Review of treatment options for refractory epilepsy: new medications and vagal nerve stimulation

PURPOSE

the choices available for patients whose partial seizures are poorly controlled include seven new antiepileptic drugs (AEDs) or vagal nerve stimulation (VNS) as add-on therapy. Comparisons are needed to help physicians and patients select among the options for treatment.

METHODS

we compared efficacy and adverse events of new treatments from controlled clinical trials of patients with uncontrolled partial seizures. Response rates (> or =50% decrease in partial seizures) at doses recommended in product labeling for adjunct therapy were tabulated for overall success (placebo response rate subtracted from AED response rate). Adverse events listed in product labeling were tabulated as complaint rates (placebo events subtracted from AED events). VNS trials used low dose stimulation as a pseudo-placebo.

RESULTS

overall success rates fell into two general groups with ranges of 12-20% for gabapentin (GBP), lamotrigine (LTG), tiagabine (TGB), zonisamide and 27-29% for levetiracetam, oxcarbazepine, and topiramate (TPM). Summary Complaint Scores also fell into two general groups with ranges of -27 to -82 for GBP, levetiracetam, TGB, zonisamide and -113 to -205 for LTG, oxcarbazepine and TPM. VNS scores were in the lower or higher success and summary complaint categories depending on whether scores from the pseudo-placebo group were subtracted from the high dose group.

CONCLUSIONS

these data allow comparisons among AEDs and VNS using similar data from standard types of clinical trials.

Use of the Medication Event Monitoring System to estimate medication compliance in patients with schizophrenia

OBJECTIVE

To determine the feasibility of using the Medication Event Monitoring System (MEMS) to estimate medication compliance in patients with schizophrenia or schizoaffective disorder.

SUBJECTS AND SETTING

Fourteen of 35 consecutive patients admitted to a psychiatric inpatient hospital with schizophrenia or schizoaffective disorder who met eligibility requirements and gave informed consent.

INTERVENTION

After random assignment to either risperidone or typical antipsychotic treatment, medication upon discharge from hospital was dispensed in a bottle with a MEMS cap which recorded the number of bottle openings and the date and time of each opening. The first 6 patients were asked to return monthly for data downloading. The next 8 were asked to return weekly during the first month and every 2 weeks thereafter; they were also paid $5 for returning each bottle.

OUTCOME MEASURES

MEMS data collected over a 6-month period and hospital readmission data.

RESULTS

Patient medication compliance data were collected from 10 (71%) of 14 patients during the first month, from 7 (58%) of 12 (2 patients dropped out) during the second and from 5 (45%) of 11 (a third patient dropped out) during months 3-6. Mean compliance rates were 63% for the first month and ranged from 56% to 45% over the next 5. First-month compliance rates were significantly lower for those who were subsequently readmitted to hospital (n = 7) than for those who were not (p < 0.01).

CONCLUSIONS

Electronic monitoring devices can be used to estimate compliance with medication regimens in patients with severe schizophrenic disorders, but there are methodological improvements that can be made to increase data recovery and compliance, and these are discussed.

Assessing the severity of seizures and epilepsy: which scales are valid?

A review of the literature on methods of seizure or epilepsy severity assessments resulted in tabulation of the seizure rating scales known as US Department of Veterans Affairs (VA), Chalfont-National Hospital, Liverpool, Hague, and others. Each of the scales reviewed has some advantages, but none of them appears to be adequate to assess seizure or epilepsy severity. Most of the scales use similar components of seizures to evaluate severity. However, the disadvantages of each scale outweigh its usefulness. New approaches are needed to assess seizure severity for individuals and for use as an outcome measure after intervention such as surgery or medication changes.

Development and validation of the Headache Needs Assessment (HANA) survey

OBJECTIVE

To develop and validate a brief survey of migraine-related quality-of-life issues. The Headache Needs Assessment (HANA) questionnaire was designed to assess two dimensions of the chronic impact of migraine (frequency and bothersomeness).

METHODS

Seven issues related to living with migraine were posed as ratings of frequency and bothersomeness. Validation studies were performed in a Web-based survey, a clinical trial responsiveness population, and a retest reliability population. Headache characteristics (eg, frequency, severity, and treatment), demographic information, and the Headache Disability Inventory were used for external validation.

