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Noncommunicable diseases (NCDs), including cancer, diabetes, hypertension, cardiovascular diseases, and chronic respiratory conditions, are the leading global causes of morbidity and mortality. Depression frequently co-occurs with these conditions, and may significantly reduce medication adherence, thereby worsening health outcomes. This narrative review examines the relationship between depression and medication adherence in patients with NCDs. It also highlights the current challenges in managing this comorbidity and explores potential strategies for improving adherence outcomes. Most studies have reported a significant negative association between depression and medication adherence in diverse NCD populations. Depressive symptoms impair motivation, memory, and executive functioning, which are essential for the maintenance of treatment regimens. However, inconsistencies across studies have been observed due to variability in the measurement of depression and adherence, study design, and control of confounding factors. Despite evidence from high-income countries supporting integrated care models such as collaborative care and cognitive behavioral therapy, implementation of these models in low- and middle-income countries remains limited. Emerging strategies, including task shifting, digital health tools (e.g., mobile health apps and telemedicine), and community-based support systems, offer promising avenues for intervention. Addressing this issue requires integrated and scalable interventions tailored to local contexts. Future research should focus on longitudinal and interventional studies, particularly in resource-limited settings, to inform policies and practices.
Noncommunicable diseases (NCDs), such as cancer, diabetes, hypertension, cardiovascular diseases, and chronic respiratory conditions, are the leading causes of morbidity and mortality globally. According to the World Health Organization (WHO), NCDs cause at least 4 million deaths each year, or 74% of all deaths worldwide [1]. Cardiovascular diseases cause the majority of deaths from NCDs, totaling 17.9 million annually, followed by cancers (9.3 million), chronic respiratory diseases (4.1 million), and diabetes and kidney diseases related to diabetes (2.0 million) [1].
NCDs and mental and neurological disorders (MNDs) are closely related and share many characteristics. These conditions can affect individuals at any stage of their life and often require long-term monitoring and management. They have common underlying factors and similar consequences, and frequently occur together. MNDs can either precede or result from NCDs and share many common determinants and consequences that often occur in the same individuals [2]. Both types of disorders present significant health challenges. Worldwide, NCDs remain the primary cause of mortality, and approximately 300 million people experience depression. NCDs account for approximately 20% of all years lived with disability, and depression is the third leading cause of disability worldwide, as assessed by disability-adjusted life-years [2].
One of the key elements in managing NCDs effectively is patient adherence to prescribed medication regimens, which can significantly reduce the risk of complications and improve quality of life [3]. However, adherence rates remain suboptimal, with many patients failing to take medications as prescribed owing to various factors, including psychological comorbidities such as depression [2].
Depression is a prevalent mental health condition, particularly among individuals with chronic illnesses such as cancer, diabetes, stroke, and cardiovascular disease [2,4]. The prevalence of depression is 2 to 4 times greater among individuals with physical NCDs than among those without such conditions, and it often has a longer duration [5].
Depression has been found to negatively influence self-care behaviors, including medication adherence, which is critical for the management of NCDs. It is estimated that up to 50% of patients with chronic diseases do not adhere to their treatment regimens [6], and depressive symptoms exacerbate this issue [7]. Depression not only diminishes motivation but also affects cognitive function, making it harder for patients to follow complex treatment protocols and maintain consistent medication intake.
Comorbidities are common between NCDs and MNDs, with each potentially serving as a precursor or consequence of the other. Individuals suffering from mental disorders such as depression and anxiety are more likely to develop conditions such as heart disease and diabetes. Conversely, individuals with NCDs, such as cancer and cardiovascular disease, are at a significantly increased risk of developing depression, with prevalence rates up to three times higher than those in the general population [2]. The coexistence of NCDs and depression leads to significantly poorer survival rates and quality of life.
Previous studies have investigated the relationship between depression and medication adherence in patients with various NCDs. Research on individuals with hypertension, diabetes, and/or kidney disease has shown that depressive symptoms can significantly reduce adherence rates and lead to worse health outcomes [8]. In a longitudinal study conducted in China, depressive symptoms mediated the relationship between neighborhood social factors and medication adherence, highlighting the complex interplay between mental health, social determinants, and chronic disease management [9]. However, to the best of our knowledge, review studies examining the association between depression and NCD medication adherence, particularly those conducted in the last decade, remain scarce.
