Factors that affect adherence to bipolar disorder treatments: a stated-preference approach

Online information seeking by patients with bipolar disorder: results from an international multisite survey

Background

Information seeking is an important coping mechanism for dealing with chronic illness. Despite a growing number of mental health websites, there is little understanding of how patients with bipolar disorder use the Internet to seek information.

Methods

A 39 question, paper-based, anonymous survey, translated into 12 languages, was completed by 1222 patients in 17 countries as a convenience sample between March 2014 and January 2016. All patients had a diagnosis of bipolar disorder from a psychiatrist. Data were analyzed using descriptive statistics and generalized estimating equations to account for correlated data.

Results

976 (81 % of 1212 valid responses) of the patients used the Internet, and of these 750 (77 %) looked for information on bipolar disorder. When looking online for information, 89 % used a computer rather than a smartphone, and 79 % started with a general search engine. The primary reasons for searching were drug side effects (51 %), to learn anonymously (43 %), and for help coping (39 %). About 1/3 rated their search skills as expert, and 2/3 as basic or intermediate. 59 % preferred a website on mental illness and 33 % preferred Wikipedia. Only 20 % read or participated in online support groups. Most patients (62 %) searched a couple times a year. Online information seeking helped about 2/3 to cope (41 % of the entire sample). About 2/3 did not discuss Internet findings with their doctor.

Conclusion

Online information seeking helps many patients to cope although alternative information sources remain important. Most patients do not discuss Internet findings with their doctor, and concern remains about the quality of online information especially related to prescription drugs. Patients may not rate search skills accurately, and may not understand limitations of online privacy. More patient education about online information searching is needed and physicians should recommend a few high quality websites.

Electronic supplementary material

The online version of this article (doi:10.1186/s40345-016-0058-0) contains supplementary material, which is available to authorized users.

What influences persistence with medicines? A multinational discrete choice experiment of 2549 patients

AIM

The aim was to examine patients' stated preferences to persist with medicines and to explore the influence of psychosocial and sociocognitive factors.

METHODS

Community-dwelling, hypertensive patients recruited from nine European countries were invited to complete a discrete choice experiment (DCE) with attributes for treatment benefits, mild yet common adverse drug reactions (ADRs), rare but potentially life-threatening ADRs and dosing frequency. Patients responded to the binary choice of which medicine would they be most likely to continue taking. Data were analyzed using a random effects logit model.

RESULTS

Two thousand five hundred and forty-nine patients from Austria (n = 321), Belgium (n = 175), England (n = 315), Germany (n = 266), Greece (n = 288), Hungary (n = 322), the Netherlands (n = 231), Poland (n = 312) and Wales (n = 319) completed the DCE. All attributes significantly influenced patients' stated preference to persist with medications (P < 0.05). Patients were willing to accept decreases in treatment benefits of 50.6 percentage points (95% CI 46.1, 57.9) for a very rare (as opposed to rare) risk of severe ADR, 28.3 percentage points (95% CI 25.2, 33.1) for a once daily instead of twice daily dosing and 0.74 percentage points (95% CI 0.67, 0.85) for a 1% point reduction in mild ADRs. Models accounting for psychosocial and sociocognitive characteristics were significantly different from the base case.

CONCLUSION

Patients' intention to persist with treatment was associated with their willingness to trade potential benefits, harms and dosing frequency. Psychosocial and sociocognitive factors influenced the extent of trading. The utility model may have value in assessing patients' likelihood of persisting with medicines and to tailor treatment to maximize persistence.

Adherence to Antipsychotic Medication in Bipolar Disorder and Schizophrenic Patients: A Systematic Review

Antipsychotics are the drugs prescribed to treat psychotic disorders; however, patients often fail to adhere to their treatment, and this has a severe negative effect on prognosis in these kinds of illnesses. Among the wide range of risk factors for treatment nonadherence, this systematic review covers those that are most important from the point of view of clinicians and patients and proposes guidelines for addressing them. Analyzing 38 studies conducted in a total of 51,796 patients, including patients with schizophrenia spectrum disorders and bipolar disorder, we found that younger age, substance abuse, poor insight, cognitive impairments, low level of education, minority ethnicity, poor therapeutic alliance, experience of barriers to care, high intensity of delusional symptoms and suspiciousness, and low socioeconomic status are the main risk factors for medication nonadherence in both types of disorder. In the future, prospective studies should be conducted on the use of personalized patient-tailored treatments, taking into account risk factors that may affect each individual, to assess the ability of such approaches to improve adherence and hence prognosis in these patients.

Understanding Patient Preferences in Medication Nonadherence: A Review of Stated Preference Data

Nonadherence is a global problem undermining the cost-effectiveness of evidence-based medications. Aligning treatment choices with patient preferences may promote adherent behaviour: eliciting patient treatment preferences may help resolve the problem of nonadherence. As there is no reliable measure of nonadherent behaviour that can be used to derive preferences, stated-preference techniques offer a robust alternative. To understand patient preferences in medication nonadherence, we systematically appraised full-text English studies (from database inception to 24 February 2014) involving participants evaluating hypothetical scenarios to elicit preferences as an explicit means to understand medication nonadherence. Study characteristics (e.g. setting, disease, stated-preference method), attribute type and influence on choice were extracted. Seventeen full-text articles (4,456 patients) were included in the review, which reports stated-preference elicitation studies across a wide range of chronic and acute conditions. All studies were conducted in high-income settings. The influence of drug-related factors was predominant in patients' preferences for treatment. Patients preferred efficacious over safe medications except when considering the duration of therapy, but dosing and cost appeared more important when contemplating adherence. Patient characteristics, particularly medication experience, significantly influenced preferences. A disparity between stated preferences for treatment and adherence was reported. When using stated-preference techniques to understand nonadherence, this manuscript highlights that there is much room for methodological development. Studies outside of high-income settings are needed, particularly in relation to chronic diseases, for which nonadherence poses a substantial economic burden to health systems and patients. To inform the problem of sustaining adherence, prospective research is needed to understand how preferences change with time. The usefulness of stated-preference techniques to inform policy and practice requires a better understanding of how stated preferences relate to actual adherence behaviour.

Hospital treatment, mortality and healthcare costs in relation to socioeconomic status among people with bipolar affective disorder

BACKGROUND

Evidence regarding the relationships between the socioeconomic status and long-term outcomes of individuals with bipolar affective disorder (BPD) is lacking.

AIMS

We aimed to estimate the effects of baseline socioeconomic status on longitudinal outcomes.

METHOD

A national cohort of adult participants with newly diagnosed BPD was identified in 2008. The effects of personal and household socioeconomic status were explored on outcomes of hospital treatment, mortality and healthcare costs, over a 3-year follow-up period (2008-2011).

RESULTS

A total of 7987 participants were recruited. The relative risks of hospital treatment and mortality were found elevated for the ones from low-income households who also had higher healthcare costs. Low premium levels did not correlate with future healthcare costs.

CONCLUSIONS

Socioeconomic deprivation is associated with poorer outcome and higher healthcare costs in BPD patients. Special care should be given to those with lower socioeconomic status to improve outcomes with potential benefits of cost savings in the following years.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© 2016 The Royal College of Psychiatrists. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Participating physician preferences regarding a pay-for-performance incentive design: a discrete choice experiment

OBJECTIVE

To determine whether the magnitude of incentives or other design attributes should be prioritized and the most important attributes, according to physicians, of the diabetes P4P (pay-for-performance) program design.

DESIGN

We implemented a discrete choice experiment (DCE) to elicit the P4P incentive design-related preferences of physicians.

PARTICIPANTS

All of the physicians (n = 248) who participated in the diabetes P4P program located in the supervisory area of the northern regional branch of the Bureau of National Health Insurance in 2009 were included. The response rate was ∼ 60%.

RESULTS

Our research found that the bonus type of incentive was the most important attribute, followed by the incentive structure and the investment magnitude.

CONCLUSIONS

Physicians may feel that good P4P designs are more important than the magnitude of the investment by the insurer. The two most important P4P designs include providing the bonus type of incentive and using pay-for-excellence plus pay-for-improvement.

