Trajectories of medication attitudes and adherence behavior change in non-adherent bipolar patients

Updated strategies for the management of poor medication adherence in patients with bipolar disorder

INTRODUCTION

Suboptimal adherence is a well-established, pervasive problem in individuals with bipolar disorder (BD) causing disability, suffering, and cost.

AREAS COVERED

This review covers new research since January 2016 regarding internal (patient-centered) and external (system level) barriers and facilitators to adherence. Measures of adherence, the efficacy of psychosocial adherence enhancement interventions in individuals with BD, and, finally, novel delivery systems for BD medication are also covered. Measures of adherence continue to fall broadly into objective measures (i.e. drug levels) and more subjective, self-report measures and a combination of these likely provides the most comprehensive picture. Efficacious components of psychosocial adherence enhancement interventions include psychoeducation, motivational interviewing, and cognitive behavioral strategies, yet methods for delivery vary. Long-acting injectable (LAI) medications for BD are the drug delivery system with the most promise for BD. Combining psychosocial components with novel drug delivery systems has the potential for establishing and maintaining medication adherence.

EXPERT OPINION

Psychosocial interventions improve adherence in individuals with BD. Psychoeducation is a necessary but not sufficient component in psychosocial interventions. LAIs should be considered earlier for adherence improvement than many treatment guidelines currently suggest. Comparative studies are lacking as is research into novel systems of medication delivery.

The RAS-24: Development and validation of an adherence-to-medication scale for severe mental illness patients

Introduction

Several studies have found that most patients with severe mental illness (SMI) and comorbid (physical) conditions are partially or wholly nonadherent to their medication regimens. Nonadherence to treatment is a serious concern, affecting the successful management of patients with SMIs. Psychiatric disorders tend to worsen and persist in nonadherent patients, worsening their overall health. The study described herein aimed to develop and validate a scale (the Ralat Adherence Scale) to measure nonadherence behaviors in a culturally sensitive way.

Materials and Methods

Guided by a previous study that explored the primary reasons for nonadherence in Puerto Rican patients, we developed a pool of 147 items linked to the concept of adherence. Nine experts reviewed the meaning, content, clarity, and relevance of the individual items, and a content validity ratio was calculated for each one. Forty items remained in the scale's first version. This version was administered to 160 patients (21-60 years old). All the participants had a diagnosis of bipolar disorder, major depressive disorder, or schizoaffective disorder. The STROBE checklist was used as the reporting guideline.

Results

The scale had very good internal consistency (Cronbach's alpha = 0.812). After a factor analysis, the scale was reduced to 24 items; the new scale had a Cronbach's alpha of 0.900.

Conclusions

This adherence scale is a self-administered instrument with very good psychometric properties; it has yielded important information about nonadherence behaviors. The scale can help health professionals and researchers to assess patient adherence or nonadherence to a medication regimen.

Is cognitive behaviour therapy applicable to individuals diagnosed with bipolar depression or suboptimal mood stabilizer treatment: a secondary analysis of a large pragmatic effectiveness trial

Background

Efficacy trials of medications and/or psychological interventions for bipolar disorders (BD) aim to recruit homogenous samples of patients who are euthymic and such populations show high levels of adherence to the treatments offered. This study describes a secondary analysis of a large-scale multi-centre pragmatic effectiveness randomized controlled trial (RCT) of cognitive behaviour therapy plus treatment as usual (CBT) or treatment as usual alone (TAU) and explores outcomes in individuals who were: (i) recruited in depressive episodes, or (ii) receiving suboptimal doses of or no mood stabilizers (MS).

Methods

Data were extract on two separate subsamples (out of 253 RCT participants). Sample 1 comprised 67 individuals in a depressive episode (CBT: 34; TAU: 33); Sample 2 comprised 39 individuals receiving suboptimal MS treatment (CBT: 19; TAU: 20). Survival analyses (adjusted for confounding variables) were used to explore recovery in Sample 1 and relapse in Sample 2.

Results

In Sample 1 (individuals with depression), Cox proportional hazards regression model revealed that the median time to recovery was significantly shorter in the CBT group (10 weeks; 95% confidence intervals (CI) 8, 17) compared to the TAU group (17 weeks; 95% CI 9, 30) [Adjusted Hazard Ratio (HR) 1.89; 95% CI 1.04, 3.4; p < 0.035]. In Sample 2 (suboptimal MS), the median time to any relapse was significantly longer in the CBT group compared to the TAU group (~ 35 versus ~ 20 weeks; Adjusted HR 2.01; 95% CI 1.01, 3.96; p < 0.05) with the difference in survival time to first depressive relapse also reaching statistical significance (X² = 14.23, df 6, p 0.027).