Given the growing prevalence of NCDs and the substantial burden they place on healthcare systems worldwide, understanding the impact of depression on medication adherence is essential. This narrative review aimed to synthesize current evidence on how depression affects adherence to NCD medications, identify gaps in the literature, and suggest strategies to improve overall patient outcomes. This review contributes to a deeper understanding of the challenges faced by patients with comorbid NCDs and depression, and provides insights into potential interventions to enhance medication adherence, thereby improving the management of chronic diseases.
Methods
A comprehensive literature search was conducted to identify studies on the impact of depression on medication adherence among patients with NCDs. The search included peer-reviewed journal articles, review papers, and longitudinal studies available in electronic databases such as PubMed, Scopus, Web of Science, PsycINFO, and Google Scholar. Keywords used in the search were “depression,” “medication adherence,” “noncommunicable diseases,” “chronic diseases,” “cancer,” “diabetes,” “hypertension,” and “cardiovascular diseases.” Data were extracted and synthesized narratively, focusing on identifying key themes.
Results
This review aimed to explore the relationship between depression and medication adherence in various NCDs. In this section, we summarize and discuss the findings of 14 studies that examined the relationship between depression and medication adherence among patients with NCDs. Most of these studies have highlighted the significant impact of depressive symptoms on medication adherence, investigating various chronic conditions, including cancer, diabetes, hypertension, and cardiovascular diseases. Table 1 summarizes the selected studies [7-20].
A meta-analysis conducted in 2011 investigated the association between depression and medication adherence among individuals with chronic illnesses in the United States [7]. The study found that depressed patients had 1.76 times higher odds of being nonadherent to medication compared to nondepressed patients (odds ratio [OR], 1.76; 95% confidence interval [CI], 1.33–2.57), based on a meta-analysis of 31 studies involving 18,245 participants. This relationship was consistent across various chronic conditions, including diabetes (OR, 1.73; 95% CI, 1.24–2.87), hyperlipidemia or hypertension (OR, 1.79; 95% CI, 1.28–2.51), and other chronic illnesses (OR, 1.80; 95% CI, 1.26–2.57). However, as this study was correlational in nature, it provided limited insights into causality and potential confounding factors.
Several studies have also supported the association between depressive symptoms and poor medication adherence. A cohort study among patients with diabetes and poor disease control found that depression was associated with significantly higher odds of poor adherence to diabetes control medications (OR, 1.98; 95% CI, 1.31–2.98), antihypertensives (OR, 2.06; 95% CI, 1.47–2.88), and low-density lipoprotein control medications (OR, 2.43; 95% CI, 1.19–4.97) [10]. Similarly, a cross-sectional study among outpatients with coronary heart disease revealed that 14% of the 204 participants experiencing depression reported not taking their medications as prescribed, compared to only 5% of the 736 participants without depression (OR, 2.8; 95% CI, 1.7–4.7; P<0.001) [11]. Moreover, a significantly higher number of individuals with depression reported forgetting to take their medication (18% vs. 9%; OR, 2.4; 95% CI, 1.6–3.8; P<0.001). Intentional nonadherence was also more common among those with depression, with 9% reporting they deliberately skipped doses, compared to 4% of nondepressed participants (OR, 2.2; 95% CI, 1.2–4.2; P=0.01).
A cross-sectional study in Taiwan also found that depressive symptoms were associated with higher odds of nonadherence among patients with NCDs (OR, 1.81; 95% CI, 1.17–2.80) [12]. Similarly, a study using multivariate analysis in women reported that a self-reported history of anxiety and/or depression was significantly associated with low to moderate adherence levels (OR, 4.89; 95% CI, 1.36–17.49) [13]. In Lebanon, a study conducted during the COVID-19 (coronavirus disease 2019) pandemic found a significant link between depression and lower medication adherence, as indicated by higher Lebanese Medication Adherence Scale scores (β=1.351) [8].
