Depression+-+In+The+Pursuit+of+Happiness

Name: Kate Gallaway Student No: 6874037  Tutor: Michelle Newcomb  Depression: In The Pursuit of Happiness **"...that all men are created equal, that they are endowed by their Creator with certain unalienable rights, that among these are Life, Liberty and the Pursuit of Happiness..."** **United States Declaration of Independence, 1776** What is happiness? Clinical psychologist Dr Ellen Kenner (2009) states that happiness is a long lasting enduring enjoyment of life: being in love with living. However, with 7.3 million Australians (45%) aged 16-85 experiencing a mental disorder at some point in their lifetime (ABS, 2009), the pursuit of happiness can seem unobtainable for some. Through the use of medications such as antidepressants, the burden of mental illness can help be relieved.

**Cultural Artefact** Chato Smith, illustrator of this cartoon, understands the hardship mental health patients go through on a daily based. Based on his own experiences of dealing with Bipolar Disorder, this cartoon epitomises the battle some mental health patients have with medication. Stewart (2011) talks of his personal experience of how stopping his medications caused his life to become twisted, affecting his family to the point his wife threatened to leave. Although he doesn't see the medications as a 'magic pill', medication allows him to remain relatively balanced so he can work and spend time with his family.

**The Public Health Issue** **"Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments."** **Haynes, 2001** Expected to become the second leading cause of disability by 2020 (WHO, 2011), depression is one of the most prevalent forms of mental illness. Although psychological therapy can be effective, the most common form of treatment worldwide is antidepressant medication. However, failure to take the medications as prescribed has been identified as a major obstacle to treatment success (Simon, 2002). The World Health Organisation (2003) lists depression as one of the nine chronic conditions to be focused on for improving medication adherence. It has been estimated by the WHO (2003) that if the problem of poor adherence is not addressed, 30 to 40% of patients will discontinue their treatment in the first 12 weeks regardless of perceived benefits or side effects. The lack of adherence has been linked to poor treatment outcomes including increased risk of relapse and recurrence (Geddes //et al.,// 2003) as well as with an increase in healthcare costs (Cantrell, Eaddy, Shah, Regan & Sokol, 2006). There are two major reasons for failure to adhere to treatment: premature discontinuation of anti depressant treatment (medication non-persistence) and the lack of consistency with the prescribed regimen in the context of ongoing use (medication non-compliance) (Chong, Aslani & Chen, 2011). While a plethora of challenges are faced when treating depression, through the development of a multi-faced intervention, it is possible to improve adherence to medication treatment and depression outcomes.