Conclusions

Adjunctive use of CBT appears to have benefits for individuals diagnosed with BD who are highly representative of the patients seen in routine clinical practice, but often excluded from efficacy RCTs. However, as this is a secondary analysis of 42% of the original RCT sample, it is important to replicate these findings in independent larger scale studies specifically designed for purpose.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-022-00259-3.

The Meaning of Recovery: The Lived Experience of Patients with Bipolar Disorder in Turkey

Recovery in mental illness refers to a process with many aspects, steps and meanings. This study aims to provide a deeper understanding of the lived experience of recovery of patients with bipolar disorder. A qualitative approach with 28 participants was performed. Data were collected through semi-structured interviews. The experiences of the individuals regarding the recovery processes were themed with the journey metaphor: the beginning of the journey, the route of the journey, a stop in the journey, the meaning of the journey. This study suggests ways clinicians must be aware of and adopted contemporary approach which recovery is defined as a process beyond treatment.

Trajectories of medication adherence in patients with Bipolar Disorder along 2 years-follow-up

BACKGROUND

Bipolar disorder (BD) is a chronic and severe mental illness. It requires a non-discontinued pharmacological treatment to prevent mood recurrences but nonadherence to medication is frequent. To this date, medication adherence in BD has been mostly evaluated in cross-sectional studies and often considered as a stable trait. We aimed to study medication adherence using a prospective person-oriented approach.

METHODS

1627 BD patients were followed on a 2 years period and assessed every 6 months. Medication adherence was evaluated at each visit with the Medication Adherence Rating Scale (MARS). A latent class mixed model (LCMM) was used to identify trajectory classes of adherence over time. Regression analyses and linear mixed model were used to search for predictors and covariables of the trajectories.

RESULTS

Three distinct and robust trajectories of medication adherence have been identified: one that starts poorly and keeps deteriorating (4.8%), one that starts poorly but improves (9%) and one that starts well and keeps improving (86.2%). A good tolerance to psychotropic medications, low depressive symptoms, the absence of comorbid eating disorders and anticonvulsant medication were associated to a better prognosis of adherence. Along the follow-up, the lower were the depressive symptoms, the better was the medication adherence (p < .001) LIMITATIONS: The use of a single measure of medication adherence although it is a validated instrument and a possible positive selection bias that might limit the generalization of our findings.

CONCLUSIONS

This study demonstrates that medication adherence in BD patients is a heterogeneous and potentially variable phenomenon.

Attitudes to Medication-Treatment Among Patients and Caregivers: A Longitudinal Comparison of Bipolar Disorder and Schizophrenia From India

BACKGROUND

Attitudes toward medication treatment are thought to significantly influence adherence in bipolar disorder (BD) and schizophrenia. However, the actual impact of patients' treatment attitudes on adherence and determinants of attitudes is still uncertain.

METHODS

A longitudinal examination of treatment attitudes and their correlates was conducted among patients with BD and their caregivers compared with those with schizophrenia. Structured assessments of symptom severity, functioning, insight, medication side effects, knowledge of illness, medication adherence, treatment attitudes, and treatment satisfaction were performed among 176 selected patients (106 with BD and 70 with schizophrenia) and their caregivers. Participants were reassessed on these parameters at 3 and 6 months.

RESULTS

Rates of nonadherence at baseline varied widely between self-reports, clinician ratings, and serum levels. Though symptoms and functioning improved with treatment, overall rates of nonadherence increased in the first 3 months because of early dropouts and remained stable thereafter. However, treatment attitudes and treatment satisfaction remained largely unchanged among patients and caregivers. Both positive and negative attitudes were commonly held and patients' attitudes did not differ between BD and schizophrenia. Patients' attitudes were significantly associated with adherence, insight, knowledge about illness, treatment satisfaction, symptom severity, social disadvantage, and side effects together with caregivers' knowledge, attitudes, and satisfaction. Caregivers of patients with schizophrenia were more knowledgeable and had more positive attitudes than patients.

CONCLUSIONS

Patients' attitudes to medication treatment are associated with adherence over time. They are relatively enduring and mainly associated with insight, knowledge of illness, and treatment satisfaction among patients and their caregivers. These findings could inform psychosocial interventions aiming to improve treatment attitudes and adherence in BD and schizophrenia.

