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Journal of Affective Disorders

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j a d

Research report

Knowledge of and attitudes towards depression and adherence to

treatment: The Antidepressant Adherence Scale (AAS)
Adel Gabriel a,, Claudio Violato b,1

University of Calgary And Calgary Health region, Canada

Department Community Health Sciences, Faculty of Medicine, 3330 Hospital Drive, NW, Calgary Canada T2N 4N1

a r t i c l e

i n f o

Article history:
Received 25 February 2010
Accepted 17 July 2010
Available online xxxx
Knowledge and attitudes
Measuring adherence

a b s t r a c t
Background: Non-adherence to treatment can result from forgetting, carelessness, stopping the
drug when feeling worse, or stopping the drug when feeling better.
Objective: To develop and psychometrically assess a brief instrument that can be easily used in
clinical practice to measure adherence to antidepressants.
Method: We developed the Antidepressants Adherence Scale (AAS); a self report rating scale
including four items to assess the degree to which forgetting, carelessness, and stopping due to
feeling worse or feeling better interfere with adherence in the last 4 weeks. Our proposed fouritem adherence instrument was developed based on previous research and theory.
Participants: Experts in mood disorders (n = 12) participated in the formal validity assessment
of the instrument, and the developed instrument was administered to patients who were
prescribed antidepressants (n = 63). All patients also completed a multiple choice question
instrument to measure knowledge of depression, and a Likert self report questionnaire to
assess attitudes towards depression and its treatment.
Results: There was 90% agreement among experts that the items were highly relevant providing
strong evidence for content validity. Also, there was empirical evidence for validity. There were
signicant correlations (p b 0.05) between knowledge and attitude subscales and adherence
items. The internal consistency reliability (Cronbach's alpha) was 0.66 for the instrument
Conclusion and signicance: Knowledge of and attitudes to depression and its treatment may
have signicant impact on the adherence to antidepressants. The AAS can be used in clinical
settings (23 min to administer) to evaluate patients' adherence to antidepressants.
2010 Published by Elsevier B.V.

1. Introduction
Adherence is dened as the extent to which a patient's
behavior coincides with medical or prescribed health advice.
Adherence is considered non-judgmental and is preferred
over the term compliance, which carries negative connotations and suggests blame for the patient (Julius et al., 2009).

Corresponding author. Tel.: +1 403 291 9122.

E-mail addresses: (A. Gabriel),
(C. Violato).
Tel.: +1 403 220 7296.

Antidepressants are effective in treatment of depression, but

poor adherence to medication is a major obstacle to sustained
remission, and to functional restoration. Adherence to antidepressants is a challenging problem in the management of
patients with depression. The goal of achieving adherence
with medical recommendations to antidepressants is to treat
depressive episodes, prevent relapses and decrease risks for
suicide. A recent study showed that 42% of patients discontinued their antidepressant treatment during the rst 30 days
and 72% had stopped within 90 days. There was also partial
non-adherence in 75% of depressed patients, culminating in
an average of 40% of days without dispensed antidepressants
being taken (Bambauer et al., 2006; Olfson et al., 2006).
Narrative reviews on adherence to pharmacological treatment

0165-0327/$ see front matter 2010 Published by Elsevier B.V.


Please cite this article as: Gabriel, A., Violato, C., Knowledge of and attitudes towards depression and adherence to treatment:
The Antidepressant Adherence Scale (AAS), J. Affect. Disord. (2010), doi:10.1016/j.jad.2010.07.013

A. Gabriel, C. Violato / Journal of Affective Disorders xxx (2010) xxxxxx

of depressive disorders are numerous, but suffer not only from

the limited availability of good quality evidence, but also from
an incomplete critical appraisal of available evidence on
interventions both for depression and for other chronic
disorders (Bollini et al., 2006).
It has been demonstrated in a number of controlled
studies that there were better medication adherence and
improved clinical outcomes for those patients with major
depression who received a comprehensive primary care
intervention that included the educational products. Patients
who received systematic patient education and ongoing
monitoring of medication adherence and depressive symptoms had high rates of using maintenance pharmacotherapy
when compared to standard-care patients (Katon et al., 1999,
2001; Lin et al., 1995; Vergouwen et al., 2003; Von Korff et al.,
2003; Unutzer et al., 2002).
2. Reasons for non-adherence
Barriers to and reasons of non-adherence are multifactorial and may include patients' factors, non-patients'
factors, and factors related to patientclinician relationship. It
is however, more important to identify the specic factors
that may be contributing to a patient's non-adherence in
order to customize interventions to target those problems.
Multiple problems may be involved, requiring a combination
of interventions (Velligan et al., 2009).
Morisky et al. (1986) have developed an instrument to
measure non-adherence to antihypertensive patients. The
theory underlying this model suggests non-adherence due to
any or all of these mechanisms: forgetting, carelessness,