A longitudinal study conducted in China examined the mediating role of self-efficacy and depressive symptoms in the relationship between community efficacy in NCD management and medication adherence. The study identified a negative association between depressive symptoms and medication adherence (β=−0.17; P=0.002), and demonstrated a serial mediation effect involving both self-efficacy and depression (β=0.009; 95% CI, 0.003–0.022). These findings suggest that enhancing community support indirectly boosts adherence by alleviating depressive symptoms [9].
Other studies have also reported a statistically significant association. For instance, a study on patients with cardiovascular disease revealed that depression was negatively correlated with treatment adherence (P=–0.26; β=0.047) [14]. In patients requiring hemodialysis, depression was found to be a significant predictor of poor adherence (P<0.001; β=–0.392) [15], and another study in the same patient group showed that depression was significantly associated with blood pressure medication nonadherence both at baseline (r=0.239; P=0.01) and at 12 weeks (r=0.20; P=0.027). In the study by Jeong and Kim [20], the authors reported a significant inverse relationship between depression and adherence among patients with breast cancer, with higher depression being linked to lower adherence.
However, not all the findings were consistent. A study involving patients with arterial hypertension who had been exposed to radiation found no association between depression and medication adherence (OR, 1.719; 95% CI, 0.690–4.279) [16]. Similarly, in another study, moderate to severe depression was only associated with nonadherence in bivariate analysis, with no significant effect observed in the adjusted multivariate model (OR, 1.28; 95% CI, 0.96–1.70) [17]. A retrospective study also found no consistent association between depressive symptoms and medication adherence across 18 months, except for a brief period between 3 and 6 months for antidiabetic medication (OR, 2.80; 95% CI, 1.38–5.65) [18]. Finally, a longitudinal study of elderly individuals with diabetes mellitus showed no significant differences in adherence to oral hypoglycaemics between those with and without depression [19].
Discussion
Depression and impact on medication adherence among patients with NCD
The evidence gathered from the 14 reviewed studies suggested a generally consistent association between depressive symptoms and lower medication adherence among patients with NCDs. Most studies, including a large scale meta-analysis and various cohort, cross-sectional, and longitudinal designs, have demonstrated that individuals with depression are more likely to exhibit poor adherence to treatment regimens for chronic conditions such as cancer, diabetes, hypertension, and cardiovascular diseases. However, the results were not consistent. A few studies reported either no significant association or only marginal effects, particularly after adjusting for potential confounders.
Inconsistencies observed in studies examining the relationship between depression and medication adherence in patients with NCDs can be attributed to several factors. First, there was considerable variation in the depression measurements. While some studies relied on clinical diagnoses, others used self-reported symptom scales with differing thresholds and sensitivities, which can lead to discrepancies in depression identification.
Similarly, the methods used to assess medication adherence vary widely, ranging from self-report questionnaires to pharmacy refill records or clinical indicators, each capturing different aspects of adherence behavior. These differences in measurement approaches make it challenging to compare the findings directly. Moreover, the studies differ in design (cross-sectional, longitudinal, or retrospective), which influences their ability to establish causality and may introduce bias. Variations in sample characteristics such as age, type of NCD, cultural context, and healthcare access also play a role in shaping both depression and adherence behaviors.
Additionally, the extent to which studies control for confounding variables differs; those with more rigorous adjustments may find weaker associations, whereas others may overestimate the link due to unmeasured confounders. Treatment-related factors such as the complexity of medication regimens are often not accounted for, further contributing to variability. Lastly, the small sample size and insufficient statistical power in some studies may have led to nonsignificant results, even when a true association exists. Together, these methodological and contextual differences explain why the results across studies are not always consistent.
Although most studies support the link between depression and poorer medication adherence in patients with NCDs, a few have reported mixed or nonsignificant results. These inconsistencies, along with diverse adherence measurement methods and population characteristics, underscore the need for further research using standardized tools and longitudinal designs to clarify the relationship and explore the underlying mechanisms.
Current challenges
Managing medication adherence in patients with NCDs who experience depression presents a range of interconnected challenges. Depression can impair motivation, concentration, and memory, which are the key factors necessary for maintaining treatment routines. Symptoms such as hopelessness and fatigue reduce the patients’ ability to take their medications consistently, whereas negative beliefs about treatment or low self-efficacy further hinder adherence [21]. This is compounded by the fact that depression and NCDs often influence each other in a cyclical pattern; poor physical health can worsen depressive symptoms, and untreated depression can lead to poorer management of chronic illness [22].
