Effects of Telephone Counseling Intervention by Pharmacists (TelCIP) on Medication Adherence; Results of a Cluster Randomized Trial.

OBJECTIVES: To assess the effect of a pharmacist telephone counseling intervention on patients' medication adherence. DESIGN: Pragmatic cluster randomized controlled trial. SETTING: 53 Community pharmacies in The Netherlands. PARTICIPANTS: Patients ≥18 years initiating treatment with antidepressants, bisphosphonates, Renin-Angiotensin System (RAS)-inhibitors, or statins (lipid lowering drugs). Pharmacies in arm A provided the intervention for antidepressants and bisphosphonates and usual care for RAS-inhibitors and statins. Pharmacies in arm B provided the intervention for RAS-inhibitors and statins and usual care for antidepressants and bisphosphonates. INTERVENTION: INTERVENTION consisted of a telephone counseling intervention 7-21 days after the start of therapy. Counseling included assessment of practical and perceptual barriers and provision of information and motivation. MAIN OUTCOME MEASURE: Primary outcome was refill adherence measured over 1 year expressed as continuous outcome and dichotomous (refill rate≥80%). Secondary outcome was discontinuation within 1 year. RESULTS: In the control arms 3627 patients were eligible and in the intervention arms 3094 patients. Of the latter, 1054 patients (34%) received the intervention. Intention to treat analysis showed no difference in adherence rates between the intervention and the usual care arm (74.7%, SD 37.5 respectively 74.5%, 37.9). More patients starting with RAS-inhibitors had a refill ratio ≥80% in the intervention arm compared to usual care (81.4 vs. 74.9% with odds ratio (OR) 1.43, 95%CI 1.11-1.99). Comparing patients with counseling to patients with usual care (per protocol analysis), adherence was statistically significant higher for patients starting with RAS-inhibitors, statins and bisphosphonates. Patients initiating antidepressants did not benefit from the intervention. CONCLUSIONS: Telephone counseling at start of therapy improved adherence in patients initiating RAS-inhibitors. The per protocol analysis indicated an improvement for lipid lowering drugs and bisphosphonates. No effect for on adherence in patients initiating antidepressants was found. The trial was registered at www.trialregister.nl under the identifier NTR3237.

Understanding Statin Non-Adherence: Knowing Which Perceptions and Experiences Matter to Different Patients.

BACKGROUND: Non-adherence to statins is substantial and is associated with numerous perceptions and experiences. However, time limits in clinical practice constrain in depth explorations of these perceptions and experiences. OBJECTIVES: To propose and examine a strategy aimed at an efficient assessment of a wide array of perceptions and experiences regarding the efficacy, side effects, and practical problems of statins. Furthermore, to assess associations between this wide array of experiences and perceptions and non-adherence and to examine whether patients' 'perceived self-efficacy' moderated these associations. METHODS: Patients were recruited through community pharmacies. A wide array of specific patient perceptions and experiences was efficiently assessed using the electronic Tailored Medicine Inventory that allows people to skip irrelevant questions. Adherence was measured through self-report and pharmacy refill data. RESULTS: Of the two-hundred twenty-nine patients who participated (mean age 63.9, standard deviation 10.2), 40%-70% doubted the necessity of or lacked knowledge about the efficacy of statins, 20%-35% of the patients were worried about joint and muscle side effects or had experienced these, and 23% had encountered practical problems regarding information about statins, intake of tablets, the package, or the blister. Experiencing more practical problems was associated with increased unintentional non-adherence (Odds ratio 1.54, 95%CI:1.13-2.10, P < 0.01), whereas worrying about side effects was associated with increased intentional non-adherence (Odds ratio 1.90, 95%CI:1.17-3.08, P < 0.01). Higher 'perceived self-efficacy' did not moderate these associations. CONCLUSIONS: Insight into patients' specific barriers with regard to appropriate statin use may reveal personal reasons for being non-adherent. The Tailored Medicine Inventory is a promising tool to devise individualized intervention strategies aimed at improving adherence by the clinician-patient alliance.

Patients' general satisfaction with telephone counseling by pharmacists and effects on satisfaction with information and beliefs about medicines: Results from a cluster randomized trial.