stopping the drug when feeling worse, or stopping the drug

when feeling better. This model is summarized in Fig. 1.
2.1. Forgetting
In a number of studies forgetfulness was found to be
prominent in patient responses as a cause of non-adherence.
Bulloch et al. (2006), for example, reported that forgetting to
take antidepressants was the most common reason for nonadherence among respondents (n = 5323) taking at least one
antidepressant. This was also replicated among patients with
bipolar mood disorders (Miasso et al., 2009). Patients with
psychiatric co-morbidity especially when there is cognitive
impairment and psychosis were less adherent than those
without comorbidity (Taj et al., 2008). Also medical comorbidity was associated with forgetfulness as a prominent cause
of non-adherence (Barfod et al., 2006; Wu et al., 2008). Some
investigators described forgetfulness as non intentional nonadherence (Ayalon et al., 2005) and differentiated between
the intentional, and non-intentional non-adherence. The non
intentional non-adherence was attributed to forgetfulness or
difculties keeping track of medication regimen, and it was
associated with greater cognitive impairment, and is more
common among the elderly than the intentional nonadherence (Barfod et al., 2006; Bulloch et al., 2006; Burra et
al., 2007; Taj et al., 2008). Early detection and treatment of
comorbid psychiatric and medical conditions and cognitive
impairments may aid in taking the appropriate steps to
improve adherence. Patients who received specic instructions about how to resolve questions regarding antidepressants were more likely to comply during the rst month of

Fig. 1. Reasons for non-adherence to antidepressants.

Please cite this article as: Gabriel, A., Violato, C., Knowledge of and attitudes towards depression and adherence to treatment:
The Antidepressant Adherence Scale (AAS), J. Affect. Disord. (2010), doi:10.1016/j.jad.2010.07.013

A. Gabriel, C. Violato / Journal of Affective Disorders xxx (2010) xxxxxx

antidepressant therapy (Lin et al., 1995). Others reported that

the chance of discontinuation was 61% less in patients who
are simply told to take the drugs for at least 6 months
compared with those who did not recall being told this
information (Bull et al., 2002).
2.2. Feeling better
It has been estimated that about one-third of patients stop
taking drugs after feeling better, three months after beginning treatment, and other investigators reported that about
half of depressed people believe they can stop their
antidepressants as soon as they begin to feel better and that
drugs can be taken as required. Stopping the drug when
feeling better should not be underemphasized, not only
because it is quite common among patients with depression,
but also because this type of omission appears to overlap with
defective knowledge, misperceptions about the illness and its
treatment, or due to the lack of effective communication with
the prescribing physician (Taj et al., 2008; Maddox et al.,
2.3. Feeling worse
In number of studies feeling worse from side effects, was
prominent cause of non-adherence. For example, in one
survey (n = 344) the most common reasons for less-thanperfect adherence were side-effects followed by forgetting to
take medication, and that although that side-effects were
common, health professionals sometimes did not ask or teach
patients about them (Ashton et al., 2005; Col et al., 1990).
Although the newer selective serotonin-reuptake inhibitors (SSRIs) are claimed to have a better prole of side-effects
than the older antidepressants, 59% of users have reported
side-effects, the most troubling being sexual dysfunction
(Kennedy et al., 2000; Rothschild, 2000). Also, stopping the
antidepressants when feeling worse was also common due to
negative experiences and intolerance to side effects such as
weight gain, and anxiety which were signicant predictor of
SSRIs discontinuation (Bambilla et al., 2005; Barfod et al.,
2006; Goethe et al., 2007; Taj et al., 2008).
2.4. Carelessness or intentional non-adherence
Poor knowledge about antidepressants and negative
attitudes towards their effectiveness or fears of their side
effects may lead to patients' reluctance to accept their
prescription or becoming careless about taking them. Lack
of knowledge about antidepressants and the negative
attitudes towards them have been a signicant determinant
of patient adherence.
Negative attitudes towards antidepressants, self and
perceived stigma about being depressed or about receiving
antidepressants and the inability to afford them may lead to a
state of carelessness about receiving treatment (Sirey et al.,
2001). In a large community survey (n = 3010), only 40% of
those with major depression considered antidepressants
helpful, whereas 40% considered them harmful and addictive
(Goldney et al., 2001). Adherence can also be inuenced
signicantly by the patientdoctor educational relationship.
Doctors' communication style, patient satisfaction and ad-