One major barrier is the underdiagnosis of depression in chronic disease care. Because depressive symptoms often overlap with physical conditions such as sleep disturbances, low energy, or poor appetite, they are frequently overlooked. Additionally, the stigma surrounding mental health, limited routine screening, and patients’ reluctance to disclose emotional distress contribute to missed diagnoses [23]. Even when depression is identified, treatment options such as antidepressants may increase the pill burden or interact with existing medications, adding complexity to the already demanding regimens.
System-level factors also play significant roles. Mental health and chronic disease services are often delivered separately, resulting in fragmented care and lack of coordination between providers [5]. Patients may receive inconsistent messages or duplicate prescriptions, thereby reducing clarity and trust. Polypharmacy is a common issue that increases the likelihood of nonadherence owing to side effects, confusion, or the sheer number of medications involved.
Furthermore, social and contextual factors, such as low health literacy, financial stress, and limited social support, can further undermine adherence [24]. In many settings, behavioral support services, such as counseling or adherence coaching, are not readily available, particularly in resource-limited contexts. This lack of comprehensive care makes it difficult to address the full scope of barriers faced by these patients.
Potential strategies for intervention
Improving medication adherence among individuals with NCDs and depression requires integrated, contextually adapted, and sustainable interventions. A systematic review of interventions in South Asia revealed a scarcity of efforts targeting depression in individuals with NCDs, with most studies being of low quality [25]. In contrast, research from high-income countries (HICs) has consistently shown that psychological interventions such as cognitive behavioral therapy (CBT) are effective in reducing depressive symptoms and improving treatment adherence among this population [26].
WHO has endorsed the integration of mental healthcare into the NCD agenda, emphasizing that psychological interventions are both effective and potentially scalable [27]. However, practical implementation requires strong leadership, dedicated funding, and ongoing monitoring and evaluation. Early diagnosis and treatment of depression in people with chronic illnesses are widely recommended because addressing mental health is essential for improving overall health outcomes and long-term adherence to NCD treatment regimens.
One promising strategy for addressing human resource constraints is task shifting, in which nonspecialist health workers are trained to deliver mental health interventions. Studies have shown that psychosocial counseling programs can be successfully implemented using this approach in low- and middle-income countries (LMICs), thereby expanding the reach of care where specialist services are limited. Task shifting is particularly relevant in contexts where access to psychiatric or advanced psychological care remains challenging.
Collaborative care models have also emerged as effective and cost-efficient tools for managing comorbid depression and NCDs. Systematic reviews and randomized controlled trials (RCTs) conducted in HICs have demonstrated that collaborative care significantly improves both depression and disease-specific outcomes such as glycemic control in diabetes. These findings have led the WHO to recommend collaborative care at the primary care level, particularly for managing coexisting chronic diseases such as diabetes, hypertension, and cancer. Evidence also indicates that such models are adaptable to LMIC contexts, although local implementation may require policy support, training, and system-level changes [28].
Digital health interventions offer additional avenues to support medication adherence and mental healthcare integration. Studies have shown that well-designed digital counseling platforms featuring engaging multimedia content and tailored educational resources can effectively complement traditional counseling methods. These platforms empower patients to manage their condition, reduce their dependency on healthcare providers, and enhance long-term treatment adherence.
mHealth applications can play a significant role by sending personalized medication reminders, tracking symptoms, and providing motivational content tailored to a user’s mood or mental state. These applications may also include features such as mood logs, educational content about managing NCDs and depression, and behavioral activation exercises that help maintain treatment engagement [29,30]. For individuals struggling with forgetfulness or a lack of motivation due to depression, simple short message service (SMS)-based reminders can be particularly useful. Two-way messaging systems also enable patients to check in with healthcare providers or receive brief encouragements, which makes them feel supported and accountable for their care.