OBJECTIVE: Assess effects of pharmacists' counseling by telephone on patients' satisfaction with counseling, satisfaction with information and beliefs about medicines for newly prescribed medicines. METHODS: A cluster randomized trial in Dutch community pharmacies. Patients ≥18 years were included when starting with antidepressants, bisphosphonates, RAS-inhibitors or statins. The intervention comprised counseling by telephone to address barriers to adherent behavior. It was supported by an interview protocol. Controls received usual care. Outcomes were effects on beliefs about medication, satisfaction with information and counseling. Data was collected with a questionnaire. RESULTS: Responses of 211 patients in nine pharmacies were analyzed. More intervention arm patients were satisfied with counseling (adj. OR 2.2 (95% CI 1.3, 3.6)). Patients with counseling were significantly more satisfied with information on 4 items, had less concerns and less frequently had a 'skeptical' attitude towards medication (adj. OR 0.5 (0.3-0.9)). Effects on most outcomes were more pronounced in men than in women. CONCLUSIONS: Telephone counseling by pharmacists improved satisfaction with counseling and satisfaction with information on some items. It had a small effect on beliefs about medicines. PRACTICE IMPLICATIONS: Pharmacists can use counseling by telephone, but more research is needed to find out which patients benefit most.

Endocrine therapy for breast cancer: assessing an array of women's treatment experiences and perceptions, their perceived self-efficacy and nonadherence.

BACKGROUND: Although adjuvant endocrine therapy effectively prevents breast cancer recurrence, nonadherence rates are substantial. We therefore examined associations of women's experiences and perceptions regarding the efficacy, side effects, and practical problems of endocrine therapy with nonadherence. Furthermore, we examined whether women's perceived self-efficacy moderated these associations. PATIENTS AND METHODS: Two hundred forty-one breast cancer patients participated. Using the electronic Tailored Medicine Inventory, which enables skipping of irrelevant items, experiences and perceptions were assessed in a comprehensive yet feasible manner. Adherence was assessed according to self-report and evaluated for agreement with adherence estimated from pharmacy refill data. RESULTS: A substantial number of women doubted the efficacy of endocrine therapy, were worried about and/or had experienced hot flushes, loss of libido, joint ache, and/or practical problems with regard to information, intake, and packaging. Experience of practical problems (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.0-5.8) and perceived self-efficacy with regard to medicine intake (OR, 0.5; 95% CI, 0.4-0.7) were associated with unintentional nonadherence. Number of side effects experienced (OR, 1.2; 95% CI, 1.05-1.4) and perceived self-efficacy with regard to learning about medication (OR, 0.6; 95% CI, 0.4-0.96) were associated with intentional nonadherence. Perceived self-efficacy did not moderate associations between women's treatment experiences and perceptions and nonadherence. CONCLUSION: Endocrine therapy is challenging for many women. Targeting women's specific experiences and perceptions and improving their perceived self-efficacy is likely to decrease intentional and unintentional nonadherence.

Effects of a TELephone Counselling Intervention by Pharmacist (TelCIP) on medication adherence, patient beliefs and satisfaction with information for patients starting treatment: study protocol for a cluster randomized controlled trial.

BACKGROUND: Adherence to medication is often low. Pharmacists may improve adherence, but a one-size-fits-all approach will not work: different patients have different needs. Goal of the current study is to assess the effectiveness of a patient-tailored, telephone-based intervention by a pharmacist at the start of pharmacotherapy aimed at improving medication adherence, satisfaction with information and counselling and the beliefs about medicines. METHODS/DESIGN: A cluster randomized controlled intervention trial in 30 Dutch pharmacies, randomly assigned to 1 of 2 intervention groups. Each group consists of an intervention arm and an usual care arm. The intervention arm in the first group is the usual care arm in the second group and vice versa. One intervention arm focuses on patients starting with antidepressants or bisphosphonates and the other on antilipaemic drugs or renin angiotensin system (RAS)-inhibitors. The intervention consists of a telephone call by a pharmacist 2 or 3 weeks after a new prescription. A random sample of pharmacies will send questionnaires 3 months after the first prescription. This contains socio-demographic questions, a measure of beliefs about medicines (BMQ), satisfaction with information received (SIMS, abbreviated) and frequency of pharmacy counselling (Consumer Quality Index, CQI, abbreviated). The primary outcome measure will be medication adherence calculated from dispensing records retrieved 12 months after the intervention. Patients' beliefs on medication, perception of the quality of information received and pharmacy counselling are secondary outcomes. DISCUSSION: The TelCIP study will determine the effectiveness of telephone counselling to improve adherence in patients initiating a new treatment. By measuring satisfaction with information and counselling and beliefs about medication the study will also give clues for the reason of a potential increase in adherence. Finally the study will provide information on which patients are most likely to benefit from this intervention. TRIAL REGISTRATION: The trial is registered at http://www.trialregister.nl under the identifier NTR3237.