RESULTS

The HANA was completed in full by 994 adults in the Web survey, with a mean total score of 77.98 +/- 40.49 (range, 7 to 175). There were no floor or ceiling effects. The HANA met the standards for validity with internal consistency reliability (Cronbach alpha =.92, eigenvalue for the single factor = 4.8, and test-retest reliability = 0.77). External validity showed a high correlation between HANA and Headache Disability Inventory total scores (0.73, P<.0001), and high correlations with disease and treatment characteristics.

CONCLUSIONS

These data demonstrate the psychometric properties of the HANA. The brief questionnaire may be a useful screening tool to evaluate the impact of migraine on individuals. The two-dimensional approach to patient-reported quality of life allows individuals to weight the impact of both frequency and bothersomeness of chronic migraines on multiple aspects of daily life.

Quality of life in schizophrenia: a comparison of instruments. Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia

Health-related quality of life in schizophrenia can be assessed by direct patient response or by a rating based on a structured interview. This study compares both types of instruments using a series of five standards: (1) sensitivity to change over time, (2) sensitivity to treatment effect, (3) correlation with symptom severity, (4) correlation with global clinical ratings, and (5) correlation with other measures of health-related quality of life. Four hundred and twenty-three inpatients with schizophrenia participating in a clinical trial comparing clozapine and haloperidol (VA Cooperative Study in Health Services #17) were evaluated using multiple measures of health-related quality of life (Lehman Quality of Life Interview; Heinrichs-Carpenter-Hanlon Quality of Life Scale; Strauss-Carpenter Level of Function scale, and clinical response.) The Quality of Life Interview showed less sensitivity to change and treatment effect, as well as lower correlations with all other measures than the Quality of Life Scale and the Level of Function scale. The latter scales showed high sensitivity to both change and treatment effect, and moderate-high correlations with other measures and with each other. The Quality of Life Scale and the Level of Function scale rater assessments appeared to be substantially more sensitive to subtle change and treatment effects than the patient-reported Quality of Life Interview for clinical trials. Health-related quality of life in schizophrenia is a more heterogeneous concept than previously appreciated.

Quantitative assessment of seizure severity for clinical trials: a review of approaches to seizure components

Quantitative assessment of seizure severity has been approached using a variety of systems. This review describes currently available methods and possible new approaches to seizure assessment for clinical trials. A review of the literature on methods of seizure assessments resulted in tabulation of the seizure rating scales known as VA, Chalfont-National Hospital, Liverpool, Hague, and the Occupational Hazard Scale. Seizures have been evaluated by simply counting all events, counting events by type, by clinician ratings, patient ratings, and combinations. Each of the scales has advantages and disadvantages. Most scales share core components: seizure frequency, seizure type, seizure duration, postictal events, postictal duration, automatisms, seizure clusters, known patterns, warnings, tongue biting, incontinence, injuries, and functional impairment. This review revealed a partial consensus about aspects of seizures that are important markers for severity. However, usefulness of the existing scales is limited by lack of data on responsiveness. New approaches are needed to assess changes in seizure severity as a result of an intervention in a clinical trial.

Cue-dose training with monetary reinforcement: pilot study of an antiretroviral adherence intervention

OBJECTIVE

To assess the feasibility and efficacy of two interventions for improving adherence to antiretroviral therapy regimens in HIV-infected subjects compared with a control intervention.

DESIGN

Randomized, controlled, pilot study.

SETTING

Department of Veterans Affairs HIV clinic and community-based HIV clinical trials site.

PARTICIPANTS

Fifty-five HIV-infected subjects on stable antiretroviral therapy regimens. Subjects were predominantly male (89%) and African American (69%), and had histories of heroin or cocaine use (80%).

INTERVENTIONS

Four weekly sessions of either nondirective inquiries about adherence (control group, C), cue-dose training, which consisted of the use of personalized cues for remembering particular dose times, and feedback about medication taking using Medication Event Monitoring System (MEMS) pill bottle caps, which record time of bottle opening (CD group), or cue-dose training combined with cash reinforcement for correctly timed bottle opening (CD+CR).

MEASUREMENTS

Opening of the pill bottle within 2 hours before or after a predetermined time was measured by MEMS.

