Table 4.

Modifying factors of therapeutic adherence identified by professionals and patients.

Dimensions	Factors	Perspective and Illustrative Quotes
		Barriers	Facilitators
Health system	Coordination with PC	Psychiatrists “The biggest barrier may be in primary care. It seems that primary care physicians are often better at first addressing hypertension training or diabetes problems or anything other than treating depression”; “There are depressions that are very easy to treat and that is also another reason for overloading psychiatrists with work. (…) There are a lot of patients who are not even minimally treated by their family doctors before referral to a psychiatrist.” (Psychiatrist 2) “I think the main problem is when the diagnosis is not correct. In other words, if you are scrupulous about the psychopathology of depression, you will apply a treatment that will be effective, but many times there are patients who are diagnosed with depression when they are not depressed. (…) Generally, the first diagnosis is made by a primary care physician (…) the diagnosis is not always the right one”; “Primary care doctors have five or seven minutes per patient. Many times, they prescribe a standard medication. (Psychiatrist 3) “I think that a PC physician prescribing an antidepressant treatment for 6–12 months before referring them to a psychiatrist is too much.” (Psychiatrist 4)	Psychiatrists “However, when the patient is treated by a psychiatrist, then we have more time to get to know the patient and the treatment is more tailored.”; “Interventions to promote adherence to treatment, either with group activities or with follow-up by phone (could improve adherence).”; “It (motivational interview) is useful, but (…) you have to be trained. It is true that I have been half trained in motivational interviews. The truth is that I need the second half.” (Psychiatrist 3)
	Accessibility and availability of professionals	Psychiatrists “There is a lack of time for professionals to explain, not only what is happening, but what the therapeutic possibilities are”; “The system is not oriented so that the patient can receive regulated psychotherapy (because of a lack of psychologists)”; “If there is not enough time to attend to a patient, there is no motivational interview or anything, because you cannot dedicate yourself to them calmly” (Psychiatrist 3) “Psychotherapeutic work is harder, that is, with the person, trying to understand their situation… These activities are more typical of psychology, but the conditions are not met, especially in the hospital setting”; “Psychologists, due to their scarcity, cannot apply the therapies as they should and that ends up with overloading.” (Psychiatrist 2) “In the end, the psychiatrist ends up trying to do psychotherapy, without being the right professional, because the right professional should be a psychologist to do therapy properly.” (Resident doctor 1) “If you are a psychiatrist, (psychotherapy) needs complementary training, and not all psychiatrists have it. It depends on the interest”; “I can’t do it with everyone (psychotherapy), I don’t have time.” (Psychiatrist 5)	Patients “I think it would be necessary to provide hospitals with more staff. I think we would reduce the treatment a lot if the doctors were not so overworked and could, perhaps, treat the illness in another way.” (Patient 8)
			Psychiatrists “I think it is essential that patients are able to consult doubts to achieve adherence, that would improve adherence.” (Psychiatrist 4) “A greater availability of consultation by psychiatry and the availability of more frequent check-ups (would improve adherence).” (Psychiatrist 2)
	Information available to the patient	Psychiatrists “I admit that sometimes it’s easier for me if they come and don’t object… I am a bit ambivalent about that.” (Resident doctor 1). “People search on the internet. Another thing is that they search on the correct website”; “It’s a bad sign when a patient comes with what the neighbor told him/her. That’s a bad sign, it’s worse than googling”; “The information is accessible (…). On professional websites, Spanish Society of Psychiatry and Ministry of Health, there are specific guides on depression. In other words, access is not the problem”; “New patients (patients who have not received information) who come for the first time to receive a treatment generally do not cause problems, I explain the treatment and that’s it.” (Psychiatrist 5). “I don’t prefer the savvy patient, who knows everything, who has read… I like to explain a little bit to them, but today, when you mention serotonin, they say yes, yes, serotonin sounds familiar to me.” (Psychiatrist 2)	Patients “I received all the information. He told me what each thing was for, how I was going to take it, how I was going to start, and he explained everything to me… He explained everything to me, the entire medication process.” (Patient 8)