Problems experienced by older people when opening medicine packaging.

OBJECTIVE: Medicine packages can cause problems in daily practice, especially among older people. This study aimed to investigate the prevalence of problems experienced by older people when opening medicine packaging and to investigate how patients manage these problems. METHODS: A convenience sample of 30 community pharmacies participated in this study. They selected a systematic sample of 30 patients over 65 years old with a recent omeprazole prescription, and a questionnaire was administered by telephone for at least 10 patients per pharmacy. KEY FINDINGS: A total of 317 patients completed the questionnaire. They received their omeprazole in a bottle (n = 179, 56.5%), push-through blister pack (n = 102, 32.2%) or peel-off blister pack (n = 36, 11.4%). Some 28.4% of all patients experienced one or more problems with opening their omeprazole packaging; most problems occurred with peel-off blisters (n = 24, 66.7% of all respondents using peel-off blisters), followed by push-through blisters (n = 34, 33.3%) and finally bottles (n = 32, 17.9%). The risk of experiencing problems with peel-off blisters and push-through blisters was higher [relative risk 3.7 (95% confidence interval 2.5-5.5) and 1.9 (1.2-2.8), respectively] than the risk of experiencing problems with opening bottles. Two-thirds of respondents reported management strategies for their problems. Most were found for problems opening bottles (n = 24, 75%), followed by push-through blisters (n = 24, 70.6%) and peel-off blisters (n = 14, 58.3%). CONCLUSIONS: One in four patients over 65 experienced difficulties opening their omeprazole packaging and not all of them reported a management strategy for their problems. Manufacturers are advised to pay more attention to the user-friendliness of product packaging. In addition, it is important that pharmacy staff clearly instruct patients on how to open their medicine packaging, or assist them in choosing the most appropriate packaging.

Pharmacy Technicians' Attention to Problems With Opening Medicine Packaging.

Background: Pharmacy technicians seem to be well equipped to engage in conversations with patients about their experiences and problems with medication, but it is unclear whether or not they systematically explain or demonstrate to patients how to use medication packaging. Objective: To explore to what extent pharmacy technicians identify problems with opening medicine packaging and how they assist patients in solving these problems. Methods: We conducted a cross-sectional study that comprised semistructured interviews, with 31 pharmacy technicians in 31 pharmacies, to assess the occurrence and type of difficulties with packagings and to suggest solutions. Results: All pharmacy technicians recognize the occurrence of packaging problems, though patients rarely report them at the pharmacy counter. Not all pharmacy technicians are familiar with opening all packaging forms, but they all describe ways to find out how to open them, which usually only happens after patients bring up problems. Solutions suggested by the pharmacy technicians include informing and counseling, changing or manipulating the packaging, and providing assisting tools. Conclusions: This study shows that although pharmacy technicians are aware that medication packaging can cause problems and are able to name or find out solutions to all these problems, there is no systematic attention for packaging at drug dispensation in most pharmacies. Discussing the handling of medication packaging should become a fixed part of drug dispensation counseling. Pharmacists should draw up working procedures to support pharmacy technicians in their counseling activities.

Disentangling breast cancer patients' perceptions and experiences with regard to endocrine therapy: nature and relevance for non-adherence.

BACKGROUND & STUDY AIMS: Adjuvant endocrine therapy effectively prevents recurrence and progression of estrogen-receptor positive breast cancer. However, studies reveal substantial non-adherence. The objective was therefore to identify the nature of the experiences and beliefs of women treated with endocrine therapy in an attempt to find potential determinants of non-adherence. METHOD: Online Focus Groups (OFGs) and individual interviews were conducted with 37 women who were treated with endocrine therapy. Sixty-three statements derived from the OFGs and 11 belief items from the Beliefs about Medicines Questionnaire (BMQ) were used in a Q-sorting task conducted with 14 of the women. The quantitative Q-sorting data were statistically analyzed with Hierarchical Cluster Analysis. RESULTS: A six cluster solution was revealed that included the clusters 'information', 'efficacy', 'tenacity', 'coping', 'side effects' and 'usage'. Women's own experiences and perceptions were not clearly delineated from the beliefs measured with the BMQ. However, women judged their own experiences and perceptions with regard to endocrine therapy as more relevant for adherence than the BMQ beliefs. CONCLUSION: In order to understand and to improve women's adherence to endocrine therapy, women's own perceptions and experiences about endocrine therapy should be targeted in addition to common beliefs that apply to a wide range of medicines.