RESULTS

Adherence to the medication as documented by MEMS was significantly enhanced during the 4-week training period in the CD+CR group, but not in the CD group, compared with the control group. Improvement was also seen in adherence to antiretroviral drugs that were not the object of training and reinforcement. Eight weeks after training and reinforcement were discontinued, adherence in the cash-reinforced group returned to near-baseline levels.

CONCLUSIONS

Cue-dose training with cash reinforcement led to transient improvement in adherence to antiretroviral therapy in a population including mostly African Americans and subjects with histories of drug abuse. However, we were not able to detect any sustained improvement beyond the active training period, and questions concerning the timing and duration of such an intervention require further study. Randomized, controlled clinical studies with objective measures of adherence can be conducted in HIV-infected subjects and should be employed for further evaluation of this and other adherence interventions.

Comparison between the QOLIE-31 and derived QOLIE-10 in a clinical trial of levetiracetam

PURPOSE

to determine whether the QOLIE-10, an abbreviated quality of life questionnaire, provides results similar to the more detailed QOLIE-31 instrument when the ten items are derived from the QOLIE-31.

METHODS

the QOLIE-31 was completed by 246 patients participating in UCB protocol N132 at baseline and after 18 weeks of treatment with levetiracetam (LEV 1000 or 3000 mg) or placebo added to standard therapy. QOLIE-10 components and total scores were calculated from the QOLIE-31 data.

RESULTS

baseline QOLIE-10 components and total score correlated highly with corresponding QOLIE-31 scores, both at baseline and follow-up (range 0.70-0.95). Changes from baseline to follow-up were significantly different (ANCOVA) among treatment groups for both the QOLIE-10 and QOLIE-31 for the total score (P = 0.02, P = 0.009, respectively), seizure worry (P = 0.005, P = 0.0003) and cognitive functioning (P = 0.01, P = 0.01). One subscale (overall QOL) showed significant change with the QOLIE-31 (P = 0.04), but not with the QOLIE-10 (P = 0.07). Differences in QOLIE-10 scores were found between responders (> or = 50% partial onset seizure reduction) and non-responders for the total score (P = 0.0001) and two components (overall QOL P = 0.002, social function P = 0.0003). In the QOLIE-31, the total score and six subscale scores (all except medication effects) were significantly different. Both instruments were able to detect change over time. Responsiveness assessed by effect sizes (- 0.1 for non-responders, 0.4 for responders, 0.8 for seizure-free patients) and the Guyatt statistic (0.1, 0.6 and 1.0, respectively) was similar for both instruments.

CONCLUSIONS

although the QOLIE-10 was designed as a screening tool, it can be scored and used in research. The total score did discern differences among treatments in a clinical trial. Nonetheless, questionnaires with multiple, multi-item subscales provide more detailed information than abbreviated forms. The QOLIE-31 is preferred where time and resources are available.

Effect of levetiracetam on epilepsy-related quality of life. N132 Study Group

PURPOSE

To evaluate the short-term effect of levetiracetam (LEV; UCB L059) as add-on therapy on health-related quality of life in the treatment of refractory partial-onset seizures.

METHODS

Patients were enrolled in protocol UCB N132 if they had >/=12 partial-onset seizures with or without secondary generalization during the 12-week baseline period with a minimum of two seizures every 4 weeks. Randomization was made to placebo, LEV 1,000 mg, or LEV 3,000 mg, with sample size based on seizure frequency reduction. The 31-item Quality of Life in Epilepsy (QOLIE-31) questionnaire was completed by 246 patients at the end of baseline and at 18-week follow-up, or earlier if withdrawn.

RESULTS

Significant differences were found among the three treatment groups for Seizure Worry (p = 0. 0003), Overall Quality of Life (p = 0.04), and Cognitive Functioning domains (p = 0.01), as well as the Total Score (p = 0.009). Responders (>/=50% partial onset seizure reduction) had significant improvements in all areas, except Medication Effect, compared with nonresponders (all p > 0.006). Clinically noticeable improvement (>/=10% change from baseline to follow-up) was perceived by LEV 3, 000 mg responders in all areas, except Emotional Well-Being, by LEV 1,000 mg responders in 5 of 9 areas, and by placebo responders in 2 of 9 areas.

CONCLUSIONS

Addition of LEV to standard medication seems to have a positive impact on health-related quality of life, particularly among responders in this short-term study. These exploratory analyses require additional studies to evaluate long-term changes in a larger population.

