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Self-Efficacy Mediates the Relationship Between Depressive Symptoms and Medication Adherence Among Hypertensive African Americans
Abstract
Many studies have documented the negative effects of depression on adherence to recommended treatment; however, little is known about the mechanism underlying this relationship. Using the Kenny and Baron analytic framework of mediation, the authors assessed whether self-efficacy mediated the relationship between depression and medication adherence in 167 hypertensive African Americans followed in a primary care practice. Depressive symptoms are associated with poor medication adherence (β = .013, p = .036) and low self-efficacy (β = —.008, p = .023). Self-efficacy is negatively associated with medication adherence at follow-up (β = —.612, p < .001). The relationship between depressive symptoms and medication adherence becomes nonsignificant when controlling for self-efficacy (β = .010, p = .087). Implications for further examination into the mediating role of self-efficacy and the deleterious effect of depression on medication adherence are discussed.
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“Moreover, higher levels of self-efficacy can buffer against the effects of depression, which is a major adverse side effect of interferon-based therapies (13;14;34).”
From Reliability and validity of a self‐efficacy instrument for hepatitis C antiviral treatment regimens (2012) · cites this paper as [34]
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“Self-efficacy has also been found to mediate the relationship between depression and adherence in patients with diabetes [49] and hypertension [50].”
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Social Support and Adherence to Treatment in Hypertensive Patients: A Meta-Analysis
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“Poor adherence has been shown to be associated with several factors, such as poor cognitive abilities [18, 19], a higher number of prescribed medications [18, 19], and the presence of depressive symptoms [20].”
Krousel-Wood, M. A., Islam, T., Muntner, P., Holt, E. W., Joyce, C., Morisky, D. E., Webber, L. S., & Frohlich, E. D. (2010) · Annals of Behavioral Medicine · doi:10.1007/s12160-010-9217-1 · Cited by 100
“More recently, a longitudinal association of depressive symptoms with self-reported low antihypertensive medication adherence, which was mediated by self-efficacy, was identified in a sample of 167 predominantly younger black women with hypertension, Medicaid insurance and enrolled in a clinical trial [37].”
Mendes, R., Martins, S. P. V., & Fernandes, L. P. N. S. (2019) · Journal of Clinical Medicine Research · doi:10.14740/jocmr3894 · Cited by 101
“Some authors [93-95] suggested that the effects of anxiety on medication adherence may be mediated by the patient’s self-efficacy expectation (i.”
BackgroundZamani‐Alavijeh, F., Araban, M., Koohestani, H. R., & Karimy, M. (2018) · Diabetology & Metabolic Syndrome · doi:10.1186/s13098-018-0342-5 · Cited by 76
“studied patients with chronic diseases and observed that patients with higher levels of self-efficacy better perform recommended health behaviors than those with lower levels [33].”
BackgroundMedication beliefs mediate between depressive symptoms and medication adherence in cystic fibrosis.
Hilliard, M. E., Eakin, M. N., Borrelli, B., Green, A., & Riekert, K. A. (2014) · Health Psychology · doi:10.1037/hea0000136 · Cited by 77
“Evidence of medication beliefs as a mediator indirectly linking depressive symptoms with adherence adds to a growing body of research across chronic conditions (Cha et al., 2008; Cherrington et al., 2010; Schoenthaler et al., 2009) and extends findings to late adolescents and adults with CF.”
MethodResultInfluentialThe association between health beliefs and medication adherence among patients with type 2 diabetes
Alatawi, Y. M., Kavookjian, J., Ekong, G. J., & Alrayees, M. M. (2015) · Research in Social and Administrative Pharmacy · doi:10.1016/j.sapharm.2015.11.006 · Cited by 73
The association of depression with adherence to antihypertensive medications: a systematic review
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“Four studies reported data on patients from single centers [29,30,31,35] and four reported studies from multiple centers [32,33,35,36].”