Living with antipsychotic medication side-effects: the experience of Australian mental health consumers

The present study explores people's experience of living with antipsychotic medication side-effects. Qualitative data were gathered through semistructured interviews with 10 mental health consumers in a community care setting in Australia. The interview transcriptions were content analysed, and enhanced by combining manifest and latent content. Important contextual cues were identified through replaying the audio-recordings. Several main themes emerged from the analysis, including the impact of side-effects, attitudes to the use of medication and side-effects, and coping strategies to manage medication side-effects. Each participant reported between six and seven side-effects on average, which were often pronounced and had a major disruptive impact on their lives. Of these effects, the most commonly mentioned was sedation, which the participants described as leaving them in a 'zombie'-like state. Most participants expressed an attitude of acceptance about the side-effects. The participants' most common strategy to manage side-effects was to change the dosage of the medication. Other common side-effect management strategies involved using other medications to control side-effects, and diverse self-help techniques, the most common of which was relaxation/distraction techniques.

What matters to patients? A systematic review of preferences for medication-associated outcomes in mental disorders

OBJECTIVE

To investigate patients' preferences for outcomes associated with psychoactive medications.

SETTING/DESIGN

Systematic review of stated preference studies. No settings restrictions were applied.

PARTICIPANTS/ELIGIBILITY CRITERIA

We included studies containing quantitative data regarding the relative value adults with mental disorders place on treatment outcomes. Studies with high risk of bias were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

We restricted the scope of our review to preferences for outcomes, including the consequences from, attributes of, and health states associated with particular medications or medication classes, and process outcomes.

RESULTS

After reviewing 11 215 citations, 16 studies were included in the systematic review. These studies reported the stated preferences from patients with schizophrenia (n=9), depression (n=4), bipolar disorder (n=2) and attention deficit hyperactive disorder (n=1). The median sample size was 81. Side effects and symptom outcomes outnumbered functioning and process outcomes. Severe disease and hospitalisation were reported to be least desirable. Patients with schizophrenia tended to value disease states as higher and side effects as lower, compared to other stakeholder groups. In depression, the ability to cope with activities was found to be more important than a depressed mood, per se. Patient preferences could not consistently be predicted from demographic or disease variables. Only a limited number of potentially important outcomes had been investigated. Benefits to patients were not part of the purpose in 9 of the 16 studies, and in 10 studies patients were not involved when the outcomes to present were selected.

CONCLUSIONS

Insufficient evidence exists on the relative value patients with mental disorders place on medication-associated outcomes. To increase patient-centredness in decisions involving psychoactive drugs, further research-with outcomes elicited from patients, and for a larger number of conditions-should be undertaken.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42013005685.

Correlates of attitudes towards mood stabilizers in individuals with bipolar disorder

OBJECTIVES

Attitudes towards medication are believed to be important for medication adherence and social factors are believed to have effects on attitudes. Only a limited literature has focused on how attitudes to medication may correlate with social factors relevant to medication adherence among individuals with bipolar disorder (BPD). This secondary analysis of baseline data from a longitudinal study examined the relationships between attitudes towards mood stabilizers and psychosocial variables.

METHODS

Community mental health clinic patients (n = 122) were assessed on the outcome variable of medication attitudes as measured by the Attitudes towards Mood Stabilizers Questionnaire (AMSQ). Independent variables included education as well as standardized measures of psychiatric symptom severity, alcohol and drug problem severity, health locus of control (the belief that one's health is self-determined versus determined by factors outside of one's own control), and psychosocial support. A hierarchical multiple regression model evaluated the relationship between AMSQ and these variables.

RESULTS

More positive medication attitudes were seen in individuals with higher levels of social support and in those who held a stronger belief that their health outcomes are determined by others, such as family or clinicians. Education, symptom severity, alcohol problem severity and drug problem severity were not significant attitudinal correlates.

CONCLUSIONS

Attitudes towards mood stabilizers are correlated with both the support a person receives from others in their social network and how much a person believes others can influence his or her health. Clinicians need to be aware of the importance of the social environment as it relates to medication attitudes and more research is needed on how treatment attitudes may actually translate into medication adherence behavior.

Nutzung von Conjoint-Analysen zur Messung von Therapiezielpräferenzen aus Patientenperspektive in der Behandlung psychischer Störungen

Hintergrund: Im Zuge der wachsenden Bedeutung von Ansätzen zur Patientenorientierung und -partizipation in der Gesundheitsversorgung gewinnt die Bestimmung subjektiver Therapiezielpräferenzen unterschiedlicher Akteure (Patienten, Behandler, Angehörige) zunehmend an Forschungsinteresse. Stated-Preference-Methods ermöglichen die systematische Untersuchung speziell patientenorientierter Fragestellungen. Ziele der Studie: Identifikation und Beschreibung (nach formalen, methodischen und inhaltlichen Merkmalen) von Studien mit Stated-Preference-Methods (Conjoint Measurements, Conjoint Analysis, Discrete Choice Experiments) in der Versorgung von Patienten mit psychischen Störungen mit dem Ziel, eine Bewertung zur Anwendbarkeit der Methode (Potential, Nutzen, Grenzen) in zukünftiger patientenorienterter Forschung abzuleiten. Methode: Systematische Literaturrecherche mit folgenden Studieneinschlusskriterien: Participants: Interventionen zur Behandlung von Patienten mit psychischer Störung; Intervention: psychotherapeutische, psychiatrische, hausärztliche Behandlungen (stationär, teil-stationär, ambulant); Comparison: Studien mit keiner (Ein-Gruppen-Design) oder mindestens einer Kontrollgruppe; Outcomes: conjoint-spezifische Angaben zu Nutzenwerten. Ergebnisse: Conjoint-Analysen werden in unterschiedlichen Forschungsdesigns und unter heterogenen Rahmenbedingungen (Stichprobe, Störungsbild, Setting, Intervention, Zieldimension) zur Messung von Therapiezielpräferenzen eingesetzt. Die Erstellung des Conjoint-Designs erfolgt in der Regel reduziert (orthogonal), mithilfe von Softwarepaketen, die Erhebung als Fragebogen. Schlussfolgerungen: Conjoint-Analysen ermöglichen differenzierte Aussagen über Therapiepräferenzstrukturen auf Basis relationaler Beurteilungsszenarien und stellen damit eine fundiertere Basis zur Verbesserung der Patientenorientierung in der Gesundheitsversorgung zur Verfügung. Die Befundlage belegt, dass sich die Methode zur Untersuchung patientenorientierter Fragestellungen (mehrheitlich zu Pharmakotherapie und Kombinationsbehandlung) in der Versorgung psychischer Störungen (depressive Störungen, ADHS, Schizophrenie, bipolare Störungen, Tabak- und Alkoholabhängigkeit und chronische Schmerzen) eignet. Allerdings ist der erfolgreiche Einsatz der Methodik an einige Voraussetzungen geknüpft (u. a. Unabhängigkeit der betrachteten Therapiezielaspekte, Designkomplexität). Forschungsbedarf besteht u. a. im Hinblick auf bisher nicht untersuchte Störungsbilder (u. a. somatoforme, Angst-, Ess-, Persönlichkeitsstörungen) und Interventionen (u. a. reine Psychotherapie, störungsspezifische Behandlungen).

Role of adverse effects in medication nonadherence in bipolar disorder

Nonadherence to medications is common and associated with poor or limited clinical outcomes in the treatment of bipolar disorder. A review of the literature discloses that adverse effects are one of the commonly reported reasons for nonadherence to mood stabilizers by patients with bipolar disorder. Nevertheless, other than such broad summaries, relatively little attention has been given to the role of adverse effects in relation to nonadherence. This review article is the first to consolidate the available data on this topic. Weight gain, perceived cognitive impairment, tremors, and sedation are the adverse effects most likely to lead to nonadherence. Further research is needed to anticipate, identify, manage, and potentially minimize the impact of adverse effects.

