From concordance to persistence: Improving medication engagement in depression and other psychiatric disorders

Concordance in psychiatry prescribing indicates the extent to which what the patient thinks about what is asked from him matches what the health caregiver thinks the patient actually does.^1,2

This concept represents a fundamental shift in psychiatric care delivery, recognizing that successful pharmacotherapy outcomes depend not only on prescribing the appropriate medication but also on establishing a partnership that respects patient beliefs, addresses concerns, and supports sustained engagement with treatment.^2,3 For healthcare professionals working with patients experiencing mental health conditions, understanding the distinctions between concordance, persistence, and treatment engagement provides essential foundations for improving long-term therapeutic outcomes in diverse global settings.^4,5

What is “Concordance” in psychiatry prescribing?

Concordance in psychiatric prescribing is a patient-centered consultation process that emphasizes shared decision-making, mutual respect, and negotiated agreement between healthcare professionals and patients regarding medication use.^6,7 Unlike the traditional paternalistic concept of “compliance”—which measures whether patients follow prescriber instructions—concordance recognizes patients as active partners who bring valuable expertise about their own experiences, preferences, values, and treatment goals.⁷

A meta-analysis found that approximately half of major psychiatric disorder patients were non-adherent to their psychotropic medication. Of these, psychotropic medication non-adherence for schizophrenia, major depressive disorders, and bipolar disorders were 56%, 50%, and 44%, respectively.⁸

While unintentional factors such as forgetfulness do contribute to missed doses, effective adherence cannot be achieved by focusing solely on memory-related lapses; instead, healthcare professionals must address the broader patient‑related drivers—such as beliefs about medication, perceived need, stigma, insight, and emotional responses—which are central to both intentional and unintentional non‑adherence, and best explored through a collaborative, concordant, shared decision‑making approach.²

Research demonstrates that when healthcare professionals engage in concordant prescribing—actively exploring patient beliefs about illness and treatment, addressing stigma and side effect concerns, and incorporating patient priorities into treatment planning—medication adherence improves.²

Practical application of concordance

Concordance in psychiatric care is strengthened when clinicians use communication strategies that actively uncover and address patients’ concerns, beliefs, and expectations. Evidence shows that both verbal and non‑verbal communication—such as clear explanations, empathic responses to emotional cues, attentive listening, and open body language—directly influence the therapeutic relationship, patient satisfaction, and adherence to treatment. By creating a consultation environment where patients feel understood and respected, clinicians support the alignment between what is asked of patients and what patients feel able and willing to do—central to achieving concordance.⁹

Supporting concordance also requires shared, collaborative decision‑making in which patients are invited to articulate preferences, consider options, and negotiate goals.⁹ Involving patients meaningfully in treatment decisions is associated with better adherence and satisfaction in bipolar disorder, and that structured methods—such as checklists, agenda‑setting, or tools like DIALOG+—help patients voice priorities and shape decisions alongside clinicians. Framing treatment transparently and optimistically when appropriate, while remaining sensitive to patient experience, further enhances alignment. Through these practices, clinicians move beyond compliance toward a partnered model that supports sustained engagement and truly concordant prescribing.⁹

What is “Persistence” for antidepressants?

Persistence is the time from initiation (first dose) to discontinuation (last dose before stopping) of antidepressant therapy.⁴ It reflects how long a patient remains on treatment, independent of day‑to‑day dosing accuracy, which is captured instead by implementation.⁵

For antidepressants, adequate persistence is essential in moderate-to-severe depression, as WHO clinical guidelines recommend continuing treatment for at least six months after remission to reduce the risk of relapse.¹⁰ Early discontinuation therefore undermines therapeutic effectiveness.¹¹

It is important to note that the 6-month minimum is measured from the point of remission, not from initiation, a clinically meaningful distinction.¹⁰ A retrospective observational study reported that 56% of patients were adherent to antidepressant (AD) therapy, whereas only 44.3% remained persistent through 6 months, suggesting that the majority patient discontinued treatment before completing the recommended minimum duration for therapeutic benefit.¹²

Clinical significance of early discontinuation

The consequences of inadequate persistence are substantial: patients who discontinue antidepressants prematurely experience increase in the risk of relapse/recurrence compared with those who persist with treatment for guideline-recommended durations.¹³

To effectively improve persistence with antidepressants, HCPs should address the key, well‑established drivers of early discontinuation.¹⁴ Research shows that many patients stop treatment due to low motivation, limited understanding of how antidepressants work, early side effects, and insufficient follow‑up support.¹⁵

• A strong therapeutic alliance—built through active listening, clear expectations, and shared decision‑making—helps patients feel supported throughout the early phase of treatment, when discontinuation risk is highest.¹⁵
• Providing simple, repeated explanations about expected timelines, common transient side effects, and the importance of continuation also improves persistence.¹⁵
• Simplifying the treatment regimen and choosing an antidepressant with a tolerability profile that fits the individual patient further reduces the likelihood of premature stopping.¹⁵
• Regular monitoring of symptoms, adverse effects, and adherence using brief validated tools, combined with practical psychoeducation and accessible follow‑up (including phone or digital touchpoints), consistently improves both adherence and clinical outcomes.¹⁵

Taken together, these strategies help patients stay on therapy long enough to achieve and maintain remission.¹⁵

Conclusion

Successful psychiatric treatment depends on collaboration between patients and clinicians, continued engagement with therapy, and active participation in care.¹⁵ Concordance emphasizes partnership and shared decision‑making, ensuring that treatment aligns with patients’ beliefs and goals.⁵ Persistence, especially with antidepressants, is critical because stopping too early greatly increases the risk of relapse.¹³ When clinicians communicate clearly, address concerns, manage early side effects, and provide regular follow‑up, patients are more likely to stay on treatment and benefit from it. Together, these practices create a supportive, collaborative approach that improves long‑term mental health outcomes.¹⁵

This article was written with the assistance of generative AI technology and reviewed for accuracy.

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