herence are interlinked. Collaborative communication by the

clinician enhances patient knowledge of the drug, improves
their satisfaction with treatment, and increases reliability of
drug use and follow-up attendance (Althaus et al., 2002;
Bultman and Svarstad, 2000). Adherence variation overall
was primarily explained by the balance between patients'
perceptions of need and harmfulness of antidepressant
medication, in that adherence is lowest when perceived
harm exceeds perceived need, and highest when perceived
need exceeds perceived harm (Aikens et al., 2005).
Notwithstanding the above review of literature, a brief
instrument for assessing adherence to antidepressants needs
to be developed and psychometrically evaluated. Accordingly,
the major purpose of the present study was to develop and
psychometrically assess a brief instrument to measure
patients' non-adherence to antidepressants in outpatients
suffering from depression, following a concise, yet comprehensive model for non-adherence.

2.5. Measuring adherence to antidepressants

Measuring and monitoring adherence is an important
aspect of effective care. Several methods were developed to
measure adherence to medication and psychotropic drugs.
Traditionally the main methods used to measure adherence
among outpatients include using pharmacy rell records
(Akincigil et al., 2007), and by following the drop-outs versus
completers with electronic monitoring and the frequency of
failure to take antidepressants by examining self reported
medication adherence (Bambauer et al., 2006; Demyttenaere
et al., 2008). Also adherence is assessed more objectively for
research purposes, based on the medication possession ratio,
which was estimated as the proportion of days for which
medication was available over each period of follow-up
(Nakonezny et al., 2008; Thompson et al., 2000; Ward et al.,
2006). Drug levels or pharmacologic markers are not
routinely feasible or practical in most practice settings, and
may not be available for many drugs and their interpretations
as a measure of adherence is complicated by potential
pharmacokinetic differences between drugs and patients
(Gordis, 1979; Kootstra-Ros et al., 2006).
There are few developed scales and drug inventories to
measure adherence, and to assess attitudes to antipsychotics in
patients with psychotic disorders, such as the brief adherence
scale (Byerly et al. 2008; Demyttenaere et al., 2004; Gabriel and
Violato, in press), the drug attitude inventory (Thompson et al.,
2000), and the attitudes towards neuroleptic treatment scale
(Kampman et al., 2000), Demyttenaere et al., 2008, and the
medication adherence rating scale for the psychoses (Fialko et
al., 2007).
Experts recommend that, if possible, clinicians also use
more objective measures (e.g., pill counts, pharmacy records,
and, when appropriate, serum levels such as are used for
lithium). A self report scale may help improve accuracy
(Velligan et al., 2009). The advantage of the interview and self
reporting method however include its feasibility in all care
settings, simplicity, and speed especially when administering a
brief adherence self report instrument. This also will allow
establishing a positive therapeutic rapport between the
patients and prescribers.