**Literature Review** Current multi-faced interventions being researched in literature employ a combination of strategies targeted towards both the patient and primary care provider. These strategies can be grouped as: educational - patient education using mainly written and audiovisual materials; behavioural - patient follow-up by either telephone or scheduled appointment and development of a behavioural or relapse plan; affective - providing emotional or general social support; and provider targeted - training for case managers and healthcare professionals. <span style="display: block; font-family: 'times new roman',times,serif; font-size: 12pt; text-align: justify;">Katon //et al// (2001) examined the use of a stepped collaborative care intervention in 386 patients with persistent depressive symptoms. The intervention consisted of 4 components: enhanced education for the patient, 2 visits with a depression specialist, refill monitoring at pharmacies and telephone monitoring and follow-up. Katon //et al//. found that the intervention group we're significantly more likely to adhere to medication in the first 6 months of treatment and in the 12 month follow up period. Additionally, they had significantly less depressive symptoms compared to the control group. Also using telemedicine based collaborative care, Fortney //et al// (2007) found that compliance was significantly improved at the 6 and 12 month mark in the intervention group. Additionally, the treatment response was improved at 6 months and remission was improved at 12 months. <span style="display: block; font-family: 'times new roman',times,serif; font-size: 12pt; text-align: justify;">Similarly, Katzelnick //et al// (2000) examined the use of telephone based treatment in addition to patient and physician education and antidepressant pharmacotherapy. From their 407 participants, Katzelnick //et al// found that compliance was significantly higher in the intervention group. Furthermore, they found that at 12 months, the intervention group reported improved levels of mental health, social functioning and general health perspectives. By using telephone care management involving interviews to monitor symptoms and provide support for medication adherence, Gensichen //et al// (2009) found that at 12 months adherence was higher and depression scores were lower in the intervention group. <span style="display: block; font-family: 'times new roman',times,serif; font-size: 12pt; text-align: justify;">In the US a study was conducted by Simon, Ludman, Tutty, Operskalski & Von Korff (2004) into using telephone psychotherapy and telephone care management for patients starting antidepressant treatment. They found that by using a combination of usual primary care from the doctor with a telephone care management program integrated with a structured 8-session cognitive- behavioural psychotherapy program, it significantly improved satisfaction and clinical outcomes for patients. <span style="display: block; font-family: 'times new roman',times,serif; font-size: 12pt; text-align: justify;">Through the use of a case manager, the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) program provides education, care management, medication support and brief psychotherapy for the patient. Unutzer //et al// (2002) found that in 1801 patients, the use of the IMPACT program significantly improved adherence and treatment response at both 6 and 12 months. Specifically, Unutzer //et al// found that at 12 months 45% of the intervention patients had a 50% or greater reduction in depression symptoms compared to 19% of the control group. Intervention patients also reported more satisfaction with depression care, lower depression severity, less functional impairment and greater quality of life. <span style="display: block; font-family: 'times new roman',times,serif; font-size: 12pt; text-align: justify;">Both Wells //et al// (2000) and Rost //et al// (2001) studied the influence of training for the healthcare professional on adherence and depression outcomes. Wells //et al// (2000) examined the Quality Improvement program, which involves training local leaders to provide clinician and patient education as well as providing access to psychotherapists and medication follow-up. Although adherence was higher at the 6 month follow up, at 12 months adherence was still better in the intervention group compared to the control group. Rost //et al// (2001) found that by providing training to two primary care physicians, a nurse and administrative staff in each intervention practice both adherence and depression severity were improved in patients starting new treatment. <span style="display: block; font-family: 'times new roman',times,serif; font-size: 12pt; text-align: justify;">Two studies investigated the effectiveness of pharmacist collaborative care interventions on improving patient adherence to medication. Both studies performed by Adler //et al// (2004) and Finley //et al// (2003) found that by using medication management, education training and general support from pharmacists, there was a significant increase in adherence to medications. <span style="display: block; font-family: 'times new roman',times,serif; font-size: 12pt; text-align: justify;">These studies highlight some evidence for the use of multi-faced interventions to improved medication adherence. The strategies employed by these studies aimed to target all affections ions affecting medication adherence problems – the patient, the healthcare professional and the health care delivery system. In general, the interventions with the greatest success involved a large number of elements and intensive patient care monitoring. Intensive patient care monitoring, such as follow-up sessions and a longer duration of intervention, are likely to have a higher impact on outcomes as depressions is an episodic and chronic illness. In addition, frequent follow-up sessions are necessary not only to reinforce the benefits of the intervention but also create a relationship between the health care professional and the patient. Although multi-faced intervention involving mental health specialists in primary health care setting were effective, this is not always practicable. Therefore, the potential role of allied health professionals are instrumental in improving depression outcomes and medication adherence. This can be achieved through care management, patient care and medication support.