Patients' satisfaction with information and experiences with counseling on cardiovascular medication received at the pharmacy.

OBJECTIVE: To assess the extent to which patients feel they have received enough information on cardiovascular drugs and experienced counseling at the pharmacy. In addition, to identify factors that are predictors for patient satisfaction with the information received. METHODS: Fifteen community pharmacies participated. New and chronic users of cardiovascular medication received a questionnaire containing sociodemographic and health questions, a measure of satisfaction with information received (SIMS), beliefs about medication (BMQ), and frequency of pharmacy counseling. RESULTS: Of the 578 respondents, 335 (58%) indicated to be unsatisfied with the information received on 3 or more SIMS items. Patients' age, beliefs about medication, duration of cardiovascular treatment and use of antithrombotics predicted patients' satisfaction with information received. Two-thirds of patients reported 'never' to have experienced 5 of 8 counseling activities at the pharmacy. CONCLUSIONS: A considerable proportion of patients are unsatisfied with the information received on cardiovascular medication. The majority of patients have only received a limited scope of medication counseling at the pharmacy. PRACTICE IMPLICATIONS: Information and counseling should be tailored to patients' needs and concerns about cardiovascular medication and the experience patients already have with treatment. Pharmacists could enhance their role in supporting patients using cardiovascular medication.

The decision to continue or discontinue treatment: experiences and beliefs of users of selective serotonin-reuptake inhibitors in the initial months--a qualitative study.

BACKGROUND: Little is known about patients' views on taking selective serotonin-reuptake inhibitors (SSRIs) and their decision-making processes regarding either continuation or discontinuation within a few months of initiating therapy. OBJECTIVE: To explore the experiences and beliefs of SSRI users in relation to initiation and execution of treatment, with the intention to identify patterns leading to discontinuation or continuation of treatment. METHODS: Semistructured qualitative interview study. Eighteen patients, older than 18 years, were interviewed 3 months after starting SSRI treatment prescribed by a general practitioner (GP), 9 of whom had discontinued (discontinuers) and 9 of whom continued treatment (continuers). RESULTS: Two main patterns lead to either discontinuation or continuation of use. Continuers were satisfied with the GP's role during initiation and execution of SSRI treatment and fully trusted their decision. Continuers' attitudes toward treatment were predominantly positive; they seemed to have little doubt about the necessity of using an SSRI and hardly considered discontinuing for fear of relapse. Discontinuers, on the other hand, seemed to be less involved in decision making and often appeared to have little confidence in their GPs. Most discontinuers felt that they lacked knowledge, and their attitude toward taking SSRIs was rather negative. Discontinuers often were unconvinced about the necessity of using an SSRI and appeared to have a strong desire to discontinue treatment. CONCLUSION: Lack of shared decision making between patient and GP, limited counseling during treatment, lack of knowledge, and patients' negative attitudes toward SSRI use and the disease itself, hampered the acceptance of the SSRI and brought on the decisional conflict to discontinue treatment. Health care professionals could be more supportive during the initial months of SSRI treatment by eliciting patients' considerations for continuing or discontinuing treatment.

Patients' perceptions and illness severity at start of antidepressant treatment in general practice.

OBJECTIVES: Patients' perceptions are important to consider when trying to understand why patients often do not follow prescriptions for antidepressant treatment. This study aimed to investigate the influence of patients' perceptions and illness severity at the start on antidepressant-medication-taking behaviour. METHODS: Eighteen community pharmacies in the Netherlands participated in this 6-month follow-up study. One hundred and ten patients presenting a first antidepressant prescription, prescribed by a general practitioner (GP), were included. A questionnaire was completed at inclusion, after 6 and 26 weeks. KEY FINDINGS: Of all 110 patients, eight (7.3%) did not initiate drug taking, 32 (29.1%) discontinued use, six (5.5%) switched to different antidepressant medication, and 64 (58.2%) continued on the same antidepressant during follow-up. Compared to continuers, non-initiators had lower belief scores for impact of illness (P = 0.044), perceived norm GP (P < 0.001), intention to take medication (P < 0.001), and attitude towards medication (P = 0.004). Furthermore, non-initiators were less severely depressed (P = 0.024). Discontinuers and continuers did not differ in illness severity at inclusion. However, discontinuers more often reported a non-specific reason for use, such as fatigue and sleeping problems (P = 0.014). Compared to continuers, switchers had higher illness severity scores at inclusion (depression, P = 0.041; anxiety, P = 0.050). During follow-up depression and anxiety severity improved for all treatment groups and reached the same level of severity at 6 months. CONCLUSIONS: Patients' illness and treatment perceptions and illness severity influence their decisions about antidepressant drug taking. Patients' care could be improved by eliciting patients' beliefs about illness and treatment and assessing illness severity before prescribing.