Please cite this article as: Gabriel, A., Violato, C., Knowledge of and attitudes towards depression and adherence to treatment:
The Antidepressant Adherence Scale (AAS), J. Affect. Disord. (2010), doi:10.1016/j.jad.2010.07.013

A. Gabriel, C. Violato / Journal of Affective Disorders xxx (2010) xxxxxx

The objective of the present study is to address the

common factors related to non-adherence, and to develop
and psychometrically assess a self report brief reliable
instrument to measure the degree to which forgetting,
carelessness, and stopping antidepressants due to feeling
worse or better, in outpatients suffering from non-psychotic
3. Method
3.1. Participants
3.1.1. Patients
Participating in the study were both male and female
consenting patients 18 to 65 years of age (n = 63). All
participants were treated as outpatients following referrals
by their family physicians. The Mini-International Neuropsychiatric Interview (M.I.N.I. screen 20012005) was used
to conrm the diagnosis of major depressive or dysthymic
episodes (Sheehan et al., 1998). Patients were included if they
had at least one episode of major depression (n = 44),
dysthymia (n = 5), or bipolar depression (n = 14). All
patients were clinically stable (i.e. not acutely depressed or
exhibiting suicidal ideas, and those who scored less N4 on the
Hamilton Rating Scale for Depression (HAM-7) (McIntyre et
al., 2005). Most of the sample were women (65%), Caucasian
(86%) and had suffered from depression for a mean number of
8.9 years (SD = 6.3).
All patients were prescribed antidepressant medication,
and all had seen their clinicians on at least two occasions for
standard treatment and standard psycho-education as a part
of standard clinical care prior to recruitment. Patients with
chronic or recent alcohol and illicit drug abuse, patients
suffering from psychotic symptoms, and patients suffering
from all degrees of mental handicap, were excluded from the
The conjoint scientic and ethics board of the University of
Calgary granted approval for the study.
3.1.2. Psychiatry experts
Both male and female experts in mood disorders were
invited to participate in the present study, (n = 12, female/
male = 2/10, mean age 52 11.6, and with mean years of
experience in mood disorders 22 12.5). There were nine at
the rank of professors, two at Associate Professors, and one at
Assistant Professor. Each expert served an invaluable role in
reviewing and providing comments, and ratings on the
relevance of the instrument to be developed, as a measure
for adherence in patients with depression, before testing the
instruments with patients suffering from depression. Three
experts were invited for an informal panel discussion of the
instrument, and reviewing the individual items in depth. Each
of the remaining, nine experts were invited for formally
rating each of the four items item for its relevancy in
measuring adherence, on a ve point Likert scale.
3.2. Procedure
The items for the instrument (k = 4) were developed
based on empirical evidence from review of literature,
theoretical knowledge, and in consultations with experts.

Four components were included in the instrument: forgetting, carelessness, stopping the drug when feeling worse, or
stopping the drug when feeling better (Morisky et al., 1986).
The initial items of non-adherence were developed by
modifying an existing instrument which was developed by
Morisky et al. (1986), to assess adherence in patients with
hypertension. The original items are as follows:
1. Do you ever forget to take your medication?
2. Are you careless at times about taking your medication?
3. When you felt better, do you sometimes stop taking your
4. When you felt worse, do you sometimes stop taking your
The modication involved converting the question items
of the original instrument, so that responses to each item will
elicit a continuous numerical response, instead of a categorical response (Yes or No). The main objectives for this
modication are the following; (1) to improve the reliability
of the original instrument, by increasing the chances for
responses, and increasing variability. The limited responses
(Yes or No), may increases the chance for error and results in
reduction of reliability, as a result of dichotomizing a
continuous variable, as some patients may have different
ideas about what constitutes a positive or negative response.
(2) To minimize recall bias of responses, by limiting the
responses about adherence, to the four week period prior the
current consultation. Therefore, the four items reecting the
common mechanisms of non-adherence, omissions, mechanisms, forgetting, carelessness, stopping the drug when feeling
worse, or stopping the drug when feeling better, were
converted to a self report questionnaire to measure the
frequency of any or all these omissions during the four weeks
following outpatient consultation and the prescription of
antidepressants, the Antidepressants Adherence Scale (AAS):
During the last four weeks,
1. How many times did you forget to take your medication?
2. How many times were you careless about taking your
3. How many times, when you felt better, how many times
did you stop taking your medication?
4. How many times, when you felt worse, how many times
did stop taking your medication?
To examine the relationship between adherence and
depression literacy (knowledge of and attitudes towards
depression and its treatments) all participants also completed
two instruments: 1) A multiple choice question (MCQ)
knowledge test (number of items = 27) of depression and
its treatment (Gabriel and Violato, 2009), and 2) a Likert self
report questionnaire instrument (number of items = 27) to
measure attitudes toward depression and its treatments
(Gabriel and Violato, in press).
4. Results
The internal consistency reliability (Cronbach's alpha) of
the modied instrument, the AAS (items = 4) was 0.66,
which is higher than the original instrument (Cronbach's
alpha = 0.61). The frequency on non-adherence in each item
of the instrument ranged from 0 to 20 times over the previous

