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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 121-127

Dropout rates and reasons for dropout from treatment among elderly patients with depression


Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication27-Dec-2018

Correspondence Address:
Dr. Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgmh.jgmh_29_17

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  Abstract 


Background: Adherence to medical treatment is a major challenge. A significant proportion of patient's dropout of treatment after the initial visit. Little is known about the reasons for such high dropouts. Aim: This study aimed to evaluate the dropout rates and reasons for dropout from treatment among elderly patients with depression attending a tertiary care psychiatry outpatient facility. Methodology: One hundred and forty consecutive new patients aged 60 years or more, attending the psychiatry walk-in clinic, diagnosed with depressive disorders were assessed at baseline and then contacted at 6 months and 1 year to evaluate the follow-up status and reasons for dropout of treatment. Results: Out of the 140 participants, 132 could be contacted after initial registration with the clinic. About two-fifths (n = 58; 41.4%) never return back to the clinic after the first visit. By 6 months and 1 year, 105 (75%) and 126 (90%) patients had dropped out of treatment. When the reason for dropout of those who dropped out “very early (i.e., never returned back)” were evaluated, the most common reason for dropout was “no relief” of symptoms, and this was closely followed by complete relief of symptoms. Among those who followed up at least once, but had dropped out at 6 months, the most common reason for dropout was complete relief of symptoms, and this was closely followed by “no relief” and “worsening of illness” being the other common reasons of dropout. Among those who dropped out after 6 months, the most common reason for dropout was complete relief of symptoms. None of the demographic variable emerged as a predictor of dropout at any time point. Few clinical variables were associated with dropout of treatment. Conclusion: Very high proportion of elderly patients with depression dropout of treatment prematurely. Providing proper information to the patients at each visit can help in reducing the treatment dropout rates.

Keywords: Adherence, depression, dropout, elderly


How to cite this article:
Grover S, Mehra A, Chakrabarti S, Avasthi A. Dropout rates and reasons for dropout from treatment among elderly patients with depression. J Geriatr Ment Health 2018;5:121-7

How to cite this URL:
Grover S, Mehra A, Chakrabarti S, Avasthi A. Dropout rates and reasons for dropout from treatment among elderly patients with depression. J Geriatr Ment Health [serial online] 2018 [cited 2019 Oct 17];5:121-7. Available from: http://www.jgmh.org/text.asp?2018/5/2/121/248626




  Introduction Top


Depression is one of the most common psychiatric disorders seen among elderly patients.[1] Community-based studies have estimated the prevalence of major depressive disorder in geriatric population to range from 1% to 5%, with higher prevalence among those with physical illnesses.[2] However, besides syndromal depression, a significant proportion of patients also experience subsyndromal depressive symptoms.[3] Depression among elderly is associated with high suicide rates,[4] negative impact on comorbid physical illness,[3] higher medical morbidity,[3] higher mortality,[5] higher risk of suicide,[5] higher rates of cognitive dysfunction and poor social functioning,[3] more health-care utilization,[6] and higher self-neglect.[3] However, depression among elderly is often overlooked, underdiagnosed, and undertreated.[7] Hence, it is not only important to recognize but also to treat depression adequately.

However, studies across all age groups suggest that medication and treatment adherence is poor among patients with mental disorders. The medication nonadherence rates have been reported to range from 18% to 93%[8],[9],[10] for different psychotropics with an average of about 50%,[11] and the treatment nonadherence rates have also been reported to range 14%–64%[12],[13],[14] with an average rate of 31.7%.[15] Treatment nonadherence can be understood as “missed appointments,” “partial adherence,” and “dropout of treatment.” “Dropouts of treatment” is understood as complete disengagement from the medical facility and there is no further follow-up. A patient is considered to have dropped out if he or she terminates treatment before an arbitrary period of treatment (e.g., 6 months to a year), when either a clinical resolution has not been achieved, or a termination has not been agreed on, or both.[12],[14] This type of dropout is often operationally defined as “having attended at least one session for the diagnostic assessment or treatment and discontinuing the assessment or treatment process on the patient's own initiative by failing to attend any further planned visit.”[13],[16]