<span style="color: #ff992d; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 24pt;">**Social and Cultural Analysis** <span style="display: block; font-family: 'times new roman',times,serif; font-size: 12pt; text-align: justify;">Leventhal and Cameron (1987) outlined five general theoretical perspectives on adherence: biomedical, behavioural, communication, cognitive and self-regulatory perspective. <span style="display: block; font-family: 'times new roman',times,serif; font-size: 12pt; text-align: justify;">The biomedical model of health and illness is a dominant perspective in many primary care settings. The biomedical approach to adherence assumes that patients more-or-less follow their doctor's orders passively including diagnosis and treatment. Non-adherence is believed to be attributed to personality aberrations of the patient, with little emphasis placed upon patients' views about their symptoms or medications. The model suggests that groups at risk of non-compliance could be identified by their personality and demographic characteristics, and these flaws could be corrected to improve patient compliance. <span style="display: block; font-family: 'times new roman',times,serif; font-size: 12pt; text-align: justify;">The importance of positive and negative reinforcement as a mode of controlling behaviour forms the basis of behavioural theory. The model consists of cues or stimuli that elicit behaviour, the rewards that reinforce behaviour, the gradual shaping of behaviour and it's automation after sufficient repetitions. Theoretically, it would be possible to control the behaviour of patients, providers and health care systems if the events were controlled before and after a behaviour. Practically, interventions could be designed to have the potential to influence behaviour at the different stages of health care, based on behavioural principles. <span style="display: block; font-family: 'times new roman',times,serif; font-size: 12pt; text-align: justify;">Through communication perspectives, the health care provider attempts to improve their skills in communicating with their patients. The model places emphasis on the importance of developing rapport, educating patients and creating an equal relationship between the patient and the health care professional. Although this approach can improve satisfaction with medical care, there is little evidence to suggest that it causes changes in adherence patterns of patients (WHO, 2003). <span style="display: block; font-family: 'times new roman',times,serif; font-size: 12pt; text-align: justify;">Cognitive behaviours and processes can be applied to adherence behaviour. Although the model can help understand how health threats are viewed by patients as well as identifying factors that are barriers to (or facilitate) adherence, the model does not address behavioural coping skills. <span style="display: block; font-family: 'times new roman',times,serif; font-size: 12pt; text-align: justify;">These conceptualisations developed in the cognitive model is integrated with environmental variables to form the self-regulation model. Patients can use their own representations of health threats, illness and treatment which can be used to guide decision making and behaviour. Therefore, for adhere to occur, it requires patients to have the belief they can manage their behaviour and environment as well as believing the issue warrants their attention and modification of behaviour. <span style="display: block; font-family: 'times new roman',times,serif; font-size: 12pt; text-align: justify;">Although a conceptual framework for organising thoughts about adherence and other health behaviours is formed from these models, no single approach can be used to form a comprehensive understanding of and intervention for adherence. However, another approach to the theoretical understanding of adhere may provide a more effective framework. <span style="display: block; font-family: 'times new roman',times,serif; font-size: 12pt; text-align: justify;">Meichenbaum and Turk (1987) suggested that there are four independent factors that influence adherence behaviour and that a deficiency in any one factor contributes to non-adherence. The four factors are: knowledge and skills about the health problem and required behaviours, their mechanisms of action and the importance of adherence; beliefs about the perceived severity, outcome expectations and response costs; motivation about the value and reinforcement and the internal attribution of success; and actions stimulated by the relevant cues, driven by information recall, evaluation and selection of behavioural options and resources. <span style="display: block; font-family: 'times new roman',times,serif; font-size: 12pt; text-align: justify;">Adherence is a problem identified in patients, but with causes extending beyond the patient. Poor adherence persists because it is a complex problem and requires more than genetic approaches. The different areas of healthcare – the patient, provider and delivery system needed to be addressed to improve adherence as it is not just a 'patient problem'. By assessing risk and delivering interventions at initial and follow-up contact, providers can have significant impact. However, providers require a system that is designed to help optimise adherence.

<span style="color: #8929a9; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 24pt;">**Artefact Analysis** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14pt;">**"There are risks to antidepressant treatment, but the risks of untreated depression are worse."** **<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14pt;">John Bailey ** <span style="color: #000000; display: block; font-family: 'Times New Roman',Times,serif; font-size: 12pt; text-align: justify;"> <span style="color: #000000; display: block; font-family: 'Times New Roman',Times,serif; font-size: 12pt; text-align: justify;">This artefact represents the dilemma mental health patients take: medication or not. As Stewart states that he, like many other suffers, stopped taking their medication. This was a turbulent time for him and his family, culminating in his wife threatening to leave. While Stewart has made a commitment to take his medications, he still refers to them as a necessary evil. While the relative merits of antidepressants are known, there is a significant problem with adherence to medication treatments, whether it is due to cost, side effects or a plethora of other issues. Although non-compliance is a problem seen in patients, its causes extend beyond into the health care system and its providers. There needs to be a public health movement across the sectors to improve the interventions available for antidepressant treatment and adhering to medications. <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">On a daily basis as a pharmacy assistant I am constantly aware of current problems with people taking medications. Despite being told constantly from pharmacies about how crucial it is to consistently take antidepressants and the dangers of suddenly stopping, patients still continue to run out. Commonly, this is due to either running out of scripts, not having enough money to pay for medications or forgetting to refill prescriptions. Although there are methods pharmacies can take to provide immediate supplies of medications, through this assignment I have learnt of more effective ways healthcare can be provided to patients taking antidepressants. I believe that in the near future there needs to be a collaborate health movement across all sectors of the health care system to ensure that patients taking antidepressants are receiving the best care possible.