Treatment Attitudes and Adherence Among Patients with Bipolar Disorder: A Systematic Review of Quantitative and Qualitative Studies

BACKGROUND

Systematic reviews about treatment attitudes of patients influencing adherence in bipolar disorder (BD) are rare.

METHODS

A systematic review was conducted according to the PRISMA guidelines and principles of thematic synthesis. Selectively identified quantitative and qualitative studies were used to examine the attitude-adherence relationship in BD, the types and correlates of treatment attitudes, and the impact of psychosocial interventions on attitudes.

RESULTS

The final list of 163 articles included 114 observational reports (incorporating 21 psychosocial intervention trials), 45 qualitative/descriptive studies, and 4 patient surveys. A positive association between treatment attitudes and adherence was found in most quantitative and qualitative studies, though the strength of the relationship was unclear. Thematic analysis of qualitative studies suggested that patient attitudes influencing adherence were based on perceived advantages and disadvantages of treatment. The principal correlates of patients' attitudes were family attitudes, the clinician-patient alliance, social support, and patients' knowledge of BD. Though negative attitudes such as denial, concerns about adverse treatment consequences, and stigmatizing effects of treatment were common, many patients believed treatment to be beneficial and necessary. The limited data on the effect of psychosocial interventions indicated that treatments selectively targeting attitudes enhanced adherence.

LIMITATIONS

The studies were heterogeneous in design; the quality was uneven (fair to poor); and the risk of bias moderate to high.

CONCLUSIONS

Despite these flaws, awareness of the existing evidence on the attitude-adherence association and other aspects of treatment attitudes in BD can help in efforts to address nonadherence in BD.

Predictors of re-attempt in a cohort of suicide attempters: A survival analysis

BACKGROUND

Suicide prevention is one of the greatest challenges in mental health policies. Since a previous suicide attempt is the main predictor of future suicidal behaviour, clinical management of suicide attempters is vital for lowering mortality. Psychopharmacological interventions are still nonspecific, and their effectiveness have often been questioned. In this study, we aim to identify predictors of suicide re-attempt in a cohort of suicide attempters, with particular focus on different aspects of psychopharmacological treatment.

METHODS

This is a prospective study. Adults presenting with a suicide attempt were approached to take part in our study, resulting in a final sample of 371 participants. Participants were followed from inclusion to next suicide attempt, death by other causes, loss of the patient, or after a maximum of two years. We conducted Kaplan-Meier survival analyses and a multivariate Cox regression model for several exposure variables.

RESULTS

During the study period, 70 participants (18,9%) re-attempted. 60% of re-attempts occurred within the first 6 months. Three factors were independently associated with risk of re-attempt in the Multivariate Cox regression model: diagnosis of a Cluster B personality disorder, good treatment compliance, and at least one previous suicide attempt prior to the index event.

LIMITATIONS

Indication bias precludes a clear interpretation of our results regarding psychopharmacological treatment. Poor adherence may also be a consequence of relapse rather than just one of its causes.

CONCLUSIONS

A correct psychopharmacological treatment is insufficient to prevent re-attempts in populations at risk. Strategies to increase compliance should be taken into account as part of prevention programs.

Reasons for Nonadherence to Psychiatric Medication and Cardiovascular Risk Factors Treatment Among Latino Bipolar Disorder Patients Living in Puerto Rico: A Qualitative Study

Latinos with bipolar disorder (BD) have a high rate of nonadherence to psychiatric medication and treatment for other medical conditions such as cardiovascular disease (CVD) risk factors than non-Latinos with BD. The aim of this study is to identify patients' perspectives on the reasons for nonadherence to psychiatric medication and for CVD risk factors conditions in outpatients with BD. Three focus group sessions were held for a total of 22 adults ranging from 23 to 60 years old. Participants had BD, Type I/II and CVD risk factors. Audio-recordings of focus groups were transcribed and a content analysis was performed. Reasons identified as barriers to adherence were somewhat different for BD medications in comparison to CVD risk factors suggesting the need for integrated interventions targeting these barriers to adherence for both BD and CVD risk factors.

Bipolar disorder and adherence: implications of manic subjective experience on treatment disruption

OBJECTIVE

Therapeutic observance is one of the cornerstones of bipolar disease prognosis. Nostalgia of previous manic phase has been described as a cause of treatment retrieval in bipolar disorder. But to date no systematic study has examined manic episode remembering stories. Our aim was to describe manic experience from the patient's point of view and its consequences on subjective relation to care and treatment adherence.