The diagnosis and treatment of bipolar disorder: decision-making in primary care

Bipolar disorder is a chronic episodic illness, characterized by recurrent episodes of manic or depressive symptoms. Patients with bipolar disorder frequently present first to primary care, but the diversity of the potential symptoms and a low index of suspicion among physicians can lead to misdiagnosis in many patients. Frequently, co-occurring psychiatric and medical conditions further complicate the differential diagnosis. A thorough diagnostic evaluation at clinical interview, combined with supportive case-finding tools, is essential to reach an accurate diagnosis. When treating bipolar patients, the primary care physician has an integral role in coordinating the multidisciplinary network. Pharmacologic treatment underpins both short- and long-term management of bipolar disorder. Maintenance treatment to prevent relapse is frequently founded on the same pharmacologic approaches that were effective in treating the acute symptoms. Regardless of the treatment approach that is selected, monitoring over the long term is essential to ensure continued symptom relief, functioning, safety, adherence, and general medical health. This article describes key decision-making steps in the management of bipolar disorder from the primary care perspective: from initial clinical suspicion to confirmation of the diagnosis to decision-making in acute and longer-term management and the importance of patient monitoring.

Olanzapine is superior to lamotrigine in the prevention of bipolar depression: a naturalistic observational study

BACKGROUND

Bipolar disorder is a highly recurrent disease and has great impact on the function of patients. Depressive symptoms consist of more than 50% of life time during the illness and may lead to self harm or suicidal behaviors. Little is known about the antidepressant effects of olanzapine, an atypical antipsychotic, as monotherapy despite its indication for preventing manic episodes. In contrast, lamotrigine, a mood stabilizer, has been proven to be effective in preventing depression in patients with bipolar disorder. However, no studies have compared the efficacy between lamotrigine and olanzapine in the maintenance treatment of bipolar disorder. This enriched naturalistic study was implemented to assess the effectiveness of olanzapine and lamotrigine as monotherapy in the prevention of recurrence of bipolar disorder.

METHODS

Patients with bipolar disorder in a euthymic state (Young's Mania Rating Scale (YMRS) score <12, and 21-item Hamilton Depression Rating Scale (HAM-D) score <7) for at least two months, having already received either olanzapine or lamotrigine as the maintenance treatment were recruited. The patients maintained with olanzapine (n = 22) were applied to olanzapine group whereas those maintained with lamotrigine (n = 29) were applied to lamotrigine group. They were followed up for 12 months. Differences in the efficacy between olanzapine and lamotrigine in recurrence prevention were analyzed. The Kaplan-Meier method was used to generate time-to-recurrence curves, and differences between the two groups were compared using the log-rank test.

RESULTS

Olanzapine had a significantly lower recurrence rate of depressive episodes than lamotrigine (20.0% vs. 57.7%, χ2 = 6.62, p = .010). However, olanzapine and lamotrigine had similar mania (15.0% vs. 0%, χ2 = 4.17, p = .075, Fisher's exact test) and any mood episode (35.0% vs. 57.7%, χ2 = 2.33, p = .127) recurrence rates. Olanzapine was significantly superior to lamotrigine in the time to recurrence of depressive episodes (χ2 = 4.55, df = 1, p = .033), but there was no difference in the time to recurrence of any mood episode (χ2 = 1.68, df = 1, p = .195).

CONCLUSIONS

This prospective naturalistic study suggests that olanzapine is more effective than lamotrigine in the prevention of depressive episodes in patients with bipolar disorder. Future large-scale randomized studies are warranted to validate our results.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT01864551.

Factors affecting treatment compliance in patients with bipolar I disorder during prophylaxis: a study from Turkey

OBJECTIVES

Treatment noncompliance is one of the most frequent causes of relapse and recurrence in patients with bipolar I disorder. Treatment compliance among patients with bipolar disorder is affected by individual patients' features, the disease itself, doctor-patient relationships and patients' socio-economic and cultural characteristics. This study aimed to determine the factors affecting treatment compliance during the treatment of bipolar disorder and contribute to current clinical strategies.

METHODS

Data were collected from 78 volunteers with bipolar I disorder in remission; all volunteers were being treated solely with mood stabilisers. Sociodemographic and clinical data were gathered through a semi-structured interview designed by researchers. The Hamilton Depression Rating Scale and the Young Mania Rating Scale were both administered to assess remission of bipolar I disorder, and a self-report scale, the Medication Adherence Rating Scale, was administered to assess medication adherence.

RESULTS

Treatment compliant patients reported that they had received adequate social support and had been sufficiently informed by their physicians about the illness and treatment. Treatment compliant individuals with higher rates of hospitalisations and the results indicate that the number of depressive episodes adversely affects treatment compliance. There was not a statistically significant difference in treatment compliance based on duration of illness, euthymia, time, total number of episodes, age of onset, predominant polarity, drug doses, number of daily medications, frequency of daily medications, or type of mood stabiliser used.

CONCLUSIONS

These results indicate that there are differences between compliant and non-compliant bipolar I disorder patients in terms of adequate social support, information provided by the physician about the illness and treatment, number of depressive episodes and number of hospitalisations.

[Treatment of manic phases of bipolar disorder: critical synthesis of international guidelines]

INTRODUCTION

Bipolar disorder (BD) is the seventh leading cause of disability per year of life among all diseases in the population aged 15 to 44. It is a group of heterogeneous diseases, with frequent comorbid psychiatric or somatic disorders, variable treatment response and frequent residual symptoms between episodes. The major impairment associated with this disorder is related to the high relapse and recurrence rates, the functional impact of comorbidities and cognitive impairment between episodes. The prognosis of the disease relies on the efficacy of relapse and recurrence prevention interventions. Given the heterogeneity of the disorder, relapse and recurrence prevention needs to develop a personalized care plan from the start of the acute phase. In such a complex situation, guideline-driven algorithms of decision are known to improve overall care of patients with bipolar disorder, compared to standard treatment decisions. Although guidelines do not account for all the situations encountered with patients, this systematic approach contributes to the development of personalized medicine.

METHODS

We present a critical review of recent international recommendations for the management of manic phases. We summarize treatment options that reach consensus (monotherapy and combination therapy) and comment on options that differ across guidelines.

RESULTS

The synthesis of recent international guidelines shows a consensus for the initial treatment for manic phases. For acute and long-term management, the anti-manic drugs proposed are traditional mood stabilizers (lithium or valproate) and atypical antipsychotics (APA - olanzapine, risperidone, aripiprazole and quetiapine). All guidelines indicate stopping antidepressant drugs during manic phases. International guidelines also present with some differences. First, as monotherapy is often non sufficient in clinical practice, combination therapy with a traditional mood stabilizer and an APA are disputed either in first line treatment for severe cases or in second line. Second, mixed episodes treatment is not consensual either and some guidelines propose in first line valproate, carbamazepine and some APA, and advice not to use lithium. On the other hand, some guidelines do not propose specific treatment for mixed episodes and group them with manic episodes management. Duration of treatment is unclear.

CONCLUSION

Guidelines utilization has shown that the systemic use by clinicians of decision algorithms in comparison to "treatment as usual" modality improves the overall care of patients with BD. Future data from cohorts of patients seem necessary to complement the existing data from clinical trials. These cohort studies will help to take into account the different individual profiles of BD and thus may help to propose a more personalized medicine.

Cost-effectiveness of asenapine in the treatment of bipolar disorder in Canada

BACKGROUND

Bipolar disorder (BPD) is prevalent and is associated with a significant economic burden. Asenapine, the first tetracyclic antipsychotic approved in Canada for the treatment of BPD, has shown a comparable efficacy profile to other atypical antipsychotics. In addition, it is associated with a favourable metabolic profile and minimal weight gain potential. This study aimed to assess the economic impact of asenapine compared to olanzapine in the treatment of BPD in Canada.

METHODS

A decision tree combined with a Markov model was constructed to assess the cost-utility of asenapine compared with olanzapine. The decision tree takes into account the occurrence of extrapyramidal symptoms (EPS), the probability of switching to a different antipsychotic, and the probability of gaining weight. The Markov model takes into account long-term metabolic complications including diabetes, hypertension, coronary heart diseases (CHDs), and stroke. Analyses were conducted from both a Canadian Ministry of Health (MoH) and a societal perspective over a five-year time horizon with yearly cycles.