Please cite this article as: Gabriel, A., Violato, C., Knowledge of and attitudes towards depression and adherence to treatment:
The Antidepressant Adherence Scale (AAS), J. Affect. Disord. (2010), doi:10.1016/j.jad.2010.07.013

A. Gabriel, C. Violato / Journal of Affective Disorders xxx (2010) xxxxxx

four weeks of consultation, and forgetfulness appeared to be

the most common reported cause of adherence omissions.
Patients were categorized as adherent or non-adherent based
on their scores on the AAS. Patients who missed taking their
medication for any reason on ve times or more during the
four weeks following psychiatric consultation were considered as non-adherent.
Based on this denition of adherence, there were 23
patients who were described as non-adherent and 40 patients
who were described as adherent. Employing analysis of
variance, there were no signicant differences among
different groups of adherence with respect to age, durations
of illness, duration of the current episode, and the number of
visits to a psychiatrist over the last six months. Also there
were no signicant differences, in the total or in individual
item scores of adherence between sexes, or among patients of
different occupations, or among ethnic groups.
4.1. Experts' responses
Experts rated items as follows: 1 = irrelevant, 2 = slightly
relevant, 3 = moderately relevant, 4 = signicantly relevant
and 5 = highly relevant. There was an overall agreement
(90%) among experts about the relevance of the instrument
to measure patient adherence to antidepressants. All items
were rated as highly or signicantly relevant (mean = 4.5,
SD = 0.6, range = 4.24.8). There were no signicant differences in ratings among experts based on their length of
4.2. The relationship between adherence, attitudes and
knowledge of depression
The knowledge instrument consisted of ve subscales
(denition, the size of the problem, risks of relapse, etiology,
presentation, biological and psychological treatments) and the
attitude instrument also consisted of ve subscales (accepting
treatments, perceived stigma, negative attitudes to antidepressants, self stigma, and preferring psychotherapy). The scale

scores from both the knowledge and attitude instruments and

the items on the non-adherence instrument were intercorrelated using the Pearson product moment correlation coefcient.
These results are summarized in Table 1.
Also a close inspection of Part A of Table 1 reveals a
number of signicant negative correlations on all subscales
(except for etiology) with adherence. These correlations
indicate that more knowledge of depression was associated
with better adherence to treatment.
For the Attitudes subscales, there was signicant correlation (r = 0.25, p b 0.05) between the score of item #3 of the
AAS During the last 4 weeks, when you felt better, how many
times did you stop taking your medication? and the score
about Perceived stigma. There were no other signicant
We also intercorrelated the items of the AAS. Item #1
scores, correlated strongly with item #2, and with item #3
(r = 0.48, p N 0.01, r = 0.49; p N 0.01). Also item 2 scores, has a
strong correlations with items #3 (r = 0.68, p N 0.01).
5. Discussion
The main ndings of present study are: 1) The AAS had an
overall adequate internal consistency reliability = 0.66, 2)
There was 90% overall agreement among experts about the
relevancy of its contents to measuring patient adherence to
antidepressants, 3) Patient adherence in our sample to
antidepressants was generally positive, with the majority
(63%) of patients were described as adherent, and 4)
Although forgetfulness was found in the current study to be
the most frequent reason of non-adherence supporting
results from previous research, we found that stopping the
antidepressants when feeling better, to be associated with
perceived stigma towards depression.
5.1. Evidence for validity of the AAS
There was a robust evidence for agreement (90%) among
experts on the relevance of the items for measuring non-

Table 1
Pearson product moment correlations between the Antidepressants Adherence Scale scores (AAS) knowledge and attitudes factors.
Part A: Correlations between the AAS and knowledge
Non-adherence items
(measured in the previous
four weeks)


Subscale 1 general Subscale 2

risk of relapse

Subscale 3 etiology

Subscale 4
presentation and

Subscale 5 biological and

psychological treatments

Stopped when felt better
Stopped when felt worse







Part B: Correlations between the AAS and Attitudes factors

Non-adherence items
Total attitude
(measured in the previous score
four weeks)

Subscale 1

Stopped when felt better
Stopped when felt worse



Subscale 2 perceived Subscale 3 negative Subscale 4 self

attitudes to



Subscale 5 preferring

Correlation is signicant at p b 0.05 level (2-tailed).