PATIENTS AND METHODS

Twelve euthymic patients with bipolar I disorder were interviewed about their former manic episodes and data was analyzed, thanks to a grounded theory method.

RESULTS

Nostalgia was an anecdotal reason for treatment retrieval in bipolar I disease. Although the manic experience was described as pleasant in a certain way, its consequences hugely tarnish the memory of it afterward. Treatment interruption appears to be mostly involuntary and state-dependent, when a euphoric subject loses insight and does not see any more benefit in having treatment.

CONCLUSION

Consciousness destructuring associated with mood elation should explain treatment disruption in bipolar I patients more than nostalgia. Taking a manic episode story into account may help patients, family, and practitioners to achieve better compliance by improving their comprehension and integration of this unusual experience.

Smartphone Applications for Educating and Helping Non-motivating Patients Adhere to Medication That Treats Mental Health Conditions: Aims and Functioning

Background: Patients prescribed with medication that treats mental health conditions benefit the most compared to those prescribed with other types of medication. However, they are also the most difficult to adhere. The development of mobile health (mHealth) applications ("apps") to help patients monitor their adherence is fast growing but with limited evidence on their efficacy. There is no evidence on the content of these apps for patients taking psychotropic medication. The aim of this study is to identify and evaluate the aims and functioning of available apps that are aiming to help and educate patients to adhere to medication that treats mental health conditions. Method: Three platform descriptions (Apple, Google, and Microsoft) were searched between October 2015 and February 2016. Included apps need to focus on adherence to medication that treats mental health conditions and use at least a reinforcement strategy. Descriptive information was extracted and apps evaluated on a number of assessment criteria using content analysis. Results: Sixteen apps were identified. All apps included self-monitoring properties like reminders and psycho-educational properties like mood logs. It was unclear how the latter were used or how adherence was measured. Major barriers to medication adherence like patients' illness and medication beliefs and attitudes were not considered nor where information to patients about mediation side effects. Very few apps were tailored and none was developed based on established theories explaining the processes for successful medication adherence like cognitions and beliefs. Reported information on app development and validation was poor. Discussion: A variety of apps with different properties that tackle both intentional and unintentional non-adherence from a different perspective are identified. An evidence-based approach and co-creation with patients is needed. This will ensure that the apps increase the possibility to impact on non-adherence. Theories like social cognition models can be useful in ensuring that patients' education, motivation, skills, beliefs, and type of adherence are taken into consideration when developing the apps. Findings from this study can help clinicians and patients make informed choices and pursue policy-makers to integrate evidence when developing future apps. Quality-assurance tools are needed to ensure the apps are systematically evaluated.

Medication non-adherence in bipolar disorder: Review of rates, demographic and clinical predictors

AIM

To conduct a systematic search for all studies examining rates and demographic and illness-related determinants of medication non-adherence in bipolar disorder (BD).

METHODS

A comprehensive literature search was undertaken of six English-language databases to identify published articles on medication non-adherence in BD from inception till December 2016. Any article, either a review or an original-research article was examined for its relevance to the subject. All such articles were manually searched to locate any further articles containing relevant information. Studies were included only if they had adequately described the patient sample, assessment methods and statistical procedures, presented their results systematically and their conclusions were congruent with the results.

RESULTS

The initial search yielded 249 articles on the subject; of these 198 articles were included. Of the 162 original-research studies, 132 had provided information on rates of medication non-adherence in BD. There was a wide variation in rates ranging from universal adherence (100%) to almost universal non-adherence (96%); this discrepancy was more due to methodological differences than true variations in rates. Notwithstanding the significant discrepancies in methodology, based on these 132 studies mean rates of 41.5%-43% and median rates of 40%-41% were obtained for medication non-adherence in BD. Rates of adherence with mood stabilizers were significantly lower than those for antipsychotics, or for medications of all classes. None of the demographic attributes were unequivocally linked to medication non-adherence in BD. Similarly, medication-related variables such as type of medications, doses, treatment regimens and side effects did not demonstrate consistent associations with non-adherence. Among clinical characteristics the presence of comorbid substance use disorder and absence of insight were the only two factors clearly linked to non-adherence in BD.

CONCLUSION

Medication non-adherence is prevalent in about a third to half of patients with BD. Demographic, illness and treatment related factors do not predict non-adherence with certainty.