<span style="color: #ff0094; font-family: 'Trebuchet MS',Helvetica,sans-serif; font-size: 24pt;">**Reflection of Other Wikis** <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Wiki Title: A review of alcohol related violence and prevention strategies in remote Indigenous communities. <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Link: http://healthculturesociety.wikispaces.com/A+review+of+alcohol+related+violence+and+prevention+strategies+in+remote+Indigenous+communities.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Response: <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Great Wiki!! <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">I really enjoyed reading your wiki Kathryn, especially about the effectiveness of the NTER intervention implemented in 2007. With the rising incidence of alcoholism and risky drinking across the whole of Australia, not only Indigenous Australia, I was wondering what your opinion was about tackling the problem on a national scale? With the increase of binge drinking, especially amongst the 18-25 year age group, I believe there needs to be a nation wide initiative to reduce drinking levels that involves both the government, clubs, pubs and bottle shops. Whether it is the implementation of alcohol restrictions nationwide, or another initiative, as drinking is such a large part of Australian culture there is a lot of work needed to be done to improve these statistics.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Wiki Title: 'I wanted to use sports for social change' (Billie Jean King) - Women in sport <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Link: http://healthculturesociety.wikispaces.com/%27I+wanted+to+use+sports+for+social+change%27+%28Billie+Jean+King%29+-+Women+in+sport

<span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Response: <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Men in sport? <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">While I completely disagree with objectifying female athletes in magazines such as Alpha or Zoo, I was wondering about your opinion of the portrayal of male athletes as sex objects. In many female magazines and advertising campaigns male athletes are also sexualised in order to sell products. Take for example Cleo's Bachelor of the Year won by swimmer Eamon Sullivan. In his photographs, like many of the other professional athletes he is topless or is wearing an unbuttoned shirt in a sexual manner. Another example would be David Beckham and his advertisements of numerous products in a sexual, almost naked manner. While there is an obvious problem with the portrayal of women in sport, I think that perhaps there needs to be a societal approach to advertising, after all sex sells.

<span style="color: #000000; display: block; font-family: 'trebuchet ms',helvetica,sans-serif; font-size: 24pt; text-align: center;">**References** <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Adler, D.A., Bungay, .M., Wilson, I.B., Pei, Y., Supran, S., Peckham, E., ... Rogers, W.H. (2004). The impact of a pharmacist intervention on 6-month outcomes in depressed primary care patients. //General Hospital Psychiatry, 26//, 199-209 <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Australian Bureau of Statistics. (2007). //Australian Social Trends, 2009:Mental Health//. Retrieved from [] <span style="color: #000000; display: block; font-family: 'Times New Roman',Times,serif; font-size: 12pt; text-align: left;">Bailey, J. (n.d.). John Bailey Quote. Retrieved November 1, 2011 from [] <span style="color: #000000; display: block; font-family: 'Times New Roman',Times,serif; font-size: 12pt; text-align: left;">Cantrell, C.R., Eaddy, M.T., Shah, M.B., Regan, T.S., & Sokol, M.C. (2006) Methods for evaluating patient adherence to antidepressant therapy: A real world comparision of adherence and economic outcomes. //Medical Care, 44//(4), 300-3 <span style="color: #000000; display: block; font-family: 'Times New Roman',Times,serif; font-size: 12pt; text-align: left;">Chong, W.W., Aslani, P., & Chen, T.F. (2011). Effectiveness of interventions to improve antidepressant medication adherence: A systematic review. //The International Journal of Clinical Practice, 65//(9), 954-75 <span style="color: #000000; font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Dobscha, S.K., Corson, K., Hickam, D.H., Perrin, N.A., Kraemer, D.F., & Gerrity, M.S. (2006). Depression decision support in primary care. //Annals of Internal Medicine, 145//, 477-87 <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Finley, P.R., Rens, H.R., Pont, J.T., Gess, S.L., Louie, C., Bull, S.A, ... Bero, L.A. (2003). Impact of a collaborative care model on depression in a primary care setting. //Pharmacotherapy, 23//, 1175-85 <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Fortney, J.C., Pyne, J.M., Edlund, M.J., Williams, D.K., Robinson, D.E., Mittal, D., & Henderson, K.J. (2007). A randomized trial of telemedicine-based collaborative care for depression. //Society of General Internal Medicine, 22//, 1086-93