Telemedicine platforms provide convenient access to counseling and follow-up consultations, which are essential for patients who may face logistical or emotional barriers to in-person visits. This continuity of care can reinforce the importance of medication adherence and provide regular monitoring of depressive symptoms [31]. Similarly, digital counseling platforms can integrate psychoeducation and CBT techniques to enhance the understanding of treatment goals and strengthen adherence. Wearable devices and smart pillboxes also offer real-time tracking of medication intake. When integrated with mobile applications, they enable caregivers and providers to detect nonadherence and intervene early. These tools can also capture data on mood, sleep, or physical activity, which may reveal patterns that help tailor individual support plans [32,33].
Additionally, digital platforms can foster peer support through moderated forums or group chats, offering a sense of community for individuals managing chronic illness and depression. This shared connection can alleviate feelings of isolation and increase the motivation to continue treatment. Some platforms even incorporate gamification and behavioral nudging, rewarding users for medication-taking behavior and promoting habit formation, which can be particularly helpful for those with diminished motivation due to depression.
Figure 1 illustrates the conceptual framework and summarizes the mechanisms discussed in this review. This demonstrates that individuals with NCDs may develop depression due to various factors. Depression impairs key cognitive functions, such as motivation, concentration, and memory, leading to reduced medication adherence. This nonadherence contributes to the progression and worsening of chronic conditions, resulting in poor health outcomes and increased comorbidities. The lower part of the figure shows evidence-based interventions that can break this negative cycle. Collaborative care models, psychological interventions, and digital health tools can enhance medication adherence by empowering patients and addressing depressive symptoms. By promoting early diagnosis, reducing the burden of depression, and supporting self-management, these interventions offer scalable and sustainable solutions for improving the outcomes of patients with comorbid NCDs and depression.
Study limitations, future research directions, and recommendations
As shown in Table 1, the studies included in this review primarily used cross-sectional designs, which limited the ability to draw causal inferences regarding the relationship between depression and medication adherence. While these studies established associations, they did not clarify the temporal sequence of depression relative to nonadherence. Cross-sectional studies have not captured the dynamic relationship between the progression of chronic diseases and fluctuations in mental health status. Longitudinal studies, such as those conducted by Zhu et al. [9], are crucial for understanding how changes in depressive symptoms over time impact adherence behaviors. To provide more generalized and comprehensive findings, a broader range of study types, such as RCTs, cohort, longitudinal, and case-control studies, should be included. Unfortunately, at the time this study was conducted, there were few studies published in the past 15 years that explored the association between depression and medication adherence in patients with NCDs.
The generalizability of these findings is limited by the geographical context in which the studies were conducted. Many of these studies were conducted in LMICs, where factors such as healthcare access, cultural views on mental health, and economic challenges related to medication adherence may differ greatly from those in HICs. For instance, research by Hamieh et al. [18] and Gentil et al. [19] illustrates that in developed countries with well-established healthcare systems, the correlation between depression and adherence may be less pronounced, potentially because of the higher level of patient knowledge and greater availability of healthcare resources and support. Another possible reason is that mental health management may already be integrated into NCDs care in developed countries [5,22,23,34-36], whereas this integration is lacking in developing countries [37,38]. In resource-constrained settings, integrating mental health care within NCD management may be considered premature [39]. The priority in these regions is often to expand basic health facilities and train more medical workers. For instance, a study by Wright et al. [39] in Bangladesh and Pakistan found that both patients and healthcare workers reported that NCD centers were overcrowded and characterized by time pressures, with waiting times reaching up to 5 hours and consultation durations as brief as 5 minutesClick or tap here to enter text.. This often led to significant frustration among the patients [39]. Ironically, the lack of integrated mental health care owing to resource constraints may contribute to higher rates of depression in developing countries than in developed ones, potentially leading to poorer medication adherence and worse health outcomes. Additionally, studies have shown that low economic status and financial difficulties are among the main factors contributing to depression in patients with NCDs [40,41]. Overall, the findings of our study indicate that, while depression generally negatively affects adherence, the relationship varies based on geographical and demographic factors, highlighting the need for more comprehensive studies and possibly localized interventions.
