in which physician communication impacts illness beliefs and behavior [13]. It is time to move beyond these traditional approaches and test new theoretical models which describe the different ways in which a provider’s communication behavior can affect an individual’s illness beliefs and behavior [9].

In this study, we examine a theoretical model which describes several ways in which a physician’s communication style can affect the beliefs and behavior of individuals who have been prescribed antidepressant medications. The model incorporates key concepts and hypotheses from the Health Communication Model (HCM) [14] and builds on previous studies of provider communication and patient participation in drug treatment [4], [15], [16], [17], [18]. Before presenting our study model, it may be useful to highlight several assumptions and concepts based on the HCM and previous communication studies. First, our proposed model views adherence behavior as an active process dependent on the nature or quality of the relationship between the client and physician. Although we recognize that other factors play a role in medication use, we believe that the quality of the provider–client relationship is highly variable and plays a significant role in determining treatment process and outcomes.

Second, our model assumes that adherence is a complex set of behaviors that require client knowledge of the treatment regimen, motivation to begin treatment, and satisfaction with treatment after it has been attempted. This means that provider communication can influence client behavior by enhancing client knowledge, by influencing his or her initial beliefs about treatment, and, ultimately, his or her satisfaction with treatment effects.

Third, the proposed model incorporates a dynamic view of adherence behavior and the treatment process. Client beliefs and feelings can change as a result of new information and support from their providers and their treatment experiences; medication taking behavior can differ in early and later phases of treatment; and client dissatisfaction can be alleviated if providers make a concerted effort to acknowledge and address client concerns during follow-up visits. It is, therefore, important to consider the provider’s initial communication style as well as his or her follow-up communication style.

Fourth, the proposed model views effective provider–client communication as a two-way process in which client feedback and participation play a critical role. It is, therefore, important to determine the extent to which providers utilize a collaborative or participatory style of communicating with the client during initial and follow-up stages of treatment. Researchers have defined and measured this collaborative or participatory style of communication in different ways [14], [16], [17]. However, it generally involves: providing clear instructions and information about the treatment and its purpose; relating to clients in an approachable, friendly, or supportive manner; soliciting and listening to the client’s views and concerns; and using a ‘participatory’ or non-authoritarian manner of problem-solving and conflict resolution. We refer to these communication behaviors as ‘collaborative’, because they are believed to foster a collaborative relationship in which the provider facilitates or enables the client to take an active role in his or her treatment.

The aim of the present study is to describe and analyze the effects of physician communication styles on the knowledge, initial beliefs, satisfaction, and adherence behavior of individuals who have been prescribed a new medication for depression. In order to stay abreast of changing beliefs and varying experiences during initial and follow-up physician–client interactions, variables are measured at two points in time. Our hypotheses are presented in Fig. 1. Briefly, we hypothesize that the physician’s initial communication style will be related to the client’s knowledge of the regimen (arrow a), client initial beliefs about the potential benefits and costs of the prescribed medication (arrow b) and physician follow-up communication style (arrow c). Clients who perceive their physician as more informative, approachable and using a participatory style during the initial visit will have better knowledge of the medication regimen and more positive beliefs about the prescribed medication after this visit with their physician (Time 1). Similarly, clients perceiving their physician as more collaborative initially will perceive the physician as more collaborative in follow-up. Clients with positive initial beliefs about the antidepressant treatment are more likely to see the physician in a follow-up visit (arrow d). Clients with more knowledge about the treatment regimen (arrow e), with more positive initial beliefs about the medication (arrow f) and who perceive the physician as closely monitoring medication use and having a participatory manner (arrow g) will be more satisfied with the antidepressant medication at Time 2. Clients who are satisfied with their medication will report more adherence (arrow h). Similarly, clients perceiving their physicians to have a more collaborative follow-up communication style will report more adherence (arrow i).

Section snippets

Overview of study design

Study participants were enrolled with the help of community pharmacists. Thirty-four pharmacies were selected randomly from a list of 74 licensed community pharmacies located in a south central Wisconsin county. Of these, 27 agreed to participate and 23 enrolled one or more study participants. Pharmacists asked eligible individuals if a researcher could call them about study participation. Individuals meeting criteria were at least 18 years of age, able to understand English and had a newly

Participants

One hundred participants completed initial and follow-up interviews. Table 1 presents client characteristics. The study sample was young, white and educated: 76% were female, 89% white, and the average age was 36 years (range, 18–84). Nearly 72% attended or graduated from college. Forty-one percent had taken antidepressants previously and 97% reported that the antidepressant was prescribed for depression. Clients reported the extent to which they experienced 12 symptoms of depression in the 2

Discussion

Our findings demonstrate that a collaborative communication style by the physician positively influences treatment outcomes by enhancing client knowledge of the medication regimen (P<0.02), client initial beliefs about the medication (P<0.001), client satisfaction with medication (P<0.01) and client medication use (P<0.03). While the initial collaborative approach does not require that information giving be exhaustive, it does require that the physician clearly communicates what to take, how

Acknowledgements

This work supported in part by a grant from NIMH (P50MH43555). We thank all clients and pharmacists who participated in the study and anonymous reviewers for helpful suggestions.

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