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“To date, only 1 study, which used an African American sample, has examined the role of self‐efficacy in mediating the relationship between depression and medication adherence in patients with hypertension (Schoenthaler et al., 2009).”
Hypertension and Depression: Coexisting Barriers to Medication Adherence
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Perceived Discrimination and Medication Adherence in Black Hypertensive Patients
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“At least two recent studies have found a significant association between self-efficacy and medication adherence among African American people with hypertension (65,66), and self-efficacy mediated the depressionYmedication adherence relationship in this population (26).”
BackgroundResultSelf-citationJneid, S., Jabbour, K., Hajj, A., Sarkis, A., Licha, H., Hallit, S. R., & Khabbaz, L. R. (2018) · Journal of Cardiovascular Pharmacology and Therapeutics · doi:10.1177/1074248418784292 · Cited by 61
Zhou, Y., Huo, Q., Du, S., Shi, X., Shi, Q., Cui, S., Feng, C., Du, X., & Wang, Y. (2022) · Patient Preference and Adherence · doi:10.2147/ppa.s337634 · Cited by 53
Factors Associated With Medication Adherence in Hypertensive Blacks
Lewis, L. M. (2012) · The Journal of Cardiovascular Nursing · doi:10.1097/jcn.0b013e318215bb8f · Cited by 52
“Most (n = 4) did not find an association.(23,29,34,35) Only 1 study found that income was related to medication adherence.”
BackgroundInfluentialBoima, V., Ademola, A., Odusola, A. O., Agyekum, F., Nwafor, C. E., & Salako, B. L. (2019) · Nigerian Journal of Clinical Practice · doi:10.4103/njcp.njcp_351_18 · Cited by 47
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“This is also consistent with findings from studies on other chronic diseases, such as rheumatoid arthritis, asthma, depression, [28, 32, 49, 50] and with studies on hypertension in African American patients.”
ResultPost‐discharge hospital utilization among adult medical inpatients with depressive symptoms
Mitchell, S. E., Paasche‐Orlow, M. K., Forsythe, S., Chetty, V. K., O’Donnell, J. K., Greenwald, J. L., Culpepper, L., & Jack, B. W. (2010) · Journal of Hospital Medicine · doi:10.1002/jhm.673 · Cited by 42
Lewis, L. M., Schoenthaler, A., & Ogedegbe, G. G. (2012) · Journal of Clinical Hypertension · doi:10.1111/j.1751-7176.2012.00591.x · Cited by 41
“Previous studies have shown inconsistent results, with some studies finding an association between age and antihypertensive medication adherence and a trend toward younger hypertensive blacks having worse adherence rates(14,20,26,27) and others finding no association.(10,12,15,28,29) Patient-level factors, such as ins…”
BackgroundResultSelf-citationBae, S. G., Kam, S., Park, K., Kim, K.-Y., Hong, N.-S., Kim, K.-S., Lee, Y., Lee, W. K., & Choe, M. S. P. (2016) · Patient Preference and Adherence · doi:10.2147/ppa.s114529 · Cited by 43
“19,20 We have limited understanding of self-efficacy when nonadherence of medication is separated into intentional and unintentional.”
Dose‐response relationship between depressive symptoms and hospital readmission
Cancino, R. S., Culpepper, L., Sadikova, E., Martin, J., Jack, B. W., & Mitchell, S. E. (2014) · Journal of Hospital Medicine · doi:10.1002/jhm.2180 · Cited by 40
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“These studies demonstrated that self-efficacy is an important predictor of medication adherence.(30,31) In our study, 73.”