RESULTS

In the treatment of BPD, asenapine is a dominant strategy over olanzapine from both a MoH and a societal perspective. In fact, asenapine is associated with lower costs and more quality-adjusted life years (QALYs). Results of the probabilistic sensitivity analysis indicated that asenapine remains a dominant strategy in 99.2% of the simulations, in both a MoH and a societal perspective, and this result is robust to the many deterministic sensitivity analyses performed.

CONCLUSIONS

This economic evaluation demonstrates that asenapine is a cost-effective strategy compared to olanzapine in the treatment of BPD in Canada.

Antidepressant dosage taken by patients with bipolar disorder: factors associated with irregularity

BACKGROUND

This study analyzed regularity in the daily dosage of antidepressants taken by patients with bipolar disorder and identified the factors associated with irregularity.

METHODS

Daily self-reported medication dosage taken and mood ratings were available from 144 patients who received treatment as usual. All 144 patients took the same antidepressant for at least 100 days. One hundred eleven of these patients were also taking a mood stabilizer. Approximate entropy (ApEn) was used to measure serial regularity in daily dosage. Regularity is the tendency that values within a time series remain the same on incremental comparisons. Drug holidays (missing three or more consecutive days) were also determined. Generalized estimating equations (GEE) were used to estimate if any demographic or clinical variables were associated with regularity.

RESULTS

Although the mean percent of days missing doses was only 18.6%, there was a wide range of regularity in the daily antidepressant dosage. Drug holidays were common, occurring in 41% of the analyses. Factors significantly associated with irregularity were as follows: total number of psychotropic medications (p = 0.005), pill burden (p = 0.005), and depression (p = 0.015). Neither the percent of days missing doses nor the drug holidays were associated with any demographic or clinical factors. For patients taking both antidepressants and mood stabilizers, there was no significant difference in regularity in daily dosage between these drugs.

DISCUSSION

There can be considerable irregularity in daily dosage despite a low percent of days missing doses. Medication regimen complexity and depressed mood are associated with increased irregularity. Daily regularity in drug dosage may be more dependent on the individual than on the specific drug. Research on the clinical impact of irregularity in daily dosage of antidepressants is needed.

Depressive residual symptoms are associated with lower adherence to medication in bipolar patients without substance use disorder: results from the FACE-BD cohort

BACKGROUND

Poor adherence to medication is frequent in Bipolar Disorder (BD). It is associated with illness severity and increases total medical cost. Several factors are associated with poor adherence but previous studies included heterogeneous cohorts of patients with and without current mood episode, with and without SUD.

METHODS

We conducted a cross-sectional study, based on the Fondamental Advanced Centers of Expertise in Bipolar Disorders. 382 patients diagnosed with BD (type I, II or NOS) according to DSM-IV, with partial or complete remission and without comorbid SUD, were included. All patients had a large standardized clinical evaluation with structured interview and self reports. Side effects were evaluated with Patient Rated Inventory of Side Effects (PRISE). Adherence behavior was measured by a self reported scale, Medication Adherence Rating Scale (MARS). Univariate analyses and linear regression models were undertaken to determine factors associated with adherence.

RESULTS

Residual depressive symptoms (β=-0.155, p=0.004), and side effects (β=-0.142, p=0.008) were the main factors associated with adherence behavior in linear regression model. We found no association with residual manic symptoms, age at assessment, marital status, number of past mood episodes as well as past psychotic symptoms.

LIMITATION

We used no other assessment than self-rating scale for adherence behavior evaluation. We had no information concerning treatment regimen and patient/family knowledge about BD.

CONCLUSIONS

Adherence behavior in bipolar patients appears to be mainly influenced by the presence of residual depressive symptoms in patients without SUD. Improvement in diagnosis and pharmacotherapy of residual depressive symptoms has to be kept in mind to face low adherence to medication.

Determinants of adherence to treatment in bipolar disorder: a comprehensive review

OBJECTIVE

Comprehensively review studies evaluating factors associated with adherence to treatment in bipolar disorder (BD), as well as the results of interventions developed to enhance adherence in this population.

METHODS

The following search engines were consulted: PubMed, Scielo, LILACS and PsycINFO. The keywords used were "Bipolar Disorder", "Factor", "Adherence", "Nonadherence", "Compliance" and "Intervention". In addition, references list of selected studies were consulted searching for relevant articles.

RESULTS

Adherence has been defined in various ways, with some considering adherence vs. nonadherence, and other including a "partial" adherence measure. In addition, methods to assess adherence differ for each study. Several factors were related to poor adherence, including patient-related factors (e.g. younger age, male gender, low level of education, alcohol and drugs comorbidity), disorder-related factors (e.g. younger age of onset, severity of BD, insight and lack of awareness of illness) and treatment-related factors (e.g. side effects of medications, effectiveness). To improve adherence, the main recommendations are to provide customized interventions focusing on the underlying causes of nonadherence, strong therapeutic alliance and different modalities based on psychoeducation.

CONCLUSION

Our results indicate that nonadherence is a multicausal phenomenon and strategies to prevent and approaches them must include enhanced therapeutic alliance, flexible topics, early intervention, group setting, and psychoeducation.

LIMITATIONS

Different definitions and measures of adherence in the literature currently moderate the generalization of the findings in this review. Further studies are necessary regarding factors of adherence in BD and interventions to improve it, especially on social factors like stigma and family.

Evaluating migraineurs' preferences for migraine treatment outcomes using a choice experiment

OBJECTIVE

The impact of migraines on patients is commonly divided between the level of impairment associated with headache symptoms (headache phase) and the quality-of-life effects immediately following the headache (post-headache phase). Evaluations of migraineurs' productivity losses and health-related quality of life have provided an understanding of the burden associated with the headache and post-headache symptoms, but do not quantify the relative importance of each phase from a patient perspective. In this study, we evaluated migraineurs' willingness to accept trade-offs among symptom severity in the headache and post-headache phases, symptom duration in the headache and post-headache phases, and symptom-free time within a general-preference theoretic framework.

METHODS

We administered a choice-format, conjoint-analysis survey, also called a discrete-choice experiment, to a sample of migraineurs from a nationally representative online consumer panel. After inclusion and exclusion criteria were applied, 510 eligible subjects completed the survey. The survey elicited choices between pairs of migraine profiles describing symptom durations and symptom-free time for the headache and post-headache phase.

RESULTS

Migraineurs in our study were strongly affected by the pain associated with the headache phase. However, experiencing difficulty with daily social and family activities in the post-headache phase also had a statistically significant impact on migraineurs' perceived level of well-being. Migraineurs reported that hypothetical treatments that limited the duration of headache symptoms without allowing them to resume their daily activities for 16 hours after a headache, on average, were less than half as good as treatments that limited both headache and post-headache symptoms.

CONCLUSION

Our results suggest that treatments that relieve and shorten symptoms during the post-headache phase can offer significant benefits to migraineurs.

Effect of pill burden on dosing preferences, willingness to pay, and likely adherence among patients with type 2 diabetes

PURPOSE

To quantify willingness-to-pay (WTP) for reducing pill burden and dosing frequency among patients with type 2 diabetes mellitus (T2DM), and to examine the effect of dosing frequency and pill burden on likely medication adherence.

PATIENTS AND METHODS

Participants were US adults with T2DM on oral antihyperglycemic therapy. Each patient completed an online discrete-choice experiment (DCE) with eight choice questions, each including a pair of hypothetical medication profiles. Each profile was defined by reduction in average glucose (AG), daily dosing, chance of mild-to-moderate stomach problems, frequency of hypoglycemia, weight change, incremental risk of congestive heart failure (CHF), and cost. Patients were asked to rate their likely adherence to the profiles presented in each question. Choice questions were based on a predetermined experimental design. Choice data were analyzed using random-parameters logit. Likely treatment adherence was analyzed using a Heckman two-stage model.