Problems with medicine packages: experiences reported to a Dutch medicine reporting system.

BACKGROUND: Practical issues such as ease of use and packaging appear to cause significant problems in daily use of medicines, but there are only few published studies about these aspects of medicine use. OBJECTIVE: To assess the type of experiences related to practical aspects of medicine use reported to an Internet-based medicine reporting system (www.meldpuntmedicijnen.nl). METHODS: All reports submitted from May 2004 to December 2007 to an Internet-based medicine reporting system in the Netherlands related to practical aspects of drug use were analyzed. The experiences were grouped into the following categories: difficulty with opening the package, other difficulties with use, and problems with printed text on packages and the information leaflet. RESULTS: Of the 5175 individuals who submitted a report, 530 submitted 611 reports on practical aspects of medicine use. More than half of the reports concerned difficulties with the opening of packages, mostly about opening blister packages (46.2%). One third of the reports were related to other problems with use, mainly package size (13.0%) and preference for different packaging (8.5%). About 1 in 10 reports was related to the printing and information on packages, mostly about unclear and confusing text print on the primary package (5.7%). In all, 25.2% of the reporters informed their prescribing physician of the problem and 38.2% informed the pharmacist or pharmacy staff. CONCLUSIONS: Some medicine users experience considerable difficulties with the packaging of their drugs; one of the major issues is opening a blister package. Packaging of pharmaceuticals needs more attention; issues need to be addressed by the pharmaceutical manufacturers, registration authorities, and, most immediately, community pharmacists.

Patients' perceptions of information received at the start of selective serotonin-reuptake inhibitor treatment: implications for community pharmacy.

BACKGROUND: Pharmacists are increasingly acknowledging their responsibility to inform and counsel patients. However, it is unclear how these tasks are implemented and whether patients' needs are being fulfilled. OBJECTIVE: To examine patients' perceptions of information received at the start of selective serotonin-reuptake inhibitor (SSRI) treatment, aiming to identify (1) information needs and (2) the potential role of the community pharmacist as information provider. METHODS: A qualitative descriptive study comprising semi-structured telephone interviews was carried out with patients who had recently started a new course of SSRI treatment. Patients were recruited through 6 Dutch community pharmacies. The interviews were guided by the following topics: type of information obtained, unmet information needs, preferred information provider, and the role of the pharmacist. RESULTS: Forty-one patients took part in an interview. Information needs varied widely among patients; overall, patients felt that they would benefit from information tailored to their needs. Many patients required more concrete and practical information on adverse effects and delayed onset of action than was provided. In addition, an explanation of the term dependency in the context of SSRI use and a discussion of the necessity for use and believed harms of long-term treatment were important to patients. Regardless of patients' needs, the role of the pharmacist was generally perceived as limited, and patients identified several pharmacy-related barriers to improved communication, including the timing of information (mainly restricted to first-time dispensing), lack of time and privacy, lack of empathy and a protocol-driven way of providing information, and inexperience of pharmacy technicians. CONCLUSIONS: Patients starting treatment with antidepressants may benefit from information tailored to their personal needs. Along with the prescribing physician, community pharmacists could have an important role in informing and counseling patients.

Initiation of antidepressant therapy: do patients follow the GP's prescription?

