“Medication career” or “Moral career”? The two sides of managing antidepressants: A meta-ethnography of patients' experience of antidepressants
Introduction
Most episodes of depression and anxiety are managed in primary care. In the UK, NICE guidelines advise that antidepressant medication should be offered routinely to all patients with moderate to severe depression before psychological interventions (National Institute for Clinical Excellence, 2004). Antidepressant prescribing has increased threefold since 1991 (Hollinghurst, Kessler, Peters, & Gunnell, 2005) and there is evidence that while many patients accept a prescription, one in three do not complete treatment (Pampallona, Bollini, Tibaldi, Kupelnick, & Munizza, 2002).
Factors thought to explain whether a patient starts or continues to take antidepressants include: patients' beliefs about their illness; resistance to viewing depression as a medical illness and the associated lack of belief about the need for antidepressants; and concerns about addiction and dependency (Byrne et al., 2006, Hansen and Kessing, 2007). If patients' resistance to medicines for chronic conditions such as diabetes, hypertension and epilepsy is founded partially on the threat medication poses to self-integrity (Campbell et al., 2003, Pound et al., 2005), one might expect the difficulties surrounding acceptance of medication for psychological disorders to be even more complex. Equally, if a meaningful decision-making relationship between practitioners and patients is routinely difficult to achieve (Cox, Britten, Hooper, & White, 2007), the possible difficulties may be exacerbated when one symptom of depression is the impaired ability to engage with decision-making.
Whilst a substantial qualitative literature now exists on patients' experiences of antidepressants, individual studies risk being lost as disparate “islands of knowledge” (Glaser & Strauss, 1971) unless some form of synthesis is undertaken. Our main aim in this synthesis was to derive new conceptual understandings of patients' experiences of antidepressants. This aim is reflected in our choice of synthesis method - meta-ethnography, which is “interpretive rather than aggregative” (Noblit & Hare, 1988: 11). In addition to building new conceptual insights, the meta-ethnography will inform a future longitudinal qualitative study that will examine the extent to which doctors and patients achieve concordance over the prescription of antidepressants for depression.
There is a large body of qualitative literature on patients' medication use. Donovan and Blake (1992) have argued that ‘compliance’ with medication is not a meaningful concept from the patient's perspective and that “an apparently irrational act of non-compliance (from the doctor's point of view) may be a very rational action when seen from the patient's point of view” (p. 509). A qualitative synthesis of studies of medicine taking found widespread “resistance” to medicines among patients, with strategies for managing medication use including “testing medicines” for adverse effects, modification of dose or use of non-pharmacological treatments alongside or instead of medicines (Pound et al., 2005). Thus, ‘non-compliance’ is recognised as a feature of patients' coping strategies, particularly those living with chronic illness (Anderson & Bury, 1988).
Models of shared decision-making (e.g. the concordance model) promote the patient's active involvement in the decision-making process (Guadagnoli and Ward, 1998, Stevenson et al., 2000). At the heart of the concordance model is the patient as decision-maker, with the professional in a supportive empathic role (Vermiere, Hearnshaw, & Van Royen, 2001). Hearnshaw and Lindenmeyer (2005) argue that “whereas compliance and adherence refer to specific patient behaviours, concordance refers to the consultation process, and resulting agreement between a health care professional and a patient… Adherence is the degree to which the patient follows the agreed concordat” (p.721). However, patients vary in the extent to which they wish to be involved in decision-making, and general practitioners' (GPs) perceptions of their patients' desire to be involved in decision-making about medicines may be inaccurate (Cox et al., 2007). This may be particularly true for depressive illness where low self-esteem may act as a barrier to involvement in decision-making. Patients may not wish to discuss psychosocial issues with their GP because they prefer to “maintain face” within consultations (Pollock, 2007), or may find it difficult to voice their expectations regarding treatment within a consultation, including their desire not to receive a prescription for antidepressants (Barry, Bradley, Britten, Stevenson, & Barber, 2000). Resistance to accepting antidepressants is often founded upon the meanings patient ascribe to medication (Pound et al., 2005).
Important contributions from social theories of illness guided our thinking in the latter stages of this meta-ethnography: Leventhal et al.'s self-regulatory model (Leventhal, Diefenbach, & Leventhal, 1992) and Fife's work on ‘meaning-making’ (Fife, 1994, Fife, 2005). Leventhal et al.'s self-regulatory model “conceptualises the adherence process” (1992: 143) by proposing that adaptation to illness involves both an emotional and cognitive dimension. Rather than the interplay of cognitive and emotional processes, we were interested in the reciprocal relationship between the decision-making process and the meaning-making process of antidepressant use. We were also influenced by Leventhal et al.'s ideas about how coping strategies and evaluation of outcomes feed back into the way the illness and medication are experienced and acted upon.
Fife explores the adaptive response to serious illness (Fife, 2005), and distinguishes between “self-meaning” (how illness affects one's identity) and ‘context meaning’ (the social circumstances surrounding the illness) (Fife, 1994). Paterson, in her work on the role of transformation in the adaptation to chronic illness, makes a similar distinction, describing a ‘restructuring of the self’ and a ‘restructuring of the illness experience’. Both theories emphasise the relationship between the meanings persons assign to a particular event and the coping strategies adopted.
We recognise that any interpretive process is shaped by theory, since as researchers we all “carry theory in our boots” (Hardman, 2000: 8). However, it is important to emphasise that these social theories of managing illness only helped us to refine the conceptual findings at the final stages of the synthesis process and did not pre-determine the synthesis. For example, the conceptualisation of the two sides of managing antidepressants (Fig. 1, Fig. 2) was developed before looking at Leventhal et al.'s and Fife's work. These social theories served to validate this conceptualisation and fed into the development of the final stage of the synthesis (Fig. 3).
Section snippets
Methods
The study had three stages: (1) systematic search; (2) critical appraisal; (3) synthesis using techniques of meta-ethnography, as originally described by Noblit and Hare (1988).
Meta-ethnography: how the papers are related
Early on in the meta-ethnography, we discerned two groups of papers with differing conceptual foci: group 1 focused on patients' decision-making relationships with practitioners (notably GPs) and group 2 focused on the effect of antidepressants on patients' self-concept and identity, with particular attention to stigma. As previously noted, this grouping was significant as we decided to synthesise group 1 and group 2 papers separately before drawing them together.
Translation of second order constructs
Following the process
Discussion
Our synthesis of 16 papers has shown how patients' experience of antidepressant use is characterised by two distinct but related processes – a decision-making process and a meaning-making process. Preferences regarding involvement in decision-making are dependent on both these processes, and as a result will vary during the treatment period and will be dependent on changes in the illness as well as responses to the medication. Garfield et al., 2004 argues that health professionals need to
Conclusion
Our synthesis has gone some way to conceptualise the interplay of the ‘moral’ and medication careers of antidepressant use: the reciprocity between the ‘meaning-making process’, in which new self-concepts emerge, and the ‘decision-making process’, in which the decision-making relationship is negotiated. However, this needs further exploration through empirical work if we are to understand the processes by which transformations in self-concept result in more involvement in decision-making and
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