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“that have explored racial differences with regards to medication adherence have been inconsistent, with some findings suggesting that the independent effect of depression on adherence may be higher in whites than in other ethnic groups,(46) and other studies indicating no racial differences on the impact of depression…”
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“Modifiable patient factors demonstrated to be associated with nonadherence to medications include knowledge, attitudes, or medication beliefs,(20,21) forgetfulness,(22,23,39) and lack of medication self-efficacy.(40,41) The community pharmacy’s interventions were carefully designed and implemented to address these fac…”
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“It is hypothesized that negative cognitive appraisals resulting from depression diminish personal confidence and subsequent engagement in self-care activities.(33) Replication studies using large epidemiologic cohorts are needed to confirm the mechanistic role of self-efficacy in the relationship between depressive sy…”
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“Empirical evidence supports this assertion in other populations where self-efficacy has been found to mediate the relationship between social support and depression with adherence in adults with diabetes (Sacco et al., 2005) and hypertension (Schoenthaler et al., 2009).”
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“…Health Questionnaire (PHQ-8; Kroenke et al., 2009) as a covariate because depression has been associated with negative assessments of individual capabilities and self-efficacy in patients with diabetes (Schoenthaler et al., 2009), as well as with treatment nonadherence (Gonzalez et al., 2008).”
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Updates to Adherence to Hypertension Medications
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Effect of depression onset on adherence to medication among hypertensive patients
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“whether depression actually leads to poorer adherence or whether poor adherence only is one marker of depression) due to cross-sectional designs used in most previous work [11,14,15,18,21] or because in the longitudinal studies the patients were already depressed at baseline [22], making it impossible to detect the ti…”
ResultAntidepressant medication can improve hypertension in elderly patients with depression
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“Medication-use self-efficacy, the belief or confidence in one’s ability to successfully take medication in the context of one’s daily life, is associated with medicationuse behavior in rheumatoid arthritis [24], HIV infection [25], and hypertension [26].”
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“Based on the conceptual framework of this study and IFSMT theory [13], individuals with a higher self-efficacy are more likely to follow the behavioural changes necessary to manage their condition, and may have better medication adherence [47, 48].”
Agyemang, A. A., Mezuk, B. R., Perrin, P. B., & Rybarczyk, B. D. (2014) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2014.02.011 · Cited by 24
“Depression has also been shown to be associated with poorer medication adherence among Blacks with comorbid HT and depression [53, 54].”
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“(9) In our previous work, we have also shown that Black hypertensive patients with depressive symptoms were less likely to adhere to their medications because of low selfefficacy.(10) Accordingly, path b depicts the direct negative effect of depressive symptoms on medication adherence, whereas path c represents the in…”
BackgroundSelf-citationWilliams, T., Evans, L., Robertson, A., Hardy, L., Roy, S., Lewis, D., & Glendinning, F. (2020) · Frontiers in Sports and Active Living · doi:10.3389/fspor.2020.00116 · Cited by 25
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“The lack of confidence in one's ability to take medications under less than optimal conditions has also been implicated as a contributor to poor adherence and was a recurring theme among patients we interviewed [14,15].”
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Medication Adherence and Its Associated Factors Among Outpatients with Heart Failure
Jarab, A. S., Al-Qerem, W. A., Hamam, H., Alzoubi, K. H., Heshmeh, S. A., Mukattash, T. L., & Alefishat, E. A. (2023) · Patient Preference and Adherence · doi:10.2147/ppa.s410371 · Cited by 18
“Consistent with this study results, a study conducted on African Americans revealed that lower educational attainment was an independent predictor of medication non-adherence among patients with hypertension.(33) Another study reported that educational level significantly affected medication adherence in African Ameri…”
ResultRelationships between determinants of adjuvant endocrine therapy adherence in breast cancer
Lee, J. Y., & Min, Y. H. (2018) · BMC Women s Health · doi:10.1186/s12905-018-0522-3 · Cited by 18
“A Schoenthaler, G Ogedegbe and JP Allegrante [31] found that self-efficacy played a mediating role between depression and medication adherence in hypertensive patients.”