A Reexamination of Nonpsychiatric Medication Adherence in Individuals With Bipolar Disorder and Medical Comorbidities

Individuals with bipolar disorder (BD) have high rates of nonadherence, medical illness, and premature mortality. This analysis reexamined correlates of poor adherence to nonpsychiatric medication in 73 patients with BD and medical comorbidities. The majority was female (74%) and African American (77%) with mean age of 48.08 (SD, 8.04) years, mean BD duration of 28.67 (SD, 10.24) years, mean years of education of 12.01 (SD, 1.87), and mean proportion of days with missed doses in past week of 43.25 (SD, 31.14). Sex, age, education, race, and living alone did not correlate with adherence. More BD medications and more severe psychiatric symptoms correlated with worse adherence. Specifically, poor adherence correlated with the retardation and vegetative factors of Montgomery-Åsberg Depression Rating Scale and affect factor of the Brief Psychiatric Rating Scale. Among poorly adherent patients with BD and medical comorbidities, the number of BD medications, tension/anxiety, and somatic symptoms of depression related to worse nonpsychiatric medication adherence.

Attitudes toward antipsychotic treatment among patients with bipolar disorders and their clinicians: a systematic review

INTRODUCTION

Antipsychotics are recommended as first-line therapy for acute mania and maintenance treatment of bipolar disorder; however, published literature suggests their real-world use remains limited. Understanding attitudes toward these medications may help identify barriers and inform personalized therapy. This literature review evaluated patient and clinician attitudes toward the use of antipsychotics for treating bipolar disorder.

MATERIALS AND METHODS

A systematic search of the Cochrane Library, Ovid MEDLINE, Embase, and BIOSIS Previews identified English language articles published between January 1, 2000, and June 15, 2016, that reported attitudinal data from patients, health care professionals, or caregivers; treatment decision-making; or patient characteristics that predicted antipsychotic use for bipolar disorder. Results were analyzed descriptively.

RESULTS

Of the 209 references identified, 11 met the inclusion criteria and were evaluated. These articles provided attitudinal information from 1,418 patients with bipolar disorder and 1,282 treating clinicians. Patients' attitudes toward antipsychotics were generally positive. Longer duration of clinical stability was associated with positive attitudes. Implementation of psychoeducational and adherence enhancement strategies could improve patient attitudes. Limited data suggest clinicians' perceptions of antipsychotic efficacy and tolerability may have the greatest impact on their prescribing patterns. Because the current real-world evidence base is inadequate, clinician attitudes may reflect a relative lack of experience using antipsychotics in patients with bipolar disorder.

CONCLUSION

Although data are very limited, perceived tolerability and efficacy concerns shape both patient and clinician attitudes toward use of antipsychotic drugs in bipolar disorder. Additional studies are warranted.

Medication Adherence in Patients with Bipolar Disorder: A Comprehensive Review

Poor medication adherence is a pervasive problem that causes disability and suffering as well as extensive financial costs among individuals with bipolar disorder (BD). Barriers to adherence are numerous and cross multiple levels, including factors related to bipolar pathology and those unique to an individual's circumstances. External factors, including treatment setting, healthcare system, and broader health policies, can also affect medication adherence in people with BD. Fortunately, advances in research have suggested avenues for improving adherence. A comprehensive review of adherence-enhancement interventions for the years 2005-2015 is included. Specific bipolar adherence-enhancement approaches that target knowledge gaps, cognitive patterns, specific barriers, and motivation may be helpful, as may approaches that capitalize on technology or novel drug-delivery systems. However, much work remains to optimally facilitate long-term medication adherence in people with BD. For adherence-enhancement approaches to be widely adapted, they need to be easily accessible, affordable, and practical.

A comparative meta-analysis of TEMPS scores across mood disorder patients, their first-degree relatives, healthy controls, and other psychiatric disorders

BACKGROUND

The Temperament Evaluation Memphis, Pisa, Paris and San Diego Auto-questionnaire (TEMPS) is validated to assess temperament in clinical and non-clinical samples. Scores vary across bipolar disorder (BD), major depressive disorder (MDD), attention-deficit/hyperactivity disorder (ADHD), borderline personality disorder (BPD) and healthy controls (HCs), but a meta-analysis is missing.

METHODS

Meta-analysis of studies comparing TEMPS scores in patients with mood disorders or their first-degree relatives to each other, or to a psychiatric control group or HCs.