RESULTS

Of the 1,114 patients who completed the survey, 90 had lower dosing burden (<5 pills/day taken once/day or as needed) for all medications, and 1,024 had higher dosing burden (≥5 pills/day or more than once/day). Reduction in AG was valued most highly by patients. Hypoglycemia, chance of mild-to-moderate stomach problems, weight change, incremental risk of CHF, and daily dosing were less valued. Patients with higher current dosing burden had lower WTP for more convenient dosing schedules than patients with lower current dosing burden. Changes in dosing and cost impacted likely adherence. The magnitude of the impact of dosing on likely adherence was higher for patients with lower current dosing burden than for patients with higher current dosing burden.

CONCLUSION

Patients with T2DM were willing to pay for improvements in efficacy, side effects, and dosing. Patients' WTP for more convenient dosing depended on current dosing burden, as did the effect of these attributes on likely adherence.

Understanding rational non-adherence to medications. A discrete choice experiment in a community sample in Australia

Background

In spite of the potential impact upon population health and expenditure, interventions promoting medication adherence have been found to be of moderate effectiveness and cost effectiveness. Understanding the relative influence of factors affecting patient medication adherence decisions and the characteristics of individuals associated with variation in adherence will lead to a better understanding of how future interventions should be designed and targeted. This study aims to explore medication-taking decisions that may underpin intentional medication non-adherence behaviour amongst a community sample and the relative importance of medication specific factors and patient background characteristics contributing to those decisions.

Methods

A discrete choice experiment conducted through a web-enabled online survey was used to estimate the relative importance of eight medication factors (immediate and long-term medication harms and benefits, cost, regimen, symptom severity, alcohol restrictions) on the preference to continue taking a medication. To reflect more closely what usually occurs in practice, non-disease specific medication and health terms were used to mimic decisions across multiple medications and conditions.161 general community participants, matching the national Australian census data (age, gender) were recruited through an online panel provider (participation rate: 10%) in 2010.

Results

Six of the eight factors (i.e. immediate and long-term medication harms and benefits, cost, and regimen) had a significant influence on medication choice. Patient background characteristics did not improve the model. Respondents with private health insurance appeared less sensitive to cost then those without private health insurance. In general, health outcomes, framed as a side-effect, were found to have a greater influence over adherence than outcomes framed as therapeutic benefits.

Conclusions

Medication-taking decisions are the subject of rational choices, influenced by the attributes of treatments and potentially amenable to intervention through education, strategic pricing and the altering of dosing characteristics. Understanding individual treatment preferences is thus an important step to improving adherence support provision in practice. Re-framing future interventions and policies to support rational and informed individual patient choices, is the way forward to realising the full potential health and economic benefits from the efficacious use of medications.

Motivational interviewing: addressing ambivalence to improve medication adherence in patients with bipolar disorder

Poor adherence to psychotropic medication is a significant issue for patients with bipolar disorder. The effectiveness of medication treatment is limited by high rates of medication non-adherence among this population. Motivational Interviewing is an evidence-based intervention that has been efficacious in promoting behavioral health regimens and treatment recommendations, including medication adherence. By using a patient-centered approach, Motivational Interviewing has been shown to enhance patients' insight and attitudes toward treatment. This article aims to describe to mental health nurses how to use Motivational Interviewing with bipolar patients to address ambivalence and improve adherence to psychotropic medication regimens.

Correlates of medication adherence among patients with bipolar disorder: results of the bipolar evaluation of satisfaction and tolerability (BEST) study: a nationwide cross-sectional survey

OBJECTIVE

To identify and describe correlates of medication adherence in a large, national sample of outpatients with bipolar disorder.

METHOD

Data were collected via a self-report, Web-based survey in January and February of 2008 from US patients aged 18-65 years who reported a diagnosis of bipolar disorder and current use of psychotropic medication. Patients with a Composite International Diagnostic Interview-bipolar disorder (CIDI-bipolar disorder) score ≥ 7, indicating a high risk of bipolar disorder, were included in the analyses. Medication adherence was assessed via the Morisky Medication Adherence Scale, with scores ≥ 2 being considered nonadherent. The primary analysis was a multivariate binomial logistic regression with adherence as the dependent variable. Covariates included patient demographics, physical health measures including Medical Outcomes Study 8-item Short-Form Health Survey physical summary score, number of manic and depressive episodes, 24-item Behavior and Symptom Identification Scale (BASIS-24), Liverpool University Neuroleptic Side-Effect Rating Scale (LUNSERS), Satisfaction With Antipsychotic Medication scale (SWAM), and current psychiatric medication use.

RESULTS

Nearly half (49.5%) of the 1,052 bipolar patients in the analysis were classified as being nonadherent. Adherence was positively associated with college degree, higher SWAM total score, and monotherapy treatment. Adherence was negatively associated with female sex, alcohol use, BASIS-24 total score, and LUNSERS total score.

CONCLUSIONS

Nonadherence is common among patients with bipolar disorder. By addressing tolerability issues and treatment satisfaction, which are both significant correlates of adherence, health care providers may be able to improve adherence and, ultimately, treatment outcomes.

Patient preferences and assessment of likely adherence to hepatitis C virus treatment

To estimate patient preferences for attributes of hepatitis C virus (HCV) treatment and patients' assessment of the likely effect of treatment attributes on treatment adherence, HCV patients ≥18 years old completed an online survey that included nine 2-alternative choice questions. Each choice question was defined by the probability of sustained viral response (Efficacy), injection frequency (Frequency), duration of flu-like symptoms after every injection (Flu), injection device (Device), average number of days of work missed each week (Lost Work Days), probability of reversible hair thinning while on treatment (Alopecia) and probability of developing clinical depression while on treatment (Depression). We estimated a mean relative importance weight for each attribute. Patients also answered three rating questions to assess the extent to which treatment attributes might affect adherence. Hundred and fifty patients completed the survey. Efficacy was the most important attribute with a mean relative importance weight of 10 [95% CI: 7.9-12.1]. The remaining attributes were ranked in order of importance as follows: Depression (4.4 [95% CI: 3.6-5.1]), Flu Days(Frequency×Flu) (3.7 [95% CI: 2.2-5.3]), Lost Work Days (2.9 [95% CI: 2.3-3.5]), Alopecia (1.3 [95% CI: 0.7-1.9]) and Device (1.2 [95% CI: 0.4-2.0]). Patients with prior treatment experience were less likely to indicate that treatment attributes would affect adherence. Patients also indicated that increases in the number of flu days would increase the likelihood of nonadherence to treatment. Sustained viral response is the most important treatment attribute to patients but treatment side effects might affect treatment adherence.

Medication adherence, ethnicity, and the influence of multiple psychosocial and financial barriers

Medication adherence is critical for patients with bipolar disorder to avoid symptom exacerbation and diminished quality of life. Most analyses consider adherence barriers individually rather than conjointly, while neglecting potential ethnic differences. 435 patients in the Continuous Improvement for Veterans in Care--Mood Disorders study reported multiple financial and psychosocial factors influencing adherence. Logistic regression modeled adherence as a function of perceived barriers, including cost burden, access, binge drinking, poor therapeutic alliance, and medication beliefs. Nearly half the cohort experienced adherence difficulty, averaging 2.8 barriers, with minority veterans reporting lower adherence than white patients, particularly financial burden and treatment access. Total barriers were significantly associated with worse adherence (OR = 1.24 per barrier), notably poor medication beliefs, binge drinking, and difficulty accessing psychiatric specialists (ORs of 2.41, 1.95 and 1.73, respectively). Veterans with bipolar disorder experience numerous adherence barriers, with certain obstacles proving especially pernicious. Fortunately tailored clinical interventions can improve adherence, particularly by addressing modifiable risk factors.

Association between median family income and self-reported mood symptoms in bipolar disorder

OBJECTIVE

There is broad consensus from epidemiologic research that lower socioeconomic status is related to poorer health. This study investigated the relation between median family income and self-reported mood symptoms in patients with bipolar disorder who reside in the United States.

