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Article history:
Received 25 February 2010
Accepted 17 July 2010
Available online xxxx
Keywords:
Depression
Knowledge and attitudes
Measuring adherence
Antidepressants
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).
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
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
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
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
medication?
4. When you felt worse, do you sometimes stop taking your
medication?
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
medication?
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
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)
Total
knowledge
score
Subscale 3 etiology
Subscale 4
presentation and
symptoms
Forgot
Careless
Stopped when felt better
Stopped when felt worse
0.20
0.43
0.42
0.20
0.13
0.12
0.12
0.26
0.09
0.05
0.08
0.234
0.01
0.30
0.30
0.06
0.11
0.36
0.36
0.25
0.14
0.14
0.27
0.19
Subscale 1
accepting
treatments
Forgot
Careless
Stopped when felt better
Stopped when felt worse
0.12
0.02
0.03
0.028
0.10
0.03
0.01
0.09
0.04
0.03
0.03
0.18
0.13
0.18
0.03
0.14
Subscale 5 preferring
psychotherapy
0.10
0.03
0.01
0.09
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
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.
Acknowledgements
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