Few studies have focused on dropout rates and treatment nonadherence among elderly patients with mental disorders. Data suggest that treatment dropout rates among elderly with depression vary from 13% to 52%.[17],[18],[19],[20],[21] In terms of reasons for dropout, some of the studies have evaluated the predictors of dropout among elderly patients with depression. One of the studies, which compared elderly with young patients, reported that although younger patients reported higher perceived stigma than the elderly patients, but stigma predicted treatment discontinuation among the elderly only.[22] Another study from the Netherlands, evaluated the ethnic similarities and differences in treatment of depression at the outpatient level, reported that timeliness and treatment intensity was better for ethnic Dutch patients when compared with Moroccan, Turkish, and other non-Western patients.[23]

There are few studies from India, which have focused on the dropout rates of patients attending the psychiatric outpatient services of the general hospital psychiatric units,[15],[24],[25],[26],[27],[28],[29],[30] “Walk-in clinics” services of mental hospitals,[31] dropout rates of patients attending rural psychiatric clinics,[32] and a private psychiatric clinic.[33] The dropout rates across the different studies have varied between 21% and 59%, depending on the definition used for “dropout.” Most of these studies suggest that, majority of the patients, who dropout, do so after their initial visit. Dropout rate after initial visit from the rural psychiatric clinic was reported to be as high as 52%[32] and from the private psychiatric clinic to be 50%.[33] Factors which have been shown to be associated with treatment dropout include male gender, long distance, long waiting time, longer duration of illness, poor motivation for treatment, belonging to rural background, being illiterate, and poor treatment satisfaction.[34],[35],[36],[37],[38],[39],[40] Another recent study from Gujarat evaluated the dropout rates of patients attending the psychiatry outpatients and reported dropout rates of 51.94%–59.56% after the first visit.[41]

Although many studies have evaluated the dropout rates, there is a dearth of information about the reasons for dropout from treatment. A study from India evaluated the reasons for dropout from the psychiatric outpatient clinic. This study included 180 newly diagnosed patients, out of whom 14.4% (n = 26) dropped out of treatment after the initial visit and another 7.7% (n = 14) dropped out of treatment after the second visit. With the passage of time, the dropout rate decreased. The common reasons reported to retain the patient in the treatment net included trust, rapport, first-dose effect, and immediate response to patient query. Patients, who dropped out of treatment after 3–4 visits, did so due to side effects, treatment response, economic factor, and distance and timings of the outpatient clinic.[42] Surprisingly, there are no studies on dropout rates and reasons for the treatment dropout among elderly patients with depression from India. Accordingly, this study aimed to evaluate the dropout rates and reasons for dropout from treatment among elderly patients with depression attending a tertiary care psychiatry outpatient facility.


  Methodology Top


This naturalistic, longitudinal, follow-up study was carried out at the Outpatient Setting of a tertiary care hospital in North India. This study was approved by the ethics committee of the institute, and all the patients were recruited after obtaining written informed consent.

Any patients can walk-in to the psychiatry outpatient clinic. For registration with the clinic, the patient has to pay only rupees 10. Thereafter, no fee is collected for subsequent consultations for 6 months. All the patients who were registered with psychiatry outpatient clinic are initially assessed by a senior resident (qualified psychiatrist), who on the basis of information provided by the patient, accompanying family members and mental status examination makes a clinical diagnosis as per the International Classification of Diseases, tenth revision (ICD-10). Depending on the need, patients are started on psychotropic medications. Few psychotropic, such as imipramine, trifluoperazine, chlorpromazine, lithium, escitalopram, olanzapine, and alprazolam are provided free of cost from the hospital's dispensary. These medicines are dispensed for 1 month, after which patient is required to come for refill. If medications other than those available in the dispensary are prescribed than the patient has to pay from their own pocket. After the initial evaluation, patients are given a follow-up date for a subsequent visit after a period ranging from 1 week to month. In subsequent visits, the patients undergo detail evaluation, by a junior resident (MD trainee), and the case is discussed with the consultant, and a final diagnosis is made based on the available information, medical records, mental status examination, and investigations if available. The diagnosis is made as per the ICD-10 criteria. Based on the final diagnosis, a management plan is formulated. Depression is usually managed with pharmacological measures (antidepressant, antipsychotics, and anxiolytics depending on the need), nonpharmacological measures (psychotherapy), electroconvulsive therapy, and repetitive transcranial magnetic stimulation. Consultations are sought from specialists from other departments in the institute, based on the type of physical comorbidity. Most of the patients are managed on outpatient basis, and few are admitted for 2–6 weeks in the psychiatry inpatient unit. Many patients from other departments are also referred for management of psychiatric morbidity.