METHODS

Two hundred eighty-four patients with bipolar disorder provided daily self-reported mood ratings for 6 months (50,054 days of data). Regardless of income, all patients were treated by a psychiatrist, took psychotropic medications, and participated in computerized self-monitoring throughout the study. Median family income was obtained from US census tract data. The association between income and mood was analyzed using income as both a continuous and categorical variable. Demographic characteristics were compared by income group. Education level was included in the analysis a priori.

RESULTS

Both the continuous and categorical approaches found a positive association between income and euthymia, a negative association between income and manic/hypomanic symptoms including those due to mixed states, and no association between income and depressive symptoms. Patients in the lower-income group spent 12.4% fewer days euthymic than those in the upper-income group and 9.7% fewer days euthymic than those in the middle-income group. Patients in the lower-income group spent 7.1% more days with manic/hypomanic symptoms than those in the upper-income group. There was no association between education and income.

CONCLUSION

Median family income is associated with mood symptoms in patients with bipolar disorder. Inclusion of income as a measure of socioeconomic status is recommended for future studies of outcome in bipolar disorder.

Review of the safety, efficacy, and side effect profile of asenapine in the treatment of bipolar 1 disorder

OBJECTIVE

Asenapine is approved for acute manic and mixed states in bipolar disorder. The objective is to review the efficacy of asenapine in bipolar disorder, with a particular focus on acceptability and adherence to treatment.

METHODS

FIVE CLINICAL TRIALS WERE CONDUCTED IN BIPOLAR DISORDER MANIC OR MIXED STATES: two 3-week trials (n = 976) comparing asenapine to placebo, a 9-week extension (n = 504), and a 40-week extension (n = 107). One trial was conducted comparing asenapine to placebo (n = 326) as adjunctive therapy for subjects with an incomplete response to lithium or valproate. All trials were conducted in the USA and internationally.

RESULTS

Asenapine was found to be efficacious for manic and mixed states in bipolar disorder compared with placebo control, and compares equally well to olanzapine on efficacy measures after 3 weeks of treatment. Asenapine was not found to be efficacious for depression symptoms. Common asenapine side effects in the 40-week extension trial were sedation, insomnia, and dizziness, and 31% reported clinically significant weight gain, compared with 55% reporting clinically significant weight gain with olanzapine. Additionally, 18% had clinically significant changes in fasting blood glucose levels compared to 22% of those on olanzapine. In terms of patient acceptability, one concern may be sublingual administration requiring no liquids or food for 10 minutes after dosing and a twice-daily regimen. Suggestions about addressing barriers to adherence and acceptability are provided.

CONCLUSION

Asenapine is a promising new medication in bipolar disorder. Asenapine in the long-term has a more favorable weight gain profile compared to olanzapine. No benefit was seen for depression symptoms, a major patient-reported concern. Some side effects do not remit after the short-term trials in at least 10% of patients.

Adaptive choice-based conjoint analysis: a new patient-centered approach to the assessment of health service preferences

Conjoint analysis (CA) has emerged as an important approach to the assessment of health service preferences. This article examines Adaptive Choice-Based Conjoint Analysis (ACBC) and reviews available evidence comparing ACBC with conventional approaches to CA. ACBC surveys more closely approximate the decision-making processes that influence real-world choices. Informants begin ACBC surveys by completing a build-your-own (BYO) task identifying the level of each attribute that they prefer. The ACBC software composes a series of attribute combinations clustering around each participant's BYO choices. During the Screener section, informants decide whether each of these concepts is a possibility or not. Probe questions determine whether attribute levels consistently included in or excluded from each informant's Screener section choices reflect 'Unacceptable' or 'Must Have' simplifying heuristics. Finally, concepts identified as possibilities during the Screener section are carried forward to a Choice Tournament. The winning concept in each Choice Tournament set advances to the next choice set until a winner is determined.A review of randomized trials and cross-over studies suggests that, although ACBC surveys require more time than conventional approaches to CA, informants find ACBC surveys more engaging. In most studies, ACBC surveys yield lower standard errors, improved prediction of hold-out task choices, and better estimates of real-world product decisions than conventional choice-based CA surveys.

Medication preferences and adherence among individuals with severe mental illness and psychiatric advance directives

OBJECTIVE

Psychiatric advance directives allow patients with severe mental illness to document their preferences for particular medications. This study investigated the role of psychiatric advance directives in treatment choice and medication adherence.

METHODS

A total of 123 persons with severe mental illness recorded medication preferences in psychiatric advance directives. The authors compared medication preferences to prescribed medications over 12 months, determined concordance between preferred and prescribed medications, and examined the effect of concordance on medication adherence at 12 months.

RESULTS

Participants requested a median of two medications in their psychiatric advance directives (range from zero to six) and refused a median of one medication (range from zero to ten). Between baseline and follow-up there was a 27% increase in the number of medications prescribed that had been requested on the psychiatric advance directive (Wilcoxon matched pairs, p<.001). After correction for the number of medications listed in the psychiatric advance directive, a 10% increase in concordance remained significant (p<.001). Being prescribed at least one medication requested in the psychiatric advance directive predicted higher medication adherence at 12 months, after the analysis controlled for relevant covariates (odds ratio=7.8, 95% confidence interval=1.8-34.0).

CONCLUSIONS

Providing information about medication preferences in psychiatric advance directives may increase prescribing of patient-preferred medications even in noncrisis settings. Patients who were prescribed medications that they requested in advance were significantly more likely to adhere to medications, supporting the benefit of patient participation in medication choice. Psychiatric advance directives appear to be a clinically useful conduit for communicating patient medication preferences.

Quantifying women's stated benefit-risk trade-off preferences for IBS treatment outcomes

BACKGROUND

The Food and Drug Administration, currently, is exploring quantitative benefit-risk methods to support regulatory decision-making. A scientifically valid method for assessing patients' benefit-risk trade-off preferences is needed to compare risks and benefits in a common metric.

OBJECTIVES

The study aims to quantify the maximum acceptable risk (MAR) of treatment-related adverse events (AEs) that women with diarrhea-predominant irritable bowel syndrome (IBS) are willing to accept in exchange for symptom relief.

RESEARCH DESIGN

A stated-choice survey was used to elicit trade-off preferences among constructed treatment profiles, each defined by symptom severity and treatment-related AEs. Symptom attributes included frequency of abdominal pain and discomfort, frequency of diarrhea, and frequency of urgency. AE attributes included frequency of mild-to-moderate constipation and the risk of four possible serious AEs.

SUBJECTS

A Web-enabled survey was administered to 589 female US residents at least 18 years of age with a self-reported diagnosis of diarrhea-predominant IBS.

MEASURES

Preference weights and MAR were estimated using mixed-logit methods.

RESULTS

SUBJECTS were willing to accept higher risks of serious AEs in return for treatments offering better symptom control. For an improvement from the lowest to the highest of four benefit levels, subjects were willing to tolerate a 2.65% increase in impacted-bowel risk, but only a 1.34% increase in perforated-bowel risk.

CONCLUSIONS

Variation in MARs across AE types is consistent with the relative seriousness of the AEs. Stated-preference methods offer a scientifically valid approach to quantifying benefit-risk trade-off preferences that can be used to inform regulatory decision-making.

Medication preferences and adherence among individuals with severe mental illness and psychiatric advance directives

OBJECTIVE

Psychiatric advance directives allow patients with severe mental illness to document their preferences for particular medications. This study investigated the role of psychiatric advance directives in treatment choice and medication adherence.

METHODS

A total of 123 persons with severe mental illness recorded medication preferences in psychiatric advance directives. The authors compared medication preferences to prescribed medications over 12 months, determined concordance between preferred and prescribed medications, and examined the effect of concordance on medication adherence at 12 months.

RESULTS

Participants requested a median of two medications in their psychiatric advance directives (range from zero to six) and refused a median of one medication (range from zero to ten). Between baseline and follow-up there was a 27% increase in the number of medications prescribed that had been requested on the psychiatric advance directive (Wilcoxon matched pairs, p<.001). After correction for the number of medications listed in the psychiatric advance directive, a 10% increase in concordance remained significant (p<.001). Being prescribed at least one medication requested in the psychiatric advance directive predicted higher medication adherence at 12 months, after the analysis controlled for relevant covariates (odds ratio=7.8, 95% confidence interval=1.8-34.0).