<span style="color: #000000; display: block; font-family: 'Times New Roman',Times,serif; font-size: 12pt; text-align: left;">Geddes, J.R., Carney, S.M., Davies, C., Furukawa, T.A., Kupfer, D.J., Frank, E., & Goodwin, G.M. (2003). Relapse prevention with antidepressant drug treatment in depressive disorders: A systematic review. //The Lancet, 361//, 653-61 <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Gensichen, J., Von Korff, M., Peitz, M., Munth, C., Beyer, M., Guthlin, C., ... Gerlach, F.M. (2009). Case management for depression by health care assistants in small primary care practices. //Annals of Internal Medicine, 151,// 369-78

<span style="color: #000000; display: block; font-family: 'Times New Roman',Times,serif; font-size: 12pt; text-align: left;">Haynes, R.B. (2001). Interventions for helping patients to follow prescriptions for medications. //Cochrane Database of Systematic Reviews, 1// Katon, W., Rutter, C., Ludman, E.J., Van Korff, M., Lin, E., Simon, G, ... Unutzer, J. (2001). A randomized trial of relapse prevention of depression in primary care. //Archives of General Psychiatry, 58//, 241-47 <span style="color: #000000; display: block; font-family: 'Times New Roman',Times,serif; font-size: 12pt; text-align: left;">Katzelnick, D.J., Simon, G.E., Pearson, S.D., Manning, W.G., Helstead, C.P., Henk, H.J., ... Kobak, K. (2000). Randomized trial of a depression management program in high utilizers of medical care. //Archives of Family Medicine, 9//, 345-51 <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Kenner, E. (2009). What is happiness? Retrieved from [|www,drkenner.com/what_is_happiness.htm] <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Leventhal, H., & Cameron, L. (1987). Behavioral theories and the problem of compliance. //Patient Education and Counselling, 10//, 117-38 <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Meichenbaum, D., & Turk, D.C. (1987). //Facilitating treatment adherence: A practitioner's guidebook.// New York: Plenum Press <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Rost, K., Nutting, P., Smith, J., Werner, J., & Duan, N. (2001). Improving depression outcomes in community primary care practice. //Journal of General Internal Medicine, 16//, 149-49 <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Simon, G.E. (2002). Evidence review: Efficacy and effectiveness of antidepressant treatment in primary care. //General Hospital Psychiatry, 14//, 237-47 <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Simon, G.E., Ludman, E.J., Tutty, S., Operskalski, B., & Von Korff, M. (2004). Telephone psychotherapy and telephone care management for primary care patients starting antidepressant treatment. //Journal of the American Medical Association, 292//(8), 935-42 <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Stewart, C. (2011). Psych meds: 'A necessary evil or a magic pill.' Retrieved from [] <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">United States of America Government. (n.d.). Declaration of Independence: a transcript. Retrieved November 1, 2011 from [] <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Ututzer, J., Katon, W., Callahan, C.M., Williams, J.W., Hunkler, E, Harpole, L, ... Langston, C. (2002). Collaborative care management of late-life depression in the primary care setting. //Journal of the American Medical Association, 288//(22), 2836-45 <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">Wells, K.B., Sherbourne, C., Schoenbaum, M., Duan, N., Meredith, L., Unutzer, J, ... Rubenstein, L.V. (2000). Impact of disseminating quality improvement programs for depression in managed primary care. //Journal of the American Medical Association, 283//(2), 212-220 <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">World Health Organisation. (2003). //Adherence to long-term therapies: Evidence for action//. Retrieved from the World Health Organisation website [] <span style="font-family: 'Times New Roman',Times,serif; font-size: 12pt;">World Health Organisation. (2011). Depression. Retrieved from []