For this study, consecutive new patients aged ≥60 years, attending the psychiatry walk-in clinic, diagnosed with depressive disorders were approached. To be included in the study, the patients were required to have an episode of depression, lasting for >1-month duration. Patients who were very sick, uncooperative, or refused consent were excluded from this study. Patients with bipolar depression and comorbid dementia were also excluded.

Data presented as part of this paper originated from the longitudinal study, which evaluated the course and outcome of depression among elderly patients attending the psychiatry outpatient services of a tertiary care hospital. This study evaluated the medication adherence, treatment adherence, and outcome of depression by 1 year of registration with the clinic. As part of this study, patients diagnosed with depressive disorders as per the ICD-10 were followed up at 6 months and 1 year. Those who dropped out (i.e., did not attend the psychiatry services, beyond 1 month of the scheduled appointment) were contacted telephonically and asked the reasons for disengagement from the services. Management was not interfered in any manner as part of this study. Data in relation to dropout pattern is being published separately.[43] In this paper, data in relation to reasons for dropout from treatment are discussed.

At the baseline, besides assessment of sociodemographic and clinical profile, patients were assessed on Geriatric Depression Scale (GDS-30),[44] Patient Health Questionnaire-15 (PHQ-15),[45] Generalized Anxiety Disorder-7 (GAD-7),[46] and Attitude toward the psychotropic medication scale.[47]

Follow-up pattern, improvement, and reasons for dropout

All the patients were telephonically contacted at 6 months (±7 days) and 1 year (±7 days) after initial registration. At this assessment, they were asked about their follow-up pattern, which was also cross checked from the treatment records and registration counter (i.e., number of follow-ups after initial registration, appointment missed, and last follow-up date) and current level of symptoms (rated on a 100-point Likert scale). Those who had dropped out (i.e., had not followed up beyond 1 month of their last scheduled date) were asked about their reasons for dropout. For this patients/their primary caregivers who accompanied the patient to the hospital at the initial visit were asked an open-ended question and their responses were noted down. If patients/relative gave more than one reason for dropout, all the responses were recorded.

Descriptive analysis included determination of mean and standard deviation (SD) for continuous variables and frequencies along with percentages for categorical variables.


  Results Top


This study included 140 patients. The mean age at the time of assessment was 65.4 (SD-5.4) years. The mean duration of formal school education for the study participants was 8.5 (SD-5.7) years. Majority of the participants were male (62.9%), currently married (79.3%), from nonnuclear families (63.6%), and middle socioeconomic status (62.1%). Participants from the rural background (53.6%) outnumbered those from urban background. About two-fifth (39.3%) of the participants were on paid employment.

Majority of the patients had first episode depression (62.1%) and others had recurrent depressive disorder (37.9%). The duration of the current episode was 9.1 (SD-19.8) months. In most of the patients, the depressive episode was of insidious onset (97.9%), and one-fourth (22.1%) of patients had a significant life event as a precipitating factor for the current episode. About two-third of the patients had at least one comorbid physical illness, with hypertension being the most common physical comorbidity seen in 67 (35.7%) patients, and this was followed by diabetes mellitus in 30 (21.4%) patients. Other comorbidities such as cataract (n = 20; 14.3%), hypothyroidism (n = 2; 1.4%), Parkinson's disease (n = 5; 3.6%), both diabetes mellitus and hypothyroidism (n = 5; 3.6%), and other physical comorbidities (n = 11; 7.85%) were present in few patients. Few patients were also diagnosed with a comorbid psychiatric diagnosis (n = 21). Except for one patient, all patients were prescribed antidepressants at the initial visit. Among the antidepressants, the most common drug prescribed was escitalopram (n = 53; 40.7%), followed by mirtazapine (n = 45;32.1%), sertraline (n = 13; 9.3%), venlafaxine (n = 11; 7.9%), imipramine (n = 7; 5%), amitriptyline (n = 3; 2.1%), fluoxetine (n = 2;1.4%), clomipramine (n = 1; 0.7%), and dothiepin (n = 1; 0.7%). Half of the patients were prescribed benzodiazepine, and among it, clonazepam was the most common drug. Only 17 patients were prescribed antipsychotics. Majority of the patients (n = 97) were on more than one medication. The mean GDS score of the study sample was 23.8 (SD-7.39; range: 10–30). Majority of the participants (n = 65; 83.6%) had severe depression as per GDS (i.e., a score of ≥ 20). In terms of severity of somatic symptoms, the mean PHQ-15 total score was 7.35 (SD-3.5; range 1–14); about two-third of the patients had mild somatization (n = 77; 60.2%) as indicated by total score of 5–9. The mean GAD-7 score for the study sample was 11.3 (SD-5.1; range 2–21). More than half of the patient had moderate-to-severe anxiety. Majority of the patients had a favorable attitude toward psychotropic medications. The mean positive attitude subscale score was 17.3 (SD-3.1), and the mean negative attitude subscale score was 23.3 (SD-3.2). Overall total attitude toward psychotropic scale score was 40.6 (SD-4.9).