Brief report: Adolescents' attitudes toward epilepsy: further validation of the Child Attitude Toward Illness Scale (CATIS)

OBJECTIVE

To examine adolescents' attitudes toward having epilepsy using the Child Attitude Toward Illness Scale (CATIS) and to provide further psychometric validation of the scale in this population.

METHODS

Participants were 197 adolescents aged 11 to 17 years who completed the CATIS at two points and two external validation scales. Test-retest and internal consistency reliability and construct validity were computed. Analysis of variance was used to examine differences in attitudes according to gender, age, and epilepsy severity.

RESULTS

Girls, older adolescents, and those with more severe epilepsy had more negative attitudes toward having epilepsy than boys, younger adolescents, and those with moderate or mild epilepsy, respectively. Psychometric analyses yielded excellent internal consistency reliability and good test-retest reliability. The CATIS was moderately correlated with self-esteem and mastery, supporting its construct validity.

CONCLUSIONS

The CATIS is a useful and psychometrically sound tool to assess adolescents' attitudes toward having chronic illness.

Alcohol exposure during the first two trimesters equivalent alters granule cell number and neurotrophin expression in the developing rat olfactory bulb

Although alcohol has been shown to affect brain development adversely, the underlying mechanism of alcohol's actions are poorly understood. The present study addressed the hypothesis that alcohol affects growth factor availability during critical periods of neural growth by measuring the mRNA expression of brain-derived neurotrophic factor (BDNF), a potent developmental growth factor. Multiple offspring of timed-pregnant rat dams given alcohol (6.0 g/kg per day) or control treatments during gestation were sacrificed at either embryonic (E) day 21 or E33 (usually postnatal day 10) when their olfactory bulbs were processed for molecular analyses or neuron counting. BDNF mRNA levels were measured by reverse-transcription-polymerase chain reaction, and DNA methylation of the BDNF gene was quantified by Southern blot analyses following digestion with methylation-sensitive enzymes. Estimates of total granule cell number were obtained by counting those cells using unbiased stereological techniques. There was a significant decrease in BDNF mRNA levels in the alcohol-exposed offspring of both ages compared with controls. In addition, the number of olfactory bulb granule cells significantly decreased in the E33 but not the E21 rat pups exposed to alcohol compared with their appropriate aged controls. Finally, BDNF DNA of alcohol-exposed animals was less susceptible to digestion with the methylation-sensitive enzyme HpaII compared with controls, suggesting that the DNA of the alcohol exposed pups was hypermethylated. Our results indicate that exposure to alcohol during early brain development in the rat, a period equivalent to the first two trimesters in humans, can have a detrimental effect on normal development of the olfactory bulb by reducing the number of BDNF-synthesizing neurons. Although the exact mechanism for the alcohol-induced neuronal loss is unknown, the inappropriate transcription of the BDNF gene is one mechanism that may account for the complexity of effects observed in offspring exposed to heavy alcohol exposure in utero.

Quality of life assessment in clinical practice

Health-related quality of life (HRQOL) includes aspects of physical, psychological, and social well-being issues for people with epilepsy. QOLIE questionnaires can be used to assess the effects of seizures and medications on cognitive function, memory, mood, physical health, and health perceptions. Monitoring HRQOL in epilepsy allows patients to express their concerns about a variety of issues affected by the diagnosis that often are not brought to the attention of the physician.

Phase I trial of the selective mitochondrial toxin MKT077 in chemo-resistant solid tumours

BACKGROUND

MKT077 is a rhodacyanine dye analogue which preferentially accumulates in tumour cell mitochondria. It is cytotoxic to a range of tumours. In this phase I study, MKT077 was administered as a five-day infusion once every three weeks.

PATIENTS AND METHODS

Ten patients, median age 59 (38-70) years, with advanced solid cancers were treated at three dose levels: 30, 40 and 50 mg/m2/day for a total of 18 cycles. 31Phosphorus magnetic resonance spectroscopy (MRS) was used to evaluate the effect of MKT077 on skeletal muscle mitochondrial function.

RESULTS

The predominant toxicity was recurrent reversible functional renal impairment (grade 2, two patients). One patient with renal cancer attained stable disease and the remainder progressive disease. There were no MRS changes in the first or second treatment cycles but one patient received 11 treatment cycles and developed changes consistent with a mitochondrial myopathy. Mean values for all pharmacokinetic parameters were at sub micromolar levels and did not exceed IC50 values (> or = 1 microM).