BackgroundInfluentialHigh Blood Pressure Medication Adherence Among Urban, African Americans in the Midwest United States
Schober, D. J., Tate, M., Rodriguez, D., Ruppar, T. M., Williams, J., & Lynch, E. (2021) · Journal of Racial and Ethnic Health Disparities · doi:10.1007/s40615-020-00819-2 · Cited by 17
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Adherence to Antihypertensive Therapy and Its Determinants: A Systematic Review
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“Furthermore, depression might lead to low adherence through the mechanism of low self-efficacy, as has been previously described [77,78].”
Williams, N. J., Jean‐Louis, G., Pandey, A. K., Ravenell, J. E., Boutin‐Foster, C., & Ogedegbe, G. G. (2014) · Patient Preference and Adherence · doi:10.2147/ppa.s53617 · Cited by 15
“31 32–34 In our analysis, sex was not related to adherence status.”
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Stamoulis, T., Dragioti, E., Gouva, M., Mantzoukas, S., & Κourakos, M. (2024) · Materia Socio Medica · doi:10.5455/msm.2024.36.65-72 · Cited by 13
“Furthermore, only 13 studies (33,34,36–38,42–49) provided the prevalence rate of depressive symptoms, ranging from 4% (47) as the lowest to 43% (44) as the highest.”
BackgroundMethodInfluentialOdusola, A. O., Nelissen, H. E., Hendriks, M. E., Schultsz, C., Wit, F. W. N. M., Bolarinwa, O. A., Akande, T. M., Agyemang, C. O., Ogedegbe, G. G., Agbede, K., et al. (2015) · World Journal of Cardiovascular Diseases · doi:10.4236/wjcd.2015.57021 · Cited by 12
Self-citationGrant, A. B., Seixas, A. A., Frederickson, K. C., Butler, M. J., Tobin, J. N., Jean‐Louis, G., & Ogedegbe, G. G. (2015) · Journal of Clinical Hypertension · doi:10.1111/jch.12736 · Cited by 11
“Some studies indicate that self-efficacy is associated with medication adherence in hypertensive blacks.(43,44) In a previous study that explored patient-related barriers to BP control, 23.”
BackgroundSelf-citationLee, S., Jeong, K.-H., Lee, S., & Park, H. (2022) · Healthcare · doi:10.3390/healthcare10112322 · Cited by 17
Spikes, T. A., Higgins, M. K., Lewis, T. T., & Dunbar, S. B. (2020) · The Journal of Cardiovascular Nursing · doi:10.1097/jcn.0000000000000671 · Cited by 11
Oh, H., & Ell, K. (2016) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2016.04.003 · Cited by 11
“For some patients, depression care may motivate daily self-care via enriching psychological resources, such as improved self-efficacy or optimism [9].”
BackgroundAlvarez, C., Perrin, N., Carson, K. A., Marsteller, J. A., Cooper, L. A., & RICH LIFE Project Investigators (2022) · American Journal of Hypertension · doi:10.1093/ajh/hpac123 · Cited by 10
Daniali, S. S., Darani, F. M., Tavassoli, E., Afshari, A., Forouzande, F., & Eslami, A. A. (2018) · Iranian Journal of Psychiatry and Behavioral Sciences · doi:10.5812/ijpbs.10161 · Cited by 10
“Depression is also known as a mediator for medication adherence in diabetic and hypertensive patients (25, 26).”
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“Further, self-efficacy was also found as a mediator in the association between mental health and medication adherence [32, 33].”
BackgroundHealth risk appraisal for older people 5: self-efficacy in patient–doctor interactions
Raymond, M., Iliffe, S., Kharicha, K., Harari, D., Swift, C. G., Gillmann, G., & Stuck, A. E. (2011) · Primary Health Care Research & Development · doi:10.1017/s1463423611000296 · Cited by 10
“For example, in a study of adherence to antihypertensive medication in African Americans, depressive symptoms were associated with poor medication adherence and low self-efficacy (Schoenthaler et al., 2007) but this relationship became non-significant when controlling for self-efficacy.”