Dropouts at different time points

Out of the 140 participants, 132 could be contacted at 6 months and/or at 1 year after initial registration with the clinic. The small proportion (n = 8) could not be contacted because of wrong phone numbers and on reviewing their treatment details, it became apparent that they had never followed up after the initial visit. A significant number of patients, i.e., 58 (41.4%) never return back to the clinic after the first visit. By 3 months, about two-third (65.7%; n = 92) dropped out from the clinic. By 6 months, 105 (75%) patients dropped out of treatment. By 1 year, 126 (90%) patients had dropped out of treatment. During the 1-year period, out of the 132 patients whose information was available, only 4 patients had expired (expired at 2 months [n = 1], 5 months [n = 1] and 8–9 months [n = 2]). Overall mean number of follow-up to 1 year was 2.2 (SD-2.7; range 0–14; median 1.0). The pattern of dropout is shown in [Table 1].
Table 1: Follow-up and dropout pattern of the study sample (n=140)

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Demographic and clinical predictors of dropout

Depending on the dropout status (very early, early, intermediate, and late dropout), predictors for dropout were evaluated. Compared to patients who continued to follow-up after the initial visit, those who dropped out of treatment after the first visit (very early dropout; n = 58) more often had acute onset of illness (FE = 0.016*), had a precipitating factor for the onset of the illness (χ2= −4.74; P = 0.029*), had a comorbid physical illness (χ2= −3.93; P = 0.047*), and lower somatic symptom severity as assessed by PHQ-15 (t-test = −2.23; P = 0.027*). Both the groups did not differ on any of the other demographic and clinical variables, including attitude toward medication.

When those who dropped out early from the treatment (n = 91) were compared with those who were on regular follow-up at 3 months (n = 39), both the groups did not differ significantly on any of the demographic and clinical variables, including attitude toward medication. Similarly, when the “intermediate dropout (i.e., by 6 months)” (n = 103) were compared with rest of the sample (n = 35), significant differences were seen in the lower number of medications being prescribed (t-test = −3.037; P = 0.003), lower severity of GAD score at the baseline (t-test = −2.415; P = 0.017), and lower severity of GDS score at the baseline (t-test = −2.322; P = 0.022) in the intermediate dropout group.

Reasons for dropout

Out of the 126 patients who dropped out, 114 patients could be contacted. As stated earlier, 8 patients could not be contacted, and 4 had expired. Information for dropout was available for 95 patients at 6 months and for another 19 patients at 1 year. Patients had the option of giving more than one reason for dropout from treatment. As shown in [Table 2], among those who dropped out within 6 months of registration with the clinic, the most common reason for dropout was complete relief of symptoms (45.3%), and this was followed by no relief of symptoms (28.4%) and worsening of illness (13.7%). Among those who dropped out at 6 months to 1 year, the most common reason for dropout was complete relief and this was followed by “not willing to follow-up” (21.1%) [Table 3].
Table 2: Reason of dropout

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Table 3: Reasons for dropout of patients who did not follow-up at least once (n=50) and those followed up at least once after registration

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When the reason for “very early” dropout were evaluated, the most common reason was “no relief” of symptoms and this was closely followed by complete relief of symptoms. Among those who followed up at least once, but had dropped out at 6 months, the most common reason for dropout was complete relief of symptoms, and this was closely followed by “no relief” and “worsening of illness” being the other common reasons of dropout. Among those who dropped out after 6 months, the most common reason for dropout was complete relief of symptoms.