			Psychiatrists “I prefer they come informed, and they consult with me about their doubts, because they can sometimes come misinformed…” (Psychiatrist 1). “I think that information prior to treatment is essential (to promote adherence). If you explain everything to them before giving them a treatment, and they understand what the process is going to be, they accept it many times”; “My experience is that it depends on the information. Many times, it is not entirely correct or the websites where patients find information are not entirely reliable. Then, they come with a bad expectation.” (Resident doctor 1) “I prefer informed patients, well-informed patients, because I think that teamwork is necessary. At least, we are two experts.” (Psychiatrist 5)
	Doctor-patient relationship		Patients “In that aspect (adherence), I am super motivated by the doctor. I totally trust her”; “I think that medical support is essential. It is (depression) something that we don’t understand, we can’t find an explanation for it, and so you have to seek help from people who are trained in the matter, who know, to start getting out of it. Then, of course, you also have to do your bit, that is, you cannot wait for the medication to take effect, but you also have to put in a little on your part.” (Patient 9) “I have not read the prospects; I fully trust my psychiatrist.” (Patient 1) “The help of a psychiatrist has been very good for me. The advice he gives you, the guidelines you can follow.” (Patient 10)
			Psychiatrists “The therapeutic link, that is, the trust you have with the doctor who treats you (the psychiatrist or the primary care doctor) (is an important adherence factor).” (Psychiatrist 3) “If the patient normally trusts you, if you give him the option to consult doubts and such, he usually pays attention to you, but it is important that he trusts you.” (Psychiatrist 5)
	SDM	Psychiatrists “There are many patients who are not very interested in that (SDM), but what they simply want is for the doctor to prescribe them something and they don’t even get into discussing anything.” (Psychiatrist 1) “I try (do SDM), but I recognize that I cannot apply regulated psychotherapy (due to lack of time)”; “Well, it is true that I do not always do it perfectly. Sometimes the time is pressing and well…” (Psychiatrist 4) “Few psychiatrists say, ‘we would have this treatment and that and you choose’”; “Many times, they leave the decision to us (professionals), even if you tell them, they tell you, ‘Whatever you see best, I don’t understand.’” (Resident doctor 1) “This has to be done, I can’t tell you if it is done regularly, but it has to be done”; “There is a lack of time for professionals to explain not only what is happening but also what the therapeutic possibilities are”; “It is true that there are colleagues who feel more comfortable with paternalism:—‘you have to take this because I say so’”; “The time, the lack of time. If you have little time, you cannot apply shared decision-making because it requires time.” (Psychiatrist 3)	Patients “Yes, the psychiatrist and I were talking about it, and she listened to me. Then, we made the decision together”; “In my case, she explained the pros and cons to me, but since it’s an issue I don’t understand, I take the medication, and then if I feel bad, I ask her to change it.” (Patient 3)
			Psychiatrists “If you give the patient options that are more appropriate to their preferences, I think that it becomes the main positive conditioning factor for adherence”; “I really like to involve the patient in treatment options.” (Psychiatrist 2). “This has to be done (SDM), I can’t tell you if it is done regularly, but it has to be done”; “There are patients who ask you this (pseudoscience). I think that the patient’s decision must be respected as long as he is well informed”; “I would take into account the functionality of the patient, and by functionality, I mean work or daily living activities (…), and then I would also take into account the patient’s preferences.” (Psychiatrist 3) “Involving the patient is essential in the improvement process.” (Psychiatrist 4) “Especially in adherence (it has a positive influence), when a patient feels that they have decided on their treatment, that they are not obliged, they take it more easily.” (Psychiatrist 5). “I think the decision is made by the patient, it is clear, no matter how many pills you prescribe.” (Resident doctor 1)