Self-efficacy for managing hypertension and comorbid conditions
Lee, M. J., Romero, S., Jia, H., Velozo, C. A., Gruber‐Baldini, A. L., & Shulman, L. M. (2019) · World Journal of Hypertension · doi:10.5494/wjh.v9.i3.30 · Cited by 9
Reliability and validity of a self‐efficacy instrument for hepatitis C antiviral treatment regimens
Bonner, J. E., Esserman, D., & Evon, D. M. (2012) · Journal of Viral Hepatitis · doi:10.1111/j.1365-2893.2011.01550.x · Cited by 8
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“, 2017), nevertheless, preliminary research in this area suggests it is a promising area for interventions in adherence (Schoenthaler et al., 2009), as stronger relationships between medical professionals and patients can lead to better buy-in, increased patient satisfaction, and improved treatment outcomes (Fuertes e…”
BackgroundAlshaikhi, S. A., Alfaqih, F. H., Alrashdi, A. K., Alamri, F. A., Alzubaidi, A. S., Alnashri, A. I., Alsharidi, B., Alshreef, S. M., Almantashri, A. S., Alshaikhi, O. A., et al. (2025) · BMC Endocrine Disorders · doi:10.1186/s12902-025-01894-4 · Cited by 9
“Self-efficacy emerges as a crucial determinant of health behaviour, influencing self-care practices and, consequently, glycemic control and QoL outcomes [15, 16, 17, 18].”
Bos, P., Wouters, E., Danhieux, K., van Olmen, J., Remmen, R., Klipstein‐Grobusch, K., Boateng, D., & Buffel, V. (2024) · BMC Public Health · doi:10.1186/s12889-024-19010-x · Cited by 6
“…pathways, thereby potentially negatively affecting one another [36], depression and anxiety may lead to lower treatment adherence [37, 38] by reducing one’s perceived self-efficacy [39] and impairing one’s interest in and cognitive ability to follow treatment recommendations [40].”
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Hypertension among the uninsured: Tensions and challenges
Schlomann, P., Virgin, S. M., Schmitke, J. A., et al. (2011) · Journal of the American Academy of Nurse Practitioners · doi:10.1111/j.1745-7599.2011.00616.x · Cited by 5
Zhang, M., Chen, W., Xu, Y., Fang, J., Liu, Y., Liu, X., & Song, L. (2025) · BMC Family Practice · doi:10.1186/s12875-025-02739-8 · Cited by 4
“First, medical services can immediately and significantly motivate patients to follow medical advice by relieving their symptoms [47, 48].”
Metadata
- Authors
- Schoenthaler, A., Ogedegbe, G., & Allegrante, J. P.
- Affiliations
- Columbia University (US)
- Venue
- Health Education & Behavior
- Publisher
- SAGE Publications
- Published
- 2006-11-27
- Volume
- 36
- Issue
- 1
- Pages
- 127-137
- ISSN
- 1090-1981 (ISSN-L)
- 1552-6127
- OpenAlex
- W1995969486
- Cited by
- 139
- References
- 39
- Citations by year
- 2026: 3 · 2025: 5 · 2024: 13 · 2023: 3 · 2022: 6 · 2021: 4 · 2020: 10 · 2019: 5 · 2018: 8 · 2017: 7 · 2016: 11 · 2015: 12 · 2014: 16 · 2013: 6 · 2012: 10
- FWCI
- 0.89
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Health Education & Behavior (publishedVersion)
- PubMed (publishedVersion)
- Funders
- U.S. Public Health Service (F31 081926-01)
- National Heart, Lung, and Blood Institute (R24HL076857, R01HL069408)
- Topics
- Health Sciences › Medicine › Family Practice › Medication Adherence and Compliance
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
- Keywords
- self-efficacy, depressive symptoms, medication adherence, hypertension, African Americans, mediation, primary care
- MeSH terms
- Analysis of Variance, Antihypertensive Agents, Black or African American, Depression, Female, Humans, Hypertension, Male, Middle Aged, Comorbidity, Self Efficacy, Medication Adherence
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