Correlation is signicant at p b 0.01 level (2-tailed).

Please cite this article as: Gabriel, A., Violato, C., Knowledge of and attitudes towards depression and adherence to treatment:
The Antidepressant Adherence Scale (AAS), J. Affect. Disord. (2010), doi:10.1016/j.jad.2010.07.013

A. Gabriel, C. Violato / Journal of Affective Disorders xxx (2010) xxxxxx

adherence to antidepressants, and convergent validity was

demonstrated in the positive signicant correlations between
the scores of the instrument's four items.
The inverse relationships (negative correlations) between
score performances on the MCQ knowledge instrument'
subscales and the AAS score items, suggest that participants
who are more knowledgeable about the illness and its
treatments are likely to be more adherent to antidepressants.
There is further validity evidence by the nding that the
scores of the AAS items being careless about taking the
antidepressants or stopping when feeling better correlated
signicantly negatively with the performance on the total
MCQ score.
Further criterion related validity evidence comes from the
inverse relationship between non-adherence attitudes towards depression. As expected, there was signicant positive
correlation between the non-adherence scores of the AAS,
and the perceived stigma subscale of the attitudes scale
especially among patients who indicated that they stopped
the antidepressants once they felt better with the treatment.
This is in concordance with the ndings of others. It has been
estimated that one-third to one-half of patients stop taking
drugs within 3 months after starting of treatment because
they are feeling better (Col et al., 1990; Maddox et al.,
1994). Negative attitudes such as self stigma appear to be an
obstacle to antidepressants (Angermeyer et al., 2005; Benkert
et al., 1997). Finally, the intercorrelations between the AAS
items also provide evidence of criterion-related validity.
In conclusion, there is a relationship between poor adherence
and the lack of knowledge of depression and its treatment, and
the negative attitudes to antidepressants, providing validity
evidence for the instrument.
5.2. Limitations
There were some limitations of the present study. The
sample was not large, was homogenous, and all patients were
recruited from a psychiatric practice, rather than from the
community. Future research should include larger, more
heterogeneous sample from various community clinics.
5.3. Conclusion
We developed a brief instrument with evidence of
reliability and validity, to measure non-adherence in patients
with non-psychotic depression. Since it measures and targets
the main four areas of medication non-adherence, this
instrument can help and guide clinicians in exploring, with
their patients areas of non-adherence which proved to be
multifactorial. The developed instrument can provide the
busy clinician with a focussed framework for exploring any of
the four main reasons of drug non-adherence discussed.
The AAS is brief, simple, and feasible for ofce administration and needs only 23 min to complete. This brief
screening instrument to measure complex multi-factorial
causes of non-adherence will be very useful for a focused
exploration by the clinician of one or more of the areas of
non-adherence. Each of the four items, however, will need
further exploration with the patient to understand in more
details the causes of the non-adherence.

Role of the funding source

This research project was supported by a research grant from University
of Calgary.

Conict of interests
There is no any nancial, personal or other relationships with other
people or organizations within the last three years of beginning the work
submitted that could inappropriately inuenced, or be perceived to inuence
our work.

We would like to extend sincere thanks to all faculties
who participated in the validity assessments of this instrument. Special thanks to Professors John Rush, University of
Texas, Dallas Texas, and to Terence Ketter and Jennifer Culver
from Stanford University. Also the Department of Psychiatry
in Calgary, we are grateful to Professors John Towes, Aubery
Levine, Don Addington, Scott Patten. Also, we are grateful to
Drs. Margaret Oakander, Peter Lam, Steven Simpson, Robin
Reesal, and Jian Li Wang.
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Please cite this article as: Gabriel, A., Violato, C., Knowledge of and attitudes towards depression and adherence to treatment:
The Antidepressant Adherence Scale (AAS), J. Affect. Disord. (2010), doi:10.1016/j.jad.2010.07.013