Patient, family, and socioeconomic environmental	Socioeconomic and family context	Patients “Sometimes, when you get a very severe depression and you don’t recognize yourself, nor do your relatives recognize you, because you seem (to be) another person.” (Patient 8)	Psychiatrists “When there is family support, there is always greater adherence, because the family is there, saying ‘come on, you have to take it, you have to put up with it.’” (Resident doctor 1) “I think there should be more ‘society’, more neighborhood associations, more sense of having a family, a society, which you and others belong to” (Psychiatrist 4) “Illness awareness (favors adherence). That they know that they are sick and that they want to get better seems fundamental to me.” (Psychiatrist 4) “Apart from the information, the involvement of family members (is important). Asking a family member to prepare the medication and supervise it. I have also used that strategy”; “The involvement of family members, telling a family member to prepare the medication and supervise it. Yes, I have also used that strategy”; “The information and involvement of relatives (is very important) for taking treatment”. (Psychiatrist 3) “Another influence is that someone is supervising, especially older people, (…), because it is also a determining factor for the patient to take the medication”. (Psychiatrist 1)
Disease and treatment itself	Depression	Psychiatrists “Severe depression depletes resources, but when it is a mild or moderate depression, it (it) requires a normal effort”; “Real depressions are those that require less work. On the other hand, depressions with personality disorders, with family and social problems are the ones that require the most work.” (Psychiatrist 4) “An endogenous depression hits you and you want to cure yourself, like any other disease. People who have an underlying neurosis do not always want to be cured, and the most difficult thing is being able to cure them when they don’t want to be cured; it’s quite complicated.” (Psychiatrist 5) “If we are treating a very, very severe case of major depression, (…) we have to prioritize the drug treatment before using another type of strategy.” (Psychiatrist 1) “Those depressions with social, anxiety, family factors (…) are the ones that involve more work. In my opinion, due to the lack of psychological support.” (Psychiatrist 2)	Patients “I have had depression before and I got better on my own, but in this case, I needed medication. It was impossible to get better alone; therefore, medication was essential in this case.” (Patient 1) “I don’t care about the side effects. I was lying on a bed; I did not care what the pills did to me. The fear is what will happen when I stop taking the pills.” (Patient 3)
			Psychiatrists “You have to be very meticulous, identifying what the characteristics of the patient are in all senses, that is, in the personal sphere, in the field of health, what are the other pathologies that they have”; “I would take into account the functionality of the patient, and by functionality I mean work or daily living activities (…), and then I would also take into account the patient’s preferences.” (Psychiatrist 3)
	Medication	Patients “The times to take it, there are many a day. It makes it difficult for me on a day-to-day basis, at work…” (Patient 4) “Those of us who take pills have the hope of one day being the same as before.” (Patient 2) “The delay of the therapeutic effect, which many times both in the sense of beginning the treatment and at the end. That there is that delay between when you start taking the treatment and its effectiveness once you have a relapse. The truth is that this favors non-adherence a lot…” (Patient 9) “Antidepressants do not have an immediate effect; therefore, they take time to take effect and you start taking that and say: ‘Oh my God, this doesn’t do anything for me, what am I taking?’” (Patient 8) “In my case, I did a lot of research on medication side effects and that made me ask the doctor to reduce my medication. This matters a lot to me.” (Patient 3) “It is true that the medication has helped me, but it is also true that it has some very bad side effects and that sometimes I can’t stand it, I can’t stand it.” (Patient 10)	Psychiatrists “Pharmacological treatment has some protocols, in other words, this part is not very complex.” (Psychiatrist 2) “The problem is that many of the patients are resistant (to treatment). (…) So, first, you have to investigate more, especially the psychopharmacological approach that has been used.” (Psychiatrist 1)
		Psychiatrists “The main reason for lack of adherence is side effects.” (Psychiatrist 3)

PC: primary care; SDM: shared decision-making.