CONCLUSIONS

Providing information about medication preferences in psychiatric advance directives may increase prescribing of patient-preferred medications even in noncrisis settings. Patients who were prescribed medications that they requested in advance were significantly more likely to adhere to medications, supporting the benefit of patient participation in medication choice. Psychiatric advance directives appear to be a clinically useful conduit for communicating patient medication preferences.

Aripiprazole as adjunct to a mood stabilizer and citalopram in bipolar depression: a randomized placebo-controlled pilot study

OBJECTIVE

The use of atypical antipsychotics (AAPs) for the treatment of unipolar and bipolar depression has been more and more frequently evaluated, and aripiprazole showed positive effects in the treatment of unipolar depression. However, no placebo-controlled studies of adjunctive aripiprazole for the treatment of bipolar depression have been performed yet.

METHODS

In this prospective, double-blind, placebo-controlled, randomized trial, 23 inpatients with bipolar depression according to DSM-IV criteria were included. Before randomization, patients had to be on a constant mood stabilizer treatment with lithium or valproate for at least 1 week. After inclusion, all patients were openly treated with additional citalopram and with additional aripiprazole or placebo for 6 weeks. The primary outcome parameter was the reduction in depressive symptoms according to the Hamilton Depression Rating Scale (HDRS) within 6 weeks.

RESULTS

After 6 weeks of treatment, the HDRS score decreased in both groups. There was no significant difference between both the groups at any point of time with respect to the HDRS.

CONCLUSIONS

Derived from this small pilot study, adjunctive aripiprazole does not seem to be a promising strategy for the acute treatment of bipolar depression. However, this lack of additional benefit seems to stem from the already good effectiveness of the control group, namely the treatment with citalopram.

Assessment of adherence problems in patients with serious and persistent mental illness: recommendations from the Expert Consensus Guidelines

Poor adherence to medication treatment can have devastating consequences for patients with serious mental illness. The literature review and recommendations in this article concerning assessment of adherence are reprinted from The Expert Consensus Guideline Series: Adherence Problems in Patients with Serious and Persistent Mental Illness, published in 2009. The expert consensus survey contained 39 questions (521 options) that asked about defining nonadherence, extent of adherence problems in schizophrenia and bipolar disorder, risk factors for nonadherence, assessment methods, and interventions for specific types of adherence problems. The survey was completed by 41 (85%) of the 48 experts to whom it was sent. When evaluating adherence, the experts considered it important to assess both behavior and attitude, although they considered actual behavior most important. They also noted the importance of distinguishing patients who are not willing to take medication from those who are willing but not able to take their medication as prescribed due to forgetfulness, misunderstanding of instructions, or financial or environmental problems, since this will affect the type of intervention needed. Although self- and physician report are most commonly used to clinically assess adherence, they are often inaccurate and may underestimate nonadherence. The experts believe that more accurate information will be obtained by asking about any problems patients are having or anticipate having taking medication rather than if they have been taking their medication; They also recommended speaking with family or caregivers, if the patient gives permission, as well as using more objective measures (e.g., pill counts, pharmacy records, smart pill containers if available, and, when appropriate, medication plasma levels). Use of a validated self-report scale may also help improve accuracy. For patients who appear adherent to medication, the experts recommended monthly assessments for adherence, with additional assessments if there is a noticeable symptomatic change. If there is concern about adherence, they recommended more frequent (e.g., weekly) assessments. The article concludes with suggestions for clinical interview techniques for assessing adherence.

Adherence according to Mary Poppins: strategies to make the medicine go down

PURPOSE

This article reviews the prevalence, risk factors, and burden of nonadherence in mood and psychotic disorders, and presents evidence-based, disease-specific strategies shown to improve adherence.

CONCLUSION

A comprehensive approach based on the goal of remission, designed around the patient's individual needs, facilitates adherence, leads to improved quality of life, and reduces disease burden.

PRACTICE IMPLICATIONS

Adherence in mood and psychotic disorders can be improved when providers take time to build trusting relationships; identify risk factors; anticipate nonadherence; individualize treatment; and educate patients, families, and other healthcare providers.

Enhancing medication adherence in patients with bipolar disorder

OBJECTIVES

Medication adherence contributes to the efficacy-effectiveness gap of treatment in patients with bipolar disorder. This paper aims to examine the challenges involved in improving medication adherence in bipolar disorder, and to extract some suggestions for future directions from the core psychosocial studies that have targeted adherence as a primary or secondary outcome.

METHODS

A search was conducted for articles that focused on medication adherence in bipolar disorder, with emphasis on publications from 1996 to 2008 using Medline, Web of Science, CINAHL PLUS, and PsychINFO. The following key words were used: adherence, compliance, alliance, adherence assessment, adherence measurement, risk factors, psychosocial interventions, and psycho-education.

RESULTS

There are a number of challenges to understanding non-adherence including the difficulty in defining and measuring it and the various risk factors that need to be considered when aiming to enhance adherence. Nevertheless, the importance of addressing adherence is evidenced by the connection between adherence problems and poor outcome. Despite these challenges, a number of small psychosocial studies targeting adherence as a primary outcome point to the potential usefulness of psycho-education aimed at improving knowledge, attitudes, and adherence behavior, but more large scale randomized controlled trials are needed in this area. Evidence of improved outcomes from larger randomized controlled trials of psychosocial interventions that target medication adherence as a secondary outcome suggests that tackling other factors besides medication adherence may also be an advantage. While some of these larger studies demonstrate an improvement in medication adherence, the translation of these interventions into real life settings may not always be practical. A person centered approach that considers risk factors for non-adherence and barriers to other health behaviors may assist with the development of more targeted briefer interventions. Integral to improving medication adherence is the delivery of psycho-education, and attention needs to be paid to the implementation, and timing of psycho-education. Progress in the understanding of how medicines work may add to the credibility of psycho-education in the future.

CONCLUSIONS

Enhancement of treatment adherence in bipolar patients is a necessary and promising management component as an adjunct to pharmacotherapy. The current literature on psychosocial interventions that target medication adherence in bipolar disorder points to the possibility of refining the concept of non-adherence and adapting psycho-education to the needs of certain subgroups of people with bipolar disorder. Large scale randomized controlled trials of briefer or more condensed interventions are needed that can inform clinical practice.

Difficult to swallow: patient preferences for alternative valproate pharmaceutical formulations

OBJECTIVE

To determine the degree to which swallowing valproate (VP) tablets is an issue, the proportion of patients who would prefer an alternative formulation, and the predictors of preference.

METHODS

A quantitative telephone survey of eligible adults (n = 400, >/=18 years old) who currently take (n = 236) or previously took (n = 164) VP tablets within the past 6 months was conducted.

RESULTS

More than half of the patients indicated that VP tablets were 'uncomfortable to swallow' (68.5%, n = 274) and were 'very interested' (65.8%, n = 263) in medications that were easier to swallow. When choosing conceptually between taking VP tablet once/day or an equally safe and effective but significantly smaller soft gel capsule twice per day, the 82.8%, (n = 331) preferred the soft gel capsule. In the multivariate regression analysis, perceiving soft gel capsules to be easier to swallow (OR = 73.54; 95% CI = 15.01 to 360.40) and taking VP more frequently (OR = 2.02; 95% CI = 1.13 to 3.61) were significant predictors of soft gel capsule treatment preference.

CONCLUSION

VP users would prefer a formulation that is easier to swallow, even if it is needed to be taken twice per day. When choosing between medications with similar efficacy and safety, physicians can consider patient preferences to optimize conditions for medication adherence.

Medication treatment perceptions, concerns and expectations among depressed individuals with Type I Bipolar Disorder

BACKGROUND

Subjective experience of illness affects outcomes among populations with bipolar disorder (BD). This cross-sectional study combined qualitative and quantitative approaches to evaluate perceived treatment effects, concerns and expectations among 90 individuals with BD.