  Discussion Top


Treatment nonadherence can lead to huge personal and social costs. At the level of the sufferer, treatment nonadherence can lead to poor quality of life, difficulty in daily functioning, inability to take care of self, deterioration in one's mental health status, and relapse of depression. At the societal level, treatment nonadherence can lead to increased costs mainly arising out of the loss of productivity due to absenteeism and premature retirement.[12],[48],[49],[50] Hence, it is important to have more information about the reasons for dropout among elderly patients with depression. To the best of our knowledge, this is the first study from India, which evaluated the reasons for dropout of treatment among elderly patients with depression.

In the present study, 90% of the elderly patients, moved out of the treatment by 1 year. Majority of the dropouts (n = 58; 41.4%) occurred after the initial registration, without any subsequent follow-up visits. Over the period, although the proportion of patient who dropped out from treatment kept on reducing, that is, by 3 months additional 24.3%, at 6 months additional 9.3% and by 1 year 15% patients dropped out of treatment. During the 1-year period, out of the 132 patients whose information was available, only 4 patients had expired (expired at 2 months [n = 1], 5 months [n = 1], and 8–9 months n = 2). Overall mean number of follow-up during the 1-year period was 2.2 (SD-2.7; range 0–14; median 1.0). The dropout pattern noticed in the present study is similar to that noted in earlier studies from India which have evaluated adult patients, which also suggest high dropout rate after the initial registration with the clinic and gradual decline in dropout rates with the passage of time.[42] The very high dropout rates after the initial visit should be a cause of concern. In terms of reasons for dropout of treatment, the most common reasons reported by patients who dropped out early (i.e., after the first visit) were no relief of symptoms and complete relief of symptoms. Other common reasons reported were worsening of illness, long distance, poor family support, partial relief of symptoms, side effects, presence of physical illness, not prescribed medications and belief that they do not have psychiatric illness.

The previous studies which have evaluated the predictors of treatment dropout in patients with psychiatric disorders suggest that, treatment dropout rates are higher among patients who are young, male, living alone, have lower level of education, divorced, unmarried or widowed, from lower socioeconomic status, unemployed, are in job of lower social scale, lower level of treatment satisfaction, higher severity of illness at the baseline, lack of previous history of psychiatric treatment, prescription of only pharmacotherapy or psychotherapy (in contrast to prescription of both), involvement of more than one therapist in the treatment, and lack of past psychiatric history.[51] Studies from India have reported male gender, long distance, long waiting time, longer duration of illness, poor motivation for treatment, belonging to rural background, being illiterate and poor treatment satisfaction to be associated with dropping out of treatment.[25],[26],[27],[28],[29],[30],[31],[32],[33]

In the present study, none of the demographic variables was found to be associated with dropout at any time after the initial registration with the clinic. Among the clinical variables, having acute onset of illness, life event as precipitating factor for the onset of the illness, presence of comorbid physical illness, and lower somatic symptom severity were associated with early dropout rates. When the findings of the present study are compared with the existing literature, certain differences are noted. These differences could be due to methodological differences such as inclusion of patients of all age group (elderly vs. all age group), type of setting (public sector vs. private setting), and diagnostic variance (depression vs. any psychiatric diagnosis). Withstanding these differences, it can be said that the factors associated with dropout of treatment among elderly may be different than those seen other age groups. In the present study, later dropout (i.e., by 6 months) was associated with prescription of lower number of medications, lower severity of anxiety, and depression at the baseline. These findings are supported by the existing literature which suggests that lower severity of illness is associated with high dropout rates.[52],[53]