CONCLUSIONS

Because of the renal toxicity, and animal studies showing MKT077 causes eventual irreversible renal toxicity, further recruitment was halted. The study shows, however, that it is feasible to target mitochondria with rhodacyanine analogues, if drugs with higher therapeutic indices could be developed.

Development of the Quality of Life in Epilepsy Inventory for Adolescents: the QOLIE-AD-48

PURPOSE

We report the development of an instrument to assess health-related quality of life (HRQOL) in adolescents with epilepsy.

METHODS

A sample of 197 English-speaking adolescents (aged 11-17 years) with epilepsy completed a test questionnaire of 88 items. Also included were mastery and self-esteem scales to assess external validity. A parent simultaneously completed an 11-item questionnaire to evaluate the child's HRQOL. Both adolescent and parent questionnaires were repeated in 2-4 weeks. Demographic information and information pertaining to seizures were collected at baseline along with assessment of systemic and neurologic toxicity.

RESULTS

The QOLIE-AD-48 contains 48 items in eight subscales: epilepsy impact (12 items), memory/concentration (10), attitudes toward epilepsy (four), physical functioning (five), stigma (six), social support (four), school behavior (four), health perceptions (three), and a total summary score, with higher scores indicating better HRQOL. Internal construct validity was demonstrated in a single-factor solution for the eight dimensions. All correlations were statistically significant at p < 0.05 level. Internal consistency reliability estimated by Cronbach's alpha coefficient was 0.74 for the summary score and ranged from a low of 0.52 (three-item Health Perceptions Scale) to 0.73-0.94 for the other individual scales. Good test-retest reliability was found for the overall measure (0.83). Summary score correlations with the two external validity scales, self-efficacy and self-esteem were 0.65 and 0.54, respectively. Statistically significant differences in summary scores indicating that HRQOL was increasingly better for adolescents as seizure severity decreases (no seizures = 77+/-13, low = 70+/-17, high = 63+/-17) were found among seizure-severity groups.

CONCLUSIONS

These data describe the development of a robust instrument to evaluate HRQOL in adolescents with epilepsy. Empiric analyses provide strong evidence that the QOLIE-AD-48 is both a reliable and valid measure for adolescents with epilepsy.

New antiepileptic drugs: comparison of key clinical trials

PURPOSE

Data accrued from clinical trials of five new antiepileptic drugs (AEDs) are compared for efficacy in reducing seizures and self-reported adverse events as a basis of selection among new AEDs. Drawbacks to use of these data also are demonstrated.

METHODS

A review of double-blind, placebo-controlled clinical trials of a new AED or placebo added to a standard AED provided data on reduction of complex partial seizures (CPSs). Success is > or =50% fewer CPSs with a new AED or placebo; Overall Improvement is the success rate with drug minus the success rate with placebo. Adverse events were tabulated from product-labeling lists of COSTART items (incidence, > or =5%). The Summary Complaint score is the total number of reports of individual events for each AED.

RESULTS

Efficacy data demonstrate differences in Overall Improvement rates among five new AEDs and placebos (p = 0.001). However, rates of response to placebo also differed significantly among trials (p = 0.01). Adverse events predominantly affect central nervous system, psychiatric, and general body systems. However, patients in the placebo control groups did not consistently report adverse effects. Summary Complaint scores differ among the five new AEDs, but variability in use of COSTART terms nullifies comparisons.

CONCLUSIONS

Comparisons of data for five new AEDs provide information for selection among treatments when a second drug is needed to improve control of CPSs. However, significant differences among the control groups and other problems make comparisons between trials problematic. The final choice should be based on the need of the individual patient for superior seizure control versus minimal adverse effects.

Consequences of intermittent treatment for hypertension: the case for medication compliance and persistence

OBJECTIVE

To review patient compliance with once-daily antihypertensive medications and the impact of partial compliance on healthcare outcomes.

DATA SOURCES

A MEDLINE search of the literature using the terms "patient compliance," "antihypertensive medications," and "hypertension" for the period 1976-1996 was conducted. In addition, papers cited in reference lists of source articles were reviewed.