METHODS

Adults with Type I BD, mean age 36.6 years, 51% women, completed a semi-structured interview that was audio taped, transcribed, coded and analyzed along emergent themes. Quantitative scales measured depressive symptoms (Hamilton Depression Scale/HAM-D), psychopathology (Clinical Global Impression/CGI), and insight and treatment attitudes (Insight and Treatment Attitudes Questionnaire/ITAQ).

RESULTS

Individuals had moderate depression and psychopathology with good insight into need for treatment. Drug treatment was perceived as beneficial, by "stabilizing" or "balancing" mood (42%, N=38), decreasing anxiety/depressive symptoms (19%, N=17) and improving sleep (10%, N=9). While 39%, (N=35) of individuals denied medication concerns, nearly 29%, (N=26) feared possible long-term effects, particularly diabetes or liver/kidney damage. Media stories and advertisements contributed to medication fears. Hopes and expectations for treatment ranged from those that were symptom or functional status-based, such as desiring mood stabilization and elimination of specific symptoms (23%, N=21), to more global hopes such as "being normal" (20%, N=18) or "cured" (18%, N=16).

LIMITATIONS

Limitations include relatively small sample, lack of a comparator, inclusion of only depressed individuals and those willing to discuss their illness experience.

CONCLUSIONS

While individuals with BD appreciate the effects of medications, concerns regarding adverse effects and discrepancy between actual and hoped-for outcomes can be substantial. Subjective experience with medications using qualitative and quantitative methods should be explored in order to optimize treatment collaboration and outcomes.

Bipolar disorder: What effect does treatment adherence have on risk of suicidal behavior?

Bipolar disorder is associated with high risk for suicidal behavior. Lack of adherence to treatment is one factor that may be partly responsible for this common complication. We searched MEDLINE with the combination of the key words "compliance" or "adherence" with "suicide" and "bipolar", limited to English language papers published between 1990 and July 2008.We evaluate the existent literature studying the influence of treatment adherence on suicidality among these patients. Our findings show a limited number of studies addressing this issue, mostly conducted with patients enrolled in lithium clinics. Results suggest an association between non-adherence and an increased risk of suicidal behavior among bipolar patients. Whether non-adherence leads to increase risk of suicidality due to specific properties of interventions such as lithium treatment or simply is secondary to mood stabilization is still an open question.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2009

The Canadian Network for Mood and Anxiety Treatments (CANMAT) published guidelines for the management of bipolar disorder in 2005, with a 2007 update. This second update, in conjunction with the International Society for Bipolar Disorders (ISBD), reviews new evidence and is designed to be used in conjunction with the previous publications. The recommendations for the management of acute mania remain mostly unchanged. Lithium, valproate, and several atypical antipsychotics continue to be first-line treatments for acute mania. Tamoxifen is now suggested as a third-line augmentation option. The combination of olanzapine and carbamazepine is not recommended. For the management of bipolar depression, lithium, lamotrigine, and quetiapine monotherapy, olanzapine plus selective serotonin reuptake inhibitor (SSRI), and lithium or divalproex plus SSRI/bupropion remain first-line options. New data support the use of adjunctive modafinil as a second-line option, but also indicate that aripiprazole should not be used as monotherapy for bipolar depression. Lithium, lamotrigine, valproate, and olanzapine continue to be first-line options for maintenance treatment of bipolar disorder. New data support the use of quetiapine monotherapy and adjunctive therapy for the prevention of manic and depressive events, aripiprazole monotherapy for the prevention of manic events, and risperidone long-acting injection monotherapy and adjunctive therapy, and adjunctive ziprasidone for the prevention of mood events. Bipolar II disorder is frequently overlooked in treatment guidelines, but has an important clinical impact on patients' lives. This update provides an expanded look at bipolar II disorder.

Multiple sclerosis patients' benefit-risk preferences: serious adverse event risks versus treatment efficacy

OBJECTIVE

The aim of this study is to estimate the willingness of multiple sclerosis (MS) patients to accept life-threatening adverse event risks in exchange for improvements in their MS related health outcomes.

METHODS

MS patients completed a survey questionnaire that included a series of choice-format conjoint tradeoff tasks. Patients chose hypothetical treatments from pairs of treatment alternatives with varying levels of clinical efficacy and associated risks.

RESULTS

Among the 651 patients who completed the survey, delay in years to disability progression was the most important factor in treatment preferences. In return for decreases in relapse rates from 4 to 1 and increases in delay in progression from 3 to 5 years, patients were willing to accept a 0.38% annual risk of death or disability from PML, a 0.39% annual risk of death from liver failure or a 0.48% annual risk of death from leukemia.

CONCLUSIONS

Medical interventions carry risks of adverse outcomes that must be evaluated against their clinical benefits. Most MS patients indicated they are willing to accept risks in exchange for clinical efficacy. Patient preferences for potential benefits and risks can assist in decision-making.

Treatment preferences and medication adherence of people with Type 2 diabetes using oral glucose-lowering agents

AIMS

Medication non-adherence is particularly common in patients with Type 2 diabetes. We constructed a discrete-choice experiment to examine the relative importance of oral glucose-lowering medication features and to estimate the likely effect of effectiveness and side effects on medication adherence in patients with Type 2 diabetes in the UK and the USA.

METHODS

Preferences were elicited using a cross-sectional, web-enabled survey. Patients with a self-reported physician-made diagnosis of Type 2 diabetes, who were currently taking oral glucose-lowering medications were recruited through an existing online chronic-disease panel. In each discrete-choice question, patients were asked to choose between two hypothetical medication alternatives, each defined by improvement in glycated haemoglobin, frequency of mild-to-moderate hypoglycaemia, water retention, weight gain, mild stomach upset and medication-related cardiovascular risk. Patients were also asked to indicate how likely they would be to miss or skip doses of each hypothetical medication.

RESULTS

Two hundred and four patients in the UK and 203 patients in the USA completed the survey. Preferences did not differ between the two countries. Overall, glucose control was the most important medication feature, followed by medication-related cardiovascular risk and weight gain, respectively. Water retention was not important to patients. Weight gain and cardiovascular risk had significant negative effects on likely medication adherence.

CONCLUSIONS

While patients with Type 2 diabetes believe glucose control is important, medication side effects and risks influence patients' treatment choices. Medication-related weight gain and cardiovascular risk are significant predictors of likely medication non-adherence.

Predictors of nonadherence among individuals with bipolar disorder receiving treatment in a community mental health clinic

BACKGROUND

Subjective experience of illness is a critical component of treatment adherence in populations with bipolar disorder (BPD). This cross-sectional analysis examined clinical and subjective variables in relation to adherence in 140 individuals with BPD receiving treatment with mood-stabilizing medication.

METHODS

Nonadherence was defined as missing 30% or more of medication on the Tablets Routine Questionnaire, a self-reported measure of medication treatment adherence. Adherent and nonadherent groups were compared on measures of attitudes toward illness and treatment including the Attitudes toward Mood Stabilizers Questionnaire, the Insight and Treatment Attitudes Questionnaire, the Rating of Medication Influences, and the Multidimensional Health Locus of Control Scale.

RESULTS

Except for substance abuse comorbidity, adherent individuals (n = 113, 80.7%) did not differ from nonadherent individuals (n = 27, 19.3%) on clinical variables. However, nonadherent individuals had reduced insight into illness, more negative attitudes toward medications, fewer reasons for adherence, and more perceived reasons for nonadherence compared with adherent individuals. The strongest attitudinal predictors for nonadherence were difficulties with medication routines (odds ratio = 2.2) and negative attitudes toward drugs in general (odds ratio = 2.3).

LIMITATIONS

Results interpretation is limited by cross-sectional design, self-report methodology, and sample size.

CONCLUSIONS

Comorbid substance abuse, negative attitudes toward mood-stabilizing medication, and difficulty managing to take medication in the context of one's daily schedule are primary determinants of medication treatment adherence. A patient-centered collaborative model of care that addresses negative attitudes toward medication and difficulty coping with medication routines may be ideally suited to address individual adherence challenges.