When the reason for dropout was enquired from patients, those who dropped out of treatment after the initial registration reported lack of relief (38%) as the most common reason for dropout. A small proportion of patients also reported worsening of illness (12%) and partial relief (4%) of symptoms as the reasons for dropout. However, about one-third (36%) of the patients also reported “complete relief of symptoms” as the most common reason for dropout of treatment. However, when the reasons for dropout of treatment of all the patients who had dropped out of treatment were considered, complete relief of symptom was the most common reason for dropout, suggesting that with the passage of time, lack of relief as a reason for dropout decreases. As there is lack of data among elderly patients with depression, it is not possible to compare the findings with the existing literature. However, when these findings are compared with the existing literature for adult patients with various psychiatric disorders, certain similarities emerged. The studies involving heterogeneous psychiatric diagnostic groups of any age group have also reported that lack of relief of symptoms and complete relief of symptoms as common reasons for dropout of treatment.[42],[54]

About half of the patients who dropped out of treatment after the initial registration with the clinic reported “lack of relief/partial relief/worsening of illness” as a reason for their dropout. This finding reflects the basic human nature, where everyone wants to get rid of the illness as early as possible. However, it is well known that antidepressant medications are associated with a lag period and paradoxical worsening of anxiety. Hence, the expectation or experience of the patient does not match the clinical premise and contributes to high dropout rates. Keeping this fact in view, it is important for the clinicians to psychoeducate the patients at the initial visit about the lag period, paradoxical worsening of symptoms, and expected side effects. In addition, patients must be informed that they can report back early to the clinician in case they are not improving or their symptoms are getting worse. Further, this finding also suggests that there is a need to develop innovative methods to reduce the early dropout rates. This can be done by providing a telephonic access to the patient, in case they feel the need to contact the treating team.

A significant proportion of patients also dropped out of treatment due to “complete relief of symptoms.” Previous studies have also reported reasons such as first dose effect to be associated with early dropout of treatment.[42] The proportion of patients who reported complete relief of symptoms as the reason increased with the passage of time. This possibly reflects that patients own decision to stop treatment and lack of collaboration between the patients and the therapist in terms of determining termination of treatment. This also suggests that there is a need on the part of the clinicians to inform the patients about the continued need for treatment despite relief of symptoms. Accordingly, at every visit clinicians should inform the patients that they need to continue medications, despite relief of symptoms and any decision to stop treatment must be discussed with the clinicians. Similarly, the issue of worsening of illness due to noncompliance or stoppage of medications must be addressed.

A small proportion of patients attributed the dropout of treatment to medication side effects. This finding is supported by previous studies[42],[55],[56],[57],[58] and suggest that patients need to be informed adequately about the anticipated side effects and what to do in case they experience side effects.

Other treatment facility related reasons which were reported less frequently included willingness to follow-up with senior clinicians, long waiting time, and long distance. These findings suggest that patient's wishes about treatment must be respected. Further long waiting time can be addressed by scheduling the appointments at a particular time during the follow-up. Long distance as a reason for dropout has been mentioned in a number of previous studies done on adult populations.[29],[31],[59] Long distance as a reason for dropout basically reflects lack of mental health services at the community level and the need to develop the same at the priority for the elderly.

Other less common reasons for dropping out of treatment in the present study included logistic reasons such as distance, lack of family support, undergoing a surgery, having a physical illness, being out of station, problems at home, and accident suggest that logistic reasons are not the most common reasons for dropout. The previous studies among adult patients have also reported poor family support is the reason for treatment dropout.[55],[56],[57],[58]

The present study has certain limitations in the form of small sample size and patients attending the psychiatry outpatient clinic of a public sector tertiary care hospital. Hence, the findings cannot be generalized to other treatment settings. The present study evaluated the reasons for dropout by asking one open-ended question, and no specific instrument or checklist was used to evaluate all the reasons for dropout. It is quite possible that there could be more reasons for dropping out of treatment. The present study did not evaluate the specific side effects associated with disengagement from treatment. This study did not evaluate the therapist-related variables and attitude and knowledge of patients toward mental illness. The future studies must evaluate these factors to improve knowledge in this area.


  Conclusion Top


This study shows that a very high proportion of elderly patients with depression dropout of treatment. Majority of the dropouts are possibly related to the lack of information provided to the patients about the treatment. Providing proper information to the patients about the lag period of antidepressants for relief of symptoms, paradoxical anxiety with antidepressants and how to manage the same, side effects of antidepressants and how to deal with them and need for continuation of treatment despite relief of symptoms can help in reducing the treatment dropout rates.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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