BACKGROUND: The question whether patients actually start drug taking after having received a first antidepressant prescription is often overlooked. AIM: To determine the incidence of patients who do not fill or fill only a single antidepressant prescription at the pharmacy, and to identify associated patient characteristics. DESIGN OF STUDY: Retrospective study linking a general practice to a pharmacy dispensing database. SETTING: General practice in the Netherlands. STUDY POPULATION: patients who received a first-time antidepressant prescription from a GP. Three patient groups were identified: patients who did not fill the prescription (non-fillers); patients who filled only a single prescription (single Rx-fillers); and patients who filled at least two consecutive prescriptions. Non-fillers and single Rx-fillers were combined into a group of decliners. RESULTS: Of all 965 patients, 41 (4.2%) did not fill the prescription, and 229 (23.7%) filled only a single prescription. Patients who consulted their GP for a non-specific indication, rather than for depression, anxiety, panic, or obsessive-compulsive disorder, were almost three times more likely (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.8 to 3.9) to decline treatment. Further, the risk of declining was almost fivefold higher (OR = 4.8, 95% CI = 2.1 to 11.3) in non-Western immigrants, and almost twofold higher (OR = 1.8, 95% CI = 1.2 to 2.8) in patients >60 years of age. CONCLUSION: Over one in four patients who receive a first-time antidepressant prescription decline treatment; they either do not initiate drug taking or do not persist with antidepressant use for longer than 2 weeks.

Does the length of the first antidepressant treatment episode influence risk and time to a second episode?

Antidepressant treatment in primary care is inconsistent with treatment recommendations, and many patients discontinue treatment within 6 months. How this affects treatment outcomes is unknown. The aim of this study was to assess how length of the first antidepressant episode influences risk and time to a second treatment episode within 5 years.The study population included 9423 adults (67% women; mean age, 47.3 years) who initiated selective serotonin reuptake inhibitor use in 1998 or 1999. Based on the length of the first antidepressant treatment episode, patients were divided into early discontinuers (<6 months), continuing users (6-12 months), and persistent users (>12 months). The Cox proportional hazards model was used to estimate risk ratios (RRs) for the association between the length of the first antidepressant treatment episode and time to reinitiating antidepressant treatment.Time to a second treatment episode did not differ significantly between continuing users and early discontinuers (RR, 0.99; 95% confidence interval, 0.92-1.07). Persistent users showed a higher risk of experiencing a second treatment episode than early discontinuers (RR, 1.23; 95% confidence interval, 1.15-1.32).In conclusion, the risk of experiencing a second antidepressant treatment episode did not differ for those who used antidepressants for 6 to 12 months and those who discontinued early. In general, there is limited information on how length of an antidepressant treatment episode influences the risk of reinitiating treatment of patients in primary care. More research is needed to investigate the effectiveness of antidepressant drug treatment patterns in preventing relapse or recurrence in primary care populations.

Characteristics and reasons associated with nonacceptance of selective serotonin-reuptake inhibitor treatment.

BACKGROUND: Studies have shown that up to 38% of patients who start treatment with antidepressants fill only a single prescription at the pharmacy, apparently not accepting treatment. OBJECTIVE: To determine characteristics and reasons associated with nonacceptance of selective serotonin-reuptake inhibitor (SSRI) treatment. METHODS: A retrospective study was conducted in 37 community pharmacies in the Netherlands; patients who presented a prescription from a general practitioner (GP) for a newly started SSRI treatment were selected. Nonaccepters were defined as patients who filled only one SSRI prescription; patients who received at least 3 fills of an SSRI prescription were defined as accepters. Patient characteristics were obtained from automated dispensing records and from questionnaires. Areas of evaluation included sociodemographics, disease, and treatment. Nonaccepters were asked their reasons for not filling second prescriptions. RESULTS: Of the patients who started SSRI treatment, 22.0% were nonaccepters, filling only a single prescription. Fifty-seven nonaccepters and 128 accepters were included in our analysis. Nonacceptance was more common among patients with a low level of education (OR 2.6; 95% CI 1.1 to 5.9) and in patients who reported nonspecific symptoms like fatigue, stress, and restlessness as the reason for SSRI use (OR 2.7; 95% CI 1.4 to 5.5). Of the nonaccepters, 29.8% (n = 17) did not start SSRI use, and 70.2% (n = 40) discontinued SSRI use within 2 weeks. Fear of adverse effects and the actual occurrence of adverse effects were main reasons for not accepting SSRI treatment. Of the nonaccepters, 55.0% discontinued treatment without informing their GPs. CONCLUSIONS: Acceptance of SSRI treatment is a decisive moment in a patient's adherence to treatment initiated by his or her GP and deserves more attention; GPs and pharmacists should address treatment issues, especially in groups at risk for nonacceptance.