STUDY SELECTION

Articles were selected if they described patterns of compliance, including rates for differing dosing regimens. Articles discussing once-daily dosing were selected only if they included information on the methodology for compliance assessment. Thirteen reports met these criteria.

DATA SYNTHESIS

Patterns of compliance vary, with only a partial relationship to dosing regimens. Overall compliance was 76% for once-daily antihypertensive medications, with a wide range found (53% to 85%). These data were comparable to the mean 75% compliance found for other medical disorders.

CONCLUSIONS

Persistence with treatment is necessary for reduction of long-term consequences of hypertension. Enhancing compliance with antihypertensive medications could thus have a profound impact on health outcomes. Once-daily dosing should be coupled with selection of a drug with long duration of action to overcome problems of missed doses. Widespread adoption of simple compliance enhancement methods could lead to decreased morbidity and mortality from cardiovascular disease and stroke.

Enhanced positive cloud-to-ground lightning in thunderstorms ingesting smoke from fires

Smoke from forest fires in southern Mexico was advected into the U.S. southern plains from April to June 1998. Cloud-to-ground lightning (CG) flash data from the National Lightning Detection Network matched against satellite-mapped aerosol plumes imply that thunderstorms forming in smoke-contaminated air masses generated large amounts of lightning with positive polarity (+CGs). During 2 months, nearly half a million flashes in the southern plains exhibited +CG percentages that were triple the climatological norm. The peak currents in these +CGs were double the expected value. These thunderstorms also produced abnormally high numbers of mesospheric optical sprites.

Complex partial and secondarily generalized seizure patients: cognitive functioning prior to treatment with antiepileptic medication. VA Epilepsy Cooperative Study 264 Group

This investigation of cognitive functioning in patients with symptomatic localization-related (partial) epilepsy prior to administration of antiepileptic medication is part of a nationwide prospective, double-blind study of drug efficacy and longitudinal changes in cognition associated with seizure disorders. Recently-diagnosed patients with complex partial or secondarily generalized tonic clonic seizures, equated for age, education and IQ, were compared with normal controls on a battery of neuropsychological tests: verbal and figural memory measures (Rey auditory verbal learning test, Rey Osterrieth complex figure), and a brief behavioral toxicity battery comprising measures of motor function, concentration and mental flexibility (Lafayette grooved pegboard, controlled word association test, Stroop, paced auditory serial addition test [PASAT]). Control subjects perform significantly better than both groups of seizure patients on several measures of motor speed/integration and memory, specifically the pegboard and the RAVLT learning (3-5) and recall trials. Secondarily generalized seizure patients show greatest impairment. They perform significantly worse than patients with complex partial seizures and control subjects on the controlled word association test and the most demanding Stroop color word trial, both measures of concentration and mental flexibility. These findings document deficits in memory as well as concentration and motor function in complex partial and in secondarily generalized seizure patients prior to treatment with antiepileptic medication.

Compliance with medication regimens for mental and physical disorders

OBJECTIVE

The authors reviewed research on medication compliance in psychiatric treatment and compared compliance rates with compliance rates in treatment of physical disorders.

METHODS

MEDLINE was used to locate reports in the literature on medication compliance in psychiatric treatment for the years 1975 through 1996. These reports and studies cited in the reports were reviewed to determine the methods used to assess compliance and the compliance rates reported. Ten reports describing assessment methods and including medication compliance rates for antidepressant medication and 24 reports for antipsychotic medication were selected. They were compared with 12 reports that used microelectronic monitoring to assess medication compliance of patients with a range of nonpsychiatric disorders.

RESULTS

Studies of psychiatric patients used various methods of estimating medication compliance, including interviews with patients, clinicians' judgment, and pill counts, but overall showed low rates of compliance. Patients receiving antipsychotics took an average of 58 percent of the recommended amount of the medications, with a range from 24 to 90 percent. Patients receiving antidepressants took 65 percent of the recommended amount, with a range from 40 to 90 percent. The mean compliance rate for patients with physical disorders was 76 percent, with a range from 60 to 92 percent, although the microelectronic monitoring showed frequent omission of doses and discontinuation of medication.

CONCLUSIONS

Compliance with medication regimens among patients with psychiatric disorders may be lower than among patients with physical disorders. However, the difference may be largely attributable to the methods used for estimating compliance. The findings suggest the need for new and improved methods for monitoring compliance and increasing patients' compliance with pharmacotherapy.