RESULTS

Twenty-six studies were meta-analyzed with patients with BD (n= 2025), MDD (n=1283), ADHD (n=56) and BPD (n=43), relatives of BD (n=436), and HCs (n=1757). Cyclothymic (p<0.001) and irritable TEMPS scores (p<0.001) were higher in BD than MDD (studies=12), and in MDD vs HCs (studies=8). Cyclothymic (p<0.001), irritable (p<0.001) and anxious (p=0.03) scores were higher in BD than their relatives, who, had higher scores than HCs. No significant differences emerged between ADHD and BD (studies=3);

CONCLUSION

Affective temperaments are on a continuum, with increasing scores ranging from HCs through MDD to BD regarding cyclothymic and irritable temperament, from MDD through BD to HC regarding hyperthymic temperament, and from HC through BD relatives to BD regarding cyclothymic, irritable and anxious temperament. Depressive and anxious temperaments did not differ between BD and MDD, being nonetheless the lowest in HCs. BD did not differ from ADHD in any investigated TEMPS domain.

LIMITATIONS

Different TEMPS versions, few studies comparing BD with ADHD or BPD, no correlation with other questionnaires.

Getting to wellness: The potential of the athletic model of marginal gains for the treatment of bipolar disorder

OBJECTIVE

People with bipolar disorder frequently have persistent symptoms, continued problems functioning and comorbid medical conditions. We propose applying the athletic coaching concept of marginal gains to help patients address these challenges to achieve wellness.

METHOD

We review the concept of marginal gains and potential interventions to improve long-term outcomes for bipolar patients.

RESULTS

Evidence exists to help bipolar patients with diet and exercise, gradual behavioral change, mobile applications and peer support.

CONCLUSION

Marginal gains, small and doable improvements across a broad range of areas, have great potential to improve the lives of people with bipolar disorder.

Biological Rhythm and Bipolar Disorder: Twelve-Month Follow-Up of a Randomized Clinical Trial

The objective was to evaluate the effect of psychoeducation on biological rhythm and in the reduction of depressive, anxious, and manic symptoms at 12 months' follow-up. This was a randomized clinical trial with young adults aged 18 to 29 years, diagnosed with bipolar disorder. Biological rhythm was assessed with the Biological Rhythm Interview Assessment in Neuropsychiatry (BRIAN). Participants were randomized for combined intervention (psychoeducation plus medication) or treatment-as-usual (medication alone). The sample consisted of 61 patients (29 TAU; 32 combined intervention). Although it failed to separate by a marginal difference, the combined intervention seems to be more effective than TAU in relation to improvement of depressive symptoms at post-intervention (p = 0.074) and regulation of sleep/social domain at 6 months' follow-up (p = 0.057). Improvement of depressive symptoms as well as regulation of sleep and social activities are known to prevent episode onset and thus improve long-term outcomes.

Symptom severity, self-reported adherence, and electronic pill monitoring in poorly adherent patients with bipolar disorder

OBJECTIVES

This analysis of screening and baseline data from an ongoing trial examined self-report versus automated adherence monitoring and assessed the relationship between bipolar disorder (BD) symptoms and adherence in 104 poorly adherent individuals.

METHODS

Adherence was measured with the Tablets Routine Questionnaire (TRQ) and the Medication Event Monitoring System (MEMS). Symptoms were measured with the Montgomery-Åsberg Depression Rating Scale (MADRS), the Young Mania Rating Scale (YMRS), and the Brief Psychiatric Rating Scale (BPRS).

RESULTS

The mean age of the sample was 46.3 years [standard deviation (SD) = 9.41 years], with 72% (n = 75) women and 71% (n = 74) African American subjects. Adherence improved from screening to baseline, with a mean missed drug proportion measured by TRQ of 61.43% (SD = 26.48%) versus a baseline mean of 46.61% (SD = 30.55%). The mean proportion of missed medication using MEMS at baseline was 66.43% (SD = 30.40%). The correlation between TRQ and MEMS was 0.47. The correlation between a single index drug and all BD medications was 0.95. Symptoms were generally positively correlated with TRQ (worse adherence = more severe symptoms), but in most instances was only at a trend level (p > 0.05), with the exception of the correlations between baseline TRQ and MADRS and BPRS, which were positive (r = 0.20 and r = 0.21, respectively) and significant (p ≤ 0.05).

CONCLUSIONS

In patients with BD, monitoring increased adherence by 15%. MEMS identified 20% more non-adherence than self-report. Using a standard procedure to identify a single index drug for adherence monitoring may be one way to assess global adherence in patients with BD receiving polypharmacy treatment. Greater BD symptom severity may be a clinical indicator to assess for adherence problems.