An important, yet underexplored, area in the current literature is the role of technology in mitigating the effects of depression on medication adherence. While digital health solutions, such as mobile applications, SMS reminders, telemedicine, and wearable devices, offer promising tools to enhance treatment engagement and provide mental health support, few studies have rigorously examined their effectiveness in populations with comorbid depression and NCDs [29,30,32]. These interventions can deliver psychoeducation, symptom tracking, motivational reinforcement, and even cognitive behavioral support, often with greater scalability and lower costs than traditional care models. Moreover, digital platforms can be tailored to specific cultural and linguistic contexts, thereby expanding their potential reach into underserved regions. Nevertheless, the current evidence based on these innovations remains fragmented and is often limited to pilot studies or high-income settings.
Future research should therefore prioritize the use of longitudinal and experimental designs to explore causal pathways and evaluate the impact of integrated interventions that combine pharmacological, psychosocial, and technological components. Standardizing the tools used to assess depression and adherence will strengthen future comparisons and facilitate evidence synthesis. There is a pressing need to examine how digital and telehealth tools can be implemented effectively in collaborative care models, particularly in resource-limited environments. Simultaneously, national policies must promote the integration of mental health services into NCD care, provide training for nonspecialist health workers to deliver psychological support, and allocate sufficient resources to sustain such programs. A comprehensive, context-sensitive approach, anchored in technological innovation and system-level reform, is crucial for addressing the complex and cyclical relationship between depression and medication adherence in NCD care.
Conclusion
This narrative review underscores the critical impact of depression on medication adherence in patients with NCDs. Given that NCDs are the leading causes of global morbidity and mortality, addressing the mental health aspects of patient care is essential for improving treatment outcomes and reducing healthcare costs. These findings indicate a robust association between depression and lower adherence rates, which may have significant implications for disease management and patient well-being.
To effectively combat the challenges posed by depression, healthcare providers must adopt integrated care models that prioritize mental health support and traditional chronic disease management strategies. Future research should focus on identifying and evaluating targeted interventions to enhance medication adherence in patients with depression. By addressing these intertwined issues, we can work toward better health outcomes and a more comprehensive approach to managing NCDs.
Article Information
Conflict of interest
No potential conflict of interest relevant to this article was reported.
Funding
None.
Data availability
Data of this research are available from the corresponding author upon reasonable request.
Author contribution
Conceptualization: UKH, BW. Data Curation: UKH, BW. Formal Analysis: UKH, AS. Investigation: UKH, BW, AS. Methodology: UKH, BW. Project Administration: UKH, BW. Software: UKH. Validation: BW, AS, ZS. Visualization: UKH. Writing–original draft: UKH. Writing–review & editing: UKH, BW, AS, ZS. Final approval of the manuscript: all authors.
Figure. 1.
Integrated model of influence of depression on medication adherence. NCD, noncommunicable diseases.
Table 1.
Key findings from studies identifying an association between depression and medication adherence in NCD
Outpatients with stable CHD from two Veterans Affairs Medical Centers (San Francisco and Palo Alto), one university medical center (the University of California, San Francisco), and nine community health clinics across northern California.
Cross-sectional
Patients with CHD and depression are nearly three times more likely to be nonadherent to their treatment.
Patients with breast cancer from one hospital in South Korea (n=183)
Cross-sectional study
Depression affected 66.1% of breast cancer patients (16.9% mild, 27.3% moderate, 21.9% severe). Medication adherence was low in 58.5% of patients. A significant inverse relationship was found: higher depression was linked to lower adherence.
NCD, noncommunicable diseases; CHD, coronary heart disease ; CONSTANCES, Cohorte des Consultants des Centres d’Examens de Santé.
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Outpatients with stable CHD from two Veterans Affairs Medical Centers (San Francisco and Palo Alto), one university medical center (the University of California, San Francisco), and nine community health clinics across northern California.
Cross-sectional
Patients with CHD and depression are nearly three times more likely to be nonadherent to their treatment.
Patients with breast cancer from one hospital in South Korea (n=183)
Cross-sectional study
Depression affected 66.1% of breast cancer patients (16.9% mild, 27.3% moderate, 21.9% severe). Medication adherence was low in 58.5% of patients. A significant inverse relationship was found: higher depression was linked to lower adherence.
Table 1. Key findings from studies identifying an association between depression and medication adherence in NCD
NCD, noncommunicable diseases; CHD, coronary heart disease ; CONSTANCES, Cohorte des Consultants des Centres d’Examens de Santé.
